{"question": "A 23-year-old pregnant woman at 22 weeks gestation presents with burning upon urination. She states it started 1 day ago and has been worsening despite drinking more water and taking cranberry extract. She otherwise feels well and is followed by a doctor for her pregnancy. Her temperature is 97.7°F (36.5°C), blood pressure is 122/77 mmHg, pulse is 80/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for an absence of costovertebral angle tenderness and a gravid uterus. Which of the following is the best treatment for this patient?", "answer": "Nitrofurantoin", "options": {"A": "Ampicillin", "B": "Ceftriaxone", "C": "Ciprofloxacin", "D": "Doxycycline", "E": "Nitrofurantoin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old", "weeks presents", "burning", "urination", "states", "started 1 day", "worsening", "cranberry", "well", "followed by", "doctor", "pregnancy", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "absence", "costovertebral angle tenderness", "gravid uterus", "following", "best"]}
{"question": "A 3-month-old baby died suddenly at night while asleep. His mother noticed that he had died only after she awoke in the morning. No cause of death was determined based on the autopsy. Which of the following precautions could have prevented the death of the baby?", "answer": "Placing the infant in a supine position on a firm mattress while sleeping", "options": {"A": "Placing the infant in a supine position on a firm mattress while sleeping", "B": "Routine postnatal electrocardiogram (ECG)", "C": "Keeping the infant covered and maintaining a high room temperature", "D": "Application of a device to maintain the sleeping position", "E": "Avoiding pacifier use during sleep"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 month old baby died", "night", "asleep", "died only", "awoke in", "morning", "cause of death", "based", "autopsy", "following", "prevented", "death", "baby"]}
{"question": "A mother brings her 3-week-old infant to the pediatrician's office because she is concerned about his feeding habits. He was born without complications and has not had any medical problems up until this time. However, for the past 4 days, he has been fussy, is regurgitating all of his feeds, and his vomit is yellow in color. On physical exam, the child's abdomen is minimally distended but no other abnormalities are appreciated. Which of the following embryologic errors could account for this presentation?", "answer": "Abnormal migration of ventral pancreatic bud", "options": {"A": "Abnormal migration of ventral pancreatic bud", "B": "Complete failure of proximal duodenum to recanalize", "C": "Error in neural crest cell migration", "D": "Abnormal hypertrophy of the pylorus", "E": "Failure of lateral body folds to move ventrally and fuse in the midline"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["week old infant", "pediatrician's office", "born", "complications", "not", "medical problems", "time", "past", "days", "fussy", "regurgitating", "feeds", "vomit", "yellow", "color", "child's abdomen", "distended", "abnormalities", "following embryologic errors", "account"]}
{"question": "A pulmonary autopsy specimen from a 58-year-old woman who died of acute hypoxic respiratory failure was examined. She had recently undergone surgery for a fractured femur 3 months ago. Initial hospital course was uncomplicated, and she was discharged to a rehab facility in good health. Shortly after discharge home from rehab, she developed sudden shortness of breath and had cardiac arrest. Resuscitation was unsuccessful. On histological examination of lung tissue, fibrous connective tissue around the lumen of the pulmonary artery is observed. Which of the following is the most likely pathogenesis for the present findings?", "answer": "Thromboembolism", "options": {"A": "Thromboembolism", "B": "Pulmonary ischemia", "C": "Pulmonary hypertension", "D": "Pulmonary passive congestion", "E": "Pulmonary hemorrhage"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["pulmonary autopsy", "58 year old woman", "died", "acute hypoxic respiratory failure", "examined", "recently", "surgery", "fractured femur 3 months", "Initial hospital course", "uncomplicated", "rehab facility", "discharge home", "rehab", "sudden shortness of breath", "cardiac", "Resuscitation", "unsuccessful", "histological examination", "lung tissue", "fibrous connective tissue", "lumen of", "pulmonary artery", "observed", "following", "pathogenesis", "present findings"]}
{"question": "A 20-year-old woman presents with menorrhagia for the past several years. She says that her menses “have always been heavy”, and she has experienced easy bruising for as long as she can remember. Family history is significant for her mother, who had similar problems with bruising easily. The patient's vital signs include: heart rate 98/min, respiratory rate 14/min, temperature 36.1°C (96.9°F), and blood pressure 110/87 mm Hg. Physical examination is unremarkable. Laboratory tests show the following: platelet count 200,000/mm3, PT 12 seconds, and PTT 43 seconds. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Von Willebrand disease", "options": {"A": "Factor V Leiden", "B": "Hemophilia A", "C": "Lupus anticoagulant", "D": "Protein C deficiency", "E": "Von Willebrand disease"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["20 year old woman presents", "menorrhagia", "past", "years", "menses", "always", "heavy", "easy bruising", "long", "Family history", "significant", "similar", "bruising easily", "patient's vital signs include", "heart rate 98 min", "respiratory rate", "min", "temperature 36", "96 9F", "blood pressure", "87 mm Hg", "unremarkable", "Laboratory tests", "following", "platelet count 200", "mm3", "PT", "seconds", "PTT", "seconds", "following", "most likely cause", "patients symptoms"]}
{"question": "A 40-year-old zookeeper presents to the emergency department complaining of severe abdominal pain that radiates to her back, and nausea. The pain started 2 days ago and slowly increased until she could not tolerate it any longer. Past medical history is significant for hypertension and hypothyroidism. Additionally, she reports that she was recently stung by one of the zoo’s smaller scorpions, but did not seek medical treatment. She takes aspirin, levothyroxine, oral contraceptive pills, and a multivitamin daily. Family history is noncontributory. Today, her blood pressure is 108/58 mm Hg, heart rate is 99/min, respiratory rate is 21/min, and temperature is 37.0°C (98.6°F). On physical exam, she is a well-developed, obese female that looks unwell. Her heart has a regular rate and rhythm. Radial pulses are weak but symmetric. Her lungs are clear to auscultation bilaterally. Her lateral left ankle is swollen, erythematous, and painful to palpate. An abdominal CT is consistent with acute pancreatitis. Which of the following is the most likely etiology for this patient’s disease?", "answer": "Scorpion sting", "options": {"A": "Aspirin", "B": "Oral contraceptive pills", "C": "Scorpion sting", "D": "Hypothyroidism", "E": "Obesity"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old", "presents", "emergency department", "severe abdominal", "radiates", "back", "nausea", "pain started 2 days", "slowly increased", "not", "longer", "Past medical history", "significant", "hypertension", "hypothyroidism", "reports", "recently stung", "one", "smaller scorpions", "not", "medical treatment", "aspirin", "levothyroxine", "oral contraceptive pills", "multivitamin daily", "Family history", "Today", "blood pressure", "58 mm Hg", "heart rate", "99 min", "respiratory rate", "min", "temperature", "98", "well", "obese female", "looks unwell", "heart", "regular rate", "rhythm", "Radial pulses", "weak", "symmetric", "lungs", "clear", "auscultation", "lateral", "swollen", "erythematous", "painful to", "abdominal CT", "acute pancreatitis", "following", "etiology", "patients disease"]}
{"question": "A 25-year-old primigravida presents to her physician for a routine prenatal visit. She is at 34 weeks gestation, as confirmed by an ultrasound examination. She has no complaints, but notes that the new shoes she bought 2 weeks ago do not fit anymore. The course of her pregnancy has been uneventful and she has been compliant with the recommended prenatal care. Her medical history is unremarkable. She has a 15-pound weight gain since the last visit 3 weeks ago. Her vital signs are as follows: blood pressure, 148/90 mm Hg; heart rate, 88/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉). The blood pressure on repeat assessment 4 hours later is 151/90 mm Hg. The fetal heart rate is 151/min. The physical examination is significant for 2+ pitting edema of the lower extremity. Which of the following tests o should confirm the probable condition of this patient?", "answer": "24-hour urine protein", "options": {"A": "Bilirubin assessment", "B": "Coagulation studies", "C": "Hematocrit assessment", "D": "Leukocyte count with differential", "E": "24-hour urine protein"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old primigravida presents", "physician", "routine", "weeks gestation", "confirmed by", "ultrasound examination", "complaints", "notes", "new shoes", "2 weeks", "not fit", "course", "pregnancy", "compliant", "medical history", "unremarkable", "pound weight gain", "last", "weeks", "vital signs", "follows", "blood pressure", "90 mm Hg", "heart rate", "88 min", "respiratory rate", "min", "temperature", "36", "97", "blood", "repeat assessment", "hours later", "90 mm Hg", "fetal heart rate", "min", "significant", "pitting edema", "lower extremity", "following tests", "confirm", "probable condition", "patient"]}
{"question": "A 3900-g (8.6-lb) male infant is delivered at 39 weeks' gestation via spontaneous vaginal delivery. Pregnancy and delivery were uncomplicated but a prenatal ultrasound at 20 weeks showed a defect in the pleuroperitoneal membrane. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Gastric fundus in the thorax", "options": {"A": "Gastric fundus in the thorax", "B": "Pancreatic ring around the duodenum", "C": "Small and cystic kidneys", "D": "Hypertrophy of the gastric pylorus", "E": "Large bowel in the inguinal canal"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["male infant", "delivered", "weeks", "gestation", "spontaneous vaginal delivery", "Pregnancy", "delivery", "uncomplicated", "prenatal ultrasound", "20 weeks", "defect", "pleuroperitoneal membrane", "Further", "to", "following findings"]}
{"question": "A 62-year-old woman presents for a regular check-up. She complains of lightheadedness and palpitations which occur episodically. Past medical history is significant for a myocardial infarction 6 months ago and NYHA class II chronic heart failure. She also was diagnosed with grade I arterial hypertension 4 years ago. Current medications are aspirin 81 mg, atorvastatin 10 mg, enalapril 10 mg, and metoprolol 200 mg daily. Her vital signs are a blood pressure of 135/90 mm Hg, a heart rate of 125/min, a respiratory rate of 14/min, and a temperature of 36.5°C (97.7°F). Cardiopulmonary examination is significant for irregular heart rhythm and decreased S1 intensity. ECG is obtained and is shown in the picture (see image). Echocardiography shows a left ventricular ejection fraction of 39%. Which of the following drugs is the best choice for rate control in this patient?", "answer": "Digoxin", "options": {"A": "Atenolol", "B": "Verapamil", "C": "Diltiazem", "D": "Propafenone", "E": "Digoxin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["62 year old woman presents", "regular check-up", "lightheadedness", "palpitations", "occur", "Past medical history", "significant", "myocardial infarction", "months", "NYHA class II chronic heart failure", "diagnosed", "grade I arterial hypertension 4", "Current medications", "enalapril 10 mg", "metoprolol 200 mg daily", "vital signs", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "Cardiopulmonary", "significant", "irregular heart rhythm", "decreased S1 intensity", "ECG", "obtained", "picture", "see", "Echocardiography", "left ventricular ejection fraction", "following drugs", "best", "rate control", "patient"]}
{"question": "A 35-year-old male presents to his primary care physician with complaints of seasonal allergies. He has been using intranasal vasoconstrictors several times per day for several weeks. What is a likely sequela of the chronic use of topical nasal decongestants?", "answer": "Persistent congestion", "options": {"A": "Epistaxis", "B": "Hypertension", "C": "Permanent loss of smell", "D": "Persistent nasal crusting", "E": "Persistent congestion"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old male presents", "primary care physician", "complaints", "seasonal allergies", "using intranasal vasoconstrictors", "times per day", "several weeks", "likely sequela of", "chronic use", "topical nasal decongestants"]}
{"question": "A 46-year-old woman comes to the physician because of a 2-week history of diplopia and ocular pain when reading the newspaper. She also has a 3-month history of amenorrhea, hot flashes, and increased sweating. She reports that she has been overweight all her adult life and is happy to have lost 6.8-kg (15-lb) of weight in the past 2 months. Her pulse is 110/min, and blood pressure is 148/98 mm Hg. Physical examination shows moist palms and a nontender thyroid gland that is enlarged to two times its normal size. Ophthalmologic examination shows prominence of the globes of the eyes, bilateral lid retraction, conjunctival injection, and an inability to converge the eyes. There is no pain on movement of the extraocular muscles. Visual acuity is 20/20 bilaterally. Neurologic examination shows a fine resting tremor of the hands. Deep tendon reflexes are 3+ with a shortened relaxation phase. Which of the following is the most likely cause of this patient's ocular complaints?", "answer": "Glycosaminoglycan accumulation in the orbit", "options": {"A": "Granulomatous inflammation of the cavernous sinus", "B": "Abnormal communication between the cavernous sinus and the internal carotid artery", "C": "Glycosaminoglycan accumulation in the orbit", "D": "Bacterial infection of the orbital contents", "E": "Sympathetic hyperactivity of levator palpebrae superioris\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "2-week history", "diplopia", "ocular pain", "newspaper", "3 month history of amenorrhea", "hot flashes", "increased sweating", "reports", "overweight", "adult", "to", "lost", "kg", "weight", "past", "months", "pulse", "min", "blood pressure", "98 mm Hg", "moist", "nontender thyroid gland", "enlarged", "two times", "normal size", "Ophthalmologic examination", "prominence", "globes", "eyes", "bilateral lid retraction", "conjunctival injection", "to", "eyes", "pain", "movement", "extraocular muscles", "Visual acuity", "20/20", "Neurologic examination", "fine", "tremor of", "hands", "Deep tendon reflexes", "3", "shortened", "phase", "following", "most likely cause", "patient's ocular complaints"]}
{"question": "A 1-year-old boy presents to the emergency department with weakness and a change in his behavior. His parents state that they first noticed the change in his behavior this morning and it has been getting worse. They noticed the patient was initially weak in his upper body and arms, but now he won’t move his legs with as much strength or vigor as he used to. Physical exam is notable for bilateral ptosis with a sluggish pupillary response, a very weak sucking and gag reflex, and shallow respirations. The patient is currently drooling and his diaper is dry. The parents state he has not had a bowel movement in over 1 day. Which of the following is the pathophysiology of this patient’s condition?", "answer": "Blockade of presynaptic acetylcholine release at the neuromuscular junction", "options": {"A": "Antibodies against postsynaptic nicotinic cholinergic ion channels", "B": "Autoantibodies against the presynaptic voltage-gated calcium channels", "C": "Autoimmune demyelination of peripheral nerves", "D": "Blockade of presynaptic acetylcholine release at the neuromuscular junction", "E": "Lower motor neuron destruction in the anterior horn"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "emergency department", "weakness", "state", "first", "morning", "getting worse", "patient", "initially weak", "upper body", "arms", "now", "move", "legs", "strength", "used to", "notable", "bilateral ptosis", "sluggish pupillary response", "very weak sucking", "gag reflex", "shallow respirations", "patient", "currently drooling", "diaper", "dry", "state", "not", "bowel movement", "1 day", "following", "pathophysiology", "patients condition"]}
{"question": "A 9-month-old female is brought to the emergency department after experiencing a seizure. She was born at home and was normal at birth according to her parents. Since then, they have noticed that she does not appear to be achieving developmental milestones as quickly as her siblings, and often appears lethargic. Physical exam reveals microcephaly, very light pigmentation (as compared to her family), and a \"musty\" body odor. The varied manifestations of this disease can most likely be attributed to which of the following genetic principles?", "answer": "Pleiotropy", "options": {"A": "Anticipation", "B": "Incomplete penetrance", "C": "Multiple gene mutations", "D": "Pleiotropy", "E": "Variable expressivity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old female", "brought", "emergency department", "seizure", "born at home", "normal at birth", "Since then", "not appear to", "often appears lethargic", "reveals microcephaly", "very light pigmentation", "musty", "body odor", "varied manifestations of", "disease", "most likely", "attributed", "following genetic"]}
{"question": "A 23-year-old man comes to the physician for evaluation of decreased hearing, dizziness, and ringing in his right ear for the past 6 months. Physical examination shows multiple soft, yellow plaques and papules on his arms, chest, and back. There is sensorineural hearing loss and weakness of facial muscles bilaterally. His gait is unsteady. An MRI of the brain shows a 3-cm mass near the right internal auditory meatus and a 2-cm mass at the left cerebellopontine angle. The abnormal cells in these masses are most likely derived from which of the following embryological structures?", "answer": "Neural crest", "options": {"A": "Neural tube", "B": "Surface ectoderm", "C": "Neural crest", "D": "Notochord", "E": "Mesoderm"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old man", "physician", "decreased", "dizziness", "ringing in", "right ear", "past 6 months", "multiple soft", "yellow plaques", "papules", "arms", "chest", "back", "sensorineural hearing loss", "weakness", "facial muscles", "gait", "unsteady", "MRI of", "brain", "3", "mass", "right internal auditory meatus", "2 cm mass", "left cerebellopontine angle", "abnormal cells", "masses", "most likely derived", "following embryological structures"]}
{"question": "A 62-year-old woman comes to the physician because of coughing and fatigue during the past 2 years. In the morning, the cough is productive of white phlegm. She becomes short of breath walking up a flight of stairs. She has hypertension and hyperlipidemia. She has recently retired from working as a nurse at a homeless shelter. She has smoked 1 pack of cigarettes daily for 40 years. Current medications include ramipril and fenofibrate. Her temperature is 36.5°C (97.7°F), respirations are 24/min, pulse is 85/min, and blood pressure is 140/90 mm Hg. Scattered wheezing and rhonchi are heard throughout both lung fields. There are no murmurs, rubs, or gallops but heart sounds are distant. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Progressive obstruction of expiratory airflow", "options": {"A": "Chronic decrease in pulmonary compliance", "B": "Local accumulation of kinins", "C": "Mycobacterial invasion of pulmonary parenchyma", "D": "Progressive obstruction of expiratory airflow", "E": "Incremental loss of functional residual capacity\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "physician", "coughing", "fatigue", "past", "years", "morning", "cough", "productive", "white phlegm", "short of breath", "hypertension", "hyperlipidemia", "recently retired", "nurse", "homeless shelter", "smoked 1 pack", "cigarettes daily", "40 years", "Current medications include ramipril", "fenofibrate", "temperature", "36", "97", "respirations", "min", "pulse", "85 min", "blood pressure", "90 mm Hg", "Scattered wheezing", "rhonchi", "heard", "lung fields", "murmurs", "rubs", "heart sounds", "distant", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 68-year-old man presents to the emergency department with leg pain. He states that the pain started suddenly while he was walking outside. The patient has a past medical history of diabetes, hypertension, obesity, and atrial fibrillation. His temperature is 99.3°F (37.4°C), blood pressure is 152/98 mmHg, pulse is 97/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for a cold and pale left leg. The patient’s sensation is markedly diminished in the left leg when compared to the right, and his muscle strength is 1/5 in his left leg. Which of the following is the best next step in management?", "answer": "Heparin drip", "options": {"A": "CT angiogram", "B": "Graded exercise and aspirin", "C": "Heparin drip", "D": "Surgical thrombectomy", "E": "Tissue plasminogen activator"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "leg pain", "states", "pain started", "outside", "patient", "past medical diabetes", "hypertension", "obesity", "atrial fibrillation", "temperature", "99", "blood pressure", "98 mmHg", "pulse", "97 min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "cold", "pale left leg", "patients sensation", "markedly diminished", "left leg", "right", "muscle strength", "1/5", "left leg", "following", "best next step"]}
{"question": "A 76-year-old African American man presents to his primary care provider complaining of urinary frequency. He wakes up 3-4 times per night to urinate while he previously only had to wake up once per night. He also complains of post-void dribbling and difficulty initiating a stream of urine. He denies any difficulty maintaining an erection. His past medical history is notable for non-alcoholic fatty liver disease, hypertension, hyperlipidemia, and gout. He takes aspirin, atorvastatin, enalapril, and allopurinol. His family history is notable for prostate cancer in his father and lung cancer in his mother. He has a 15-pack-year smoking history and drinks alcohol socially. On digital rectal exam, his prostate is enlarged, smooth, and non-tender. Which of the following medications is indicated in this patient?", "answer": "Tamsulosin", "options": {"A": "Clonidine", "B": "Hydrochlorothiazide", "C": "Midodrine", "D": "Oxybutynin", "E": "Tamsulosin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["76 year old", "man presents", "primary care provider", "urinary frequency", "wakes up", "times", "night to", "only", "to wake up", "night", "post-void dribbling", "difficulty initiating", "stream of urine", "difficulty", "erection", "past medical history", "notable", "non-alcoholic fatty liver disease", "hypertension", "hyperlipidemia", "gout", "aspirin", "atorvastatin", "enalapril", "allopurinol", "family history", "notable", "prostate cancer", "lung cancer", "smoking history", "alcohol", "digital rectal exam", "prostate", "enlarged", "smooth", "non-tender", "following medications", "indicated", "patient"]}
{"question": "A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past 4 months. The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal. He has tried to go for a walk after dinner to help with digestion, but his complaints have only increased. For the past 3 weeks he has also had symptoms while climbing the stairs to his apartment. He has type 2 diabetes mellitus, hypertension, and stage 2 peripheral arterial disease. He has smoked one pack of cigarettes daily for the past 45 years. He drinks one to two beers daily and occasionally more on weekends. His current medications include metformin, enalapril, and aspirin. He is 168 cm (5 ft 6 in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2. His temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg. On physical examination, the abdomen is soft and nontender with no organomegaly. Foot pulses are absent bilaterally. An ECG shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?", "answer": "Cardiac stress test", "options": {"A": "Esophagogastroduodenoscopy", "B": "CT scan of the abdomen", "C": "Hydrogen breath test", "D": "Cardiac stress test", "E": "Abdominal ultrasonography of the right upper quadrant"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "of recurrent episodes", "nausea", "abdominal discomfort", "past", "months", "discomfort", "upper abdomen", "sometimes occurs", "eating", "big", "to go", "dinner to help", "digestion", "complaints", "only increased", "past", "weeks", "symptoms", "climbing", "apartment", "type 2 diabetes mellitus", "hypertension", "peripheral arterial disease", "smoked one pack", "cigarettes daily", "past", "years", "one", "two", "daily", "occasionally", "weekends", "current medications include metformin", "enalapril", "aspirin", "5 ft 6", "tall", "kg", "BMI", "kg/m2", "temperature", "36", "97", "pulse", "min", "blood pressure", "mm Hg", "abdomen", "soft", "nontender", "organomegaly", "Foot pulses", "absent", "ECG", "abnormalities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 27-year-old female presents to general medical clinic for a routine checkup. She has a genetic disease marked by a mutation in a chloride transporter. She has a history of chronic bronchitis. She has a brother with a similar history of infections as well as infertility. Which of the following is most likely true regarding a potential vitamin deficiency complication secondary to this patient's chronic illness?", "answer": "It may manifest itself as a prolonged PT", "options": {"A": "It may result in connective tissue defects", "B": "It may result in corneal vascularization", "C": "It may result in the triad of confusion, ophthalmoplegia, and ataxia", "D": "It may be exacerbated by excessive ingestion of raw eggs", "E": "It may manifest itself as a prolonged PT"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old female presents", "general medical clinic", "routine checkup", "genetic disease marked", "mutation", "transporter", "history of chronic bronchitis", "similar history", "infections", "infertility", "following", "true", "potential vitamin deficiency complication secondary to", "patient's chronic illness"]}
{"question": "A previously healthy 36-year-old man comes to the physician for a yellow discoloration of his skin and dark-colored urine for 2 weeks. He does not drink any alcohol. Physical examination shows jaundice. Abdominal and neurologic examinations show no abnormalities. Serum studies show increased levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). A liver biopsy is performed and a photomicrograph after periodic acid-Schiff-staining is shown. Which of the following is the most likely additional finding in this patient?", "answer": "Bullous changes of the lung bases on chest CT", "options": {"A": "Tropheryma whipplei-specific RNA on PCR", "B": "Bullous changes of the lung bases on chest CT", "C": "Beading of intra- and extrahepatic bile ducts on ERCP", "D": "Myocardial iron deposition on cardiovascular MRI", "E": "Dark corneal ring on slit-lamp examination"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 36 year old man", "physician", "yellow discoloration", "skin", "dark-colored urine", "2 weeks", "not", "alcohol", "jaundice", "Abdominal", "neurologic examinations", "abnormalities", "Serum studies", "increased levels", "alanine aminotransferase", "ALT", "aspartate aminotransferase", "AST", "liver biopsy", "performed", "photomicrograph", "periodic acid-Schiff-staining", "following", "additional finding", "patient"]}
{"question": "A 69-year-old male presents to the emergency room with back pain. He has a history of personality disorder and metastatic prostate cancer and was not a candidate for surgical resection. He began chemotherapy but discontinued due to unremitting nausea. He denies any bowel or bladder incontinence. He has never had pain like this before and is demanding morphine. The nurse administers IV morphine and he feels more comfortable. Vital signs are stable. On physical examination you note tenderness to palpation along the lower spine, weakness in the bilateral lower extremities, left greater than right. Neurological examination is also notable for hyporeflexia in the knee and ankle jerks bilaterally. You conduct a rectal examination, which reveals saddle anesthesia. Regarding this patient, what is the most likely diagnosis and the appropriate next step in management?", "answer": "The most likely diagnosis is cauda equina syndrome and steroids should be started prior to MRI", "options": {"A": "The most likely diagnosis is cauda equina syndrome and steroids should be started prior to MRI", "B": "The most likely diagnosis is cauda equina syndrome and steroids should be started after to MRI", "C": "The most likely diagnosis is cauda equina syndrome and the patient should be rushed to radiation", "D": "The most likely diagnosis is conus medullaris syndrome and steroids should be started prior to MRI", "E": "The most likely diagnosis is conus medullaris syndrome and steroids should be started after to MRI"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["69 year old male presents", "emergency room", "back pain", "history of personality disorder", "metastatic prostate cancer", "not", "surgical resection", "began chemotherapy", "discontinued due to", "nausea", "bowel", "bladder incontinence", "never", "pain", "before", "demanding morphine", "nurse administers IV morphine", "more", "Vital signs", "stable", "note tenderness", "palpation", "lower spine", "weakness in", "bilateral lower extremities", "left greater than right", "Neurological examination", "notable", "hyporeflexia", "knee", "ankle jerks", "rectal examination", "reveals saddle anesthesia", "patient", "diagnosis", "appropriate next step"]}
{"question": "An investigator is studying the function of the lateral nucleus of the hypothalamus in an experimental animal. Using a viral vector, the genes encoding chloride-conducting channelrhodopsins are injected into this nucleus. Photostimulation of the channels causes complete inhibition of action potential generation. Persistent photostimulation is most likely to result in which of the following abnormalities in these animals?", "answer": "Anorexia", "options": {"A": "Hypothermia", "B": "Hyperthermia", "C": "Polydipsia", "D": "Nocturnal hyperactivity", "E": "Anorexia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "function", "lateral nucleus", "hypothalamus", "Using", "viral vector", "genes", "channelrhodopsins", "injected", "nucleus", "channels causes complete inhibition", "Persistent", "to result", "following abnormalities", "animals"]}
{"question": "A 52-year-old woman comes to the physician because of a 6-month history of generalized fatigue, low-grade fever, and a 10-kg (22-lb) weight loss. Physical examination shows generalized pallor and splenomegaly. Her hemoglobin concentration is 7.5 g/dL and leukocyte count is 41,800/mm3. Leukocyte alkaline phosphatase activity is low. Peripheral blood smear shows basophilia with myelocytes and metamyelocytes. Bone marrow biopsy shows cellular hyperplasia with proliferation of immature granulocytic cells. Which of the following mechanisms is most likely responsible for this patient's condition?", "answer": "Unregulated expression of the ABL1 gene", "options": {"A": "Overexpression of the c-KIT gene", "B": "Cytokine-independent activation of the JAK-STAT pathway", "C": "Loss of function of the APC gene", "D": "Altered expression of the retinoic acid receptor gene", "E": "Unregulated expression of the ABL1 gene"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "month history", "generalized fatigue", "low-grade fever", "a 10 kg", "weight loss", "generalized pallor", "splenomegaly", "hemoglobin concentration", "7.5 g/dL", "leukocyte count", "800 mm3", "Leukocyte alkaline phosphatase activity", "low", "Peripheral blood smear", "basophilia", "myelocytes", "metamyelocytes", "Bone marrow biopsy", "cellular hyperplasia", "proliferation", "immature granulocytic", "following mechanisms", "responsible", "patient's condition"]}
{"question": "A 42-year-old woman is in the hospital recovering from a cholecystectomy performed 3 days ago that was complicated by cholangitis. She is being treated with IV piperacillin-tazobactam. She calls the nurse to her room because she says that her heart is racing. She also demands that someone come in to clean the pile of garbage off of the floor because it is attracting flies. Her pulse is 112/min, respiratory rate is 20/min, temperature is 38.0°C (100.4°F), and blood pressure is 150/90 mm Hg. On physical examination, the patient appears sweaty, distressed, and unable to remain still. She is oriented to person, but not place or time. Palpation of the abdomen shows no tenderness, rebound, or guarding. Which of the following is the most likely diagnosis in this patient?", "answer": "Delirium tremens", "options": {"A": "Acute cholangitis", "B": "Alcoholic hallucinosis", "C": "Delirium tremens", "D": "Hepatic encephalopathy", "E": "Thyroid storm"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "hospital recovering", "cholecystectomy performed 3 days", "complicated", "cholangitis", "treated with IV piperacillin-tazobactam", "calls", "nurse", "room", "heart", "demands", "pile", "floor", "pulse", "min", "respiratory rate", "20 min", "temperature", "100", "blood pressure", "90 mm Hg", "patient appears sweaty", "unable to", "oriented to person", "not place", "time", "Palpation of", "abdomen", "tenderness", "guarding", "following", "diagnosis", "patient"]}
{"question": "A 48-year-old woman comes to the emergency department because of a photosensitive blistering rash on her hands, forearms, and face for 3 weeks. The lesions are not itchy. She has also noticed that her urine has been dark brown in color recently. Twenty years ago, she was successfully treated for Coats disease of the retina via retinal sclerotherapy. She is currently on hormonal replacement therapy for perimenopausal symptoms. Her aunt and sister have a history of a similar skin lesions. Examination shows multiple fluid-filled blisters and oozing erosions on the forearms, dorsal side of both hands, and forehead. There is hyperpigmented scarring and patches of bald skin along the sides of the blisters. Laboratory studies show a normal serum ferritin concentration. Which of the following is the most appropriate next step in management to induce remission in this patient?", "answer": "Begin phlebotomy therapy", "options": {"A": "Pursue liver transplantation", "B": "Begin oral thalidomide therapy", "C": "Begin phlebotomy therapy", "D": "Begin oral hydroxychloroquine therapy", "E": "Begin subcutaneous deferoxamine therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old woman", "emergency department", "of", "photosensitive blistering", "hands", "forearms", "face", "weeks", "lesions", "not itchy", "urine", "dark brown", "color recently", "Twenty years", "treated", "Coats", "retina", "retinal sclerotherapy", "currently", "hormonal replacement", "perimenopausal symptoms", "history of", "similar skin lesions", "Examination", "multiple fluid", "blisters", "erosions", "forearms", "dorsal side", "hands", "forehead", "hyperpigmented scarring", "patches", "bald skin", "sides", "blisters", "Laboratory studies", "normal serum ferritin concentration", "following", "most appropriate next step", "to induce remission in", "patient"]}
{"question": "A 53-year-old man comes to the emergency department because of severe right-sided flank pain for 3 hours. The pain is colicky, radiates towards his right groin, and he describes it as 8/10 in intensity. He has vomited once. He has no history of similar episodes in the past. Last year, he was treated with naproxen for swelling and pain of his right toe. He has a history of hypertension. He drinks one to two beers on the weekends. Current medications include amlodipine. He appears uncomfortable. His temperature is 37.1°C (99.3°F), pulse is 101/min, and blood pressure is 130/90 mm Hg. Examination shows a soft, nontender abdomen and right costovertebral angle tenderness. An upright x-ray of the abdomen shows no abnormalities. A CT scan of the abdomen and pelvis shows a 7-mm stone in the proximal ureter and grade I hydronephrosis on the right. Which of the following is most likely to be seen on urinalysis?", "answer": "Urinary pH: 4.7", "options": {"A": "Urinary pH: 7.3", "B": "Urinary pH: 4.7", "C": "Hexagon shaped crystals", "D": "Positive nitrites test", "E": "Largely positive urinary protein"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "of severe right-sided flank pain", "hours", "pain", "colicky", "radiates", "right groin", "8/10", "intensity", "vomited", "history of similar episodes", "past", "year", "treated with naproxen", "swelling", "pain", "right toe", "history of hypertension", "one", "two", "weekends", "Current medications include amlodipine", "appears", "temperature", "99", "pulse", "min", "blood pressure", "90 mm Hg", "soft", "nontender abdomen", "right costovertebral angle tenderness", "upright x-ray of", "abdomen", "abnormalities", "CT scan", "abdomen", "pelvis", "7-mm stone", "proximal ureter", "grade I hydronephrosis", "right", "following", "to", "seen", "urinalysis"]}
{"question": "A 5-year-old girl is brought to the clinic by her mother for excessive hair growth. Her mother reports that for the past 2 months she has noticed hair at the axillary and pubic areas. She denies any family history of precocious puberty and reports that her daughter has been relatively healthy with an uncomplicated birth history. She denies any recent illnesses, weight change, fever, vaginal bleeding, pain, or medication use. Physical examination demonstrates Tanner stage 4 development. A pelvic ultrasound shows an ovarian mass. Laboratory studies demonstrates an elevated level of estrogen. What is the most likely diagnosis?", "answer": "Granulosa cell tumor", "options": {"A": "Congenital adrenal hyperplasia", "B": "Granulosa cell tumor", "C": "Idiopathic precocious puberty", "D": "McCune-Albright syndrome", "E": "Sertoli-Leydig tumor"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old girl", "brought", "clinic", "excessive hair growth", "reports", "past", "months", "hair", "axillary", "pubic areas", "family history", "precocious puberty", "reports", "uncomplicated birth history", "recent illnesses", "weight change", "fever", "vaginal bleeding", "pain", "medication use", "Tanner", "development", "pelvic ultrasound", "ovarian mass", "Laboratory studies", "elevated level", "estrogen", "diagnosis"]}
{"question": "A 16-year-old boy is brought to the physician by his mother because she is worried about his behavior. Yesterday, he was expelled from school for repeatedly skipping classes. Over the past 2 months, he was suspended 3 times for bullying and aggressive behavior towards his peers and teachers. Once, his neighbor found him smoking cigarettes in his backyard. In the past, he consistently maintained an A grade average and had been a regular attendee of youth group events at their local church. The mother first noticed this change in behavior 3 months ago, around the time at which his father moved out after discovering his wife was having an affair. Which of the following defense mechanisms best describes the change in this patient's behavior?", "answer": "Acting out", "options": {"A": "Suppression", "B": "Acting out", "C": "Projection", "D": "Passive aggression", "E": "Regression"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "worried", "behavior", "expelled from school", "repeatedly skipping", "past", "months", "suspended 3 times", "bullying", "teachers", "found", "smoking cigarettes", "backyard", "past", "maintained", "grade average", "regular", "youth", "local church", "first", "months", "time", "moved out", "following", "best", "patient's"]}
{"question": "A 63-year-old woman presents to her primary-care doctor for a 2-month history of vision changes, specifically citing the gradual onset of double vision. Her double vision is present all the time and does not get better or worse throughout the day. She has also noticed that she has a hard time keeping her right eye open, and her right eyelid looks 'droopy' in the mirror. Physical exam findings during primary gaze are shown in the photo. Her right pupil is 6 mm and poorly reactive to light. The rest of her neurologic exam is unremarkable. Laboratory studies show an Hb A1c of 5.0%. Which of the following is the next best test for this patient?", "answer": "MR angiography of the head", "options": {"A": "CT head (non-contrast)", "B": "Direct fundoscopy", "C": "Intraocular pressures", "D": "MR angiography of the head", "E": "Temporal artery biopsy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old woman presents", "primary-care doctor", "2 month history", "vision changes", "gradual onset", "double vision", "double vision", "present", "time", "not", "better", "hard time keeping", "right eye open", "right eyelid looks", "mirror", "Physical exam findings", "primary gaze", "right pupil", "6 mm", "poorly reactive to light", "neurologic exam", "unremarkable", "Laboratory studies", "Hb A1c", "5.0", "following", "next best test", "patient"]}
{"question": "An investigator is studying the modification of newly formed polypeptides in plated eukaryotic cells. After the polypeptides are released from the ribosome, a chemically-tagged protein attaches covalently to lysine residues on the polypeptide chain, forming a modified polypeptide. When a barrel-shaped complex is added to the cytoplasm, the modified polypeptide lyses, resulting in individual amino acids and the chemically-tagged proteins. Which of the following post-translational modifications has most likely occurred?", "answer": "Ubiquitination", "options": {"A": "Acylation", "B": "Glycosylation", "C": "Phosphorylation", "D": "Carboxylation", "E": "Ubiquitination"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "modification", "formed polypeptides", "plated", "polypeptides", "released", "ribosome", "a", "tagged protein", "lysine residues", "polypeptide chain", "forming", "modified polypeptide", "barrel-shaped complex", "added", "cytoplasm", "modified polypeptide lyses", "resulting in", "amino acids", "tagged proteins", "following", "most likely"]}
{"question": "A 38-year-old man presents to his physician with double vision persisting for a week. When he enters the exam room, the physician notes that the patient has a broad-based gait. The man’s wife informs the doctor that he has been an alcoholic for the last 5 years and his consumption of alcohol has increased significantly over the past few months. She also reports that he has become indifferent to his family members over time and is frequently agitated. She also says that his memory has been affected significantly, and when asked about a particular detail, he often recollects it incorrectly, though he insists that his version is the true one. On physical examination, his vital signs are stable, but when the doctor asks him where he is, he seems to be confused. His neurological examination also shows nystagmus. Which of the following options describes the earliest change in the pathophysiology of the central nervous system in this man?", "answer": "Decreased α-ketoglutarate dehydrogenase activity in astrocytes", "options": {"A": "Decreased α-ketoglutarate dehydrogenase activity in astrocytes", "B": "Increased extracellular concentration of glutamate", "C": "Increased astrocyte lactate", "D": "Breakdown of the blood-brain barrier", "E": "Increased fragmentation of deoxyribonucleic acid within the neurons"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "physician", "double vision", "week", "enters", "exam room", "physician notes", "patient", "broad-based gait", "mans", "informs", "doctor", "alcoholic", "years", "increased", "past", "months", "reports", "indifferent", "time", "frequently agitated", "memory", "affected", "detail", "often", "version", "true one", "vital signs", "stable", "doctor", "to", "confused", "neurological examination", "nystagmus", "following options", "earliest change", "pathophysiology", "central nervous system", "man"]}
{"question": "A 69-year-old man is brought by his son to the emergency department with weakness in his right arm and leg. The man insists that he is fine and blames his son for \"creating panic\". Four hours ago the patient was having tea with his wife when he suddenly dropped his teacup. He has had difficulty moving his right arm since then and cannot walk because his right leg feels stuck. He has a history of hypertension and dyslipidemia, for which he currently takes lisinopril and atorvastatin, respectively. He is allergic to aspirin and peanuts. A computerized tomography (CT) scan shows evidence of an ischemic stroke. Which medication would most likely prevent such attacks in this patient in the future?", "answer": "Clopidogrel", "options": {"A": "Abciximab", "B": "Alteplase", "C": "Urokinase", "D": "Celecoxib", "E": "Clopidogrel"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["69 year old man", "brought", "emergency department", "weakness", "right arm", "leg", "man", "fine", "creating panic", "Four hours", "patient", "difficulty moving", "right arm", "then", "right leg", "history of hypertension", "dyslipidemia", "currently", "lisinopril", "atorvastatin", "allergic", "aspirin", "computerized tomography", "scan", "ischemic stroke", "medication", "most likely prevent", "attacks", "patient", "future"]}
{"question": "A 70-year-old man presents to a medical clinic reporting blood in his urine and lower abdominal pain for the past few days. He is also concerned about urinary frequency and urgency. He states that he recently completed a cycle of chemotherapy for non-Hodgkin lymphoma. Which medication in the chemotherapy regimen most likely caused his symptoms?", "answer": "Cyclophosphamide", "options": {"A": "Cytarabine", "B": "Methotrexate", "C": "Rituximab", "D": "Cyclophosphamide", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man presents", "medical clinic", "blood", "urine", "lower abdominal pain", "past", "days", "urinary frequency", "urgency", "states", "recently completed", "cycle", "chemotherapy", "non-Hodgkin lymphoma", "medication", "chemotherapy", "likely caused", "symptoms"]}
{"question": "A 27-year-old man presents to the emergency department after a dog bite. The patient was intoxicated and pulled the dog’s tail while it was eating. The dog belongs to his friend and is back at his friend’s house currently. Physical exam is notable for a dog bite on the patient’s right arm. The wound is irrigated and explored with no retained bodies found. A tetanus vaccination is administered. Which of the following is appropriate management of this patient?", "answer": "Administer amoxicillin-clavulanic acid", "options": {"A": "Administer amoxicillin-clavulanic acid", "B": "Administer the rabies vaccine and rabies immunoglobulin", "C": "Administer trimethoprim-sulfamethoxazole", "D": "Close the wound with sutures and discharge the patient", "E": "Discharge the patient with outpatient follow up"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "emergency department", "dog bite", "patient", "pulled", "tail", "eating", "back", "house currently", "notable", "dog bite", "patients right arm", "wound", "irrigated", "retained bodies found", "tetanus vaccination", "administered", "following", "appropriate", "patient"]}
{"question": "A 19-year-old woman, accompanied by her parents, presents after a one-week history of abnormal behavior, delusions, and unusual aggression. She denies fever, seizures or illicit drug use. Family history is negative for psychiatric illnesses. She was started on risperidone and sent home with her parents. Three days later, she is brought to the emergency department with fever and confusion. She is not verbally responsive. At the hospital, her temperature is 39.8°C (103.6°F), the blood pressure is 100/60 mm Hg, the pulse rate is 102/min, and the respiratory rate is 16/min. She is extremely diaphoretic and appears stiff. She has spontaneous eye-opening but she is not verbally responsive and she is not following commands. Laboratory studies show:\nSodium 142 mmol/L\nPotassium 5.0 mmol/L\nCreatinine 1.8 mg/dl\nCalcium 10.4 mg/dl\nCreatine kinase 9800 U/L\nWhite blood cells 14,500/mm3\nHemoglobin 12.9 g/dl\nPlatelets 175,000/mm3\nUrinalysis shows protein 1+, hemoglobin 3+ with occasional leukocytes and no red blood casts. What is the best first step in the management of this condition?", "answer": "Stop risperidone", "options": {"A": "Dantrolene", "B": "Intravenous hydration", "C": "Paracetamol", "D": "Stop risperidone", "E": "Switch risperidone to clozapine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "presents", "one-week history", "abnormal behavior", "delusions", "unusual", "fever", "seizures", "illicit drug use", "Family history", "negative", "psychiatric illnesses", "started", "risperidone", "sent home", "Three days later", "brought", "emergency department", "fever", "confusion", "not", "responsive", "hospital", "temperature", "blood pressure", "100 60 mm Hg", "pulse rate", "min", "respiratory rate", "min", "extremely diaphoretic", "appears stiff", "spontaneous eye opening", "not", "responsive", "not following", "Laboratory studies", "Sodium", "mmol", "0 mmol", "8 mg dl", "mg dl Creatine", "blood cells", "500", "Hemoglobin", "g", "Urinalysis", "protein 1", "hemoglobin", "occasional", "red blood casts", "best first step", "management", "condition"]}
{"question": "A 35-year-old woman comes to the physician because of a 1-month history of double vision, difficulty climbing stairs, and weakness when trying to brush her hair. She reports that these symptoms are worse after she exercises and disappear after she rests for a few hours. Physical examination shows drooping of her right upper eyelid that worsens when the patient is asked to gaze at the ceiling for 2 minutes. There is diminished motor strength in the upper extremities. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Myasthenia gravis", "options": {"A": "Myasthenia gravis", "B": "Polymyositis", "C": "Amyotrophic lateral sclerosis", "D": "Guillain-Barré syndrome", "E": "Multiple sclerosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "physician", "month history", "double vision", "difficulty climbing stairs", "weakness", "to brush", "hair", "reports", "symptoms", "worse", "exercises", "hours", "drooping", "right upper eyelid", "worsens", "patient", "to gaze", "2 minutes", "diminished motor strength", "upper extremities", "abnormalities", "following", "diagnosis"]}
{"question": "A 6-year-old male who recently immigrated to the United States from Asia is admitted to the hospital with dyspnea. Physical exam reveals a gray pseudomembrane in the patient's oropharynx along with lymphadenopathy. The patient develops myocarditis and expires on hospital day 5. Which of the following would have prevented this patient's presentation and decline?", "answer": "Circulating IgG against AB exotoxin", "options": {"A": "Increased CD4+ T cell count", "B": "Secretory IgA against viral proteins", "C": "Increased IgM preventing bacterial invasion", "D": "Circulating IgG against AB exotoxin", "E": "Improved IgE release from mast cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male", "recently", "United States", "Asia", "dyspnea", "reveals", "gray pseudomembrane", "patient's oropharynx", "lymphadenopathy", "patient", "myocarditis", "hospital day 5", "following", "prevented", "patient's"]}
{"question": "A 12-year-old boy who recently emigrated from Pakistan presents with fever, muscle pain, and weakness of the trunk, abdomen, and legs. The patient’s mother says that he has not been vaccinated. Physical examination reveals fasciculation and flaccid paralysis of the lower limbs. A CSF analysis reveals lymphocytosis with normal glucose and protein levels. A throat swab reveals an RNA virus. Which of the following would most likely be destroyed by the virus in this patient?", "answer": "Anterior horn of the spinal cord", "options": {"A": "Basal ganglia", "B": "Posterior horn cells of the spinal cord", "C": "Myelin sheath of neurons", "D": "Muscle cells", "E": "Anterior horn of the spinal cord"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "recently", "Pakistan presents", "fever", "muscle pain", "weakness", "trunk", "abdomen", "legs", "patients", "not", "vaccinated", "reveals fasciculation", "flaccid paralysis of", "lower limbs", "CSF analysis reveals lymphocytosis", "normal glucose", "protein levels", "throat swab reveals", "following", "most likely", "destroyed", "patient"]}
{"question": "A researcher is studying the properties of an enzyme that adds phosphate groups to glucose. She discovers that the enzyme is present in most body tissues and is located in the cytoplasm of the cells expressing the enzyme. She decides to mix this enzyme under subphysiologic conditions with varying levels of glucose in order to determine the kinetic properties of the enzyme. Specifically, she adds increasing levels of glucose at a saturating concentration of phosphate and sees that the rate at which glucose becomes phosphorylated gets faster at higher levels of glucose. She observes that this rate approaches a maximum speed and calls this speed Y. She then determines the concentration of glucose that is needed to make the enzyme function at half the speed Y and calls this concentration X. Which of the following is most likely true about the properties of this enzyme?", "answer": "Low X and low Y", "options": {"A": "High X and high Y", "B": "High X and low Y", "C": "Low X and high Y", "D": "Low X and infinite Y", "E": "Low X and low Y"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["researcher", "studying", "properties", "enzyme", "adds phosphate groups", "glucose", "enzyme", "present", "body tissues", "cytoplasm", "cells", "enzyme", "to mix", "enzyme", "conditions", "levels", "glucose", "order to", "properties", "enzyme", "adds increasing levels", "glucose", "concentration", "phosphate", "sees", "rate", "glucose", "gets faster", "higher levels", "glucose", "observes", "rate approaches", "maximum speed", "calls", "speed", "then", "concentration", "glucose", "needed to make", "enzyme function", "half", "speed", "calls", "concentration", "following", "true", "properties", "enzyme"]}
{"question": "A 31-year-old G2P2 female at 40 weeks gestation presents to the hospital following a rush of water that came from her vagina. She is 4 cm dilated and 80% effaced. Fetal heart tracing shows a pulse of 155/min with variable decelerations. About 12 hours after presentation, she gives birth to a 6 lb 15 oz baby boy with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Which of the following structures is responsible for inhibition of female internal genitalia?", "answer": "Sertoli cells", "options": {"A": "Spermatogonia", "B": "Allantois", "C": "Syncytiotrophoblast", "D": "Sertoli cells", "E": "Leydig cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["31 year old", "female", "40 weeks presents", "hospital following", "rush", "water", "vagina", "4", "dilated", "80", "Fetal heart", "pulse", "min", "variable decelerations", "12 hours", "gives birth", "oz baby boy", "APGAR scores", "8", "5 minutes", "following structures", "responsible", "inhibition", "female internal genitalia"]}
{"question": "A 43-year-old woman presents to the emergency department complaining of palpitations, dry cough, and shortness of breath for 1 week. She immigrated to the United States from Korea at the age of 20. She says that her heart is racing and she has never felt these symptoms before. Her cough is dry and is associated with shortness of breath that occurs with minimal exertion. Her past medical history is otherwise unremarkable. She has no allergies and is not currently taking any medications. She is a nonsmoker and an occasional drinker. She denies illicit drug use. Her blood pressure is 100/65 mm Hg, pulse is 76/min, respiratory rate is 23/min, and temperature is 36.8°C (98.2°F). Her physical examination is significant for bibasilar lung crackles and a non-radiating, low-pitched, mid-diastolic rumbling murmur best heard at the apical region. In addition, she has jugular vein distention and bilateral pitting edema in her lower extremities. Which of the following best describes the infectious agent that led to this patient’s condition?", "answer": "A bacterium that induces complete lysis of the red cells of a blood agar plate with an oxygen-sensitive cytotoxin", "options": {"A": "A bacterium that induces partial lysis of red cells with hydrogen peroxide", "B": "A bacterium that induces complete lysis of the red cells of a blood agar plate with an oxygen-sensitive cytotoxin", "C": "A bacterium that induces heme degradation of the red cells of a blood agar plate", "D": "A bacterium that does not lyse red cells", "E": "A bacterium that requires an anaerobic environment to grow properly"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "palpitations", "dry cough", "shortness of breath", "1 week", "United States", "Korea", "age", "20", "heart", "never", "symptoms", "cough", "dry", "associated with shortness of breath", "occurs", "minimal exertion", "past medical history", "unremarkable", "allergies", "not currently", "medications", "nonsmoker", "occasional drinker", "illicit drug use", "blood pressure", "100 65 mm Hg", "pulse", "76 min", "respiratory rate", "23 min", "temperature", "36", "98", "significant", "lung crackles", "non radiating", "low-pitched", "mid-diastolic rumbling murmur best heard", "apical region", "addition", "jugular vein distention", "bilateral pitting edema", "lower extremities", "following best", "led", "patients condition"]}
{"question": "A male neonate is being examined by a pediatrician. His mother informs the doctor that she had a mild fever with rash, muscle pain, and swollen and tender lymph nodes during the second month of gestation. The boy was born at 39 weeks gestation via spontaneous vaginal delivery with no prenatal care. On physical examination, the neonate has normal vital signs. Retinal examination reveals the findings shown in the image. Which of the following congenital heart defects is most likely to be present in this neonate?", "answer": "Patent ductus arteriosus", "options": {"A": "Atrial septal defect", "B": "Ventricular septal defect", "C": "Tetralogy of Fallot", "D": "Patent ductus arteriosus", "E": "Double outlet right ventricle"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["male neonate", "examined", "pediatrician", "informs", "doctor", "mild fever with rash", "muscle pain", "swollen", "tender lymph nodes", "second month", "gestation", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "neonate", "normal vital signs", "Retinal examination reveals", "findings", "following congenital heart defects", "to", "present", "neonate"]}
{"question": "A 4-year-old boy is brought to the emergency department by his parents. He is lethargic and confused and has a severe headache, vomiting, and a high-grade fever since earlier that day. His mother reports that the child was doing well until 2 days ago when he developed a fever and green nasal discharge. The patient has a history of neonatal sepsis, meningococcemia at 18 months of age, and pneumococcal pneumonia at 2 and 3 years of age. His scheduled vaccinations are up to date. His blood pressure is 70/50 mm Hg, heart rate is 120/min, respiratory rate is 22/min, and temperature is 39.3°C (102.4°F). On examination, the child is lethargic and his skin is pale, with several petechiae over his buttocks. There is a purulent nasal discharge from both nostrils. The lungs are clear to auscultation bilaterally. Heart sounds are normal. There is marked neck rigidity. Cerebrospinal fluid analysis shows the following results:\nOpening pressure 100 mm H2O\nAppearance cloudy\nProtein 500 mg/dL (5 g/L)\nWhite blood cells 2500/μL (polymorphonuclear predominance)\nProtein 450 mg/dL (4.5 g/L)\nGlucose 31 mg/dL (1.7 mmol/L)\nCulture positive for N. meningitidis\nWhich of the following immunological processes is most likely to be impaired in this child?", "answer": "Formation of C5-9 complex", "options": {"A": "Production of IL-2 by Th1 cells", "B": "Activation of TCRs by MHC-II", "C": "Formation of C5-9 complex", "D": "Cleavage of C2 component of complement into C2a and C2b", "E": "Oxidative burst in macrophages"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "emergency department", "lethargic", "confused", "severe headache", "vomiting", "high-grade fever since earlier", "day", "reports", "child", "well", "2 days", "fever", "green nasal discharge", "patient", "history of neonatal sepsis", "meningococcemia", "months", "age", "pneumococcal pneumonia", "3 years", "age", "scheduled vaccinations", "date", "blood pressure", "70 50 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "child", "lethargic", "skin", "pale", "several petechiae", "buttocks", "purulent nasal discharge", "nostrils", "lungs", "clear", "auscultation", "Heart sounds", "normal", "marked neck rigidity", "Cerebrospinal fluid analysis", "following results", "Opening pressure 100 mm H2O Appearance cloudy Protein 500 mg/dL", "5 g/L", "White blood cells 2500 L", "predominance", "Protein 450 mg/dL", "4.5 g/L", "Glucose 31 mg/dL", "1.7 mmol/L", "Culture positive", "following immunological processes", "to", "impaired", "child"]}
{"question": "A 66-year-old woman with chronic obstructive pulmonary disease is brought to the emergency department because of fever, body aches, malaise, and a dry cough. She has smoked one pack of cigarettes daily for 30 years but quit smoking 1 year ago. She lives with her daughter and her granddaughter, who attends daycare. Her temperature is 38.1°C (101°F). Physical examination shows bilateral conjunctivitis, rhinorrhea, and erythematous tonsils without exudates. Further testing confirms infection with an enveloped orthomyxovirus. Administration of a drug with which of the following mechanisms of action is most appropriate?", "answer": "Inhibition of neuraminidase", "options": {"A": "Inhibition of nucleoside reverse transcriptase", "B": "Inhibition of DNA polymerase", "C": "Inhibition of proton translocation", "D": "Inhibition of neuraminidase", "E": "Inhibition of protease"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["66 year old woman", "chronic obstructive pulmonary disease", "brought", "emergency department", "fever", "body aches", "malaise", "dry cough", "smoked one pack", "cigarettes daily", "30 years", "smoking 1 year", "lives with", "daughter", "attends daycare", "temperature", "bilateral conjunctivitis", "rhinorrhea", "erythematous tonsils", "exudates", "Further testing confirms infection", "orthomyxovirus", "Administration", "drug", "of", "following mechanisms", "action", "most appropriate"]}
{"question": "A 38-year-old woman undergoes hemithyroidectomy for treatment of localized, well-differentiated papillary thyroid carcinoma. The lesion is removed with clear margins. However, during the surgery, a structure lying directly adjacent to the superior thyroid artery at the upper pole of the thyroid lobe is damaged. This patient is most likely to experience which of the following symptoms?", "answer": "Voice pitch limitation", "options": {"A": "Voice pitch limitation", "B": "Ineffective cough", "C": "Weakness of shoulder shrug", "D": "Difficulty swallowing", "E": "Shortness of breath"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "hemithyroidectomy", "treatment of localized", "well-differentiated papillary thyroid carcinoma", "lesion", "removed", "clear margins", "surgery", "structure lying directly adjacent to", "superior thyroid artery", "upper", "thyroid lobe", "damaged", "patient", "to", "following symptoms"]}
{"question": "A 27-year-old man presents to the emergency room with persistent fever, nausea, and vomiting for the past 3 days. While waiting to be seen, he quickly becomes disoriented and agitated. Upon examination, he has visible signs of difficulty breathing with copious oral secretions and generalized muscle twitching. The patient’s temperature is 104°F (40°C), blood pressure is 90/64 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 90% on room air. When the nurse tries to place a nasal cannula, the patient becomes fearful and combative. The patient is sedated and placed on mechanical ventilation. Which of the following is a risk factor for the patient’s most likely diagnosis?", "answer": "Spelunking", "options": {"A": "Contaminated beef", "B": "Epiglottic cyst", "C": "Influenza vaccination", "D": "Mosquito bite", "E": "Spelunking"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["27 year old man presents", "emergency room", "persistent fever", "nausea", "vomiting", "past 3 days", "waiting to", "seen", "disoriented", "agitated", "visible signs", "difficulty breathing", "copious oral secretions", "generalized muscle twitching", "patients temperature", "blood pressure", "90 64 mmHg", "pulse", "88 min", "respirations", "min", "90", "room air", "nurse", "to place", "nasal cannula", "patient", "fearful", "combative", "patient", "sedated", "mechanical ventilation", "following", "a", "factor", "patients", "likely diagnosis"]}
{"question": "A 21-year-old man presents to the emergency department after sustaining a stab wound to the neck at a local farmer's market. The patient is otherwise healthy and is complaining of pain. The patient is able to offer the history himself. His temperature is 97.6°F (36.4°C), blood pressure is 120/84 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam demonstrates a 3 cm laceration 1 cm inferior to the mastoid process on the right side. The patient's breath sounds are clear and he is protecting his airway. No stridor or difficulty breathing is noted. Which of the following is the most appropriate next step in the management of this patient?", "answer": "CT angiogram", "options": {"A": "Arteriography", "B": "CT angiogram", "C": "Intubation", "D": "Observation and blood pressure monitoring", "E": "Surgical exploration"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["21-year-old man presents", "emergency department", "sustaining", "stab", "neck", "local farmer's market", "patient", "healthy", "pain", "patient", "able to", "history", "temperature", "97", "36", "blood pressure", "84 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "3", "laceration 1", "inferior", "mastoid process", "right side", "patient's breath sounds", "clear", "airway", "stridor", "difficulty breathing", "noted", "following", "most appropriate next step", "patient"]}
{"question": "A 13-year-old girl presents to a medical office for the evaluation of a lump on the front of her neck. The patient denies pain, but states that the mass bothers her because “it moves when I swallow”. The physical examination reveals a midline neck mass that is above the hyoid bone but below the level of the mandible. The mass is minimally mobile and feels fluctuant without erythema. The patient is afebrile and all vital signs are stable. A complete blood count and thyroid function tests are performed and are within normal limits. What is the most likely cause of this patient’s presentation?", "answer": "Cyst formation in a persistent thyroglossal duct", "options": {"A": "Persistent thyroid tissue at the tongue base", "B": "Deletion of the 22q11 gene", "C": "Thyroid hyperplasia due to iodine deficiency", "D": "Cyst formation in a persistent thyroglossal duct", "E": "Lymph node enlargement"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "medical office", "lump", "front of", "neck", "patient", "pain", "states", "mass", "moves", "I swallow", "reveals", "midline neck mass", "hyoid bone", "level", "mandible", "mass", "mobile", "fluctuant", "erythema", "patient", "afebrile", "vital signs", "stable", "complete blood count", "thyroid function tests", "performed", "normal limits", "most likely cause", "patients"]}
{"question": "A 35-year-old woman with a history of Crohn disease presents for a follow-up appointment. She says that lately, she has started to notice difficulty walking. She says that some of her friends have joked that she appears to be walking as if she was drunk. Past medical history is significant for Crohn disease diagnosed 2 years ago, managed with natalizumab for the past year because her intestinal symptoms have become severe and unresponsive to other therapies. On physical examination, there is gait and limb ataxia present. Strength is 4/5 in the right upper limb. A T1/T2 MRI of the brain is ordered and is shown. Which of the following is the most likely diagnosis?", "answer": "Progressive multifocal encephalopathy (PML)", "options": {"A": "Sporadic Creutzfeldt-Jakob disease (sCJD)", "B": "Variant Creutzfeldt-Jakob disease (vCJD)", "C": "Subacute sclerosing panencephalitis (SSPE)", "D": "Progressive multifocal encephalopathy (PML)", "E": "West Nile encephalitis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "history of Crohn disease presents", "follow-up appointment", "started", "difficulty walking", "appears to", "drunk", "Past medical history", "significant", "Crohn disease diagnosed 2 years", "natalizumab", "past year", "intestinal symptoms", "severe", "unresponsive", "therapies", "gait", "limb ataxia present", "Strength", "4/5", "right upper limb", "T1", "MRI of", "brain", "ordered", "following", "diagnosis"]}
{"question": "A 23-year-old G1 at 10 weeks gestation based on her last menstrual period is brought to the emergency department by her husband due to sudden vaginal bleeding. She says that she has mild lower abdominal cramps and is feeling dizzy and weak. Her blood pressure is 100/60 mm Hg, the pulse is 100/min, and the respiration rate is 15/min. She says that she has had light spotting over the last 3 days, but today the bleeding increased markedly and she also noticed the passage of clots. She says that she has changed three pads since the morning. She has also noticed that the nausea she was experiencing over the past few days has subsided. The physician examines her and notes that the cervical os is open and blood is pooling in the vagina. Products of conception can be visualized in the os. The patient is prepared for a suction curettage. Which of the following is the most likely cause for the pregnancy loss?", "answer": "Chromosomal abnormalities", "options": {"A": "Sexually transmitted disease (STD)", "B": "Rh immunization", "C": "Antiphospholipid syndrome", "D": "Chromosomal abnormalities", "E": "Trauma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old G1", "10 weeks based", "last menstrual period", "brought", "emergency department", "due to sudden vaginal bleeding", "mild lower abdominal cramps", "dizzy", "weak", "blood pressure", "100 60 mm Hg", "pulse", "100 min", "respiration rate", "min", "light spotting", "3 days", "today", "bleeding increased markedly", "passage", "clots", "changed three pads", "morning", "nausea", "past", "days", "physician", "notes", "cervical os", "open", "blood", "pooling", "vagina", "Products of conception", "visualized", "os", "patient", "prepared", "suction curettage", "following", "most likely cause", "pregnancy loss"]}
{"question": "An 8-month-old boy is brought to a medical office by his mother. The mother states that the boy has been very fussy and has not been feeding recently. The mother thinks the baby has been gaining weight despite not feeding well. The boy was delivered vaginally at 39 weeks gestation without complications. On physical examination, the boy is noted to be crying in his mother’s arms. There is no evidence of cyanosis, and the cardiac examination is within normal limits. The crying intensifies when the abdomen is palpated. The abdomen is distended with tympany in the left lower quadrant. You suspect a condition caused by the failure of specialized cells to migrate. What is the most likely diagnosis?", "answer": "Hirschsprung disease", "options": {"A": "Meckel diverticulum", "B": "DiGeorge syndrome", "C": "Pyloric stenosis", "D": "Duodenal atresia", "E": "Hirschsprung disease"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old boy", "brought", "medical office", "states", "boy", "very fussy", "not", "recently", "baby", "gaining weight", "not", "well", "boy", "delivered", "weeks gestation", "complications", "boy", "noted to", "arms", "cyanosis", "normal limits", "abdomen", "abdomen", "distended", "tympany", "left lower quadrant", "condition caused", "failure", "specialized cells to migrate", "diagnosis"]}
{"question": "A 60-year-old man seeks evaluation at a medical office due to leg pain while walking. He says the pain starts in his buttocks and extends to his thighs and down to his calves. Previously, the pain resolved with rest, but the pain now persists in his feet, even during rest. His past medical history is significant for diabetes mellitus, hypertension, and cigarette smoking. The vital signs are within normal limits. The physical examination shows an atrophied leg with bilateral loss of hair. Which of the following is the most likely cause of this patient’s condition?", "answer": "Narrowing and calcification of vessels", "options": {"A": "Decreased permeability of endothelium", "B": "Narrowing and calcification of vessels", "C": "Peripheral emboli formation", "D": "Thrombus formation", "E": "Weakening of vessel wall"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old man", "office", "leg pain", "pain starts", "buttocks", "extends", "thighs", "calves", "pain resolved", "pain now", "feet", "past medical history", "significant", "diabetes mellitus", "hypertension", "cigarette smoking", "vital signs", "normal limits", "atrophied leg", "bilateral loss", "following", "most likely cause", "patients condition"]}
{"question": "A 52-year-old man presents to the emergency department with chest pain radiating to his left jaw and arm. He states that he had experienced similar symptoms when playing basketball. The medical history is significant for diabetes mellitus, hypertension, and GERD, for which he takes metformin, hydrochlorothiazide, and pantoprazole, respectively. The blood pressure is 150/90 mm Hg, the pulse is 100/min, and the respirations are 15/min. The ECG reveals ST elevation in leads V3-V6. He is hospitalized for an acute MI and started on treatment. The next day he complains of dizziness and blurred vision. Repeat vital signs were as follows: blood pressure 90/60 mm Hg, pulse 72/min, and respirations 12/min. The laboratory results were as follows:\nSerum chemistry\nSodium 143 mEq/L\nPotassium 4.1 mEq/L\nChloride 98 mEq/L\nBicarbonate 22 mEq/L\nBlood urea nitrogen  26 mg/dL\nCreatinine 2.3 mg/dL\nGlucose 120 mg/dL\nWhich of the following drugs is responsible for this patient’s lab abnormalities?", "answer": "Lisinopril", "options": {"A": "Digoxin", "B": "Pantoprazole", "C": "Lisinopril", "D": "Atorvastatin", "E": "Nitroglycerin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "chest pain radiating to", "left jaw", "arm", "states", "similar symptoms", "playing basketball", "medical history", "significant", "diabetes mellitus", "hypertension", "GERD", "metformin", "hydrochlorothiazide", "pantoprazole", "blood pressure", "90 mm Hg", "pulse", "100 min", "respirations", "min", "ECG reveals ST elevation", "leads V3 V6", "hospitalized", "acute MI", "started on treatment", "next day", "dizziness", "blurred vision", "Repeat vital signs", "follows", "blood pressure 90 60 mm Hg", "pulse 72 min", "respirations", "min", "laboratory results", "follows", "Serum", "mEq/L Potassium", "98", "Creatinine", "Glucose", "following drugs", "responsible", "patients lab abnormalities"]}
{"question": "A 28-year-old woman is brought to the hospital by her boyfriend. She has had three days of fever and headache followed by one day of worsening confusion and hallucinations. She also becomes agitated when offered water. Her temperature is 101°F (38.3°C). Two months prior to presentation, the couple was camping and encountered bats in their cabin. In addition to an injection shortly after exposure, what would have been the most effective treatment for this patient?", "answer": "A killed vaccine within ten days of exposure", "options": {"A": "A toxoid vaccine within ten days of exposure", "B": "A killed vaccine within ten days of exposure", "C": "Oseltamivir within one week of exposure", "D": "Venom antiserum within hours of exposure", "E": "Doxycycline for one month after exposure"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "hospital", "three days", "fever", "headache followed by one day", "worsening confusion", "hallucinations", "agitated", "offered water", "temperature", "Two months prior to", "couple", "injection", "exposure", "most effective", "patient"]}
{"question": "A 60-year-old man comes to the physician for an examination prior to a scheduled cholecystectomy. He has hypertension treated with hydrochlorothiazide. His mother had chronic granulomatous disease of the lung. He works in a glass manufacturing plant. He has smoked two packs of cigarettes daily for 38 years. His vital signs are within normal limits. Examination shows no abnormalities. Laboratory studies are within the reference range. An x-ray of the chest is shown. Which of the following is the most appropriate next step in management?", "answer": "Request previous chest x-ray", "options": {"A": "Perform arterial blood gas analysis", "B": "Perform CT-guided biopsy", "C": "Perform diffusion capacity of the lung for carbon monoxide", "D": "Measure angiotensin-converting enzyme", "E": "Request previous chest x-ray"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["60 year old man", "physician", "prior to", "scheduled cholecystectomy", "hypertension treated with hydrochlorothiazide", "chronic granulomatous disease of the lung", "glass manufacturing plant", "smoked two packs", "cigarettes daily", "years", "vital signs", "normal limits", "abnormalities", "Laboratory studies", "reference range", "x-ray of", "chest", "following", "most appropriate next step"]}
{"question": "You are examining a 3-day-old newborn who was delivered vaginally without any complications. The newborn presents with vomiting, hyperventilation, lethargy, and seizures. Blood work demonstrates hyperammonemia, elevated glutamine levels, and decreased blood urea nitrogen. A CT scan demonstrates cerebral edema. Defects in which of the following enzymes would result in a clinical presentation similar to this infant?", "answer": "Carbamoyl phosphate synthetase I", "options": {"A": "Phenylalanine hydroxylase", "B": "Branched-chain ketoacid dehydrogenase", "C": "Homogentisate oxidase", "D": "Cystathionine synthase", "E": "Carbamoyl phosphate synthetase I"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["examining", "3 day old newborn", "delivered", "complications", "newborn presents", "vomiting", "hyperventilation", "lethargy", "seizures", "Blood", "hyperammonemia", "elevated glutamine levels", "decreased blood urea nitrogen", "CT scan", "cerebral edema", "Defects", "following enzymes", "result", "similar", "infant"]}
{"question": "A 48-year-old man with HIV comes to the physician because of skin lesions over his face and neck for 2 weeks. They are not itchy or painful. He does not have fever or a sore throat. He was treated for candidal esophagitis 3 months ago. He is sexually active with his wife, who knows of his condition, and uses condoms consistently. He is currently receiving triple antiretroviral therapy with lamivudine, abacavir, and efavirenz. He is 175 cm (5 ft 9 in) tall and weighs 58 kg (128 lb); BMI is 18.8 kg/m2. Examination shows multiple skin colored papules over his face and neck with a dimpled center. Cervical lymphadenopathy is present. The remainder of the examination is unremarkable. His hemoglobin concentration is 12.1 g/dL, leukocyte count is 4,900/mm3, and platelet count is 143,000/mm3; serum studies and urinalysis show no abnormalities. CD4+ T-lymphocyte count is 312/mm3 (normal ≥ 500). Which of the following is the most likely cause of this patient's findings?", "answer": "Poxvirus", "options": {"A": "A herpesvirus", "B": "Bartonella", "C": "Papillomavirus", "D": "Poxvirus", "E": "Coccidioides\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["48 year old man", "HIV", "physician", "of skin lesions", "face", "neck", "2 weeks", "not itchy", "painful", "not", "fever", "sore throat", "treated", "candidal esophagitis", "months", "sexually active", "condition", "uses condoms", "currently receiving triple antiretroviral therapy", "lamivudine", "abacavir", "efavirenz", "5 ft 9", "tall", "58 kg", "BMI", "kg/m2", "multiple skin colored papules", "face", "neck", "dimpled center", "lymphadenopathy", "present", "unremarkable", "hemoglobin concentration", "g/dL", "leukocyte count", "4 900 mm3", "platelet count", "mm3", "serum studies", "urinalysis", "abnormalities", "CD4", "T-lymphocyte count", "312 mm3", "normal", "500", "following", "most likely cause", "patient's findings"]}
{"question": "A 55-year-old man comes to the physician because of fatigue and worsening abdominal pain for 4 weeks. He also reports excessive night sweats and a 5.4-kg (12-lb) weight loss during this time. He has a neck swelling for 4 days. Physical examination shows a nontender, enlarged, and fixed supraclavicular lymph node. There is splenomegaly. A CT scan of the thorax and abdomen shows massively enlarged axillary, mediastinal, and cervical lymph nodes. Analysis of an excised cervical lymph node shows lymphocytes with a high proliferative index that stain positive for CD20. Which of the following is the most likely diagnosis?", "answer": "Diffuse large B-cell lymphoma", "options": {"A": "Adult T-cell lymphoma", "B": "Burkitt lymphoma", "C": "Follicular lymphoma", "D": "Diffuse large B-cell lymphoma", "E": "Hodgkin lymphoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "fatigue", "worsening abdominal", "weeks", "reports excessive night sweats", "5.4 kg", "weight loss", "time", "neck swelling", "4 days", "nontender", "enlarged", "fixed supraclavicular", "splenomegaly", "CT scan", "thorax", "abdomen", "massively enlarged axillary", "mediastinal", "cervical lymph nodes", "Analysis", "lymphocytes", "high proliferative index", "positive", "CD20", "following", "diagnosis"]}
{"question": "A 26-year-old G1P0 woman at 32-weeks gestation presents for follow-up ultrasound. She was diagnosed with gestational diabetes during her second trimester, but admits to poor glucose control and non-adherence to insulin therapy. Fetal ultrasound reveals an asymmetric, enlarged interventricular septum, left ventricular outflow tract obstruction, and significantly reduced ejection fraction. Which of the following is the most appropriate step in management after delivery?", "answer": "Medical management", "options": {"A": "Emergent open fetal surgery", "B": "Cardiac magnetic resonance imaging", "C": "Cardiac catheterization", "D": "Chest radiograph", "E": "Medical management"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "woman", "weeks presents", "follow-up ultrasound", "diagnosed", "gestational diabetes", "second trimester", "poor", "non", "insulin therapy", "Fetal reveals", "asymmetric", "enlarged interventricular septum", "left ventricular outflow tract obstruction", "reduced ejection fraction", "following", "most appropriate step", "delivery"]}
{"question": "A recent study attempted to analyze whether increased \"patient satisfaction\" driven healthcare resulted in increased hospitalization. In this hospital, several of the wards adopted new aspects of \"patient satisfaction\" driven healthcare, whereas the remainder of the hospital continued to use existing protocols. Baseline population characteristics and demographics were collected at the start of the study. At the end of the following year, hospital use was assessed and compared between the two groups. Which of the following best describes this type of study?", "answer": "Prospective cohort", "options": {"A": "Retrospective cohort", "B": "Prospective cohort", "C": "Retrospective case-control", "D": "Prospective case-control", "E": "Cross-sectional study"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["recent study", "to", "increased", "patient satisfaction", "resulted", "increased", "hospital", "several", "wards adopted new aspects", "patient satisfaction", "hospital", "to use", "Baseline population characteristics", "collected", "start", "study", "end", "following year", "hospital use", "two groups", "following best"]}
{"question": "A new screening test utilizing a telemedicine approach to diagnosing diabetic retinopathy has been implemented in a diabetes clinic. An ophthalmologist’s exam was also performed on all patients as the gold standard for diagnosis. In a pilot study of 500 patients, the screening test detected the presence of diabetic retinopathy in 250 patients. Ophthalmologist exam confirmed a diagnosis of diabetic retinopathy in 200 patients who tested positive in the screening test, as well as 10 patients who tested negative in the screening test. What is the sensitivity, specificity, positive predictive value, and negative predictive value of the screening test?", "answer": "Sensitivity = 95%, Specificity = 83%, PPV = 80%, NPV = 96%", "options": {"A": "Sensitivity = 83%, Specificity = 95%, PPV = 80%, NPV = 96%", "B": "Sensitivity = 83%, Specificity = 95%, PPV = 96%, NPV = 80%", "C": "Sensitivity = 95%, Specificity = 83%, PPV = 96%, NPV = 80%", "D": "Sensitivity = 80%, Specificity = 95%, PPV = 96%, NPV = 83%", "E": "Sensitivity = 95%, Specificity = 83%, PPV = 80%, NPV = 96%"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["new", "approach", "diagnosing diabetic retinopathy", "implemented", "diabetes clinic", "ophthalmologists exam", "performed", "patients", "gold", "diagnosis", "500 patients", "detected", "presence", "diabetic retinopathy", "patients", "Ophthalmologist exam confirmed", "diagnosis", "diabetic retinopathy", "200 patients", "positive", "10 patients", "negative", "sensitivity", "specificity", "positive predictive value", "negative predictive value of", "screening test"]}
{"question": "A healthy 22-year-old male participates in a research study you are leading to compare the properties of skeletal and cardiac muscle. You conduct a 3-phased experiment with the participant. In the first phase, you get him to lift up a 2.3 kg (5 lb) weight off a table with his left hand. In the second phase, you get him to do 20 burpees, taking his heart rate to 150/min. In the third phase, you electrically stimulate his gastrocnemius with a frequency of 50 Hz. You are interested in the tension and electrical activity of specific muscles as follows: Biceps in phase 1, cardiac muscle in phase 2, and gastrocnemius in phase 3. What would you expect to be happening in the phases and the respective muscles of interest?", "answer": "Increase of tension in all phases", "options": {"A": "Recruitment of small motor units at the start of experiments 1 and 2", "B": "Increase of tension in experiments 2 and 3, with the same underlying mechanism", "C": "Recruitment of large motor units followed by small motor units in experiment 1", "D": "Fused tetanic contraction at the end of all three experiments", "E": "Increase of tension in all phases"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old male", "leading to", "properties", "skeletal", "cardiac muscle", "3-phased", "to lift", "kg", "5", "weight", "table", "left hand", "to", "20", "heart rate", "min", "gastrocnemius", "frequency", "50 Hz", "tension", "electrical", "specific muscles", "follows", "Biceps", "phase 1", "cardiac muscle", "phase 2", "gastrocnemius", "phase 3", "to", "phases", "muscles"]}
{"question": "A 20-year-old male comes into your office two days after falling during a pick up basketball game. The patient states that the lateral aspect of his knee collided with another player's knee. On exam, the patient's right knee appears the same size as his left knee without any swelling or effusion. The patient has intact sensation and strength in both lower extremities. The patient's right knee has no laxity upon varus stress test, but is more lax upon valgus stress test when compared to his left knee. Lachman's test and posterior drawer test both have firm endpoints without laxity. Which of the following structures has this patient injured?", "answer": "Medial collateral ligament", "options": {"A": "Posterior cruciate ligament", "B": "Anterior cruciate ligament", "C": "Medial collateral ligament", "D": "Lateral collateral ligament", "E": "Medial meniscus"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["20 year old male", "office two days", "falling", "pick", "patient states", "lateral aspect of", "knee", "knee", "exam", "patient's right knee appears", "same size", "left knee", "swelling", "effusion", "patient", "intact sensation", "strength", "lower extremities", "patient's right knee", "laxity", "varus stress test", "more lax", "valgus stress test", "left knee", "Lachman's test", "posterior drawer test", "firm endpoints", "laxity", "following structures", "patient injured"]}
{"question": "A 4-year-old boy is brought to the physician because of swelling around his eyes for 4 days. The swelling is most severe in the morning and milder by bedtime. Ten days ago, he had a sore throat that resolved spontaneously. His temperature is 37°C (98.6°F), pulse is 103/min, and blood pressure is 88/52 mm Hg. Examination shows 3+ pitting edema of the lower extremities and periorbital edema. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 15.3 g/dL\nLeukocyte count 10,500/mm3\nPlatelet count 480,000/mm3\nSerum\nUrea nitrogen 36 mg/dL\nGlucose 67 mg/dL\nCreatinine 0.8 mg/dL\nAlbumin 2.6 mg/dL\nUrine\nBlood negative\nGlucose negative\nProtein 4+\nRBC none\nWBC 0–1/hpf\nFatty casts numerous\nProtein/creatinine ratio 6.8 (N ≤0.2)\nSerum complement concentrations are within the reference ranges. Which of the following is the most appropriate next step in management?\"", "answer": "Prednisone therapy", "options": {"A": "Enalapril therapy", "B": "Furosemide therapy", "C": "Anti-streptolysin O levels", "D": "Prednisone therapy", "E": "Cyclosporine therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "brought", "physician", "of swelling", "eyes", "4 days", "swelling", "most severe", "morning", "milder", "bedtime", "sore throat", "resolved", "temperature", "98", "pulse", "min", "blood pressure", "88", "mm Hg", "3", "pitting edema of", "lower extremities", "periorbital edema", "abnormalities", "Laboratory studies", "mm3 Platelet count", "mg", "mg", "Creatinine", "Urine", "negative", "RBC", "WBC", "hpf", "casts numerous Protein/creatinine ratio", "N 0.2", "Serum complement concentrations", "reference ranges", "following", "most appropriate next step"]}
{"question": "An 18-year-old man comes to the clinic with his mom for “pins and needles” of both of his arms. He denies any past medical history besides a recent anterior cruciate ligament (ACL) tear that was repaired 1 week ago. The patient reports that the paresthesias are mostly located along the posterior forearms, left more than the right. What physical examination finding would you expect from this patient?", "answer": "Loss of wrist extension", "options": {"A": "Loss of arm abduction", "B": "Loss of finger abducton", "C": "Loss of forearm flexion and supination", "D": "Loss of thumb opposition", "E": "Loss of wrist extension"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "clinic", "mom", "pins", "needles", "arms", "past medical history", "recent anterior cruciate ligament", "tear", "repaired 1 week", "patient reports", "paresthesias", "mostly", "posterior forearms", "left more", "right", "physical examination finding", "patient"]}
{"question": "A 9-year-old girl is resuscitated after the administration of an erroneous dose of intravenous phenytoin for recurrent seizures. This incident is reported to the authorities. A thorough investigation reveals various causative factors leading to the event. One important finding is a verbal misunderstanding of the dose of phenytoin between the ordering senior resident and the receiving first-year resident during the handover of the patient. To minimize the risk of this particular error in the future, the most appropriate management is to implement which of the following?", "answer": "Closed-loop communication", "options": {"A": "Closed-loop communication", "B": "Near miss", "C": "Root cause analysis", "D": "Sentinel event", "E": "Two patient identifiers"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "resuscitated", "administration", "dose", "intravenous phenytoin", "recurrent seizures", "reported", "reveals various", "factors leading", "event", "One important finding", "verbal", "dose", "phenytoin", "ordering", "resident", "receiving first year resident", "To", "error", "future", "most appropriate", "to", "following"]}
{"question": "You are the team physician for an NBA basketball team. On the morning of an important playoff game, an EKG of a star player, Mr. P, shows findings suspicious for hypertrophic cardiomyopathy (HCM). Mr. P is an otherwise healthy, fit, professional athlete.\n\nThe playoff game that night is the most important of Mr. P's career. When you inform the coach that you are thinking of restricting Mr. P's participation, he threatens to fire you. Later that day you receive a phone call from the owner of the team threatening a lawsuit should you restrict Mr. P's ability to play. Mr. P states that he will be playing in the game \"if it's the last thing I do.\"\n\nWhich of the following is the most appropriate next step?", "answer": "Educate Mr. P about the risks of HCM", "options": {"A": "Consult with a psychiatrist to have Mr. P committed", "B": "Call the police and have Mr. P arrested", "C": "Allow Mr. P to play against medical advice", "D": "Educate Mr. P about the risks of HCM", "E": "Schedule a repeat EKG for the following morning"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["physician", "NBA basketball", "morning", "important", "EKG", "star", "Mr", "findings suspicious", "hypertrophic cardiomyopathy", "Mr", "healthy", "fit", "professional athlete", "night", "the most important", "Mr", "P", "nform ", "oach ", "estricting  r.", "'", "rticipation, ", " f re y", "ter t", "y y", "ceive a", "one call f", "strict M . ", "s", "lity to pl y. M", " P", "t tes th", "ying in", " thi", ".", "owing is ", " app opriate nex  ste ?"]}
{"question": "A 37-year-old woman presents to the emergency department complaining of generalized malaise, weakness, headache, nausea, vomiting, and diarrhea; she last felt well roughly two days ago. She is otherwise healthy, and takes no medications. Her vital signs are: T 38.0, HR 96 beats per minute, BP 110/73, and O2 sat 96% on room air. Examination reveals a somewhat ill-appearing woman; she is drowsy but arousable and has no focal neurological deficits. Initial laboratory studies are notable for hematocrit 26%, platelets of 80,000/mL, and serum creatinine of 1.5 mg/dL. Which of the following is the most appropriate treatment at this time?", "answer": "Plasma exchange therapy", "options": {"A": "High-dose glucocorticoids", "B": "Cyclophosphamide and rituximab", "C": "Vancomycin and cefepime", "D": "Plasma exchange therapy", "E": "Urgent laparoscopic splenectomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "generalized malaise", "weakness", "headache", "nausea", "vomiting", "diarrhea", "last", "well", "two days", "healthy", "medications", "vital signs", "T", "0", "96 beats per minute", "BP", "O2 sat 96", "room air", "reveals", "somewhat ill appearing woman", "drowsy", "focal neurological deficits", "Initial laboratory studies", "notable", "hematocrit", "platelets", "80", "mL", "serum creatinine", "mg dL", "following", "most appropriate treatment", "time"]}
{"question": "A 5-week-old infant born at 36 weeks' gestation is brought to the physician for a well-child examination. Her mother reports that she previously breastfed her for 15 minutes every 2 hours but now feeds her for 40 minutes every 4 hours. The infant has six wet diapers and two stools daily. She currently weighs 3500 g (7.7 lb) and is 52 cm (20.4 in) in length. Vital signs are with normal limits. Cardiopulmonary examination shows a grade 4/6 continuous murmur heard best at the left infraclavicular area. After confirming the diagnosis via echocardiography, which of the following is the most appropriate next step in management of this patient?", "answer": "Indomethacin infusion", "options": {"A": "Prostaglandin E1 infusion", "B": "Indomethacin infusion", "C": "Surgical ligation", "D": "Reassurance and follow-up", "E": "Percutaneous surgery"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 week old infant born", "36 weeks", "gestation", "brought", "physician", "well", "reports", "breastfed", "15 minutes", "2 hours", "now feeds", "40 minutes", "4 hours", "infant", "six wet diapers", "two stools daily", "currently", "3500 g", "20", "length", "Vital signs", "normal limits", "Cardiopulmonary", "continuous murmur heard best", "left infraclavicular area", "confirming", "diagnosis", "echocardiography", "following", "most appropriate next step", "patient"]}
{"question": "A 51-year-old woman comes to the physician because of a 1-day history of right flank pain and bloody urine. Over the past 2 weeks, she has also developed progressive lower extremity swelling and a 3-kg (7-lb) weight gain. She has a history of chronic hepatitis B infection, which was diagnosed 10 years ago. She frequently flies from California to New York for business. She appears fatigued. Her pulse is 98/min, respirations are 18/min, and blood pressure is 135/75 mm Hg. Examination shows periorbital edema, a distended abdomen, and 2+ edema of the lower extremities. The lungs are clear to auscultation. A CT scan of the abdomen shows a nodular liver with ascites, a large right kidney with abundant collateral vessels, and a filling defect in the right renal vein. Urinalysis shows 4+ protein, positive glucose, and fatty casts. Which of the following is the most likely underlying cause of this patient's renal vein findings?", "answer": "Loss of antithrombin III", "options": {"A": "Acquired factor VIII deficiency", "B": "Loss of antithrombin III", "C": "Impaired estrogen degradation", "D": "Antiphospholipid antibodies", "E": "Paraneoplastic erythropoietin production"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "1-day history", "right flank pain", "bloody urine", "past 2 weeks", "progressive lower extremity swelling", "3 kg", "weight gain", "history of chronic hepatitis B infection", "diagnosed", "frequently", "California", "New York", "business", "appears fatigued", "pulse", "98 min", "respirations", "min", "blood pressure", "75 mm Hg", "periorbital edema", "distended abdomen", "2", "edema of", "lower extremities", "lungs", "clear", "auscultation", "CT scan", "abdomen", "nodular liver", "ascites", "large right", "abundant collateral", "defect", "right renal vein", "Urinalysis", "4", "protein", "positive glucose", "casts", "following", "underlying cause", "patient's renal findings"]}
{"question": "A 57-year-old man comes to the physician for a follow-up evaluation of chronic, retrosternal chest pain. The pain is worse at night and after heavy meals. He has taken oral pantoprazole for several months without any relief of his symptoms. Esophagogastroduodenoscopy shows ulcerations in the distal esophagus and a proximally dislocated Z-line. A biopsy of the distal esophagus shows columnar epithelium with goblet cells. Which of the following microscopic findings underlie the same pathomechanism as the cellular changes seen in this patient?", "answer": "Squamous epithelium in the bladder", "options": {"A": "Pseudostratified columnar epithelium in the bronchi", "B": "Squamous epithelium in the bladder", "C": "Paneth cells in the duodenum", "D": "Branching muscularis mucosa in the jejunum", "E": "Disorganized squamous epithelium in the endocervix"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["57 year old man", "physician", "follow-up", "of chronic", "retrosternal chest pain", "pain", "worse", "night", "heavy meals", "oral pantoprazole", "months", "Esophagogastroduodenoscopy", "ulcerations", "distal esophagus", "dislocated Z-line", "biopsy of", "distal esophagus", "following", "same", "cellular changes seen", "patient"]}
{"question": "A 37-year-old woman comes to the physician because of a 6-month history of weight loss, bloating, and diarrhea. She does not smoke or drink alcohol. Her vital signs are within normal limits. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2. Physical examination shows bilateral white spots on the temporal half of the conjunctiva, dry skin, and a hard neck mass in the anterior midline that does not move with swallowing. Urinalysis after a D-xylose meal shows an increase in renal D-xylose excretion. Which of the following is most likely to have prevented this patient's weight loss?", "answer": "Pancreatic enzyme replacement", "options": {"A": "Gluten-free diet", "B": "Pancreatic enzyme replacement", "C": "Tetracycline therapy", "D": "Mesalamine therapy", "E": "Lactose-free diet"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "month history", "weight loss", "bloating", "diarrhea", "not smoke", "vital signs", "normal limits", "5 ft 8", "tall", "54 kg", "BMI", "kg/m2", "bilateral white spots", "temporal half", "conjunctiva", "dry skin", "hard neck mass", "anterior midline", "not move", "swallowing", "Urinalysis", "a D xylose", "increase", "renal", "xylose excretion", "following", "to", "prevented", "patient's weight loss"]}
{"question": "A 52-year-old man presents for a routine checkup. Past medical history is remarkable for stage 1 systemic hypertension and hepatitis A infection diagnosed 10 years ago. He takes aspirin, rosuvastatin, enalapril daily, and a magnesium supplement every once in a while. He is planning to visit Ecuador for a week-long vacation and is concerned about malaria prophylaxis before his travel. The physician advised taking 1 primaquine pill every day while he is there and for 7 consecutive days after leaving Ecuador. On the third day of his trip, the patient develops an acute onset headache, dizziness, shortness of breath, and fingertips and toes turning blue. His blood pressure is 135/80 mm Hg, heart rate is 94/min, respiratory rate is 22/min, temperature is 36.9℃ (98.4℉), and blood oxygen saturation is 97% in room air. While drawing blood for his laboratory workup, the nurse notes that his blood has a chocolate brown color. Which of the following statements best describes the etiology of this patient’s most likely condition?", "answer": "It is a type B adverse drug reaction.", "options": {"A": "The patient’s condition is due to consumption of water polluted with nitrates.", "B": "This condition resulted from primaquine overdose.", "C": "The patient had pre-existing liver damage caused by viral hepatitis.", "D": "The condition developed because of his concomitant use of primaquine and magnesium supplement.", "E": "It is a type B adverse drug reaction."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "routine checkup", "Past medical history", "stage 1 systemic hypertension", "hepatitis A infection diagnosed", "aspirin", "rosuvastatin", "enalapril daily", "magnesium supplement", "planning to", "Ecuador", "week long", "malaria prophylaxis", "physician", "1 primaquine pill", "day", "7 consecutive days", "Ecuador", "third day", "trip", "patient", "acute headache", "dizziness", "shortness of breath", "fingertips", "toes turning blue", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "blood oxygen saturation", "97", "room air", "drawing blood", "laboratory workup", "nurse notes", "blood", "chocolate brown color", "following", "best", "etiology", "patients", "likely condition"]}
{"question": "A 31-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the emergency department for sudden leakage of clear vaginal fluid. Her pregnancy has been uncomplicated. Her first child was born at term by vaginal delivery. She has no history of serious illness. 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 in the cervical canal. 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 and ampicillin", "options": {"A": "Administer betamethasone, ampicillin, and proceed with cesarean section", "B": "Administer ampicillin and perform amnioinfusion", "C": "Administer ampicillin and test amniotic fluid for fetal lung maturity", "D": "Administer betamethasone and ampicillin", "E": "Administer betamethasone, ampicillin, and proceed with induction of labor"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old woman", "gravida 2", "para 1", "weeks", "gestation", "emergency department", "sudden leakage", "clear vaginal", "pregnancy", "uncomplicated", "first child", "born", "term", "vaginal delivery", "history", "serious illness", "not", "alcohol", "smoke cigarettes", "Current medications include", "temperature", "98 9F", "pulse", "70 min", "respirations", "min", "blood pressure", "mm Hg", "Speculum", "cervical canal", "fetal heart rate", "reactive", "min", "uterine contractions", "testing", "positive", "started", "indomethacin", "following", "most appropriate next step"]}
{"question": "A 16-year-old girl is brought to the emergency department by her friends who say that she took a whole bottle of her mom’s medication. They do not know which medication it was she ingested. The patient is slipping in and out of consciousness and is unable to offer any history. Her temperature is 39.6°C (103.2°F), the heart rate is 135/min, the blood pressure is 178/98 mm Hg, and the respiratory rate is 16/min. On physical examination, there is significant muscle rigidity without tremor or clonus. Which of the following is the best course of treatment for this patient?", "answer": "Dantrolene", "options": {"A": "Naloxone", "B": "Dantrolene", "C": "Fenoldopam", "D": "Cyproheptadine", "E": "Flumazenil"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "emergency department", "whole bottle", "moms medication", "not", "medication", "patient", "out", "consciousness", "unable to", "history", "temperature", "heart rate", "min", "blood pressure", "98 mm Hg", "respiratory rate", "min", "significant muscle", "tremor", "clonus", "following", "best course", "treatment", "patient"]}
{"question": "A 68-year-old woman is brought to the emergency department because of fever, productive cough, and dyspnea for 3 days. She has had upper back pain for 3 months, which is worse after activity. She takes ibuprofen for pain relief. She has no history of smoking. The temperature is 39.5°C (103.1°F), the blood pressure is 100/70 mm Hg, the pulse is 95/min, and the respirations are 22/min. Lung auscultation shows rales in the left lower lobe area. Painful lymph nodes (1 × 1 cm) are palpated in the left axillary and cervical regions. There is point tenderness along several thoracic vertebrae. Laboratory studies are pending. A skull X-ray and lung window thoracic computed tomography scan are shown. Which of the following disorders most likely played a role in this patient’s acute condition?", "answer": "Multiple myeloma", "options": {"A": "Metastatic breast cancer", "B": "Multiple myeloma", "C": "Non-small cell lung cancer", "D": "Paget’s disease", "E": "Primary hyperparathyroidism"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "fever", "productive cough", "dyspnea", "3 days", "upper back pain", "months", "ibuprofen", "pain relief", "history of smoking", "temperature", "blood pressure", "100 70 mm Hg", "pulse", "95 min", "respirations", "min", "Lung auscultation", "rales", "left lower lobe area", "Painful lymph nodes", "1", "1", "left axillary", "cervical regions", "point tenderness", "thoracic vertebrae", "Laboratory studies", "skull X-ray", "lung window", "computed tomography scan", "following disorders", "likely played", "role", "patients acute condition"]}
{"question": "A 22-year-old woman presents to the emergency department with a 2-day history of severe blistering. She says that she woke up 2 days ago with a number of painful blisters in her mouth and has since been continuing to develop blisters of her cutaneous skin all over her body and the mucosa of her mouth. She has no past medical history and has never experienced these symptoms before. Physical exam reveals a diffuse vesicular rash with painful, flaccid blisters that separate easily with gentle rubbing. The function of which of the following proteins is most likely disrupted in this patient?", "answer": "Cadherin", "options": {"A": "Cadherin", "B": "Collagen", "C": "Integrin", "D": "Keratin", "E": "T-cell receptor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "2-day history", "severe blistering", "woke up 2 days", "number", "painful blisters", "mouth", "since", "to", "blisters of", "cutaneous", "body", "the mucosa of", "mouth", "past medical history", "never", "symptoms", "reveals", "diffuse vesicular", "painful", "flaccid blisters", "separate easily", "gentle", "function", "following proteins", "most likely disrupted", "patient"]}
{"question": "A 3-week-old boy is brought to the emergency department by his parents because of a 3-day history of progressive lethargy and difficulty feeding. He was born at term and did not have difficulty feeding previously. His temperature is 39.4°C (103°F), pulse is 220/min, respirations are 45/min, and blood pressure is 50/30 mm Hg. Pulse oximetry on 100% oxygen shows an oxygen saturation of 97%. Examination shows dry mucous membranes, delayed capillary refill time, and cool skin with poor turgor. Despite multiple attempts by the nursing staff, they are unable to establish peripheral intravenous access. Which of the following is the most appropriate next step in management?", "answer": "Intraosseous cannulation", "options": {"A": "Rapid sequence intubation", "B": "Intramuscular epinephrine", "C": "Internal jugular vein cannulation", "D": "Intraosseous cannulation", "E": "Ultrasound-guided antecubital vein cannulation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 week old boy", "brought", "emergency department", "3-day history", "progressive lethargy", "difficulty feeding", "born", "term", "not", "difficulty", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "50 30 mm Hg", "Pulse oximetry", "100", "oxygen saturation", "97", "dry mucous membranes", "delayed capillary refill time", "cool skin", "poor turgor", "multiple", "nursing staff", "unable to establish peripheral intravenous access", "following", "most appropriate next step"]}
{"question": "A previously healthy 10-year-old boy is brought to the emergency room by his mother 5 hours after the onset of abdominal pain and nausea. Over the past 2 weeks, he has also had progressive abdominal pain and a 4-kg (8.8-lb) weight loss. The mother reports that her son has been drinking more water than usual during this period. Last week he wet his bed three times despite being completely toilet-trained since 3 years of age. His temperature is 37.8°C (100°F), pulse is 128/min, respirations are 35/min, and blood pressure is 95/55 mm Hg. He appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Serum laboratory studies show:\nNa+ 133 mEq/L\nK+ 5.9 mEq/L\nCl- 95 mEq/L\nHCO3- 13 mEq/L\nUrea nitrogen 25 mg/dL\nCreatinine 1.0 mg/dL\nUrine dipstick is positive for ketones and glucose. Further evaluation is most likely to reveal which of the following?\"", "answer": "Decreased total body potassium", "options": {"A": "Decreased total body potassium", "B": "Increased total body sodium", "C": "Increased arterial pCO2", "D": "Hypervolemia", "E": "Serum glucose concentration > 600 mg/dL"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy 10 year old boy", "brought", "emergency room", "hours", "onset", "abdominal", "nausea", "past 2 weeks", "progressive abdominal pain", "4 kg", "8.8", "weight loss", "reports", "drinking more water", "usual", "period", "Last week", "wet", "bed three times", "completely toilet trained since", "years", "age", "temperature", "pulse", "min", "respirations", "35 min", "blood pressure", "95", "mm Hg", "appears lethargic", "deep", "labored breathing", "dry mucous membranes", "abdomen", "soft", "diffuse tenderness", "palpation", "guarding", "Serum laboratory studies", "Na", "mEq/L", "5", "HCO3", "Urea", "mg Creatinine 1 0 mg dL Urine dipstick", "positive", "ketones", "glucose", "Further", "to reveal", "following"]}
{"question": "A 70-year-old Caucasian male visits your office regularly for treatment of New York Heart association class IV congestive heart failure. Which of the following medications would you add to this man's drug regimen in order to improve his overall survival?", "answer": "Spironolactone", "options": {"A": "Spironolactone", "B": "Amiloride", "C": "Hydrochlorothiazide", "D": "Furosemide", "E": "Acetazolamide"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["70 year old", "male", "office", "treatment", "New York Heart association class IV", "congestive", "failure", "following medications", "add", "man's drug regimen", "order to", "overall survival"]}
{"question": "Several hours after vaginal delivery, a male newborn delivered at full-term develops tachycardia and tachypnea. His blood pressure is within normal limits. Pulse oximetry on room air shows an oxygen saturation of 79% in the right hand and 61% in the left foot. Physical examination shows bluish discoloration of the face and trunk, supraclavicular and intercostal retractions, and a machine-like murmur over the precordium. Bedside echocardiography shows pulmonary and systemic circulation are in parallel rather than in series. What is the most appropriate pharmacotherapy for this patient?", "answer": "Alprostadil", "options": {"A": "Sildenafil", "B": "Alprostadil", "C": "Metoprolol", "D": "Indomethacin", "E": "Dopamine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Several hours", "vaginal delivery", "male newborn delivered", "full-term", "tachycardia", "tachypnea", "blood pressure", "normal limits", "Pulse oximetry", "room air", "oxygen saturation", "right hand", "61", "left foot", "discoloration", "face", "trunk", "supraclavicular", "intercostal retractions", "machine", "murmur", "precordium", "echocardiography", "pulmonary", "systemic circulation", "in parallel", "in series", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 5-year-old male visits his pediatrician for a check-up. His height corresponds to the 99th percentile for his age, and pubic hair is present upon physical examination. Serum renin and potassium levels are high, as is 17-hydroxyprogesterone. Which of the following is likely deficient in this patient?", "answer": "21-hydroxylase", "options": {"A": "17a-hydroxylase", "B": "11ß-hydroxylase", "C": "21-hydroxylase", "D": "Aromatase", "E": "5a-reductase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old male", "pediatrician", "check-up", "height", "99th percentile", "age", "pubic hair", "present", "Serum renin", "potassium levels", "high", "17-hydroxyprogesterone", "following", "likely deficient", "patient"]}
{"question": "A 41-year-old African American woman presents with her husband to her primary care doctor for evaluation of depression and anxiety. She reports a 2-week history of rapid onset sadness with no clear inciting factor. She is accompanied by her husband who notes that she has had at least three similar episodes that have occurred over the past two years. He also notes that she has been “more emotional” lately and seems confused throughout the day. She has had to leave her job as a librarian at her child’s elementary school. Her past medical history is notable for two diagnostic laparoscopies for recurrent episodes of abdominal pain of unknown etiology. Her family history is notable for psychosis in her mother and maternal grandfather. Her temperature is 99°F (37.2°C), blood pressure is 125/75 mmHg, pulse is 75/min, and respirations are 17/min. On exam, she is disheveled and appears confused and disoriented. Her attention span is limited and she exhibits emotional lability. This patient’s condition is most likely due to a defect in an enzyme that metabolizes which of the following compounds?", "answer": "Porphobilinogen", "options": {"A": "Aminolevulinic acid", "B": "Coproporphyrinogen III", "C": "Hydroxymethylbilane", "D": "Porphobilinogen", "E": "Protoporphyrin IX"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "primary care doctor", "depression", "anxiety", "reports", "2-week history", "rapid onset", "clear", "factor", "notes", "three similar episodes", "past two years", "notes", "more emotional", "confused", "day", "to", "librarian", "childs elementary school", "past medical history", "notable", "two diagnostic laparoscopies", "recurrent episodes of abdominal pain", "unknown etiology", "family history", "notable", "psychosis", "temperature", "blood pressure", "75 mmHg", "pulse", "75 min", "respirations", "min", "exam", "appears confused", "disoriented", "limited", "emotional lability", "patients condition", "due to", "defect", "enzyme", "following compounds"]}
{"question": "A 32-year-old woman presents to her primary care physician for a general wellness appointment. The patient has no complaints currently and just wants to be sure that she is in good health. The patient has a past medical history of asthma, hypertension, and anxiety. Her current medications include albuterol, fluticasone, hydrochlorothiazide, lisinopril, and fexofenadine. Her temperature is 99.5°F (37.5°C), blood pressure is 165/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. On exam, you note a healthy young woman with a lean habitus. Cardiac exam reveals a S1 and S2 heart sound with a normal rate. Pulmonary exam is clear to auscultation bilaterally with good air movement. Abdominal exam reveals a bruit, normoactive bowel sounds, and an audible borborygmus. Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and reflexes in the upper and lower extremities. Which of the following is the best next step in management?", "answer": "Ultrasound with doppler", "options": {"A": "Raise lisinopril dose", "B": "Add furosemide", "C": "Ultrasound with doppler", "D": "CT of the abdomen", "E": "No additional management needed"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "general wellness appointment", "patient", "complaints currently", "to", "sure", "patient", "past medical", "hypertension", "anxiety", "current medications include albuterol", "fluticasone", "hydrochlorothiazide", "lisinopril", "fexofenadine", "temperature", "99", "blood pressure", "95 mmHg", "pulse", "70 min", "respirations", "min", "oxygen saturation", "98", "room air", "exam", "note", "healthy young woman", "reveals", "S1", "S2 heart", "normal", "Pulmonary exam", "clear", "auscultation", "good", "Abdominal exam reveals", "bruit", "bowel sounds", "borborygmus", "Neurological exam reveals cranial nerves II XII", "intact", "normal strength", "reflexes", "upper", "lower extremities", "following", "best next step"]}
{"question": "A 46-year-old man comes to the emergency department because of a 10-day history of right upper quadrant abdominal pain. He has also been feeling tired and nauseous for the past 6 weeks. On examination, scleral icterus is present. Abdominal examination shows tenderness to palpation in the right upper quadrant. The liver edge is palpated 2 cm below the right costal margin. Laboratory studies show:\nAspartate aminotransferase 1780 U/L\nAlanine aminotransferase 2520 U/L\nHepatitis A IgM antibody Negative\nHepatitis B surface antigen Negative\nHepatitis B surface antibody Negative\nHepatitis B core IgM antibody Positive\nHepatitis C antibody Positive\nHepatitis C RNA Negative\nWhich of the following is the best course of action for this patient?\"", "answer": "Supportive therapy", "options": {"A": "Ribavirin and interferon", "B": "Supportive therapy", "C": "Tenofovir", "D": "Emergency liver transplantation", "E": "Pegylated interferon-alpha"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "a 10 day history", "right upper quadrant abdominal pain", "tired", "nauseous", "past", "weeks", "scleral icterus", "present", "Abdominal", "tenderness", "palpation", "right upper quadrant", "liver edge", "2 cm", "right costal margin", "Laboratory studies", "U", "2520", "Hepatitis A", "antibody", "Positive", "RNA", "following", "best course", "action", "patient"]}
{"question": "A 5-year-old boy who recently emigrated from Nigeria is brought to the emergency department because of a 2-day history of lower leg weakness, swallowing difficulty, and drooling of saliva. He has not yet received any childhood vaccinations. Two days after admission, the patient develops shortness of breath. Pulse oximetry shows an oxygen saturation of 64%. Despite resuscitative efforts, the patient dies of respiratory failure. At autopsy, examination of the spinal cord shows destruction of the anterior horn cells. Neurological examination of this patient would have most likely shown which of the following findings?", "answer": "Hyporeflexia", "options": {"A": "Positive Babinski sign", "B": "Hyporeflexia", "C": "Sensory loss", "D": "Myoclonus", "E": "Pronator drift"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "recently", "Nigeria", "brought", "emergency department", "of", "2-day history", "lower leg weakness", "swallowing difficulty", "drooling", "saliva", "not", "received", "childhood vaccinations", "Two days", "patient", "shortness of breath", "Pulse oximetry", "oxygen saturation", "64", "resuscitative efforts", "patient dies", "respiratory failure", "autopsy", "spinal cord", "destruction", "Neurological", "most likely", "following findings"]}
{"question": "A 30-year-old woman is brought to the urgent care clinic by her husband. She complains of numbness around her lips and a tingling sensation in her hands and feet. She underwent near-total thyroidectomy for an enlarged thyroid gland a month ago. Vital signs include: blood pressure is 130/70 mm Hg, pulse is 72/min, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). A surgical incision scar is present in the anterior aspect of the neck. The attending physician inflates the blood pressure cuff above 150 mm Hg and observes the patient a couple of minutes while measuring her blood pressure. The patient develops sudden stiffness and tingling in her hand. Blood test results are as follows:\nHemoglobin (Hb%) 10.2 g/dL\nWhite blood cell count 7000/mm3\nPlatelet count 160,000/mm3\nCalcium, serum (Ca2+) 6.0 mg/dL\nAlbumin 4 g/dL\nAlanine aminotransferase (ALT), serum 15 U/L\nAspartate aminotransferase (AST), serum 8 U/L\nSerum creatinine 0.5 mg/dL\nUrea 27 mg/dL\nSodium 137 mEq/L\nPotassium 4.5 mEq/L\nMagnesium 2.5 mEq/L\nUrinalysis shows no white or red blood cells and leukocyte esterase is negative. Which of the following is the next best step in the management of this patient?", "answer": "Serum parathyroid hormone (PTH) level", "options": {"A": "CT scan abdomen with pancreatic protocol", "B": "Thyroid function tests", "C": "Serum vitamin D level", "D": "24-hour urinary calcium", "E": "Serum parathyroid hormone (PTH) level"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["30 year old woman", "brought", "urgent care clinic", "numbness", "lips", "tingling", "hands", "feet", "total thyroidectomy", "enlarged thyroid gland", "month", "Vital signs include", "blood pressure", "70 mm Hg", "pulse", "72 min", "respiratory rate", "min", "temperature", "98", "surgical scar", "present", "anterior aspect", "neck", "attending physician", "blood pressure cuff", "mm Hg", "observes", "patient", "couple", "minutes", "measuring", "blood pressure", "patient", "sudden stiffness", "tingling", "hand", "Blood test results", "follows", "Hemoglobin", "Hb", "g", "White blood cell count", "Platelet", "Calcium", "serum", "Ca2", "6 0 mg/dL Albumin 4 g", "Alanine aminotransferase", "ALT", "serum", "U/L Aspartate aminotransferase", "AST", "serum", "U", "creatinine 0.5", "dL", "Sodium", "Potassium", "Magnesium 2", "Urinalysis", "white", "red blood cells", "leukocyte esterase", "negative", "following", "next best step", "patient"]}
{"question": "A woman with coronary artery disease is starting to go for a walk. As she begins, her heart rate accelerates from a resting pulse of 60 bpm until it reaches a rate of 120 bpm, at which point she begins to feel a tightening in her chest. She stops walking to rest and the tightening resolves. This has been happening to her consistently for the last 6 months. Which of the following is a true statement?", "answer": "Increasing the heart rate decreases the relative amount of time spent during diastole", "options": {"A": "Increasing the heart rate increases the amount of time spent during each cardiac cycle", "B": "Increasing the heart rate decreases the relative amount of time spent during diastole", "C": "Perfusion of the myocardium takes place primarily during systole", "D": "Perfusion of the myocardium takes place equally throughout the cardiac cycle", "E": "This patient's chest pain is indicative of transmural ischemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["woman", "coronary artery disease", "starting to go", "begins", "heart rate accelerates", "pulse", "60", "reaches", "rate", "point", "begins to", "chest", "stops", "to", "last", "months", "following", "true"]}
{"question": "A 22-year-old female presents to her physician for evaluation of a vaginal discharge, itching, and irritation. She recently started a new relationship with her boyfriend, who is her only sexual partner. He does not report any genitourinary symptoms. She takes oral contraceptives and does not use  barrier contraception. The medical history is unremarkable. The vital signs are within normal limits. A gynecologic examination reveals a thin, yellow, frothy vaginal discharge with a musty, unpleasant odor and numerous punctate red maculae on the ectocervix. The remainder of the exam is normal. Which of the following organisms will most likely be revealed on wet mount microscopy?", "answer": "Motile round or oval-shaped microorganisms", "options": {"A": "Budding yeasts cells and/or pseudohyphae", "B": "Epithelial cells covered by numerous bacterial cells", "C": "Motile round or oval-shaped microorganisms", "D": "Numerous rod-shaped bacteria", "E": "Chains of cocci"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female presents", "physician", "vaginal discharge", "itching", "irritation", "recently started", "new relationship", "only", "not report", "genitourinary symptoms", "oral contraceptives", "not use", "barrier contraception", "medical history", "unremarkable", "vital signs", "normal limits", "reveals", "thin", "yellow", "frothy vaginal discharge", "musty", "odor", "numerous punctate red maculae", "ectocervix", "exam", "normal", "following", "most likely", "revealed", "wet mount microscopy"]}
{"question": "A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of generalized reddening of her skin and itching for the past 2 weeks. Her symptoms occur every evening before bedtime and last for about 30 minutes. Three months ago, atorvastatin was stopped after she experienced progressively worsening neck and back pain. Statin therapy was reinitiated at lower doses 3 weeks ago but had to be stopped again after her musculoskeletal symptoms recurred. Her menses occur irregularly at 2–3 month intervals and last for 3–4 days. She has smoked one pack of cigarettes daily for the past 30 years. Her current medications include lisinopril and niacin. Her brother died of colonic adenocarcinoma, and her father died of small cell lung cancer. She is 169 cm (5 ft 6 in) tall and weighs 83 kg (183 lb); BMI is 29 kg/m2. Her vital signs are within normal limits. Physical examination shows no abnormalities. Serum lipid studies show:\nTotal cholesterol 247 mg/dL\nHDL-cholesterol 39 mg/dL\nLDL-cholesterol 172 mg/dL\nTriglycerides 152 mg/dL\nWhich of the following is the most appropriate next step in management?\"", "answer": "Administer ibuprofen", "options": {"A": "Administer ibuprofen", "B": "Measure urine hydroxyindoleacetic acid levels", "C": "Measure urine metanephrine levels", "D": "Switch lisinopril to hydrochlorothiazide", "E": "Switch niacin to fenofibrate"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "hypertension", "hyperlipidemia", "physician", "generalized reddening", "skin", "itching", "past 2 weeks", "symptoms occur", "evening", "bedtime", "last", "30 minutes", "Three months", "atorvastatin", "stopped", "worsening neck", "back pain", "Statin therapy", "lower doses", "weeks", "to", "stopped", "musculoskeletal symptoms", "menses occur", "23 month intervals", "last", "days", "smoked one pack", "cigarettes daily", "past 30 years", "current medications include lisinopril", "niacin", "died", "colonic adenocarcinoma", "died of small cell lung cancer", "5 ft 6", "tall", "83 kg", "BMI", "29 kg/m2", "vital signs", "normal limits", "abnormalities", "Serum lipid studies", "Total cholesterol", "mg/dL HDL", "Triglycerides", "following", "most appropriate next step"]}
{"question": "Five days after undergoing right knee arthroplasty for osteoarthritis, a 68-year-old man has severe pain in this right knee preventing him from participating in physical therapy. On the third postoperative day when the dressing was changed, the surgical wound appeared to be intact, slightly swollen, and had a clear secretion. He has a history of diabetes, hyperlipidemia, and hypertension. Current medications include metformin, enalapril, and simvastatin. His temperature is 37.3°C (99.1°F), pulse is 94/min, and blood pressure is 130/88 mm Hg. His right knee is swollen, erythematous, and tender to palpation. There is pain on movement of the joint. The medial parapatellar skin incision appears superficially opened in its proximal and distal part with yellow-green discharge. There is blackening of the skin on both sides of the incision. Which of the following is the next best step in the management of this patient?", "answer": "Surgical debridement", "options": {"A": "Surgical debridement", "B": "Nafcillin therapy", "C": "Removal of prostheses", "D": "Vacuum dressing", "E": "Antiseptic dressing\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["right knee arthroplasty", "osteoarthritis", "year old man", "severe pain in", "right knee preventing", "participating", "physical therapy", "third postoperative day", "dressing", "changed", "surgical wound appeared to", "intact", "slightly swollen", "clear secretion", "history", "diabetes", "hyperlipidemia", "hypertension", "Current medications include metformin", "enalapril", "simvastatin", "temperature", "99", "pulse", "min", "blood pressure", "88 mm Hg", "right knee", "swollen", "erythematous", "tender", "palpation", "pain on movement", "joint", "medial parapatellar skin incision appears", "opened", "proximal", "distal part", "discharge", "skin", "sides", "incision", "following", "next best step", "patient"]}
{"question": "A 53-year-old woman comes to the physician in February because of a 1-day history of fever, chills, headache, and dry cough. She also reports malaise and generalized muscle aches. She works as a teacher at a local high school, where there was recently an outbreak of influenza. She has a history of intermittent asthma, for which she takes albuterol as needed. She declined the influenza vaccine offered in the fall because her sister told her that a friend developed a flulike illness after receiving the vaccine. She is worried about possibly becoming ill and cannot afford to miss work. Her temperature is 37.9°C (100.3°F), heart rate is 58/min, and her respirations are 12/min. Physical examination is unremarkable. Her hemoglobin concentration is 14.5 g/dL, leukocyte count is 9,400/mm3, and platelet count is 280,000/mm3. In addition to analgesia, which of the following is the most appropriate next step in management?", "answer": "Oseltamivir", "options": {"A": "Supportive therapy only", "B": "Amantadine", "C": "Inactivated influenza vaccine", "D": "Oseltamivir", "E": "Live attenuated influenza vaccine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "February", "1-day history", "fever", "chills", "headache", "dry cough", "reports malaise", "generalized muscle aches", "teacher", "local high school", "recently", "influenza", "history of intermittent asthma", "albuterol as needed", "influenza vaccine offered", "fall", "flulike illness", "receiving", "vaccine", "worried", "possibly", "ill", "to miss", "temperature", "100", "heart rate", "58 min", "respirations", "min", "unremarkable", "hemoglobin concentration", "g/dL", "leukocyte count", "400 mm3", "platelet count", "mm3", "analgesia", "following", "most appropriate next step"]}
{"question": "Red-green color blindness, an X-linked recessive disorder, has an incidence of 1/200 in males in a certain population. What is the probability of a phenotypically normal male and female having a child with red-green color blindness?", "answer": "1/400", "options": {"A": "1/200", "B": "199/200", "C": "1/100", "D": "1/400", "E": "99/100"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Red-green color blindness", "X-linked recessive disorder", "incidence", "200", "certain", "probability", "normal male", "female", "child", "red-green color blindness"]}
{"question": "A 45-year-old man is transferred to the intensive care unit from the emergency department for acute respiratory failure. He was rushed to the hospital after developing progressive respiratory distress over the last 24 hours. His medical history is significant for long-standing severe persistent asthma, hypertension, and several bouts of community and hospital-acquired pneumonia. His medications include amlodipine, lisinopril, inhaled fluticasone, salmeterol, and oral prednisone. He is a lifelong non-smoker and drinks alcohol occasionally on the weekends. He works as a sales executive and went to Hawaii a month ago. In the emergency department, he was started on broad-spectrum antibiotics and bronchodilators. His respiratory failure progressively worsens, and on day 2 of admission, he requires mechanical ventilator support. Chest X-ray shows multiple nodules bilaterally in the lower lobes. Flexible bronchoscopy is performed and the bronchoalveolar lavage sample from the medial segment of the right lower lobe shows neutrophils, and the fungal preparation shows Aspergillus fumigatus. A video-assisted thoracoscopy is performed and biopsy from the right lower lobe is taken which shows plugging of the terminal bronchioles with mucus, inflammatory cells, and fungal vascular invasion. Which of the following is the most likely mechanism responsible for the biopsy findings?", "answer": "Defects in the immune response", "options": {"A": "Defects in the immune response", "B": "The production of a superantigen by Aspergillus fumigatus", "C": "Aspergillus fumigatus suppresses the production of IgA", "D": "Aspergillus fumigatus suppresses the production of IgM", "E": "Suppression of the innate immune system by Aspergillus fumigatus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "transferred", "intensive care unit", "emergency department", "acute respiratory failure", "rushed", "hospital", "progressive respiratory distress", "24 hours", "medical history", "significant", "long standing severe persistent asthma", "hypertension", "several bouts", "hospital-acquired pneumonia", "medications include amlodipine", "lisinopril", "inhaled fluticasone", "salmeterol", "oral prednisone", "lifelong non-smoker", "alcohol occasionally", "weekends", "executive", "to Hawaii", "month", "emergency department", "started", "broad spectrum", "bronchodilators", "respiratory failure", "worsens", "day 2", "mechanical ventilator support", "Chest X-ray", "multiple nodules", "lower lobes", "Flexible bronchoscopy", "performed", "bronchoalveolar lavage", "medial segment", "right lower lobe", "fungal preparation", "video-assisted thoracoscopy", "performed", "biopsy", "right lower lobe", "plugging", "terminal bronchioles", "mucus", "fungal vascular invasion", "following", "mechanism responsible", "biopsy findings"]}
{"question": "A 70-year-old man comes to the physician because of a 4-month history of epigastric pain, nausea, and weakness. He has smoked one pack of cigarettes daily for 50 years and drinks one alcoholic beverage daily. He appears emaciated. He is 175 cm (5 ft 9 in) tall and weighs 47 kg (103 lb); BMI is 15 kg/m2. He is diagnosed with gastric cancer. Which of the following cytokines is the most likely direct cause of this patient’s examination findings?", "answer": "IL-6", "options": {"A": "TGF-β", "B": "IL-6", "C": "IL-2", "D": "IFN-α", "E": "TNF-β"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["70 year old man", "physician", "4 month history", "epigastric pain", "nausea", "weakness", "smoked one pack", "cigarettes daily", "50 years", "one", "daily", "appears emaciated", "5 ft 9", "tall", "kg", "BMI", "kg/m2", "diagnosed", "gastric cancer", "following cytokines", "direct cause", "findings"]}
{"question": "A 40-year-old woman comes to the physician because of a 1-week history of fatigue, dark urine, and a feeling of heaviness in her legs. Two weeks ago, she returned from a vacation to Brazil, where she spent most of her days exploring the city of Rio de Janeiro on foot. She also gained 3 kg (7 lb) during her vacation. She has systemic lupus erythematosus. Her only medication is hydroxychloroquine. Her temperature is 37.5°C (99.5°F), pulse is 78/min, and blood pressure is 162/98 mm Hg. Physical examination shows 2+ pretibial edema bilaterally. Urinalysis shows:\nBlood 3+\nProtein 1+\nRBC 6–8/hpf with dysmorphic features\nRBC casts numerous\nWBC 8/hpf\nWBC casts rare\nBacteria negative\nWhich of the following is the most likely cause of this patient's leg findings?\"", "answer": "Salt retention", "options": {"A": "Venous insufficiency", "B": "Lymphatic obstruction", "C": "Increased capillary permeability", "D": "Renal protein loss", "E": "Salt retention"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "physician", "1-week history", "fatigue", "dark urine", "feeling of heaviness", "legs", "Two weeks", "returned", "Brazil", "spent most", "days", "city", "Rio de", "foot", "gained 3 kg", "systemic lupus erythematosus", "only medication", "hydroxychloroquine", "temperature", "99", "pulse", "min", "blood pressure", "98 mm Hg", "2", "edema", "Urinalysis", "Blood", "Protein 1", "RBC", "hpf", "dysmorphic features", "casts numerous WBC", "hpf", "casts rare Bacteria negative", "following", "most likely cause", "patient", "eg  indings?"]}
{"question": "A 67-year-old woman with advanced bladder cancer comes to the physician for a follow-up examination. She is currently undergoing chemotherapy with an agent that forms cross-links between DNA strands. Serum studies show a creatinine concentration of 2.1 mg/dL and a blood urea nitrogen concentration of 30 mg/dL. Urine dipstick of a clean-catch midstream specimen shows 2+ protein and 1+ glucose. Prior to initiation of chemotherapy, her laboratory values were within the reference range. In addition to hydration, administration of which of the following would most likely have prevented this patient's current condition?", "answer": "Amifostine", "options": {"A": "Mesna", "B": "Aprepitant", "C": "Amifostine", "D": "Rasburicase", "E": "Leucovorin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old woman", "advanced bladder", "physician", "follow-up examination", "currently", "chemotherapy", "agent", "forms cross-links", "DNA strands", "Serum studies", "creatinine concentration", "2", "mg dL", "blood urea nitrogen concentration", "mg/dL", "Urine", "clean-catch", "specimen", "2", "protein", "1", "glucose", "Prior to initiation", "chemotherapy", "laboratory values", "reference range", "hydration", "administration", "following", "most likely", "prevented", "patient's current condition"]}
{"question": "A 57-year-old post-menopausal woman comes to the physician because of intermittent, bloody post-coital vaginal discharge for the past month. She does not have pain with intercourse. Eleven years ago, she had LSIL on a routine Pap smear and testing for high-risk HPV strains was positive. Colposcopy showed CIN 1. She has not returned for follow-up Pap smears since then. She is sexually active with her husband only, and they do not use condoms. She has smoked half a pack of cigarettes per day for the past 25 years and does not drink alcohol. On speculum exam, a 1.4 cm, erythematous exophytic mass with ulceration is noted on the posterior wall of the upper third of the vagina. Which of the following is the most probable histopathology of this mass?", "answer": "Squamous cell carcinoma", "options": {"A": "Squamous cell carcinoma", "B": "Basal cell carcinoma", "C": "Melanoma", "D": "Sarcoma botryoides", "E": "Adenocarcinoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["57 year old post-menopausal woman", "physician", "of intermittent", "bloody post-coital vaginal discharge", "past month", "not", "Eleven years", "LSIL", "routine Pap smear", "testing", "strains", "positive", "Colposcopy", "CIN 1", "not returned", "follow-up Pap smears", "then", "sexually active", "only", "not use condoms", "smoked half", "pack", "cigarettes", "day", "past", "years", "not", "alcohol", "speculum exam", "erythematous exophytic mass", "ulceration", "noted", "posterior wall of", "upper third of", "vagina", "following", "histopathology", "mass"]}
{"question": "Three days after starting a new drug for malaria prophylaxis, a 19-year-old college student comes to the physician because of dark-colored urine and fatigue. He has not had any fever, dysuria, or abdominal pain. He has no history of serious illness. Physical examination shows scleral icterus. Laboratory studies show a hemoglobin of 9.7 g/dL and serum lactate dehydrogenase of 234 U/L. Peripheral blood smear shows poikilocytes with bite-shaped irregularities. Which of the following drugs has the patient most likely been taking?", "answer": "Primaquine", "options": {"A": "Pyrimethamine", "B": "Primaquine", "C": "Dapsone", "D": "Ivermectin", "E": "Doxycycline"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Three days", "starting", "new", "malaria", "year old", "physician", "dark-colored urine", "fatigue", "not", "fever", "dysuria", "abdominal pain", "history", "serious illness", "Physical examination", "scleral icterus", "Laboratory studies", "a hemoglobin", "g/dL", "serum lactate dehydrogenase", "L", "Peripheral blood smear", "poikilocytes", "bite shaped irregularities", "following drugs", "patient", "likely"]}
{"question": "You are reviewing raw data from a research study performed at your medical center examining the effectiveness of a novel AIDS screening examination. The study enrolled 250 patients with confirmed AIDS, and 240 of these patients demonstrated a positive screening examination. The control arm of the study enrolled 250 patients who do not have AIDS, and only 5 of these patients tested positive on the novel screening examination. What is the NPV of this novel test?", "answer": "245 / (245 + 10)", "options": {"A": "245 / (245 + 10)", "B": "245 / (245 + 5)", "C": "240 / (240 + 5)", "D": "240 / (240 + 15)", "E": "240 / (240 + 10)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["reviewing", "performed", "medical center examining", "effectiveness", "novel AIDS screening examination", "study enrolled", "patients", "confirmed AIDS", "patients", "positive screening examination", "arm", "enrolled", "patients", "not", "AIDS", "only", "patients", "positive", "novel screening examination", "NPV", "novel test"]}
{"question": "A P1G0 diabetic woman is at risk of delivering at 30 weeks gestation. Her obstetrician counsels her that there is a risk the baby could have significant pulmonary distress after it is born. However, she states she will administer a drug to the mother to help prevent this from occurring. By what action will this drug prevent respiratory distress in the premature infant?", "answer": "Increasing the secretory product of type II alveolar cells", "options": {"A": "Suppressing the neonatal immune system", "B": "Increasing the secretory product of type II alveolar cells", "C": "Preventing infection of immature lungs", "D": "Reducing the secretory product of type II alveolar cells", "E": "Promoting increased surface tension of alveoli"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["diabetic woman", "at risk", "delivering", "30 weeks gestation", "obstetrician counsels", "baby", "significant pulmonary distress", "born", "states", "administer", "drug", "to help prevent", "occurring", "action", "drug prevent respiratory distress", "premature infant"]}
{"question": "A case-control study is conducted to investigate the association between the use of phenytoin during pregnancy in women with epilepsy and the risk for congenital malformations. The odds ratio of congenital malformations in newborns born to women who were undergoing treatment with phenytoin is 1.74 (P = 0.02) compared to newborns of women who were not treated with phenytoin. Which of the following 95% confidence intervals is most likely reported for this association?", "answer": "1.34 to 2.36", "options": {"A": "1.75 to 2.48", "B": "0.56 to 1.88", "C": "0.36 to 0.94", "D": "1.34 to 2.36", "E": "0.83 to 2.19"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["to investigate", "association", "use phenytoin", "pregnancy", "women", "epilepsy", "congenital malformations", "odds ratio", "congenital malformations", "newborns born", "treatment", "phenytoin", "1 74", "P", "0.02", "newborns", "not treated with phenytoin", "following 95", "confidence intervals", "most likely reported", "association"]}
{"question": "A 5-year-old boy presents with altered mental status and difficulty breathing for the past couple of hours. The patient’s father, a mechanic, says the boy accidentally ingested an unknown amount of radiator fluid. The patient’s vital signs are: temperature 37.1°C (98.8.F), pulse 116/min, blood pressure 98/78 mm Hg, and respiratory rate 42/min. On physical examination, cardiopulmonary auscultation reveals deep, rapid respirations with no wheezing, rhonchi, or crepitations. An ABG reveals the blood pH to be 7.2 with an anion gap of 16 mEq/L. Urinalysis reveals the presence of oxalate crystals. Which of the following is the most appropriate antidote for the poison that this patient has ingested?", "answer": "Fomepizole", "options": {"A": "Flumazenil", "B": "Succimer", "C": "Methylene blue", "D": "Fomepizole", "E": "Dimercaprol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old boy presents", "altered mental status", "difficulty breathing", "past couple", "hours", "patients", "boy", "unknown amount", "fluid", "patients vital signs", "temperature", "98", "F", "pulse", "min", "blood pressure 98", "mm Hg", "respiratory rate", "min", "cardiopulmonary auscultation reveals deep", "rapid", "wheezing", "rhonchi", "crepitations", "ABG reveals", "blood pH to", "7.2", "anion gap", "mEq/L", "Urinalysis reveals", "presence of oxalate crystals", "following", "most appropriate antidote", "poison", "patient"]}
{"question": "A 45-year-old man with HIV comes to the physician because of multiple lesions on his chest and lower extremities. The lesions have progressively increased in size and are not painful or pruritic. Current medications include abacavir, dolutegravir, and lamivudine. A photograph of the lesions is shown. His CD4+ T-lymphocyte count is 450/mm3 (normal ≥ 500/mm3). A skin biopsy shows multiple spindle-shaped cells and lymphocytic infiltrate. Which of the following is the most appropriate pharmacotherapy?", "answer": "Alpha-interferon", "options": {"A": "Ganciclovir", "B": "Nitazoxanide", "C": "Alpha-interferon", "D": "Amphotericin B", "E": "Doxycycline"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "HIV", "physician", "of multiple lesions", "chest", "lower extremities", "lesions", "increased in size", "not painful", "Current medications include abacavir", "dolutegravir", "lamivudine", "photograph", "lesions", "CD4", "lymphocyte count", "450 mm3", "normal", "500 mm3", "skin biopsy", "multiple", "shaped", "lymphocytic infiltrate", "following", "most appropriate pharmacotherapy"]}
{"question": "An 18-year-old man presents to the office, complaining of an itchy patch on his torso that appeared one week ago. The patient is on the college wrestling team and is concerned he will not be able to compete if it gets infected. He has no significant medical history, and his vital signs are within normal limits. On examination, there is an erythematous, scaly plaque with central clearing at approximately the level of rib 6 on the left side of his torso. What diagnostic test would be most appropriate at this time?", "answer": "KOH preparation", "options": {"A": "Sabouraud agar", "B": "Eaton agar", "C": "Thayer-Martin agar", "D": "KOH preparation", "E": "Wood’s lamp examination"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "office", "itchy patch", "torso", "appeared one week", "patient", "college", "not", "able to", "gets infected", "significant medical history", "vital signs", "normal limits", "erythematous", "scaly plaque", "central", "approximately", "level", "rib 6", "left side", "torso", "diagnostic test", "most appropriate", "time"]}
{"question": "A 65-year-old man with no significant medical history begins to have memory loss and personality changes. Rapidly, over the next few months his symptoms increase in severity. He experiences a rapid mental deterioration associated with sudden, jerking movements, particularly in response to being startled. He has gait disturbances as well. Eventually, he lapses into a coma and dies approximately ten months after the onset of symptoms. Which of the following would most likely be seen on autopsy of the brain in this patient?", "answer": "C", "options": {"A": "A", "B": "B", "C": "C", "D": "D", "E": "E"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65-year-old man", "significant medical history begins to", "memory loss", "personality changes", "Rapidly", "next", "months", "symptoms increase", "severity", "rapid mental deterioration associated with sudden", "jerking movements", "response", "gait disturbances", "well", "coma", "approximately ten months", "onset", "symptoms", "following", "most likely", "seen", "autopsy", "brain", "patient"]}
{"question": "A 32-year-old woman with type 1 diabetes mellitus is brought to the emergency department by her husband because of a 2-day history of profound fatigue and generalized weakness. One week ago, she increased her basal insulin dose because of inadequate control of her glucose concentrations. Neurologic examination shows hyporeflexia. An ECG shows T-wave flattening and diffuse ST-segment depression. Which of the following changes are most likely to occur in this patient's kidneys?", "answer": "Increased activity of H+/K+ antiporter in α-intercalated cells", "options": {"A": "Increased activity of H+/K+ antiporter in α-intercalated cells", "B": "Decreased activity of epithelial Na+ channels in principal cells", "C": "Decreased activity of Na+/K+/2Cl- cotransporter in the loop of Henle", "D": "Decreased activity of Na+/H+ antiporter in the proximal convoluted tubule", "E": "Increased activity of luminal K+ channels in principal cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "type 1 diabetes mellitus", "brought", "emergency department", "2-day history", "profound fatigue", "generalized weakness", "One week", "increased", "basal", "of inadequate control", "glucose concentrations", "Neurologic examination", "hyporeflexia", "ECG", "T-wave flattening", "diffuse ST-segment depression", "following changes", "to occur", "patient's kidneys"]}
{"question": "A newborn male is evaluated in the hospital nursery 24 hours after birth for cyanosis. The patient was born at 38 weeks gestation to a 36-year-old gravida 3 via cesarean section for fetal distress. The patient’s mother received inconsistent prenatal care, and the delivery was uncomplicated. The patient’s Apgar evaluation was notable for acrocyanosis at both 1 and 5 minutes of life. The patient’s mother denies any family history of congenital heart disease. The patient’s father has a past medical history of hypertension, and one of the patient’s older siblings was recently diagnosed with autism spectrum disorder. The patient’s birth weight was 3180 g (7 lb 0 oz). In the hospital nursery, his temperature is 99.3°F (37.4°C), blood pressure is 66/37 mmHg, pulse is 179/min, and respirations are 42/min. On physical exam, the patient is in moderate distress. He has low-set ears, orbital hypertelorism, and a cleft palate. The patient is centrally cyanotic. A chest CT shows thymic hypoplasia. Echocardiography demonstrates a single vessel emanating from both the right and left ventricle.\n\nThis patient should be urgently evaluated for which of the following acute complications?", "answer": "Neuromuscular irritability", "options": {"A": "Cerebral edema", "B": "Hypoglycemia", "C": "Neuromuscular irritability", "D": "Rhabdomyolysis", "E": "Shortening of the QT interval"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["newborn male", "hospital nursery 24 hours after birth", "cyanosis", "patient", "born", "weeks gestation", "36 year old gravida 3", "cesarean section", "fetal distress", "patients", "received inconsistent", "delivery", "uncomplicated", "Apgar", "notable", "acrocyanosis", "1", "5 minutes", "patients", "family history of congenital heart disease", "patients", "past medical", "one", "patients", "recently diagnosed", "autism spectrum disorder", "patients birth weight", "g", "0 oz", "hospital nursery", "temperature", "99", "blood pressure", "66", "mmHg", "pulse", "min", "respirations", "min", "patient", "moderate distress", "low-set ears", "orbital hypertelorism", "cleft palate", "patient", "cyanotic", "chest CT", "thymic hypoplasia", "Echocardiography", "single vessel", "right", "left ventricle", "patient", "following acute complications"]}
{"question": "A 29-year-old woman comes to the physician because of intermittent episodes of sharp chest pain and palpitations. She appears nervous. Her pulse is 115/min and irregularly irregular, and blood pressure is 139/86 mmHg. Examination shows a fine tremor on both hands and digital swelling; the extremities are warm. There is retraction of the right upper eyelid. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Propranolol", "options": {"A": "Amiodarone", "B": "Propylthiouracil", "C": "Warfarin", "D": "Methimazole", "E": "Propranolol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old woman", "physician", "of intermittent episodes", "sharp chest pain", "palpitations", "appears nervous", "pulse", "min", "irregular", "blood pressure", "mmHg", "fine", "hands", "digital swelling", "extremities", "warm", "retraction of", "right upper eyelid", "following", "most appropriate next step", "patient"]}
{"question": "A 23-year-old female is found by her roommate in her dormitory. The patient has a history of Type 1 Diabetes Mellitus and was binge drinking the night prior with friends at a local bar. The patient is brought to the emergency department, where vital signs are as follow: T 97.3 F, HR 119 bpm, BP 110/68 mmHg, RR 24, SpO2 100% on RA. On physical exam, the patient is clammy to touch, mucous membranes are tacky, and she is generally drowsy and disoriented. Finger stick glucose is 342 mg/dL; additional lab work reveals: Na: 146 K: 5.6 Cl: 99 HCO3: 12 BUN: 18 Cr: 0.74. Arterial Blood Gas reveals: pH 7.26, PCO2 21, PO2 102. Which of the following statements is correct regarding this patient's electrolyte and acid/base status?", "answer": "The patient has an anion gap metabolic acidosis with decreased total body potassium", "options": {"A": "The patient has a primary respiratory alkalosis with a compensatory metabolic acidosis", "B": "The patient has a metabolic acidosis with hyperkalemia from increased total body potassium", "C": "The patient has an anion gap metabolic acidosis as well as a respiratory acidosis", "D": "The patient has an anion gap metabolic acidosis with decreased total body potassium", "E": "The patient has a non-anion gap metabolic acidosis with decreased total body sodium"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old female", "found", "dormitory", "patient", "history of Type 1 Diabetes Mellitus", "night prior", "local", "patient", "brought", "emergency department", "vital signs", "follow", "T 97 3 F", "BP", "mmHg", "RR", "100", "RA", "patient", "clammy", "touch", "mucous membranes", "drowsy", "disoriented", "Finger stick glucose", "mg/dL", "additional lab", "reveals", "Na", "K", "5.6", "99 HCO3", "Cr", "0.74", "Arterial Blood Gas reveals", "pH 7", "PCO2", "PO2", "following", "correct", "patient's electrolyte", "acid/base status"]}
{"question": "A 36-year-old man is admitted to the hospital because of a 1-day history of epigastric pain and vomiting. He has had similar episodes of epigastric pain in the past. He drinks 8 oz of vodka daily. Five days after admission, the patient develops aspiration pneumonia and sepsis. Despite appropriate therapy, the patient dies. At autopsy, the pancreas appears gray, enlarged, and nodular. Microscopic examination of the pancreas shows localized deposits of calcium. This finding is most similar to an adaptive change that can occur in which of the following conditions?", "answer": "Congenital CMV infection", "options": {"A": "Primary hyperparathyroidism", "B": "Chronic kidney disease", "C": "Sarcoidosis", "D": "Congenital CMV infection", "E": "Multiple myeloma\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old man", "1-day history", "epigastric pain", "vomiting", "similar episodes of epigastric pain", "past", "oz", "daily", "Five days", "patient", "aspiration pneumonia", "sepsis", "appropriate therapy", "patient", "autopsy", "pancreas appears gray", "enlarged", "nodular", "Microscopic examination", "pancreas", "localized deposits", "calcium", "finding", "most similar", "adaptive change", "occur", "following conditions"]}
{"question": "A 37-year-old patient is being evaluated for involuntary movements, difficulty swallowing food, and personality change. He has entered a clinical trial that is studying the interaction of certain neuromediators in patients with similar (CAG) n trinucleotide repeat disorders. The laboratory results of 1  of the candidates for the clinical trial are presented below:\nAcetylcholine ↓\nDopamine ↑\nGamma-aminobutyric acid (GABA) ↓\nNorepinephrine unchanged\nSerotonin unchanged\nWhich trinucleotide disorder most likely represents the diagnosis of this patient?", "answer": "Huntington's disease", "options": {"A": "Myotonic dystrophy", "B": "Friedreich's ataxia", "C": "Fragile X syndrome", "D": "Huntington's disease", "E": "Spinobulbar muscular atrophy"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old patient", "involuntary movements", "difficulty swallowing food", "personality change", "entered", "studying", "interaction", "certain", "patients", "similar", "n trinucleotide repeat disorders", "laboratory results", "Acetylcholine", "Dopamine", "Gamma-aminobutyric acid", "Norepinephrine unchanged Serotonin unchanged", "disorder", "likely", "diagnosis", "patient"]}
{"question": "A 65-year-old man with hypertension comes to the physician for a routine health maintenance examination. Current medications include atenolol, lisinopril, and atorvastatin. His pulse is 86/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this physical examination finding?", "answer": "Decreased compliance of the left ventricle", "options": {"A": "Decreased compliance of the left ventricle", "B": "Myxomatous degeneration of the mitral valve", "C": "Inflammation of the pericardium", "D": "Dilation of the aortic root", "E": "Thickening of the mitral valve leaflets"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65-year-old man", "hypertension", "physician", "routine", "Current medications include atenolol", "lisinopril", "atorvastatin", "pulse", "min", "respirations", "min", "blood pressure", "95 mm Hg", "following", "most likely cause", "physical examination finding"]}
{"question": "A 55-year-old man presents to the hospital with chief complaints of unintentional weight loss, anorexia, fever, and sweating. The patient has pleuritic chest pain, progressive dyspnea, and dry cough. There is no history of orthopnea or paroxysmal nocturnal dyspnea. On examination, the patient is afebrile and pericardial friction rub is noted. ECG shows diffuse ST-segment elevation in V1-V4 along with T wave inversion. Chest X-ray and CT scan show anterior and inferior pericardial eggshell calcification. Echocardiography reveals thickened pericardium and signs of diastolic right ventricular collapse. Pericardial fluid is sent for Ziehl-Neelsen staining to detect acid-fast bacilli. Mycobacterium tuberculosis is detected by PCR. What is the most likely mechanism associated with the patient’s condition?", "answer": "Dystrophic calcification", "options": {"A": "Metastatic calcifications", "B": "Dystrophic calcification", "C": "Primary amyloidosis", "D": "Secondary amyloidosis", "E": "Age-related amyloidosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "hospital", "chief complaints of unintentional weight loss", "anorexia", "fever", "sweating", "patient", "pleuritic chest pain", "progressive dyspnea", "dry cough", "history", "orthopnea", "paroxysmal nocturnal dyspnea", "patient", "afebrile", "pericardial friction rub", "noted", "ECG", "diffuse ST-segment elevation", "V1", "T wave inversion", "Chest X-ray", "CT scan", "anterior", "inferior pericardial eggshell", "Echocardiography reveals thickened pericardium", "signs", "diastolic right ventricular collapse", "Pericardial fluid", "sent", "to detect acid-fast bacilli", "Mycobacterium tuberculosis", "detected", "PCR", "mechanism associated with", "patients condition"]}
{"question": "A 7-month-old infant with Tetralogy of Fallot is brought to the emergency department by her parents because of a 1-day history of fever, cough, and difficulty breathing. She was born at 29 weeks of gestation. Her routine immunizations are up-to-date. She is currently in the 4th percentile for length and 2nd percentile for weight. She appears ill. Her temperature is 39.1°C (102.3°F). Physical examination shows diffuse wheezing, subcostal retractions, and bluish discoloration of the fingertips. Administration of which of the following would most likely have prevented this patient's current condition?", "answer": "Palivizumab", "options": {"A": "Ribavirin", "B": "Oseltamivir", "C": "Ganciclovir", "D": "Ceftriaxone", "E": "Palivizumab"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old infant", "Tetralogy of Fallot", "brought", "emergency department", "1-day history", "fever", "cough", "difficulty breathing", "born", "29 weeks of gestation", "routine immunizations", "date", "currently", "4th percentile", "length", "2nd percentile", "weight", "appears ill", "temperature", "diffuse wheezing", "subcostal retractions", "bluish discoloration of", "fingertips", "Administration", "following", "most likely", "prevented", "patient's current condition"]}
{"question": "A 62-year-old woman has been receiving amoxicillin for acute sinusitis for 12 days. She develops a macular rash on her neck, back, and torso. The amoxicillin is therefore changed to cephalexin for an additional week. The rash resolves, but she returns complaining of fatigue, flank pain, and fever that has persisted despite the resolution of the sinusitis. She has a history of essential hypertension, hyperlipidemia, and gastric reflux. She has been on a stable regimen of lisinopril, simvastatin, and omeprazole. Today, her vital signs reveal: temperature 37.9°C (100.2°F), blood pressure 145/90 mm Hg, regular pulse 75/min, and respirations 16/min. The physical examination is unremarkable. Serum urea and creatinine are elevated. Urinalysis shows leukocyturia, but urine bacterial culture is negative. A urine cytospin stained with Hansel’s solution reveals 3% binucleated cells with eosinophilic, granular cytoplasm. Which of the following is the most likely diagnosis?", "answer": "Acute interstitial nephritis", "options": {"A": "Acute interstitial nephritis", "B": "Acute glomerulonephritis", "C": "Acute tubular necrosis", "D": "Acute vascular injury", "E": "IgA nephropathy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old woman", "receiving amoxicillin", "acute sinusitis", "days", "macular", "neck", "back", "torso", "amoxicillin", "changed to cephalexin", "additional week", "rash", "returns", "fatigue", "flank pain", "fever", "resolution", "sinusitis", "history of essential hypertension", "hyperlipidemia", "gastric reflux", "stable regimen", "lisinopril", "simvastatin", "omeprazole", "Today", "vital signs reveal", "temperature", "100", "blood pressure", "90 mm Hg", "regular pulse 75 min", "respirations", "min", "unremarkable", "Serum urea", "creatinine", "elevated", "Urinalysis", "leukocyturia", "urine bacterial", "negative", "urine", "stained", "Hansels solution reveals 3", "binucleated cells", "eosinophilic", "granular cytoplasm", "following", "diagnosis"]}
{"question": "A 61-year-old man with a history of stage IIIa lung adenocarcinoma that has been treated with wedge resection and chemotherapy presents to the primary care clinic. He is largely asymptomatic, but he demonstrates a persistent microcytic anemia despite iron supplementation. Colonoscopy performed 3 years earlier was unremarkable. His past medical history is significant for diabetes mellitus type II, hypertension, acute lymphoblastic leukemia as a child, and hypercholesterolemia. He currently smokes 1 pack of cigarettes per day, drinks a glass of pinot grigio per day, and currently denies any 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. On physical examination, his pulses are bounding, complexion is pale, but breath sounds remain clear. Oxygen saturation was initially 91% on room air, with a new oxygen requirement of 2 L by nasal cannula. Which of the following lab values would suggest anemia of chronic disease as the underlying etiology?", "answer": "Decreased serum iron and transferrin, increased ferritin, normal serum transferrin receptor", "options": {"A": "Decreased serum iron and transferrin, increased ferritin, normal serum transferrin receptor", "B": "Decreased serum iron, increased transferrin, decreased ferritin, increased serum transferrin receptor", "C": "Increased serum iron and transferrin, increased ferritin, normal serum transferrin receptor", "D": "Decreased serum iron and transferrin, decreased ferritin, normal serum transferrin receptor", "E": "Increased serum iron and transferrin, decreased ferritin, normal serum transferrin receptor"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["61 year old man", "history of stage IIIa lung adenocarcinoma", "treated with wedge resection", "chemotherapy presents", "primary care clinic", "asymptomatic", "persistent microcytic", "iron supplementation", "Colonoscopy performed 3 years earlier", "unremarkable", "past medical history", "significant", "diabetes mellitus type II", "hypertension", "acute lymphoblastic leukemia", "child", "hypercholesterolemia", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "currently", "illicit drug use", "vital signs include", "temperature", "36", "98", "blood pressure", "74 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "pulses", "bounding", "complexion", "pale", "breath sounds", "clear", "Oxygen saturation", "initially", "room air", "new", "requirement", "nasal cannula", "following lab values", "anemia of chronic disease", "underlying etiology"]}
{"question": "A 62-year-old woman presents to her physician with a painless breast mass on her left breast for the past 4 months. She mentions that she noticed the swelling suddenly one day and thought it would resolve by itself. Instead, it has been slowly increasing in size. On physical examination of the breasts, the physician notes a single non-tender, hard, and fixed nodule over left breast. An ultrasonogram of the breast shows a solid mass, and a fine-needle aspiration biopsy confirms the mass to be lobular carcinoma of the breast. When the patient asks about her prognosis, the physician says that the prognosis can be best determined after both grading and staging of the tumor. Based on the current diagnostic information, the physician says that they can only grade, but no stage, the neoplasm. Which of the following facts about the neoplasm is currently available to the physician?", "answer": "The tumor cells exhibit marked nuclear atypia.", "options": {"A": "The tumor cells exhibit marked nuclear atypia.", "B": "The tumor invades the pectoralis major.", "C": "The tumor has metastasized to the axillary lymph nodes.", "D": "The tumor has not metastasized to the contralateral superior mediastinal lymph nodes.", "E": "The tumor has spread via blood-borne metastasis."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old woman presents", "physician", "painless breast", "left", "past", "months", "swelling", "one day", "slowly increasing in size", "physical examination", "breasts", "physician notes", "single non-tender", "hard", "fixed nodule", "left breast", "ultrasonogram", "breast", "solid mass", "fine-needle aspiration biopsy confirms", "mass to", "lobular carcinoma of the breast", "patient", "prognosis", "physician", "prognosis", "best determined", "staging", "tumor", "Based", "current diagnostic", "physician", "only grade", "stage", "neoplasm", "following facts", "neoplasm", "currently available", "physician"]}
{"question": "A 67-year-old woman has fallen from the second story level of her home while hanging laundry. She was brought to the emergency department immediately and presented with severe abdominal pain. The patient is anxious, and her hands and feet feel very cold to the touch. There is no evidence of bone fractures, superficial skin wounds, or a foreign body penetration. Her blood pressure is 102/67 mm Hg, respirations are 19/min, pulse is 87/min, and temperature is 36.7°C (98.0°F). Her abdominal exam reveals rigidity and severe tenderness. A Foley catheter and nasogastric tube are inserted. The central venous pressure (CVP) is 5 cm H2O. The medical history is significant for hypertension. Which of the following is best indicated for the evaluation of this patient?", "answer": "Ultrasound", "options": {"A": "X-Ray", "B": "Ultrasound", "C": "Peritoneal lavage", "D": "CT scan", "E": "Diagnostic laparotomy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old woman", "second level", "hanging laundry", "brought", "emergency department immediately", "severe abdominal", "patient", "anxious", "hands", "feet", "very cold to", "touch", "of bone fractures", "superficial skin", "foreign body penetration", "blood pressure", "67 mm Hg", "respirations", "min", "pulse", "87 min", "temperature", "36", "98", "abdominal exam reveals rigidity", "severe tenderness", "Foley catheter", "nasogastric tube", "central venous pressure", "5 cm H2O", "medical history", "significant", "hypertension", "following", "best indicated"]}
{"question": "A 74-year-old female is brought to the emergency department because of a 2-week history of increasing weakness and chills. She also notes difficulty breathing for the last three days. Eight weeks ago, she underwent left hemicolectomy for adenocarcinoma of the colon. She subsequently developed a severe urinary tract infection, was treated in the intensive care unit for four days, and was discharged from the hospital three weeks ago. She has type 2 diabetes mellitus, osteoporosis with lumbar pain, hypertension, and atrial fibrillation. She has smoked one pack of cigarettes daily for 50 years. She does not drink alcohol and has never used illicit drugs. Current medications include warfarin, metformin, lisinopril, and aspirin. She appears lethargic and has a large conjunctival hemorrhage in her left eye. Her temperature is 39.3°C (102.7°F), pulse is 112/min, respirations are 25/min, and blood pressure is 126/79 mm Hg. Cardiac auscultation reveals a new holosystolic murmur over the apex. Abdominal examination shows mild, diffuse tenderness throughout the upper quadrants and a well-healed 12-cm paramedian scar. There are multiple tender nodules on the palmar surface of her fingertips. Funduscopic examination shows retinal hemorrhages with pale centers. An ECG shows atrial fibrillation and right bundle branch block. Which of the following is the most likely underlying etiology of this patient's condition?", "answer": "Enterococcus faecalis infection", "options": {"A": "Pulmonary metastases", "B": "Streptococcus sanguinis infection", "C": "Cardiobacterium hominis infection", "D": "Aspergillus fumigatus infection", "E": "Enterococcus faecalis infection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["74 year old female", "brought", "emergency department", "2-week history", "increasing weakness", "chills", "notes difficulty breathing", "three days", "Eight weeks", "left hemicolectomy", "adenocarcinoma of the colon", "severe urinary tract infection", "treated", "intensive care unit", "four days", "discharged from", "hospital three weeks", "type 2 diabetes mellitus", "osteoporosis", "lumbar pain", "hypertension", "atrial fibrillation", "smoked one pack", "cigarettes daily", "50 years", "not", "alcohol", "never used illicit drugs", "Current medications include warfarin", "metformin", "lisinopril", "aspirin", "appears lethargic", "large conjunctival hemorrhage", "left eye", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Cardiac auscultation reveals", "new holosystolic murmur", "apex", "Abdominal", "mild", "diffuse tenderness", "upper quadrants", "well healed", "paramedian scar", "multiple tender nodules", "palmar surface of", "fingertips", "Funduscopic", "retinal hemorrhages", "pale centers", "ECG", "atrial fibrillation", "right bundle branch block", "following", "underlying etiology", "patient's condition"]}
{"question": "A 61-year-old woman presents to her physician with a persistent cough. She has been unable to control her cough and also is finding it increasingly difficult to breathe. The cough has been persistent for about 2 months now, but 2 weeks ago she started noticing streaks of blood in the sputum regularly after coughing. Over the course of 4 months, she has also observed an unusual loss of 10 kg (22 lb) in her weight. She has an unchanged appetite and remains fairly active, which makes her suspicious as to the cause of her weight loss. Another troublesome concern for her is that on a couple occasions over the past few weeks, she has observed herself drenched in sweat when she wakes up in the morning. Other than having a 35 pack-year smoking history, her medical history is insignificant. She is sent for a chest X-ray which shows a central nodule of about 13 mm located in the hilar region. Which of the following would be the next best step in the management of this patient?", "answer": "Mediastinoscopy", "options": {"A": "Chemotherapy", "B": "Mediastinoscopy", "C": "Radiotherapy", "D": "Surgical removal", "E": "Repeat surveillance after 6 months"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["61 year old woman presents", "physician", "persistent cough", "unable to control", "cough", "finding", "difficult to", "cough", "persistent", "months now", "2 weeks", "started", "blood", "sputum", "coughing", "course", "months", "observed", "unusual loss", "10 kg", "weight", "unchanged appetite", "active", "makes", "suspicious", "cause of", "weight loss", "couple", "past", "weeks", "observed", "sweat", "wakes up", "morning", "35", "smoking history", "medical history", "sent", "chest X-ray", "central nodule", "mm", "hilar region", "following", "next best step", "patient"]}
{"question": "A 2-year-old boy is brought to the emergency department by his parents after they found him to be lethargic and febrile. His current symptoms started 1 week ago and initially consisted of a sore throat and a runny nose. He subsequently developed a fever and productive cough that has become worse over time. Notably, this patient has previously presented with pneumonia and gastroenteritis 8 times since he was born. On presentation, the patient's temperature is 103°F (39.4°C), blood pressure is 90/50 mmHg, pulse is 152/min, and respirations are 38/min. Based on clinical suspicion, an antibody panel is obtained and the results show low levels of IgG and IgA relative to the level of IgM. The expression of which of the following genes is most likely abnormal in this patient?", "answer": "CD40L", "options": {"A": "CD40L", "B": "STAT3", "C": "LYST", "D": "CD18", "E": "NADPH oxidase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2 year old boy", "brought", "emergency department", "found", "to", "lethargic", "febrile", "current symptoms started 1 week", "initially consisted", "sore throat", "runny nose", "fever", "productive cough", "worse", "time", "patient", "pneumonia", "gastroenteritis", "times", "born", "patient's temperature", "blood pressure", "90 50 mmHg", "pulse", "min", "respirations", "min", "Based", "clinical", "antibody panel", "obtained", "results", "IgA", "level", "IgM", "expression", "following genes", "abnormal", "patient"]}
{"question": "A 71-year-old man comes to the emergency department because of a 2-month history of severe muscle cramps and back pain. He says that he is homeless and has not visited a physician in the past 20 years. He is 183 cm (6 ft 0 in) tall and weighs 62 kg (137 lb); BMI is 18.5 kg/m2. His blood pressure is 154/88 mm Hg. Physical examination shows pallor, multiple cutaneous excoriations, and decreased sensation over the lower extremities. Serum studies show:\nCalcium 7.2 mg/dL\nPhosphorus 5.1 mg/dL\nGlucose 221 mg/dL\nCreatinine 4.5 mg/dL\nAn x-ray of the spine shows alternating sclerotic and radiolucent bands in the lumbar and thoracic vertebral bodies. Which of the following is the most likely explanation for these findings?\"", "answer": "Secondary hyperparathyroidism", "options": {"A": "Tertiary hyperparathyroidism", "B": "Secondary hyperparathyroidism", "C": "Primary hypoparathyroidism", "D": "Pseudohypoparathyroidism", "E": "Multiple myeloma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "2 month history", "severe muscle cramps", "back pain", "homeless", "not", "physician", "past 20 years", "6 ft 0", "tall", "62 kg", "BMI", "kg/m2", "blood pressure", "88 mm Hg", "pallor", "multiple cutaneous excoriations", "decreased sensation", "lower extremities", "Serum studies", "Calcium", "mg/dL Phosphorus", "Glucose", "Creatinine", "x-ray of", "spine", "alternating sclerotic", "radiolucent bands", "lumbar", "thoracic vertebral bodies", "following", "findings"]}
{"question": "A 23-year-old woman presents to her primary care physician for knee pain. The patient states it started yesterday and has been steadily worsening. She recently joined a volleyball team to try to get into shape as she was informed that weight loss would be beneficial for her at her last physical exam. She states that she has been repetitively pivoting and twisting on her knee while playing volleyball. The patient has a past medical history of polycystic ovarian syndrome and is currently taking oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 137/88 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals an obese woman with facial hair. Physical exam is notable for tenderness that is mediated with palpation over the medial aspect of the tibia just inferior to the patella. Her BMI is 37 kg/m^2. The rest of the exam of the lower extremity is not remarkable. Which of the following is the most likely diagnosis?", "answer": "Pes anserine bursitis", "options": {"A": "Medial collateral ligament tear", "B": "Medial meniscus tear", "C": "Osteoarthritis", "D": "Patellofemoral syndrome", "E": "Pes anserine bursitis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old woman presents", "primary care physician", "knee pain", "patient states", "started", "worsening", "recently", "to", "to get", "shape", "informed", "weight loss", "last", "states", "pivoting", "twisting", "knee", "playing", "patient", "past medical polycystic ovarian syndrome", "currently", "oral contraceptive pills", "temperature", "98", "36", "blood pressure", "88 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "reveals", "obese woman", "facial hair", "notable", "tenderness", "mediated", "palpation", "medial aspect", "tibia", "inferior", "patella", "BMI", "kg/m", "exam", "lower extremity", "not", "following", "diagnosis"]}
{"question": "A 47-year-old woman comes to the physician because of a 6-week history of fatigue and low-grade fever. She has no history of serious illness except for a bicuspid aortic valve, diagnosed 10 years ago. She does not use illicit drugs. Her temperature is 37.7°C (99.9°F). Physical examination shows petechiae under the fingernails and multiple tender, red nodules on the fingers. A new grade 2/6 diastolic murmur is heard at the right second intercostal space. Which of the following is the most likely causal organism?", "answer": "Streptococcus sanguinis", "options": {"A": "Enterococcus faecalis", "B": "Staphylococcus epidermidis", "C": "Streptococcus pyogenes", "D": "Streptococcus sanguinis", "E": "Streptococcus pneumoniae"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "week history", "fatigue", "low-grade fever", "history", "serious illness", "bicuspid aortic valve", "diagnosed", "not use illicit drugs", "temperature", "99 9F", "petechiae", "fingernails", "multiple tender", "red nodules on", "fingers", "new", "diastolic murmur", "heard", "right second intercostal space", "following", "causal"]}
{"question": "A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?", "answer": "Preserved fine touch", "options": {"A": "Impaired proprioception sense", "B": "Preserved fine touch", "C": "Preserved crude touch", "D": "Hyperreflexia at the level of the lesion", "E": "Normal bladder function"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "rushed", "emergency department", "motor vehicle accident", "patient states", "weakness", "numbness in", "legs", "reports pain", "lower back", "airway", "breathing", "circulation", "intact", "Neurologic exam", "significant", "bilateral lower extremity flaccid paralysis", "impaired pain", "temperature sensation", "T10 T11", "normal", "computerized tomography scan", "spine", "performed", "vertebral burst fracture", "body", "level", "T11", "following findings", "most likely present", "patient"]}
{"question": "A 58-year-old obese woman presents with painless postmenopausal bleeding for the past 5 days. A recent endometrial biopsy confirmed endometrial cancer, and the patient is scheduled for total abdominal hysterectomy and bilateral salpingo-oophorectomy. Past medical history is significant for stress incontinence and diabetes mellitus type 2. Menarche was at age 11 and menopause was at age 55. The patient has 4 healthy children from uncomplicated pregnancies, who were all formula fed. Current medications are topical estrogen and metformin. Family history is significant for breast cancer in her grandmother at age 80. Which of the following aspects of this patient’s history is associated with a decreased risk of breast cancer?", "answer": "Multiple pregnancies", "options": {"A": "Early menarche", "B": "Obesity", "C": "Formula feeding", "D": "Endometrial cancer", "E": "Multiple pregnancies"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old obese woman presents", "painless postmenopausal bleeding", "past", "days", "recent endometrial biopsy confirmed endometrial cancer", "patient", "scheduled", "total abdominal hysterectomy", "bilateral salpingo-oophorectomy", "Past medical history", "significant", "stress incontinence", "diabetes mellitus type 2", "Menarche", "age", "menopause", "age", "patient", "4 healthy", "uncomplicated", "formula fed", "Current medications", "topical estrogen", "metformin", "Family history", "significant", "breast cancer", "age 80", "following aspects", "associated with", "of breast cancer"]}
{"question": "A middle-aged homeless man is found lying unresponsive on the streets by the police and is rushed to the emergency department. His vital signs include: blood pressure 110/80 mm Hg, pulse rate 100/min, and respirations 10/min and shallow. On physical examination, his extremities are cold and clammy. Pupils are constricted and non-reactive. His blood glucose is 55 mg/dL. IV access is established immediately with the administration of dextrose and naloxone. In half an hour, the patient is fully conscious, alert and responsive. He denies any medical illnesses, hospitalizations, or surgeries in the past. Physical examination reveals injection track marks along both arms. He admits to the use of cocaine and heroin. He smokes cigarettes and consumes alcohol. His vital signs are now stable. A urine sample is sent for toxicology screening. Which of the following was the most likely cause of this patient’s respiratory depression?", "answer": "Opioid intoxication", "options": {"A": "Hallucinogen toxicity", "B": "Cocaine abuse", "C": "Hypoglycemia", "D": "Alcohol intoxication", "E": "Opioid intoxication"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["middle-aged homeless man", "found lying unresponsive", "streets", "police", "rushed", "emergency department", "vital signs include", "blood pressure", "80 mm Hg", "pulse rate 100 min", "respirations 10/min", "shallow", "extremities", "cold", "clammy", "Pupils", "constricted", "non-reactive", "blood glucose", "mg/dL", "IV access", "established immediately", "administration", "dextrose", "naloxone", "half", "hour", "patient", "fully conscious", "alert", "responsive", "medical illnesses", "surgeries", "past", "reveals injection track marks", "arms", "use of cocaine", "heroin", "smokes cigarettes", "alcohol", "vital signs", "now stable", "urine sample", "sent", "toxicology screening", "following", "most likely cause", "patients respiratory depression"]}
{"question": "A 47-year-old female with a history of hypertension presents to your outpatient clinic for numbness, tingling in her right hand that has been slowly worsening over the last several months. She has tried using a splint but receives minimal relief. She is an analyst for a large consulting firm and spends most of her workday in front of a computer. Upon examination, you noticed that the patient has a prominent jaw and her hands appear disproportionately large. Her temperature is 99 deg F (37.2 deg C), blood pressure is 154/72 mmHg, pulse is 87/min, respirations are 12/min. A fasting basic metabolic panel shows: Na: 138 mEq/L, K: 4.1 mEq/L, Cl: 103 mEq/L, CO2: 24 mEq/L, BUN: 12 mg/dL, Cr: 0.8 mg/dL, Glucose: 163 mg/dL. Which of the following tests would be most helpful in identifying the underlying diagnosis?", "answer": "Measurement of insulin-like growth factor 1 alone and growth hormone levels after oral glucose", "options": {"A": "Measurement of serum morning cortisol levels and dexamethasone suppression test", "B": "Measurement of insulin-like growth factor 1 alone and growth hormone levels after oral glucose", "C": "Measurement of thyroid stimulating hormone", "D": "Measurement of serum growth hormone alone", "E": "Measurement of insulin-like growth factor 1 levels alone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female", "history of hypertension presents", "outpatient clinic", "numbness", "tingling", "right", "slowly worsening", "months", "using", "splint", "receives minimal relief", "analyst", "large", "firm", "spends most", "workday", "computer", "patient", "prominent jaw", "hands appear", "large", "temperature", "99 deg F", "blood pressure", "72 mmHg", "pulse", "87 min", "respirations", "min", "fasting basic metabolic panel", "Na", "mEq/L", "K", "4.1 mEq/L", "mEq/L", "CO2", "mEq/L", "mg/dL", "Cr", "0.8 mg/dL", "Glucose", "mg/dL", "following tests", "most helpful", "underlying diagnosis"]}
{"question": "A 17-year-old woman is rushed into the emergency department by her father who found her collapsed in her bedroom 15 minutes before the ambulance's arrival. There was an empty bottle of clomipramine in her bedroom which her mother takes for her depression. Vital signs include the following: respiratory rate 8/min, pulse 130/min, and blood pressure 100/60 mm Hg. On physical examination, the patient is unresponsive to vocal and tactile stimuli. Oral mucosa and tongue are dry, and the bladder is palpable. A bedside electrocardiogram (ECG) shows widening of the QRS complexes. Which of the following would be the best course of treatment in this patient?", "answer": "Sodium bicarbonate", "options": {"A": "Sodium bicarbonate", "B": "Lidocaine", "C": "Induced vomiting", "D": "Norepinephrine", "E": "Diazepam"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "rushed", "emergency department", "found", "collapsed", "bedroom 15 minutes", "ambulance's arrival", "empty bottle", "clomipramine", "bedroom", "depression", "Vital signs include", "following", "respiratory rate", "min", "pulse", "min", "blood pressure 100 60 mm Hg", "patient", "unresponsive", "vocal", "tactile", "Oral mucosa", "tongue", "dry", "bladder", "palpable", "electrocardiogram", "widening", "QRS complexes", "following", "best course", "treatment", "patient"]}
{"question": "A 3-year-old girl is brought to the physician by her 30-year-old mother, who reports that her daughter has been passing multiple foul-smelling, bulky stools with flatulence every day for the last 6 months. The girl was born in Guatemala, and soon after her birth, her parents moved to the United States so that they could access better healthcare. During pregnancy, the mother had little prenatal care, but labor and delivery were uneventful. However, the newborn had significant abdominal distention immediately at birth that increased when she ate or yawned. She failed to pass stool in the first 24 hours of life and had greenish-black vomitus. The parents report similar symptoms in other family members. After diagnosis, the girl underwent a procedure that alleviated her symptoms; however, there was no remission. Her abdominal X-ray (see the first image) and barium contrast enema (second image) from when she was born is shown. Her blood pressure is 100/68 mm Hg, heart rate is 96/min, respiratory rate is 19/min, and temperature is 36.7°C (98.0°F). The girl is in the 10th percentile for height and weight. On physical exam, she has periumbilical and midepigastric tenderness to palpation without rebound tenderness or guarding. There is a slight genu varum deformity and bony tenderness noted in her legs. She has foul-smelling flatulation 2–3 times during the visit. Her rectosphincteric reflex is intact. She has decreased fecal elastase and a negative D-xylose test. Which of the following is the most appropriate long-term treatment for her condition?", "answer": "Enzyme-replacement therapy", "options": {"A": "Enzyme-replacement therapy", "B": "Broad-spectrum antibiotics", "C": "Rectal suction biopsy and surgical correction (Hirschsprung)", "D": "Duodenal atresia repair", "E": "Cholecalciferol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "physician", "30 year old", "reports", "passing multiple foul-smelling", "bulky stools", "flatulence", "day", "6 months", "girl", "born in Guatemala", "birth", "moved to", "United States so", "access better", "pregnancy", "little", "labor", "delivery", "newborn", "significant abdominal distention immediately at birth", "increased", "ate", "yawned", "failed to pass stool", "first 24 hours", "black vomitus", "report similar symptoms", "family members", "diagnosis", "girl", "procedure", "symptoms", "remission", "abdominal X-ray", "see", "first", "barium contrast", "second", "born", "blood pressure", "100", "mm Hg", "heart rate", "96 min", "respiratory rate", "min", "temperature", "36", "98", "girl", "percentile", "height", "weight", "periumbilical", "tenderness", "palpation", "rebound tenderness", "guarding", "slight genu varum deformity", "bony tenderness noted", "legs", "smelling", "23 times", "visit", "reflex", "intact", "decreased fecal elastase", "negative", "xylose test", "following", "most appropriate", "condition"]}
{"question": "A 60-year-old, multiparous, woman comes to the physician because of urinary leakage for the past 4 months. She involuntarily loses a small amount of urine after experiencing a sudden, painful sensation in the bladder. She wakes up at night several times to urinate, and she sometimes cannot make it to the bathroom in time. She has diabetes mellitus type 2 controlled with insulin and a history of pelvic organ prolapse, for which she underwent surgical treatment 5 years ago. Menopause was 11 years ago. She drinks 4-5 cups of coffee daily. Pelvic examination shows no abnormalities, and a Q-tip test is negative. Ultrasound of the bladder shows a normal postvoid residual urine. Which of the following is the underlying cause of this patient's urinary incontinence?", "answer": "Increased detrusor muscle activity", "options": {"A": "Recurrent pelvic organ prolapse", "B": "Decreased pelvic floor muscle tone", "C": "Increased detrusor muscle activity", "D": "Increased urine bladder volumes", "E": "Decreased estrogen levels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old", "multiparous", "woman", "physician", "of urinary leakage", "past", "months", "small amount", "urine", "sudden", "painful sensation", "bladder", "wakes up", "night", "times to", "sometimes", "make", "bathroom", "time", "diabetes mellitus type 2 controlled", "insulin", "history", "pelvic organ prolapse", "surgical", "years", "Menopause", "years", "4-5 cups of", "daily", "Pelvic examination", "abnormalities", "Q test", "negative", "Ultrasound", "bladder", "normal postvoid residual", "following", "underlying cause of", "patient's urinary incontinence"]}
{"question": "A 35-year-old woman with type 1 diabetes mellitus comes to the emergency department for evaluation of a 1-month history of fever, fatigue, loss of appetite, and a 3.6-kg (8-lb) weight loss. She has also had a cough for the last 2 months. She reports recent loss of pubic hair. The patient immigrated from the Philippines 7 weeks ago. Her mother has systemic lupus erythematosus. She has never smoked and does not drink alcohol. Her only medication is insulin, but she sometimes misses doses. She is 165 cm (5 ft 5 in) tall and weighs 49 kg (108 lb); BMI is 18 kg/m2. She appears lethargic. Her temperature is 38.9°C (102°F), pulse is 58/min, and blood pressure is 90/60 mm Hg. Examination shows decreased sensation to touch and vibration over both feet. The remainder of the examination shows no abnormalities. Serum studies show:\nNa+ 122 mEq/L\nCl- 100 mEq/L\nK+ 5.8 mEq/L\nGlucose 172 mg/dL\nAlbumin 2.8 g/dL\nCortisol 2.5 μg/dL\nACTH 531.2 pg/mL (N=5–27 pg/mL)\nCT scan of the abdomen with contrast shows bilateral adrenal enlargement. Which of the following is the most likely underlying mechanism of this patient's symptoms?\"", "answer": "Infection with acid-fast bacilli", "options": {"A": "Adrenal infarction", "B": "Adrenal hemorrhage", "C": "Pituitary tumor", "D": "Infection with acid-fast bacilli", "E": "Autoimmune adrenalitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "type 1 diabetes mellitus", "emergency department", "month history", "fever", "fatigue", "loss of appetite", "3.6 kg", "weight loss", "cough", "months", "reports recent loss of pubic hair", "patient", "Philippines", "weeks", "systemic lupus erythematosus", "never smoked", "not", "alcohol", "only medication", "insulin", "sometimes misses doses", "5 ft 5", "tall", "kg", "BMI", "kg/m2", "appears lethargic", "temperature", "pulse", "58 min", "blood pressure", "90 60 mm Hg", "decreased sensation", "touch", "vibration", "feet", "abnormalities", "Serum studies", "Na", "mEq/L", "100", "5", "Glucose", "mg dL Albumin", "g dL Cortisol", "ACTH", "pg/mL", "N 527 pg/mL", "CT scan", "abdomen", "contrast", "bilateral", "enlargement", "following", "underlying mechanism", "patient", "ymptoms?"]}
{"question": "A 53-year-old man is brought to the emergency department following an episode of loss of consciousness 1 hour ago. He had just finished micturating, when he fell down. His wife heard the noise and found him unconscious on the floor. He regained consciousness after 30 seconds and was able to talk normally with his wife immediately. There was no urinary incontinence. On arrival, he is alert and oriented. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Serum concentrations of glucose, creatinine, and electrolytes are within the reference range. An electrocardiogram shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Situational syncope", "options": {"A": "Cardiovascular syncope", "B": "Situational syncope", "C": "Emotional syncope", "D": "Neurocardiogenic syncope", "E": "Arrhythmogenic syncope"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department following", "episode of loss", "consciousness", "hour", "finished", "fell", "heard", "found", "unconscious", "floor", "consciousness", "30 seconds", "able to talk", "immediately", "urinary incontinence", "arrival", "alert", "oriented", "Cardiopulmonary", "abnormalities", "Neurologic examination", "focal findings", "Serum", "glucose", "creatinine", "electrolytes", "reference range", "electrocardiogram", "abnormalities", "following", "diagnosis"]}
{"question": "A 3000-g (6.6-lb) female newborn is delivered at term to a 23-year-old primigravid woman. The mother has had no prenatal care. Immunization records are not available. Cardiac examination shows a continuous heart murmur. There are several bluish macules on the skin that do not blanch with pressure. Slit lamp examination shows cloudy lenses in both eyes. The newborn does not pass his auditory screening tests. Which of the following is the most likely diagnosis?", "answer": "Congenital rubella infection", "options": {"A": "Congenital parvovirus infection", "B": "Congenital toxoplasmosis", "C": "Congenital rubella infection", "D": "Congenital cytomegalovirus infection", "E": "Congenital syphilis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3000", "female newborn", "delivered", "term", "23 year old primigravid woman", "not available", "continuous heart murmur", "several", "macules", "skin", "not blanch", "pressure", "Slit lamp examination", "cloudy lenses", "eyes", "newborn", "not pass", "auditory screening tests", "following", "diagnosis"]}
{"question": "A group of investigators conducted a randomized controlled trial to compare the effectiveness of rivaroxaban to warfarin for ischemic stroke prevention in patients with atrial fibrillation. A total of 14,000 participants were enrolled and one half was assigned to each of the cohorts. The patients were followed prospectively for 3 years. At the conclusion of the trial, the incidence of ischemic stroke in participants taking rivaroxaban was 1.7% compared to 2.2% in participants taking warfarin. The hazard ratio is calculated as 0.79 and the 95% confidence interval is reported as 0.64 to 0.97. If the study was conducted with a total of 7,000 participants, which of the following changes would most be expected?", "answer": "Increased confidence interval range", "options": {"A": "Increased risk of selection bias", "B": "Decreased hazard ratio", "C": "Increased confidence interval range", "D": "Decreased type I error rate", "E": "Increased risk of confounding bias"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigators", "to", "effectiveness", "rivaroxaban", "warfarin", "ischemic", "patients", "atrial fibrillation", "total", "enrolled", "one half", "assigned", "patients", "followed", "years", "incidence", "ischemic stroke", "rivaroxaban", "1.7", "warfarin", "hazard ratio", "calculated", "0", "95", "confidence interval", "reported", "0.64", "0 97", "study", "total", "following changes", "most"]}
{"question": "A 48-year-old woman comes to the physician for the evaluation of a left breast mass that she noticed 4 weeks ago. It has rapidly increased in size during this period. Vital signs are within normal limits. Examination shows large dense breasts; a 6-cm, nontender, multinodular mass is palpated in the upper outer quadrant of the left breast. There are no changes in the skin or nipple. There is no palpable cervical or axillary adenopathy. Mammography shows a smooth polylobulated mass. An image of a biopsy specimen is shown. Which of the following is the most likely diagnosis?", "answer": "Phyllodes tumor", "options": {"A": "Comedocarcinoma", "B": "Invasive ductal carcinoma", "C": "Fibroadenoma", "D": "Phyllodes tumor", "E": "Invasive lobular carcinoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["48 year old woman", "physician", "left breast mass", "4 weeks", "rapidly increased in size", "period", "Vital signs", "normal limits", "large dense breasts", "nontender", "multinodular mass", "upper outer quadrant of", "left breast", "nipple", "palpable cervical", "axillary adenopathy", "Mammography", "smooth", "mass", "biopsy specimen", "following", "diagnosis"]}
{"question": "An investigator is studying obesity in mice. Over the course of 2 weeks, mice in the experimental group receive a daily injection with a synthetic analog of an endogenous hormone. Compared to the control group, the hormone-injected mice eat more and gain significantly more weight. Which of the following is the most likely explanation for the observed weight gain in the experimental group?", "answer": "Ghrelin stimulation of the lateral hypothalamus", "options": {"A": "Cholecystokinin stimulation of the nucleus tractus solitarius", "B": "Somatostatin inhibition of the anterior pituitary", "C": "Leptin stimulation of the ventromedial hypothalamus", "D": "Ghrelin stimulation of the lateral hypothalamus", "E": "Glucagon stimulation of hepatocytes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "course", "2 weeks", "experimental group receive", "daily injection", "of", "endogenous hormone", "hormone-injected", "eat", "gain", "weight", "following", "observed weight gain", "experimental group"]}
{"question": "A 52-year-old man presents to the emergency department because of pain and swelling in his left leg over the past few hours. He traveled from Sydney to Los Angeles 2 days ago. He has had type 2 diabetes mellitus for 10 years and takes metformin for it. He has smoked a pack of cigarettes daily for 25 years. His temperature is 36.9°C (98.4°F), the blood pressure is 140/90 mm Hg, and the pulse is 90/min. On examination, the left calf is 5 cm greater in circumference than the right. The left leg appears more erythematous than the right with dilated superficial veins. Venous duplex ultrasound shows non-compressibility. Which of the following best represents the mechanism of this patient’s illness?", "answer": "Impaired venous blood flow", "options": {"A": "Impaired arterial blood flow", "B": "Impaired venous blood flow", "C": "Impaired lymphatic blood flow", "D": "Subcutaneous soft-tissue infection that may extend to the deep fascia", "E": "Infection of the dermis and subcutaneous tissues"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "pain", "swelling", "left", "past", "hours", "Los Angeles", "days", "type 2 diabetes mellitus", "metformin", "smoked", "pack", "cigarettes daily", "years", "temperature", "36", "98", "blood pressure", "90 mm Hg", "pulse", "90 min", "left calf", "5", "greater", "circumference", "right", "left leg appears more erythematous", "right", "dilated superficial", "duplex ultrasound", "non compressibility", "following best", "mechanism", "patients illness"]}
{"question": "A man returns home late at night to find his 15-year-old son and 40-year-old wife unconscious in the family room. He immediately summons emergency services. In the field, pulse oximetry shows oxygen saturation at 100% for both patients. 100% yet they both appear cyanotic. Both patients are provided with 2L of oxygen by way of nasal cannula on the way to the hospital. An arterial blood gas is performed on the teenager and reveals pH of 7.35, PaCO2 of 31.8 mm Hg, PaO2 of 150 mm Hg, HCO3- of 20 mEq/L, SaO2 of 80%, and a COHb of 18%. What is the most likely cause of his condition?", "answer": "Carbon monoxide poisoning", "options": {"A": "Anemic hypoxia", "B": "Diffusion-limited hypoxia", "C": "Methemoglobinemia", "D": "Carbon monoxide poisoning", "E": "Ischemic hypoxia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["man returns home late", "night to find", "year old", "40 year old", "unconscious", "room", "immediately", "field", "pulse oximetry", "oxygen saturation", "100", "patients", "100", "appear cyanotic", "patients", "oxygen by", "nasal cannula", "hospital", "arterial blood gas", "performed", "teenager", "reveals pH", "7 35", "31", "mm Hg", "PaO2", "mm Hg", "HCO3", "20 mEq/L", "80", "COHb", "most likely cause", "condition"]}
{"question": "A 28-year-old research assistant is brought to the emergency department for severe chemical burns 30 minutes after accidentally spilling hydrochloric acid on himself. The burns cover both hands and forearms. His temperature is 37°C (98.6°F), pulse is 112/min, respirations are 20/min, and blood pressure is 108/82 mm Hg. Initial stabilization and resuscitation is begun, including respiratory support, fluid resuscitation, and cardiovascular stabilization. The burned skin is irrigated with saline water to remove the chemical agent. Which of the following is the most appropriate method to verify adequate fluid infusion in this patient?", "answer": "Urinary output\n\"", "options": {"A": "Heart rate", "B": "The Parkland formula", "C": "Blood pressure", "D": "Pulmonary capillary wedge pressure", "E": "Urinary output\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "assistant", "brought", "emergency department", "severe chemical burns 30 minutes", "spilling", "burns cover", "hands", "forearms", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "mm Hg", "Initial stabilization", "resuscitation", "begun", "including respiratory support", "fluid resuscitation", "cardiovascular stabilization", "burned skin", "irrigated", "to remove", "following", "most appropriate method to verify adequate fluid infusion", "patient"]}
{"question": "A 61-year-old female with congestive heart failure and type 2 diabetes is brought to the emergency room by her husband because of an altered mental status. He states he normally helps her be compliant with her medications, but he had been away for several days. On physical exam, her temperature is 37.2 C, BP 85/55, and HR 130. Serum glucose is 500 mg/dL. Which of the following is the first step in the management of this patient?", "answer": "IV NS", "options": {"A": "IV ½ NS", "B": "IV NS", "C": "IV D5W", "D": "Subcutaneous insulin injection", "E": "IV insulin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["61 year old female", "congestive heart failure", "type 2 diabetes", "brought", "emergency room", "altered mental status", "states", "helps", "compliant", "medications", "days", "temperature", "BP 85", "Serum glucose", "500 mg/dL", "following", "first step", "patient"]}
{"question": "A 27-year-old G2P2002 is recovering in the hospital on postpartum day 3 after a low transverse C-section. During morning rounds, she reports a “pus-like” discharge and shaking chills overnight. She also endorses increased uterine cramping compared to the day before, but her postpartum course has otherwise been uneventful with a well-healing incision and normal vaginal bleeding. The patient’s prenatal care was complicated by HIV with a recent viral load of 400 copies/mL, type I diabetes well controlled on insulin, and a history of herpes simplex virus encephalitis in her first child. She did not have any genital lesions during the most recent pregnancy. Four days ago, she presented to the obstetric triage unit after spontaneous rupture of membranes and onset of labor. She made slow cervical change and reached full dilation after 16 hours, but there was limited fetal descent. Cephalopelvic disproportion was felt to be the reason for arrest of descent, so prophylactic ampillicin was administered and C-section was performed. A vaginal hand was required to dislodge the fetus’s head from the pelvis, and a healthy baby boy was delivered. On postpartum day 3, her temperature is 101.5°F (38.6°C), blood pressure is 119/82 mmHg, pulse is 100/min, and respirations are 14/min. Her incision looks clean and dry, there is mild suprapubic tenderness, and a foul yellow discharge tinged with blood is seen on her pad. Which of the following is the most significant risk factor for this patient’s presentation?", "answer": "C-section after onset of labor", "options": {"A": "HIV positive status", "B": "Prolonged rupture of membranes", "C": "C-section after onset of labor", "D": "History of herpes simplex virus in previous pregnancy", "E": "Maternal diabetes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old", "recovering", "hospital", "postpartum day 3", "low transverse", "section", "reports", "pus", "discharge", "shaking chills overnight", "increased uterine cramping", "day", "postpartum course", "well healing incision", "normal vaginal bleeding", "patients", "complicated", "HIV", "recent viral load", "400 copies/mL", "type I diabetes well controlled", "insulin", "history of", "encephalitis", "first child", "not", "genital lesions", "recent pregnancy", "Four days", "obstetric triage unit", "spontaneous rupture of membranes", "onset of labor", "made slow cervical change", "reached full dilation", "hours", "limited fetal descent", "Cephalopelvic disproportion", "to", "arrest", "descent", "prophylactic", "administered", "C-section", "performed", "vaginal hand", "required to", "head", "pelvis", "healthy baby boy", "delivered", "postpartum day 3", "temperature", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "min", "incision looks", "dry", "mild suprapubic tenderness", "yellow discharge tinged", "blood", "seen", "pad", "following", "most significant risk factor", "patients"]}
{"question": "A 34-year-old man comes to the physician because of fatigue and shortness of breath with moderate exertion for the past 2 months. Over the past 10 days, he has had low-grade fevers and night sweats. He has no history of serious illness except for a bicuspid aortic valve diagnosed 5 years ago. He has smoked one pack of cigarettes daily for 10 years and drinks 3–5 beers on social occasions. He does not use illicit drugs. The patient takes no medications. He appears weak. His temperature is 37.7°C (99.9°F), pulse is 70/min, and blood pressure is 128/64 mm Hg. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard best at the right sternal border and second intercostal space. There are several hemorrhages underneath his fingernails on both hands and multiple tender, red nodules on his fingers. Which of the following is the most likely causal organism?", "answer": "Streptococcus sanguinis", "options": {"A": "Staphylococcus epidermidis", "B": "Streptococcus sanguinis", "C": "Streptococcus pneumoniae", "D": "Streptococcus pyogenes", "E": "Candida albicans"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "fatigue", "shortness of breath", "past", "months", "past 10 days", "low-grade fevers", "night sweats", "history", "serious illness", "bicuspid aortic valve diagnosed", "smoked one pack", "cigarettes daily", "35", "social occasions", "not use illicit drugs", "patient", "medications", "appears weak", "temperature", "99 9F", "pulse", "70 min", "blood pressure", "64 mm Hg", "lungs", "clear", "auscultation", "systolic murmur", "heard best", "right sternal border", "second intercostal space", "several hemorrhages", "fingernails", "hands", "multiple tender", "red nodules on", "fingers", "following", "causal"]}
{"question": "A 24-year-old man presents to the emergency department after a motor vehicle collision. He was the front seat and unrestrained driver in a head on collision. His temperature is 99.2°F (37.3°C), blood pressure is 90/65 mmHg, pulse is 152/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam is notable for a young man who opens his eyes spontaneously and is looking around. He answers questions with inappropriate responses but discernible words. He withdraws from pain but does not have purposeful movement. Which of the following is this patient’s Glasgow coma scale?", "answer": "11", "options": {"A": "7", "B": "9", "C": "11", "D": "13", "E": "15"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "motor vehicle collision", "front", "driver", "head", "collision", "temperature", "99", "blood pressure", "90 65 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "100", "room air", "notable", "young man", "opens", "eyes", "looking", "inappropriate responses", "discernible", "pain", "not", "purposeful movement", "following", "patients Glasgow coma scale"]}
{"question": "A 34-year-old Caucasian female presents at the ER with fever and sharp pain in her chest upon coughing and inhalation. Three weeks earlier she presented to her rheumatologist with a butterfly rash, joint pain and fatigue and was given a diagnosis of systemic lupus erythematosus. A friction rub is present upon physical exam. Which of the following do you most suspect in this patient?", "answer": "Pericarditis", "options": {"A": "Pulmonary hypertension", "B": "Interstitial lung disease", "C": "Acute myocardial infarction", "D": "Pericarditis", "E": "Pericardial tamponade"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "female presents", "ER", "fever", "sharp pain", "chest", "coughing", "inhalation", "Three weeks earlier", "rheumatologist", "butterfly rash", "joint pain", "fatigue", "given", "diagnosis", "systemic lupus erythematosus", "friction rub", "present", "following", "most", "patient"]}
{"question": "A 47-year-old man with a history of alcoholism undergoes an upper endoscopy, which reveals a superficial mucosal tear in the distal esophagus. Laboratory results show a metabolic alkalosis. What is the most likely mechanism of the acid/base disturbance in this patient?", "answer": "Vomiting", "options": {"A": "B12 deficiency", "B": "Anemia", "C": "Vomiting", "D": "Hypokalemia", "E": "Hepatic cirrhosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "history of alcoholism", "upper endoscopy", "reveals", "superficial mucosal tear", "distal esophagus", "Laboratory results", "metabolic alkalosis", "mechanism", "acid base disturbance", "patient"]}
{"question": "A 60-year-old man comes to the physician because of flank pain, rash, and blood-tinged urine for 1 day. Two months ago, he was started on hydrochlorothiazide for hypertension. He takes acetaminophen for back pain. Examination shows a generalized, diffuse maculopapular rash. Serum studies show a creatinine concentration of 3.0 mg/dL. Renal ultrasonography shows no abnormalities. Which of the following findings is most likely to be observed in this patient?", "answer": "Urinary eosinophils", "options": {"A": "Urinary crystals on Brightfield microscopy", "B": "Dermal IgA deposition on skin biopsy", "C": "Crescent-shape extracapillary cell proliferation", "D": "Mesangial IgA deposits on renal biopsy", "E": "Urinary eosinophils"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["60 year old man", "physician", "flank pain", "rash", "blood urine", "1 day", "Two months", "started", "hydrochlorothiazide", "hypertension", "acetaminophen", "back pain", "generalized", "diffuse maculopapular rash", "Serum studies", "creatinine concentration", "3.0 mg/dL", "Renal ultrasonography", "abnormalities", "following findings", "to", "observed", "patient"]}
{"question": "Nucleic acid amplification testing (NAAT) of first-void urine confirms infection with Chlamydia trachomatis. Treatment with the appropriate pharmacotherapy is started. Which of the following health maintenance recommendations is most appropriate at this time?", "answer": "Avoid sun exposure", "options": {"A": "Avoid sun exposure", "B": "Avoid drinking alcohol", "C": "Avoid sexual activity for the next month", "D": "Take medication with food", "E": "Schedule an ophthalmology consultation\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Nucleic acid amplification testing", "first void urine confirms infection", "Chlamydia trachomatis", "Treatment", "appropriate pharmacotherapy", "started", "following", "most appropriate", "time"]}
{"question": "A 14-year-old boy presents as a new patient to your practice. While conducting your physical exam, you observe the findings depicted in Figures A and B. Which of the following additional findings would most likely be found in this patient?", "answer": "Iris hamartomas", "options": {"A": "The presence of ash-leaf spots", "B": "A family history of seizures and mental retardation", "C": "Facial angiofibromas", "D": "Iris hamartomas", "E": "A white tuft of scalp hair since birth"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "new patient", "observe", "findings", "following additional findings", "most likely", "found", "patient"]}
{"question": "An investigator who studies virology obtains a biopsy from the ulcer base of an active genital herpes lesion for viral culture. The cultured virions, along with herpes simplex virions of a different phenotype, are cointroduced into a human epithelial cell in vitro. The progeny viruses are found to have phenotypes that are distinct from the parent strains. Sequencing of these progeny viruses shows that most genomes have material from both parent strains. These findings are best explained by which of the following terms?", "answer": "Recombination", "options": {"A": "Complementation", "B": "Recombination", "C": "Phenotypic mixing", "D": "Reassortment", "E": "Transduction"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studies virology obtains", "biopsy", "ulcer base of", "active genital", "viral culture", "virions", "herpes simplex virions", "different phenotype", "human epithelial cell in vitro", "viruses", "found to", "phenotypes", "strains", "Sequencing", "viruses", "genomes", "strains", "findings", "best", "following terms"]}
{"question": "A 22-year-old man is rushed to the emergency room with constant, severe right lower abdominal pain that started 7 hours ago in the periumbilical region and later shifted to the right lower quadrant with a gradual increase in intensity. The patient’s blood pressure is 110/80 mm Hg, the heart rate is 76/min, the respiratory rate is 17/min, and the temperature is 37.5℃ (99.5℉). The physical examination shows tenderness, muscle guarding, and rebound over the right lower quadrant of the abdomen. Abdominal sonography shows a dilated appendix with a periappendiceal fluid collection. He is diagnosed with acute appendicitis and undergoes a laparoscopic appendectomy. The histopathologic examination of the removed appendix is shown in the image. Which of the following substances is responsible for attracting the marked cells to the inflamed tissue?", "answer": "IL-8", "options": {"A": "IL-7", "B": "IL-8", "C": "CCL-11", "D": "CXCL-9", "E": "IL-10"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "rushed", "emergency room", "constant", "severe right lower abdominal pain", "started 7 hours", "periumbilical region", "later shifted to the right lower quadrant", "gradual increase", "intensity", "patients blood pressure", "80 mm Hg", "heart rate", "76 min", "respiratory rate", "min", "temperature", "99.5", "tenderness", "muscle guarding", "rebound", "right lower quadrant", "abdomen", "sonography", "dilated appendix", "fluid collection", "diagnosed", "acute appendicitis", "laparoscopic appendectomy", "histopathologic examination", "removed appendix", "following", "responsible", "marked", "tissue"]}
{"question": "A 65-year-old man presents to his primary care physician for a pre-operative evaluation. He is scheduled for cataract surgery in 3 weeks. His past medical history is notable for diabetes, hypertension, and severe osteoarthritis of the right knee. His medications include metformin, hydrochlorothiazide, lisinopril, and aspirin. His surgeon ordered blood work 1 month ago, which showed a hemoglobin of 14.2 g/dL, INR of 1.2, and an hemoglobin A1c of 6.9%. His vital signs at the time of the visit show BP: 130/70 mmHg, Pulse: 80, RR: 12, and T: 37.2 C. He has no current complaints and is eager for his surgery. Which of the following is the most appropriate course of action for this patient at this time?", "answer": "Medically clear the patient for surgery", "options": {"A": "Medically clear the patient for surgery", "B": "Repeat the patient's CBC and coagulation studies", "C": "Perform an EKG", "D": "Schedule the patient for a stress test and ask him to delay surgery for at least 6 months", "E": "Tell the patient he will have to delay his surgery for at least 1 year"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old man presents", "primary care physician", "pre-operative evaluation", "scheduled", "cataract", "3 weeks", "past medical history", "notable", "diabetes", "hypertension", "severe osteoarthritis of", "right knee", "medications include metformin", "hydrochlorothiazide", "lisinopril", "aspirin", "surgeon ordered blood", "month", "a hemoglobin", "g", "INR", "hemoglobin A1c", "vital signs", "time", "BP", "70 mmHg", "Pulse", "80", "T", "current complaints", "surgery", "following", "most appropriate course", "action", "patient", "time"]}
{"question": "A 19-year-old African female refugee has been granted asylum in Stockholm, Sweden and has been living there for the past month. She arrived in Sweden with her 2-month-old infant, whom she exclusively breast feeds. Which of the following deficiencies is the infant most likely to develop?", "answer": "Vitamin D", "options": {"A": "Vitamin A", "B": "Vitamin B1", "C": "Vitamin D", "D": "Vitamin E", "E": "Vitamin C"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "female", "granted asylum", "Sweden", "living", "past month", "Sweden", "her 2 month old infant", "breast feeds", "following deficiencies", "infant", "to"]}
{"question": "A 10-year-old girl is brought to the emergency department by her mother 30 minutes after having had a seizure. When her mother woke her up that morning, the girl's entire body stiffened and she started shaking vigorously for several minutes. Her mother also reports that over the past few months, her daughter has had multiple episodes of being unresponsive for less than a minute, during which her eyelids were fluttering. The girl did not recall these episodes afterwards. Upon arrival, she appears drowsy. Neurologic examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy to prevent recurrence of this patient's symptoms?", "answer": "Valproate", "options": {"A": "Phenytoin", "B": "Lorazepam", "C": "Ethosuximide", "D": "Topiramate", "E": "Valproate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["A 10 year old girl", "brought", "emergency department", "30 minutes", "seizure", "woke", "morning", "girl's entire body", "started shaking vigorously", "minutes", "reports", "past", "months", "multiple episodes of", "unresponsive", "minute", "eyelids", "fluttering", "girl", "not", "episodes", "arrival", "appears drowsy", "Neurologic examination", "abnormalities", "following", "most appropriate pharmacotherapy to prevent recurrence", "patient's symptoms"]}
{"question": "A 48-year-old female complains of tingling sensation in her fingertips as well as the skin around her mouth which woke her up from sleep. She is in the postoperative floor as she just underwent a complete thyroidectomy for papillary thyroid cancer. Her temperature is 37° C (98.6° F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/88 mm Hg. While recording the blood pressure, spasm of the muscles of the hand and forearm is seen. What is the next best step in the management of this patient?", "answer": "Calcium replacement", "options": {"A": "No treatment is necessary, this is expected following surgery", "B": "Propylthiouracil", "C": "Magnesium replacement", "D": "Albumin infusion", "E": "Calcium replacement"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["48 year old female", "tingling sensation", "fingertips", "skin", "mouth", "woke", "sleep", "postoperative floor", "complete thyroidectomy", "papillary thyroid cancer", "temperature", "98", "F", "respirations", "min", "pulse", "67 min", "blood pressure", "88 mm Hg", "recording", "blood pressure", "spasm of", "muscles", "hand", "forearm", "seen", "next best step", "patient"]}
{"question": "A 23-year old man is brought to the emergency department by his brother after trying to jump out of a moving car. He says that the Federal Bureau of Investigation has been following him for the last 7 months. He recently quit his job at a local consulting firm to work on his mission to rid the world from evil. He does not smoke, drink alcoholic beverages, or use illicit drugs. He takes no medications. His temperature is 36.7°C (98.1°F), pulse is 90/min, respirations are 20/min, and blood pressure is 120/86 mm Hg. On mental status examination, his response to the first question lasted 5 minutes without interruption. He switched topics a number of times and his speech was pressured. He spoke excessively about his plan to “bring absolute justice to the world”. He has a labile affect. There is no evidence of suicidal ideation. A toxicology screen is negative. He is admitted to the hospital for his symptoms and starts therapy. One week later, he develops difficulty walking and a tremor that improves with activity. Which of the following is the most likely cause of this patient's latest symptoms?", "answer": "Dopamine antagonist", "options": {"A": "Dopamine antagonist", "B": "Acetylcholine antagonist", "C": "Serotonin–norepinephrine reuptake inhibitor", "D": "Histamine antagonist", "E": "Selective serotonin reuptake inhibitor"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old man", "brought", "emergency department", "jump out", "moving car", "following", "last", "months", "recently", "local", "firm to", "to rid", "not smoke", "use illicit", "medications", "temperature", "36", "98", "pulse", "90 min", "respirations", "20 min", "blood pressure", "mm Hg", "mental status", "response", "first", "lasted 5 minutes", "interruption", "switched topics", "number of times", "speech", "pressured", "spoke excessively", "plan to", "absolute justice", "labile affect", "suicidal ideation", "toxicology screen", "negative", "symptoms", "starts therapy", "One week later", "difficulty walking", "tremor", "improves", "activity", "following", "most likely cause", "patient's latest symptoms"]}
{"question": "A 10-year-old boy is referred to a pediatric neurologist by his pediatrician for lower extremity weakness. The boy is healthy with no past medical history, but his parents began to notice that he was having difficulty at football practice the previous day. Over the course of the past 24 hours, the boy has become increasingly clumsy and has been “tripping over himself.” On further questioning, the boy had a viral illness the previous week and was out of school for 2 days. Today, the patient’s temperature is 99.3°F (37.4°C), blood pressure is 108/72 mmHg, pulse is 88/min, respirations are 12/min. On motor exam, the patient has 5/5 strength in hip flexion, 5/5 strength in knee extension and flexion, 3/5 strength in foot dorsiflexion, and 5/5 strength in foot plantarflexion. The findings are the same bilaterally. On gait exam, the patient exhibits foot drop in both feet. Which of the following areas would the patient most likely have diminished sensation?", "answer": "First dorsal webspace of foot", "options": {"A": "Anteromedial thigh", "B": "First dorsal webspace of foot", "C": "Lateral foot", "D": "Lateral plantar foot", "E": "Medial plantar foot"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A 10 year old boy", "referred", "pediatric neurologist", "pediatrician", "lower extremity weakness", "boy", "healthy", "past medical history", "began to", "difficulty", "football", "previous day", "course", "past 24 hours", "boy", "clumsy", "further", "boy", "viral illness", "previous week", "out", "school", "2 days", "Today", "patients temperature", "99", "blood pressure", "72 mmHg", "pulse", "88 min", "respirations", "min", "motor exam", "patient", "5/5 strength", "hip flexion", "5/5 strength", "knee extension", "flexion", "3", "strength", "foot dorsiflexion", "5/5 strength", "foot plantarflexion", "findings", "same", "gait exam", "patient", "foot drop", "following areas", "patient", "likely", "diminished sensation"]}
{"question": "A 35-year-old woman comes to the physician because of a 1-day history of swelling and pain in the left leg. Two days ago, she returned from a business trip on a long-distance flight. She has alcohol use disorder. Physical examination shows a tender, swollen, and warm left calf. Serum studies show an increased homocysteine concentration and a methylmalonic acid concentration within the reference range. Further evaluation of this patient is most likely to show which of the following serum findings?", "answer": "Decreased folate concentration", "options": {"A": "Increased pyridoxine concentration", "B": "Increased fibrinogen concentration", "C": "Decreased cobalamin concentration", "D": "Decreased protein C concentration", "E": "Decreased folate concentration"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old woman", "physician", "1-day history", "swelling", "pain in", "left leg", "Two days", "returned", "business trip", "long distance", "alcohol use disorder", "tender", "swollen", "warm left calf", "Serum studies", "increased homocysteine concentration", "methylmalonic acid concentration", "reference range", "Further", "to", "following serum findings"]}
{"question": "A 28-year-old woman comes to the emergency department because of increasing abdominal pain for 2 days. The pain is diffuse and constant, and she describes it as 7 out of 10 in intensity. She has also had numbness in her lower extremities for 12 hours. She has type 1 diabetes mellitus, migraine with aura, and essential tremor. She appears uncomfortable. She is oriented to place and person only. Her temperature is 37°C (98.6°F), pulse is 123/min, and blood pressure is 140/70 mm Hg. Examination shows a distended abdomen with no tenderness to palpation. Bowel sounds are decreased. Muscle strength and sensation is decreased in the lower extremities. There is a tremor of the right upper extremity. Urinalysis shows elevated levels of aminolevulinic acid and porphobilinogen. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Primidone", "options": {"A": "Primidone", "B": "Amitriptyline", "C": "Flunarizine", "D": "Metoclopramide", "E": "Sumatriptan"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "emergency department", "of increasing abdominal pain", "2 days", "pain", "diffuse", "constant", "out", "10", "intensity", "numbness", "lower extremities", "12 hours", "type 1 diabetes mellitus", "migraine with aura", "essential tremor", "appears", "oriented to place", "only", "temperature", "98", "pulse", "min", "blood pressure", "70 mm Hg", "distended abdomen", "tenderness", "palpation", "Bowel sounds", "decreased", "Muscle strength", "sensation", "decreased", "lower extremities", "tremor", "right", "Urinalysis", "elevated levels", "aminolevulinic acid", "porphobilinogen", "following", "most likely cause", "patient's symptoms"]}
{"question": "One week after undergoing sigmoidectomy with end colostomy for complicated diverticulitis, a 67-year-old man has upper abdominal pain. During the surgery, he was transfused two units of packed red blood cells. His postoperative course was uncomplicated. Two days ago, he developed fever. He is currently receiving parenteral nutrition through a central venous catheter. He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia. He is oriented to person, but not to place and time. Prior to admission, his medications included metformin, valsartan, aspirin, and atorvastatin. His temperature is 38.9°C (102.0°F), pulse is 120/min, and blood pressure is 100/60 mmHg. Examination shows jaundice of the conjunctivae. Abdominal examination shows tenderness to palpation in the right upper quadrant. There is no rebound tenderness or guarding; bowel sounds are hypoactive. Laboratory studies show:\nLeukocytes 13,500 /mm3\nSegmented neutrophils 75 %\nSerum\nAspartate aminotransferase 140 IU/L\nAlanine aminotransferase 85 IU/L\nAlkaline phosphatase 150 IU/L\nBilirubin\nTotal 2.1 mg/dL\nDirect 1.3 mg/dL\nAmylase 20 IU/L\nWhich of the following is the most likely diagnosis in this patient?\"", "answer": "Acalculous cholecystitis", "options": {"A": "Acalculous cholecystitis", "B": "Small bowel obstruction", "C": "Anastomotic insufficiency", "D": "Acute pancreatitis", "E": "Hemolytic transfusion reaction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["One week", "sigmoidectomy", "end colostomy", "complicated diverticulitis", "67 year old man", "upper abdominal pain", "surgery", "two units", "packed red blood cells", "postoperative course", "uncomplicated", "Two days", "fever", "currently receiving parenteral nutrition", "central venous catheter", "type 2 diabetes mellitus", "hypertension", "hypercholesterolemia", "oriented to person", "not to place", "time", "medications included metformin", "valsartan", "aspirin", "atorvastatin", "temperature", "pulse", "min", "blood pressure", "100 60 mmHg", "jaundice", "conjunctivae", "Abdominal", "tenderness", "palpation", "right upper quadrant", "rebound tenderness", "guarding", "bowel sounds", "hypoactive", "Laboratory studies", "Leukocytes", "500", "mm3 Segmented neutrophils 75", "Serum Aspartate aminotransferase", "IU/L Alanine aminotransferase 85", "Bilirubin Total", "1 mg/dL Direct 1", "mg/dL Amylase 20 IU/L", "following", "diagnosis", "patient"]}
{"question": "An 82-year-old comes to the physician for a routine checkup. He feels well. He has a history of hypertension, peripheral vascular disease, carotid stenosis, and mild dementia. His father had Parkinson's disease and died of a stroke at the age of 74 years. He has smoked one-half pack of cigarettes daily for 30 years but quit at the age of 50 years. He drinks alcohol in moderation. Current medications include aspirin and lisinopril. He appears healthy. His temperature is 36.9°C (98.4°F), pulse is 73/min, respirations are 12/min, and blood pressure is 142/92 mmHg. Examination shows decreased pedal pulses bilaterally. Ankle jerk and patellar reflexes are absent bilaterally. Sensation to light touch, pinprick, and proprioception is intact bilaterally. Muscle strength is 5/5 bilaterally. He describes the town he grew up in with detail but only recalls one of three words after 5 minutes. Which of the following is the most appropriate next step in management for these findings?", "answer": "No further workup required", "options": {"A": "No further workup required", "B": "Carbidopa-levodopa", "C": "CT scan of the head", "D": "Prescribe thiamine supplementation", "E": "Lumbar puncture"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "physician", "routine checkup", "well", "history of hypertension", "peripheral vascular disease", "carotid stenosis", "mild dementia", "Parkinson's disease", "died", "stroke", "age", "74 years", "smoked one half pack", "cigarettes daily", "30 years", "age", "50 years", "alcohol", "moderation", "Current medications include aspirin", "lisinopril", "appears healthy", "temperature", "36", "98", "pulse", "min", "respirations", "min", "blood pressure", "mmHg", "decreased pedal pulses", "Ankle jerk", "patellar reflexes", "absent", "Sensation", "light touch", "intact", "Muscle strength", "5/5", "town", "detail", "only", "one", "three", "5 minutes", "following", "most appropriate next step", "findings"]}
{"question": "A 28-year-old woman with a history of intravenous drug use is brought to the emergency department because of a 1-day history of fatigue, yellow eyes, confusion, and blood in her stools. She appears ill. Her temperature is 38.1°C (100.6°F). Physical examination shows pain in the right upper quadrant, diffuse jaundice with scleral icterus, and bright red blood in the rectal vault. Further evaluation demonstrates virions in her blood, some of which have a partially double-stranded DNA genome while others have a single-stranded RNA genome. They are found to share an identical lipoprotein envelope. This patient is most likely infected with which of the following pathogens?", "answer": "Deltavirus", "options": {"A": "Calicivirus", "B": "Filovirus", "C": "Hepevirus", "D": "Herpesvirus", "E": "Deltavirus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "emergency department", "1-day history", "fatigue", "yellow eyes", "confusion", "blood in", "stools", "appears ill", "temperature", "100", "pain", "right upper quadrant", "diffuse jaundice", "scleral", "bright red blood", "rectal vault", "Further evaluation", "virions", "blood", "double-stranded DNA genome", "others", "genome", "found to", "identical lipoprotein envelope", "patient", "most likely infected", "following"]}
{"question": "A 45-year-old woman comes to the physician because of a 2-week history of fatigue and excessive thirst. During this period, she has not been able to sleep through the night because of the frequent urge to urinate. She also urinates more than usual during the day. She drinks 4–5 liters of water and 1–2 beers daily. She has autosomal dominant polycystic kidney disease, hypertension treated with lisinopril, and bipolar disorder. Therapy with valproic acid was begun after a manic episode 3 months ago. Vital signs are within normal limits. Irregular flank masses are palpated bilaterally. The remainder of the examination shows no abnormalities. Laboratory studies show:\nSerum\nNa+ 152 mEq/L\nK+ 4.1 mEq/L\nCl− 100 mEq/L\nHCO3− 25 mEq/L\nCreatinine 1.8 mg/dL\nOsmolality 312 mOsmol/kg\nGlucose 98 mg/dL\nUrine osmolality 190 mOsmol/kg\nThe urine osmolality does not change after 3 hours despite no fluid intake or after administration of desmopressin. Which of the following is the most appropriate next step in management?\"", "answer": "Hydrochlorothiazide therapy", "options": {"A": "Further water restriction", "B": "Amiloride therapy", "C": "Begin infusion of 3% saline", "D": "Hydrochlorothiazide therapy", "E": "Desmopressin therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "2-week history", "fatigue", "excessive thirst", "period", "not", "able to sleep", "night", "frequent", "to", "more", "usual", "day", "liters", "water", "daily", "autosomal dominant polycystic kidney disease", "hypertension treated with lisinopril", "bipolar disorder", "Therapy", "valproic acid", "begun", "manic episode", "months", "Vital signs", "normal limits", "Irregular flank masses", "abnormalities", "Laboratory studies", "Serum", "mEq K", "4", "100", "HCO3", "mg Osmolality 312", "kg Glucose", "Urine", "kg", "urine osmolality", "not change", "hours", "fluid intake", "administration", "desmopressin", "following", "most appropriate next step"]}
{"question": "A 54-year-old G2P2 presents to her gynecologist's office with complaints of frequent hot flashes, malaise, insomnia, and mild mood swings for 2 weeks. She has also noticed some pain with intercourse and vaginal dryness during this time. She is otherwise healthy besides hyperlipidemia, controlled on atorvastatin. She has no other past medical history, but underwent hysterectomy for postpartum hemorrhage. She is desiring of a medication to control her symptoms. Which of the following is the most appropriate short-term medical therapy in this patient for symptomatic relief?", "answer": "Hormonal replacement therapy with estrogen alone", "options": {"A": "Hormonal replacement therapy with estrogen alone", "B": "Hormonal replacement therapy with combined estrogen/progesterone", "C": "Hormonal replacement therapy with progesterone alone", "D": "Paroxetine", "E": "Gabapentin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["54 year old", "presents", "gynecologist's office", "complaints", "frequent hot flashes", "malaise", "insomnia", "mild mood swings", "2 weeks", "vaginal dryness", "time", "healthy", "hyperlipidemia", "controlled", "atorvastatin", "past medical history", "hysterectomy", "postpartum", "medication to control", "symptoms", "following", "most appropriate short-term medical", "patient"]}
{"question": "A 28-year-old man is brought to the physician by his wife because she is worried about his unusual behavior. Two weeks ago, he was promoted and is now convinced that he will soon take over the firm. He has been working overtime at the office and spends most of his nights at parties. Whenever he comes home, he asks his wife to have sex with him and rarely sleeps more than 3 hours. He has a history of a similar episode and several periods of depression over the past 2 years. He currently takes no medications. He appears impatient, repeatedly jumps up from his seat, and says, “I have more important things to do.” There is no evidence of suicidal ideation. Urine toxicology screening is negative. Long-term treatment with lithium is started. Which of the following parameters should be regularly assessed in this patient while he is undergoing treatment?", "answer": "Serum thyroid-stimulating hormone", "options": {"A": "Serum thyroid-stimulating hormone", "B": "Serum aminotransferases", "C": "Complete blood count with differential", "D": "Serum glucose", "E": "Urine culture"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "physician", "worried", "unusual behavior", "Two weeks", "now", "firm", "overtime", "office", "spends most", "nights", "home", "to", "sex", "rarely sleeps more", "hours", "history of", "similar episode", "several periods", "depression", "past", "years", "currently", "medications", "appears impatient", "repeatedly jumps", "I", "more important", "suicidal ideation", "Urine toxicology", "negative", "lithium", "started", "following parameters", "assessed", "patient", "treatment"]}
{"question": "A 58-year-old man presents to the emergency department for evaluation of intermittent chest pain over the past 6 months. His history reveals that he has had moderate exertional dyspnea and 2 episodes of syncope while working at his factory job. These episodes of syncope were witnessed by others and lasted roughly 30 seconds. The patient states that he did not have any seizure activity. His vital signs include: blood pressure 121/89 mm Hg, heart rate 89/min, temperature 37.0°C (98.6°F), and respiratory rate 16/min. Physical examination reveals a crescendo-decrescendo systolic murmur in the right second intercostal area. An electrocardiogram is performed, which shows left ventricular hypertrophy. Which of the following is the best next step for this patient?", "answer": "Transthoracic echocardiography", "options": {"A": "Cardiac chamber catheterization", "B": "Chest radiograph", "C": "Computed tomography (CT) chest scan without contrast", "D": "Transesophageal echocardiography", "E": "Transthoracic echocardiography"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old man presents", "emergency department", "of intermittent chest pain", "past 6 months", "history reveals", "moderate exertional dyspnea", "2 episodes of syncope", "factory", "episodes of syncope", "others", "lasted", "30 seconds", "patient states", "not", "seizure activity", "vital signs include", "blood pressure", "mm Hg", "heart rate", "min", "temperature", "98", "respiratory rate", "min", "reveals", "crescendo-decrescendo systolic murmur", "right second", "area", "electrocardiogram", "performed", "left ventricular hypertrophy", "following", "best next step", "patient"]}
{"question": "A 42-year-old male presents to the emergency department due to severe headaches and palpitations. He has had previous episodes of sweating and headache, but this episode was particularly disabling. Upon presentation, he appears pale and diaphoretic. His temperature is 99.3°F (37.4°C), blood pressure is 162/118 mmHg, pulse is 87/min, and respirations are 20/min. Based on clinical suspicion, an abdominal CT scan is obtained, which shows a retroperitoneal mass. This patient's increased heart rate is most likely due to a change in activity of which of the following channels?", "answer": "Hyperpolarization-activated, nucleotide-gated channels", "options": {"A": "Hyperpolarization-activated, nucleotide-gated channels", "B": "L-type calcium channels", "C": "T-type calcium channels", "D": "Voltage-gated sodium channels", "E": "Voltage-gated potassium channels"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "emergency department", "severe headaches", "palpitations", "previous episodes of sweating", "headache", "episode", "appears pale", "diaphoretic", "temperature", "99", "blood pressure", "mmHg", "pulse", "87 min", "respirations", "20 min", "Based", "clinical", "abdominal CT", "obtained", "retroperitoneal mass", "patient's increased heart rate", "due to", "change", "following"]}
{"question": "A 24-year-old woman presents to the labor and delivery floor in active labor at 40 weeks gestation. She has a prolonged course but ultimately vaginally delivers an 11 pound boy. On post operative day 2, she is noted to have uterine tenderness and decreased bowel sounds. She states she has been urinating more frequently as well. Her temperature is 102°F (38.9°C), blood pressure is 118/78 mmHg, pulse is 111/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-distended abdomen and a tender uterus. Pulmonary exam reveals minor bibasilar crackles. Initial laboratory studies and a urinalysis are pending. Which of the following is the most likely diagnosis?", "answer": "Endometritis", "options": {"A": "Atelectasis", "B": "Chorioamnionitis", "C": "Deep vein thrombosis", "D": "Endometritis", "E": "Urinary tract infection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "labor", "delivery floor", "active", "40 weeks gestation", "prolonged course", "delivers", "pound boy", "post operative day 2", "noted to", "uterine tenderness", "decreased bowel sounds", "states", "more frequently", "well", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "non distended abdomen", "tender uterus", "Pulmonary exam reveals minor", "crackles", "Initial laboratory studies", "urinalysis", "following", "diagnosis"]}
{"question": "A 52-year-old farmer presents to his physician with a puncture wound on his left shin. He got this wound accidentally when he felt unwell and went out to his garden \"to catch some air\". He reports he had been treated for tetanus 35 years ago and has received the Tdap vaccine several times since then, but he does not remember when he last received the vaccine. His vital signs are as follows: the blood pressure is 110/80 mm Hg, heart rate is 91/min, respiratory rate is 19/min, and temperature is 37.8°C (100.0°F). On physical examination, he is mildly dyspneic and pale. Lung auscultation reveals diminished vesicular breath sounds in the lower lobes bilaterally with a few inspiratory crackles heard over the left lower lobe. There is a puncture wound 1 cm in diameter that is contaminated with soil in the middle third of the patient’s shin. You order blood tests and an X-ray, and now you are arranging his wound treatment. How should tetanus post-exposure prevention be performed in this case?", "answer": "The patient should receive both tetanus toxoid-containing vaccine and human tetanus immunoglobulin.", "options": {"A": "The patient should only be administered human tetanus immunoglobulin, because he is acutely ill and febrile, which are contraindications for tetanus toxoid-containing vaccine administration.", "B": "The patient does not need tetanus post-exposure prevention, because he has a past medical history of tetanus.", "C": "The patient does not need tetanus post-exposure prevention, because he received the Tdap vaccine several times in the past.", "D": "The patient should receive both tetanus toxoid-containing vaccine and human tetanus immunoglobulin.", "E": "The patient should be administered only the Tdap vaccine, because it is a minor wound with a small area of possible toxin absorption."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old farmer presents", "physician", "puncture wound", "left shin", "got", "wound", "unwell", "out", "garden", "to catch", "air", "reports", "treated", "tetanus 35 years", "received", "Tdap vaccine", "times", "then", "not", "last received", "vaccine", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "100", "mildly dyspneic", "pale", "Lung auscultation reveals diminished vesicular breath sounds", "lower lobes", "few inspiratory crackles heard", "left lower lobe", "puncture wound", "diameter", "middle third", "patients shin", "order blood tests", "X-ray", "now", "wound treatment", "tetanus post-exposure prevention", "performed", "case"]}
{"question": "A 74-year-old woman is brought to the physician by her husband because of difficulty sleeping for several years. She says that she has been gradually sleeping less each night over the past 2 years. It takes her 20–25 minutes to fall asleep each night and she wakes up earlier in the morning than she used to. On average, she sleeps 5–6 hours each night. She says that she has also been waking up several times per night and needs about 20 minutes before she is able to fall back to sleep. She feels mildly tired in the afternoon but does not take any naps. Her husband reports that she does not snore. The patient drinks two cups of coffee each morning, but she does not smoke or drink alcohol. She takes a 45 minute walk with her husband and their dog every other day. She is 160 cm (5 ft 3 in) tall and weighs 55 kg (121 lb); BMI is 21 kg/m2. Vital signs are within normal limits. On mental status examination, she appears cooperative with a mildly anxious mood and a full range of affect. Which of the following is the most appropriate next step in management?", "answer": "Reassurance", "options": {"A": "Sleep restriction", "B": "Flurazepam", "C": "Reassurance", "D": "Bilevel positive airway pressure (BiPAP)", "E": "Paradoxical intention"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old woman", "brought", "physician", "difficulty sleeping", "several years", "sleeping less", "night", "past 2 years", "minutes to fall asleep", "night", "wakes up earlier", "morning", "used to", "average", "sleeps", "hours", "night", "waking up", "times", "night", "needs", "20 minutes", "able to fall back to sleep", "mildly tired", "afternoon", "not", "naps", "reports", "not snore", "patient", "two cups", "morning", "not smoke", "minute", "day", "5 ft", "tall", "kg", "BMI", "kg/m2", "Vital signs", "normal limits", "mental status", "appears", "mildly anxious mood", "full range", "following", "most appropriate next step"]}
{"question": "A 63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management?", "answer": "Open surgical repair", "options": {"A": "Surgical drainage", "B": "Antibiotic therapy", "C": "Open surgical repair", "D": "Surgical exploration of the testicle", "E": "Laparoscopic surgical repair"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["63 year old man", "emergency department", "of pain", "left", "past hour", "pain began", "returned", "out", "10", "intensity", "vomited", "hospital", "swelling of", "left groin", "past", "months", "chronic obstructive pulmonary disease", "hypertension", "Current medications include amlodipine", "albuterol inhaler", "salmeterol-fluticasone inhaler", "appears", "temperature", "99", "pulse", "min", "blood pressure", "84 mm Hg", "tender bulge", "left side", "inguinal ligament", "extends", "left scrotum", "lying", "applying external", "not", "swelling", "Coughing", "not make", "swelling bulge further", "erythema", "abdomen", "distended", "Bowel sounds", "hyperactive", "Scattered rhonchi", "heard", "lung fields", "following", "most appropriate next step"]}
{"question": "Certain glucose transporters that are expressed predominantly on skeletal muscle cells and adipocytes are unique compared to those transporters found on other cell types within the body. Without directly affecting glucose transport in other cell types, which of the following would be most likely to selectively increase glucose uptake in skeletal muscle cells and adipocytes?", "answer": "Increased levels of circulating insulin", "options": {"A": "Increased levels of circulating insulin", "B": "Decreased levels of circulating insulin", "C": "Increased plasma glucose concentration", "D": "Decreased plasma glucose concentration", "E": "It is physiologically impossible to selectively increase glucose uptake in specific cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Certain glucose transporters", "unique", "transporters found", "body", "directly affecting glucose transport", "following", "increase glucose uptake"]}
{"question": "A 12-year-old boy presents to your office with facial swelling and dark urine. He has no other complaints other than a sore throat 3 weeks ago that resolved after 6 days. He is otherwise healthy, lives at home with his mother and 2 cats, has no recent history of travel ,and no sick contacts. On physical examination his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 19/min, and pulse oximetry is 99% on room air. Cardiopulmonary and abdominal examinations are unremarkable. There is mild periorbital and pedal edema. Urinalysis shows 12-15 RBC/hpf, 2-5 WBC/hpf, and 30 mg/dL protein. Which additional finding would you expect to see on urinalysis?", "answer": "RBC casts", "options": {"A": "WBC casts", "B": "Granular casts", "C": "Hyaline", "D": "RBC casts", "E": "Fatty casts"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "office", "facial swelling", "dark urine", "complaints", "sore throat", "weeks", "resolved", "6 days", "healthy", "lives at home", "2 cats", "recent history of travel", "sick", "temperature", "blood pressure", "85 mmHg", "pulse", "80 min", "respirations", "min", "pulse oximetry", "99", "room air", "Cardiopulmonary", "abdominal", "unremarkable", "mild periorbital", "pedal edema", "Urinalysis", "RBC/hpf", "2-5 WBC/hpf", "30 mg/dL protein", "additional finding", "to see", "urinalysis"]}
{"question": "A 65-year-old male with a history of CHF presents to the emergency room with shortness of breath, lower leg edema, and fatigue. He is diagnosed with acute decompensated congestive heart failure, was admitted to the CCU, and treated with a medication that targets beta-1 adrenergic receptors preferentially over beta-2 adrenergic receptors. The prescribing physician explained that this medication would only be used temporarily as its efficacy decreases within one week due to receptor downregulation. Which of the following was prescribed?", "answer": "Dobutamine", "options": {"A": "Epinephrine", "B": "Milrinone", "C": "Isoproterenol", "D": "Norepinephrine", "E": "Dobutamine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["65-year-old male", "history", "CHF presents", "emergency room", "shortness of breath", "lower leg edema", "fatigue", "diagnosed", "acute decompensated congestive heart failure", "treated with", "medication", "targets beta-1 adrenergic receptors", "physician", "medication", "only", "used", "efficacy decreases", "one week", "following"]}
{"question": "A 27-year-old man presents to his primary care physician for his first appointment. He recently was released from prison. The patient wants a checkup before he goes out and finds a job. He states that lately he has felt very fatigued and has had a cough. He has lost roughly 15 pounds over the past 3 weeks. He attributes this to intravenous drug use in prison. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air. The patient is started on appropriate treatment. Which of the following is the most likely indication to discontinue this patient's treatment?", "answer": "Elevated liver enzymes", "options": {"A": "Elevated liver enzymes", "B": "Hyperuricemia", "C": "Optic neuritis", "D": "Peripheral neuropathy", "E": "Red body excretions"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "primary care physician", "first appointment", "recently", "released from prison", "patient", "checkup", "out", "finds", "states", "very fatigued", "cough", "lost", "pounds", "past", "weeks", "attributes", "in prison", "temperature", "99", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "started", "appropriate treatment", "following", "to discontinue"]}
{"question": "A 60-year-old male presents for a routine health check-up. The patient complains of reduced exercise tolerance for the past 2 years. Also, in the past year, he has noticed chest pain after climbing the stairs in his home. He has no significant past medical history or current medications. The patient reports a 45-pack-year smoking history. The vital signs include temperature 37.0°C (98.6°F), blood pressure 160/100 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 99% on room air. His body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. Laboratory studies show:\nSerum total cholesterol 265 mg/dL\nHDL 22 mg/dL\nLDL 130 mg/dL\nTriglycerides 175 mg/dL \nHDL: high-density lipoprotein; LDL: low-density lipoprotein\nWhich of the following vascular pathologies is most likely present in this patient?", "answer": "Atherosclerosis", "options": {"A": "Medial calcific sclerosis", "B": "Lymphedema", "C": "Deep venous thrombosis", "D": "Hyperplastic arteriosclerosis", "E": "Atherosclerosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["60 year old male presents", "routine health check-up", "patient", "reduced exercise tolerance", "past", "years", "past year", "chest pain", "climbing", "home", "significant past medical history", "current medications", "patient reports", "smoking history", "vital signs include temperature", "98", "blood pressure", "100 mm Hg", "pulse 72 min", "respiratory rate", "min", "oxygen saturation 99", "room air", "body mass index", "kg/m2", "unremarkable", "Laboratory studies", "Serum total cholesterol", "mg/dL", "Triglycerides", "high-density lipoprotein", "low-density lipoprotein", "following vascular pathologies", "most likely present", "patient"]}
{"question": "An 88-year-old woman with no significant medical history is brought to the emergency room by her daughter after a fall, where the woman lightly hit her head against a wall. The patient is lucid and complains of a mild headache. The daughter indicates that her mother did not lose consciousness after the fall. On exam, there are no focal neurological deficits, but you decide to perform a CT scan to be sure there is no intracranial bleeding. The CT scan are within normal limits and head MRI is preformed (shown). Which of the following conditions has the most similar risk factor to this patient's condition?", "answer": "Thoracic aortic aneurysm", "options": {"A": "Prinzmetal's angina", "B": "Thoracic aortic aneurysm", "C": "Abdominal aortic aneurysm", "D": "Raynaud's phenomenon", "E": "Pulmonary embolism"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["88 year old woman", "significant medical history", "brought", "emergency room", "fall", "woman lightly hit", "head", "wall", "patient", "lucid", "mild headache", "not", "consciousness", "fall", "exam", "focal neurological deficits", "to perform", "CT scan to", "sure", "intracranial bleeding", "CT scan", "normal limits", "head MRI", "following conditions", "most similar risk factor", "patient's condition"]}
{"question": "While explaining the effects of hypokalemia and hyperkalemia on the cardiac rhythm, a cardiologist explains that the electrophysiology of cardiac tissue is unique. He mentions that potassium ions play an important role in the electrophysiology of the heart, and the resting membrane potential of the cardiac myocytes is close to the equilibrium potential of K+ ions. This is because of the high resting potassium conductance of the ventricular myocytes, which is regulated by specific potassium channels. These are open at rest and are closed when there is depolarization. Which of the following potassium channels is the cardiologist talking about?", "answer": "Inward rectifier IK1 potassium channels", "options": {"A": "Inward rectifier IK1 potassium channels", "B": "Inward rectifier IKACh potassium channels", "C": "Fast delayed rectifier IKr potassium channels", "D": "Slow delayed rectifier IKs potassium channels", "E": "Transient outward current Ito potassium channels"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["effects", "hypokalemia", "hyperkalemia", "cardiac rhythm", "cardiologist", "electrophysiology", "cardiac", "unique", "potassium ions play", "important role", "electrophysiology", "heart", "resting membrane potential", "close", "equilibrium potential", "K", "ions", "high", "potassium conductance", "specific potassium channels", "open", "closed", "following potassium channels", "cardiologist talking about"]}
{"question": "A 34-year-old man presents to his dermatologist with white scaly papules and plaques on his extensor arms, elbows, knees, and shins. Scaly and flaky eruptions are also present on his ears, eyebrows, and scalp. He describes the lesions as being itchy and irritating. When the scales are scraped away, pinpoint bleeding is noted. His vital signs are unremarkable, and physical examination is otherwise within normal limits. Which of the following is the best initial test for this patient’s condition?", "answer": "No tests are necessary", "options": {"A": "Skin biopsy", "B": "Serum autoantibodies", "C": "Plain film X-rays of the hands and feet", "D": "No tests are necessary", "E": "Wood’s lamp"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "dermatologist", "white scaly papules", "plaques", "extensor arms", "elbows", "knees", "shins", "Scaly", "flaky eruptions", "present", "ears", "eyebrows", "scalp", "lesions", "itchy", "scales", "scraped", "pinpoint bleeding", "noted", "vital signs", "unremarkable", "normal limits", "following", "best initial test", "patients condition"]}
{"question": "A 35-year-old man presents with a mass on the central part of his neck. He reports it has been growing steadily for the past 2 weeks, and he has also been experiencing fatigue and recurrent fevers. No significant past medical history. The patient denies any smoking history, or alcohol or recreational drug use. He denies any recent travel in the previous 6 months. On physical examination, there are multiple enlarged submandibular and cervical lymph nodes that are firm, mobile, and non-tender. A biopsy of one of the lymph nodes is performed and shows predominantly lymphocytes and histiocytes present in a pattern ‘resembling popcorn’. A flow cytometry analysis demonstrates cells that are CD19 and CD20 positive and CD15 and CD30 negative. Which of the following is the most likely diagnosis in this patient?", "answer": "Nodular lymphocyte-predominant Hodgkin lymphoma", "options": {"A": "Lymphocyte rich classical Hodgkin lymphoma", "B": "Nodular lymphocyte-predominant Hodgkin lymphoma", "C": "Nodular sclerosis classical Hodgkin lymphoma", "D": "Mixed cellularity classical Hodgkin lymphoma", "E": "Lymphocyte depleted Hodgkin lymphoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man presents", "mass", "central part", "neck", "reports", "past 2 weeks", "fatigue", "recurrent fevers", "significant past medical history", "patient", "smoking history", "alcohol", "recreational drug use", "recent", "previous", "months", "multiple enlarged submandibular", "cervical lymph nodes", "firm", "mobile", "non-tender", "biopsy of one", "lymph nodes", "performed", "lymphocytes", "present", "pattern", "flow cytometry analysis", "cells", "CD19", "CD20 positive", "CD15", "CD30 negative", "following", "diagnosis", "patient"]}
{"question": "A 3550-g (7-lb 13-oz) male newborn is delivered at 37 weeks' gestation to a 28-year-old woman. Apgar scores are 9 and 10 at 1 and 5 minutes, respectively. His vital signs are within normal limits. Physical examination shows no abnormalities. Routine neonatal screening tests show mildly elevated TSH concentrations. Ultrasonography of the neck shows a complete absence of both lobes of the thyroid gland. This patient's normal physical examination findings, despite the total absence of a thyroid gland, is best explained by which of the following mechanisms?", "answer": "Transplacental transmission of thyroxine", "options": {"A": "Transplacental transmission of thyroxine", "B": "Presence of lingual thyroid tissue", "C": "Molecular mimicry of hCG subunit", "D": "Production of TSH-receptor antibodies", "E": "Degradation of thyroid-binding globulin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["g", "oz", "male newborn", "delivered", "weeks", "gestation", "year old woman", "Apgar scores", "10", "5 minutes", "vital signs", "normal limits", "abnormalities", "Routine neonatal screening tests", "mildly elevated TSH", "Ultrasonography of", "neck", "complete absence of", "lobes", "thyroid gland", "patient's normal physical examination", "total absence", "thyroid gland", "best", "following mechanisms"]}
{"question": "A 2-month-old boy is brought to the physician by his mother because of poor weight gain and irritability since delivery. He is at the 10th percentile for height and below the 5th percentile for weight. Physical examination shows conjunctival pallor. Laboratory studies show:\nHemoglobin 11.2 g/dL\nMean corpuscular hemoglobin 24.2 pg/cell\nMean corpuscular volume 108 μm3\nSerum\nAmmonia 26 μmol/L (N=11–35 μmol/L)\nA peripheral blood smear shows macrocytosis of erythrocytes and hypersegmented neutrophils. Supplementation with folate and cobalamin is begun. Two months later, his hemoglobin concentration is 11.1 g/dL and mean corpuscular volume is 107 μm3. The patient's condition is most likely caused by failure of which of the following enzymatic reactions?\"", "answer": "Orotate to uridine 5'-monophosphate", "options": {"A": "Ornithine and carbamoylphosphate to citrulline", "B": "Glucose-6-phosphate to 6-phosphogluconate", "C": "Hypoxanthine to inosine monophosphate", "D": "Phosphoenolpyruvate to pyruvate", "E": "Orotate to uridine 5'-monophosphate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 month old boy", "brought", "physician", "poor weight gain", "irritability", "delivery", "percentile", "height", "5th percentile", "weight", "conjunctival pallor", "Laboratory studies", "Hemoglobin", "g", "Mean", "pg cell", "volume", "Ammonia", "mol", "N", "mol", "peripheral blood smear", "macrocytosis", "erythrocytes", "hypersegmented neutrophils", "Supplementation", "folate", "cobalamin", "begun", "Two months later", "hemoglobin concentration", "g/dL", "mean corpuscular volume", "m3", "patient", "ondition ", "ost  ikely  aused ", "ailure ", "ollowing "]}
{"question": "A previously healthy 40-year-old woman comes to the physician because of a 3-day history of fever, headaches, and fatigue. She also reports a persistent tingling sensation in her right hand and numbness in her right arm that started this morning. Physical examination shows pallor, mild scleral icterus, and petechiae on her forearms and legs. On mental status examination, she appears confused and is only oriented to person. Laboratory studies show:\nHemoglobin 11.1 mg/dL\nPlatelet count 39,500/mm3\nBleeding time 9 minutes\nProthrombin time 14 seconds\nPartial thromboplastin time 35 seconds\nSerum\nCreatinine 1.7 mg/dL\nTotal bilirubin 2.1 mg/dL\nA peripheral blood smear shows fragmented erythrocytes. Which of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Antibodies against ADAMTS13", "options": {"A": "Antibodies against ADAMTS13", "B": "Antibodies against GpIIb/IIIa", "C": "Absence of platelet GpIIb/IIIa receptors", "D": "Mutation of the PIGA gene", "E": "Antibodies against double-stranded DNA"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy 40 year old woman", "physician", "3-day history", "fever", "headaches", "fatigue", "reports", "persistent tingling sensation", "right hand", "numbness", "right arm", "started", "morning", "pallor", "mild scleral icterus", "petechiae", "forearms", "legs", "mental status", "appears confused", "only oriented to person", "Laboratory studies", "Hemoglobin", "mg", "count", "500 mm3 Bleeding time", "minutes Prothrombin time", "seconds Partial thromboplastin time", "Serum Creatinine", "Total", "peripheral blood smear", "fragmented erythrocytes", "following", "underlying cause", "patient", "ondition?"]}
{"question": "A 45-year-old woman comes to the office with a 2-week history of rectal bleeding that occurs every day with her bowel movements. She denies any pain during defecation. Apart from this, she does not have any other complaints. Her past medical history is insignificant except for 5 normal vaginal deliveries. Her vitals are a heart rate of 72/min, a respiratory rate of 15/min, a temperature of 36.7°C (98.1°F), and a blood pressure of 115/85 mm Hg. On rectovaginal examination, there is a palpable, non-tender, prolapsed mass that can be pushed back by the examiner's finger into the anal sphincter. What is the most likely diagnosis?", "answer": "Hemorrhoids", "options": {"A": "Anal fissure", "B": "Anorectal fistula", "C": "Rectal ulcer", "D": "Proctitis", "E": "Hemorrhoids"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "office", "2-week history", "rectal bleeding", "occurs", "day", "bowel movements", "pain", "defecation", "not", "complaints", "past medical history", "normal vaginal deliveries", "heart rate", "72 min", "respiratory rate", "min", "temperature", "36", "98", "blood pressure", "85 mm Hg", "rectovaginal examination", "palpable", "non-tender", "prolapsed mass", "pushed back", "finger", "anal sphincter", "diagnosis"]}
{"question": "A 60-year-old man comes to the physician’s office with jaundice. Liver ultrasound reveals a shrunken liver and biopsy reveals cirrhosis. Hepatitis serologies are below:\n\nAnti-HAV: negative\nHBsAg: negative\nHBsAb: positive\nHBeAg: negative\nAnti-HBe: negative\nAnti-HBc: negative\nAnti-HCV: positive\n\nThe hepatitis C viral load is 1,000,000 copies/mL. The patient is started on an antiviral regimen including sofosbuvir. What is the mechanism of action of this drug?", "answer": "Inhibits RNA-dependent RNA polymerase", "options": {"A": "Inhibits synthesis of DNA-dependent DNA polymerase", "B": "Inhibits hepatitis C protease", "C": "Inhibits reverse transcriptase", "D": "Inhibits integrase", "E": "Inhibits RNA-dependent RNA polymerase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["60 year old man", "physicians office", "jaundice", "Liver ultrasound reveals", "shrunken liver", "biopsy reveals cirrhosis", "Hepatitis serologies", "Anti-HAV", "negative HBsAg", "negative HBsAb", "positive", "negative Anti-HBe", "negative Anti-HBc", "negative Anti-HCV", "positive", "hepatitis C viral load", "1", "copies", "patient", "started", "antiviral regimen including sofosbuvir", "mechanism of action", "drug"]}
{"question": "A 55-year-old Chinese man presents to the office with a complaint of progressive unilateral nasal obstruction for 10 months. Though he was able to tolerate his symptoms at the beginning, he can’t breathe properly through the obstructed nostril anymore. Also, a bloody nasal discharge has started recently through the occluded nostril. He also complains of double vision during the past 2 months but did not pay attention to it until now. Past medical history is insignificant except for occasional sore throats.\nHis vitals include: blood pressure of 120/88 mm Hg, respiratory rate of 14/min, pulse of 88/min, temperature 37.0°C (98.6°F).\nBlood analysis shows:\nHemoglobin 15 g/dL\nHematocrit 46%\nLeukocyte count 15000/mm3\nNeutrophils 72%\nLymphocytes 25%\nMonocytes 3%\nMean corpuscular volume 95 fL\nPlatelet count 350,000/mm3\nWhich of the following viral etiology is most likely associated with the development of this patient’s condition?", "answer": "Epstein-Barr virus", "options": {"A": "Human papillomavirus", "B": "HIV", "C": "Epstein-Barr virus", "D": "Hepatitis B virus", "E": "Human T lymphotropic virus type I"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "man presents", "office", "complaint", "progressive unilateral nasal obstruction", "10 months", "able to", "symptoms", "beginning", "cant", "obstructed nostril", "bloody nasal discharge", "started recently", "occluded nostril", "double vision", "past", "months", "not pay", "now", "Past medical history", "occasional sore throats", "include", "blood pressure", "88 mm Hg", "respiratory rate", "min", "pulse", "88 min", "temperature", "98", "Blood analysis", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count 15000 mm3 Neutrophils 72", "Mean corpuscular volume", "fL Platelet count", "following viral etiology", "most likely associated with", "development", "patients condition"]}
{"question": "A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?", "answer": "CT head", "options": {"A": "Alteplase", "B": "Aspirin", "C": "CT head", "D": "CTA head", "E": "MRI brain"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "began slurring", "speech", "facial asymmetry", "dinner approximately 30 minutes", "past medical history", "hypertension", "diabetes", "temperature", "99", "blood pressure", "99 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room", "Neurologic exam reveals right upper", "lower extremity weakness", "asymmetric smile", "following", "next best step"]}
{"question": "A 7-year-old boy is brought to the physician for recurrent 3–4 minutes episodes of facial grimacing and staring over the past month. He is nonresponsive during these episodes and does not remember them afterward. He recalls a muddy taste in his mouth before the onset of symptoms. One week ago, his brother witnessed an episode where he woke up, stared, and made hand gestures. After the incident, he felt lethargic and confused. Examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Complex partial seizure", "options": {"A": "Absence seizures", "B": "Myoclonic seizure", "C": "Simple partial seizures", "D": "Breath-holding spell", "E": "Complex partial seizure"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "recurrent", "minutes episodes of facial grimacing", "staring", "past month", "episodes", "not", "muddy taste", "mouth", "onset", "symptoms", "One week", "episode", "woke up", "stared", "made hand", "lethargic", "confused", "abnormalities", "following", "diagnosis"]}
{"question": "A group of scientists is studying the mechanism by which the human papillomavirus (HPV) vaccine confers immunity. They observe that during the inoculation of test subjects, mammals with certain viral proteins result in the organism’s antigen-presenting cells (APCs) absorbing the antigen and presenting it on major histocompatibility complex (MHC) class 1 molecules. Which of the following is the correct term for the process that the scientists are observing in this inoculation?", "answer": "Cross-presentation", "options": {"A": "Endogenous antigen presentation", "B": "Cross-presentation", "C": "Priming of CD4+ T cells", "D": "Adhesion", "E": "Ubiquitination"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["scientists", "studying", "mechanism", "human papillomavirus", "vaccine", "immunity", "observe", "inoculation", "test subjects", "certain viral proteins result", "major histocompatibility complex", "class 1", "following", "correct term", "process", "scientists", "observing", "inoculation"]}
{"question": "A 21-year-old woman presents with the complaints of nausea, vomiting, and diarrhea for 5 days. She adds that she has fever and abdominal cramping as well. She had recently attended a large family picnic and describes eating many varieties of cold noodle salads. Her past medical history is insignificant. Her temperature is 37.5°C (99.6°F), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 92/68 mm Hg. Physical examination is non-contributory. Given the clinical information provided and most likely diagnosis, which of the following would be the next best step in the management of this patient?", "answer": "Replacement of fluids and electrolytes", "options": {"A": "IV antibiotic therapy to prevent disseminated disease", "B": "Replacement of fluids and electrolytes", "C": "Empiric therapy assuming multi-drug resistance", "D": "Short course of oral antibiotics to prevent asymptomatic carrier state", "E": "Prolonged oral antibiotics"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["21-year-old woman presents", "complaints", "nausea", "vomiting", "diarrhea", "5 days", "adds", "fever", "abdominal cramping", "well", "recently attended", "eating", "cold", "past medical history", "temperature", "99", "respiratory rate", "min", "pulse", "67 min", "blood pressure", "mm Hg", "non contributory", "Given", "clinical information", "likely diagnosis", "following", "next best step", "patient"]}
{"question": "An investigator is studying biomolecular mechanisms in human cells. A radioactive isotope that is unable to cross into organelles is introduced into a sample of cells. The cells are then fragmented via centrifugation and the isotope-containing components are isolated. Which of the following reactions is most likely to be present in this cell component?", "answer": "Glucose-6-phosphate to 6-phosphogluconolactone", "options": {"A": "Glucose-6-phosphate to glucose", "B": "Fatty acyl-CoA to acetyl-CoA", "C": "Carbamoyl phosphate to citrulline", "D": "Glucose-6-phosphate to 6-phosphogluconolactone", "E": "Isocitrate to α-ketoglutarate"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "mechanisms", "human cells", "unable to", "organelles", "introduced", "cells", "cells", "then fragmented", "centrifugation", "containing components", "isolated", "following reactions", "to", "present", "cell component"]}
{"question": "A 30-year-old man comes to the physician for his annual health maintenance examination. The patient has no particular health concerns. He has a history of bilateral cryptorchidism treated with orchidopexy at 8 months of age. This patient is at increased risk for which of the following?", "answer": "Teratocarcinoma", "options": {"A": "Teratocarcinoma", "B": "Sertoli cell tumor", "C": "Leydig cell tumor", "D": "Yolk sac tumor", "E": "Testicular lymphoma\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old man", "physician", "annual health maintenance examination", "patient", "history", "bilateral cryptorchidism treated with orchidopexy", "months", "age", "patient", "increased risk", "following"]}
{"question": "A 28-year-old woman comes to the emergency department because of a 2-day history of dark urine, increasing abdominal pain, and a tingling sensation in her arms and legs. She has a history of epilepsy. Her current medication is phenytoin. She is nauseated and confused. Following the administration of hemin and glucose, her symptoms improve. The beneficial effect of this treatment is most likely due to inhibition of which of the following enzymes?", "answer": "Aminolevulinate acid synthase", "options": {"A": "Aminolevulinate dehydratase", "B": "Aminolevulinate acid synthase", "C": "Ferrochelatase", "D": "Porphobilinogen deaminase", "E": "Uroporphyrinogen decarboxylase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "2-day history", "dark urine", "increasing abdominal pain", "tingling sensation", "arms", "legs", "history of epilepsy", "current medication", "phenytoin", "nauseated", "confused", "Following", "administration", "hemin", "glucose", "symptoms", "effect", "treatment", "due to inhibition", "following enzymes"]}
{"question": "A 2-year-old boy is brought to the emergency department by his parents because of fever and recurrent episodes of jerky movements of his extremities for the past 6 hours. Pregnancy and delivery were uncomplicated, and development was normal until the age of 1 year. The parents report that he has had gradual loss of speech, vision, and motor skills over the past year. During this time, he has been admitted to the hospital three times because of myoclonic seizures. Physical examination shows hypertonicity of the upper and lower extremities. Fundoscopic examination shows pallor of the optic disc bilaterally. An MRI of the brain shows brain atrophy and hyperintensity of the periventricular and subcortical areas. Two days after admission, the patient dies. Histopathologic examination of the brain shows aggregation of globoid cells and loss of glial cells. The patient’s condition was most likely caused by a deficiency of which of the following enzymes?", "answer": "β-Galactocerebrosidase", "options": {"A": "Sphingomyelinase", "B": "Arylsulfatase A", "C": "β-Glucocerebrosidase", "D": "β-Hexosaminidase A", "E": "β-Galactocerebrosidase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 year old boy", "brought", "emergency department", "fever", "recurrent episodes of jerky", "extremities", "past", "hours", "Pregnancy", "delivery", "uncomplicated", "development", "normal", "age", "year", "report", "gradual loss of speech", "vision", "motor skills", "past year", "time", "three times", "myoclonic seizures", "hypertonicity", "upper", "lower extremities", "Fundoscopic", "pallor of the optic disc", "MRI of", "brain", "brain atrophy", "subcortical areas", "Two days", "Histopathologic", "brain", "aggregation", "cells", "loss", "patients condition", "most likely caused", "deficiency", "following enzymes"]}
{"question": "An obese, 66-year-old woman comes to the physician for a routine health maintenance examination. She feels well but is unhappy about being overweight. She reports that she feels out of breath when walking for more than one block and while climbing stairs. She has tried to lose weight for several years without success. She goes for a walk 3 times a week but she has difficulty following a low-calorie diet. During the past 12 months, she has had two urinary tract infections that were treated with fosfomycin. She has type 2 diabetes mellitus and osteoarthritis. Her only current medication is metformin. She has never smoked. She is 160 cm (5 ft 3 in) tall and weighs 100 kg (220 lb); BMI is 39.1 kg/m2. Vital signs are within normal limits. Physical examination shows cracking in both knees on passive movement. The remainder of the examination shows no abnormalities. Serum studies show an HbA1c of 9.5%, and a fasting serum glucose concentration of 158 mg/dL. An ECG shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?", "answer": "Exenatide", "options": {"A": "Topiramate", "B": "Exenatide", "C": "Pioglitazone", "D": "Acarbose", "E": "Phentermine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["obese", "66 year old woman", "physician", "routine", "well", "unhappy", "overweight", "reports", "out of breath", "one block", "to", "weight", "years", "times", "week", "difficulty following", "low-calorie diet", "past 12 months", "two urinary tract infections", "treated with fosfomycin", "type 2 diabetes mellitus", "osteoarthritis", "only current medication", "metformin", "never smoked", "5 ft", "tall", "100 kg", "BMI", "kg/m2", "Vital signs", "normal", "Physical examination", "cracking", "knees", "passive movement", "abnormalities", "Serum studies", "9.5", "fasting serum glucose concentration", "mg dL", "ECG", "abnormalities", "following", "most appropriate pharmacotherapy"]}
{"question": "A 62-year-old man comes to the physician for a follow-up examination. One month ago, therapy with lisinopril was initiated for treatment of hypertension. His blood pressure is 136/86 mm Hg. Urinalysis shows a creatinine clearance of 92 mL/min. The patient's serum creatinine concentration is most likely closest to which of the following values?", "answer": "1.1 mg/dL", "options": {"A": "1.4 mg/dL", "B": "2.3 mg/dL", "C": "2.0 mg/dL", "D": "1.1 mg/dL", "E": "1.7 mg/dL"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man", "physician", "follow-up examination", "One month", "therapy", "lisinopril", "initiated", "blood pressure", "mm Hg", "Urinalysis", "creatinine clearance", "mL/min", "patient's serum concentration", "closest", "following values"]}
{"question": "A 21-year-old woman presents to the emergency department with complaints of intermittent bouts of lower abdominal and pelvic pain over the last week. The pain is primarily localized to the right side and is non-radiating. The patient is not sexually active at this time and is not currently under any medication. At the hospital, her vitals are normal. A pelvic examination reveals a tender palpable mass on the right adnexal structure. A pelvic CT scan reveals a 7-cm solid adnexal mass that was surgically removed with the ovary. Histological evaluation indicates sheets of uniform cells resembling a 'fried egg', consistent with dysgerminoma. Which of the following tumor markers is most likely elevated with this type of tumor?", "answer": "Lactate dehydrogenase (LDH)", "options": {"A": "Lactate dehydrogenase (LDH)", "B": "Beta-human chorionic gonadotropin (beta-hCG)", "C": "Alpha-fetoprotein (AFP)", "D": "Inhibin A", "E": "Cancer antigen 125 (CA-125)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["21-year-old woman presents", "emergency department", "complaints", "intermittent bouts", "lower abdominal", "pelvic pain", "week", "pain", "localized", "right side", "non radiating", "patient", "not sexually active", "time", "not currently", "medication", "hospital", "normal", "pelvic examination reveals", "tender palpable mass", "right adnexal structure", "pelvic CT scan reveals", "solid adnexal mass", "surgically removed", "ovary", "Histological", "sheets", "uniform cells", "fried egg", "dysgerminoma", "following tumor markers", "most likely elevated", "type", "tumor"]}
{"question": "A 25-year-old woman, gravida 2, para 1, comes to the physician for her initial prenatal visit at 18 weeks’ gestation. She is a recent immigrant from Thailand. Her history is significant for anemia since childhood that has not required any treatment. Her mother and husband have anemia, as well. She has no history of serious illness and takes no medications. Her vital signs are within normal limits. Fundal height measures at 22 weeks. Ultrasound shows polyhydramnios and pleural and peritoneal effusion in the fetus with fetal subcutaneous edema. Which of the following is the most likely clinical course for this fetus?", "answer": "Intrauterine fetal demise", "options": {"A": "Asymptomatic anemia", "B": "Carrier state", "C": "Intrauterine fetal demise", "D": "Neonatal death", "E": "Normal development with regular blood transfusion"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "physician", "weeks gestation", "recent immigrant", "Thailand", "history", "significant", "anemia", "childhood", "not required", "treatment", "anemia", "well", "history", "serious illness", "medications", "vital signs", "normal limits", "Fundal height measures", "weeks", "Ultrasound", "polyhydramnios", "pleural", "peritoneal effusion", "fetus", "fetal subcutaneous", "following", "clinical course", "fetus"]}
{"question": "A 62-year-old woman comes to the physician because of increasing blurring of vision in both eyes. She says that the blurring has made it difficult to read, although she has noticed that she can read a little better if she holds the book below or above eye level. She also requires a bright light to look at objects. She reports that her symptoms began 8 years ago and have gradually gotten worse over time. She has hypertension and type 2 diabetes mellitus. Current medications include glyburide and lisinopril. When looking at an Amsler grid, she says that the lines in the center appear wavy and bent. An image of her retina, as viewed through fundoscopy is shown. Which of the following is the most likely diagnosis?", "answer": "Age-related macular degeneration\n\"", "options": {"A": "Central serous retinopathy", "B": "Hypertensive retinopathy", "C": "Diabetic retinopathy", "D": "Cystoid macular edema", "E": "Age-related macular degeneration\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["62 year old woman", "physician", "of increasing blurring", "vision", "eyes", "blurring", "made", "difficult to", "little better", "holds", "above eye level", "bright light to look", "reports", "symptoms began", "years", "gotten worse", "time", "hypertension", "type 2 diabetes mellitus", "Current medications include glyburide", "lisinopril", "looking", "Amsler grid", "lines", "center appear wavy", "bent", "viewed", "fundoscopy", "following", "diagnosis"]}
{"question": "A 50-year-old woman presents with esophageal varices, alcoholic cirrhosis, hepatic encephalopathy, portal hypertension, and recent onset confusion. The patient’s husband does not recall her past medical history but knows her current medications and states that she is quite disciplined about taking them. Current medications are spironolactone, labetalol, lactulose, and furosemide. Her temperature is 38.3°C (100.9°F), heart rate is 115/min, blood pressure is 105/62 mm Hg, respiratory rate is 12/min, and oxygen saturation is 96% on room air. On physical examination, the patient is disoriented, lethargic, and poorly responsive to commands. A cardiac examination is unremarkable. Lungs are clear to auscultation. The abdomen is distended, tense, and mildly tender. Mild asterixis is present. Neurologic examination is normal. The digital rectal examination reveals guaiac negative stool. Laboratory findings are significant for the following:\nBasic metabolic panel Unremarkable\nPlatelet count 95,500/µL\nLeukocyte count 14,790/µL\nHematocrit 33% (baseline is 30%)\nWhich of the following would most likely be of diagnostic value in this patient?", "answer": "Abdominal paracentesis", "options": {"A": "Noncontrast CT of the head", "B": "Therapeutic trial of lactulose", "C": "Esophagogastroduodenoscopy", "D": "Abdominal paracentesis", "E": "Serum ammonia level"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old woman presents", "esophageal varices", "alcoholic cirrhosis", "hepatic encephalopathy", "portal hypertension", "recent onset confusion", "patients", "not", "past medical history", "current medications", "states", "Current medications", "spironolactone", "labetalol", "lactulose", "furosemide", "temperature", "100 9F", "heart rate", "min", "blood pressure", "62 mm Hg", "respiratory rate", "min", "oxygen saturation", "96", "room air", "patient", "disoriented", "lethargic", "poorly responsive", "unremarkable", "Lungs", "clear", "auscultation", "abdomen", "distended", "tense", "mildly tender", "Mild asterixis", "present", "Neurologic examination", "normal", "digital rectal examination reveals guaiac negative stool", "Laboratory findings", "significant", "following", "Basic metabolic panel Unremarkable Platelet count 95 500 L Leukocyte count", "Hematocrit", "baseline", "30", "following", "most likely", "diagnostic value", "patient"]}
{"question": "A 23-year-old woman is brought to the emergency department 8 hours after the sudden onset of shortness of breath and pleuritic chest pain. She has cystic fibrosis and, during the past year, has had 4 respiratory exacerbations that have required hospitalization. Current medications include an inhaled bronchodilator, an inhaled corticosteroid, inhaled N-acetylcysteine, and azithromycin. The patient appears chronically ill. Her temperature is 37.9°C (100.2°F), pulse is 96/min, respirations are 22/min and labored, and blood pressure is 106/64 mm Hg. Pulse oximetry on 2 L/min of oxygen via nasal cannula shows an oxygen saturation of 96%. Examination shows an increased anteroposterior chest diameter. There is digital clubbing. Chest excursions and tactile fremitus are decreased on the right side. On auscultation of the chest, breath sounds are significantly diminished over the right lung field and diffuse wheezing is heard over the left lung field. Which of the following is the most likely underlying cause of this patient's current symptoms?", "answer": "Apical subpleural cyst", "options": {"A": "Bronchial hyperresponsiveness", "B": "Inflammation of costal cartilage", "C": "Infection with gram-negative coccobacilli", "D": "Apical subpleural cyst", "E": "Increased pulmonary capillary permeability"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old woman", "brought", "emergency department 8 hours", "sudden onset of shortness", "breath", "pleuritic chest pain", "cystic fibrosis", "past year", "4 respiratory exacerbations", "required hospitalization", "Current medications include", "inhaled bronchodilator", "inhaled corticosteroid", "inhaled", "acetylcysteine", "azithromycin", "patient appears chronically ill", "temperature", "100", "pulse", "96 min", "respirations", "min", "labored", "blood pressure", "64 mm Hg", "Pulse oximetry", "L/min", "oxygen", "nasal cannula", "oxygen saturation", "96", "increased", "chest diameter", "digital clubbing", "Chest", "tactile fremitus", "decreased", "right side", "auscultation", "chest", "breath sounds", "diminished", "right lung field", "diffuse wheezing", "heard", "left lung field", "following", "underlying cause", "patient's current symptoms"]}
{"question": "A 61-year-old diabetic woman is brought to the emergency department with the complaint of multiple bouts of abdominal pain in the last 24 hours. She says that the pain is dull aching in nature, radiates to the back, and worsens with meals. She also complains of nausea and occasional vomiting. She has been hospitalized repeatedly in the past with similar complaints. 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. On physical exam, dark hyperpigmentation of the axillary skin is noted. Her blood test report from last month is given below:\nGlycated hemoglobin (HbA1c): 9.1%\nTriglyceride: 675 mg/dL\nLDL-Cholesterol: 102 mg/dL\nHDL-Cholesterol: 35 mg/dL\nTotal Cholesterol: 250 mg/dL\nSerum Creatinine: 1.2 mg/dL\nBUN:  12 mg/dL\nAlkaline phosphatase: 100 U/L\nAlanine aminotransferase: 36 U/L\nAspartate aminotransferase: 28 U/L\nWhat is the most likely diagnosis in this case?", "answer": "Pancreatitis", "options": {"A": "Cholecystitis", "B": "Choledocholithiasis", "C": "Pancreatitis", "D": "Duodenal peptic ulcer", "E": "Gallbladder cancer"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["61 year old diabetic woman", "brought", "emergency department", "complaint", "multiple bouts", "abdominal pain", "last 24 hours", "pain", "dull aching", "nature", "radiates", "back", "worsens", "meals", "nausea", "occasional vomiting", "hospitalized repeatedly", "past", "similar complaints", "temperature", "98", "F", "respiratory rate", "min", "pulse", "min", "blood pressure", "mm Hg", "dark hyperpigmentation of the axillary skin", "noted", "blood test report", "month", "given", "Glycated hemoglobin", "Triglyceride", "675 mg/dL LDL-Cholesterol", "mg/dL HDL-Cholesterol", "35 mg/dL Total Cholesterol", "mg dL Serum Creatinine", "1.2 mg dL BUN", "mg/dL Alkaline phosphatase", "100 U/L Alanine aminotransferase", "36 U/L Aspartate aminotransferase", "U/L", "most likely diagnosis", "case"]}
{"question": "An 82-year-old woman is admitted to the hospital because of wet gangrene on her right leg. Two days after admission, she becomes increasingly confused and tachypneic. She is intubated and ventilatory support is initiated. Her temperature is 39.6°C (102.5°F), pulse is 127/min, and blood pressure is 83/47 mm Hg. The ventilator is set at a FiO2 of 100% and a respiratory rate of 20/min. An arterial blood gas checked 30 minutes after intubation shows a PCO2 of 41 mm Hg and a PO2 of 55 mm Hg. Despite appropriate care, the patient dies from respiratory failure. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Fluid in the alveolar space", "options": {"A": "Hyperinflation of the lungs", "B": "Emboli in the pulmonary vasculature", "C": "Nodular thickening of the interlobular septa", "D": "Abscess in the lung parenchyma", "E": "Fluid in the alveolar space"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "of wet gangrene", "right leg", "Two days", "confused", "tachypneic", "intubated", "support", "initiated", "temperature", "pulse", "min", "blood pressure", "83", "mm Hg", "ventilator", "set", "FiO2", "100", "respiratory rate", "20 min", "arterial blood gas", "30 minutes", "intubation", "PCO2", "mm Hg", "PO2", "mm Hg", "appropriate", "patient dies", "respiratory", "Further evaluation", "to", "following findings"]}
{"question": "A 57-year-old florist presents to his family physician with nodular lesions on his right hand and forearm. He explains that he got pricked by a rose thorn on his right \"pointer finger\" where the first lesions appeared, and the other lesions then began to appear in an ascending manner. The physician prescribed a medication and warned him of gynecomastia as a side effect if taken for long periods of time. Which of the following is the mechanism of action of the medication?", "answer": "Inhibits ergosterol synthesis", "options": {"A": "Inhibits ergosterol synthesis", "B": "Binds to ergosterol, forming destructive pores in cell membrane", "C": "Inhibits squalene epoxidase", "D": "Inhibits formation of beta glucan", "E": "Disrupts microtubule function"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["57 year old florist presents", "family physician", "nodular lesions", "right hand", "forearm", "got pricked", "rose", "right", "pointer finger", "first lesions appeared", "lesions then began to appear", "ascending", "physician", "medication", "gynecomastia", "side effect", "long periods", "time", "following", "mechanism of action", "medication"]}
{"question": "A 58-year-old woman presents to the physician’s office with vaginal bleeding. The bleeding started as a spotting and has increased and has become persistent over the last month. The patient is G3P1 with a history of polycystic ovary syndrome and type 2 diabetes mellitus. She completed menopause 4 years ago. She took cyclic estrogen-progesterone replacement therapy for 1 year at the beginning of menopause. Her weight is 89 kg (196 lb), height 157 cm (5 ft 2 in). Her vital signs are as follows: blood pressure 135/70 mm Hg, heart rate 78/min, respiratory rate 12/min, and temperature 36.7℃ (98.1℉). Physical examination is unremarkable. Transvaginal ultrasound reveals an endometrium of 6 mm thickness. Speculum examination shows a cervix without focal lesions with bloody discharge from the non-dilated external os. On pelvic examination, the uterus is slightly enlarged, movable, and non-tender. Adnexa is non-palpable. What is the next appropriate step in the management of this patient?", "answer": "Endometrial biopsy", "options": {"A": "Hysteroscopy with dilation and curettage", "B": "Medroxyprogesterone acetate therapy", "C": "Endometrial biopsy", "D": "Saline infusion sonography", "E": "Hysteroscopy with targeted biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["58 year old woman presents", "physicians office", "vaginal bleeding", "bleeding started", "spotting", "increased", "persistent", "month", "patient", "history", "polycystic ovary syndrome", "type 2 diabetes mellitus", "completed menopause", "years", "cyclic estrogen progesterone replacement therapy", "year", "beginning", "menopause", "weight", "kg", "height", "5 ft 2", "vital signs", "follows", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "98", "unremarkable", "Transvaginal ultrasound reveals", "endometrium of", "mm thickness", "Speculum", "cervix", "focal lesions", "bloody discharge", "non dilated external os", "pelvic examination", "uterus", "slightly enlarged", "movable", "non-tender", "Adnexa", "non-palpable", "next appropriate step", "patient"]}
{"question": "A student is reviewing the various effects that can be plotted on a dose-response curve. He has observed that certain drugs can work as an agonist and an antagonist at a particular site. He has plotted a particular graph (as shown below) and is checking for other responses that can be measured on the same graph. He learned that drug B is less potent than drug A. Drug B also reduces the potency of drug A when combined in the same solution; however, if additional drug A is added to the solution, the maximal efficacy (Emax) of drug A increases. He wishes to plot another curve for drug C. He learns that drug C works on the same molecules as drugs A and B, but drug C reduces the maximal efficacy (Emax) of drug A significantly when combined with drug A. Which of the following best describes drug C?", "answer": "Non-competitive antagonist", "options": {"A": "Competitive antagonist", "B": "Non-competitive antagonist", "C": "Inverse agonist", "D": "Full agonist", "E": "Reversible antagonist"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["reviewing", "various effects", "dose-response curve", "observed", "certain drugs", "agonist", "antagonist", "site", "responses", "measured", "same", "drug", "less potent than drug", "Drug", "combined", "same solution", "additional drug", "added", "solution", "maximal efficacy", "drug", "increases", "wishes to", "curve", "drug", "drug", "same", "drugs", "drug", "maximal efficacy", "drug", "combined", "drug", "following best", "drug"]}
{"question": "You are seeing a patient in clinic who recently started treatment for active tuberculosis. The patient is currently being treated with rifampin, isoniazid, pyrazinamide, and ethambutol. The patient is not used to taking medicines and is very concerned about side effects. Specifically regarding the carbohydrate polymerization inhibiting medication, which of the following is a known side effect?", "answer": "Vision loss", "options": {"A": "Cutaneous flushing", "B": "Elevated liver enzymes", "C": "Paresthesias of the hands and feet", "D": "Vision loss", "E": "Arthralgias"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["seeing", "patient in clinic", "recently started treatment", "active", "patient", "currently", "treated with rifampin", "isoniazid", "pyrazinamide", "ethambutol", "patient", "not used", "medicines", "very", "side effects", "carbohydrate", "medication", "following", "known side effect"]}
{"question": "A 32-year-old man visits his primary care physician for a routine health maintenance examination. During the examination, he expresses concerns about not wanting to become a father. He has been sexually active and monogamous with his wife for the past 5 years, and they inconsistently use condoms for contraception. He tells the physician that he would like to undergo vasectomy. His wife is also a patient under the care of the physician and during her last appointment, she expressed concerns over being prescribed any drugs that could affect her fertility because she would like to conceive soon. Which of the following is the most appropriate action by the physician regarding this patient's wish to undergo vasectomy?", "answer": "Explain the procedure's benefits, alternatives, and potential complications", "options": {"A": "Insist that the patient returns with his wife to discuss the risks and benefits of the procedure together", "B": "Explain the procedure's benefits, alternatives, and potential complications", "C": "Refer the patient to a psychotherapist to discuss his reluctance to have children", "D": "Call the patient's wife to obtain her consent for the procedure", "E": "Discourage the patient from undergoing the procedure because his wife wants children"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "primary care physician", "routine health", "not", "to", "sexually active", "past", "years", "use condoms", "contraception", "physician", "to", "vasectomy", "physician", "last appointment", "over", "drugs", "fertility", "to", "following", "most appropriate action", "physician", "patient's wish to", "vasectomy"]}
{"question": "A 48-year-old man is brought to the emergency department by his wife 20 minutes after she witnessed him vigorously shaking for about 1 minute. During this episode, he urinated on himself. He feels drowsy and has nausea. He has a history of chronic alcoholism; he has been drinking 15 beers daily for the past 3 days. Before this time, he drank 8 beers daily. His last drink was 2 hours ago. He appears lethargic. His vital signs are within normal limits. Physical and neurologic examinations show no other abnormalities. On mental status examination, he is confused and not oriented to time. Laboratory studies show:\nHematocrit 44.0%\nLeukocyte count 12,000/mm3\nPlatelet count 320,000/mm3\nSerum\nNa+ 112 mEq/L\nCl- 75 mEq/L\nK+ 3.8 mEq/L\nHCO3- 13 mEq/L\nUrea nitrogen 6 mEq/L\nCreatinine 0.6 mg/dL\nAlbumin 2.1 g/dL\nGlucose 80 mg/dL\nUrgent treatment for this patient's current condition puts him at increased risk for which of the following adverse events?\"", "answer": "Osmotic myelinolysis", "options": {"A": "Cerebral edema", "B": "Cardiac arrhythmia", "C": "Hyperglycemia", "D": "Osmotic myelinolysis", "E": "Wernicke encephalopathy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["48 year old man", "brought", "emergency department", "20 minutes", "vigorously shaking", "minute", "episode", "drowsy", "nausea", "history of chronic alcoholism", "drinking", "daily", "past 3 days", "time", "daily", "last", "2 hours", "appears lethargic", "vital signs", "normal limits", "Physical", "neurologic examinations", "abnormalities", "mental status", "confused", "not oriented to time", "Laboratory studies", "Leukocyte count", "Platelet count", "mEq", "HCO3", "mg dL Albumin", "treatment", "patient", "urrent  ondition ", "ncreased risk ", "ollowing  dverse events?"]}
{"question": "A 48-year-old man presents early in the morning to the emergency department with a burning sensation in his chest. He describes a crushing feeling below the sternum and reports some neck pain on the left side. Furthermore, he complains of difficulty breathing. Late last night, he had come home and had eaten a family size lasagna by himself while watching TV. His past medical history is significant for type 2 diabetes and poorly controlled hypertension. The patient admits he often neglects to take his medications and has not been following his advised diet. His current medications are aspirin, metformin, and captopril. Examination reveals a distressed, overweight male sweating profusely. Which of the following is most likely to be found on auscultation?", "answer": "Fourth heart sound", "options": {"A": "Diminished breath sounds", "B": "Ejection systolic murmur", "C": "Expiratory wheezes", "D": "Fixed splitting of the second heart sound", "E": "Fourth heart sound"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["48 year old man presents early", "morning", "emergency department", "burning sensation", "chest", "crushing", "sternum", "reports", "neck pain", "left side", "difficulty breathing", "Late", "night", "home", "eaten", "TV", "past medical history", "significant", "type 2 diabetes", "poorly controlled hypertension", "patient", "often neglects to", "medications", "not", "following", "diet", "current medications", "aspirin", "metformin", "captopril", "reveals", "overweight male sweating", "following", "to", "found", "auscultation"]}
{"question": "A 76-year-old man is brought to the emergency room because of one episode of hemoptysis. His pulse is 110/min. Physical examination shows pallor; there is blood in the oral cavity. Examination of the nasal cavity with a nasal speculum shows active bleeding from the posterior nasal cavity. Tamponade with a balloon catheter is attempted without success. The most appropriate next step in the management is ligation of a branch of a vessel of which of the following arteries?", "answer": "Maxillary artery", "options": {"A": "Ophthalmic artery", "B": "Anterior cerebral artery", "C": "Facial artery", "D": "Occipital artery", "E": "Maxillary artery"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["76 year old man", "brought", "emergency room", "of one episode", "hemoptysis", "pulse", "min", "pallor", "blood in", "cavity", "nasal", "nasal speculum", "active bleeding", "posterior nasal cavity", "Tamponade", "balloon catheter", "most appropriate next step", "ligation", "branch", "vessel", "following arteries"]}
{"question": "A researcher is studying how arachidonic acid metabolites mediate the inflammatory response in rats. She has developed multiple enzyme inhibitors that specifically target individual proteins in the arachidonic acid pathway. She injects these inhibitors in rats who have been exposed to common bacterial pathogens and analyzes their downstream effects. In one of her experiments, she injects a leukotriene B4 inhibitor into a rat and observes an abnormal cell response. Which of the following interleukins would most closely restore the function of one of the missing products?", "answer": "Interleukin 8", "options": {"A": "Interleukin 1", "B": "Interleukin 2", "C": "Interleukin 4", "D": "Interleukin 5", "E": "Interleukin 8"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["researcher", "studying", "arachidonic acid metabolites", "inflammatory response", "multiple enzyme inhibitors", "target", "proteins", "arachidonic acid", "injects", "exposed", "common bacterial", "downstream effects", "one", "injects a leukotriene B4 inhibitor", "observes", "response", "following interleukins", "most", "function", "one", "missing"]}
{"question": "A 23-year-old man comes to the physician because of recurrent episodes of chest pain, shortness of breath, palpitations, and a sensation of choking. The symptoms usually resolve with deep breathing exercises after about 5 minutes. He now avoids going to his graduate school classes because he is worried about having another episode. Physical examination is unremarkable. Treatment with lorazepam is initiated. The concurrent intake of which of the following drugs should be avoided in this patient?", "answer": "Diphenhydramine", "options": {"A": "Diphenhydramine", "B": "Phenelzine", "C": "Naloxone", "D": "Fluoxetine", "E": "Ondansetron"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old man", "physician", "recurrent episodes", "chest pain", "shortness of breath", "palpitations", "sensation", "choking", "symptoms usually", "deep breathing exercises", "about", "minutes", "now", "graduate school", "worried", "episode", "unremarkable", "Treatment", "lorazepam", "initiated", "concurrent intake", "following drugs", "patient"]}
{"question": "A 17-year-old girl with a BMI of 14.5 kg/m2 is admitted to the hospital for the treatment of anorexia nervosa. The patient is administered intravenous fluids and is supplied with 1,600 calories daily with an increase of 200 calories each day. On day 5 of treatment, the patient manifests symptoms of weakness and confusion, and dark brown urine. Which of the following clinical conditions is the most likely cause of the patient's symptoms?", "answer": "Hypophosphatemia", "options": {"A": "Hypercalcemia", "B": "Hyperkalemia", "C": "Hypermagnesemia", "D": "Hypophosphatemia", "E": "Thiamine deficiency"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "BMI", "kg/m2", "treatment", "anorexia nervosa", "patient", "administered", "600 calories daily", "increase", "200 calories", "day", "day 5", "treatment", "patient manifests symptoms", "weakness", "confusion", "dark", "following clinical conditions", "most likely cause", "patient's symptoms"]}
{"question": "A 25-year-old woman is brought to the emergency department after being involved in a rear-end collision, in which she was the restrained driver of the back car. On arrival, she is alert and active. She reports pain in both knees and severe pain over the right groin. Temperature is 37°C (98.6°F), pulse is 116/min, respirations are 19/min, and blood pressure is 132/79 mm Hg. Physical examination shows tenderness over both knee caps. The right groin is tender to palpation. The right leg is slightly shortened, flexed, adducted, and internally rotated. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Posterior hip dislocation", "options": {"A": "Femoral neck fracture", "B": "Anterior hip dislocation", "C": "Femoral shaft fracture", "D": "Posterior hip dislocation", "E": "Pelvic fracture\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "involved", "rear-end collision", "restrained driver of", "back car", "arrival", "alert", "active", "reports pain in both knees", "severe pain", "right", "Temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "tenderness", "knee", "right groin", "tender", "palpation", "right leg", "slightly shortened", "flexed", "internally rotated", "abnormalities", "following", "diagnosis"]}
{"question": "An investigator is studying human genetics and cell division. A molecule is used to inhibit the exchange of genetic material between homologous chromosomes. Which of the following phases of the cell cycle does the molecule target?", "answer": "Prophase I", "options": {"A": "Telophase I", "B": "Metaphase II", "C": "Prophase II", "D": "Prophase I", "E": "Anaphase I"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying human genetics", "cell division", "used to inhibit", "exchange", "genetic material", "homologous chromosomes", "following phases", "cell cycle"]}
{"question": "An investigator is studying neuronal regeneration. For microscopic visualization of the neuron, an aniline stain is applied. After staining, only the soma and dendrites of the neurons are visualized, not the axon. Presence of which of the following cellular elements best explains this staining pattern?", "answer": "Rough endoplasmic reticulum", "options": {"A": "Microtubule", "B": "Nucleus", "C": "Lysosome", "D": "Golgi apparatus", "E": "Rough endoplasmic reticulum"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "regeneration", "microscopic visualization", "aniline", "applied", "staining", "only", "soma", "dendrites", "visualized", "not", "axon", "Presence of", "following cellular", "best", "staining pattern"]}
{"question": "A 67-year-old woman presents to a surgeon with a painless, slowly growing ulcer in the periauricular region for the last 2 months. On physical examination, there is an irregular-shaped ulcer, 2 cm x 1 cm in its dimensions, with irregular margins and crusting over the surface. The woman is a fair-skinned individual who loves to go sunbathing. There is no family history of malignancy. After a complete physical examination, the surgeon performs a biopsy of the lesion under local anesthesia and sends the tissue for histopathological examination. The pathologist confirms the diagnosis of squamous cell carcinoma of the skin. When she asks about the cause, the surgeon explains that there are many possible causes, but it is likely that she has developed squamous cell carcinoma on her face due to repeated exposure to ultraviolet rays from the sun, especially ultraviolet B (UVB) rays. If the surgeon’s opinion is correct, which of the following mechanisms is most likely involved in the pathogenesis of the condition?", "answer": "Intrastrand cross-linking of thymidine residues in DNA", "options": {"A": "Intrastrand cross-linking of thymidine residues in DNA", "B": "Gain-of-function mutations of TP53", "C": "Upregulation of expression of cyclin D2", "D": "Activation of transcription factor NF-κB", "E": "DNA damage caused by the formation of reactive oxygen species"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old woman presents", "surgeon", "painless", "slowly", "ulcer", "region", "last", "months", "irregular shaped ulcer", "2", "dimensions", "irregular margins", "crusting", "surface", "woman", "fair-skinned", "to go", "family history", "malignancy", "surgeon performs", "biopsy", "lesion", "local anesthesia", "sends", "tissue", "histopathological examination", "pathologist confirms the diagnosis of squamous cell carcinoma", "skin", "cause", "surgeon", "possible causes", "likely", "squamous cell carcinoma", "face due to repeated exposure", "ultraviolet rays", "sun", "surgeons", "correct", "following mechanisms", "most likely involved", "pathogenesis", "condition"]}
{"question": "A 67-year-old man presents to the physician with profuse watery diarrhea along with fever and crampy abdominal pain. He has been taking an antibiotic course of cefixime for about a week to treat a respiratory tract infection. At the doctor’s office, his pulse is 112/min, the blood pressure is 100/66 mm Hg, the respirations are 22/min, and the temperature is 38.9°C (102.0°F). His oral mucosa appears dry and his abdomen is soft with vague diffuse tenderness. A digital rectal examination is normal. Laboratory studies show:\nHemoglobin 11.1 g/dL\nHematocrit 33%\nTotal leucocyte count 16,000/mm3\nSerum lactate 0.9 mmol/L\nSerum creatinine 1.1 mg/dL\nWhat is most likely to confirm the diagnosis?", "answer": "Identification of C. difficile toxin in stool", "options": {"A": "Identification of C. difficile toxin in stool", "B": "Stool culture", "C": "Colonoscopy", "D": "Abdominal X-ray", "E": "CT scan of the abdomen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man presents", "physician", "watery diarrhea", "fever", "crampy abdominal pain", "course", "cefixime", "about", "week to treat", "respiratory tract infection", "doctors office", "pulse", "min", "blood pressure", "100 66 mm Hg", "respirations", "min", "temperature", "oral mucosa appears dry", "abdomen", "soft", "vague diffuse tenderness", "digital rectal examination", "normal", "Laboratory studies", "Hemoglobin", "g dL Hematocrit 33", "Total leucocyte count", "Serum lactate", "9 mmol/L", "creatinine", "mg dL", "to confirm", "diagnosis"]}
{"question": "A 45-year-old man presents to the emergency department with fever and easy bruising for 3 days. He has had fatigue for 2 weeks. He has no past medical history, and takes no medications. Excessive bleeding from intravenous lines was reported by the nurse. He does not smoke or drink alcohol. The temperature is 38.2°C (102.6°F), pulse is 105/min, respiration rate is 18/min, and blood pressure is 110/70 mm Hg. On physical examination, he has multiple purpura on the lower extremities and several ecchymoses on the lower back and buttocks. Petechiae are noticed on the soft palate. Cervical painless lymphadenopathy is detected on both sides. The examination of the lungs, heart, and abdomen shows no other abnormalities. The laboratory test results are as follows:\nHemoglobin 8 g/dL\nMean corpuscular volume 90 μm3\nLeukocyte count 18,000/mm3\nPlatelet count 10,000/mm3\nPartial thromboplastin time (activated) 60 seconds\nProthrombin time 25 seconds (INR: 2.2)\nFibrin split products Positive\nLactate dehydrogenase, serum 1,000 U/L\nA Giemsa-stained peripheral blood smear is shown by the image. Intravenous fluids, blood products, and antibiotics are given to the patient. Based on the most likely diagnosis, which of the following is the best therapy for this patient at this time?", "answer": "All-trans retinoic acid (ATRA)", "options": {"A": "All-trans retinoic acid (ATRA)", "B": "Citarubin plus daunorubicin", "C": "Hematopoietic cell transplantation", "D": "Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)", "E": "Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "fever", "easy bruising", "3 days", "fatigue", "2 weeks", "past medical history", "medications", "Excessive bleeding", "intravenous lines", "not smoke", "temperature", "pulse", "min", "respiration rate", "min", "blood pressure", "70 mm Hg", "multiple purpura", "lower extremities", "several ecchymoses", "lower back", "buttocks", "Petechiae", "soft palate", "Cervical painless lymphadenopathy", "detected", "sides", "lungs", "heart", "abdomen", "abnormalities", "laboratory test results", "follows", "Hemoglobin", "g", "Mean corpuscular volume 90 m3 Leukocyte count", "mm3 Platelet count", "Partial thromboplastin time", "60 seconds Prothrombin time", "INR", "2.2", "Fibrin split products Positive Lactate dehydrogenase", "serum", "U/L", "Giemsa-stained peripheral blood smear", "blood products", "given", "patient", "Based", "likely diagnosis", "following", "best therapy", "patient", "time"]}
{"question": "A 2-month-old is brought to the physician for a well-child examination. She was born at 39 weeks gestation via spontaneous vaginal delivery and is exclusively breastfed. She weighed 3,400 g (7 lb 8 oz) at birth. At the physician's office, she appears well. Her pulse is 136/min, the respirations are 41/min, and the blood pressure is 82/45 mm Hg. She weighs 5,200 g (11 lb 8 oz) and measures 57.5 cm (22.6 in) in length. The remainder of the physical examination is normal. Which of the following developmental milestones has this patient most likely met?", "answer": "Smiles in response to face", "options": {"A": "Absence of asymmetric tonic neck reflex", "B": "Monosyllabic babble", "C": "Reaches for objects", "D": "Smiles in response to face", "E": "Stares at own hand"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["2 month old", "brought", "physician", "well", "born", "weeks gestation", "spontaneous vaginal delivery", "breastfed", "3 400", "oz", "birth", "physician's office", "appears well", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "5 200 g", "8 oz", "measures 57", "length", "normal", "following", "patient", "likely met"]}
{"question": "A 40-year-old female comes in with several months of unintentional weight loss, epigastric pain, and a sensation of abdominal pressure. She has diabetes well-controlled on metformin but no other prior medical history. She has not previously had any surgeries. On physical exam, her doctor notices brown velvety areas of pigmentation on her neck. Her doctor also notices an enlarged, left supraclavicular node. Endoscopic findings show a stomach wall that appears to be grossly thickened. Which of the following findings would most likely be seen on biopsy?", "answer": "Cells with central mucin pool", "options": {"A": "Cells with central mucin pool", "B": "Keratin pearls", "C": "Psammoma bodies", "D": "Peyer's patches", "E": "Noncaseating granulomas"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old female", "several months of unintentional weight loss", "epigastric pain", "sensation of abdominal pressure", "diabetes well-controlled", "metformin", "prior medical history", "not", "surgeries", "doctor", "brown", "areas", "pigmentation", "neck", "doctor", "enlarged", "left supraclavicular node", "Endoscopic findings", "stomach wall", "appears to", "thickened", "following findings", "most likely", "seen", "biopsy"]}
{"question": "A 6-year-old boy is brought to the emergency room by ambulance, accompanied by his kindergarten teacher. Emergency department staff attempt to call his parents, but they cannot be reached. The boy’s medical history is unknown. According to his teacher, the boy was eating in the cafeteria with friends when he suddenly complained of itching and developed a widespread rash. Physical exam is notable for diffuse hives and tongue edema. His pulse is 100/min and blood pressure is 90/60 mmHg. The boy appears frightened and tells you that he does not want any treatment until his parents arrive. Which of the following is the next best step in the management of this patient?", "answer": "Immediately administer epinephrine and sedate and intubate the patient", "options": {"A": "Continue calling the patient’s parents and do not intubate until verbal consent is obtained over the phone", "B": "Immediately administer epinephrine and sedate and intubate the patient", "C": "Obtain written consent to intubate from the patient’s teacher", "D": "Obtain written consent to intubate from the patient", "E": "Wait for the patient's parents to arrive, calm the patient, and provide written consent before intubating"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency room", "ambulance", "kindergarten teacher", "Emergency department staff", "to call", "reached", "boys medical history", "unknown", "teacher", "boy", "eating", "itching", "widespread rash", "notable", "diffuse hives", "tongue edema", "pulse", "100 min", "blood pressure", "90 60 mmHg", "boy appears", "not", "treatment", "following", "next best step", "patient"]}
{"question": "A 12-month-old boy is brought to the physician for a well-child examination. He was born at 38 weeks' gestation and was 48 cm (19 in) in length and weighed 3061 g (6 lb 12 oz); he is currently 60 cm (24 in) in length and weighs 7,910 g (17 lb 7 oz). He can walk with one hand held and can throw a small ball. He can pick up an object between his thumb and index finger. He can wave 'bye-bye'. He can say 'mama', 'dada' and 'uh-oh'. He cries if left to play with a stranger alone. Physical examination shows no abnormalities. Which of the following is most likely delayed in this child?", "answer": "Growth", "options": {"A": "Language skills", "B": "Gross motor skills", "C": "Growth", "D": "Fine motor skills", "E": "Social skills"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "physician", "well", "born", "weeks", "gestation", "48", "length", "g", "oz", "currently 60", "length", "7", "g", "17", "7 oz", "one hand held", "throw", "small ball", "pick", "thumb", "index finger", "wave", "left to play", "alone", "abnormalities", "following", "most likely delayed", "child"]}
{"question": "A 27-year-old woman presents to the emergency department with right lower quadrant abdominal pain and vaginal spotting. She denies diarrhea, constipation, or blood in the stool. The medical history is unremarkable. She does not use tobacco or drink alcohol. She is sexually active with her husband and uses an IUD for contraception. The temperature is 37.2 °C (99.0°F), the blood pressure is 110/70 mm Hg, the pulse is 80/min, and the respiratory rate is 12/min. The physical examination reveals localized tenderness in the right adnexa, but no masses are palpated. The LMP was 8 weeks ago. Which of the following is most likely associated with this patient’s diagnosis?", "answer": "Positive urinary beta-HCG and no intrauterine mass", "options": {"A": "Physical examination reveals rebound tenderness and tenderness at McBurney’s point", "B": "Positive urinary beta-HCG and no intrauterine mass", "C": "Abdominal x-ray shows free air under the diaphragm", "D": "Barium enema shows true diverticuli in the colon", "E": "Positive urinary beta-HCG and some products of conception in the uterus"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old woman presents", "emergency department", "right lower quadrant abdominal pain", "vaginal spotting", "diarrhea", "constipation", "blood in", "stool", "medical history", "unremarkable", "not use tobacco", "sexually active", "uses", "IUD", "contraception", "temperature", "99", "blood pressure", "70 mm Hg", "pulse", "80 min", "respiratory rate", "min", "reveals localized tenderness", "right", "masses", "LMP", "weeks", "following", "most likely associated with", "patients diagnosis"]}
{"question": "A 58-year-old man with a past medical history of diabetes, hypertension, and hyperlipidemia was brought into the emergency department by his wife after she observed him go without sleep for several days and recently open and max out several credit cards. She also reports that he has quit his bartending job and has been excessively talkative and easily annoyed for the last several weeks. The patient has no previous psychiatric history. Routine medical examination, investigations, and toxicology rule out a medical cause or substance abuse. Lab results are consistent with chronically impaired renal function. What is the single best treatment for this patient?", "answer": "Valproic acid", "options": {"A": "Valproic acid", "B": "Lithium", "C": "Gabapentin", "D": "Pregabalin", "E": "Lamotrigine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old man", "past medical history of diabetes", "hypertension", "hyperlipidemia", "brought", "emergency department", "observed", "go", "sleep", "several days", "recently open", "out", "reports", "excessively", "easily", "weeks", "patient", "previous psychiatric history", "Routine", "toxicology rule out", "medical cause", "substance abuse", "Lab results", "impaired renal function", "single best"]}
{"question": "A 42-year-old woman comes to the physician for the evaluation of a 1-month history of dull lower abdominal pain, decreased appetite, and a 5-kg (11-lb) weight loss. Physical examination shows no abnormalities. Pelvic ultrasonography shows bilateral ovarian enlargement and free fluid in the rectouterine pouch. Biopsy specimens from the ovaries show multiple, round, mucin-filled cells with flat, peripheral nuclei. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Gastric wall thickening", "options": {"A": "Decreased TSH levels", "B": "Increased testosterone levels", "C": "Dark blue peritoneal spots", "D": "Gastric wall thickening", "E": "Elevated β-hCG levels"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history", "dull lower abdominal pain", "decreased appetite", "5 kg", "weight loss", "abnormalities", "Pelvic ultrasonography", "bilateral ovarian enlargement", "free fluid", "rectouterine pouch", "Biopsy specimens", "ovaries", "multiple", "round", "mucin", "cells", "flat", "peripheral nuclei", "Further", "of", "patient", "to", "following findings"]}
{"question": "A 71-year-old man presents to the clinic with complaints of right wrist pain for 2 days. On examination, redness and swelling were noted on the dorsal aspect of his right wrist. He had  pain with extreme range of motion of the wrist. His history includes 2 hip replacements, 2 previous episodes of gout in both first metatarsophalangeal joints, and hypertension. Two days later, the swelling had increased in the dorsal aspect of his right wrist and hand. Wrist flexion was limited to 80% with severe pain. The pain was present on palpation of the scaphoid bone. Due to the suspicion of fracture, the patient was referred to his general practitioner for radiographs. These findings were consistent with gouty arthritis. What is the most likely cytokine involved in this process?", "answer": "IL-1", "options": {"A": "IL-1", "B": "IL-10", "C": "INFγ", "D": "IL-4", "E": "IL-5"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "clinic", "complaints of right wrist pain", "2 days", "redness", "swelling", "noted", "dorsal aspect of", "right wrist", "pain with extreme range of motion", "wrist", "history includes 2 hip replacements", "2 previous episodes of gout", "first metatarsophalangeal joints", "hypertension", "Two days later", "swelling", "increased", "dorsal aspect of", "right wrist", "hand", "Wrist flexion", "limited", "80", "severe pain", "pain", "present", "palpation of", "scaphoid bone", "Due to", "fracture", "patient", "referred", "general practitioner", "radiographs", "findings", "gouty arthritis", "cytokine involved", "process"]}
{"question": "A group of investigators have conducted a randomized clinical trial to evaluate the efficacy of adding a novel adenosine A1 receptor agonist to the standard anti-epileptic treatment in reducing the frequency of focal seizures. It was found that patients taking the combination regimen (n = 200) had a lower seizure frequency compared to patients taking the standard treatment alone (n = 200; p < 0.01). However, several participants taking the novel drug reported severe drowsiness. The investigators administered a survey to both the combination treatment group and standard treatment group to evaluate whether the drowsiness interfered with daily functioning using a yes or no questionnaire. Results are shown:\nInterference with daily functioning Yes (number of patients) No (number of patients)\nCombination treatment group 115 85\nStandard treatment group 78 122\nWhich of the following statistical methods would be most appropriate for assessing the statistical significance of these results?\"", "answer": "Chi-square test", "options": {"A": "Multiple linear regression", "B": "Chi-square test", "C": "Unpaired t-test", "D": "Paired t-test", "E": "Analysis of variance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigators", "to", "efficacy", "adding a novel adenosine receptor agonist", "standard anti epileptic treatment", "reducing", "frequency", "focal", "found", "patients", "combination regimen", "n", "200", "lower seizure frequency", "patients", "alone", "n", "200", "p", "0.01", "several", "novel drug reported severe drowsiness", "investigators administered", "survey", "combination treatment group", "group to", "drowsiness interfered", "daily functioning using", "yes", "Results", "Interference", "daily functioning Yes", "number of patients", "number of patients", "Combination treatment group", "85 Standard", "following", "most appropriate", "statistical significance", "results"]}
{"question": "A 39-year-old male presents to your office with nodular skin lesions that progress from his right hand to right shoulder. The patient reports that the initial lesion, currently necrotic and ulcerative, developed from an injury he received while weeding his shrubs a couple weeks earlier. The patient denies symptoms of respiratory or meningeal disease. Which of the following most likely characterizes the pattern of this patient’s skin lesions:", "answer": "Ascending lymphangitis", "options": {"A": "Contact dermatitis", "B": "Hematogenous dissemination", "C": "Dermatophyte colonization", "D": "Ascending lymphangitis", "E": "Arthropod bite"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "office", "nodular skin lesions", "progress", "right hand", "right shoulder", "patient reports", "initial lesion", "currently necrotic", "ulcerative", "injury", "received", "weeding", "couple weeks earlier", "patient", "symptoms", "respiratory", "meningeal disease", "following most likely", "pattern", "patients skin lesions"]}
{"question": "A 17-year-old Latin American woman with no significant past medical history or family history presents to her pediatrician with concerns about several long-standing skin lesions. She notes that she has had a light-colored rash on her chest and abdomen that has been present for the last 2 years. The blood pressure is 111/81 mm Hg, pulse is 82/min, respiratory rate is 16/min, and temperature is 37.3°C (99.1°F). Physical examination reveals numerous hypopigmented macules over her chest and abdomen. No lesions are seen on her palms or soles. When questioned, she states that these lesions do not tan like the rest of her skin when exposed to the sun. The remainder of her review of systems is negative. What is the most likely cause of these lesions?", "answer": "Malassezia yeast", "options": {"A": "Malassezia yeast", "B": "Cutaneous T cell lymphoma", "C": "Post-viral immunologic reaction", "D": "TYR gene dysfunction in melanocytes", "E": "Treponema pallidum infection"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "woman", "significant past medical history", "family history presents", "pediatrician", "long standing skin lesions", "notes", "light-colored rash", "chest", "abdomen", "present", "years", "blood pressure", "81 mm Hg", "pulse", "min", "respiratory rate", "min", "temperature", "99", "reveals numerous hypopigmented macules", "chest", "abdomen", "lesions", "seen", "soles", "states", "lesions", "not", "exposed", "sun", "of", "review", "systems", "negative", "most likely cause", "lesions"]}
{"question": "A 45-year-old male presents to the emergency room complaining of severe diarrhea. He recently returned from a business trip to Bangladesh. Since returning, he has experienced several loose bloody stools per day that are accompanied by abdominal cramping and occasional nausea and vomiting. His temperature is 101.7°F (38.7°C), blood pressure is 100/60 mmHg, pulse is 120/min, and respirations are 20/min. On examination, he demonstrates mild tenderness to palpation throughout his abdomen, delayed capillary refill, and dry mucus membranes. Results from a stool sample and subsequent stool culture are pending. What is the mechanism of action of the toxin elaborated by the pathogen responsible for this patient’s current condition?", "answer": "Inhibition of 60S ribosomal subunit", "options": {"A": "ADP-ribosylation of elongation factor 2", "B": "Phospholipid degradation", "C": "Stimulation of guanylyl cyclase", "D": "ADP-ribosylation of a G protein", "E": "Inhibition of 60S ribosomal subunit"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old male presents", "emergency room", "severe diarrhea", "recently returned", "business trip", "Bangladesh", "Since returning", "loose bloody", "day", "abdominal cramping", "occasional nausea", "vomiting", "temperature", "blood pressure", "100 60 mmHg", "pulse", "min", "respirations", "20 min", "mild tenderness", "palpation", "abdomen", "delayed capillary refill", "dry mucus membranes", "Results", "stool sample", "subsequent stool culture", "mechanism of action", "toxin", "responsible", "patients current condition"]}
{"question": "An 80-year-old woman seeks evaluation at an outpatient clinic for a firm nodular lump on the left side of her labia. The medical history is notable for hypertension, coronary artery disease status post CABG, and lichen sclerosus of the vagina that was treated with an over-the-counter steroid cream as needed. She first noticed the lump about 5 months ago. On physical examination, the temperature is 37°C (98.6°F), the blood pressure is 135/89 mm Hg, the pulse is 95/min, and the respiratory rate is 17/min. Examination of the genital area reveals a small nodular lump on the left labium majus with visible excoriations, but no white plaque-like lesions. What is the next best step in management?", "answer": "Vulvar punch biopsy", "options": {"A": "HPV DNA testing", "B": "Estrogen level measurement", "C": "Pap smear", "D": "Vulvar punch biopsy", "E": "Potassium hydroxide test after scraping of the lesion"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["80 year old woman", "outpatient clinic", "firm nodular lump", "left side", "labia", "medical history", "notable", "hypertension", "coronary artery disease status post CABG", "lichen sclerosus", "vagina", "treated with", "over-the-counter", "as needed", "first", "lump", "months", "temperature", "98", "blood pressure", "mm Hg", "pulse", "95 min", "respiratory rate", "min", "Examination", "genital area reveals", "small nodular lump", "left labium majus", "visible excoriations", "white plaque-like lesions", "next best step"]}
{"question": "A 75-year-old male is hospitalized for bloody diarrhea and abdominal pain after meals. Endoscopic work-up and CT scan lead the attending physician to diagnose ischemic colitis at the splenic flexure. Which of the following would most likely predispose this patient to ischemic colitis:", "answer": "Obstruction of the abdominal aorta following surgery", "options": {"A": "Increased splanchnic blood flow following a large meal", "B": "Essential hypertension", "C": "Obstruction of the abdominal aorta following surgery", "D": "Hyperreninemic hyperaldosteronism secondary to type II diabetes mellitus", "E": "Juxtaglomerular cell tumor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old male", "hospitalized", "bloody diarrhea", "abdominal pain", "meals", "Endoscopic work-up", "CT scan lead", "attending physician to diagnose ischemic colitis", "splenic flexure", "following", "most likely", "patient", "ischemic colitis"]}
{"question": "Two days following the home birth of her son, a mother brings the infant to the pediatric emergency room because of bilious vomiting. He is unable to pass meconium and his abdomen is distended. Endoscopic biopsy of the proximal colon demonstrates an absence of Meissner’s and Auerbach’s plexi in the bowel wall. Which of the following is the most likely diagnosis?", "answer": "Hirschsprung’s disease", "options": {"A": "Hirschsprung’s disease", "B": "Ileocecal intussusception", "C": "Meckel’s diverticulum", "D": "Juvenile polyposis syndrome", "E": "Volvulus of the sigmoid colon"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Two days following", "home birth", "infant", "bilious vomiting", "unable to pass meconium", "abdomen", "distended", "Endoscopic biopsy of", "proximal colon", "absence", "Auerbachs plexi", "bowel wall", "following", "diagnosis"]}
{"question": "A 49-year-old man comes to the physician because of a 6-month history of increasing fatigue and reduced libido. He also complains of joint pain in both of his hands. His vital signs are within normal limits. Physical examination shows tanned skin and small testes. The second and third metacarpophalangeal joints of both hands are tender to palpation and range of motion is limited. The liver is palpated 2 to 3 cm below the right costal margin. Histopathologic examination of a liver biopsy specimen shows intracellular material that stains with Prussian blue. This patient is at greatest risk for developing which of the following complications?", "answer": "Restrictive cardiomyopathy", "options": {"A": "Colorectal carcinoma", "B": "Restrictive cardiomyopathy", "C": "Rheumatoid arthritis", "D": "Pancreatic adenocarcinoma", "E": "Non-Hodgkin lymphoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "month history", "increasing fatigue", "reduced libido", "joint pain", "hands", "vital signs", "normal", "Physical examination", "tanned skin", "small testes", "second", "third", "joints of", "hands", "tender", "palpation", "range of motion", "limited", "liver", "2", "3 cm", "right costal margin", "Histopathologic examination of", "liver biopsy", "intracellular", "stains", "Prussian blue", "patient", "greatest", "following complications"]}
{"question": "A general surgery intern is paged to the bedside of a 59-year-old male who underwent a successful sigmoidectomy for treatment of recurrent diverticulitis. The patient's nurse just recorded a temperature of 38.7 C, and relates that the patient is complaining of chills. The surgery was completed 8 hours ago and was complicated by extensive bleeding, with an estimated blood loss of 1,700 mL. Post-operative anemia was diagnosed after a hemoglobin of 5.9 g/dL was found; 2 units of packed red blood cells were ordered, and the transfusion was initiated 90 minutes ago. The patient's vital signs are as follows: T 38.7 C, HR 88, BP 138/77, RR 18, SpO2 98%. Physical examination does not show any abnormalities. After immediately stopping the transfusion, which of the following is the best management of this patient's condition?", "answer": "Monitor patient and administer acetaminophen", "options": {"A": "Hydrate with 1 L bolus of normal saline followed by maintenance fluids at 125 cc/hr", "B": "Monitor patient and administer acetaminophen", "C": "Prescribe diphenhydramine", "D": "Start supplemental oxygen by nasal cannula", "E": "Initiate broad spectrum antibiotics"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["general surgery intern", "59 year old male", "successful sigmoidectomy", "treatment", "recurrent diverticulitis", "patient's nurse", "recorded", "temperature", "relates", "patient", "chills", "surgery", "completed 8 hours", "complicated", "extensive bleeding", "estimated blood loss of 1", "mL", "Post-operative anemia", "diagnosed", "a hemoglobin", "5.9 g/dL", "found", "2 units", "packed red blood cells", "ordered", "transfusion", "initiated 90 minutes", "patient's vital signs", "follows", "T", "88", "BP", "RR", "98", "not", "abnormalities", "immediately stopping", "transfusion", "following", "best management", "patient's"]}
{"question": "A 22-year-old man presents to the emergency department with anxiety. The patient states that he is very anxious and has not been able to take his home anxiety medications. He is requesting to have his home medications administered. The patient has a past medical history of anxiety and depression. His current medications include clonazepam, amitriptyline, and lorazepam. Notably, the patient has multiple psychiatric providers who currently care for him. His temperature is 99.2°F (37.3°C), blood pressure is 130/85 mmHg, pulse is 112/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for an anxious, sweating, and tremulous young man who becomes more confused during his stay in the emergency department. Which of the following should be given to this patient?", "answer": "Diazepam", "options": {"A": "Diazepam", "B": "Flumazenil", "C": "Midazolam", "D": "Sodium bicarbonate", "E": "Supportive therapy and monitoring"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "anxiety", "patient states", "very anxious", "not", "able to", "home anxiety medications", "to", "home medications administered", "patient", "past medical anxiety", "depression", "current medications include clonazepam", "amitriptyline", "lorazepam", "patient", "multiple psychiatric providers", "currently", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "100", "room air", "notable", "anxious", "sweating", "tremulous young man", "more confused", "emergency department", "following", "given", "patient"]}
{"question": "An 18-year-old female returning from a trip to a developing country presents with diarrhea and pain in the abdominal region. Microscopic evaluation of the stool reveals the presence of RBC's and WBC's. The patient reports poor sewage sanitation in the region she visited. The physician suspects a bacterial infection and culture reveals Gram-negative rods that are non-lactose fermenting. The A subunit of the bacteria's toxin acts to:", "answer": "Inhibit the 60S ribosome", "options": {"A": "Inhibit the 60S ribosome", "B": "Lyse red blood cells", "C": "Prevent phagocytosis", "D": "Inhibit exocytosis of ACh from synaptic terminals", "E": "ADP-ribosylate the Gs protein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female returning", "trip", "developing country presents", "diarrhea", "pain", "abdominal region", "Microscopic evaluation", "stool reveals", "presence", "WBC's", "patient reports poor", "region", "physician", "bacterial infection", "culture reveals", "non lactose", "subunit", "bacteria's toxin acts to"]}
{"question": "A 51-year-old man with a recent diagnosis of peptic ulcer disease currently treated with an oral proton pump inhibitor twice daily presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. On physical exam, you find his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Given the following options, what is the next best step in patient management?", "answer": "Urgent CT abdomen and pelvis", "options": {"A": "Abdominal radiographs", "B": "Urgent CT abdomen and pelvis", "C": "Upper endoscopy", "D": "H. pylori testing", "E": "Serum gastrin level"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "recent diagnosis", "peptic ulcer disease currently treated with", "oral proton pump inhibitor twice daily presents", "urgent care center", "acute abdominal pain", "began", "hours", "find", "abdomen to", "mildly distended", "tender", "palpation", "positive", "rebound tenderness", "Given", "following options", "next best step", "patient"]}
{"question": "A 31-year-old male presents to the emergency room following an altercation with patrons at a local grocery store. He is acting aggressively toward hospital staff and appears to be speaking to non-existent individuals. On examination he is tachycardic and diaphoretic. Horizontal and vertical nystagmus is noted. The patient eventually admits to taking an illegal substance earlier in the evening. Which of the following mechanisms of action is most consistent with the substance this patient took?", "answer": "NMDA receptor antagonist", "options": {"A": "Adenosine antagonist", "B": "Biogenic amine reuptake inhibitor", "C": "Mu receptor agonist", "D": "GABA agonist", "E": "NMDA receptor antagonist"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["31 year old male presents", "emergency room following", "local grocery store", "acting", "hospital staff", "appears to", "non", "tachycardic", "diaphoretic", "Horizontal", "vertical nystagmus", "noted", "patient", "earlier", "evening", "of", "following mechanisms", "action", "most", "patient"]}
{"question": "A 29-year-old female presents to her primary care provider complaining of pain and stiffness in her hands and knees. She reports that the stiffness is worse in the morning and appears to get better throughout the day. She is otherwise healthy and denies any recent illness. She does not play sports. On examination, her metacarpal-phalangeal (MCP) and proximal interphalangeal (PIP) joints are swollen and erythematous. Her distal interphalangeal (DIP) joints appear normal. She exhibits pain with both passive and active range of motion in her knees bilaterally. Serological analysis reveals high titers of anti-cyclic citrullinated peptide antibodies. Which of the following processes underlies this patient’s condition?", "answer": "Synovial hypertrophy and pannus formation", "options": {"A": "Precipitation of monosodium urate crystals in the intra-articular space", "B": "Post-infectious inflammation of the articular surfaces", "C": "Aseptic necrosis of articular cartilage and subchondral bone", "D": "Degenerative deterioration of articular cartilage", "E": "Synovial hypertrophy and pannus formation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old female presents", "primary care provider", "pain", "stiffness", "hands", "knees", "reports", "stiffness", "worse", "morning", "appears to", "better", "day", "healthy", "recent illness", "not play", "metacarpal phalangeal", "proximal interphalangeal", "joints", "swollen", "erythematous", "distal interphalangeal", "joints appear normal", "pain", "passive", "active range of motion", "knees", "Serological analysis reveals high titers", "anti-cyclic citrullinated peptide antibodies", "following processes", "patients condition"]}
{"question": "A 28-year-old man presents for severe abdominal pain and is diagnosed with appendicitis. He is taken for emergent appendectomy. During the procedure, the patient has massive and persistent bleeding requiring a blood transfusion. The preoperative laboratory studies showed a normal bleeding time, normal prothrombin time (PT), an INR of 1.0, and a normal platelet count. Postoperatively, when the patient is told about the complications during the surgery, he recalls that he forgot to mention that he has a family history of an unknown bleeding disorder. The postoperative laboratory tests reveal a prolonged partial thromboplastin time (PTT). Which of the following is the most likely diagnosis in this patient?", "answer": "Hemophilia A", "options": {"A": "Hemophilia A", "B": "Bernard-Soulier syndrome", "C": "Glanzman syndrome", "D": "Thrombotic thrombocytopenic purpura", "E": "von Willebrand disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "severe abdominal", "diagnosed", "appendicitis", "appendectomy", "procedure", "patient", "massive", "persistent bleeding", "blood transfusion", "preoperative laboratory studies", "normal bleeding time", "normal prothrombin time", "INR", "1.0", "normal platelet count", "patient", "complications", "surgery", "forgot to", "family history of", "unknown bleeding disorder", "postoperative laboratory tests reveal", "prolonged partial thromboplastin time", "following", "diagnosis", "patient"]}
{"question": "An 11-year-old girl is brought to the emergency department because of high-grade fever, headache, and nausea for 3 days. She avoids looking at any light source because this aggravates her headache. She has acute lymphoblastic leukemia and her last chemotherapy cycle was 2 weeks ago. She appears lethargic. Her temperature is 40.1°C (104.2°F), pulse is 131/min and blood pressure is 100/60 mm Hg. Examination shows a stiff neck. The pupils are equal and reactive to light. Neck flexion results in flexion of the knee and hip. Muscle strength is decreased in the right upper extremity. Deep tendon reflexes are 2+ bilaterally. Sensation is intact. Extraocular movements are normal. Two sets of blood cultures are obtained. Which of the following is the most appropriate next step in management?", "answer": "Antibiotic therapy", "options": {"A": "CT scan of the head", "B": "MRI of the brain", "C": "Antibiotic therapy", "D": "Lumbar puncture", "E": "Acyclovir therapy\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "emergency department", "high-grade fever", "headache", "nausea", "3 days", "looking", "light source", "aggravates", "headache", "acute lymphoblastic leukemia", "last chemotherapy cycle", "2 weeks", "appears lethargic", "temperature", "40", "pulse", "min", "blood pressure", "100 60 mm Hg", "stiff neck", "pupils", "equal", "reactive to light", "Neck flexion results in flexion of", "knee", "hip", "Muscle", "decreased", "right upper extremity", "Deep tendon reflexes", "2", "Sensation", "intact", "Extraocular movements", "normal", "Two sets of blood cultures", "obtained", "following", "most appropriate next step"]}
{"question": "A 49-year-old man presents to a new primary care provider complaining of fatigue and occasional fever over the last month. These symptoms are starting to affect his job and he would like treatment. The physician runs a standard metabolic panel that shows elevated AST and ALT. The patient is then tested for hepatitis viruses. He is hepatitis C positive. The patient and his doctor discuss treatment options and agree upon pegylated interferon and oral ribavirin. Which side-effect is most likely while taking the ribavirin?", "answer": "Hemolytic anemia", "options": {"A": "Hemolytic anemia", "B": "Drug-associated lupus", "C": "Leukopenia", "D": "Hyperthyroidism", "E": "Rash"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "new primary care provider", "fatigue", "occasional fever", "month", "symptoms", "starting to", "treatment", "physician runs", "standard metabolic panel", "elevated AST", "ALT", "patient", "then", "hepatitis", "positive", "patient", "doctor", "treatment options", "agree", "interferon", "oral ribavirin", "side-effect", "ribavirin"]}
{"question": "A 45-year-old immigrant presents with unintentional weight loss, sleep hyperhidrosis, and a persistent cough. He says these symptoms have been present for quite some time. Upon imaging, many granulomas in the upper lobes are present. It is noted that these apical granulomas have centers of necrosis that appear cheese-like in appearance. Encircling the area of necrosis are large cells with cytoplasms pale in color. Of the following surface markers, which one is specific for these cells?", "answer": "CD14", "options": {"A": "CD8", "B": "CD4", "C": "CD3", "D": "CD14", "E": "CD20"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "unintentional weight loss", "sleep hyperhidrosis", "persistent cough", "symptoms", "present", "time", "imaging", "granulomas", "upper lobes", "present", "noted", "apical granulomas", "centers", "necrosis", "appear", "appearance", "Encircling", "area", "necrosis", "cytoplasms pale", "color", "following surface markers", "one", "specific", "cells"]}
{"question": "A 27-year-old woman comes to the emergency room because of fever and severe left knee pain for the past week. She has not sustained any trauma or injury to the area, nor has she traveled or taken part in outdoor activities in the recent past. She is sexually active with one male partner, and they use condoms inconsistently. She appears ill. Her temperature is 38°C (100.4°F), pulse is 98/min, respirations are 17/min, and blood pressure is 106/72 mm Hg. Physical examination shows multiple painless pustular lesions on her ankles and the dorsum and soles of her feet bilaterally, as well as a swollen, erythematous, exquisitely tender left knee. Her wrists are also mildly edematous and tender, with pain on extension. X-ray of the knees shows tissue swelling. Arthrocentesis of the knee shows yellow purulent fluid. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 58,000/mm3 with 93% neutrophils and no crystals. Which of the following is the most appropriate pharmacotherapy?", "answer": "Intramuscular ceftriaxone and oral azithromycin", "options": {"A": "Oral penicillin V", "B": "Oral hydroxychloroquine", "C": "Intramuscular ceftriaxone and oral azithromycin", "D": "Oral doxycycline", "E": "Intramuscular ceftriaxone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old woman", "emergency room", "fever", "severe left knee pain", "past week", "not sustained", "trauma", "injury", "area", "part", "outdoor activities", "recent past", "sexually active", "one male", "use condoms", "appears ill", "temperature", "100", "pulse", "98 min", "respirations", "min", "blood pressure", "72 mm Hg", "multiple painless pustular lesions", "ankles", "dorsum", "soles of", "feet", "swollen", "erythematous", "tender left", "wrists", "mildly edematous", "tender", "pain", "extension", "X-ray", "knees", "tissue swelling", "Arthrocentesis of", "knee", "yellow purulent fluid", "Gram stain", "negative", "Analysis", "synovial fluid", "leukocyte count", "58", "mm3", "crystals", "following", "most appropriate pharmacotherapy"]}
{"question": "A 30-year-old man presents with restlessness and an inability to sit or lie down for the past 2 days. Past medical history is significant for schizophrenia, diagnosed 3 weeks ago and managed medically. Vital signs are a blood pressure of 140/90 mm Hg and a pulse of 96/min. On physical examination, the patient is fidgety and anxious but well-oriented. Which of the following is the most likely diagnosis in this patient?", "answer": "Akathisia", "options": {"A": "Psychotic agitation", "B": "Essential tremor", "C": "Acute muscular dystonia", "D": "Drug-induced parkinsonism", "E": "Akathisia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["30 year old man presents", "restlessness", "sit", "past", "days", "medical history", "significant", "schizophrenia", "diagnosed 3 weeks", "Vital signs", "blood pressure", "90 mm Hg", "pulse", "96 min", "patient", "fidgety", "anxious", "well oriented", "following", "diagnosis", "patient"]}
{"question": "In a previous experiment infecting hepatocytes, it was shown that viable HDV virions were only produced in the presence of a co-infection with HBV. To better understand which HBV particle was necessary for the production of viable HDV virions, the scientist encoded in separate plasmids the various antigens/proteins of HBV and co-infected the hepatocytes with HDV. In which of the experiments would viable HDV virions be produced in conjunction with the appropriate HBV antigen/protein?", "answer": "HBsAg", "options": {"A": "HBsAg", "B": "HBV DNA polymerase", "C": "HBcAg", "D": "HBV RNA polymerase", "E": "HBeAg"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["previous", "infecting", "viable", "virions", "only", "presence of", "co infection", "better", "particle", "viable", "virions", "scientist", "separate plasmids", "various", "co infected", "viable", "virions", "appropriate"]}
{"question": "A 61-year-old woman presents to her primary care physician for a routine check-up. Physical examination demonstrates asymmetric peripheral neuropathy in her feet. The patient has no previous relevant history and denies any symptoms of diabetes. Routine blood work shows normal results, and she is referred to a hematologist. Subsequent serum protein electrophoresis demonstrates a slightly elevated gamma globulin level, and monoclonal gammopathy of undetermined significance is diagnosed. Which of the following diseases is most likely to develop over the course of this patient’s condition?", "answer": "Multiple myeloma", "options": {"A": "Waldenström macroglobulinemia", "B": "Multiple myeloma", "C": "Acute myelocytic leukemia", "D": "Chronic lymphocytic leukemia", "E": "Chronic myelocytic leukemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old woman presents", "primary care physician", "routine check-up", "Physical examination", "asymmetric peripheral neuropathy", "feet", "patient", "previous relevant history", "symptoms", "diabetes", "Routine blood", "normal results", "referred to", "hematologist", "Subsequent serum protein electrophoresis", "slightly elevated gamma globulin level", "monoclonal gammopathy of undetermined significance", "diagnosed", "following diseases", "to", "course", "patients condition"]}
{"question": "A 71-year-old man presents to his primary care physician because he is increasingly troubled by a tremor in his hands. He says that the tremor is worse when he is resting and gets better when he reaches for objects. His wife reports that he has been slowing in his movements and also has difficulty starting to walk. His steps have been short and unsteady even when he is able to initiate movement. Physical exam reveals rigidity in his muscles when tested for active range of motion. Histology in this patient would most likely reveal which of the following findings?", "answer": "Alpha-synuclein", "options": {"A": "Alpha-synuclein", "B": "Intracellular hyperphosphorylated tau", "C": "Hyperphosphorylated tau inclusion bodies", "D": "Large intracellular vacuoles", "E": "Perivascular inflammation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "tremor", "hands", "tremor", "worse", "gets better", "reaches", "reports", "slowing", "movements", "difficulty starting to", "steps", "short", "unsteady", "able to initiate movement", "reveals rigidity", "muscles", "tested", "active range of motion", "Histology", "patient", "most likely reveal", "following findings"]}
{"question": "A 52-year-old man is brought to the emergency department while on vacation with a history of sudden onset vertigo and difficulty walking. He was in normal health since starting his vacation a week ago, but today he is suffering from a loss of balance, mild headache, and has had 5–6 episodes of vomiting over the last few hours. He denies fever, neck pain, head trauma, weakness, and diplopia. Past medical history is significant for hypertension and dyslipidemia. His medications include valsartan and atorvastatin, but he missed several doses since leaving for this trip. Blood pressure is 198/112 mm Hg, the heart rate is 76/min, the respiratory rate is 16/min, and the temperature is 37.0°C (98.6°F). The patient is awake and oriented to time, place, and person. Extraocular movements are within normal limits. Muscle strength is normal in all 4 extremities. An urgent head CT is ordered and shown in the picture. What additional clinical features be expected in this patient?", "answer": "Inability to perform repetitive alternating movements", "options": {"A": "Inability to comprehend commands", "B": "Inability to perform repetitive alternating movements", "C": "Inability to speak fluently", "D": "Right-sided neglect", "E": "Right-sided visual field loss"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "history of sudden onset vertigo", "difficulty walking", "normal", "starting", "week", "today", "suffering", "loss of balance", "mild headache", "episodes of vomiting", "last", "hours", "fever", "neck pain", "head trauma", "weakness", "diplopia", "Past medical history", "significant", "hypertension", "dyslipidemia", "medications include valsartan", "atorvastatin", "missed several doses", "trip", "Blood pressure", "mm Hg", "heart rate", "76 min", "respiratory rate", "min", "temperature", "98", "patient", "awake", "oriented to time", "place", "Extraocular movements", "normal limits", "Muscle strength", "normal", "extremities", "urgent head CT", "ordered", "picture", "additional clinical features", "patient"]}
{"question": "A 65-year-old man presents with painless swelling of the neck over the past week. He also has noted severe night sweats, which require a change of clothes and bed linens the next day. His medical history is significant for long-standing hypertension. He received a kidney transplant 6 years ago. His current medications include amlodipine, metoprolol, furosemide, aspirin, tacrolimus, and mycophenolate. His family history is significant for his sister, who died last year from lymphoma. A review of systems is positive for a 6-kg (13.2-lb) unintentional weight loss over the past 2 months. His vital signs include: temperature 37.8℃ (100.0℉) and blood pressure 120/75 mm Hg. On physical examination, there are multiple painless lymph nodes, averaging 2 cm in diameter, palpable in the anterior and posterior triangles of the neck bilaterally. Axillary and inguinal lymphadenopathy is palpated on the right side. Abdominal examination is significant for a spleen of 16 cm below the cost margin on percussion. Laboratory studies are significant for the following:\nHemoglobin 9 g/dL\nMean corpuscular volume 88 μm3\nLeukocyte count 12,000/mm3\nPlatelet count 130,000/mm3\nCreatinine 1.1 mg/dL\nLactate dehydrogenase (LDH) 1 000 U/L\nA peripheral blood smear is unremarkable. Which of the following is the most likely diagnosis in this patient?", "answer": "Non-Hodgkin’s lymphoma (NHL)", "options": {"A": "Chronic lymphocytic leukemia (CLL)", "B": "Drug-induced lymphadenopathy", "C": "Cytomegalovirus infection", "D": "Multiple myeloma", "E": "Non-Hodgkin’s lymphoma (NHL)"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["65 year old man presents", "painless swelling of the neck", "past week", "noted severe night sweats", "change", "clothes", "bed linens", "next day", "medical history", "significant", "long standing hypertension", "received", "kidney transplant", "years", "current medications include amlodipine", "metoprolol", "furosemide", "aspirin", "tacrolimus", "mycophenolate", "family history", "significant", "died last year", "lymphoma", "review of systems", "positive", "kg", "unintentional weight loss", "past", "months", "vital signs include", "temperature", "100 0", "blood pressure", "75 mm Hg", "multiple painless lymph nodes", "averaging 2", "diameter", "palpable", "anterior", "posterior triangles of", "neck", "Axillary", "inguinal lymphadenopathy", "right side", "Abdominal", "significant", "spleen", "cost margin", "percussion", "Laboratory studies", "significant", "following", "Hemoglobin", "g dL Mean corpuscular volume", "Leukocyte 12", "mm3 Platelet count", "Creatinine 1", "mg dL Lactate dehydrogenase", "U L", "peripheral blood smear", "unremarkable", "following", "diagnosis", "patient"]}
{"question": "A 56-year-old man is brought to the emergency department by his neighbor 2 hours after ingesting an unknown substance in a suicide attempt. He is confused and unable to provide further history. His temperature is 39.1°C (102.3°F), pulse is 124/min, respiratory rate is 12/min, and blood pressure is 150/92 mm Hg. His skin is dry. Pupils are 12 mm and minimally reactive. An ECG shows no abnormalities. Which of the following is the most appropriate treatment for this patient's condition?", "answer": "Physostigmine", "options": {"A": "Sodium bicarbonate", "B": "Physostigmine", "C": "N-acetylcysteine", "D": "Glucagon", "E": "Flumazenil"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "hours", "suicide attempt", "confused", "unable to", "further history", "temperature", "pulse", "min", "respiratory rate", "min", "blood pressure", "mm Hg", "skin", "dry", "Pupils", "mm", "reactive", "ECG", "abnormalities", "following", "most appropriate treatment", "patient's condition"]}
{"question": "An 81-year-old man presents to his primary care physician for his yearly exam. His past medical history is significant for osteopenia, nephrolithiasis, and hypertension. His family history is significant for relatives who had early onset kidney failure. He takes occasional acetaminophen and supplemental calcium/vitamin D. He is physically active with a normal body mass index (BMI) and has no current concerns. Review of his laboratory results today were compared with those from 15 years ago with the following findings:\n\nResults today:\nSerum creatinine concentration: 1.1 mg/dL\nUrine creatinine concentration: 100 mg/dL\nUrine volume: 1000 mL/day\n\nResults 15 years ago:\nSerum creatinine concentration: 1.1 mg/dL\nUrine creatinine concentration: 120 mg/dL\nUrine volume: 1000 mL/day\n\nWhich is the most likely cause of these changes in his creatinine clearance?", "answer": "Normal aging", "options": {"A": "Benign prostatic hyperplasia", "B": "Nephrolithiasis", "C": "Normal aging", "D": "Polycystic kidney disease", "E": "Renovascular disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["81 year old man presents", "primary care physician", "yearly exam", "past medical history", "significant", "osteopenia", "nephrolithiasis", "hypertension", "family history", "significant", "early onset kidney failure", "occasional acetaminophen", "supplemental calcium/vitamin D", "active", "normal body mass index", "current", "laboratory results today", "years", "following findings", "Results today", "Serum concentration", "1.1 mg/dL Urine creatinine concentration", "100 mg/dL Urine volume", "mL/day", "Results", "years", "Serum concentration", "1.1 mg/dL Urine creatinine concentration", "mg/dL Urine volume", "mL/day", "most likely cause", "changes"]}
{"question": "A 72-year-old man presents to his primary care provider complaining of fatigue, mild headache, and discomfort with chewing for roughly 1 week. Before this, he felt well overall, but now is he is quite bothered by these symptoms. His medical history is notable for hypertension and hyperlipidemia, both controlled. On examination, he is uncomfortable but nontoxic-appearing. There is mild tenderness to palpation over his right temporal artery, but otherwise the exam is not revealing. Prompt recognition and treatment can prevent which of the following feared complications:", "answer": "Blindness", "options": {"A": "Renal failure", "B": "Blindness", "C": "Pericarditis", "D": "Pulmonary fibrosis", "E": "Cognitive impairment"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old man presents", "primary care provider", "fatigue", "mild headache", "discomfort", "chewing", "week", "well overall", "now", "symptoms", "medical history", "notable", "hypertension", "hyperlipidemia", "controlled", "nontoxic appearing", "mild tenderness", "palpation", "right temporal artery", "exam", "not revealing", "Prompt", "treatment", "prevent", "following", "complications"]}
{"question": "A 14-month-old boy is brought to the clinic for evaluation of a rash. The rash started on the face and spread to the trunk. He also had a fever and cough for the past 2 days. His mother says that they recently immigrated from Asia and cannot provide vaccination records. The physical examination reveals a maculopapular rash on the face, trunk, and proximal limbs with no lymphadenopathy. Blue-white spots are noted on the oral mucosa and there is bilateral mild conjunctival injection. The causative agent of this condition belongs to which of the following virus families?", "answer": "ssRNA enveloped viruses", "options": {"A": "ssDNA enveloped viruses", "B": "dsRNA enveloped viruses", "C": "ssRNA naked viruses", "D": "dsRNA naked viruses", "E": "ssRNA enveloped viruses"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old boy", "brought", "clinic", "rash", "rash started", "face", "spread", "trunk", "fever", "cough", "past 2 days", "recently", "Asia", "vaccination records", "reveals", "maculopapular rash on", "face", "trunk", "proximal limbs", "lymphadenopathy", "Blue white spots", "noted", "oral mucosa", "bilateral mild conjunctival injection", "causative agent", "condition", "following"]}
{"question": "A 31-year-old G1P0 woman at 26 weeks gestation presents to the clinic for evaluation of an abnormal glucose tolerance test. She denies any symptoms, but states that she was given 50 g of oral glucose 1 week earlier and demonstrated a subsequent venous plasma glucose level of 156 mg/dL 1 hour later. The vital signs are: blood pressure, 112/78 mm Hg; pulse, 81/min; and respiratory rate, 16/min. Physical examination is within normal limits. Which of the following is the most appropriate next step in management?", "answer": "Administer an oral, 3-hour 100 g glucose dose", "options": {"A": "Repeat the 50 g oral glucose challenge", "B": "Administer an oral, 3-hour 100 g glucose dose", "C": "Advise the patient to follow an American Diabetic Association diet plan", "D": "Begin insulin treatment", "E": "Order a fetal ultrasound examination"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["31 year old", "woman", "weeks presents", "clinic", "abnormal glucose tolerance test", "symptoms", "states", "given 50 g", "oral 1 earlier", "subsequent venous", "mg/dL", "hour later", "vital signs", "blood pressure", "mm Hg", "pulse", "81 min", "respiratory rate", "min", "normal limits", "following", "most appropriate next step"]}
{"question": "A newborn of a mother with poor antenatal care is found to have a larger than normal head circumference with bulging fontanelles. Physical examination reveals a predominant downward gaze with marked eyelid retraction and convergence-retraction nystagmus. Ultrasound examination showed dilated lateral ventricles and a dilated third ventricle. Further imaging studies reveal a solid mass in the pineal region. Which of the following is the most likely finding for this patient?", "answer": "Compression of periaqueductal grey matter", "options": {"A": "Normal lumbar puncture opening pressure", "B": "Stenotic intraventricular foramina", "C": "Dilated cisterna magna", "D": "Compression of periaqueductal grey matter", "E": "Hypertrophic arachnoid granulations"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["newborn", "poor antenatal care", "found to", "larger", "normal head circumference", "bulging fontanelles", "reveals", "predominant downward gaze", "marked eyelid retraction", "convergence-retraction nystagmus", "Ultrasound examination", "dilated lateral ventricles", "dilated third ventricle", "Further imaging studies reveal", "solid mass", "pineal region", "following", "finding", "patient"]}
{"question": "A 22-year-old man comes to the physician because of a progressive swelling and pain in his right ring finger for the past 2 days. The pain began while playing football, when his finger got caught in the jersey of another player who forcefully pulled away. Examination shows that the right ring finger is extended. There is pain and swelling at the distal interphalangeal joint. When the patient is asked to make a fist, his right ring finger does not flex at the distal interphalangeal joint. There is no joint laxity. Which of the following is the most likely diagnosis?", "answer": "Rupture of the flexor digitorum profundus tendon at its point of insertion", "options": {"A": "Rupture of the flexor digitorum profundus tendon at its point of insertion", "B": "Closed fracture of the distal phalanx", "C": "Rupture of the extensor digitorum tendon at its point of insertion", "D": "Inflammation of the flexor digitorum profundus tendon sheath", "E": "Slipping of the central band of the extensor digitorum tendon"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "progressive swelling", "pain", "right ring finger", "past 2 days", "pain began", "playing football", "finger", "caught", "jersey", "pulled", "right ring finger", "extended", "pain", "swelling", "distal", "patient", "to make", "fist", "right ring finger", "not", "distal interphalangeal joint", "joint laxity", "following", "diagnosis"]}
{"question": "A 50-year-old man comes to the physician for a routine checkup. He has had a progressively increasing swelling on the nape of his neck for 2 months. He does not have a fever or any discharge from the swelling. He underwent a colectomy for colon cancer at the age of 43 years. He has type 2 diabetes mellitus, hypertension, and osteoarthritis of the left knee. Current medications include insulin glargine, metformin, enalapril, and naproxen. He has worked as a traffic warden for the past 6 years and frequently plays golf. He appears healthy. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 130/86 mm Hg. Examination of the neck shows a 2.5-cm (1-in) firm, mobile, and painless nodule. The skin over the nodule cannot be pinched. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. A photograph of the lesion is shown. Which of the following is the most likely diagnosis?", "answer": "Epidermoid cyst", "options": {"A": "Actinic keratosis", "B": "Epidermoid cyst", "C": "Dermatofibroma", "D": "Lipoma", "E": "Squamous cell carcinoma\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["50 year old man", "physician", "routine checkup", "increasing swelling", "the nape of", "neck", "2 months", "not", "fever", "discharge", "swelling", "colectomy", "colon cancer", "age", "years", "type 2 diabetes mellitus", "hypertension", "osteoarthritis of", "left knee", "Current medications include insulin glargine", "metformin", "enalapril", "naproxen", "traffic warden", "past", "years", "frequently plays", "appears healthy", "temperature", "99", "pulse", "88 min", "blood pressure", "mm Hg", "Examination of", "neck", "2.5", "1", "firm", "mobile", "painless nodule", "skin", "nodule", "pinched", "lungs", "clear", "auscultation", "abnormalities", "photograph", "lesion", "following", "diagnosis"]}
{"question": "A 67-year-old man comes to the physician because of a 3-day history of fever, chills, headache, and fatigue. He appears ill. His temperature is 39°C (102.2°F). Analysis of nasal secretions shows infection with an enveloped, single-stranded segmented RNA virus. In response to infection with this pathogen, certain cells present antigens from the pathogen to CD8+ T-lymphocytes. Which of the following statements about the molecules used for the presentation of these antigens is most accurate?", "answer": "The molecule consists of a heavy chain associated with β2 microglobulin", "options": {"A": "The antigens are loaded onto the molecule within lysosomes", "B": "The molecule consists of a heavy chain associated with β2 microglobulin", "C": "The molecule is made up of 2 chains of equal length", "D": "The molecule is selectively expressed by antigen-presenting cells", "E": "The molecule is a product of the HLA-DP, HLA-DQ, and -DR genes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["67 year old man", "physician", "3-day history", "fever", "chills", "headache", "fatigue", "appears ill", "temperature", "Analysis", "infection", "segmented", "response", "infection", "certain cells present", "following", "used", "presentation", "antigens", "most accurate"]}
{"question": "A 58-year-old female, being treated on the medical floor for community-acquired pneumonia with levofloxacin, develops watery diarrhea. She reports at least 9 episodes of diarrhea within the last two days, with lower abdominal discomfort and cramping. Her temperature is 98.6° F (37° C), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Her physical examination is unremarkable. Laboratory testing shows:\nHb%   13 gm/dL\nTotal count (WBC):   13,400/mm3\nDifferential count:    \n  Neutrophils: 80%\n  Lymphocytes: 15%\n  Monocytes: 5%\nESR:   33 mm/hr\nWhat is the most likely diagnosis?", "answer": "C. difficile colitis", "options": {"A": "Ulcerative colitis", "B": "C. difficile colitis", "C": "Irritable bowel syndrome", "D": "Osmotic diarrhea", "E": "Giardiasis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old female", "treated", "medical floor", "community-acquired pneumonia", "levofloxacin", "watery diarrhea", "reports", "episodes", "diarrhea", "last two days", "lower abdominal discomfort", "cramping", "temperature", "98", "F", "respiratory rate", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "unremarkable", "Laboratory testing", "Hb", "gm dL Total count", "WBC", "400 mm3 Differential count", "80", "Lymphocytes", "5", "ESR", "mm", "diagnosis"]}
{"question": "A 7-year-old girl presents to her primary care physician for a routine check-up. The physician allows the medical student to perform a physical examination. The medical student notes hearing impairment as well as the findings show in Figures A and B. Radiographs show indications of multiple old fractures of the humerus that have healed. After questioning the girl’s parents, the medical student learns that in addition, the patient is extremely picky with her food and eats a diet consisting mainly of cereal and pasta. What is the most likely etiology of the patient’s disease?", "answer": "Deficiency of type 1 collagen", "options": {"A": "Decreased bone mineral density", "B": "Defective mineralization of cartilage", "C": "Deficiency of type 1 collagen", "D": "Dietary deficiency of ascorbic acid", "E": "Non-accidental trauma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl presents", "primary care physician", "routine check-up", "physician", "medical student to perform", "medical student notes hearing impairment", "findings", "Radiographs", "of multiple old fractures", "humerus", "healed", "girls", "medical student", "addition", "patient", "extremely", "food", "eats", "diet consisting", "etiology", "patients disease"]}
{"question": "A 47-year-old man comes to the physician because of abdominal pain and foul-smelling, watery diarrhea for several days. He has not had nausea, vomiting, or blood in the stool. He has a history of alcohol use disorder and recently completed a 7-day course of clindamycin for pneumonia. He has not traveled out of the United States. Which of the following toxins is most likely to be involved in the pathogenesis of this patient's symptoms?", "answer": "Clostridioides difficile cytotoxin", "options": {"A": "Shiga toxin", "B": "Cholera toxin", "C": "Cereulide toxin", "D": "Clostridioides difficile cytotoxin", "E": "Alpha toxin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "abdominal pain", "smelling", "watery diarrhea", "days", "not", "nausea", "vomiting", "blood in", "stool", "history of alcohol use disorder", "recently completed", "7-day course", "clindamycin", "pneumonia", "not traveled out of", "United States", "following toxins", "to", "involved", "pathogenesis", "patient's symptoms"]}
{"question": "A 6-year-old boy presents to the clinic because of monosymptomatic enuresis for the past month. Urinalysis, detailed patient history, and fluid intake, stool, and voiding diary from a previous visit all show no abnormalities. The parent and child are referred for education and behavioral therapy. Enuresis decreases but persists. Both the patient and his mother express concern and want this issue to resolve as soon as possible. Which of the following is the most appropriate next step in management?", "answer": "Enuresis alarm", "options": {"A": "Behavioral therapy", "B": "DDAVP", "C": "Enuresis alarm", "D": "Oxybutynin", "E": "Reassurance"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "clinic", "of", "enuresis", "past month", "Urinalysis", "detailed patient history", "fluid intake", "stool", "voiding", "previous", "abnormalities", "child", "referred", "education", "behavioral therapy", "Enuresis decreases", "patient", "issue to", "possible", "following", "most appropriate next step"]}
{"question": "A 32-year-old homeless woman is brought to the emergency department by ambulance 30 minutes after the police found her on the sidewalk. On arrival, she is unresponsive. Her pulse is 76/min, respirations are 6/min, and blood pressure is 110/78 mm Hg. Examination shows cool, dry skin. The pupils are pinpoint and react sluggishly to light. Intravenous administration of a drug is initiated. Two minutes after treatment is started, the patient regains consciousness and her respirations increase to 12/min. The drug that was administered has the strongest effect on which of the following receptors?", "answer": "μ-receptor", "options": {"A": "M1 receptor", "B": "Ryanodine receptor", "C": "μ-receptor", "D": "GABAA receptor", "E": "5-HT2A receptor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old homeless woman", "brought", "emergency department", "ambulance 30 minutes", "police found", "sidewalk", "arrival", "unresponsive", "pulse", "76 min", "respirations", "min", "blood pressure", "mm Hg", "cool", "dry skin", "pupils", "pinpoint", "light", "Intravenous", "drug", "initiated", "Two minutes", "started", "patient", "consciousness", "respirations increase", "min", "drug", "administered", "strongest effect", "following receptors"]}
{"question": "An infectious disease investigator is evaluating the diagnostic accuracy of a new interferon-gamma-based assay for diagnosing tuberculosis in patients who have previously received a Bacillus Calmette-Guérin (BCG) vaccine. Consenting participants with a history of BCG vaccination received an interferon-gamma assay and were subsequently evaluated for tuberculosis by sputum culture. Results of the study are summarized in the table below.\nTuberculosis, confirmed by culture No tuberculosis Total\nPositive interferon-gamma assay 90 6 96\nNegative interferon-gamma assay 10 194 204\nTotal 100 200 300\nBased on these results, what is the sensitivity of the interferon-gamma-based assay for the diagnosis of tuberculosis in this study?\"", "answer": "90/100", "options": {"A": "194/200", "B": "90/100", "C": "90/96", "D": "100/300", "E": "194/204"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["infectious disease investigator", "diagnostic accuracy", "new interferon-gamma based assay", "diagnosing tuberculosis", "patients", "received", "Calmette", "vaccine", "Consenting", "history of", "vaccination received", "interferon-gamma assay", "tuberculosis", "sputum culture", "Results", "study", "table", "Tuberculosis", "confirmed by culture", "tuberculosis Total Positive interferon-gamma assay 90", "Negative", "100", "Based", "results", "sensitivity", "interferon-gamma based assay", "diagnosis", "tuberculosis", "study"]}
{"question": "Several patients at a local US hospital present with chronic secretory diarrhea. Although there are multiple potential causes of diarrhea present in these patients, which of the following is most likely the common cause of their chronic secretory diarrhea?", "answer": "Medications", "options": {"A": "Lymphocytic colitis", "B": "Medications", "C": "Lactose intolerance", "D": "Carcinoid tumor", "E": "Crohn’s disease with ileitis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Several patients", "local", "hospital present", "chronic secretory", "multiple potential causes", "diarrhea present", "patients", "following", "common cause", "chronic secretory"]}
{"question": "A 27-year-old woman with sickle cell disease and at 39-weeks' gestation is brought to the emergency department in active labor. She has had multiple episodes of acute chest syndrome and has required several transfusions in the past. She has a prolonged vaginal delivery complicated by postpartum bleeding, and she receives a transfusion of 1 unit of packed red blood cells. One hour later, the patient experiences acute flank pain. Her temperature is 38.7°C (101.6°F), pulse is 115/min, respirations are 24/min, and blood pressure is 95/55 mm Hg. Foley catheter shows dark brown urine. Further evaluation of this patient is most likely to show which of the following?", "answer": "Positive direct Coombs test", "options": {"A": "Bilateral pulmonary infiltrates on chest x-ray", "B": "Serum antibodies against class I HLA antigens", "C": "Positive direct Coombs test", "D": "Positive blood cultures", "E": "Low levels of serum IgA immunoglobulins"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old woman", "sickle cell disease", "weeks", "gestation", "brought", "emergency department", "active labor", "multiple episodes of acute chest syndrome", "required", "transfusions", "past", "prolonged vaginal delivery complicated", "postpartum bleeding", "receives", "transfusion of", "packed red blood cells", "One hour later", "patient", "acute flank", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "95", "mm Hg", "Foley catheter", "dark", "Further", "to", "following"]}
{"question": "A 17-year-old man is brought by his mother to his pediatrician in order to complete medical clearance forms prior to attending college. During the visit, his mother asks about what health risks he should be aware of in college. Specifically, she recently saw on the news that some college students were killed by a fatal car crash. She therefore asks about causes of death in this population. Which of the following is true about the causes of death in college age individuals?", "answer": "More of them die from homicide than cancer", "options": {"A": "More of them die from suicide than injuries", "B": "More of them die from homicide than injuries", "C": "More of them die from homicide than suicide", "D": "More of them die from cancer than suicide", "E": "More of them die from homicide than cancer"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "pediatrician", "order to complete medical clearance forms prior to attending college", "college", "recently saw", "killed", "fatal car crash", "causes of death", "population", "following", "true", "causes of death", "college age"]}
{"question": "A 7-month old boy, born to immigrant parents from Greece, presents to the hospital with pallor and abdominal distention. His parents note that they recently moved into an old apartment building and have been concerned about their son's exposure to chipped paint from the walls. On physical exam, the patient is found to have hepatosplenomegaly and frontal skull bossing. Hemoglobin electrophoresis reveals markedly increased HbF and HbA2 levels. What would be the most likely findings on a peripheral blood smear?", "answer": "Microcytosis and hypochromasia of erythrocytes", "options": {"A": "Basophilic stippling of erythrocytes", "B": "Macrocytosis of erythrocytes with hypersegmented neutrophils", "C": "Microcytosis and hypochromasia of erythrocytes", "D": "Schistocytes and normocytic erythrocytes", "E": "Sickling of erythrocytes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "born", "Greece", "presents", "hospital", "pallor", "abdominal distention", "note", "recently moved", "old apartment building", "exposure", "paint", "walls", "patient", "found to", "hepatosplenomegaly", "frontal skull bossing", "Hemoglobin electrophoresis reveals markedly increased HbF", "HbA2 levels", "findings", "peripheral blood smear"]}
{"question": "A 51-year-old woman comes to the physician because of progressively worsening lower back pain. The pain radiates down the right leg to the lateral side of the foot. She has had no trauma, urinary incontinence, or fever. An MRI of the lumbar spine shows disc degeneration and herniation at the level of L5–S1. Which of the following is the most likely finding on physical examination?", "answer": "Weak achilles tendon reflex", "options": {"A": "Difficulty walking on heels", "B": "Exaggerated patellar tendon reflex", "C": "Diminished sensation of the anus and genitalia", "D": "Weak achilles tendon reflex", "E": "Diminished sensation of the anterior lateral thigh\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "worsening lower back pain", "pain radiates", "right leg", "lateral side of", "foot", "trauma", "urinary incontinence", "fever", "MRI of", "lumbar spine", "disc degeneration", "herniation", "level", "following", "finding", "physical examination"]}
{"question": "A 52-year-old woman comes to the physician because of a 4-month history of progressive pain and stiffness of the fingers of her right hand that is worse at the end of the day. She works as a hair dresser and has to take frequent breaks to rest her hand. She has hypertension, for which she takes hydrochlorothiazide. Two weeks ago, she completed a course of oral antibiotics for a urinary tract infection. Her sister has systemic lupus erythematosus. She drinks one to two beers daily and occasionally more on weekends. Over the past 2 weeks, she has been taking ibuprofen as needed for the joint pain. Her vital signs are within normal limits. Physical examination shows swelling, joint-line tenderness, and decreased range of motion of the right first metacarpophalangeal joint as well as the 2nd and 4th distal interphalangeal joints of the right hand. Discrete, hard, mildly tender swellings are palpated over the 2nd and 4th distal interphalangeal joints of the right hand. Which of the following is the most likely underlying mechanism for these findings?", "answer": "Degenerative disease of the joints", "options": {"A": "Monosodium urate crystal precipitation in the joints", "B": "Bacterial infection of the joint space", "C": "Autoimmune-mediated cartilage erosion", "D": "Degenerative disease of the joints", "E": "Calcium pyrophosphate dihydrate crystal precipitation in the joints"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "4 month history", "progressive pain", "stiffness of", "fingers", "right hand", "end", "to", "frequent breaks to", "hand", "hypertension", "hydrochlorothiazide", "Two weeks", "completed", "course", "oral", "urinary tract infection", "systemic lupus erythematosus", "one", "two", "daily", "occasionally", "weekends", "past 2 weeks", "ibuprofen as needed", "joint pain", "vital signs", "normal", "Physical examination", "swelling", "joint line tenderness", "decreased range of motion", "right first metacarpophalangeal joint", "2nd", "4th distal interphalangeal joints of the right hand", "Discrete", "hard", "mildly tender swellings", "2nd", "4th distal interphalangeal joints of the right hand", "following", "underlying mechanism", "findings"]}
{"question": "A 51-year-old man presents to his dermatologist because of severe stomatitis and superficial skin erosions over his trunk. His condition started 2 months ago and was unresponsive to oral antibiotics and antiherpetic medications. He has no history of a similar rash. His medical history is remarkable for type 2 diabetes mellitus and essential hypertension. The physical examination reveals numerous flaccid blisters and bullae which rupture easily. Nikolsky's sign is positive. Which of the following best represents the etiology of this patient’s condition?", "answer": "Anti-desmoglein-3 antibodies", "options": {"A": "Anti-hemidesmosome antibodies", "B": "Increased mitotic activity of basal and suprabasal cells", "C": "Cutaneous T cell lymphoma", "D": "Anti-desmoglein-3 antibodies", "E": "Dermatophyte infection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "dermatologist", "severe stomatitis", "superficial skin", "trunk", "condition started 2 months", "unresponsive", "oral", "medications", "history", "similar rash", "medical history", "type 2 diabetes mellitus", "essential hypertension", "reveals numerous flaccid", "bullae", "rupture easily", "Nikolsky's sign", "positive", "following best", "etiology", "patients condition"]}
{"question": "A 50-year-old male presents to his primary care physician for a routine check-up. He reports that he is doing well overall without any bothersome symptoms. His past medical history is significant only for hypertension, which has been well controlled with losartan. Vital signs are as follows: T 37.0 C, HR 80, BP 128/76, RR 14, SpO2 99%. Physical examination does not reveal any concerning abnormalities. The physician recommends a fecal occult blood test at this visit to screen for the presence of any blood in the patient's stool that might be suggestive of an underlying colorectal cancer. Which of the following best describes this method of disease prevention?", "answer": "Secondary prevention", "options": {"A": "Primordial prevention", "B": "Primary prevention", "C": "Secondary prevention", "D": "Tertiary prevention", "E": "Quaternary prevention"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["50 year old male presents", "primary care physician", "routine check-up", "reports", "well overall", "symptoms", "past medical history", "significant only", "hypertension", "well controlled", "losartan", "Vital signs", "follows", "T", "0", "80", "BP", "76", "RR", "99", "not reveal", "abnormalities", "physician", "fecal occult blood test", "to screen", "presence", "blood", "patient's stool", "suggestive of", "underlying colorectal cancer", "following best", "method", "disease prevention"]}
{"question": "A 57-year-old man presents to the emergency department because of pain in the center of his chest that is radiating down his left arm and up the left side of his neck. The pain started suddenly 30 minutes ago while the patient was at work. The patient describes the pain as squeezing in nature, 10/10 in intensity, and is associated with nausea and difficulty breathing. He has had type 2 diabetes mellitus for 15 years, hypertension for 10 years, and dyslipidemia, but he denies any history of a cardiac problem. He has a 40-pack-year history of smoking but does not drink alcohol. Vital signs include: blood pressure 80/40 mm Hg, regular pulse 90/min, and temperature 37.2°C (98.9°F). Chest auscultation reveals diffuse bilateral rales with no murmurs. ECG reveals convex ST-segment elevation in leads V1 to V6 and echocardiogram shows anterolateral hypokinesis, retrograde blood flow into the left atrium, and an ejection fraction of 45%. Which of the following best describe the mechanism of this patient’s illness?", "answer": "Occlusion of the left anterior descending artery with rupture of a papillary muscle", "options": {"A": "Occlusion of the right coronary artery, with infarction of the conduction system", "B": "Occlusion of the left anterior descending artery with rupture of a papillary muscle", "C": "Occlusion of the left anterior descending artery with interventricular septal rupture", "D": "Ventricular free wall rupture", "E": "Mitral leaflet thickening and fibrosis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["57 year old man presents", "emergency department", "pain", "center", "chest", "radiating", "left arm", "left side of", "neck", "pain started", "30 minutes", "patient", "patient", "pain", "squeezing", "nature", "10", "intensity", "associated with nausea", "difficulty breathing", "type 2 diabetes mellitus", "years", "hypertension", "dyslipidemia", "history", "cardiac problem", "40", "history of smoking", "not", "alcohol", "Vital signs include", "blood pressure 80 40 mm Hg", "regular pulse 90 min", "temperature", "98 9F", "Chest auscultation reveals diffuse bilateral rales", "murmurs", "ECG reveals convex ST-segment elevation", "leads V1", "V6", "echocardiogram", "anterolateral hypokinesis", "retrograde blood", "left atrium", "ejection fraction", "following best", "mechanism", "patients illness"]}
{"question": "A 29-year-old African American female presents to your office with extreme fatigue and bilateral joint pain. Serologies demonstrate the presence of rheumatoid factor along with anti-Smith and anti-dsDNA antibodies. A VDRL syphilis test is positive. You order a coagulation profile, which reveals normal bleeding time, normal PT, and prolonged PTT as well as normal platelet count. Further evaluation is most likely to reveal which of the following?", "answer": "History of multiple spontaneous abortions", "options": {"A": "Palmar rash", "B": "HLA-B27 positivity", "C": "Factor VIII deficiency", "D": "History of multiple spontaneous abortions", "E": "Immune thrombocytopenia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old", "female presents", "office", "extreme fatigue", "bilateral joint pain", "Serologies", "presence", "rheumatoid factor", "Smith", "anti-dsDNA antibodies", "VDRL syphilis", "positive", "order", "coagulation profile", "reveals normal bleeding time", "normal PT", "prolonged PTT", "normal platelet count", "Further", "to reveal", "following"]}
{"question": "A 31-year-old man comes to the physician because of a 5-day history of fever, chills, and dyspnea. His temperature is 38.9°C (102°F) and pulse is 90/min. Cardiac examination shows a murmur. In addition to other measures, cardiac catheterization is performed. A graph showing the results of the catheterization is shown. This patient most likely has which of the following valvular heart defects?", "answer": "Aortic regurgitation", "options": {"A": "Mitral stenosis", "B": "Mitral regurgitation", "C": "Pulmonary regurgitation", "D": "Aortic regurgitation", "E": "Aortic stenosis\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["31 year old man", "physician", "5-day history", "fever", "chills", "dyspnea", "temperature", "pulse", "90 min", "murmur", "measures", "performed", "results", "catheterization", "patient", "likely", "following valvular heart defects"]}
{"question": "A 54-year-old woman comes to the physician because of a painful skin lesion on her right leg for 1 month. It initially started out as a small red spot but has rapidly increased in size during this period. She remembers an ant bite on her leg prior to the lesion occurring. She was treated for anterior uveitis 8 months ago with corticosteroids. She has Crohn's disease, type 2 diabetes mellitus, and hypertension. Current medications include insulin, mesalamine, enalapril, and aspirin. She returned from Wisconsin after visiting her son 2 months ago. Her temperature is 37.6°C (98°F), pulse is 98/min, and blood pressure is 126/88 mm Hg. Examination shows pitting pedal edema of the lower extremities. There is a 4-cm tender ulcerative lesion on the anterior right leg with a central necrotic base and purplish irregular borders. There are dilated tortuous veins in both lower legs. Femoral and pedal pulses are palpated bilaterally. Which of the following is the most likely diagnosis?", "answer": "Pyoderma gangrenosum", "options": {"A": "Ecthyma gangrenosum", "B": "Pyoderma gangrenosum", "C": "Blastomycosis", "D": "Squamous cell carcinoma", "E": "Basal cell carcinoma\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["54 year old woman", "physician", "of", "painful skin lesion", "right leg", "1 month", "initially started out", "small red spot", "rapidly increased in size", "period", "ant bite", "leg", "lesion occurring", "treated", "anterior uveitis", "months", "corticosteroids", "Crohn's disease", "type 2 diabetes mellitus", "hypertension", "Current medications include insulin", "mesalamine", "enalapril", "aspirin", "returned", "Wisconsin", "months", "temperature", "pulse", "98 min", "blood pressure", "88 mm Hg", "pitting pedal edema of", "lower extremities", "4 cm tender ulcerative lesion", "anterior right leg", "central necrotic base", "irregular borders", "dilated tortuous veins", "lower legs", "Femoral", "pedal pulses", "following", "diagnosis"]}
{"question": "A primary care physician is recently receiving more negative online reviews from his patients. He is increasingly feeling tired and has written 2 wrong prescriptions over the past month alone. Currently, on his panel, he has a list of 1,051 patients, half of whom are geriatric patients. He spends approx. 51 hours per week visiting about 20 patients a day. He has no history of a serious illness and takes no medications. An evaluation by a psychiatrist shows no primary psychiatric disorders. According to recent national surveys, which of the following do physicians more frequently recognize as a contributor to this physician’s current condition?", "answer": "Excessive bureaucratic tasks", "options": {"A": "The number of patients on his panel", "B": "Excessive bureaucratic tasks", "C": "Working too many hours", "D": "Concern over online reputation", "E": "The number of geriatric patients on his panel"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["primary care physician", "recently receiving more negative", "reviews", "patients", "tired", "written 2 wrong prescriptions", "past month alone", "Currently", "panel", "patients", "half", "geriatric patients", "spends", "hours per week", "20 patients", "day", "history", "serious illness", "medications", "psychiatrist", "primary psychiatric", "recent", "following", "physicians", "frequently", "physicians current condition"]}
{"question": "A 42-year-old Caucasian woman is enrolled in a randomized controlled trial to study cardiac function in the setting of several different drugs. She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured. During this experiment, which of the following represents the relative conduction speed through the heart from fastest to slowest?", "answer": "Purkinje fibers > atria > ventricles > AV node", "options": {"A": "Atria > Purkinje fibers > ventricles > AV node", "B": "AV node > ventricles > atria > Purkinje fibers", "C": "Purkinje fibers > ventricles > atria > AV node", "D": "Purkinje fibers > atria > ventricles > AV node", "E": "Purkinje fibers > AV node > ventricles > atria"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman", "enrolled", "to study cardiac", "setting", "different drugs", "started", "verapamil", "to exercise", "50", "VO2", "several cardiac parameters", "measured", "following", "relative conduction speed", "heart", "fastest", "slowest"]}
{"question": "A 7-year-old boy comes to the physician because of a generalized rash for 3 days. Over the past 5 days, he has also had a high fever and a sore throat. His 16-year-old sister was treated for infectious mononucleosis 2 weeks ago. He returned from a summer camp a week ago. His immunizations are up-to-date. Three years ago, he required intubation after an allergic reaction to dicloxacillin. The patient appears ill. His temperature is 38.2°C (100.8°F). Examination shows circumferential oral pallor. Cervical lymphadenopathy is present. There is tonsillar erythema and exudate. A confluent, blanching, punctate erythematous rash with a rough texture is spread over his trunk and extremities. His hemoglobin concentration is 13.3 g/dL, leukocyte count is 12,000/mm3, and erythrocyte sedimentation rate is 43 mm/h. Which of the following is the most appropriate next step in management?", "answer": "Azithromycin therapy", "options": {"A": "Acyclovir therapy", "B": "Doxycycline therapy", "C": "Amoxicillin therapy", "D": "Azithromycin therapy", "E": "Cephalexin therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "physician", "of", "generalized rash", "3 days", "past", "days", "high fever", "sore throat", "year old", "treated", "infectious mononucleosis 2 weeks", "returned", "summer camp", "week", "immunizations", "date", "Three years", "required intubation", "allergic reaction", "dicloxacillin", "patient appears ill", "temperature", "100", "circumferential oral pallor", "Cervical lymphadenopathy", "present", "tonsillar erythema", "exudate", "confluent", "blanching", "punctate erythematous rash", "texture", "spread", "trunk", "extremities", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "erythrocyte sedimentation rate", "mm/h", "following", "most appropriate next step"]}
{"question": "A 30-year-old woman comes to the physician because of a swelling on her neck for 5 months. It has gradually enlarged in size and is mildly painful. She has also had intermittent episodes of throbbing headache, sweating, and palpitations over the past 3 months. Menses occur at regular 28-day intervals and last for 4–5 days. She does not smoke, occasionally consumes alcohol on weekends. She appears thin and pale. Her temperature is 38.7°C (101.7°F), pulse is 112/min, and blood pressure is 140/90 mm Hg. Examination shows a firm, 3-cm swelling on the neck that moves with swallowing; there is no lymphadenopathy. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:\nHemoglobin 13 g/dL\nLeukocyte count 9500/mm3\nPlatelet count 230,000/mm3\nSerum\nNa+ 136 mEq/L\nK+ 3.5 mEq/L\nCl- 104 mEq/L\nTSH 2.3 μU/mL\nCalcitonin 300 ng/dL (Normal < 5 ng/dL)\nAn electrocardiogram shows sinus tachycardia. Which of the following laboratory abnormalities is most likely to be seen?\"", "answer": "Increased plasma metanephrines", "options": {"A": "Increased serum gastrin", "B": "Increased serum cortisol", "C": "Increased urinary 5-HIAA", "D": "Increased serum T3 levels", "E": "Increased plasma metanephrines"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["30 year old woman", "physician", "of", "swelling", "neck", "5 months", "enlarged", "size", "mildly painful", "intermittent episodes of throbbing", "sweating", "palpitations", "past 3 months", "Menses occur", "regular", "day intervals", "last", "days", "not smoke", "occasionally", "alcohol", "weekends", "appears thin", "pale", "temperature", "pulse", "min", "blood pressure", "90 mm Hg", "firm", "3", "swelling", "neck", "moves", "swallowing", "lymphadenopathy", "Cardiopulmonary", "abnormalities", "Laboratory studies", "Hemoglobin", "g dL", "mm3 Platelet count", "Serum", "K", "Calcitonin 300 ng dL", "Normal", "5 ng/dL", "electrocardiogram", "sinus tachycardia", "following laboratory abnormalities", "to", "seen"]}
{"question": "A 31-year-old G3P1 woman who is at 37 weeks of gestation is brought into the emergency department by her husband after repeated twitching. According to the husband, they were watching TV when she suddenly became unresponsive and her hands and legs started shaking. The episode lasted about 5 minutes and she “seemed to be sleeping afterwards.” Her past medical history is significant for pregnancy induced hypertension. The patient is tired but responsive and denies urinary incontinence, paresthesia, fever, upper respiratory signs, or new medication changes. She denies a history of seizures. Her temperature is 99°F (37°C), blood pressure is 186/97 mmHg, pulse is 96/min, and respirations are 12/min. Physical examination demonstrates a lethargic patient with moderate right upper quadrant tenderness. What is the most appropriate next step for this patient?", "answer": "Intravenous magnesium sulfate", "options": {"A": "Emergency cesarean section", "B": "Expectant management", "C": "Intravenous ampicillin and gentamicin", "D": "Intravenous infusion of oxytocin", "E": "Intravenous magnesium sulfate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["31 year old", "woman", "weeks of gestation", "brought", "emergency department", "repeated twitching", "unresponsive", "hands", "legs started shaking", "episode lasted", "5 minutes", "to", "sleeping", "past medical history", "significant", "pregnancy induced hypertension", "patient", "tired", "responsive", "urinary incontinence", "paresthesia", "fever", "upper respiratory signs", "new medication changes", "history", "seizures", "temperature", "blood pressure", "97 mmHg", "pulse", "96 min", "respirations", "min", "lethargic patient", "moderate right upper quadrant tenderness", "most appropriate next step", "patient"]}
{"question": "A 65-year-old man was picked up by the security personnel for voiding urine and defecating at an inappropriate place in the community. On questioning, he was making offensive remarks and behaving inappropriately. On physical examination, the physician observed an ataxic gait and amnesia. Initial urine drug screen is negative for any drugs of abuse. Which is the most likely pathological finding present in this patient?", "answer": "Pick bodies", "options": {"A": "Drug abuse", "B": "PrPSC Sheets", "C": "Lewy bodies", "D": "Pick bodies", "E": "Amyloid plaques"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old man", "personnel", "voiding urine", "inappropriate place", "making", "physician observed", "ataxic gait", "amnesia", "Initial urine drug screen", "negative", "drugs of abuse", "pathological finding present", "patient"]}
{"question": "A 52-year-old man undergoes an exercise stress test for a 1-week history of squeezing substernal chest pain that is aggravated by exercise and relieved by rest. During the test, there is a substantial increase in the breakdown of glycogen in the muscle cells. Which of the following changes best explains this intracellular finding?", "answer": "Activation of phosphorylase kinase", "options": {"A": "Decrease in protein kinase A", "B": "Activation of phosphorylase kinase", "C": "Increase in glucose-6-phosphate", "D": "Activation of protein phosphatase", "E": "Inactivation of glycogen synthase kinase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "exercise stress test", "1-week history of", "chest pain", "aggravated by exercise", "relieved by", "test", "increase", "following changes best", "intracellular finding"]}
{"question": "A 35-year-old man presents to the general practitioner with a skin rash that has been present for 2 days. The rash appeared suddenly and has progressively gotten worse. It started off as an erythematous lesion on the back of his hands and also over his nose. The lesions over his hands have become bullous and tense. He has never experienced similar symptoms before. He just got back from a canoeing trip during a very hot and sunny weekend. Physical exam is significant for erythematous, vesicular lesions over the nape of the neck and bridge of the nose as well as tense bullae over the dorsum of both hands. The attending physician suspects a defect in the synthesis of heme and orders some blood tests. Which of the following precursors will most likely be elevated in this patient?", "answer": "Uroporphyrinogen III", "options": {"A": "Uroporphyrinogen III", "B": "Hydroxymethylbilane", "C": "Porphobilinogen", "D": "δ-Aminolevulinic acid", "E": "Protoporphyrin IX"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old man presents", "general practitioner", "skin rash", "present", "2 days", "rash appeared", "gotten worse", "started", "erythematous", "back of", "hands", "nose", "lesions", "hands", "bullous", "tense", "never", "similar symptoms", "got back", "trip", "very hot", "sunny weekend", "significant", "erythematous", "vesicular lesions", "nape", "neck", "bridge of", "nose", "tense bullae", "dorsum of", "hands", "attending physician", "defect", "orders", "blood tests", "following", "most likely", "elevated", "patient"]}
{"question": "A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?", "answer": "Uterine rupture", "options": {"A": "Abruptio placentae", "B": "Vasa previa", "C": "Uterine rupture", "D": "Uterine inertia", "E": "Amniotic fluid embolism"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "gestation", "emergency department", "of vaginal bleeding", "past hour", "patient reports", "contractions prior to", "onset of", "bleeding", "contractions stopped", "bleeding started", "severe abdominal", "first child", "delivered", "lower segment transverse cesarean", "fetal heart rate", "pulse", "min", "respirations", "min", "blood pressure", "90 60 mm Hg", "diffuse abdominal tenderness", "rebound", "guarding", "contractions", "fetal heart rate", "recurrent variable decelerations", "following", "diagnosis"]}
{"question": "A 5-year-old boy is brought to the emergency department by his parents for difficulty breathing. He was playing outside in the snow and had progressive onset of wheezing and gasping. His history is notable for eczema and nut allergies. The patient has respirations of 22/min and is leaning forward with his hands on his legs as he is seated on the table. Physical examination is notable for inspiratory and expiratory wheezes on exam. A nebulized medication is started and begins to relieve his breathing difficulties. Which of the following is increased in this patient as a result of this medication?", "answer": "Cyclic AMP", "options": {"A": "Diacylglycerol", "B": "Cyclic GMP", "C": "Cyclic AMP", "D": "Protein kinase C", "E": "ATP"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "difficulty breathing", "playing outside", "progressive onset", "wheezing", "gasping", "history", "notable", "eczema", "nut allergies", "patient", "respirations", "min", "forward", "hands", "legs", "seated", "table", "Physical examination", "notable", "inspiratory", "expiratory wheezes", "exam", "nebulized medication", "started", "begins to relieve", "breathing difficulties", "following", "increased", "patient", "result", "medication"]}
{"question": "A 78-year-old male with history of coronary artery disease, status post coronary stent placement currently on aspirin and clopidogrel was found down in his bathroom by his wife. His GCS score was 3 and an accurate physical exam is limited. A stat non-contrast CT scan of his brain demonstrated a large right parietal intracranial hemorrhage with surrounding edema. He was promptly transferred to the intensive care unit (ICU) for monitoring. Over the next day, his mental status continues to worsen but repeat CT scan shows no new bleeding. In addition, the patient’s urinary output has been >200 cc/hr over the last several hours and increasing. His temperature is 99.0 deg F (37.2 deg C), blood pressure is 125/72 mmHg, pulse is 87/min, and respirations are 13/min. Which of the following values would most likely correspond to the patient’s urine specific gravity, urine osmolality, plasma osmolality, and serum sodium?", "answer": "Low, Low, High, High", "options": {"A": "High, High, Low, Low", "B": "Low, High, High, High", "C": "Low, Low, High, Low", "D": "Low, Low, High, High", "E": "High, Low, Low, High"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year", "male", "history of coronary artery disease", "status coronary currently", "aspirin", "clopidogrel", "found", "bathroom", "GCS score", "3", "accurate", "limited", "stat non contrast CT scan of", "brain", "large right parietal intracranial", "surrounding edema", "transferred", "intensive care unit", "next day", "mental status", "to worsen", "repeat CT scan", "new bleeding", "addition", "patients urinary output", "200 cc", "hours", "increasing", "temperature", "99 0 deg F", "37 2", "blood pressure", "72 mmHg", "pulse", "87 min", "respirations", "min", "following values", "most likely", "patients urine specific gravity", "urine osmolality", "plasma osmolality", "serum sodium"]}
{"question": "A 53-year-old woman comes to the physician for a follow-up examination. One month ago, she was diagnosed with carcinoma of the left breast. She underwent a lumpectomy for a 2.1-cm mass and sentinel lymph node biopsy 2 weeks ago. The biopsy of the breast mass showed margin-free invasive ductal carcinoma; immunohistochemistry showed the carcinoma is estrogen-receptor and progesterone-receptor negative, and HER2-receptor positive. The lymph node biopsy was negative for metastases. Examination shows a healing surgical incision over the left breast. There is no palpable axillary lymphadenopathy. Her physician decides to initiate treatment with appropriate pharmacotherapy. Which of the following is the most appropriate next step in management?", "answer": "Echocardiography", "options": {"A": "Echocardiography", "B": "Fundoscopy", "C": "Dual energy x-ray absorptiometry scan", "D": "X-ray of the chest", "E": "Endometrial biopsy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "One month", "diagnosed", "carcinoma of the left breast", "lumpectomy", "mass", "sentinel lymph node biopsy", "weeks", "biopsy of", "breast mass", "margin free invasive ductal carcinoma", "immunohistochemistry", "carcinoma", "estrogen-receptor", "progesterone-receptor negative", "HER2 receptor positive", "lymph node biopsy", "negative", "metastases", "healing", "left", "palpable axillary lymphadenopathy", "physician", "to initiate treatment", "appropriate pharmacotherapy", "following", "most appropriate next step"]}
{"question": "Three weeks after birth, an infant girl develops episodes of apnea. She has become increasingly lethargic over the past two days, and experienced two episodes of apnea lasting 10 seconds each within the last day. She was born at 31 weeks of gestation and weighed 1600-g (3-lb 8-oz). Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. She takes no medications. Her temperature is 36.7°C (98.0°F), pulse is 185/min, respirations are 60/min and irregular, and blood pressure is 70/35 mm Hg. She appears pale. Physical examination shows no abnormalities. Laboratory studies show a hemoglobin of 6.5 g/dL, a reticulocyte count of 0.5%, and a mean corpuscular volume of 92 μm3. Leukocyte count, platelet count, total bilirubin and indirect bilirubin are all within reference range. Which of the following is the most likely underlying mechanism of this patient's anemia?", "answer": "Impaired erythropoietin production", "options": {"A": "Defective δ-aminolevulinic acid synthase", "B": "Bone marrow suppression", "C": "Glucose-6-phosphate dehydrogenase deficiency", "D": "Iron deficiency", "E": "Impaired erythropoietin production"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Three weeks after birth", "infant girl", "episodes of apnea", "lethargic", "past two days", "two episodes of apnea lasting 10 seconds", "last day", "born", "31 weeks of gestation", "1600", "oz", "Apgar scores", "5 minutes", "medications", "temperature", "36", "98", "pulse", "min", "respirations", "60 min", "irregular", "blood pressure", "70 35 mm Hg", "appears pale", "abnormalities", "Laboratory studies", "a hemoglobin", "g/dL", "reticulocyte count", "0.5", "mean corpuscular volume", "m3", "Leukocyte", "platelet count", "total bilirubin", "indirect bilirubin", "reference range", "following", "underlying mechanism", "patient's anemia"]}
{"question": "A 45-year-old woman presents to the physician with a 6-month history of progressive shortness of breath. She now has to stop to rest three or four times whenever she climbs the stairs to her apartment on the third floor. She reports chronic, nonproductive cough and wheezing, for which she uses ipratropium inhalers. She has a 25 pack-year smoking history. On examination, the blood pressure is 130/80 mm Hg, the pulse rate is 95/min, the temperature is 36.6°C (97.8°F), and the respiratory rate is 26/min. Chest auscultation reveals bilateral crepitations. Cardiac auscultation reveals normal S1 and S2 without murmurs or added sounds. Arterial blood gas analysis shows:\npH 7.36 (reference: 7.35–7.45)\nHCO3- 32 mEq/L  (reference 22–28 mEq/L)\nPco2 48 mm Hg  (reference: 33–45 mm Hg)\nPo2 63 mm Hg (reference: 75–105 mm Hg)\nO2 saturation 91% (reference: 94–99%)\nWhich of the following would you expect to find in this patient?", "answer": "Decreased diffusing capacity of the lungs for carbon monoxide (DLCO)", "options": {"A": "Decreased lung residual volume", "B": "Decreased diffusing capacity of the lungs for carbon monoxide (DLCO)", "C": "Increased FEV1/FVC ratio", "D": "Shift of the flow volume loop to the right", "E": "Decreased lung compliance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "month history of progressive shortness", "breath", "now", "to stop to", "three", "four times", "climbs", "apartment", "third floor", "reports chronic", "nonproductive cough", "wheezing", "uses ipratropium inhalers", "smoking history", "blood pressure", "80 mm Hg", "pulse rate", "95 min", "temperature", "36", "97", "respiratory rate", "min", "Chest auscultation reveals bilateral crepitations", "Cardiac auscultation reveals normal S1", "S2", "murmurs", "added", "Arterial blood gas analysis", "pH 7 36", "HCO3", "mEq/L", "mEq/L", "Pco2 48 mm Hg", "mm Hg", "Po2 63 mm Hg", "mm Hg", "O2 saturation", "following", "to find", "patient"]}
{"question": "A 27-year-old man is brought to a psychiatrist by his mother who is concerned that he has become increasingly distant. When asked, he says that he is no longer going out because he is afraid of going outside by himself. He says that ever since he was a teenager, he was uncomfortable in large crowds and on public transportation. He now works from home and rarely leaves his house except on mandatory business. Which of the following personality disorders is most likely genetically associated with this patient's disorder?", "answer": "Dependent", "options": {"A": "Antisocial", "B": "Dependent", "C": "Histrionic", "D": "Paranoid", "E": "Schizotypal"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old man", "brought", "psychiatrist", "distant", "longer", "out", "outside", "ever", "teenager", "large", "public transportation", "now works", "home", "rarely", "house", "mandatory business", "following personality disorders", "associated with", "patient's disorder"]}
{"question": "A 26-year-old woman presents with sudden-onset pain in her lower back. She says she was exercising in the gym several hours ago when she felt a sharp pain. The pain is radiating down the side of her leg and into her foot. On physical exam, her vital signs are as follows: HR 95, BP 120/70, T 37.2 degrees C. She has extreme pain shooting down her leg with a straight leg raise. Her sensation to light touch and pin-prick is intact throughout. Which of the following is the most likely diagnosis?", "answer": "Disc herniation", "options": {"A": "Disc herniation", "B": "Osteomyelitis", "C": "Cauda equina syndrome", "D": "Spinal stenosis", "E": "Ankylosing spondylitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "sudden-onset pain", "lower back", "exercising", "hours", "sharp pain", "pain", "radiating", "side", "leg", "foot", "vital signs", "follows", "95", "BP", "70", "T", "degrees C", "extreme pain", "leg", "straight leg raise", "sensation", "light touch", "pin prick", "intact", "following", "diagnosis"]}
{"question": "A 34-year-old man with AIDS comes to the physician because of a 2-day history of decreasing vision and seeing black spots in his right eye. He has no pain and the left eye is asymptomatic. He was treated for fungal esophagitis 6 months ago with fluconazole. He was diagnosed with Kaposi's sarcoma 2 years ago. Current medications include efavirenz, tenofovir, emtricitabine, azithromycin, trimethoprim-sulfamethoxazole, multivitamins, and a nutritional supplement. He is 170 cm (5 ft 7 in) tall and weighs 45 kg (99 lbs);BMI is 15.6 kg/m2. His temperature is 37°C (98.6°F), pulse is 89/min, and blood pressure is 110/70 mm Hg. Examination shows cervical lymphadenopathy. There are multiple violaceous plaques seen over his trunk and extremities. Fundoscopic examination shows granular yellow-white opacities around the retinal vessels and multiple areas of dot-blot hemorrhages. His CD4+ T-lymphocyte count is 36/mm3. Which of the following is the most likely diagnosis?", "answer": "Cytomegalovirus retinitis", "options": {"A": "Cytomegalovirus retinitis", "B": "Herpes simplex keratitis", "C": "Toxoplasma retinitis", "D": "HIV retinopathy", "E": "Varicella zoster retinitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "AIDS", "physician", "2-day history", "decreasing vision", "seeing black spots", "right eye", "pain", "left eye", "asymptomatic", "treated", "fungal esophagitis", "months", "fluconazole", "diagnosed", "Kaposi's sarcoma 2 years", "Current medications include efavirenz", "tenofovir", "emtricitabine", "azithromycin", "trimethoprim-sulfamethoxazole", "multivitamins", "5 ft", "tall", "kg", "99 lbs", "BMI", "kg/m2", "temperature", "98", "pulse", "min", "blood pressure", "70 mm Hg", "cervical lymphadenopathy", "multiple violaceous plaques seen", "trunk", "extremities", "Fundoscopic", "granular yellow white opacities", "retinal vessels", "multiple areas", "dot-blot hemorrhages", "CD4", "lymphocyte count", "36 mm3", "following", "diagnosis"]}
{"question": "A 45-year old man comes to the physician because of a painless neck lump and a 2-month history of difficulty swallowing. He has a history of recurrent nephrolithiasis and episodic hypertension. Physical examination shows a 3 × 3-cm, nontender nodule at the level of the thyroid cartilage. A photomicrograph of a section of tissue obtained by core needle biopsy of the nodule is shown. Which of the following is the most likely diagnosis?", "answer": "Medullary carcinoma", "options": {"A": "Follicular carcinoma", "B": "Anaplastic carcinoma", "C": "Non-Hodgkin lymphoma", "D": "Papillary carcinoma", "E": "Medullary carcinoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "painless neck lump", "2 month history", "difficulty swallowing", "history of recurrent nephrolithiasis", "episodic hypertension", "3", "3", "nontender nodule", "the level of", "thyroid cartilage", "photomicrograph", "section", "tissue obtained", "core needle biopsy", "nodule", "following", "diagnosis"]}
{"question": "A 17-year-old boy is brought to the physician because of increasing pain and swelling of his right knee for 12 days. He has had episodes of pain with urination for 3 weeks. He had a painful, swollen left ankle joint that resolved without treatment one week ago. His mother has rheumatoid arthritis. He is sexually active with 2 female partners and uses condoms inconsistently. He appears anxious. His temperature is 38°C (100.4°F), pulse is 68/min, and blood pressure is 100/80 mm Hg. Examination shows bilateral inflammation of the conjunctiva. The right knee is tender, erythematous, and swollen; range of motion is limited by pain. There is tenderness at the left Achilles tendon insertion site. Genital examination shows no abnormalities. Laboratory studies show:\nHemoglobin 14.5 g/dL\nLeukocyte count 12,300/mm3\nPlatelet count 310,000/mm3\nErythrocyte sedimentation rate 38 mm/h\nSerum\nUrea nitrogen 18 mg/dL\nGlucose 89 mg/dL\nCreatinine 1.0 mg/dL\nUrine\nProtein negative\nBlood negative\nWBC 12–16/hpf\nRBC 1–2/hpf\nAn ELISA test for HIV is negative. Arthrocentesis is done. The synovial fluid is cloudy and a Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 26,000/mm3 and 75% neutrophils. Which of the following is the most likely diagnosis?\"", "answer": "Reactive arthritis", "options": {"A": "Septic arthritis", "B": "Rheumatoid arthritis", "C": "Lyme arthritis", "D": "Reactive arthritis", "E": "Syphilitic arthritis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "increasing pain", "swelling of", "right knee", "days", "episodes of pain", "urination", "weeks", "painful", "swollen left ankle joint", "resolved", "treatment one week", "rheumatoid arthritis", "sexually active", "female", "uses condoms", "appears anxious", "temperature", "100", "pulse", "min", "blood pressure", "100 80 mm Hg", "bilateral inflammation of", "conjunctiva", "right knee", "tender", "erythematous", "swollen", "range of motion", "limited", "pain", "tenderness", "left Achilles tendon insertion site", "Genital examination", "abnormalities", "Laboratory studies", "Hemoglobin", "count", "mm3 Platelet count", "rate", "h Serum", "Glucose", "Creatinine", "Protein negative", "WBC", "hpf", "ELISA test", "HIV", "negative", "Arthrocentesis", "synovial fluid", "cloudy", "Gram stain", "negative", "Analysis", "synovial fluid", "leukocyte count", "mm3", "75", "following", "diagnosis"]}
{"question": "A 72-year-old man presents to his primary care provider to discuss the frequency with which he wakes up at night to urinate. He avoids drinking liquids at night, but the symptoms have progressively worsened. The medical history is significant for hypertension and hyperlipidemia. He takes lisinopril, atorvastatin, and a multivitamin every day. Today, the vital signs include: blood pressure 120/80 mm Hg, heart rate 90/min, respiratory rate 17/min, and temperature 37.0°C (98.6°F). On physical examination, he appears tired. The heart has a regular rate and rhythm and the lungs are clear to auscultation bilaterally. A bedside bladder ultrasound reveals a full bladder. A digital rectal exam reveals an enlarged and symmetric prostate free of nodules, that is consistent with benign prostatic enlargement. He also has a history of symptomatic hypotension with several episodes of syncope in the past. The patient declines a prostate biopsy that would provide a definitive diagnosis and requests less invasive treatment. Which of the following is recommended to treat this patient’s enlarged prostate?", "answer": "Finasteride", "options": {"A": "Tamsulosin", "B": "Finasteride", "C": "Prazosin", "D": "Tadalafil", "E": "Leuprolide"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old man presents", "primary care provider to", "frequency", "wakes up", "night to", "drinking", "night", "symptoms", "worsened", "medical history", "significant", "hypertension", "hyperlipidemia", "lisinopril", "atorvastatin", "multivitamin", "day", "Today", "vital signs include", "blood pressure", "80 mm Hg", "heart rate 90 min", "respiratory rate", "min", "temperature", "98", "appears tired", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "bladder ultrasound reveals", "full bladder", "digital rectal exam reveals", "enlarged", "symmetric prostate free", "nodules", "benign prostatic enlargement", "history of symptomatic hypotension", "several episodes of syncope", "past", "patient", "prostate biopsy", "definitive diagnosis", "less invasive treatment", "following", "to treat", "patients enlarged prostate"]}
{"question": "A 63-year-old man comes to the physician for the evaluation of a skin lesion on his chest. He first noticed the lesion 2 months ago and thinks that it has increased in size since then. The lesion is not painful or pruritic. He has type 2 diabetes mellitus, hypercholesterolemia, and glaucoma. The patient has smoked 1 pack of cigarettes daily for the last 40 years and drinks two to three beers on the weekend. Current medications include metformin, atorvastatin, topical timolol, and a multivitamin. Vital signs are within normal limits. The lesion is partly elevated on palpation and does not change its form on pinching. A photograph of the lesion is shown. Which of the following is the most likely diagnosis?", "answer": "Malignant melanoma", "options": {"A": "Malignant melanoma", "B": "Keratoacanthoma", "C": "Lentigo maligna", "D": "Seborrheic keratosis", "E": "Basal cell carcinoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man", "physician", "evaluation", "skin", "chest", "first", "lesion", "months", "increased in size", "then", "lesion", "not painful", "type 2 diabetes mellitus", "hypercholesterolemia", "glaucoma", "patient", "smoked 1 pack", "cigarettes daily", "last 40 years", "two", "three", "weekend", "Current medications include metformin", "atorvastatin", "topical timolol", "multivitamin", "Vital signs", "normal limits", "lesion", "elevated", "palpation", "not change", "form", "pinching", "photograph", "lesion", "following", "diagnosis"]}
{"question": "A case-control study looking to study the relationship between infection with the bacterium Chlamydia trachomatis and having multiple sexual partners was conducted in the United States. A total of 100 women with newly diagnosed chlamydial infection visiting an outpatient clinic for sexually transmitted diseases (STDs) were compared with 100 women from the same clinic who were found to be free of chlamydia and other STDs. The women diagnosed with this infection were informed that the potential serious consequences of the disease could be prevented only by locating and treating their sexual partners. Both groups of women were queried about the number of sexual partners they had had during the preceding 3 months. The group of women with chlamydia reported an average of 4 times as many sexual partners compared with the group of women without chlamydia; the researchers, therefore, concluded that women with chlamydia visiting the clinic had significantly more sexual partners compared with women who visited the same clinic but were not diagnosed with chlamydia. What type of systematic error could have influenced the results of this study?", "answer": "Reporting bias", "options": {"A": "Ascertainment bias", "B": "Lost-to-follow-up bias", "C": "Response bias", "D": "Detection bias", "E": "Reporting bias"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["looking to study", "relationship", "infection", "bacterium", "multiple sexual partners", "United States", "total", "100", "diagnosed chlamydial infection", "outpatient clinic", "sexually transmitted diseases", "100", "same clinic", "found to", "free", "STDs", "diagnosed", "infection", "informed", "potential serious consequences of", "disease", "prevented only", "treating", "number of sexual partners", "preceding", "months", "reported", "average", "times", "researchers", "concluded", "clinic", "same clinic", "not diagnosed", "type", "systematic error", "results", "study"]}
{"question": "A 34-year-old man is brought to the emergency department 3 hours after being bitten by a rattlesnake. He was hiking in the Arizona desert when he accidentally stepped on the snake and it bit his right leg. His pulse is 135/min and blood pressure is 104/81 mm Hg. Examination shows right lower leg swelling, ecchymosis, and blistering. Right ankle dorsiflexion elicits severe pain. A manometer inserted in the lateral compartment of the lower leg shows an intracompartmental pressure of 67 mm Hg. In addition to administration of the antivenom, the patient undergoes fasciotomy. Two weeks later, he reports difficulty in walking. Neurologic examination shows a loss of sensation over the lower part of the lateral side of the right leg and the dorsum of the right foot. Right foot eversion is 1/5. There is no weakness in dorsiflexion. Which of the following nerves is most likely injured in this patient?", "answer": "Superficial peroneal nerve", "options": {"A": "Tibial nerve", "B": "Sural nerve", "C": "Deep peroneal nerve", "D": "Superficial peroneal nerve", "E": "Saphenous nerve"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "hours", "bitten", "rattlesnake", "Arizona desert", "stepped", "bit", "right leg", "pulse", "min", "blood pressure", "81 mm Hg", "right", "ecchymosis", "blistering", "Right ankle dorsiflexion elicits severe pain", "manometer", "lateral compartment of", "lower leg", "pressure", "67 mm Hg", "In addition to administration", "antivenom", "patient", "fasciotomy", "Two weeks later", "reports difficulty in walking", "Neurologic examination", "loss of sensation", "lower part of", "lateral side", "right leg", "dorsum of", "right foot", "eversion", "1/5", "weakness", "following nerves", "most likely injured", "patient"]}
{"question": "A 31-year-old woman visits the clinic with chronic diarrhea on most days for the past four months. She also complains of lower abdominal discomfort and cramping, which is relieved by episodes of diarrhea. She denies any recent change in her weight. Bowel movements are preceded by a sensation of urgency, associated with mucus discharge, and followed by a feeling of incomplete evacuation. The patient went camping several months earlier, and another member of her camping party fell ill recently. Her temperature is 37° C (98.6° F), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Her physical examination is unremarkable. A routine stool examination is within normal limits and blood test results show:\nHb%   13 gm/dL\nTotal count (WBC):   11,000/mm3\nDifferential count:    \n  Neutrophils: 70%\n  Lymphocytes: 25%\n  Monocytes: 5%\nESR:   10 mm/hr\nWhat is the most likely diagnosis?", "answer": "Irritable bowel syndrome", "options": {"A": "Irritable bowel syndrome", "B": "Crohn’s disease", "C": "Ulcerative colitis", "D": "Giardiasis", "E": "Laxative abuse"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["31 year old woman", "clinic", "chronic diarrhea", "days", "past four months", "lower abdominal discomfort", "cramping", "relieved by episodes of diarrhea", "recent change in", "weight", "Bowel movements", "preceded", "sensation", "urgency", "associated with mucus discharge", "followed by", "incomplete evacuation", "patient", "months earlier", "member", "fell ill recently", "temperature", "98", "F", "respiratory rate", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "unremarkable", "routine stool examination", "normal limits", "blood test results", "Hb", "gm dL Total count", "WBC", "mm3 Differential count", "70", "Lymphocytes", "5", "ESR", "10 mm", "diagnosis"]}
{"question": "A 24-year-old man presents to his primary care physician for a persistent and low grade headache as well as trouble focusing. The patient was seen in the emergency department 3 days ago after hitting his head on a branch while biking under the influence of alcohol. His head CT at the time was normal, and the patient was sent home with follow up instructions. Since the event, he has experienced trouble focusing on his school work and feels confused at times while listening to lectures. He states that he can’t remember the lectures and also says he has experienced a sensation of vertigo at times. On review of systems, he states that he has felt depressed lately and has had trouble sleeping, though he denies any suicidal or homicidal ideation. His temperature is 98.2°F (36.8°C), blood pressure is 122/65 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient’s neurological and cardiopulmonary exam are within normal limits. Which of the following is the best next step in management?", "answer": "Rest and primary care follow up", "options": {"A": "Cognitive behavioral therapy", "B": "CT scan of the head without contrast", "C": "Fluoxetine", "D": "Rest and primary care follow up", "E": "Thiamine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician", "persistent", "low grade headache", "patient", "seen in", "emergency department 3 days", "hitting", "head", "branch", "biking", "alcohol", "head CT", "time", "normal", "patient", "sent home", "follow up instructions", "event", "school", "confused", "times", "listening", "states", "cant", "sensation", "vertigo", "times", "review of systems", "states", "depressed", "trouble sleeping", "suicidal", "homicidal ideation", "temperature", "98", "36", "blood pressure", "65 mmHg", "pulse", "70 min", "respirations", "min", "oxygen saturation", "98", "room air", "patients neurological", "cardiopulmonary exam", "normal limits", "following", "best next step"]}
{"question": "While playing the catcher position in baseball, a 27-year-old male sustained a blow to his left testes which required surgical removal. Upon awakening from anesthesia, he jokes to his wife that he is now half the man that she once knew. Which of the following scenarios is a similar ego defense as the one above?", "answer": "A recently divorced man states he will finally be able to watch a football game without nagging", "options": {"A": "A religious woman with homosexual desires speaks out against gay marriage", "B": "A husband angry at his wife takes out his anger on his employees", "C": "A short-tempered male lifts weights to deal with his anger", "D": "A cheating husband accuses his wife of doing the same", "E": "A recently divorced man states he will finally be able to watch a football game without nagging"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["playing", "position", "baseball", "27 year old male sustained", "blow", "left testes", "required surgical removal", "awakening", "anesthesia", "now half", "man", "following scenarios", "similar ego", "one above"]}
{"question": "A 31-year-old man comes to the physician because of severe muscle pain and fever for 4 days. He likes to go hunting and consumed bear meat 1 month ago. Examination shows periorbital edema and generalized muscle tenderness. His leukocyte count is 12,000/mm3 with 19% eosinophils. The release of major basic protein in response to this patient’s infection is most likely a result of which of the following?", "answer": "Antibody-dependent cell-mediated cytotoxicity", "options": {"A": "Immune complex-dependent complement activation", "B": "Interaction between Th1 cells and macrophages", "C": "Increased expression of MHC class I molecules", "D": "Increased expression of MHC class II molecules", "E": "Antibody-dependent cell-mediated cytotoxicity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["31 year old man", "physician", "severe muscle", "fever", "4 days", "to go", "month", "periorbital edema", "generalized muscle tenderness", "leukocyte count", "mm3", "eosinophils", "release", "major basic protein", "response", "patients infection", "result"]}
{"question": "A 65-year-old patient with a history of COPD and open-angle glaucoma in the left eye has had uncontrolled intraocular pressure (IOP) for the last few months. She is currently using latanoprost eye drops. Her ophthalmologist adds another eye drop to her regimen to further decrease her IOP. A week later, the patient returns because of persistent dim vision. On exam, she has a small fixed pupil in her left eye as well as a visual acuity of 20/40 in her left eye compared to 20/20 in her right eye. Which of the following is the mechanism of action of the medication most likely prescribed in this case?", "answer": "Opening the canal of Schlemm by contracting the ciliary muscle", "options": {"A": "Inhibiting the production of aqueous humor by the ciliary epithelium", "B": "Closing the trabecular mesh by relaxing the ciliary muscles", "C": "Opening the canal of Schlemm by contracting the ciliary muscle", "D": "Increasing reabsorption of aqueous humor by the ciliary epithelium", "E": "Increasing the permeability of sclera to aqueous humor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65-year-old patient", "history", "COPD", "open-angle glaucoma", "left eye", "uncontrolled intraocular pressure", "months", "currently using latanoprost eye drops", "ophthalmologist adds", "eye drop", "regimen", "further decrease", "IOP", "week later", "patient returns", "persistent dim vision", "exam", "small fixed pupil", "left eye", "visual acuity", "20/40", "left eye", "20/20", "right eye", "following", "mechanism of action", "medication", "likely", "case"]}
{"question": "A 47-year-old man presents to the clinic with a 10-day history of a sore throat and fever. He has a past medical history significant for ulcerative colitis and chronic lower back pain. He smokes at least 1 pack of cigarettes daily for 10 years. The father of the patient died of colon cancer at the age of 50. He takes sulfasalazine and naproxen. The temperature is 38.9°C (102.0°F), the blood pressure is 131/87 mm Hg, the pulse is 74/min, and the respiratory rate is 16/min. On physical examination, the patient appears tired and ill. His pharynx is erythematous with exudate along the tonsillar crypts. The strep test comes back positive. In addition to treating the bacterial infection, what else would you recommend for the patient at this time?", "answer": "Colonoscopy", "options": {"A": "Fecal occult blood testing", "B": "Flexible sigmoidoscopy", "C": "Low-dose CT", "D": "Colonoscopy", "E": "PSA and digital rectal exam"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "clinic", "10 day history", "sore throat", "fever", "past medical history significant", "ulcerative colitis", "chronic lower back pain", "smokes at least", "pack", "cigarettes daily", "patient died of colon cancer", "age", "50", "sulfasalazine", "naproxen", "temperature", "blood pressure", "87 mm Hg", "pulse", "74 min", "respiratory rate", "min", "patient appears tired", "ill", "pharynx", "erythematous", "exudate", "tonsillar crypts", "strep test", "back positive", "treating", "bacterial infection", "else", "patient", "time"]}
{"question": "A patient with HCC and a long history of alcohol dependence and chronic hepatitis C has been using the mTOR inhibitor Metalimus 100 mg for cancer treatment. Her cancer has shown a partial response. She also has a history of hypertension and poorly controlled type 2 diabetes mellitus complicated by diabetic retinopathy. Current medications include enalapril and insulin. She asks her oncologist and hepatologist if she could try Noxbinle (tumorolimus) for its purported survival benefit in treating HCC. Based on the data provided in the drug advertisement, which of the following statements is most accurate?", "answer": "The patient is not a good candidate for Noxbinle due to her history of diabetes", "options": {"A": "The patient is not a good candidate for Noxbinle due to her history of hypertension", "B": "The patient is not a good candidate for Noxbinle due to her history of diabetes", "C": "The patient should start Noxbinle 50 mg because of the survival benefit relative to Metalimus 100 mg", "D": "The patient should start Noxbinle 100 mg because of the survival benefit relative to Metalimus 100 mg", "E": "The patient should start Noxbinle 50 mg because of her history of alcohol use disorder and hepatitis C"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["patient", "HCC", "long history", "alcohol dependence", "chronic hepatitis C", "using", "mTOR inhibitor", "100 mg", "cancer treatment", "cancer", "partial response", "history of hypertension", "poorly controlled type 2 diabetes mellitus complicated", "diabetic retinopathy", "Current medications include enalapril", "insulin", "oncologist", "hepatologist", "survival benefit", "treating HCC", "drug", "following", "most accurate"]}
{"question": "A 22-year-old G4P2 at 35 weeks gestation presents to the hospital after she noticed that \"her water broke.\" Her prenatal course is unremarkable, but her obstetric history includes postpartum hemorrhage after her third pregnancy, attributed to a retained placenta. The patient undergoes augmentation of labor with oxytocin and within four hours delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Three minutes later, the placenta passes the vagina, but a smooth mass attached to the placenta continues to follow. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 20/min. What is the most likely complication in the absence of intervention?", "answer": "Hemorrhagic shock", "options": {"A": "Heart failure", "B": "Hemorrhagic shock", "C": "Hypertension", "D": "Hyperthermia", "E": "Tachypnea"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "35 weeks gestation presents", "hospital", "water", "prenatal course", "unremarkable", "obstetric history includes postpartum hemorrhage", "third pregnancy", "attributed", "retained placenta", "patient", "augmentation of labor", "oxytocin", "four hours delivers", "male infant", "Apgar scores", "8", "5 minutes", "Three minutes later", "placenta passes", "vagina", "smooth mass", "placenta", "to follow", "temperature", "98", "blood pressure", "70 mmHg", "pulse", "90 min", "respirations", "20 min", "complication", "absence", "intervention"]}
{"question": "A 40-year-old nulliparous woman with no significant medical history presents to your office with shortness of breath and increased abdominal girth over the past month. The initial assessment demonstrates that the patient has a right-sided hydrothorax, ascites, and a large ovarian mass. Surgery is performed to remove the ovarian mass, and the patient's ascites and pleural effusion resolve promptly. What is the most likely diagnosis?", "answer": "Meigs syndrome", "options": {"A": "Metastatic colon cancer", "B": "Metastatic lung cancer", "C": "Metastatic ovarian cancer", "D": "Meigs syndrome", "E": "Nephrotic syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["40 year old nulliparous woman", "significant medical history presents", "office", "shortness of breath", "increased abdominal", "past month", "initial assessment", "patient", "right-sided hydrothorax", "ascites", "large ovarian", "Surgery", "performed to remove", "ovarian mass", "patient's ascites", "pleural effusion", "diagnosis"]}
{"question": "A 32-year-old man comes to the physician for a follow-up examination. He has a 2-month history of increasing generalized fatigue and severe pruritus. He has hypertension and ulcerative colitis which was diagnosed via colonoscopy 5 years ago. Current medications include lisinopril and rectal mesalamine. He is sexually active with 2 female partners and uses condoms inconsistently. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 130/84 mm Hg. Examination shows scleral icterus and multiple scratch marks on the trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 11.5 g/dL\nLeukocyte count 7500/mm3\nPlatelet count 280,000/mm3\nSerum\nNa+ 138 mEq/L\nCl- 101 mEq/L\nK+ 4.7 mEq/L\nUrea nitrogen 18 mg/dL\nGlucose 91 mg/dL\nCreatinine 0.8 mg/dL\nBilirubin\nTotal 1.5 mg/dL\nDirect 0.9 mg/dL\nAlkaline phosphatase 460 U/L\nAST 75 U/L\nALT 78 U/L\nAnti-nuclear antibody negative\nAntimitochondrial antibodies negative\nAbdominal ultrasound shows thickening of the bile ducts and focal bile duct dilatation. Which of the following is the most likely diagnosis?\"", "answer": "Primary sclerosing cholangitis", "options": {"A": "Autoimmune hepatitis", "B": "Primary sclerosing cholangitis", "C": "Primary biliary cholangitis", "D": "Hepatitis B infection", "E": "IgG4-associated cholangitis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "follow-up examination", "2 month history", "increasing generalized fatigue", "severe pruritus", "hypertension", "ulcerative colitis", "diagnosed", "colonoscopy", "years", "Current medications include lisinopril", "rectal mesalamine", "sexually active", "female", "uses condoms", "temperature", "99", "pulse", "min", "blood pressure", "84 mm Hg", "scleral icterus", "multiple scratch marks", "trunk", "extremities", "lungs", "clear", "auscultation", "abdomen", "soft", "nontender", "abnormalities", "Laboratory studies", "Hemoglobin", "Leukocyte count 7500 mm3 Platelet count", "L", "Urea nitrogen", "mg", "mg", "Creatinine 0", "1", "Direct 0.9 mg Alkaline phosphatase", "U/L AST", "ALT", "Anti-nuclear antibody negative Antimitochondrial antibodies", "Abdominal ultrasound", "thickening", "bile ducts", "focal bile duct dilatation", "following", "diagnosis"]}
{"question": "An 82-year-old woman is brought to the emergency department after losing consciousness at her nursing home. She had been watching TV for several hours and while getting up to use the bathroom, she fell and was unconscious for several seconds. She felt dizzy shortly before the fall. She does not have a headache or any other pain. She has a history of hypertension, intermittent atrial fibrillation, and stable angina pectoris. Current medications include warfarin, aspirin, hydrochlorothiazide, and a nitroglycerin spray as needed. Her temperature is 36.7°C (98.1°F), pulse is 100/min and regular, and blood pressure is 102/56 mm Hg. Physical exam shows a dry tongue. A fold of skin that is pinched on the back of her hand unfolds after 2 seconds. Cardiopulmonary examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Elevated blood urea nitrogen concentration", "options": {"A": "Elevated serum concentration of cardiac enzymes", "B": "Absent P waves on ECG", "C": "Elevated blood urea nitrogen concentration", "D": "Hypodense lesions on CT scan of the head", "E": "Elevated serum creatine kinase concentration"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "consciousness", "nursing home", "TV", "hours", "getting", "use", "bathroom", "fell", "unconscious", "seconds", "dizzy", "fall", "not", "headache", "pain", "history of hypertension", "intermittent atrial fibrillation", "stable angina pectoris", "Current medications include warfarin", "aspirin", "hydrochlorothiazide", "as needed", "temperature", "36", "98", "pulse", "100 min", "regular", "blood pressure", "mm Hg", "dry tongue", "fold", "skin", "pinched", "back of", "hand", "seconds", "Cardiopulmonary", "abnormalities", "Further", "to", "following findings"]}
{"question": "A 38-year-old woman comes to the physician because of a 10-month history of nonbloody diarrhea and recurrent episodes of flushing and wheezing. She does not take any medications. Physical examination shows a hyperpigmented rash around the base of her neck. Cardiac examination shows a grade 4/6, holosystolic murmur in the 5th intercostal space at the left midclavicular line. Echocardiography shows left-sided endocardial and valvular fibrosis with moderate mitral regurgitation; there are no septal defects or right-sided valvular defects. Urinalysis shows increased 5-hydroxyindoleacetic acid concentration. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Tumor in the lung without metastasis", "options": {"A": "Tumor in the pancreas without metastasis", "B": "Tumor in the lung without metastasis", "C": "Tumor in the left atrium with hepatic metastasis", "D": "Tumor in the appendix without metastasis", "E": "Tumor in the descending colon with hepatic metastasis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "a 10 month history", "diarrhea", "recurrent episodes of flushing", "wheezing", "not", "medications", "hyperpigmented rash", "base of", "neck", "holosystolic murmur", "5th intercostal space", "left midclavicular line", "Echocardiography", "left-sided endocardial", "valvular fibrosis", "moderate mitral regurgitation", "septal defects", "right-sided valvular defects", "Urinalysis", "increased 5-hydroxyindoleacetic acid concentration", "Further", "to", "following findings"]}
{"question": "A 4-year-old boy is brought to the clinic by his mother with fever and a rash. The patient’s mother says his symptoms started 1 week ago with the acute onset of fever and a runny nose, which resolved over the next 3 days. Then, 4 days later, she noted a rash on his face, which, after a day, spread to his neck, torso, and extremities. The patient denies any pruritus or pain associated with the rash. No recent history of sore throat, chills, or upper respiratory infection. The patient has no significant past medical history and takes no medications. The vital signs include: temperature 37.2°C (99.9°F) and pulse 88/min. On physical examination, there is a maculopapular rash on his face, torso, and extremities, which spares the palms and soles. The appearance of the rash is shown in the exhibit (see image below). Which of the following would most likely confirm the diagnosis in this patient?", "answer": "ELISA for parvovirus B-19 IgM and IgG antibodies", "options": {"A": "Throat culture", "B": "Assay for IgM and IgG against measles virus", "C": "Serology for human herpesvirus-6 IgM antibodies", "D": "ELISA for IgG antibodies against Rubella virus", "E": "ELISA for parvovirus B-19 IgM and IgG antibodies"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old boy", "brought", "clinic", "mother", "fever", "rash", "patients", "symptoms started 1 week", "acute onset", "fever", "runny nose", "resolved", "next 3 days", "Then", "4 days later", "noted", "rash on", "face", "day", "spread", "neck", "torso", "extremities", "patient", "pruritus", "pain associated with", "rash", "recent history", "sore throat", "chills", "upper respiratory infection", "patient", "significant past medical history", "medications", "vital signs include", "temperature", "99 9F", "pulse 88 min", "maculopapular rash on", "face", "torso", "extremities", "soles", "appearance", "rash", "see", "following", "most likely confirm", "diagnosis", "patient"]}
{"question": "A 24-year-old woman presents to her physician’s office complaining of a worsening cough with large volumes of mucoid sputum in her phlegm every morning and thickened foul smell sputum almost every time she coughs. She says that this cough started about one month ago and has been increasing in intensity. Over the counter medications are ineffective. Past medical history is significant for cystic fibrosis diagnosed at the age of 6 years old, and pneumonia twice in the past 2 years. Other than a cough, she has no fever or any other concerns. A sputum samples grows aerobic, non-lactose fermenting, oxidase-positive, gram-negative bacillus. Which of the following treatment regimens is the most beneficial for her at this time?", "answer": "Intravenous ciprofloxacin", "options": {"A": "Amoxicillin and clavulanic acid", "B": "Postural drainage of the chest", "C": "Surgical therapy", "D": "Trimethoprim and sulfamethoxazole", "E": "Intravenous ciprofloxacin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "physicians office complaining of", "worsening cough", "large volumes of mucoid sputum", "phlegm", "morning", "thickened", "smell sputum almost", "time", "coughs", "cough started", "one month", "increasing", "intensity", "Over the counter medications", "Past medical history", "significant", "cystic fibrosis diagnosed", "age", "years old", "pneumonia twice", "past", "years", "cough", "fever", "sputum samples", "aerobic", "non lactose", "oxidase positive", "following treatment regimens", "most", "time"]}
{"question": "A 7-month-old boy is brought to the pediatrician for a change in his behavior. The patient has been breastfeeding up until this point and has been meeting his developmental milestones. He is in the 90th percentile for weight and 89th percentile for height. This past week, the patient has been lethargic, vomiting, and has been refusing to eat. The patient's parents state that he had an episode this morning where he was not responsive and was moving his extremities abnormally followed by a period of somnolence. The patient's past medical history is notable for shoulder dystocia and poorly managed maternal diabetes during the pregnancy. His temperature is 99.5°F (37.5°C), blood pressure is 60/30 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a lethargic infant with a sweet smell to his breath. Which of the following is most likely deficient in this patient?", "answer": "Aldolase B", "options": {"A": "Aldolase B", "B": "Galactose-1-phosphate uridyltransferase", "C": "Glucose", "D": "Branched chain alpha-ketoacid dehydrogenase", "E": "Ornithine transcarbamolase"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "pediatrician", "patient", "breastfeeding", "point", "90th percentile", "weight", "percentile", "height", "past week", "patient", "lethargic", "vomiting", "to eat", "patient's", "state", "episode", "morning", "not responsive", "moving", "extremities", "followed by", "period", "somnolence", "patient's past", "notable", "shoulder dystocia", "poorly", "diabetes during", "pregnancy", "temperature", "99", "blood pressure", "60 30 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "note", "lethargic infant", "sweet smell", "breath", "following", "deficient", "patient"]}
{"question": "A 21-year-old woman is admitted to the hospital for severe malnutrition with a BMI of 15 kg/m2. Past medical history is significant for chronic anorexia nervosa. During the course of her stay, she is treated with parenteral fluids and nutrition management. On the 4th day, her status changes. Her blood pressure is 110/75 mm Hg, heart rate is 120/min, respiratory rate is 25/min, and temperature is 37.0°C (98.6°F). On physical exam, her heart is tachycardic with a regular rhythm and her lungs are clear to auscultation bilaterally. She appears confused, disoriented, and agitated. Strength in her lower extremities is 4/5. What is the next step in management?", "answer": "Measure electrolytes", "options": {"A": "MRI of the brain", "B": "Arrange for outpatient counseling", "C": "Measure electrolytes", "D": "Administer insulin", "E": "Doppler ultrasound on lower extremities"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["21-year-old woman", "severe malnutrition", "BMI of", "kg/m2", "Past medical", "significant", "chronic anorexia nervosa", "course", "treated with parenteral fluids", "4th day", "status changes", "blood pressure", "75 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "heart", "tachycardic", "regular rhythm", "lungs", "clear", "auscultation", "appears confused", "disoriented", "agitated", "Strength", "lower extremities", "4/5", "next step"]}
{"question": "A 62-year-old man comes to the physician because of a 5-day history of fatigue, fever, and chills. For the past 9 months, he has had hand pain and stiffness that has progressively worsened. He started a new medication for these symptoms 3 months ago. Medications used prior to that included ibuprofen, prednisone, and hydroxychloroquine. He does not smoke or drink alcohol. Examination shows a subcutaneous nodule at his left elbow, old joint destruction with boutonniere deformity, and no active joint warmth or tenderness. The remainder of the physical examination shows no abnormalities. His hemoglobin concentration is 10.5 g/dL, leukocyte count is 3500/mm3, and platelet count is 100,000/mm3. Which of the following is most likely to have prevented this patient's laboratory abnormalities?", "answer": "Leucovorin", "options": {"A": "Cobalamin", "B": "Amifostine", "C": "Pyridoxine", "D": "Leucovorin", "E": "Mesna\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man", "physician", "5-day history", "fatigue", "fever", "chills", "past", "months", "hand pain", "stiffness", "worsened", "started", "new medication", "symptoms 3 months", "Medications used prior to", "included ibuprofen", "prednisone", "hydroxychloroquine", "not smoke", "subcutaneous nodule", "left elbow", "old joint destruction", "boutonniere deformity", "active joint warmth", "tenderness", "abnormalities", "hemoglobin concentration", "10.5 g/dL", "leukocyte count", "3500 mm3", "platelet count", "100", "mm3", "following", "to", "prevented", "patient's laboratory abnormalities"]}
{"question": "Please refer to the summary above to answer this question\nAn ECG is most likely to show which of the following findings in this patient?\"\n\"Patient Information\nAge: 64 years\nGender: F, self-identified\nEthnicity: unspecified\nSite of Care: emergency department\nHistory\nReason for Visit/Chief Concern: “My chest hurts, especially when I take a deep breath.”\nHistory of Present Illness:\n2-hour history of chest pain\npain described as “sharp”\npain rated 6/10 at rest and 10/10 when taking a deep breath\nPast Medical History:\nrheumatoid arthritis\nmajor depressive disorder\nMedications:\nmethotrexate, folic acid, fluoxetine\nAllergies:\npenicillin\nPsychosocial History:\ndoes not smoke\ndrinks one glass of bourbon every night\nPhysical Examination\nTemp Pulse Resp BP O2 Sat Ht Wt BMI\n36.7°C\n(98°F)\n75/min 17/min 124/75 mm Hg –\n163 cm\n(5 ft 4 in)\n54 kg\n(120 lb)\n20 kg/m2\nAppearance: sitting forward at the edge of a hospital bed, uncomfortable\nNeck: no jugular venous distension\nPulmonary: clear to auscultation\nCardiac: regular rate and rhythm; normal S1 and S2; no murmurs; a scratching sound is best heard over the left sternal border; pain is not reproducible on palpation; pain is worse when the patient is lying back and improved by leaning forward\nAbdominal: no tenderness, guarding, masses, bruits, or hepatosplenomegaly\nExtremities: tenderness to palpation, stiffness, and swelling of the metacarpophalangeal and proximal interphalangeal joints of the fingers; swan neck deformities and ulnar deviation of several fingers; firm, nontender nodules on the extensor aspects of the left forearm; no edema\nNeurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits\"", "answer": "Diffuse, concave ST-segment elevations", "options": {"A": "S waves in lead I, Q waves in lead III, and inverted T waves in lead III", "B": "Diffuse, concave ST-segment elevations", "C": "Sawtooth-appearance of P waves", "D": "Peaked T waves and ST-segment elevations in leads V1-V6", "E": "Alternating high and low amplitude QRS complexes"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["refer", "above to", "ECG", "to", "following findings", "patient", "Patient Age", "64 years Gender", "F", "identified Ethnicity", "unspecified Site of Care", "emergency department History Reason for Visit", "chest", "I", "deep breath", "History of Present Illness", "2-hour history of chest pain", "sharp pain", "6/10", "10", "deep breath Past Medical History", "rheumatoid arthritis major depressive disorder Medications", "methotrexate", "folic acid", "fluoxetine Allergies", "penicillin Psychosocial History", "not smoke", "one glass", "night", "Temp Pulse Resp BP O2 Sat Ht Wt BMI 36", "75 min", "mm Hg", "5 ft 4", "54 kg", "20 kg/m2 Appearance", "sitting forward", "edge", "hospital bed", "Neck", "jugular venous distension Pulmonary", "clear to auscultation Cardiac", "regular rate", "rhythm", "normal S1", "S2", "murmurs", "sound", "best heard", "left sternal border", "pain", "not reproducible", "palpation", "pain", "worse", "patient", "lying back", "improved", "forward Abdominal", "tenderness", "guarding", "masses", "bruits", "hepatosplenomegaly Extremities", "tenderness", "palpation", "stiffness", "swelling", "proximal interphalangeal joints of", "fingers", "swan neck deformities", "ulnar deviation of", "fingers", "firm", "nontender nodules", "extensor aspects", "left forearm", "edema Neurologic", "alert", "oriented", "cranial nerves", "intact", "focal neurologic deficits"]}
{"question": "A 16-year-old boy is brought to the physician for a follow-up appointment. He has a seizure disorder treated with valproic acid. He has always had difficulties with his schoolwork. He was able to walk independently at the age of 2 years and was able to use a fork and spoon at the age of 3 years. Ophthalmic examination shows hyperpigmented iris nodules bilaterally. A photograph of his skin examination findings is shown. This patient is at increased risk for which of the following conditions?", "answer": "Pheochromocytoma", "options": {"A": "Vestibular schwannoma", "B": "Hemangioblastoma", "C": "Pheochromocytoma", "D": "Leptomeningeal angioma", "E": "Cardiac rhabdomyoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "follow-up appointment", "seizure disorder treated with valproic acid", "always", "difficulties", "able to", "age", "years", "able to use", "fork", "spoon", "age of", "years", "Ophthalmic examination", "hyperpigmented iris", "photograph of", "skin examination findings", "patient", "increased risk", "following conditions"]}
{"question": "A 52-year-old woman presents to her primary care physician with a chief complaint of diarrhea. She states that it has been going on for the past month and started after she ate a burger cooked over a campfire. She endorses having lost 10 pounds during this time. The patient has no other complaints other than hoarseness which has persisted during this time. The patient has a past medical history of obesity, hypothyroidism, diabetes, and anxiety. Her current medications include insulin, metformin, levothyroxine, and fluoxetine. She currently drinks 4 to 5 alcoholic beverages per day. Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy obese woman. Cardiopulmonary exam is within normal limits. HEENT exam is notable for a mass on the thyroid. Abdominal exam is notable for a candida infection underneath the patient's pannus. Pelvic exam is notable for a white, fish-odored discharge. Laboratory values are as follows:\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 4,500 cells/mm^3 with normal differential\nPlatelet count: 190,000/mm^3\n\nSerum:\nNa+: 141 mEq/L\nCl-: 102 mEq/L\nK+: 5.5 mEq/L\nHCO3-: 24 mEq/L\nGlucose: 122 mg/dL\nCa2+: 7.1 mg/dL\n\nWhich of the following could also be found in this patient?", "answer": "Episodic hypertension and headaches", "options": {"A": "Acute renal failure", "B": "Acute liver failure", "C": "Episodic hypertension and headaches", "D": "Bitemporal hemianopsia", "E": "Schistocytes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "chief complaint", "diarrhea", "states", "past month", "started", "ate", "lost 10 pounds", "time", "patient", "complaints", "hoarseness", "time", "patient", "past medical", "hypothyroidism", "diabetes", "anxiety", "current medications include insulin", "metformin", "levothyroxine", "fluoxetine", "currently", "4", "5", "day", "temperature", "99", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "note", "healthy obese woman", "Cardiopulmonary exam", "normal limits", "HEENT exam", "notable", "mass", "thyroid", "Abdominal exam", "notable", "candida infection", "patient's pannus", "Pelvic exam", "notable", "white", "discharge", "Laboratory values", "follows", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "4 500 cells mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "5.5 mEq/L HCO3", "mEq/L Glucose", "mg/dL Ca2", "mg/dL", "following", "found", "patient"]}
{"question": "A 27-year-old female presents to her OB/GYN for a check-up. During her visit, a pelvic exam and Pap smear are performed. The patient does not have any past medical issues and has had routine gynecologic care with normal pap smears every 3 years since age 21. The results of the Pap smear demonstrate atypical squamous cells of undetermined significance (ASCUS). Which of the following is the next best step in the management of this patient?", "answer": "Perform an HPV DNA test", "options": {"A": "Repeat Pap smear in 1 year", "B": "Repeat Pap smear in 3 years", "C": "Perform an HPV DNA test", "D": "Perform colposcopy", "E": "Perform a Loop Electrosurgical Excision Procedure (LEEP)"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old female presents", "OB/GYN", "check-up", "pelvic exam", "Pap smear", "performed", "patient", "not", "past medical issues", "routine gynecologic", "normal pap smears", "3 years", "age", "results", "Pap smear", "following", "next best step", "patient"]}
{"question": "A 19-year-old man comes to the physician for the evaluation of progressive difficulty climbing stairs over the last 2 years. During this period, he has also had problems with running, occasional falls, and standing from a chair. He has not had any vision problems or muscle cramping. There is no personal or family history of serious illness. Neurological examination shows deep tendon reflexes are 2+ bilaterally and sensation to pinprick and light touch is normal. Musculoskeletal examination shows enlarged calf muscles bilaterally. He has a waddling gait. Laboratory studies show a creatine kinase level of 1700 U/L. Which of the following is the most appropriate next step to confirm the diagnosis?", "answer": "Genetic analysis", "options": {"A": "Tensilon test", "B": "Anti-Jo-1 antibodies measurement", "C": "CT scan of the chest", "D": "Electromyography", "E": "Genetic analysis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "progressive difficulty climbing stairs", "last", "years", "period", "occasional falls", "standing", "chair", "not", "vision problems", "muscle cramping", "personal", "family history", "serious illness", "Neurological examination", "deep tendon reflexes", "2", "sensation", "light touch", "normal", "enlarged calf muscles", "waddling gait", "Laboratory studies", "creatine kinase level", "U/L", "following", "most appropriate next step to confirm", "diagnosis"]}
{"question": "An 11-year-old man presents with fever and joint pain for the last 3 days. His mother says that he had a sore throat 3 weeks ago but did not seek medical care at that time. The family immigrated from the Middle East 3 years ago. The patient has no past medical history. The current illness started with a fever and a swollen right knee that was very painful. The following day, his knee improved but his left elbow became swollen and painful. While in the waiting room, his left knee is also becoming swollen and painful. Vital signs include: temperature 38.7°C (101.6°F), and blood pressure 110/80 mm Hg. On physical examination, the affected joints are swollen and very tender to touch, and there are circular areas of redness on his back and left forearm (as shown in the image). Which of the following is needed to establish a diagnosis of acute rheumatic fever in this patient?", "answer": "Positive anti-streptococcal serology", "options": {"A": "Elevated erythrocyte sedimentation rate (ESR)", "B": "Elevated leukocyte count", "C": "No other criterion is needed to establish the diagnosis of acute rheumatic fever", "D": "Prolonged PR interval", "E": "Positive anti-streptococcal serology"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "fever", "joint pain", "3 days", "sore throat", "weeks", "not", "medical care", "time", "Middle East", "years", "patient", "past medical history", "current illness started", "fever", "swollen right", "very painful", "following day", "knee improved", "left elbow", "swollen", "painful", "waiting room", "left knee", "swollen", "painful", "Vital signs include", "temperature", "blood pressure", "80 mm Hg", "affected joints", "swollen", "very tender", "touch", "circular areas", "redness", "back", "left forearm", "following", "needed to establish", "diagnosis", "acute rheumatic fever", "patient"]}
{"question": "A 41-year-old woman is referred by her radiation oncologist to the medical genetics clinic. She was recently diagnosed with an infiltrating ductal carcinoma of the breast. She has a previous history of colonic polyps for which she undergoes bi-annual colonoscopy. The maternal and paternal family history is unremarkable for polyps and malignant or benign tumors. However, the patient reports that her 10-year-old son has dark brown pigmentation on his lips, and she also had similar pigmentation as a child. Histology of colonic polyps in this patient will most likely reveal which of the following?", "answer": "Hamartomatous polyp", "options": {"A": "Hyperplastic polyps", "B": "Adenomatous polyps", "C": "Inflammatory polyps", "D": "Retention polyps", "E": "Hamartomatous polyp"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "referred", "radiation oncologist", "medical genetics clinic", "recently diagnosed", "infiltrating ductal carcinoma of the breast", "previous history of colonic polyps", "annual colonoscopy", "paternal family history", "unremarkable", "polyps", "malignant", "benign tumors", "patient reports", "10 year old", "dark brown pigmentation", "lips", "similar pigmentation", "child", "Histology", "colonic polyps", "patient", "most likely reveal", "following"]}
{"question": "A 40-year-old woman presents to her primary care physician with a 5-month history of worsening bladder discomfort. Her discomfort is relieved by voiding. She voids 10–15 times per day and wakes up 2–3 times per night to void. She has not had any involuntary loss of urine. She has tried cutting down on fluids and taking NSAIDs to reduce the discomfort with minimal relief. Her past medical history is significant for bipolar disorder. She is sexually active with her husband but reports that intercourse has recently become painful. Current medications include lithium. Her temperature is 37°C (98.6°F), pulse is 65/min, and blood pressure is 110/80 mm Hg. Examination shows tenderness to palpation of her suprapubic region. Urinalysis shows:\nColor clear\npH 6.7\nSpecific gravity 1.010\nProtein 1+\nGlucose negative\nKetones negative\nBlood negative\nNitrite negative\nLeukocyte esterase negative\nWBC 0/hpf\nSquamous epithelial cells 2/hpf\nBacteria None\nA pelvic ultrasound shows a postvoid residual urine is 25 mL. A cystoscopy shows a normal urethra and normal bladder mucosa. Which of the following is the most likely diagnosis?\"", "answer": "Interstitial cystitis", "options": {"A": "Urinary tract infection", "B": "Overactive bladder", "C": "Interstitial cystitis", "D": "Urinary retention", "E": "Diabetes insipidus"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old woman presents", "primary care physician", "5 month history", "worsening bladder discomfort", "discomfort", "relieved by voiding", "voids", "times per day", "wakes up 23 times", "night", "void", "not", "loss", "urine", "cutting", "fluids", "NSAIDs to", "discomfort", "minimal relief", "past medical history", "significant", "bipolar disorder", "sexually active", "reports", "intercourse", "recently", "painful", "Current medications include lithium", "temperature", "98", "pulse", "65 min", "blood pressure", "80 mm Hg", "tenderness", "palpation", "suprapubic region", "Urinalysis", "Color", "pH", "7 Specific gravity", "Protein 1", "negative Ketones", "Blood", "Leukocyte esterase", "WBC 0 hpf", "cells", "Bacteria", "pelvic ultrasound", "postvoid residual urine", "mL", "cystoscopy", "normal urethra", "normal bladder mucosa", "following", "diagnosis"]}
{"question": "A 55-year-old woman presents to her primary care provider with a 2-month history of insidious onset of left shoulder pain. It only occurs at the extremes of her range of motion and has made it difficult to sleep on the affected side. She has noticed increasing difficulty with activities of daily living, including brushing her hair and putting on or taking off her blouse and bra. She denies a history of shoulder trauma, neck pain, arm/hand weakness, numbness, or paresthesias. Her medical history is remarkable for type 2 diabetes mellitus, for which she takes metformin and glipizide. Her physical examination reveals a marked decrease in both active and passive range of motion of the left shoulder, with forwarding flexion to 75°, abduction to 75°, external rotation to 45°, and internal rotation to 15° with significant pain. Rotator cuff strength is normal. AP, scapular Y, and axillary plain film radiographs are reported as normal. Which of the following is the most likely diagnosis?", "answer": "Adhesive capsulitis", "options": {"A": "Degenerative cervical spine disease", "B": "Adhesive capsulitis", "C": "Rotator cuff injury", "D": "Subacromial impingement syndrome", "E": "Glenohumeral arthritis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care provider", "2 month history", "insidious onset", "left shoulder pain", "only occurs", "extremes of", "range", "motion", "made", "difficult to sleep", "affected side", "increasing difficulty", "including brushing", "hair", "blouse", "bra", "history", "shoulder trauma", "neck pain", "arm hand", "numbness", "paresthesias", "medical history", "type 2 diabetes mellitus", "metformin", "glipizide", "reveals", "marked decrease", "active", "passive range of motion of", "left shoulder", "forwarding flexion", "75", "abduction", "75", "external rotation", "internal rotation", "significant pain", "Rotator cuff strength", "normal", "AP", "scapular", "axillary plain film radiographs", "reported", "normal", "following", "diagnosis"]}
{"question": "A 70-year-old man comes to the physician because of right-sided back pain, red urine, and weight loss for the last 4 months. He has smoked one pack of cigarettes daily for 40 years. A CT scan of the abdomen shows a large right-sided renal mass. Biopsy of the mass shows polygonal clear cells filled with lipids. Which of the following features is necessary to determine the tumor grade in this patient?", "answer": "Degree of mitotic activity", "options": {"A": "Size of malignant proliferation", "B": "Invasion of surrounding structures", "C": "Degree of mitotic activity", "D": "Response to chemotherapy", "E": "Involvement of regional lymph nodes\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old man", "physician", "right-sided back pain", "red urine", "weight loss", "months", "smoked one pack", "cigarettes daily", "40 years", "CT scan", "abdomen", "large right-sided renal mass", "Biopsy", "polygonal", "lipids", "following features", "to", "tumor grade", "patient"]}
{"question": "A previously healthy 46-year-old woman comes to her physician because of an itchy rash on her legs. She denies any recent trauma, insect bites, or travel. Her vital signs are within normal limits. Examination of the oral cavity shows white lace-like lines on the buccal mucosa. A photograph of the rash is shown. A biopsy specimen of the skin lesion is most likely to show which of the following?", "answer": "Lymphocytes at the dermoepidermal junction", "options": {"A": "Decreased thickness of the stratum granulosum", "B": "Inflammation of subcutaneous adipose tissue", "C": "Lymphocytes at the dermoepidermal junction", "D": "Proliferation of vascular endothelium", "E": "Deposition of antibodies around epidermal cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old woman", "physician", "of", "itchy", "legs", "recent trauma", "insect bites", "vital signs", "normal limits", "Examination of", "oral cavity", "white lace", "lines", "buccal mucosa", "photograph", "rash", "biopsy specimen", "skin lesion", "to", "following"]}
{"question": "A 48-year-old female presents to the emergency room with mental status changes.\nLaboratory analysis of the patient's serum shows:\nNa 122 mEq/L\nK 3.9 mEq/L\nHCO3 24 mEq/L\nBUN 21 mg/dL\nCr 0.9 mg/dL\nCa 8.5 mg/dL\nGlu 105 mg/dL\n\nUrinalysis shows:\nOsmolality 334 mOsm/kg\nNa 45 mEq/L\nGlu 0 mg/dL\n\nWhich of the following is the most likely diagnosis?", "answer": "Lung cancer", "options": {"A": "Aspirin overdose", "B": "Diarrhea", "C": "Diabetes insipidus", "D": "Primary polydipsia", "E": "Lung cancer"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["48 year old female presents", "emergency room", "mental status changes", "Laboratory analysis", "patient's serum", "Na", "mEq K", "HCO3", "mg dL Cr 0", "mg dL", "8 5", "Glu", "Urinalysis", "Osmolality", "mOsm/kg Na", "mEq/L Glu 0 mg/dL", "following", "diagnosis"]}
{"question": "On the 4th day of hospital admission due to pneumonia, a 69-year-old woman develops non-bloody diarrhea and abdominal pain. She is currently treated with ceftriaxone. Despite the resolution of fever after the first 2 days of admission, her temperature is now 38.5°C (101.3°F). On physical examination, she has mild generalized abdominal tenderness without abdominal guarding or rebound tenderness. Laboratory studies show re-elevation of leukocyte counts. Ceftriaxone is discontinued. Given the most likely diagnosis in this patient, which of the following is the most sensitive test?\n ", "answer": "Stool culture for bacterial isolation and toxin presence", "options": {"A": "Endoscopy ", "B": "Enzyme immunoassay glutamate dehydrogenase ", "C": "Gram stain of stool sample ", "D": "Nucleic acid amplification test", "E": "Stool culture for bacterial isolation and toxin presence"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["4th day", "hospital", "pneumonia", "69 year old woman", "non bloody diarrhea", "abdominal pain", "currently treated with ceftriaxone", "resolution", "fever", "first 2 days", "temperature", "now", "mild generalized abdominal tenderness", "guarding", "rebound tenderness", "Laboratory studies", "re elevation", "leukocyte counts", "Ceftriaxone", "discontinued", "Given", "diagnosis", "patient", "following", "most sensitive test"]}
{"question": "A 2-year-old boy is brought to the physician for a well-child examination. Since infancy, he has frequently had large-volume stools that are loose and greasy. He was treated for otitis media twice in the past year. He has a history of recurrent respiratory tract infections since birth. He is at the 5th percentile for height and 3rd percentile for weight. Vital signs are within normal limits. Examination shows softening of the occipital and parietal bones. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Which of the following is the most likely cause of this patient's symptoms?", "answer": "CFTR gene mutation", "options": {"A": "Deficient α1 antitrypsin", "B": "Gliadin autoantibodies", "C": "CFTR gene mutation", "D": "Absent T cells", "E": "Impaired ciliary function"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["2 year old boy", "brought", "physician", "well", "infancy", "frequently", "large volume stools", "loose", "greasy", "treated", "otitis media twice", "past year", "history", "recurrent respiratory tract infections", "birth", "5th percentile", "height", "3rd percentile", "weight", "Vital signs", "normal limits", "softening", "occipital", "parietal bones", "Scattered expiratory wheezing", "rhonchi", "heard", "lung fields", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 77-year-old woman is brought to her primary care provider by her daughter with behavioral changes and an abnormally bad memory for the past few months. The patient’s daughter says she sometimes gets angry and aggressive while at other times she seems lost and stares at her surroundings. Her daughter also reports that she has seen her mother talking to empty chairs. The patient says she sleeps well during the night but still feels sleepy throughout the day. She has no problems getting dressed and maintaining her one bedroom apartment. Past medical history is significant for mild depression and mild osteoporosis. Current medications include escitalopram, alendronic acid, and a multivitamin. The patient is afebrile, and her vital signs are within normal limits. On physical examination, the patient is alert and oriented and sitting comfortably in her chair. A mild left-hand tremor is noted. Muscle strength is 5 out of 5 in the upper and lower extremities bilaterally, but muscle tone is slightly increased. She can perform repetitive alternating movements albeit slowly. She walks with a narrow gait and has mild difficulty turning. Which of the following is the most likely diagnosis in this patient?", "answer": "Lewy body dementia", "options": {"A": "Alzheimer's disease", "B": "Delirium", "C": "Frontotemporal dementia", "D": "Lewy body dementia", "E": "Serotonin syndrome"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "primary care provider", "behavioral changes", "bad memory", "past", "months", "patients", "sometimes gets", "aggressive", "times", "lost", "stares", "surroundings", "reports", "seen", "talking", "empty chairs", "patient", "sleeps well", "night", "sleepy", "day", "getting dressed", "one bedroom apartment", "Past medical history", "significant", "mild depression", "mild osteoporosis", "Current medications include escitalopram", "alendronic acid", "multivitamin", "patient", "afebrile", "vital signs", "normal limits", "patient", "alert", "oriented", "sitting", "chair", "mild left-hand tremor", "noted", "Muscle strength", "5 out of 5", "upper", "lower extremities", "muscle tone", "slightly increased", "perform repetitive alternating movements", "slowly", "walks", "narrow gait", "mild difficulty turning", "following", "diagnosis", "patient"]}
{"question": "A 49-year-old man comes to the physician because of severe, shooting pain in his lower back for the past 2 weeks. The pain radiates down the back of both legs and started after he lifted a concrete manhole cover from the ground. Physical examination shows decreased sensation to light touch bilaterally over the lateral thigh area and lateral calf bilaterally. Patellar reflex is decreased on both sides. The passive raising of either the right or left leg beyond 30 degrees triggers a shooting pain down the leg past the knee. Which of the following is the most likely underlying cause of this patient's current condition?", "answer": "Herniation of nucleus pulposus into vertebral canal", "options": {"A": "Involuntary contraction of the paraspinal muscles", "B": "Inflammatory degeneration of the spine", "C": "Compromised integrity of the vertebral body", "D": "Herniation of nucleus pulposus into vertebral canal", "E": "Inflammatory reaction in the epidural space"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "of severe", "shooting pain in", "lower back", "past 2 weeks", "pain radiates", "back of", "legs", "started", "cover", "decreased", "light", "lateral thigh area", "lateral calf", "Patellar reflex", "decreased", "sides", "passive", "right", "left leg", "30 degrees triggers", "shooting", "leg past", "knee", "following", "underlying cause", "patient's current condition"]}
{"question": "A 23-year-old patient with a past medical history of anxiety and appropriately treated schizophrenia presents to the emergency department for a first time seizure. The patient was at home eating dinner when he began moving abnormally and did not respond to his mother, prompting her to bring him in. His symptoms persisted in the emergency department and were successfully treated with diazepam. The patient is discharged and scheduled for a follow up appointment with neurology the next day for treatment. The patient returns to his neurologist 1 month later for a checkup. Physical exam is notable for carpopedal spasm when his blood pressure is being taken. Cranial nerves II-XII are grossly intact and his gait is stable. Which of the following is the most likely explanation of this patient's current presentation?", "answer": "P450 induction", "options": {"A": "Acute renal failure", "B": "Elevated blood levels of a medication", "C": "Increased water consumption", "D": "P450 induction", "E": "Sub-therapeutic dose"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old patient", "past medical history of anxiety", "treated schizophrenia presents", "emergency department", "first time seizure", "patient", "at home eating dinner", "began moving", "not", "prompting", "to", "symptoms", "emergency department", "treated with diazepam", "patient", "scheduled", "follow up appointment", "neurology", "next day", "treatment", "patient returns", "neurologist 1 month later", "checkup", "notable", "carpopedal spasm", "blood pressure", "Cranial nerves II XII", "intact", "gait", "stable", "following", "explanation", "patient's current"]}
{"question": "A 16-year-old boy comes to the physician because of a 1-week history of difficulty swallowing, a foreign body sensation at the back of his throat, and trouble breathing at night. He has just recovered from an upper respiratory tract infection that began 5 days ago. On questioning, he reports that he has had similar symptoms in the past each time he has had an upper respiratory tract infection. Physical examination shows a 3 x 2-cm, nontender, rubbery midline mass at the base of the tongue. His skin is dry and cool. An image of his technetium-99m pertechnetate scan is shown. Which of the following is the most likely underlying cause of this patient’s condition?", "answer": "Arrested endodermal migration from pharyngeal floor", "options": {"A": "Ductal obstruction of the sublingual salivary glands", "B": "Chronic infection of the palatine and lingual tonsils", "C": "Arrested endodermal migration from pharyngeal floor", "D": "Persistent epithelial tract between the foramen cecum and thyroid isthmus", "E": "Failure of obliteration of the second branchial cleft"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "physician", "1-week history", "difficulty swallowing", "foreign body sensation", "back of", "throat", "trouble breathing", "night", "recovered", "upper respiratory tract infection", "began 5 days", "reports", "similar symptoms", "past", "time", "upper respiratory tract infection", "3", "2", "nontender", "rubbery midline mass", "the base of", "tongue", "skin", "dry", "cool", "pertechnetate scan", "following", "underlying cause", "patients condition"]}
{"question": "A previously healthy 44-year-old man is brought by his coworkers to the emergency department 45 minutes after he became light-headed and collapsed while working in the boiler room of a factory. He did not lose consciousness. His coworkers report that 30 minutes prior to collapsing, he told them he was nauseous and had a headache. The patient appears sweaty and lethargic. He is not oriented to time, place, or person. The patient’s vital signs are as follows: temperature 41°C (105.8°F); heart rate 133/min; respiratory rate 22/min; and blood pressure 90/52 mm Hg. Examination shows equal and reactive pupils. Deep tendon reflexes are 2+ bilaterally. His neck is supple. A 0.9% saline infusion is administered. A urinary catheter is inserted and dark brown urine is collected. The patient’s laboratory test results are as follows:\nLaboratory test\nBlood\nHemoglobin 15 g/dL\nLeukocyte count 18,000/mm3\nPlatelet count 51,000/mm3\nSerum\nNa+ 149 mEq/L\nK+ 5.0 mEq/L\nCl- 98 mEq/L\nUrea nitrogen 42 mg/dL\nGlucose 88 mg/dL\nCreatinine 1.8 mg/dL\nAspartate aminotransferase (AST, GOT) 210\nAlanine aminotransferase (ALT, GPT) 250\nCreatine kinase 86,000 U/mL\nWhich of the following is the most appropriate next step in patient management?", "answer": "Ice water immersion", "options": {"A": "Acetaminophen therapy", "B": "Dantrolene", "C": "Evaporative cooling", "D": "Ice water immersion", "E": "Hemodialysis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department 45 minutes", "light-headed", "collapsed", "boiler room", "factory", "not", "consciousness", "report", "30 minutes prior to collapsing", "nauseous", "headache", "patient appears sweaty", "lethargic", "not oriented to time", "place", "patients vital signs", "follows", "temperature", "heart rate", "min", "respiratory rate", "min", "blood pressure 90", "mm Hg", "equal", "reactive pupils", "Deep tendon reflexes", "2", "neck", "supple", "0.9", "saline infusion", "administered", "urinary catheter", "dark", "collected", "patients laboratory test results", "follows", "Blood", "Leukocyte count", "mm3", "K", "0", "98", "42 mg", "Aspartate", "AST", "Alanine aminotransferase", "ALT", "GPT", "Creatine kinase", "U/mL", "following", "most appropriate next step", "patient"]}
{"question": "A 35-year-old male anesthesiologist presents to the occupational health clinic after a needlestick exposure while obtaining an arterial line in a patient with cirrhosis. In addition to a standard bloodborne pathogen laboratory panel sent for all needlestick exposures at his hospital, additional hepatitis panels are ordered upon the patient's request. The patient's results are shown below:\n\nHIV 4th generation Ag/Ab: Negative/Negative\nHepatitis B surface antigen (HBsAg): Negative\nHepatitis C antibody: Negative\nAnti-hepatitis B surface antibody (HBsAb): Positive\nAnti-hepatitis B core IgM antibody (HBc IgM): Negative\nAnti-hepatitis B core IgG antibody (HBc IgG): Positive\n\nWhat is the most likely explanation of the results above?", "answer": "Immune due to infection", "options": {"A": "Acute infection", "B": "Chronic infection", "C": "Immune due to infection", "D": "Immune due to vaccination", "E": "Window period"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old male anesthesiologist presents", "occupational health clinic", "needlestick exposure", "obtaining", "arterial line", "patient", "cirrhosis", "standard", "laboratory panel sent", "needlestick exposures", "hospital", "additional hepatitis panels", "ordered", "patient's request", "HIV 4th generation Ag", "Negative", "Hepatitis B surface antigen", "Negative Hepatitis C antibody", "Negative", "hepatitis B surface antibody", "HBsAb", "Positive Anti hepatitis B core IgM antibody", "HBc IgM", "Negative Anti hepatitis B core IgG antibody", "HBc", "Positive", "results above"]}
{"question": "A 75-year-old woman presents to her physician with a cough and shortness of breath. She says that cough gets worse at night and her shortness of breath occurs with moderate exertion or when lying flat. She says these symptoms have been getting worse over the last 6 months. She mentions that she has to use 3 pillows while sleeping in order to relieve her symptoms. She denies any chest pain, chest tightness, or palpitations. Past medical history is significant for hypertension and diabetes mellitus type 2. Her medications are amiloride, glyburide, and metformin. Family history is significant for her father who also suffered diabetes mellitus type 2 before his death at 90 years old. The patient says she drinks alcohol occasionally but denies any smoking history. Her blood pressure is 130/95 mm Hg, temperature is 36.5°C (97.7°F), and heart rate is 100/min. On physical examination, she has a sustained apical impulse, a normal S1 and S2, and a loud S4 without murmurs. There are bilateral crackles present bilaterally. A chest radiograph shows a mildly enlarged cardiac silhouette. A transesophageal echocardiogram is performed and shows a normal left ventricular ejection fraction. Which of the following myocardial changes is most likely present in this patient?", "answer": "Ventricular hypertrophy with sarcomeres duplicated in parallel", "options": {"A": "Ventricular hypertrophy with sarcomeres duplicated in series", "B": "Macrophages with hemosiderin", "C": "Ventricular hypertrophy with sarcomeres duplicated in parallel", "D": "Asymmetric hypertrophy of the interventricular septum", "E": "Granuloma consisting of lymphocytes, plasma cells and macrophages surrounding necrotic"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old woman presents", "physician", "cough", "shortness of breath", "cough gets worse", "night", "shortness of breath occurs", "lying flat", "symptoms", "getting worse", "months", "to use 3 pillows", "sleeping", "order to relieve", "symptoms", "chest pain", "chest tightness", "palpitations", "Past medical history", "significant", "hypertension", "diabetes mellitus type 2", "medications", "amiloride", "glyburide", "metformin", "Family history", "significant", "suffered diabetes mellitus type 2", "death", "90 years old", "patient", "alcohol occasionally", "smoking history", "blood pressure", "95 mm Hg", "temperature", "36", "97", "heart rate", "100 min", "sustained", "normal S1", "S2", "loud S4", "murmurs", "bilateral crackles present", "chest radiograph", "mildly enlarged cardiac silhouette", "transesophageal echocardiogram", "performed", "normal left", "following myocardial changes", "most likely present", "patient"]}
{"question": "A 62-year-old woman presents to the emergency department with a 2-hour history of sharp chest pain. She says that the pain is worse when she inhales and is relieved by sitting up and leaning forward. Her past medical history is significant for rheumatoid arthritis, myocardial infarction status post coronary artery bypass graft, and radiation for breast cancer 20 years ago. Physical exam reveals a rubbing sound upon cardiac auscultation as well as increased jugular venous distention on inspiration. Pericardiocentesis is performed revealing grossly bloody fluid. Which of the following is most specifically associated with this patient's presentation?", "answer": "Malignancy", "options": {"A": "Malignancy", "B": "Myocardial infarction", "C": "Rheumatoid arthritis", "D": "Uremia", "E": "Viral illness"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old woman presents", "emergency department", "2-hour history of sharp chest pain", "pain", "worse", "inhales", "relieved by sitting", "forward", "past medical history", "significant", "rheumatoid arthritis", "myocardial infarction status post coronary artery bypass graft", "radiation", "breast cancer 20 years", "Physical exam reveals", "rubbing sound", "cardiac", "increased jugular venous distention", "inspiration", "Pericardiocentesis", "performed revealing", "bloody fluid", "following", "most", "associated with", "patient's"]}
{"question": "Four days after admission to the hospital for anorexia nervosa, a 20-year-old woman has new-onset palpitations and paresthesias in all four limbs. Prior to admission, she was found unconscious by her parents on the floor of a residential treatment center. The patient was started on a trial of nutritional rehabilitation upon arrival to the hospital. Her temperature is 36°C (96.8°F), pulse is 47/min, and blood pressure is 90/60 mmHg. She is 160 cm tall and weighs 35 kg; BMI is 14 kg/m2. The patient appears emaciated. Examination shows lower leg edema. A 2/6 holosystolic murmur is heard over the 5th intercostal space at the midclavicular line. AN ECG shows intermittent supraventricular tachycardia and QTc prolongation. Serum studies show:\nDay 2 Day 4\nPotassium (mEq/L) 3.5 2.7\nCalcium (mg/dL) 8.5 7.8\nMagnesium (mEq/L) 1.2 0.5\nPhosphorus (mg/dL) 3.6 1.5\nWhich of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Increased insulin release", "options": {"A": "Thiamine deficiency", "B": "Rapid gastric emptying", "C": "Uncompensated metabolic alkalosis", "D": "Increased insulin release", "E": "Euthyroid sick syndrome"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Four days", "hospital", "anorexia nervosa", "20 year old woman", "new-onset palpitations", "paresthesias", "four limbs", "found unconscious", "floor", "residential treatment center", "patient", "started", "nutritional rehabilitation", "arrival", "hospital", "temperature", "96", "pulse", "min", "blood pressure", "90 60 mmHg", "tall", "35 kg", "BMI", "kg/m2", "patient appears emaciated", "lower leg edema", "2/6 holosystolic murmur", "heard", "5th intercostal space", "midclavicular line", "ECG", "intermittent supraventricular tachycardia", "QTc prolongation", "Serum studies", "Day", "4 Potassium", "mEq/L", "3.5", "Calcium", "mg/dL", "8", "8 Magnesium", "mEq/L", "Phosphorus", "mg/dL", "3", "5", "following", "underlying cause", "patient", "ondition?"]}
{"question": "A 17-year-old boy comes to the emergency department because of a 3-day history of pain in his left wrist. That morning the pain increased and he started to have chills and malaise. Last week he had self-resolving left knee pain. He is otherwise healthy and has not had any trauma to the wrist. He recently returned from a camping trip to Minnesota. He is sexually active with one female partner, who uses a diaphragm for contraception. His temperature is 37.7°C (99.9°F). Examination shows several painless violaceous vesiculopustular lesions on the dorsum of both wrists and hands; two lesions are present on the left palm. There is swelling and erythema of the left wrist with severe tenderness to palpation and passive movement. Which of the following is the most likely diagnosis?", "answer": "Disseminated gonococcal infection", "options": {"A": "Lyme arthritis", "B": "Acute rheumatic fever", "C": "Systemic lupus erythematosus", "D": "Disseminated gonococcal infection", "E": "Reactive arthritis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "emergency department", "3-day history", "pain", "left wrist", "morning", "pain increased", "started to", "chills", "malaise", "week", "resolving left", "healthy", "not", "trauma", "wrist", "recently returned", "trip", "Minnesota", "sexually active", "one female", "uses", "diaphragm", "contraception", "temperature", "99 9F", "several painless violaceous vesiculopustular lesions", "dorsum of", "wrists", "hands", "two lesions", "present", "left palm", "swelling", "erythema of", "left wrist", "severe tenderness", "palpation", "passive movement", "following", "diagnosis"]}
{"question": "A 53-year-old man with obesity and heart disease presents to your outpatient clinic with complaints of orthopnea, significant dyspnea on minimal exertion, nausea, vomiting, and diarrhea. He says that his old doctor gave him \"some pills\" that he takes in varying amounts every morning. Physical exam is significant for a severely displaced point of maximal impulse, bilateral rales in the lower lung fields, an S3 gallop, and hepatomegaly. You decide to perform an EKG (shown in figure A). Suddenly, his rhythm changes to ventricular tachycardia followed by ventricular fibrillation, and he syncopizes and expires despite resuscitative efforts. High levels of which medication are most likely responsible?", "answer": "Digoxin", "options": {"A": "Digoxin", "B": "Propranolol", "C": "Verapamil", "D": "Amiodarone", "E": "Lidocaine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "obesity", "heart disease presents", "outpatient clinic", "complaints", "orthopnea", "significant dyspnea on minimal exertion", "nausea", "vomiting", "diarrhea", "old doctor gave", "pills", "amounts", "morning", "significant", "a severely displaced point", "maximal impulse", "bilateral rales", "lower lung fields", "S3 gallop", "hepatomegaly", "to perform", "EKG", "rhythm changes", "ventricular tachycardia followed by ventricular fibrillation", "resuscitative efforts", "High levels", "medication", "responsible"]}
{"question": "A 7-year-old African-American boy presents to his physician with fatigue, bone and abdominal pain, and mild jaundice. The pain is dull and remitting, and the patient complains it sometimes migrates from one extremity to another. His mother reports that his jaundice and pain have occurred periodically for the past 5 years. At the time of presentation, his vital signs are as follows: the blood pressure is 80/50 mm Hg, the heart rate is 87/min, the respiratory rate is 17/min, and the temperature is 36.5°C (97.7°F). On physical examination, the patient appears to be pale with mildly icteric sclera and mucous membranes. On auscultation, there is a soft systolic ejection murmur, and palpation reveals hepatosplenomegaly. His musculoskeletal examination shows no abnormalities. Laboratory investigations show the following results:\nComplete blood count\nErythrocytes\n3.7 x 106/mm3\nHgb\n11 g/dL\nTotal leukocyte count\nNeutrophils\nLymphocytes\nEosinophils\nMonocytes\nBasophils\n7,300/mm3\n51%\n40%\n2%\n7%\n0\nPlatelet count\n151,000/mm3\nChemistry\nTotal bilirubin\n3.1 mg/dL (53 µmol/L)\nDirect bilirubin\n0.5 mg/dL (8.55 µmol/L)\nA peripheral blood smear shows numerous sickle-shaped red blood cells. Among other questions, the patient’s mother asks you how his condition would influence his vaccination schedule. Which of the following statements is true regarding vaccination in this patient?", "answer": "The patient should receive serogroup B meningococcal vaccination at the age of 10 years.", "options": {"A": "The patient should not receive meningococcal, pneumococcal, or Haemophilus influenzae vaccines, because they are likely to cause complications or elicit disease in his case.", "B": "The patient should receive serogroup B meningococcal vaccination at the age of 10 years.", "C": "The patient should receive serogroup D meningococcal vaccination as soon as possible, because he is at higher risk of getting serogroup B meningococcal infection than other children.", "D": "The patient should receive the pneumococcal polysaccharide vaccine as soon as possible, because he is at higher risk of getting pneumococcal infection than other children.", "E": "The patient’s condition does not affect his chances to get any infection; thus, additional vaccinations are not advised."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "boy presents", "physician", "fatigue", "bone", "abdominal pain", "mild jaundice", "pain", "dull", "remitting", "patient", "sometimes migrates", "one extremity", "reports", "jaundice", "pain", "periodically", "past", "years", "time", "vital signs", "follows", "blood pressure", "80 50 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "temperature", "36", "97", "patient appears to", "pale", "mildly icteric", "mucous membranes", "auscultation", "soft murmur", "palpation reveals hepatosplenomegaly", "abnormalities", "Laboratory", "following results", "Complete blood count", "mm3 Hgb", "dL", "leukocyte", "300", "40", "0", "1", "dL", "mol/L", "Direct bilirubin 0.5 mg/dL", "mol", "peripheral blood smear", "numerous sickle shaped red blood cells", "patients", "condition", "vaccination schedule", "following", "true", "vaccination", "patient"]}
{"question": "A 52-year-old man presents to his primary care physician for generalized pain. The patient states that he feels like his muscles and bones are in constant pain. This has persisted for the past several weeks, and his symptoms have not improved with use of ibuprofen or acetaminophen. The patient has a past medical history of alcohol abuse, repeat episodes of pancreatitis, constipation, and anxiety. He has a 22 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note generalized tenderness/pain of the patient's extremities. Abdominal exam reveals normoactive bowel sounds and is non-tender. Dermatologic exam is unremarkable. Laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 7,500/mm^3 with normal differential\nPlatelet count: 147,000/mm^3\n\nSerum:\nNa+: 138 mEq/L\nCl-: 100 mEq/L\nK+: 4.2 mEq/L\nHCO3-: 24 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.2 mg/dL\nAlkaline phosphatase: 252 U/L\nLipase: 30 U/L\nAST: 12 U/L\nALT: 10 U/L\n\nWhich of the following is associated with this patient's condition?", "answer": "Hearing loss", "options": {"A": "Hearing loss", "B": "Bence Jones proteins", "C": "Hypercalcemia", "D": "Adenocarcinoma of the gallbladder", "E": "Obstructive jaundice"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "generalized pain", "patient states", "muscles", "bones", "constant pain", "past", "weeks", "symptoms", "not improved", "use of ibuprofen", "acetaminophen", "patient", "past medical history of alcohol abuse", "repeat episodes of pancreatitis", "constipation", "anxiety", "smoking history", "temperature", "99", "blood pressure", "95 mmHg", "pulse", "70 min", "respirations", "min", "oxygen saturation", "99", "room air", "note generalized tenderness pain", "patient's extremities", "Abdominal exam reveals", "bowel sounds", "non-tender", "Dermatologic exam", "unremarkable", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "7 500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4.2 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1 0 mg/dL Ca2", "10", "mg/dL Alkaline phosphatase", "U/L Lipase", "30 U/L AST", "U/L ALT", "10 U/L", "following", "associated with", "patient's condition"]}
{"question": "A 26-year-old woman comes to the physician because of a 3-day history of redness, foreign body sensation, and discharge of both eyes. She reports that her eyes feel “stuck together” with yellow crusts every morning. She has a 3-year history of nasal allergies; her sister has allergic rhinitis. She is sexually active with 2 male partners and uses an oral contraceptive; they do not use condoms. Vital signs are within normal limits. Visual acuity is 20/20 in both eyes. Ophthalmic examination shows edema of both eyelids, bilateral conjunctival injection, and a thin purulent discharge. Examination of the cornea, anterior chamber, and fundus is unremarkable. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?", "answer": "Topical erythromycin", "options": {"A": "Topical natamycin", "B": "Topical prednisolone acetate", "C": "Topical erythromycin", "D": "Artificial tears", "E": "Oral erythromycin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "3-day history", "redness", "foreign body sensation", "discharge of", "eyes", "reports", "eyes", "together", "yellow crusts", "morning", "3 year history of nasal allergies", "allergic rhinitis", "sexually active", "male", "uses", "oral contraceptive", "not use condoms", "Vital signs", "normal limits", "Visual acuity", "20/20", "eyes", "examination", "edema of", "eyelids", "bilateral conjunctival injection", "thin purulent discharge", "Examination of", "cornea", "anterior chamber", "fundus", "unremarkable", "abnormalities", "following", "most appropriate pharmacotherapy"]}
{"question": "A 59-year-old man is brought to the emergency department by paramedics following a high-speed motor vehicle collision. The patient complains of excruciating chest pain, which he describes as tearing. Further history reveals that the patient is healthy, taking no medications, and is not under the influence of drugs or alcohol. On physical examination, his heart rate is 97/min. His blood pressure is 95/40 mm Hg in the right arm and 60/30 mm Hg in the left arm. Pulses are absent in the right leg and diminished in the left. A neurological examination is normal. A chest X-ray reveals a widened mediastinum. Which of the following is the most likely etiology of this patient's condition?", "answer": "Traumatic aortic dissection", "options": {"A": "Rib fracture", "B": "Traumatic aortic dissection", "C": "Myocardial rupture", "D": "Pulmonary contusion", "E": "Diaphragmatic rupture"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old man", "brought", "emergency department", "paramedics following", "high speed motor vehicle collision", "patient", "of excruciating chest pain", "tearing", "Further history reveals", "patient", "healthy", "medications", "not", "drugs", "alcohol", "heart rate", "97 min", "blood pressure", "95 40 mm Hg", "right arm", "60 30 mm Hg", "left arm", "Pulses", "absent", "right", "diminished", "left", "neurological examination", "normal", "chest X-ray reveals", "widened mediastinum", "following", "etiology", "patient's condition"]}
{"question": "A 23-year-old man presents to the emergency department with shortness of breath. The patient was at a lunch hosted by his employer. He started to feel his symptoms begin when he started playing football outside with a few of the other employees. The patient has a past medical history of atopic dermatitis and asthma. His temperature is 98.3°F (36.8°C), blood pressure is 87/58 mmHg, pulse is 150/min, respirations are 22/min, and oxygen saturation is 85% on room air. Which of the following is the best next step in management?", "answer": "IM epinephrine", "options": {"A": "Albuterol and norepinephrine", "B": "Albuterol and prednisone", "C": "IM epinephrine", "D": "IV epinephrine", "E": "IV fluids and 100% oxygen"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old man presents", "emergency department", "shortness of breath", "patient", "lunch", "employer", "started to", "symptoms begin", "started playing football outside", "employees", "patient", "past medical atopic dermatitis", "asthma", "temperature", "98", "36", "blood pressure", "87 58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "85", "room air", "following", "best next step"]}
{"question": "A 32-year-old G1P0 woman presents to her obstetrician for a prenatal visit. She is 30 weeks pregnant. She reports some fatigue and complains of urinary urgency. Prior to this pregnancy, she had no significant medical history. She takes a prenatal vitamin and folate supplements daily. Her mother has diabetes, and her brother has coronary artery disease. On physical examination, the fundal height is 25 centimeters. A fetal ultrasound shows a proportional reduction in head circumference, trunk size, and limb length. Which of the following is the most likely cause of the patient’s presentation?", "answer": "Rubella infection", "options": {"A": "Antiphospholipid syndrome", "B": "Cigarette smoking", "C": "Gestational diabetes", "D": "Pre-eclampsia", "E": "Rubella infection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "woman presents", "obstetrician", "30 weeks pregnant", "reports", "fatigue", "urinary urgency", "pregnancy", "significant medical history", "prenatal vitamin", "folate supplements daily", "diabetes", "coronary artery disease", "fundal height", "centimeters", "fetal ultrasound", "proportional reduction", "head circumference", "trunk size", "limb length", "following", "most likely cause", "patients"]}
{"question": "A 71-year-old male presents to the emergency department after having a generalized tonic-clonic seizure. His son reports that he does not have a history of seizures but has had increasing confusion and weakness over the last several weeks. An electrolyte panel reveals a sodium level of 120 mEq/L and a serum osmolality of 248 mOsm/kg. His urine is found to have a high urine osmolality. His temperature is 37° C (98.6° F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/88 mm Hg. On examination he is disoriented, his pupils are round and reactive to light and accommodation and his mucous membranes are moist. His heart has a regular rhythm without murmurs, his lungs are clear to auscultation bilaterally, the abdomen is soft, and his extremities have no edema but his muscular strength is 3/5 bilaterally. There is hyporeflexia of all four extremities. What is the most likely cause of his symptoms?", "answer": "Syndrome of Inappropriate Antidiuretic Hormone (SIADH)", "options": {"A": "Syndrome of Inappropriate Antidiuretic Hormone (SIADH)", "B": "Sheehan’s syndrome", "C": "Lithium use", "D": "Diabetic ketoacidosis", "E": "Hereditary diabetes insipidus"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male presents", "emergency department", "generalized tonic-clonic seizure", "reports", "not", "history", "seizures", "increasing confusion", "weakness", "weeks", "electrolyte panel reveals", "sodium level", "mEq/L", "serum osmolality", "mOsm/kg", "urine", "found to", "high urine osmolality", "temperature", "98", "F", "respirations", "min", "pulse", "67 min", "blood pressure", "88 mm Hg", "disoriented", "pupils", "round", "reactive to light", "accommodation", "mucous membranes", "moist", "heart", "regular rhythm", "murmurs", "lungs", "clear", "auscultation", "abdomen", "soft", "extremities", "edema", "muscular strength", "3/5", "hyporeflexia", "four extremities", "most likely cause", "symptoms"]}
{"question": "A 69-year-old woman presents with pain in her hip and groin. She states that the pain is present in the morning, and by the end of the day it is nearly unbearable. Her past medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, insulin, and ibuprofen. The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms. She also states that she recently fell off the treadmill while exercising at the gym. On physical exam you note an obese woman. There is pain, decreased range of motion, and crepitus on physical exam of her right hip. The patient points to the areas that cause her pain stating that it is mostly over the groin. The patient's skin turgor reveals tenting. Radiography is ordered.\n\nWhich of the following is most likely to be found on radiography?", "answer": "Loss of joint space and osteophytes", "options": {"A": "Loss of joint space and osteophytes", "B": "Hyperdense foci in the ureters", "C": "Femoral neck fracture", "D": "Posterior displacement of the femoral head", "E": "Normal radiography"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["69 year old woman presents", "pain", "hip", "groin", "states", "pain", "present", "morning", "end", "day", "nearly", "past medical history", "notable", "treated episode of acute renal failure", "diabetes mellitus", "obesity", "hypertension", "current medications include losartan", "metformin", "insulin", "ibuprofen", "patient recently started", "high doses", "vitamin D", "help", "symptoms", "states", "recently fell", "treadmill", "exercising", "note", "obese woman", "pain", "decreased range of motion", "crepitus", "right hip", "patient points", "areas", "cause", "pain stating", "mostly", "groin", "patient's skin turgor reveals tenting", "Radiography", "ordered", "following", "to", "found", "radiography"]}
{"question": "A 35-year-old woman presents to a physician’s office for a follow-up visit. She recently underwent a complete physical examination with routine laboratory tests. She also had a Pap smear and testing for sexually transmitted diseases. Since her divorce 2 years ago, she had sexual encounters with random men at bars or social events and frequently did not use any form of contraception during sexual intercourse. She was shown to be positive for the human immunodeficiency virus (HIV). Combination anti-retroviral treatment is initiated including zidovudine, didanosine, and efavirenz. One week later, she is rushed to the hospital where she is diagnosed with acute pancreatitis. Which of the following precautions will be required after pancreatitis resolves with treatment?", "answer": "Replace didanosine with lamivudine", "options": {"A": "Frequent monitoring of CD4+ cell count", "B": "Add ritonavir to the HIV treatment regimen", "C": "Replace efavirenz with nevirapine", "D": "Check hemoglobin levels", "E": "Replace didanosine with lamivudine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old woman presents", "physicians office", "recently", "complete physical examination", "routine laboratory tests", "Pap smear", "testing", "sexually transmitted diseases", "divorce", "years", "random", "bars", "frequently", "not use", "form", "contraception", "sexual intercourse", "to", "positive", "human immunodeficiency virus", "Combination", "treatment", "initiated including zidovudine", "didanosine", "efavirenz", "One week later", "rushed", "hospital", "diagnosed", "acute pancreatitis", "following", "required", "pancreatitis", "treatment"]}
{"question": "A primigravida at 10+5 weeks gestation registers in an obstetric clinic for prenatal care. She has noted a rash that is rough with red-brown spots on her palms. The rapid plasma reagin (RPR) test is positive. The diagnosis is confirmed by darkfield microscopy. What is the fetus at risk for secondary to the mother’s condition?", "answer": "Saddle nose", "options": {"A": "Seizures", "B": "Vision loss", "C": "Saddle nose", "D": "Chorioretinitis", "E": "Muscle atrophy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["primigravida", "10+5 weeks gestation", "obstetric clinic", "prenatal", "noted", "rash", "red brown", "rapid plasma reagin", "RPR", "test", "positive", "diagnosis", "confirmed by darkfield microscopy", "fetus at risk", "secondary", "condition"]}
{"question": "A 35-year-old woman that has recently immigrated from Southeast Asia is brought to the emergency department due to a 3-week history of fatigue, night sweats, and enlarged lymph nodes and persistent fever. These symptoms have been getting worse during the past week. She has no history of any cardiac or pulmonary disease. A chest X-ray reveals ipsilateral hilar enlargement and a rounded calcified focus near the right hilum. A Mantoux test is positive. Sputum samples are analyzed and acid-fast bacilli are identified on Ziehl-Neelsen staining. The patient is started on a 4 drug regimen. She returns after 6 months to the emergency department with complaints of joint pain, a skin rash that gets worse with sunlight and malaise. The antinuclear antibody (ANA) and anti-histone antibodies are positive. Which of the following drugs prescribed to this patient is the cause of her symptoms?", "answer": "Isoniazid", "options": {"A": "Rifampicin", "B": "Isoniazid", "C": "Pyrazinamide", "D": "Ethambutol", "E": "Streptomycin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old woman", "recently", "Southeast Asia", "brought", "emergency department due to", "week history", "fatigue", "night sweats", "enlarged lymph nodes", "persistent fever", "symptoms", "getting worse", "past week", "history", "cardiac", "pulmonary disease", "chest X-ray reveals ipsilateral hilar enlargement", "rounded calcified focus", "right hilum", "Mantoux test", "positive", "Sputum samples", "acid-fast bacilli", "identified", "patient", "regimen", "returns", "months", "emergency department", "complaints", "joint pain", "skin rash", "gets worse", "malaise", "antinuclear antibody", "anti-histone antibodies", "positive", "following drugs", "patient", "cause", "symptoms"]}
{"question": "A 71-year-old African American man is brought to the emergency department with sudden onset lower limb paralysis and back pain. He has had generalized bone pain for 2 months. He has no history of severe illnesses. He takes ibuprofen for pain. On examination, he is pale. The vital signs include: temperature 37.1°C (98.8°F), pulse 68/min, respiratory rate 16/min, and blood pressure 155/90 mm Hg. The neurologic examination shows paraparesis. The 8th thoracic vertebra is tender to palpation. X-ray of the thoracic vertebrae confirms a compression fracture at the same level. The laboratory studies show the following:\nLaboratory test\nHemoglobin 9 g/dL\nMean corpuscular volume 95 μm3\nLeukocyte count 5,000/mm3\nPlatelet count 240,000/mm3\nESR 85 mm/hr\nSerum\nNa+ 135 mEq/L\nK+ 4.2 mEq/L\nCl− 113 mEq/L\nHCO3− 20 mEq/L\nCa+ 11.8 mg/dL\nAlbumin 4 g/dL\nUrea nitrogen 38 mg/dL\nCreatinine 2.2 mg/dL\nWhich of the following is the most likely mechanism underlying this patient’s vertebral fracture?", "answer": "Proliferation of tumor cells", "options": {"A": "Acidosis-induced bone lysis", "B": "Bone demineralization", "C": "Increased mechanical pressure", "D": "Increased osteoblastic activity", "E": "Proliferation of tumor cells"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "man", "brought", "emergency department", "sudden onset lower", "back pain", "generalized bone", "months", "history", "severe illnesses", "ibuprofen", "pain", "pale", "vital signs include", "temperature", "98", "pulse", "min", "respiratory rate", "min", "blood pressure", "90 mm Hg", "neurologic examination", "paraparesis", "8th thoracic vertebra", "tender", "palpation", "X-ray", "thoracic vertebrae confirms", "compression", "same level", "laboratory studies", "following", "test Hemoglobin 9 g dL Mean corpuscular volume", "5", "hr Serum", "mEq L K", "Cl", "Ca", "mg dL", "Creatinine", "following", "mechanism", "patients vertebral fracture"]}
{"question": "A 24-year-old male was in a motor vehicle accident that caused him to fracture his femur and pelvis. After 2 days in the hospital, the patient became delirious, tachypneic, and a petechial rash was found in his upper extremities. Which of the following is most likely responsible for this patient’s symptoms?", "answer": "Fat microglobules in the microvasculature", "options": {"A": "Thrombotic clot in the pulmonary artery", "B": "Fat microglobules in the microvasculature", "C": "Type I and type II pneumocyte damage due to neutrophils", "D": "Aspiration of oropharyngeal contents", "E": "Alveolar foamy exudates with disc shaped cysts seen with methenamine silver stain"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "motor vehicle accident", "caused", "to fracture", "femur", "pelvis", "2 days in", "hospital", "patient", "delirious", "tachypneic", "petechial rash", "found", "upper extremities", "following", "responsible", "patients symptoms"]}
{"question": "A 48-year-old man with a 30-pack-year history comes to the physician for a follow-up examination 6 months after a chest CT showed a solitary 5-mm solid nodule in the upper lobe of the right lung. The follow-up CT shows that the size of the nodule has increased to 2 cm. Ipsilateral mediastinal lymph node involvement is noted. A biopsy of the pulmonary nodule shows small, dark blue tumor cells with hyperchromatic nuclei and scarce cytoplasm. Cranial MRI and skeletal scintigraphy show no evidence of other metastases. Which of the following is the most appropriate next step in management?", "answer": "Cisplatin-etoposide therapy and radiotherapy", "options": {"A": "Wedge resection", "B": "Radiation therapy", "C": "Cisplatin-etoposide therapy and radiotherapy", "D": "Right lobectomy", "E": "Gefitinib therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old man", "30", "history", "physician", "follow-up", "6 months", "chest CT", "solitary", "solid nodule", "the upper lobe of", "right lung", "follow-up CT", "size of", "nodule", "increased", "Ipsilateral mediastinal", "noted", "biopsy", "pulmonary", "small", "dark blue tumor cells", "hyperchromatic nuclei", "cytoplasm", "Cranial MRI", "skeletal scintigraphy", "metastases", "following", "most appropriate next step"]}
{"question": "A newborn born at 33 weeks of gestation has a respiratory rate of 70/min and a heart rate of 148/min 2 hours after birth. He is grunting and has intercostal and subcostal retractions. He has peripheral cyanosis as well. An immediate chest radiograph is taken which shows a fine reticular granulation with ground glass appearance on both lungs. Which of the following is the most likely diagnosis?", "answer": "Respiratory distress syndrome", "options": {"A": "Pneumothorax", "B": "Transient tachypnea of the newborn", "C": "Respiratory distress syndrome", "D": "Cyanotic congenital heart disease", "E": "Bacterial pneumonia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["newborn born", "weeks of gestation", "respiratory rate", "70 min", "heart rate", "min", "hours after birth", "subcostal retractions", "peripheral cyanosis", "well", "immediate chest radiograph", "fine reticular granulation", "ground glass appearance", "lungs", "following", "diagnosis"]}
{"question": "A hospitalized 70-year-old woman, who recently underwent orthopedic surgery, develops severe thrombocytopenia of 40,000/mm3 during her 7th day of hospitalization. She has no other symptoms and has no relevant medical history. All of the appropriate post-surgery prophylactic measures had been taken. Her labs from the 7th day of hospitalization are shown here:\nThe complete blood count results are as follows:\nHemoglobin 13 g/dL\nHematocrit 38%\nLeukocyte count 8,000/mm3\nNeutrophils 54%\nBands 3%\nEosinophils 1%\nBasophils 0%\nLymphocytes 33%\nMonocytes 7%\nPlatelet count 40,000/mm3\nThe coagulation tests are as follows:\nPartial thromboplastin time (activated) 85 seconds\nProthrombin time 63 seconds\nReticulocyte count 1.2%\nThrombin time < 2 seconds deviation from control\nThe lab results from previous days were within normal limits. What is the most likely cause of the thrombocytopenia?", "answer": "Heparin-induced thrombocytopenia", "options": {"A": "DIC", "B": "Thrombotic microangiopathy", "C": "Immune thrombocytopenia", "D": "Myelodysplasia", "E": "Heparin-induced thrombocytopenia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["hospitalized 70 year old woman", "recently", "orthopedic surgery", "severe thrombocytopenia", "40", "mm3", "day", "symptoms", "relevant medical history", "appropriate post-surgery prophylactic measures", "labs", "day", "complete blood count results", "follows", "Hemoglobin", "g", "Leukocyte 8", "mm3 Neutrophils", "Bands", "Eosinophils 1", "Basophils 0", "33", "Monocytes 7", "Platelet count 40", "coagulation tests", "follows", "Partial thromboplastin time", "85 seconds Prothrombin time 63", "Reticulocyte count", "Thrombin time", "2 seconds deviation", "control", "lab results", "previous days", "normal limits", "most likely cause", "thrombocytopenia"]}
{"question": "A 57-year-old man presents to his physician with dyspnea on exertion and rapid heartbeat. He denies any pain during these episodes. He works as a machine operator at a solar panels manufacturer. He has a 21-pack-year history of smoking. The medical history is significant for a perforated ulcer, in which he had to undergo gastric resection and bypass. He also has a history of depression, and he is currently taking escitalopram. The family history is unremarkable. The patient weighs 69 kg (152 lb). His height is 169 cm (5 ft 7 in). The vital signs include: blood pressure 140/90 mm Hg, heart rate 95/min, respiratory rate 12/min, and temperature 36.6℃ (97.9℉). Lung auscultation reveals widespread wheezes. Cardiac auscultation shows decreased S1 and grade 1/6 midsystolic murmur best heard at the apex. Abdominal and neurological examinations show no abnormalities. A subsequent echocardiogram shows increased left ventricular mass and an ejection fraction of 50%. Which of the options is a risk factor for the condition detected in the patient?", "answer": "Smoking", "options": {"A": "The patient’s body mass", "B": "History of gastric bypass surgery", "C": "Exposure to heavy metals", "D": "Smoking", "E": "Escitalopram intake"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["57 year old man presents", "physician", "dyspnea on exertion", "rapid heartbeat", "pain", "episodes", "machine", "solar panels", "history of smoking", "medical history", "significant", "perforated ulcer", "to", "gastric resection", "bypass", "history of depression", "currently", "escitalopram", "family history", "unremarkable", "patient", "69 kg", "height", "5 ft", "vital signs include", "blood pressure", "90 mm Hg", "heart rate 95 min", "respiratory rate", "min", "temperature 36", "97", "Lung auscultation reveals widespread wheezes", "Cardiac auscultation", "decreased S1", "midsystolic murmur best heard", "apex", "Abdominal", "neurological examinations", "abnormalities", "subsequent echocardiogram", "increased left ventricular mass", "ejection fraction of 50", "options", "a", "factor", "condition detected", "patient"]}
{"question": "A 25-year-old man presents to the emergency department with bilateral eye pain. The patient states it has slowly been worsening over the past 48 hours. He admits to going out this past weekend and drinking large amounts of alcohol and having unprotected sex but cannot recall a predisposing event. The patient's vitals are within normal limits. Physical exam is notable for bilateral painful and red eyes with opacification and ulceration of each cornea. The patient's contact lenses are removed and a slit lamp exam is performed and shows bilateral corneal ulceration. Which of the following is the best treatment for this patient?", "answer": "Gatifloxacin eye drops", "options": {"A": "Acyclovir", "B": "Erythromycin ointment", "C": "Gatifloxacin eye drops", "D": "Intravitreal vancomycin and ceftazidime", "E": "Topical dexamethasone and refrain from wearing contacts"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "bilateral eye pain", "patient states", "slowly", "worsening", "past 48 hours", "to", "out", "past weekend", "drinking large amounts", "alcohol", "predisposing event", "patient's", "normal limits", "notable", "bilateral painful", "red eyes", "opacification", "ulceration", "cornea", "patient's contact lenses", "removed", "slit lamp exam", "performed", "bilateral corneal ulceration", "following", "best"]}
{"question": "A 73-year-old man is brought in by his wife with a history of progressive personality changes. The patient’s wife says that, over the past 3 years, he has become increasingly aggressive and easily agitated, which is extremely out of character for him. His wife also says that he has had several episodes of urinary incontinence in the past month. He has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. The patient is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. The patient takes the mini-mental status examination (MMSE) and scores 28/30. A T2 magnetic resonance image (MRI) of the head is performed and the results are shown in the exhibit (see image). Which of the following is the next best diagnostic step in the management of this patient?", "answer": "Lumbar puncture", "options": {"A": "Noncontrast CT of the head", "B": "Contrast MRI of the head", "C": "Lumbar puncture", "D": "Brain biopsy", "E": "Serum ceruloplasmin level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "history", "progressive personality changes", "patients", "past", "years", "aggressive", "easily agitated", "extremely out", "character", "several episodes of urinary incontinence", "past month", "significant past medical history", "patient", "history of smoking", "recreational drug use", "patient", "afebrile", "vital signs", "normal limits", "unremarkable", "patient", "mini-mental status examination", "scores", "30", "magnetic resonance", "head", "performed", "results", "see", "following", "next best diagnostic step", "patient"]}
{"question": "A 25-year-old woman presents to the emergency department with palpitations, sweating, and blurry vision after playing volleyball on the beach. She denies chest pain and shortness of breath. She states that these episodes occur often, but resolve after eating a meal or drinking a sugary soda. Past medical history is unremarkable, and she takes no medications. Temperature is 37°C (98.6°F), blood pressure is 135/80 mm Hg, pulse is 102/min, and respirations are 18/min. Fingerstick blood glucose level is 42 g/dL. ECG reveals sinus tachycardia. Urinalysis and toxicology are noncontributory. Appropriate medical therapy is administered and she is discharged with an appointment for a fasting blood draw within the week. Laboratory results are as follows:\nBlood glucose 45 mg/dL\nSerum insulin  20 microU/L (N: < 6 microU/L)\nSerum proinsulin 10 microU/L (N: < 20% of total insulin)\nC-peptide level  0.8 nmol/L (N: < 0.2 nmol/L)\nSulfonylurea Negative\nIGF-2  Negative\nWhat is the most likely cause of this patient’s hypoglycemia?", "answer": "Beta cell tumor of the pancreas", "options": {"A": "Heat stroke", "B": "Delta cell tumor of the pancreas", "C": "Exogenous insulin", "D": "Beta cell tumor of the pancreas", "E": "Alpha cell tumor of the pancreas"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "palpitations", "sweating", "blurry vision", "playing", "beach", "chest pain", "shortness of breath", "states", "episodes occur often", "eating", "drinking", "sugary", "Past medical history", "unremarkable", "medications", "Temperature", "98", "blood pressure", "80 mm Hg", "pulse", "min", "respirations", "min", "Fingerstick blood glucose level", "g/dL", "ECG reveals sinus tachycardia", "Urinalysis", "toxicology", "Appropriate medical therapy", "administered", "appointment", "fasting blood", "week", "Laboratory results", "follows", "Blood glucose", "mg dL Serum insulin", "L", "N", "Serum proinsulin 10", "N", "20", "total insulin", "C-peptide level", "0.8 nmol/L", "N", "0.2 nmol/L", "Sulfonylurea Negative IGF-2", "most likely cause", "patients hypoglycemia"]}
{"question": "A 12-month-old boy is brought in by his mother who is worried about pallor. She says that the patient has always been fair-skinned, but over the past month relatives have commented that he appears more pale. The mother says that the patient seems to tire easy, but plays well with his older brother and has even started to walk. She denies bloody or black stools, easy bruising, or excess bleeding. She states that he is a picky eater, but he loves crackers and whole milk. On physical examination, pallor of the conjunctiva is noted. There is a grade II systolic ejection murmur best heard over the lower left sternal border that increases when the patient is supine. Labs are drawn as shown below:\n\nLeukocyte count: 6,500/mm^3 with normal differential\nHemoglobin: 6.4 g/dL\nPlatelet count: 300,000/mm^3\nMean corpuscular volume (MCV): 71 µm^3\nReticulocyte count: 2.0%\n\nSerum iron: 34 mcg/dL\nSerum ferritin: 6 ng/mL (normal range 7 to 140 ng/mL)\nTotal iron binding capacity (TIBC): 565 mcg/dL (normal range 240 to 450 mcg/dL)\n\nOn peripheral blood smear, there is microcytosis, hypochromia, and mild anisocytosis without basophilic stippling. Which of the following is the next best step in management for the patient’s diagnosis?", "answer": "Limit milk intake", "options": {"A": "Administer deferoxamine", "B": "Echocardiogram", "C": "Limit milk intake", "D": "Measure folate level", "E": "Measure lead level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "worried", "pallor", "patient", "always", "fair-skinned", "past month", "appears more pale", "patient", "to tire easy", "plays well", "started to", "bloody", "black stools", "easy bruising", "excess bleeding", "states", "picky eater", "pallor", "conjunctiva", "noted", "systolic ejection murmur best heard", "lower left sternal border", "increases", "patient", "supine", "Labs", "Leukocyte count", "6 500 mm 3", "normal differential Hemoglobin", "6.4 g/dL Platelet count", "300", "mm", "Mean corpuscular volume", "m", "Reticulocyte count", "2 0", "Serum iron", "mcg/dL Serum ferritin", "ng/mL", "normal range 7", "ng mL", "Total iron binding capacity", "mcg/dL", "normal range", "450 mcg/dL", "peripheral blood smear", "microcytosis", "hypochromia", "mild anisocytosis", "basophilic stippling", "following", "next best step", "patients diagnosis"]}
{"question": "A 58-year-old man presents to the emergency department with a chief complaint of ringing in his ears that started several hours previously that has progressed to confusion. The patient denies any history of medical problems except for bilateral knee arthritis. He was recently seen by an orthopedic surgeon to evaluate his bilateral knee arthritis but has opted to not undergo knee replacement and prefers medical management. His wife noted that prior to them going on a hike today, he seemed confused and not himself. They decided to stay home, and roughly 14 hours later, he was no longer making any sense. Physical exam is notable for a confused man. The patient's vitals are being performed and his labs are being drawn. Which of the following is most likely to be seen on blood gas analysis?", "answer": "pH: 7.30, PaCO2: 15 mmHg, HCO3-: 16 mEq/L", "options": {"A": "pH: 7.30, PaCO2: 15 mmHg, HCO3-: 16 mEq/L", "B": "pH: 7.31, PaCO2: 31 mmHg, HCO3-: 15 mEq/L", "C": "pH: 7.37, PaCO2: 41 mmHg, HCO3-: 12 mEq/L", "D": "pH: 7.41, PaCO2: 65 mmHg, HCO3-: 34 mEq/L", "E": "pH: 7.47, PaCO2: 11 mmHg, HCO3-: 24 mEq/L"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old man presents", "emergency department", "chief complaint", "ringing", "ears", "started several hours", "progressed", "confusion", "patient", "history of medical", "bilateral knee arthritis", "recently seen by", "orthopedic surgeon to", "bilateral knee arthritis", "opted to not", "knee replacement", "medical", "noted", "prior to", "today", "confused", "not", "to", "home", "hours later", "longer making", "sense", "notable", "confused man", "patient's", "performed", "labs", "following", "to", "seen", "blood gas analysis"]}
{"question": "A 56-year-old woman is referred to your office with mammography results showing a dense, spiculated mass with clustered microcalcifications. The family history is negative for breast, endometrial, and ovarian cancers. She was formerly a flight attendant and since retirement, she has started a strict Mediterranean diet because she was \"trying to compensate for her lack of physical activity\". She is the mother of two. She breastfed each infant for 18 months, as recommended by her previous physician. Her only two surgical procedures have been a breast augmentation with implants and tubal ligation. The physical examination is unremarkable. There are no palpable masses and no nipple or breast skin abnormalities. The patient lacks a family history of breast cancer. Which of the following is the most significant risk factor for the development of breast cancer in this patient?", "answer": "Occupation", "options": {"A": "Sedentarism", "B": "Breastfeeding", "C": "Mediterranean diet", "D": "Breast implants", "E": "Occupation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "referred", "office", "mammography results", "dense", "spiculated mass", "clustered microcalcifications", "family history", "negative", "breast", "endometrial", "ovarian cancers", "formerly", "flight attendant", "since retirement", "started", "Mediterranean diet", "to compensate", "lack of physical activity", "two", "breastfed", "infant", "months", "previous physician", "only two surgical procedures", "breast augmentation", "implants", "tubal ligation", "unremarkable", "nipple", "breast", "patient lacks", "family history of breast cancer", "following", "the most significant risk factor", "development of breast cancer", "patient"]}
{"question": "A 29-year-old woman is brought to the emergency department after an episode of syncope. For the past 10 days, she has had dyspnea and palpitations occurring with mild exertion. The patient returned from a hiking trip in Upstate New York 5 weeks ago. Except for an episode of flu with fever and chills a month ago, she has no history of serious illness. Her temperature is 37.3°C (99.1°F), pulse is 45/min, respirations are 21/min, and blood pressure is 148/72 mm Hg. A resting ECG is shown. Two-step serological testing confirms the diagnosis. Which of the following is the most appropriate treatment?", "answer": "Intravenous ceftriaxone", "options": {"A": "Intravenous ceftriaxone", "B": "Beta blocker", "C": "Oral doxycycline", "D": "Atropine", "E": "Permanent pacemaker implantation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old woman", "brought", "emergency department", "episode of syncope", "past 10 days", "dyspnea", "palpitations occurring", "mild exertion", "patient returned", "trip", "New York", "weeks", "Except for", "episode of flu", "fever", "chills", "month", "history", "serious illness", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "72 mm Hg", "ECG", "Two step serological testing confirms", "diagnosis", "following", "most appropriate treatment"]}
{"question": "A 64-year-old male presents to his primary care physician. Laboratory work-up and physical examination are suggestive of a diagnosis of prostatic adenocarcinoma. A tissue biopsy is obtained, which confirms the diagnosis. Which of the following is indicative of metastatic disease?", "answer": "New-onset lower back pain", "options": {"A": "Decreased serum alkaline phosphatase", "B": "Elevated prostatic acid phosphatase (PAP)", "C": "Involvement of the periurethral zone", "D": "New-onset lower back pain", "E": "Palpation of a hard nodule on digital rectal examination"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["64 year old male presents", "primary care physician", "Laboratory work-up", "suggestive of", "diagnosis", "prostatic adenocarcinoma", "tissue biopsy", "obtained", "confirms", "diagnosis", "following", "metastatic disease"]}
{"question": "A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most consistent with his presentation?", "answer": "Left-sided Brown-Sequard (hemisection)", "options": {"A": "Left-sided Brown-Sequard (hemisection)", "B": "Right-sided Brown-Sequard (hemisection)", "C": "Anterior cord syndrome", "D": "Posterior cord syndrome", "E": "Syringomelia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["patient", "known spinal cord ependymoma presents", "neurologist", "check up", "difficulty walking", "attributes", "left", "exam", "noted to", "1/5 strength", "left lower extremity", "decreased vibration", "position sensation", "left lower extremity", "decreased pain", "temperature sensation", "right lower extremity", "following spinal cord lesions", "most"]}
{"question": "A 2500-g (5-lb 8-oz) female newborn delivered at 37 weeks' gestation develops rapid breathing, grunting, and subcostal retractions shortly after birth. Despite appropriate lifesaving measures, the newborn dies 2 hours later. Autopsy shows bilateral renal agenesis. Which of the following is the most likely underlying cause of this newborn's respiratory distress?", "answer": "Decreased amniotic fluid ingestion", "options": {"A": "Decreased amniotic fluid ingestion", "B": "Injury to the diaphragmatic innervation", "C": "Displacement of intestines into the pleural cavity", "D": "Collapse of the supraglottic airway", "E": "Surfactant inactivation and epithelial inflammation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2500", "oz", "female newborn delivered", "weeks", "gestation", "rapid breathing", "subcostal retractions", "birth", "appropriate lifesaving measures", "newborn", "hours later", "Autopsy", "bilateral renal agenesis", "following", "underlying cause of", "newborn's respiratory distress"]}
{"question": "A 53-year-old man comes to the physician for recurring fever and night sweats for the past 6 months. The fevers persist for 7 to 10 days and then subside completely for about a week before returning again. During this period, he has also noticed two painless lumps on his neck that have gradually increased in size. Over the past year, he has had an 8.2-kg (18.1 lbs) weight loss. Two years ago, he had a severe sore throat and fever, which was diagnosed as infectious mononucleosis. He has smoked a pack of cigarettes daily for the past 10 years. He does not drink alcohol. His job involves monthly international travel to Asia and Africa. He takes no medications. His temperature is 39°C (102.2°F), pulse is 90/min, respirations are 22/min, and blood pressure is 105/60 mm Hg. Physical examination shows 2 enlarged, nontender, fixed cervical lymph nodes on each side of the neck. Microscopic examination of a specimen obtained on biopsy of a cervical lymph node is shown. Which of the following additional findings is most likely present in this patient?", "answer": "CD15/30 positive cells", "options": {"A": "Anti-viral capsid antigen IgG and IgM positive", "B": "CD15/30 positive cells", "C": "Auer rods on peripheral smear", "D": "Leukocyte count > 500,000/μL", "E": "Acid fast bacilli in the sputum"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "recurring fever", "night sweats", "past 6 months", "fevers", "10 days", "then", "completely", "week", "returning", "period", "two painless lumps on", "neck", "increased in size", "past year", "kg", "lbs", "weight loss", "Two years", "severe sore throat", "fever", "diagnosed", "infectious mononucleosis", "smoked", "pack", "cigarettes daily", "past", "not", "alcohol", "monthly international travel", "Asia", "Africa", "medications", "temperature", "pulse", "90 min", "respirations", "min", "blood pressure", "60 mm Hg", "2 enlarged", "nontender", "fixed cervical lymph nodes", "side of", "neck", "Microscopic examination", "obtained", "biopsy of", "cervical lymph node", "following additional findings", "most likely present", "patient"]}
{"question": "A 17-year-old male presents with altered mental status. He was recently admitted to the hospital due to a tibial fracture suffered while playing soccer. His nurse states that he is difficult to arouse. His temperature is 98.6 deg F (37 deg C), blood pressure is 130/80 mm Hg, pulse is 60/min, and respirations are 6/min. Exam is notable for pinpoint pupils and significant lethargy. Which of the following describes the mechanism of action of the drug likely causing this patient's altered mental status?", "answer": "Neuronal hyperpolarization due to potassium efflux", "options": {"A": "Neuronal hyperpolarization due to potassium efflux", "B": "Neuronal depolarization due to potassium influx", "C": "Neuronal hyperpolarization due to sodium influx", "D": "Neuronal depolarization due to sodium efflux", "E": "Neuronal hyperpolarization due to chloride influx"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "altered mental status", "recently", "tibial fracture suffered", "playing", "nurse states", "difficult", "temperature", "98", "deg F", "blood pressure", "80 mm Hg", "pulse", "60 min", "respirations", "min", "Exam", "notable", "pinpoint pupils", "significant lethargy", "following", "mechanism of action", "drug likely causing", "patient's altered mental status"]}
{"question": "A 7-year-old boy is brought to the emergency department because of sudden-onset abdominal pain that began 1 hour ago. Three days ago, he was diagnosed with a urinary tract infection and was treated with nitrofurantoin. There is no personal history of serious illness. His parents emigrated from Kenya before he was born. Examination shows diffuse abdominal tenderness, mild splenomegaly, and scleral icterus. Laboratory studies show:\nHemoglobin 9.8 g/dL\nMean corpuscular volume 88 μm3\nReticulocyte count 3.1%\nSerum\nBilirubin\nTotal 3.8 mg/dL\nDirect 0.6 mg/dL\nHaptoglobin 16 mg/dL (N=41–165 mg/dL)\nLactate dehydrogenase 179 U/L\nWhich of the following is the most likely underlying cause of this patient's symptoms?\"", "answer": "Enzyme deficiency in red blood cells", "options": {"A": "Enzyme deficiency in red blood cells", "B": "Defective red blood cell membrane proteins", "C": "Defect in orotic acid metabolism", "D": "Lead poisoning", "E": "Absent hemoglobin beta chain"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "sudden abdominal", "began 1 hour", "Three days", "diagnosed", "urinary tract infection", "treated with nitrofurantoin", "personal history", "serious illness", "Kenya", "born", "diffuse abdominal tenderness", "mild splenomegaly", "scleral icterus", "Laboratory studies", "Hemoglobin", "g dL Mean corpuscular volume", "Serum Bilirubin Total", "mg dL Direct 0.6 mg dL Haptoglobin", "dL", "N", "mg/dL", "Lactate dehydrogenase", "U L", "following", "underlying cause", "patient", "ymptoms?"]}
{"question": "A 72-year-old man comes to the physician with chills, nausea, and diffuse muscle aches for 3 days. His niece had similar symptoms 2 weeks ago and H1N1 influenza strain was isolated from her respiratory secretions. He received his influenza vaccination 2 months ago. His temperature is 38°C (100.4°F). A rapid influenza test is positive. Which of the following mechanisms best explains this patient's infection despite vaccination?", "answer": "Random point mutations within viral genome", "options": {"A": "Random point mutations within viral genome", "B": "Complementing with functional viral proteins", "C": "Exchange of viral genes between chromosomes", "D": "Reassortment of viral genome segments", "E": "Acquisition of viral surface proteins"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old man", "physician", "chills", "nausea", "diffuse muscle aches", "3 days", "similar symptoms", "weeks", "H1N1 influenza strain", "isolated", "respiratory secretions", "received", "influenza vaccination", "months", "temperature", "100", "rapid influenza test", "positive", "following mechanisms best", "patient's infection", "vaccination"]}
{"question": "A 34-year-old G1P0 woman gives birth to a male infant at 35 weeks gestation. The child demonstrates a strong cry and moves all his arms and legs upon birth. Respirations are slow and irregular. His temperature is 99.1°F (37.3°C), blood pressure is 100/55 mmHg, pulse is 115/min, and respirations are 18/min. At a follow up appointment, the physician notices that the infant’s torso and upper extremities are pink while his lower extremities have a bluish hue. Which of the following will most likely be heard on auscultation of the patient’s chest?", "answer": "Continuous systolic and diastolic murmur at left upper sternal border", "options": {"A": "Rumbling noise in late diastole", "B": "Early diastolic decrescendo murmur at the left sternal border", "C": "Holosystolic murmur radiating to the right sternal border", "D": "Holosystolic murmur radiating to the axilla", "E": "Continuous systolic and diastolic murmur at left upper sternal border"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "woman gives birth", "male infant", "35 weeks gestation", "child", "strong", "moves", "arms", "legs", "birth", "Respirations", "slow", "irregular", "temperature", "99", "blood pressure", "100", "mmHg", "pulse", "min", "respirations", "min", "follow up appointment", "physician", "infants torso", "upper extremities", "pink", "lower extremities", "following", "most likely", "heard", "auscultation", "patients chest"]}
{"question": "Blood cultures are sent to the laboratory. Intravenous antibiotic therapy is started. Transesophageal echocardiography shows a large, oscillating vegetation attached to the tricuspid valve. There are multiple small vegetations attached to tips of the tricuspid valve leaflets. There is moderate tricuspid regurgitation. The left side of the heart and the ejection fraction are normal. Which of the following is the most likely causal organism of this patient's conditions?", "answer": "Staphylococcus aureus", "options": {"A": "Streptococcus sanguinis", "B": "Enterococcus faecalis", "C": "Staphylococcus epidermidis", "D": "Neisseria gonorrhoeae", "E": "Staphylococcus aureus"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Blood cultures", "sent", "laboratory", "Intravenous antibiotic therapy", "started", "Transesophageal echocardiography", "large", "vegetation", "tricuspid valve", "multiple small vegetations", "tips of", "tricuspid valve leaflets", "moderate tricuspid regurgitation", "left side of", "heart", "ejection fraction", "normal", "following", "causal", "patient's conditions"]}
{"question": "A 59-year-old male presents to the emergency room complaining of substernal chest pain. He reports a three-hour history of dull substernal chest pain that radiates into his left arm and jaw. He has experienced similar chest pain before that was brought on with exertion, but this pain is more severe and occurred with rest. His past medical history includes gout, hypertension, diabetes mellitus, and hyperlipidemia. An EKG demonstrates ST segment depression. Serum troponin is elevated. In addition to aspirin, oxygen, and morphine, he is started on a sublingual medication. What is the main physiologic effect of this medication?", "answer": "Decrease preload", "options": {"A": "Decrease preload", "B": "Increase preload", "C": "Decrease afterload", "D": "Increase contractility", "E": "Decrease heart rate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old male presents", "emergency room", "substernal chest pain", "reports", "three hour history of dull", "chest pain", "radiates", "left arm", "jaw", "similar chest pain", "brought", "exertion", "pain", "more severe", "past medical history includes gout", "hypertension", "diabetes mellitus", "hyperlipidemia", "EKG", "ST segment depression", "Serum troponin", "elevated", "aspirin", "oxygen", "morphine", "started", "sublingual medication", "main physiologic effect", "medication"]}
{"question": "A 6-day-old male newborn is brought to the physician by his mother for the evaluation of yellowing of his skin and eyes for one day. The mother reports that she is breastfeeding her son about 7 times per day. She also states that her son had two wet diapers and two bowel movements yesterday. He was born at 38 weeks' gestation and weighed 3500 g (7.7 lb); he currently weighs 3000 g (6.6 lb). His newborn screening was normal. His temperature is 37°C (98.6°F), pulse is 180/min, and blood pressure is 75/45 mm Hg. Physical examination shows scleral icterus, widespread jaundice, and dry mucous membranes. The remainder of the examination shows no abnormalities. Serum studies show:\nBilirubin\nTotal 9 mg/dL\nDirect 0.7 mg/dL\nAST 15 U/L\nALT 15 U/L\nWhich of the following is the most appropriate next step in the management of this patient?\"", "answer": "Increasing frequency of breastfeeding", "options": {"A": "Intravenous immunoglobulin", "B": "Phenobarbital", "C": "Increasing frequency of breastfeeding", "D": "Abdominal sonography", "E": "Phototherapy\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["day old male newborn", "brought", "physician", "the", "of yellowing", "skin", "eyes", "one day", "reports", "breastfeeding", "times", "day", "states", "two wet diapers", "two bowel movements", "born", "weeks", "estation ", "500   ", "urrently ", "000   ", "ewborn screening ", "ormal.", "emperature ", "8.", "ulse ", "in,", "lood pressure ", "5/", "m Hg.", "cleral icterus,", "idespread  aundice,", "ry  ucous membranes.", "bnormalities.", "erum  tudies ", "ilirubin Total ", "L  irect  .", "g/dL  ST  5  /L  LT ", "ollowing ", "ost  ppropriate  ext  tep ", "atient?"]}
{"question": "A 25-year-old woman is rushed to the emergency department after she was found unconscious in a house fire. She has no previous medical history available. At the hospital, the vital signs include: blood pressure 110/70 mm Hg, temperature 36.0°C (97.0°F), and heart rate 76/min with oxygen saturation 99% on room air. On physical exam she is unconscious. There are superficial burns on her hands and parts of her face. Her face and clothes are blackened with soot. What is the 1st best step while treating this patient?", "answer": "Administer 100% oxygen", "options": {"A": "Penicillamine", "B": "Sodium nitrite", "C": "Administer 100% oxygen", "D": "Pyridoxine (vitamin B6)", "E": "N-acetylcysteine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "rushed", "emergency department", "found unconscious", "house fire", "previous medical history available", "hospital", "vital signs include", "blood pressure", "70 mm Hg", "temperature 36", "97", "heart rate 76 min", "oxygen saturation 99", "room air", "unconscious", "superficial", "hands", "parts of", "face", "face", "clothes", "1st best step", "treating", "patient"]}
{"question": "A 39-year-old woman is brought to the emergency department in a semi-unconscious state by her neighbor who saw her lose consciousness. There was no apparent injury on the primary survey. She is not currently taking any medications. She has had loose stools for the past 3 days and a decreased frequency of urination. No further history could be obtained. The vital signs include: blood pressure 94/62 mm Hg, temperature 36.7°C (98.0°F), pulse 105/min, and respiratory rate 10/min. The skin appears dry. Routine basic metabolic panel, urine analysis, urine osmolality, and urine electrolytes are pending. Which of the following lab abnormalities would be expected in this patient?", "answer": "Serum blood urea nitrogen/creatinine (BUN/Cr) > 20", "options": {"A": "Urine osmolality < 350 mOsm/kg", "B": "Urine Na+ > 40 mEq/L", "C": "Fractional excretion of sodium (FENa) > 2%", "D": "Serum blood urea nitrogen/creatinine (BUN/Cr) > 20", "E": "Serum creatinine < 1 mg/dL"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "unconscious state", "saw", "consciousness", "injury", "primary survey", "not currently", "medications", "loose stools", "past 3 days", "decreased frequency of urination", "further history", "obtained", "vital signs include", "blood pressure", "62 mm Hg", "temperature 36", "98", "pulse", "min", "respiratory rate 10/min", "skin appears dry", "Routine basic metabolic panel", "urine analysis", "urine osmolality", "urine electrolytes", "following lab abnormalities", "patient"]}
{"question": "A 45-year-old man is brought to the emergency department following a house fire. Following initial stabilization, the patient is transferred to the ICU for management of his third-degree burn injuries. On the second day of hospitalization, a routine laboratory panel is obtained, and the results are demonstrated below. Per the nurse, he remains stable compared to the day prior. His temperature is 99°F (37°C), blood pressure is 92/64 mmHg, pulse is 98/min, respirations are 14/min, and SpO2 is 98%. A physical examination demonstrates an unresponsive patient with extensive burn injuries throughout his torso and lower extremities.\n\nHemoglobin: 13 g/dL\nHematocrit: 36%\nLeukocyte count: 10,670/mm^3 with normal differential\nPlatelet count: 180,000/mm^3\n\nSerum:\nNa+: 135 mEq/L\nCl-: 98 mEq/L\nK+: 4.7 mEq/L\nHCO3-: 25 mEq/L \nBUN: 10 mg/dL \nGlucose: 123 mg/dL\nCreatinine: 1.8 mg/dL\nThyroid-stimulating hormone: 4.3 µU/mL\nTriiodothyronine: 48 ng/dL\nThyroxine: 10 ug/dL\nCa2+:  8.7 mg/dL\nAST: 89 U/L\nALT: 135 U/L\n\nWhat is the best course of management for this patient?", "answer": "Continued management of his burn wounds", "options": {"A": "Continued management of his burn wounds", "B": "Immediate administration of propanolol", "C": "Increase opioid dosage", "D": "Regular levothyroxine sodium injections", "E": "Start patient on intravenous ceftriaxone and vancomycin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department following", "house fire", "Following initial stabilization", "patient", "third-degree burn injuries", "second day", "routine laboratory panel", "obtained", "results", "nurse", "stable", "day prior", "temperature", "blood pressure", "64 mmHg", "pulse", "98 min", "respirations", "min", "98", "unresponsive patient", "extensive burn injuries", "torso", "lower extremities", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "10 670 mm 3", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "98 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "10 mg/dL", "Glucose", "mg/dL Creatinine", "1.8 mg/dL Thyroid-stimulating hormone", "4", "U/mL Triiodothyronine", "48 ng", "10 ug/dL Ca2", "mg/dL AST", "U/L ALT", "U/L", "best course", "patient"]}
{"question": "A 17-year-old boy comes to the physician because of fever, fatigue, and a sore throat for 12 days. He was prescribed amoxicillin at another clinic and now has a diffuse rash all over his body. He was treated for gonorrhea one year ago. He has multiple sexual partners and uses condoms inconsistently. He appears lethargic and thin. His BMI is 19.0 kg/m2. His temperature is 38.4°C (101.1°F), pulse 94/min, blood pressure 106/72 mm Hg. Examination shows a morbilliform rash over his extremities. Oropharyngeal examination shows tonsillar enlargement and erythema with exudates. Tender cervical and inguinal lymphadenopathy is present. Abdominal examination shows mild splenomegaly. Laboratory studies show:\nHemoglobin 14 g/dL\nLeukocyte count 13,200/mm3\nPlatelet count 160,000/mm3\nWhich of the following is the next best step in management?\"", "answer": "Heterophile agglutination test", "options": {"A": "Throat swab culture", "B": "Anti-CMV IgM", "C": "ELISA for HIV", "D": "Heterophile agglutination test", "E": "Flow cytometry"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "physician", "fever", "fatigue", "sore throat", "days", "amoxicillin", "clinic", "now", "diffuse rash", "body", "treated", "gonorrhea one year ago", "multiple sexual partners", "uses condoms", "appears lethargic", "thin", "BMI", "0 kg/m2", "temperature", "pulse", "min", "blood pressure", "72 mm Hg", "morbilliform", "extremities", "Oropharyngeal", "tonsillar enlargement", "erythema", "exudates", "Tender cervical", "inguinal lymphadenopathy", "present", "Abdominal", "mild splenomegaly", "Laboratory studies", "Hemoglobin", "g Leukocyte count", "200 mm3 Platelet count", "following", "next best step"]}
{"question": "A 71-year-old man presents to the primary care clinic with non-specific complaints of fatigue and malaise. His past medical history is significant for diabetes mellitus type II, hypertension, non-seminomatous testicular cancer, and hypercholesterolemia. He currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and he currently denies any 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. On examination, his physician notices cervical and inguinal lymphadenopathy bilaterally, as well as splenomegaly. The patient comments that he has lost 18.1 kg (40 lb) over the past 6 months without a change in diet or exercise, which he was initially not concerned about. The physician orders a complete blood count and adds on flow cytometry. Based on his age and overall epidemiology, which of the following is the most likely diagnosis?", "answer": "Chronic lymphocytic leukemia", "options": {"A": "Acute lymphocytic leukemia", "B": "Acute myelogenous leukemia", "C": "Chronic lymphocytic leukemia", "D": "Chronic myelogenous leukemia", "E": "Hairy cell leukemia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care clinic", "non-specific complaints", "fatigue", "malaise", "past medical history", "significant", "diabetes mellitus type II", "hypertension", "non seminomatous testicular cancer", "hypercholesterolemia", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "currently", "illicit drug use", "vital signs include", "temperature", "36", "98", "blood pressure", "74 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "physician", "cervical", "inguinal lymphadenopathy", "splenomegaly", "patient", "lost", "kg", "40", "past 6 months", "change", "diet", "exercise", "initially not", "about", "physician orders", "complete blood count", "adds", "flow cytometry", "Based", "age", "overall epidemiology", "following", "diagnosis"]}
{"question": "A 69-year-old man comes to his cardiologist for a follow-up visit. He is being considered for a new drug therapy that works by modulating certain proteins released from the heart in patients with heart failure. A drug called candoxatril is being investigated for its ability to inhibit the action of an endopeptidase that breaks down a vasodilatory mediator released from the heart, as well as, endothelin and bradykinin. This mediator is known to promote the excretion of sodium from the body and improve the ejection fraction. One of its side effects is its ability to increase angiotensin II levels which causes harm to patients with heart failure. Therefore, to improve efficacy and reduce its adverse effects, candoxatril has to be used in conjunction with angiotensin receptor blockers. Which of the following is most likely to increase as a result of this drug regimen?", "answer": "Natriuretic peptides", "options": {"A": "Thromboxane", "B": "Nitric oxide", "C": "Leukotrienes", "D": "Acetylcholine", "E": "Natriuretic peptides"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["69 year old man", "cardiologist", "new drug", "modulating certain proteins released", "heart", "patients", "heart", "drug called candoxatril", "investigated", "ability to inhibit", "breaks down", "mediator released", "heart", "endothelin", "bradykinin", "mediator", "known to", "excretion", "sodium", "body", "ejection fraction", "One of", "side effects", "ability to increase angiotensin II levels", "causes harm", "patients", "heart failure", "to", "efficacy", "adverse effects", "candoxatril", "to", "used", "angiotensin receptor blockers", "following", "to increase", "result", "drug regimen"]}
{"question": "Seventy-two hours after admission for an acute myocardial infarction, a 48-year-old man develops dyspnea and a productive cough with frothy sputum. Physical examination shows coarse crackles in both lungs and a blowing, holosystolic murmur heard best at the apex. ECG shows Q waves in the anteroseptal leads. Pulmonary capillary wedge pressure is 23 mm Hg. Which of the following is the most likely cause of this patient’s current condition?", "answer": "Rupture of the chordae tendinae", "options": {"A": "Postmyocardial infarction syndrome", "B": "Aortic root dilation", "C": "Rupture of the chordae tendinae", "D": "Rupture of the ventricular free wall", "E": "Rupture of the interventricular septum"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Seventy-two hours", "acute myocardial infarction", "48 year old man", "dyspnea", "productive cough", "frothy sputum", "coarse crackles", "lungs", "blowing", "holosystolic murmur heard best", "apex", "ECG", "Q waves", "leads", "Pulmonary capillary wedge pressure", "23 mm Hg", "following", "most likely cause", "patients current condition"]}
{"question": "A 45-year-old man comes to the physician because of a productive cough and dyspnea. He has smoked one pack of cigarettes daily for 15 years. His temperature is 38.8°C (102°F). Physical examination shows decreased breath sounds and dullness on percussion above the right lower lobe. An x-ray of the chest shows a right lower lobe density and a small amount of fluid in the right pleural space. The patient's symptoms improve with antibiotic treatment, but he develops right-sided chest pain one week later. Pulmonary examination shows new scratchy, high-pitched breath sounds on auscultation of the right lobe. Histologic examination of a pleural biopsy specimen is most likely to show which of the following findings?", "answer": "Fibrin-rich infiltrate", "options": {"A": "Cholesterol-rich infiltrate", "B": "Fibrin-rich infiltrate", "C": "Dense bacterial infiltrate", "D": "Epithelioid infiltrate with central necrosis", "E": "Red blood cell infiltrate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "productive cough", "dyspnea", "smoked one pack", "cigarettes daily", "years", "temperature", "decreased breath sounds", "dullness", "percussion", "right lower lobe", "x-ray of", "chest", "right lower lobe density", "small amount", "fluid", "right pleural space", "patient's symptoms", "antibiotic treatment", "right-sided chest pain one week later", "Pulmonary", "new scratchy", "high-pitched breath sounds", "auscultation", "right lobe", "Histologic examination", "pleural", "to", "following findings"]}
{"question": "A 50-year-old obese woman presents for a follow-up appointment regarding microcalcifications found in her left breast on a recent screening mammogram. The patient denies any recent associated symptoms. The past medical history is significant for polycystic ovarian syndrome (PCOS), for which she takes metformin. Her menarche occurred at age 11, and the patient still has regular menstrual cycles. The family history is significant for breast cancer in her mother at the age of 72. The review of systems is notable for a 6.8 kg (15 lb) weight loss in the past 2 months. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 130/70 mm Hg, pulse 82/min, respiratory rate 17/min, and oxygen saturation 98% on room air. On physical examination, the patient is alert and cooperative. The breast examination reveals no palpable masses, lymphadenopathy, or evidence of skin retraction. An excisional biopsy of the left breast is performed, and histologic examination demonstrates evidence of non-invasive malignancy. Which of the following is the most appropriate course of treatment for this patient?", "answer": "Lumpectomy", "options": {"A": "Observation with bilateral mammograms every 6 months", "B": "Tamoxifen", "C": "Radiotherapy", "D": "Lumpectomy", "E": "Bilateral mastectomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["50 year old obese woman presents", "follow-up appointment", "microcalcifications found", "left breast", "recent screening mammogram", "patient", "recent associated symptoms", "past medical history", "significant", "polycystic ovarian syndrome", "metformin", "menarche", "age", "patient", "regular menstrual cycles", "family history", "significant", "breast cancer", "mother", "age", "72", "review of systems", "notable", "6.8 kg", "weight loss", "past", "months", "vital signs include", "temperature", "98", "blood pressure", "70 mm Hg", "pulse", "min", "respiratory rate", "min", "oxygen saturation 98", "room air", "patient", "alert", "breast examination reveals", "lymphadenopathy", "skin retraction", "excisional biopsy of the left breast", "performed", "histologic examination", "non", "following", "most appropriate course", "treatment", "patient"]}
{"question": "An 18-month-old boy presents to the clinic with his mother for evaluation of a rash around the eyes and mouth. His mother states that the rash appeared 2 weeks ago and seems to be very itchy because the boy scratches his eyes often. The patient is up to date on all of his vaccinations and is meeting all developmental milestones. He has a history of asthma that was recently diagnosed. On examination, the patient is playful and alert. He has scaly, erythematous skin surrounding both eyes and his mouth. Bilateral pupils are equal and reactive to light and accommodation, and conjunctiva is clear, with no evidence of jaundice or exudates. The pharynx and oral mucosa are within normal limits, and no lesions are present. Expiratory wheezes can be heard in the lower lung fields bilaterally. What is this most likely diagnosis in this patient?", "answer": "Atopic dermatitis", "options": {"A": "Viral conjunctivitis", "B": "Bronchiolitis", "C": "Impetigo", "D": "Atopic dermatitis", "E": "Scalded skin syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy presents", "clinic", "rash", "eyes", "mouth", "states", "rash appeared 2 weeks", "to", "very itchy", "boy scratches", "eyes often", "patient", "date", "of", "vaccinations", "history of asthma", "recently diagnosed", "patient", "playful", "alert", "scaly", "erythematous skin surrounding", "eyes", "mouth", "Bilateral pupils", "equal", "reactive to light", "accommodation", "conjunctiva", "clear", "jaundice", "exudates", "pharynx", "oral mucosa", "normal limits", "lesions", "present", "Expiratory wheezes", "heard", "lower lung fields", "diagnosis", "patient"]}
{"question": "A 63-year-old man presents to the emergency department with periorbital swelling. He states that he was gardening, came inside, looked in the mirror, and then noticed his eyelids were swollen. He denies pain, pruritus, or visual disturbances. He states that he was drinking “a lot of water\" to prevent dehydration, because it was hot outside this morning. His medical history is significant for rheumatoid arthritis. He takes methotrexate and acetaminophen as needed. The patient’s temperature is 98°F (36.7°C), blood pressure is 168/108 mmHg, and pulse is 75/min. Physical examination is notable for periorbital edema, hepatomegaly, and bilateral 1+ pitting lower extremity edema. Labs and a urinalysis are obtained, as shown below:\n\nLeukocyte count: 11,000/mm^3\nHemoglobin: 14 g/dL\n\nSerum:\nNa: 138 mEq/L\nK+: 4.3 mEq/L\nCl-: 104 mEq/L\nHCO3-: 25 mEq/L\nUrea nitrogen: 26 mg/dL\nCreatinine: 1.4 mg/dL\nGlucose: 85 mg/dL\nAspartate aminotransferase (AST, GOT): 15 U/L\nAlanine aminotransferase (ALT, GPT): 19 U/L\nAlbumin: 2.0 g/dL\n\nUrine:\nProtein: 150 mg/dL\nCreatinine: 35 mg/dL\n\nAn abdominal ultrasound reveals an enlarged liver with heterogeneous echogenicity and enlarged kidneys with increased echogenicity in the renal parenchyma. A biopsy of the kidney is obtained. Which of the following biopsy findings is associated with the patient’s most likely diagnosis?", "answer": "Apple green birefringence with Congo red staining", "options": {"A": "Apple green birefringence with Congo red staining", "B": "Glomerular basement membrane splitting", "C": "Kimmelstiel-Wilson nodules", "D": "Subepithelial dense deposits", "E": "Tubulointerstitial fibrosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man presents", "emergency department", "periorbital swelling", "states", "looked", "mirror", "then", "eyelids", "swollen", "pain", "pruritus", "visual disturbances", "states", "drinking", "lot", "water", "to prevent dehydration", "hot outside", "morning", "medical history", "significant", "rheumatoid arthritis", "methotrexate", "acetaminophen as needed", "patients temperature", "36", "blood pressure", "mmHg", "pulse", "75 min", "notable", "periorbital edema", "hepatomegaly", "bilateral", "pitting lower extremity edema", "Labs", "urinalysis", "obtained", "Leukocyte count", "mm", "Hemoglobin", "g/dL", "Serum", "Na", "mEq/L K", "4", "mEq/L", "mEq/L HCO3", "mEq/L Urea nitrogen", "mg/dL Creatinine", "1.4 mg/dL Glucose", "85 mg/dL Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L Albumin", "2 0 g/dL", "Urine", "Protein", "mg/dL Creatinine", "35 mg/dL", "abdominal ultrasound reveals", "enlarged liver", "heterogeneous echogenicity", "enlarged kidneys", "increased echogenicity", "renal parenchyma", "biopsy of", "kidney", "obtained", "following biopsy findings", "associated with", "patients", "likely diagnosis"]}
{"question": "A 68-year-old woman presents to her primary care physician for a regular check-up. She complains of swelling of her legs and face, which is worse in the morning and decreases during the day. She was diagnosed with type 2 diabetes mellitus a year ago and prescribed metformin, but she has not been compliant with it preferring ‘natural remedies’ over the medications. She does not have a history of cardiovascular disease or malignancy. Her vital signs are as follows: blood pressure measured on the right hand is 130/85 mm Hg, on the left hand, is 110/80 mm Hg, heart rate is 79/min, respiratory rate is 16/min, and the temperature is 36.6℃ (97.9°F). Physical examination reveals S1 accentuation best heard in the second intercostal space at the right sternal border. Facial and lower limbs edema are evident. The results of the laboratory tests are shown in the table below.\nFasting plasma glucose  164 mg/dL\nHbA1c 10.4%\nTotal cholesterol 243.2 mg/dL\nTriglycerides 194.7 mg/dL\nCreatinine 1.8 mg/dL\nUrea nitrogen 22.4 mg/dL\nCa2+ 9.6 mg/dL\nPO42- 38.4 mg/dL\nWhich of the following statements best describes this patient’s condition?", "answer": "If measured in this patient, there would be an increased PTH level.", "options": {"A": "If measured in this patient, there would be an increased PTH level.", "B": "The calcitriol level is unlikely to be affected in this patient.", "C": "Hypoparathyroidism is most likely the cause of the patient’s altered laboratory results.", "D": "Increase in 1α, 25(OH)2D3 production is likely to contribute to alteration of the patient’s laboratory values.", "E": "There is an error in Ca2+ measurement because the level of serum calcium is always decreased in the patient’s condition."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "regular check-up", "of swelling", "legs", "face", "worse", "morning", "decreases", "day", "diagnosed", "type 2 diabetes mellitus", "year", "metformin", "not", "compliant", "natural remedies", "medications", "not", "history of cardiovascular disease", "malignancy", "vital signs", "follows", "blood pressure measured", "right hand", "85 mm Hg", "left hand", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97 9F", "reveals S1", "best heard", "second intercostal space", "right sternal border", "Facial", "lower limbs edema", "results", "laboratory tests", "table", "Fasting plasma", "mg/dL", "10.4", "Total cholesterol", "Creatinine", "Urea nitrogen", "Ca2", "PO42", "following", "best", "patients condition"]}
{"question": "An otherwise healthy 27-year-old man presents to the Emergency Department with dark urine and left flank pain. He has had a fever, sore throat, and malaise for the last 2 days. Vital signs reveal a temperature of 38.1°C (100.5°F), blood pressure of 120/82 mm Hg, and a pulse of 95/min. His family history is noncontributory. Physical examination reveals enlarged tonsils with tender anterior cervical lymphadenopathy. Urinalysis shows pink urine with 20–25 red cells/high power field and 2+ protein. This patient’s condition is most likely due to which of the following?", "answer": "Diffuse mesangial IgA deposition", "options": {"A": "Inherited abnormalities in type IV collagen", "B": "Autoantibodies against alpha-3 chain of type IV collagen", "C": "C3 nephritic factor", "D": "Immune complex deposition", "E": "Diffuse mesangial IgA deposition"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy 27 year old man presents", "Emergency Department", "dark urine", "left flank pain", "fever", "sore throat", "malaise", "2 days", "Vital signs reveal", "temperature", "100", "blood pressure", "mm Hg", "pulse", "95 min", "family history", "reveals enlarged tonsils", "tender anterior cervical lymphadenopathy", "Urinalysis", "pink", "red cells/high power field", "2", "protein", "patients condition", "due to"]}
{"question": "A 70-year-old man is brought to the emergency department with complaints of chest pain for the last 2 hours. He had been discharged from the hospital 10 days ago when he was admitted for acute myocardial infarction. It was successfully treated with percutaneous coronary intervention. During the physical exam, the patient prefers to hunch forwards as this decreases his chest pain. He says the pain is in the middle of the chest and radiates to his back. Despite feeling unwell, the patient denies any palpitations or shortness of breath. Vitals signs include: pulse 90/min, respiratory rate 20/min, blood pressure 134/82 mm Hg, and temperature 36.8°C (98.2°F). The patient is visibly distressed and is taking shallow breaths because deeper breaths worsen his chest pain. An ECG shows diffuse ST elevations. Which of the following should be administered to this patient?", "answer": "Ibuprofen", "options": {"A": "Ibuprofen", "B": "Heparin", "C": "Levofloxacin", "D": "Propranolol", "E": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old man", "brought", "emergency department", "complaints of chest pain", "last", "hours", "10", "acute myocardial infarction", "treated with percutaneous coronary intervention", "patient", "forwards", "decreases", "chest pain", "pain", "middle", "chest", "radiates", "back", "unwell", "patient", "palpitations", "shortness of breath", "signs include", "pulse 90 min", "respiratory rate 20 min", "blood pressure", "mm Hg", "temperature 36", "98", "patient", "shallow breaths", "deeper breaths worsen", "chest pain", "ECG", "diffuse ST elevations", "following", "administered", "patient"]}
{"question": "A 55-year-old female presents to her primary care physician complaining of a mass in her mid-thigh. The mass has grown slowly over the past six months and is not painful. The patient’s past medical history is notable for hypertension and hyperlipidemia. She takes lisinopril and rosuvastatin. On examination, there is a firm, immobile mass on the medial aspect of the distal thigh. She has full range of motion and strength in her lower extremities and patellar reflexes are 2+ bilaterally. A biopsy of the mass reveals multiple pleomorphic smooth muscle cells with nuclear atypia. The patient subsequently initiates radiation therapy with plans to undergo surgical resection. This tumor will most strongly stain for which of the following?", "answer": "Desmin", "options": {"A": "Chromogranin", "B": "Desmin", "C": "Cytokeratin", "D": "Glial fibrillary acidic protein", "E": "Neurofilament"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female presents", "primary care physician", "mass", "mid thigh", "mass", "slowly", "past six months", "not painful", "patients past medical history", "notable", "hypertension", "hyperlipidemia", "lisinopril", "rosuvastatin", "firm", "immobile mass", "medial aspect of", "distal thigh", "full range of motion", "strength", "lower extremities", "patellar reflexes", "2", "biopsy", "mass reveals multiple", "nuclear atypia", "patient", "initiates radiation therapy", "plans to", "surgical resection", "tumor", "most"]}
{"question": "A 27-year-old woman presents to the emergency department for fever and generalized malaise. Her symptoms began approximately 3 days ago, when she noticed pain with urination and mild blood in her urine. Earlier this morning she experienced chills, flank pain, and mild nausea. Approximately 1 month ago she had the \"flu\" that was rhinovirus positive and was treated with supportive management. She has a past medical history of asthma. She is currently sexually active and uses contraception inconsistently. She occasionally drinks alcohol and denies illicit drug use. Family history is significant for her mother having systemic lupus erythematosus. Her temperature is 101°F (38.3°C), blood pressure is 125/87 mmHg, pulse is 101/min, and respirations are 18/min. On physical examination, she appears uncomfortable. There is left-sided flank, suprapubic, and costovertebral angle tenderness. Urine studies are obtained and a urinalysis is demonstrated below:\n\nColor: Amber\npH: 6.8\nLeukocyte: Positive\nProtein: Trace\nGlucose: Negative\nKetones: Negative\nBlood: Positive\nNitrite: Positive\nLeukocyte esterase: Positive\nSpecific gravity: 1.015\n\nIf a renal biopsy is performed in this patient, which of the following would most likely be found on pathology?", "answer": "Suppurative inflammation with interstitial neutrophilic infiltration", "options": {"A": "Diffuse capillary and glomerular basement membrane thickening", "B": "Focal and segmental sclerosis of the glomeruli and mesangium", "C": "Mesangial proliferation", "D": "Normal appearing glomeruli", "E": "Suppurative inflammation with interstitial neutrophilic infiltration"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old woman presents", "emergency department", "fever", "generalized malaise", "symptoms began approximately", "days", "pain", "urination", "mild blood in", "urine", "Earlier", "morning", "chills", "flank pain", "mild nausea", "Approximately", "month", "flu", "rhinovirus positive", "treated with", "past medical", "currently sexually active", "uses contraception", "occasionally", "alcohol", "illicit drug use", "Family history", "significant", "systemic lupus erythematosus", "temperature", "blood pressure", "87 mmHg", "pulse", "min", "respirations", "min", "appears", "left-sided flank", "suprapubic", "costovertebral angle tenderness", "Urine studies", "obtained", "urinalysis", "Color", "Amber pH", "Positive Protein", "Trace Glucose", "Negative Ketones", "Negative Blood", "Positive Nitrite", "Positive Leukocyte esterase", "Positive Specific gravity", "1", "renal biopsy", "performed", "patient", "following", "most likely", "found", "pathology"]}
{"question": "A 20-year-old man, who was previously healthy, is taken to the emergency department due to agitation during the past 24 hours. During the past week, his family members noticed a yellowish coloring of his skin and eyes. He occasionally uses cocaine and ecstasy, and he drinks alcohol (about 20 g) on weekends. The patient also admits to high-risk sexual behavior and does not use appropriate protection. Physical examination shows heart rate of 94/min, respiratory rate of 13/min, temperature of 37.0°C (98.6°F), and blood pressure of 110/60 mm Hg. The patient shows psychomotor agitation, and he is not oriented to time and space. Other findings include asterixis, jaundice on the skin and mucous membranes, and epistaxis. The rest of the physical examination is normal. The laboratory tests show:\nHemoglobin 16.3 g/dL\nHematocrit 47%\nLeukocyte count 9,750/mm3\nNeutrophils 58%\nBands 2%\nEosinophils 1%\nBasophils 0%\nLymphocytes 24%\nMonocytes 2%\nPlatelet count 365,000/mm3\nBilirubin 25 mg/dL\nAST 600 IU/L\nALT 650 IU/L\nTP activity < 40%\nINR 1,5\nWhat is the most likely diagnosis?", "answer": "Fulminant hepatic failure", "options": {"A": "Hemolytic uremic syndrome", "B": "Alcoholic hepatitis", "C": "Fulminant hepatic failure", "D": "Ecstasy intoxication", "E": "Cocaine-abstinence syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old man", "healthy", "emergency department due to agitation", "past 24 hours", "past week", "coloring of", "skin", "eyes", "occasionally uses cocaine", "ecstasy", "alcohol", "about 20 g", "weekends", "patient", "high-risk sexual behavior", "not use appropriate protection", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "blood pressure", "60 mm Hg", "patient", "psychomotor agitation", "not oriented to time", "space", "findings include asterixis", "jaundice", "skin", "mucous membranes", "epistaxis", "normal", "laboratory tests", "Hemoglobin", "Hematocrit", "count", "mm3", "Bands", "Basophils", "Lymphocytes", "Platelet count", "Bilirubin", "IU/L ALT", "TP", "40", "INR", "5", "diagnosis"]}
{"question": "A 31-year-old woman is brought to the physician because of increasing restlessness over the past 2 weeks. She reports that she continuously paces around the house and is unable to sit still for more than 10 minutes at a time. During this period, she has had multiple episodes of anxiety with chest tightness and shortness of breath. She was diagnosed with a psychotic illness 2 months ago. Her current medications include haloperidol and a multivitamin. She appears agitated. Vital signs are within normal limits. Physical examination shows no abnormalities. The examination was interrupted multiple times when she became restless and began to walk around the room. To reduce the likelihood of the patient developing her current symptoms, a drug with which of the following mechanisms of action should have been prescribed instead of her current medication?", "answer": "5-HT2Areceptor antagonism", "options": {"A": "H2 receptor antagonism", "B": "NMDA receptor antagonism", "C": "GABA receptor antagonism", "D": "5-HT2Areceptor antagonism", "E": "α2 receptor antagonism"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old woman", "brought", "physician", "of increasing restlessness", "past 2 weeks", "reports", "paces", "house", "unable to sit", "10 minutes", "time", "period", "multiple episodes of anxiety", "chest tightness", "shortness of breath", "diagnosed", "psychotic illness", "months", "current medications include haloperidol", "multivitamin", "appears agitated", "Vital signs", "normal", "Physical examination", "abnormalities", "interrupted multiple times", "restless", "began to", "room", "To", "likelihood", "patient", "current symptoms", "drug", "of", "following mechanisms", "action", "current medication"]}
{"question": "A 62-year-old man presents to the emergency department with shortness of breath on exertion and fatigue. He says that his symptoms onset gradually 5 days ago and have progressively worsened. Past medical history is significant for chronic alcoholism. His vital signs are blood pressure 100/60 mm Hg, temperature 36.9°C (98.4°F), respiratory rate 18/min, and pulse 98/min. On physical examination, there is bilateral pedal edema and decreased sensation in both feet. Basal crackles and rhonchi are heard on pulmonary auscultation bilaterally. Cardiac exam is unremarkable. A chest radiograph shows a maximal horizontal cardiac diameter to a maximal horizontal thoracic ratio of 0.7. A deficiency of which of the following vitamins is most likely responsible for this patient’s condition?\n ", "answer": "Thiamine", "options": {"A": "Thiamine", "B": "Riboflavin", "C": "Vitamin C", "D": "Niacin", "E": "Folic acid"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old man presents", "emergency department", "shortness of breath", "exertion", "fatigue", "symptoms onset", "days", "worsened", "Past medical history", "significant", "chronic alcoholism", "vital signs", "blood pressure 100 60 mm Hg", "temperature 36", "98", "respiratory rate", "min", "pulse 98 min", "bilateral pedal edema", "decreased sensation", "feet", "Basal crackles", "rhonchi", "heard", "pulmonary auscultation", "unremarkable", "chest radiograph", "maximal horizontal cardiac diameter", "ratio", "0.7", "A deficiency of", "following vitamins", "responsible", "patients condition"]}
{"question": "A 60-year-old woman sought evaluation at an urgent care clinic after developing breathlessness 30 minutes earlier. She also developed swelling of the tongue and lips. She has heart failure and was recently diagnosed with hypertension. She was started on a medication, the first dose of which she took this afternoon before her symptoms started. Her blood pressure is 167/88 mm Hg, the respiratory rate is 17/min, and the pulse is 78/min. The physical examination reveals a skin rash on the back and abdomen. There is a mild swelling of the lips and tongue. Chest auscultation does not reveal any abnormal breath sounds. Which of the following medications most likely led to her current symptoms?", "answer": "Captopril", "options": {"A": "Captopril", "B": "Amlodipine", "C": "Clonidine", "D": "Hydrochlorothiazide (HCTZ)", "E": "Propranolol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["60 year old woman", "urgent care clinic", "breathlessness 30 minutes earlier", "swelling of", "tongue", "lips", "heart failure", "recently diagnosed", "hypertension", "started", "medication", "first dose", "afternoon", "symptoms started", "blood pressure", "88 mm Hg", "respiratory rate", "min", "pulse", "min", "reveals", "skin rash", "back", "abdomen", "mild swelling of the lips", "tongue", "Chest auscultation", "not reveal", "abnormal breath sounds", "following medications", "likely led", "current symptoms"]}
{"question": "A 30-year-old woman presents for pregnancy counseling. She says she has a 8 week history of chronic diarrhea. She is also found to be intolerant to heat and has been significantly losing her hair. She denies any recent changes to her diet. The patient is afebrile and her vital signs are within normal limits. Her weight today is 45.0 kg (99.2 lb) which is 4.5 kg (10 lb) less than her weight during her last visit 2 months back. On physical examination, the patient is anxious and has a non-intention tremor. Significant exophthalmos is present. Laboratory findings are significant for a low TSH, elevated free T4 and free T3, and a positive thyroid stimulating immunoglobulin assay. She still wants to conceive a baby and asks for an appropriate treatment that is safe in pregnancy. Which of the following best describes the therapy she will most likely receive during her pregnancy for her thyroid disorder?", "answer": "Thyroid peroxidase inhibitors", "options": {"A": "Thyroidectomy and thyroid replacement", "B": "Beta-blockers", "C": "Radiation", "D": "Thyroid peroxidase inhibitors", "E": "Plasmapheresis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["30 year old woman presents", "pregnancy counseling", "week history", "chronic diarrhea", "found to", "intolerant", "hair", "recent changes", "diet", "patient", "afebrile", "vital signs", "normal limits", "weight today", "0 kg", "99", "4.5 kg", "10", "less than", "weight", "last", "months back", "patient", "anxious", "non intention tremor", "Significant exophthalmos", "present", "Laboratory findings", "significant", "low", "elevated free T4", "free T3", "positive thyroid stimulating immunoglobulin assay", "to", "baby", "appropriate treatment", "pregnancy", "following best", "therapy", "most likely receive", "pregnancy", "thyroid disorder"]}
{"question": "A 45-year-old man was shown to have a blood pressure of 142/90 mm Hg at a health fair. Despite modifying his lifestyle, his blood pressure remained elevated on 2  separate subsequent occasions. He was prescribed an anti-hypertensive medication. After 3 weeks, the swelling of the lips shown in the accompanying photograph was observed. What is the most likely cause of this finding?", "answer": "Lisinopril", "options": {"A": "Verapamil", "B": "Amlodipine", "C": "Lisinopril", "D": "Hydrochlorothiazide", "E": "Furosemide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "to", "blood pressure", "90 mm Hg", "fair", "modifying", "blood pressure", "elevated", "separate subsequent occasions", "anti-hypertensive medication", "3 weeks", "the swelling of", "lips", "photograph", "observed", "most likely cause", "finding"]}
{"question": "A 13-year-old girl is brought to the physician because of worsening fever, headache, photophobia, and nausea for 2 days. One week ago, she returned from summer camp. She has received all age-appropriate immunizations. Her temperature is 39.1°C (102.3°F). She is oriented to person, place, and time. Physical examination shows a maculopapular rash. There is rigidity of the neck; forced flexion of the neck results in involuntary flexion of the knees and hips. Cerebrospinal fluid studies show:\nOpening pressure 120 mm H2O\nAppearance Clear\nProtein 47 mg/dL\nGlucose 68 mg/dL\nWhite cell count 280/mm3\nSegmented neutrophils 15%\nLymphocytes 85%\nWhich of the following is the most likely causal organism?\"", "answer": "Echovirus", "options": {"A": "Echovirus", "B": "Listeria monocytogenes", "C": "Herpes simplex virus", "D": "Streptococcus pneumoniae", "E": "Neisseria meningitidis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "physician", "worsening fever", "headache", "photophobia", "nausea", "2 days", "One week", "returned", "summer camp", "received", "age appropriate immunizations", "temperature", "oriented to person", "place", "time", "maculopapular rash", "rigidity", "neck", "forced flexion", "neck results", "flexion of", "knees", "hips", "Cerebrospinal fluid studies", "Opening pressure", "mm H2O Appearance", "Protein", "mg/dL Glucose", "dL White", "count", "mm3 Segmented neutrophils", "Lymphocytes", "following", "causal"]}
{"question": "A 5-year-old boy presents to his pediatrician for a well-child visit. His mother reports him to be doing well and has no concerns. 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. On physical exam, he is noted to have a right upper extremity blood pressure of 150/80 mm Hg. 2+ radial pulses and trace femoral pulses are felt. Cardiac auscultation reveals a regular rate and rhythm with a normal S1 and S2. A 2/6 long systolic murmur with systolic ejection click is heard over left sternal border and back. The point of maximal impact is normal Which of the following is the most likely diagnosis?", "answer": "Coarctation of the aorta", "options": {"A": "Takayasu arteritis", "B": "Interrupted aortic arch", "C": "Pheochromocytoma", "D": "Coarctation of the aorta", "E": "Essential hypertension"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["5 year old boy presents", "pediatrician", "reports", "to", "well", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "noted to", "right blood pressure", "mm Hg", "radial pulses", "trace femoral pulses", "Cardiac auscultation reveals", "regular rate", "rhythm", "normal S1", "S2", "2/6 long systolic murmur", "ejection click", "heard", "left sternal border", "back", "point", "maximal impact", "normal", "following", "diagnosis"]}
{"question": "A 28-year-old woman comes to the physician for a follow-up examination. Two months ago, she underwent left renal transplantation for recurrent glomerulonephritis. At the time of discharge, her creatinine was 0.9 mg/dL. She feels well. Current medications include tacrolimus and azathioprine. Her pulse is 85/min and blood pressure is 135/75 mmHg. Physical examination shows a well-healed surgical scar on her left lower abdomen. The remainder of the examination shows no abnormalities. The patient should be monitored for which of the following adverse effects of her medications?", "answer": "Kidney injury", "options": {"A": "Teeth discoloration", "B": "Gingival hyperplasia", "C": "Hepatic necrosis", "D": "Kidney injury", "E": "Polycythemia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "Two months", "left", "recurrent glomerulonephritis", "time", "discharge", "creatinine", "0.9 mg/dL", "well", "Current medications include tacrolimus", "azathioprine", "pulse", "85 min", "blood pressure", "75 mmHg", "well healed surgical scar", "left lower abdomen", "abnormalities", "patient", "monitored", "following adverse effects", "medications"]}
{"question": "A 42-year-old woman comes to the physician because of a 12 month history of progressive fatigue and shortness of breath with exertion. Five years ago, she emigrated from Eastern Europe. She has smoked one pack of cigarettes daily for 20 years. She has a history of using methamphetamines and cocaine but quit 5 years ago. Vital signs are within normal limits. Physical examination shows jugular venous pulsations 9 cm above the sternal angle. The lungs are clear to auscultation. There is a normal S1 and a loud, split S2. An impulse can be felt with the fingers left of the sternum. The abdomen is soft and nontender. The fingertips are enlarged and the nails are curved. There is pitting edema around the ankles bilaterally. An x-ray of the chest shows pronounced central pulmonary arteries and a prominent right heart border. Which of the following is most likely to confirm the diagnosis?", "answer": "Right-heart catheterization", "options": {"A": "CT angiography", "B": "Doppler echocardiography", "C": "High-resolution CT of the lung", "D": "Right-heart catheterization", "E": "Serologic testing"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history", "progressive fatigue", "shortness of breath", "exertion", "Five years", "Eastern Europe", "smoked one pack", "cigarettes daily", "20 years", "history", "using methamphetamines", "cocaine", "years", "Vital signs", "normal", "Physical examination", "venous", "sternal angle", "lungs", "clear", "auscultation", "normal S1", "loud", "split S2", "impulse", "fingers left", "sternum", "abdomen", "soft", "nontender", "fingertips", "enlarged", "nails", "curved", "pitting", "ankles", "x-ray of", "chest", "central pulmonary arteries", "prominent right heart border", "following", "to confirm", "diagnosis"]}
{"question": "A 29-year-old man is admitted to the emergency department following a motorcycle accident. The patient is severely injured and requires life support after splenectomy and evacuation of a subdural hematoma. Past medical history is unremarkable. The patient’s family members, including wife, parents, siblings, and grandparents, are informed about the patient’s condition. The patient has no living will and there is no durable power of attorney. The patient must be put in an induced coma for an undetermined period of time. Which of the following is responsible for making medical decisions for the incapacitated patient?", "answer": "The spouse", "options": {"A": "An older sibling", "B": "The parents", "C": "Physician", "D": "Legal guardian", "E": "The spouse"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old man", "emergency department following", "motorcycle accident", "patient", "severely injured", "life support", "splenectomy", "evacuation of", "subdural hematoma", "Past medical history", "unremarkable", "patients", "including", "condition", "patient", "living will", "patient", "induced coma", "undetermined period", "time", "following", "medical", "patient"]}
{"question": "An 11-year-old girl is brought to the physician by her parents because of a mildly pruritic rash on her trunk and extremities for 2 days. One week ago, she developed a low-grade fever, rhinorrhea, and headache, followed by a facial rash 4 days later. The facial rash did not involve the perioral skin. Her temperature is 37.4°C (99.3°F). A photograph of the rash on her lower arms is shown. Which of the following is the most likely diagnosis?", "answer": "Erythema infectiosum", "options": {"A": "Rubella", "B": "Erythema infectiosum", "C": "Hand, foot, and mouth disease", "D": "Exanthem subitum", "E": "Scarlet fever"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "mildly pruritic rash", "trunk", "extremities", "2", "One", "low-grade fever", "rhinorrhea", "headache", "followed by", "facial rash 4 days later", "facial rash", "not", "perioral skin", "temperature", "99", "photograph", "rash", "lower arms", "following", "diagnosis"]}
{"question": "An 11-year-old boy is brought to the emergency department by his parents with a 2-day history of fever, malaise, and productive cough. On presentation, he is found to be very weak and is having difficulty breathing. His past medical history is significant for multiple prior infections requiring hospitalization including otitis media, upper respiratory infections, pneumonia, and sinusitis. His family history is also significant for a maternal uncle who died of an infection as a child. Lab findings include decreased levels of IgG, IgM, IgA, and plasma cells with normal levels of CD4 positive cells. The protein that is most likely defective in this patient has which of the following functions?", "answer": "Protein phosphorylation", "options": {"A": "Actin polymerization", "B": "Autoimmune regulation", "C": "Lysosomal trafficking", "D": "Nucleotide salvage", "E": "Protein phosphorylation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "emergency department", "2-day history", "fever", "malaise", "productive cough", "found to", "very weak", "difficulty breathing", "past medical history", "significant", "multiple prior infections", "including otitis media", "upper respiratory infections", "pneumonia", "sinusitis", "family history", "significant", "died", "infection", "child", "Lab findings include decreased levels", "IgG", "IgA", "plasma cells", "normal levels", "CD4 positive", "protein", "defective", "patient", "following functions"]}
{"question": "A two-month-old female presents to the emergency department for difficulty feeding. The patient was born at 38 weeks gestation to a 29-year-old primigravid via vaginal delivery. The newborn period has thus far been uncomplicated. The patient has been exclusively breastfed since birth. Her parents report that feeding had previously seemed to be going well, and the patient has been gaining weight appropriately. Over the past several days, the patient’s mother has noticed that the patient seems to tire out before the end of the feeding. She has also noticed that the patient begins to appear short of breath and has a bluish discoloration of her lips. The patient’s height and weight were in the 20th and 10th percentile at birth, respectively. Her current height and weight are in the 20th and 15th percentiles, respectively. Her temperature is 98.0°F (36.7°C), blood pressure is 60/48 mmHg, pulse is 143/min, and respirations are 40/min. On physical exam, the patient is in no acute distress and appears well developed. A systolic crescendo-decrescendo murmur can be heard at the left upper sternal border. Her abdomen is soft, non-tender, and non-distended. During the abdominal exam, the patient begins crying and develops cyanosis of the perioral region.\n\nWhich of the following is the best initial test to diagnose this patient’s condition?", "answer": "Echocardiogram", "options": {"A": "Chest radiograph", "B": "CT angiography", "C": "Electrocardiogram", "D": "Echocardiogram", "E": "Genetic testing"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["two month old female presents", "emergency department", "difficulty feeding", "patient", "born", "weeks gestation", "29 year old primigravid", "vaginal delivery", "newborn period", "far", "uncomplicated", "patient", "breastfed", "birth", "report", "to", "well", "patient", "gaining weight", "past", "days", "patients", "patient", "to tire out", "end", "patient begins to appear short of breath", "discoloration", "lips", "patients height", "weight", "percentile", "birth", "current height", "weight", "percentiles", "temperature", "98", "36", "blood pressure", "60 48 mmHg", "pulse", "min", "respirations", "40 min", "patient", "acute distress", "appears well", "systolic crescendo-decrescendo murmur", "heard", "left upper sternal border", "abdomen", "soft", "non-tender", "non distended", "abdominal exam", "patient begins", "cyanosis", "perioral region", "following", "best initial test to diagnose", "patients condition"]}
{"question": "A 4-year-old male is evaluated for frequent epistaxis and mucous membrane bleeding. Physical examination shows diffuse petechiae on the patient’s distal extremities. Peripheral blood smear shows an absence of platelet clumping. An ELISA binding assay reveals that platelet surfaces are deficient in GIIb/IIIa receptors. Serum platelet count is normal. Which of the following is the most likely diagnosis?", "answer": "Glanzmann’s thrombasthenia", "options": {"A": "Hemophilia A", "B": "Thrombotic thrombocytopenic purpura", "C": "Bernard-Soulier disease", "D": "Idiopathic thrombocytopenic purpura", "E": "Glanzmann’s thrombasthenia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["4 year old male", "frequent epistaxis", "mucous membrane bleeding", "diffuse petechiae", "patients distal extremities", "Peripheral blood smear", "absence", "platelet clumping", "ELISA", "assay reveals", "surfaces", "deficient", "GIIb", "receptors", "Serum platelet count", "normal", "following", "diagnosis"]}
{"question": "A 45-year-old man was a driver in a motor vehicle collsion. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?", "answer": "Intubation", "options": {"A": "100% oxygen", "B": "Emergency open fracture repair", "C": "Exploratory laparoscopy", "D": "Intubation", "E": "Packed red blood cells"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "driver", "motor vehicle", "patient", "not able to", "medical history", "initial presentation", "temperature", "97", "36", "blood pressure", "74 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "exam", "not open", "eyes", "pain", "makes incomprehensible sounds", "signs", "trauma", "chest", "abdomen", "abdomen", "distended", "markedly tender", "palpation", "open deformity of", "left femur", "best initial step"]}
{"question": "An 81-year-old woman comes to the emergency department due to a left-sided paralysis for the past 2 hours. Her husband says her symptoms began suddenly, and she is also unable to speak. Her pulse is 90/min, respirations are 18/min, temperature is 36.8°C (98.2°F), and blood pressure is 150/98 mm Hg. An ECG is obtained and is shown below. Which of the following is the most probable cause of the patient's paralysis?", "answer": "Cardioembolic stroke", "options": {"A": "Cardioembolic stroke", "B": "Cocaine toxicity", "C": "Conversion disorder", "D": "Hemorrhagic disorder", "E": "Rupture of berry aneurysm"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["81 year old woman", "emergency department due to", "left-sided paralysis", "past", "hours", "symptoms began", "unable", "speak", "pulse", "90 min", "respirations", "min", "temperature", "36", "98", "blood pressure", "98 mm Hg", "ECG", "obtained", "following", "cause", "patient's paralysis"]}
{"question": "A 52-year-old female with a history of poorly-controlled diabetes presents to her primary care physician because of pain and tingling in her hands. These symptoms began several months ago and have been getting worse such that they interfere with her work as a secretary. She says that the pain is worse in the morning and she has been woken up at night by the pain. The tingling sensations have been located primarily in the thumb, index and middle fingers. On physical exam atrophy of the thenar eminence is observed and the pain is reproduced when the wrist is maximally flexed. The most likely cause of this patient's symptoms affects which of the nerves shown in the image provided?", "answer": "D", "options": {"A": "A", "B": "B", "C": "C", "D": "D", "E": "E"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "history", "poorly-controlled diabetes presents", "primary care physician", "pain", "tingling", "hands", "symptoms began several months", "getting worse", "interfere", "secretary", "pain", "worse", "morning", "woken up", "night", "pain", "tingling sensations", "thumb", "index", "middle fingers", "atrophy", "thenar eminence", "observed", "pain", "wrist", "flexed", "most likely cause", "patient's symptoms", "nerves"]}
{"question": "A 57-year-old man is brought to the emergency department because of a 2-day history of fever and right upper quadrant abdominal pain. Examination shows jaundice. Ultrasonography of the abdomen shows cholelithiasis and marked dilation of the biliary duct. An ERCP is performed and reveals pus with multiple brown concrements draining from the common bile duct. Which of the following is the most likely underlying cause of the patient's findings?", "answer": "Increased β-glucuronidase activity", "options": {"A": "Increased alanine aminotransferase activity", "B": "Decreased heme oxygenase activity", "C": "Decreased HMG-coenzyme A reductase activity", "D": "Increased cholesterol 7-α hydroxylase activity", "E": "Increased β-glucuronidase activity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["57 year old man", "brought", "emergency department", "2-day history", "fever", "right upper quadrant abdominal pain", "jaundice", "Ultrasonography of", "abdomen", "cholelithiasis", "marked dilation of", "biliary duct", "ERCP", "performed", "reveals pus", "multiple brown", "draining", "common bile duct", "following", "underlying cause", "patient's findings"]}
{"question": "A 9-year-old boy presents for incision and drainage of a small abscess on his left thigh. No significant past medical history. No current medications. Before the procedure, the patient is allowed to inhale colorless, sweet-smelling gas. After the procedure, the patient receives 3–4 minutes of high flow oxygen through a nasal mask. The pulse oximetry shows an oxygen saturation of 94%. This patient was oxygenated at the end of the procedure to prevent which of the following complications?", "answer": "Diffusion hypoxia", "options": {"A": "Malignant hyperthermia", "B": "Cardiac arrhythmias", "C": "Raised intracranial pressure", "D": "Hepatotoxicity", "E": "Diffusion hypoxia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy presents", "incision", "drainage of", "small abscess", "left thigh", "significant past medical history", "current medications", "procedure", "patient", "inhale colorless", "sweet smelling gas", "procedure", "patient receives", "minutes", "high", "oxygen", "nasal mask", "pulse oximetry", "oxygen saturation", "patient", "end", "procedure to prevent", "following complications"]}
{"question": "A 50-year-old man presents to his primary care physician with a chief complaint of chest pain that is squeezing in nature. He used to have similar symptoms in the past while playing tennis with his friends. Yesterday, while moving furniture in his new home, he experienced this pain that lasted for 20 minutes and radiated towards his jaw and shoulder. He has been diagnosed with diabetes mellitus and hypertension for over 10 years and regularly takes his medications. The pain is not associated with nausea, vomiting, food intake, sweating, or cough. On physical examination, the patient is not in acute distress. His blood pressure is 135/85 mm Hg, heart rate is 80/min, respiratory rate is 16/min, temperature is 36.9°C (98.5°F), and BMI is 30 kg/m2. On physical examination, bilateral vesicular breath sounds are heard with absent chest tenderness. Cardiovascular examination reveals normal S1 and S2 without any abnormal sounds or murmur. Abdominal examination is within normal limit. What is the most likely cause of this patient’s condition?", "answer": "Myocardial ischemia", "options": {"A": "GERD", "B": "Musculoskeletal pain", "C": "Rib fracture", "D": "Anxiety", "E": "Myocardial ischemia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["50 year old man presents", "primary care physician", "chief complaint of chest pain", "squeezing", "nature", "used to", "similar symptoms", "past", "playing", "moving furniture", "new home", "pain", "lasted", "20 minutes", "radiated", "jaw", "shoulder", "diagnosed", "diabetes mellitus", "hypertension", "medications", "pain", "not associated with nausea", "vomiting", "food intake", "sweating", "cough", "patient", "not", "acute distress", "blood pressure", "85 mm Hg", "heart rate", "80 min", "respiratory rate", "min", "temperature", "36", "98", "BMI", "30 kg/m2", "bilateral vesicular breath sounds", "heard", "absent chest", "reveals normal S1", "S2", "abnormal", "murmur", "Abdominal", "normal limit", "most likely cause", "patients condition"]}
{"question": "A 55-year-old man presents to his physician with a complaint of recurrent episodes of palpitations over the past 2 weeks. He also mentions that he tends to tire easily. He denies chest pain, breathlessness, dizziness, or syncope, but has a history of ischemic heart disease. He smokes 1 pack of cigarettes every day and drinks alcohol occasionally. The physical examination revealed a temperature of 36.9°C (98.4°F), a pulse of 124/min (irregular), a blood pressure of 142/86 mm Hg, and a respiratory rate of 16/min. Auscultation of his chest is normal with an absence of rales overall lung fields. An ECG was significant for fibrillatory waves and an irregular RR interval. Thus, the physician concludes that the symptoms are due to atrial fibrillation. The patient is prescribed oral diltiazem. Which of the following side effects should the physician warn the patient about?", "answer": "Bilateral pedal edema", "options": {"A": "Hypoglycemia", "B": "Bilateral pedal edema", "C": "Bloody diarrhea", "D": "Stevens-Johnson syndrome", "E": "Multifocal atrial tachycardia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "physician", "complaint of recurrent episodes", "palpitations", "past 2 weeks", "to tire easily", "chest pain", "breathlessness", "dizziness", "syncope", "history of ischemic heart disease", "smokes 1 pack", "cigarettes", "day", "alcohol occasionally", "revealed", "temperature", "36", "98", "pulse", "min", "irregular", "blood pressure", "mm Hg", "respiratory rate", "min", "Auscultation", "chest", "normal", "absence of rales overall lung fields", "ECG", "significant", "irregular RR interval", "physician concludes", "symptoms", "due to atrial fibrillation", "patient", "oral diltiazem", "following side effects", "physician", "patient"]}
{"question": "A 51-year-old female presents to her primary care physician complaining of body aches and constipation. She reports that her “bones hurt” and that she has experienced worsening constipation over the past few months. Her medical history is notable for three kidney stones within the past year that both passed spontaneously. Her vital signs are stable. Physical examination reveals a small nodule near the right inferior pole of the thyroid. Which of the following sets of serum findings is most likely in this patient?", "answer": "Increased calcium, decreased phosphate, increased parathyroid hormone", "options": {"A": "Increased calcium, decreased phosphate, increased parathyroid hormone", "B": "Decreased calcium, increased phosphate, increased parathyroid hormone", "C": "Increased calcium, decreased phosphate, decreased parathyroid hormone", "D": "Decreased calcium, increased phosphate, decreased parathyroid hormone", "E": "Normal calcium, normal phosphate, normal parathyroid hormone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female presents", "primary care physician", "body aches", "constipation", "reports", "bones", "worsening constipation", "past", "months", "medical history", "notable", "three kidney stones", "past year", "passed", "vital signs", "stable", "reveals", "small nodule", "the right of", "thyroid", "following sets", "serum findings", "patient"]}
{"question": "A 12-hour old male infant is seen in the newborn nursery. He was born full term by vaginal delivery to a 40-year-old G4P3-->4 mother. Her pregnancy and delivery were uncomplicated, notable only for declining genetic testing. On exam, her son has a flat face, a fold in the upper eyelid, palpebral fissures that appear to slant upwards, and small ears. The diagnostic test for her son’s most likely condition should be conducted during which of the following phases of the cell cycle?", "answer": "Metaphase", "options": {"A": "Prophase", "B": "Metaphase", "C": "Anaphase", "D": "Telophase", "E": "S-phase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["12-hour old male infant", "seen", "newborn nursery", "born full term", "vaginal delivery", "40 year old", "4", "pregnancy", "delivery", "uncomplicated", "notable only", "declining genetic testing", "exam", "flat face", "fold", "upper eyelid", "palpebral fissures", "appear", "small ears", "diagnostic test", "likely condition", "following phases", "cell cycle"]}
{"question": "A 40-year-old woman with a past medical history significant for pernicious anemia and vitiligo presents to the physician with the chief complaints of heat intolerance and frequent palpitations. The patient does not take birth control and her urine pregnancy test is negative today. Physical exam reveals a patient that is hyper-reflexive with a non-tender symmetrically enlarged thyroid gland. You order thyroid function tests for workup. What thyroid function values are most expected?", "answer": "T4 elevated, free T4 elevated, T3 elevated, TSH decreased", "options": {"A": "T4 elevated, free T4 normal, T3 elevated, thyroid stimulating hormone (TSH) normal", "B": "T4 elevated, free T4 elevated, T3 elevated, TSH elevated", "C": "T4 elevated, free T4 elevated, T3 elevated, TSH decreased", "D": "T4 decreased, free T4 decreased, T3 decreased, TSH decreased", "E": "T4 normal, free T4 normal, T3 normal, TSH elevated"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old woman", "past medical history significant", "pernicious anemia", "vitiligo presents", "physician", "chief complaints of heat intolerance", "frequent palpitations", "patient", "not", "birth control", "urine pregnancy test", "negative today", "reveals", "patient", "hyper", "non-tender", "enlarged thyroid gland", "order thyroid function tests", "workup", "thyroid function values", "most"]}
{"question": "A 75-year-old woman presents to her primary care physician with her son because she is convinced that people are stealing from her. Her son claims she has been misplacing her medications and money throughout the house. She recently lost her husband to old age and has become reclusive and no longer wants people to visit. Physical examination is unremarkable and the patient is oriented to person, time, and place. A mini-mental status examination (MMSE) is performed and she has difficulty recalling words after 5 minutes and also has problems with serial subtraction. Which of the following is the most likely diagnosis in this patient?", "answer": "Dementia", "options": {"A": "Delirium", "B": "Dementia", "C": "Histrionic personality disorder", "D": "Schizoid personality disorder", "E": "Schizophrenia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old woman presents", "primary care physician", "medications", "money", "house", "recently lost", "old age", "reclusive", "longer", "to", "unremarkable", "patient", "oriented to person", "time", "place", "mini-mental status examination", "performed", "difficulty", "5 minutes", "serial", "following", "diagnosis", "patient"]}
{"question": "A 67-year-old man comes to the office due to pain in the lower part of his calves on his afternoon walk to get the mail. The pain is relieved by rest. It started slowly about 6 months ago and has become more painful over time. He has a history of hypertension, hyperlipidemia, diabetes mellitus, and smoking. Medications include hydrochlorothiazide, atorvastatin, metformin, and a multivitamin that he takes daily. The patient does not smoke and only drinks socially. Today, his blood pressure is 145/90 mm Hg, pulse is 75/min, respiratory rate is 17/min, and temperature is 37.6°C (99.6°F). On physical exam, he appears mildly obese and healthy. His heart has a regular rate and rhythm, and his lungs are clear to auscultation bilaterally. Examination of the legs shows atrophic changes and diminished pedal pulses. A measure of his ankle brachial index (ABI) is 0.89. Which of the following is the most appropriate initial treatment?", "answer": "A referral to a supervised exercise program", "options": {"A": "Enoxaparin", "B": "Metoprolol", "C": "A recommendation to perform pedal pumping exercises", "D": "A recommendation to walk more", "E": "A referral to a supervised exercise program"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["67 year old man", "office due to pain in", "lower part of", "calves", "afternoon", "to", "mail", "pain", "relieved by", "started slowly", "months", "more painful", "time", "history of hypertension", "hyperlipidemia", "diabetes mellitus", "smoking", "Medications include hydrochlorothiazide", "atorvastatin", "metformin", "multivitamin", "daily", "patient", "not smoke", "only", "Today", "blood pressure", "90 mm Hg", "pulse", "75 min", "respiratory rate", "min", "temperature", "99", "appears mildly obese", "healthy", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "Examination of", "legs", "atrophic changes", "diminished pedal", "measure", "ankle brachial index", "0", "following", "most appropriate initial treatment"]}
{"question": "A 27-year-old man presents to his primary care physician with worsening cough and asthma. The patient reports that he was in his usual state of health until 1 month ago, when he developed a cold. Since then his cold has improved, but he continues to have a cough and worsening asthma symptoms. He says that he has been using his rescue inhaler 3 times a day with little improvement. He is studying for an accounting exam and states that his asthma is keeping him up at night and making it hard for him to focus during the day. The patient admits to smoking tobacco. His smoking has increased from a half pack per day since he was 17 years old to 1 pack per day during the past month to cope with the stress of his exam. The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 75/min, and respirations are 15/min with an oxygen saturation of 97% on room air. Physically examination is notable for mild expiratory wheezes bilaterally. Labs are obtained, as shown below:\n\nSerum:\nNa+: 144 mEq/L\nCl-: 95 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 23 mEq/L\nUrea nitrogen: 24 mg/dL\nGlucose: 100 mg/dL\nCreatinine: 1.6 mg/dL\n\nLeukocyte count and differential:\nLeukocyte count: 13,000/mm^3\nSegmented neutrophils: 63%\nEosinophils: 15%\nBasophils: < 1%\nLymphocytes: 20%\nMonocytes: 1.3%\nHemoglobin: 13.5 g/dL\nHematocrit: 50%\nPlatelets: 200,000/mm^3\n\nUrinalysis reveals proteinuria and microscopic hematuria. Which of the following is associated with the patient’s most likely diagnosis?", "answer": "p-ANCA levels", "options": {"A": "c-ANCA levels", "B": "Hepatitis B surface antigen", "C": "IgA deposits", "D": "p-ANCA levels", "E": "Smoking"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "primary care physician", "worsening cough", "asthma", "patient reports", "usual state of health", "1 month", "cold", "Since then", "cold", "improved", "to", "cough", "worsening asthma symptoms", "using", "inhaler", "times", "day", "little", "studying", "exam", "states", "asthma", "keeping", "night", "making", "hard", "focus", "day", "patient", "smoking tobacco", "smoking", "increased", "half pack", "day", "old", "day", "past month to", "stress", "exam", "patients temperature", "blood pressure", "74 mmHg", "pulse", "75 min", "respirations", "min", "97", "room air", "notable", "mild expiratory wheezes", "Labs", "obtained", "Serum", "Na", "mEq/L", "95 mEq/L K", "4", "mEq/L HCO3", "23 mEq/L Urea nitrogen", "mg/dL Glucose", "100 mg/dL Creatinine", "1.6 mg/dL", "Leukocyte count", "differential", "Leukocyte count", "mm", "Segmented neutrophils", "63", "Eosinophils", "Basophils", "1", "Lymphocytes", "20", "1", "Hemoglobin", "g/dL Hematocrit", "50", "Platelets", "200", "mm", "Urinalysis reveals proteinuria", "microscopic hematuria", "following", "associated with", "patients", "likely diagnosis"]}
{"question": "A 25-year-old man is brought to the physician because of fatigue, lethargy, and lower leg swelling for 2 weeks. He also noticed that his urine appeared darker than usual and for the last 2 days he has passed only small amounts of urine. His temperature is 37.5°C (98.6°F), pulse is 88/min, respirations are 15/min, and blood pressure is 154/98 mm Hg. Examination shows 2+ pretibial edema bilaterally. Laboratory studies show:\nHemoglobin 10.9 g/dL\nLeukocyte count 8200/mm3\nPlatelet count 220,000/mm3\nSerum\nNa+ 137 mEq/L\nCl- 102 mEq/L\nK+ 4.8 mEq/L\nHCO3- 22 mEq/L\nGlucose 85 mg/dL\nUrea nitrogen 34 mg/dL\nCreatinine 1.4 mg/dL\nUrine\nBlood 2+\nProtein 3+\nGlucose negative\nRBC 10–12/HPF with dysmorphic features\nRBC casts numerous\nRenal biopsy specimen shows a crescent formation in the glomeruli with extracapillary cell proliferation. Which of the following is the most appropriate next step in management?\"", "answer": "Administer methylprednisolone", "options": {"A": "Administer rituximab", "B": "Administer lisinopril", "C": "Perform hemodialysis", "D": "Administer methylprednisolone", "E": "Administer cyclosporine A"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "physician", "fatigue", "lethargy", "lower leg swelling", "2 weeks", "urine appeared darker", "usual", "last 2 days", "passed only small amounts", "urine", "temperature", "98", "pulse", "88 min", "respirations", "min", "blood pressure", "98 mm Hg", "2", "edema", "Laboratory studies", "10", "g", "Platelet count", "137", "4", "mg", "Urea nitrogen", "mg", "Creatinine", "Urine", "HPF", "dysmorphic features", "casts numerous Renal biopsy specimen", "crescent formation", "glomeruli", "cell proliferation", "following", "most appropriate next step"]}
{"question": "A 54-year-old man comes to the physician because of a painful mass in his left thigh for 3 days. He underwent a left lower limb angiography for femoral artery stenosis and had a stent placed 2 weeks ago. He has peripheral artery disease, coronary artery disease, hypercholesterolemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 34 years. Current medications include enalapril, aspirin, simvastatin, metformin, and sitagliptin. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 116/72 mm Hg. Examination shows a 3-cm (1.2-in) tender, pulsatile mass in the left groin. The skin over the area of the mass shows no erythema and is cool to the touch. A loud bruit is heard on auscultation over this area. The remainder of the examination shows no abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities. Duplex ultrasonography shows an echolucent sac connected to the common femoral artery, with pulsatile and turbulent blood flow between the artery and the sac. Which of the following is the most appropriate next best step in management?", "answer": "Ultrasound-guided thrombin injection", "options": {"A": "Ultrasound-guided thrombin injection", "B": "Coil embolization", "C": "Ultrasound-guided compression", "D": "Schedule surgical repair", "E": "Covered stent implantation\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["54 year old man", "physician", "of", "painful mass", "left thigh", "3 days", "left lower limb angiography", "femoral artery stenosis", "stent", "2 weeks", "peripheral artery disease", "coronary artery disease", "hypercholesterolemia", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "years", "Current medications include enalapril", "aspirin", "simvastatin", "metformin", "sitagliptin", "temperature", "36", "pulse", "88 min", "blood pressure", "72 mm Hg", "3", "1.2", "tender", "pulsatile mass", "left", "skin", "area of", "mass", "erythema", "cool", "touch", "loud bruit", "heard", "auscultation", "area", "abnormalities", "Results", "complete blood count", "serum electrolyte", "abnormalities", "Duplex ultrasonography", "sac", "common femoral artery", "pulsatile", "turbulent blood flow", "artery", "sac", "following", "most appropriate next best step"]}
{"question": "A 57-year-old woman presents to the emergency department with acute onset vomiting, vertigo, throbbing headache, and weakness. She says that the symptoms started when she went to dinner with friends and had a drink of alcohol. Her past medical history is significant for type 2 diabetes, and she was recently started on a new medication for this disease. She says that she was warned that she might experiences these symptoms as a side effect of a new medication, but she did not realize how severe they would be. Which of the following describes the mechanism of action for the most likely diabetes drug that this patient started taking?", "answer": "Closing potassium channels", "options": {"A": "Binding to peroxisome proliferator-activating receptors", "B": "Closing potassium channels", "C": "Decreasing hepatic gluconeogenesis", "D": "Inhibiting alpha-glucosidase", "E": "Inhibiting dipeptidyl peptidase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["57 year old woman presents", "emergency department", "acute vomiting", "vertigo", "throbbing headache", "weakness", "symptoms started", "dinner", "past medical history", "significant", "type 2 diabetes", "recently started", "new medication", "disease", "symptoms", "side effect", "new medication", "not", "severe", "following", "mechanism of action", "diabetes drug", "patient started"]}
{"question": "A 58-year-old woman is brought to the emergency department for shortness of breath and chest pain. Pulmonary angiography shows a large saddle embolus in the pulmonary arteries. Emergency drug therapy is administered and she is admitted to the hospital for observation. A follow-up CT scan of the chest shortly after admission shows that the thrombus has disappeared. Five hours later, the patient is found to be lethargic with slurred speech. Physical examination shows decreased consciousness, dysarthria, and optic disc swelling bilaterally. Which of the following is the most likely cause of her neurological symptoms?", "answer": "Intracerebral hemorrhage\n\"", "options": {"A": "Acute metabolic encephalopathy", "B": "Idiopathic intracranial hypertension", "C": "Drug-induced hypotension", "D": "Embolic cerebrovascular accident", "E": "Intracerebral hemorrhage\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old woman", "brought", "emergency department", "shortness of breath", "chest pain", "Pulmonary angiography", "large saddle embolus", "pulmonary", "Emergency drug", "administered", "observation", "follow-up CT scan of", "chest", "thrombus", "Five hours later", "patient", "found to", "lethargic", "slurred speech", "decreased consciousness", "dysarthria", "optic disc swelling", "following", "most likely cause", "neurological symptoms"]}
{"question": "A 6-day-old infant who was born via uncomplicated vaginal delivery at 39 weeks of gestation is brought to the family physician for poor feeding. The mother received adequate prenatal care throughout the pregnancy, and has no medical conditions. On physical exam, the infant's temperature is 36.5°C (97.7°F), blood pressure is 70/45 mmHg, pulse is 170/min, and respirations are 40/min. The infant has dry mucous membranes, capillary refill of 4 seconds, and a depressed anterior fontanelle. No abdominal masses are noted. Genital exam shows enlargement of the clitoris with fusion of the labioscrotal folds. Serum chemistry is remarkable for hyponatremia and hyperkalemia. The infant's karyotype is 46,XX. Which of the following findings are most likely to be discovered upon further workup?", "answer": "Increased sex hormones, increased 17-hydroxyprogesterone", "options": {"A": "Increased aldosterone, decreased cortisol", "B": "Decreased aldosterone, increased 11-deoxycorticosterone", "C": "Increased sex hormones, increased 17-hydroxyprogesterone", "D": "Increased sex hormones, decreased renin activity", "E": "Decreased cortisol, decreased sex hormones"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["day old infant", "born", "uncomplicated vaginal", "weeks of gestation", "brought", "family physician", "poor feeding", "received adequate prenatal", "pregnancy", "medical conditions", "infant's temperature", "36", "97", "blood pressure", "70", "mmHg", "pulse", "min", "respirations", "40 min", "infant", "dry mucous membranes", "capillary refill", "seconds", "depressed anterior", "abdominal masses", "noted", "Genital exam", "enlargement", "clitoris", "fusion", "folds", "Serum chemistry", "hyponatremia", "hyperkalemia", "infant's karyotype", "XX", "following findings", "to", "further workup"]}
{"question": "A 24-year-old man is brought to the physician because of increasing pain and swelling of the left knee for 2 months. The pain has awoken him from his sleep on multiple occasions. He tried ibuprofen but has had no relief of his symptoms. There is no family or personal history of serious illness. Vital signs are within normal limits. On examination, the left knee is mildly swollen and tender; range of motion is limited by pain. An x-ray of the left knee is shown. Which of the following is the most likely diagnosis?", "answer": "Osteoclastoma", "options": {"A": "Chondrosarcoma", "B": "Fibrous dysplasia", "C": "Aneurysmal bone cyst", "D": "Osteoclastoma", "E": "Ewing sarcoma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "physician", "increasing pain", "swelling of", "left knee", "2 months", "pain", "awoken", "sleep", "multiple occasions", "ibuprofen", "personal history", "serious", "Vital", "normal limits", "left knee", "mildly swollen", "tender", "range of motion", "limited", "pain", "x-ray of", "left knee", "following", "diagnosis"]}
{"question": "A 12-year-old boy is brought in by his parents as they are concerned about his behavior. He is constantly arguing with his parents and blatantly defying their every request. In school, he is known for being intentionally tardy and for defying his teachers. Upon further questioning of the patient you learn about some of his recent behaviors such as beginning smoking to bother his parents. You also notice that he is disrespectful towards you. You then learn that he has also gotten into weekly fights with his peers at school with no apparent cause. In addition, last week he was seen hitting one of the local neighborhood cats with a baseball bat trying to kill it. The patient lives at home with his two parents in a pre-World War II house that was recently renovated. Physical exam is unremarkable.\n\nLaboratory values are as follows:\n\nNa: 140 mmol/L\nK: 4.5 mmol/L\nCl: 100 mmol/L\nGlucose: 80 mg/dL\nCa: 10 mmol/L\nMg: 3 mEq/L\nCr: 0.8 mg/dL\nBUN: 10 mg/dL\nSerum lead: < .01 µg/dL\nHb: 15 g/dL\nHct: 45%\nMCV: 95\nUrine toxicology: negative\n\nAs the patient leaves the office you notice him stealing all of the candy from the office candy bowl. The patient seems unconcerned about his behavior overall. Which of the following statements is most likely to be true in this patient?", "answer": "The patient's symptoms could progress to antisocial personality disorder", "options": {"A": "This patient will likely function normally despite continuing to defy authority figures", "B": "This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood", "C": "Environmental exposures are likely causing this patient's behavior", "D": "The patient's symptoms could progress to antisocial personality disorder", "E": "Strong D2 antagonists are first-line pharmacotherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "behavior", "constantly", "In school", "known", "tardy", "teachers", "further", "patient", "recent behaviors", "beginning smoking to", "then", "gotten", "weekly", "school", "cause", "addition", "last week", "seen hitting one", "local neighborhood cats", "baseball bat", "to kill", "patient lives at home", "two", "pre", "house", "recently", "unremarkable", "Laboratory values", "follows", "Na", "mmol/L K", "4.5 mmol/L", "100 mmol/L Glucose", "80 mg/dL Ca", "10 mmol/L Mg", "3 mEq/L Cr", "0.8 mg dL BUN", "10 mg/dL Serum lead", "g/dL Hb", "g/dL Hct", "MCV", "95 Urine toxicology", "negative", "patient", "office", "office", "patient", "behavior overall", "following", "to", "true", "patient"]}
{"question": "A 24-hour-old girl is found to be cyanotic in the newborn nursery. She was born via spontaneous vaginal delivery at 38 weeks gestation to a gravida 1, para 0 healthy mother who received routine prenatal care. The patient is small for her gestational age. She manifests lower-extremity cyanosis along with a mesh-like mass on the back of her neck. Her vital signs are: pulse, 150/min; respirations, 48/min; and blood pressure, 120/80 mm Hg in the right arm, 124/82 mm Hg in the left arm, 80/40 mm Hg in the right leg, and 85/45 mm Hg in the left leg. Femoral pulses are 1+ and delayed. Cardiac examination shows a continuous murmur in the interscapular area. Auscultation of the lung reveals faint crackles at the base of the lung fields bilaterally. Which of the following is the most appropriate next step in management?", "answer": "Administration of alprostadil", "options": {"A": "Administration of alprostadil", "B": "Arteriogram", "C": "Echocardiography", "D": "Indomethacin", "E": "Lower extremity Doppler"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["hour old girl", "found to", "cyanotic", "newborn nursery", "born", "spontaneous vaginal delivery", "weeks gestation", "gravida 1", "para 0 healthy", "received routine prenatal care", "patient", "small for", "gestational age", "manifests lower-extremity cyanosis", "mesh", "mass", "the back of", "neck", "vital signs", "pulse", "min", "respirations", "48 min", "blood pressure", "80 mm Hg", "right arm", "mm Hg", "left arm", "80 40 mm Hg", "right leg", "85", "mm Hg", "left leg", "Femoral pulses", "1", "delayed", "continuous murmur", "area", "Auscultation", "lung reveals faint crackles", "the base of", "lung fields", "following", "most appropriate next step"]}
{"question": "A 5-year-old boy is brought to the emergency department for right elbow swelling and pain 45 minutes after he fell while playing on the monkey bars during recess. He has been unable to move his right elbow since the fall. Examination shows ecchymosis, swelling, and tenderness of the right elbow; range of motion is limited by pain. The remainder of the examination shows no abnormalities. An x-ray of the right arm is shown. Which of the following is the most likely complication of this patient's injury?", "answer": "Absent radial pulse", "options": {"A": "Polymicrobial infection", "B": "Absent radial pulse", "C": "Impaired extension of the wrist and hand", "D": "Avascular necrosis of the humeral head", "E": "Adhesive capsulitis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "right", "pain 45 minutes", "fell", "playing", "bars", "unable to move", "right elbow", "fall", "ecchymosis", "swelling", "tenderness", "right", "range of motion", "limited", "pain", "abnormalities", "x-ray", "right arm", "following", "complication of", "patient's injury"]}
{"question": "A 3-month-old boy presents for routine health maintenance. The patient has coarse facial features and stiff joint movements with restricted passive and active range of motion. He also has problems following objects with his eyes and seems not to focus on anything. On physical examination, the corneas are clouded, and the patient fails to meet any 3-month developmental milestones. Genetic testing and histopathology are performed and reveal failure of a cellular structure to phosphorylate mannose residues on glycoproteins. An electron microscopy image of one of this patient’s cells is shown. Which of the following is the most likely diagnosis in this patient?", "answer": "Inclusion cell disease", "options": {"A": "Kartagener syndrome", "B": "Adrenoleukodystrophy", "C": "Inclusion cell disease", "D": "Diamond-Blackfan anemia", "E": "Tay-Sachs disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 month old boy presents", "routine", "patient", "coarse facial features", "stiff joint movements", "restricted passive", "active range of motion", "following", "eyes", "not", "focus", "corneas", "clouded", "patient fails to", "3 month", "Genetic testing", "histopathology", "performed", "reveal failure", "cellular to", "mannose residues", "glycoproteins", "electron microscopy", "one", "patients cells", "following", "diagnosis", "patient"]}
{"question": "A 36-year-old woman comes to the physician for a routine gynecological examination. She feels well. Menses occur with normal flow at regular 28-day intervals and last for 3 to 5 days. Her last menstrual period was 20 days ago. She is sexually active with one male partner and they use condoms inconsistently. Her sister was diagnosed with breast cancer at the age of 40 years. She drinks a glass of wine occasionally with dinner and has smoked 10 cigarettes daily for the past 15 years. The patient's vital signs are within normal limits. Physical examination including a complete pelvic exam shows no abnormalities. Urine pregnancy test is negative. A Pap smear shows atypical glandular cells. Which of the following is the most appropriate next step in management?", "answer": "Perform colposcopy with endocervical and endometrial sampling", "options": {"A": "Repeat cervical cytology at 12 months", "B": "Perform colposcopy with endocervical and endometrial sampling", "C": "Perform a diagnostic loop electrosurgical excision", "D": "Perform colposcopy and cytology every 6 months for 2 years", "E": "Perform colposcopy with endocervical sampling"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["36 year old woman", "physician", "routine gynecological examination", "well", "Menses occur", "normal", "regular", "day intervals", "last", "5 days", "last menstrual period", "20 days", "sexually active", "one male", "use condoms", "diagnosed", "breast cancer", "age", "40", "glass", "occasionally", "dinner", "smoked", "cigarettes daily", "past", "patient's vital signs", "normal", "Physical examination including", "complete pelvic exam", "abnormalities", "Urine pregnancy test", "negative", "Pap smear", "following", "most appropriate next step"]}
{"question": "A 59-year-old male presents to his primary care physician complaining of muscle weakness. Approximately 6 months ago, he started to develop gradually worsening right arm weakness that progressed to difficulty walking about three months ago. His past medical history is notable for a transient ischemic attack, hypertension, hyperlipidemia, and diabetes mellitus. He takes aspirin, lisinopril, atorvastatin, metformin, and glyburide. He does not smoke and he drinks alcohol occasionally. Physical examination reveals 4/5 strength in right shoulder abduction and right arm flexion. A tremor is noted in the right hand. Strength is 5/5 throughout the left upper extremity. Patellar reflexes are 3+ bilaterally. Sensation to touch and vibration is intact in the bilateral upper and lower extremities. Tongue fasciculations are noted. Which of the following is the most appropriate treatment in this patient?", "answer": "Riluzole", "options": {"A": "Natalizumab", "B": "Selegeline", "C": "Bromocriptine", "D": "Benztropine", "E": "Riluzole"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["59 year old male presents", "primary care physician", "muscle", "Approximately", "months", "started to", "worsening right", "progressed", "difficulty walking", "three months", "past medical history", "notable", "transient ischemic attack", "hypertension", "hyperlipidemia", "diabetes mellitus", "aspirin", "lisinopril", "atorvastatin", "metformin", "glyburide", "not smoke", "alcohol occasionally", "reveals 4/5 strength", "right shoulder abduction", "right", "tremor", "noted", "right", "Strength", "5/5", "left upper extremity", "Patellar reflexes", "3", "Sensation", "touch", "vibration", "intact", "bilateral upper", "lower extremities", "Tongue fasciculations", "noted", "following", "most appropriate", "patient"]}
{"question": "A 65-year-old man presents to the emergency department for sudden weakness. The patient states that he was at home enjoying his morning coffee when his symptoms began. He says that his left arm suddenly felt very odd and weak thus prompting him to come to the ED. The patient has a past medical history of diabetes, COPD, hypertension, anxiety, alcohol abuse, and PTSD. He recently fell off a horse while horseback riding but claims to not have experienced any significant injuries. He typically drinks 5-7 drinks per day and his last drink was yesterday afternoon. His current medications include insulin, metformin, atorvastatin, lisinopril, albuterol, and fluoxetine. His temperature is 99.5°F (37.5°C), blood pressure is 177/118 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 93% on room air. On physical exam, you note an elderly man who is mildly confused. Cardiopulmonary exam demonstrates bilateral expiratory wheezes and a systolic murmur along the right upper sternal border that radiates to the carotids. Neurological exam reveals cranial nerves II-XII as grossly intact with finger-nose exam mildly abnormal on the left and heel-shin exam within normal limits. The patient has 5/5 strength in his right arm and 3/5 strength in his left arm. The patient struggles to manipulate objects such as a pen with his left hand. The patient is given a dose of diazepam and started on IV fluids. Which of the following is the most likely diagnosis in this patient?", "answer": "Lipohyalinosis", "options": {"A": "Berry aneurysm rupture", "B": "Bridging vein tear", "C": "Cerebellar bleeding", "D": "Hypertensive encephalopathy", "E": "Lipohyalinosis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["65 year old man presents", "emergency department", "sudden weakness", "patient states", "at home", "morning", "symptoms began", "left arm", "very odd", "weak", "prompting", "to", "patient", "past medical diabetes", "COPD", "hypertension", "anxiety", "alcohol abuse", "PTSD", "recently fell", "to not", "significant injuries", "5 7", "day", "last", "afternoon", "current medications include insulin", "metformin", "atorvastatin", "lisinopril", "albuterol", "fluoxetine", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "note", "elderly man", "mildly confused", "Cardiopulmonary exam", "bilateral expiratory wheezes", "systolic murmur", "right upper sternal border", "radiates", "carotids", "Neurological exam reveals cranial nerves II XII", "intact", "finger nose exam mildly abnormal", "left", "heel shin exam", "normal limits", "patient", "5/5 strength", "right arm", "3/5 strength", "left arm", "patient", "to manipulate", "pen", "left hand", "patient", "given", "dose", "diazepam", "started", "following", "diagnosis", "patient"]}
{"question": "An 18-year-old male was brought to the emergency room after he caused an accident by driving at a slow speed as he was entering the freeway. He appears to have sustained no major injuries just minor scratches and lacerations, but appears to be paranoid, anxious, and is complaining of thirst. He has conjunctival injection and has slowed reflexes. A police officer explained that he had confiscated contraband from the vehicle of the male. Which of the following substances was most likely used by the male?", "answer": "Marijuana", "options": {"A": "Phencyclidine (PCP)", "B": "Cocaine", "C": "Heroin", "D": "Alprazolam", "E": "Marijuana"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old male", "brought", "emergency room", "caused", "slow speed", "entering", "freeway", "appears to", "sustained", "major injuries", "minor scratches", "lacerations", "appears to", "anxious", "thirst", "conjunctival injection", "slowed reflexes", "police officer", "vehicle", "male", "following", "most likely used by", "male"]}
{"question": "A 37-year-old woman presents to the emergency department with right upper quadrant (RUQ) pain. She reports that the pain is not new and usually starts within half an hour of eating a meal. The pain has been previously diagnosed as biliary colic, and she underwent a cholecystectomy three months ago for symptomatic biliary colic. Her liver reportedly looked normal at that time. The patient dates the onset of these episodes to shortly after she underwent a sleeve gastrectomy several years ago, and the episodes were more severe immediately following that surgery. Her postsurgical course was otherwise uncomplicated, and she has lost fifty pounds since then. She has a past medical history of hypertension, hyperlipidemia, diabetes mellitus, osteoarthritis, and obesity. She denies alcohol or tobacco use. Her home medications are hydrochlorothiazide, enalapril, atorvastatin, and vitamin supplements. RUQ ultrasound reveals a surgically absent gallbladder and a dilated common bile duct without evidence of stones. Magnetic resonance cholangiopancreatography (MRCP) shows no evidence of biliary compression or obstruction, and endoscopic retrograde cholangiopancreatography (ERCP) shows no evidence of biliary stones or sludge. Laboratory tests are performed which reveal the following:\n\nALT: 47 U/L\nAST: 56 U/L\nAlkaline phosphatase: 165 U/L\nTotal bilirubin: 1.6 g/dL\nAmylase: 135 U/L\nLipase: 160 U/L\n\nWhich of the following is definitive treatment of this patient's condition?", "answer": "Sphincterotomy", "options": {"A": "Pancreaticoduodenectomy", "B": "Biliary stent", "C": "Pancreatic enzyme replacement", "D": "Sphincterotomy", "E": "Surgical revascularization"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "right upper quadrant", "pain", "reports", "pain", "not new", "usually starts", "half", "hour", "eating", "pain", "diagnosed", "biliary colic", "cholecystectomy three months", "symptomatic biliary colic", "liver", "looked normal", "time", "patient dates", "onset of", "episodes", "sleeve gastrectomy", "years", "episodes", "more severe immediately following", "surgery", "course", "uncomplicated", "lost fifty pounds since then", "past medical", "hyperlipidemia", "diabetes mellitus", "osteoarthritis", "obesity", "alcohol", "tobacco use", "home medications", "hydrochlorothiazide", "enalapril", "atorvastatin", "RUQ ultrasound reveals", "surgically absent gallbladder", "dilated common bile duct", "stones", "Magnetic resonance cholangiopancreatography", "biliary compression", "obstruction", "endoscopic retrograde cholangiopancreatography", "biliary stones", "sludge", "Laboratory tests", "performed", "reveal", "following", "ALT", "U/L AST", "U/L Alkaline phosphatase", "U/L Total bilirubin", "1.6 g/dL Amylase", "U/L Lipase", "U/L", "following", "definitive treatment", "patient's condition"]}
{"question": "A 14-year-old male presents to the emergency department with altered mental status. His friends who accompanied him said that he complained of abdominal pain while camping. They denied his consumption of anything unusual from the wilderness, or any vomiting or diarrhea. His temperature is 100.5°F (38.1°C), blood pressure is 95/55 mmHg, pulse is 130/min, and respirations are 30/min. His pupils are equal and reactive to light bilaterally. The remainder of the physical exam is unremarkable. His basic metabolic panel is displayed below:\n\nSerum:\nNa+: 116 mEq/L\nCl-: 70 mEq/L\nK+: 4.0 mEq/L\nHCO3-: 2 mEq/L\nBUN: 50 mg/dL\nGlucose: 1010 mg/dL\nCreatinine: 1.2 mg/dL\n\nWhile the remainder of his labs are pending, the patient becomes bradypneic and is intubated. His ventilator is adjusted to volume control assist-control with a respiratory rate (RR) of 14/min, tidal volume (Vt) of 350 mL, positive end-expiratory pressure (PEEP) of 5 cm H2O, and fractional inspired oxygen (FiO2) of 40%. His height is 5 feet 5 inches. Intravenous fluids and additional medical therapy are administered. An arterial blood gas obtained after 30 minutes on these settings shows the following:\n\npH: 7.05\npCO2 :40 mmHg\npO2: 150 mmHg\nSaO2: 98%\n\nWhat is the best next step in management?", "answer": "Increase respiratory rate and tidal volume", "options": {"A": "Increase respiratory rate", "B": "Increase respiratory rate and tidal volume", "C": "Increase tidal volume", "D": "Increase tidal volume and positive end-expiratory pressure", "E": "Increase positive end-expiratory pressure"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male presents", "emergency department", "altered mental status", "abdominal pain", "denied", "consumption", "unusual", "wilderness", "vomiting", "diarrhea", "temperature", "100", "blood pressure", "95", "mmHg", "pulse", "min", "respirations", "30/min", "pupils", "equal", "reactive to light", "unremarkable", "basic metabolic panel", "displayed", "Serum", "Na", "mEq/L", "70 mEq/L K", "4 0 mEq/L HCO3", "2 mEq/L", "50 mg/dL Glucose", "mg/dL Creatinine", "1.2 mg/dL", "labs", "patient", "bradypneic", "intubated", "ventilator", "adjusted", "volume control assist control", "respiratory", "min", "tidal volume", "Vt", "350 mL", "positive end-expiratory pressure", "cm H2O", "fractional inspired oxygen", "of 40", "height", "5 feet 5 inches", "additional medical", "administered", "arterial blood gas obtained", "30 minutes", "settings", "following", "pH", "pCO2", "40 mmHg pO2", "mmHg", "best next step"]}
{"question": "A 50-year-old woman comes to the physician because of multiple, ulcerative skin lesions that occur over various parts of her body. She reports that these rashes first appeared 6 months ago. They occur episodically and usually start as reddish spots, which then expand in size and ulcerate over the next ten days. They resolve spontaneously and reappear at another location a few days later. Over the past 6 months, has had multiple episodes of diarrhea. She has lost 8 kg weight over this period and feels tired constantly. She has not had fever. She was treated for deep venous thrombosis 3 years ago, and took medication for it for 6 months after the episode. Her vital signs are within normal limits. She appears pale and has multiple, tender, ulcerative skin lesions on her legs and buttocks. Her hemoglobin is 9.6 mg/dL, mean corpuscular volume is 82 μm3, and fingerstick blood glucose concentration is 154 mg/dL. Her serum glucagon is elevated. Abdominal ultrasonography reveals a 5.6 cm, well-demarcated, hypoechoic mass in the pancreatic body and multiple, small masses in the liver of variable echogenicity. Which of the following is the most appropriate next step in management of this patient?", "answer": "Administration of octreotide", "options": {"A": "Measurement of serum zinc levels", "B": "Endoscopic ultrasonongraphy", "C": "Obtaining cancer antigen 19-9 levels", "D": "Administration of octreotide", "E": "Measurement of glycated hemoglobin\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["50 year old woman", "physician", "multiple", "ulcerative skin lesions", "occur", "various parts of", "body", "reports", "rashes first appeared", "months", "occur", "usually start", "spots", "then expand", "size", "ulcerate", "next", "location", "few days later", "past 6 months", "multiple episodes of diarrhea", "lost", "kg weight", "period", "tired constantly", "not", "fever", "treated", "deep venous thrombosis", "years", "medication", "months", "episode", "vital signs", "normal limits", "appears pale", "multiple", "tender", "ulcerative lesions", "legs", "buttocks", "hemoglobin", "mg/dL", "mean corpuscular volume", "m3", "fingerstick blood glucose concentration", "mg/dL", "serum glucagon", "elevated", "Abdominal ultrasonography reveals", "5.6", "well", "mass", "pancreatic", "multiple", "small masses", "liver", "variable echogenicity", "following", "most appropriate next step", "patient"]}
{"question": "A 52-year-old female presents to her primary care physician for medical evaluation prior to an elective hip replacement surgery. She has hypertension and diabetes, both of which are well controlled on oral medications. She also admits to occasional use of recreational injection drugs so a panel of serologies are obtained. Based on the results, the patient is found to have had a previous infection with hepatitis B from which she has fully recovered. Which of the following is a characteristic of the immunoglobulin subtype that most likely binds to hepatitis B core antigen in this patient?", "answer": "It exists as a monomer", "options": {"A": "It exists as a monomer", "B": "It exists as a dimer", "C": "It exists as a pentamer", "D": "It activates mast cells", "E": "It is only activated by multivalent immunogens"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female presents", "primary care physician", "prior to", "elective hip replacement surgery", "hypertension", "diabetes", "well controlled", "oral medications", "occasional use of recreational injection drugs", "panel", "serologies", "obtained", "Based", "results", "patient", "found to", "a previous infection", "hepatitis", "recovered", "following", "a characteristic", "immunoglobulin", "most likely", "patient"]}
{"question": "A 40-year-old woman, gravida 2, para 2, comes to the physician because of fatigue, nausea, joint pain, and mild flank pain for 2 months. She has refractory acid reflux and antral and duodenal peptic ulcers for which she takes omeprazole. She also has chronic, foul-smelling, light-colored diarrhea. Five years ago she was successfully treated for infertility with bromocriptine. She reports recently feeling sad and unmotivated at work. She does not smoke or drink alcohol. She is 175 cm (5 ft 9 in) tall and weighs 100 kg (220 lb); BMI is 32.7 kg/m2. Her temperature is 37°C (98.8°F), pulse is 78/min, and blood pressure is 150/90 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is moderately distended and diffusely tender to palpation. There is mild costovertebral angle tenderness. Her serum calcium concentration is 12 mg/dL, phosphorus concentration is 2 mg/dL, and parathyroid hormone level is 900 pg/mL. Abdominal ultrasound shows mobile echogenic foci with acoustic shadowing in her ureteropelvic junctions bilaterally. A mutation in which of the following genes is most likely present in this patient?", "answer": "MEN1", "options": {"A": "NF2", "B": "VHL", "C": "C-Kit", "D": "RET", "E": "MEN1"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "gravida 2", "para 2", "physician", "fatigue", "nausea", "joint pain", "mild flank", "months", "refractory acid reflux", "antral", "duodenal peptic ulcers", "omeprazole", "chronic", "smelling", "light-colored diarrhea", "Five years", "treated", "infertility", "bromocriptine", "reports recently", "not smoke", "5 ft 9", "tall", "100 kg", "BMI", "kg/m2", "temperature", "98", "pulse", "min", "blood pressure", "90 mm Hg", "Cardiopulmonary", "abnormalities", "abdomen", "moderately distended", "tender", "palpation", "mild costovertebral angle tenderness", "serum concentration", "mg/dL", "phosphorus concentration", "2 mg/dL", "parathyroid hormone level", "900 pg/mL", "Abdominal ultrasound", "mobile echogenic foci", "acoustic shadowing", "ureteropelvic junctions", "following", "most likely present", "patient"]}
{"question": "A 45-year-old woman comes to the physician because of multiple episodes of dizziness over the past 3 months. Episodes last between 20 minutes and 1 hour. During the episodes she experiences the sudden onset of spinning sensations and imbalance, associated with a ringing in her left ear. She also reports progressive left-sided hearing loss and is unable to follow conversations in noisy surroundings. She has had an upper respiratory infection for the past 5 days, which is being treated with erythromycin. She has been otherwise healthy. Her vital signs are within normal limits. Examination shows no abnormalities. Pure tone audiometry shows a combined low- and high-frequency sensory loss of the left ear with normal hearing in the mid frequencies. Which of the following is the most appropriate initial step in management?", "answer": "Reduce caffeine intake", "options": {"A": "Reduce caffeine intake", "B": "Begin topiramate therapy", "C": "Perform Epley maneuver", "D": "Discontinue erythromycin", "E": "Begin fluoxetine therapy\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "of multiple episodes", "dizziness", "past 3 months", "Episodes last", "20 minutes", "1 hour", "episodes", "sudden onset", "spinning sensations", "imbalance", "associated with", "ringing", "left ear", "reports progressive left-sided hearing loss", "unable to follow", "surroundings", "upper respiratory infection", "past 5 days", "treated with erythromycin", "healthy", "vital signs", "normal limits", "abnormalities", "Pure tone audiometry", "combined low", "high-frequency sensory loss of", "left ear", "normal hearing", "frequencies", "following", "most appropriate initial step"]}
{"question": "A 23-year-old woman comes to the emergency department for increasing abdominal pain and confusion for 3 days. The pain is constant and she describes it as 8 out of 10 in intensity. She has the strong feeling that she is being watched. She has not had a bowel movement for 2 days. She began experiencing tingling in parts of her lower extremities 4 hours ago. She consumed a large number of alcoholic beverages prior to the onset of the abdominal pain. Her temperature is 38°C (100.8°F), pulse is 113/min, and blood pressure is 148/88 mm Hg. She appears distracted and admits to hearing whispering intermittently during the examination, which shows a distended abdomen and mild tenderness to palpation diffusely. There is no guarding or rebound tenderness present. Bowel sounds are decreased. There is weakness of the iliopsoas and hamstring muscles. Sensation is decreased over the lower extremities. Deep tendon reflexes are 2+ in the lower extremities. Mental status examination shows she is oriented only to person and place. A complete blood count and serum concentrations of electrolytes, glucose, creatinine are within the reference range. Which of the following is the most appropriate next step in management?", "answer": "Hemin therapy", "options": {"A": "Chlordiazepoxide", "B": "Hemin therapy", "C": "Haloperidol therapy", "D": "Chloroquine", "E": "Glucose"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "emergency department", "increasing abdominal pain", "confusion", "3 days", "pain", "constant", "out", "10", "intensity", "strong", "not", "bowel movement", "2 days", "began", "tingling", "parts of", "lower extremities", "hours", "large number", "prior to", "onset", "abdominal", "temperature", "100", "pulse", "min", "blood pressure", "88 mm Hg", "appears distracted", "hearing whispering", "distended abdomen", "mild tenderness", "palpation", "guarding", "rebound tenderness present", "Bowel sounds", "decreased", "weakness", "iliopsoas", "hamstring muscles", "Sensation", "decreased", "lower extremities", "Deep tendon reflexes", "2", "lower extremities", "Mental status", "oriented only", "place", "complete blood count", "serum", "electrolytes", "glucose", "creatinine", "reference range", "following", "most appropriate next step"]}
{"question": "A 4-year-old boy is brought to his pediatrician by his mother for a physical exam before summer camp. They have no complaints or concerns at this time. He was born at 37 weeks gestation by cesarean delivery. The delivery was complicated by an omphalocele and macrosomia. During infancy and into early childhood, he struggled to breathe and eat due to an enlarged tongue. Growth and development were mostly normal with mild uneven growth of his body. He has one uncle that had similar symptoms and is alive and well. The child is up to date on all vaccines and is meeting developmental goals. He enjoys school and playing with his friends. His heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 36.9°C (98.4°F). Overall the child appears healthy. Physical exam findings include known hemihypertrophy of the right side along with a mildly enlarged tongue. This patient is at increased risk of developing which of the following?", "answer": "Wilms tumor", "options": {"A": "Scoliosis", "B": "Alzheimer's disease", "C": "Diabetes mellitus", "D": "Wilms tumor", "E": "Sudden infant death syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "brought", "pediatrician", "summer camp", "complaints", "time", "born", "weeks gestation", "cesarean delivery", "delivery", "complicated", "omphalocele", "macrosomia", "infancy", "early childhood", "to", "eat due to", "enlarged tongue", "Growth", "development", "mostly normal", "mild", "growth", "body", "one", "similar symptoms", "alive", "well", "child", "date", "vaccines", "developmental", "school", "playing", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "36", "98", "Overall", "child appears healthy", "Physical exam findings include known hemihypertrophy", "right side", "mildly enlarged tongue", "patient", "increased risk", "following"]}
{"question": "A 72-year-old man is brought to your office by his daughter due to concern over recent behavioral changes. Over the last several months he has had increasing difficulty with remembering recent events. She mentions that he is embarrassed due to a new inability to control urination. His medical history is significant for hypertension and insomnia. His medications include alprazolam and hydrochlorothiazide. On physical exam, he is oriented to time and place and thinks his daughter is exaggerating; however, when asked to recall 3 items, the patient refuses to continue the mental status exam. He has 5/5 strength bilaterally. He walks in short strides by sliding his feet across the floor. Which of the following would you expect to see in his patient?", "answer": "Distortion of corona radiata fibers", "options": {"A": "Distortion of corona radiata fibers", "B": "Atrophy of the caudate and putamen", "C": "Atrophy of the subthalamic nucleus", "D": "Depigmentation of the substantia nigra pars compacta", "E": "Convex hemorrhage that does not cross suture lines"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old man", "brought", "office", "due to", "recent behavioral changes", "last", "months", "increasing difficulty", "recent", "embarrassed due to", "new", "to control urination", "medical history", "significant", "hypertension", "insomnia", "medications include alprazolam", "hydrochlorothiazide", "oriented to time", "place", "exaggerating", "to", "3", "patient", "to", "mental status exam", "5/5 strength", "walks", "short", "sliding", "feet", "floor", "following", "to see", "patient"]}
{"question": "An 11-year-old boy is brought to the pediatrician by his mother for vomiting. The patient has been vomiting for the past week, and his symptoms have not been improving. His symptoms are worse in the morning and tend to improve throughout the day. The patient also complains of occasional headaches and had diarrhea several days ago. The patient eats a balanced diet and does not drink soda or juice. The patient's brothers both had diarrhea recently that resolved spontaneously. His temperature is 99.5°F (37.5°C), blood pressure is 80/45 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. On physical exam, the patient appears to be in no acute distress. Cardiopulmonary exam reveals a minor flow murmur. Neurological exam reveals cranial nerves II-XII as grossly intact with mild narrowing of the patient's visual fields. The patient's gait is stable, and he is able to jump up and down. Which of the following is the most likely direct cause of this patient's presentation?", "answer": "Remnant of Rathke's pouch", "options": {"A": "Non-enveloped, (+) ssRNA virus", "B": "Gram-negative microaerophilic bacteria", "C": "Gram-positive enterotoxin", "D": "Intracerebellar mass", "E": "Remnant of Rathke's pouch"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "pediatrician", "vomiting", "patient", "vomiting", "past week", "symptoms", "not", "improving", "symptoms", "worse", "morning", "to", "day", "patient", "occasional headaches", "diarrhea", "days", "patient eats", "balanced diet", "not", "patient's", "diarrhea recently", "resolved", "temperature", "99", "blood pressure", "80", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient appears to", "acute distress", "Cardiopulmonary exam reveals", "minor flow murmur", "Neurological exam reveals cranial nerves II XII", "intact", "mild narrowing", "patient's visual fields", "patient's gait", "stable", "able to jump", "down", "following", "direct cause", "patient's"]}
{"question": "A 35-year-old man is brought to the emergency department by his wife because of a 1-week history of progressive confusion, myalgia, and nausea. His wife says that he first reported headaches and fatigue 10 days ago, and since then “he has not been himself”. He has refused to drink any liquids for the last day. Two months ago, he helped his neighbor remove a raccoon's den from her backyard. He appears agitated. His temperature is 100.8°F (38.2°C). Examination shows excessive drooling. Muscle tone and deep tendon reflexes are increased bilaterally. Administration of which of the following is most likely to have prevented this patient's condition?", "answer": "Chemically-inactivated virus", "options": {"A": "RNA-dependent DNA polymerase inhibitor", "B": "Chemically-inactivated virus", "C": "Live attenuated vaccine", "D": "Immunoglobulin against a bacterial protein", "E": "Inosine monophosphate dehydrogenase inhibitor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man", "brought", "emergency department", "of", "1-week history", "progressive confusion", "myalgia", "nausea", "first reported headaches", "fatigue 10 days", "since then", "not", "to", "day", "Two months", "helped", "remove", "den", "backyard", "appears agitated", "temperature", "100", "excessive drooling", "Muscle tone", "deep tendon reflexes", "increased", "Administration", "following", "to", "prevented", "patient's condition"]}
{"question": "A 29-year-old patient presents to her primary care physician with persistent amenorrhea and inability to breastfeed over the last 5 months. She says that she has also been very tired since her baby was born and this fatigue was accompanied by an inability to deal with cold weather despite having no problem with cold prior to becoming pregnant. She has gained an additional 5 pounds since delivery. Review of her hospital records reveals that she had a vaginal delivery that was complicated by severe hemorrhage and episodes of hypotension. Which of the following hormone levels is most likely to be normal in this patient?", "answer": "Aldosterone", "options": {"A": "Follicle-stimulating hormone (FSH)", "B": "Prolactin", "C": "Thyroid hormone", "D": "Cortisol", "E": "Aldosterone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old patient presents", "primary care physician", "persistent amenorrhea", "to breastfeed", "months", "very tired", "baby", "born", "fatigue", "to", "problem", "cold", "pregnant", "gained", "additional", "pounds", "delivery", "Review", "hospital records reveals", "vaginal delivery", "complicated", "severe hemorrhage", "episodes of hypotension", "following hormone levels", "to", "normal", "patient"]}
{"question": "A 35-year-old G2P1 delivers a boy in the 40th week of gestation. The pregnancy was uncomplicated. The newborn had Apgar scores of 7 and 9 at the 1st and 5th minutes, respectively. On physical examination, the newborn is noted to have a left-sided cleft lip. The hard palate and nose are normal. Which of the following statements describes the cause of the abnormality?", "answer": "Failure of fusion of the left maxillary prominence and the medial nasal process of the frontonasal prominence", "options": {"A": "Failure of development of the first pharyngeal arch", "B": "Failure of fusion of the left maxillary prominence and the medial nasal process of the frontonasal prominence", "C": "Partial resorption of the first pharyngeal arch", "D": "Failure of fusion of the left maxillary prominence and the lateral nasal process of the frontonasal prominence", "E": "Failure of development of the left maxillary prominence"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old", "delivers", "boy", "week", "gestation", "pregnancy", "uncomplicated", "newborn", "Apgar scores", "7", "1st", "5th minutes", "newborn", "noted to", "left sided cleft lip", "hard palate", "nose", "normal", "following", "cause", "abnormality"]}
{"question": "A 17-year-old male is diagnosed with acne vulgaris during a visit to a dermatologist. He is prescribed a therapy that is a derivative of vitamin A. He has no other significant past medical history. Which of the following is the major side-effect of this therapy?", "answer": "Hyperlipidemia", "options": {"A": "Hyperglycemia", "B": "Hyperlipidemia", "C": "Fatigue", "D": "Xerophthalmia", "E": "Alopecia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "diagnosed", "acne vulgaris", "dermatologist", "therapy", "a derivative", "vitamin", "significant past medical history", "following", "major side", "therapy"]}
{"question": "A 70-year-old man presented to a medical clinic for a routine follow-up. He has had hypertension for 20 years and is currently on multiple anti-hypertensive medications. The blood pressure is 150/100 mm Hg. The remainder of the examinations were within normal limits. Echocardiography showed some changes in the left ventricle. What is the most likely reason for the change?", "answer": "Increase in cardiac cell size", "options": {"A": "Disordered growth of the cardiac cells", "B": "Replacement of cardiac cells into stronger red fiber skeletal cells", "C": "Decrease in cardiac cell size", "D": "Increase in cardiac cell size", "E": "Increase in number of normal cardiac cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man", "medical clinic", "routine follow-up", "hypertension", "20 years", "currently", "multiple anti-hypertensive medications", "blood pressure", "100 mm Hg", "normal limits", "Echocardiography", "changes", "left ventricle", "most likely"]}
{"question": "A 33-year-old female presents to her primary care physician complaining of heat intolerance and difficulty sleeping over a one month period. She also reports that she has lost 10 pounds despite no changes in her diet or exercise pattern. More recently, she has developed occasional unprovoked chest pain and palpitations. Physical examination reveals a nontender, mildly enlarged thyroid gland. Her patellar reflexes are 3+ bilaterally. Her temperature is 99°F (37.2°C), blood pressure is 135/85 mmHg, pulse is 105/min, and respirations are 18/min. Laboratory analysis is notable for decreased TSH. Which of the following pathophysiologic mechanisms contributed to the cardiovascular symptoms seen in this patient?", "answer": "Increased sensitivity of ß1-adrenergic receptors", "options": {"A": "Increased numbers of a1-adrenergic receptors", "B": "Decreased numbers of a1-adrenergic receptors", "C": "Decreased numbers of a2-adrenergic receptors", "D": "Decreased sensitivity of ß2-adrenergic receptors", "E": "Increased sensitivity of ß1-adrenergic receptors"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female presents", "primary care physician", "of heat intolerance", "difficulty sleeping", "one month period", "reports", "lost 10 pounds", "changes", "diet", "exercise pattern", "recently", "occasional", "chest pain", "palpitations", "reveals", "nontender", "mildly enlarged thyroid gland", "patellar reflexes", "3", "temperature", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "Laboratory analysis", "notable", "decreased TSH", "following pathophysiologic mechanisms", "cardiovascular symptoms seen", "patient"]}
{"question": "A neonate suffering from neonatal respiratory distress syndrome is given supplemental oxygen. Which of the following is a possible consequence of oxygen therapy in this patient?", "answer": "Blindness", "options": {"A": "Atelectasis", "B": "Anosmia", "C": "Atopy", "D": "Blindness", "E": "Cardiac anomalies"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["neonate suffering", "neonatal respiratory distress syndrome", "given supplemental oxygen", "following", "possible consequence of oxygen therapy", "patient"]}
{"question": "A 59-year-old woman comes to the physician because of a 2-month history of fatigue and abdominal discomfort. Over the past 6 months, she has had a 5.4-kg (12-lb) weight loss. She takes no medications. Her temperature is 37.8°C (100°F), pulse is 70/min, respirations are 13/min, and blood pressure is 125/80 mm Hg. Cardiopulmonary examination shows no abnormalities. The spleen is palpated 3 cm below the left costal margin. Laboratory studies show:\nHemoglobin 9.4 g/dL\nMean corpuscular volume 86 μm3\nLeukocyte count 58,000/mm3\nSegmented neutrophils 54%\nBands 8%\nLymphocytes 7%\nMyelocytes 5%\nMetamyelocytes 10%\nPromyelocytes 4%\nBlasts 5%\nMonocytes 1%\nEosinophils 4%\nBasophils 2%\nPlatelet count 850,000/mm3\nSerum\nCreatinine\n0.9 mg/dL\nLDH 501 U/L\nBone marrow biopsy shows hyperplastic myelopoiesis with granulocytosis. Which of the following is the most appropriate next step in management?\"", "answer": "Cytogenetic studies", "options": {"A": "Cytarabine and daunorubicin", "B": "Serum protein electrophoresis", "C": "Cytogenetic studies", "D": "All-trans retinoic acid", "E": "Observation and follow-up"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old woman", "physician", "2 month history", "fatigue", "abdominal discomfort", "past 6 months", "5.4 kg", "weight loss", "medications", "temperature", "pulse", "70 min", "respirations", "min", "blood pressure", "80 mm Hg", "Cardiopulmonary", "abnormalities", "spleen", "3 cm", "left costal margin", "Laboratory studies", "Hemoglobin", "volume", "count", "Monocytes", "2", "Platelet count", "Serum", "LDH", "L Bone marrow biopsy", "hyperplastic myelopoiesis", "granulocytosis", "following", "most appropriate next step"]}
{"question": "A 70-year-old man presents to his physician for evaluation of fullness and swelling of the left side of the abdomen over the last month. During this time, he has had night sweats and lost 2 kg (4.4 lb) unintentionally. He has no history of severe illness and takes no medications. The vital signs include: blood pressure 115/75 mm Hg, pulse 75/min, and temperature 36.8℃ (98.2℉). The abdomen has asymmetric distention. Percussion and palpation of the left upper quadrant reveal splenomegaly. No lymphadenopathy is detected. Heart and lung examination shows no abnormalities. The laboratory studies show the following:\nHemoglobin 9.5 g/dL\nMean corpuscular volume 95 μm3\nLeukocyte count 8,000/mm3\nPlatelet count 240,000/mm3\nUltrasound shows a spleen size of 15 cm, mild hepatomegaly, and mild ascites. The peripheral blood smear shows teardrop-shaped and nucleated red blood cells (RBCs) and immature myeloid cells. Marrow is very difficult to aspirate but reveals hyperplasia of all 3 lineages. The tartrate-resistant acid phosphatase (TRAP) test is negative. The cytogenetic analysis is negative for translocation between chromosomes 9 and 22. Which of the following laboratory findings is most likely to be present in this patient?", "answer": "JAK-2 mutation", "options": {"A": "Monoclonal elevation of IgG", "B": "Hair-like cell-membrane projections", "C": "JAK-2 mutation", "D": "Philadelphia chromosome", "E": "Reed-Sternburg cells"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man presents", "physician", "fullness", "swelling of", "left side", "abdomen", "last month", "time", "night sweats", "lost 2 kg", "4.4", "history", "severe illness", "medications", "vital signs include", "blood pressure", "75 mm Hg", "pulse 75 min", "temperature 36", "98", "abdomen", "asymmetric distention", "Percussion", "palpation", "left upper quadrant reveal splenomegaly", "lymphadenopathy", "detected", "Heart", "lung", "abnormalities", "laboratory studies", "following", "Hemoglobin 9.5 g/dL Mean corpuscular volume", "m3 Leukocyte count 8", "mm3 Platelet count", "Ultrasound", "spleen size", "mild hepatomegaly", "mild ascites", "peripheral blood smear", "teardrop shaped", "nucleated red blood cells", "Marrow", "very difficult to aspirate", "reveals hyperplasia", "tartrate-resistant acid phosphatase", "test", "negative", "negative", "translocation", "chromosomes 9", "following laboratory findings", "to", "present", "patient"]}
{"question": "A physician is choosing whether to prescribe losartan or lisinopril to treat hypertension in a 56-year-old male. Relative to losartan, one would expect treatment with lisinopril to produce which of the following changes in the circulating levels of these peptides?", "answer": "Bradykinin increase; angiotensin II decrease", "options": {"A": "Bradykinin increase; angiotensin II decrease", "B": "Renin decrease; angiotensin 1 increase", "C": "Aldosterone increase; bradykinin decrease", "D": "Renin decrease; angiotensin II increase", "E": "Angiotensin II increase; bradykinin decrease"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["physician", "to", "losartan", "lisinopril to treat hypertension", "year old male", "Relative", "losartan", "one", "treatment", "lisinopril to", "following changes", "circulating levels", "peptides"]}
{"question": "A 20-year-old man presents to the urgent care clinic complaining of nausea and vomiting for the past 2 hours. He just returned from a boating trip with his father, and while aboard they shared some packed potato salad and ham sandwiches. His dad denies any nausea or vomiting but does report minor dizziness. On examination he appears pale. The patient reports similar symptoms in the past when he was on a cruise trip to the Bahamas. What is the best medication for this patient at this time?", "answer": "Diphenhydramine", "options": {"A": "Diphenhydramine", "B": "Guaifenesin", "C": "Loperamide", "D": "Loratadine", "E": "Ondansetron"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["20 year old man presents", "urgent care clinic", "nausea", "vomiting", "past", "hours", "returned", "trip", "shared", "packed", "ham", "nausea", "vomiting", "report minor dizziness", "appears pale", "patient reports similar symptoms", "past", "trip", "Bahamas", "best medication", "patient", "time"]}
{"question": "A 51-year-old man comes to the physician because of a 4-day history of fever and cough productive of foul-smelling, dark red, gelatinous sputum. He has smoked 1 pack of cigarettes daily for 30 years and drinks two 12-oz bottles of beer daily. An x-ray of the chest shows a cavity with air-fluid levels in the right lower lobe. Sputum culture grows gram-negative rods. Which of the following virulence factors is most likely involved in the pathogenesis of this patient's condition?", "answer": "Capsular polysaccharide", "options": {"A": "Exotoxin A", "B": "IgA protease", "C": "Heat-stable toxin", "D": "P-fimbriae", "E": "Capsular polysaccharide"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "4-day history", "fever", "cough productive", "smelling", "dark red", "gelatinous sputum", "smoked 1 pack", "cigarettes daily", "30 years", "two", "oz bottles", "daily", "x-ray of", "chest", "cavity with air fluid levels", "right lower lobe", "Sputum culture", "following virulence factors", "most likely involved", "pathogenesis", "patient's condition"]}
{"question": "A 16-year-old girl is brought to the physician for evaluation of severe acne on her face, chest, and back for the past 2 years. She has no itching or scaling. She has been treated in the past with a combination of oral cephalexin and topical benzoyl peroxide without clinical improvement. She is sexually active with one male partner, and they use condoms inconsistently. She does not smoke, drink alcohol, or use illicit drugs. There is no personal or family history of serious illness. Her vital signs are within normal limits. Examination shows mild facial scarring and numerous open comedones and sebaceous skin lesions on her face, chest, and back. Before initiating treatment, which of the following is the most appropriate next step?", "answer": "Measure serum beta-hCG levels", "options": {"A": "Administer oral contraceptives", "B": "Screen for depression with a questionnaire", "C": "Switch cephalexin to doxycycline", "D": "Measure serum beta-hCG levels", "E": "Measure creatinine kinase levels"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "severe acne", "face", "chest", "back", "past", "years", "itching", "scaling", "treated", "past", "combination", "oral cephalexin", "topical benzoyl peroxide", "clinical", "sexually active", "one male", "use condoms", "not smoke", "use illicit", "personal", "family history", "serious illness", "vital signs", "normal limits", "mild facial scarring", "numerous open comedones", "skin lesions", "face", "chest", "back", "initiating treatment", "following", "most appropriate next step"]}
{"question": "A 75-year-old woman is brought to the physician by her daughter for a 4-month history of increasing difficulty recognizing her friends and family. She has had to rely on recognizing haircuts, gait, and voices because she cannot remember their faces. Neurologic examination shows that she is able to recognize objects and name facial features such as the eyes and nose. On mental status examination, she is alert and has no deficits in cognition or short-term memory. An MRI of her head shows an inhomogenous 2-cm mass with perifocal edema in her brain. Which of the following brain regions is most likely affected?", "answer": "Right ventral occipitotemporal cortex", "options": {"A": "Left posterior parietal cortex", "B": "Right posterior superior temporal cortex", "C": "Left hippocampus", "D": "Right superior parietal cortex", "E": "Right ventral occipitotemporal cortex"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["75 year old woman", "brought", "physician", "month history", "increasing difficulty", "to", "gait", "voices", "faces", "Neurologic examination", "able to", "name facial features", "eyes", "nose", "mental status", "alert", "deficits", "cognition", "MRI of", "head", "mass", "edema", "brain", "following brain regions", "most likely affected"]}
{"question": "A 25-year-old male patient presents to your clinic in significant distress. He states he has excruciating, stabbing pain around the left side of his head, and his left eye will not stop tearing. These types of headaches have been occurring for the past week every morning when he awakens and last around 60 minutes. He denies any aura, nausea, or vomiting. He denies any other past medical history. What is this patient's diagnosis?", "answer": "Cluster headache", "options": {"A": "Migraine headache", "B": "Cluster headache", "C": "Chronic paroxysmal hemicrania (CPH)", "D": "Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT) syndrome", "E": "Trigeminal neuralgia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male patient presents", "clinic", "significant distress", "states", "excruciating", "stabbing pain", "left side of", "head", "left eye", "not stop tearing", "types", "headaches", "occurring", "past week", "morning", "last", "60 minutes", "aura", "nausea", "vomiting", "past medical history", "patient's diagnosis"]}
{"question": "A 42-year-old woman presents to the physician because of an abnormal breast biopsy report following suspicious findings on breast imaging. Other than being concerned about her report, she feels well. She has no history of any serious illnesses and takes no medications. She does not smoke. She consumes wine 1–2 times per week with dinner. There is no significant family history of breast or ovarian cancer. Vital signs are within normal limits. Physical examination shows no abnormal findings. The biopsy shows lobular carcinoma in situ (LCIS) in the left breast. Which of the following is the most appropriate next step in management?", "answer": "Careful observation + routine mammography", "options": {"A": "Breast irradiation + tamoxifen", "B": "Careful observation + routine mammography", "C": "Left mastectomy + axillary dissection + local irradiation", "D": "Lumpectomy + breast irradiation", "E": "Lumpectomy + routine screening"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "abnormal breast report following suspicious findings", "breast imaging", "report", "well", "history", "serious illnesses", "medications", "not smoke", "times", "week", "dinner", "significant family history", "breast", "ovarian cancer", "Vital signs", "normal", "Physical examination", "abnormal findings", "biopsy", "lobular carcinoma in situ", "left breast", "following", "most appropriate next step"]}
{"question": "A 33-year-old woman comes to the emergency department because of a 3-day history of lower abdominal pain and severe burning with urination. Two years ago, she was diagnosed with cervical cancer and was successfully treated with a combination of radiation and chemotherapy. She has systemic lupus erythematosus and finished a course of cyclophosphamide 3 weeks ago. She is sexually active with multiple male and female partners and uses a diaphragm for contraception. She has smoked two packs of cigarettes daily for 12 years. Current medication includes hydroxychloroquine. Her temperature is 36.6°C (97.9°F), pulse is 84/min, and blood pressure is 136/84 mm Hg. The abdomen is soft and there is tenderness to palpation over the pelvic region. Laboratory studies show:\nHemoglobin 13.1 g/dL\nLeukocyte count 7,400/mm3\nPlatelet count 210,000/mm3\nUrine\npH 7\nWBC 62/hpf\nRBC 12/hpf\nProtein negative\nNitrites positive\nWhich of the following is the most likely underlying mechanism of this patient's condition?\"", "answer": "Ascending infection", "options": {"A": "Radiation-induced inflammation", "B": "Ascending infection", "C": "Sexually transmitted infection", "D": "Hematogenous spread of infection", "E": "Neural hypersensitivity"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "3-day history", "lower abdominal pain", "severe burning", "urination", "Two years", "diagnosed", "cervical cancer", "treated with", "combination", "radiation", "chemotherapy", "systemic lupus erythematosus", "finished", "course", "cyclophosphamide", "weeks", "sexually active", "multiple male", "female", "uses", "diaphragm", "contraception", "smoked two packs", "cigarettes daily", "years", "Current medication includes hydroxychloroquine", "temperature", "36", "97 9F", "pulse", "84 min", "blood pressure", "84 mm Hg", "abdomen", "soft", "tenderness", "palpation", "pelvic region", "Laboratory studies", "Hemoglobin", "g", "Leukocyte", "7 400 mm3 Platelet count", "Urine pH", "WBC 62 hpf", "positive", "following", "underlying mechanism", "patient", "ondition?"]}
{"question": "An 81-year-old man comes to the emergency department with severe left ear pain and drainage for 3 days. He has a history of poorly-controlled type 2 diabetes mellitus. He appears uncomfortable. Physical examination of the ear shows marked periauricular erythema, exquisite tenderness on palpation, and granulation tissue in the external auditory canal. The most likely causal pathogen produces an exotoxin that acts by a mechanism most similar to a toxin produced by which of the following organisms?", "answer": "Corynebacterium diphtheriae", "options": {"A": "Corynebacterium diphtheriae", "B": "Bordetella pertussis", "C": "Shigella dysenteriae", "D": "Staphylococcus aureus", "E": "Bacillus anthracis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["81 year old man", "emergency department", "severe left ear pain", "drainage", "3 days", "history of poorly controlled type 2 diabetes mellitus", "appears", "Physical examination of", "ear", "marked", "erythema", "tenderness", "palpation", "granulation tissue", "external auditory canal", "causal", "exotoxin", "acts", "mechanism most similar", "toxin", "following"]}
{"question": "A 24-year-old woman of Ashkenazi Jewish descent presents with recurrent bloody diarrhea and abdominal pain. She says she feels well otherwise. Review of systems is significant for a 4 kg weight loss over the past month. Physical examination is significant for multiple aphthous oral ulcers. Colonoscopy reveals a cobblestone pattern of lesions of the mucosa of the intestinal wall involving the sigmoid colon. The patient is informed of the diagnosis and medication to treat her condition is prescribed. On a follow-up visit 6 weeks later, the patient presents with non-productive cough, chest pain, dyspnea on exertion, and worsening oral lesions. A chest radiograph reveals a diffuse interstitial pattern. Which of the following enzymes is inhibited by the medication most likely prescribed for her initial diagnosis?", "answer": "Dihydrofolate reductase", "options": {"A": "Thymidylate synthase", "B": "Dihydrofolate reductase", "C": "Hypoxanthine guanine-phosphoribosyltransferase (HGPRT)", "D": "DNA polymerase", "E": "Thymidine kinase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "descent presents", "recurrent bloody", "abdominal pain", "well", "Review of systems", "significant", "kg weight loss", "past month", "significant", "multiple aphthous oral ulcers", "Colonoscopy reveals", "pattern of lesions", "mucosa", "intestinal wall involving", "sigmoid colon", "patient", "informed", "diagnosis", "medication to treat", "condition", "follow-up", "6 weeks later", "patient presents", "non-productive cough", "chest pain", "dyspnea on exertion", "worsening oral lesions", "chest radiograph reveals", "diffuse interstitial", "following enzymes", "inhibited", "medication", "likely", "initial diagnosis"]}
{"question": "A 5-year-old girl swallows a marble while playing and is rushed to the hospital by her mother. The patient’s mother says she suddenly started to cough violently and made \"funny breathing\" sounds for a few minutes which then resolved. Her pulse is 100/min and respirations are 28/min. Physical examination reveals a girl in no obvious distress and breathing comfortably. There are diminished breath sounds and mild expiratory wheezing over the lower right lung field. A chest X-ray is performed which shows a round foreign body about 1 cm ×1 cm in the lower portion of the right inferior lobe. Which of the following changes in blood flow through the affected part of the lung would most likely be present in this patient?", "answer": "Blood flow would be decreased due to arterial vasoconstriction.", "options": {"A": "Blood flow would be increased due to arterial vasodilation.", "B": "Blood flow would be increased due to active hyperemia.", "C": "Blood flow would be unchanged due to autoregulation.", "D": "Blood flow would be unchanged due to decreased surfactant.", "E": "Blood flow would be decreased due to arterial vasoconstriction."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["5 year old girl swallows", "playing", "rushed", "hospital", "patients", "started to cough", "made", "breathing", "sounds", "minutes", "then resolved", "pulse", "100 min", "respirations", "min", "reveals", "girl", "distress", "breathing", "diminished breath sounds", "mild expiratory wheezing", "lower right lung field", "chest X-ray", "performed", "round foreign body", "lower portion", "right inferior lobe", "following changes", "blood flow", "affected part of", "lung", "most likely", "present", "patient"]}
{"question": "A patient presents with periods of severe headaches and flushing however every time they have come to the physician they have not experienced any symptoms. The only abnormal finding is a blood pressure of 175 mmHg/100 mmHg. It is determined that the optimal treatment for this patient is surgical. Prior to surgery which of the following noncompetitive inhibitors should be administered?", "answer": "Phenoxybenzamine", "options": {"A": "Atropine", "B": "Isoproterenol", "C": "Propranolol", "D": "Phentolamine", "E": "Phenoxybenzamine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["patient presents", "periods", "severe headaches", "flushing", "time", "physician", "not", "symptoms", "only abnormal finding", "blood pressure", "mmHg 100", "optimal", "surgical", "surgery", "following", "administered"]}
{"question": "A 55-year-old man with no significant medical history returns for follow-up of a fasting blood glucose (FBG) of 110 mg/dL. His mother had a myocardial infarction at age 52. He weighs 90 kg and his body mass index is 35 kg/m2. His repeat FBG is 160 mg/dL and hemoglobin A1c (HbA1c) is 7.0%. He is started on metformin but is lost to follow-up. Two years later, his HbA1c is 7.6% despite maximal metformin usage, so the patient is started on glyburide. Three months later, his HbA1c is 7.3% while on both medications, and subsequently prescribed glargine and aspart. Three months later, he is brought by his wife to the emergency department for evaluation of altered mental status. His electronic medical record notes that he was started on nitrofurantoin recently for an urinary tract infection. He is disoriented to place and time. His temperature is 99°F (37.2°C), blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 26/min. His basic metabolic panel is shown below:\n\nSerum:\nNa+: 119 mEq/L\nCl-: 90 mEq/L\nK+: 4.2 mEq/L\nHCO3-: 24 mEq/L\nBUN: 25 mg/dL\nGlucose: 1,400 mg/dL\nCreatinine: 1.9 mg/dL\n\nHis urine dipstick is negative for ketones. A peripheral intravenous line is established. What is the best initial step in management?", "answer": "Lactated ringer's solution", "options": {"A": "3% hypertonic saline", "B": "Regular insulin", "C": "Lactated ringer's solution", "D": "Glargine insulin", "E": "Regular insulin and potassium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "significant medical history returns", "follow-up", "fasting blood glucose", "mg/dL", "myocardial infarction", "age", "90 kg", "body mass index", "35 kg/m2", "repeat FBG", "mg/dL", "hemoglobin A1c", "0", "started", "metformin", "lost to follow-up", "Two years later", "HbA1c", "maximal metformin usage", "patient", "started", "glyburide", "Three months later", "HbA1c", "medications", "glargine", "aspart", "Three months later", "brought", "emergency department", "altered", "notes", "started", "nitrofurantoin recently", "urinary tract infection", "disoriented to place", "time", "temperature", "blood pressure", "90 60 mmHg", "pulse", "min", "respirations", "min", "basic metabolic panel", "Serum", "Na", "mEq/L", "90 mEq/L K", "4.2 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "1 400 mg/dL Creatinine", "1.9 mg/dL", "urine dipstick", "negative", "ketones", "peripheral intravenous line", "established", "best initial step"]}
{"question": "A 33-year-old woman comes to the emergency department for the evaluation of a headache and increased sweating for the last two hours. The patient also reports palpitations and nausea. Yesterday, she was started on venlafaxine for treatment-resistant depression. She took citalopram for four weeks, but stopped three days ago because her symptoms of depression did not improve. She does not smoke or drink alcohol. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 150/90 mm Hg. On mental status examination, the patient is only oriented to person, but not to place or time. Examination shows tremors in all extremities. She has impaired gait. Deep tendon reflexes are 3+ bilaterally. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Increased CNS serotonergic activity", "options": {"A": "Abnormal ryanodine receptor", "B": "Increased CNS serotonergic activity", "C": "Dopamine receptor blockade", "D": "Anticholinergic toxicity", "E": "Suspected amphetamine intake"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "headache", "increased sweating", "two hours", "patient", "reports palpitations", "nausea", "started", "venlafaxine", "treatment-resistant depression", "citalopram", "four weeks", "stopped three days", "symptoms of depression", "not", "not smoke", "temperature", "pulse", "min", "blood pressure", "90 mm Hg", "mental status", "patient", "only oriented to person", "not to place", "time", "tremors", "extremities", "impaired gait", "Deep tendon reflexes", "3", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 67-year-old man with stable coronary artery disease comes to the physician for a follow-up examination. Aside from occasional exertional chest pain on mowing the lawn or prolonged jogging, he feels well. He goes jogging for 20 minutes once a week and takes a tablet of sublingual nitroglycerine prior to his run to prevent anginal chest pain. The patient would like to run longer distances and asks the physician whether he could increase the dose of the drug prior to running. Administration of higher dosages of this drug is most likely to result in which of the following?", "answer": "Reflex sympathetic activity", "options": {"A": "Rebound angina", "B": "Development of tolerance", "C": "Reflex sympathetic activity", "D": "Anaphylactic reaction", "E": "Coronary artery vasospasm"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "stable coronary artery disease", "physician", "follow-up examination", "occasional exertional chest pain on", "prolonged", "well", "20 minutes", "week", "run to prevent anginal chest pain", "patient", "to run longer distances", "physician", "increase", "dose", "drug prior to", "Administration", "higher dosages", "drug", "to result"]}
{"question": "A 35-year-old man presents with a 1-day-history of pain and difficulty moving his right shoulder. He was cleaning his attic when he fell through onto the floor below and landed on his outstretched right hand. He tried over-the-counter analgesics which did not help. Past medical history is unremarkable. The patient is afebrile and vital signs are within normal limits. On physical examination, there are no visible deformities in the shoulder or upper extremities bilaterally. When he is asked to abduct his right shoulder above his head, he could not move his right shoulder initially. He is able to do so only when he is assisted to complete a full abduction. There is no sensory loss in any part of the upper limbs. Peripheral pulses are 2+ bilaterally. A MRI of the right shoulder is performed (shown in the image). Which of the following structures is most likely injured?", "answer": "Supraspinatus tendon", "options": {"A": "Infraspinatus tendon", "B": "Supraspinatus tendon", "C": "Deltoid muscle", "D": "Subscapularis tendon", "E": "Teres minor tendon"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man presents", "1-day history", "pain", "difficulty moving", "right shoulder", "attic", "fell", "floor", "landed", "right hand", "over-the-counter analgesics", "not help", "Past medical history", "unremarkable", "patient", "afebrile", "vital signs", "normal limits", "visible deformities", "shoulder", "upper extremities", "to", "right", "head", "not move", "right shoulder initially", "able", "only", "assisted to complete", "full abduction", "sensory loss", "part of", "upper limbs", "Peripheral pulses", "2", "MRI of", "right shoulder", "performed", "following structures", "most likely injured"]}
{"question": "A 42-year-old woman is brought to the emergency department because of intermittent sharp right upper quadrant abdominal pain and nausea for the past 10 hours. She has vomited 3 times. There is no associated fever, chills, diarrhea, or urinary symptoms. She has 2 children who both attend high school. She appears uncomfortable. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb). Her BMI is 32 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 100/min, and blood pressure is 140/90 mm Hg. She has mild scleral icterus. On physical examination, her abdomen is soft and nondistended, with tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. Laboratory studies show the following:\nBlood\nHemoglobin count 14 g/dL\nLeukocyte count 9,000 mm3\nPlatelet count 160,000 mm3\nSerum\nAlkaline phosphatase 238 U/L\nAspartate aminotransferase 60 U/L\nBilirubin  \nTotal 2.8 mg/dL\nDirect 2.1 mg/dL\nWhich of the following is the most appropriate next step in diagnosis?", "answer": "Transabdominal ultrasonography", "options": {"A": "Computed tomography (CT) scan of the abdomen", "B": "Endoscopic retrograde cholangiopancreatography (ERCP)", "C": "Hepatobiliary iminodiacetic acid (HIDA) scan of the biliary tract", "D": "Supine and erect X-rays of the abdomen", "E": "Transabdominal ultrasonography"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "emergency department", "intermittent sharp right upper quadrant abdominal pain", "nausea", "past 10 hours", "vomited 3 times", "associated fever", "chills", "diarrhea", "urinary symptoms", "has", "children", "attend high school", "appears", "5 ft 5", "tall", "kg", "BMI", "kg/m2", "temperature", "98", "pulse", "100 min", "blood pressure", "90 mm Hg", "mild scleral icterus", "abdomen", "soft", "tenderness", "palpation", "right upper quadrant", "guarding", "Bowel sounds", "normal", "Laboratory studies", "following", "Hemoglobin count", "g dL Leukocyte", "mm3", "Alkaline phosphatase", "Aspartate aminotransferase 60", "Total 2", "dL Direct 2.1 mg/dL", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 2-year-old boy is brought to the physician by his parents because of difficulty walking and cold feet for the past 2 months. His parents report that he tires quickly from walking. The patient was born at 37 weeks' gestation and has met all developmental milestones. There is no personal or family history of serious illness. He is at the 50th percentile for height and 40th percentile for weight. His temperature is 36.9°C (98.4°F), pulse is 119/min, respirations are 32/min, and blood pressure is 135/85 mm Hg. A grade 2/6 systolic murmur is heard in the left paravertebral region. Pedal pulses are absent. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Low tissue oxygenation in the legs", "options": {"A": "Rib notching", "B": "Low tissue oxygenation in the legs", "C": "Interarm difference in blood pressure", "D": "Right ventricular outflow obstruction", "E": "Increased R wave amplitude in V5-V6 on ECG"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "brought", "physician", "difficulty walking", "cold feet", "past", "months", "report", "tires", "patient", "born", "weeks", "gestation", "met", "personal", "family history", "serious illness", "50th percentile", "height", "percentile", "weight", "temperature", "36", "98", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "systolic murmur", "heard", "left paravertebral region", "Pedal pulses", "absent", "Further", "to", "following findings"]}
{"question": "A 62-year-old man is brought to the emergency department because of syncope. He reports sudden onset of palpitations followed by loss of consciousness while carrying his groceries to his car. He is unable to recall any further details and does not have any chest pain or dizziness. He has a history of hypertension, type 2 diabetes mellitus, gastroparesis, and osteoarthritis of the knees. Medications include lisinopril, metformin, and ondansetron as needed for nausea. He also takes methadone daily for chronic pain. Apart from an abrasion on his forehead, he appears well. His temperature is 37.2 °C (98.9 F), heart rate is 104/min and regular, and blood pressure is 135/70 mm Hg. While he is in the emergency department, he loses consciousness again. Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis that spontaneously resolves after 30 seconds. Results of a complete blood count, serum electrolyte concentrations, and serum thyroid studies show no abnormalities. Cardiac enzymes are within normal limits. Which of the following is the most likely underlying cause of this patient's syncope?", "answer": "Prolonged QT interval", "options": {"A": "Prolonged QT interval", "B": "Fast accessory conduction pathway", "C": "Prinzmetal angina", "D": "Brugada syndrome", "E": "Hypomagnesemia\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man", "brought", "emergency department", "syncope", "reports sudden onset", "palpitations followed by loss of consciousness", "car", "unable to", "further details", "not", "chest pain", "dizziness", "history of hypertension", "type 2 diabetes mellitus", "gastroparesis", "osteoarthritis of", "knees", "Medications include lisinopril", "metformin", "ondansetron as needed", "nausea", "methadone daily", "chronic", "abrasion", "forehead", "appears well", "temperature", "98", "F", "heart rate", "min", "regular", "blood pressure", "70 mm Hg", "emergency department", "consciousness", "Telemetry", "polymorphic ventricular tachycardia", "cyclic", "QRS axis", "30 seconds", "Results", "complete blood count", "serum electrolyte", "serum thyroid studies", "abnormalities", "Cardiac", "normal limits", "following", "underlying cause", "patient's syncope"]}
{"question": "A 27-year-old man presents to the emergency department with nausea and vomiting. The patient started experiencing these symptoms shortly after arriving home from going out to eat at a seafood restaurant. His symptoms progressed and now he reports having an odd metallic taste in his mouth, diffuse pruritus, and blurry vision. His temperature is 99.0°F (37.2°C), blood pressure is 120/72 mmHg, pulse is 50/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam reveals bradycardia and an inability of the patient to differentiate hot versus cold; no rash can be appreciated on exam. Which of the following is the most likely etiology of this patient’s symptoms?", "answer": "Ciguatoxin", "options": {"A": "Ciguatoxin", "B": "Scombrotoxin", "C": "Tetrodotoxin", "D": "Type I hypersensitivity reaction", "E": "Viral gastroenteritis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "emergency department", "nausea", "vomiting", "patient started", "symptoms", "home", "out to eat", "restaurant", "symptoms progressed", "now", "reports", "odd metallic taste", "mouth", "diffuse pruritus", "blurry vision", "temperature", "99", "blood pressure", "72 mmHg", "pulse", "50 min", "respirations", "min", "oxygen saturation", "99", "room air", "reveals bradycardia", "patient to differentiate hot", "cold", "rash", "exam", "following", "etiology", "patients symptoms"]}
{"question": "A 43-year-old man comes to the physician because of increasing shortness of breath for 1 month. He has been using two pillows at night but frequently wakes up feeling as if he is choking. Five months ago, he underwent surgery for creation of an arteriovenous fistula in his left upper arm. He has hypertension and chronic kidney disease due to reflux nephropathy. He receives hemodialysis three times a week. His current medications are enalapril, vitamin D3, erythropoietin, sevelamer, and atorvastatin. His temperature is 37.1°C (98.8°F), respirations are 22/min, pulse is 103/min and bounding, and blood pressure is 106/58 mm Hg. Examination of the lower extremities shows bilateral pitting pedal edema. There is jugular venous distention. A prominent thrill is heard over the brachiocephalic arteriovenous fistula. There are crackles heard at both lung bases. Cardiac examination shows an S3 gallop. The abdomen is soft and nontender. Which of the following is the most likely cause of this patient's symptoms?", "answer": "High-output heart failure", "options": {"A": "AV fistula aneurysm", "B": "Dialysis disequilibrium syndrome", "C": "Pulmonary embolism", "D": "Constrictive pericarditis", "E": "High-output heart failure"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of increasing shortness", "breath", "1 month", "using two pillows", "night", "frequently wakes up", "choking", "Five months", "surgery", "creation of", "arteriovenous fistula", "left upper arm", "hypertension", "chronic kidney disease due to reflux nephropathy", "receives hemodialysis three times", "week", "current medications", "enalapril", "vitamin D3", "erythropoietin", "sevelamer", "atorvastatin", "temperature", "98", "respirations", "min", "pulse", "min", "bounding", "blood pressure", "58 mm Hg", "Examination of the lower extremities", "bilateral pitting pedal edema", "jugular venous distention", "prominent thrill", "heard", "arteriovenous fistula", "crackles heard", "lung bases", "S3 gallop", "abdomen", "soft", "nontender", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 38-year-old woman, gravida 2, para 2, is brought to the emergency department by her husband after an episode of unconsciousness. She delivered a healthy infant two weeks ago and the postpartum course was complicated by severe vaginal bleeding, for which she required 4 units of packed red blood cells. Since the blood transfusion, she has had decreased milk production and has felt fatigued. Her pulse is 118/min and blood pressure is 104/63 mm Hg. Her finger-stick glucose concentration is 34 mg/dL. Serum thyroid-stimulating hormone and thyroxine levels are low and the serum sodium level is 132 mEq/L. Which of the following is the most likely cause of this patient's condition?", "answer": "Pituitary ischemia", "options": {"A": "Postpartum thyroiditis", "B": "Lactotrophic adenoma", "C": "Adrenal hemorrhage", "D": "Hypothalamic infarction", "E": "Pituitary ischemia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "gravida 2", "para 2", "brought", "emergency department", "episode of unconsciousness", "delivered", "healthy infant two weeks", "postpartum course", "complicated", "severe vaginal bleeding", "required 4 units", "packed red blood cells", "blood transfusion", "decreased milk production", "pulse", "min", "blood pressure", "63 mm Hg", "finger-stick glucose concentration", "mg/dL", "Serum thyroid-stimulating hormone", "thyroxine levels", "low", "serum sodium level", "mEq/L", "following", "most likely cause", "patient's condition"]}
{"question": "A 71-year-old man is brought to the emergency department by his daughter after she found him to be extremely confused at home. She says that he appeared to be fine in the morning; however, upon returning home, she found that he was slumped in his chair and was hard to arouse. She was worried that he may have taken too many medications and rushed him to the emergency department. His past medical history is significant for bipolar disorder and absence seizures. He does not smoke and drinks 4 alcoholic beverages per night on average. On physical exam, he is found to have a flapping tremor of his hands, pitting ankle edema, and gynecomastia. He does not appear to have any focal neurologic deficits. Which of the following lab findings would most likely be seen in this patient?", "answer": "Increased prothrombin time", "options": {"A": "Increased anticonvulsant levels", "B": "Increased antidepressant levels", "C": "Increased bleeding time", "D": "Increased d-dimer levels", "E": "Increased prothrombin time"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "found", "to", "extremely confused at home", "appeared to", "fine", "morning", "returning home", "found", "chair", "hard", "worried", "medications", "rushed", "emergency department", "past medical history", "significant", "bipolar disorder", "absence seizures", "not smoke", "4", "night", "average", "found to", "flapping tremor of", "hands", "pitting ankle edema", "gynecomastia", "not appear to", "focal neurologic deficits", "following lab findings", "most likely", "seen", "patient"]}
{"question": "A 22-year-old man seeks help from a physician for his heroin addiction. He tells the doctor that he started using heroin at the age of 17 and gradually started increasing the dose. He has been trying to quit for the last 6 months after realizing the negative consequences of his addiction but has not succeeded because of the withdrawal symptoms. The physician suggests a drug that can be taken within a supervised rehabilitation program as a substitute for heroin to help alleviate withdrawal symptoms. The drug will then be tapered over time. He is further informed by the physician that this drug is not to be taken by the patient on his own and will not work in an emergency situation related to heroin withdrawal. Which of the following drugs is most likely to have been recommended by the physician?", "answer": "Methadone", "options": {"A": "Codeine", "B": "Clonidine", "C": "Methadone", "D": "Naloxone", "E": "Naltrexone"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "help", "physician", "heroin addiction", "doctor", "started using heroin", "age", "started increasing", "dose", "to", "months", "negative consequences of", "addiction", "not", "withdrawal symptoms", "physician", "drug", "rehabilitation program", "heroin to help", "withdrawal symptoms", "drug", "then", "time", "further informed", "physician", "drug", "not to", "patient", "not", "related", "heroin withdrawal", "following drugs", "to", "physician"]}
{"question": "A 48-year-old man is unable to pass urine after undergoing open abdominal surgery. His physical examination and imaging findings suggest that the cause of his urinary retention is non-obstructive and is most probably due to urinary bladder atony. He is prescribed a new selective muscarinic (M3) receptor agonist, which improves his symptoms. Which of the following is most likely involved in the mechanism of action of this new drug?", "answer": "Activation of phospholipase C", "options": {"A": "Inhibition of adenylyl cyclase", "B": "Inhibition of guanylyl cyclase", "C": "Activation of phospholipase C", "D": "Increased transmembrane K+ conductance", "E": "Increased transmembrane Na+ conductance"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["48 year old man", "unable to pass urine", "open abdominal surgery", "imaging findings", "cause of", "urinary retention", "non-obstructive", "most", "due to urinary bladder atony", "new", "muscarinic", "M3", "receptor agonist", "improves", "symptoms", "following", "most likely involved", "mechanism of action", "new drug"]}
{"question": "A 17-year-old boy comes to the physician because of body aches and sore throat for 1 week. He has no history of serious illness and takes no medications. He lives with his parents; they recently adopted a cat from an animal shelter. He is sexually active with one female partner, and they use condoms consistently. His temperature is 38.7°C (101.7°F), pulse is 99/min, and blood pressure is 110/72 mm Hg. Examination shows bilateral posterior cervical lymphadenopathy. The pharynx is red and swollen. Laboratory studies show:\nHemoglobin 15 g/dL\nLeukocyte count 11,500/mm3\nSegmented neutrophils 48%\nBand forms 2%\nBasophils 0.5%\nEosinophils 1%\nLymphocytes 45%\nMonocytes 3.5%\nWhen the patient's serum is added to a sample of horse erythrocytes, the cells aggregate together. Which of the following is the most likely causal pathogen?\"", "answer": "Epstein-Barr virus", "options": {"A": "Epstein-Barr virus", "B": "Cytomegalovirus", "C": "Human immunodeficiency virus", "D": "Influenza virus", "E": "Toxoplasma gondii"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "physician", "body aches", "sore throat", "1 week", "history", "serious illness", "medications", "lives with", "parents", "recently adopted", "cat", "shelter", "sexually active", "one female", "use condoms", "temperature", "pulse", "99 min", "blood pressure", "72 mm Hg", "bilateral posterior cervical lymphadenopathy", "pharynx", "red", "swollen", "Laboratory studies", "Hemoglobin", "g Leukocyte count 11 500 mm3 Segmented neutrophils 48", "Band forms", "0.5", "Lymphocytes", "patient", "erum ", "dded ", "ample ", "rythrocytes,", "ells  ggregate  ogether.", "ollowing ", "ausal "]}
{"question": "An 8-year-old boy is brought to the emergency department with severe dyspnea, fatigue, and vomiting. His mother reports that he has been lethargic for the last several days with an increase in urine output. She thinks he may even be losing weight, despite eating and drinking more than normal for the last couple weeks. Laboratory results are notable for glucose of 440, potassium of 5.8, pH of 7.14 and HCO3 of 17. After administrating IV fluids and insulin, which of the following would you expect?", "answer": "Decrease in serum potassium", "options": {"A": "Increase in serum glucose", "B": "Increase in anion gap", "C": "Decrease in serum potassium", "D": "Decrease in pH", "E": "Decrease in serum bicarbonate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "emergency department", "severe dyspnea", "fatigue", "vomiting", "reports", "lethargic", "days", "increase", "urine output", "weight", "eating", "drinking", "normal", "last couple weeks", "Laboratory results", "notable", "glucose", "440", "potassium", "5.8", "pH", "7", "HCO3", "insulin", "following"]}
{"question": "A 49-year-old woman presents to the emergency room with bloody stool and malaise. She developed a fever and acute left lower quadrant abdominal pain earlier in the day. She has had 2 bowel movements with bright red blood. Her past medical history is notable for hyperlipidemia, hypertension, and diabetes mellitus. She takes lovastatin, hydrochlorothiazide, metformin, glyburide, and aspirin. Her temperature is 102.9°F (39.4°C), blood pressure is 101/61 mmHg, pulse is 110/min, and respirations are 22/min. On exam, she is fully alert and oriented. She is tender in the left lower quadrant. A computerized tomography (CT) scan is performed demonstrating acute diverticulitis. She is admitted and started on broad-spectrum antibiotics. 48 hours later, her urine output is significantly decreased. Her abdominal pain has improved but she has started vomiting and appears confused. She has new bilateral lower extremity edema and decreased breath sounds at the lung bases. Laboratory analysis upon admission and 48 hours later is shown below:\n\nAdmission:\nHemoglobin: 11.9 g/dl\nHematocrit: 34%\nLeukocyte count: 11,500/mm^3\nPlatelet count: 180,000/ mm^3\n\nSerum:\nNa+: 141 mEq/L\nCl-: 103 mEq/L\nK+: 4.5 mEq/L\nHCO3-: 23 mEq/L\nBUN: 21 mg/dL\nGlucose: 110 mg/dL\nCreatinine: 0.9 mg/dL\n\n48 hours later:\nHemoglobin: 10.1 g/dl\nHematocrit: 28%\nLeukocyte count: 11,500 cells/mm^3\nPlatelet count: 195,000/ mm^3\n\nSerum:\nNa+: 138 mEq/L\nCl-: 100 mEq/L\nK+: 5.1 mEq/L\nHCO3-: 24 mEq/L\nBUN: 30 mg/dL\nGlucose: 120 mg/dL\nCreatinine: 2.1 mg/dL\n\nWhich of the following findings would most likely be seen on urine microscopy?", "answer": "Muddy brown casts", "options": {"A": "Fatty casts", "B": "Hyaline casts", "C": "Muddy brown casts", "D": "Waxy casts", "E": "White blood cell casts"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency room", "bloody stool", "malaise", "fever", "acute left lower quadrant abdominal pain earlier", "day", "2 bowel movements", "bright red blood", "past medical history", "notable", "hyperlipidemia", "hypertension", "diabetes mellitus", "lovastatin", "hydrochlorothiazide", "metformin", "glyburide", "aspirin", "temperature", "9F", "blood pressure", "61 mmHg", "pulse", "min", "respirations", "min", "exam", "alert", "oriented", "tender", "left lower quadrant", "computerized tomography", "scan", "performed", "acute diverticulitis", "started", "broad spectrum", "48 hours later", "urine output", "decreased", "abdominal pain", "improved", "started vomiting", "appears confused", "new bilateral lower extremity edema", "decreased breath sounds", "lung bases", "Laboratory analysis", "48 hours later", "Hemoglobin", "g/dl Hematocrit", "Leukocyte count", "500 mm", "Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.5 mEq/L HCO3", "23 mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "0.9 mg/dL", "48 hours later", "Hemoglobin", "10", "g/dl Hematocrit", "Leukocyte count", "500 cells mm", "Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "5", "mEq/L HCO3", "mEq/L", "30 mg/dL Glucose", "mg/dL Creatinine", "2.1 mg/dL", "following findings", "most likely", "seen", "urine microscopy"]}
{"question": "A 50-year-old man is brought to the emergency department by his wife because of lethargy and confusion for the past 24 hours. He has also had a productive cough for the past year and has had a 10-kg (22-lb) weight loss over the past 6 months. He has a history of multiple sclerosis and has not had an acute exacerbation in over 10 years. For the past 30 years, he has smoked 2 packs of cigarettes daily. He drinks 2 beers every day after work. His temperature is 37.0°C (98.6°F), pulse is 90/min, blood pressure is 130/90 mm Hg, and respirations are 22/min. On examination, the patient appears lethargic and cannot state his name or his location. Physical examination reveals scattered wheezing bilaterally. Deep tendon reflexes cannot be elicited. Laboratory studies show:\nSerum\nNa+ 115 mEq/L\nK+ 4.5 mEq/L\nHCO3- 22 mEq/L\nGlucose 70 mg/dL\nBlood urea nitrogen 8 mg/dL\nUrine osmolality 450 mOsmol/kg H2O\nUrine sodium 70 mEq/L\nAn x-ray of the chest reveals a central lung mass. Which of the following is the next best step in management?\"", "answer": "Administer hypertonic saline", "options": {"A": "Order CT scan of the chest", "B": "Administer furosemide", "C": "Administer hypertonic saline", "D": "Administer demeclocycline", "E": "Administer conivaptan"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["50 year old man", "brought", "emergency department", "lethargy", "confusion", "past 24 hours", "productive cough", "past year", "a 10 kg", "weight loss", "past 6 months", "history", "multiple sclerosis", "not", "acute exacerbation", "past 30 years", "smoked 2 packs", "cigarettes daily", "2", "day", "temperature", "98", "pulse", "90 min", "blood pressure", "90 mm Hg", "respirations", "min", "patient appears lethargic", "state", "name", "location", "reveals scattered wheezing", "Deep tendon reflexes", "elicited", "Laboratory studies", "Serum", "mEq K", "4", "HCO3", "70", "Blood urea nitrogen", "Urine", "450 mOsmol/kg H2O", "sodium", "x-ray of", "chest reveals", "central lung mass", "following", "next best step"]}
{"question": "A 55-year-old man presents to the physician with complaints of 5 days of watery diarrhea, fever, and bloating. He has not noticed any blood in his stool. He states that his diet has not changed recently, and his family has been spared from diarrhea symptoms despite eating the same foods that he has been cooking at home. He has no history of recent travel outside the United States. His only medication is high-dose omeprazole, which he has been taking daily for the past few months to alleviate his gastroesophageal reflux disease (GERD). Which of the following is the most appropriate initial test to work up this patient’s symptoms?", "answer": "Stool toxin assay", "options": {"A": "Colonoscopy", "B": "Fecal occult blood test", "C": "Stool culture", "D": "Stool ova and parasite", "E": "Stool toxin assay"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "physician", "complaints", "5 days", "watery diarrhea", "fever", "bloating", "not", "blood in", "stool", "states", "diet", "not changed recently", "diarrhea symptoms", "eating", "same", "at home", "history of recent travel outside", "United States", "only medication", "high-dose omeprazole", "daily", "past", "months to", "gastroesophageal reflux disease", "following", "most appropriate initial test", "work up", "patients symptoms"]}
{"question": "A 49-year-old woman presents to her primary care doctor in late December with malaise. She reports worsening fatigue, myalgias, headache, and malaise that started 1 day ago. She works as a lunch lady at an elementary school. Her past medical history is notable for a distal radius fracture after a fall 2 years ago, but she is otherwise healthy and takes no medications. She does not smoke or drink alcohol. She is married and has 3 adult children who are healthy. Her temperature is 102.9°F (39.4°C), blood pressure is 101/61 mmHg, pulse is 112/min, and respirations are 21/min. On exam, she appears lethargic and uncomfortable but is able to answer questions appropriately. Breath sounds are normal bilaterally. She is started on intravenous fluids and a pharmacologic agent for treatment. Which of the following is the most likely mechanism of action of the drug being used to treat this patient?", "answer": "Neuraminidase inhibitor", "options": {"A": "DNA polymerase inhibitor", "B": "Neuraminidase inhibitor", "C": "Protease inhibitor", "D": "Reverse transcriptase inhibitor", "E": "RNA-dependent polymerase inhibitor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care doctor", "late December", "malaise", "reports worsening fatigue", "myalgias", "headache", "malaise", "started 1 day", "lunch", "elementary school", "past medical history", "notable", "distal radius fracture", "fall", "years", "healthy", "medications", "not smoke", "married", "3", "healthy", "temperature", "9F", "blood pressure", "61 mmHg", "pulse", "min", "respirations", "min", "exam", "appears lethargic", "able to", "Breath sounds", "normal", "started", "pharmacologic", "treatment", "following", "mechanism of action", "drug", "used to treat", "patient"]}
{"question": "A 78-year-old woman is brought to the emergency ward by her son for lethargy and generalized weakness. The patient speaks in short utterances and does not make eye contact with the provider or her son throughout the interview and examination. You elicit that the patient lives with her son and daughter-in-law, and she reports vague weakness for the last couple days. The emergency room provider notices 3-4 healing bruises on the patient's upper extremities; otherwise, examination is not revealing. Routine chemistries and blood counts are unremarkable; non-contrast head CT demonstrates normal age-related changes. Which of the following is the most appropriate next step in management?", "answer": "Ask the patient's son to leave the room", "options": {"A": "Perform lumbar puncture", "B": "Question the patient regarding abuse or neglect", "C": "Question the patient's son regarding the home situation", "D": "Ask the patient's son to leave the room", "E": "Call Adult Protective Services to report the patient's son"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency ward", "lethargy", "generalized weakness", "patient speaks", "short", "not make eye contact with", "provider", "elicit", "patient lives with", "son", "reports vague weakness", "couple days", "emergency provider", "healing bruises", "patient's upper extremities", "not revealing", "Routine chemistries", "blood counts", "unremarkable", "non contrast head CT", "normal age related changes", "following", "most appropriate next step"]}
{"question": "A 23-year-old woman presents with fever, chills, nausea, and urinary urgency and frequency. She says that her symptoms began 4 days ago and have progressively worsened. Her past medical history is significant for a 6-month history of recurrent urinary tract infections (UTIs). Her vital signs include: temperature 39.0°C (102.2°F), blood pressure 100/70 mm Hg, pulse 92/min, and respiratory rate 25/min. On physical examination, there is moderate left costovertebral angle tenderness. Laboratory findings are significant for the following:\nWBC 8,500/mm3\nRBC 4.20 x 106/mm3\nHematocrit 41.5%\nHemoglobin 13.0 g/dL\nPlatelet count 225,000/mm3\nUrinalysis\nColor Dark yellow\nClarity Turbid\npH 6.5\nSpecific gravity 1.026\nGlucose None\nKetones None\nNitrites Positive\nLeukocyte esterase Positive\nBilirubin Negative\nUrobilirubin 0.6 mg/dL\nProtein Trace\nBlood None\nWBC 25/hpf\nBacteria Many\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Pyelonephritis", "options": {"A": "Pyelonephritis", "B": "Uncomplicated cystitis", "C": "Complicated cystitis", "D": "UTI", "E": "Acute obstructing nephrolithiasis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old woman presents", "fever", "chills", "nausea", "urinary urgency", "frequency", "symptoms began 4 days", "worsened", "past medical history", "significant", "month history of recurrent urinary tract infections", "vital signs include", "temperature", "blood pressure 100 70 mm Hg", "pulse", "min", "respiratory rate", "min", "moderate left costovertebral angle tenderness", "Laboratory findings", "significant", "following", "WBC 8 500 mm3", "4 20", "Hematocrit", "Hemoglobin", "0 g/dL Platelet count 225", "Urinalysis Color Dark", "Clarity Turbid pH", "Specific gravity", "Glucose", "Ketones", "Positive Leukocyte esterase", "Bilirubin Negative", "0.6 mg/dL Protein Trace Blood", "WBC", "hpf Bacteria", "following", "diagnosis", "patient"]}
{"question": "A 44-year-old man comes to the physician because of a 2-week history of lower extremity swelling and frothy urine. He has a history of chronic hepatitis C infection. Physical examination shows 3+ pitting edema of the lower legs and ankles. Further evaluation of this patient is most likely to show which of the following?", "answer": "Increased lipoproteins", "options": {"A": "Decreased blood urea nitrogen", "B": "Decreased cholesterol", "C": "Increased lipoproteins", "D": "Decreased cystatin C", "E": "Increased antithrombin III"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "2-week history", "lower extremity swelling", "frothy urine", "history of chronic hepatitis C infection", "3", "pitting edema of", "lower legs", "ankles", "Further", "to", "following"]}
{"question": "A 72-year-old male presents to his primary care physician complaining of increased urinary frequency and a weakened urinary stream. He has a history of gout, obesity, diabetes mellitus, and hyperlipidemia. He currently takes allopurinol, metformin, glyburide, and rosuvastatin. His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 90/min, and respirations are 18/min. Physical examination reveals an enlarged, non-tender prostate without nodules or masses. An ultrasound reveals a uniformly enlarged prostate that is 40mL in size. His physician starts him on a new medication. After taking the first dose, the patient experiences lightheadedness upon standing and has a syncopal event. Which of the following mechanisms of action is most consistent with the medication in question?", "answer": "Alpha-1-adrenergic receptor antagonist", "options": {"A": "Dihydropyridine calcium channel blocker", "B": "Alpha-1-adrenergic receptor antagonist", "C": "Alpha-2-adrenergic receptor agonist", "D": "Non-selective alpha receptor antagonist", "E": "Selective muscarinic agonist"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old male presents", "primary care physician", "increased urinary frequency", "urinary stream", "history of gout", "obesity", "diabetes mellitus", "hyperlipidemia", "currently", "allopurinol", "metformin", "glyburide", "rosuvastatin", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "90 min", "respirations", "min", "reveals", "enlarged", "non-tender prostate", "nodules", "masses", "ultrasound reveals", "enlarged prostate", "size", "physician starts", "new medication", "first dose", "patient", "lightheadedness", "standing", "syncopal event", "of", "following mechanisms", "action", "most", "medication"]}
{"question": "A 39-year-old male presents with muscle weakness in his upper and lower extremities. The patient has also noticed some trouble with swallowing. On physical exam, signs of hyperreflexia, spasticity, fasciculations, and muscle atrophy are present in an asymmetric fashion. Tongue fasciculations are also present. No sensory loss is noted. The patient does not report any abnormality with his bowel or bladder function. What will most likely be found on muscle biopsy?", "answer": "Denervation and reinnervation of the muscle", "options": {"A": "Mitochondrial proliferation leading to ragged appearance in Gomori trichrome stain", "B": "Perimysial CD4+ infiltration and perifascicular atrophy", "C": "CD8+ infiltrating within the fascicle", "D": "Denervation and reinnervation of the muscle", "E": "Larval cysts"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male presents", "muscle", "upper", "lower extremities", "patient", "swallowing", "signs", "hyperreflexia", "spasticity", "fasciculations", "muscle atrophy", "present", "asymmetric", "Tongue fasciculations", "present", "sensory loss", "noted", "patient", "not report", "abnormality", "bowel", "bladder function", "most likely", "found", "muscle biopsy"]}
{"question": "A 38-year-old woman comes to the physician for a follow-up examination. She was diagnosed with immune thrombocytopenic purpura at the age of 37 years and has been treated with glucocorticoids and intravenous immune globulin. She has visited the emergency department 3 times in the past 4 months for nose bleeds, which required cauterization. Her platelet counts on her previous visits were 18,320/mm3, 17,500/mm3, and 19,100/mm3. Current medications include dexamethasone and a multivitamin. She has no children. Her immunizations are up-to-date. Vital signs are within normal limits. Examination shows petechiae on the bilateral lower extremities. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender; there is no organomegaly. Her hemoglobin concentration is 13.3 g/dL, leukocyte count is 8,100/mm3, and platelet count is 13,000/mm3. Her blood type is A negative. Serology for hepatitis C and HIV is negative. Which of the following is the most appropriate next step in management?", "answer": "Schedule splenectomy", "options": {"A": "Romiplostim therapy", "B": "Rituximab therapy", "C": "Danazol therapy", "D": "Observation and follow-up", "E": "Schedule splenectomy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "diagnosed", "immune thrombocytopenic purpura", "age", "years", "treated with glucocorticoids", "intravenous immune globulin", "emergency department 3 times", "past", "months", "nose bleeds", "required cauterization", "platelet counts", "previous", "320 mm3", "500 mm3", "100 mm3", "Current medications include dexamethasone", "multivitamin", "children", "immunizations", "date", "Vital signs", "normal limits", "petechiae", "bilateral lower extremities", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "organomegaly", "hemoglobin concentration", "g/dL", "leukocyte count", "100 mm3", "platelet count", "mm3", "blood type", "A negative", "Serology", "hepatitis C", "HIV", "negative", "following", "most appropriate next step"]}
{"question": "A 54-year-old man is brought to the physician by his wife because of progressive difficulty walking during the past 3 months. He has not been able to walk without assistance for the past month and has started to use a wheelchair. He also reports having urinary incontinence for 1 year. His wife says that he has begun to slur his words and has become very difficult to understand. His temperature is 37.0°C (98.6°F), pulse is 70/min, and respirations are 16/min. His blood pressure is 130/80mm Hg while sitting and 110/65mm Hg when standing. He is oriented to person and place but not to time. Neurological examination shows a mild tremor in his right hand and rigidity in his upper and lower extremities. He is unable to perform repetitive rotary forearm movements. Which of the following is the most likely diagnosis?", "answer": "Multiple system atrophy", "options": {"A": "Multiple system atrophy", "B": "Parkinson disease", "C": "Friedreich ataxia", "D": "Corticobasal degeneration", "E": "Normal pressure hydrocephalus"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["54 year old man", "brought", "physician", "progressive difficulty walking", "past 3 months", "not", "able to", "assistance", "past month", "started to use", "wheelchair", "reports", "urinary incontinence", "year", "begun to slur", "very difficult to", "temperature", "98", "pulse", "70 min", "respirations", "min", "blood pressure", "Hg", "sitting", "Hg", "standing", "oriented to person", "place", "not", "time", "Neurological examination", "mild tremor", "right hand", "rigidity", "upper", "lower extremities", "unable to perform repetitive", "forearm movements", "following", "diagnosis"]}
{"question": "A 28-year-old primigravid woman at 36 weeks' gestation comes to the emergency department for 2 hours of contractions. Her pregnancy has been uncomplicated. The contractions occur once every 20–30 minutes, last less than 30 seconds, and have been consistent in intensity and duration since onset. During that time there has been an increase in fetal movements. Her temperature is 37.1°C (98.8°F), pulse is 98/min, and blood pressure is 104/76 mm Hg. Pelvic examination shows clear cervical mucus and a firm uterus consistent in size with a 36-week gestation. The cervix is 0% effaced and undilated; the vertex is at -3 station. The fetal heart rate is reassuring. After an hour of monitoring in the emergency department, the character of the contractions and pelvic examination findings remain unchanged. Which of the following is the most appropriate next step?", "answer": "Reassurance and discharge", "options": {"A": "Administer tocolytics", "B": "Offer local or regional anesthesia", "C": "Admit for continuous monitoring", "D": "Reassurance and discharge", "E": "Perform cesarean delivery"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old primigravid woman", "36 weeks", "gestation", "emergency department", "2 hours", "contractions", "pregnancy", "uncomplicated", "contractions occur once", "minutes", "last", "30 seconds", "intensity", "duration", "onset", "time", "increase", "fetal movements", "temperature", "98", "pulse", "98 min", "blood pressure", "76 mm Hg", "Pelvic examination", "clear cervical mucus", "firm uterus", "size", "36 week gestation", "cervix", "0", "vertex", "3 station", "fetal heart rate", "hour", "emergency department", "character", "contractions", "pelvic", "unchanged", "following", "most appropriate next step"]}
{"question": "A 28-year-old woman is brought to the emergency department by a friend after fainting at work and hitting her head. She is conscious, alert, and in pain as she sustained a deep laceration above her right orbit. When asked about prior fainting episodes, she says that she has had them since childhood, but she felt it was \"nothing serious\". She also says she has frequent palpitations, shortness of breath, nausea, and, at times, chest pain and attributes this to \"working too hard.\" Her pulse is 110/min, respirations are 20/min, temperature is 37.4°C (99.3°F), and blood pressure is 110/78 mm Hg. Physical examination shows tachycardia and mild hypotension. The patient's electrocardiogram is obtained. Which of the following drugs is the preferable choice for first line treatment of the patient's condition?", "answer": "Magnesium sulfate", "options": {"A": "Calcium gluconate", "B": "Epinephrine", "C": "Flecainide", "D": "Magnesium sulfate", "E": "Procainamide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "fainting", "hitting", "head", "alert", "pain", "sustained", "deep laceration", "right orbit", "prior fainting episodes", "since childhood", "serious", "frequent palpitations", "shortness of breath", "nausea", "times", "chest pain", "attributes", "hard", "pulse", "min", "respirations", "20 min", "temperature", "99", "blood pressure", "mm Hg", "tachycardia", "mild hypotension", "patient", "lectrocardiogram ", "btained.", "ollowing  rugs ", "hoice ", "irst line treatment ", "atient'", "ndition?"]}
{"question": "A 61-year-old G4P3 presents with a 5-year history of involuntary urine loss on coughing, sneezing, and physical exertion. She denies urine leakage at night. She has been menopausal since 51 years of age. She is otherwise healthy and is not on any medications, including hormone replacement therapy. The weight is 78 kg (172 lb) and the height is 156 cm (5.1 ft). The vital signs are within normal limits. The physical examination shows no costovertebral angle tenderness. The neurologic examination is unremarkable. The gynecologic examination revealed pale and thin vulvar and vaginal mucosa. The external urethral opening appears normal; there is urine leakage when the patient is asked to cough. The Q-tip test is positive. The bimanual exam reveals painless bulging of the anterior vaginal wall. Which of the following findings are most likely to be revealed by cystometry?", "answer": "Normal residual volume, no involuntary detrusor contractions", "options": {"A": "Normal residual volume, involuntary detrusor contractions on maximal bladder filling", "B": "Increased residual volume, no involuntary detrusor contractions", "C": "Normal residual volume, involuntary detrusor contractions on minimal bladder filling", "D": "Increased residual volume, involuntary detrusor contractions on maximal bladder filling", "E": "Normal residual volume, no involuntary detrusor contractions"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["61 year old", "presents", "year history", "urine loss", "coughing", "sneezing", "physical exertion", "urine leakage", "night", "menopausal", "years", "age", "healthy", "not", "medications", "including hormone replacement therapy", "weight", "kg", "height", "5", "ft", "vital signs", "normal limits", "costovertebral angle tenderness", "neurologic examination", "unremarkable", "revealed pale", "thin vulvar", "vaginal mucosa", "external urethral opening appears normal", "urine leakage", "patient", "to cough", "Q test", "positive", "bimanual exam reveals painless bulging of", "anterior vaginal wall", "following findings", "to", "revealed", "cystometry"]}
{"question": "A 20-year-old woman is brought in by police for trying to break into a museum after hours. The patient states that she is a detective on the trail of a master collusion scheme and needs the artifacts from the museum to prove her case. Her family reports that she has been acting strangely for the past week. She has been up perusing the internet all night without taking breaks. Her husband states that she has had increased sexual interest for the past week; however, he did not report this to the physician when he first noticed it. The patient is unable to offer a history as she cannot be redirected from her current theory. Her temperature is 99.0°F (37.2°C), blood pressure is 122/81 mmHg, pulse is 97/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable only for a highly-energized patient. Laboratory studies are ordered as seen below.\n\nUrine:\nColor: Yellow\nNitrite: Negative\nBacteria: Negative\nLeukocytes: Negative\nhCG: Positive\nBenzodiazepines: Negative\nBarbiturate: Negative\nCocaine: Negative\nAcetaminophen: Negative\n\nWhich of the following is the most appropriate next step in management?", "answer": "Haloperidol", "options": {"A": "Electroconvulsive therapy", "B": "Fluoxetine", "C": "Haloperidol", "D": "Lithium", "E": "Valproic acid"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["20 year old woman", "brought", "police", "to break", "museum", "hours", "patient states", "detective", "trail", "master", "needs", "artifacts", "museum to", "case", "reports", "acting", "past week", "internet", "night", "breaks", "states", "increased sexual interest", "past week", "not report", "physician", "first", "patient", "unable to", "history", "current", "temperature", "99", "blood pressure", "81 mmHg", "pulse", "97 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable only", "highly", "patient", "Laboratory studies", "ordered", "seen", "Urine", "Color", "Yellow Nitrite", "Negative Bacteria", "Negative", "Negative hCG", "Positive Benzodiazepines", "Negative Barbiturate", "Negative Cocaine", "Negative Acetaminophen", "Negative", "following", "most appropriate next step"]}
{"question": "Six hours after delivery, a 3050-g (6-lb 12-oz) male newborn is noted to have feeding intolerance and several episodes of bilious vomiting. He was born at term to a healthy 35-year-old woman following a normal vaginal delivery. The pregnancy was uncomplicated, but the patient's mother had missed several of her prenatal checkups. The patient's older brother underwent surgery for pyloric stenosis as an infant. Vital signs are within normal limits. Physical examination shows epicanthus, upward slanting of the eyelids, low-set ears, and a single transverse palmar crease. The lungs are clear to auscultation. A grade 2/6 holosystolic murmur is heard at the left mid to lower sternal border. Abdominal examination shows a distended upper abdomen and a concave-shaped lower abdomen. There is no organomegaly. An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis?", "answer": "Duodenal atresia", "options": {"A": "Necrotizing enterocolitis", "B": "Duodenal atresia", "C": "Hirschsprung's disease", "D": "Hypertrophic pyloric stenosis", "E": "Meconium ileus"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Six hours", "delivery", "g", "oz", "male newborn", "noted to", "feeding intolerance", "several episodes of bilious vomiting", "born", "term", "healthy 35 year old woman following", "normal vaginal", "pregnancy", "uncomplicated", "patient's", "missed", "prenatal", "patient's", "surgery", "pyloric stenosis", "infant", "Vital signs", "normal", "Physical examination", "epicanthus", "upward", "eyelids", "low-set ears", "single transverse palmar crease", "lungs", "clear", "auscultation", "holosystolic murmur", "heard", "left", "to lower sternal border", "Abdominal", "distended upper", "concave-shaped lower abdomen", "organomegaly", "x-ray of", "abdomen", "following", "diagnosis"]}
{"question": "A researcher is examining the relationship between socioeconomic status and IQ scores. The IQ scores of young American adults have historically been reported to be distributed normally with a mean of 100 and a standard deviation of 15. Initially, the researcher obtains a random sampling of 300 high school students from public schools nationwide and conducts IQ tests on all participants. Recently, the researcher received additional funding to enable an increase in sample size to 2,000 participants. Assuming that all other study conditions are held constant, which of the following is most likely to occur as a result of this additional funding?", "answer": "Decrease in standard error of the mean", "options": {"A": "Increase in range of the confidence interval", "B": "Decrease in standard deviation", "C": "Decrease in standard error of the mean", "D": "Increase in risk of systematic error", "E": "Increase in probability of type II error"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["researcher", "examining", "relationship", "socioeconomic status", "scores", "scores", "young", "adults", "reported to", "distributed", "mean", "100", "standard deviation", "Initially", "researcher obtains", "300", "public schools", "tests", "Recently", "researcher received additional funding to", "increase in", "size", "2", "study conditions", "held constant", "following", "to occur", "result", "additional funding"]}
{"question": "A 27-year-old male presents to his primary care physician complaining of pain with urination and eye redness. He reports that he developed these symptoms approximately one week ago. He also has noticed left knee and right heel pain that started a few days ago. He denies any recent trauma. He had an episode of abdominal pain and diarrhea ten days ago that resolved. He has otherwise felt well. On exam, he walks with a limp and his conjunctivae are erythematous. Laboratory findings are notable for an elevated erythrocyte sedimentation rate (ESR) and elevated C-reactive protein (CRP). Which of the following is most likely associated with this patient’s condition?", "answer": "HLA-B27 haplotype", "options": {"A": "HLA-B27 haplotype", "B": "HLA-DR4 haplotype", "C": "Anti-cyclic citrullinated peptide (anti-CCP) antibody", "D": "Anti-centromere antibody", "E": "Rheumatoid factor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old male presents", "primary care physician", "pain", "urination", "eye redness", "reports", "symptoms approximately one week", "left knee", "right", "started", "few days", "recent trauma", "episode of abdominal pain", "diarrhea", "resolved", "well", "exam", "walks", "limp", "conjunctivae", "erythematous", "Laboratory findings", "notable", "elevated erythrocyte sedimentation rate", "elevated C-reactive protein", "following", "most likely associated with", "patients condition"]}
{"question": "A 4-year-old boy is brought to the pediatrician by his mother for a routine medical examination. His medical history is relevant for delayed gross motor milestones. The mother is concerned about a growth delay because both of his brothers were twice his size at this age. Physical examination reveals a well-groomed and healthy boy with a prominent forehead and short stature, in addition to shortened upper and lower extremities with a normal vertebral column. The patient’s vitals reveal: temperature 36.5°C (97.6°F); pulse 60/min; and respiratory rate 17/min and a normal intelligence quotient (IQ). A mutation in which of the following genes is the most likely cause underlying the patient’s condition?", "answer": "Fibroblast growth factor receptor 3", "options": {"A": "Alpha-1 type I collagen", "B": "Fibrillin-1", "C": "Fibroblast growth factor receptor 3", "D": "Insulin-like growth factor 1 receptor", "E": "Runt-related transcription factor 2"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "pediatrician", "routine", "medical history", "relevant", "delayed gross motor milestones", "growth delay", "twice", "size", "age", "reveals", "well groomed", "healthy boy", "prominent forehead", "short stature", "shortened upper", "lower extremities", "normal vertebral column", "patients", "reveal", "temperature 36", "97", "pulse 60 min", "respiratory rate", "min", "normal", "following", "most likely cause", "patients condition"]}
{"question": "An investigator is studying brachial artery reactivity in women with suspected coronary heart disease. The brachial artery diameter is measured via ultrasound before and after intra-arterial injection of acetylcholine. An increase of 7% in the vascular diameter is noted. The release of which of the following is most likely responsible for the observed effect?", "answer": "Nitric oxide from endothelial cells", "options": {"A": "Nitric oxide from endothelial cells", "B": "Endothelin from the peripheral vasculature", "C": "Serotonin from neuroendocrine cells", "D": "Norepinephrine from the adrenal medulla", "E": "Atrial natriuretic peptide from atrial myocytes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying brachial artery reactivity", "suspected", "brachial artery diameter", "measured", "ultrasound", "intra-arterial injection", "acetylcholine", "increase", "vascular diameter", "noted", "release", "following", "responsible", "observed effect"]}
{"question": "A 28-year-old female in the 2nd trimester of pregnancy is diagnosed with primary Toxoplasma gondii infection. Her physician fears that the fetus may be infected in utero. Which of the following are associated with T. gondii infection in neonates?", "answer": "Hydrocephalus, chorioretinitis, intracranial calcifications", "options": {"A": "Patent ductus arteriosus, cataracts, deafness", "B": "Temporal encephalitis, vesicular lesions", "C": "Hutchinson’s teeth, saddle nose, short maxilla", "D": "Deafness, seizures, petechial rash", "E": "Hydrocephalus, chorioretinitis, intracranial calcifications"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "2nd trimester", "pregnancy", "diagnosed", "primary Toxoplasma gondii infection", "physician", "fetus", "infected in utero", "following", "associated with", "infection", "neonates"]}
{"question": "A 62-year-old man comes to the physician because of a swollen and painful right knee for the last 3 days. He has no history of joint disease. His vital signs are within normal limits. Examination shows erythema and swelling of the right knee, with limited range of motion due to pain. Arthrocentesis of the right knee joint yields 7 mL of cloudy fluid with a leukocyte count of 29,000/mm3 (97% segmented neutrophils). Compensated polarized light microscopy of the aspirate is shown. Which of the following is the most likely underlying mechanism of this patient's knee pain?", "answer": "Calcium pyrophosphate deposition", "options": {"A": "Bacterial infection of the joint", "B": "Calcium pyrophosphate deposition", "C": "Mechanical stress and trauma", "D": "Immune complex-mediated cartilage destruction", "E": "Monosodium urate deposition"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old man", "physician", "swollen", "painful right knee", "3 days", "history disease", "vital signs", "normal limits", "erythema", "swelling of", "right knee", "with limited range of motion due to pain", "Arthrocentesis", "right knee joint", "7 mL", "cloudy fluid", "leukocyte count", "29", "mm3", "97", "segmented neutrophils", "Compensated polarized light microscopy", "aspirate", "following", "underlying mechanism", "patient's knee pain"]}
{"question": "A new treatment for hemorrhagic stroke, which is a life-threatening clinical condition that occurs when a diseased blood vessel in the brain ruptures or leaks, was evaluated as soon as it hit the market by an international group of neurology specialists. In those treated with the new drug, a good outcome was achieved in 30%, while those treated with the current standard of care had a good outcome in just 10% of cases. The clinicians involved in this cohort study concluded that the newer drug is more effective and prompted for urgent changes in the guidelines addressing hemorrhagic stroke incidents. According to the aforementioned percentages, how many patients must be treated with the new drug to see 1 additional good outcome?", "answer": "5", "options": {"A": "5", "B": "10", "C": "15", "D": "20", "E": "30"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["new treatment", "hemorrhagic stroke", "life-threatening clinical condition", "occurs", "blood vessel", "brain ruptures", "leaks", "hit", "market", "international group", "neurology specialists", "treated with", "new drug", "good outcome", "30", "treated with", "current", "good outcome", "10", "cases", "clinicians involved", "cohort study concluded", "newer drug", "more effective", "prompted", "urgent changes", "hemorrhagic stroke", "percentages", "patients", "treated with", "new drug to see 1 additional good outcome"]}
{"question": "A 54-year-old man is brought to the emergency department 1 hour after the sudden onset of shortness of breath, epigastric pain, and sweating. He has no history of similar symptoms. He has hypertension and type 2 diabetes mellitus. Current medications include amlodipine and metformin. He has smoked one pack of cigarettes daily for 20 years. He appears weak and pale. His pulse is 56/min, respirations are 18/min, and blood pressure is 100/70 mm Hg. Cardiac examination shows normal heart sounds. The lungs are clear to auscultation. The skin is cold to the touch. An ECG is shown. Bedside transthoracic echocardiography shows normal left ventricular function. High-dose aspirin is administered. Administration of which of the following is most appropriate next step in management?", "answer": "Normal saline bolus\n\"", "options": {"A": "Intravenous atropine", "B": "Intravenous morphine", "C": "Sublingual nitroglycerin", "D": "Phenylephrine infusion", "E": "Normal saline bolus\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["54 year old man", "brought", "emergency department", "hour", "sudden onset of shortness", "breath", "epigastric pain", "sweating", "history", "similar symptoms", "hypertension", "type 2 diabetes mellitus", "Current medications include amlodipine", "metformin", "smoked one pack", "cigarettes daily", "20 years", "appears weak", "pale", "pulse", "min", "respirations", "min", "blood pressure", "100 70 mm Hg", "normal heart sounds", "lungs", "clear", "auscultation", "skin", "cold to", "touch", "ECG", "Bedside transthoracic echocardiography", "normal left ventricular function", "High-dose aspirin", "administered", "Administration", "following", "most appropriate next step"]}
{"question": "An investigator studying targeted therapy in patients with gastrointestinal stromal tumors requires a reliable test to determine the spatial distribution of CD117-positive cells in biopsy specimens. Which of the following is the most appropriate test?", "answer": "Immunohistochemistry", "options": {"A": "Flow cytometry", "B": "Immunohistochemistry", "C": "Western blot", "D": "Northern blot", "E": "Fluorescence in-situ hybridization\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator studying targeted therapy", "patients", "gastrointestinal stromal tumors", "reliable test to", "spatial distribution", "CD117", "biopsy specimens", "following", "most appropriate test"]}
{"question": "In an attempt to create other selective dopamine 1 (D1) agonists, a small pharmaceutical company created a cell-based chemical screen that involved three modified receptors - alpha 1 (A1), beta 1 (B1), and D1. In the presence of D1 stimulation, the cell would produce an mRNA that codes for a fluorescent protein; however, if the A1 or B1 receptors are also stimulated at the same time, the cells would degrade the mRNA of the fluorescent protein thereby preventing it from being produced. Which of the following would best serve as a positive control for this experiment?", "answer": "Fenoldopam", "options": {"A": "Bromocriptine", "B": "Dobutamine", "C": "Dopamine", "D": "Epinephrine", "E": "Fenoldopam"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["to create", "dopamine", "agonists", "small pharmaceutical company created", "cell based", "screen", "involved three modified receptors", "alpha 1", "beta", "D1", "presence", "D1 stimulation", "cell", "mRNA", "a fluorescent protein", "A1", "B1 receptors", "same time", "cells", "mRNA", "fluorescent protein", "preventing", "following", "best"]}
{"question": "A 56-year-old woman comes to the physician because of a 2-year-history of intermittent upper abdominal pain that occurs a few hours after meals and occasionally wakes her up in the middle of the night. She reports that the pain is relieved with food intake. Physical examination shows no abnormalities. Endoscopy shows a 0.5 x 0.5 cm ulcer on the posterior wall of the duodenal bulb. A biopsy specimen obtained from the edge of the ulcer shows hyperplasia of submucosal glandular structures. Hyperplasia of these cells most likely results in an increase of which of the following?", "answer": "Bicarbonate secretion", "options": {"A": "Glycoprotein synthesis", "B": "Antigen presentation", "C": "Lysozyme secretion", "D": "Hydrochloric acid secretion", "E": "Bicarbonate secretion"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "2 year history", "intermittent upper", "occurs", "few hours after meals", "occasionally wakes", "middle", "night", "reports", "pain", "relieved with food intake", "abnormalities", "Endoscopy", "0", "ulcer", "posterior wall of", "duodenal bulb", "biopsy specimen obtained", "edge", "ulcer", "hyperplasia", "submucosal glandular structures", "cells", "likely results", "increase"]}
{"question": "The balance between glycolysis and gluconeogenesis is regulated at several steps, and accumulation of one or more products/chemicals can either promote or inhibit one or more enzymes in either pathway. Which of the following molecules if increased in concentration can promote gluconeogenesis?", "answer": "Acetyl-CoA", "options": {"A": "AMP", "B": "ADP", "C": "Insulin", "D": "Fructose-2,6-biphosphate", "E": "Acetyl-CoA"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["balance", "steps", "accumulation", "one", "more", "either", "inhibit one", "more", "following", "increased", "concentration"]}
{"question": "A 37-year-old man who had undergone liver transplantation 7 years ago, presents to the physician because of yellowish discoloration of the skin, sclera, and urine. He is on regular immunosuppressive therapy and is well-adherent to the treatment. He has no comorbidities and is not taking any other medication. He provides a history of similar episodes of yellowish skin discoloration 6–7 times since he underwent liver transplantation. Physical examination shows clinical jaundice. Laboratory studies show:\nWhile blood cell (WBC) count 4,400/mm3\nHemoglobin 11.1 g/dL\nSerum creatinine 0.9 mg/dL\nSerum bilirubin (total) 44 mg/dL\nAspartate transaminase (AST) 1,111 U/L\nAlanine transaminase (ALT) 671 U/L\nSerum gamma-glutamyl transpeptidase 777 U/L\nAlkaline phosphatase 888 U/L\nProthrombin time 17 seconds\nA Doppler ultrasound shows significantly reduced blood flow into the transplanted liver. A biopsy of the transplanted liver is likely to show which of the following histological features?", "answer": "Interstitial cellular infiltration with parenchymal fibrosis, obliterative arteritis", "options": {"A": "Normal architecture of bile ducts and hepatocytes", "B": "Broad fibrous septations with formation of micronodules", "C": "Ballooning degeneration of hepatocytes", "D": "Irregularly shaped nodules of regenerating hepatocytes with peripheral halo", "E": "Interstitial cellular infiltration with parenchymal fibrosis, obliterative arteritis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "liver transplantation", "years", "presents", "physician", "of", "discoloration", "skin", "sclera", "urine", "regular immunosuppressive therapy", "well adherent", "treatment", "comorbidities", "not", "medication", "history of similar episodes", "skin discoloration 67 times", "liver transplantation", "clinical jaundice", "Laboratory studies", "blood", "count", "Hemoglobin", "g dL Serum 0.9 mg dL", "bilirubin", "total", "mg dL Aspartate transaminase", "1 111 U/L Alanine transaminase", "Serum gamma-glutamyl transpeptidase", "phosphatase", "Prothrombin time", "seconds", "Doppler ultrasound", "reduced blood flow", "transplanted liver", "biopsy of", "transplanted liver", "likely to", "following histological features"]}
{"question": "A 14-year-old girl is brought to the physician after she accidentally cut her right forearm earlier that morning while working with her mother's embroidery scissors. She has no history of serious illness. The mother says she went to elementary and middle school abroad and is not sure if she received all of her childhood vaccinations. She appears healthy. Her temperature is 37°C (98.6 °F), pulse 90/min, and blood pressure is 102/68 mm Hg. Examination shows a clean 2-cm laceration on her right forearm with surrounding edema. There is no erythema or discharge. The wound is irrigated with water and washed with soap. Which of the following is the most appropriate next step in management?", "answer": "Administer Tdap only", "options": {"A": "Administer DTaP only", "B": "Intravenous metronidazole", "C": "Administer Tdap only", "D": "Administer TIG only", "E": "No further steps are necessary"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "cut", "right forearm earlier", "morning", "scissors", "history", "serious illness", "middle school", "not sure", "received", "childhood vaccinations", "appears healthy", "temperature", "98", "F", "pulse 90 min", "blood pressure", "mm Hg", "cm laceration", "right forearm", "surrounding edema", "erythema", "discharge", "wound", "irrigated", "water", "washed", "soap", "following", "most appropriate next step"]}
{"question": "A 27-year-old woman comes to the physician because of a 3-day history of a sore throat and fever. Her temperature is 38.5°C (101.3°F). Examination shows edematous oropharyngeal mucosa and enlarged tonsils with purulent exudate. There is tender cervical lymphadenopathy. If left untreated, which of the following conditions is most likely to occur in this patient?", "answer": "Dilated cardiomyopathy", "options": {"A": "Toxic shock syndrome", "B": "Polymyalgia rheumatica", "C": "Rheumatoid arthritis", "D": "Dilated cardiomyopathy", "E": "Erythema multiforme"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old woman", "physician", "3-day history", "sore throat", "fever", "temperature", "edematous oropharyngeal mucosa", "enlarged", "purulent exudate", "tender cervical lymphadenopathy", "left untreated", "following conditions", "to occur", "patient"]}
{"question": "A 72-year-old man comes to his primary care provider because of double vision and headache. He says these symptoms developed suddenly last night and have not improved. He has had type 2 diabetes mellitus for 32 years and essential hypertension for 19 years for which he takes metformin and lisinopril. His last recorded A1c was 9.4%. He has smoked 10 to 15 cigarettes a day for the past 35 years. Family history is significant for chronic kidney disease in his mother. Vital signs reveal a temperature of 36.9 °C (98.42°F), blood pressure of 137/82 mm Hg, and pulse of 72/min. On examination, there is ptosis of the right eye and it is deviated down and out. Visual acuity is not affected in either eye. Which of the following cranial nerves is most likely impaired in this patient?", "answer": "Oculomotor nerve", "options": {"A": "Trochlear nerve", "B": "Oculomotor nerve", "C": "Abducens nerve", "D": "Optic nerve", "E": "Facial nerve"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old man", "primary care provider", "double vision", "headache", "symptoms", "last night", "not improved", "type 2 diabetes mellitus", "years", "essential hypertension", "years", "metformin", "lisinopril", "last recorded A1c", "smoked 10", "cigarettes", "day", "past 35 years", "Family history", "significant", "chronic kidney disease", "Vital signs reveal", "temperature", "36", "98", "blood pressure", "mm Hg", "pulse", "72 min", "ptosis", "right eye", "deviated", "out", "Visual acuity", "not affected", "eye", "following cranial nerves", "most likely impaired", "patient"]}
{"question": "A 3-year-old boy is brought to the emergency department with abdominal pain. His father tells the attending physician that his son has been experiencing severe stomach aches over the past week. They are intermittent in nature, but whenever they occur he cries and draws up his knees to his chest. This usually provides some relief. The parents have also observed mucousy stools and occasional bloody stools that are bright red with blood clots. They tell the physician that their child has never experienced this type of abdominal pain up to the present. 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. On physical exam, his vitals are generally normal with a slight fever and mild tachycardia. The boy appears uncomfortable. An abdominal exam reveals a sausage-shaped mass in the right upper abdomen. Which of the following is the most common cause of these symptoms?", "answer": "Idiopathic", "options": {"A": "Meckel's diverticulum", "B": "Enlarged mesenteric lymph node", "C": "Gastrointestinal infection", "D": "Henoch-Schonlein purpura", "E": "Idiopathic"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "abdominal pain", "attending physician", "severe stomach aches", "past week", "intermittent", "nature", "occur", "knees", "chest", "usually", "relief", "observed", "stools", "occasional bloody stools", "bright red", "blood clots", "physician", "child", "never", "type of abdominal pain", "present", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "normal", "slight fever", "mild tachycardia", "boy appears", "abdominal exam reveals", "shaped mass in", "right upper abdomen", "following", "most common cause", "symptoms"]}
{"question": "A 51-year-old man presents complaining of decreased vibratory sense in his lower limbs. Physical exam reveals a widened pulse pressure and a decrescendo murmur occurring after the S2 heart sound. After further questioning, he also reports he experienced a maculopapular rash over his trunk, palms and soles many years ago that resolved on its own. In order to evaluate the suspected diagnosis, the physician FIRST tested for which of the following?", "answer": "Agglutination of antibodies with beef cardiolipin", "options": {"A": "Agglutination of antibodies with beef cardiolipin", "B": "Indirect immunofluoresence of the patient’s serum and killed T. palladium", "C": "Cytoplasmic inclusions on Giemsa stain", "D": "Agglutination of patients serum with Proteus O antigens", "E": "Gram negative, oxidase positive, comma shaped bacteria growing at 42 degrees C"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "decreased vibratory sense", "lower limbs", "reveals", "widened pulse pressure", "decrescendo murmur occurring", "S2 heart sound", "further", "reports", "maculopapular rash", "trunk", "soles", "years", "resolved", "order to", "suspected diagnosis", "physician FIRST"]}
{"question": "A 28-year-old woman comes to the physician for genetic counseling prior to conception. For the past year, she has had intermittent episodes of headache, nausea, abdominal pain, and tingling of her fingers. She also complains of dark urine during the episodes. Her mother and maternal uncle have similar symptoms and her father is healthy. Her husband is healthy and there is no history of serious illness in his family. Serum studies show elevated concentrations of porphobilinogen and δ-aminolevulinic acid. What is the probability of this patient having a child with the same disease as her?", "answer": "50%", "options": {"A": "67%", "B": "50%", "C": "25%", "D": "100%", "E": "0%"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "genetic counseling prior to conception", "past year", "intermittent episodes of headache", "nausea", "abdominal pain", "tingling", "fingers", "dark urine", "episodes", "similar symptoms", "healthy", "healthy", "history", "serious illness", "family", "Serum studies", "elevated", "porphobilinogen", "aminolevulinic acid", "probability", "patient", "child", "same disease"]}
{"question": "Three days after undergoing cardiac catheterization and coronary angioplasty for acute myocardial infarction, a 70-year-old man develops shortness of breath at rest. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current medications include aspirin, clopidogrel, atorvastatin, sublingual nitroglycerin, metoprolol, and insulin. He appears diaphoretic. His temperature is 37°C (98.6°F), pulse is 120/min, respirations are 22/min, and blood pressure is 100/55 mm Hg. Crackles are heard at both lung bases. Cardiac examination shows a new grade 3/6 holosystolic murmur heard best at the cardiac apex. An ECG shows sinus rhythm with T wave inversion in leads II, III, and aVF. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Papillary muscle rupture", "options": {"A": "Early infarct-associated pericarditis", "B": "Ventricular septal rupture", "C": "Postmyocardial infarction syndrome", "D": "Coronary artery dissection", "E": "Papillary muscle rupture"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Three days", "coronary angioplasty", "acute myocardial infarction", "70 year old man", "shortness of breath", "hypertension", "hyperlipidemia", "type 2 diabetes mellitus", "current medications include aspirin", "clopidogrel", "atorvastatin", "sublingual nitroglycerin", "metoprolol", "insulin", "appears diaphoretic", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "100", "mm Hg", "Crackles", "heard", "lung bases", "new", "holosystolic murmur heard best", "cardiac apex", "ECG", "sinus rhythm", "T wave inversion", "leads", "III", "aVF", "following", "explanation", "patient's"]}
{"question": "An investigator is studying the mechanism of HIV infection in cells obtained from a human donor. The effect of a drug that impairs viral fusion and entry is being evaluated. This drug acts on a protein that is cleaved off of a larger glycosylated protein in the endoplasmic reticulum of the host cell. The protein that is affected by the drug is most likely encoded by which of the following genes?", "answer": "env", "options": {"A": "rev", "B": "gag", "C": "pol", "D": "env", "E": "tat"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "mechanism", "HIV infection", "cells obtained", "human donor", "effect of", "drug", "viral fusion", "drug acts", "a protein", "cleaved", "a larger", "protein", "endoplasmic reticulum", "host cell", "protein", "affected", "drug", "most likely", "following genes"]}
{"question": "A 54-year-old man comes to the physician for a follow-up examination. One week ago, he was treated in the emergency department for chest pain, palpitations, and dyspnea. As part of his regimen, he was started on a medication that irreversibly inhibits the synthesis of thromboxane A2 and prostaglandins. Which of the following is the most likely adverse effect of this medication?", "answer": "Gastrointestinal hemorrhage", "options": {"A": "Chronic rhinosinusitis", "B": "Acute interstitial nephritis", "C": "Gout attack", "D": "Tinnitus", "E": "Gastrointestinal hemorrhage"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["54 year old man", "physician", "follow-up examination", "One week", "treated", "emergency department", "chest pain", "palpitations", "dyspnea", "part of", "regimen", "started", "medication", "inhibits", "thromboxane A2", "prostaglandins", "following", "adverse effect", "medication"]}
{"question": "A 66-year-old man undergoes a coronary artery bypass grafting. Upon regaining consciousness, he reports that he cannot see from either eye and cannot move his arms. Physical examination shows bilaterally equal, reactive pupils. A fundoscopy shows no abnormalities. An MRI of the brain shows wedge-shaped cortical infarcts in both occipital lobes. Which of the following is the most likely cause of this patient's current symptoms?", "answer": "Systemic hypotension\n\"", "options": {"A": "Amyloid angiopathy", "B": "Lipohyalinosis", "C": "Cardiac embolism", "D": "Atherothrombosis", "E": "Systemic hypotension\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["66 year old man", "coronary artery bypass grafting", "consciousness", "reports", "see", "eye", "move", "arms", "equal", "reactive pupils", "fundoscopy", "abnormalities", "MRI of", "brain", "wedge-shaped cortical infarcts", "occipital lobes", "following", "most likely cause", "patient's current symptoms"]}
{"question": "A 74-year-old man presents to the emergency room with abdominal pain. He reports acute onset of left lower quadrant abdominal pain and nausea three hours prior to presentation. The pain is severe, constant, and non-radiating. He has had two maroon-colored bowel movements since the pain started. His past medical history is notable for hypertension, hyperlipidemia, atrial fibrillation, insulin-dependent diabetes mellitus, and rheumatoid arthritis. He takes lisinopril, hydrochlorothiazide, atorvastatin, dabigatran, methotrexate. He has a 60 pack-year smoking history and drinks 1-2 beers per day. He admits to missing some of his medications recently because he was on vacation in Hawaii. His last colonoscopy was 4 years ago which showed diverticular disease in the descending colon and multiple sessile polyps in the sigmoid colon which were removed. His temperature is 100.1°F (37.8°C), blood pressure is 145/85 mmHg, pulse is 100/min, and respirations are 20/min. On exam, he has notable abdominal distention and is exquisitely tender to palpation in all four abdominal quadrants. Bowel sounds are absent. Which of the following is the most likely cause of this patient’s condition?", "answer": "Cardiac thromboembolism", "options": {"A": "Cardiac thromboembolism", "B": "Duodenal compression", "C": "Perforated intestinal mucosal herniation", "D": "Paradoxical thromboembolism", "E": "Splanchnic vasoconstriction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["74 year old man presents", "emergency room", "abdominal pain", "reports acute onset", "left lower quadrant abdominal pain", "nausea three hours prior to", "pain", "severe", "constant", "non radiating", "two maroon colored bowel movements", "pain started", "past medical history", "notable", "hypertension", "hyperlipidemia", "atrial fibrillation", "insulin-dependent diabetes mellitus", "rheumatoid arthritis", "lisinopril", "hydrochlorothiazide", "atorvastatin", "dabigatran", "methotrexate", "60", "smoking history", "1", "day", "missing", "medications recently", "Hawaii", "last colonoscopy", "4 years", "diverticular disease", "descending colon", "multiple sessile polyps in", "sigmoid colon", "removed", "temperature", "100", "blood pressure", "85 mmHg", "pulse", "100 min", "respirations", "20 min", "exam", "notable abdominal distention", "tender", "palpation", "four abdominal", "Bowel sounds", "absent", "following", "most likely cause", "patients condition"]}
{"question": "A 7-year-old boy is brought to the physician by his father because of a 1-day history of a pruritic rash on his trunk and face. Five days ago, he developed low-grade fever, nausea, and diarrhea. Physical examination shows a lace-like erythematous rash on the trunk and face with circumoral pallor. The agent most likely causing symptoms in this patient has selective tropism for which of the following cells?", "answer": "Erythroid progenitor cells", "options": {"A": "Epithelial cells", "B": "T lymphocytes", "C": "Erythroid progenitor cells", "D": "Sensory neuronal cells", "E": "Monocytes\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "1-day history", "pruritic rash", "trunk", "face", "low-grade fever", "nausea", "diarrhea", "lace", "erythematous", "trunk", "face", "circumoral pallor", "agent", "likely causing symptoms", "patient", "tropism", "following cells"]}
{"question": "A 43-year-old woman presents to your clinic for the evaluation of an abnormal skin lesion on her forearm. The patient is worried because her mother passed away from melanoma. You believe that the lesion warrants biopsy for further evaluation for possible melanoma. Your patient is concerned about her risk for malignant disease. What is the most important prognostic factor of melanoma?", "answer": "Depth of invasion of atypical cells", "options": {"A": "S-100 tumor marker present", "B": "Evolution of lesion over time", "C": "Age at presentation", "D": "Depth of invasion of atypical cells", "E": "Level of irregularity of the borders"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic", "evaluation", "abnormal", "forearm", "patient", "worried", "passed", "melanoma", "lesion", "biopsy", "further", "possible melanoma", "patient", "malignant disease", "most important prognostic factor", "melanoma"]}
{"question": "A 30-year-old woman presents to her physician for her annual checkup. She has diabetes mellitus, type 1 and takes insulin regularly. She reports no incidents of elevated or low blood sugar and that she is feeling energetic and ready to face the morning every day. Her vital signs and physical are normal. On the way home from her checkup she stops by the pharmacy and picks up her prescription of insulin. Later that night she takes a dose. What is the signaling mechanism associated with this medication?", "answer": "Activation of tyrosine kinase", "options": {"A": "Increased permeability of the cell membrane to positively charged molecules", "B": "Increased permeability of the cell membrane to negatively charged molecules", "C": "Activation of tyrosine kinase", "D": "Increased concentration intracellular cAMP", "E": "Rapid and direct upregulation of enzyme transcription"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old woman presents", "physician", "annual checkup", "diabetes mellitus", "type 1", "insulin", "reports", "elevated", "low blood sugar", "energetic", "ready to face", "morning", "day", "vital signs", "physical", "normal", "home", "checkup", "stops", "pharmacy", "picks", "insulin", "Later", "night", "dose", "signaling mechanism associated with", "medication"]}
{"question": "A 14-year-old girl comes to the physician because of excessive flow and duration of her menses. Since menarche a year ago, menses have occurred at irregular intervals and lasted 8–9 days. Her last menstrual period was 5 weeks ago with passage of clots. She has no family or personal history of serious illness and takes no medications. She is at the 50th percentile for height and 20th percentile for weight. Physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Inadequate gonadotropin production", "options": {"A": "Embryonal rhabdomyosarcoma", "B": "Endometrial polyp", "C": "Inadequate gonadotropin production", "D": "Defective von Willebrand factor", "E": "Excessive androgen production"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "excessive", "duration", "menses", "menarche", "year", "menses", "irregular intervals", "lasted", "days", "last menstrual period", "5 weeks", "passage", "clots", "personal history", "serious illness", "medications", "50th percentile", "height", "percentile", "weight", "abnormalities", "urine pregnancy test", "negative", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 3-week-old boy is brought to the pediatrician by his parents for a circumcision. The circumcision was uncomplicated; however, after a few hours, the diaper contained blood, and the bleeding has not subsided. A complete blood count was ordered, which was significant for a platelet count of 70,000/mm3. On peripheral blood smear, the following was noted (figure A). The prothrombin time was 12 seconds, partial thromboplastin time was 32 seconds, and bleeding time was 13 minutes. On platelet aggregation studies, there was no response with ristocetin. This result was not corrected with the addition of normal plasma. There was a normal aggregation response with the addition of ADP. Which of the following is most likely true of this patient's underlying disease?", "answer": "Decreased GpIb", "options": {"A": "Decreased GpIIb/IIIa", "B": "Adding epinephrine would not lead to platelet aggregation", "C": "Responsive to desmopressin", "D": "Decreased GpIb", "E": "Protein C resistance"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["3 week old boy", "brought", "pediatrician", "circumcision", "circumcision", "uncomplicated", "few hours", "diaper contained blood", "bleeding", "not", "complete blood count", "ordered", "significant", "platelet count", "70", "mm3", "peripheral blood smear", "following", "noted", "prothrombin time", "seconds", "partial thromboplastin time", "seconds", "bleeding time", "minutes", "platelet aggregation studies", "response", "ristocetin", "result", "not corrected", "addition", "normal plasma", "normal aggregation response", "addition", "ADP", "following", "true", "patient's", "disease"]}
{"question": "A 57-year-old man presents to the emergency department with shortness of breath. He was eating dinner with his family during the holidays and felt very short of breath, thus prompting him to come in. The patient has a past medical history of diabetes, hypertension, 2 myocardial infarctions, and obesity. Physical exam is notable for bilateral pulmonary crackles and a jugular venous distension. Chest radiography reveals an enlarged cardiac silhouette and blunting of the costophrenic angles. The patient is started on a medication for his acute symptoms. Two hours later, he states his symptoms have vastly improved and repeat chest radiography is notable for an enlarged cardiac silhouette. Which of the following is a property of the medication most likely given?", "answer": "Chronic use leads to long-term nephrogenic adaptations", "options": {"A": "Can lead to respiratory depression", "B": "Causes venodilation and a decrease in preload", "C": "Increases cardiac contractility and afterload", "D": "Increases cardiac contractility and decreases afterload", "E": "Chronic use leads to long-term nephrogenic adaptations"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["57 year old man presents", "emergency department", "shortness of breath", "eating dinner", "very short of breath", "prompting", "to", "patient", "past medical diabetes", "hypertension", "2 myocardial infarctions", "obesity", "notable", "bilateral pulmonary crackles", "jugular venous distension", "Chest radiography reveals", "enlarged cardiac silhouette", "blunting", "costophrenic angles", "patient", "started", "medication", "acute symptoms", "Two hours later", "states", "symptoms", "improved", "repeat chest radiography", "notable", "enlarged cardiac silhouette", "following", "property", "medication", "likely given"]}
{"question": "A 47-year-old woman presents to her physician for difficulty swallowing. She states that she intentionally delayed seeing a physician for this issue. She says her primary issue with swallowing is that her mouth always feels dry so she has difficulty chewing food to the point that it can be swallowed. On physical examination, her oral mucosa appears dry. Both of her eyes also appear dry. Several enlarged lymph nodes are palpated. Which of the following patterns of reactive lymphadenitis is most commonly associated with this patient’s presentation?", "answer": "Follicular hyperplasia", "options": {"A": "Sinus hyperplasia", "B": "Follicular hyperplasia", "C": "Paracortical hyperplasia", "D": "Diffuse hyperplasia", "E": "Mixed B and T cell hyperplasia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "difficulty swallowing", "states", "delayed seeing", "physician", "issue", "primary issue", "swallowing", "mouth always", "dry so", "difficulty", "point", "swallowed", "oral mucosa appears dry", "eyes", "appear dry", "enlarged lymph nodes", "following patterns", "reactive lymphadenitis", "most", "associated with", "patients"]}
{"question": "A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?", "answer": "Surgical resection of the mass", "options": {"A": "Chemotherapy", "B": "Seizure prophylaxis and palliative pain therapy", "C": "Irradiation to the breasts", "D": "Irradiation to the brain mass", "E": "Surgical resection of the mass"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old female", "worsening headaches", "past month", "headaches", "usually generalized", "frequently occur", "sleep", "not", "history of migraines", "types", "headaches", "past medical history", "significant", "breast cancer", "diagnosed", "year", "treated with mastectomy", "recovered", "returned to", "CT scan", "brain now", "solitary cortical", "mass surrounded", "edema", "left hemisphere", "brain", "grey white junction", "further", "most appropriate next step", "patient"]}
{"question": "A 42-year-old woman comes to the physician because of progressive weakness. She has noticed increasing difficulty performing household chores and walking her dog over the past month. Sometimes she feels too fatigued to cook dinner. She has noticed that she feels better after sleeping. She does not have chest pain, shortness of breath, or a history of recent illness. She has no personal history of serious illness and takes no medications. She has smoked two packs of cigarettes daily for 25 years. She appears fatigued. Her temperature is 37°C (98.8°F), pulse is 88/min, and blood pressure is 148/80 mm Hg. Pulse oximetry shows an oxygen saturation of 98% in room air. Bilateral expiratory wheezes are heard at both lung bases. Examination shows drooping of the upper eyelids. There is diminished motor strength in her upper extremities. Her sensation and reflexes are intact. A treatment with which of the following mechanisms of action is most likely to be effective?", "answer": "Inhibition of acetylcholinesterase", "options": {"A": "Inhibition of acetylcholinesterase", "B": "Stimulation of B2 adrenergic receptors", "C": "Removing autoantibodies, immune complexes, and cytotoxic constituents from serum", "D": "Reactivation of acetylcholinesterase", "E": "Competitive blocking of the muscarinic receptor"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "progressive weakness", "increasing difficulty", "past month", "Sometimes", "fatigued to cook dinner", "better", "sleeping", "not", "chest pain", "shortness of breath", "history", "recent illness", "personal history", "serious illness", "medications", "smoked two packs", "cigarettes daily", "years", "appears fatigued", "temperature", "98", "pulse", "88 min", "blood pressure", "80 mm Hg", "Pulse oximetry", "oxygen saturation", "98", "room air", "Bilateral expiratory wheezes", "heard", "lung bases", "drooping", "upper eyelids", "diminished motor strength", "upper extremities", "sensation", "reflexes", "intact", "treatment", "of", "following mechanisms", "action", "to", "effective"]}
{"question": "An investigator is studying cardiomyocytes in both normal and genetically modified mice. Both the normal and genetically modified mice are observed after aerobic exercise and their heart rates are recorded and compared. After a 10-minute session on a treadmill, the average pulse measured in the normal mice is 680/min, whereas in the genetically modified mice it is only 160/min. Which of the following is most likely to account for the increased heart rate seen in the normal mice?", "answer": "Greater T-tubule density", "options": {"A": "Greater cardiomyocyte size", "B": "Lower threshold potential for Ca2+ channel opening", "C": "Greater ratio of heart to body weight", "D": "Lower number of gap junctions", "E": "Greater T-tubule density"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "normal", "modified", "normal", "modified", "observed", "aerobic exercise", "heart rates", "recorded", "10 minute", "treadmill", "average pulse measured", "normal", "min", "modified", "only", "min", "following", "to account", "increased heart rate seen", "normal"]}
{"question": "A 54-year-old man presents to his primary care physician with a 2-month-history of diarrhea. He says that he feels the urge to defecate 3-4 times per day and that his stools have changed in character since the diarrhea began. Specifically, they now float, stick to the side of the toilet bowl, and smell extremely foul. His past medical history is significant for several episodes of acute pancreatitis secondary to excessive alcohol consumption. His symptoms are found to be due to a deficiency in an enzyme that is resistant to bile salts. Which of the following enzymes is most likely deficient in this patient?", "answer": "Colipase", "options": {"A": "Amylase", "B": "Chymotrypsin", "C": "Colipase", "D": "Enterokinase", "E": "Lipase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["54 year old man presents", "primary care physician", "2 month history", "diarrhea", "3", "times per day", "stools", "changed", "character", "diarrhea began", "now float", "stick", "side", "toilet", "smell extremely", "past medical history", "significant", "episodes of acute pancreatitis secondary to excessive alcohol consumption", "symptoms", "found to", "due to", "deficiency", "enzyme", "resistant to bile salts", "following enzymes", "deficient", "patient"]}
{"question": "A 50-year-old woman comes to the physician because of worsening pain and swelling of her left knee. For the past year, she has had pain in her knees and hands bilaterally, but never this severe. During this period, she has also had difficulties moving around for about an hour in the mornings and has been sweating more than usual, especially at night. She has been sexually active with a new partner for the past 4 weeks, and they use condoms inconsistently. She occasionally drinks alcohol. The day before she drank 6 beers because she was celebrating a friend's birthday. Her temperature is 38.5°C (101.3°F), blood pressure is 110/70 mm Hg, and pulse is 92/min. The left knee is erythematous, swollen, and tender; movement is restricted due to pain. There is swelling of the metacarpophalangeal joints and proximal interphalangeal joints bilaterally. Arthrocentesis of the knee with synovial fluid analysis shows a greenish, turbid fluid, a cell count of 68,000 WBC/μL and Gram-negative diplococci. An x-ray of the affected knee is most likely to show which of the following findings?", "answer": "Joint space narrowing and bone erosions", "options": {"A": "Calcifications and osteolysis with moth-eaten appearance", "B": "Osteophytes and subchondral cysts", "C": "Irregularity or fragmentation of the tubercle", "D": "Calcification of the meniscal and hyaline cartilage", "E": "Joint space narrowing and bone erosions"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["50 year old woman", "physician", "worsening pain", "swelling of", "left knee", "past year", "pain in", "knees", "hands", "never", "severe", "period", "difficulties moving", "about", "hour", "mornings", "sweating more", "usual", "night", "sexually active", "new", "past 4 weeks", "use condoms", "occasionally", "alcohol", "day", "temperature", "blood pressure", "70 mm Hg", "pulse", "min", "left knee", "erythematous", "swollen", "tender", "movement", "restricted due to pain", "swelling of", "joints", "proximal interphalangeal joints", "Arthrocentesis", "knee", "synovial fluid analysis", "turbid fluid", "count", "WBC", "x-ray", "affected knee", "to", "following findings"]}
{"question": "A 35-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to the office for a prenatal visit. She reports increased urinary frequency but otherwise feels well. Pregnancy and delivery of her first child were uncomplicated. Her vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 16-week gestation. Urinalysis shows mild glucosuria. Laboratory studies show a non-fasting serum glucose concentration of 110 mg/dL. Which of the following is the most likely explanation for this patient's glucosuria?", "answer": "Increased glomerular filtration rate", "options": {"A": "Decreased insulin production", "B": "Decreased SGLT2 expression", "C": "Increased glomerular filtration barrier permeability", "D": "Decreased insulin sensitivity", "E": "Increased glomerular filtration rate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old woman", "gravida 2", "para 1", "weeks", "gestation", "office", "reports increased urinary frequency", "well", "Pregnancy", "delivery", "first child", "uncomplicated", "vital signs", "normal limits", "Pelvic examination", "uterus", "size", "week gestation", "Urinalysis", "mild glucosuria", "Laboratory studies", "non fasting serum glucose concentration", "mg dL", "following", "explanation", "patient's glucosuria"]}
{"question": "A 10-month-old boy is referred to the hospital because of suspected severe pneumonia. During the first month of his life, he had developed upper airway infections, bronchitis, and diarrhea. He has received all the immunizations according to his age. He failed to thrive since the age of 3 months. A month ago, he had a severe lung infection with cough, dyspnea, and diarrhea, and was unresponsive to an empiric oral macrolide. Upon admission to his local hospital, the patient has mild respiratory distress and crackles on auscultation. The temperature is 39.5°C (103.1°F), and the oxygen saturation is 95% on room air. The quantitative immunoglobulin tests show increased IgG, IgM, and IgA. The peripheral blood smear shows leukocytosis and normochromic normocytic anemia. The chloride sweat test and tuberculin test are negative. The chest X-ray reveals bilateral pneumonia. The bronchoalveolar lavage and gram stain report gram-negative bacteria with a growth of Burkholderia cepacia on culture. The laboratory results on admission are as follows:\nLeukocytes 36,600/mm3\nNeutrophils 80%\nLymphocytes 16%\n  Eosinophils 1%\nMonocytes 2%\nHemoglobin 7.6 g/dL\nCreatinine 0.8 mg/dL\nBUN 15 mg/dL\nWhich of the following defects of neutrophil function is most likely responsible?", "answer": "Absent respiratory burst", "options": {"A": "Absent respiratory burst", "B": "Leukocyte adhesion molecule deficiency", "C": "X-linked agammaglobulinemia", "D": "Phagocytosis defect", "E": "Lysosomal trafficking defect"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 month old boy", "suspected severe pneumonia", "first month", "upper airway infections", "bronchitis", "diarrhea", "received", "immunizations", "age", "failed to thrive", "age", "months", "month", "severe lung infection", "cough", "dyspnea", "diarrhea", "unresponsive", "empiric oral macrolide", "local", "patient", "mild respiratory distress", "crackles", "auscultation", "temperature", "oxygen saturation", "95", "room air", "quantitative immunoglobulin tests", "increased IgG", "IgA", "peripheral blood smear", "leukocytosis", "normochromic normocytic anemia", "chloride sweat test", "tuberculin test", "negative", "chest X-ray reveals bilateral pneumonia", "bronchoalveolar lavage", "gram", "report gram negative bacteria", "growth", "Burkholderia cepacia", "culture", "laboratory results on admission", "follows", "36 600 mm3", "80", "16", "Eosinophils 1", "Hemoglobin", "g/dL Creatinine 0.8 mg", "mg", "following defects", "function", "responsible"]}
{"question": "A 74-year-old man presents to the physician with a painful lesion over his right lower limb which began 2 days ago. He says that the lesion began with pain and severe tenderness in the area. The next day, the size of the lesion increased and it became erythematous. He also mentions that a similar lesion had appeared over his left lower limb 3 weeks earlier, but it disappeared after a few days of taking over the counter analgesics. There is no history of trauma, and the man does not have any known medical conditions. On physical examination, the physician notes a cordlike tender area with erythema and edema. There are no signs suggestive of deep vein thrombosis or varicose veins. Which of the following malignancies is most commonly associated with the lesion described in the patient?", "answer": "Adenocarcinoma of pancreas", "options": {"A": "Basal cell carcinoma", "B": "Multiple myeloma", "C": "Malignant melanoma", "D": "Squamous cell carcinoma of head and neck", "E": "Adenocarcinoma of pancreas"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["74 year old man presents", "physician", "painful lesion", "right lower limb", "began 2 days", "lesion began", "pain", "severe tenderness", "area", "next day", "size of", "lesion increased", "erythematous", "similar lesion", "appeared", "left lower limb", "weeks earlier", "days", "over the counter analgesics", "history", "trauma", "man", "not", "known medical conditions", "physician notes", "tender area", "erythema", "edema", "signs suggestive of deep vein thrombosis", "varicose veins", "following malignancies", "most", "associated with", "lesion", "patient"]}
{"question": "A 53-year-old man is being evaluated for a 3-week history of fatigue, difficulty to concentrate, dyspnea with exertion, dizziness, and digital pain that improves with cold. He has smoked half a pack of cigarettes a day since he was 20. His current medical history involves hypertension. He takes enalapril daily. The vital signs include a blood pressure of 131/82 mm Hg, a heart rate of 95/min, and a temperature of 36.9°C (98.4°F). On physical examination, splenomegaly is found. A complete blood count reveals thrombocytosis of 700,000 cells/m3. Lab work further shows decreased serum iron, iron saturation, and serum ferritin and increased total iron binding capacity. A blood smear reveals an increased number of abnormal platelets, and a bone marrow aspirate confirmed the presence of dysplastic megakaryocytes. A mutation on his chromosome 9 confirms the physician’s suspicion of a certain clonal myeloproliferative disease. The patient is started on hydroxyurea. What is the most likely diagnosis?", "answer": "Essential thrombocythemia", "options": {"A": "Myelofibrosis with myeloid metaplasia", "B": "Essential thrombocythemia", "C": "Chronic myelogenous leukemia", "D": "Polycythemia vera", "E": "Aplastic anemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "week history", "fatigue", "difficulty to concentrate", "dyspnea", "exertion", "dizziness", "digital pain", "improves", "cold", "smoked half", "pack", "cigarettes", "day", "20", "current medical history", "hypertension", "enalapril daily", "vital signs include", "blood pressure", "mm Hg", "heart rate", "95 min", "temperature", "36", "98", "splenomegaly", "found", "complete blood count reveals thrombocytosis", "700", "cells m3", "Lab", "further", "decreased serum iron", "iron saturation", "serum ferritin", "increased total iron binding capacity", "blood smear reveals", "increased number of abnormal platelets", "bone marrow aspirate confirmed", "presence", "dysplastic megakaryocytes", "mutation", "chromosome", "confirms", "physicians", "certain clonal myeloproliferative disease", "patient", "started", "hydroxyurea", "diagnosis"]}
{"question": "A 50-year-old Caucasian man presents for a routine checkup. He does not have any current complaint. He is healthy and takes no medications. He has smoked 10–15 cigarettes per day for the past 10 years. His family history is negative for gastrointestinal disorders. Which of the following screening tests is recommended for this patient according to the United States Preventive Services Task Force (USPSTF)?", "answer": "Colonoscopy for colorectal cancer", "options": {"A": "Prostate-specific antigen for prostate cancer", "B": "Carcinoembryonic antigen for colorectal cancer ", "C": "Abdominal ultrasonography for abdominal aortic aneurysm", "D": "Low-dose computerized tomography for lung cancer", "E": "Colonoscopy for colorectal cancer"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["50 year old", "man presents", "routine checkup", "not", "current complaint", "healthy", "medications", "smoked", "cigarettes", "day", "past", "family history", "negative", "gastrointestinal disorders", "following", "patient", "United States"]}
{"question": "A 76-year-old man comes to the physician for a follow-up examination. One week ago, he was prescribed azithromycin for acute bacterial sinusitis. He has a history of atrial fibrillation treated with warfarin and metoprolol. Physical examination shows no abnormalities. Compared to one month ago, laboratory studies show a mild increase in INR. Which of the following best explains this patient's laboratory finding?", "answer": "Depletion of intestinal flora", "options": {"A": "Depletion of intestinal flora", "B": "Inhibition of cytochrome p450", "C": "Increased non-protein bound warfarin fraction", "D": "Drug-induced hepatotoxicity", "E": "Increased gastrointestinal absorption of warfarin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["76 year old man", "physician", "follow-up examination", "One week", "azithromycin", "acute bacterial sinusitis", "history of atrial fibrillation treated with warfarin", "metoprolol", "abnormalities", "one month", "laboratory studies", "mild increase", "INR", "following best", "patient's laboratory finding"]}
{"question": "A 2-week-old male newborn is brought to the physician because his mother has noticed her son has occasional bouts of \"\"turning blue in the face\"\" while crying. He also tires easily and sweats while feeding. He weighed 2150 g (4 lb 11 oz) at birth and has gained 200 g (7 oz). The baby appears mildly cyanotic. Examination shows a 3/6 systolic ejection murmur heard over the left upper sternal border. A single S2 is present. An echocardiography confirms the diagnosis. Which of the following factors is the main determinant of the severity of this patient's cyanosis?\"", "answer": "Right ventricular outflow obstruction", "options": {"A": "Right ventricular outflow obstruction", "B": "Left ventricular outflow obstruction", "C": "Right ventricular hypertrophy", "D": "Ventricular septal defect", "E": "Atrial septal defect"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2 week old male newborn", "brought", "physician", "occasional bouts", "turning blue", "face", "tires easily", "sweats", "g", "oz", "birth", "gained 200 g", "oz", "baby appears mildly cyanotic", "3/6 systolic ejection murmur heard", "left upper sternal border", "single S2", "present", "echocardiography confirms", "diagnosis", "following factors", "main determinant", "severity", "patient", "yanosis?"]}
{"question": "A 19-year-old man presents to an orthopedic surgeon to discuss repair of his torn anterior cruciate ligament. He suffered the injury during a college basketball game 1 week ago and has been using a knee immobilizer since the accident. His past medical history is significant for an emergency appendectomy when he was 12 years of age. At that time, he said that he never wanted to have surgery again. At this visit, the physician explains the procedure to him in detail including potential risks and complications. The patient acknowledges and communicates his understanding of both the diagnosis as well as the surgery and decides to proceed with the surgery in 3 weeks. Afterward, he signs a form giving consent for the operation. Which of the following statements is true about this patient?", "answer": "He has the right to revoke his consent at any time", "options": {"A": "He cannot provide consent because he lacks capacity", "B": "He did not need to provide consent for this procedure since it is obviously beneficial", "C": "He has the right to revoke his consent at any time", "D": "His consent is invalid because his decision is not stable over time", "E": "His parents also need to give consent to this operation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "orthopedic surgeon to", "repair of", "torn anterior cruciate ligament", "suffered", "injury", "college", "1", "using", "knee immobilizer", "past medical history", "significant", "emergency appendectomy", "years", "age", "time", "never wanted to", "surgery", "physician", "procedure", "detail including potential", "complications", "patient", "communicates", "diagnosis", "surgery", "to", "surgery", "3 weeks", "signs", "form giving consent", "operation", "following", "true", "patient"]}
{"question": "A 55-year-old male presents with complaints of intermittent facial flushing. He also reports feeling itchy after showering. On review of systems, the patient says he has been having new onset headaches recently. On physical exam, his vital signs, including O2 saturation, are normal. He has an abnormal abdominal mass palpable in the left upper quadrant. A complete blood count reveals: WBCs 6500/microliter; Hgb 18.2 g/dL; Platelets 385,000/microliter. Which of the following is most likely responsible for his presentation?", "answer": "Tyrosine kinase mutation", "options": {"A": "Elevated serum erythropoietin levels", "B": "Fibrosis of bone marrow", "C": "Tyrosine kinase mutation", "D": "BCR-ABL fusion", "E": "Chronic hypoxemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male presents", "complaints", "intermittent facial flushing", "reports", "itchy", "showering", "review of systems", "patient", "new onset headaches recently", "vital signs", "including O2 saturation", "normal", "abnormal abdominal mass palpable", "left upper quadrant", "complete blood count reveals", "WBCs", "microliter", "Hgb", "g/dL", "Platelets 385", "microliter", "following", "responsible"]}
{"question": "A 42-year-old Caucasian male presents to your office with hematuria and right flank pain. He has no history of renal dialysis but has a history of recurrent urinary tract infections. You order an intravenous pyelogram, which reveals multiple cysts of the collecting ducts in the medulla. What is the most likely diagnosis?", "answer": "Medullary sponge kidney", "options": {"A": "Simple retention cysts", "B": "Acquired polycystic kidney disease", "C": "Autosomal dominant polycystic kidney disease", "D": "Medullary sponge kidney", "E": "Chronic renal failure"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "male presents", "office", "hematuria", "right flank pain", "history of renal dialysis", "history of recurrent urinary tract infections", "order", "intravenous pyelogram", "reveals multiple cysts", "collecting ducts", "medulla", "diagnosis"]}
{"question": "A 28-year-old woman presents with severe vertigo. She also reports multiple episodes of vomiting and difficulty walking. The vertigo is continuous, not related to the position, and not associated with tinnitus or hearing disturbances. She has a past history of acute vision loss in her right eye that resolved spontaneously several years ago. She also experienced left-sided body numbness 3 years ago that also resolved rapidly. She only recently purchased health insurance and could not fully evaluate the cause of her previous symptoms at the time they presented. The patient is afebrile and her vital signs are within normal limits. On physical examination, she is alert and oriented. An ophthalmic exam reveals horizontal strabismus. There is no facial asymmetry and her tongue is central on the protrusion. Gag and cough reflexes are intact. Muscle strength is 5/5 bilaterally. She has difficulty maintaining her balance while walking and is unable to perform repetitive alternating movements with her hands. Which of the following is the best course of treatment for this patient’s condition?", "answer": "High-doses of corticosteroids", "options": {"A": "Acyclovir", "B": "Azathioprine", "C": "High doses of glucose", "D": "High-doses of corticosteroids", "E": "Plasma exchange"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "severe", "reports multiple episodes of vomiting", "difficulty walking", "vertigo", "not related", "position", "not associated with tinnitus", "hearing disturbances", "past history of acute vision loss", "right eye", "resolved", "years", "left-sided body numbness", "years", "resolved rapidly", "only recently", "not", "cause", "previous symptoms", "time", "patient", "afebrile", "vital signs", "normal limits", "alert", "oriented", "ophthalmic exam reveals horizontal strabismus", "facial asymmetry", "tongue", "central", "protrusion", "Gag", "cough reflexes", "intact", "Muscle strength", "5/5", "difficulty", "balance", "unable to perform repetitive alternating movements", "hands", "following", "best course", "treatment", "patients condition"]}
{"question": "A 19-year-old man is brought to the emergency department by the resident assistant of his dormitory for strange behavior. He was found locked out of his room, where the patient admitted to attending a fraternity party before becoming paranoid that the resident assistant would report him to the police. The patient appears anxious. His pulse is 105/min, and blood pressure is 142/85 mm Hg. Examination shows dry mucous membranes and bilateral conjunctival injection. Further evaluation is most likely to show which of the following?", "answer": "Impaired reaction time", "options": {"A": "Tactile hallucinations", "B": "Pupillary constriction", "C": "Synesthesia", "D": "Sense of closeness to others", "E": "Impaired reaction time"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "resident assistant", "dormitory", "strange behavior", "found locked out", "room", "patient", "attending", "resident assistant", "report", "police", "patient appears anxious", "pulse", "min", "blood pressure", "85 mm Hg", "dry mucous membranes", "bilateral conjunctival injection", "Further", "to", "following"]}
{"question": "A 23-year-old primigravid woman comes to the physician at 36 weeks' gestation for her first prenatal visit. She confirmed the pregnancy with a home urine pregnancy kit a few months ago but has not yet followed up with a physician. She takes no medications. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Laboratory studies show:\nHemoglobin 10.6 g/dL\nSerum\nGlucose 88 mg/dL\nHepatitis B surface antigen negative\nHepatitis C antibody negative\nHIV antibody positive\nHIV load 11,000 copies/mL (N < 1000 copies/mL)\nUltrasonography shows an intrauterine fetus consistent in size with a 36-week gestation. Which of the following is the most appropriate next step in management of this patient?\"", "answer": "Start cART and schedule cesarean delivery at 38 weeks' gestation", "options": {"A": "Intrapartum zidovudine and vaginal delivery when labor occurs", "B": "Start cART and schedule cesarean delivery at 38 weeks' gestation", "C": "Start cART and prepare for vaginal delivery at 38 weeks' gestation", "D": "Intrapartum zidovudine and cesarean delivery at 38 weeks' gestation", "E": "Conduct cesarean delivery immediately"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old primigravid woman", "physician", "36 weeks", "estation ", "onfirmed ", "regnancy ", "ome  rine ", "it ", "ew  onths ", "ot ", "ollowed up ", "hysician.", "edications.", "ital signs ", "ormal limits.", "elvic examination ", "terus ", "ize ", "6- eek gestation.", "aboratory studies ", "0.6 ", "erum ", "epatitis B surface antigen ", "ntibody ", "IV antibody ", "oad ", "opies/mL ", " ", "opies/mL)", "ltrasonography ", "ntrauterine  etus ", "ize ", "6- eek gestation.", "ollowing ", "ost  ppropriate  ext  tep ", "atient?"]}
{"question": "A 54-year-old woman comes to the emergency department because of drooping on the left side of her face since that morning. She also reports difficulty closing her eyes and chewing. During the neurologic examination, the physician asks the patient to open her jaw against resistance. Which of the following muscles is most likely activated in this movement?", "answer": "Lateral pterygoid", "options": {"A": "Lateral pterygoid", "B": "Masseter", "C": "Orbicularis oris", "D": "Hyoglossus", "E": "Buccinator"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old woman", "emergency department", "drooping", "left side", "face", "morning", "reports difficulty closing", "eyes", "chewing", "neurologic examination", "physician", "patient to open", "jaw", "resistance", "following muscles", "most likely", "movement"]}
{"question": "A 45-year-old female with a history of gastroesophageal reflux disease presents to her family physician with symptoms of epigastric pain right after a meal. The physician performs a urea breath test which is positive and the patient is started on appropriate medical therapy. Three days later at a restaurant, she experienced severe flushing, tachycardia, hypotension, and vomiting after her first glass of wine. Which of the following is the mechanism of action of the medication causing this side effect?", "answer": "Forms toxic metabolites that damage bacterial DNA", "options": {"A": "Blocks the synthesis of the peptidoglycan layer", "B": "Blocks protein synthesis by binding to the 50S ribosomal subunit inhibiting protein translocation", "C": "Binds to the 30S ribosomal subunit preventing attachment of the aminoacyl-tRNA", "D": "Forms toxic metabolites that damage bacterial DNA", "E": "Inhibits the H+/K+ ATPase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "history of gastroesophageal reflux disease presents", "family physician", "symptoms", "epigastric right", "physician performs", "urea breath", "positive", "patient", "started", "appropriate medical", "Three days later", "restaurant", "severe flushing", "tachycardia", "hypotension", "vomiting", "first glass", "following", "mechanism of action", "medication causing", "side effect"]}
{"question": "A 53-year-old woman presents to your office with several months of fatigue and abdominal pain. The pain is dull in character and unrelated to meals. She has a history of type 2 diabetes mellitus and rheumatic arthritis for which she is taking ibuprofen, methotrexate, and metformin. She has 2-3 drinks on the weekends and does not use tobacco products. On physical examination, there is mild tenderness to palpation in the right upper quadrant. The liver span is 15 cm at the midclavicular line. Laboratory results are as follows:\n\nSerum:\nNa+: 135 mEq/L\nCl-: 100 mEq/L\nK+: 3.7 mEq/L\nHCO3-: 24 mEq/L\nBUN: 13 mg/dL\nCreatinine: 1.0 mg/dL\nAlkaline phosphatase: 100 U/L\nAST: 70 U/L\nALT: 120 U/L\nBilirubin (total): 0.5 mg/dL\nBilirubin (conjugated): 0.1 mg/dL\nAmylase: 76 U/L\n\nWhat is the most likely cause of her clinical presentation?", "answer": "Fatty infiltration of hepatocytes", "options": {"A": "Copper accumulation in hepatocytes", "B": "Fatty infiltration of hepatocytes", "C": "Autoimmune destruction of the intralobular bile ducts", "D": "Alcohol-induced destruction of hepatocytes", "E": "Drug-induced liver damage"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "office", "several months", "fatigue", "abdominal pain", "pain", "dull", "character", "unrelated", "meals", "history of type 2 diabetes mellitus", "rheumatic arthritis", "ibuprofen", "methotrexate", "metformin", "has", "weekends", "not use tobacco products", "mild tenderness", "palpation", "right upper quadrant", "liver span", "midclavicular line", "Laboratory results", "follows", "Serum", "Na", "mEq/L", "100 mEq/L K", "3", "mEq/L HCO3", "mEq/L", "mg/dL Creatinine", "1 0 mg/dL Alkaline phosphatase", "100 U/L AST", "70 U/L ALT", "U/L Bilirubin", "total", "0.5 mg/dL Bilirubin", "conjugated", "0.1 mg/dL Amylase", "76 U/L", "most likely cause"]}
{"question": "A 24-year-old man presents with low-grade fever and shortness of breath for the last 3 weeks. Past medical history is significant for severe mitral regurgitation status post mitral valve replacement five years ago. His temperature is 38.3°C (101.0°F) and respiratory rate is 18/min. Physical examination reveals vertical hemorrhages under his nails, multiple painless erythematous lesions on his palms, and two tender, raised nodules on his fingers. Cardiac auscultation reveals a new-onset 2/6 holosystolic murmur loudest at the apex with the patient in the left lateral decubitus position. A transesophageal echocardiogram reveals vegetations on the prosthetic valve. Blood cultures reveal catalase-positive, gram-positive cocci. Which of the following characteristics is associated with the organism most likely responsible for this patient’s condition?", "answer": "Novobiocin sensitive", "options": {"A": "Hemolysis", "B": "Optochin sensitive", "C": "Coagulase positive", "D": "DNAse positive", "E": "Novobiocin sensitive"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "low-grade fever", "shortness of breath", "last", "weeks", "Past medical history", "significant", "severe mitral regurgitation", "mitral valve replacement five years", "temperature", "respiratory rate", "min", "reveals vertical hemorrhages", "nails", "multiple painless erythematous lesions", "two tender", "raised nodules on", "fingers", "Cardiac auscultation reveals", "new-onset", "murmur loudest", "apex", "patient", "left lateral decubitus position", "transesophageal echocardiogram reveals vegetations", "prosthetic valve", "Blood cultures reveal catalase positive", "following characteristics", "associated with", "likely responsible", "patients condition"]}
{"question": "A 23-year-old woman with asthma is brought to the emergency department because of shortness of breath and wheezing for 20 minutes. She is unable to speak more than a few words at a time. Her pulse is 116/min and respirations are 28/min. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination of the lungs shows decreased breath sounds and scattered end-expiratory wheezing over all lung fields. Treatment with high-dose continuous inhaled albuterol is begun. This patient is at increased risk for which of the following adverse effects?", "answer": "Hypokalemia", "options": {"A": "Miosis", "B": "Hypoglycemia", "C": "Hypokalemia", "D": "Sedation", "E": "Urinary frequency"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "asthma", "brought", "emergency department", "of shortness", "breath", "wheezing", "20 minutes", "unable", "speak more", "time", "pulse", "min", "respirations", "min", "Pulse oximetry", "room air", "oxygen saturation", "lungs", "decreased breath sounds", "scattered end", "lung fields", "Treatment", "high-dose", "inhaled albuterol", "begun", "patient", "increased risk", "following adverse effects"]}
{"question": "A 59-year-old man comes to the physician because of a 4-month history of a pruritic rash. His symptoms have not improved despite treatment with over-the-counter creams. During this period, he has also had a 6-kg (13.5-lb) weight loss. Examination shows a scaly rash over his chest, back, and thighs. A photograph of the rash on his thighs is shown. A biopsy of the skin lesions shows clusters of neoplastic cells with cerebriform nuclei within the epidermis. This patient's condition is most likely caused by the abnormal proliferation of which of the following cell types?", "answer": "T cells", "options": {"A": "T cells", "B": "Keratinocytes", "C": "Mast cells", "D": "Melanocytes", "E": "B cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old man", "physician", "4 month history", "pruritic rash", "symptoms", "not improved", "treatment", "over-the-counter", "period", "kg", "weight loss", "scaly rash", "chest", "back", "thighs", "photograph", "rash", "thighs", "biopsy of", "skin lesions", "clusters", "nuclei", "epidermis", "patient's condition", "most likely caused", "abnormal proliferation", "following cell types"]}
{"question": "A 6-year-old boy is brought in by his mother to his pediatrician for headache and nausea. His headaches began approximately 3 weeks ago and occur in the morning. Throughout the 3 weeks, his nausea has progressively worsened, and he had 2 episodes of emesis 1 day ago. On physical exam, cranial nerves are grossly intact, and his visual field is intact. The patient has a broad-based gait and difficulty with heel-to-toe walking, as well as head titubation. Fundoscopy demonstrates papilledema. A T1 and T2 MRI of the brain is demonstrated in Figures A and B, respectively. Which of the following is most likely the diagnosis?", "answer": "Medulloblastoma", "options": {"A": "Craniopharyngioma", "B": "Ependymoma", "C": "Medulloblastoma", "D": "Pilocytic astrocytoma", "E": "Pinealoma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "pediatrician", "headache", "nausea", "headaches began approximately", "weeks", "occur", "morning", "3 weeks", "nausea", "worsened", "2 episodes of emesis 1", "cranial nerves", "intact", "visual field", "intact", "patient", "broad-based gait", "difficulty", "heel-to-toe walking", "head titubation", "Fundoscopy", "papilledema", "T1", "MRI of", "brain", "following", "diagnosis"]}
{"question": "A simple experiment is performed to measure the breakdown of sucrose into glucose and fructose by a gut enzyme that catalyzes this reaction. A glucose meter is used to follow the breakdown of sucrose into glucose. When no enzyme is added to the sucrose solution, the glucose meter will have a reading of 0 mg/dL; but when the enzyme is added, the glucose meter will start to show readings indicative of glucose being formed. Which of the following diabetic pharmacological agents, when added before the addition of the gut enzyme to the sucrose solution, will maintain a reading of 0 mg/dL?", "answer": "Acarbose", "options": {"A": "Insulin", "B": "Glyburide", "C": "Metformin", "D": "Acarbose", "E": "Exenatide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["simple", "performed to measure", "glucose", "fructose", "gut enzyme", "reaction", "glucose meter", "used to follow", "glucose", "enzyme", "added", "sucrose solution", "glucose meter", "0 mg/dL", "enzyme", "added", "glucose meter", "start to", "glucose", "formed", "following diabetic pharmacological agents", "added", "addition", "gut enzyme", "sucrose solution", "0 mg/dL"]}
{"question": "Three days into hospitalization for a fractured distal femur, a 33-year-old man develops dyspnea and confusion. He has no history of a serious illness. He is unable to answer any questions or follow any commands. His blood pressure is 145/90 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 36.7°C (98.1°F). His oxygen saturation is 90% on 80% FiO2. On examination, purpura is noted on the anterior chest, head, and neck. Inspiratory crackles are heard in both lung fields. Arterial blood gas analysis on 80% FiO2 shows:\npH 7.54\nPCO2 17 mm Hg\nPO2 60 mm Hg\nHCO3− 22 mEq/L\nA chest X-ray is shown. Which of the following best explains the cause of these findings?", "answer": "Fat embolism", "options": {"A": "Acute respiratory distress syndrome", "B": "Fat embolism", "C": "Hospital-acquired pneumonia", "D": "Pulmonary contusion", "E": "Pulmonary thromboembolism"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Three days", "fractured distal femur", "year old man", "dyspnea", "confusion", "history", "serious illness", "unable to", "follow", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "36 min", "temperature", "36", "98", "oxygen saturation", "90", "80", "FiO2", "purpura", "noted", "anterior chest", "head", "neck", "Inspiratory crackles", "heard", "lung fields", "Arterial blood gas analysis", "80", "FiO2", "pH", "PCO2 17 mm Hg PO2", "HCO3 22 mEq/L", "chest X-ray", "following best", "cause", "findings"]}
{"question": "A 32-year-old woman comes to the emergency department for a 2-week history of right upper quadrant abdominal pain. She has also been feeling tired and nauseous for the past 5 weeks. She has a history of depression and suicidal ideation. She is a social worker for an international charity foundation. She used intravenous illicit drugs in the past but quit 4 months ago. Her only medication is sertraline. Her temperature is 37.8°C (100.0°F), pulse is 100/min, and blood pressure is 128/76 mm Hg. She is alert and oriented. Scleral icterus is present. Abdominal examination shows tenderness to palpation in the right upper quadrant. The liver edge is palpated 3 cm below the right costal margin. There is no rebound tenderness or guarding. The abdomen is non-distended and the fluid wave test is negative. She is able to extend her arms with wrists in full extension and hold them steady without flapping. Laboratory studies show:\nHemoglobin 13.8 g/dL\nLeukocytes 13,700/mm3\nPlatelets 165,000/mm3\nProthrombin time 14 seconds\nPartial thromboplastin time 35 seconds\nSerum:\nTotal bilirubin 4.8 mg/dL\nDirect bilirubin 1.3 mg/dL\nAspartate aminotransferase 1852 U/L\nAlanine aminotransferase 2497 U/L\nUrea nitrogen 21 mg/dL\nCreatinine 1.2 mg/dL\nHepatitis A IgM antibody Negative\nHepatitis B surface antigen Negative\nHepatitis B surface antibody Negative\nHepatitis B core IgM antibody Positive\nHepatitis C antibody Positive\nHepatitis C RNA Negative\nUrine beta-hCG Negative\nWhich of the following is the most appropriate next step in management?\"", "answer": "Supportive therapy", "options": {"A": "Pegylated interferon-alpha", "B": "Supportive therapy", "C": "Tenofovir", "D": "Ribavirin and interferon", "E": "Vaccination against Hepatitis B"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "2-week history", "right upper quadrant abdominal pain", "tired", "nauseous", "past", "weeks", "history of depression", "suicidal ideation", "social worker", "used intravenous illicit drugs", "past", "months", "only medication", "sertraline", "temperature", "100", "pulse", "100 min", "blood pressure", "76 mm Hg", "alert", "oriented", "Scleral icterus", "present", "Abdominal", "tenderness", "palpation", "right upper quadrant", "liver edge", "3 cm", "right costal margin", "rebound tenderness", "guarding", "abdomen", "non distended", "fluid wave test", "negative", "able to extend", "arms", "wrists", "full extension", "hold", "steady", "flapping", "Laboratory studies", "Hemoglobin 13", "g", "mm3", "Prothrombin time 14 seconds Partial thromboplastin time 35", "Serum", "Total", "mg", "Direct bilirubin", "mg", "Creatinine", "antibody", "Positive", "beta-hCG", "following", "most appropriate next step"]}
{"question": "A 57-year-old man comes to the physician because of sudden-onset fever, malaise, and pain and swelling of his wrists and ankles that began a week ago. One month ago, he was started on hydralazine for adjunctive treatment of hypertension. His temperature is 37.8°C (100°F). Examination shows swelling, tenderness, warmth, and erythema of both wrists and ankles; range of motion is limited. Further evaluation is most likely to show an increased level of which of the following autoantibodies?", "answer": "Anti-histone", "options": {"A": "Anti-dsDNA", "B": "Anti-Smith", "C": "Anti-β2-glycoprotein", "D": "Anti-histone", "E": "Anti-Jo-1"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["57 year old man", "physician", "sudden fever", "malaise", "pain", "swelling", "wrists", "ankles", "began", "week", "One month", "started", "hydralazine", "adjunctive", "hypertension", "temperature", "swelling", "tenderness", "warmth", "erythema of", "wrists", "ankles", "range of motion", "limited", "Further", "to", "increased level", "following autoantibodies"]}
{"question": "A 64-year-old man who recently immigrated to the United States from Haiti comes to the physician because of a 3-week history of progressively worsening exertional dyspnea and fatigue. For the past few days, he has also had difficulty lying flat due to trouble breathing. Over the past year, he has had intermittent fever, night sweats, and cough but he has not been seen by a physician for evaluation of these symptoms. His temperature is 37.8°C (100°F). An x-ray of the chest is shown. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Jugular venous distention on inspiration", "options": {"A": "Elimination of S2 heart sound splitting with inspiration", "B": "Head bobbing in synchrony with heart beat", "C": "\"Prominent \"\"a\"\" wave on jugular venous pressure tracing\"", "D": "Jugular venous distention on inspiration", "E": "Crescendo-decrescendo systolic ejection murmur"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["64 year old man", "recently", "United States", "Haiti", "physician", "3 week history", "worsening exertional dyspnea", "fatigue", "past", "days", "difficulty lying flat due to trouble breathing", "past year", "intermittent fever", "night sweats", "cough", "not", "seen by", "physician", "temperature", "x-ray of", "chest", "Further", "to", "following findings"]}
{"question": "A 55-year-old man with a past medical history of obesity and hyperlipidemia suddenly develops left-sided chest pain and shortness of breath while at work. He relays to coworkers that the pain is intense and has spread to his upper left arm over the past 10 minutes. He reports it feels a lot like the “heart attack” he had a year ago. He suddenly collapses and is unresponsive. Coworkers perform cardiopulmonary resuscitation for 18 minutes until emergency medical services arrives. Paramedics pronounce him dead at the scene. Which of the following is the most likely cause of death in this man?", "answer": "Ventricular tachycardia", "options": {"A": "Aortic dissection", "B": "Atrial fibrillation", "C": "Free wall rupture", "D": "Pericarditis", "E": "Ventricular tachycardia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "past medical", "hyperlipidemia", "left-sided chest pain", "shortness of breath", "relays to", "pain", "intense", "spread", "upper left arm", "past 10 minutes", "reports", "lot", "heart attack", "year", "collapses", "unresponsive", "perform cardiopulmonary resuscitation", "minutes", "Paramedics", "dead", "following", "most likely cause of death", "man"]}
{"question": "A previously healthy 13-year-old girl is brought to the physician for evaluation of a 2-month history of fatigue. She reports recurrent episodes of pain in her right wrist and left knee. During this period, she has had a 4-kg (8.8-lb) weight loss. Her mother has rheumatoid arthritis. Her temperature is 38°C (100.4°F). Examination shows diffuse lymphadenopathy. Oral examination shows several painless oral ulcers. The right wrist and the left knee are swollen and tender. Laboratory studies show a hemoglobin concentration of 9.8 g/dL, a leukocyte count of 2,000/mm3, and a platelet count of 75,000/mm3. Urinalysis shows excessive protein. This patient's condition is associated with which of the following laboratory findings?", "answer": "Anti-dsDNA antibodies", "options": {"A": "Leukocytoclastic vasculitis with IgA and C3 immune complex deposition", "B": "Anti-dsDNA antibodies", "C": "Anti-citrullinated peptide antibodies", "D": "Excessive lymphoblasts", "E": "Positive HLA-B27 test"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy", "year old girl", "brought", "physician", "month history", "fatigue", "reports recurrent episodes of pain", "right wrist", "left knee", "period", "4 kg", "8.8", "weight loss", "rheumatoid arthritis", "temperature", "100", "diffuse lymphadenopathy", "several painless oral ulcers", "right wrist", "left knee", "swollen", "tender", "Laboratory studies", "a hemoglobin concentration", "dL", "leukocyte count", "mm3", "platelet count", "75", "mm3", "Urinalysis", "excessive protein", "patient's condition", "associated with", "following laboratory findings"]}
{"question": "A 23-year-old man comes to the emergency department because of palpitations, dizziness, and substernal chest pain for three hours. The day prior, he was at a friend’s wedding, where he consumed seven glasses of wine. The patient appears diaphoretic. His pulse is 220/min and blood pressure is 120/84 mm Hg. Based on the patient's findings on electrocardiography, the physician diagnoses atrial fibrillation with rapid ventricular response and administers verapamil for rate control. Ten minutes later, the patient is unresponsive and loses consciousness. Despite resuscitative efforts, the patient dies. Histopathologic examination of the heart at autopsy shows an accessory atrioventricular conduction pathway. Electrocardiography prior to the onset of this patient's symptoms would most likely have shown which of the following findings?", "answer": "Slurred upstroke of the QRS complex", "options": {"A": "Slurred upstroke of the QRS complex", "B": "Cyclic alteration of the QRS axis", "C": "Epsilon wave following the QRS complex", "D": "Prolongation of the QT interval", "E": "Positive Sokolow-Lyon index"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old man", "emergency department", "palpitations", "dizziness", "substernal chest pain", "three hours", "day prior", "seven glasses", "patient appears diaphoretic", "pulse", "min", "blood pressure", "84 mm Hg", "Based", "patient's findings", "electrocardiography", "physician diagnoses atrial fibrillation with rapid ventricular response", "administers verapamil", "rate control", "Ten minutes later", "patient", "unresponsive", "consciousness", "resuscitative efforts", "patient dies", "Histopathologic", "autopsy", "accessory atrioventricular pathway", "Electrocardiography prior to", "onset", "patient's symptoms", "most likely", "following findings"]}
{"question": "A typically healthy 27-year-old woman presents to the physician because of a 3-week history of fatigue, headache, and dry cough. She does not smoke or use illicit drugs. Her temperature is 37.8°C (100.0°F). Chest examination shows mild inspiratory crackles in both lung fields. An X-ray of the chest shows diffuse interstitial infiltrates bilaterally. A Gram stain of saline-induced sputum shows no organisms. Inoculation of the induced sputum on a cell-free medium that is enriched with yeast extract, horse serum, cholesterol, and penicillin G grows colonies that resemble fried eggs. Which of the following is the most appropriate next step in management?", "answer": "Oral azithromycin", "options": {"A": "Intravenous ceftriaxone", "B": "Intravenous ceftriaxone and oral azithromycin", "C": "Intravenous clindamycin", "D": "Oral amoxicillin", "E": "Oral azithromycin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy 27 year old woman presents", "physician", "3 week history", "fatigue", "headache", "dry cough", "not smoke", "use illicit", "temperature", "100", "Chest examination", "mild inspiratory crackles", "lung fields", "X-ray of", "chest", "diffuse interstitial infiltrates", "Gram stain", "induced sputum", "Inoculation", "induced sputum", "medium", "yeast extract", "cholesterol", "penicillin G", "colonies", "fried", "following", "most appropriate next step"]}
{"question": "A 59-year-old Caucasian man with a history of hypertension and emphysema is brought to the hospital because of progressive lethargy and confusion. The patient has been experiencing poor appetite for the past 3 months and has unintentionally lost 9 kg (19.8 lb). He was a smoker for 35 years and smoked 1 pack daily, but he quit 5 years ago. He takes lisinopril and bisoprolol for hypertension and has no allergies. On examination, the patient appears cachectic. He responds to stimulation but is lethargic and unable to provide any significant history. His blood pressure is 138/90 mm Hg, heart rate is 100/min, and his oxygen saturation on room air is 90%. His mucous membranes are moist, heart rate is regular without murmurs or an S3/S4 gallop, and his extremities are without any edema. His pulmonary examination shows mildly diminished breath sounds in the right lower lobe with bilateral wheezing. His laboratory values are shown:\nSodium 110 mEq/L\nPotassium 4.1 mEq/L\nChloride 102 mEq/L\nCO2 41 mm Hg\nBUN 18\nCreatinine 1.3 mg/dL\nGlucose 93 mg/dL\nUrine osmolality 600 mOsm/kg H2O\nPlasma osmolality 229 mEq/L\nWBC 8,200 cells/mL\nHgb 15.5 g/dL\nArterial blood gas pH 7.36/pCO2 60/pO2 285\nChest X-ray demonstrates a mass in the right upper lobe. What is the most appropriate treatment to address the patient’s hyponatremia?", "answer": "3% saline at 35 mL/h", "options": {"A": "Dextrose with 20 mEq/L KCl at 250 mL/h", "B": "0.9% saline at 125 mL/h", "C": "0.45% saline at 100 mL/h", "D": "3% saline at 35 mL/h", "E": "0.45% saline with 30 mEq/L KCl at 100 mL/h"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["59 year old", "man", "history of hypertension", "emphysema", "brought", "hospital", "progressive lethargy", "confusion", "patient", "poor appetite", "past 3 months", "lost", "kg", "smoker", "35 years", "smoked 1 pack daily", "lisinopril", "bisoprolol", "hypertension", "allergies", "patient appears cachectic", "stimulation", "lethargic", "unable to", "significant history", "blood pressure", "90 mm Hg", "heart rate", "100 min", "oxygen saturation", "room air", "90", "mucous membranes", "moist", "heart rate", "regular", "murmurs", "S3 S4", "extremities", "edema", "pulmonary", "mildly diminished breath sounds", "right lower lobe", "bilateral wheezing", "laboratory values", "mEq/L", "mm", "mg dL", "mg dL", "H2O", "gas", "X", "mass", "right upper lobe", "most appropriate treatment to", "patients hyponatremia"]}
{"question": "A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?", "answer": "Testicular ultrasound", "options": {"A": "Needle biopsy", "B": "Testicular ultrasound", "C": "MRI abdomen and pelvis", "D": "CT abdomen and pelvis", "E": "Send labs"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old male presents", "testicular mass of unknown duration", "patient states", "first", "unusual", "right testicle two weeks", "states", "not", "urgent", "not painful", "not changed", "first", "mass", "patient", "pain", "exam", "patients right testicle", "non-tender", "firm mass", "negative transillumination test", "mass", "non reducible", "following", "best next step"]}
{"question": "A 1-year-old boy is brought to the emergency department after his mother witnessed him swallow a nickel-sized battery a few hours ago. She denies any episodes of vomiting or hematemesis. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 95/45 mm Hg, pulse 140/min, respiratory rate 15/min, and oxygen saturation 99% on room air. On physical examination, the patient is alert and responsive. The oropharynx is clear. The cardiac exam is significant for a grade 2/6 holosystolic murmur loudest at the left lower sternal border. The lungs are clear to auscultation. The abdomen is soft and nontender with no hepatosplenomegaly. Bowel sounds are present. What is the most appropriate next step in the management of this patient?", "answer": "Immediate endoscopic removal", "options": {"A": "Induce emesis to expel the battery", "B": "Induce gastrointestinal motility with metoclopramide to expel the battery", "C": "Reassurance and observation for the next 24 hours", "D": "Computed tomography (CT) scan to confirm the diagnosis ", "E": "Immediate endoscopic removal"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "emergency department", "swallow", "nickel sized battery", "few hours", "episodes of vomiting", "hematemesis", "vital signs include", "temperature", "98", "blood pressure 95", "mm Hg", "pulse", "min", "respiratory rate", "min", "oxygen saturation 99", "room air", "patient", "alert", "responsive", "oropharynx", "clear", "significant", "holosystolic murmur loudest", "left lower sternal border", "lungs", "clear", "auscultation", "abdomen", "soft", "nontender", "hepatosplenomegaly", "Bowel sounds", "present", "most appropriate next step", "patient"]}
{"question": "A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?", "answer": "Intubation and mechanical ventilation", "options": {"A": "Insertion of nasogastric tube and enteral nutrition", "B": "Intravenous antibiotic therapy", "C": "Intubation and mechanical ventilation", "D": "Intravenous corticosteroid therapy", "E": "Immediate bronchoscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old soldier", "brought back", "military treatment facility 45 minutes", "sustaining injuries", "building fire", "attack", "building", "20 minutes", "arrival", "confused", "appears", "Glasgow Coma Score", "pulse", "min", "respirations", "min", "blood pressure", "70 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "96", "multiple second-degree burns", "chest", "bilateral upper extremities", "third-degree burns", "face", "black", "seen", "nose", "mouth", "lungs", "clear", "auscultation", "Cardiac examination", "abnormalities", "abdomen", "soft", "nontender", "Intravenous fluid resuscitation", "begun", "following", "most appropriate next step"]}
{"question": "A 49-year-old woman presents to her primary care physician for a routine health maintenance examination. She says that she is currently feeling well and has not noticed any acute changes in her health. She exercises 3 times a week and has tried to increase the amount of fruits and vegetables in her diet. She has smoked approximately 1 pack of cigarettes every 2 days for the last 20 years. Her last pap smear was performed 2 years ago, which was unremarkable. Her past medical history includes hypertension and type II diabetes. Her mother was diagnosed with breast cancer at 62 years of age. The patient is 5 ft 5 in (165.1 cm), weighs 185 lbs (84 kg), and has a BMI of 30.8 kg/m^2. Her blood pressure is 155/98 mmHg, pulse is 90/min, and respirations are 18/min. Physical examination is unremarkable. Lipid studies demonstrate an LDL cholesterol of 130 mg/dL and an HDL cholesterol of 42 mg/dL. Which of the following is the best next step in management?", "answer": "Statin therapy", "options": {"A": "Chest radiography", "B": "Colonoscopy", "C": "Mammogram", "D": "Pap smear", "E": "Statin therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care physician", "routine", "currently", "well", "not", "acute changes", "exercises 3 times", "week", "to increase", "amount", "smoked approximately", "pack", "cigarettes", "2 days", "20 years", "last pap smear", "performed 2 years", "unremarkable", "past medical history includes hypertension", "type II diabetes", "diagnosed", "breast cancer", "62 years", "age", "patient", "5 ft 5", "lbs", "84 kg", "BMI", "30 8 kg m", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "unremarkable", "Lipid studies", "LDL cholesterol", "mg/dL", "HDL cholesterol", "mg/dL", "following", "best next step"]}
{"question": "A 24-year-old woman with a past medical history of anorexia nervosa presents to the clinic due to heavy menses, bleeding gums, and easy bruisability. She says she is trying to lose weight by restricting her food intake. She has taken multiple courses of antibiotics for recurrent sinusitis over the past month. No other past medical history or current medications. She is not sexually active. Her vital signs are as follows: temperature 37.0°C (98.6°F), blood pressure 90/60 mm Hg, heart rate 100/min, respiratory rate 16/min. Her BMI is 16 kg/m2. Her physical examination is significant for ecchymosis on the extremities, dry mucous membranes, and bleeding gums. A gynecological exam is non-contributory. Laboratory tests show a prolonged PT, normal PTT, and normal bleeding time. CBC shows microcytic anemia, normal platelets, and normal WBC. Her urine pregnancy test is negative. Which of the following is the most likely cause of her condition?", "answer": "Vitamin K deficiency", "options": {"A": "Vitamin K deficiency", "B": "Acute myelogenous leukemia", "C": "Missed miscarriage", "D": "Immune thrombocytopenic purpura", "E": "Physical abuse"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "past medical history of anorexia nervosa presents", "clinic", "heavy menses", "bleeding gums", "easy bruisability", "to", "weight", "restricting", "food intake", "multiple courses", "recurrent sinusitis", "past month", "past medical history", "current medications", "not sexually active", "vital signs", "follows", "temperature", "98", "blood pressure 90 60 mm Hg", "heart rate 100 min", "respiratory rate", "min", "BMI", "kg/m2", "significant", "ecchymosis", "extremities", "dry mucous membranes", "bleeding gums", "non contributory", "Laboratory tests", "prolonged PT", "normal PTT", "normal bleeding time", "CBC", "microcytic anemia", "normal platelets", "normal WBC", "urine pregnancy test", "negative", "following", "most likely cause", "condition"]}
{"question": "A 65-year-old obese female presents to the emergency room complaining of severe abdominal pain. She reports pain localized to the epigastrium that radiates to the right scapula. The pain occurred suddenly after a fast food meal with her grandchildren. Her temperature is 100.9°F (38.2°C), blood pressure is 140/85 mmHg, pulse is 108/min, and respirations are 20/min. On examination, she demonstrates tenderness to palpation in the epigastrium. She experiences inspiratory arrest during deep palpation of the right upper quadrant but this exam finding is not present on the left upper quadrant. A blockage at which of the following locations is most likely causing this patient’s symptoms?", "answer": "Cystic duct", "options": {"A": "Common hepatic duct", "B": "Ampulla of Vater", "C": "Cystic duct", "D": "Pancreatic duct of Wirsung", "E": "Common bile duct"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old obese female presents", "emergency room", "severe abdominal", "reports pain localized", "epigastrium", "radiates", "right scapula", "pain", "temperature", "100 9F", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "20 min", "tenderness", "palpation", "epigastrium", "inspiratory arrest", "deep", "right upper quadrant", "exam finding", "not present", "left upper quadrant", "blockage", "following locations", "most likely causing", "patients symptoms"]}
{"question": "A 27-year-old Asian woman presents to her primary care physician with joint pain and a headache. She has had intermittent joint and muscle pain for the past several months in the setting of a chronic headache. She states that the pain seems to migrate from joint to joint, and her muscles typically ache making it hard for her to sleep. The patient's past medical history is non-contributory, and she is currently taking ibuprofen for joint pain. Physical exam is notable for an asymmetrical pulse in the upper extremities. The patient has lost 10 pounds since her previous visit 2 months ago. Laboratory values are notable for an elevated C-reactive protein and erythrocyte sedimentation rate. Which of the following is the best next step in management?", "answer": "Prednisone", "options": {"A": "Anti-dsDNA level", "B": "Methotrexate", "C": "Prednisone", "D": "Recommend exercise and optimize the patient's sleep regimen", "E": "Temporal artery biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old", "woman presents", "primary care physician", "joint pain", "headache", "intermittent joint", "muscle pain", "past", "months", "setting", "chronic headache", "states", "pain", "to migrate", "joint", "joint", "muscles", "ache making", "hard", "to sleep", "patient's past", "non contributory", "currently", "ibuprofen", "joint pain", "notable", "asymmetrical pulse", "upper extremities", "patient", "lost 10 pounds", "previous", "months", "Laboratory values", "notable", "elevated C-reactive protein", "erythrocyte sedimentation rate", "following", "best next step"]}
{"question": "Your colleague has been reading the literature on beta-carotene supplementation and the risk of heart disease. She thinks they may share a clinically relevant association and would like to submit an editorial to a top journal. Upon final literature review, she discovers a newly published study that refutes any association between beta-carotene and heart disease. Your colleague is upset; you suggest that she, instead, mathematically pool the results from all of the studies on this topic and publish the findings. What type of study design are you recommending to your colleague?", "answer": "Meta-analysis", "options": {"A": "Randomized control trial", "B": "Systematic review", "C": "Case-cohort study", "D": "Meta-analysis", "E": "Cross-sectional study"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["literature", "beta-carotene supplementation", "the", "of heart disease", "relevant association", "to submit", "top journal", "final", "study", "association", "beta-carotene", "heart disease", "pool", "results", "studies", "topic", "findings", "type"]}
{"question": "A 15-year-old girl comes to the physician with her father for evaluation of short stature. She feels well overall but is concerned because all of her friends are taller than her. Her birth weight was normal. Menarche has not yet occurred. Her father says he also had short stature and late puberty. The girl is at the 5th percentile 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 12 years. Further evaluation of this patient is most likely to show which of the following sets of laboratory findings?\n $$$ FSH %%% LH %%% Estrogen %%% GnRH $$$", "answer": "Normal normal normal normal", "options": {"A": "↓ ↓ ↓ ↓", "B": "↓ ↓ ↑ ↓", "C": "Normal normal normal normal", "D": "↑ ↑ ↓ ↑", "E": "Normal normal ↓ normal"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "short stature", "well overall", "birth weight", "normal", "Menarche", "not", "short stature", "late puberty", "girl", "5th percentile", "height", "percentile", "weight", "Breast development", "Tanner", "Pubic", "axillary hair", "absent", "x-ray", "left hand", "wrist", "bone age", "years", "Further evaluation", "patient", "to", "following sets", "laboratory findings", "LH", "Estrogen", "GnRH"]}
{"question": "In which of the following pathological states would the oxygen content of the trachea resemble the oxygen content in the affected alveoli?", "answer": "Pulmonary embolism", "options": {"A": "Emphysema", "B": "Pulmonary fibrosis", "C": "Pulmonary embolism", "D": "Foreign body obstruction distal to the trachea", "E": "Exercise"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["following pathological states", "oxygen content", "trachea", "oxygen content", "affected alveoli"]}
{"question": "A previously healthy 32-year-old man comes to the physician because of a 1-week history of upper back pain, dyspnea, and a sensation of pressure in his chest. He has had no shortness of breath, palpitations, fevers, or chills. He emigrated from Ecuador when he was 5 years old. He does not smoke or drink alcohol. He takes no medications. He is 194 cm (6 ft 4 in) tall and weighs 70.3 kg (155 lb); BMI is 19 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 73/min, respirations are 15/min, and blood pressure is 152/86 mm Hg in the right arm and 130/72 mg Hg in the left arm. Pulmonary examination shows faint inspiratory wheezing bilaterally. A CT scan of the chest with contrast is shown. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Cystic medial necrosis", "options": {"A": "Infection with Trypanosoma cruzi", "B": "Cystic medial necrosis", "C": "Large-vessel vasculitis", "D": "Atherosclerotic plaque formation", "E": "Congenital narrowing of the aortic arch"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old man", "physician", "of", "1-week history", "upper back pain", "dyspnea", "sensation of pressure", "chest", "shortness of breath", "palpitations", "fevers", "chills", "Ecuador", "old", "not smoke", "medications", "6 ft 4", "tall", "70", "kg", "BMI", "kg/m2", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "right arm", "72 mg Hg", "left", "Pulmonary", "faint inspiratory wheezing", "CT scan of", "chest", "contrast", "following", "underlying cause", "patient's condition"]}
{"question": "A 26-year-old woman presents to the emergency department with fever, chills, lower quadrant abdominal pain, and urinary frequency for the past week. Her vital signs include temperature 38.9°C (102.0°F), pulse 110/min, respirations 16/min, and blood pressure 122/78 mm Hg. Physical examination is unremarkable. Urinalysis reveals polymorphonuclear leukocytes (PMNs) > 10 cells/HPF and the presence of bacteria (> 105 CFU/mL). Which of the following is correct concerning the most likely microorganism responsible for this patient’s condition?", "answer": "Gram-negative rod-shaped bacilli", "options": {"A": "Nonmotile, pleomorphic rod-shaped, gram-negative bacilli ", "B": "Pear-shaped motile protozoa", "C": "Gram-negative rod-shaped bacilli", "D": "Gram-positive cocci that grow in clusters", "E": "Gram-positive cocci that grow in chains"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "fever", "chills", "lower quadrant abdominal pain", "urinary frequency", "past week", "vital signs include temperature", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "unremarkable", "Urinalysis reveals polymorphonuclear leukocytes", "PMNs", "10 cells/HPF", "presence of bacteria", "CFU/mL", "following", "correct", "responsible", "patients condition"]}
{"question": "A 30-year-old man comes to the emergency department because of the sudden onset of back pain beginning 2 hours ago. Beginning yesterday, he noticed that his eyes started appearing yellowish and his urine was darker than normal. Two months ago, he returned from a trip to Greece, where he lived before immigrating to the US 10 years ago. Three days ago, he was diagnosed with latent tuberculosis and started on isoniazid. He has worked as a plumber the last 5 years. His temperature is 37.4°C (99.3°F), pulse is 80/min, and blood pressure is 110/70 mm Hg. Examination shows back tenderness and scleral icterus. Laboratory studies show:\nHematocrit 29%\nLeukocyte count 8000/mm3\nPlatelet count 280,000/mm3\nSerum\nBilirubin\nTotal 4 mg/dL\nDirect 0.7 mg/dL\nHaptoglobin 15 mg/dL (N=41–165 mg/dL)\nLactate dehydrogenase 180 U/L\nUrine\nBlood 3+\nProtein 1+\nRBC 2–3/hpf\nWBC 2–3/hpf\nWhich of the following is the most likely underlying cause of this patient's anemia?\"", "answer": "Absence of reduced glutathione", "options": {"A": "Crescent-shaped erythrocytes", "B": "Absence of reduced glutathione", "C": "Inhibition of aminolevulinate dehydratase", "D": "Absence of uridine 5'-monophosphate", "E": "Defective ankyrin in the RBC membrane"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old man", "emergency department", "sudden onset", "back pain beginning 2 hours", "Beginning", "eyes started appearing", "urine", "darker", "normal", "Two months", "returned", "trip", "Greece", "lived", "Three days", "diagnosed", "latent tuberculosis", "started", "isoniazid", "plumber", "last", "years", "temperature", "99", "pulse", "80 min", "blood pressure", "70 mm Hg", "back tenderness", "scleral icterus", "Laboratory studies", "Hematocrit", "Leukocyte count", "mm3 Platelet count", "Serum Bilirubin Total 4 mg/dL Direct 0.7 mg dL Haptoglobin", "dL", "N", "mg/dL", "Lactate dehydrogenase", "U/L Urine Blood 3", "Protein 1", "RBC", "hpf WBC", "following", "underlying cause", "patient", "nemia?"]}
{"question": "A 69-year-old Caucasian man presents for a routine health maintenance examination. He feels well. He has no significant past medical history. He takes aspirin for the occasional headaches that he has had for over several years. He exercises every day and does not smoke. His father was diagnosed with a hematologic malignancy at 79 years old. The patient’s vital signs are within normal limits. Physical examination shows no abnormalities. The laboratory test results are as follows:\nHemoglobin 14.5 g/dL\nLeukocyte count 62,000/mm3\nPlatelet count 350,000/mm3\nA peripheral blood smear is obtained (shown on the image). Which of the following best explains these findings?", "answer": "Chronic lymphocytic leukemia", "options": {"A": "Acute lymphoid leukemia", "B": "Acute myeloid leukemia", "C": "Adult T cell leukemia", "D": "Chronic lymphocytic leukemia", "E": "Hairy cell leukemia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old", "man presents", "routine", "well", "significant past medical history", "aspirin", "occasional headaches", "over several years", "exercises", "day", "not smoke", "diagnosed", "hematologic malignancy", "years old", "patients vital signs", "normal limits", "abnormalities", "laboratory test results", "follows", "Hemoglobin", "g Leukocyte count 62", "mm3 Platelet count 350", "peripheral blood smear", "obtained", "following best", "findings"]}
{"question": "A 62-year-old woman is referred to a tertiary care hospital with a history of diplopia and fatigue for the past 3 months. She has also noticed difficulty in climbing the stairs and combing her hair. She confirms a history of 2.3 kg (5.0 lb) weight loss in the past 6 weeks and constipation. Past medical history is significant for type 2 diabetes mellitus. She has a 50-pack-year cigarette smoking history. Physical examination reveals a blood pressure of 135/78 mm Hg supine and 112/65 while standing, a heart rate of 82/min supine and 81/min while standing, and a temperature of 37.0°C (98.6°F). She is oriented to time and space. Her right upper eyelid is slightly drooped. She has difficulty in abducting the right eye. Pupils are bilaterally equal and reactive to light with accommodation. The corneal reflex is intact. Muscle strength is reduced in the proximal muscles of all 4 limbs, and the lower limbs are affected more when compared to the upper limbs. Deep tendon reflexes are bilaterally absent. After 10 minutes of cycling, the reflexes become positive. Sensory examination is normal. Diffuse wheezes are heard on chest auscultation. Which of the following findings is expected?", "answer": "Incremental pattern on repetitive nerve conduction studies", "options": {"A": "Antibodies against muscle-specific kinase", "B": "Elevated serum creatine kinase", "C": "Incremental pattern on repetitive nerve conduction studies", "D": "Periventricular plaques on MRI of the brain", "E": "Thymoma on CT scan of the chest"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["62 year old woman", "history", "diplopia", "fatigue", "past 3 months", "difficulty", "climbing", "combing", "hair", "confirms", "history", "kg", "5 0", "weight loss", "past", "weeks", "constipation", "Past medical history", "significant", "type 2 diabetes mellitus", "cigarette smoking", "Physical examination reveals", "blood pressure", "mm Hg supine", "65", "standing", "heart rate", "min supine", "81 min", "standing", "temperature", "98", "oriented to time", "space", "right upper eyelid", "slightly", "difficulty", "right eye", "Pupils", "equal", "reactive to light", "accommodation", "corneal reflex", "intact", "Muscle strength", "reduced", "proximal muscles of", "limbs", "lower limbs", "affected more", "upper limbs", "Deep tendon reflexes", "absent", "10 minutes", "cycling", "reflexes", "positive", "Sensory", "normal", "Diffuse wheezes", "heard", "chest auscultation", "following findings"]}
{"question": "A 60-year-old man is brought to the emergency department by police officers because he was acting strangely in public. The patient was found talking nonsensically to characters on cereal boxes in the store. Past medical history is significant for multiple hospitalizations for alcohol-related injuries and seizures. The patient’s vital signs are within normal limits. Physical examination shows a disheveled male who is oriented to person, but not time or place. Neurologic examination shows nystagmus and severe gait ataxia. A T1/T2 MRI is performed and demonstrates evidence of damage to the mammillary bodies. The patient is given the appropriate treatment for recovering most of his cognitive functions. However, significant short-term memory deficits persist. The patient remembers events from his past such as the school and college he attended, his current job, and the names of family members quite well. Which of the following is the most likely diagnosis in this patient?", "answer": "Korsakoff's syndrome", "options": {"A": "Delirium", "B": "Delirium tremens", "C": "Korsakoff's syndrome", "D": "Schizophrenia", "E": "Wernicke encephalopathy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "brought", "emergency department", "police officers", "acting", "patient", "found talking", "boxes", "store", "Past medical history", "significant", "multiple", "alcohol related injuries", "seizures", "patients vital signs", "normal", "Physical examination", "male", "oriented to person", "not time", "place", "Neurologic examination", "nystagmus", "severe gait ataxia", "T1", "MRI", "performed", "damage", "mammillary bodies", "patient", "given", "appropriate treatment", "recovering", "significant", "deficits", "patient", "past", "school", "college", "attended", "current", "names", "family members", "well", "following", "diagnosis", "patient"]}
{"question": "A 43-year-old woman presents to her primary care physician for a general wellness appointment. The patient states that sometimes she has headaches and is ashamed of her body habitus. Otherwise, the patient has no complaints. The patient's 90-year-old mother recently died of breast cancer. The patient smokes 1 pack of cigarettes per day. She drinks 2-3 glasses of red wine per day with dinner. She has been considering having a child as she has just been promoted to a position that gives her more time off and a greater income. The patient's current medications include lisinopril, metformin, and a progesterone intrauterine device (IUD). On physical exam, you note a normal S1 and S2 heart sound. Pulmonary exam is clear to auscultation bilaterally. The patient's abdominal, musculoskeletal, and neurological exams are within normal limits. The patient is concerned about her risk for breast cancer and asks what she can do to reduce her chance of getting this disease. Which of the following is the best recommendation for this patient?", "answer": "Exercise and reduce alcohol intake", "options": {"A": "Switch to oral contraceptive pills for contraception", "B": "Begin breastfeeding", "C": "Test for BRCA1 and 2", "D": "Recommend monthly self breast exams", "E": "Exercise and reduce alcohol intake"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care physician", "general wellness appointment", "patient states", "sometimes", "headaches", "ashamed", "body", "patient", "complaints", "patient's 90 year old", "recently died of breast cancer", "patient smokes", "pack", "cigarettes", "day", "2-3 glasses of", "day", "dinner", "child", "position", "gives", "more time", "greater income", "patient's current medications include lisinopril", "metformin", "progesterone intrauterine device", "note", "normal S1", "S2 heart sound", "Pulmonary exam", "clear", "auscultation", "patient's abdominal", "musculoskeletal", "neurological exams", "normal limits", "patient", "breast cancer", "to", "chance", "getting", "disease", "following", "best", "patient"]}
{"question": "A 12-year-old boy is brought to his pediatrician with a high fever. He was feeling fatigued yesterday and then developed a high fever overnight that was accompanied by chills and malaise. This morning he also started complaining of headaches and myalgias. He has otherwise been healthy and does not take any medications. He says that his friends came down with the same symptoms last week. He is given oseltamivir and given instructions to rest and stay hydrated. He is also told that this year the disease is particularly infectious and is currently causing a global pandemic. He asks the physician why the same virus can infect people who have already had the disease and is told about a particular property of this virus. Which of the following properties is required for the viral genetic change that permits global pandemics of this virus?", "answer": "Segmented genomic material", "options": {"A": "Concurrent infection with 2 viruses", "B": "Crossing over of homologous regions", "C": "Point mutations in the viral genetic code", "D": "One virus that produces a non-functional protein", "E": "Segmented genomic material"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "pediatrician", "high fever", "fatigued", "then", "high fever overnight", "chills", "malaise", "morning", "started", "headaches", "myalgias", "healthy", "not", "medications", "same symptoms last week", "given oseltamivir", "given instructions to", "hydrated", "year", "disease", "infectious", "currently causing", "global", "physician", "same", "infect", "disease", "property", "following properties", "required", "viral genetic change", "global"]}
{"question": "A 52-year-old woman presents to the clinic with complaints of intermittent chest pain for 3 days. The pain is retrosternal, 3/10, and positional (laying down seems to make it worse). She describes it as “squeezing and burning” in quality, is worse after food intake and emotional stress, and improves with antacids. The patient recently traveled for 4 hours in a car. Past medical history is significant for osteoarthritis, hypertension and type 2 diabetes mellitus, both of which are moderately controlled. Medications include ibuprofen, lisinopril, and hydrochlorothiazide. She denies palpitations, dyspnea, shortness of breath, weight loss, fever, melena, or hematochezia. What is the most likely explanation for this patient’s symptoms?", "answer": "Incompetence of the lower esophageal sphincter", "options": {"A": "Blood clot within the lungs", "B": "Decreased gastric mucosal protection", "C": "Incompetence of the lower esophageal sphincter", "D": "Insufficient blood supply to the myocardium", "E": "Temporary blockage of the bile duct"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "clinic", "complaints of intermittent chest pain", "3 days", "pain", "retrosternal", "10", "positional", "laying", "to make", "worse", "squeezing", "burning", "quality", "worse", "food intake", "emotional stress", "improves", "antacids", "patient recently", "hours", "car", "Past medical history", "significant", "osteoarthritis", "hypertension", "type 2 diabetes mellitus", "moderately controlled", "Medications include ibuprofen", "lisinopril", "hydrochlorothiazide", "palpitations", "dyspnea", "shortness of breath", "weight loss", "fever", "melena", "hematochezia", "patients symptoms"]}
{"question": "A 24-year-old man presents to the emergency department for severe abdominal pain for the past day. The patient states he has had profuse, watery diarrhea and abdominal pain that is keeping him up at night. The patient also claims that he sees blood on the toilet paper when he wipes and endorses having lost 5 pounds recently. The patient's past medical history is notable for IV drug abuse and a recent hospitalization for sepsis. His temperature is 99.5°F (37.5°C), blood pressure is 120/68 mmHg, pulse is 100/min, respirations are 14/min, and oxygen saturation is 98% on room air. On physical exam, you note a young man clutching his abdomen in pain. Abdominal exam demonstrates hyperactive bowel sounds and diffuse abdominal tenderness. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?", "answer": "Vancomycin", "options": {"A": "Metronidazole", "B": "Vancomycin", "C": "Clindamycin", "D": "Mesalamine enema", "E": "Supportive therapy and ciprofloxacin if symptoms persist"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "severe abdominal", "past day", "patient states", "watery diarrhea", "abdominal pain", "keeping", "night", "patient", "sees blood on", "toilet paper", "wipes", "lost 5 pounds recently", "patient's past", "notable", "IV drug abuse", "recent", "sepsis", "temperature", "99", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "note", "young man", "abdomen", "pain", "exam", "hyperactive bowel sounds", "diffuse abdominal tenderness", "Cardiopulmonary exam", "normal limits", "following", "next best step"]}
{"question": "A 57-year-old man is brought to the emergency department for worsening pain and swelling of his left ankle for the past 2 hours. The pain is severe and awakened him from sleep. He has hypertension and hyperlipidemia. Current medications include hydrochlorothiazide and pravastatin. His temperature is 37.8°C (100.1°F), pulse is 105/min, and blood pressure is 148/96 mm Hg. Examination shows exquisite tenderness, erythema, and edema of the left ankle; active and passive range of motion is limited by pain. Arthrocentesis of the ankle joint yields cloudy fluid with a leukocyte count of 19,500/mm3 (80% segmented neutrophils). Gram stain is negative. A photomicrograph of the joint fluid aspirate under polarized light is shown. Which of the following is the most appropriate pharmacotherapy?", "answer": "Colchicine", "options": {"A": "Probenecid", "B": "Colchicine and allopurinol", "C": "Triamcinolone and probenecid", "D": "Colchicine", "E": "Ketorolac and aspirin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["57 year old man", "brought", "emergency department", "worsening pain", "swelling", "left", "past", "hours", "pain", "severe", "sleep", "hypertension", "hyperlipidemia", "Current medications include hydrochlorothiazide", "pravastatin", "temperature", "100", "pulse", "min", "blood pressure", "96 mm Hg", "tenderness", "erythema", "edema", "left", "active", "passive range of motion", "limited", "pain", "Arthrocentesis of", "ankle joint", "cloudy fluid", "leukocyte count", "19 500 mm3", "80", "segmented neutrophils", "Gram stain", "negative", "photomicrograph", "joint fluid aspirate", "following", "most appropriate pharmacotherapy"]}
{"question": "A 37-year-old man presents to the physician because of dysphagia and regurgitation for the past 5 years. In recent weeks, it has become very difficult for him to ingest solid or liquid food. He has lost 3 kg (6 lb) during this time. He was admitted to the hospital last year because of pneumonia. Three years ago, he had an endoscopic procedure which partially improved his dysphagia. He takes amlodipine and nitroglycerine before meals. His vital signs are within normal limits. BMI is 19 kg/m2. Physical examination shows no abnormalities. A barium swallow X-ray is shown. Which of the following patterns of esophageal involvement is the most likely cause of this patient’s condition?", "answer": "Absent peristalsis and impaired lower esophageal sphincter relaxation", "options": {"A": "Abnormal esophageal contraction with deglutition lower esophageal sphincter relaxation", "B": "Absent peristalsis and impaired lower esophageal sphincter relaxation", "C": "Poor pharyngeal propulsion and upper esophageal sphincter obstruction", "D": "Sequenced inhibition followed by contraction of the musculature along the esophagus", "E": "Severely weak peristalsis and patulous lower esophageal sphincter"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "physician", "dysphagia", "regurgitation", "past", "years", "recent weeks", "very difficult", "to", "solid", "liquid food", "lost 3 kg", "time", "year", "pneumonia", "Three years", "endoscopic procedure", "improved", "dysphagia", "amlodipine", "nitroglycerine", "meals", "vital signs", "normal", "BMI", "kg/m2", "abnormalities", "barium swallow X-ray", "following patterns", "esophageal involvement", "most likely cause", "patients condition"]}
{"question": "A 23-year-old woman is seen by her primary care physician. The patient has a several year history of excessive daytime sleepiness. She also reports episodes where she suddenly falls to the floor after her knees become weak, often during a laughing spell. She has no other significant past medical history. Her primary care physician refers her for a sleep study, which confirms the suspected diagnosis. Which of the following laboratory findings would also be expected in this patient?", "answer": "Undetectable CSF hypocretin-1", "options": {"A": "Increased serum methoxyhemoglobin", "B": "Reduced serum hemoglobin", "C": "Undetectable CSF hypocretin-1", "D": "Increased CSF oligoclonal bands", "E": "Increased serum ESR"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "seen by", "primary care physician", "patient", "several year history", "excessive daytime sleepiness", "reports episodes", "falls", "floor", "knees", "weak", "often", "spell", "significant past medical history", "primary care physician refers", "sleep study", "confirms", "suspected diagnosis", "following laboratory findings", "patient"]}
{"question": "A 30-year-old woman comes to the physician with her husband because they have been trying to conceive for 15 months with no success. They have been sexually active at least twice a week. The husband sometimes has difficulties maintaining erection during sexual activity. During attempted vaginal penetration, the patient has discomfort and her pelvic floor muscles tighten up. Three years ago, the patient was diagnosed with body dysmorphic disorder. There is no family history of serious illness. She does not smoke or drink alcohol. She takes no medications. Vital signs are within normal limits. Pelvic examination shows normal appearing vulva without redness; there is no vaginal discharge. An initial attempt at speculum examination is aborted after the patient's pelvic floor muscles tense up and she experiences discomfort. Which of the following is the most likely diagnosis?", "answer": "Genitopelvic pain disorder", "options": {"A": "Vulvodynia", "B": "Vulvovaginitis", "C": "Painful bladder syndrome", "D": "Genitopelvic pain disorder", "E": "Endometriosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old woman", "physician", "to", "months", "sexually active", "twice", "week", "sometimes", "difficulties", "erection", "vaginal penetration", "patient", "discomfort", "pelvic floor muscles", "Three years", "patient", "diagnosed", "body dysmorphic disorder", "family history", "serious illness", "not smoke", "medications", "Vital signs", "normal limits", "Pelvic examination", "normal appearing vulva", "redness", "vaginal discharge", "initial", "speculum", "aborted", "patient's pelvic floor muscles tense", "discomfort", "following", "diagnosis"]}
{"question": "An otherwise healthy 76-year-old man is brought to the physician because of poor sleep for the past several years. Every night he has been sleeping less and taking longer to fall asleep. During the day, he feels tired and has low energy and difficulty concentrating. Sleep hygiene and relaxation techniques have failed to improve his sleep. He would like to start a short-term pharmacological therapy trial but does not want a drug that makes him drowsy during the day. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Zaleplon", "options": {"A": "Temazepam", "B": "Diphenhydramine", "C": "Suvorexant", "D": "Zaleplon", "E": "Flurazepam"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 76 year old man", "brought", "physician", "of poor sleep", "past", "years", "night", "sleeping less", "longer to fall asleep", "day", "tired", "difficulty concentrating", "relaxation techniques", "failed to", "sleep", "to start", "short-term pharmacological", "not", "drug", "makes", "drowsy", "day", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 23-year-old man is brought to the emergency department by ambulance following a motor vehicle accident. He was pinned between 2 cars for several hours. The patient has a history of asthma. He uses an albuterol inhaler intermittently. The patient was not the driver, and admits to having a few beers at a party prior to the accident. His vitals in the ambulance are stable. Upon presentation to the emergency department, the patient is immediately brought to the operating room for evaluation and surgical intervention. It is determined that the patient’s right leg has a Gustilo IIIC injury in the mid-shaft of the tibia with a severely comminuted fracture. The patient’s left leg suffered a similar injury but with damage to the peroneal nerve. The anesthesiologist begins to induce anesthesia. Which of the following agents would be contraindicated in this patient?", "answer": "Succinylcholine", "options": {"A": "Etomidate", "B": "Halothane", "C": "Neostigmine", "D": "Propofol", "E": "Succinylcholine"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old man", "brought", "emergency department", "ambulance following", "motor vehicle accident", "pinned", "cars", "several hours", "patient", "history of asthma", "uses", "albuterol inhaler", "patient", "not", "driver", "few", "ambulance", "stable", "emergency department", "patient", "immediately brought", "operating room", "surgical intervention", "patients right leg", "injury", "shaft", "tibia", "severely comminuted fracture", "patients left leg suffered", "similar injury", "damage", "peroneal nerve", "anesthesiologist begins to induce anesthesia", "following agents", "contraindicated", "patient"]}
{"question": "A 3-year-old girl is brought to the physician for a well-child visit. Her father is concerned about the color and strength of her teeth. He says that most of her teeth have had stains since the time that they erupted. She also has a limp when she walks. Examination shows brownish-gray discoloration of the teeth. She has lower limb length discrepancy; her left knee-to-ankle length is 4 cm shorter than the right. Which of the following drugs is most likely to have been taken by this child's mother when she was pregnant?", "answer": "Tetracycline", "options": {"A": "Trimethoprim", "B": "Ciprofloxacin", "C": "Gentamicin", "D": "Chloramphenicol", "E": "Tetracycline"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3 year old girl", "brought", "physician", "color", "strength", "teeth", "most", "teeth", "stains", "time", "limp", "walks", "gray discoloration of", "teeth", "lower limb length discrepancy", "left", "ankle length", "4", "shorter", "right", "following drugs", "to", "pregnant"]}
{"question": "A 2300-g (5.07-lb) male newborn is delivered at term to a 39-year-old woman. Examination shows a sloping forehead, a flat nasal bridge, increased interocular distance, low-set ears, a protruding tongue, a single palmar crease and an increased gap between the first and second toe. There are small white and brown spots in the periphery of both irises. The abdomen is distended. An x-ray of the abdomen shows two large air-filled spaces in the upper quadrant. This patient's condition is most likely associated with which of the following cardiac anomalies?", "answer": "Atrioventricular septal defect", "options": {"A": "Patent ductus arteriosus", "B": "Atrial septal defects", "C": "Atrioventricular septal defect", "D": "Tetralogy of Fallot", "E": "Ventricular septal defect"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["g", "male newborn", "delivered", "term", "year old woman", "sloping forehead", "flat nasal bridge", "increased", "distance", "low-set ears", "protruding tongue", "single palmar crease", "increased gap", "first", "second toe", "brown spots", "periphery", "irises", "abdomen", "distended", "x-ray of", "abdomen", "two large air", "spaces", "upper quadrant", "patient's condition", "most likely associated with", "following cardiac anomalies"]}
{"question": "A 47-year-old woman comes to the physician because of a 3-week history of generalized fatigue, mild fever, abdominal pain, and nausea. She attended the state fair over a month ago, where she tried a number of regional foods, and wonders if it might have been caused by something she ate. She has also noticed darkening of her urine, which she attributes to not drinking enough water recently. She has type 2 diabetes mellitus. She drinks 1–2 beers daily. She works as nursing assistant in a rehabilitation facility. Current medications include glyburide, sitagliptin, and a multivitamin. She appears tired. Her temperature is 38.1°C (100.6°F), pulse is 99/min, and blood pressure is 110/74 mm Hg. Examination shows mild scleral icterus. The liver is palpated 2–3 cm below the right costal margin and is tender. Laboratory studies show:\nHemoglobin 10.6 g/dL\nLeukocyte count 11600/mm3\nPlatelet count 221,000/mm3\nSerum\nUrea nitrogen 26 mg/dL\nGlucose 122 mg/dL\nCreatinine 1.3 mg/dL\nBilirubin 3.6 mg/dL\nTotal 3.6 mg/dL\nDirect 2.4 mg/dL\nAlkaline phosphatase 72 U/L\nAST 488 U/L\nALT 798 U/L\nHepatitis A IgG antibody (HAV-IgG) positive\nHepatitis B surface antigen (HBsAg) positive\nHepatitis B core IgG antibody (anti-HBc) positive\nHepatitis B envelope antigen (HBeAg) positive\nHepatitis C antibody (anti-HCV) negative\nWhich of the following is the most likely diagnosis?\"", "answer": "Active chronic hepatitis B infection", "options": {"A": "Inactive chronic hepatitis B infection", "B": "Acute hepatitis B infection", "C": "Active chronic hepatitis B infection", "D": "Resolved acute hepatitis B infection", "E": "Alcoholic hepatitis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "3 week history", "generalized fatigue", "mild fever", "abdominal pain", "nausea", "attended", "state fair", "month", "number", "regional", "caused", "ate", "urine", "attributes to not drinking", "water recently", "type 2 diabetes mellitus", "daily", "nursing assistant", "rehabilitation facility", "Current medications include glyburide", "sitagliptin", "multivitamin", "appears tired", "temperature", "100", "pulse", "99 min", "blood pressure", "74 mm Hg", "mild scleral icterus", "liver", "23 cm", "right costal margin", "tender", "Laboratory studies", "Hemoglobin 10.6 g", "Leukocyte", "Platelet count", "Urea nitrogen", "Creatinine 1", "Total", "Direct 2 mg Alkaline phosphatase 72 U/L AST", "ALT", "Hepatitis", "IgG", "positive", "B", "core", "anti-HBc", "positive Hepatitis B envelope antigen", "positive Hepatitis C antibody", "anti-HCV", "negative", "following", "diagnosis"]}
{"question": "A 5-year-old boy is brought to the emergency department for evaluation of a progressive rash that started 2 days ago. The rash began on the face and progressed to the trunk and extremities. Over the past week, he has had a runny nose, a cough, and red, crusty eyes. He immigrated with his family from Turkey 3 months ago. His father and his older brother have Behcet disease. Immunization records are unavailable. The patient appears irritable and cries during the examination. His temperature is 40.0°C (104°F). Examination shows general lymphadenopathy and dry mucous membranes. Skin turgor is decreased. There is a blanching, partially confluent erythematous maculopapular exanthema. Examination of the oral cavity shows two 5-mm aphthous ulcers at the base of the tongue. His hemoglobin concentration is 11.5 g/dL, leukocyte count is 6,000/mm3, and platelet count is 215,000/mm3. Serology confirms the diagnosis. Which of the following is the most appropriate next step in management?", "answer": "Vitamin A supplementation", "options": {"A": "Intravenous immunoglobulin (IVIG)", "B": "Oral acyclovir", "C": "Vitamin A supplementation", "D": "Reassurance and follow-up in 3 days", "E": "Oral penicillin V"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "progressive rash", "started 2 days", "rash began", "face", "progressed", "trunk", "extremities", "past week", "runny nose", "cough", "red", "crusty eyes", "Turkey", "months", "Behcet disease", "unavailable", "patient appears irritable", "temperature", "40", "general lymphadenopathy", "dry mucous membranes", "Skin", "decreased", "blanching", "confluent erythematous maculopapular exanthema", "two", "mm aphthous ulcers", "the base of", "tongue", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "Serology confirms", "diagnosis", "following", "most appropriate next step"]}
{"question": "A 7-year-old boy presents to the ER with progressive dysphagia over the course of 3 months and a new onset fever for the past 24 hours. The temperature in the ER was 39.5°C (103.1°F). There are white exudates present on enlarged tonsils (Grade 2). Routine blood work reveals a WBC count of 89,000/mm3, with the automatic differential yielding a high (> 90%) percentage of lymphocytes. A peripheral blood smear is ordered, demonstrating the findings in the accompanying image. The peripheral smear is submitted to pathology for review. After initial assessment, the following results are found on cytologic assessment of the cells:\nTdT: positive\nCALLA (CD 10): positive\nWhich of the following cell markers are most likely to be positive as well? ", "answer": "CD 19", "options": {"A": "CD 8", "B": "CD 2", "C": "CD 7", "D": "CD 19", "E": "CD 5"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "ER", "progressive dysphagia", "course", "months", "new onset fever", "past 24 hours", "temperature", "ER", "white exudates present", "enlarged tonsils", "Routine blood", "reveals", "WBC count", "mm3", "automatic differential", "high", "90", "percentage", "lymphocytes", "peripheral blood smear", "ordered", "findings", "peripheral smear", "submitted", "pathology", "initial assessment", "following results", "found", "cytologic", "cells", "TdT", "positive CALLA", "CD 10", "positive", "following cell markers", "to", "positive", "well"]}
{"question": "A 74-year-old man presents to the emergency department with sudden onset of abdominal pain that is most felt around the umbilicus. The pain began 16 hours ago and has no association with meals. He has not been vomiting, but he has had several episodes of bloody loose bowel movements. He was hospitalized 1 week ago for an acute myocardial infarction. He has had diabetes mellitus for 35 years and hypertension for 20 years. He has smoked 15–20 cigarettes per day for the past 40 years. His temperature is 36.9°C (98.4°F), blood pressure is 95/65 mm Hg, and pulse is 95/min. On physical examination, the patient is in severe pain, there is a mild periumbilical tenderness, and a bruit is heard over the epigastric area. Which of the following is the most likely diagnosis?", "answer": "Acute mesenteric ischemia", "options": {"A": "Chronic mesenteric ischemia", "B": "Colonic ischemia", "C": "Acute mesenteric ischemia", "D": "Peptic ulcer disease", "E": "Irritable bowel syndrome"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old man presents", "emergency department", "sudden", "abdominal", "most", "umbilicus", "pain began", "hours", "association", "meals", "not", "vomiting", "several episodes of bloody loose bowel movements", "hospitalized 1 week", "acute myocardial infarction", "diabetes mellitus", "35 years", "hypertension", "20 years", "smoked", "cigarettes", "day", "past 40 years", "temperature", "36", "98", "blood pressure", "95 65 mm Hg", "pulse", "95 min", "patient", "severe pain", "mild periumbilical tenderness", "bruit", "heard", "epigastric area", "following", "diagnosis"]}
{"question": "A 33-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of frequent contractions. The contractions are 40 seconds each, occurring every 2 minutes, and increasing in intensity. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her current medications include 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. There is clear fluid in the vulva and the introitus. The cervix is dilated to 5 cm, 70% effaced, and station of the head is -2. A fetal ultrasound shows polyhydramnios, a median cleft lip, and fused thalami. The corpus callosum, 3rd ventricle, and lateral ventricles are absent. The spine shows no abnormalities and there is a four chamber heart. Which of the following is the most appropriate next step in management?", "answer": "Allow vaginal delivery", "options": {"A": "Perform cesarean delivery", "B": "Allow vaginal delivery", "C": "Initiate misoprostol therapy", "D": "Perform dilation and evacuation", "E": "Initiate nifedipine therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "gestation", "emergency department", "frequent contractions", "contractions", "40 seconds", "occurring", "2 minutes", "increasing", "intensity", "first child", "delivered", "lower segment transverse cesarean", "fetal heart rate", "current medications include folic acid", "multivitamin", "temperature", "36", "98", "heart rate", "88 min", "blood pressure", "76 mm Hg", "Contractions", "abdomen", "vulva", "introitus", "cervix", "dilated", "70", "station", "head", "2", "fetal ultrasound", "polyhydramnios", "median cleft lip", "fused thalami", "corpus callosum", "3rd ventricle", "lateral ventricles", "absent", "spine", "abnormalities", "four chamber heart", "following", "most appropriate next step"]}
{"question": "A 34-year-old man comes to the physician for a 2-month history of an itchy rash on his forearm. He feels well otherwise and has not had any fever or chills. He returned from an archaeological expedition to Guatemala 4 months ago. Skin examination shows a solitary, round, pink-colored plaque with central ulceration on the right wrist. There is right axillary lymphadenopathy. A photomicrograph of a biopsy specimen from the lesion is shown. Which of the following is the most likely causal organism?", "answer": "Leishmania braziliensis", "options": {"A": "Treponema pallidum", "B": "Trypanosoma brucei", "C": "Ancylostoma duodenale", "D": "Borrelia burgdorferi", "E": "Leishmania braziliensis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "2 month history", "itchy rash", "forearm", "well", "not", "fever", "chills", "returned", "Guatemala", "months", "Skin examination", "solitary", "round", "pink-colored plaque", "central ulceration", "right wrist", "right", "photomicrograph", "biopsy specimen", "lesion", "following", "causal"]}
{"question": "A 59-year-old woman comes to the physician because of a 1-month history of episodic cough and shortness of breath. The cough is nonproductive and worsens when she climbs stairs and during the night. She has not had chest pain or palpitations. Eight weeks ago, she had fever, sore throat, and nasal congestion. She has a 10-year history of hypertension. She has smoked half a pack of cigarettes daily for 16 years. Her only medication is enalapril. Her pulse is 78/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Diffuse end-expiratory wheezes are heard on pulmonary auscultation. An x-ray of the chest shows no abnormalities. Spirometry shows an FEV1:FVC ratio of 65% and an FEV1 of 60%. Which of the following is the most likely diagnosis?", "answer": "Asthma", "options": {"A": "Pneumonia", "B": "Gastroesophageal reflux disease", "C": "Side effect of medication", "D": "Asthma", "E": "Chronic bronchitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["59 year old woman", "physician", "of", "month history", "episodic cough", "shortness of breath", "cough", "worsens", "climbs stairs", "night", "not", "chest pain", "palpitations", "Eight weeks", "fever", "sore throat", "nasal congestion", "a 10 year history of hypertension", "smoked half", "pack", "cigarettes daily", "years", "only medication", "enalapril", "pulse", "min", "respirations", "min", "blood pressure", "95 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "96", "Diffuse end-expiratory wheezes", "heard", "pulmonary auscultation", "x-ray of", "chest", "abnormalities", "Spirometry", "FEV1:FVC ratio", "65", "FEV1", "60", "following", "diagnosis"]}
{"question": "A 2850-g (6-lb 5-oz) newborn is delivered at term to a 19-year-old primigravid woman via normal spontaneous vaginal delivery. The mother has had no prenatal care. Examination of the newborn in the delivery room shows a small, retracted jaw and hypoplasia of the zygomatic arch. This patient's condition is most likely caused by abnormal development of the structure that also gives rise to which of the following?", "answer": "Incus", "options": {"A": "Facial nerve", "B": "Cricothyroid muscle", "C": "Incus", "D": "Greater horn of hyoid", "E": "Platysma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["g", "oz", "newborn", "delivered", "term", "year old primigravid woman", "normal spontaneous vaginal delivery", "Examination", "newborn", "delivery room", "small", "retracted jaw", "hypoplasia", "zygomatic arch", "patient's condition", "most likely caused", "abnormal", "structure", "gives"]}
{"question": "A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?", "answer": "Gallstone in the cystic duct", "options": {"A": "Dilated common bile duct with intrahepatic biliary dilatation", "B": "Gallstone in the cystic duct", "C": "Fistula formation between the gallbladder and bowel", "D": "Decreased echogenicity of the liver", "E": "Enlargement of the pancreas with peripancreatic fluid"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "epigastric abdominal pain", "started", "worse", "past", "hours", "intermittent pain similar", "never lasted", "long", "temperature", "soft abdomen", "normal bowel sounds", "patient", "sudden inspiratory arrest", "right upper quadrant palpation", "alkaline phosphatase", "total bilirubin", "amylase", "aspartate aminotransferase levels", "reference ranges", "Abdominal imaging", "to", "following findings"]}
{"question": "A 15-year-old boy is brought to the physician by his father because he has been waking up frequently during the night to urinate. Apart from occasional headaches, he has no other complaints. His family recently emigrated from Tanzania and his medical history is unknown. His father was diagnosed with sickle cell disease at the age of 5. Physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 14.5 g/dL\nHematocrit 44%\nMCV 90 fL\nReticulocytes 1.5%\nA hemoglobin electrophoresis shows:\nHbA 55%\nHbS 43%\nHbF 1%\nThis patient is at greatest risk for which of the following conditions?\"", "answer": "Renal papillary necrosis", "options": {"A": "Avascular osteonecrosis", "B": "Clear cell renal carcinoma", "C": "Renal papillary necrosis", "D": "Functional asplenia", "E": "Ischemic stroke\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "waking up frequently", "night to", "occasional headaches", "complaints", "recently", "Tanzania", "medical history", "unknown", "diagnosed", "sickle cell disease", "age", "abnormalities", "Laboratory studies", "Hemoglobin", "g dL Hematocrit", "MCV 90 fL Reticulocytes 1", "hemoglobin electrophoresis", "HbA", "HbS", "HbF 1", "patient", "greatest", "following conditions"]}
{"question": "A 71-year-old woman comes to the physician because of an 8-month history of fatigue. Laboratory studies show a hemoglobin concentration of 13.3 g/dL, a serum creatinine concentration of 0.9 mg/dL, and a serum alkaline phosphatase concentration of 100 U/L. Laboratory evaluation of which of the following parameters would be most helpful in determining the cause of this patient's symptoms?", "answer": "Gamma-glutamyl transpeptidase", "options": {"A": "Cancer antigen 27-29", "B": "Lactate dehydrogenase", "C": "Ferritin", "D": "Gamma-glutamyl transpeptidase", "E": "Calcitriol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history", "fatigue", "Laboratory studies", "a hemoglobin concentration", "3 g/dL", "serum creatinine concentration", "0.9 mg dL", "serum alkaline phosphatase concentration", "100 U/L", "Laboratory", "following parameters", "most helpful", "determining", "cause", "patient's symptoms"]}
{"question": "A laboratory physician investigates the chromosomes of a fetus with a suspected chromosomal anomaly. She processes a cell culture obtained by amniocentesis. Prior to staining and microscopic examination of the fetal chromosomes, a drug that blocks cell division is added to the cell culture. In order to arrest chromosomes in metaphase, the physician most likely added a drug that is also used for the treatment of which of the following conditions?", "answer": "Acute gouty arthritis", "options": {"A": "Trichomonas vaginitis", "B": "Acute gouty arthritis", "C": "Herpes zoster", "D": "Testicular cancer", "E": "Polycythemia vera"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["laboratory physician investigates", "chromosomes", "fetus", "suspected chromosomal anomaly", "processes", "cell culture obtained", "amniocentesis", "staining", "microscopic", "fetal chromosomes", "drug", "blocks cell division", "added", "cell culture", "order to arrest chromosomes", "metaphase", "physician", "likely added", "drug", "used", "treatment of", "following conditions"]}
{"question": "Following gastric surgery, a 45-year-old woman complains of severe nausea and vomiting on the 2nd postoperative day. On physical examination, her vitals are stable and examination of the abdomen reveals no significant abnormality. The patient is already receiving a maximum dosage of ondansetron. Metoclopramide is given, and she experiences significant relief from nausea and vomiting. Which of the following best explains the mechanism of action of this drug?", "answer": "Inhibition of dopamine receptors in the area postrema", "options": {"A": "Inhibition of dopamine receptors in the area postrema", "B": "Inhibition of serotonin receptors on the nucleus tractus solitarius", "C": "Stimulation of motilin receptors in gastrointestinal smooth muscle", "D": "Enhancement of small intestinal and colonic motility by dopamine antagonism", "E": "Decreased esophageal peristaltic amplitude"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Following gastric surgery", "year old woman", "severe nausea", "vomiting", "2nd postoperative day", "stable", "examination of", "abdomen reveals", "significant abnormality", "patient", "receiving", "maximum dosage", "ondansetron", "Metoclopramide", "given", "significant relief", "nausea", "vomiting", "following best", "mechanism of action", "drug"]}
{"question": "A 32-year-old woman is found unconscious on the office floor just before lunch by her colleagues. She had previously instructed them on the location of an emergency kit in case this ever happened so they are able to successfully inject her with the substance inside. Her past medical history is significant for type 1 diabetes for which she takes long acting insulin as well as periprandial rapid acting insulin injections. She has previously been found unconscious once before when she forgot to eat breakfast. The substance inside the emergency kit most likely has which of the following properties.", "answer": "Promotes gluconeogenesis in the liver", "options": {"A": "Inhibits activity of pancreatic alpha and beta cells", "B": "Promotes gluconeogenesis in the liver", "C": "Promotes glucose release from skeletal muscles", "D": "Promotes glucose uptake in muscles", "E": "Promotes glycogen formation in the liver"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "found unconscious", "office floor", "lunch", "location", "emergency kit", "case", "able", "inject", "past medical history", "significant", "type 1 diabetes", "long acting insulin", "rapid acting insulin injections", "found unconscious", "before", "forgot to eat breakfast", "emergency kit", "likely", "following properties"]}
{"question": "A 6-year-old girl is brought to the physician because of a generalized pruritic rash for 3 days. Her mother has noticed fluid oozing from some of the lesions. She was born at term and has been healthy except for an episode of bronchitis 4 months ago that was treated with azithromycin. There is no family history of serious illness. Her immunization records are unavailable. She attends elementary school but has missed the last 5 days. She appears healthy. Her temperature is 38°C (100.4°F). Examination shows a maculopapular rash with crusted lesions and vesicles over the entire integument, including the scalp. Her hemoglobin concentration is 13.1 g/dL, leukocyte count is 9800/mm3, and platelet count is 319,000/mm3. Which of the following is the most appropriate next best step?", "answer": "Calamine lotion", "options": {"A": "Vitamin A therapy", "B": "Rapid strep test", "C": "Tzanck test", "D": "Measles IgM titer", "E": "Calamine lotion"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "of", "generalized pruritic rash", "3 days", "fluid", "lesions", "born", "term", "healthy", "episode of bronchitis", "months", "treated with azithromycin", "family history", "serious illness", "unavailable", "attends elementary school", "missed", "last", "days", "appears healthy", "temperature", "100", "maculopapular rash", "crusted lesions", "vesicles", "entire integument", "including", "scalp", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "following", "most appropriate next best step"]}
{"question": "A 3-month-old boy is brought to the emergency room by his mother for 2 days of difficulty breathing. He was born at 35 weeks gestation but has otherwise been healthy. She noticed a cough and some trouble breathing in the setting of a runny nose. His temperature is 100°F (37.8°C), blood pressure is 64/34 mmHg, pulse is 140/min, respirations are 39/min, and oxygen saturation is 93% on room air. Pulmonary exam is notable for expiratory wheezing and crackles throughout and intercostal retractions. Oral mucosa is noted to be dry. Which of the following is the most appropriate diagnostic test?", "answer": "No further testing needed", "options": {"A": "Chest radiograph", "B": "No further testing needed", "C": "Polymerase chain reaction", "D": "Sputum culture", "E": "Viral culture"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 month old boy", "brought", "emergency room", "2 days", "difficulty breathing", "born", "35 weeks gestation", "healthy", "cough", "breathing", "setting", "nose", "temperature", "blood pressure", "64", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "room", "Pulmonary exam", "notable", "expiratory wheezing", "crackles", "intercostal retractions", "Oral mucosa", "noted to", "dry", "following", "most appropriate diagnostic test"]}
{"question": "A 2200-g (4-lbs 13-oz) female newborn is delivered at term to a 37-year-old gravida 2, para 1 woman. The newborn is at the 10th percentile for length, 14th percentile for weight, and 3rd percentile for head circumference. Examination shows “punched-out“ skin lesions on the scalp, cleft lip, and a small chin. There is a convex-shaped deformity of the plantar surface of the feet. Auscultation shows a holosystolic murmur heard best at the left lower sternal border. Some of her intestines protrude through the umbilicus, covered by a thin membranous sac. An MRI of the brain shows a single ventricle and a fusion of the basal ganglia. Which of the following additional findings is most likely to be seen in this patient?", "answer": "Polydactyly", "options": {"A": "Polydactyly", "B": "Webbed neck", "C": "Single palmar crease", "D": "Overlapping fingers", "E": "Hypoplastic philtrum"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["g", "lbs", "oz", "female newborn", "delivered", "term", "year old gravida 2", "para 1 woman", "newborn", "percentile", "length", "percentile", "weight", "3rd percentile", "head", "Examination", "punched out skin lesions", "scalp", "cleft lip", "small chin", "convex-shaped deformity of", "plantar surface", "feet", "Auscultation", "holosystolic murmur heard best", "left lower sternal border", "intestines", "umbilicus", "covered", "thin membranous sac", "MRI of", "brain", "single ventricle", "fusion of the basal ganglia", "following additional findings", "to", "seen", "patient"]}
{"question": "A 39-year-old woman presents to the emergency department with fever, cough, and shortness of breath. She reports developing flu-like symptoms 7 days ago but progressively worsened to the point where she experiences dyspnea on exertion. Her cough is accompanied by a mild amount of yellow sputum. Past medical history is notable for a previous admission to the hospital for pneumonia 4 months ago and an admission for bacteremia 6 weeks ago. She additionally has a history of IV heroin abuse, but her last use of heroin was 3 years ago. Temperature is 101.2°F (38.4°C), blood pressure is 104/70 mmHg, pulse is 102/min, and respirations are 20/min. Physical examination demonstrates coarse upper airway breath sounds over the right lower lung field. A faint 1/6 non-radiating systolic flow murmur is auscultated at the first right intercostal space. Abdominal examination is significant for moderate splenomegaly. Tenderness of the wrists and fingers is elicited on palpation, and range of motion is restricted. The patient comments that her range of motion and pain usually improve as the day goes on. Which of the following laboratory abnormalities is most likely to be found in this patient?", "answer": "Neutropenia", "options": {"A": "Decreased anion gap", "B": "Flow cytometry positive for CD11c and CD2", "C": "Leukocytosis with left-shift", "D": "Neutropenia", "E": "Positive HIV serology"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "fever", "cough", "shortness of breath", "reports", "flu-like symptoms", "days", "worsened", "point", "dyspnea on exertion", "cough", "mild amount of yellow sputum", "Past medical", "notable", "previous", "hospital", "pneumonia", "months", "bacteremia", "weeks", "history of IV heroin abuse", "last use of heroin", "3 years", "Temperature", "blood pressure", "70 mmHg", "pulse", "min", "respirations", "20 min", "coarse upper airway breath sounds", "right lower lung field", "faint", "non radiating systolic flow murmur", "first right intercostal space", "Abdominal", "significant", "moderate splenomegaly", "Tenderness", "wrists", "fingers", "elicited", "palpation", "range of motion", "restricted", "patient", "range of motion", "pain usually", "day", "following laboratory abnormalities", "to", "found", "patient"]}
{"question": "A 72-year-old man presents to his primary care physician complaining of pain and bulging in his groin. He is otherwise healthy and has never had surgery. He is referred to a general surgeon, and is scheduled for an elective hernia repair the following week. On closer inspection in the operating room, the surgeon notes a hernia sac that protrudes through the external inguinal ring, bypassing the inguinal canal. Which of the following accurately describes this patient's condition?", "answer": "Direct inguinal hernia", "options": {"A": "Direct hiatal hernia", "B": "Indirect femoral hernia", "C": "Direct incisional hernia", "D": "Isolated rectus diastasis", "E": "Direct inguinal hernia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["72 year old man presents", "primary care physician", "pain", "bulging", "groin", "healthy", "never", "surgery", "referred", "general surgeon", "scheduled", "elective hernia repair", "following week", "inspection", "operating room", "surgeon notes", "hernia sac", "external inguinal ring", "bypassing", "inguinal canal", "following", "patient's condition"]}
{"question": "A 65-year-old man comes to the physician for evaluation of a neck mass and weight loss. He first noticed the growing mass 2 months ago. The mass is not painful. He also has decreased appetite and intermittent abdominal pain. He has lost 10 kg (22 lb) of weight over the past 3 months. Sometimes, he wakes up in the morning drenched in sweat. He takes daily over-the-counter multivitamins. He appears pale. His pulse is 65/min, blood pressure is 110/70 mm Hg, and temperature is 38.1°C (100.6°F). Physical exam shows a painless, golf ball-sized mass in the anterior triangle of the neck. A biopsy shows large cells with a bilobed nucleus that are CD15- and CD30-positive. Laboratory analysis of serum shows a calcium level of 14.5 mg/dL and a parathyroid hormone level of 40 pg/mL. Which of the following is the most likely explanation of this patient's laboratory findings?", "answer": "Ectopic vitamin D production", "options": {"A": "Osteoblastic metastasis", "B": "Ectopic vitamin D production", "C": "Ectopic PTH-related protein production", "D": "Multivitamin overdose", "E": "Osteolytic metastasis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old man", "physician", "of", "neck mass", "weight loss", "first", "mass", "months", "mass", "not painful", "decreased appetite", "intermittent abdominal pain", "lost 10 kg", "weight", "past 3 months", "Sometimes", "wakes up", "morning", "sweat", "daily over-the-counter multivitamins", "appears pale", "pulse", "65 min", "blood pressure", "70 mm Hg", "temperature", "100", "painless", "golf ball sized mass", "anterior triangle of", "neck", "biopsy", "large cells", "bilobed nucleus", "CD15", "CD30-positive", "Laboratory analysis", "serum", "calcium level", "mg/dL", "parathyroid hormone level", "40 pg/mL", "following", "explanation", "patient's laboratory findings"]}
{"question": "A 29-year-old African American woman presents with incidentally noted bilateral hilar lymphadenopathy on a recent chest radiograph for the evaluation of pneumonia 1 month earlier. Upon questioning, she reports a cough, dyspnea, and angina. The report provided by a previous ophthalmologic consultation did not demonstrate any eye abnormalities. Clinical laboratory pathologic analysis reveals an elevated level of angiotensin-converting enzyme. Her physical examination reveals no obvious abnormalities. Her vital signs show a heart rate of 76/min, respiratory rate of 16/min, and blood pressure of 123/73 mm Hg. Of the following options, which is the mechanism of the reaction causing hilar adenopathy in this patient?", "answer": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "options": {"A": "Type I–anaphylactic hypersensitivity reaction", "B": "Type II–cytotoxic hypersensitivity reaction", "C": "Type III–immune complex-mediated hypersensitivity reaction", "D": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "E": "Type III and IV–mixed immune complex and cell-mediated hypersensitivity reactions"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["29 year old", "woman presents", "noted bilateral hilar lymphadenopathy", "recent chest radiograph", "pneumonia", "month earlier", "reports", "cough", "dyspnea", "angina", "report", "previous ophthalmologic", "not", "eye abnormalities", "Clinical laboratory pathologic analysis reveals", "elevated level", "angiotensin-converting enzyme", "reveals", "abnormalities", "vital signs", "heart rate", "76 min", "respiratory rate", "min", "blood pressure", "mm Hg", "following options", "mechanism", "reaction causing hilar adenopathy", "patient"]}
{"question": "Ten days after starting a new medication, a 60-year-old man is brought to the emergency department after a 3-minute episode of myoclonic jerking movements and urinary incontinence. After regaining consciousness, the patient had no recollection of what happened and seemed confused. He has bipolar disorder, which has been controlled with maintenance therapy for the past 15 years. Physical examination shows dry oral mucosa, muscle fasciculations, and bilateral hand tremors. His speech is slow, and he is disoriented. Which of the following drugs most likely precipitated this patient's current condition?", "answer": "Celecoxib", "options": {"A": "Valproic acid", "B": "Theophylline", "C": "Fluoxetine", "D": "Celecoxib", "E": "Metoprolol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["starting", "new medication", "60 year old man", "brought", "emergency department", "3 minute episode of myoclonic jerking movements", "urinary incontinence", "consciousness", "patient", "confused", "bipolar disorder", "controlled", "maintenance therapy", "past 15 years", "Physical examination", "dry oral", "muscle fasciculations", "bilateral hand tremors", "speech", "slow", "disoriented", "following drugs", "likely precipitated", "patient's current condition"]}
{"question": "A previously healthy 2-year-old boy is brought to the emergency department because of a 2-day history of fever and pain in the left lower extremity. His mother says that he has refused to walk for the last two days and has had a poor appetite. He returned from a weekend camping trip about a month ago. His maternal cousin died of osteosarcoma at the age of 12. His immunizations are up-to-date. He is at the 80th percentile for height and 70th percentile for weight. He appears ill. His temperature is 39.3°C (102.7°F), pulse is 115/min, respirations are 19/min, and blood pressure is 95/50 mm Hg. Examination of the left hip shows tenderness; range of motion is limited. Minimal attempts to rotate the hip cause severe discomfort. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12 g/dL\nLeukocyte count 19,800/mm3\nPlatelet count 254,000/mm3\nErythrocyte sedimentation rate 55 mm/h\nSerum\nGlucose 80 mg/dL\nCRP 15 mg/L\nX-rays of the pelvis shows a widened acetabular space on the left side. Which of the following is the most appropriate next step in management?\"", "answer": "Synovial fluid drainage plus cefazolin therapy", "options": {"A": "Vancomycin therapy", "B": "Synovial fluid drainage plus cefazolin therapy", "C": "Trimethoprim/sulfamethoxazole therapy", "D": "Arthroscopic drainage of hip", "E": "Doxycycline therapy\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "2-day history", "fever", "pain in the left lower extremity", "to", "two days", "poor appetite", "returned", "weekend", "trip", "month", "died", "osteosarcoma", "age", "immunizations", "date", "80th percentile", "height", "percentile", "weight", "appears ill", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "95 50 mm Hg", "Examination", "left", "tenderness", "range of motion", "limited", "Minimal", "to rotate", "hip cause severe discomfort", "abnormalities", "Laboratory studies", "Hemoglobin", "g dL Leukocyte", "19 800 mm3 Platelet count", "Erythrocyte sedimentation rate", "mm/h Serum Glucose 80 mg", "CRP", "L X-rays", "pelvis", "widened acetabular space", "left", "following", "most appropriate next step"]}
{"question": "A 51-year-old male presents to his primary care provider for a normal check-up. He reports that he “hasn’t felt like himself” recently. He describes feeling down for the past 8 months since his mother passed away. He has had trouble sleeping and has unintentionally lost 15 pounds. He feels guilty about his mother’s death but cannot articulate why. His performance at work has declined and he has stopped running, an activity he used to enjoy. He has not thought about hurting himself or others. Of note, he also complains of numbness in his feet and fingers and inability to maintain an erection. His past medical history is notable for diabetes. He is on metformin. His temperature is 98.6°F (37°C), blood pressure is 125/65 mmHg, pulse is 90/min, and respirations are 16/min. On exam, he is alert and oriented with intact memory and normal speech. He appears tired with a somewhat flattened affect. The best medication for this patient inhibits which of the following processes?", "answer": "Norepinephrine and serotonin reuptake", "options": {"A": "Serotonin reuptake only", "B": "Norepinephrine and serotonin reuptake", "C": "Amine degradation", "D": "Norepinephrine and dopamine reuptake", "E": "Dopamine receptor activation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "primary care provider", "normal check-up", "reports", "hasnt", "recently", "past", "months", "passed", "trouble sleeping", "lost", "pounds", "mothers death", "performance at work", "stopped", "activity", "used", "not", "others", "note", "numbness", "feet", "fingers", "to", "erection", "past medical history", "notable", "diabetes", "metformin", "temperature", "98", "blood pressure", "65 mmHg", "pulse", "90 min", "respirations", "min", "exam", "alert", "oriented", "intact memory", "normal speech", "appears tired", "somewhat flattened", "best medication", "patient inhibits", "following processes"]}
{"question": "A 35-year-old man arrives at the emergency department within minutes after a head-on motor vehicle accident. He suffered from blunt abdominal trauma, several lacerations to his face as well as lacerations to his upper and lower extremities. The patient is afebrile, blood pressure is 45/25 mmHg and pulse is 160/minute. A CBC is obtained and is most likely to demonstrate which of the following?", "answer": "Hb 15 g/dL, Hct 45%", "options": {"A": "Hb 5 g/dL, Hct 20%", "B": "Hb 5 g/dL, Hct 30%", "C": "Hb 15 g/dL, Hct 45%", "D": "Hb 20 g/dL, Hct 60%", "E": "Hb 17 g/dL, Hct 20%"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old man", "emergency department", "minutes", "head", "motor vehicle accident", "suffered", "blunt abdominal trauma", "several lacerations", "face", "lacerations", "upper", "lower extremities", "patient", "afebrile", "blood pressure", "mmHg", "pulse", "minute", "CBC", "obtained", "to", "following"]}
{"question": "A 28-year-old man comes to the physician because of a 3-month history of pain in his left shoulder. He is physically active and plays baseball twice a week. The pain is reproduced when the shoulder is externally rotated against resistance. Injury of which of the following tendons is most likely in this patient?", "answer": "Infraspinatus", "options": {"A": "Teres major", "B": "Pectoralis major", "C": "Infraspinatus", "D": "Supraspinatus", "E": "Subscapularis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "3 month history", "pain", "left shoulder", "physically active", "plays baseball twice", "week", "pain", "shoulder", "externally rotated", "resistance", "Injury of", "following tendons", "patient"]}
{"question": "A 58-year-old woman presents to the physician with a throbbing headache. She says she had it for the last year and it’s usually located in the right temporal area. There is localized tenderness over the scalp. During the last 2 weeks, she experienced 3 episodes of transient loss of vision on the right side, without ocular pain. On physical examination, her vital signs are normal. Palpation reveals that the pulsations of the superficial temporal artery on the right side are reduced in amplitude. Laboratory studies show:\nBlood hemoglobin 10.7 g/dL (6.64 mmol/L)\nLeukocyte count 8,000/mm3 (8.0 x 109/L)\nPlatelet count 470,000/mm3 (470 x 109/L)\nErythrocyte sedimentation rate 60 mm/h (60 mm/h)\nWhich of the following conditions is most likely to co-exist with the presenting complaint in this woman?", "answer": "Polymyalgia rheumatica", "options": {"A": "Amyloidosis", "B": "Dermatomyositis", "C": "Fibromyalgia", "D": "Polymyalgia rheumatica", "E": "Sjogren’s syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old woman presents", "physician", "throbbing headache", "last year", "usually", "right temporal area", "localized tenderness", "scalp", "last", "weeks", "3 episodes of transient loss", "vision", "right side", "ocular pain", "vital signs", "normal", "Palpation reveals", "superficial temporal artery", "right side", "reduced", "amplitude", "Laboratory studies", "Blood hemoglobin 10", "g", "64 mmol/L", "Leukocyte count", "mm3", "0", "Platelet count", "mm3", "Erythrocyte sedimentation rate 60 mm/h", "following conditions", "co", "presenting complaint", "woman"]}
{"question": "A researcher is studying proteins that contribute to intestinal epithelial permeability. He has isolated intestinal tissue from several mice. After processing the tissue into its individual components, he uses a Western blot analysis to identify a protein that forms part of a multi-protein complex at the apical aspect of epithelial cells. The complex is known to provide a diffusion barrier between the apical and basolateral aspects of epithelial cells. Which of the following proteins is this researcher most likely investigating?", "answer": "Claudin", "options": {"A": "Integrin", "B": "Connexon", "C": "Desmoglein", "D": "E-cadherin", "E": "Claudin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["researcher", "studying proteins", "intestinal epithelial", "isolated intestinal tissue", "mice", "tissue", "components", "uses", "Western blot analysis to", "a protein", "forms part of a multi protein complex", "apical aspect", "epithelial cells", "complex", "known to", "diffusion barrier", "apical", "aspects of epithelial cells", "following proteins", "researcher", "likely investigating"]}
{"question": "A 38-year-old woman is evaluated for a difficult-to-control hypertension. Her symptoms include sleep interruption because of frequent waking up for voiding and frequent headaches. She has smoked 10 cigarettes daily for the past 5 years. Family history is insignificant. Her vital signs include a blood pressure of 170/96 mm Hg, pulse of 90/min, and temperature of 36.7°C (98.0°F). Physical examination is unremarkable. Her lab results are shown:\nSerum sodium 146 mEq/L\nSerum potassium 4 mEq/L\nSerum bicarbonate 29 mEq/L\nHer plasma aldosterone concentration (PAC): plasma renin activity (PRA) ratio measured after following all precautions is found to be elevated. Oral salt loading testing reveals a lack of aldosterone suppression. A computerized tomography (CT) scan of the adrenal glands shows a 2 cm mass on the left side. Which of the following is the best next step for this patient?", "answer": "Adrenal venous sampling", "options": {"A": "Renal angiogram", "B": "Adrenal venous sampling", "C": "Measurement of 11-deoxycortisol", "D": "Left laparoscopic adrenalectomy", "E": "Treatment with eplerenone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "difficult", "control hypertension", "symptoms include sleep interruption", "frequent waking", "voiding", "frequent headaches", "smoked 10 cigarettes daily", "past 5 years", "Family history", "vital signs include", "blood pressure", "96 mm Hg", "pulse", "90 min", "temperature", "36", "98", "unremarkable", "lab results", "Serum", "mEq", "potassium", "bicarbonate 29", "plasma aldosterone concentration", "plasma renin activity", "ratio measured", "following", "found to", "elevated", "Oral salt", "testing reveals", "lack", "aldosterone suppression", "computerized tomography", "scan", "adrenal glands", "2 cm mass", "left side", "following", "best next step", "patient"]}
{"question": "A 43-year-old woman comes to the office with a 3-day history of a rash. She's had a rash across her neck, shoulders, and the palms of her hands for the past five days. She's also had large-volume watery diarrhea for the same period of time. Past medical history is notable for acute myeloid leukemia, for which she received a stem cell transplant from a donor about two months prior. Physical exam reveals a faint red maculopapular rash across her neck, shoulders, and hands, as well as an enlarged liver and spleen. Labs are notable for a total bilirubin of 10. Which of the following is the mechanism of this patient's pathology?", "answer": "Graft T cells against host antigens", "options": {"A": "Drug hypersensitivity reaction", "B": "Pre-existing host antibodies against graft antigens", "C": "Host antibodies that have developed against graft antigens", "D": "Host CD8+ T cells against graft antigens", "E": "Graft T cells against host antigens"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "office", "3-day history", "rash", "rash", "neck", "shoulders", "palms of", "hands", "past", "volume watery diarrhea", "same period", "time", "Past medical history", "notable", "acute myeloid leukemia", "received", "stem cell", "donor", "two months prior", "reveals", "faint red maculopapular rash", "neck", "shoulders", "hands", "enlarged liver", "spleen", "Labs", "notable", "total bilirubin", "10", "following", "mechanism", "patient's pathology"]}
{"question": "A 27-year-old man who recently emigrated as a refugee from Somalia presents with fever, weight loss, fatigue, and exertional chest pain. He says his symptoms began 3 weeks ago and that his appetite has decreased and he has lost 3 kg (6.6 lb) in the last 3 weeks. He denies any history of cardiac disease. His past medical history is unremarkable. The patient admits that he has always lived in poor hygienic conditions in overcrowded quarters and in close contact with cats. His vital signs include: blood pressure 120/60 mm Hg, pulse 90/min, and temperature 38.0°C (100.4°F). Physical examination reveals generalized pallor. A cardiac examination reveals an early diastolic murmur loudest at the left third intercostal space. Abdominal examination reveals a tender and mildly enlarged spleen. Prominent axillary lymphadenopathy is noted. Laboratory investigations reveal a WBC count of 14,500/μL with 5% bands and 93% polymorphonuclear cells. An echocardiogram reveals a 5-mm vegetation on the aortic valve with moderate regurgitation. Three sets of blood cultures are taken over 24 hours followed by empiric antibiotic therapy with gentamicin and vancomycin. The blood cultures show no growth after 5 days. Following a week of empiric therapy, the patient continues to deteriorate. Which of the following would most likely confirm the diagnosis in this patient?", "answer": "Bartonella serology", "options": {"A": "Bartonella serology", "B": "Q fever serology", "C": "Peripheral blood smear", "D": "HIV polymerase chain reaction", "E": "Epstein-Barr virus heterophile antibody"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old man", "recently", "Somalia presents", "fever", "weight loss", "fatigue", "exertional chest pain", "symptoms began 3 weeks", "appetite", "decreased", "lost 3 kg", "6.6", "last", "weeks", "history of cardiac disease", "past medical history", "unremarkable", "patient", "always lived", "poor hygienic conditions", "quarters", "close contact", "cats", "vital signs include", "blood pressure", "60 mm Hg", "pulse 90 min", "temperature", "100", "reveals generalized pallor", "reveals", "early diastolic murmur loudest", "left third intercostal space", "Abdominal", "reveals", "tender", "mildly enlarged spleen", "Prominent axillary lymphadenopathy", "noted", "Laboratory", "reveal", "WBC", "500", "5", "bands", "echocardiogram reveals", "5-mm vegetation", "aortic valve", "moderate regurgitation", "Three sets of blood cultures", "24 hours followed by empiric antibiotic therapy", "gentamicin", "vancomycin", "blood cultures", "growth", "5 days", "Following", "week", "empiric therapy", "patient", "to deteriorate", "following", "most likely confirm", "diagnosis", "patient"]}
{"question": "Four days after having been admitted to the hospital for a pulmonary contusion and whiplash injury sustained in a motor vehicle collision, a 66-year-old woman complains of severe pain in her right flank and muscle spasms. She also has nausea with two episodes of vomiting and abdominal bloating. Her pain had previously been well controlled with acetaminophen every 6 hours. She underwent umbilical hernia repair surgery two years ago. She takes sertraline for depression. Her temperature is 36.5°C (97.7°F), pulse is 99/min, respirations are 17/min, and blood pressure is 102/72 mm Hg. After administration of 0.5 L of crystalloid fluids, blood pressure improves to 118/79 mm Hg. Multiple ecchymoses are present over the anterior abdominal wall in a pattern that follows the course of a seatbelt. There are ecchymoses of the flanks bilaterally. Bowel sounds are absent. There is tenderness to palpation in all four quadrants with voluntary guarding. Her hemoglobin is 7.9 g/dL, leukocyte count is 8,500/mm3, platelet count is 350,000/mm3, prothrombin time is 11 seconds, and activated partial thromboplastin time is 33 seconds. An x-ray of the abdomen shows obliteration of the right psoas shadow and uniform distribution of gas in the small bowel, colon, and rectum without air-fluid levels. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Retroperitoneal hemorrhage", "options": {"A": "Small bowel perforation", "B": "Intraabdominal adhesions", "C": "Spinal cord injury", "D": "Retroperitoneal hemorrhage", "E": "Acute mesenteric ischemia\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Four days", "pulmonary contusion", "whiplash injury sustained", "motor vehicle collision", "66 year old woman", "severe pain", "right flank", "muscle spasms", "nausea with two episodes of vomiting", "abdominal bloating", "pain", "well controlled", "acetaminophen", "6 hours", "umbilical hernia repair surgery two years", "sertraline", "depression", "temperature", "36", "97", "pulse", "99 min", "respirations", "min", "blood pressure", "72 mm Hg", "administration", "0.5 L", "crystalloid fluids", "blood pressure improves", "mm Hg", "Multiple ecchymoses", "present", "anterior abdominal wall", "pattern", "follows", "course", "seatbelt", "ecchymoses", "flanks", "Bowel sounds", "absent", "tenderness", "palpation", "four quadrants", "guarding", "hemoglobin", "g/dL", "leukocyte count", "500 mm3", "platelet count", "350", "mm3", "prothrombin time", "seconds", "activated partial thromboplastin time", "seconds", "x-ray of", "abdomen", "obliteration", "right", "shadow", "uniform distribution", "gas", "small bowel", "colon", "rectum", "air-fluid levels", "following", "explanation", "patient's"]}
{"question": "A 65-year-old man comes to the physician because of a 2-week history of chest pain that begins after walking at a brisk pace for 2 blocks. The pain does not radiate anywhere and is hard to localize. He has had similar episodes in the past 6 months and was prescribed sublingual nitroglycerin, which helps relieve the pain. The patient has hypertension and type 2 diabetes mellitus. He takes lisinopril and metformin daily. He appears well. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 145/90 mm Hg. Examination shows a regular heart rhythm. S1 and S2 are normal. The lungs are clear to auscultation. There is no peripheral edema. Which of the following is the most likely explanation for the improvement of this patient's chest pain?", "answer": "Decreased end-diastolic pressure\n\"", "options": {"A": "Delayed electrical conduction", "B": "Decreased venous pooling", "C": "Coronary arterial vasodilation", "D": "Increased atherosclerotic plaque stability", "E": "Decreased end-diastolic pressure\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["65 year old man", "physician", "of", "2-week history", "chest pain", "begins", "brisk pace", "blocks", "pain", "not radiate", "hard to localize", "similar episodes", "past 6 months", "sublingual nitroglycerin", "helps relieve", "pain", "patient", "hypertension", "type 2 diabetes mellitus", "lisinopril", "metformin daily", "appears well", "temperature", "98", "pulse", "75 min", "blood pressure", "90 mm Hg", "regular heart rhythm", "S1", "S2", "normal", "lungs", "clear", "auscultation", "peripheral edema", "following", "of", "patient's chest pain"]}
{"question": "A 34-year-old woman presents with confusion, drowsiness, and headache. The patient’s husband says her symptoms began 2 days ago and have progressively worsened with an acute deterioration of her mental status 2 hours ago. The patient describes the headaches as severe, localized to the frontal and periorbital regions, and worse in the morning. Review of symptoms is significant for a mild, low-grade fever, fatigue, and nausea for the past week. Past medical history is significant for HIV infection for which she is not currently receiving therapy. Her CD4+ T cell count last month was 250/mm3. The blood pressure is 140/85 mm Hg, the pulse rate is 90/min, and the temperature is 37.7°C (100.0°F). On physical examination, the patient is conscious but drowsy. Papilledema is present. No pain is elicited with extension of the leg at the knee joint. The remainder of the physical examination is negative. Laboratory findings, including panculture, are ordered. A noncontrast CT scan of the head is negative and is followed by a lumbar puncture. CSF analysis is significant for:\nOpening pressure 250 mm H2O (70-180 mm H2O)\nGlucose 30 mg/dL (40-70 mg/dL)\nProtein 100 mg/dL (<40 mg/dL)\nCell count 20/mm3 (0-5/mm3)\nWhich of the following additional findings would most likely be found in this patient?", "answer": "CSF India ink stain shows encapsulated yeast cells", "options": {"A": "CSF shows a positive acid-fast bacillus stain", "B": "CSF shows gram negative diplococci", "C": "CSF India ink stain shows encapsulated yeast cells", "D": "Gram-positive diplococci are present on microscopy", "E": "Multiple ring-enhancing lesions are seen on a CT scan"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "confusion", "drowsiness", "headache", "patients", "symptoms began 2 days", "worsened", "acute deterioration of", "status", "hours", "patient", "headaches", "severe", "localized", "frontal", "periorbital regions", "worse", "morning", "symptoms", "significant", "mild", "low-grade fever", "fatigue", "nausea", "past week", "Past medical history", "significant", "HIV infection", "not currently receiving therapy", "count last month", "mm3", "blood pressure", "85 mm Hg", "pulse rate", "90 min", "temperature", "100", "patient", "drowsy", "Papilledema", "present", "pain", "elicited", "extension", "leg", "knee joint", "negative", "Laboratory findings", "including", "ordered", "CT scan of", "head", "negative", "followed by", "lumbar puncture", "CSF analysis", "significant", "Opening pressure", "mm H2O", "70", "mm H2O", "Glucose 30 mg/dL", "40 70 mg/dL", "Protein 100 mg/dL", "40 mg/dL", "Cell count 20 mm3", "0-5 mm3", "following additional findings", "most likely", "found", "patient"]}
{"question": "A 55-year-old male is started on nitrate therapy for treatment of stable angina. He experiences significant and immediate relief of his symptoms within minutes of starting therapy. Approximately 48 hours after initiating this new medication, he notes return of chest pain and pressure with exertion that no longer responds to continued nitrate use. Which of the following 24-hour dosing schedules would most likely explain this patient's response to nitrate treatment?", "answer": "Transdermal nitroglycerin patch placed at 7AM then removed and replaced with another at 7PM", "options": {"A": "Transdermal nitroglycerin patch placed at 7AM then removed and replaced with another at 7PM", "B": "PO regular-release isosorbide dinitrate taken at 8AM, noon, and 5PM", "C": "Transdermal nitroglycerin patch placed at bedtime and removed at 7AM without replacement", "D": "Transdermal nitroglycerin patch placed upon awakening in the morning and removed at 7PM without replacement", "E": "PO extended release isosorbide-5-mononitrate once daily at 8AM"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male", "started", "nitrate therapy", "treatment", "stable angina", "significant", "immediate", "minutes", "starting therapy", "Approximately 48 hours", "initiating", "new medication", "notes return of chest pain", "pressure", "exertion", "longer", "nitrate use", "following", "hour dosing", "most likely", "response to nitrate"]}
{"question": "A 68-year-old woman comes to the physician for a follow-up visit for elevated blood pressure. Two weeks ago, her blood pressure was 154/78 mm Hg at a routine visit. Subsequent home blood pressure measurements at days 5, 10, and 14 have been: 156/76 mm Hg, 158/80 mm Hg, and 160/80 mm Hg. She has trouble falling asleep but otherwise feels well. She had a cold that resolved with over-the-counter medication 2 weeks ago. She has a history of primary hypothyroidism and a cyst in the right kidney, which was found incidentally 20 years ago. She takes levothyroxine. She is 178 cm (5 ft 10 in) tall and weighs 67 kg (148 lb); BMI is 21.3 kg/m2. Her pulse is 82/min, and blood pressure is 162/79 mm Hg. Examination shows no abnormalities. Laboratory studies, including thyroid function studies, serum electrolytes, and serum creatinine, are within normal limits. Which of the following is the most likely underlying cause of this patient's blood pressure findings?", "answer": "Decrease in arterial compliance", "options": {"A": "Increase in kidney size", "B": "Decrease in arterial compliance", "C": "Medication-induced vasoconstriction", "D": "Decrease in baroreceptor sensitivity", "E": "Increase in aldosterone production"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "elevated blood pressure", "Two weeks", "blood pressure", "mm Hg", "routine visit", "Subsequent home", "days 5", "10", "76 mm Hg", "80 mm Hg", "80 mm Hg", "trouble falling asleep", "well", "cold", "resolved", "over-the-counter medication 2 weeks", "history of primary hypothyroidism", "cyst", "right", "found", "20 years", "levothyroxine", "5 ft 10", "tall", "67 kg", "BMI", "kg/m2", "pulse", "min", "blood pressure", "mm Hg", "abnormalities", "Laboratory studies", "including thyroid function studies", "serum electrolytes", "serum creatinine", "normal limits", "following", "underlying cause", "patient's blood pressure findings"]}
{"question": "An 9-month-old infant is brought to the physician because of a generalized nonpruritic rash for 2 days. The rash began on her trunk and spread to her extremities. Five days ago, she was taken to the emergency department for fever of 40.5°C (104.9°F) and a 1-minute generalized tonic-clonic seizure. She was born at term and has no history of serious illness. Her immunizations are up-to-date. Current medications include acetaminophen. Her temperature is 37.2°C (99.0°F) and pulse is 120/min. Examination shows a maculopapular rash that blanches on pressure. A photograph of the rash is shown. Posterior auricular lymphadenopathy is present. Which of the following is the most likely diagnosis?", "answer": "Roseola infantum", "options": {"A": "Kawasaki disease", "B": "Drug allergy", "C": "Impetigo", "D": "Roseola infantum", "E": "Rubella"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old infant", "brought", "physician", "of", "generalized nonpruritic rash", "2 days", "rash began", "trunk", "spread", "extremities", "emergency department", "fever", "40", "9F", "minute generalized tonic-clonic seizure", "born", "term", "history", "serious illness", "immunizations", "date", "Current medications include acetaminophen", "temperature", "99", "pulse", "min", "maculopapular rash", "blanches", "pressure", "photograph", "rash", "Posterior auricular lymphadenopathy", "present", "following", "diagnosis"]}
{"question": "An 11-month-old boy is brought to the physician by his adoptive mother for the evaluation of seizures and musty-smelling urine. His immunizations are up-to-date. His height and weight are both below the 10th percentile. He is pale and has blue eyes. He cannot pull himself up from a seated position to stand and does not crawl. Which of the following genetic principles best explains the variety of phenotypic traits seen in this patient?", "answer": "Pleiotropy", "options": {"A": "Variable expressivity", "B": "Pleiotropy", "C": "Incomplete penetrance", "D": "Anticipation", "E": "Loss of heterozygosity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "physician", "seizures", "musty smelling urine", "immunizations", "date", "height", "weight", "percentile", "pale", "blue eyes", "pull", "seated position", "stand", "not crawl", "following genetic", "best", "phenotypic traits seen", "patient"]}
{"question": "A 24-year-old woman is in the intensive care unit for the management of a severe acute asthma exacerbation. She is currently intubated and sedated, and she is receiving intravenous steroids, continuous nebulized beta-agonists, and anticholinergic therapy via breathing treatments. On hospital day 2, she has a new fever to 38.9°C (102.0°F). Chest X-ray shows a right lower lobe consolidation. Blood cultures are collected, and she is started empirically on intravenous cefepime and daptomycin. On hospital day 4, she continues to be febrile; chest X-ray shows interval worsening of the right lower lobe opacity. Which of the following is the most likely reason for treatment failure in this patient?", "answer": "Inactivation of the medicine in the target tissue", "options": {"A": "Abnormally rapid clearance of the medicines by the kidney", "B": "Abnormally rapid metabolism of the medicines by the liver", "C": "Inactivation of the medicine in the target tissue", "D": "Low bioavailability of the medicines", "E": "Poor delivery of the medicines to the target tissue"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "intensive care unit", "of", "severe acute asthma exacerbation", "currently intubated", "sedated", "receiving intravenous steroids", "nebulized beta agonists", "anticholinergic therapy", "breathing treatments", "hospital", "new fever", "Chest X-ray", "right lower lobe consolidation", "Blood cultures", "collected", "started", "intravenous cefepime", "daptomycin", "hospital", "to", "febrile", "chest X-ray", "interval worsening", "right lower lobe opacity", "following", "most likely reason for treatment failure", "patient"]}
{"question": "A 53-year-old Asian woman comes to the physician because of a 2-month history of severe pain in her right leg while walking. She used to be able to walk a half-mile (800-m) to the grocery store but has been unable to walk 200 meters without stopping because of the pain over the past month. She can continue to walk after a break of around 5 minutes. She has hypertension, atrial fibrillation, and type 2 diabetes mellitus. She has smoked one pack of cigarettes daily for the past 32 years. Current medications include metformin, enalapril, aspirin, and warfarin. Vital signs are within normal limits. Examination shows an irregularly irregular pulse. The right lower extremity is cooler than the left lower extremity. The skin over the right leg appears shiny and dry. Femoral pulses are palpated bilaterally; pedal pulses are diminished on the right side. Which of the following is the most appropriate next step in management?", "answer": "Ankle-brachial index", "options": {"A": "MRI spine screening", "B": "Duplex ultrasonography", "C": "Nerve conduction studies", "D": "Ankle-brachial index", "E": "Biopsy of tibial artery"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman", "physician", "2 month history", "severe pain", "right leg", "used to", "able to", "half mile", "800 m", "grocery store", "unable to", "200 meters", "stopping", "of", "pain", "past month", "to", "break", "5 minutes", "hypertension", "atrial fibrillation", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "past", "years", "Current medications include metformin", "enalapril", "aspirin", "warfarin", "Vital signs", "normal limits", "irregular pulse", "right lower extremity", "cooler", "left lower extremity", "skin", "right leg appears shiny", "dry", "Femoral pulses", "pedal pulses", "diminished", "right side", "following", "most appropriate next step"]}
{"question": "A 27-year-old woman develops progressive difficulty breathing after a long day of chores in a dusty house. These chores included brushing the family dog, vacuuming, dusting, and sweeping. She occasionally gets these episodes once or twice a year and has her medication on hand. Her symptoms are reversed by inhaling a β2-adrenergic receptor agonist. Which of the following chemical mediators is responsible for this patient’s breathing difficulties?", "answer": "Leukotrienes", "options": {"A": "Bradykinin", "B": "Leukotrienes", "C": "Endorphins", "D": "Serotonin", "E": "Histamine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old woman", "progressive difficulty breathing", "long day", "house", "included brushing", "dusting", "occasionally gets", "episodes", "twice", "year", "medication", "hand", "symptoms", "reversed", "inhaling", "2 adrenergic receptor agonist", "following", "mediators", "responsible", "patients breathing difficulties"]}
{"question": "Nine healthy subjects participate in a study of gastric secretions. Subjects are asked to eat a meal at hour 0, at which time 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 mediators is most active at point A in the graph?", "answer": "Acetylcholine", "options": {"A": "Prostaglandin", "B": "Secretin", "C": "Somatostatin", "D": "Glucose-dependent insulinotropic peptide", "E": "Acetylcholine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["Nine", "gastric secretions", "to eat", "hour 0", "time", "pH", "stomach contents", "rate", "stomach acid secretions", "measured", "next", "hours", "Results", "study", "following mediators", "most active", "point A"]}
{"question": "A 43-year-old Caucasian woman is admitted to the hospital with acute onset right upper quadrant (RUQ) pain. The pain started 6 hours ago after the patient had a large meal at a birthday party and has progressively worsened. She recalls having similar pain before but not so intense. No significant past medical history. Current medications are only oral contraceptive. Vitals are blood pressure 140/80 mm Hg, heart rate 79/min, respiratory rate 14/min, and temperature 37.6℃ (99.7℉). The patient’s BMI is 36.3 kg/m2. On exam, the patient appears slightly jaundiced. Her cardiac and respiratory examinations are within normal limits. Abdominal palpation reveals tenderness to palpation in the RUQ with no rebound or guarding, and there is an inspiratory arrest on deep palpation in this region. The remainder of the examination is within normal limits.\nLaboratory tests are significant for the following:\nRBC count 4.1 million/mm3\nHb 13.4 mg/dL\nLeukocyte count 11,200/mm3\nESR 22 mm/hr\nPlatelet count 230,000/mm3\nTotal bilirubin 2 mg/dL\nDirect bilirubin 1.1 mg/dL\nALT 20 IU/L\nAST 18 IU/L\nAmylase 33 IU/L\nUltrasound of the abdomen shows the following result (see image):\nThe common bile duct (CBD) (not shown in the image) is not dilated. Which of the following procedures is most appropriate for the treatment of this patient?", "answer": "Laparoscopic cholecystectomy", "options": {"A": "Open cholecystectomy", "B": "Endoscopic retrograde cholangiopancreatography", "C": "Laparoscopic cholecystectomy", "D": "Percutaneous cholecystostomy", "E": "Shock wave lithotripsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "woman", "acute onset right upper quadrant", "pain", "pain started 6 hours", "patient", "large", "worsened", "similar pain", "not", "intense", "significant past medical history", "Current medications", "only oral contraceptive", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "patients BMI", "36", "kg/m2", "exam", "patient appears slightly jaundiced", "cardiac", "respiratory examinations", "normal limits", "Abdominal palpation reveals tenderness", "palpation", "RUQ", "guarding", "inspiratory arrest", "deep", "region", "normal limits", "Laboratory tests", "significant", "following", "RBC count", "mm3", "mg", "Leukocyte count 11 200", "ESR", "hr Platelet count", "Total bilirubin", "mg", "Direct bilirubin", "20", "L", "Amylase", "Ultrasound", "abdomen", "following result", "see", "common bile duct", "not", "not dilated", "following procedures", "most appropriate", "treatment", "patient"]}
{"question": "A 38-year-old man comes to the physician because of severe muscle pain and swelling of his eyelids for 3 days. He has also had fever and chills during this period. For the last 2 days, he has had severe pain in his mouth while chewing. He had an episode of diarrhea a month ago for which he did not seek medical care. He has no history of serious illness. His sister has dermatomyositis. He returned from a hunting trip to eastern Europe 45 days ago. His temperature is 38.1°C (100.6°F), pulse is 80/min, and blood pressure is 130/70 mm Hg. Examination shows periorbital edema and severe generalized muscle tenderness. There are splinter hemorrhages on both hands. Laboratory studies show:\nHemoglobin 14.2 g/dL\nLeukocyte count 12,500/mm3\nSegmented neutrophils 60%\nEosinophils 18%\nLymphocytes 20%\nMonocytes 2%\nSerum\nGlucose 117 mg/dL\nCreatinine 1.1 mg/dL\nAlkaline phosphatase 72 U/L\nCreatine kinase 765 U/L\nUrinalysis is within normal limits. Which of the following is most likely to have prevented this patient's condition?\"", "answer": "Cooking meat to 71°C (160°F)", "options": {"A": "Clean drinking water", "B": "Cooking meat to 71°C (160°F)", "C": "Influenza vaccine", "D": "Consume pasteurized dairy products", "E": "Metronidazole at the onset of diarrhea"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "severe muscle", "swelling of", "eyelids", "3 days", "fever", "chills", "period", "last 2 days", "severe", "mouth", "chewing", "episode of diarrhea", "month", "not", "medical care", "history", "serious illness", "dermatomyositis", "returned", "trip", "eastern Europe", "days", "temperature", "100", "pulse", "80 min", "blood pressure", "70 mm Hg", "periorbital edema", "severe generalized muscle tenderness", "splinter", "hands", "Laboratory studies", "Hemoglobin", "Leukocyte count 12", "mm3 Segmented", "60", "Eosinophils 18", "Lymphocytes 20", "Monocytes", "Glucose", "1", "phosphatase 72", "L", "Urinalysis", "normal limits", "following", "to", "prevented", "patient", "ondition?"]}
{"question": "A 28-year-old man comes to the physician for a pre-employment examination. He has no history of serious illness and takes no medications. A screening blood test is performed in which peptides are added to the sample to stimulate in vitro production of interferon-gamma, which is then measured using an enzyme-linked immunosorbent assay. This test is most likely to be helpful in diagnosing infection with which of the following pathogens?", "answer": "Mycobacterium tuberculosis", "options": {"A": "Human immunodeficiency virus", "B": "Staphylococcus aureus", "C": "Hepatitis B virus", "D": "Mycobacterium tuberculosis", "E": "Legionella pneumophila"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "pre employment", "history", "serious illness", "medications", "screening blood", "performed", "peptides", "added", "to", "in vitro production", "interferon-gamma", "then measured using", "enzyme-linked immunosorbent assay", "test", "to", "helpful", "diagnosing infection", "following"]}
{"question": "A 23-year-old woman comes to the physician because of a 5-month history of a pruritic rash on the bilateral upper extremities. She has no history of serious illness and takes no medications. A skin biopsy of the rash shows intraepidermal accumulation of edematous fluid and widening of intercellular spaces between keratinocytes. Which of the following is the most likely diagnosis?", "answer": "Eczematous dermatitis", "options": {"A": "Psoriasis vulgaris", "B": "Lichen planus", "C": "Dermatitis herpetiformis", "D": "Acanthosis nigricans", "E": "Eczematous dermatitis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["23 year old woman", "physician", "5 month history", "pruritic rash", "bilateral upper extremities", "history", "serious illness", "medications", "skin biopsy of", "rash", "intraepidermal accumulation of edematous fluid", "widening of intercellular spaces", "following", "diagnosis"]}
{"question": "A 52-year-old man with a 20+ year history of smoking comes in today to talk about quitting. His wife has recently been trying to quit, and she wants him to quit with her. He has been resistant in the past, but he is now very willing to talk with you about it. Today, he seems like he really wants to make a change. What stage of change does this behavior correspond to?", "answer": "Preparation", "options": {"A": "Precontemplation", "B": "Contemplation", "C": "Preparation", "D": "Action", "E": "Maintenance"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "20", "history of smoking", "today", "talk", "recently", "to", "resistant", "past", "now very willing", "talk", "about", "Today", "to make", "change", "stage", "change", "behavior", "to"]}
{"question": "A 28-year-old woman is brought into the clinic by her husband with concerns that she might be depressed. She delivered a healthy newborn a week and a half ago without any complications. Since then, she has been having trouble sleeping, eating poorly, and has stopped playing with the baby. The patient says she feels like she is drained all the time and feels guilty for not doing more for the baby. Which of the following is the best course of treatment for this patient?", "answer": "Reassurance", "options": {"A": "Reassurance", "B": "Fluoxetine", "C": "Amitriptyline ", "D": "Risperidone", "E": "No treatment"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "clinic", "depressed", "delivered", "healthy newborn", "week", "half", "complications", "then", "trouble sleeping", "eating poorly", "stopped playing", "baby", "patient", "drained", "time", "not", "more", "baby", "following", "best course", "treatment", "patient"]}
{"question": "A 51-year-old man presents to the emergency department with complaints of upper abdominal pain for the last several hours. He says that the pain travels to his back and is less severe when he leans forward. He is diagnosed with acute pancreatitis following enzyme analysis and CT scan of the abdomen and is subsequently managed in intensive care unit (ICU) with IV fluids, analgesics, nasogastric decompression, and supportive therapy. He recovers quickly and is discharged within a week. However, after 5 weeks, the patient develops projectile vomiting containing food but no bile. Physical examination shows visible peristalsis from left to right in the upper abdomen. A repeat CT scan is done. Which of the following is the next best step in the management of this patient?", "answer": "Endoscopic drainage", "options": {"A": "Need no management as this will resolve spontaneously", "B": "Octreotide infusion to reduce all gastrointestinal secretions", "C": "External percutaneous drainage of the lesion", "D": "Endoscopic drainage", "E": "Intravenous fluids, analgesia, and antiemetics"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "complaints", "upper abdominal pain", "last", "hours", "pain", "back", "less severe", "forward", "diagnosed", "acute pancreatitis following enzyme analysis", "CT scan", "abdomen", "in intensive care unit", "analgesics", "nasogastric decompression", "supportive therapy", "recovers", "week", "5 weeks", "patient", "projectile vomiting containing food", "bile", "visible peristalsis", "left", "right", "upper", "repeat CT scan", "following", "next best step", "patient"]}
{"question": "A 13-year-old boy is brought to the physician because of a 5-day history of a rash on his chest and back. His mother initially noticed only a few lesions on his back, but since then the rash has spread to his chest. His family returned from a trip to the Caribbean 2 weeks ago. His mother started using a new laundry detergent 8 days ago. He has type 1 diabetes mellitus controlled with insulin. His mother has Hashimoto thyroiditis and his brother has severe facial acne. His temperature is 37.2°C (99°F), pulse is 81/min, and blood pressure is 115/74 mm Hg. Examination of the skin shows multiple, nontender, round, white macules on the chest and trunk. There is fine scaling when the lesions are scraped with a spatula. There are no excoriation marks. The remainder of the examination shows no abnormalities. Which of the following is the most likely underlying mechanism of this patient's symptoms?", "answer": "Increased growth of Malassezia globosa", "options": {"A": "Autoimmune destruction of melanocytes", "B": "Increased sebum production", "C": "Increased growth of Malassezia globosa", "D": "Exposure to human herpes virus 7", "E": "Antigen uptake by Langerhans cells"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "5-day history", "rash", "chest", "back", "initially", "only", "few lesions", "back", "since then", "rash", "spread", "chest", "returned", "trip", "Caribbean", "weeks", "started using", "new", "days", "type 1 diabetes mellitus controlled", "insulin", "Hashimoto thyroiditis", "severe facial acne", "temperature", "pulse", "81 min", "blood pressure", "74 mm Hg", "Examination of", "skin", "multiple", "nontender", "round", "white macules", "chest", "trunk", "fine scaling", "lesions", "scraped", "spatula", "excoriation marks", "abnormalities", "following", "underlying mechanism", "patient's symptoms"]}
{"question": "A 72-year-old woman is brought to the emergency department because of increasing abdominal pain for 6 hours. The pain is dull and diffuse over her abdomen and radiates to her lower back bilaterally. Three weeks ago, she was diagnosed with atrial fibrillation and started on warfarin. Her only other medication is 1 g of acetaminophen daily for osteoarthritis of her knees. Her pulse is 87/min and blood pressure is 112/75 mm Hg. Physical examination shows abdominal tenderness to palpation at both lower quadrants. A CT scan of the abdomen shows a retroperitoneal mass and hazy margins of the surrounding structures. In addition to discontinuation of warfarin, the most appropriate next step in management is administration of which of the following?", "answer": "Phytonadione and prothrombin complex concentrate", "options": {"A": "Fresh frozen plasma and tranexamic acid", "B": "Aminocaproic acid and packed red blood cells", "C": "Factor VIII and von Willebrand factor", "D": "Phytonadione and prothrombin complex concentrate", "E": "Protamine sulfate and hydroxyethyl starch"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "of increasing abdominal pain", "hours", "pain", "dull", "diffuse", "abdomen", "radiates", "lower back", "Three weeks", "diagnosed", "atrial fibrillation", "started", "warfarin", "only", "medication", "1 g", "acetaminophen daily", "osteoarthritis of", "knees", "pulse", "87 min", "blood pressure", "75 mm Hg", "abdominal tenderness", "palpation", "lower quadrants", "CT scan", "abdomen", "retroperitoneal mass", "margins", "surrounding structures", "In addition to discontinuation", "warfarin", "most appropriate next step", "administration"]}
{"question": "A 36-year-old man presents to a psychiatrist for management of nicotine dependence. He has been a heavy smoker for the past 20 years. He has unsuccessfully attempted to quit smoking many times. He has seen multiple physicians for nicotine dependence. They prescribed nicotine replacement therapy and varenicline. He has also taken two antidepressants and participated in talk therapy. He asks the psychiatrist whether there are other alternatives. The psychiatrist explains that nicotine replacement therapy, non-nicotine pharmacotherapy, and talk therapy are the best options for the management of nicotine dependence. He tells the patient he can take a second-line medication for non-nicotine pharmacotherapy because the first-line medication failed. Which of the following medications would the psychiatrist most likely use to manage this patient’s nicotine dependence?", "answer": "Clonidine", "options": {"A": "Buprenorphine", "B": "Clonidine", "C": "Lorazepam", "D": "Methadone", "E": "Topiramate"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["36 year old man presents", "psychiatrist", "nicotine dependence", "heavy smoker", "past 20 years", "to", "smoking", "times", "seen multiple physicians", "nicotine dependence", "nicotine replacement therapy", "varenicline", "two antidepressants", "talk therapy", "psychiatrist", "psychiatrist", "nicotine replacement therapy", "non nicotine pharmacotherapy", "talk therapy", "best options", "nicotine dependence", "patient", "second line medication", "non nicotine pharmacotherapy", "first line medication failed", "following medications", "psychiatrist", "likely use to", "patients nicotine dependence"]}
{"question": "A physician attempts to study cirrhosis in his state. Using a registry of admitted patients over the last 10 years at the local hospital, he isolates all patients who have been diagnosed with cirrhosis. Subsequently, he contacts this group of patients, asking them to complete a survey assessing their prior exposure to alcohol use, intravenous drug abuse, blood transfusions, personal history of cancer, and other medical comorbidities. An identical survey is given to an equal number of patients in the registry who do not carry a prior diagnosis of cirrhosis. Which of the following is the study design utilized by this physician?", "answer": "Case-control study", "options": {"A": "Case-control study", "B": "Cohort study", "C": "Cross-sectional study", "D": "Meta-analysis", "E": "Randomized controlled trial"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["physician", "to study cirrhosis", "state", "Using", "last", "local hospital", "isolates", "patients", "diagnosed", "cirrhosis", "contacts", "group", "patients", "to complete", "survey", "prior", "use", "intravenous drug abuse", "blood transfusions", "personal history of cancer", "medical comorbidities", "identical survey", "given to", "equal number of patients", "not carry", "prior diagnosis", "cirrhosis", "following", "physician"]}
{"question": "A 17-year-old male presents to your office complaining of polyuria, polydipsia, and unintentional weight loss of 12 pounds over the past 3 months. On physical examination, the patient is tachypneic with labored breathing. Which of the following electrolyte abnormalities would you most likely observe in this patient?", "answer": "Hyperkalemia", "options": {"A": "Alkalemia", "B": "Hyperkalemia", "C": "Hypoglycemia", "D": "Hypermagnesemia", "E": "Hyperphosphatemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "office", "polyuria", "polydipsia", "unintentional weight loss of", "pounds", "past 3 months", "patient", "tachypneic", "labored breathing", "following electrolyte abnormalities", "most likely observe", "patient"]}
{"question": "A 54-year-old man comes to the physician because of generalized fatigue and numbness of his legs and toes for 5 months. He has hypertension and hypercholesterolemia. He underwent a partial gastrectomy for peptic ulcer disease 15 years ago. Current medications include amlodipine and atorvastatin. He is a painter. His temperature is 37°C (98.6°F), pulse is 101/min, respirations are 17/min, and blood pressure is 122/82 mm Hg. Examination shows conjunctival pallor and glossitis. Sensation to vibration and position is absent over the lower extremities. He has a broad-based gait. The patient sways when he stands with his feet together and closes his eyes. His hemoglobin concentration is 10.1 g/dL, leukocyte count is 4300/mm3, and platelet count is 110,000/mm3. Which of the following laboratory findings is most likely to be seen in this patient?", "answer": "Elevated methylmalonic acid levels", "options": {"A": "Decreased serum iron levels", "B": "Oligoclonal bands in cerebrospinal fluid", "C": "Elevated methylmalonic acid levels", "D": "Basophilic stippling on peripheral smear", "E": "Positive rapid plasma reagin test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["54 year old man", "physician", "generalized fatigue", "numbness", "legs", "toes", "months", "hypertension", "hypercholesterolemia", "partial gastrectomy", "peptic ulcer disease", "years", "Current include amlodipine", "atorvastatin", "painter", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "conjunctival pallor", "glossitis", "Sensation", "vibration", "position", "absent", "lower extremities", "broad-based gait", "patient", "stands", "feet together", "closes", "eyes", "hemoglobin concentration", "10", "g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "following laboratory findings", "to", "seen", "patient"]}
{"question": "A 5-year-old male is brought to his pediatrician after recurrent, prolonged upper respiratory infections over a period of several months. Physical exam reveals petechiae on the patient’s legs and arms. Laboratory studies show hemoglobin: 10 g/L, platelet count: 35,000/mm^3, leukocyte count: 6,600/mm^3. A bone marrow aspiration shows an abundance of lymphoblasts indicative of acute lymphoblastic leukemia (ALL). Positive immunostaining for which of the following would support a diagnosis of precursor B-cell leukemia?", "answer": "CD19, CD10", "options": {"A": "TdT, HER-2", "B": "CD2, CD8", "C": "CD19, CD10", "D": "CD30, CD15", "E": "CD4, CD5"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old male", "brought", "pediatrician", "recurrent", "prolonged upper respiratory infections", "period", "months", "reveals petechiae", "patients legs", "arms", "Laboratory studies", "hemoglobin", "10 g/L", "platelet count", "35", "mm", "leukocyte count", "6 600 mm 3", "bone marrow aspiration", "abundance", "lymphoblasts", "acute lymphoblastic leukemia", "Positive", "following", "support", "diagnosis", "B-cell leukemia"]}
{"question": "The objective of one case-control study was to assess whether a history of past trauma represents a risk factor for the development of spondyloarthritis. Cases of spondyloarthritis were compared with a random sample taken from the general population in regards to a history of prior trauma. This kind of history, which in turn increased the likelihood of being subjected to X-ray imaging investigations, led to a higher likelihood of diagnosing spondyloarthritis in these individuals compared with the general population. This resulted in a significantly higher proportion of spondyloarthritis in study participants with prior trauma, with the resulting overestimation of related odds ratio. In which case is the bias in this example more likely to occur?", "answer": "If the outcome is ascertained through electronic health records", "options": {"A": "If the outcome is ascertained through electronic health records", "B": "If the outcome is assessed systematically regardless of exposure", "C": "If the outcome is ascertained while the exposed status is masked", "D": "If the study participants are followed at the same time intervals", "E": "If the study participants are subjected to identical tests at each visit"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["objective", "one", "to", "history of past trauma", "a", "factor", "development", "spondyloarthritis", "Cases", "to", "history", "prior trauma", "kind", "history", "turn increased", "likelihood", "subjected", "X-ray imaging investigations", "led", "higher likelihood", "diagnosing spondyloarthritis", "resulted", "significantly higher proportion", "spondyloarthritis", "study", "prior trauma", "resulting", "related odds ratio", "case", "likely to occur"]}
{"question": "A 67-year-old man presents to the emergency department with trouble urinating. The patient states that in general he has had difficulty urinating but recently, it has taken significant effort for him to initiate a urinary stream. He finds himself unable to completely void and states he has suprapubic tenderness as a result. These symptoms started suddenly 3 days ago. The patient has a history of benign prostatic hyperplasia, constipation, and diabetes mellitus. His current medications include finasteride, sodium docusate, and hydrochlorothiazide. He recently started taking phenylephrine for seasonal allergies. The patient’s last bowel movement was 2 days ago. His temperature is 99.0°F (37.2°C), blood pressure is 167/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 100% on room air. Physical exam is notable for suprapubic tenderness, and an ultrasound reveals 750 mL of fluid in the bladder. Which of the following is the most likely etiology of this patient’s symptoms?", "answer": "Medication-induced symptoms", "options": {"A": "Constipation", "B": "Medication-induced symptoms", "C": "Prostatic adenocarcinoma", "D": "Urinary tract infection", "E": "Worsening benign prostatic hypertrophy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old man presents", "emergency department", "patient states", "general", "difficulty urinating", "recently", "significant effort", "to initiate", "urinary stream", "finds", "unable to completely void", "states", "suprapubic tenderness", "result", "symptoms started", "days", "patient", "history of benign prostatic hyperplasia", "constipation", "diabetes mellitus", "current medications include finasteride", "sodium docusate", "hydrochlorothiazide", "recently started", "phenylephrine", "seasonal allergies", "patients last bowel movement", "2 days", "temperature", "99", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "100", "room air", "notable", "suprapubic tenderness", "ultrasound reveals 750 mL", "fluid", "bladder", "following", "etiology", "patients symptoms"]}
{"question": "A 26-year-old woman, gravida 2, para 1, at 26 weeks’ gestation, comes to the emergency department because of pain and swelling in her right calf. Physical examination shows an increased circumference of the right calf. The leg is warm and tender on palpation. Dorsiflexion of the right foot elicits calf pain. An ultrasound of the right leg shows a noncompressible popliteal vein. Which of the following is the most appropriate pharmacotherapy for this patient's condition?", "answer": "Heparin", "options": {"A": "Aspirin", "B": "Clopidogrel", "C": "Heparin", "D": "Rivaroxaban", "E": "Warfarin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks gestation", "emergency department", "pain", "swelling", "right", "increased circumference", "right calf", "leg", "warm", "tender", "palpation", "Dorsiflexion of", "right foot elicits calf pain", "ultrasound", "right leg", "popliteal vein", "following", "most appropriate pharmacotherapy", "patient's condition"]}
{"question": "A 4-year-old boy is brought to the physician by his mother because of generalized weakness and difficulty walking for the past month. Laboratory studies show a hemoglobin concentration of 6.6 g/dL, mean corpuscular volume of 74 μm3, platelet count of 150,000/mm3, and serum total bilirubin of 2 mg/dl. An MRI of the spine shows low signal intensity in all vertebral bodies and a small epidural mass compressing the spinal canal at the level of L1. A CT scan of the head shows osteopenia with widening of the diploic spaces in the skull. A biopsy of the epidural mass shows erythroid colonies with an abundance of megakaryocytes and myeloid cells. Which of the following is the most likely diagnosis?", "answer": "Beta-thalassemia\n\"", "options": {"A": "G6PD deficiency", "B": "Aplastic anemia", "C": "Lead poisoning", "D": "Multiple myeloma", "E": "Beta-thalassemia\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["4 year old boy", "brought", "physician", "generalized weakness", "difficulty walking", "past month", "Laboratory studies", "hemoglobin concentration", "g/dL", "mean corpuscular volume", "74 m3", "platelet count", "mm3", "serum total bilirubin", "2 mg dl", "MRI of", "spine", "vertebral bodies", "small epidural mass compressing", "spinal canal", "level", "L1", "CT scan of", "head", "osteopenia", "widening", "diploic spaces", "skull", "biopsy", "epidural mass", "erythroid colonies", "abundance", "megakaryocytes", "following", "diagnosis"]}
{"question": "A 32-year-old woman comes to the physician because of weight gain, generalized weakness, and irregular menstrual cycles for the past 16 months. She began having symptoms of insomnia and depression 10 months ago. More recently, she has been having difficulties rising from a chair. She has a 2-year history of hypertension. Current medications include citalopram and hydrochlorothiazide. She is 168 cm (5 ft 6 in) tall and weighs 100 kg (220 lb). BMI is 36 kg/m2. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. She appears tired and has a full, plethoric face and central obesity. Examination of the skin shows violaceous linear striations on her lower abdomen. Two midnight serum cortisol studies show measurements of 288 μg/L and 253 μg/L (N < 90); a 24-hour urinary cortisol measurement was 395 μg (N < 300). Upon follow-up laboratory examination, the patient's serum ACTH levels were also elevated at 136 pg/mL (N = 7–50). Which of the following is the most appropriate next step in evaluation?", "answer": "High-dose dexamethasone suppression test", "options": {"A": "MRI of the head with contrast", "B": "Measure ACTH levels in inferior petrosal sinuses", "C": "High-dose dexamethasone suppression test", "D": "CT scan of the abdomen with contrast", "E": "Bilateral adrenalectomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "weight gain", "generalized weakness", "irregular menstrual cycles", "past", "months", "began", "symptoms", "insomnia", "depression 10 months", "recently", "difficulties", "2 year history of hypertension", "Current include citalopram", "hydrochlorothiazide", "5 ft 6", "tall", "100 kg", "BMI", "36 kg/m2", "pulse", "min", "respirations", "min", "blood pressure", "76 mm Hg", "appears tired", "full", "plethoric face", "central obesity", "Examination of", "skin", "violaceous linear striations", "lower abdomen", "Two midnight serum cortisol studies", "measurements", "g/L", "g/L", "N", "90", "24-hour urinary cortisol measurement", "g", "300", "follow-up laboratory examination", "patient's serum ACTH levels", "elevated", "pg/mL", "N", "750", "following", "most appropriate next step"]}
{"question": "A 43-year-old woman is found in the hospital to have a plasma sodium concentration of 126 mg/dL. She was hospitalized after she expressed suicidal ideations and was started on a medication for major depressive disorder. Her past medical history is significant for diabetes for which she is currently taking metformin. Her blood pressure while in the hospital has been around 130/85 mmHg and she is not taking any other medications. Urinalysis shows a serum osmolality of 1085 mOsm/L. Which of the following best describes the cell bodies of the cells that are behaving abnormally in this patient?", "answer": "Located in the hypothalamus", "options": {"A": "Acidophils in the anterior pituitary", "B": "Basophils in the anterior pituitary", "C": "Chromophobes in the anterior pituitary", "D": "Located in the hypothalamus", "E": "Located in the posterior pituitary"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "found", "hospital to", "plasma concentration", "mg/dL", "hospitalized", "suicidal ideations", "started", "medication", "major depressive disorder", "past medical history", "significant", "diabetes", "currently", "metformin", "blood pressure", "hospital", "85 mmHg", "not", "medications", "Urinalysis", "serum osmolality", "mOsm/L", "following best", "cell", "cells", "patient"]}
{"question": "A 41-year-old nulliparous woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year she has been feeling healthy. She is sexually active and uses an intrauterine device with copper for contraception. She has smoked one pack of cigarettes daily for 20 years. She is 160 cm (5 ft 3 in) tall and weighs 88 kg (194 lb); BMI is 34.4 kg/m2. Bimanual pelvic examination shows an irregularly enlarged uterus. A transvaginal ultrasound reveals a singular 4 cm, hypoechoic mass inside the myometrial wall. Which of the following is the most likely cause of this finding?", "answer": "Leiomyoma", "options": {"A": "Leiomyoma", "B": "Endometrial cancer", "C": "Endometrial hyperplasia", "D": "Endometrial polyp", "E": "Uterine leiomyosarcoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old nulliparous woman", "physician", "annual pelvic examination", "Pap smear", "past year", "healthy", "sexually active", "uses", "intrauterine device", "copper", "contraception", "smoked one pack", "cigarettes daily", "20 years", "5 ft", "tall", "88 kg", "BMI", "kg/m2", "Bimanual pelvic", "enlarged uterus", "transvaginal ultrasound reveals", "singular", "mass", "myometrial wall", "following", "most likely cause", "finding"]}
{"question": "A 52-year-old man comes to the physician for a routine health maintenance examination. He feels well. His blood pressure is 125/70 mm Hg. His glomerular filtration rate is calculated to be 105 mL/min/1.73 m2 and glucose clearance is calculated to be 103 mL/min. This patient is most likely being treated with which of the following agents?", "answer": "Canagliflozin", "options": {"A": "Metformin", "B": "Canagliflozin", "C": "Ifosfamide", "D": "Glipizide", "E": "Acarbose"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "routine", "well", "blood pressure", "70 mm Hg", "glomerular filtration rate", "calculated to", "mL/min", "m2", "glucose clearance", "calculated to", "mL/min", "patient", "most likely", "treated with", "following agents"]}
{"question": "An 18-month-old boy is brought in by his parents for a routine check-up. The parents state that the patient still has not had any language development, and they are concerned about developmental delay. Of note, they have also noticed that the patient’s facial features have changed significantly in the last year. The patient also seems to have trouble visually focusing on objects or on the television. On exam, the patient's temperature is 98.2°F (36.8°C), blood pressure is 108/72 mmHg, pulse is 86/min, and respirations are 14/min. Of interest, the patient has not increased much in length or weight in the past 3 months. He is now in the 25th percentile for weight but is in the 90th percentile for head circumference. The patient does not appear to have any gross or fine motor deficiencies. Of note, he has coarse facial features that were not previously noted, including a long face, prominent forehead, and protruding eyes. The patient has corneal clouding bilaterally. At rest, the patient keeps his mouth hanging open. After extensive workup, the patient is found to have 2 mutated copies of the IDUA gene, with no production of the protein iduronidase. Which of the following is the likely mutation found in this disease?", "answer": "Nonsense mutation", "options": {"A": "Chromosomal translocation", "B": "Interstitial deletion", "C": "Missense mutation", "D": "Nonsense mutation", "E": "Silent mutation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "routine check-up", "state", "patient", "not", "developmental delay", "note", "patients facial features", "changed", "year", "patient", "to", "focusing", "television", "exam", "patient's temperature", "98", "36", "blood pressure", "72 mmHg", "pulse", "min", "respirations", "min", "patient", "not increased much", "length", "weight", "past 3 months", "now", "percentile", "weight", "90th percentile", "head circumference", "patient", "not appear to", "gross", "fine motor deficiencies", "note", "coarse facial features", "not", "noted", "including", "long face", "prominent forehead", "protruding eyes", "patient", "corneal clouding", "patient keeps", "mouth hanging open", "extensive workup", "patient", "found to", "2 mutated copies", "IDUA gene", "protein iduronidase", "following", "likely mutation found", "disease"]}
{"question": "A 29-year-old man is brought to the emergency department 20 minutes after being stabbed in the left thigh. His pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a 2-cm wound overlying a pulsatile mass on the left anterior thigh, 4 cm below the inguinal crease. A thrill is palpated, and a bruit is heard over this area. Peripheral pulses are normal bilaterally. The patient is at greatest risk for which of the following?", "answer": "High-output cardiac failure", "options": {"A": "Pudendal nerve compression", "B": "High-output cardiac failure", "C": "Iliac artery aneurysm", "D": "Femoral head necrosis", "E": "Erectile dysfunction"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["29 year old man", "brought", "emergency department 20 minutes", "stabbed", "left thigh", "pulse", "min", "respirations", "20 min", "blood pressure", "70 mm Hg", "2", "wound", "pulsatile mass", "left anterior thigh", "4", "inguinal", "thrill", "bruit", "heard", "area", "Peripheral pulses", "normal", "patient", "greatest", "following"]}
{"question": "A 69-year-old man presents to his primary care physician for pain when he walks. He states that the pain is the worst in his left great toe but is also present in his hips and knees. He says that his symptoms are worse with activity and tend to improve with rest. His symptoms have progressively worsened over the past several years. He has a past medical history of obesity, type II diabetes mellitus, smoking, and hypertension. He drinks roughly ten beers per day. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient has a recent travel history to Bangkok where he admits to having unprotected sex. On physical exam, examination of the lower extremity results in pain. There is crepitus of the patient's hip when his thigh is flexed and extended. Which of the following is the most likely diagnosis?", "answer": "Osteoarthritis", "options": {"A": "Osteoarthritis", "B": "Rheumatoid arthritis", "C": "Infectious arthritis", "D": "Gout", "E": "Pseudogout"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["69 year old man presents", "primary care physician", "pain", "walks", "states", "pain", "worst", "left great toe", "present", "hips", "knees", "symptoms", "to", "symptoms", "worsened", "past", "years", "past medical", "type II diabetes mellitus", "smoking", "hypertension", "current medications include metformin", "insulin", "lisinopril", "hydrochlorothiazide", "patient", "recent", "history", "to", "examination of the lower extremity results", "pain", "crepitus", "patient's hip", "thigh", "flexed", "extended", "following", "diagnosis"]}
{"question": "A 51-year-old woman presents to your office with 2 weeks of fatigue and generalized weakness. She has a past medical history of diabetes, hypertension, and hyperlipidemia. She was recently diagnosed with rheumatoid arthritis and started on disease-modifying therapy. She states she has felt less able to do things she enjoys and feels guilty she can't play sports with her children. Review of systems is notable for the patient occasionally seeing a small amount of bright red blood on the toilet paper. Laboratory studies are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 7,700/mm^3 with normal differential\nPlatelet count: 207,000/mm^3\nMCV: 110 fL\n\nWhich of the following is the most likely etiology of this patient's fatigue?", "answer": "Medication side effect", "options": {"A": "Depression", "B": "Gastrointestinal bleed", "C": "Iron deficiency", "D": "Medication side effect", "E": "Vitamin B12 deficiency"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "office", "2 weeks", "fatigue", "generalized weakness", "past medical diabetes", "hypertension", "hyperlipidemia", "recently diagnosed", "rheumatoid arthritis", "started", "disease modifying therapy", "states", "less able", "play", "Review of systems", "notable", "patient occasionally seeing", "small amount", "bright red blood", "toilet paper", "Laboratory studies", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "7 700 mm", "normal differential Platelet count", "mm", "MCV", "fL", "following", "etiology", "patient's fatigue"]}
{"question": "A 34-year-old man presents with acute-onset fever and weakness followed by shifting neurologic deficits (aphasia, motor deficits), which have lasted for a few days. His relatives add that his quantity of urine has reduced significantly over the last few days. He has never had any similar symptoms. Laboratory findings are significant for the following:\nHb 8.6 g/dL\nWBC 6.5 × 1000/mm3\nPlatelets 43 × 1000/mm3\nCr 3.1 mg/dL\nBUN 25 mg/dL\nNa+ 136 mg/dL\nK+ 4.2 mg/dL\nCl- 101 mg/dL\nHCO3- 24 mg/dL\nGlu 101 mg/dL\nExamination of the peripheral smear shows the presence of schistocytes, helmet cells, and spherocytes. \nWhich of the following is true regarding this patient's condition?", "answer": "Plasmapheresis is the treatment of choice.", "options": {"A": "The condition is caused by the deficiency of a sodium transporter.", "B": "A platelet transfusion should be given.", "C": "Bleeding time will be normal.", "D": "Splenectomy should be performed as early as possible.", "E": "Plasmapheresis is the treatment of choice."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "acute-onset fever", "weakness followed by shifting neurologic deficits", "aphasia", "motor deficits", "lasted", "days", "add", "quantity", "urine", "reduced", "days", "never", "similar symptoms", "Laboratory findings", "significant", "following", "Hb 8", "dL WBC", "mm3 Platelets", "3 1 mg dL BUN", "mg", "Na", "4 2", "HCO3", "Glu", "peripheral smear", "presence", "schistocytes", "helmet cells", "spherocytes", "following", "true", "patient's condition"]}
{"question": "A 38-year-old man comes to the physician because of a 1-month history of fever and a cough productive of a moderate amount of yellowish sputum. He has had a 6-kg (13-lb) weight loss during this period. He emigrated from the Middle East around 2 years ago. His father died of lung cancer at the age of 54 years. He has smoked one pack of cigarettes daily for 18 years. He appears malnourished. His temperature is 38.1°C (100.6°F), pulse is 101/min, and blood pressure is 118/72 mm Hg. Crackles are heard on auscultation of the chest. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Laboratory studies show:\nHemoglobin 12.3 g/dL\nLeukocyte count 13,200/mm3\nPlatelet count 330,000/mm3\nErythrocyte sedimentation rate 66 mm/h\nSerum\nUrea nitrogen 16 mg/dL\nGlucose 122 mg/dL\nCreatinine 0.9 mg/dL\nUrinalysis is within normal limits. An x-ray of the chest is shown. Which of the following is the most appropriate next step in management?\"", "answer": "Collect sputum specimens for acid-fast bacilli smear microscopy, culture, and nucleic acid amplification", "options": {"A": "Perform a high-resolution CT scan of the chest", "B": "Start treatment with oral levofloxacin", "C": "Collect sputum specimens for acid-fast bacilli smear microscopy, culture, and nucleic acid amplification", "D": "Perform transbronchial lung biopsy of the suspected lesion", "E": "Perform an interferon-gamma release assay"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "month history", "fever", "cough productive", "moderate amount", "sputum", "kg", "weight loss", "period", "Middle East", "2 years", "died of lung cancer", "age", "54 years", "smoked one pack", "cigarettes daily", "years", "appears malnourished", "temperature", "100", "pulse", "min", "blood pressure", "72 mm Hg", "Crackles", "heard", "auscultation", "chest", "abnormalities", "abdomen", "soft", "nontender", "Laboratory studies", "Hemoglobin", "200 mm3 Platelet count 330", "Erythrocyte sedimentation rate", "h", "Urea nitrogen", "mg", "mg", "Creatinine 0.9", "Urinalysis", "normal limits", "x-ray of", "chest", "following", "most appropriate next step"]}
{"question": "A 5-year-old girl is brought to the physician by her mother for a 6-week history of fatigue, fever, and recurrent epistaxis. She has a history of duodenal atresia and an atrioventricular septal defect. She is at the 5th percentile for height and 30th percentile for weight. Physical examination shows painless cervical lymphadenopathy. Her hands are short and broad and there is a space between the first and second toes bilaterally. The spleen tip is palpated 3 cm below the left costal margin. Bone marrow aspirate shows leukocytosis with 50% lymphoblasts. Which of the following best explains this patient's condition?", "answer": "Meiotic nondisjunction", "options": {"A": "Meiotic nondisjunction", "B": "Deletion of a chromosome segment", "C": "Uniparental disomy", "D": "Trinucleotide repeat expansion", "E": "Unbalanced Robertsonian translocation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 year old girl", "brought", "physician", "mother", "week history", "fatigue", "fever", "recurrent epistaxis", "history of duodenal atresia", "atrioventricular septal defect", "5th percentile", "height", "percentile", "weight", "painless cervical lymphadenopathy", "hands", "short", "broad", "space", "first", "second toes", "spleen tip", "3 cm", "left costal margin", "Bone marrow aspirate", "leukocytosis", "50", "lymphoblasts", "following best", "patient's condition"]}
{"question": "A 27-year-old woman, gravida 2, para 1, at 37 weeks' gestation is admitted to the hospital in active labor. She has received routine prenatal care, but she has not been tested for group B streptococcal (GBS) colonization. Pregnancy and delivery of her first child were complicated by an infection with GBS that resulted in sepsis in the newborn. Current medications include folic acid and a multivitamin. Vital signs are within normal limits. The abdomen is nontender and contractions are felt every 4 minutes. There is clear amniotic fluid pooling in the vagina. The fetus is in a cephalic presentation. The fetal heart rate is 140/min. Which of the following is the most appropriate next step in management?", "answer": "Administer intrapartum intravenous penicillin", "options": {"A": "Reassurance", "B": "Obtain vaginal-rectal swab for GBS culture", "C": "Administer intrapartum intravenous penicillin", "D": "Obtain vaginal-rectal swab for GBS culture and nucleic acid amplification testing", "E": "Obtain vaginal-rectal swab for nucleic acid amplification testing"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old woman", "gravida 2", "para 1", "weeks", "gestation", "active labor", "received routine prenatal care", "not", "colonization", "Pregnancy", "delivery", "first child", "complicated", "infection", "resulted", "sepsis", "newborn", "Current medications include folic acid", "multivitamin", "Vital signs", "normal limits", "abdomen", "nontender", "contractions", "4 minutes", "clear amniotic pooling", "vagina", "fetus", "cephalic presentation", "fetal heart rate", "min", "following", "most appropriate next step"]}
{"question": "A 55-year-old woman presents with diarrhea and a rash. She reports having some painful reddish nodules on her legs that she noticed a week ago. She also has been having loose stools associated with cramping lower abdominal pain for the past month. This is associated with an urgency to defecate, and defecation helps relieve the abdominal pain. The stool is occasionally blood-tinged and has some mucus. She feels fatigued but denies fever, weight loss, exposure to any sick people, or history of travel recently. No significant past medical history. Her family history is significant for osteoporosis in her mother, aunt, and older sister. On physical examination, the patient has generalized pallor. There are multiple erythematous tender nodules over the extensor surface of the legs bilaterally below the level of the knee. Abdominal examination reveals mild tenderness to palpation in the left lower quadrant. A DEXA scan is performed and reveals a T-score of -1.5 at the hips and spine. Laboratory findings are significant for microcytic anemia and an elevated ESR. A colonoscopy is performed and reveals patchy inflammation of the colon with rectal sparing. The lesions are present in patches with intermittent normal colonic mucosa. The patient is started on sulfasalazine and shows a good response. However, 6 months later, she returns with a recurrence of her symptoms. A repeat colonoscopy reveals more extensive involvement of the colon and the small bowel. A second drug is added to her treatment regimen. Which of the following is the most common adverse effect associated with the use of this second drug?", "answer": "Infection", "options": {"A": "Worsening of osteoporosis", "B": "Infection", "C": "Rash", "D": "Megaloblastic anemia", "E": "Hepatotoxicity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "diarrhea", "rash", "reports", "painful", "nodules", "legs", "week", "loose stools associated with cramping lower abdominal pain", "past month", "associated with", "urgency", "defecation helps relieve", "abdominal pain", "stool", "occasionally blood-tinged", "mucus", "fatigued", "fever", "weight loss", "exposure to", "sick people", "history of travel recently", "significant past medical history", "family history", "significant", "osteoporosis", "patient", "generalized pallor", "multiple erythematous tender nodules", "extensor surface of", "legs", "level", "knee", "Abdominal", "reveals mild tenderness", "palpation", "left lower quadrant", "DEXA scan", "performed", "reveals a T score", "1", "hips", "spine", "Laboratory findings", "significant", "microcytic anemia", "elevated ESR", "colonoscopy", "performed", "reveals patchy inflammation of", "colon", "rectal", "lesions", "present", "patches", "intermittent normal colonic mucosa", "patient", "started", "sulfasalazine", "good response", "months later", "returns", "recurrence", "symptoms", "repeat colonoscopy reveals more extensive involvement", "colon", "small bowel", "second drug", "added", "treatment regimen", "following", "most common adverse effect associated with", "use of", "second drug"]}
{"question": "A 7-year-old boy presents to the emergency department with several days of high fever accompanied by runny nose, cough, and red itchy eyes. Upon further history, you learn that the family is undocumented and has not had access to primary health services. Upon physical examination you see a red, slightly bumpy rash extending from the head to the mid-chest level. If you had examined this child a prior to the development of the rash, which of the following signs may you have observed?", "answer": "Koplik spots", "options": {"A": "Parotid gland swelling", "B": "Posterior auricular lymphadenopathy", "C": "Blueberry muffin rash", "D": "Dermatomal vesicular rash", "E": "Koplik spots"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy presents", "emergency department", "several days", "high fever", "runny nose", "cough", "red itchy", "further history", "not", "access", "primary health services", "see", "red", "slightly", "rash extending", "head", "mid chest level", "examined", "child", "prior to", "development", "rash", "following signs", "observed"]}
{"question": "A 75-year-old female patient comes to the emergency department with altered mental status. She is brought in by her daughter with whom the patient lives. The patient’s daughter said they were watching TV when her mother became unresponsive. On exam the patient withdraws to pain but does not open her eyes or speak. An emergent head CT is done and shows an intracranial bleed. The patient is moved to the ICU and intubated. Further history is obtained from the daughter. The patient has a past medical history of diabetes and a previous stroke. Her medications are metformin and warfarin. The patient is compliant with all of her medications. The daughter says that the patient changed her diet about 1 month ago in response to a diet she saw on a talk show. Which of the following foods is most likely to cause the pathology seen in this patient?", "answer": "Grapefruit juice", "options": {"A": "St. John’s wort", "B": "Chili peppers", "C": "Grapefruit juice", "D": "Spinach", "E": "Green tea"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old female patient", "emergency department", "altered mental status", "brought", "patient lives", "patients", "unresponsive", "exam", "patient", "pain", "not open", "eyes", "speak", "head CT", "intracranial bleed", "patient", "moved to", "ICU", "intubated", "Further history", "obtained", "patient", "past medical diabetes", "previous stroke", "medications", "metformin", "warfarin", "patient", "compliant", "medications", "patient changed", "diet", "month", "response", "diet", "saw", "talk", "following", "to cause", "pathology seen", "patient"]}
{"question": "A 25-year-old gravida 1 para 0 woman visits an OB/GYN for her first prenatal visit and to establish care. She is concerned about the costs related to future prenatal visits, medications, procedures, and the delivery. She has no type of health insurance through her work and has previously been denied coverage by public health insurance based on her income. Since then she has been promoted and earns a higher salary. In addressing this patient, which of the following is the most appropriate counseling?", "answer": "She may be eligible for Medicaid because she is pregnant", "options": {"A": "She may be eligible for Medicaid based on her higher salary", "B": "She may be eligible for Medicaid because she is pregnant", "C": "She may be eligible for Medicare based on her higher salary", "D": "She may be eligible for Medigap based on her higher salary", "E": "She may be eligible for Medigap because she is pregnant"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old gravida 1 para 0 woman", "OB/GYN", "to establish", "costs related", "future", "medications", "procedures", "delivery", "denied coverage", "health insurance based", "income", "then", "earns", "higher salary", "patient", "following", "most appropriate counseling"]}
{"question": "A 19-year-old male with cystic fibrosis is evaluated in the clinic for regular health maintenance. He is compliant with his respiratory therapy, but states that he often \"forgets\" to take the medications before he eats. A panel of labs is drawn which reveals a moderate vitamin D deficiency. Which of the following electrolyte abnormalities might be seen as a consequence of vitamin D deficiency?", "answer": "Decreased calcium and decreased phosphate", "options": {"A": "Increased calcium and increased phosphate", "B": "Increased calcium and decreased phosphate", "C": "Decreased calcium and increased phosphate", "D": "Decreased calcium and decreased phosphate", "E": "Normal calcium and decreased phosphate"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male", "cystic fibrosis", "clinic", "regular", "compliant", "respiratory therapy", "states", "often", "forgets", "to", "medications", "eats", "panel", "labs", "reveals", "moderate vitamin D deficiency", "following electrolyte abnormalities", "seen", "a consequence of vitamin D deficiency"]}
{"question": "A 57-year-old male presents with a primary complaint of erectile dysfunction. After proper evaluation, the patient is started on daily administration of sildenafil. This medication directly causes accumulation of which of the following intracellular mediators?", "answer": "cGMP", "options": {"A": "Ca2+", "B": "cGMP", "C": "AMP", "D": "NO", "E": "ANP"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["57 year old male presents", "primary complaint", "erectile dysfunction", "patient", "started", "daily administration", "sildenafil", "medication directly causes accumulation", "following intracellular mediators"]}
{"question": "A 32-year-old Caucasian female is admitted to the emergency department with a 48-hour history of severe and diffuse abdominal pain, nausea, vomiting, and constipation. Her personal history is unremarkable except for an ectopic pregnancy 5 years ago. Upon admission, she is found to have a blood pressure of 120/60 mm Hg, a pulse of 105/min, a respiratory rate 20/min, and a body temperature of 37°C (98.6°F). She has diffuse abdominal tenderness, hypoactive bowel sounds, and mild distention on examination of her abdomen. Rectal and pelvic examination findings are normal. An abdominal plain film of the patient is given. What is the most likely cause of this patient’s condition?", "answer": "Adhesions", "options": {"A": "Malrotation", "B": "Hernia", "C": "Adhesions", "D": "Enlarged Peyer’s plaques", "E": "Gastrointestinal malignancy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "female", "emergency department", "48-hour history", "severe", "diffuse abdominal", "nausea", "vomiting", "constipation", "personal history", "unremarkable", "ectopic pregnancy 5 years", "found to", "blood pressure", "60 mm Hg", "pulse", "min", "respiratory rate 20 min", "body temperature", "98", "diffuse abdominal tenderness", "hypoactive bowel sounds", "mild distention", "examination of", "abdomen", "Rectal", "pelvic", "normal", "abdominal plain film", "patient", "given", "most likely cause", "patients condition"]}
{"question": "A 32-year-old woman presents with three-days of vaginal burning, itching, and pain with intercourse. She is in a monogamous relationship with her husband and has an intrauterine device for contraception. Her past medical history is unremarkable, except for recently being treated with antibiotics for sinusitis. Pelvic exam is remarkable for vulvar excoriations, vaginal wall edema, and thick, white discharge in the vault. Wet mount with KOH staining reveals budding filaments with pseudohyphae and hyphae. Which of the following is the most appropriate treatment?", "answer": "Fluconazole", "options": {"A": "Fluconazole", "B": "Itraconazole", "C": "Metronidazole", "D": "Posaconazole", "E": "Voriconazole"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "three days", "vaginal burning", "itching", "relationship", "intrauterine device", "contraception", "past medical history", "unremarkable", "recently", "treated with", "sinusitis", "Pelvic exam", "vulvar excoriations", "vaginal edema", "thick", "white discharge", "vault", "Wet mount", "KOH staining reveals budding filaments", "following", "most appropriate treatment"]}
{"question": "A 2-week-old female newborn is brought to the physician for the evaluation of red eyes with discharge for 2 days. She was born at 39 weeks' gestation to a 22-year-old woman. Pregnancy and delivery were uncomplicated. The mother received irregular prenatal care during the second half of the pregnancy. The newborn weighed 3700 g (8 lb 2.5 oz) at birth, and no congenital anomalies were noted. She currently weighs 4000 g (8 lb 13 oz). Examination of the newborn shows pink skin. The lungs are clear to auscultation. There is mucopurulent discharge in both eyes and mild eyelid swelling. Polymerase chain reaction assay of conjunctival scraping confirms the diagnosis. Which of the following is the most appropriate next step in management?", "answer": "Oral erythromycin administration", "options": {"A": "Reassurance and follow-up in 1 week", "B": "Intravenous acyclovir administration", "C": "Oral doxycycline administration", "D": "Oral erythromycin administration", "E": "Topical silver nitrate administration"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["2 week old female newborn", "brought", "physician", "red eyes", "discharge", "2 days", "born", "weeks", "gestation", "year old woman", "Pregnancy", "delivery", "uncomplicated", "received irregular prenatal", "second", "pregnancy", "newborn", "3700", "oz", "birth", "congenital anomalies", "noted", "currently", "4000", "oz", "Examination", "newborn", "pink skin", "lungs", "clear", "auscultation", "mucopurulent discharge", "eyes", "mild eyelid swelling", "Polymerase chain reaction assay of conjunctival scraping confirms", "diagnosis", "following", "most appropriate next step"]}
{"question": "A 40-year-old woman was admitted to the surgical service after an uncomplicated appendectomy. She underwent surgery yesterday and had an uneventful postoperative course. However, she now complains that she is unable to completely void. She also complains of pain in the suprapubic area. You examine her and confirm the tenderness and fullness in the suprapubic region. You ask the nurse to perform a bladder scan, which reveals 450cc. What is the next appropriate step in management?", "answer": "Catheterization", "options": {"A": "Oral bethanechol chloride", "B": "Neostigmine methylsulfate injection", "C": "Intravenous neostigmine methylsulfate", "D": "Intravenous furosemide", "E": "Catheterization"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "uncomplicated appendectomy", "surgery", "postoperative course", "now", "unable to completely void", "pain", "suprapubic area", "confirm", "tenderness", "fullness", "suprapubic region", "nurse to perform", "bladder scan", "reveals", "next appropriate step"]}
{"question": "A 42-year-old woman presents to her family physician with a headache. The patient reports that the symptoms started about 2 hours ago when she woke up and have not improved. She states the pain is moderate, throbbing, tight in character, and is located in the occipital region bilaterally. The patient denies any visual and audio disturbances, nausea, and vomiting. She recalls 2 similar headaches in the past month. She has no other relevant medical history. Current medications are alendronate and a daily multivitamin. The patient works long hours as a corporate attorney. A review of systems is significant for mild photophobia. Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 70/min, the respiratory rate is 18/min, and the oxygen saturation is 98% on room air. On physical exam, the patient is alert and oriented. There is moderate tenderness to palpation diffusely over the upper posterior cervical muscles and occipital region of the scalp. The remainder of the physical exam is normal. Laboratory tests are normal. Urine pregnancy test is negative. What is the next best step in management?", "answer": "Recommend lifestyle changes, relaxation techniques, and massage therapy", "options": {"A": "Non-contrast CT of the head and neck", "B": "T1/T2 MRI of the head and neck", "C": "Temporal artery biopsy", "D": "Administer high-flow oxygen, ibuprofen 200 mg orally, and sumatriptan 6 mg subcutaneously", "E": "Recommend lifestyle changes, relaxation techniques, and massage therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "family physician", "headache", "patient reports", "symptoms started", "hours", "woke up", "not improved", "states", "pain", "moderate", "throbbing", "tight", "character", "occipital region", "patient", "visual", "audio disturbances", "nausea", "vomiting", "2 similar headaches", "past month", "relevant medical history", "Current medications", "alendronate", "daily multivitamin", "patient", "long hours", "attorney", "review of systems", "significant", "mild photophobia", "temperature", "98", "blood pressure", "70 mm Hg", "pulse", "70 min", "respiratory rate", "min", "oxygen saturation", "98", "room air", "patient", "alert", "oriented", "moderate tenderness", "palpation", "upper posterior cervical muscles", "occipital", "scalp", "normal", "Laboratory", "normal", "Urine test", "negative", "next best step"]}
{"question": "A 27-year-old man comes to the physician for a follow-up examination. Paroxetine therapy was initiated 6 weeks ago for a major depressive episode. He now feels much better and says he is delighted with his newfound energy. He gets around 8 hours of sleep nightly. His appetite has increased. Last year, he had two episodes of depressed mood, insomnia, and low energy during which he had interrupted his job training and stopped going to the gym. Now, he has been able to resume his job at a local bank. He also goes to the gym three times a week to work out and enjoys reading books again. His temperature is 36.5°C (97.7°F), pulse is 70/min, and blood pressure is 128/66 mm Hg. Physical and neurologic examinations show no abnormalities. On mental status examination, he describes his mood as \"\"good.” Which of the following is the most appropriate next step in management?\"", "answer": "Continue paroxetine therapy for 2 years", "options": {"A": "Continue paroxetine therapy for 2 years", "B": "Switch from paroxetine to venlafaxine therapy", "C": "Discontinue paroxetine", "D": "Continue paroxetine therapy for 6 months", "E": "Switch from paroxetine to lithium therapy\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man", "physician", "follow-up examination", "Paroxetine therapy", "initiated", "weeks", "major depressive episode", "now", "much better", "energy", "gets", "hours of sleep", "appetite", "increased", "Last year", "two episodes of depressed mood", "insomnia", "interrupted", "stopped", "Now", "able to resume", "local bank", "three times", "week", "work out", "temperature", "36", "97", "pulse", "70 min", "blood pressure", "66 mm Hg", "Physical", "neurologic examinations", "abnormalities", "mental status", "mood", "good", "following", "most appropriate next step"]}
{"question": "A 15-year-old girl comes to the physician because of a 2-year history of irregular menstrual bleeding. Menses have occurred at irregular 45- to 60-day intervals since menarche at the age of 13 years. Her last menstrual period was 5 weeks ago and lasted for 7 days with heavy flow and no cramping. She is not sexually active. She is 171 cm (5 ft 7 in) tall and weighs 58 kg (128 lb); BMI is 20 kg/m2. Her temperature is 36.6°C (97.8°F), pulse is 80/min, and blood pressure is 110/60 mm Hg. Pelvic examination shows a normal-appearing vagina and cervix. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. The remainder of the physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Anovulation", "options": {"A": "Pituitary adenoma", "B": "Endometriosis", "C": "Polycystic ovary syndrome", "D": "Anovulation", "E": "Ovarian insufficiency\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "physician", "2 year history", "irregular menstrual bleeding", "Menses", "irregular", "60 day intervals", "menarche at", "age", "years", "last menstrual period", "5 weeks", "lasted", "7 days", "heavy", "cramping", "not sexually active", "5 ft", "tall", "58 kg", "BMI", "20 kg/m2", "temperature", "36", "97", "pulse", "80 min", "blood pressure", "60 mm Hg", "Pelvic examination", "normal appearing vagina", "cervix", "Bimanual examination", "normal-sized uterus", "palpable adnexal masses", "abnormalities", "urine pregnancy test", "negative", "following", "explanation", "patient's"]}
{"question": "A 7-year-old boy is brought by his parents to his pediatrician due to progressive fatigue and shortness of breath while playing sports. He is otherwise healthy with no known medical disorders and no other symptoms. 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. On physical examination, his temperature is 36.9ºC (98.4ºF), pulse rate is 90/min, blood pressure is 100/70 mm Hg, and respiratory rate is 18/min. Pulses in all four extremities are equal and normally palpated; there is no radio-femoral delay. The pediatrician suspects a congenital heart disease after auscultation of the heart. Which of the following congenital heart diseases is most likely to present with the clinical features listed above?", "answer": "Atrial septal defect", "options": {"A": "Aortopulmonary window defect", "B": "Coarctation of the aorta", "C": "Complete atrioventricular septal defect", "D": "Atrial septal defect", "E": "Double-outlet right ventricle with subaortic ventricular septal defect"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "to", "pediatrician due", "progressive fatigue", "shortness of breath", "playing", "known medical", "symptoms", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "temperature", "36", "98", "pulse rate", "90 min", "blood pressure", "100 70 mm Hg", "respiratory rate", "min", "Pulses", "four extremities", "equal", "radio femoral delay", "pediatrician", "congenital heart disease", "auscultation of", "of the following congenital heart diseases", "to present", "clinical features", "above"]}
{"question": "A previously healthy 17-year-old boy is brought to the emergency department by his mother for further evaluation after elective removal of his wisdom teeth. During the procedure, the patient had persistent bleeding from the teeth's surrounding gums. Multiple gauze packs were applied with minimal effect. The patient has a history of easy bruising. The mother says her brother had similar problems when his wisdom teeth were removed, and that he also has a history of easy bruising and joint swelling. The patient takes no medications. His temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 108/74 mm Hg. Laboratory studies show:\nHematocrit 35%\nLeukocyte count 8,500/mm3\nPlatelet count 160,000/mm3\nProthrombin time 15 sec\nPartial thromboplastin time 60 sec\nBleeding time 6 min\nFibrin split products negative\nSerum\nUrea nitrogen 20 mg/dL\nCreatinine 1.0 mg/dL\nBilirubin\nTotal 1.0 mg/dL\nDirect 0.5 mg/dL\nLactate dehydrogenase 90 U/L\nPeripheral blood smear shows normal-sized platelets. Which of the following is the most likely diagnosis?\"", "answer": "Hemophilia", "options": {"A": "Von Willebrand disease", "B": "Glanzmann thrombasthenia", "C": "Immune thrombocytopenia", "D": "Hemophilia", "E": "Bernard-Soulier syndrome"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "further", "elective removal of", "wisdom teeth", "procedure", "patient", "persistent bleeding from", "teeth", "urrounding  ums.", "ultiple  auze  acks ", "pplied ", "inimal  ffect.", "atient ", "istory ", "asy bruising.", "imilar ", "isdom teeth ", "emoved,", "istory ", "asy bruising ", "oint swelling.", "atient ", "edications.", "emperature ", "8.", "ulse ", "0/ in,", "lood pressure ", "4  m Hg.", "aboratory studies ", "eukocyte count ", "latelet count ", "ime ", "artial thromboplastin time ", "leeding ", "plit ", "rea nitrogen ", "reatinine ", "ilirubin ", "irect  .5  g/dL  actate dehydrogenase  0  /   eripheral blood smear ", "ormal-sized  latelets.", "ollowing ", "iagnosis?"]}
{"question": "A 48-year-old man with a history of diabetes mellitus presents to his primary care physician with lethargy, joint pain, and impotence. Lab evaluation is notable for a ferritin of 1400 ug/L (nl <300 ug/L), increased total iron, increased transferrin saturation, and decreased total iron binding capacity. All of the following are true regarding this patient's condition EXCEPT:", "answer": "It may improve with calcium chelators", "options": {"A": "It may lead to a decline in cardiac function", "B": "It may improve with serial phlebotomy", "C": "It may improve with calcium chelators", "D": "It is associated with an increased risk for hepatocellular carcinoma", "E": "It results in skin bronzing"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old man", "history of diabetes mellitus presents", "primary care physician", "lethargy", "joint pain", "impotence", "Lab", "notable", "ferritin", "ug/L", "nl", "300 ug/L", "increased total iron", "increased transferrin saturation", "decreased total iron binding capacity", "following", "true", "patient's condition"]}
{"question": "A 68-year-old man is brought to the clinic by his daughter who has noticed behavioral changes and frequent headaches for the past 2 weeks. The patient’s daughter says he has been having memory and simple calculation issues, gets upset easily, and his grip strength has dramatically declined. The patient was completely normal prior to these recent changes and used to be able to perform his activities of daily living without a problem. He has a past medical history significant for hypertension, stable angina, and benign prostatic hypertrophy, as well as frequent falls with the last one occurring 1 month ago. Physical examination is remarkable for dyscalculia, short-term memory deficits, and decreased grip strength (4/5) in his right hand. 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 condition?", "answer": "Tearing of bridging veins", "options": {"A": "Arteriovenous malformation", "B": "Tearing of bridging veins", "C": "Tearing of the middle meningeal artery", "D": "Dural arteriovenous fistula", "E": "Charcot-Bouchard aneurysm"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "clinic", "behavioral changes", "frequent headaches", "past 2 weeks", "patients", "memory", "issues", "gets", "easily", "grip strength", "patient", "completely normal prior to", "recent changes", "used to", "able to perform", "problem", "past medical history significant", "hypertension", "stable angina", "benign prostatic hypertrophy", "frequent falls", "one occurring 1 month", "dyscalculia", "deficits", "decreased grip strength", "4/5", "right hand", "CT of", "head", "performed", "following", "etiology", "patient condition"]}
{"question": "A 30-year-old woman, gravida 1, para 0, at 40 weeks' gestation is admitted to the hospital in active labor. Pregnancy was complicated by iron deficiency anemia treated with iron supplements. At the beginning of the first stage of labor, there are coordinated, regular, rhythmic contractions of high intensity that occur approximately every 10 minutes. Four hours later, the cervix is 100% effaced and 10 cm dilated; the vertex is at -1 station. Over the next two hours, there is minimal change in in fetal descent; vertex is still at -1 station. Fetal birth weight is estimated at the 75th percentile. The fetal heart rate is 145/min and is reactive with no decelerations. Contractions occurs approximately every 2 minutes with adequate pressure. Epidural anesthesia was not given, as the patient is coping well with pain. Which of the following is the most appropriate next step in management?", "answer": "Observation for another hour", "options": {"A": "Administration of terbutaline", "B": "Cesarean section", "C": "Vacuum-assisted delivery", "D": "Observation for another hour", "E": "Epidural anesthesia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old woman", "gravida 1", "para 0", "40 weeks", "gestation", "active labor", "Pregnancy", "complicated", "iron deficiency anemia treated with iron supplements", "beginning of", "first stage", "labor", "coordinated", "regular", "rhythmic contractions", "occur approximately", "10 minutes", "Four hours later", "cervix", "100", "10", "dilated", "vertex", "at", "1 station", "next two hours", "minimal change", "fetal descent", "vertex", "station", "Fetal birth weight", "estimated", "percentile", "fetal heart rate", "min", "reactive", "Contractions occurs approximately", "2 minutes", "adequate pressure", "Epidural anesthesia", "not given", "patient", "well", "pain", "following", "most appropriate next step"]}
{"question": "A 23-year-old woman, gravida 2, para 1, at 26 weeks gestation comes to the physician for a routine prenatal visit. Physical examination shows a uterus consistent in size with a 26-week gestation. Fetal ultrasonography shows a male fetus with a thick band constricting the right lower arm; the limb distal to the constrictive band cannot be visualized. The most likely condition is an example of which of the following embryological abnormalities?", "answer": "Disruption", "options": {"A": "Deformation", "B": "Agenesis", "C": "Disruption", "D": "Malformation", "E": "Aplasia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "gravida 2", "para 1", "weeks gestation", "physician", "routine", "Physical examination", "uterus", "size", "week gestation", "Fetal ultrasonography", "male fetus", "thick band constricting", "right lower arm", "limb distal", "constrictive band", "visualized", "condition", "following embryological abnormalities"]}
{"question": "A 47-year-old man presents to the emergency department due to a rash. He states the rash started last night and is very concerning to him. The patient cannot remember being exposed to any environmental stimuli such as new detergents or poison ivy. The patient recently started following with a primary care provider who is helping him manage his arthritis and a new onset cough. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 125/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for the findings of coalescing erythematous macules, bullae, desquamation, and mucositis only on the upper half of his back. Cardiopulmonary exam and abdominal exam are within normal limits. Inspection of the patient’s oropharynx reveals ulcers and erythema. Which of the following is the most likely diagnosis?", "answer": "Steven-Johnson syndrome", "options": {"A": "Erythema multiforme", "B": "Herpes simplex virus", "C": "Herpes zoster", "D": "Steven-Johnson syndrome", "E": "Toxic epidermal necrolysis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "rash", "states", "rash started last night", "very", "patient", "exposed", "new", "patient recently started following", "primary care provider", "helping", "arthritis", "new onset cough", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "findings", "erythematous macules", "bullae", "desquamation", "mucositis only", "upper half of", "back", "Cardiopulmonary exam", "abdominal exam", "normal", "Inspection", "patients oropharynx reveals ulcers", "erythema", "following", "diagnosis"]}
{"question": "A 12-year-old boy presents to the pediatrician with complaints of chronic cough for the past two years. The cough is present during the day, especially after returning from school. His school teacher says he does not cough at school. The cough is absent while he is asleep, although it increases during examinations or when he experiences boredom. His mother reports that there was a one-month period where he did not cough, but during that month, he used to shrug his shoulders frequently, especially when he was stressed or fatigued. There is no history of sneezing, nasal discharge, nasal congestion, headache, ear symptoms, or breathing difficulty. Detailed history does not suggest the presence of a mood disorder, obsessive-compulsive symptoms, or attention-deficit/hyperactivity disorder. There is no past history of a known neurological disorder, and there is no history of substance abuse. On physical examination, his vital signs are stable. Examination of his respiratory and cardiovascular systems is normal. However, the pediatrician notes repeated eye blinking; upon asking about eye blinking, the mother reports that he has had this habit since he was almost eight years old. Further inquiry suggests that eye blinking, coughing, and grunting disappear for a few weeks without explanation, only to reappear again. Which of the following drugs is likely to be most effective to control this patient’s symptoms?", "answer": "Haloperidol", "options": {"A": "Atomoxetine", "B": "Clonidine", "C": "Fluoxetine", "D": "Haloperidol", "E": "Levetiracetam"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "pediatrician", "complaints", "chronic cough", "past two years", "cough", "present", "day", "returning", "school", "school teacher", "not cough", "school", "cough", "absent", "asleep", "increases", "reports", "one-month period", "not cough", "month", "used to", "shoulders frequently", "stressed", "fatigued", "history", "sneezing", "nasal discharge", "nasal congestion", "headache", "ear symptoms", "breathing difficulty", "Detailed history", "not", "presence", "mood disorder", "symptoms", "attention-deficit/hyperactivity disorder", "past history of", "known neurological disorder", "history of substance abuse", "vital signs", "stable", "Examination", "respiratory", "cardiovascular systems", "normal", "pediatrician", "repeated eye blinking", "eye blinking", "reports", "almost eight years old", "Further", "eye blinking", "coughing", "weeks", "only", "following drugs", "likely to", "effective to control", "patients symptoms"]}
{"question": "A 27-year-old woman consults an obstetrician as she is planning to become pregnant. She has been diagnosed with HIV (human immunodeficiency virus) infection recently and is currently taking antiretroviral therapy (HAART), as prescribed by her physician. The obstetrician emphasizes the importance of antenatal and peripartum antiretroviral therapy for reducing the risk of mother-to-child transmission of HIV. She also tells the patient that certain antiretroviral drugs, if taken during pregnancy, increase the risk of birth defects in the fetus. She gives a printed list of such drugs to the woman for educational and informational purposes. Which of the following drugs are most likely to be present on the list?", "answer": "Efavirenz and Delavirdine", "options": {"A": "Abacavir and Didanosine", "B": "Efavirenz and Delavirdine", "C": "Lamivudine and Nevirapine", "D": "Lopinavir and Ritonavir", "E": "Nelfinavir and Saquinavir"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old woman", "obstetrician", "planning to", "pregnant", "diagnosed", "HIV", "human immunodeficiency virus", "infection recently", "currently", "antiretroviral therapy", "HAART", "physician", "obstetrician", "importance", "antenatal", "peripartum antiretroviral therapy", "reducing", "risk", "mother-to-child transmission", "HIV", "patient", "certain antiretroviral drugs", "pregnancy", "increase", "birth defects", "fetus", "gives", "woman", "educational", "purposes", "following drugs", "to", "present"]}
{"question": "A 1-month-old baby is brought to the emergency department because he had a coughing spell while feeding and turned blue. The mother says that the blue color went away when she picked the baby up and brought his knees to his chest. The physician orders a chest X-ray which shows a boot-shaped heart and he tells the mother that the baby has a condition that is caused by an anterosuperior displacement of the infundibular septum. What are the 4 features of the baby’s cardiac condition?", "answer": "Pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect, overriding aorta", "options": {"A": "Pulmonary stenosis, left ventricular hypertrophy, ventricular septal defect, overriding aorta", "B": "Pulmonary regurgitation, left ventricular hypertrophy, ventricular septal defect, overriding aorta", "C": "Pulmonary regurgitation, right ventricular hypertrophy, atrial septal defect, overriding aorta", "D": "Pulmonary stenosis, right ventricular hypertrophy, atrial septal defect, overriding pulmonary artery", "E": "Pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect, overriding aorta"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old baby", "brought", "emergency department", "coughing spell", "turned blue", "blue color", "baby", "brought", "knees", "chest", "physician orders", "chest X-ray", "boot shaped heart", "baby", "condition", "caused", "anterosuperior displacement", "infundibular septum", "4 features", "cardiac"]}
{"question": "A 16-year-old girl is brought to the physician by her mother because she has not had her menstrual period yet. At birth, she was found to have partial labial fusion and clitoromegaly. The mother reports that during the pregnancy she had noticed abnormal hair growth on her chin. The girl has severe acne. Three years ago, she broke her wrist after a minor trauma. Last year, she sustained a spinal compression fracture after lifting a box during a move. She currently takes oral isotretinoin and an oral contraceptive. The patient is at the 97th percentile for height and 50th percentile for weight. Physical examination shows numerous inflamed pustules on her face and upper back. Breast development is at Tanner stage I. The patient refuses to have a pelvic examination. A pelvic ultrasound shows ovaries with multiple cysts and a normal uterus. Which of the following is the most likely diagnosis?", "answer": "Aromatase deficiency", "options": {"A": "Polycystic ovary syndrome", "B": "Congenital adrenal hyperplasia", "C": "Hyperprolactinemia", "D": "Turner syndrome", "E": "Aromatase deficiency"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "not", "menstrual period", "birth", "found to", "partial labial fusion", "clitoromegaly", "reports", "pregnancy", "abnormal hair growth", "chin", "girl", "severe acne", "Three years", "broke", "wrist", "minor", "year", "sustained", "spinal compression fracture", "box", "move", "currently", "oral isotretinoin", "oral contraceptive", "patient", "percentile", "height", "50th percentile", "weight", "numerous inflamed pustules", "face", "upper back", "Breast development", "Tanner I", "patient", "to", "pelvic examination", "pelvic ultrasound", "ovaries", "multiple", "normal uterus", "following", "diagnosis"]}
{"question": "A 6-month-old infant is brought to the physician’s office by his parents due to a fever, cough, and shortness of breath. The cough is dry and has been progressively worsening for the past 48 hours along with the shortness of breath. His fever never exceeded 37.8°C (100.0°F) at home. The parents say that he has also had abundant nasal drainage and loss of appetite. He is irritable and vomited twice during this period. He has no relevant medical or family history.\nHis vitals are the following:\nPulse rate 165/min\nRespiratory rate 77/min\nTemperature 38.0°C (100.4°F)\nOn physical examination, there is nasal congestion with thick secretions, accompanied by nasal flaring. On chest examination, intercostal retractions are seen and diffuse wheezing on both sides are heard on auscultation. What is the most likely cause?", "answer": "Bronchiolitis", "options": {"A": "Asthma", "B": "Sinusitis", "C": "Rhinopharyngitis", "D": "Bronchiolitis", "E": "Laryngotracheitis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old infant", "brought", "physicians office", "due to", "fever", "cough", "shortness of breath", "cough", "dry", "worsening", "past 48 hours", "shortness of breath", "fever never", "100", "at home", "abundant nasal drainage", "loss of appetite", "irritable", "vomited twice", "period", "relevant medical", "family history", "following", "Pulse rate", "min Respiratory rate", "Temperature", "100", "nasal congestion", "thick secretions", "nasal flaring", "chest examination", "intercostal retractions", "seen", "diffuse wheezing", "sides", "heard", "auscultation", "cause"]}
{"question": "A 67-year-old woman comes to the physician because of fever, chills, myalgias, and joint pain 1 month after undergoing aortic prosthetic valve replacement due to high-grade aortic stenosis. She does not drink alcohol or use illicit drugs. Her temperature is 39.3°C (102.8°F). She appears weak and lethargic. Physical examination shows crackles at both lung bases and a grade 2/6, blowing diastolic murmur over the right sternal border. Laboratory studies show leukocytosis and an elevated erythrocyte sedimentation rate. The causal organism is most likely to have which of the following characteristics?", "answer": "Novobiocin-sensitive, coagulase-negative cocci", "options": {"A": "Alpha hemolytic, optochin-sensitive diplococci", "B": "Novobiocin-sensitive, coagulase-negative cocci", "C": "Catalase-negative cocci that grows in 6.5% saline", "D": "Beta hemolytic, bacitracin-sensitive cocci", "E": "Alpha hemolytic, optochin-resistant cocci"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["67 year old woman", "physician", "fever", "chills", "myalgias", "joint pain", "month", "aortic", "valve replacement", "high-grade aortic stenosis", "not", "alcohol", "use illicit", "temperature", "appears weak", "lethargic", "crackles", "lung bases", "blowing diastolic murmur", "right sternal border", "Laboratory studies", "leukocytosis", "elevated erythrocyte sedimentation rate", "causal", "to", "following characteristics"]}
{"question": "A 42-year-old woman presents to her primary care provider with vision loss. She reports that twice over the last 2 weeks she has had sudden “black out” of the vision in her right eye. She notes that both episodes were painless and self-resolved over approximately a minute. The patient’s past medical history is significant for hypertension, diet-controlled diabetes mellitus, and hypothyroidism. Her family history is notable for coronary artery disease in the patient’s father and multiple sclerosis in her mother. Ophthalmologic and neurologic exam is unremarkable. Which of the following is the best next step in management?", "answer": "Ultrasound of the carotid arteries", "options": {"A": "Check serum inflammatory markers", "B": "Emergent referral to ophthalmology", "C": "Intravenous dexamethasone", "D": "MRI of the brain", "E": "Ultrasound of the carotid arteries"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care provider", "vision loss", "reports", "twice", "2 weeks", "sudden black out", "vision", "right eye", "notes", "episodes", "painless", "resolved over approximately", "minute", "patients past medical history", "significant", "hypertension", "diet-controlled diabetes mellitus", "hypothyroidism", "family history", "notable", "coronary artery disease", "patients", "multiple sclerosis", "Ophthalmologic", "neurologic exam", "unremarkable", "following", "best next step"]}
{"question": "A 37-year-old man presents to his primary care provider with dysphagia. He notes that his symptoms began several weeks ago and have worsened over time. He now has trouble swallowing solids and liquids. He denies any other symptoms. He has no significant past medical history. Travel history reveals a recent trip to South America but no other travel outside the United States. His temperature is 100°F (37.8°C), blood pressure is 120/81 mmHg, pulse is 99/min, respirations are 14/min, and oxygen saturation is 98% on room air. HEENT exam is unremarkable. He has no palpable masses in his abdomen. What is the most appropriate next step in management?", "answer": "Barium swallow", "options": {"A": "Barium swallow", "B": "Endoscopy", "C": "Manometry", "D": "Myotomy", "E": "Nifurtimox"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "dysphagia", "notes", "symptoms began several weeks", "worsened", "time", "now", "swallowing solids", "symptoms", "significant past medical history", "reveals", "recent trip", "South America", "outside", "United States", "temperature", "blood pressure", "81 mmHg", "pulse", "99 min", "respirations", "min", "oxygen saturation", "98", "room", "HEENT exam", "unremarkable", "palpable masses", "abdomen", "most appropriate next step"]}
{"question": "A 61-year-old woman presents for a routine health visit. She complains of generalized fatigue and lethargy on most days of the week for the past 4 months. She has no significant past medical history and is not taking any medications. She denies any history of smoking or recreational drug use but states that she drinks “socially” approx. 6 nights a week. She says she also enjoys a “nightcap,” which is 1–2 glasses of wine before bed every night. The patient is afebrile, and her vital signs are within normal limits. On physical examination, there is significant pallor of the mucous membranes. Laboratory findings are significant for a mean corpuscular volume (MCV) of 72 fL, leukocyte count of 4,800/mL, hemoglobin of 11.0 g/dL, and platelet count of 611,000/mL. She is started on oral ferrous sulfate supplements. On follow-up, her laboratory parameters show no interval change in her MCV or platelet level. Which of the following is the best next step in the management of this patient?", "answer": "Continue oral ferrous sulfate and supplement with ascorbic acid", "options": {"A": "Transfuse the patient with whole blood", "B": "Continue oral ferrous sulfate and supplement with ascorbic acid", "C": "Continue oral ferrous sulfate and supplement with omeprazole", "D": "Administer folate", "E": "Administer iron intravenously"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["61 year old woman presents", "routine", "generalized fatigue", "lethargy", "days of the week", "past", "months", "significant past medical history", "not", "medications", "history of smoking", "recreational drug use", "states", "nights", "week", "glasses", "bed", "night", "patient", "afebrile", "vital signs", "normal limits", "significant pallor", "mucous membranes", "Laboratory findings", "significant", "mean corpuscular volume", "72 fL", "leukocyte count", "4 800 mL", "hemoglobin", "11.0 g", "platelet count", "mL", "started", "oral ferrous sulfate supplements", "follow-up", "laboratory parameters", "interval change", "MCV", "level", "following", "best next step", "patient"]}
{"question": "A 41-year-old man with HIV comes to the physician because of rectal bleeding and itching for 2 weeks. During this period, he has also had pain with defecation. Four months ago, he was diagnosed with anogenital warts that were treated with cryotherapy. Over the past year, he has been sexually active with 3 male partners. He uses condoms inconsistently. Current medications are zidovudine, emtricitabine, and efavirenz. Digital rectal examination and anoscopy show an exophytic mass on the anal margin that is protruding into the anal canal. The mass is tender to palpation and bleeds easily on contact. Laboratory studies show a leukocyte count of 7,600/mm3 and a CD4+ T-lymphocyte count of 410/mm3 (N ≥ 500). A biopsy specimen of the lesion shows a well-differentiated squamous cell carcinoma. Which of the following cellular processes was most likely involved in the pathogenesis of this patient's malignancy?", "answer": "Inactivation of TP53 gene\n\"", "options": {"A": "Activation of c-myc gene", "B": "Inactivation of VHL gene", "C": "Activation of TAX gene", "D": "Inactivation of WT1 gene", "E": "Inactivation of TP53 gene\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "HIV", "physician", "rectal bleeding", "itching", "2 weeks", "period", "pain", "defecation", "Four months", "diagnosed", "anogenital warts", "treated with cryotherapy", "past year", "sexually active", "male", "uses condoms", "Current medications", "zidovudine", "emtricitabine", "efavirenz", "Digital rectal examination", "exophytic mass", "anal", "protruding", "anal canal", "mass", "tender", "palpation", "bleeds easily", "contact", "Laboratory studies", "leukocyte count", "7 600 mm3", "CD4", "lymphocyte count", "mm3", "N", "500", "biopsy", "lesion", "well-differentiated squamous cell carcinoma", "following cellular processes", "most likely involved", "pathogenesis", "patient's malignancy"]}
{"question": "A 3-year-old child is brought to the emergency department by his parents. The child presents with significant rapid breathing and appears unwell. On examination, his liver size is 1.5 times larger than children of his age, and he has mild pitting edema in his legs. This child is also in the lower weight-age and height-age percentiles. On auscultation, mild rales were noted and a fixed split S2 was heard on inspiration. There is no family history of congenital disorders or metabolic syndromes. Which of the following is the likely diagnosis?", "answer": "Atrial septal defect", "options": {"A": "Liver failure", "B": "Atrial septal defect", "C": "Patent foramen ovale", "D": "Endocardial cushion syndrome", "E": "Transposition of the great vessels"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 year", "brought", "emergency department", "child presents", "significant rapid breathing", "appears unwell", "liver size", "1.5 times larger", "children", "age", "mild pitting", "legs", "child", "lower weight age", "height age percentiles", "auscultation", "mild rales", "noted", "fixed split S2", "heard", "inspiration", "family history of congenital disorders", "metabolic syndromes", "following", "likely diagnosis"]}
{"question": "A neurophysiologist describes the mechanism of a specific type of synaptic transmission to his students. While illustrating this, he points out that when the action potential reaches the presynaptic terminal of a chemical synapse, the voltage-gated Ca2+ channels open. Ca2+ ions trigger the release of neurotransmitters from vesicles in the presynaptic terminal. In this type of synaptic transmission, increased cytosolic Ca2+ levels cause the release of a neurotransmitter from small vesicles with dense cores. Which of the following neurotransmitters is most likely to be the one that is released into the synaptic cleft in this type of synapse?", "answer": "Epinephrine", "options": {"A": "Follicle stimulating hormone", "B": "Epinephrine", "C": "Glycine", "D": "GABA (γ-amino butyric acid)", "E": "Glutamate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["mechanism", "specific", "synaptic transmission", "points out", "action potential reaches", "presynaptic terminal", "chemical synapse", "voltage-gated Ca2", "channels open", "Ca2", "trigger", "release", "neurotransmitters", "vesicles", "presynaptic terminal", "type", "synaptic transmission", "increased cytosolic Ca2", "levels cause", "release", "neurotransmitter", "small vesicles", "dense cores", "following neurotransmitters", "to", "one", "released", "synaptic cleft", "type", "synapse"]}
{"question": "A 32-year-old man with a history of major depressive disorder is brought to the emergency department by his wife because of a sudden onset of restlessness and disorientation that developed 3 hours ago. The patient’s wife says that he suddenly started sweating, having tremors, and mumbling to himself. Yesterday, the patient visited his psychiatrist with worsening depression who added phenelzine to his current treatment regimen.  No other significant past medical history. His temperature is 39.7°C (103.5°F), blood pressure is 145/90 mm Hg, and pulse is 115/min. On physical examination, the skin is flushed. Mucous membranes are dry, and pupils are dilated. There is pronounced clonus in the extremities bilaterally. Babinski sign is present bilaterally. All the patient’s medications are discontinued, and intravenous fluids are started. Which of the following drugs most likely interacted with phenelzine to cause this patient’s condition?", "answer": "Sertraline", "options": {"A": "Mirtazapine", "B": "Bupropion", "C": "Sertraline", "D": "Olanzapine", "E": "Lithium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "history of major depressive disorder", "brought", "emergency department", "sudden onset", "restlessness", "disorientation", "3 hours", "patients", "started sweating", "tremors", "patient", "psychiatrist", "worsening depression", "added phenelzine", "current", "significant past medical history", "temperature", "blood pressure", "90 mm Hg", "pulse", "min", "skin", "flushed", "Mucous membranes", "dry", "pupils", "dilated", "clonus", "extremities", "Babinski sign", "present", "patients medications", "discontinued", "started", "following drugs", "likely", "phenelzine to cause", "patients condition"]}
{"question": "A 55-year-old woman comes to your office because she noticed the growth of unwanted hair on her upper lip, chin, and chest. She has also noticed an increase in blackheads and pimples on her skin. Her female partner has also recently brought to her attention the deepening of her voice, weight gain, and changes in her external genitalia that generated some personal relationship issues. The patient is frustrated as these changes have appeared over the course of the last 8 months. She claims that she was feeling completely normal before all of these physical changes started. Physical examination shows dark coarse stubbles distributed along her upper lip, chin, chest, back, oily skin, and moderately inflamed acne. Pelvic examination reveals a clitoris measuring 12 mm long, a normal sized mobile retroverted uterus, and a firm, enlarged left ovary. What is the most likely diagnosis of this patient?", "answer": "Sertoli-Leydig cell tumour", "options": {"A": "Thecoma", "B": "Sertoli-Leydig cell tumour", "C": "Adrenocortical carcinoma", "D": "Granulosa cell tumour", "E": "Polycystic ovarian syndrome (PCOS)"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "office", "growth", "hair", "upper lip", "chin", "chest", "increase", "blackheads", "pimples", "skin", "female", "recently brought", "deepening", "voice", "weight gain", "changes", "external genitalia", "personal relationship", "patient", "changes", "appeared", "course", "months", "completely normal", "physical changes started", "dark coarse", "distributed", "upper lip", "chin", "chest", "back", "oily skin", "moderately inflamed acne", "Pelvic examination reveals", "clitoris measuring", "mm long", "normal sized mobile retroverted uterus", "firm", "enlarged left ovary", "diagnosis", "patient"]}
{"question": "A 44-year-old female presents to her primary care physician with complaints of headache, fatigue, muscle weakness, and frequent urination. These issues have developed and worsened over the past month. She has no significant prior medical or surgical history other than cholecystitis managed with cholecystectomy 5 years ago. Her vital signs at today's visit are as follows: T 37.1 C, HR 77, BP 158/98, RR 12, and SpO2 99%. Physical examination is significant for tetany, mild abdominal distension, reduced bowel sounds, and hypertensive retinal changes on fundoscopic exam. The physician orders a laboratory and imaging work-up based on his suspected diagnosis. An abdominal CT scan shows an 8 cm unilateral left adrenal mass suggestive of an adrenal adenoma. Which of the following sets of laboratory findings would be most likely in this patient?", "answer": "Metabolic alkalosis, hypernatremia, hypokalemia", "options": {"A": "Metabolic acidosis, hypernatremia, hyperkalemia", "B": "Metabolic acidosis, hyponatremia, hyperkalemia", "C": "Metabolic acidosis, hypernatremia, hypokalemia", "D": "Metabolic alkalosis, hypernatremia, hyperkalemia", "E": "Metabolic alkalosis, hypernatremia, hypokalemia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old female presents", "primary care physician", "complaints", "headache", "fatigue", "muscle weakness", "frequent urination", "issues", "worsened", "past month", "significant prior medical", "surgical history", "cholecystitis", "cholecystectomy", "years", "vital signs", "today's", "follows", "T", "BP", "98", "RR", "99", "significant", "tetany", "mild abdominal distension", "reduced bowel sounds", "hypertensive retinal changes", "fundoscopic exam", "physician orders", "laboratory", "imaging work-up based", "suspected diagnosis", "abdominal CT", "unilateral left adrenal mass suggestive of", "adrenal adenoma", "following sets", "laboratory findings", "patient"]}
{"question": "A 58-year-old woman comes to the physician because of a 6-month history of difficulty walking, clumsiness of her arms and legs, and slurred speech. Physical examination shows masked facies and a slow, shuffling gait. When her ankles are passively flexed, there is involuntary, jerky resistance. Treatment is initiated with a combination of levodopa and carbidopa. The addition of carbidopa is most likely to decrease the risk of which of the following potential adverse drug effects?", "answer": "Orthostatic hypotension", "options": {"A": "Resting tremor", "B": "Orthostatic hypotension", "C": "Urinary retention", "D": "Visual hallucinations", "E": "Dyskinesia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old woman", "physician", "month history", "difficulty walking", "clumsiness", "arms", "legs", "slurred speech", "masked facies", "slow", "shuffling gait", "ankles", "flexed", "involuntary", "jerky resistance", "Treatment", "initiated", "combination", "levodopa", "carbidopa", "addition", "carbidopa", "to decrease", "following potential adverse drug effects"]}
{"question": "A 12-month-old boy is brought to the pediatrician for a routine examination. Past medical history is significant for a pyloric myomectomy at 2 months of age after a few episodes of projectile vomiting. He has reached all appropriate developmental milestones. He currently lives with his parents and pet cat in a house built in the 1990s. He was weaned off of breast milk at 6 months of age. He is a very picky eater, but drinks 5–6 glasses of whole milk a day. The patient's height and weight are in the 50th percentile for his age and sex. The vital signs are within normal limits except for the presence of slight tachycardia. Physical examination reveals an alert infant with a slight pallor. Abdomen is soft and nondistended. A grade 2/6 systolic ejection murmur is noted in the left upper sternal border. Which of the following will most likely be expected in this patient's laboratory results?", "answer": "Decreased hemoglobin", "options": {"A": "Decreased vitamin B12 levels", "B": "Increased lead levels", "C": "Increased Hb S levels", "D": "Decreased hemoglobin", "E": "Metabolic alkalosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "pediatrician", "routine", "Past medical history", "significant", "pyloric myomectomy", "months", "age", "few episodes of projectile vomiting", "reached", "appropriate", "currently lives with", "parents", "1990s", "weaned", "breast milk", "months", "age", "very picky eater", "glasses", "day", "patient's height", "weight", "50th percentile", "age", "sex", "vital signs", "normal limits except for", "presence", "slight tachycardia", "Physical", "reveals", "alert infant", "slight pallor", "Abdomen", "soft", "grade", "systolic ejection murmur", "noted", "left upper sternal border", "following", "most likely", "patient's laboratory results"]}
{"question": "A 47-year-old woman presents to a local medical shelter while on a mission trip with her church to help rebuild homes after a hurricane. She has been experiencing severe nausea, vomiting, and diarrhea for the last 2 days and was feeling too fatigued to walk this morning. On presentation, her temperature is 99.2°F (37.3°C), blood pressure is 95/62 mmHg, pulse is 121/min, and respirations are 17/min. Physical exam reveals decreased skin turgor, and a stool sample reveals off-white watery stools. Gram stain reveals a gram-negative, comma-shaped organism that produces a toxin. Which of the following is consistent with the action of the toxin most likely involved in the development of this patient's symptoms?", "answer": "Increased adenylyl cyclase activity", "options": {"A": "Activation of receptor tyrosine kinase", "B": "Cleavage of junctional proteins", "C": "Decreased ribosomal activity", "D": "Increased adenylyl cyclase activity", "E": "Increased membrane permeability"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "local medical shelter", "trip", "church to help", "homes", "hurricane", "severe nausea", "vomiting", "diarrhea", "2 days", "fatigued to", "morning", "temperature", "99", "blood pressure", "95 62 mmHg", "pulse", "min", "respirations", "min", "reveals decreased skin turgor", "stool sample reveals off white watery stools", "Gram stain reveals", "gram negative", "shaped", "toxin", "following", "action", "toxin", "likely involved", "development", "patient's symptoms"]}
{"question": "A 48-year-old woman with alpha-1-antitrypsin deficiency undergoes a lung transplant. She tolerates the surgery well, but 3 years later develops inflammation and fibrosis in her terminal bronchioles. Which of the following best describes the pathophysiology of this patient's deterioration?", "answer": "Lymphocytic inflammation of the bronchiolar wall", "options": {"A": "Staphylocuccus aureus pneumonia", "B": "Cytotoxic T lymphocytes reacting against foreign MHCs", "C": "Lymphocytic inflammation of the bronchiolar wall", "D": "T-cell mediated vascular damage", "E": "Proliferation of grafted immunocompetent T cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["48 year old woman", "alpha-1-antitrypsin deficiency", "lung transplant", "surgery well", "3 years later", "inflammation", "fibrosis", "terminal bronchioles", "following best", "pathophysiology", "patient's"]}
{"question": "A 8-month-old girl is brought to her pediatrician because her mom is concerned that she may have a \"lazy eye\". She was born prematurely at 33 weeks and was 3 pounds at birth. Her mother also says that there is a history of visual problems that run in the family, which is why she wanted to make sure that her daughter was evaluated early. On presentation, she is found to have eyes that are misaligned both horizontally and vertically. Physical examination and labs reveal no underlying disorders, and the patient is discharged with occlusion therapy to help correct the misalignment. Which of the following would most likely have also been seen on physical exam?", "answer": "Asymmetric corneal light reflex", "options": {"A": "Asymmetric corneal light reflex", "B": "Bitemporal hemianopsia", "C": "Increased intraocular pressure", "D": "Fundus neovascularization", "E": "Nystagmus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old girl", "brought", "pediatrician", "mom", "lazy eye", "born", "weeks", "3 pounds", "birth", "history", "visual", "run in", "wanted to make sure", "early", "found to", "eyes", "misaligned", "labs reveal", "underlying disorders", "patient", "occlusion therapy to help correct", "misalignment", "following", "most likely", "seen"]}
{"question": "A 13-year-old teenage girl was brought to the emergency department by her mom after she collapsed. Her mom reports that she was at a birthday party when all of a sudden she fell. She reported left foot weakness and has been limping ever since. The patient has been healthy and had an uncomplicated birth history, though her mom reports that she just recovered from a cold. She currently lives with her younger sister and mother as her parents recently divorced. She does well in school and has a handful of good friends. Her physical exam demonstrated normal bulk and tone, 5/5 strength in all motions, 2+ and symmetric reflexes at biceps, triceps and knees. She had 1+ ankle reflex on left. What is the most likely explanation for her symptoms?", "answer": "Conversion disorder", "options": {"A": "Cerebral vascular accident", "B": "Conversion disorder", "C": "Guillain-Barre syndrome", "D": "Multiple sclerosis", "E": "Myasthenia gravis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old teenage girl", "brought", "emergency department", "mom", "collapsed", "mom reports", "sudden", "fell", "reported left", "limping ever", "patient", "healthy", "uncomplicated birth history", "mom reports", "recovered", "cold", "currently lives", "recently divorced", "well", "school", "good", "normal bulk", "tone", "5/5 strength", "motions", "2", "symmetric reflexes", "biceps", "triceps", "knees", "1", "ankle", "left", "symptoms"]}
{"question": "A 30-year-old woman presents to her family doctor requesting sleeping pills. She is a graduate student and confesses that she is a “worry-a-holic,” which has been getting worse for the last 6 months as the due date for her final paper is approaching. During this time, she feels more on edge, irritable, and is having difficulty sleeping. She has already tried employing good sleep hygiene practices, including a switch to non-caffeinated coffee. Her past medical history is significant for depression in the past that was managed medically. No current medications. The patient’s family history is significant for her mother who has a panic disorder. Her vital signs are within normal limits. Physical examination reveals a mildly anxious patient but is otherwise normal. Which of the following is the most effective treatment for this patient’s condition?", "answer": "Buspirone", "options": {"A": "Buspirone", "B": "Bupropion", "C": "Desensitization therapy", "D": "Relaxation training", "E": "Diazepam"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "family doctor", "graduate student", "worry", "getting worse", "months", "due date", "final paper", "approaching", "time", "more", "edge", "irritable", "difficulty sleeping", "employing good", "including", "switch", "non", "past medical history", "significant", "depression", "past", "current medications", "patients family history", "significant", "panic disorder", "vital signs", "normal", "Physical examination reveals", "mildly anxious patient", "normal", "following", "most effective treatment", "patients condition"]}
{"question": "A 25-year-old woman presents to the emergency department with nausea and vomiting. She denies any recent illnesses, sick contacts, or consumption of foods outside of her usual diet. She reports smoking marijuana at least three times a day. Her temperature is 97.7°F (36.5°C), blood pressure is 90/74 mmHg, pulse is 100/min, respirations are 10/min, and SpO2 is 94% on room air. Her conjunctiva are injected. Her basic metabolic panel is obtained below.\n\nSerum:\nNa+: 132 mEq/L\nCl-: 89 mEq/L\nK+: 2.9 mEq/L\nHCO3-: 30 mEq/L\nBUN: 35 mg/dL\nGlucose: 80 mg/dL\nCreatinine: 1.5 mg/dL\nMagnesium: 2.0 mEq/L\n\nShe continues to have multiple bouts of emesis and dry retching. What is the next best step in management?", "answer": "Administer ondansetron and isotonic saline with potassium", "options": {"A": "Obtain an urine toxin screen", "B": "Administer ondansetron per oral and provide oral rehydration solution", "C": "Administer ondansetron and isotonic saline with potassium", "D": "Administer metoclopramide and 1/2 normal saline with potassium", "E": "Administer ondansetron and 1/2 normal saline with dextrose"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "nausea", "vomiting", "recent illnesses", "sick", "usual diet", "reports", "three times", "day", "temperature", "97", "36", "blood pressure", "90 74 mmHg", "pulse", "100 min", "respirations", "10/min", "room air", "conjunctiva", "injected", "basic metabolic panel", "obtained", "Serum", "Na", "mEq/L", "mEq/L K", "2.9 mEq/L HCO3", "30 mEq/L", "35 mg/dL Glucose", "80 mg/dL Creatinine", "1.5 mg Magnesium", "2 0 mEq/L", "to", "multiple bouts", "emesis", "dry retching", "next best step"]}
{"question": "A 34-year-old male is brought to the emergency department by fire and rescue following a motor vehicle accident in which the patient was an unrestrained driver. The paramedics report that the patient was struck from behind by a drunk driver. He was mentating well at the scene but complained of pain in his abdomen. The patient has no known past medical history. In the trauma bay, his temperature is 98.9°F (37.2°C), blood pressure is 86/51 mmHg, pulse is 138/min, and respirations are 18/min. The patient is somnolent but arousable to voice and pain. His lungs are clear to auscultation bilaterally. He is diffusely tender to palpation on abdominal exam with bruising over the left upper abdomen. His distal pulses are thready, and capillary refill is delayed bilaterally. Two large-bore peripheral intravenous lines are placed to bolus him with intravenous 0.9% saline. Chest radiograph shows multiple left lower rib fractures.\n\nWhich of the following parameters is most likely to be seen in this patient?", "answer": "Decreased pulmonary capillary wedge pressure", "options": {"A": "Decreased systemic vascular resistance", "B": "Decreased pulmonary capillary wedge pressure", "C": "Increased mixed venous oxygen saturation", "D": "Increased cardiac output", "E": "Increased right atrial pressure"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male", "brought", "emergency department", "fire", "following", "motor vehicle accident", "patient", "driver", "paramedics report", "patient", "struck", "well", "pain", "abdomen", "patient", "known past medical history", "trauma bay", "temperature", "98 9F", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "patient", "somnolent", "to voice", "pain", "lungs", "clear", "auscultation", "tender", "palpation", "abdominal exam", "bruising", "left", "distal pulses", "thready", "capillary refill", "delayed", "Two large bore peripheral intravenous lines", "bolus", "intravenous 0.9", "saline", "Chest radiograph", "multiple left lower rib fractures", "following parameters", "to", "seen", "patient"]}
{"question": "A 26-year-old Caucasian G1 presents at 35 weeks gestation with mild vaginal bleeding. She reports no abdominal pain or uterine contractions. She received no prenatal care after 20 weeks gestation because she was traveling. Prior to the current pregnancy, she used oral contraception. At 22 years of age she underwent a cervical polypectomy. She has a 5 pack-year smoking history. The blood pressure is 115/70 mmHg, the heart rate is 88/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Abdominal palpation reveals no uterine tenderness or contractions. The fundus is palpable between the umbilicus and the xiphoid process. An ultrasound exam shows placental extension over the internal cervical os. Which of the following factors present in this patient is the risk factor for her condition?", "answer": "Smoking", "options": {"A": "Intake of oral contraceptives", "B": "History of cervical polyp", "C": "Nulliparity", "D": "Smoking", "E": "White race"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "G1 presents", "35 weeks gestation", "mild vaginal", "reports", "abdominal pain", "uterine contractions", "received", "20 weeks gestation", "current pregnancy", "used oral contraception", "years", "age", "cervical polypectomy", "5 year smoking history", "blood pressure", "70 mmHg", "heart rate", "88 min", "respiratory rate", "min", "temperature", "36", "98", "Abdominal palpation reveals", "uterine tenderness", "contractions", "fundus", "palpable", "umbilicus", "xiphoid process", "ultrasound exam", "placental extension", "internal cervical os", "following factors present", "patient", "risk factor", "condition"]}
{"question": "A 7-year-old girl is brought to the physician by her father because of a dry cough, nasal congestion, and intermittent wheezing during the past 2 months. Since birth, she has had four upper respiratory tract infections that resolved without treatment and one episode of acute otitis media treated with antibiotics. She has a history of eczema. Her temperature is 37.1°C (98.7°F), and respirations are 28/min. Physical examination shows a shallow breathing pattern and scattered expiratory wheezing throughout both lung fields. Which of the following is the most appropriate next step in diagnosing this patient’s condition?", "answer": "Spirometry", "options": {"A": "Methacholine challenge test", "B": "Arterial blood gas analysis", "C": "Chest x-ray", "D": "Serum IgE levels", "E": "Spirometry"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "dry cough", "nasal congestion", "intermittent wheezing", "past", "months", "birth", "four upper respiratory tract infections", "resolved", "treatment", "one episode of acute otitis media treated with", "history of eczema", "temperature", "98", "respirations", "min", "shallow", "scattered expiratory wheezing", "lung fields", "following", "most appropriate next step", "diagnosing", "patients condition"]}
{"question": "A 42-year-old man comes to the physician for 1 month of worsening right knee pain. He has not had any trauma other than stubbing his toe 3 days ago at the garage where he works as a mechanic. Examination of the right knee shows swelling and erythema with fluctuance over the inferior patella. There is tenderness on palpation of the patella but no joint line tenderness or warmth. The range of flexion is limited because of the pain. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Inflammation of periarticular fluid-filled sac", "options": {"A": "Inflammation of the patellar tendon", "B": "Noninflammatory degeneration of the joint", "C": "Infection of the joint", "D": "Deposition of crystals in the joint", "E": "Inflammation of periarticular fluid-filled sac"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "1 month", "worsening right knee pain", "not", "trauma", "toe 3 days", "garage", "right knee", "swelling", "erythema", "fluctuance", "inferior patella", "tenderness", "palpation", "patella", "joint line tenderness", "warmth", "range", "flexion", "limited", "pain", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 17-year-old man presents to his primary care physician with a bilateral tremor of the hands. He is a senior in high school and during the year, his grades have plummeted to the point that he is failing. He says his memory is now poor, and he has trouble focusing on tasks. His behavior has changed in the past 6 months, in that he has frequent episodes of depression, separated by episodes of bizarre behavior, including excessive alcohol drinking and shoplifting. His parents have started to suspect that he is using street drugs, which he denies. His handwriting has become very sloppy. His parents have noted slight slurring of his speech. Family history is irrelevant. Physical examination reveals upper extremity tremors, mild dystonia of the upper extremities, and mild incoordination involving his hands. The patient’s eye is shown. Which of the following best represents the etiology of this patient illness?", "answer": "Mineral accumulation in the basal ganglia", "options": {"A": "Mineral accumulation in the basal ganglia", "B": "Central nervous system demyelination", "C": "Loss of dopaminergic neurons in the nigrostriatal pathway", "D": "Autosomal dominant, trinucleotide repeat disorder", "E": "Autoimmune process following infection with group A streptococci"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "bilateral tremor of", "hands", "year", "point", "failing", "memory", "now poor", "behavior", "changed", "past 6 months", "frequent episodes of depression", "separated", "episodes of bizarre behavior", "including excessive alcohol drinking", "shoplifting", "started to", "using street drugs", "very", "noted slight slurring", "speech", "Family history", "reveals upper extremity tremors", "mild dystonia", "upper extremities", "mild incoordination involving", "hands", "patients eye", "following best", "etiology", "patient illness"]}
{"question": "A 4-year-old boy presents to the emergency department with a 1 hour history of severe knee pain after he bumped his knee against a door. He has no past medical history though his parents say that he seems to bruise fairly easily. His parents say that they are afraid he may have accidentally taken his grandfather's warfarin medication. On presentation, he is found to have an erythematous, warm, swollen knee. Based on this presentation, a panel of laboratory tests are ordered with the following results:\n\nBleeding time: 3 minutes\nProthrombin time (PT): 12 seconds\nPartial thromboplastin time (PTT): 56 seconds\nMixing studies show no change in the above lab values\n\nWhich of the following is most likely the cause of this patient's symptoms?", "answer": "Production of an autoantibody", "options": {"A": "Deficiency in a coagulation factor", "B": "Deficiency of von Willebrand factor", "C": "Platelet defect", "D": "Production of an autoantibody", "E": "Warfarin toxicity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy presents", "emergency department", "hour history", "severe knee", "knee", "door", "past medical history", "to bruise", "easily", "warfarin medication", "found to", "erythematous", "warm", "swollen knee", "Based", "panel", "laboratory tests", "ordered", "following results", "Bleeding time", "3 minutes Prothrombin time", "seconds Partial thromboplastin time", "seconds Mixing studies", "lab", "following", "cause", "patient's symptoms"]}
{"question": "A 40-year-old man comes to the physician for a follow-up examination. He feels well. He has no urinary urgency, increased frequency, dysuria, or gross hematuria. He has a history of recurrent urinary tract infections. His last urinary tract infection was 3 months ago and was treated with ciprofloxacin. Current medications include a multivitamin. He has smoked one pack of cigarettes daily for 18 years. Vital signs are within normal limits. The abdomen is soft and nontender. There is no costovertebral angle tenderness. Laboratory studies show:\nHemoglobin 11.2 g/dL\nLeukocyte count 9,500/mm3\nPlatelet count 170,000/mm3\nSerum\nNa+ 135 mEq/L\nK+ 4.9 mEq/L\nCl- 101 mEq/L\nUrea nitrogen 18 mg/dL\nCreatinine 0.6 mg/dL\nUrine\nBlood 2+\nProtein negative\nRBC 5–7/hpf, normal shape and size\nRBC casts negative\nWBC 0–2/hpf\nBacteria negative\nUrine cultures are negative. Urine analysis is repeated and shows similar results. A cystoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?\"", "answer": "CT urography\n\"", "options": {"A": "Annual urinalysis", "B": "Transrectal ultrasound", "C": "Voided urine cytology", "D": "Reassurance", "E": "CT urography\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old man", "physician", "follow-up examination", "well", "urinary urgency", "increased frequency", "dysuria", "gross hematuria", "history of recurrent urinary tract infections", "last urinary tract infection", "3 months", "treated with ciprofloxacin", "Current medications include", "multivitamin", "smoked one pack", "cigarettes daily", "years", "Vital signs", "normal limits", "abdomen", "soft", "nontender", "costovertebral angle tenderness", "Laboratory studies", "Hemoglobin", "Platelet count", "Serum Na", "L", "Cl", "6", "negative RBC", "hpf", "normal shape", "size", "casts negative WBC", "hpf Bacteria", "Urine", "negative", "Urine analysis", "repeated", "similar results", "cystoscopy", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 40-year-old man presents with severe fatigue, dyspnea on exertion, and weight loss. He reports a weight loss of 15 kg (33.0 lb) over the past 3 months and feels full almost immediately after starting to eat, often feeling nauseous and occasionally vomiting. Past medical history is not significant. However, the patient reports a 10-pack-year smoking history. His temperature is 37.0°C (98.6°F), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Physical examination reveals paleness and conjunctival pallor. Abdominal examination reveals an ill-defined nontender mass in the epigastric region along with significant hepatomegaly. Routine laboratory studies show a hemoglobin level of 7.2 g/dL. A contrast CT scan of the abdomen is presented below. Which of the following structures is most helpful in the anatomical classification of gastrointestinal bleeding in this patient?", "answer": "Ligament of Treitz", "options": {"A": "Ligament of Treitz", "B": "Hepatoduodenal ligament", "C": "Ampulla of Vater", "D": "Sphincter of Oddi", "E": "Portal vein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old man presents", "severe fatigue", "dyspnea on exertion", "weight loss", "reports", "weight loss of", "kg", "0", "past 3 months", "full almost immediately", "starting", "eat", "often", "nauseous", "occasionally vomiting", "Past medical history", "not significant", "patient reports a 10", "smoking history", "temperature", "98", "respiratory rate", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "reveals paleness", "conjunctival pallor", "Abdominal", "reveals", "ill", "nontender mass", "epigastric", "significant hepatomegaly", "Routine laboratory studies", "a hemoglobin level", "g", "contrast", "abdomen", "following structures", "most helpful", "anatomical classification", "gastrointestinal bleeding", "patient"]}
{"question": "A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?", "answer": "Transmural tear", "options": {"A": "Dilated and tortuous veins", "B": "Inflammation of the pericardium", "C": "Mucosal tear", "D": "Pericardial fluid accumulation", "E": "Transmural tear"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "history of alcohol abuse", "cirrhosis presents", "emergency department", "vomiting", "patient", "aggressive", "combative", "emotionally labile", "to", "restrained", "patient", "to vomit", "blood", "noted", "vomitus", "temperature", "99", "blood pressure", "88 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "100", "room air", "patient", "of sudden onset chest pain", "rasping sound", "heard", "heart", "following", "pathophysiology", "likely diagnosis"]}
{"question": "A 74-year-old male is brought to the emergency department 1 hour after he fell from the top of the staircase at home. He reports pain in his neck as well as weakness of his upper extremities. He is alert and immobilized in a cervical collar. He has hypertension treated with hydrochlorthiazide. His pulse is 90/min and regular, respirations are 18/min, and blood pressure is 140/70 mmHg. Examination shows bruising and midline cervical tenderness. Neurologic examination shows diminished strength and sensation to pain and temperature in the upper extremities, particularly in the hands. Upper extremity deep tendon reflexes are absent. Strength, sensation, and reflexes in the lower extremities are intact. Anal sensation and tone are present. Babinski's sign is absent bilaterally. Which of the following is most likely to confirm the cause of this patient's neurologic examination findings?", "answer": "MRI of the cervical spine without contrast", "options": {"A": "CT angiography of the neck", "B": "CT of the cervical spine with contrast", "C": "Cervical myelography", "D": "X-ray of the cervical spine", "E": "MRI of the cervical spine without contrast"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["74 year old male", "brought", "emergency department", "hour", "fell", "top of", "staircase at home", "reports pain in", "neck", "weakness", "upper extremities", "alert", "immobilized", "cervical collar", "hypertension treated with", "pulse", "90 min", "regular", "respirations", "min", "blood pressure", "70 mmHg", "bruising", "midline cervical tenderness", "Neurologic examination", "diminished strength", "sensation", "pain", "temperature", "upper extremities", "hands", "Upper extremity deep tendon reflexes", "absent", "Strength", "sensation", "reflexes", "lower extremities", "intact", "Anal sensation", "tone", "present", "Babinski's sign", "absent", "following", "to confirm", "cause of", "patient's neurologic examination findings"]}
{"question": "A 36-year old pregnant woman (gravida 4, para 1) presents at week 11 of pregnancy. Currently, she has no complaints. She had an uncomplicated 1st pregnancy that ended in an uncomplicated vaginal delivery at the age of 28 years. Her male child was born healthy, with normal physical and psychological development over the years. Two of her previous pregnancies were spontaneously terminated in the 1st trimester. Her elder sister has a child born with Down syndrome. The patient denies smoking and alcohol consumption. Her blood analysis reveals the following findings:\n  Measured values\nBeta human chorionic gonadotropin (beta-hCG) High\nPregnancy-associated plasma protein-A (PAPP-A) Low\nWhich of the following is the most appropriate next step in the management of this patient?", "answer": "Recommend chorionic villus sampling with subsequent cell culturing and karyotyping", "options": {"A": "Offer a blood test for rubella virus, cytomegalovirus, and toxoplasma IgG", "B": "Perform an ultrasound examination with nuchal translucency and crown-rump length measurement", "C": "Recommend chorionic villus sampling with subsequent cell culturing and karyotyping", "D": "Recommend amniocentesis with subsequent cell culturing and karyotyping", "E": "Schedule a quadruple test at the 15th week of pregnancy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old", "gravida 4", "para 1", "presents", "week", "pregnancy", "Currently", "complaints", "uncomplicated 1st pregnancy", "ended", "uncomplicated vaginal", "age", "years", "male child", "born healthy", "normal physical", "years", "Two", "previous pregnancies", "terminated", "1st trimester", "elder", "child born", "Down syndrome", "patient", "smoking", "blood analysis reveals", "following findings", "Measured values Beta human chorionic gonadotropin", "High Pregnancy-associated plasma protein-A", "Low", "following", "most appropriate next step", "patient"]}
{"question": "A 63-year-old man is brought to the emergency department by the police after he was found in the streets lying unconscious on the ground. Both of his pupils are normal in size and reactive to light. There are no obvious signs of head trauma. The finger prick test shows a blood glucose level of 20 mg/dL. He has been brought to the emergency department due to acute alcohol intoxication several times. The vital signs include: blood pressure 100/70 mm Hg, heart rate 110/min, respiratory rate 22/min, and temperature 35℃ (95℉). On general examination, he is pale looking and disheveled with an odor of EtOH. On physical examination, the abdomen is soft and non-tender with no hepatosplenomegaly. After giving a bolus of intravenous dextrose, thiamine, and naloxone, he spontaneously opens his eyes. Blood and urine samples are drawn for toxicology screening. The blood alcohol level comes out to be 300 mg/dL. What will be the most likely laboratory findings in this patient?", "answer": "Macrocytosis MCV > 100fL", "options": {"A": "Schistocytes", "B": "Hypersegmented neutrophils", "C": "Sickle cells", "D": "Macrocytosis MCV > 100fL", "E": "Howell-Jolly bodies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old man", "brought", "emergency department", "police", "found", "streets lying unconscious", "pupils", "normal", "size", "reactive to light", "signs", "head trauma", "finger", "blood glucose level", "20 mg/dL", "brought", "emergency department", "acute alcohol intoxication", "times", "vital signs include", "blood pressure 100 70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 35", "95", "general", "pale looking", "EtOH", "abdomen", "soft", "non-tender", "hepatosplenomegaly", "giving", "bolus", "intravenous", "thiamine", "naloxone", "opens", "eyes", "Blood", "urine samples", "toxicology screening", "blood alcohol level", "out to", "300 mg/dL", "laboratory findings", "patient"]}
{"question": "A 65-year-old man comes to his primary care physician with a 6-month history of bilateral calf pain. The pain usually occurs after walking his dog a few blocks and is more severe on the right side. He has coronary artery disease, essential hypertension, and type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 43 years and drinks two alcoholic beverages a day. Current medications include metformin, lisinopril, and aspirin. He is 183 cm (5 ft 11 in) tall and weighs 113 kg (250 lb); BMI is 34.9 kg/m2. His temperature is 37°C (98.6°F), pulse is 84/min, and blood pressure is 129/72 mm Hg. Cardiac examination shows a gallop without murmurs. The legs have shiny skin with reduced hair below the knee. Femoral and popliteal pulses are palpable bilaterally. Dorsal pedal pulses are 1+ on the left and absent on the right. Ankle-brachial index (ABI) is performed in the office. ABI is 0.5 in the right leg, and 0.6 in the left leg. Which of the following is the most appropriate initial step in management?", "answer": "Graded exercise therapy", "options": {"A": "Graded exercise therapy", "B": "Propranolol therapy", "C": "Spinal cord stimulation", "D": "Vascular bypass surgery", "E": "Percutaneous transluminal angioplasty with stenting"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old man", "primary care physician", "month history of bilateral calf pain", "pain usually occurs", "few blocks", "more severe", "right side", "coronary artery disease", "essential hypertension", "type 2 diabetes mellitus", "smoked two packs", "cigarettes daily", "years", "two", "day", "Current medications include metformin", "lisinopril", "aspirin", "5 ft", "tall", "kg", "BMI", "kg/m2", "temperature", "98", "pulse", "84 min", "blood pressure", "72 mm Hg", "murmurs", "legs", "shiny", "reduced hair", "knee", "Femoral", "popliteal pulses", "palpable", "Dorsal pedal pulses", "1", "left", "absent", "right", "Ankle-brachial index", "performed", "office", "ABI", "0.5", "right leg", "0.6", "left leg", "following", "most appropriate initial step"]}
{"question": "A previously healthy 25-year-old man comes to the physician because of a 1-week history of fever and fluid release from painful lumps in his right groin. He had an atraumatic ulceration of his penis about 1 month ago that was not painful and resolved on its own within 1 week. He works at an animal shelter for abandoned pets. He is sexually active with multiple male partners and does not use condoms. His temperature is 38.5°C (101.3°F). Examination of the groin shows numerous tender nodules with purulent discharge. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal pathogen?", "answer": "Chlamydia trachomatis", "options": {"A": "Bartonella henselae", "B": "Treponema pallidum", "C": "Chlamydia trachomatis", "D": "Haemophilus ducreyi", "E": "Klebsiella granulomatis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "1-week history", "fever", "fluid release", "painful lumps", "right groin", "ulceration", "penis", "1 month", "not painful", "resolved", "1 week", "shelter", "abandoned", "sexually active", "male", "not use condoms", "temperature", "groin", "numerous tender nodules", "purulent discharge", "abnormalities", "following", "causal"]}
{"question": "A 67-year-old man comes to the physician because of numbness and burning sensation of his legs for the past week. He also complains that his stools have been larger and rougher than usual. He has non-Hodgkin lymphoma and is currently receiving chemotherapy with prednisone, vincristine, rituximab, cyclophosphamide, and doxorubicin. He has received 4 cycles of chemotherapy, and his last chemotherapy cycle was 2 weeks ago. His temperature is 37.1°C (98.8°F), pulse is 89/min, and blood pressure is 122/80 mm Hg. Examination shows decreased muscle strength in the distal muscles of the lower extremities. Ankle jerk is 1+ bilaterally and knee reflex is 2+ bilaterally. Sensation to pain, vibration, and position is decreased over the lower extremities. Serum concentrations of glucose, creatinine, electrolytes, and calcium are within the reference range. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Adverse effect of vincristine", "options": {"A": "Adverse effect of vincristine", "B": "Spinal cord compression", "C": "Paraneoplastic autoantibodies", "D": "Guillain-Barré syndrome", "E": "Charcot–Marie–Tooth disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man", "physician", "numbness", "burning sensation of", "legs", "past week", "stools", "larger", "usual", "non-Hodgkin lymphoma", "currently receiving chemotherapy", "prednisone", "vincristine", "rituximab", "cyclophosphamide", "doxorubicin", "received 4 cycles", "chemotherapy", "last chemotherapy cycle", "2 weeks", "temperature", "98", "pulse", "min", "blood pressure", "80 mm Hg", "decreased muscle strength", "distal muscles of", "lower extremities", "Ankle jerk", "1", "knee reflex", "2", "Sensation", "pain", "vibration", "position", "decreased", "lower extremities", "Serum", "glucose", "creatinine", "electrolytes", "calcium", "reference range", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 76-year-old Japanese man is admitted to the hospital because of a 3-month history of loose stools and worsening peripheral edema. He also reports fatigue, a 10-pound weight loss over the past 6 weeks, and a tingling sensation in his hands and feet over the same time period. Aside from the family dog, he has not had contact with animals for over 1 year and has not traveled outside the country. He has hypertension and benign prostatic hyperplasia. Five years ago, he underwent a partial gastrectomy with jejunal anastomosis for gastric cancer. Current medications include hydrochlorothiazide and tamsulosin. His temperature is 36.8°C (98.2°F), pulse is 103/min, and blood pressure is 132/83 mm Hg. Examination shows a soft and nontender abdomen. There is a well-healed scar on the upper abdomen. Cardiopulmonary examination shows no abnormalities. The conjunctivae appear pale. Sensation to vibration and position is absent over the lower extremities. His hemoglobin concentration is 9.9 g/dL, MCV is 108 μm3, total protein 3.9 g/dL, and albumin 1.9 g/dL. Which of the following is the most likely cause of this patient's condition?", "answer": "Bacterial overgrowth", "options": {"A": "Neoplastic growth", "B": "Increased intestinal motility", "C": "Bacterial overgrowth", "D": "Bypass of the pyloric sphincter", "E": "Anastomotic stricture"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["76 year old", "man", "3 month history", "loose stools", "worsening peripheral edema", "reports fatigue", "a 10 pound weight loss", "past", "weeks", "tingling", "hands", "feet", "same time period", "not", "contact with animals", "over", "year", "not", "outside", "country", "hypertension", "benign prostatic hyperplasia", "Five years", "partial gastrectomy", "jejunal anastomosis", "gastric cancer", "Current medications include hydrochlorothiazide", "tamsulosin", "temperature", "36", "98", "pulse", "min", "blood pressure", "83 mm Hg", "soft", "nontender abdomen", "well healed scar", "upper", "Cardiopulmonary examination", "abnormalities", "conjunctivae appear pale", "Sensation", "vibration", "position", "absent", "lower extremities", "hemoglobin concentration", "g/dL", "MCV", "m3", "total protein", "g/dL", "albumin", "g/dL", "following", "most likely cause", "patient's condition"]}
{"question": "A 7-week-old male presents to the pediatrician for vomiting. His parents report that three weeks ago the patient began vomiting after meals. They say that the vomitus appears to be normal stomach contents without streaks of red or green. His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and soy. Despite these adjustments, the vomiting has become more frequent and forceful. The patient’s mother reports that he is voiding about four times per day and that his urine looks dark yellow. The patient has fallen one standard deviation off his growth curve. The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the third trimester, for which she was treated with azithromycin. In the office, the patient's temperature is 98.7°F (37.1°C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min. On physical exam, the patient looks small for his age. His abdomen is soft, non-tender, and non-distended.\n\nWhich of the following is the best next step in management?", "answer": "Intravenous hydration", "options": {"A": "Abdominal ultrasound", "B": "Intravenous hydration", "C": "MRI of the head", "D": "Pyloromyotomy", "E": "Thickening feeds"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["week old male presents", "pediatrician", "vomiting", "report", "three weeks", "patient began vomiting", "meals", "vomitus appears to", "normal stomach", "red", "green", "repositioning", "mealtimes", "switching", "formula to", "soy", "adjustments", "vomiting", "more frequent", "patients", "reports", "voiding", "four times", "day", "urine looks dark yellow", "patient", "fallen one standard deviation", "growth curve", "patient's", "reports", "pregnancy", "uncomplicated", "episode of sinusitis", "third trimester", "treated with azithromycin", "office", "patient's temperature", "98", "blood pressure", "58", "mmHg", "pulse", "min", "respirations", "min", "patient looks small for", "age", "abdomen", "soft", "non-tender", "non distended", "following", "best next step"]}
{"question": "An investigator is studying nutritional deficiencies in humans. A group of healthy volunteers are started on a diet deficient in pantothenic acid. After 4 weeks, several of the volunteers develop irritability, abdominal cramps, and burning paresthesias of their feet. These symptoms are fully reversed after reintroduction of pantothenic acid to their diet. The function of which of the following enzymes was most likely impaired in the volunteers during the study?", "answer": "Alpha-ketoglutarate dehydrogenase", "options": {"A": "Gamma-glutamyl carboxylase", "B": "Methionine synthase", "C": "Dopamine beta-hydroxylase", "D": "Glutathione reductase", "E": "Alpha-ketoglutarate dehydrogenase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying nutritional deficiencies", "humans", "started", "diet deficient", "pantothenic acid", "4 weeks", "several", "volunteers", "irritability", "abdominal cramps", "burning paresthesias", "feet", "symptoms", "reversed", "reintroduction", "pantothenic acid", "diet", "function", "following enzymes", "most likely impaired", "volunteers", "study"]}
{"question": "A 64-year-old man presents to his primary care physician's office for a routine check-up. His past medical history is significant for type 2 diabetes mellitus, hypertension, chronic atrial fibrillation, and ischemic cardiomyopathy. On his last visit three months ago, he was found to have hyperkalemia, at which time lisinopril and spironolactone were removed from his medication regimen. Currently, his medications include coumadin, aspirin, metformin, glyburide, metoprolol, furosemide, and amlodipine. His T is 37 C (98.6 F), BP 154/92 mm Hg, HR 80/min, and RR 16/min. His physical exam is notable for elevated jugular venous pressure, an S3 heart sound, and 1+ pitting pedal edema. His repeat lab work at the current visit is as follows:\n\nSodium: 138 mEq/L, potassium: 5.7 mEq/L, chloride 112 mEq/L, bicarbonate 18 mEq/L, BUN 29 mg/dL, and creatinine 2.1 mg/dL.\n\nWhich of the following is the most likely cause of this patient's acid-base and electrolyte abnormalities?", "answer": "Renal tubular acidosis", "options": {"A": "Furosemide", "B": "Chronic renal failure", "C": "Glyburide", "D": "Renal tubular acidosis", "E": "Amlodipine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["64 year old man presents", "primary care physician's office", "routine check-up", "past medical history", "significant", "type 2 diabetes mellitus", "hypertension", "chronic atrial fibrillation", "ischemic cardiomyopathy", "last", "three months", "found to", "hyperkalemia", "time lisinopril", "spironolactone", "removed", "medication regimen", "Currently", "medications include coumadin", "aspirin", "metformin", "glyburide", "metoprolol", "furosemide", "amlodipine", "T", "98", "F", "BP", "mm Hg", "80 min", "RR", "min", "notable", "elevated jugular venous pressure", "S3 heart sound", "1", "pitting pedal edema", "repeat lab", "current", "follows", "Sodium", "mEq/L", "potassium", "5", "mEq/L", "mEq/L", "bicarbonate", "mEq/L", "29 mg/dL", "creatinine", "mg/dL", "following", "most likely cause", "patient's acid base", "electrolyte abnormalities"]}
{"question": "A 17-year-old boy comes to the physician because of a 3-month history of pain in his right shoulder. He reports that he has stopped playing for his high school football team because of persistent difficulty lifting his right arm. Physical examination shows impaired active abduction of the right arm from 0 to 15 degrees. After passive abduction of the right arm to 15 degrees, the patient is able to raise his arm above his head. The dysfunctional muscle in this patient is most likely to be innervated by which of the following nerves?", "answer": "Suprascapular nerve", "options": {"A": "Suprascapular nerve", "B": "Long thoracic nerve", "C": "Axillary nerve", "D": "Upper subscapular nerve", "E": "Accessory nerve"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "physician", "3 month history", "pain", "right shoulder", "reports", "stopped playing", "high school football", "persistent difficulty lifting", "right arm", "impaired active abduction", "right arm", "0", "15 degrees", "passive abduction", "right arm", "degrees", "patient", "able to", "arm", "head", "dysfunctional muscle", "patient", "to", "following nerves"]}
{"question": "A 72-year-old man is brought to the physician by his son because of gradually progressive yellow discoloration of his skin and generalized pruritus for the past 2 weeks. During this period, his appetite has decreased and he has had a 6.3-kg (14-lb) weight loss. He reports that his stool appears pale and his urine is very dark. Three years ago, he had an episode of acute upper abdominal pain that was treated with IV fluids, NSAIDs, and dietary modification. He has stopped drinking alcohol since then; he used to drink 1–2 beers daily for 40 years. He has smoked a pack of cigarettes daily for the past 50 years. His vital signs are within normal limits. Physical examination shows yellowing of the conjunctivae and skin. The abdomen is soft and nontender; a soft, cystic mass is palpated in the right upper quadrant. Serum studies show:\nBilirubin, total 5.6 mg/dL\nDirect 4.8 mg/dL\nAlkaline phosphatase 192 U/L\nAST 32 U/L\nALT 34 U/L\nAbdominal ultrasonography shows an anechoic cystic mass in the subhepatic region and dilation of the intrahepatic and extrahepatic bile ducts. Which of the following is the most likely diagnosis?\"", "answer": "Pancreatic adenocarcinoma", "options": {"A": "Pancreatic adenocarcinoma", "B": "Choledocholithiasis", "C": "Alcoholic hepatitis", "D": "Cholecystitis", "E": "Budd-Chiari syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["72 year old man", "brought", "physician", "progressive yellow discoloration", "skin", "generalized pruritus", "past 2 weeks", "period", "appetite", "decreased", "6.3 kg", "weight loss", "reports", "stool appears pale", "urine", "very dark", "Three years", "episode of acute upper", "treated with", "NSAIDs", "dietary modification", "stopped drinking alcohol", "then", "used to", "daily", "40 years", "smoked", "pack", "cigarettes daily", "past 50 years", "vital signs", "normal limits", "yellowing", "conjunctivae", "skin", "abdomen", "soft", "nontender", "soft", "cystic", "right upper quadrant", "Serum studies", "Bilirubin", "total", "mg/dL Direct 4.8 mg/dL Alkaline phosphatase", "U/L AST", "ALT", "Abdominal ultrasonography", "cystic mass", "subhepatic region", "dilation", "intrahepatic", "extrahepatic bile ducts", "following", "diagnosis"]}
{"question": "A 2-day-old infant dies of severe respiratory distress following a gestation complicated by persistent oligohydramnios. Upon examination at autopsy, the left kidney is noted to selectively lack cortical and medullary collecting ducts. From which of the following embryological structures do the cortical and medullary collecting ducts arise?", "answer": "Ureteric bud", "options": {"A": "Pronephros", "B": "Mesonephros", "C": "Paramesonephric duct", "D": "Metanephric mesenchyme", "E": "Ureteric bud"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2-day old infant", "severe respiratory distress following", "gestation complicated", "persistent oligohydramnios", "examination", "autopsy", "left kidney", "noted to", "lack cortical", "medullary collecting ducts", "following embryological structures", "cortical", "medullary collecting ducts"]}
{"question": "A 2-year-old child is brought to the emergency department with rapid breathing and a severe cyanotic appearance of his lips, fingers, and toes. He is known to have occasional episodes of mild cyanosis, especially when he is extremely agitated. This is the worst episode of this child’s life, according to his parents. He was born with an APGAR score of 8 via a normal vaginal delivery. His development is considered delayed compared to children of his age. History is significant for frequent squatting after strenuous activity. On auscultation, there is evidence of a systolic ejection murmur at the left sternal border. On examination, his oxygen saturation is 71%, blood pressure is 81/64 mm Hg, respirations are 42/min, pulse is 129/min, and temperature is 36.7°C (98.0°F). Which of the following will most likely be seen on chest x-ray (CXR)?", "answer": "Boot-shaped heart", "options": {"A": "Egg on a string", "B": "Boot-shaped heart", "C": "Displaced tricuspid valve", "D": "Pre-ductal coarctation of the aorta", "E": "Atrial septal defect"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year", "brought", "emergency department", "rapid breathing", "severe cyanotic appearance of", "lips", "fingers", "toes", "known to", "occasional episodes of mild cyanosis", "extremely agitated", "worst episode of", "childs", "born", "APGAR score", "8", "normal vaginal", "development", "delayed", "children", "age", "History", "significant", "frequent squatting", "auscultation", "systolic ejection murmur", "left sternal border", "oxygen saturation", "blood pressure", "81 64 mm Hg", "respirations", "min", "pulse", "min", "temperature", "36", "98", "following", "most likely", "seen", "chest x-ray", "CXR"]}
{"question": "An 11-year-old boy is brought to a pediatrician by his parents with the complaint of progressive behavioral problems for the last 2 years. His parents report that he always looks restless at home and is never quiet. His school teachers frequently complain that he cannot remain seated for long during class, often leaving his seat to move around the classroom. A detailed history of his symptoms suggests a diagnosis of attention-deficit/hyperactivity disorder. The parents report that he has taken advantage of behavioral counseling several times without improvement. The pediatrician considers pharmacotherapy and plans to start methylphenidate at a low dose, followed by regular follow-up. Based on the side effect profile of the medication, which of the following components of the patient’s medical history should the pediatrician obtain before starting the drug?", "answer": "Past history of Kawasaki disease", "options": {"A": "Past history of recurrent wheezing", "B": "Past history of Kawasaki disease", "C": "Past history of recurrent fractures", "D": "Past history of idiopathic thrombocytopenic purpura", "E": "Past history of Guillain-Barré syndrome"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "complaint", "progressive behavioral problems", "last", "years", "report", "always looks restless", "home", "never quiet", "school teachers frequently", "seated", "long", "often", "to move", "classroom", "detailed history", "symptoms", "diagnosis", "attention-deficit/hyperactivity disorder", "report", "times", "pediatrician", "pharmacotherapy", "plans to start methylphenidate", "low dose", "followed by regular", "Based", "side effect profile", "medication", "of", "following components", "patients medical history", "pediatrician obtain before starting", "drug"]}
{"question": "A 2-year-old boy with a history of recurrent respiratory infections is brought to the physician for a follow-up examination. His height and weight are both at the 20th percentile. Crackles are heard in both lower lung fields. Cardiac auscultation shows a grade 3/6 holosystolic murmur over the left lower sternal border and a diastolic rumble heard best at the apex. If left untreated, this patient is most likely to develop which of the following?", "answer": "Digital clubbing", "options": {"A": "Thrombocytosis", "B": "Secondary hypertension", "C": "Aortic dissection", "D": "Digital clubbing", "E": "Chronic kidney disease\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["2 year old boy", "history", "recurrent respiratory infections", "brought", "physician", "follow-up examination", "height", "weight", "percentile", "Crackles", "heard", "lower lung fields", "Cardiac auscultation", "holosystolic murmur", "left lower sternal border", "diastolic rumble heard best", "apex", "left untreated", "patient", "to", "following"]}
{"question": "A previously healthy 57-year-old man comes to the emergency department because of acute retrosternal chest pain that radiates to his back. The pain started suddenly while he was having dinner. A few moments prior to the onset of the pain, he experienced discomfort when trying to eat or drink anything. On the way to the hospital he took a sublingual nitrate tablet that he had at home, which helped relieve the pain. His pulse is 80/min, respirations are 14/min, and blood pressure is 144/88 mm Hg. Examination shows no other abnormalities. An ECG shows a normal sinus rhythm with no ST-segment abnormalities. An esophagogram is done and shows areas of diffuse, uncoordinated spasms in several segments along the length of the esophagus. This patient's condition is most likely to show which of the following findings?", "answer": "Esophageal manometry shows simultaneous multi-peak contractions", "options": {"A": "Esophageal manometry shows simultaneous multi-peak contractions", "B": "Endoscopy shows multiple mucosal erosions", "C": "Ultrasonography shows a mass at the gastroesophageal junction", "D": "Serology shows elevated CK-MB levels", "E": "Esophageal manometry shows hypertensive contractions"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy 57 year old man", "emergency department", "acute retrosternal", "radiates", "back", "pain started", "dinner", "few", "prior to", "onset", "pain", "discomfort", "to eat", "hospital", "sublingual nitrate tablet", "at home", "helped relieve", "pain", "pulse", "80 min", "respirations", "min", "blood pressure", "88 mm Hg", "abnormalities", "ECG", "normal sinus rhythm", "ST-segment abnormalities", "esophagogram", "areas", "diffuse", "uncoordinated spasms", "several segments", "length", "esophagus", "patient's condition", "to", "following findings"]}
{"question": "A 24-year-old woman presents with fever, abdominal pain, and bloody bowel movements. She says her symptoms onset 2 days ago and have not improved. She describes the abdominal pain as moderate, cramping in character, and poorly localized. 1 week ago, she says she was on a camping trip with her friends and had barbecued chicken which she thought tasted strange. The patient denies any chills, hemoptysis, hematochezia, or similar symptoms in the past. The vital signs include: pulse 87/min and temperature 37.8°C (100.0°F). Physical examination is significant for moderate tenderness to palpation in the periumbilical region with no rebound or guarding. Stool is guaiac positive. Which of the following is a complication associated with this patient’s most likely diagnosis?", "answer": "Guillain-Barré syndrome", "options": {"A": "Typhoid", "B": "Appendicitis", "C": "Toxic megacolon", "D": "Guillain-Barré syndrome", "E": "Hemolytic uremic syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "fever", "abdominal pain", "bloody bowel movements", "symptoms onset", "days", "not improved", "abdominal pain", "moderate", "cramping", "character", "poorly localized", "1 week", "trip", "tasted", "patient", "chills", "hemoptysis", "hematochezia", "similar symptoms", "past", "vital signs include", "pulse 87 min", "temperature", "100", "significant", "moderate tenderness", "palpation", "periumbilical region", "guarding", "Stool", "guaiac positive", "following", "complication associated with", "patients", "likely diagnosis"]}
{"question": "A 17-year-old female presents to her pediatrician due to lack of menstruation. She states that she developed breasts 4 years ago but has not experienced menses yet. The patient denies abdominal pain and has no past medical history. Her mother underwent menarche at age 13. The patient is a volleyball player at school, is single, and has never attempted intercourse. At this visit, her temperature is 98.3°F (36.8°C), blood pressure is 110/76 mmHg, pulse is 72/min, and respirations are 14/min. She is 5 feet 7 inches tall and weighs 116 pounds (BMI 18.2 kg/m^2). Exam shows Tanner IV breasts, Tanner I pubic hair, and minimal axillary hair. External genitalia are normal, but the vagina is a 5-centimeter blind pouch. Genetic testing is performed. Which of the following is the best next step in management?", "answer": "Gonadectomy", "options": {"A": "Gonadectomy", "B": "Estrogen replacement therapy", "C": "Vaginoplasty", "D": "Obtain FSH and estrogen levels", "E": "ACTH stimulation test"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old female presents", "pediatrician due to lack of menstruation", "states", "breasts", "years", "not", "menses", "patient", "abdominal pain", "past medical history", "menarche at age", "patient", "school", "single", "never", "intercourse", "temperature", "98", "36", "blood pressure", "76 mmHg", "pulse", "72 min", "respirations", "min", "5 feet", "inches tall", "pounds", "BMI", "kg/m", "Exam", "Tanner IV breasts", "Tanner I pubic hair", "minimal axillary hair", "External genitalia", "normal", "vagina", "5 centimeter blind pouch", "Genetic testing", "performed", "following", "best next step"]}
{"question": "A 60-year-old man comes to the physician because of a 6-month history of progressively worsening urinary frequency. He feels the urge to urinate every hour or two, which restricts his daily activities and interferes with his sleep. He has no fever, hematuria, or burning pain on micturition. He has hypertension and type 2 diabetes mellitus. Current medications include metformin and amlodipine. He does not smoke and drinks 1 to 2 beers daily. His vital signs are within normal limits. Abdominal examination shows no abnormalities. Digital rectal examination shows a nontender, firm, symmetrically enlarged prostate with no nodules. Which of the following is the most appropriate next step in management?", "answer": "Urinalysis", "options": {"A": "Urinalysis", "B": "Prostate ultrasonography", "C": "Urine cytology", "D": "Serum prostate-specific antigen level", "E": "Uroflowmetry"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["60 year old man", "physician", "month history", "worsening urinary frequency", "to", "hour", "two", "restricts", "interferes with", "sleep", "fever", "hematuria", "burning pain on micturition", "hypertension", "type 2 diabetes mellitus", "Current medications include metformin", "amlodipine", "not smoke", "1", "2", "daily", "vital signs", "normal limits", "Abdominal", "abnormalities", "Digital rectal examination", "nontender", "firm", "enlarged", "nodules", "following", "most appropriate next step"]}
{"question": "A 5-year-old boy is brought to the pediatric clinic for evaluation of fever, pain, swelling in the left leg, and limping. Review of systems and history is otherwise unremarkable. The vital signs include: pulse 110/min, temperature 38.1°C (100.6°F), and blood pressure 100/70 mm Hg. On examination, there is a tender swelling over the lower part of his left leg. Which 1 of the following X-ray findings is most suggestive of Ewing’s sarcoma?", "answer": "X-ray showing lytic bone lesion with periosteal reaction", "options": {"A": "Mixed lytic and blastic appearance in the X-ray", "B": "X-ray showing lytic bone lesion with periosteal reaction", "C": "X-ray showing broad-based projections from the surface of the bone", "D": "X-ray showing deep muscle plane displacement from the metaphysis", "E": "X-ray showing a sharply marginated radiolucent area within the apophysis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "pediatric clinic", "fever", "pain", "swelling", "left", "limping", "Review of systems", "history", "unremarkable", "vital signs include", "pulse", "min", "temperature", "100", "blood pressure 100 70 mm Hg", "tender swelling", "lower part of", "left leg", "1", "following X-ray findings", "most suggestive of Ewings sarcoma"]}
{"question": "A 25-year-old homeless woman presents to an urgent care clinic complaining of vaginal bleeding. She also has vague lower right abdominal pain which started a few hours ago and is increasing in intensity. The medical history is significant for chronic hepatitis C infection, and she claims to take a pill for it ‘every now and then.’ The temperature is 36.0°C (98.6°F), the blood pressure is 110/70 mmHg, and the pulse is 80/min. The abdominal examination is positive for localized right adnexal tenderness; no rebound tenderness or guarding is noted. A transvaginal ultrasound confirms a 2.0 cm gestational sac in the right fallopian tube. What is the next appropriate step in the management of this patient? Immunodeficiency (RA, SLE, and Crohns)", "answer": "Surgery", "options": {"A": "Surgery", "B": "IV fluids, then surgery", "C": "Methotrexate", "D": "Pelvic CT without contrast", "E": "Tubal ligation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old homeless woman presents", "urgent care clinic", "vaginal bleeding", "vague lower right abdominal pain", "started", "few hours", "increasing", "intensity", "medical history", "significant", "chronic", "to", "pill", "now", "then", "temperature", "36", "98", "blood pressure", "70 mmHg", "pulse", "80 min", "abdominal", "positive", "localized right adnexal tenderness", "rebound tenderness", "guarding", "noted", "transvaginal ultrasound confirms", "2.0 cm gestational sac", "right fallopian tube", "next appropriate step", "patient", "Immunodeficiency", "RA", "SLE", "Crohns"]}
{"question": "A 29-year-old man presents to the primary care clinic in June for post-discharge follow-up. The patient was recently admitted to the hospital after a motor vehicle collision. At that time he arrived at the emergency department unconscious, hypotensive, and tachycardic. Abdominal CT revealed a hemoperitoneum due to a large splenic laceration; he was taken to the operating room for emergency splenectomy. Since that time he has recovered well without complications. Prior to the accident, he was up-to-date on all of his vaccinations. Which of the following vaccinations should be administered at this time?", "answer": "13-valent pneumococcal conjugate vaccine", "options": {"A": "13-valent pneumococcal conjugate vaccine", "B": "Inactivated (intramuscular) influenza vaccine", "C": "Live attenuated (intranasal) influenza vaccine", "D": "Measles-mumps-rubella vaccine", "E": "Tetanus booster vaccine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old man presents", "primary care clinic", "June", "post-discharge follow-up", "patient", "recently", "motor vehicle collision", "time", "emergency department unconscious", "hypotensive", "tachycardic", "Abdominal CT revealed", "hemoperitoneum due to", "large splenic laceration", "operating room", "emergency splenectomy", "time", "recovered well", "complications", "date", "of", "vaccinations", "following vaccinations", "administered", "time"]}
{"question": "A 4-year-old boy is brought to the emergency department by his mother after cutting his buttock on a piece of broken glass. There is a 5-cm curvilinear laceration over the patient's right buttock. His vital signs are unremarkable. The decision to repair the laceration is made. Which of the following will offer the longest anesthesia for the laceration repair?", "answer": "Bupivacaine with epinephrine", "options": {"A": "Bupivacaine", "B": "Bupivacaine with epinephrine", "C": "Lidocaine", "D": "Lidocaine mixed with bupivacaine", "E": "Lidocaine with epinephrine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "emergency department", "cutting", "buttock", "piece", "glass", "5 cm", "laceration", "patient's right buttock", "vital signs", "unremarkable", "to repair", "laceration", "made", "following", "longest anesthesia", "laceration repair"]}
{"question": "A 58-year-old woman comes to the emergency department because of a 2-day history of worsening upper abdominal pain. She reports nausea and vomiting, and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 132/85 mm Hg. Examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. Laboratory studies show:\nHemoglobin 13 g/dL\nLeukocyte count 16,000/mm3\nSerum\nUrea nitrogen\n25 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 (N = 14–280)\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 is begun. Twelve hours later, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?\"", "answer": "Endoscopic retrograde cholangiopancreatography\n\"", "options": {"A": "Abdominal CT scan", "B": "Laparoscopic cholecystectomy", "C": "Percutaneous cholecystostomy", "D": "Extracorporeal shock wave lithotripsy", "E": "Endoscopic retrograde cholangiopancreatography\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old woman", "emergency department", "2-day history", "worsening upper abdominal pain", "reports nausea", "vomiting", "unable to", "oral intake", "appears", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "discoloration", "sclera", "abdomen", "tender", "right upper quadrant", "abdominal distention", "organomegaly", "Laboratory studies", "Hemoglobin", "g", "Leukocyte 16", "mm3 Serum Urea nitrogen", "Creatinine", "Alkaline phosphatase", "L Alanine aminotransferase", "Total", "Direct 2.7 mg/dL Lipase", "U/L", "N", "Ultrasound", "right upper quadrant", "dilated intrahepatic", "extrahepatic bile ducts", "multiple hyperechoic spheres", "gallbladder", "pancreas", "not well visualized", "Intravenous fluid resuscitation", "antibiotic therapy", "ceftriaxone", "metronidazole", "begun", "Twelve hours later", "patient appears", "ill", "not oriented to time", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "following", "most appropriate next step"]}
{"question": "A 49-year-old woman presents to the office because of tremors for 2 months. She says that her hands have been shaking a lot, especially when she feels stressed. In addition, she has been sweating more than usual and has lost 8 kg (17.6 lb) in the last 2 months. She has a past medical history of vitiligo. Her vital signs are a heart rate of 98/min, a respiratory rate of 14/min, a temperature of 37.6°C (99.7°F), and a blood pressure of 115/75 mm Hg. Physical examination shows a fine, bilateral hand tremor and a diffuse goiter. Which of the following hormonal imbalances is most likely present?", "answer": "Low TSH, high free T4, and high free T3", "options": {"A": "High TSH, high freeT4, and high free T3", "B": "High TSH, low free T4, and low free T3", "C": "High TSH, normal free T4, and normal free T3", "D": "Low TSH, high free T4, and high free T3", "E": "Low TSH, normal free T4, and normal free T3"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "office", "of tremors", "months", "hands", "shaking", "lot", "stressed", "addition", "sweating more", "usual", "lost", "kg", "last", "months", "past medical vitiligo", "vital signs", "heart rate", "98 min", "respiratory rate", "min", "temperature", "99", "blood pressure of", "75 mm Hg", "Physical examination", "fine", "bilateral hand", "diffuse goiter", "following hormonal imbalances", "present"]}
{"question": "A 14-year-old boy is brought to the emergency department because of acute left-sided chest pain and dyspnea following a motor vehicle accident. His pulse is 122/min and blood pressure is 85/45 mm Hg. Physical examination shows distended neck veins and tracheal displacement to the right side. The left chest is hyperresonant to percussion and there are decreased breath sounds. This patient would most benefit from needle insertion at which of the following anatomical sites?", "answer": "2nd left intercostal space along the midclavicular line", "options": {"A": "2nd left intercostal space along the midclavicular line", "B": "5th left intercostal space along the midaxillary line", "C": "8th left intercostal space along the posterior axillary line", "D": "Subxiphoid space in the left sternocostal margin", "E": "5th left intercostal space along the midclavicular line"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "acute left-sided chest pain", "dyspnea following", "motor vehicle accident", "pulse", "min", "blood pressure", "85", "mm Hg", "distended neck", "tracheal displacement", "right side", "left chest", "hyperresonant", "percussion", "decreased breath sounds", "patient", "benefit", "needle insertion", "following anatomical sites"]}
{"question": "Five days after undergoing an open colectomy and temporary colostomy for colon cancer, a 73-year-old man develops severe pain and swelling of the left calf. He was diagnosed with colon cancer 3 months ago. He has hypothyroidism and hypertension. His father died of colon cancer at the age of 68. He does not smoke. Prior to admission, his medications included levothyroxine, amlodipine, and carvedilol. Since the surgery, he has also been receiving unfractionated heparin, morphine, and piperacillin-tazobactam. He is 172 cm (5 ft 8 in) tall and weighs 101 kg (223 lb); BMI is 34.1 kg/m2. He appears uncomfortable. His temperature is 38.1°C (100.6°F), pulse is 103/min, and blood pressure is 128/92 mm Hg. Examination shows multiple necrotic lesions over bilateral thighs. The left calf is erythematous, tender, and swollen. Dorsiflexion of the left foot elicits pain behind the knee. The abdomen is soft and nontender. There is a healing midline incision and the colostomy is healthy and functioning. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 12,100/mm3\nPlatelet count 78,000/mm3\nProthrombin time 18 seconds (INR = 1.1)\nActivated partial thromboplastin time 46 seconds\nSerum\nNa+ 138 mEq/L\nCl- 103 mEq/L\nK+ 4.1 mEq/L\nUrea nitrogen 18 mg/dL\nGlucose 101 mg/dL\nCreatinine 1.1 mg/dL\nWhich of the following is the most appropriate next step in management?\"", "answer": "Switch from unfractionated heparin to argatroban therapy", "options": {"A": "Switch from unfractionated heparin to warfarin therapy", "B": "Switch from unfractionated heparin to argatroban therapy", "C": "Administer vitamin K", "D": "Transfuse platelet concentrate", "E": "Administer fresh frozen plasma\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["open colectomy", "temporary colostomy", "colon cancer", "year old man", "severe pain", "swelling of", "left calf", "diagnosed", "colon cancer", "months", "hypothyroidism", "hypertension", "died of colon cancer", "age", "not smoke", "medications included levothyroxine", "amlodipine", "carvedilol", "surgery", "receiving unfractionated heparin", "morphine", "piperacillin-tazobactam", "5 ft 8", "tall", "kg", "BMI", "kg/m2", "appears", "temperature", "100", "pulse", "min", "blood pressure", "mm Hg", "multiple necrotic lesions", "bilateral thighs", "left calf", "erythematous", "tender", "swollen", "Dorsiflexion of", "left foot elicits pain", "knee", "abdomen", "soft", "nontender", "healing midline", "colostomy", "healthy", "functioning", "abnormalities", "Laboratory studies", "Hemoglobin 13.6 g Leukocyte count 12 100 mm3 Platelet count", "Prothrombin time", "seconds", "INR", "1.1", "Activated partial thromboplastin time", "Serum", "mEq", "K", "4", "Urea 18 mg/dL", "dL Creatinine", "following", "most appropriate next step"]}
{"question": "A previously healthy 13-year-old boy is brought to the physician because of a lump beneath his right nipple that he discovered 1 week ago while showering. He has allergic rhinitis treated with cetirizine. He is at the 65th percentile for height and 80th percentile for weight. Examination shows a mildly tender, firm, 2-cm subareolar mass in the right breast; there are no nipple or skin changes. The left breast shows no abnormalities. Sexual development is Tanner stage 3. Which of the following is the most likely explanation for this patient's breast lump?", "answer": "Normal development", "options": {"A": "Leydig cell tumor", "B": "Adverse effect of medication", "C": "Invasive ductal carcinoma", "D": "Normal development", "E": "Hyperprolactinemia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "of", "lump", "right nipple", "1 week", "showering", "allergic rhinitis treated with cetirizine", "percentile", "height", "80th percentile", "weight", "mildly tender", "firm", "2", "subareolar mass in", "right breast", "nipple", "skin changes", "left breast", "abnormalities", "Sexual development", "Tanner", "following", "explanation", "patient's breast lump"]}
{"question": "A 23-year-old female presents with a seven-day history of abdominal pain, and now bloody diarrhea that brings her to her primary care physician. Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools. She has a family history notable for a father with CAD and a mother with primary sclerosing cholangitis. Upon further workup, she is found to have the following on colonoscopy and biopsy, Figures A and B respectively. Serum perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) is positive. This patient's disease is likely to also include which of the following features?", "answer": "Continuous progression beginning in the rectum", "options": {"A": "Perianal disease", "B": "Continuous progression beginning in the rectum", "C": "Fistulae and stricture formation", "D": "Worse disease severity near the ileocecal valve", "E": "Cobblestoning and skip lesions"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old female presents", "history", "abdominal pain", "now bloody diarrhea", "primary care physician", "Review of systems", "notable", "pound unintentional weight loss", "intermittent loose stools", "family history notable", "CAD", "primary sclerosing cholangitis", "further workup", "found to", "following", "colonoscopy", "biopsy", "Serum perinuclear antineutrophil cytoplasmic antibodies", "positive", "patient's disease", "likely", "include", "following features"]}
{"question": "A 42-year-old man comes to the physician for a routine health maintenance examination. He feels well but has had several episodes of “finger pallor” over the past 4 months. During these episodes, the 4th finger of his left hand turns white. The color usually returns within 20 minutes, followed by redness and warmth of the finger. The episodes are not painful. The complaints most commonly occur on his way to work, when it is very cold outside. One time, it happened when he was rushing to the daycare center because he was late for picking up his daughter. The patient has gastroesophageal reflux disease treated with lansoprazole. His vital signs are within normal limits. The blood flow to the hand is intact on compression of the ulnar artery at the wrist, as well as on compression of the radial artery. When the patient is asked to immerse his hands in cold water, a change in the color of the 4th digit of his left hand is seen. A photograph of the affected hand is shown. His hemoglobin concentration is 14.2 g/dL, serum creatinine is 0.9 mg/dL, and ESR is 35 mm/h. Which of the following is the most appropriate next step in management?", "answer": "Serologic testing", "options": {"A": "Discontinue lansoprazole", "B": "Oral aspirin", "C": "Digital subtraction angiography", "D": "Serologic testing", "E": "Topical nitroglycerin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "routine", "well", "several episodes of finger pallor", "past", "months", "episodes", "4th finger of", "left hand turns white", "color usually returns", "20 minutes", "followed by redness", "warmth", "finger", "episodes", "not painful", "complaints", "occur", "to", "very cold outside", "rushing", "daycare center", "late", "picking", "patient", "gastroesophageal reflux disease treated with lansoprazole", "vital signs", "normal limits", "blood flow", "hand", "intact", "compression", "ulnar artery", "wrist", "as well", "compression", "radial artery", "patient", "to", "hands", "cold", "change", "color of", "4th digit", "left hand", "seen", "photograph", "affected hand", "hemoglobin concentration", "g/dL", "serum creatinine", "0.9 mg/dL", "ESR", "35 mm/h", "following", "most appropriate next step"]}
{"question": "A 7-year-old boy presents to your office with facial eczema. He has a history of recurrent infections, including multiple episodes of pneumonia that lasted several weeks and otitis media. Laboratory measurements of serum immunoglobulins show increased IgE and IgA but decreased IgM. Which of the following additional abnormalities would you expect to observe in this patient?", "answer": "Thrombocytopenia", "options": {"A": "Thrombocytopenia", "B": "Leukopenia", "C": "Anemia", "D": "Pancreatic insufficiency", "E": "NADPH oxidase deficiency"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "office", "facial eczema", "history", "recurrent infections", "including multiple episodes of pneumonia", "lasted", "weeks", "otitis media", "serum immunoglobulins", "increased IgE", "IgA", "decreased IgM", "following additional abnormalities", "to observe", "patient"]}
{"question": "A 26-year-old student arrives to student health for persistent diarrhea. She states that for the past 2 months she has had foul-smelling diarrhea and abdominal cramping. She also reports increased bloating, flatulence, and an unintentional 4 lb weight loss. Prior to 2 months ago, she had never felt these symptoms before. She denies other extra-gastrointestinal symptoms. The patient is an avid hiker and says her symptoms have caused her to miss recent camping trips. The patient has tried to add more fiber to her diet without relief. She feels her symptoms worsen with milk or cheese. Her medical history is insignificant and she takes no medications. She drinks whiskey socially, but denies smoking tobacco or using any illicit drugs. She is sexually active with her boyfriend of 2 years. She went to Mexico 6 months ago and her last multi-day backpacking trek was about 3 months ago in Vermont. Physical examination is unremarkable. A stool sample is negative for fecal occult blood. Which of the following is an associated adverse effect of the most likely treatment given to manage the patient’s symptoms?", "answer": "Disulfiram-like reaction", "options": {"A": "Disulfiram-like reaction", "B": "Osteoporosis", "C": "Photosensitivity", "D": "QT prolongation", "E": "Tendon rupture"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "persistent diarrhea", "states", "past", "months", "smelling diarrhea", "abdominal cramping", "reports increased bloating", "flatulence", "unintentional", "weight loss", "2 months", "never", "symptoms", "extra gastrointestinal symptoms", "patient", "avid", "symptoms", "caused", "to miss recent", "patient", "to add more", "relief", "symptoms worsen", "milk", "medical history", "medications", "smoking tobacco", "using", "illicit drugs", "sexually active", "years", "Mexico", "months", "last multi day", "trek", "about", "months", "Vermont", "unremarkable", "stool sample", "negative", "fecal occult blood", "following", "associated adverse effect", "likely treatment given to", "patients symptoms"]}
{"question": "A 71-year-old man with hypertension comes to the physician for a follow-up examination. Cardiovascular exam shows the point of maximal impulse to be in the mid-axillary line. A transthoracic echocardiogram shows concentric left ventricular hypertrophy with a normal right ventricle. Which of the following is the most likely underlying mechanism of this patient's ventricular hypertrophy?", "answer": "Accumulation of sarcomeres in parallel", "options": {"A": "Accumulation of glycogen", "B": "Accumulation of protein fibrils", "C": "Deposition of endomyocardial collagen", "D": "Accumulation of sarcomeres in parallel", "E": "Infiltration of T lymphocytes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "hypertension", "physician", "follow-up examination", "Cardiovascular exam", "point", "maximal impulse to", "mid-axillary line", "transthoracic echocardiogram", "concentric left ventricular hypertrophy", "normal right ventricle", "following", "underlying mechanism", "patient's ventricular hypertrophy"]}
{"question": "A 62-year-old man comes to the physician because of increased frequency of urination. He also says that he needs to urinate 4 to 5 times nightly and has difficulty initiating a urinary stream. He has had several episodes of acute cystitis treated with ciprofloxacin during the past year. Digital rectal examination shows a firm, symmetrically enlarged, non-tender prostate. This patient is most likely to develop which of the following complications?", "answer": "Inflammation of the renal interstitium", "options": {"A": "Abscess formation in the prostate", "B": "Irreversible decrease in renal function", "C": "Impaired intracavernosal blood flow", "D": "Inflammation of the renal interstitium", "E": "Blastic bone lesions"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man", "physician", "of increased frequency", "urination", "needs to", "4 to 5 times", "difficulty initiating", "urinary stream", "several episodes of acute cystitis treated with ciprofloxacin", "past year", "Digital rectal examination", "firm", "enlarged", "non-tender prostate", "patient", "to", "following complications"]}
{"question": "A 9-year-old boy is brought to a psychologist by his mother because his teachers frequently complain about his behavioral problems at school. The patient’s mother reports that his concerning behavior started at a young age. She says he is disrespectful to family members and to his teachers at school. He also talks back to everyone. Grounding him and limiting his freedom has not improved his behavior. His grades have never been very good, and he is quite isolated at school. After a further review of the patient’s medical history and a thorough physical exam, the physician confirms the diagnosis of oppositional defiant disorder. Which of the following additional symptoms would most likely present in this patient?", "answer": "Blaming others for his own misbehavior", "options": {"A": "History of deliberately damaging furniture", "B": "Blaming others for his own misbehavior", "C": "Staying out of home at nights despite restrictions", "D": "Fights at school", "E": "Frequently leaving his seat during class despite instructions by the teacher"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "psychologist", "teachers frequently", "behavioral problems", "school", "patients", "reports", "behavior started", "young age", "teachers", "school", "talks back", "limiting", "not improved", "behavior", "never", "very good", "isolated", "school", "further", "of", "patients medical history", "physician confirms", "diagnosis", "oppositional defiant disorder", "following additional symptoms", "most likely present", "patient"]}
{"question": "A 42-year-old woman comes to the physician because of stiffness and pain in multiple joints. She says that the fingers on both of her hands have become increasingly stiff and difficult to move over the past 8 months. She also complains of nails that break easily and look spotty as well as chronic back pain. She had a urinary tract infection a year ago that was treated with antibiotics. She is sexually active with 2 male partners and uses condoms inconsistently. Her vitals are within normal limits. A photograph of her right hand is shown. There are multiple, well-demarcated red plaques with silvery-white scales over the shins and back. Serum studies show a negative rheumatoid factor and ANA. Which of the following is the most likely diagnosis?", "answer": "Psoriatic arthritis\n\"", "options": {"A": "Secondary syphilis", "B": "Ankylosing spondylitis", "C": "Rheumatoid arthritis", "D": "Systemic lupus erythematosus", "E": "Psoriatic arthritis\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "stiffness", "pain in multiple joints", "fingers", "of", "hands", "stiff", "difficult to move", "past", "months", "nails", "break easily", "look spotty", "chronic back pain", "urinary tract infection", "year", "treated with", "sexually active", "male", "uses condoms", "normal limits", "photograph", "right hand", "multiple", "well", "red plaques", "silvery white scales", "shins", "back", "Serum studies", "negative rheumatoid factor", "following", "diagnosis"]}
{"question": "A 70-year-old women presents to her primary care physician with sudden episodes of dizziness that resolve in certain positions. On further questioning she describes a false sense of motion with occasional spinning sensation consistent with vertigo. She denies any recent illnesses or hearing loss aside from presbycusis. Her vital signs are normal. During the physical exam the the patient reports an episode of vertigo after transitioning from sitting to supine and horizontal nystagmus is concurrently noted. What is the mostly likely diagnosis?", "answer": "Benign Paroxysmal Positional Vertigo (BPPV)", "options": {"A": "Vestibular migraine", "B": "Meniere's disease", "C": "Labyrinthitis", "D": "Benign Paroxysmal Positional Vertigo (BPPV)", "E": "Vestibular neuritis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["70 year old", "presents", "primary care physician", "sudden episodes of dizziness", "certain positions", "further", "false sense", "occasional spinning sensation", "vertigo", "recent illnesses", "hearing loss", "presbycusis", "vital signs", "normal", "patient reports", "episode of vertigo", "transitioning", "sitting", "supine", "horizontal nystagmus", "noted", "mostly likely diagnosis"]}
{"question": "A 6-year-old girl is brought to the physician by her father because of a 3-day history of sore throat, abdominal pain, nausea, vomiting, and high fever. She has been taking acetaminophen for the fever. Physical examination shows cervical lymphadenopathy, pharyngeal erythema, and a bright red tongue. Examination of the skin shows a generalized erythematous rash with a rough surface that spares the area around the mouth. Which of the following is the most likely underlying mechanism of this patient's rash?", "answer": "Erythrogenic toxin-induced cytokine release", "options": {"A": "Anti-M protein antibody cross-reaction", "B": "Subepithelial immune complex deposition", "C": "Erythrogenic toxin-induced cytokine release", "D": "Bacterial invasion of the deep dermis", "E": "Paramyxovirus-induced cell damage"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "3-day history", "sore throat", "abdominal pain", "nausea", "vomiting", "high fever", "acetaminophen", "fever", "cervical lymphadenopathy", "pharyngeal erythema", "bright", "Examination of", "skin", "generalized erythematous", "surface", "area", "mouth", "following", "underlying mechanism", "patient's rash"]}
{"question": "A 37-year-old woman is being evaluated for difficulty with swallowing for the past few months. She explains that she experiences difficulty swallowing solid foods only. Her medical history is relevant for hypothyroidism and migraines. Her current medications include daily levothyroxine and acetaminophen as needed for pain. The vital signs include blood pressure 110/90 mm Hg, pulse rate 55/min, and respiratory rate 12/min. On physical examination, her abdomen is non-tender. Her voice is hoarse, but there is no pharyngeal hyperemia on oral examination. On cardiac auscultation, an opening snap followed by an early to mid-diastolic rumble is heard over the apex. A barium swallow X-ray is performed and is unremarkable. Echocardiography shows an enlarged left atrium and abnormal blood flow through 1 of the atrioventricular valves. What is the most likely valve abnormality seen in this patient?", "answer": "Mitral valve stenosis", "options": {"A": "Mitral valve stenosis", "B": "Mitral valve regurgitation", "C": "Aortic valve stenosis", "D": "Aortic valve regurgitation", "E": "Mitral valve prolapse"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "difficulty", "swallowing", "past", "months", "difficulty swallowing", "only", "medical history", "relevant", "hypothyroidism", "migraines", "current medications include daily levothyroxine", "acetaminophen as needed", "pain", "vital signs include blood pressure", "90 mm Hg", "pulse rate", "min", "respiratory rate", "min", "abdomen", "non-tender", "voice", "hoarse", "pharyngeal hyperemia", "oral", "cardiac auscultation", "opening snap followed by", "early", "mid diastolic rumble", "heard", "apex", "barium swallow X-ray", "performed", "unremarkable", "Echocardiography", "enlarged left atrium", "abnormal blood flow", "valves", "valve abnormality seen", "patient"]}
{"question": "In a lab experiment, a researcher treats early cells of the erythrocyte lineage with a novel compound called Pb82. Pb82 blocks the first step of heme synthesis. However, the experiment is controlled such that the cells otherwise continue to develop into erythrocytes. At the end of the experiment, the cells have developed into normal erythrocytes except that they are devoid of heme. A second compound, anti-Pb82 is administered which removes the effect of Pb82.\n\nWhich of the following is likely to be true of the mature red blood cells in this study?", "answer": "The cells will not produce heme since they lack mitochondria", "options": {"A": "The cells will now produce heme", "B": "The cells will not produce heme since they lack mitochondria", "C": "The cells will not produce heme because they lack cytosol", "D": "The cells will not produce heme because they lack nucleoli", "E": "The cells will not produce heme because they lack iron"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["lab", "researcher treats early", "novel compound called", "blocks", "first step", "controlled", "cells", "to", "erythrocytes", "end", "cells", "normal erythrocytes except", "heme", "second compound", "administered", "removes", "effect", "following", "likely to", "true", "study"]}
{"question": "A 47-year-old man presents with upper GI (upper gastrointestinal) bleeding. The patient is known to have a past medical history of peptic ulcer disease and was previously admitted 4 years ago for the same reason. He uses proton-pump inhibitors for his peptic ulcer. Upon admission, the patient is placed on close monitoring, and after 8 hours, his hematocrit is unchanged. The patient has also been hemodynamically stable after initial fluid resuscitation. An upper endoscopy is performed. Which of the following endoscopy findings most likely indicates that this patient will not experience additional GI bleeding in the next few days?", "answer": "Clean-based ulcer", "options": {"A": "Visible non-bleeding vessel", "B": "Gastric ulcer with arteriovenous malformations", "C": "Visible bleeding vessel", "D": "Adherent clot on ulcer", "E": "Clean-based ulcer"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "upper GI", "upper gastrointestinal", "bleeding", "patient", "known to", "past medical", "4 years", "same", "uses proton-pump inhibitors", "peptic ulcer", "patient", "close", "8 hours", "hematocrit", "unchanged", "patient", "hemodynamically stable", "initial fluid resuscitation", "upper endoscopy", "performed", "following endoscopy findings", "likely", "patient", "not", "additional GI bleeding", "next", "days"]}
{"question": "A study is conducted to find an association between serum cholesterol and ischemic heart disease. Data is collected, and patients are classified into either the \"high cholesterol\" or \"normal cholesterol\" group and also into groups whether or not the patient experiences stable angina. Which type of data analysis is most appropriate for this study?", "answer": "Chi-squared", "options": {"A": "Analysis of variance", "B": "Attributable risk", "C": "Chi-squared", "D": "Pearson correlation", "E": "T-test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["study", "to find", "association", "serum cholesterol", "ischemic heart disease", "Data", "collected", "patients", "high cholesterol", "normal cholesterol", "group", "groups", "not", "patient", "stable angina", "type", "analysis", "most appropriate", "study"]}
{"question": "A 42-year-old man is brought to the emergency department by his wife because of a 1-day history of progressive confusion. He recently lost his job. He has a history of chronic alcoholism and has been drinking 14 beers daily for the past week. Before this time, he drank 6 beers daily. He appears lethargic. His vital signs are within normal limits. Serum studies show a sodium level of 111 mEq/L and a potassium level of 3.7 mEq/L. Urgent treatment for this patient's current condition increases his risk for which of the following adverse events?", "answer": "Osmotic myelinolysis", "options": {"A": "Wernicke encephalopathy", "B": "Cerebral edema", "C": "Cardiac arrythmia", "D": "Osmotic myelinolysis", "E": "Hyperglycemia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "of", "1-day history", "progressive confusion", "recently lost", "history of chronic alcoholism", "drinking", "daily", "past week", "time", "daily", "appears lethargic", "vital signs", "normal limits", "Serum studies", "sodium level", "mEq/L", "potassium", "3", "mEq/L", "Urgent treatment", "patient's current condition increases", "following adverse events"]}
{"question": "A 25-year-old man presents to his primary care physician for trouble with focus and concentration. The patient states that he has lived at home with his parents his entire life but recently was able to get a job at a local factory. Ever since the patient has started working, he has had trouble focusing at his job. He is unable to stay focused on any task. His boss often observes him \"daydreaming\" with a blank stare off into space. His boss will have to yell at him to startle him back to work. The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment. He has tried going to bed early for the past month but is unable to fall asleep until two hours prior to his alarm. The patient fears that if this continues he will lose his job. Which of the following is the best initial step in management?", "answer": "Bright light therapy", "options": {"A": "Ethosuximide", "B": "Polysomnography", "C": "Bright light therapy", "D": "Modafinil", "E": "Zolpidem"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care physician", "focus", "concentration", "patient states", "lived at home", "entire life", "recently", "able to", "local factory", "patient", "started", "unable to", "focused", "boss often observes", "blank stare", "space", "boss", "to", "back to work", "patient states", "fatigued", "time", "sometimes", "fall asleep", "operating equipment", "bed early", "past month", "unable to fall asleep", "two hours", "alarm", "patient", "following", "best initial step"]}
{"question": "A 7-year-old boy is brought to the physician because of a 4-day history of fever, headache, earache, and sore throat that is worse when swallowing. He has not had a runny nose or cough. He had a similar problem 1 year ago for which he was prescribed amoxicillin, but after developing a skin rash and facial swelling he was switched to a different medication. His immunizations are up-to-date. He is at the 75th percentile for height and the 50th percentile for weight. His temperature is 38.9°C (102°F), pulse is 136/min, and respirations are 28/min. Examination of the oral cavity reveals a coated tongue, red uvula, and enlarged right tonsil covered by a whitish membrane. The deep cervical lymph nodes are enlarged and tender. A throat swab is taken for culture. What is the next most appropriate step in the management of this patient?", "answer": "Erythromycin", "options": {"A": "Penicillin V", "B": "Total tonsillectomy", "C": "Fluconazole", "D": "Erythromycin", "E": "Cefixime"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "4-day history", "fever", "headache", "earache", "sore throat", "worse", "swallowing", "not", "runny nose", "cough", "similar problem", "year", "amoxicillin", "skin rash", "facial swelling", "switched", "different medication", "immunizations", "date", "percentile", "height", "50th percentile", "weight", "temperature", "pulse", "min", "respirations", "min", "reveals", "coated tongue", "red uvula", "enlarged right covered", "membrane", "deep cervical lymph nodes", "enlarged", "tender", "throat swab", "culture", "next", "appropriate step", "patient"]}
{"question": "A 24-year-old male medical student presents into the university clinic concerned about his stool. He has admitted to spending a great deal of time looking back down into the toilet bowl after he has had a bowel movement and even more time later thinking about all the ways his stool is abnormal. A stool sample was collected and was reported to be grossly normal. The patient understands the results and even agrees with the physician but is still bothered by his thoughts. Two weeks later, he is still thinking about his stool and makes another appointment with a different physician. Which of the following disorders is most likely to be associated with this patient’s condition?", "answer": "Tourette syndrome", "options": {"A": "Tourette syndrome", "B": "Obsessive-compulsive personality disorder", "C": "Major depression", "D": "Paraphilia", "E": "Coprophilia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male medical student presents", "university clinic", "stool", "spending", "great", "time looking back", "toilet", "bowel movement", "time later", "stool", "abnormal", "stool sample", "collected", "reported to", "normal", "patient", "results", "agrees", "physician", "Two weeks later", "stool", "makes", "appointment", "different physician", "following disorders", "to", "associated with", "patients condition"]}
{"question": "A 28-year-old woman G1P0 presents at 38 weeks of gestation for a standard prenatal visit. She endorses occasional mild lower back pain but otherwise remains asymptomatic. Her past medical history is significant for HIV for which she is treated with azidothymidine (AZT). Her vital signs and physical exam are unremarkable. Her current HIV viral titer level is 1,400 copies. If she were to go into labor today, what would be the next and most important step for the prevention of vertical HIV transmission to the newborn?", "answer": "Urge the patient to have a cesarean section delivery", "options": {"A": "Increase AZT dose", "B": "Add nevirapine to the patient’s AZT", "C": "Treat the newborn with AZT following delivery", "D": "Avoid breastfeeding", "E": "Urge the patient to have a cesarean section delivery"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "presents", "weeks of gestation", "standard", "occasional mild lower back pain", "asymptomatic", "past medical history", "significant", "HIV", "treated with azidothymidine", "vital signs", "unremarkable", "current HIV viral titer level", "1 400 copies", "to go", "labor today", "next", "important step", "prevention", "vertical HIV transmission", "newborn"]}
{"question": "A 52-year-old man comes to the physician because of right knee pain and swelling for 2 days. Four days ago, he tripped at home and landed on his knees. He reports an episode of diarrhea 3 weeks ago that resolved after 4 days without treatment. He has a history of hypertension and hypercholesterolemia, and was recently diagnosed with parathyroid disease. He drinks 1–2 ounces of whiskey daily and occasionally more on weekends. His brother has ankylosing spondylitis. Vital signs are within normal limits. Examination of the right leg shows an abrasion below the patella. There is swelling and tenderness of the right knee; range of motion is limited by pain. Arthrocentesis of the right knee joint yields 15 mL of cloudy fluid with a leukocyte count of 26,300/mm3 (91% segmented neutrophils). Microscopic examination of the synovial fluid under polarized light shows rhomboid-shaped, weakly positively birefringent crystals. Which of the following is the strongest predisposing factor for this patient's condition?", "answer": "Hyperparathyroidism", "options": {"A": "Dyslipidemia", "B": "Local skin abrasion", "C": "Alcohol consumption", "D": "Hyperparathyroidism", "E": "Recent gastrointestinal infection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "right", "swelling", "2 days", "Four", "tripped at home", "landed", "knees", "reports", "episode of diarrhea", "weeks", "resolved", "4 days", "treatment", "history of hypertension", "hypercholesterolemia", "recently diagnosed", "parathyroid disease", "ounces", "daily", "occasionally", "weekends", "ankylosing spondylitis", "Vital signs", "normal limits", "Examination of", "right leg", "abrasion", "patella", "swelling", "tenderness", "right", "range of motion", "limited", "pain", "Arthrocentesis", "right", "mL", "cloudy fluid", "leukocyte count", "300 mm3", "segmented neutrophils", "Microscopic examination", "synovial fluid", "rhomboid shaped", "crystals", "following", "strongest predisposing factor", "patient's condition"]}
{"question": "A 24-year-old man comes to the physician for a routine health maintenance examination. He feels well. He has type 1 diabetes mellitus. His only medication is insulin. He immigrated from Nepal 2 weeks ago . He lives in a shelter. He has smoked one pack of cigarettes daily for the past 5 years. He has not received any routine childhood vaccinations. The patient appears healthy and well nourished. He is 172 cm (5 ft 8 in) tall and weighs 68 kg (150 lb); BMI is 23 kg/m2. His temperature is 36.8°C (98.2°F), pulse is 72/min, and blood pressure is 123/82 mm Hg. Examination shows a healed scar over his right femur. The remainder of the examination shows no abnormalities. A purified protein derivative (PPD) skin test is performed. Three days later, an induration of 13 mm is noted. Which of the following is the most appropriate initial step in the management of this patient?", "answer": "Obtain a chest x-ray", "options": {"A": "Perform interferon-γ release assay", "B": "Obtain a chest x-ray", "C": "Administer isoniazid for 9 months", "D": "Perform PCR of the sputum", "E": "Collect sputum sample for culture"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "routine", "well", "type 1 diabetes mellitus", "only medication", "insulin", "Nepal 2 weeks", "lives", "shelter", "smoked one pack", "cigarettes daily", "past", "years", "not received", "routine childhood vaccinations", "patient appears healthy", "well nourished", "5 ft 8", "tall", "kg", "BMI", "23 kg/m2", "temperature", "36", "98", "pulse", "72 min", "blood pressure", "mm Hg", "healed scar", "right femur", "abnormalities", "purified protein derivative", "skin test", "performed", "Three days later", "induration", "mm", "noted", "following", "most appropriate initial step", "patient"]}
{"question": "A 38-year-old man is brought to the emergency department after losing consciousness upon rising from his chair at work. The patient has had progressive cough, shortness of breath, fever, and chills for 6 days but did not seek medical attention for these symptoms. He appears distressed, flushed, and diaphoretic. He is 170 cm (5 ft 7 in) tall and weighs 120 kg (265 lbs); BMI is 41.5 kg/m2. His temperature is 39.4°C (102.9°F), pulse is 129/min, respirations are 22/min, and blood pressure is 91/50 mm Hg when supine. Crackles and bronchial breath sounds are heard over the right posterior hemithorax. A 2/6 midsystolic blowing murmur is heard along the left upper sternal border. Examination shows diffuse diaphoresis, flushed extremities, and dullness to percussion over the right posterior hemithorax. The abdomen is soft and nontender. Multiple nurses and physicians have been unable to attain intravenous access. A large-bore central venous catheter is inserted into the right internal jugular vein by standard sterile procedure. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Chest X-ray", "options": {"A": "Administer intravenous levofloxacin", "B": "Echocardiogram", "C": "Bronchoscopy", "D": "CT scan of the chest", "E": "Chest X-ray"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "consciousness", "chair", "patient", "progressive cough", "shortness of breath", "fever", "chills", "6 days", "not", "medical", "symptoms", "appears", "flushed", "diaphoretic", "5 ft", "tall", "kg", "lbs", "BMI", "kg/m2", "temperature", "9F", "pulse", "min", "respirations", "min", "blood pressure", "50 mm Hg", "supine", "Crackles", "bronchial breath sounds", "heard", "right hemithorax", "2/6 midsystolic blowing murmur", "heard", "left upper sternal border", "diffuse diaphoresis", "flushed extremities", "dullness", "percussion", "right hemithorax", "abdomen", "soft", "nontender", "Multiple nurses", "physicians", "unable to", "intravenous access", "large-bore central venous catheter", "right internal jugular vein", "standard sterile procedure", "following", "most appropriate next step", "patient"]}
{"question": "A scientist is studying mechanisms by which cancer drugs work to kill tumor cells. She is working to optimize the function of a drug class in order to reduce toxicity and increase potency for the target. After synthesizing a variety of analogs for the drug class, she tests these new pharmacologic compounds against a panel of potential targets. Assay results show that there is significant binding to a clustered group of proteins. Upon examining these proteins, she finds that the proteins add a phosphate group to an aromatic amino acid sidechain. Which of the following disorders would most likely be treated by this drug class?", "answer": "Chronic myeloid leukemia", "options": {"A": "Brain tumors", "B": "HER2 negative breast cancer", "C": "Chronic myeloid leukemia", "D": "Testicular cancer", "E": "Non-Hodgkin lymphoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["scientist", "studying mechanisms", "cancer drugs", "to kill", "to", "function", "drug", "order to", "toxicity", "increase potency", "target", "drug", "tests", "new pharmacologic compounds", "panel", "potential targets", "Assay results", "significant binding", "clustered", "proteins", "examining", "proteins", "finds", "proteins add", "phosphate", "aromatic amino acid", "following disorders", "most likely", "treated", "drug"]}
{"question": "A pharmaceutical company conducts a randomized clinical trial in an attempt to show that their new anticoagulant drug, Aclotsaban, prevents more thrombotic events following total knee arthroplasty than the current standard of care. However, a significant number of patients are lost to follow-up or fail to complete treatment according to the study arm to which they were assigned. Despite this, the results for the patients who completed the course of Aclotsaban are encouraging. Which of the following techniques is most appropriate to use in order to attempt to prove the superiority of Aclotsaban?", "answer": "Intention-to-treat analysis", "options": {"A": "Per-protocol analysis", "B": "Intention-to-treat analysis", "C": "As-treated analysis", "D": "Sub-group analysis", "E": "Non-inferiority analysis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["to", "new anticoagulant drug", "prevents more thrombotic", "following total knee arthroplasty", "the current standard of", "significant number of patients", "lost to follow-up", "fail to complete", "study arm", "assigned", "completed", "course", "following techniques", "most appropriate to use", "order to", "to"]}
{"question": "A 56-year-old woman with a history of alcoholic cirrhosis and recurrent esophageal varices who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement is brought to the emergency room by her daughter due to confusion and agitation. Starting this morning, the patient has appeared sleepy, difficult to arouse, and slow to respond to questions. Her temperature is 97.6°F (36.4°C), blood pressure is 122/81 mmHg, pulse is 130/min, respirations are 22/min, and oxygen saturation is 98% on room air. She repeatedly falls asleep and is combative during the exam. Laboratory values are notable for a potassium of 3.0 mEq/L. The patient is given normal saline with potassium. Which of the following is the most appropriate treatment for this patient?", "answer": "Lactulose", "options": {"A": "Ciprofloxacin", "B": "Lactulose", "C": "Nadolol", "D": "Protein-restricted diet", "E": "Rifampin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "history", "alcoholic cirrhosis", "recurrent esophageal varices", "recently", "transjugular intrahepatic portosystemic shunt", "placement", "brought", "emergency room", "due to confusion", "agitation", "Starting", "morning", "patient", "appeared sleepy", "difficult", "slow to", "temperature", "97", "36", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "repeatedly falls asleep", "combative", "exam", "Laboratory values", "notable", "potassium", "3.0 mEq/L", "patient", "given normal", "potassium", "following", "most appropriate", "patient"]}
{"question": "A 28-year-old man comes to the physician because of a 1-week history of weakness in the fingers of his right hand. One week ago, he experienced sudden pain in his right forearm during weight training. He has no history of serious illness. Physical examination shows impaired flexion of the proximal interphalangeal joints, while flexion of the distal interphalangeal joints is intact. Which of the following muscles is most likely injured?", "answer": "Flexor digitorum superficialis", "options": {"A": "Palmaris longus", "B": "Flexor carpi radialis", "C": "Flexor carpi ulnaris", "D": "Flexor digitorum superficialis", "E": "Flexor digitorum profundus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "1-week history", "weakness", "fingers of", "right hand", "One week", "sudden pain in", "right forearm", "history", "serious illness", "Physical examination", "impaired flexion", "proximal interphalangeal joints", "flexion", "distal interphalangeal joints", "intact", "following muscles", "most likely injured"]}
{"question": "A 45-year-old homeless man is brought to the emergency department by the police. He was found intoxicated and passed out in a library. The patient has a past medical history of IV drug abuse, diabetes, alcohol abuse, and malnutrition. The patient has been hospitalized previously for multiple episodes of pancreatitis and sepsis. Currently, the patient is minimally responsive and only withdraws his extremities in response to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam is notable for tachycardia, a diastolic murmur at the left lower sternal border, and bilateral crackles on pulmonary exam. The patient is started on IV fluids, vancomycin, and piperacillin-tazobactam. Laboratory values are ordered as seen below.\n\nHemoglobin: 9 g/dL\nHematocrit: 30%\nLeukocyte count: 11,500/mm^3 with normal differential\nPlatelet count: 297,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.0 mEq/L\nHCO3-: 28 mEq/L\nBUN: 33 mg/dL\nGlucose: 60 mg/dL\nCreatinine: 1.7 mg/dL\nCa2+: 9.7 mg/dL\nPT: 20 seconds\naPTT: 60 seconds\nAST: 1,010 U/L\nALT: 950 U/L\n\nThe patient is admitted to the medical floor. Five days later, the patient's neurological status has improved. His temperature is 99.5°F (37.5°C), blood pressure is 130/90 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 99% on room air. Laboratory values are repeated as seen below.\n\nHemoglobin: 10 g/dL\nHematocrit: 32%\nLeukocyte count: 9,500/mm^3 with normal differential\nPlatelet count: 199,000/mm^3\n\nSerum:\nNa+: 140 mEq/L\nCl-: 102 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 24 mEq/L\nBUN: 31 mg/dL\nGlucose: 100 mg/dL\nCreatinine: 1.6 mg/dL\nCa2+: 9.0 mg/dL\nPT: 40 seconds\naPTT: 90 seconds\nAST: 150 U/L\nALT: 90 U/L\n\nWhich of the following is the best description of this patient’s current status?", "answer": "Fulminant liver failure", "options": {"A": "Recovery from acute alcoholic liver disease", "B": "Recovery from ischemic liver disease", "C": "Recovery from acute renal failure", "D": "Acute renal failure", "E": "Fulminant liver failure"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old homeless man", "brought", "emergency department", "police", "found", "passed out", "library", "patient", "past medical history of IV drug abuse", "diabetes", "alcohol abuse", "malnutrition", "patient", "hospitalized", "multiple episodes of pancreatitis", "sepsis", "Currently", "patient", "responsive", "only", "painful", "temperature", "99", "blood pressure", "90 48 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "95", "room air", "notable", "tachycardia", "diastolic murmur", "left lower sternal border", "bilateral crackles", "pulmonary exam", "patient", "started", "vancomycin", "piperacillin-tazobactam", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "30", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4 0 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "60 mg/dL Creatinine", "1.7 mg/dL Ca2", "dL PT", "20 seconds aPTT", "60 seconds AST", "1", "U/L ALT", "950 U/L", "patient", "medical floor", "later", "patient's neurological", "improved", "temperature", "99", "blood pressure", "90 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "Laboratory values", "repeated", "seen", "Hemoglobin", "10 g/dL Hematocrit", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4", "mEq/L HCO3", "mEq/L", "31 mg/dL Glucose", "100 mg/dL Creatinine", "1.6 mg/dL Ca2", "0", "dL PT", "40 seconds aPTT", "90 seconds AST", "U/L ALT", "90 U/L", "following", "best", "patients current status"]}
{"question": "A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?", "answer": "Proceed with additional surgery without obtaining consent", "options": {"A": "Decrease the patient's sedation until he is able to give consent", "B": "Proceed with additional surgery without obtaining consent", "C": "Ask the patient's brother in the waiting room to consent", "D": "Contact the patient's healthcare POA to consent", "E": "Close the patient and obtain re-consent for a second operation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "of sudden abdominal", "hours", "a point scale", "rates", "pain", "abdominal pain", "worst", "right upper quadrant", "atrial fibrillation", "hyperlipidemia", "temperature", "pulse", "min", "blood pressure", "mm Hg", "patient appears", "ill", "distended abdomen", "tenderness", "palpation", "quadrants", "guarding", "Murphy's sign", "positive", "Right upper quadrant ultrasound", "thickening", "gallbladder wall", "sludging", "gallbladder", "pericolic fat stranding", "acute cholecystitis", "grants permission", "cholecystectomy", "out", "town", "business trip", "today", "induction", "anesthesia", "surgeon removes", "gallbladder", "finds", "portion", "small intestine", "necrotic due to", "large thromboembolism occluding", "branch of", "superior mesenteric artery", "treatment", "additional surgery", "small bowel resection", "thromboendarterectomy", "following", "most appropriate next step"]}
{"question": "A 35-year-old woman, gravida 2, para 2, comes to the physician with intermenstrual bleeding and heavy menses for the past 4 months. She does not take any medications. Her father died of colon cancer at the age of 42 years. A curettage sample shows dysplastic tall, columnar, cells in the endometrium without intervening stroma. Germline sequencing shows a mutation in the MLH1 gene. Which of the following is the most likely underlying cause of neoplasia in this patient?", "answer": "Instability of short tandem DNA repeats", "options": {"A": "Accumulation of double-stranded DNA breaks", "B": "Defective checkpoint control transitions", "C": "Inability to excise bulky DNA adducts", "D": "Instability of short tandem DNA repeats", "E": "Impaired repair of deaminated DNA bases"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "gravida 2", "para 2", "physician", "intermenstrual bleeding", "heavy menses", "past", "months", "not", "medications", "died of colon cancer", "age", "years", "curettage sample", "dysplastic tall", "columnar", "cells", "endometrium", "stroma", "Germline sequencing", "mutation", "MLH1 gene", "following", "underlying cause", "neoplasia", "patient"]}
{"question": "A 45-year-old woman presents with heavy menstrual bleeding between her periods. The patient also complains of experiencing an irregular menstrual cycle, weight loss, bloating, and constipation. She has had 3 uncomplicated pregnancies, all of which ended with normal vaginal deliveries at term. She has never taken oral contraception, and she does not take any medication at the time of presentation. She has no family history of any gynecological malignancy; however, her grandfather and mother had colon cancer that was diagnosed before they turned 50. On physical examination, the patient appears pale. Gynecological examination reveals a bloody cervical discharge and slight uterine enlargement. Endometrial biopsy reveals endometrial adenocarcinoma. Colonoscopy reveals several polyps located in the ascending colon, which are shown to be adenocarcinomas on histological evaluation. Which of the following mechanisms of DNA repair is likely to be disrupted in this patient?", "answer": "Mismatch repair", "options": {"A": "Nucleotide-excision repair", "B": "Base-excision repair", "C": "Mismatch repair", "D": "Homologous recombination", "E": "Non-homologous end joining"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "heavy", "periods", "patient", "irregular menstrual cycle", "weight loss", "bloating", "constipation", "3 uncomplicated pregnancies", "ended", "normal vaginal deliveries", "term", "never", "oral contraception", "not", "medication", "time", "family history", "gynecological malignancy", "colon cancer", "diagnosed", "turned 50", "patient appears pale", "reveals", "bloody cervical discharge", "slight uterine enlargement", "Endometrial biopsy reveals endometrial adenocarcinoma", "Colonoscopy reveals several polyps", "ascending colon", "to", "adenocarcinomas", "histological", "following mechanisms", "likely to", "disrupted", "patient"]}
{"question": "A 29-year-old woman comes to the clinic for complaints of fatigue and palpitations for the past 3 days. She reports that even standing up and walking around takes “a lot of energy.” She was forced to call in sick today to her work as a kindergarten teacher. She denies any previous episodes but does endorse symmetric joint pain of her hands, wrists, knees, and ankles that was worse in the morning over the past week that self-resolved. She also reports a runny nose and congestion. Past medical history is unremarkable. Physical examination demonstrates splenomegaly, pallor, and generalized weakness; there is no lymphadenopathy. What is the most likely explanation for this patient’s symptoms?", "answer": "Mutation of ankyrin", "options": {"A": "Anemia of chronic disease", "B": "Infection with Ebstein-Barr virus", "C": "Mutation of ankyrin", "D": "Rheumatoid arthritis", "E": "Substitution of glutamic acid with valine at the beta chain"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "clinic", "complaints", "fatigue", "palpitations", "past 3 days", "reports", "standing up", "lot", "energy", "forced to call", "sick today", "kindergarten teacher", "previous episodes", "symmetric joint pain of", "hands", "wrists", "knees", "ankles", "worse", "morning", "past week", "resolved", "reports", "runny nose", "congestion", "Past medical history", "unremarkable", "Physical examination", "splenomegaly", "pallor", "generalized weakness", "lymphadenopathy", "patients symptoms"]}
{"question": "A research lab is investigating the rate of replication of a variety of human cells in order to better understand cancer metastasis. The cell shown in the image is of particular interest and is marked with a high concern for malignant potential. Which of the following is most closely associated with an increased potential for malignancy?", "answer": "Euchromatin", "options": {"A": "Euchromatin", "B": "Nucleosomes", "C": "Heterochromatin", "D": "H1 protein", "E": "Methylated DNA"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["lab", "investigating", "rate", "replication", "human", "order", "better", "cancer metastasis", "cell", "marked", "high", "malignant potential", "following", "most", "associated with", "increased potential", "malignancy"]}
{"question": "A 6-year-old boy is brought in for evaluation by his adopted mother due to trouble starting 1st grade. His teacher has reported that he has been having trouble focussing on tasks and has been acting out while in class. His family history is unknown as he was adopted 2 years ago. His temperature is 36.2°C (97.2°F), pulse is 80/min, respirations are 20/min, and blood pressure 110/70 mm Hg. Visual inspection of the boy’s face shows a low set nasal bridge, a smooth philtrum, and small lower jaw. Which of the following findings would also likely be found on physical exam?", "answer": "Holosystolic murmur", "options": {"A": "Holosystolic murmur", "B": "Wide notched teeth", "C": "Limb hypoplasia", "D": "Cataracts", "E": "Congenital deafness"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "adopted", "starting 1st grade", "teacher", "reported", "focussing", "family history", "unknown", "adopted 2 years", "temperature", "36", "97", "pulse", "80 min", "respirations", "20 min", "blood pressure", "70 mm Hg", "boys face", "low set nasal bridge", "smooth philtrum", "small lower jaw", "following findings", "likely", "found"]}
{"question": "A 36-year-old woman with a past medical history of diabetes comes to the emergency department for abdominal pain. She reports that a long time ago her gynecologist told her that she had “some cysts in her ovaries but not to worry about it.” The pain started last night and has progressively gotten worse. Nothing seems to make it better or worse. She denies headache, dizziness, chest pain, dyspnea, diarrhea, or constipation; she endorses nausea, dysuria for the past 3 days, and chills. Her temperature is 100.7°F (38.2°C), blood pressure is 132/94 mmHg, pulse is 104/min, and respirations are 14/min. Physical examination is significant for right lower quadrant and flank pain with voluntary guarding. What is the most likely pathophysiology of this patient’s condition?", "answer": "Ascending infection of the urinary tract", "options": {"A": "Ascending infection of the urinary tract", "B": "Cessation of venous drainage from the ovaries", "C": "Inflammation of the appendix", "D": "Irritation of the peritoneal lining", "E": "Vesicoureteral reflex"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["36 year old woman", "past medical history of diabetes", "emergency department", "abdominal pain", "reports", "long time", "gynecologist", "cysts", "ovaries", "not", "worry", "pain started last night", "gotten worse", "to make", "better", "worse", "headache", "dizziness", "chest pain", "dyspnea", "diarrhea", "constipation", "nausea", "dysuria", "past 3 days", "chills", "temperature", "100", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "significant", "right lower quadrant", "flank pain", "guarding", "pathophysiology", "patients condition"]}
{"question": "A 71-year-old African American man diagnosed with high blood pressure presents to the outpatient clinic. In the clinic, his blood pressure is 161/88 mm Hg with a pulse of 88/min. He has had similar blood pressure measurements in the past, and you initiate captopril. He presents back shortly after initiation with extremely swollen lips, tongue, and face. After captopril is discontinued, what is the most appropriate step for the management of his high blood pressure?", "answer": "Initiate a thiazide diuretic", "options": {"A": "Reinitiate captopril", "B": "Switch to ramipril", "C": "Initiate an ARB ", "D": "Initiate a beta-blocker", "E": "Initiate a thiazide diuretic"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "man diagnosed", "high blood pressure presents", "outpatient clinic", "clinic", "blood pressure", "88 mm Hg", "pulse", "min", "similar", "past", "initiate captopril", "presents back", "initiation", "extremely swollen lips", "tongue", "face", "captopril", "discontinued", "most", "step", "high blood pressure"]}
{"question": "A 61-year-old white man presents to the emergency department because of progressive fatigue and shortness of breath on exertion and while lying down. He has had type 2 diabetes mellitus for 25 years and hypertension for 15 years. He is taking metformin and captopril for his diabetes and hypertension. He has smoked 10 cigarettes per day for the past 12 years and drinks alcohol occasionally. His temperature is 36.7°C (98.0°F) and blood pressure is 130/60 mm Hg. On physical examination, his arterial pulse shows a rapid rise and a quick collapse. An early diastolic murmur is audible over the left upper sternal border. Echocardiography shows severe chronic aortic regurgitation with a left ventricular ejection fraction of 55%–60% and mild left ventricular hypertrophy. Which of the following is an indication for aortic valve replacement in this patient?", "answer": "Presence of symptoms of left ventricular dysfunction", "options": {"A": "Old age", "B": "Long history of systemic hypertension", "C": "Presence of symptoms of left ventricular dysfunction", "D": "Long history of diabetes mellitus", "E": "Ejection fraction > 55%"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["61 year old white man presents", "emergency department", "progressive fatigue", "shortness of breath", "exertion", "lying", "type 2 diabetes mellitus", "years", "hypertension", "years", "metformin", "captopril", "diabetes", "hypertension", "smoked 10 cigarettes", "day", "past", "years", "alcohol occasionally", "temperature", "36", "98", "blood pressure", "60 mm Hg", "arterial pulse", "rapid", "quick collapse", "early diastolic murmur", "left upper sternal border", "Echocardiography", "severe chronic aortic", "left ventricular ejection fraction of", "60", "mild left ventricular hypertrophy", "following", "aortic valve replacement", "patient"]}
{"question": "A 50-year-old woman presents with a severe headache and vomiting. She says that symptoms onset after attending a wine tasting at the local brewery. She says that her headache is mostly at the back of her head and that she has been nauseous and vomited twice. Past medical history is significant for depression diagnosed 20 years ago but now well-controlled with medication. She also has significant vitamin D deficiency. Current medications are phenelzine and a vitamin D supplement. The patient denies any smoking history, alcohol or recreational drug use. On physical examination, the patient is diaphoretic. Her pupils are dilated. Which of the following is most likely to be elevated in this patient?", "answer": "Blood pressure", "options": {"A": "Serum creatinine", "B": "Temperature", "C": "Creatine phosphokinase", "D": "Blood pressure", "E": "Aspartate aminotransferase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old woman presents", "severe headache", "vomiting", "symptoms onset", "attending", "tasting", "local brewery", "headache", "mostly", "back of", "head", "nauseous", "vomited twice", "Past medical history", "significant", "depression diagnosed 20 years", "now well", "medication", "significant vitamin D deficiency", "Current medications", "phenelzine", "vitamin D supplement", "patient", "smoking history", "alcohol", "recreational drug use", "patient", "diaphoretic", "pupils", "dilated", "following", "to", "elevated", "patient"]}
{"question": "A 45-year-old man undergoes a parathyroidectomy given recurrent episodes of dehydration and kidney stones caused by hypercalcemia secondary to an elevated PTH level. He is recovering on the surgical floor on day 3. His temperature is 97.6°F (36.4°C), blood pressure is 122/81 mmHg, pulse is 84/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient is complaining of perioral numbness currently. What is the most appropriate management of this patient?", "answer": "Calcium gluconate", "options": {"A": "Calcium gluconate", "B": "Observation", "C": "Potassium", "D": "TSH level", "E": "Vitamin D"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "parathyroidectomy", "recurrent episodes of dehydration", "kidney stones caused", "hypercalcemia secondary to", "elevated", "level", "recovering", "surgical floor", "day 3", "temperature", "97", "36", "blood pressure", "81 mmHg", "pulse", "84 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "perioral numbness currently", "most appropriate", "patient"]}
{"question": "A 51-year-old woman comes to the physician because of daytime sleepiness and dry mouth for one month. She says her sleepiness is due to getting up to urinate several times each night. She noticed increased thirst about a month ago and now drinks up to 20 cups of water daily. She does not feel a sudden urge prior to urinating and has not had dysuria. She has a history of multiple urinary tract infections and head trauma following a suicide attempt 3 months ago. She has bipolar I disorder and hypertension. She has smoked one pack of cigarettes daily for 25 years. Examination shows poor skin turgor. Mucous membranes are dry. Expiratory wheezes are heard over both lung fields. There is no suprapubic tenderness. She describes her mood as “good” and her affect is appropriate. Neurologic examination shows tremor in both hands. Laboratory studies show a serum sodium of 151 mEq/L and an elevated antidiuretic hormone. Urine osmolality is 124 mOsm/kg H2O. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Mood stabilizer intake", "options": {"A": "Hypothalamic injury", "B": "Neuroleptic malignant syndrome", "C": "Paraneoplastic syndrome", "D": "Primary hyperaldosteronism", "E": "Mood stabilizer intake"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "daytime sleepiness", "dry mouth", "one month", "sleepiness", "due to getting", "several times", "night", "increased thirst", "month", "now drinks", "20 cups", "water daily", "not", "sudden", "prior to", "not", "dysuria", "history of multiple urinary tract infections", "head trauma following", "suicide attempt", "months", "bipolar I disorder", "hypertension", "smoked one pack", "cigarettes daily", "years", "poor skin turgor", "Mucous membranes", "dry", "Expiratory wheezes", "heard", "lung fields", "suprapubic tenderness", "appropriate", "Neurologic examination", "tremor", "hands", "Laboratory studies", "serum sodium", "mEq/L", "elevated antidiuretic hormone", "Urine osmolality", "mOsm/kg H2O", "following", "explanation", "patient's"]}
{"question": "A 61-year-old man with hypertension and hyperlipidemia comes to the physician for a 4-month history of recurrent episodes of retrosternal chest pain, shortness of breath, dizziness, and nausea. The episodes usually start after physical activity and subside within minutes of resting. He has smoked one pack of cigarettes daily for 40 years. He is 176 cm (5 ft 9 in) tall and weighs 95 kg (209 lb); BMI is 30 kg/m2. His blood pressure is 160/100 mm Hg. Coronary angiography shows an atherosclerotic lesion with stenosis of the left anterior descending artery. Compared to normal healthy coronary arteries, increased levels of platelet-derived growth factor (PDGF) are found in this lesion. Which of the following is the most likely effect of this factor?", "answer": "Intimal migration of smooth muscles cells", "options": {"A": "Increased expression of vascular cell-adhesion molecules", "B": "Calcification of the atherosclerotic plaque core", "C": "Intimal migration of smooth muscles cells", "D": "Ingestion of cholesterol by mature monocytes", "E": "Invasion of T-cells through the disrupted endothelium"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["61 year old man", "hypertension", "hyperlipidemia", "physician", "month history of recurrent episodes", "retrosternal chest pain", "shortness of breath", "dizziness", "nausea", "episodes usually start", "minutes", "smoked one pack", "cigarettes daily", "40 years", "5 ft 9", "tall", "95 kg", "BMI", "30 kg/m2", "blood pressure", "100 mm Hg", "Coronary angiography", "atherosclerotic lesion", "stenosis", "left anterior descending artery", "normal healthy coronary arteries", "increased levels", "platelet-derived growth factor", "found", "lesion", "following", "effect", "factor"]}
{"question": "A 62-year-old man presents with dry and brittle toenails for the past couple of years. Past medical history is significant for diabetes mellitus type 2, diagnosed 30 years ago, managed with metformin and sitagliptin daily. He is an office clerk and will be retiring next year. On physical examination, his toenails are shown in the image. Which of the following is an adverse effect of the recommended treatment for this patient’s most likely condition?", "answer": "Hepatitis", "options": {"A": "Chronic renal failure", "B": "Hypothyroidism", "C": "Chronic depression", "D": "Pancytopenia", "E": "Hepatitis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["62 year old man presents", "dry", "brittle toenails", "past couple of years", "medical", "significant", "diabetes mellitus type 2", "diagnosed 30 years", "metformin", "sitagliptin daily", "office clerk", "retiring next year", "toenails", "following", "adverse effect", "treatment", "patients", "likely condition"]}
{"question": "A 7-year-old boy is brought to the physician by his mother because of a limp for the last 3 weeks. He has also had right hip pain during this period. The pain is aggravated when he runs. He had a runny nose and fever around a month ago that resolved with over-the-counter medications. He has no history of serious illness. His development is adequate for his age. His immunizations are up-to-date. He appears healthy. He is at the 60th percentile for height and at 65th percentile for weight. Vital signs are within normal limits. Examination shows an antalgic gait. The right groin is tender to palpation. Internal rotation and abduction of the right hip is limited by pain. The remainder of the examination shows no abnormailities. His hemoglobin concentration is 11.6 g/dL, leukocyte count is 8,900/mm3, and platelet count is 130,000/mm3. An x-ray of the pelvis is shown. Which of the following is the most likely underlying mechanism?", "answer": "Avascular necrosis of the femoral head", "options": {"A": "Unstable proximal femoral growth plate", "B": "Bacterial infection of the joint", "C": "Viral infection", "D": "Immune-mediated synovial inflammation", "E": "Avascular necrosis of the femoral head"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "limp", "last", "weeks", "right hip pain", "period", "pain", "aggravated", "runs", "runny nose", "fever", "month", "resolved", "over-the-counter medications", "history", "serious illness", "development", "adequate", "age", "immunizations", "date", "appears healthy", "percentile", "height", "percentile", "weight", "Vital signs", "normal limits", "antalgic gait", "right groin", "tender", "palpation", "Internal rotation", "abduction", "right", "limited", "pain", "hemoglobin concentration", "g/dL", "leukocyte count", "900 mm3", "platelet count", "mm3", "x-ray", "pelvis", "following", "underlying mechanism"]}
{"question": "A 30-year-old woman, gravida 2, para 1, comes for a prenatal visit at 33 weeks' gestation. She delivered her first child spontaneously at 38 weeks' gestation; pregnancy was complicated by oligohydramnios. She has no other history of serious illness. Her blood pressure is 100/70 mm Hg. On pelvic examination, uterine size is found to be smaller than expected for dates. The fetus is in a longitudinal lie, with vertex presentation. The fetal heart rate is 144/min. Ultrasonography shows an estimated fetal weight below the 10th percentile, and decreased amniotic fluid volume. Which of the following is the most appropriate next step in this patient?", "answer": "Serial nonstress tests", "options": {"A": "Reassurance only", "B": "Serial nonstress tests", "C": "Weekly fetal weight estimation", "D": "Amnioinfusion", "E": "Emergent cesarean delivery"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old woman", "gravida 2", "para 1", "weeks", "gestation", "delivered", "first child", "weeks", "gestation", "pregnancy", "complicated", "oligohydramnios", "history", "serious illness", "blood pressure", "100 70 mm Hg", "pelvic examination", "uterine size", "found to", "smaller", "dates", "fetus", "longitudinal", "vertex presentation", "fetal heart rate", "min", "Ultrasonography", "estimated fetal", "percentile", "decreased amniotic fluid volume", "following", "most appropriate next step", "patient"]}
{"question": "A 24-year-old newly immigrated mother arrives to the clinic to discuss breastfeeding options for her newborn child. Her medical history is unclear as she has recently arrived from Sub-Saharan Africa. You tell her that unfortunately she will not be able to breastfeed until further testing is performed. Which of the following infections is an absolute contraindication to breastfeeding?", "answer": "Human Immunodeficiency Virus (HIV)", "options": {"A": "Hepatitis B", "B": "Hepatitis C", "C": "Latent tuberculosis", "D": "Human Immunodeficiency Virus (HIV)", "E": "All of the above"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "clinic to", "breastfeeding options", "newborn child", "medical history", "recently", "Sub-Saharan Africa", "not", "able to breastfeed", "further testing", "performed", "following infections", "absolute contraindication", "breastfeeding"]}
{"question": "A 32-year-old man presents with a 1-week history of progressive diplopia followed by numbness and tingling in his hands and feet, some weakness in his extremities, and occasional difficulty swallowing. He was recently diagnosed with Hodgkin's lymphoma and started on a chemotherapeutic regimen that included bleomycin, doxorubicin, cyclophosphamide, vincristine, and prednisone. He denies fever, recent viral illness, or vaccination. On neurological examination, he has bilateral ptosis. His bilateral pupils are 5 mm in diameter and poorly responsive to light and accommodation. He has a bilateral facial weakness and his gag reflex is reduced. Motor examination using the Medical Research Council scale reveals a muscle strength of 4/5 in the proximal muscles of upper extremities bilaterally and 2/5 in distal muscles. In his lower extremities, hip muscles are mildly weak bilaterally, and he has bilateral foot drop. Deep tendon reflexes are absent. Sensory examination reveals a stocking-pattern loss to all sensory modalities in the lower extremities up to the middle of his shins. A brain MRI is normal. Lumbar puncture is unremarkable. His condition can be explained by a common adverse effect of which of the following drugs?", "answer": "Vincristine", "options": {"A": "Bleomycin", "B": "Cyclophosphamide", "C": "Doxorubicin", "D": "Prednisone", "E": "Vincristine"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "1-week history", "progressive diplopia followed by numbness", "tingling", "hands", "feet", "weakness", "extremities", "occasional difficulty swallowing", "recently diagnosed", "Hodgkin's lymphoma", "started", "chemotherapeutic regimen", "included bleomycin", "doxorubicin", "cyclophosphamide", "vincristine", "prednisone", "fever", "recent viral illness", "vaccination", "neurological examination", "bilateral ptosis", "bilateral pupils", "5 mm", "diameter", "poorly responsive", "light", "accommodation", "bilateral facial weakness", "gag reflex", "reduced", "Motor", "using", "scale reveals", "muscle strength", "proximal muscles of upper extremities", "2/5", "distal muscles", "lower extremities", "hip muscles", "mildly weak", "bilateral foot drop", "Deep tendon reflexes", "absent", "Sensory", "reveals", "stocking pattern loss", "sensory", "lower extremities", "middle", "shins", "brain MRI", "normal", "Lumbar puncture", "unremarkable", "condition", "common", "effect of", "following drugs"]}
{"question": "A 72-year-old Caucasian woman presents with three months of progressive central vision loss accompanied by wavy distortions in her vision. She has hypertension controlled with metoprolol but has no other past medical history. Based on this clinical history she is treated with intravitreal injections of a medication. What is the mechanism of action of the treatment most likely used in this case?", "answer": "Inhibit choroidal neovascularization", "options": {"A": "Decrease ciliary body production of aqueous humor", "B": "Crosslink corneal collagen", "C": "Inhibit choroidal neovascularization", "D": "Pneumatic retinopexy", "E": "Increase outflow of aqueous humor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old", "woman presents", "three months of progressive central vision loss", "wavy distortions", "vision", "hypertension controlled", "metoprolol", "past medical history", "Based", "clinical history", "treated with", "injections of", "medication", "mechanism of action", "treatment", "likely"]}
{"question": "A 19-year-old South Asian male presents to the family physician concerned that he is beginning to go bald. He is especially troubled because his father and grandfather \"went completely bald by the age of 25,\" and he is willing to try anything to prevent his hair loss. The family physician prescribes a medication that prevents the conversion of testosterone to dihydrotestosterone. Which of the following enzymes is inhibited by this medication?", "answer": "5-alpha-reductase", "options": {"A": "Desmolase", "B": "Aromatase", "C": "5-alpha-reductase", "D": "cGMP phosophodiesterase", "E": "Cyclooxygenase 2"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "male presents", "family physician", "beginning to go bald", "completely bald", "age", "willing to", "to prevent", "hair loss", "family physician", "medication", "prevents", "conversion", "testosterone", "dihydrotestosterone", "following enzymes", "inhibited", "medication"]}
{"question": "A 24-year-old woman presents to her primary care physician’s office complaining of right foot pain for the last week. She first noticed this pain when she awoke from bed one morning and describes it as deep at the bottom of her heel. The pain improved as she walked around her apartment but worsened as she attended ballet practice. The patient is a professional ballerina and frequently rehearses for up to 10 hours a day, and she is worried that this heel pain will prevent her from appearing in a new ballet next week. She has no past medical history and has a family history of sarcoidosis in her mother and type II diabetes in her father. She drinks two glasses of wine a week and smokes several cigarettes a day but denies illicit drug use. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 117/68 mmHg, pulse is 80/min, and respirations are 13/min. Examination of the right foot shows no overlying skin changes or swelling, but when the foot is dorsiflexed, there is marked tenderness to palpation of the bottom of the heel. The remainder of her exam is unremarkable. Which of the following is the best next step in management?", "answer": "Resting of the foot", "options": {"A": "Orthotic shoe inserts", "B": "Glucocorticoid injection", "C": "Plain radiograph of the foot", "D": "Resting of the foot", "E": "Ultrasound of the foot"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "primary care physicians office", "right", "last week", "first", "pain", "awoke", "bed one morning", "deep", "bottom", "heel", "pain improved", "apartment", "worsened", "attended", "patient", "professional", "frequently", "10 hours", "day", "worried", "heel pain", "prevent", "appearing", "new", "next week", "past medical history", "family history of sarcoidosis", "type II diabetes", "two glasses", "week", "smokes several cigarettes", "day", "illicit drug use", "patients temperature", "98", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "Examination of", "right foot", "skin changes", "swelling", "foot", "dorsiflexed", "marked tenderness", "palpation", "bottom", "heel", "exam", "unremarkable", "following", "best next step"]}
{"question": "A 35-year-old man presents with acute onset of chest pain, trouble breathing, and abdominal pain. He says he had recently been training for a triathlon competition when, over the past week, he noticed that he was getting more tired than usual. He figured that it was due to his age since most of the people training with him were in their 20s. However, after completing a particularly difficult workout over this last weekend he noticed left-sided chest pain that did not radiate, and abdominal pain, worse on the right side. The pain persisted after he stopped exercising. This morning he noticed red urine. The patient reports similar past episodes of red urine after intense exercise or excessive alcohol intake for the past 5 years, but says it has never been accompanied by pain. Past medical history is significant for a urinary tract infection last week, treated with trimethoprim-sulfamethoxazole. Physical examination is significant for a systolic flow murmur loudest at the right upper sternal border and right upper quadrant tenderness without guarding or rebound. Laboratory findings are significant for the following:\nHemoglobin 8.5 g/dL\nPlatelets 133,000/µL\nTotal bilirubin 6.8 mg/dL\nLDH 740 U/L\nHaptoglobin 25 mg/dL\nAn abdominal MRI with contrast is performed which reveals hepatic vein thrombosis. Which of the following laboratory tests would most likely to confirm the diagnosis in this patient?", "answer": "Flow cytometry", "options": {"A": "Peripheral blood smear", "B": "Flow cytometry", "C": "Hemoglobin electrophoresis", "D": "Genetic testing", "E": "Sucrose hemolysis test"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old man presents", "acute onset of chest pain", "trouble breathing", "abdominal pain", "recently", "training", "past week", "getting more tired", "usual", "due to", "age", "most", "training", "20s", "completing", "difficult workout", "weekend", "left-sided chest pain", "not radiate", "abdominal pain", "worse", "right side", "pain", "stopped exercising", "morning", "red urine", "patient reports similar past episodes of red urine", "intense exercise", "excessive alcohol intake", "past", "years", "never", "pain", "Past medical history", "significant", "urinary tract infection", "week", "treated with trimethoprim-sulfamethoxazole", "significant", "systolic flow murmur loudest", "right upper sternal border", "right upper quadrant tenderness", "guarding", "Laboratory findings", "significant", "following", "Hemoglobin 8.5 g/dL Platelets", "L Total", "mg", "LDH", "U", "Haptoglobin", "mg", "abdominal MRI with contrast", "performed", "reveals hepatic vein thrombosis", "following laboratory tests", "to confirm", "diagnosis", "patient"]}
{"question": "A 32-year-old man comes to the physician because of a 3-week history of recurrent thumb pain that worsens with exposure to cold temperatures. Examination shows a 6-mm, blue-red papule under the left thumbnail. The overlying area is extremely tender to palpation. The thumbnail is slightly pitted and cracked. This lesion most likely developed from which of the following types of cells?", "answer": "Modified smooth muscle cells", "options": {"A": "Dysplastic melanocytes", "B": "Modified smooth muscle cells", "C": "Hyperpigmented fibroblasts", "D": "Injured nerve cells", "E": "Basal epidermal cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "3 week history", "recurrent thumb pain", "worsens", "exposure", "6-mm", "blue-red papule", "left thumbnail", "area", "extremely tender", "palpation", "thumbnail", "slightly pitted", "cracked", "lesion", "likely", "following"]}
{"question": "A 25-year-old man presents to his primary care physician with a chief complaint of \"failing health.\" He states that he typically can converse with animals via telepathy, but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past eight months. On physical exam, you note a healthy young man who is dressed in an all burlap ensemble. When you are obtaining the patient's medical history there are several times he is attempting to telepathically connect with the animals in the vicinity. Which of the following is the most likely diagnosis?", "answer": "Schizotypal personality disorder", "options": {"A": "Schizoid personality disorder", "B": "Schizotypal personality disorder", "C": "Schizophrenia", "D": "Schizophreniform disorder", "E": "Brief psychotic disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "chief complaint", "failing", "states", "animals", "right now due to", "begun", "little", "not currently", "medications", "patient lives alone", "food store", "states", "symptoms", "past eight months", "note", "healthy young man", "dressed", "burlap", "obtaining", "patient", "edical history ", "everal  imes ", "o ", "nimals ", "ollowing ", "iagnosis?"]}
{"question": "An 18-month-old boy is brought in to the pediatrician by his mother for concerns that her child is becoming more and more yellow over the past two days. She additionally states that the boy has been getting over a stomach flu and has not been able to keep down any food. The boy does not have a history of neonatal jaundice. On exam, the patient appears slightly sluggish and jaundiced with icteric sclera. His temperature is 99.0°F (37.2°C), blood pressure is 88/56 mmHg, pulse is 110/min, and respirations are 22/min. His labs demonstrate an unconjugated hyperbilirubinemia of 16 mg/dL. It is determined that the best course of treatment for this patient is phenobarbital to increase liver enzyme synthesis. Which of the following best describes the molecular defect in this patient?", "answer": "Missense mutation in the UGT1A1 gene", "options": {"A": "Deletion in the SLCO1B1 gene", "B": "Silent mutation in the UGT1A1 gene", "C": "Mutation in the promoter region of the UGT1A1 gene", "D": "Missense mutation in the UGT1A1 gene", "E": "Nonsense mutation in the UGT1A1 gene"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "pediatrician", "child", "more", "more yellow", "past two days", "states", "boy", "getting", "stomach flu", "not", "able to keep", "food", "boy", "not", "history of neonatal jaundice", "exam", "patient appears slightly sluggish", "jaundiced", "icteric", "temperature", "99", "blood pressure", "88", "mmHg", "pulse", "min", "respirations", "min", "labs", "unconjugated hyperbilirubinemia", "mg/dL", "best course", "treatment", "patient", "phenobarbital to increase liver", "following best", "molecular defect", "patient"]}
{"question": "A 41-year-old G3P3 woman presents with acute on chronic right upper quadrant abdominal pain. She says that her current symptoms acutely onset 8 hours ago after eating a large meal and have not improved. She describes the pain as severe, sharp and cramping in character, and localized to the right upper quadrant. She also describes feeling nauseous. The patient says she has had similar less severe episodes intermittently for the past 2 years, usually precipitated by the intake of fatty foods. She denies any history of fever or jaundice. Vital signs are stable. Physical examination is unremarkable, and laboratory findings show normal liver function tests and normal serum bilirubin and serum amylase levels. Ultrasonography of the abdomen reveals multiple stones in the gallbladder. The patient is managed symptomatically for this episode, and after a few months, undergoes elective cholecystectomy, which reveals multiple stones in her gallbladder as shown in the figure (see image). Which of the following best describes these gallstones?", "answer": "They are formed due to bile supersaturated with cholesterol.", "options": {"A": "They are formed due to elevated uric acid in the blood.", "B": "They are formed due to the release of beta-glucuronidase from infecting bacteria.", "C": "These are usually radiopaque on X-ray imaging.", "D": "They are formed due to bile supersaturated with cholesterol.", "E": "These are seen in patients with chronic hemolysis."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "acute on chronic right upper quadrant abdominal pain", "current symptoms", "onset 8 hours", "eating", "large", "not improved", "pain", "severe", "sharp", "cramping", "character", "localized", "right upper quadrant", "nauseous", "patient", "similar", "severe episodes", "past", "years", "usually precipitated", "intake", "history", "fever", "jaundice", "Vital signs", "stable", "unremarkable", "laboratory findings", "normal liver function tests", "normal serum", "serum amylase levels", "Ultrasonography of", "abdomen reveals multiple stones", "gallbladder", "patient", "episode", "few months", "elective cholecystectomy", "reveals multiple stones", "gallbladder", "see", "following best", "gallstones"]}
{"question": "A 40-year-old male is brought into the emergency department as the unrestrained passenger in a motor vehicle collision. On presentation he is obtunded with multiple ecchymoses on his chest and abdomen. There is marked distortion of his left lower extremity. His blood pressure is 90/64 mmHg, pulse is 130/min, and respirations are 24/min. Physical exam is limited by the patient’s mental state. The patient appears to be in pain while breathing and has tenderness to palpation of the abdomen. Neck veins are distended. Auscultation of the lungs reveals absent breath sounds on the left and hyperresonance to percussion. An emergent procedure is done and the patient improves. Had a chest radiograph of the patient been obtained on presentation to the ED, which of the following findings would most likely have been seen?", "answer": "Tracheal deviation to the right", "options": {"A": "Consolidation of the left lower lobe", "B": "Bilateral fluffy infiltrates at the lung bases", "C": "Collection of fluid in the left lung base", "D": "Tracheal deviation to the left", "E": "Tracheal deviation to the right"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["40 year old male", "brought", "emergency department", "motor vehicle collision", "obtunded", "multiple ecchymoses", "chest", "abdomen", "marked distortion", "left lower extremity", "blood pressure", "90 64 mmHg", "pulse", "min", "respirations", "min", "limited", "patients mental state", "patient appears to", "pain", "breathing", "tenderness", "palpation of", "abdomen", "Neck", "distended", "Auscultation", "lungs reveals absent breath sounds", "left", "hyperresonance", "percussion", "procedure", "patient improves", "chest radiograph of", "patient", "obtained", "following findings", "most likely", "seen"]}
{"question": "A 55-year-old woman presents to the emergency department with chest pain, shortness of breath, and weakness. She has no known past medical history and generally refuses to see a physician for health issues. Review of systems is notable for chronic, severe gastroesophageal reflux disease and chronic diarrhea. Her temperature is 98.3°F (36.8°C), blood pressure is 177/105 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 97% on room air. Laboratory values are ordered as seen below.\n\nHemoglobin: 10 g/dL\nHematocrit: 30%\nLeukocyte count: 4,500/mm^3 with normal differential\nPlatelet count: 192,400/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 101 mEq/L\nK+: 6.3 mEq/L\nBUN: 65 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 3.1 mg/dL\n\nNotably, the patient requires nursing to help her with most tasks such as putting on her gown and manipulating a cup of water given poor mobility of her hands. She also has recurrent episodes of severe hand pain, which self resolve. The patient is given calcium, insulin, and dextrose and started on dialysis. Which of the following is the most appropriate medical therapy for this patient?", "answer": "Captopril", "options": {"A": "Captopril", "B": "Furosemide", "C": "Hydrochlorothiazide", "D": "Labetalol", "E": "Nifedipine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "chest pain", "shortness of breath", "weakness", "known past medical history", "to see", "physician", "issues", "Review of systems", "notable", "chronic", "severe gastroesophageal reflux disease", "chronic diarrhea", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "97", "room air", "Laboratory values", "ordered", "seen", "Hemoglobin", "10 g/dL Hematocrit", "30", "Leukocyte count", "4 500 mm", "normal differential Platelet count", "400 mm", "Serum", "Na", "mEq/L", "mEq/L K", "6", "mEq", "65 mg/dL Glucose", "99 mg/dL Creatinine", "3.1 mg/dL", "patient", "nursing to help", "as", "gown", "manipulating", "cup", "water", "poor mobility", "hands", "recurrent episodes of severe hand", "patient", "given calcium", "insulin", "dextrose", "started", "dialysis", "following", "most appropriate medical", "patient"]}
{"question": "A 42-year-old woman presents to the emergency department in active labor. She has had no prenatal care and is unsure of the gestational age. Labor progresses rapidly and spontaneous vaginal delivery of a baby boy occurs 3 hours after presentation. On initial exam, the child is 1.9 kg (4.2 lb) with a small head and jaw. A sac-like structure containing intestine, as can be seen in the picture, protrudes from the abdominal wall. What complication is closely associated with this presentation?", "answer": "Cardiac defect", "options": {"A": "Duodenal atresia", "B": "Lack of abdominal wall muscles", "C": "Dehydration and necrosis of bowel", "D": "Cardiac defect", "E": "Twisting of the bowel around itself"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "active labor", "unsure", "gestational age", "Labor progresses rapidly", "spontaneous vaginal delivery", "baby boy occurs 3 hours", "initial exam", "child", "1.9 kg", "4.2", "small head", "jaw", "sac", "structure containing intestine", "seen", "picture", "abdominal wall", "complication", "associated with"]}
{"question": "A 27-year-old man presents to the emergency department with weakness and a fever for the past week. The patient is homeless and has a past medical history of alcohol and IV drug abuse. His temperature is 102°F (38.9°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tremulous patient with antecubital scars and a murmur over the left lower sternal border. Blood cultures are drawn and the patient is started on vancomycin and ceftriaxone and is admitted to the ICU. The patient's fever and symptoms do not improve despite antibiotic therapy for which the initial identified organism is susceptible. Cultures currently reveal MRSA as one of the infective organisms. Which of the following is the best next step in management?", "answer": "Transesophageal echocardiography", "options": {"A": "CT scan of the chest", "B": "Nafcillin and piperacillin-tazobactam", "C": "Obtain new blood cultures", "D": "Transesophageal echocardiography", "E": "Vancomycin and gentamicin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "emergency department", "weakness", "fever", "past week", "patient", "homeless", "past medical alcohol", "IV drug abuse", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "tremulous patient", "antecubital scars", "murmur", "left lower sternal border", "Blood cultures", "patient", "started", "vancomycin", "ceftriaxone", "ICU", "patient's fever", "symptoms", "not", "antibiotic therapy", "initial identified", "susceptible", "Cultures currently reveal MRSA", "one", "following", "best next step"]}
{"question": "A 52-year-old man presents to the his primary care physician complaining of an ongoing cough. He reports that the cough started 1 year ago after a “bad cold” and then never resolved. He feels the cough is getting worse, sometimes the cough is dry, but often the cough will bring up a clear to white mucus, especially in the morning. The patient has hypertension and peripheral artery disease. He takes aspirin and lisinopril. He started smoking at age 16, and now smokes 2 packs of cigarettes a day. He has 1-2 beers a couple nights of the week with dinner. He denies illicit drug use. Which of the following cell types within the lung is most likely to undergo metaplasia caused by smoking?", "answer": "Pseudostratified columnar", "options": {"A": "Pseudostratified columnar", "B": "Simple cuboidal", "C": "Simple squamous", "D": "Stratified squamous", "E": "Transitional"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician complaining of", "cough", "reports", "cough started 1 year", "bad cold", "then never resolved", "cough", "getting worse", "sometimes", "cough", "dry", "often", "cough", "clear", "white mucus", "morning", "patient", "hypertension", "peripheral artery disease", "aspirin", "lisinopril", "started smoking", "age 16", "now smokes 2 packs", "cigarettes", "day", "has", "couple nights", "week", "dinner", "illicit drug use", "following", "lung", "to", "metaplasia caused", "smoking"]}
{"question": "A 64-year-old woman presents to the emergency room with complaints of severe, whole-body itching. She states that she first noticed her symptoms while in the bathtub at home. She has never had symptoms like this before. However, over the previous several months she has had episodes of severe joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet. Her past medical history is significant for type II diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate, respectively. In addition, she was found to have a deep vein thrombosis of her left leg three months prior to presentation. The patient’s temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min. Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms. The patient’s laboratory tests are shown below.\n\nSerum:\nNa+: 135 mEq/L\nCl-: 100 mEq/L\nK+: 5.0 mEq/L\nHCO3-: 22 mEq/L\nBUN: 19 mg/dL\nGlucose: 130 mg/dL\nCreatinine: 1.0 mg/dL\n\nHematocrit: 64%\nLeukocyte count: 19,000 cells/mm^3 with normal differential\nPlatelet count: 900,000/mm^3\n\nWhat is the best next step in treatment of this patient's underlying condition?", "answer": "Hydroxyurea", "options": {"A": "Diphenhydramine", "B": "Hydroxyurea", "C": "Cyclophosphamide", "D": "Febuxostat", "E": "Prednisone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["64 year old woman presents", "emergency room", "complaints", "severe", "whole-body itching", "states", "first", "symptoms", "bathtub at home", "never", "symptoms", "previous", "months", "episodes of severe joint swelling", "pain", "hands", "redness", "burning pain", "swelling of", "hands", "feet", "past medical history", "significant", "type II diabetes mellitus", "hypertension", "osteoporosis", "metformin", "enalapril", "alendronate", "addition", "found to", "deep vein thrombosis of", "left leg three months", "patients temperature", "98", "pulse", "80 min", "blood pressure", "85 mmHg", "respirations", "min", "notable", "woman", "discomfort", "excoriations", "skin", "forearms", "patients laboratory tests", "Serum", "Na", "mEq/L", "100 mEq/L K", "5 0 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1 0 mg/dL", "Hematocrit", "64", "Leukocyte count", "cells mm", "normal differential Platelet count", "900", "mm", "best next step", "treatment", "patient's", "condition"]}
{"question": "A 43-year-old woman, gravida 2, para 2, comes to the physician because of a 6-month history of heavy, irregular menstrual bleeding. Pelvic examination shows blood and clots in the posterior fornix and normal-appearing internal and external genitalia. An endometrial biopsy specimen shows straight uniform tubular glands lined with tall pseudostratified columnar epithelial cells with high mitotic activity embedded in an edematous stroma. Increased activity of which of the following is directly responsible for the histologic appearance of the biopsy specimen?", "answer": "Aromatase", "options": {"A": "Luteinizing hormone", "B": "Corpus luteum", "C": "5-alpha-reductase", "D": "Theca externa cells", "E": "Aromatase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "gravida 2", "para 2", "physician", "month history", "heavy", "irregular", "Pelvic examination", "blood", "clots", "posterior fornix", "normal appearing internal", "external genitalia", "endometrial biopsy specimen", "straight uniform tubular glands lined", "tall", "high mitotic activity embedded", "edematous stroma", "Increased activity", "following", "directly responsible", "histologic appearance", "biopsy"]}
{"question": "A 2-year-old girl presents with high fever, restlessness, and a generalized papulovesicular rash. Past medical history is significant for varicella pneumonia and disseminated cytomegalovirus infection during the 1st year of her life. She was delivered vaginally to a primigravid 22-year-old woman from an uncomplicated pregnancy and was breastfed up to 9 months of age. She is up to date with her vaccines and is meeting all developmental milestones. The vital signs include blood pressure 70/45 mm Hg, heart rate 110/min, respiratory rate 27/min, and temperature 38.0°C (100.4°F). Physical examination demonstrates a generalized papulovesicular rash without a tendency to fuse. The rest of the physical examination is unremarkable for any pathological findings. Disseminated herpes virus infection is suspected. The child is also assessed for primary immunodeficiency. Flow cytometry reveals the absence of CD56 positive cells. Which of the following is true regarding these cells in this patient?", "answer": "They have cell surface receptors for detecting MHC 1 on other cells", "options": {"A": "They are the part of adaptive immunity", "B": "They have cell surface receptors for detecting MHC 1 on other cells", "C": "They need MHC class 1 to be expressed on the cell to eliminate it", "D": "They differentiate from the myeloid progenitor", "E": "These cells also express the T cell receptor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 year old girl presents", "high fever", "restlessness", "generalized papulovesicular rash", "Past medical history", "significant", "varicella pneumonia", "disseminated cytomegalovirus infection", "1st year", "delivered", "primigravid", "year old woman", "uncomplicated pregnancy", "breastfed", "months", "age", "date", "vaccines", "vital signs include blood pressure 70", "mm Hg", "heart rate", "min", "respiratory rate 27 min", "temperature", "100", "generalized", "rash", "fuse", "unremarkable", "pathological findings", "Disseminated herpes virus infection", "suspected", "child", "primary immunodeficiency", "Flow cytometry reveals", "absence", "CD56", "following", "true", "cells", "patient"]}
{"question": "A 12-year-old male child presents to the emergency department with a fever, dry cough, and shortness of breath. The condition began approximately 5 days ago with a rise in body temperature up to 38.7°C (101.7℉), headache, myalgias, and runny nose. Three days after the onset, the patient started to develop a non-productive cough and later, dyspnea. His vital signs are as follows: blood pressure is 100/70 mm Hg, heart rate is 91/min, respiratory rate is 29/min, and temperature is 38.1℃ (100.6℉). On examination, his oxygen saturation is 88%. The patient has a mild pharyngeal erythema and cervical lymphadenopathy. Lung auscultation shows no remarkable findings. Chest radiograph shows patchy reticular opacities best visualized in the perihilar region. A sputum culture is positive for Mycoplasma pneumoniae. Which of the following is consistent with the patient’s condition?", "answer": "Increased A-a gradient, increased diffusion distance", "options": {"A": "Normal A-a gradient, increased diffusion distance", "B": "Decreased A-a gradient, increased diffusion distance", "C": "Decreased A-a gradient, decreased diffusion distance", "D": "Increased A-a gradient, increased diffusion distance", "E": "Increased A-a gradient, decreased diffusion distance"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male presents", "emergency department", "fever", "dry cough", "shortness of breath", "condition began approximately 5 days", "body temperature", "headache", "myalgias", "runny nose", "Three days", "onset", "patient started to", "non-productive cough", "later", "dyspnea", "vital signs", "follows", "blood pressure", "100 70 mm Hg", "heart rate", "min", "respiratory rate", "29 min", "temperature", "100", "oxygen saturation", "88", "patient", "mild pharyngeal erythema", "cervical lymphadenopathy", "Lung auscultation", "findings", "Chest radiograph", "patchy reticular opacities best visualized", "region", "sputum culture", "positive", "following", "patients condition"]}
{"question": "A 49-year-old man comes to the physician for evaluation of several painless, pruritic lesions on his left forearm that he first noticed 4 days ago. They were initially pink marks that progressed into blisters before ulcerating. He has also had a headache for 1 week. His temperature is 38.1°C (100.6°F). A photograph of one of the lesions is shown. There is pronounced edema of the surrounding skin and painless swelling of the left axillary lymph nodes. Which of the following is the greatest risk factor for this patient's condition?", "answer": "Wool handling", "options": {"A": "Pool swimming", "B": "Cat scratch", "C": "Wool handling", "D": "Sexual contact", "E": "Spider bite"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "painless", "lesions", "left forearm", "first", "4 days", "initially pink marks", "progressed", "blisters", "ulcerating", "headache", "1 week", "temperature", "100", "photograph", "one", "lesions", "edema of", "surrounding skin", "painless swelling of", "left axillary lymph nodes", "following", "greatest risk factor", "patient's condition"]}
{"question": "A 76-year-old woman comes in for a routine checkup with her doctor. She is concerned that she feels tired most days and has difficulty doing her household chores. She complains that she gets fatigued and breathless with mild exertion. Past medical history is significant for diabetes mellitus, chronic kidney disease from prolonged elevated blood sugar, and primary biliary cirrhosis. Medications include lisinopril, insulin, and metformin. Family medicine is noncontributory. She drinks one beer every day. Today, she has a heart rate of 98/min, respiratory rate of 17/min, blood pressure of 110/65 mm Hg, and a temperature of 37.0°C (98.6°F). General examination shows that she is pale and haggard looking. She has a heartbeat with a regular rate and rhythm and her lungs are clear to auscultation bilaterally. A complete blood count (CBC) is as follows:\nLeukocyte count: 12,000/mm3\nRed blood cell count: 3.1 million/mm3\nHemoglobin: 11.0 g/dL\nMCV: 85 um3\nMCH: 27 pg/cell\nPlatelet count: 450,000/mm3\nFecal occult blood test is negative. What is the most likely cause of her anemia?", "answer": "Chronic kidney disease", "options": {"A": "Chronic kidney disease", "B": "Acute bleeding", "C": "Alcoholism", "D": "Liver disease", "E": "Colorectal cancer"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["76 year old woman", "routine checkup", "doctor", "tired", "days", "difficulty", "gets fatigued", "breathless", "mild exertion", "Past medical history", "significant", "diabetes mellitus", "chronic kidney disease", "prolonged elevated blood sugar", "primary biliary cirrhosis", "Medications include lisinopril", "insulin", "metformin", "Family medicine", "one", "day", "Today", "heart rate", "98 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "98", "General", "pale", "looking", "heartbeat", "regular rate", "rhythm", "lungs", "clear", "auscultation", "complete blood count", "CBC", "follows", "Leukocyte count", "mm3 Red blood cell count", "3.1 million mm3 Hemoglobin", "0 g/dL MCV", "85 um3 MCH", "27 pg/cell Platelet count", "450", "mm3 Fecal occult blood test", "negative", "most likely cause", "anemia"]}
{"question": "A 23-year-old Caucasian G2P1 presents for a routine prenatal care visit at 25 weeks gestation. She has no complaints and the pregnancy has been uncomplicated thus far. The previous pregnancy was complicated by pre-eclampsia and she delivered a small-for-gestational-age girl at 36 weeks gestation. The pre-pregnancy weight was 73 kg (161 lb), and she now weighs 78 kg (172 lb). Her height is 155 cm. The blood pressure is 120/80 mm Hg, the heart rate is 91/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Her physical examination is normal and the gynecologic examination corresponds to 25 weeks gestation. An oral glucose tolerance test (OGTT) with a 75-g glucose load was abnormal with a 1-h glucose level of 189 mg/dL. Which of the following is a risk factor for the patient’s condition?", "answer": "re-pregnancy BMI", "options": {"A": "Patient age", "B": "Patient ethnicity", "C": "re-pregnancy BMI", "D": "History of pre-eclampsia", "E": "History of birth of a small-for-gestational-age baby"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old", "presents", "routine prenatal care", "weeks gestation", "complaints", "pregnancy", "uncomplicated", "far", "previous pregnancy", "complicated", "pre-eclampsia", "delivered", "small-for-gestational-age girl", "36 weeks", "pre-pregnancy weight", "kg", "now", "kg", "height", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "normal", "weeks gestation", "oral glucose tolerance test", "75-g", "load", "abnormal", "glucose level", "mg/dL", "following", "a", "factor", "patients condition"]}
{"question": "A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache?", "answer": "Large-vessel vasculitis", "options": {"A": "Tension headache", "B": "Large-vessel vasculitis", "C": "Polyarteritis nodosa", "D": "Hyperthyroidism", "E": "Cluster headache"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "2 month history", "right-sided headache", "generalized fatigue", "pain", "weakness", "stiffness", "shoulders", "hips", "stiffness", "worse", "morning", "usually improves", "minutes", "activity", "Three months", "fell", "hit", "head", "kitchen", "temperature", "100", "normal muscle strength", "bilateral upper", "lower extremities", "range of motion of", "shoulder", "hip", "mildly limited", "pain", "Deep tendon reflexes", "2", "erythrocyte sedimentation rate", "mm/h", "serum creatine kinase", "36 mg/dL", "following", "underlying cause", "patient's headache"]}
{"question": "Three days after delivery, a 4000-g (8.8-lb) male newborn has several episodes of right-sided arm and leg twitching and lip smacking. These shaking episodes have occurred about six times over the last hour and have lasted for about 40 seconds. He has also had rapid breathing and poor feeding. He has not had fever or trauma. He was born at 37 weeks' gestation. Pregnancy and delivery were uncomplicated. There is no family history of serious illness. His temperature is 37°C (98.6°F), pulse is 230/min, and respirations are 70/min. He appears irritable and jittery. There are intermittent spasms present. The remainder of the examination shows no abnormalities. Laboratory studies show a serum calcium concentration of 6 mg/dL and a serum parathyroid hormone concentration of 150 pg/mL. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Maternal familial hypocalciuric hypercalcemia", "options": {"A": "Maternal familial hypocalciuric hypercalcemia", "B": "Neonatal ingestion of formula with high phosphate load", "C": "Neonatal hypoglycemia", "D": "Increased neonatal thyroid hormone secretion", "E": "Maternal opioid abuse during pregnancy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Three days", "delivery", "4000", "male newborn", "several episodes of right-sided arm", "leg twitching", "lip smacking", "shaking episodes", "six times", "last hour", "lasted", "40 seconds", "rapid breathing", "poor feeding", "not", "fever", "trauma", "born", "weeks", "gestation", "Pregnancy", "delivery", "uncomplicated", "family history", "serious illness", "temperature", "98", "pulse", "min", "respirations", "70 min", "appears irritable", "intermittent spasms present", "abnormalities", "Laboratory studies", "serum calcium concentration", "mg dL", "serum parathyroid hormone concentration", "pg/mL", "following", "underlying cause", "patient's condition"]}
{"question": "A 25-year-old man presents with a nodule on his right foot. He says that he first noticed the nodule last week. It has not undergone any change in size and color. He denies any history of trauma or fever. Past medical history is significant for HIV, diagnosed 6 years ago. He is currently not on antiretroviral therapy. His last CD4+ T cell count was 0.19 x 109/L. He is afebrile, and his vital signs are within normal limits. On physical examination, there is a 3 cm x 4 cm nodule on the right foot, tan brown in color, non-tender, and covered with a fine scale. A biopsy of the nodule is performed and histopathological analysis reveals the proliferation of blood vessels with overgrown endothelial cells. Histological staining of the biopsy tissue reveals gram-negative bacilli. Which of the following is the best course of treatment for this patient?", "answer": "Erythromycin", "options": {"A": "Cefazolin", "B": "Penicillin", "C": "Vancomycin", "D": "Erythromycin", "E": "Interferon-α"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "nodule", "right foot", "first", "nodule", "week", "not", "change in size", "color", "history", "trauma", "fever", "Past medical history", "significant", "HIV", "diagnosed", "years", "currently not", "antiretroviral therapy", "last CD4", "T cell count", "0.19", "afebrile", "vital signs", "normal limits", "3", "4", "nodule", "right", "tan brown", "color", "non-tender", "covered", "fine scale", "biopsy", "nodule", "performed", "histopathological analysis reveals", "proliferation", "blood vessels", "endothelial cells", "Histological staining", "biopsy tissue reveals", "following", "best course", "treatment", "patient"]}
{"question": "A 17-year-old boy is brought to the physician by his father because of a 7-month history of fatigue, recurrent leg cramps, and increased urinary frequency. His pulse is 94/min and blood pressure is 118/85 mm Hg. Physical examination shows dry mucous membranes. Laboratory studies show:\nSerum\nNa+ 130 mEq/L\nK+ 2.8 mEq/L\nCl- 92 mEq/L\nMg2+ 1.1 mEq/L\nCa2+ 10.6 mg/dL\nAlbumin 5.2 g/dL\nUrine\nCa2+ 70 mg/24 h\nCl- 375 mEq/24h (N = 110–250)\nArterial blood gas analysis on room air shows a pH of 7.55 and an HCO3- concentration of 45 mEq/L. Impaired function of which of the following structures is the most likely cause of this patient's condition?\"", "answer": "Distal convoluted tubule", "options": {"A": "Ascending loop of Henle", "B": "Distal convoluted tubule", "C": "Descending loop of Henle", "D": "Collecting duct", "E": "Proximal convoluted tubule"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "month history", "fatigue", "recurrent leg cramps", "increased urinary frequency", "pulse", "min", "blood pressure", "85 mm Hg", "dry mucous membranes", "Laboratory studies", "mEq", "K", "8", "Cl", "Mg2", "Ca2", "10.6 mg", "g", "h", "24h", "N", "Arterial blood gas analysis", "room air", "pH", "7", "HCO3", "concentration", "mEq/L", "Impaired function", "following structures", "most likely cause", "patient", "ondition?"]}
{"question": "A 66-year-old male presents to the emergency room with shortness of breath with exertion and at rest for the past 5 days. His shortness of breath is mostly at night, and he is also concerned about bilateral leg swelling. He is a heart failure patient who is being managed with oral medication and has been compliant with his drugs. Physical examination reveals an elderly man in respiratory distress with abdominal distention and bilateral pitting ankle edema. Respiratory rate is 32/min, SpO2 is 93% in room air, and coarse crepitations are heard on both lung bases. Pulse rate is 73/min and barely palpable. His blood pressure is 79/54 mm Hg. On auscultation, a blowing holosystolic murmur is heard at the apex radiating to the left axilla. An echocardiography shows an ejection fraction of 18%. The physician decides to include an inotropic agent in his current medication. What would likely result from this intervention?", "answer": "A decrease in the interval between the heart sounds S1 and S2", "options": {"A": "A decrease in the systemic vascular resistance", "B": "A decrease in the interval between the heart sounds S1 and S2", "C": "An increase in the left ventricular end-systolic volume", "D": "A decrease in the interval between the heart sounds S2 and S1", "E": "A decrease in the left ventricular end-diastolic pressure"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["66 year old male presents", "emergency room", "shortness of breath", "exertion", "past", "days", "shortness of breath", "mostly", "night", "bilateral leg swelling", "heart patient", "oral medication", "compliant", "drugs", "reveals", "elderly man", "respiratory distress", "abdominal distention", "bilateral pitting ankle edema", "Respiratory rate", "min", "room air", "coarse crepitations", "heard", "lung bases", "Pulse rate", "min", "palpable", "blood pressure", "54 mm Hg", "auscultation", "blowing holosystolic murmur", "heard", "apex radiating", "left axilla", "echocardiography", "ejection fraction", "physician", "to include", "inotropic agent", "current medication", "likely result", "intervention"]}
{"question": "A geriatric investigator is evaluating the consistency of Alzheimer dementia diagnoses based on clinical symptoms. Patients with known chart diagnoses of Alzheimer dementia were evaluated by multiple physicians during a fixed time interval. Each evaluator was blinded to the others' assessments. The extent to which the diagnosis by one physician was replicated by another clinician examining the same patient is best described by which of the following terms?", "answer": "Precision", "options": {"A": "Validity", "B": "Specificity", "C": "Predictive value", "D": "Precision", "E": "Sensitivity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["geriatric investigator", "consistency", "Alzheimer dementia diagnoses based", "clinical symptoms", "Patients", "known chart diagnoses", "Alzheimer dementia", "multiple physicians", "fixed time interval", "evaluator", "others", "extent", "diagnosis", "one physician", "replicated", "clinician examining", "same patient", "best", "following terms"]}
{"question": "A 19-year-old woman presents with irregular menstrual cycles for the past 3 years and facial acne. Patient says she had menarche at the age of 11, established a regular cycle at 13, and had regular menses until the age of 16. Patient is sexually active with a single partner, and they use barrier contraception. They currently do not plan to get pregnant. There is no significant past medical history and she takes no current medications. Vitals are temperature 37.0℃ (98.6℉), blood pressure 125/85 mm Hg, pulse 69/min, respiratory rate 14/min, and oxygen saturation 99% on room air. Physical examination is significant for multiple comedones on her face. She also has hair on her upper lip, between her breasts, along with the abdominal midline, and on her forearms. There is hyperpigmentation of the axillary folds and near the nape of the neck. Laboratory tests are significant for the following:\nSodium   141 mEq/L\nPotassium   4.1 mEq/L\nChloride  101 mEq/L\nBicarbonate  25 mEq/L\nBUN  12 mg/dL\nCreatinine  1.0 mg/dL\nGlucose (fasting)   131 mg/dL \n  Bilirubin, conjugated 0.2 mg/dL\nBilirubin, total   1.0 mg/dL\nAST (SGOT)    11 U/L\nALT (SGPT)        12 U/L\nAlkaline Phosphatase 45 U/L\n  WBC  6,500/mm3\nRBC 4.80 x 106/mm3 \nHematocrit  40.5%\nHemoglobin  14.0 g/dL\nPlatelet Count   215,000/mm3\n  TSH    4.4 μU/mL   \nFSH   73 mIU/mL\nLH   210 mIU/mL\nTestosterone, total  129 ng/dL (ref: 6-86 ng/dL)\nβ-hCG  1 mIU/mL\nWhich of the following is the best course of treatment for this patient?", "answer": "Oral contraceptives", "options": {"A": "Finasteride", "B": "Oral contraceptives", "C": "Clomiphene", "D": "Goserelin", "E": "Letrozole"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "irregular menstrual cycles", "past", "years", "facial acne", "Patient", "menarche at", "age", "established", "regular cycle", "regular menses", "age", "16", "Patient", "sexually active", "use barrier contraception", "currently", "not plan to", "pregnant", "significant past medical history", "current medications", "temperature", "0", "98", "blood pressure", "85 mm Hg", "pulse 69 min", "respiratory rate", "min", "oxygen saturation 99", "room air", "significant", "multiple comedones", "face", "hair", "upper lip", "breasts", "abdominal midline", "forearms", "hyperpigmentation", "axillary folds", "nape", "neck", "Laboratory tests", "significant", "following", "Sodium", "mEq", "Potassium", "Chloride", "Bicarbonate", "mg", "Creatinine", "Glucose", "fasting", "mg/dL", "Bilirubin", "conjugated 0.2 mg/dL Bilirubin", "total", "0 mg/dL AST", "U/L ALT", "12 U Alkaline Phosphatase", "U", "WBC", "6 500 mm3 RBC", "80", "Hematocrit", "40 5", "Hemoglobin", "0 g dL Platelet Count", "215", "mL", "mIU mL LH", "Testosterone", "total", "ng/dL", "ref", "ng/dL", "hCG", "1 mIU/mL", "following", "best course", "treatment", "patient"]}
{"question": "A 41-year-old man presents to the office with pain in his right big toe. The pain started yesterday and has been progressively getting worse to the point that it is difficult to walk. He describes his right big toe as being swollen and hot to the touch. He has never had symptoms like this before. He drinks 3 beers per night. Medical history is otherwise significant for chronic kidney disease. Physical examination is notable for an overweight gentleman in moderate pain, with an erythematous, swollen and tender right toe. He is afebrile. A joint fluid analysis in this patient is most likely to show what?", "answer": "Negatively birefringent crystals", "options": {"A": "Gram negative diplococci", "B": "Negatively birefringent crystals", "C": "Positively birefringent crystals", "D": "Glucose < 40 mg/dL", "E": "Normal"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "office", "pain", "right", "pain started", "getting worse", "point", "difficult to", "right big toe", "swollen", "hot", "touch", "never", "symptoms", "3", "night", "Medical history", "significant", "chronic kidney disease", "notable", "overweight", "moderate pain", "erythematous", "swollen", "tender right toe", "afebrile", "joint fluid analysis", "patient", "to"]}
{"question": "A 56-year-old man comes to the clinic complaining of intermittent abdominal pain for the past 2 months. He reports that the pain improves with oral intake and is concentrated at the epigastric area. The pain is described as gnawing in quality and improves when he takes his wife’s ranitidine. He denies weight changes, fever, chest pain, or recent travel but endorses “brain fog” and decreased libido. An upper endoscopy reveals ulcerations at the duodenum and jejunum. Physical examination demonstrates bilateral hemianopsia, gynecomastia, and diffuse pain upon palpation at the epigastric area. Laboratory findings are demonstrated below:\n\nSerum:\nNa+: 137 mEq/dL\nCl-: 96 mEq/L\nK+: 3.9 mEq/dL\nHCO3-: 25 mEq/L\nGlucose: 110 mg/dL\nCreatinine: .7 mg/dL\nCa2+: 13.5 mg/dL\n\nWhat is the best explanation for this patient’s findings?", "answer": "Mutation of the MEN1 gene", "options": {"A": "Gastrin secreting tumor of the pancreas", "B": "Infection with Helicobacter pylori", "C": "Mutation of the APC gene", "D": "Mutation of the MEN1 gene", "E": "Mutation of the RET gene"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "clinic", "intermittent abdominal pain", "past", "months", "reports", "pain improves", "oral intake", "concentrated", "epigastric area", "pain", "gnawing", "quality", "improves", "ranitidine", "weight changes", "fever", "chest pain", "recent", "brain", "decreased libido", "upper endoscopy reveals ulcerations", "duodenum", "jejunum", "bilateral hemianopsia", "gynecomastia", "diffuse pain", "palpation", "epigastric area", "Laboratory findings", "Serum", "Na", "mEq/dL", "96 mEq/L K", "3.9 mEq/dL HCO3", "mEq/L Glucose", "mg/dL Creatinine", "mg/dL Ca2", "mg/dL", "best explanation", "patients findings"]}
{"question": "A 2980-g (6.6-lb) female newborn is brought to the emergency department by her mother because of worsening lethargy. The newborn was delivered at home 10 hours ago. The mother has had no prenatal care. The newborn's temperature is 39.7°C (103.5°F). Physical examination shows scleral icterus. Her leukocyte count is 36,000/mm3 (85% segmented neutrophils). An organism is isolated from the blood. When grown together on sheep agar, the isolated organism enlarges the area of clear hemolysis formed by Staphylococcus aureus. Which of the following is the most likely causal organism?", "answer": "Streptococcus agalactiae", "options": {"A": "Pseudomonas aeruginosa", "B": "Listeria monocytogenes", "C": "Streptococcus pyogenes", "D": "Streptocccus pneumoniae", "E": "Streptococcus agalactiae"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["female newborn", "brought", "emergency department", "worsening lethargy", "newborn", "delivered at home 10 hours", "newborn's temperature", "scleral icterus", "leukocyte count", "36", "mm3", "85", "segmented neutrophils", "isolated", "blood", "together", "agar", "isolated", "area", "clear hemolysis formed", "Staphylococcus aureus", "following", "causal"]}
{"question": "A 75-year-old man is brought to the emergency room after being found unconscious in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?", "answer": "Basilar artery", "options": {"A": "Anterior cerebral artery", "B": "Anterior spinal artery", "C": "Anterior inferior cerebellar artery", "D": "Basilar artery", "E": "Posterior cerebral artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["75 year old man", "brought", "emergency room", "found unconscious", "home", "medical history", "unknown", "not", "spontaneous movement", "extremities", "unable to", "to voice", "painful", "able blink", "move", "eyes", "vertical plane", "Based", "physical exam findings", "magnetic resonance angiogram", "most likely reveal", "occlusion", "following vessels"]}
{"question": "A 48-year-old man presents to an urgent care center with epigastric discomfort following meals and an occasional dry cough worse in the morning, both of which have increased in frequency over the past several months. He is otherwise healthy and has no additional complaints. Past medical history is significant for major depressive disorder, anxiety, and hypothyroidism. Physical examination is unremarkable. His vital signs include temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Given the following options, what is the most appropriate next step in patient management?", "answer": "Lifestyle modifications", "options": {"A": "Electrocardiography (ECG)", "B": "Lifestyle modifications", "C": "Begin omeprazole therapy", "D": "Esophagogastroduodenoscopy (EGD) with esophageal biopsy", "E": "Fluoroscopic barium swallow"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old man presents", "urgent care center", "epigastric discomfort following meals", "occasional dry cough worse", "morning", "increased", "frequency", "past", "months", "healthy", "additional complaints", "Past medical history", "significant", "major depressive disorder", "anxiety", "hypothyroidism", "unremarkable", "vital signs include temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 74 min", "respiratory rate", "min", "Given", "following options", "most appropriate next step", "patient"]}
{"question": "A 26-year-old gravida 3 para 1 is admitted to labor and delivery with uterine contractions. She is at 37 weeks gestation with no primary care provider or prenatal care. She gives birth to a boy after an uncomplicated vaginal delivery with APGAR scores of 7 at 1 minute and 8 at 5 minutes. His weight is 2.2 kg (4.4 lb) and the length is 48 cm (1.6 ft). The infant has weak extremities and poor reflexes. The physical examination reveals microcephaly, palpebral fissures, thin lips, and a smooth philtrum. A systolic murmur is heard on auscultation. Identification of which of the following factors early in the pregnancy could prevent this condition?", "answer": "Alcohol consumption", "options": {"A": "Phenytoin usage", "B": "Alcohol consumption", "C": "Maternal toxoplasmosis", "D": "Physical abuse", "E": "Maternal hypothyroidism"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old gravida 3 para 1", "to labor", "delivery", "uterine contractions", "weeks gestation", "primary care provider", "gives birth", "boy", "uncomplicated vaginal delivery", "APGAR scores", "at 1 minute", "5 minutes", "weight", "2.2 kg", "4.4", "length", "48", "1.6 ft", "infant", "weak extremities", "poor reflexes", "reveals microcephaly", "palpebral fissures", "thin lips", "smooth philtrum", "systolic murmur", "heard", "auscultation", "Identification", "following factors early", "pregnancy", "prevent", "condition"]}
{"question": "A 4-year-old boy is brought to the physician because of a rash and difficulty swallowing. His family emigrated from Nigeria 2 months ago. Examination shows an erythematous rash with fine yellow scales on his eyebrows and nasolabial folds. Oral examination shows an erythematous throat and swollen tongue. There is peeling and fissures of the skin at the corners of the mouth and cracking of the lips. His hemoglobin concentration is 9.6 g/dL; mean corpuscular volume is 89 μm3. Erythrocyte glutathione reductase assay shows an increased activity coefficient. This patient is most likely deficient in a vitamin that is a precursor to which of the following molecules?", "answer": "Flavin adenine dinucleotide", "options": {"A": "Thiamine pyrophosphate", "B": "Flavin adenine dinucleotide", "C": "Nicotinamide adenine dinucleotide", "D": "Methylcobalamin", "E": "Pyridoxal phosphate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "physician", "rash", "difficulty swallowing", "Nigeria", "months", "erythematous rash", "fine yellow scales", "eyebrows", "nasolabial folds", "erythematous throat", "swollen tongue", "peeling", "fissures of", "skin", "corners of", "mouth", "cracking", "lips", "hemoglobin concentration", "g/dL", "mean corpuscular volume", "m3", "increased activity coefficient", "patient", "deficient", "a vitamin", "following"]}
{"question": "A 16-year-old girl presents with primary amenorrhea. On exam, you note that she is short and has a shield chest. You order abdominal imaging, which suggests the presence of streak gonads.\n\nOf the choices listed below, which of the following karyotypes is possible in this patient?\n\nI: 45, XO\nII: 45XO/46XX mosaicism\nIII: 46XX with partial deletion", "answer": "I, II, and III", "options": {"A": "I only", "B": "I and II", "C": "I and III", "D": "I, II, and III", "E": "II and III"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "primary amenorrhea", "exam", "note", "short", "shield chest", "order abdominal imaging", "presence", "streak gonads", "following karyotypes", "possible", "patient", "I", "XO II", "46XX mosaicism III", "46XX", "partial deletion"]}
{"question": "A 62-year-old man seeks evaluation at an outpatient clinic for a single, red, crusty lesion on the shaft of his penis and a similar lesion on the middle finger of his left hand. He recently immigrated to the US from Africa. The lesions are painless and the physicians in his country treated him for syphilis and eczema, with no improvement. He lives with his 4th wife. He smokes 2 packs of cigarette per day and has been doing so for the last 30 years. He is not aware of any family members with malignancies or hereditary diseases. The physical examination is remarkable for an erythematous plaque, with areas of crusting, oozing, and irregular borders on the dorsal surface of the penile shaft and a similar lesion on his left middle finger (shown in the picture). The regional lymph nodes are not affected. A biopsy is obtained and the pathologic evaluation reveals cells with nuclear hyperchromasia, multinucleation, and increased mitotic figures within the follicle-bearing epithelium. What is the most likely diagnosis?", "answer": "Bowen's disease", "options": {"A": "Condyloma acuminata", "B": "Bowenoid papulosis", "C": "Lichen sclerosus", "D": "Bowen's disease", "E": "Erythroplasia of Queyrat"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man", "outpatient clinic", "single", "red", "crusty lesion", "shaft", "penis", "similar lesion", "middle finger of", "left hand", "recently", "Africa", "lesions", "painless", "physicians", "country treated", "syphilis", "eczema", "lives with", "4th wife", "smokes 2 packs", "cigarette", "day", "so", "30 years", "not", "malignancies", "hereditary diseases", "erythematous plaque", "areas", "crusting", "irregular borders", "dorsal surface of", "penile shaft", "similar lesion", "left middle finger", "picture", "regional lymph nodes", "not affected", "biopsy", "obtained", "pathologic evaluation reveals cells", "nuclear hyperchromasia", "multinucleation", "increased mitotic figures", "follicle bearing epithelium", "diagnosis"]}
{"question": "A 36-year-old male suffered a gun-shot wound to the abdomen that required an emergent exploratory laparotomy to repair and resect damaged portions of the bowel. Four days later, the patient reports increased generalized abdominal pain. His vital signs are as follows: T 38.5, HR 110, BP 110/60, RR 18, SpO2 96%. Physical exam reveals extreme tenderness to palpation of the abdomen as well as rebound tenderness, worse in the bilateral lower quadrants. The abdomen is mildly distended with guarding and decreased bowel sounds. The surgical and bullet-entrance wounds appear intact without any evidence of leakage/drainage, erythema, or warmth. Initial lab-work shows an elevated white blood cell count of 17.1 x 10^9 cells/L. A CT scan of the abdomen shows a 4 cm abscess in the left lower quadrant. Which of the following organisms is the most likely cause of this patient's current presentation?", "answer": "Bacteroides fragilis", "options": {"A": "Pseudomonas aeruginosa", "B": "Salmonella enteritidis", "C": "Bacteroides fragilis", "D": "Enterococcus species", "E": "Streptococcus bovis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["36 year old male suffered", "gun-shot", "abdomen", "required", "exploratory laparotomy to repair", "resect damaged portions", "bowel", "Four days later", "increased generalized abdominal pain", "vital signs", "follows", "T", "BP", "60", "RR", "96", "reveals extreme tenderness", "palpation of", "abdomen", "rebound tenderness", "worse", "bilateral lower quadrants", "abdomen", "mildly distended", "guarding", "decreased bowel sounds", "surgical", "bullet entrance wounds appear intact", "leakage drainage", "erythema", "warmth", "Initial lab", "elevated white blood cell count", "CT scan", "abdomen", "4", "abscess", "left lower quadrant", "following", "most likely cause", "patient's current"]}
{"question": "A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with \"You're not the boss of me.\" or \"You can't make me.\" He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can \"sometimes be difficult,\" but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?", "answer": "Oppositional defiant disorder", "options": {"A": "Conduct disorder", "B": "Oppositional defiant disorder", "C": "Antisocial personality disorder", "D": "Attention deficit disorder", "E": "Separation anxiety disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["teacher", "called to", "behavior", "year old boy", "boy", "eacher,", "isruptive ", "o  elp  lean up ", "ut- oud,", "t t", "ss o", "e me", "pa", "y th", "e ga", "s al", "l-li", "orts th", "etimes be", "ficult,\" ", "pful ar", "se an", "y good pl ying wi", "r-ol  si", "gnosis?"]}
{"question": "A 51-year-old African American man presents to his primary care physician’s office for an annual visit. He has no major concerns and says that he has been healthy for the last year. His past medical history is significant for diabetes as well as long standing hypertension that has developed gradually since his 30's; however, he has refused to take any medications. Physical exam shows no abnormal findings. Routine laboratory testing reveals the following:\n\nSerum creatinine concentration: 1.5 mg/dL\nBlood urea nitrogen: 31 mg/dL\n\nBased on these results, urine studies are conducted that reveal mild proteinuria of less than 1 g/day and no casts.\n\nWhich of the following is most likely associated with the cause of this patient's elevated creatinine?", "answer": "Cobblestone kidney", "options": {"A": "Apple-green birefringent lesions", "B": "Cobblestone kidney", "C": "Kimmelstiel-Wilson lesions", "D": "Renal cortex necrosis", "E": "String of beads on angiography"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "man presents", "primary care physicians office", "annual", "major", "healthy", "year", "past medical history", "significant", "diabetes", "long standing hypertension", "30's", "to", "medications", "abnormal findings", "Routine laboratory testing reveals", "following", "Serum concentration", "1.5 mg/dL Blood urea nitrogen", "31 mg/dL", "Based", "results", "urine studies", "reveal mild proteinuria", "1 g", "casts", "following", "most likely associated with", "cause", "patient's elevated creatinine"]}
{"question": "A 38-year-old woman comes to the physician because of an 8-week history of shortness of breath and dull chest pain. She has a history of antiphospholipid syndrome. Physical examination shows jugular venous distention. Right heart catheterization shows a mean pulmonary arterial pressure of 30 mm Hg and a pulmonary capillary wedge pressure of 10 mm Hg. Further evaluation is most likely to show which of the following?", "answer": "Dilation of the coronary sinus", "options": {"A": "Constriction of the renal afferent arteriole", "B": "Dilation of the coronary sinus", "C": "Decreased left ventricular contractility", "D": "Mitral valve leaflet thickening", "E": "Hemosiderin-laden macrophages\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "week history", "shortness", "breath", "dull chest pain", "history", "antiphospholipid syndrome", "Physical examination", "jugular venous distention", "Right heart catheterization", "mean pulmonary arterial pressure", "30 mm Hg", "pulmonary capillary wedge pressure", "10 mm Hg", "Further", "to", "following"]}
{"question": "A neonate born at 33 weeks is transferred to the NICU after a complicated pregnancy and C-section. A week after being admitted, he developed a fever and become lethargic and minimally responsive to stimuli. A lumbar puncture is performed that reveals the following:\nAppearance  Cloudy\nProtein 64 mg/dL\nGlucose 22 mg/dL\nPressure 330 mm H20\nCells 295 cells/mm³ (> 90% PMN)\nA specimen is sent to microbiology and reveals gram-negative rods. Which of the following is the next appropriate step in management?", "answer": "Start the patient on IV cefotaxime", "options": {"A": "Provide supportive measures only", "B": "MRI scan of the head", "C": "Start the patient on IV ceftriaxone", "D": "Start the patient on IV cefotaxime", "E": "Start the patient on oral rifampin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["neonate born", "weeks", "transferred", "NICU", "complicated pregnancy", "C-section", "week", "fever", "lethargic", "responsive", "lumbar puncture", "performed", "reveals", "following", "Appearance", "Cloudy Protein 64 mg Glucose", "dL Pressure 330 mm", "Cells", "90", "PMN", "sent", "microbiology", "reveals", "following", "next appropriate step"]}
{"question": "A 19-year-old woman presents to the dermatology clinic for a follow-up of worsening acne. She has previously tried topical tretinoin as well as topical and oral antibiotics with no improvement. She recently moved to the area for college and says the acne has caused significant emotional distress when it comes to making new friends. She has no significant past medical or surgical history. Family and social history are also noncontributory. The patient’s blood pressure is 118/77 mm Hg, the pulse is 76/min, the respiratory rate is 17/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals erythematous skin lesions including both open and closed comedones with inflammatory lesions overlying her face, neck, and upper back. The patient asks about oral isotretinoin. Which of the following is the most important step in counseling this patient prior to prescribing oral isotretinoin?", "answer": "Document 2 negative urine or blood pregnancy tests before beginning oral isotretinoin", "options": {"A": "Avoid direct sunlight, from 10am to 2pm", "B": "Wear a wide-brimmed hat outdoors", "C": "Use non-comedogenic sunscreen daily with SPF of at least 45", "D": "Document 2 negative urine or blood pregnancy tests before beginning oral isotretinoin", "E": "Apply topical retinoids in the evening before bed"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "dermatology clinic", "follow-up", "worsening acne", "topical", "oral", "recently moved to", "area", "college", "acne", "caused significant emotional distress", "making new", "significant past medical", "surgical history", "social history", "patients blood pressure", "mm Hg", "pulse", "76 min", "respiratory rate", "min", "temperature", "36", "97 9F", "reveals erythematous skin lesions including", "open", "closed comedones", "inflammatory lesions", "face", "neck", "upper back", "patient", "oral isotretinoin", "following", "most important step", "counseling", "patient prior to", "oral isotretinoin"]}
{"question": "A 65-year-old man comes to the physician for a routine examination. He feels well. His pulse is 80/min and blood pressure is 140/85 mm Hg. Cardiac examination shows a holosystolic murmur in the 4th intercostal space along the left sternal border that gets louder during inspiration. The increase of this patient's murmur is best explained by which of the following hemodynamic changes?", "answer": "Increased right ventricular stroke volume", "options": {"A": "Increased peripheral vascular resistance", "B": "Increased right ventricular stroke volume", "C": "Decreased pulmonary vessel capacity", "D": "Decreased left ventricular venous return", "E": "Increased systemic venous compliance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old man", "physician", "routine", "well", "pulse", "80 min", "blood pressure", "85 mm Hg", "holosystolic murmur", "4th intercostal space", "left sternal border", "gets louder", "inspiration", "increase", "patient's murmur", "best", "following hemodynamic changes"]}
{"question": "A 4-year-old boy presents with a dry cough. The patient’s mother states that the cough started a week ago and has not improved. She says the patient will have fits of forceful coughing that will last for minutes, followed by gasping as he catches his breath. Occasionally, the patient will vomit after one of these episodes. Past medical history is significant for a recent upper respiratory infection 4 weeks ago that has resolved. No current medications. Patient immunization status is incomplete because his mother believes they are harmful. Vitals are temperature 37.0°C (98.6°F), blood pressure 105/65 mm Hg, pulse 101/min, respiratory rate 27/min, and oxygen saturation 99% on room air. Cardiac exam is normal. Lungs are clear to auscultation. There are conjunctival hemorrhages present bilaterally. Which of the following correctly describes the stage of this patient’s most likely diagnosis?", "answer": "Paroxysmal stage", "options": {"A": "Catarrhal stage", "B": "Paroxysmal stage", "C": "Convalescent stage", "D": "Intermittent stage", "E": "Persistent stage"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 year old boy presents", "dry cough", "patients", "states", "cough started", "week", "not improved", "patient", "fits of", "coughing", "last", "minutes", "followed by gasping", "catches", "breath", "Occasionally", "patient", "vomit", "one of", "episodes", "Past medical history", "significant", "recent upper respiratory infection", "weeks", "resolved", "current medications", "Patient immunization", "incomplete", "temperature", "98", "blood pressure", "65 mm Hg", "pulse", "min", "respiratory rate 27 min", "oxygen saturation 99", "room air", "normal", "Lungs", "clear", "auscultation", "conjunctival hemorrhages present", "following", "stage", "patients", "likely diagnosis"]}
{"question": "A 28-year-old primigravid woman is brought to the emergency department after complaining of severe abdominal pain for 3 hours. She has had no prenatal care. There is no leakage of amniotic fluid. Since arrival, she has had 5 contractions in 10 minutes, each lasting 70 to 90 seconds. Pelvic examination shows a closed cervix and a uterus consistent in size with a 38-week gestation. Ultrasound shows a single live intrauterine fetus in a breech presentation consistent with a gestational age of approximately 37 weeks. The amniotic fluid index is 26 and the fetal heart rate is 92/min. The placenta is not detached. She is scheduled for an emergency lower segment transverse cesarean section because of a nonreassuring fetal heart rate. The infant is delivered and APGAR score is noted to be 8 at 1 minute. The doctor soon notices cyanosis of the lips and oral mucosa, which does not resolve when the infant cries. The infant is foaming at the mouth and drooling. He also has an intractable cough. Which of the following is the most likely diagnosis?", "answer": "Esophageal atresia", "options": {"A": "Esophageal atresia", "B": "Esophageal stricture", "C": "Achalasia", "D": "Pulmonary hypoplasia", "E": "Defective swallowing reflex"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old primigravid woman", "brought", "emergency department", "severe abdominal", "3 hours", "leakage of amniotic fluid", "arrival", "5 contractions", "10 minutes", "lasting 70 to 90 seconds", "Pelvic examination", "closed cervix", "uterus", "size", "week gestation", "Ultrasound", "single live intrauterine fetus", "breech presentation", "gestational age of approximately", "weeks", "fetal heart rate", "min", "placenta", "not detached", "scheduled", "emergency lower segment transverse cesarean", "fetal heart rate", "infant", "delivered", "APGAR score", "noted to", "8", "1 minute", "doctor", "cyanosis", "lips", "oral mucosa", "not", "infant cries", "infant", "foaming at", "mouth", "drooling", "intractable cough", "following", "diagnosis"]}
{"question": "A 16 year-old female is being evaluated for shortness of breath. For the last year she has had shortness of breath and subjective wheezing with exercise and intermittent coughing at night. She reports waking up from sleep coughing 1-2 times per month. She now skips gym class because of her symptoms. She denies any coughing, chest tightness, or shortness of breath on the day of her visit. On exam, her lungs are clear to auscultation bilaterally, with normal inspiratory to expiratory duration ratio. Her pulmonary function tests (PFTs) show normal FEV1 and FVC based on her age, gender, and height. She is told to inhale a medication, and her PFTs are repeated, now showing a FEV1 79% of her previous reading. The patient is diagnosed with asthma. Which of the following medications was used to diagnose the patient?", "answer": "Methacholine", "options": {"A": "Methacholine", "B": "Pilocarpine", "C": "Bethanechol", "D": "Carbachol", "E": "Physostigmine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "shortness of breath", "last year", "shortness of breath", "subjective wheezing", "exercise", "intermittent coughing", "night", "reports waking", "sleep coughing 1-2 times per month", "now skips", "symptoms", "coughing", "chest tightness", "shortness of breath", "day", "visit", "exam", "lungs", "clear", "auscultation", "normal inspiratory", "expiratory duration ratio", "pulmonary function tests", "normal FEV1", "FVC based", "age", "gender", "height", "to inhale", "medication", "PFTs", "repeated", "now", "FEV1", "previous", "patient", "diagnosed", "asthma", "following medications", "used to diagnose", "patient"]}
{"question": "A 36-year-old man is admitted to the hospital for treatment of burn wounds on his upper extremities. Analgesic therapy with an opioid drug is begun. Shortly after, the patient develops chills, diaphoresis, nausea, and abdominal pain. On further questioning, the patient reports that he has been smoking opium at home to help him \"\"deal with the depression and pain.” This patient was most likely given which of the following opioid drugs?\"", "answer": "Butorphanol", "options": {"A": "Morphine", "B": "Hydrocodone", "C": "Fentanyl", "D": "Oxycodone", "E": "Butorphanol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["36 year old man", "treatment of burn wounds", "upper extremities", "Analgesic", "opioid", "begun", "patient", "chills", "diaphoresis", "nausea", "abdominal pain", "further", "patient reports", "smoking opium at home to help", "depression", "pain", "patient", "most likely given", "following opioid drugs"]}
{"question": "A 55-year-old man comes to the physician because of heartburn for the past 2 years. He has no chest pain, dysphagia, weight loss, or fever. He has no history of any serious illnesses. He takes omeprazole daily. Vital signs are within normal limits. Body mass index (BMI) is 34 kg/m2. Physical exam shows no abnormalities. An endoscopic image of the lower esophageal sphincter is shown. Which of the following is the most important next step in management?", "answer": "Multiple endoscopic biopsies", "options": {"A": "Endoscopic mucosal ablation therapy", "B": "Esophagectomy", "C": "High-dose pantoprazole", "D": "Laparoscopic Nissen fundoplication", "E": "Multiple endoscopic biopsies"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of heartburn", "past", "years", "chest pain", "dysphagia", "weight loss", "fever", "history", "serious illnesses", "omeprazole daily", "Vital signs", "normal limits", "Body mass index", "kg/m2", "abnormalities", "endoscopic", "lower esophageal sphincter", "following", "most important next step"]}
{"question": "A 25-year-old male is brought into the emergency department by emergency medical services. The patient has a history of bipolar disease complicated by polysubstance use. He was found down in his apartment at the bottom of a staircase lying on his left arm. He was last seen several hours earlier by his roommate. He is disoriented and unable to answer any questions, but is breathing on his own. His vitals are HR 55, T 96.5, RR 18, BP 110/75. You decide to obtain an EKG as shown in Figure 1. What is the next best step in the treatment of this patient?", "answer": "Calcium gluconate", "options": {"A": "Intubation", "B": "Epinephrine", "C": "Albuterol", "D": "Insulin", "E": "Calcium gluconate"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old male", "brought", "emergency department", "patient", "history of bipolar disease complicated", "polysubstance use", "found", "apartment", "bottom of", "staircase lying", "left arm", "last seen several hours earlier", "disoriented", "unable to", "breathing", "T 96.5", "RR", "BP", "75", "to obtain", "EKG", "next best step"]}
{"question": "A 22-year-old woman is brought to the emergency department because of a 1-day history of double vision and rapidly worsening pain and swelling of her right eye. She had an upper respiratory tract infection a week ago after which she has had nasal congestion, recurrent headaches, and a purulent nasal discharge. She took antibiotics for her respiratory tract infection but did not complete the course. She has asthma treated with theophylline and inhaled β-adrenergic agonists and corticosteroids. She appears to be in severe distress. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Ophthalmic examination of the right eye shows proptosis and diffuse edema, erythema, and tenderness of the eyelids. Right eye movements are restricted and painful in all directions. The pupils are equal and reactive to light. There is tenderness to palpation over the right cheek and purulent nasal discharge in the right nasal cavity. The left eye shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Which of the following provides the strongest indication for administering intravenous antibiotics to this patient?", "answer": "Pain with eye movements", "options": {"A": "Worsening of ocular pain", "B": "Leukocytosis", "C": "Pain with eye movements", "D": "Purulent nasal discharge and right cheek tenderness", "E": "Fever\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "1-day history", "double vision", "rapidly worsening pain", "swelling of", "right eye", "upper respiratory tract infection", "week", "nasal congestion", "recurrent headaches", "purulent nasal discharge", "respiratory tract infection", "not complete", "course", "asthma treated with theophylline", "inhaled", "adrenergic agonists", "corticosteroids", "appears to", "severe distress", "temperature", "pulse", "100 min", "blood pressure", "80 mm Hg", "Ophthalmic examination of", "right eye", "proptosis", "diffuse edema", "erythema", "tenderness of", "eyelids", "Right eye movements", "restricted", "painful", "directions", "pupils", "equal", "reactive to light", "tenderness", "palpation", "right cheek", "purulent discharge", "right", "cavity", "left eye", "abnormalities", "Laboratory studies", "leukocyte count", "mm3", "following", "strongest", "administering intravenous", "patient"]}
{"question": "A 55-year-old man with a 60 pack-year smoking history is referred by his primary care physician for a pulmonary function test (PFT). A previously obtained chest x-ray is shown below. Which of the following will most likely appear in his PFT report?", "answer": "Residual volume increased, total lung capacity increased", "options": {"A": "Residual volume increased, total lung capacity decreased", "B": "Residual volume increased, total lung capacity increased", "C": "Residual volume decreased, total lung capacity increased", "D": "Residual volume normal, total lung capacity normal", "E": "Residual volume normal, total lung capacity decreased"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "60", "smoking history", "referred by", "primary care physician", "pulmonary function test", "obtained chest x-ray", "following", "most likely appear", "PFT"]}
{"question": "Fourteen days after a laparoscopic cholecystectomy for cholelithiasis, a 45-year-old woman comes to the emergency department because of persistent episodic epigastric pain for 3 days. The pain radiates to her back, occurs randomly throughout the day, and is associated with nausea and vomiting. Each episode lasts 30 minutes to one hour. Antacids do not improve her symptoms. She has hypertension and fibromyalgia. She has smoked 1–2 packs of cigarettes daily for the past 10 years and drinks 4 cans of beer every week. She takes lisinopril and pregabalin. She appears uncomfortable. Her temperature is 37°C (98.6° F), pulse is 84/min, respirations are 14/min, and blood pressure is 127/85 mm Hg. Abdominal examination shows tenderness to palpation in the upper quadrants without rebound or guarding. Bowel sounds are normal. The incisions are clean, dry, and intact. Serum studies show:\nAST 80 U/L\nALT 95 U/L\nAlkaline phosphatase 213 U/L\nBilirubin, total 1.3 mg/dL\nDirect 0.7 mg/dL\nAmylase 52 U/L\nAbdominal ultrasonography shows dilation of the common bile duct and no gallstones. Which of the following is the most appropriate next step in management?\"", "answer": "Endoscopic retrograde cholangiopancreatography", "options": {"A": "Counseling on alcohol cessation", "B": "Endoscopic retrograde cholangiopancreatography", "C": "Proton pump inhibitor therapy", "D": "Reassurance and follow-up in 4 weeks", "E": "CT scan of the abdomen"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Fourteen days", "laparoscopic cholecystectomy", "cholelithiasis", "year old woman", "emergency department", "of persistent episodic epigastric", "3 days", "pain radiates", "back", "occurs", "day", "associated with nausea", "vomiting", "episode", "30 minutes", "one hour", "Antacids", "not", "symptoms", "hypertension", "fibromyalgia", "smoked", "packs", "cigarettes daily", "past", "4 cans", "week", "lisinopril", "pregabalin", "appears", "temperature", "98", "F", "pulse", "84 min", "respirations", "min", "blood pressure", "85 mm Hg", "Abdominal", "tenderness", "palpation", "upper quadrants", "guarding", "Bowel sounds", "normal", "incisions", "dry", "intact", "Serum studies", "AST 80 U/L ALT 95", "Alkaline phosphatase", "Bilirubin", "total", "mg/dL Direct 0.7 mg/dL Amylase", "U/L Abdominal ultrasonography", "dilation", "common bile duct", "gallstones", "following", "most appropriate next step"]}
{"question": "A 53-year-old woman presents to the office complaining of an extreme, nonradiating stabbing pain in the epigastric region after having a meal. She states that it has happened several times in the past week approximately 30 minutes after eating and spontaneously resolves. A day before, the patient went to urgent care with the same complaint, but the abdominal X-ray was normal. Surgical history is remarkable for a total knee arthroplasty procedure 6 months ago. She has lost 34 kg (75 lb) since the operation because of lifestyle changes. The vital signs are normal. Laparoscopic surgical scars are well healed. Endoscopy shows benign mucosa to the proximal duodenum. A barium swallow study reveals an extremely narrowed duodenum. Which of the following structures is most likely responsible for this patient’s current symptoms?", "answer": "Superior mesenteric artery", "options": {"A": "Superior mesenteric artery", "B": "Pylorus of the stomach", "C": "Gastroduodenal artery", "D": "Gallbladder", "E": "Inferior mesenteric artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "office", "extreme", "stabbing pain", "epigastric region", "states", "times", "past approximately 30 minutes", "eating", "day", "patient", "urgent care", "same complaint", "abdominal X-ray", "normal", "Surgical history", "total knee arthroplasty procedure", "months", "lost", "kg", "75", "operation", "vital signs", "normal", "Laparoscopic surgical scars", "well healed", "Endoscopy", "benign mucosa", "proximal duodenum", "barium swallow study reveals", "extremely narrowed duodenum", "following structures", "responsible", "patients current symptoms"]}
{"question": "A 36-year-old man is seen in the emergency department for back pain that has been getting progressively worse over the last 4 days. Upon further questioning, he also notes that he has been having a tingling and burning sensation rising up from his feet to his knees bilaterally. The patient states he is having difficulty urinating and having bowel movements over the last several days. His temperature is 97.4°F (36.3°C), blood pressure is 122/80 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for weak leg flexion bilaterally along with decreased anal sphincter tone. Which of the following is the best next step in management?", "answer": "MRI", "options": {"A": "CT", "B": "Emergency surgery", "C": "Lumbar puncture", "D": "MRI", "E": "Pulmonary function tests"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["36 year old man", "seen in", "emergency department", "back pain", "getting", "further", "notes", "tingling", "burning sensation", "feet", "knees", "patient states", "difficulty urinating", "bowel movements", "days", "temperature", "97", "36", "blood pressure", "80 mmHg", "pulse", "85 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "weak leg flexion", "decreased anal sphincter tone", "following", "best next step"]}
{"question": "A 45-year-old man presents with a long history of ulcers on the bottom of his feet. He recalls having a similar looking ulcer on the side of his penis when he was 19 years old for which he never sought treatment. The patient denies any fever, chills, or constitutional symptoms. He reports multiple sexual partners and a very promiscuous sexual history. He has also traveled extensively as a writer since he was 19. The patient is afebrile, and his vital signs are within normal limits. A rapid plasma reagin (RPR) test is positive, and the result of a Treponema pallidum particle agglutination (TP-PA) is pending. Which of the following findings would most likely be present in this patient?", "answer": "Positive Romberg's sign", "options": {"A": "Hyperreflexia", "B": "Wide-based gait with a low step", "C": "Positive Romberg's sign", "D": "Memory loss", "E": "Agraphesthesia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "long history", "ulcers", "bottom of", "feet", "similar looking ulcer", "side of", "penis", "years old", "never", "treatment", "patient", "fever", "chills", "constitutional symptoms", "reports multiple sexual partners", "very promiscuous", "history", "writer", "patient", "afebrile", "vital signs", "normal limits", "rapid plasma reagin", "RPR", "test", "positive", "result", "particle agglutination", "following findings", "most likely", "present", "patient"]}
{"question": "A 44-year-old man presents for a checkup. The patient says he has to urinate quite frequently but denies any dysuria or pain on urination. Past medical history is significant for diabetes mellitus type 2 and hypertension, both managed medically, as well as a chronic mild cough for the past several years. Current medications are metformin, aspirin, rosuvastatin, captopril, and furosemide. His vital signs are an irregular pulse of 74/min, a respiratory rate of 14/min, a blood pressure of 130/80 mm Hg, and a temperature of 36.7°C (98.0°F). His BMI is 32 kg/m2. On physical examination, there are visible jugular pulsations present in the neck bilaterally. Laboratory findings are significant for the following:\nGlycated Hemoglobin (Hb A1c) 7.5%\n Fasting Blood Glucose 120 mg/dL\nSerum Electrolytes\nSodium 138 mEq/L\nPotassium 3.9 mEq/L\nChloride 101 mEq/L\nSerum Creatinine 1.3 mg/dL\nBlood Urea Nitrogen 18 mg/dL\nWhich of the following is the next best step in the management of this patient?", "answer": "Start exenatide.", "options": {"A": "Stop metformin.", "B": "Replace captopril with valsartan.", "C": "Start rosiglitazone.", "D": "Stop furosemide.", "E": "Start exenatide."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "checkup", "patient", "to", "frequently", "dysuria", "pain", "urination", "Past medical history", "significant", "diabetes mellitus type 2", "hypertension", "chronic mild cough", "past", "years", "Current medications", "metformin", "aspirin", "rosuvastatin", "captopril", "furosemide", "vital signs", "irregular pulse", "74 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "temperature", "36", "98", "BMI", "kg/m2", "visible", "present", "neck", "Laboratory findings", "significant", "following", "Glycated Hemoglobin", "Hb A1c", "Blood", "mg", "L", "mg", "Urea Nitrogen", "following", "next best step", "patient"]}
{"question": "A 39-year-old woman presents to the clinic with complaints of constipation for the past 2 weeks. She reports that it has been getting increasingly difficult to pass stool to the point that she would go for 2-3 days without going to the bathroom. Prior to this, she passed stool every day without difficulty. She denies weight changes, headaches, chest pain, or abdominal pain but endorses fatigue. Her past medical history is significant for 2 episodes of kidney stones within the past 3 months. A physical examination is unremarkable. Laboratory studies are done and the results are shown below:\n\nSerum:\nNa+: 138 mEq/L\nCl-: 97 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 24 mEq/L \nBUN: 10 mg/dL\nGlucose: 103 mg/dL\nCreatinine: 1.1 mg/dL\nThyroid-stimulating hormone: 3.1 uU/mL\nCa2+: 12.1 mg/dL\nPhosphate: 1.2 mg/dL (Normal: 2.5-4.5 mg/dL)\n\nWhat is the most likely explanation for this patient’s low phosphate levels?", "answer": "Inhibition of sodium-phosphate cotransporter at the proximal convoluted tubule (PCT)", "options": {"A": "Chronic renal disease caused by recurrent renal stones", "B": "Defective G-coupled calcium-sensing receptors in multiple tissues", "C": "Hereditary malfunction of phosphate absorption at the small brush border", "D": "Increase in calcium-sodium cotransporter activity at the distal convoluted tubule (DCT)", "E": "Inhibition of sodium-phosphate cotransporter at the proximal convoluted tubule (PCT)"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "clinic", "complaints", "constipation", "past 2 weeks", "reports", "getting", "difficult to pass stool", "point", "go", "3 days", "bathroom", "passed stool", "day", "difficulty", "weight changes", "headaches", "chest pain", "abdominal pain", "fatigue", "past medical history", "significant", "episodes of kidney stones", "past 3 months", "unremarkable", "Laboratory studies", "results", "Serum", "Na", "mEq/L", "97 mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "10 mg/dL Glucose", "mg/dL Creatinine", "1.1 mg/dL Thyroid-stimulating hormone", "3.1 uU/mL Ca2", "mg/dL Phosphate", "1.2 mg/dL", "Normal", "mg/dL", "explanation", "patients low"]}
{"question": "A 72-year-old man presents to the emergency department with a complaint of rectal bleeding. He describes blood mixed in with the stool, which is associated with a change in his normal bowel habit such that he is going more frequently than normal. He also has some crampy left-sided abdominal pain and weight loss. His symptoms started 2 months ago, but he thought they are due to lack of dietary fiber intake and excess consumption of red meat. He has had type 2 diabetes mellitus for 35 years for which he takes metformin. He also uses daily low-dose aspirin for cardioprotection and occasional naproxen for knee pain. His family history is irrelevant. On examination, his abdomen and digital rectal examination are normal. Colonoscopy shows an ulcerating mucosal lesion with a narrow bowel lumen and biopsy shows a moderately differentiated adenocarcinoma. Which of the following is the greatest risk factor for colorectal cancer in this patient?", "answer": "Increasing age", "options": {"A": "Lack of dietary fiber intake", "B": "Increasing age", "C": "Low-dose aspirin use", "D": "Metformin use", "E": "Naproxen use"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old man presents", "emergency department", "complaint", "rectal bleeding", "blood mixed", "stool", "associated with", "change", "normal bowel habit", "more frequently", "normal", "crampy left-sided abdominal pain", "weight loss", "symptoms started 2 months", "due to lack", "dietary fiber intake", "excess", "type 2 diabetes mellitus", "35 years", "metformin", "uses daily low-dose aspirin", "occasional naproxen", "knee pain", "family history", "abdomen", "digital rectal examination", "normal", "Colonoscopy", "ulcerating mucosal lesion", "narrow bowel lumen", "biopsy", "moderately differentiated adenocarcinoma", "following", "greatest risk factor", "colorectal cancer", "patient"]}
{"question": "A 2-year-old male presents to the emergency department for fatigue and lethargy. Upon presentation, the patient is found to be severely dehydrated. The patient's mother says that he has been having non-bloody diarrhea for a day. She also says that the patient has not received any vaccinations after 6 months and currently attends a daycare center. The responsible microbe is isolated and its structure is analyzed. Which of the following organisms is most likely responsible for the symptoms seen in this child.", "answer": "Rotavirus", "options": {"A": "Campylobacter jejuni", "B": "Salmonella", "C": "Shigella", "D": "Rotavirus", "E": "Norovirus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["2 year old male presents", "emergency department", "fatigue", "lethargy", "patient", "found to", "severely dehydrated", "patient's", "non bloody diarrhea", "day", "patient", "not received", "vaccinations", "months", "currently attends", "daycare center", "responsible", "isolated", "structure", "following", "responsible", "symptoms seen", "child"]}
{"question": "A 3-year-old boy is brought to the physician by his mother for the evaluation of delay in attaining developmental milestones. He could sit upright by 14 months and has not been able to walk without support. He can build a tower of 3 blocks and cannot use utensils to feed himself. He speaks in unclear 2-word phrases and cannot draw a circle yet. His mother has noticed him hitting his head against the wall on multiple occasions. He is at 20th percentile for height and at 50th percentile for weight. Vitals signs are within normal limits. Examination shows multiple lacerations of his lips and tongue. There are multiple healing wounds over his fingers. Neurological examination shows increased muscle tone in all extremities. Laboratory studies show:\nHemoglobin 10.1 g/dL\nMean corpuscular volume 103 μm3\nSerum\nNa+ 142 mEq/L\nCl- 101 mEq/:\nK+ 4.1 mEq/L\nCreatinine 1.6 mg/dL\nUric acid 12.3 mg/dL\nWhich of the following is the most likely cause of this patient's findings?\"", "answer": "Hypoxanthine-guanine phosphoribosyltransferase deficiency", "options": {"A": "FMR1 gene mutation", "B": "MECP2 gene mutation", "C": "Branched-chain alpha-ketoacid dehydrogenase complex deficiency", "D": "Hypoxanthine-guanine phosphoribosyltransferase deficiency", "E": "Microdeletion of paternal chromosome 15"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 year old boy", "brought", "physician", "delay", "sit upright", "months", "not", "able to", "support", "tower", "blocks", "use", "to", "speaks", "circle", "hitting", "head", "wall", "multiple occasions", "percentile", "height", "50th percentile", "weight", "signs", "normal limits", "multiple lacerations of", "lips", "tongue", "multiple healing", "fingers", "Neurological examination", "increased muscle tone", "extremities", "Laboratory studies", "Hemoglobin", "g Mean corpuscular volume", "m3 Serum", "mEq Cl", "K", "4", "mEq", "Creatinine", "mg dL Uric acid", "dL", "following", "most likely cause", "patient", "indings?"]}
{"question": "A 36-year-old man presents with the complaint of loose and watery stools for the past 3 days. He is now having bowel movements four to five times a day. He denies any blood or mucus in the stool. He also complains of abdominal pain and fatigue. Furthermore, he feels nauseous and does not feel like drinking anything. His urine is visibly yellow and low in volume. He recently returned from a trip to South America where he enjoyed all the local delicacies. He is most concerned about his urine color and volume. Which segment of the nephron is primarily responsible for these changes?", "answer": "Loop of Henle", "options": {"A": "Glomerulus", "B": "Proximal convoluted tubule", "C": "Proximal straight tubule", "D": "Loop of Henle", "E": "Distal tubule"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old man presents", "complaint", "loose", "watery stools", "past 3 days", "now", "bowel movements four", "five times", "day", "blood", "mucus in", "stool", "abdominal pain", "fatigue", "nauseous", "not", "drinking", "urine", "yellow", "low", "volume", "recently returned", "trip", "South America", "local", "most", "urine color", "volume", "segment", "nephron", "responsible", "changes"]}
{"question": "A 19-year-old male presents to the ER with generalized tonic-clonic seizures. He does not have a prior history of seizures and has not taken any drugs except for his daily asthma medication. Which of the following is associated with seizures:", "answer": "Theophylline", "options": {"A": "Albuterol", "B": "Ipratropium", "C": "Cromolyn", "D": "Theophylline", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "ER", "generalized tonic-clonic seizures", "not", "prior history", "seizures", "not", "drugs", "daily asthma medication", "following", "associated with seizures"]}
{"question": "Please refer to the summary above to answer this question\nThis patient is at greatest risk of damage to which of the following cardiovascular structures?\"\n\"Patient Information\nAge: 44 years\nGender: M, self-identified\nEthnicity: Caucasian\nSite of Care: office\nHistory\nReason for Visit/Chief Concern: “I am thirsty all the time, and it's getting worse.”\nHistory of Present Illness:\n6-month history of increased thirst\nhas had to urinate more frequently for 4 months; urinates every 3–4 hours\nfeels generally weaker and more tired than usual\nhas also had a 1-year history of joint pain in the hands\nPast Medical History:\ngastroesophageal reflux disease\ntension headaches\nSocial History:\nhas smoked one-half pack of cigarettes daily for 15 years\noccasionally drinks two or three beers on weekends\nused to be sexually active with his husband but has been losing interest in sexual activity for the past 6 months\nMedications:\npantoprazole, amitriptyline, multivitamin\nAllergies:\nno known drug allergies\nPhysical Examination\nTemp Pulse Resp BP O2 Sat Ht Wt BMI\n37.2°C\n(99.0°F)\n78/min 16/min 127/77 mm Hg –\n188 cm\n(6 ft 2 in)\n85 kg\n(187 lb)\n24 kg/m2\nAppearance: no acute distress\nHEENT: sclerae anicteric; no oropharyngeal erythema or exudate\nPulmonary: clear to auscultation\nCardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops\nAbdominal: no tenderness, guarding, masses, or bruits; the liver span is 15 cm\nPelvic: small, firm testes; no nodules or masses\nExtremities: tenderness to palpation and stiffness of the metacarpophalangeal joints of both hands\nSkin: diffusely hyperpigmented\nNeurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits\"", "answer": "Cardiac conduction system", "options": {"A": "Pulmonary valve", "B": "Cardiac septum", "C": "Coronary artery", "D": "Cardiac conduction system", "E": "Temporal artery\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["refer", "above to", "patient", "greatest", "damage", "following cardiovascular structures", "Patient Age", "years Gender", "M", "identified Ethnicity", "Site of Care", "office History Reason for Visit", "I", "thirsty", "time", "etting  orse.", "istory of Present Illness:", "onth  istory ", "ncreased  hirst ", "o ", "ore  requently ", "onths;", "ours ", "eaker ", "ore  ired ", "sual ", "ear  istory ", "oint pain ", "ands  ast Medical History:", "astroesophageal reflux disease  ension headaches  ocial History:", "moked  ne- alf  ack ", "igarettes  aily ", "ears  ccasionally ", "wo ", "hree ", "eekends  sed  o ", "exually active ", "nterest ", "exual  ctivity ", "ast 6 months  edications:", "antoprazole,", "mitriptyline,", "ultivitamin  llergies:", "nown  rug allergies ", "emp  ulse  esp  P  2  at  t  t  MI ", "9.", "in ", "m Hg ", "  t   ", "5  g ", "g/m2  ppearance:", "cute  istress  EENT:", "clerae  nicteric;", "ropharyngeal  rythema ", "xudate  ulmonary:", "lear  o  uscultation  ardiac:", "egular  ate ", "hythm;", "ormal  1 ", "2;", "urmurs,", "ubs,", "bdominal:", "enderness,", "uarding,", "asses,", "ruits;", "iver  pan ", "elvic:", "mall,", "irm  estes;", "odules ", "asses  xtremities:", "enderness ", "alpation ", "tiffness ", "oints ", "ands  kin:", "yperpigmented  eurologic:", "lert ", "riented;", "ranial nerves ", "ntact;", "ocal neurologic deficits\""]}
{"question": "A 50-year-old woman presents with altered taste and a gritty sensation in her eyes for the last month. She mentions that she needs to drink water frequently and often feels that her mouth and throat are dry. On physical examination, she has bilateral enlargement of the parotid glands and dry conjunctivae. Her physical examination and laboratory findings suggest a diagnosis of sicca syndrome. In addition to non-pharmacological measures, a drug is prescribed to improve symptoms related to dryness of mouth by increasing salivation. Which of the following is the mechanism of action of the drug that most likely is being prescribed to this patient?", "answer": "Selective M3 muscarinic receptor agonist", "options": {"A": "Selective M3 muscarinic receptor antagonist", "B": "Selective M1 muscarinic receptor antagonist", "C": "Selective M2 muscarinic receptor agonist", "D": "Selective M2 muscarinic receptor antagonist", "E": "Selective M3 muscarinic receptor agonist"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["50 year old woman presents", "altered taste", "gritty sensation", "eyes", "last month", "needs to", "water frequently", "often", "mouth", "throat", "dry", "bilateral enlargement of", "parotid glands", "dry conjunctivae", "laboratory findings", "diagnosis", "sicca syndrome", "non pharmacological measures", "drug", "to", "symptoms related to dryness", "mouth", "increasing salivation", "following", "mechanism of action", "drug", "likely", "patient"]}
{"question": "A 54-year-old man with alcoholism comes to the emergency department because of vomiting blood for 6 hours. He has had 3–4 episodes in which he has vomited dark red blood during this period. He has had no epigastric pain or tarry stools. On arrival, his temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 80/50 mm Hg. He is resuscitated with 0.9% saline and undergoes an emergency upper endoscopy, which shows actively bleeding varices. Band ligation of the varices is done and hemostasis is achieved. He is diagnosed with Child class B cirrhosis. He is concerned about the possibility of recurrence of such an episode. He is asked to abstain from alcohol, to which he readily agrees. In addition to non-selective beta-blocker therapy, which of the following is the most appropriate recommendation to prevent future morbidity and mortality from this condition?", "answer": "Variceal ligation", "options": {"A": "Octreotide therapy", "B": "Terlipressin", "C": "Transjugular intrahepatic portosystemic shunt", "D": "Variceal sclerotherapy", "E": "Variceal ligation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["54 year old man", "alcoholism", "emergency department", "of vomiting blood", "hours", "episodes", "vomited dark red blood", "period", "epigastric pain", "tarry stools", "arrival", "temperature", "99", "pulse", "min", "blood pressure", "80 50 mm Hg", "resuscitated", "0.9", "saline", "emergency upper endoscopy", "bleeding", "Band ligation", "hemostasis", "diagnosed", "Child", "cirrhosis", "possibility", "recurrence", "episode", "to", "alcohol", "agrees", "non", "beta-blocker therapy", "following", "most appropriate", "to prevent future morbidity", "mortality", "condition"]}
{"question": "A 38-year-old man presents to his primary care practitioner for 2 months of rectal bleeding. He also reports occasional diarrhea and abdominal pain. His family history is relevant for his father and uncle, who died from complications of colorectal cancer. Colonoscopy shows more than 10 colorectal adenomas. Which of the following genes is most likely affected in this patient?", "answer": "APC", "options": {"A": "RAS", "B": "TP53", "C": "APC", "D": "hMLH1", "E": "PPAR"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "practitioner", "2 months", "rectal bleeding", "reports occasional diarrhea", "abdominal pain", "family history", "relevant", "died", "complications", "colorectal", "Colonoscopy", "more", "10 colorectal adenomas", "following genes", "most likely affected", "patient"]}
{"question": "A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?", "answer": "Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area", "options": {"A": "Lateral radiograph (x-ray) of hips", "B": "Computed tomagraphy (CT) scan of his hips and lumbar area", "C": "Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area", "D": "Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area", "E": "AP and lateral radiographs of hips"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old male", "emergency room", "jumping from", "building", "Bilateral fractures", "femur", "stabilized", "emergency medical technicians", "patient", "lucid", "stable", "Pain only", "hips", "elicited", "Cervical exam", "not performed", "best imaging study", "patient"]}
{"question": "A 65-year-old man presents to the dermatology clinic to have a basal cell carcinoma excised from his upper back. The lesion measures 2.3 x 3.2 cm. He has a medical history significant for hypertension and diabetes mellitus type II, for which he takes lisinopril and metformin, respectively. He has had a basal cell carcinoma before which was excised in the clinic without complications. Which of the following modes of anesthesia should be used for this procedure?", "answer": "Local anesthesia", "options": {"A": "Local anesthesia", "B": "Peripheral nerve block", "C": "Spinal anesthesia", "D": "Moderate sedation", "E": "General anesthesia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old man presents", "dermatology clinic to", "basal cell carcinoma", "upper back", "lesion measures 2", "2", "medical history significant", "hypertension", "diabetes mellitus type II", "lisinopril", "metformin", "basal cell carcinoma", "clinic", "complications", "following modes", "anesthesia", "used", "procedure"]}
{"question": "A 53-year-old man is brought to the physician by his wife because of strange behavior and emotional outbursts for the past 6 months. He was previously healthy and physically active, but he recently started binge-eating candy and stopped exercising. He was fired from his job for inappropriate behavior after he undressed in the office and made lewd remarks to several female coworkers. He claims there is nothing wrong with his behavior. On mental status examination, he is alert and irritable but cooperative. Short-term recall is normal but he has some word-finding difficulties. Babinski reflex is positive bilaterally. This patient's symptoms are most likely due to a degenerative process in which of the following regions of the brain?", "answer": "Frontal cortex", "options": {"A": "Frontal cortex", "B": "Substantia nigra", "C": "Caudate nucleus", "D": "Hippocampus", "E": "Corona radiata"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "physician", "strange behavior", "emotional outbursts", "past 6 months", "healthy", "physically active", "recently started binge-eating", "stopped exercising", "fired", "inappropriate behavior", "undressed", "office", "made", "female", "wrong", "behavior", "mental status", "alert", "irritable", "Short-term", "normal", "finding difficulties", "Babinski reflex", "positive", "patient's symptoms", "due to", "degenerative process", "following regions", "brain"]}
{"question": "A 10-month-old infant is brought in by his parents because he is vomiting and not passing stool. His parents say he has vomited multiple times over the past couple of hours, but the most recent vomit was green. The patient has no significant past medical history. On physical examination, the patient is irritable and crying. On palpation in the periumbilical region, an abdominal mass is present. Emergency laparotomy is performed, which shows a part of the patient’s intestine folded into the section adjacent to it. Which of the following is the most likely diagnosis for this patient?", "answer": "Intussusception", "options": {"A": "Hirschsprung’s disease", "B": "Meckel’s diverticulum", "C": "Duodenal atresia", "D": "Pyloric stenosis", "E": "Intussusception"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["A 10 month old infant", "brought", "vomiting", "not passing stool", "vomited multiple times", "past couple", "hours", "most recent vomit", "green", "patient", "significant past medical history", "patient", "irritable", "palpation", "periumbilical region", "abdominal mass", "present", "Emergency laparotomy", "performed", "part of", "patients intestine folded", "section adjacent to", "following", "diagnosis", "patient"]}
{"question": "A 23-year-old woman comes to the physician because of increased urinary frequency and pain on urination for two days. She has had three similar episodes over the past year that resolved with antibiotic treatment. She has no history of serious illness. She is sexually active with one male partner; they do not use barrier contraception. Upon questioning, she reports that she always urinates and cleans herself after sexual intercourse. She drinks 2–3 liters of fluid daily. Her only medication is a combined oral contraceptive. Her temperature is 36.9°C (98.4°F), pulse is 65/min, and blood pressure is 122/65 mm Hg. Examination shows mild tenderness to palpation in the lower abdomen. The remainder of the examination shows no abnormalities. Urinalysis shows WBCs and rare gram-positive cocci. Which of the following is the most appropriate recommendation to prevent similar episodes in the future?", "answer": "Daily oral trimethoprim-sulfamethoxazole\n\"", "options": {"A": "Daily intake of cranberry juice", "B": "Postcoital vaginal probiotics", "C": "Treatment of the partner with intramuscular ceftriaxone", "D": "Postcoital oral amoxicillin-clavulanate", "E": "Daily oral trimethoprim-sulfamethoxazole\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old woman", "physician", "increased urinary frequency", "pain", "urination", "two days", "three similar episodes", "past year", "resolved", "antibiotic treatment", "history", "serious illness", "sexually active", "one male", "not use barrier contraception", "reports", "always", "cleans", "sexual intercourse", "23 liters", "fluid daily", "only medication", "combined oral contraceptive", "temperature", "36", "98", "pulse", "65 min", "blood pressure", "65 mm Hg", "mild tenderness", "palpation", "lower abdomen", "abnormalities", "Urinalysis", "WBCs", "rare", "following", "most appropriate", "to prevent similar episodes", "future"]}
{"question": "A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?", "answer": "Emergency fasciotomy", "options": {"A": "Ibuprofen and reassurance", "B": "Replace the cast with a sling", "C": "Radiography", "D": "Measurement of compartment pressure", "E": "Emergency fasciotomy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["patient presents", "emergency department", "arm pain", "patient recently", "open fracture of", "radius", "fell from", "ladder", "house", "Surgical reduction", "place", "patient's forearm", "cast", "then", "patient", "worsening pain in", "arm", "patient", "past medical", "asthma", "current medications include albuterol", "fluticasone", "loratadine", "lisinopril", "temperature", "99", "blood pressure", "95 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient's cast", "removed", "patient's left arm", "tender", "palpation", "Passive", "patient's wrist", "fingers elicits severe pain", "patient's left", "ulnar pulse", "palpable", "regular", "forearm", "soft", "not", "bruising", "tender", "palpation", "following", "next best step"]}
{"question": "A 4-month-old boy is brought to the pediatrician for a wellness visit. Upon examination, the physician notes severe burns on the sun-exposed areas of the skin, including the face (especially the ears and nose), dorsal aspect of the hands, shoulders, and dorsal aspect of his feet. The child has very fair skin and blond hair. The parents insist that the child has not spent any extraordinary amount of time in the sun, but they admit that they rarely apply sunscreen. Which of the following physical factors is the most likely etiology for the burns?", "answer": "UV-B radiation", "options": {"A": "Infrared radiation", "B": "Child abuse", "C": "UV-B radiation", "D": "Ionizing radiation", "E": "Gamma radiation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 month old boy", "brought", "pediatrician", "physician notes severe burns", "sun-exposed areas of", "skin", "including", "face", "ears", "nose", "dorsal aspect", "hands", "shoulders", "dorsal aspect", "feet", "child", "very fair skin", "blond hair", "child", "not spent", "amount", "time", "sun", "rarely apply", "following physical factors", "etiology", "burns"]}
{"question": "Three days after undergoing an open cholecystectomy, a 73-year-old man has fever and abdominal pain. He has hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. He had smoked one pack of cigarettes daily for 40 years but quit 1 year ago. He does not drink alcohol. Prior to admission to the hospital, his medications included lisinopril, metformin, ipratropium, and tamsulosin. He appears acutely ill and lethargic. His temperature is 39.5°C (103.1°F), pulse is 108/min, respirations are 18/min, and blood pressure is 110/84 mm Hg. He is oriented only to person. Examination shows a 10-cm subcostal incision that appears dry and non-erythematous. Scattered expiratory wheezing is heard throughout both lung fields. His abdomen is distended with tenderness to palpation over the lower quadrants. Laboratory studies show:\nHemoglobin 10.1 g/dl\nLeukocyte count 19,000/mm3\nSerum\nGlucose 180 mg/dl\nUrea Nitrogen 25 mg/dl\nCreatinine 1.2 g/dl\nLactic acid 2.5 mEq/L (N = 0.5 - 2.2 mEq/L)\nUrine\nProtein 1+\nRBC 1–2/hpf\nWBC 32–38/hpf\nWhich of the following is the most likely underlying mechanism of this patient's current condition?\"", "answer": "Bladder outlet obstruction", "options": {"A": "Wound contamination", "B": "Impaired alveolar ventilation", "C": "Peritoneal inflammation", "D": "Bladder outlet obstruction", "E": "Intraabdominal abscess formation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Three days", "open cholecystectomy", "year old man", "fever", "abdominal pain", "hypertension", "type 2 diabetes mellitus", "chronic obstructive pulmonary disease", "benign prostatic hyperplasia", "smoked one pack", "cigarettes daily", "40 years", "year", "not", "alcohol", "Prior", "medications included lisinopril", "metformin", "ipratropium", "tamsulosin", "appears", "ill", "lethargic", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "oriented only", "a 10", "subcostal incision", "appears dry", "non erythematous", "Scattered expiratory wheezing", "heard", "lung fields", "abdomen", "distended", "tenderness", "palpation", "lower quadrants", "Laboratory studies", "Hemoglobin", "g", "Leukocyte 19", "mm3", "mg", "mg", "L", "N", "mEq/L", "Urine Protein 1", "RBC", "hpf WBC", "following", "underlying mechanism", "patient", "urrent  ondition?"]}
{"question": "A 45-year-old man presents to his primary care physician complaining of increasingly frequent headaches. He also reports that his hats and wedding ring do not fit anymore. His temperature is 99°F (37.2°C), blood pressure is 145/80 mmHg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for frontal bossing, a prominent jaw, and an enlarged tongue. A chest radiograph reveals mild cardiomegaly. Serum insulin-like growth factor 1 levels are significantly elevated. Which of the following conditions is this patient at greatest risk for?", "answer": "Carpal tunnel syndrome", "options": {"A": "Pheochromocytoma", "B": "Medullary thyroid carcinoma", "C": "Osteoid osteoma", "D": "Carpal tunnel syndrome", "E": "Osteosarcoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician", "frequent headaches", "reports", "hats", "ring", "not fit", "temperature", "blood pressure", "80 mmHg", "pulse", "85 min", "respirations", "min", "notable", "frontal bossing", "prominent jaw", "enlarged tongue", "chest radiograph reveals mild cardiomegaly", "Serum insulin-like growth factor 1 levels", "elevated", "following conditions", "patient", "greatest"]}
{"question": "A 78-year-old man presents to the clinic complaining of shortness of breath at rest and with exertion. He also complains of difficulty breathing while lying down. He also is concerned because he startles from sleep and feels like he is choking. These symptoms have been bothering him for the last several weeks and they are getting worse. He has been afebrile with no known sick contacts. 6 months ago, he had an acute myocardial infarction from which he recovered and until recently had felt well. He has a history of hyperlipidemia for which he takes atorvastatin. His temperature is 37.0°C (98.6°F), the pulse is 85/min, the respiratory rate is 14/min, and the blood pressure is 110/75 mm Hg. On physical examination, his heart has a regular rate and rhythm. He has bilateral crackles in both lungs. An echocardiogram is performed and shows a left ventricular ejection fraction of 33%. What medication should be started?", "answer": "Captopril", "options": {"A": "Niacin", "B": "Captopril", "C": "Verapamil", "D": "Levofloxacin", "E": "Nitroglycerin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "clinic", "of shortness", "breath", "exertion", "difficulty breathing", "lying", "sleep", "choking", "symptoms", "last", "weeks", "getting worse", "afebrile with", "known sick contacts", "months", "acute myocardial infarction", "recovered", "recently", "well", "history of hyperlipidemia", "atorvastatin", "temperature", "98", "pulse", "85 min", "respiratory rate", "min", "blood pressure", "75 mm Hg", "heart", "regular rate", "rhythm", "bilateral crackles", "lungs", "echocardiogram", "performed", "left ventricular ejection fraction", "medication", "started"]}
{"question": "A 72-year-old man is brought in by his daughter who is concerned about his recent memory impairment. The patient’s daughter says she has noticed impairment in memory and functioning for the past month. She says that he has forgotten to pay bills and go shopping, and, as a result, the electricity was cut off due to non-payment. She also says that last week, he turned the stove on and forgot about it, resulting in a kitchen fire. The patient has lived by himself since his wife died last year. He fondly recalls living with his wife and how much he misses her. He admits that he feels ‘down’ most days of the week living on his own and doesn’t have much energy. When asked about the kitchen fire and problems with the electricity, he gets defensive and angry. At the patient’s last routine check-up 3 months ago, he was healthy with no medical problems. His vital signs are within normal limits. On physical examination, the patient appears to have a flat affect. Which of the following is the most likely diagnosis in this patient?", "answer": "Pseudodementia", "options": {"A": "Pseudodementia", "B": "Dementia", "C": "Delirium", "D": "Both dementia and delirium", "E": "Pick’s disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["72 year old man", "brought", "recent memory impairment", "patients", "impairment", "memory", "functioning", "past month", "forgotten to pay bills", "go shopping", "result", "cut off due to non payment", "last week", "turned", "stove", "forgot", "resulting in", "kitchen fire", "patient", "lived", "died last year", "living", "misses", "days of the week living", "energy", "kitchen fire", "gets", "patients last routine check-up", "months", "healthy", "medical problems", "vital signs", "normal limits", "patient appears to", "flat affect", "following", "diagnosis", "patient"]}
{"question": "A 47-year-old woman comes to the physician because of a 3-day history of fever, fatigue, loss of appetite, cough, and chest pain. Physical examination shows diffuse inspiratory crackles over the left lung field. An x-ray of the chest shows hilar lymphadenopathy and well-defined nodules with central calcifications. Urine studies show the presence of a polysaccharide antigen. A biopsy specimen of the lung shows cells with basophilic, crescent-shaped nuclei and pericellular halos located within macrophages. This patient's history is most likely to show which of the following?", "answer": "Exposure to bat droppings", "options": {"A": "Treatment with inhaled glucocorticoids", "B": "Visit to Arizona desert", "C": "Recent trip to Brazil", "D": "Previous mycobacterial infection", "E": "Exposure to bat droppings"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "3-day history", "fever", "fatigue", "loss of appetite", "cough", "chest", "Physical examination", "diffuse inspiratory crackles", "left lung field", "x-ray of", "chest", "hilar lymphadenopathy", "well-defined nodules", "central calcifications", "Urine studies", "presence", "polysaccharide", "biopsy specimen", "lung", "cells", "basophilic", "crescent shaped nuclei", "halos", "macrophages", "patient's history", "to", "following"]}
{"question": "Researchers are studying the relationship between heart disease and alcohol consumption. They review the electronic medical records of 500 patients at a local hospital during the study period and identify the presence or absence of acute coronary syndrome (ACS) and the number of alcoholic drinks consumed on the day of presentation. They find that there is a lower prevalence of acute coronary syndrome in patients who reported no alcohol consumption or 1 drink daily compared with those who reported 2 or more drinks. Which of the following is the most accurate description of this study type?", "answer": "Cross-sectional study", "options": {"A": "Randomized controlled trial", "B": "Case-control study", "C": "Cross-sectional study", "D": "Retrospective study", "E": "Prospective study"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Researchers", "studying", "relationship", "heart", "500 patients", "local hospital", "study period", "presence", "absence", "acute coronary syndrome", "number", "day", "find", "lower prevalence", "acute coronary syndrome", "patients", "reported", "1", "daily", "reported 2", "more", "following", "most accurate description", "study type"]}
{"question": "A 38-year-old man presents to his primary care provider for abdominal pain. He reports that he has had a dull, burning pain for several months that has progressively gotten worse. He also notes a weight loss of about five pounds over that time frame. The patient endorses nausea and feels that the pain is worse after meals, but he denies any vomiting or diarrhea. He has a past medical history of hypertension, and he reports that he has been under an unusual amount of stress since losing his job as a construction worker. His home medications include enalapril and daily ibuprofen, which he takes for lower back pain he developed at his job. The patient drinks 1-2 beers with dinner and has a 25-pack-year smoking history. His family history is significant for colorectal cancer in his father and leukemia in his grandmother. On physical exam, the patient is moderately tender to palpation in the epigastrium. A fecal occult test is positive for blood in the stool.\n\nWhich of the following in the patient’s history is most likely causing this condition?", "answer": "Medication use", "options": {"A": "Physiologic stress", "B": "Alcohol use", "C": "Medication use", "D": "Smoking history", "E": "Family history of cancer"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider", "abdominal pain", "reports", "dull", "burning pain", "months", "gotten worse", "notes", "weight loss of", "five pounds over", "time frame", "patient", "nausea", "pain", "worse", "meals", "vomiting", "diarrhea", "past medical", "reports", "unusual amount", "stress", "construction worker", "home medications include enalapril", "daily ibuprofen", "lower back pain", "patient", "1-2", "dinner", "smoking history", "family history", "significant", "colorectal cancer", "leukemia", "patient", "moderately tender", "palpation", "epigastrium", "fecal occult test", "positive", "blood", "stool", "following", "most likely causing", "condition"]}
{"question": "A 26-year-old man being treated for major depressive disorder returns to his psychiatrist complaining that he has grown weary of the sexual side effects. Which other medication used to treat major depressive disorder may be appropriate as a stand-alone or add-on therapy?", "answer": "Buproprion", "options": {"A": "Paroxetine", "B": "Venlafaxine", "C": "Aripiprazole", "D": "Buproprion", "E": "Cyproheptadine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "treated", "major depressive disorder returns", "psychiatrist", "side effects", "medication used to treat major depressive disorder", "appropriate", "stand-alone", "add", "therapy"]}
{"question": "A 25-year-old man presents to the emergency department with a severe pulsatile headache for an hour. He says that he is having palpitations as well. He adds that he has had several episodes of headache in the past which resolved without seeking medical attention. He is a non-smoker and does not drink alcohol. He denies use of any illicit drugs. He looks scared and anxious. His temperature is 37°C (98.6°F), respirations are 25/min, pulse is 107/min, and blood pressure is 221/161 mm Hg. An urgent urinalysis reveals elevated plasma metanephrines. What is the next best step in the management of this patient?", "answer": "Phenoxybenzamine followed by propanolol", "options": {"A": "Propranolol followed by phenoxybenzamine", "B": "Phenoxybenzamine followed by propanolol", "C": "Amlodipine", "D": "Emergent surgery", "E": "Hydralazine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "severe pulsatile headache", "hour", "palpitations", "well", "adds", "several episodes of headache", "past", "resolved", "seeking medical attention", "non-smoker", "not", "alcohol", "use", "illicit drugs", "looks", "anxious", "temperature", "98", "respirations", "min", "pulse", "min", "blood pressure", "mm Hg", "urgent urinalysis reveals elevated plasma metanephrines", "next best step", "patient"]}
{"question": "An investigator is comparing the risk of adverse effects among various antiarrhythmic medications. One of the drugs being studied primarily acts by blocking the outward flow of K+ during myocyte repolarization. Further investigation shows that the use of this drug is associated with a lower rate of ventricular tachycardia, ventricular fibrillation, and torsade de points when compared to similar drugs. Which of the following drugs is most likely being studied?", "answer": "Amiodarone", "options": {"A": "Esmolol", "B": "Sotalol", "C": "Procainamide", "D": "Verapamil", "E": "Amiodarone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "adverse effects", "various antiarrhythmic", "One", "drugs", "studied", "acts", "blocking", "outward", "K", "Further", "use", "drug", "associated with", "lower rate", "ventricular tachycardia", "ventricular fibrillation", "de points", "similar drugs", "following drugs", "most likely", "studied"]}
{"question": "A 67-year-old man presents with fatigue, progressive abdominal distention and yellow skin coloration for the past 2 weeks. He denies fever, chills, or other symptoms. Past medical history is unremarkable. He reports heavy alcohol consumption for the past several years but says he quit recently. On physical examination, the patient appears jaundiced and is ill-appearing. There is shifting dullness presents on abdominal percussion with a positive fluid wave. Sclera are icteric. Bilateral gynecomastia is present. Laboratory findings are significant for the following:\nHgb 13 g/dL\nLeukocyte count 4,500/mm3\nPlatelets 86,000/mm3\nAspartate transaminase (AST) 108 U/L\nAlanine transaminase (ALT) 55 U/L\nGGT 185 U/L\nUrea 23 mg/dL\nIron 120 μg/dL\nFerritin 180 μg/dL\nTransferrin saturation 40%\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Alcoholic liver disease", "options": {"A": "Hemochromatosis", "B": "Chronic viral hepatitis", "C": "Alcoholic liver disease", "D": "Hepatic adenoma", "E": "Non alcoholic fatty liver disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "fatigue", "progressive abdominal distention", "yellow", "past 2 weeks", "fever", "chills", "symptoms", "Past medical history", "unremarkable", "reports heavy", "past", "years", "recently", "patient appears jaundiced", "ill appearing", "shifting dullness presents", "abdominal percussion", "positive fluid wave", "Sclera", "icteric", "Bilateral gynecomastia", "present", "Laboratory findings", "significant", "following", "Hgb 13 g/dL Leukocyte count 4 500 mm3 Platelets", "Aspartate transaminase", "L Alanine transaminase", "GGT", "Iron", "Ferritin", "Transferrin saturation", "following", "diagnosis", "patient"]}
{"question": "A recent study attempted to analyze whether increased \"patient satisfaction\" driven healthcare resulted in increased hospitalization. Using this patient population, the sociodemographics, health status, and hospital use were assessed. Next year, patient satisfaction with health care providers was assessed using 5 items from the Consumer Assessment of Health Plans Survey. Which of the following best describes this study design?", "answer": "Prospective cohort", "options": {"A": "Cross-sectional study", "B": "Prospective case-control", "C": "Prospective cohort", "D": "Retrospective case-control", "E": "Retrospective cohort"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["recent study", "to", "increased", "patient satisfaction", "resulted", "increased", "Using", "patient population", "health status", "hospital use", "Next year", "patient satisfaction", "health care providers", "using 5", "Plans Survey", "following best"]}
{"question": "A 16-year-old man presents to the emergency department complaining of episodes of pounding headache, chest fluttering, and excessive sweating. He has a past history of kidney stones that are composed of calcium oxalate. He does not smoke or drink alcohol. Family history reveals that his mother died of thyroid cancer. Vital signs reveal a temperature of 37.1°C (98.7°F), blood pressure of 200/110 mm Hg and pulse of 120/min. His 24-hour urine calcium, serum metanephrines, and serum normetanephrines levels are all elevated. Mutation of which of the following genes is responsible for this patient's condition?", "answer": "RET proto-oncogene", "options": {"A": "BRAF", "B": "RET proto-oncogene", "C": "BCR-ABL", "D": "BCL2", "E": "HER-2/neu (C-erbB2)"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "of episodes", "pounding headache", "chest fluttering", "excessive sweating", "past history of kidney stones", "calcium oxalate", "not smoke", "Family history reveals", "died of thyroid cancer", "Vital signs reveal", "temperature", "98", "blood pressure", "200", "mm Hg", "pulse", "min", "hour urine calcium", "serum metanephrines", "serum normetanephrines levels", "elevated", "following", "responsible", "patient's condition"]}
{"question": "A 65-year-old man presents to his primary care physician for fatigue. The patient states that he has not been sleeping well and requests sleep medication to help him with his fatigue. He recently changed his diet to try to increase his energy and has been on a vegetarian diet for the past several months. The patient has no significant past medical history. He smokes 1 pack of cigarettes per day and drinks 5 alcoholic beverages per day. The patient has lost 12 pounds since his last visit 1 month ago. Physical exam demonstrates a tired man. He appears thin, and his skin and sclera are icteric. Abdominal ultrasound is notable for a thin-walled and enlarged gallbladder. A urine sample is collected and is noted to be amber in color. Which of the following is the most likely diagnosis?", "answer": "Pancreatic adenocarcinoma", "options": {"A": "Autoimmune hemolytic anemia", "B": "Cholangiocarcinoma", "C": "Gallbladder adenocarcinoma", "D": "Iron deficiency anemia", "E": "Pancreatic adenocarcinoma"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["65 year old man presents", "primary care physician", "fatigue", "patient states", "not", "sleeping well", "sleep medication to help", "fatigue", "recently changed", "diet to", "to increase", "energy", "vegetarian diet", "past", "months", "patient", "significant past medical history", "smokes 1 pack", "cigarettes", "day", "5", "day", "patient", "lost", "pounds", "last", "month", "tired man", "appears thin", "skin", "sclera", "icteric", "Abdominal ultrasound", "notable", "thin walled", "enlarged gallbladder", "urine sample", "collected", "noted to", "amber", "color", "following", "diagnosis"]}
{"question": "A 61-year-old man comes to the emergency department because of a 3-hour history of pain and redness of both eyes. He has new blurry vision and difficulty opening his eyes in bright surroundings. He has not had any recent trauma. He uses contact lenses daily. He had surgery on his left eye 6 months ago after a penetrative trauma caused by a splinter. His vital signs are within normal limits. Physical examination shows congestion of the perilimbal conjunctivae bilaterally. Visual acuity is decreased bilaterally. Ocular movements are normal. Slit-lamp examination shows a cornea with normal contours and leukocytes in the anterior chambers of both eyes. The eyelids, eyelashes, and lacrimal ducts show no abnormalities. Which of the following is the most likely cause of this patient's condition?", "answer": "Autoimmune reaction against retinal antigens", "options": {"A": "Reactivation of herpes zoster virus", "B": "Autoimmune reaction against retinal antigens", "C": "Corneal infection with Pseudomonas aeruginosa", "D": "Impaired drainage of aqueous humor", "E": "Age-related denaturation of lens proteins"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["61 year old man", "emergency department", "3 hour history", "pain", "redness of", "eyes", "new blurry vision", "difficulty opening", "eyes", "bright surroundings", "not", "recent trauma", "uses contact lenses daily", "surgery", "left", "months", "penetrative trauma caused", "splinter", "vital signs", "normal", "Physical examination", "congestion", "conjunctivae", "Visual acuity", "decreased", "Ocular movements", "normal", "Slit-lamp examination", "cornea", "normal contours", "the anterior chambers of", "eyes", "eyelids", "eyelashes", "lacrimal ducts", "abnormalities", "following", "most likely cause", "patient's condition"]}
{"question": "A 29-year-old woman presents with shortness of breath and chest pain for the past week. She says her chest pain is aggravated by deep breathing and she becomes short of breath while walking upstairs in her home. She also has been feeling feverish and fatigued for the past week, as well as pain in her wrists, hands, and left knee. Review of systems is significant for a 4.5 kg (10.0 lb) weight loss over the previous month Past medical history consists of 2 spontaneous abortions, both of which occurred in the 1st trimester. On physical examination, there is a pink rash present on over her face, which is aggravated by exposure to sunlight. There are decreased breath sounds on the right. A chest radiograph is performed which reveals evidence of a right pleural effusion. Serum ANA and anti-dsDNA autoantibodies are positive. Urinalysis is unremarkable. Errors with which of the following is most likely to lead to her disease?", "answer": "Fas-FasL interaction", "options": {"A": "Cytotoxic CD8+ T cells", "B": "Intrinsic pathway", "C": "Necrosis", "D": "Fas-FasL interaction", "E": "Bcl-2 overexpression"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "shortness of breath", "chest pain", "past week", "chest pain", "aggravated", "deep breathing", "short of breath", "walking upstairs in", "home", "feeling feverish", "fatigued", "past week", "pain in", "wrists", "hands", "left knee", "Review of systems", "significant", "kg", "10 0", "weight loss", "previous month Past medical history consists", "spontaneous abortions", "1st trimester", "pink rash present", "face", "aggravated", "exposure", "decreased breath sounds", "right", "chest radiograph", "performed", "reveals", "right pleural effusion", "Serum", "anti-dsDNA autoantibodies", "positive", "Urinalysis", "unremarkable", "Errors", "following", "to lead", "disease"]}
{"question": "An investigator is studying severely ill patients who experience hypoglycemia and ketonuria during times of fasting. The investigator determines that during these episodes, amino acids liberated from muscle proteins are metabolized to serve as substrates for gluconeogenesis. Nitrogen from this process is transported to the liver primarily in the form of which of the following molecules?", "answer": "Alanine", "options": {"A": "Pyruvate", "B": "Arginine", "C": "Alanine", "D": "α-ketoglutarate", "E": "Glutamate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying severely ill patients", "hypoglycemia", "ketonuria", "times", "fasting", "investigator", "episodes", "amino acids", "muscle proteins", "metabolized to", "substrates", "Nitrogen", "transported", "liver", "form", "following"]}
{"question": "A 62-year-old man presents to the emergency room with an acute myocardial infarction. Twenty-four hours after admission to the cardiac intensive care unit, he develops oliguria. Laboratory tests show that his serum BUN is 59 mg/dL and his serum creatinine is 6.2 mg/dL. Renal biopsy reveals necrosis of the proximal tubules and thick ascending limb of Henle's loop. Which of the following would you most likely observe on a microscopic examination of this patient's urine?", "answer": "Muddy brown casts", "options": {"A": "White blood cell casts", "B": "Fatty casts", "C": "Muddy brown casts", "D": "Hyaline casts", "E": "Broad waxy casts"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old man presents", "emergency room", "acute myocardial infarction", "Twenty-four hours", "cardiac intensive care unit", "oliguria", "Laboratory tests", "serum", "59 mg/dL", "serum creatinine", "6.2 mg/dL", "Renal biopsy reveals necrosis", "proximal tubules", "thick ascending limb of Henle's loop", "following", "most likely observe", "microscopic", "urine"]}
{"question": "A 26-year-old man comes to the physician because of episodic palpitations for the past 2 months. He has the feeling that sometimes his heart “skips a beat”. His father has a history of atrial fibrillation and myocardial infarction. He has smoked one pack of cigarettes daily for 5 years. He drinks 1–2 beers on the weekends. His vital signs are within normal limits. Physical examination reveals a regular pulse. Cardiopulmonary examination shows no abnormalities. Serum studies, including electrolytes and creatinine, are within normal limits. An excerpt of 24h Holter monitoring is shown. Echocardiography is normal. Which of the following is the most appropriate next step in management?", "answer": "Smoking cessation", "options": {"A": "Diltiazem therapy", "B": "Coronary angiography", "C": "Metoprolol therapy", "D": "Permanent pacemaker placement", "E": "Smoking cessation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of episodic palpitations", "past", "months", "sometimes", "heart skips", "history of atrial fibrillation", "myocardial infarction", "smoked one pack", "cigarettes daily", "weekends", "vital signs", "normal", "Physical examination reveals", "regular pulse", "Cardiopulmonary", "abnormalities", "Serum studies", "including electrolytes", "creatinine", "normal limits", "24h Holter monitoring", "Echocardiography", "normal", "following", "most appropriate next step"]}
{"question": "A 60-year-old woman is rushed to the emergency room after falling on her right elbow while walking down the stairs. She cannot raise her right arm. Her vital signs are stable, and the physical examination reveals loss of sensation over the upper lateral aspect of the right arm and shoulder. A radiologic evaluation shows a fracture of the surgical neck of the right humerus. Which of the following muscles is supplied by the nerve that is most likely damaged?", "answer": "Teres minor", "options": {"A": "Infraspinatus", "B": "Teres minor", "C": "Supraspinatus", "D": "Teres major", "E": "Subscapularis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old woman", "rushed", "emergency room", "falling", "right elbow", "right arm", "vital signs", "stable", "reveals loss of sensation", "upper lateral aspect", "right arm", "shoulder", "radiologic", "fracture of", "surgical neck of", "right humerus", "following muscles", "supplied", "nerve", "most likely damaged"]}
{"question": "A 25-year-old man presents to his gastroenterologist for trouble swallowing. The patient states that whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and shortness of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates a normal cardiopulmonary exam. His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy. Which of the following is the best next step in management?", "answer": "Gastrografin swallow", "options": {"A": "Barium swallow", "B": "Urgent surgery", "C": "Magnetic resonance imaging", "D": "Gastrografin swallow", "E": "Ultrasound"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "gastroenterologist", "swallowing", "patient states", "eats solids", "regurgitates", "back", "Given", "patient's suspected diagnosis", "gastroenterologist performs", "diagnostic test", "hours later", "patient presents", "emergency department", "chest pain", "shortness of breath", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "60 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient", "normal cardiopulmonary exam", "tenderness of", "neck", "normal oropharynx", "palpable crepitus", "clavicles", "minor lymphadenopathy", "following", "best next step"]}
{"question": "A four-year-old boy is brought to his pediatrician by his mother for recurrent nosebleeds. The mother reports that the boy has had five nosebleeds within the past 2 weeks, each lasting between 15 and 20 minutes. The patient was born at term and has been hospitalized twice for pneumonia treatment. There is no family history of serious illness. The patient is at the 8th percentile for height and the 30th percentile for weight. Vital signs are within normal limits. Examination shows a small, thin child with two flat, dark brown areas of hyperpigmentation across the upper back and a similar discoloration on the left buttock. There is bilateral esotropia. Laboratory studies show a hemoglobin concentration of 9.3 g/dL, mean corpuscular volume of 107 μm3, leukocyte count of 3,800/mm3, and platelet count of 46,000/mm3. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Defect in DNA crosslink repair", "options": {"A": "Defect in DNA crosslink repair", "B": "Mutation in WAS protein", "C": "Parvovirus B19 infection", "D": "Recent history of NSAID use", "E": "Postviral autoimmune reaction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["four year old boy", "brought", "pediatrician", "recurrent nosebleeds", "reports", "boy", "five nosebleeds", "past 2 weeks", "lasting", "20 minutes", "patient", "born", "term", "hospitalized twice", "pneumonia treatment", "family history", "serious illness", "patient", "percentile", "height", "percentile", "weight", "Vital signs", "normal limits", "small", "thin child", "two flat", "dark brown areas", "hyperpigmentation", "upper back", "similar discoloration", "left buttock", "bilateral esotropia", "Laboratory studies", "a hemoglobin concentration", "3 g/dL", "mean corpuscular volume", "m3", "leukocyte count", "800 mm3", "platelet count", "mm3", "following", "underlying cause", "patient's condition"]}
{"question": "A 21-year-old man presents to the physician with numbness and weakness in both legs for about a day. He also mentions that both thighs ache. His past medical history is not significant except for some diarrhea about 3 weeks ago. On physical examination, his temperature is 37.2ºC (99.0ºF), pulse rate is 108/min and respiratory rate is 14/min. His blood pressure is 122/82 mm Hg and 100/78 mm Hg in supine and upright positions, respectively. His neurologic evaluation reveals the presence of bilateral symmetrical weakness of the lower limbs, the absence of deep tendon reflexes, and negative Babinski sign. His sensorium and higher brain functions are normal. Which of the following options best explains the pathophysiological mechanism underlying the patient’s clinical features?", "answer": "Decreased neuronal excitability", "options": {"A": "Genetic overexpression of K+ channels in skeletal muscle", "B": "Decreased neuronal excitability", "C": "Decreased threshold for the generation and propagation of the action potential", "D": "Toxin-mediated blockade of voltage-gated fast Na+ channels", "E": "Autoantibody-mediated destruction of Ca2+ channels in the nerve endings at the neuromuscular junction"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old man presents", "physician", "numbness", "weakness in both legs", "about", "day", "thighs ache", "past medical history", "not significant", "diarrhea", "3 weeks", "temperature", "99", "pulse rate", "min", "respiratory rate", "min", "blood pressure", "mm Hg", "100", "mm Hg", "supine", "upright positions", "neurologic evaluation reveals the presence of bilateral symmetrical weakness", "lower limbs", "absence", "deep tendon reflexes", "negative Babinski sign", "sensorium", "higher brain functions", "normal", "following options best", "pathophysiological mechanism", "patients clinical features"]}
{"question": "Confident of your performance on Step 1 given your extensive utilization of Medbullets, you preemptively start to ponder your future specialty choice. You come across an analysis of lifestyle factors and how they affect medical student specialty choices. Image A depicts two scatter plots comparing the relationship between median income and weekly work hours on the difficulty of matching into specific specialties. Both associations are statistically significant. Which statement best describes the results?", "answer": "Median income has a stronger correlation with matching difficulty than weekly work hours", "options": {"A": "The harder the specialty is to match into, the higher the weekly work hours", "B": "The easier the specialty is to match into, the higher the median income", "C": "Weekly work hours has a stronger correlation with matching difficulty than median income", "D": "Median income has a stronger correlation with matching difficulty than weekly work hours", "E": "The higher the median income of a specialty the shorter the weekly work hours"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Confident", "Step 1", "extensive utilization", "start to", "future specialty", "analysis", "factors", "specialty", "two scatter", "relationship", "median income", "weekly", "hours", "difficulty", "matching", "specific specialties", "statistically significant", "best", "results"]}
{"question": "A 50-year-old man undergoes parathyroidectomy for treatment-resistant hyperparathyroidism. The procedure is complicated by brisk bleeding from an artery that travels along the external branch of the superior laryngeal nerve. To stop the bleeding, the artery is ligated at its origin. Which of the following is most likely the origin of the artery that was injured in this patient?", "answer": "External carotid artery", "options": {"A": "Subclavian artery", "B": "Internal carotid artery", "C": "External carotid artery", "D": "Thyrocervical trunk", "E": "Ascending pharyngeal artery\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["50 year old man", "parathyroidectomy", "treatment resistant hyperparathyroidism", "procedure", "complicated", "brisk bleeding", "artery", "external branch of", "superior laryngeal nerve", "To stop", "bleeding", "artery", "origin", "following", "origin", "artery", "injured", "patient"]}
{"question": "A 27-year-old man presents to the emergency department with a progressively worsening cough, wheezes, and chest tightness over the last 2 days. He has a history of moderate persistent asthma and his maintenance regimen consists of an inhaled corticosteroid, a long-acting beta-agonist, and albuterol as rescue therapy. He has not improved with his rescue inhaler despite increased use. He reports prior exposure to a person who had symptoms of a respiratory infection. His temperature is 37.4°C (99.3°F), blood pressure is 101/68 mm Hg, heart rate is 99/min, and respiratory rate is 32/min. Physical examination reveals widespread polyphonic wheezes but equal air entry. His oxygen saturation is 92% on room air. The presence of which of the following categorizes this patient’s condition as life-threatening?", "answer": "Respiratory acidosis", "options": {"A": "Peak expiratory flow rate (PEFR) >70%", "B": "Dyspnea that limits usual daily activity", "C": "Symptoms lasting for > 3 days after starting treatment", "D": "Respiratory alkalosis", "E": "Respiratory acidosis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["27 year old man presents", "emergency department", "worsening cough", "wheezes", "chest tightness", "2 days", "history of moderate persistent asthma", "regimen consists", "inhaled corticosteroid", "a long", "beta agonist", "albuterol", "therapy", "not improved", "inhaler", "increased use", "reports prior exposure", "symptoms", "respiratory", "temperature", "99", "blood pressure", "mm Hg", "heart rate", "99 min", "respiratory rate", "min", "reveals widespread", "wheezes", "equal air", "oxygen saturation", "room air", "presence", "following", "patients condition", "life-threatening"]}
{"question": "A 29-year-old woman is brought to the physician by her father because of a change in her behavior over the past 8 months. The father says that his daughter has become increasingly withdrawn; she has not answered any phone calls or visited her family and friends. The patient says that she has to stay at home because a foreign intelligence service is monitoring her. She thinks that they are using a magnetic field to read her mind. Mental status exam shows disjointed and perseverative thinking. She is anxious and has a flat affect. Which of the following is the most likely diagnosis?", "answer": "Schizophrenia", "options": {"A": "Schizophrenia", "B": "Delusional disorder", "C": "Paranoid personality disorder", "D": "Schizoid personality disorder", "E": "Schizophreniform disorder"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old woman", "brought", "physician", "change", "behavior", "past", "months", "withdrawn", "not", "phone calls", "patient", "to", "home", "foreign", "service", "using", "to", "mind", "status exam", "perseverative thinking", "anxious", "flat affect", "following", "diagnosis"]}
{"question": "A 5-year-old boy is brought to his pediatrician's office by his parents for a scheduled visit. His father tells the physician that he has observed, on several occasions, that his son has difficulty breathing. This is more prominent when he is outside playing with his friends. These symptoms are increased during the spring and winter seasons, and, of late, the boy has one such episode almost every week. During these episodes, he usually wheezes, coughs, and seems to be winded as if something was restricting his ability to breathe. These symptoms have not affected his sleep at night. This breathlessness does not limit his daily activities, and whenever he does have an episode it subsides after he gets some rest. He does not have any other pertinent medical history and is not on any medication. His physical examination does not reveal any significant findings. The pediatrician checks his expiratory flow rate in the office and estimates it to be around 85% after conducting it three times. Which of the following drugs is the pediatrician most likely to start this patient on?", "answer": "Inhaled albuterol", "options": {"A": "Inhaled salmeterol", "B": "Inhaled albuterol", "C": "High-dose budesonide", "D": "Low-dose fluticasone", "E": "Oral prednisone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "pediatrician's office", "scheduled", "physician", "observed", "several occasions", "difficulty breathing", "more prominent", "outside playing", "symptoms", "increased", "spring", "winter seasons", "late", "boy", "one", "episode almost", "week", "episodes", "usually wheezes", "coughs", "to", "winded", "restricting", "ability", "symptoms", "not affected", "sleep", "night", "breathlessness", "not limit", "episode", "gets", "not", "medical history", "not", "medication", "not reveal", "significant findings", "pediatrician checks", "expiratory flow rate", "office", "estimates", "to", "85", "three times", "following drugs", "pediatrician", "to start", "patient"]}
{"question": "An 18-year-old man presents with bloody diarrhea and weight loss. He undergoes endoscopic biopsy which shows pseudopolyps. Biopsies taken during the endoscopy show inflammation only involving the mucosa and submucosa. He is diagnosed with an inflammatory bowel disease. Which of the following was most likely found?", "answer": "Rectal involvement", "options": {"A": "Skip lesions", "B": "Noncaseating granuloma", "C": "Fistulas and strictures", "D": "Rectal involvement", "E": "Cobblestone mucosa"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "bloody diarrhea", "weight loss", "endoscopic biopsy", "pseudopolyps", "Biopsies", "endoscopy", "inflammation only involving", "mucosa", "submucosa", "diagnosed", "inflammatory bowel disease", "following", "most likely found"]}
{"question": "A 37-year-old man presents to his primary care provider complaining of bilateral arm numbness. He was involved in a motor vehicle accident 3 months ago. His past medical history is notable for obesity and psoriatic arthritis. He takes adalimumab. His temperature is 99.3°F (37.4°C), blood pressure is 130/85 mmHg, pulse is 90/min, and respirations are 18/min. On exam, superficial skin ulcerations are found on his fingers bilaterally. His strength is 5/5 bilaterally in shoulder abduction, arm flexion, arm extension, wrist extension, finger abduction, and thumb flexion. He demonstrates loss of light touch and pinprick response in the distal tips of his 2nd and 5th fingertips and over the first dorsal web space. Vibratory sense is intact in the bilateral upper and lower extremities. Which of the following nervous system structures is most likely affected in this patient?", "answer": "Ventral white commissure", "options": {"A": "Ventral white commissure", "B": "Ventral horns", "C": "Cuneate fasciculus", "D": "Anterior corticospinal tract", "E": "Spinocerebellar tract"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "bilateral arm numbness", "involved", "motor vehicle accident", "months", "past medical history", "notable", "obesity", "psoriatic arthritis", "adalimumab", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "90 min", "respirations", "min", "exam", "superficial skin ulcerations", "found", "fingers", "strength", "5/5", "shoulder abduction", "arm flexion", "arm extension", "wrist extension", "finger abduction", "thumb flexion", "loss", "light touch", "response", "distal tips", "2nd", "5th fingertips", "first dorsal web space", "Vibratory sense", "intact", "bilateral upper", "lower extremities", "of", "following nervous system structures", "most likely affected", "patient"]}
{"question": "A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities.\n\nWhich of the following is the best next step in management?", "answer": "Head CT", "options": {"A": "Lumbar puncture", "B": "Serology for Toxoplasma-specific IgG antibodies", "C": "Head CT", "D": "Empiric treatment with pyrimethamine-sulfadiazine", "E": "Empiric treatment with itraconazole"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "male", "past medical history of HIV", "CD4", "mm", "hypertension", "hyperlipidemia", "osteoarthritis presents", "emergency department", "sudden weakness of", "right hand", "reports", "weakness", "getting worse", "morning", "cup", "never", "hospitalized last year", "pneumonia", "reports inconsistent adherence", "home medications", "include raltegravir", "tenofovir", "emtricitabine", "TMP-SMX", "hydrochlorothiazide", "pravastatin", "occasional ibuprofen", "died", "myocardial infarction", "age", "60", "suffered", "stroke", "age", "72", "patient's temperature", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "neurological exam", "3/5 strength", "distal of", "right extremity", "preserved sensation", "neurological exam", "normal", "extremities", "following", "best next step"]}
{"question": "A 17-year-old girl comes to the physician because of a 12-hour history of profuse watery diarrhea with flecks of mucus that started shortly after she returned from a trip to South America. She has not had any fever or nausea. Pulse is 104/min and blood pressure is 110/65 mm Hg. Physical examination shows dry mucous membranes and decreased skin turgor. Stool culture shows gram-negative, comma-shaped, flagellated bacilli. Therapy with oral rehydration solution is initiated. Which of the following is the most likely mechanism of this patient's diarrhea?", "answer": "Luminal chloride hypersecretion due to overactivation of adenylate cyclase", "options": {"A": "Reduced ability of water absorption in the colon due to rapid intestinal transit", "B": "Fluid and electrolyte loss due to inflammation of luminal surface epithelium", "C": "Luminal chloride hypersecretion due to overactivation of adenylate cyclase", "D": "Impaired intestinal motility due to degeneration of autonomic nerves", "E": "Excessive water excretion due to osmotically active solutes in the lumen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "12-hour history", "watery diarrhea", "flecks", "mucus", "started", "returned", "trip", "South America", "not", "fever", "nausea", "Pulse", "min", "blood pressure", "65 mm Hg", "dry mucous membranes", "decreased skin turgor", "Stool culture", "shaped", "Therapy", "oral rehydration", "initiated", "following", "mechanism", "patient's diarrhea"]}
{"question": "A 16-year-old girl comes to her primary care physician for an annual check-up. She has no specific complaints. Her medical history is significant for asthma. She uses an albuterol inhaler as needed. She has no notable surgical history. Her mom had breast cancer and her grandfather died of colon cancer. She received all her childhood scheduled vaccinations up to age 8. She reports that she is doing well in school but hates math. She is sexually active with her boyfriend. They use condoms consistently, and they both tested negative recently for gonorrhea, chlamydia, syphilis and human immunodeficiency virus. She asks about birth control. In addition to educating the patient on her options for contraception, which of the following is the best next step in management?", "answer": "No HPV-related screening and administer HPV vaccine", "options": {"A": "Cytology and human papilloma virus (HPV) testing now and then every 3 years", "B": "Cytology and HPV testing now and then every 5 years", "C": "Cytology now and then every 3 years", "D": "No HPV-related screening as the patient is low risk", "E": "No HPV-related screening and administer HPV vaccine"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "primary care physician", "annual check-up", "specific complaints", "medical history", "significant", "asthma", "uses", "albuterol inhaler as needed", "notable surgical history", "mom", "breast cancer", "died of colon cancer", "received", "childhood scheduled vaccinations", "age", "reports", "well", "school", "sexually active", "use condoms", "tested negative recently", "gonorrhea", "syphilis", "human immunodeficiency virus", "birth control", "patient", "options", "contraception", "following", "best next step"]}
{"question": "A 4-year-old boy with beta thalassemia requires regular blood transfusions a few times per month because of persistent anemia. He is scheduled for a splenectomy in the next several months. Samples obtained from the boy’s red blood cells show a malformed protein with a length of 160 amino acids (in normal, healthy red blood cells, the functional protein has a length of 146 amino acids). Which of the following best accounts for these findings?", "answer": "Splice site mutation", "options": {"A": "Frameshift mutation", "B": "Missense mutation", "C": "Nonsense mutation", "D": "Silent mutation", "E": "Splice site mutation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["4 year old boy", "beta", "regular blood transfusions", "few times", "month", "persistent anemia", "scheduled", "splenectomy", "next", "months", "obtained", "boys red blood cells", "malformed protein", "length", "amino acids", "normal", "healthy red blood cells", "functional protein", "length", "amino acids", "following best accounts", "findings"]}
{"question": "A 32-year-old woman comes to the physician because she has been unable to conceive for 2 years. The patient also reports monthly episodes of pelvic and back pain accompanied by painful diarrhea for 6 years. She takes naproxen for the pain, which has provided some relief. Menses have occurred at regular 28-day intervals since menarche at the age of 11 years and last for 7 days. She is sexually active with her husband and does not use contraception. Pelvic and rectal examination shows no abnormalities. A hysterosalpingogram is unremarkable. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Endometrial tissue outside the uterine cavity", "options": {"A": "Endometrial tissue outside the uterine cavity", "B": "Smooth muscle tumor arising from the myometrium", "C": "Primary failure of the ovaries", "D": "Scarring of the fallopian tubes", "E": "Increased secretion of androgens and luteinizing hormone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "unable to", "years", "patient", "reports monthly episodes of pelvic", "back pain", "painful diarrhea", "years", "naproxen", "pain", "relief", "Menses", "regular", "day intervals", "menarche at", "age", "years", "last", "7 days", "sexually active", "not use contraception", "Pelvic", "rectal examination", "abnormalities", "hysterosalpingogram", "unremarkable", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and, hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?", "answer": "Diabetes mellitus", "options": {"A": "Diabetes mellitus", "B": "Hypertension", "C": "Family history", "D": "Obesity", "E": "Smoking"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "of chest pain", "activity", "past", "months", "medical history", "significant", "appendectomy", "age", "hypertension", "diabetes mellitus type 2", "poorly controlled", "metformin", "lisinopril", "bad", "to", "everyday", "heart attack", "2 stents", "heart", "healthy", "alcohol occasionally", "smokes", "half", "pack", "cigarettes", "day", "executive", "work", "stressful", "Today", "blood pressure", "85", "body mass index", "28.5 kg/m2", "coronary angiogram", "75", "narrowing", "left anterior descending coronary artery", "following", "most significant", "patient"]}
{"question": "A 56-year-old man is brought to the emergency department 30 minutes after falling from a height of 3 feet onto a sharp metal fence pole. He is unconscious. Physical examination shows a wound on the upper margin of the right clavicle in the parasternal line that is 3-cm-deep. Which of the following is the most likely result of this patient's injury?", "answer": "Pneumothorax due to pleural injury", "options": {"A": "Rotator cuff tear due to supraspinatus muscle injury", "B": "Pneumothorax due to pleural injury", "C": "Trapezius muscle paresis due to spinal accessory nerve injury", "D": "Hemathorax due to azygos vein injury", "E": "Traumatic aneurysm due to internal carotid artery injury"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department 30 minutes", "falling", "height of", "feet", "sharp", "pole", "unconscious", "wound", "upper margin", "right clavicle", "parasternal line", "3", "deep", "following", "most likely", "injury"]}
{"question": "A 12-hour-old newborn is urgently transferred to the neonatal intensive care unit because he is found to be cyanotic and appears blue in all four extremities. He was born to a 42-year-old G1P1 mother who underwent no prenatal screening because she did not show up to her prenatal care visits. She has poorly controlled diabetes and hypertension. On physical exam, the infant is found to have slanted eyes, a flattened head, a large tongue, and a single palmar crease bilaterally. Furthermore, a single, loud S2 murmur is appreciated in this patient. Radiography shows a large oblong-shaped heart shadow. Based on this presentation, the neonatologist starts a medication that will temporarily ensure this patient's survival pending definitive fixation of the defect. The substance that was most likely administered in this case also has which of the following effects?", "answer": "Vascular vasodilation", "options": {"A": "Decreased platelet aggregation", "B": "Increased bronchial tone", "C": "Increased uterine tone", "D": "Vascular vasoconstriction", "E": "Vascular vasodilation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["12-hour old newborn", "transferred", "neonatal intensive care unit", "found to", "cyanotic", "appears blue", "four extremities", "born", "year old G1P1", "prenatal screening", "not", "poorly controlled diabetes", "hypertension", "infant", "found to", "eyes", "flattened head", "large tongue", "single palmar crease", "single", "loud S2 murmur", "patient", "Radiography", "large", "shaped heart shadow", "Based", "neonatologist starts", "medication", "patient's survival", "definitive fixation", "defect", "most likely administered", "case", "following effects"]}
{"question": "A syndrome caused by chromosomal anomalies is being researched in the immunology laboratory. Several congenital conditions are observed among the participating patients, mostly involving the thymus and the heart. Common facial features of affected individuals are shown in the image below. Flow cytometry analysis of patient samples reveals a CD19+ and CD3- result. What kind of congenital anomaly is generally observed in these patients, specifically in the thymus?", "answer": "Aplasia", "options": {"A": "Deformation", "B": "Agenesis", "C": "Aplasia", "D": "Malformation", "E": "Disruption"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["syndrome caused", "chromosomal anomalies", "immunology", "congenital conditions", "observed", "participating patients", "mostly involving", "thymus", "heart", "Common facial features", "affected", "Flow cytometry analysis", "patient samples reveals", "CD19", "CD3", "result", "kind", "congenital anomaly", "observed", "patients", "thymus"]}
{"question": "A 65-year-old man presents to the emergency department with confusion and a change in his behavior. The patient was in his usual state of health 3 days ago. He became more confused and agitated this morning thus prompting his presentation. The patient has a past medical history of depression, hypertension, diabetes, and Parkinson disease and is currently taking fluoxetine, lisinopril, insulin, metformin, and selegiline (recently added to his medication regimen for worsening Parkinson symptoms). He also takes oxycodone and clonazepam for pain and anxiety; however, he ran out of these medications last night. His temperature is 101°F (38.3°C), blood pressure is 111/78 mmHg, pulse is 117/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam is notable for an irritable, sweaty, and confused elderly man. Neurological exam reveals hyperreflexia of the lower extremities and clonus. Which of the following is the most likely etiology of this patient’s symptoms?", "answer": "Medication complication", "options": {"A": "Bacterial infection", "B": "Electrolyte abnormality", "C": "Medication complication", "D": "Substance withdrawal", "E": "Viral infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old man presents", "emergency department", "confusion", "patient", "usual state of health 3 days", "more confused", "agitated", "morning", "prompting", "patient", "past medical history of depression", "hypertension", "diabetes", "Parkinson disease", "currently", "fluoxetine", "lisinopril", "insulin", "metformin", "selegiline", "recently added", "medication regimen", "worsening", "symptoms", "oxycodone", "clonazepam", "pain", "anxiety", "ran out", "medications last night", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "irritable", "sweaty", "confused elderly man", "Neurological exam reveals hyperreflexia", "lower extremities", "clonus", "following", "etiology", "patients symptoms"]}
{"question": "A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?", "answer": "Localized rales", "options": {"A": "Bilateral wheezing", "B": "Systolic murmur at the left sternal border", "C": "S3 gallop", "D": "Pleural friction rub", "E": "Localized rales"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old man presents", "physician", "difficulty", "breathing", "3 hours", "history of chest pain", "cough", "palpitation", "chronic smoker", "elective cholecystectomy one month back", "history", "chronic", "recurrent cough", "wheezing", "breathlessness", "temperature", "100", "pulse", "min", "blood pressure", "80 mm Hg", "respirations", "min", "arterial oxygen saturation", "98", "room air", "pulse oximetry", "detailed", "physician orders", "plasma", "level", "elevated", "contrast-enhanced computed tomography", "chest", "filling defect", "segmental pulmonary artery", "left side", "following signs", "to", "observed", "physician", "physical examination", "patients chest"]}
{"question": "A 2250-g (5.0-lb) male newborn and a 2900-g (6.4-lb) male newborn are delivered at 36 weeks' gestation to a 24-year-old, gravida 1, para 1 woman. The mother had no prenatal care. Examination of the smaller newborn shows low-set ears, retrognathia, and right-sided clubfoot. The hematocrit is 41% for the smaller newborn and 69% for the larger newborn. This pregnancy was most likely which of the following?", "answer": "Monochorionic-diamniotic monozygotic", "options": {"A": "Dichorionic-diamniotic monozygotic", "B": "Monochorionic-diamniotic monozygotic", "C": "Conjoined twins", "D": "Dichorionic-monoamniotic monozygotic", "E": "Monochorionic-monoamniotic monozygotic"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["male newborn", "male newborn", "delivered", "36 weeks", "gestation", "year old", "gravida 1", "para 1 woman", "Examination", "smaller newborn", "low-set ears", "retrognathia", "right-sided clubfoot", "hematocrit", "smaller newborn", "69", "larger newborn", "pregnancy", "following"]}
{"question": "A 54-year-old man presents to his primary care physician for back pain. His back pain worsens with standing for a prolonged period of time or climbing down the stairs and improves with sitting. Medical history is significant for hypertension, type II diabetes mellitus, and hypercholesterolemia. Neurologic exam demonstrates normal tone, 5/5 strength, and a normal sensory exam throughout the bilateral lower extremity. Skin exam is unremarkable and dorsalis pedis and posterior tibialis pulses are 3+. Which of the following is the best next step in management?", "answer": "MRI of the lumbosacral spine", "options": {"A": "Ankle-brachial index", "B": "MRI of the lumbosacral spine", "C": "Naproxen", "D": "Radiography of the lumbosacral spine", "E": "Surgical spinal decompression"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["54 year old man presents", "primary care physician", "back pain", "back pain worsens", "standing", "prolonged period", "time", "improves", "sitting", "Medical history", "significant", "hypertension", "type II diabetes mellitus", "hypercholesterolemia", "Neurologic exam", "normal tone", "5/5 strength", "normal", "bilateral lower extremity", "Skin", "unremarkable", "posterior tibialis pulses", "3", "following", "best next step"]}
{"question": "An 11-month-old boy presents with the recent loss of appetite and inability to gain weight. His diet consists mainly of cow’s milk and fruits. Family history is unremarkable. Physical examination shows conjunctival pallor. Laboratory findings are significant for the following:\nHemoglobin 9.1 g/dL\nMean corpuscular volume 75 μm3\nMean corpuscular hemoglobin 20 pg/cell\nRed cell distribution width 18%\nThe patient is presumptively diagnosed with iron deficiency anemia (IDA) and ferrous sulfate syrup is prescribed. Which of the following laboratory values would most likely change 1st in response to this treatment?", "answer": "↑ reticulocyte count", "options": {"A": "Normalization of hemoglobin", "B": "↑ reticulocyte count", "C": "Anisocytosis", "D": "↓ mean corpuscular hemoglobin", "E": "↓ Mentzer index"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old boy presents", "recent loss of appetite", "to gain weight", "diet consists", "Family history", "unremarkable", "conjunctival pallor", "Laboratory findings", "significant", "following", "Hemoglobin", "g", "Mean corpuscular volume", "m3", "pg/cell Red cell distribution width", "patient", "diagnosed", "iron deficiency anemia", "ferrous sulfate", "following laboratory values", "most likely change 1st", "response", "treatment"]}
{"question": "A 45-year-old woman presents to the office with a complaint of generalized weakness that has been getting worse over the last few months. She says that she just does not have the energy for her daily activities. She gets winded quite easily when she takes her dog for a walk in the evening. She says that her mood is generally ok and she gets together with her friends every weekend. She works as a teacher at a local elementary school and used to have frequent headaches while at work. Her husband is a commercial pilot and is frequently away for extended periods of time. Her only son is a sophomore in college and visits her every other week. She has had issues in the past with hypertension, but her blood pressure is currently well-controlled because she is compliant with her medication. She is currently taking atorvastatin and lisinopril. The blood pressure is 130/80 mm Hg, the pulse is 90/min, the temperature is 36.7°C (98.0°F), and the respirations are 16/min. On examination, she appears slightly pale and lethargic. Her ECG today is normal and recent lab work shows the following:\nSerum creatinine 1.5 mg/dL\nEstimated GFR 37.6 mL/min\nHemoglobin (Hb%) 9 mg/dL\nMean corpuscular hemoglobin (MCH) 27 pg\nMean corpuscular hemoglobin concentration (MCHC) 36 g/dL\nMean corpuscular volume (MCV) 85 fL\nReticulocyte count 0.1%\nErythrocyte count 2.5 million/mm3\nSerum iron 160 μg/dL\nSerum ferritin 150 ng/mL\nTotal iron binding capacity 105 μg/dL\nSerum vitamin B12 254 pg/mL\nSerum folic acid 18 ng/mL\nThyroid stimulating hormone 3.5 μU/mL\nWhich of the following will most likely help her?", "answer": "Start her on erythropoietin.", "options": {"A": "Start oral iron supplements.", "B": "Start her on fluoxetine.", "C": "Start her on erythropoietin.", "D": "Start vitamin B12 with folic acid.", "E": "Transfuse red blood cells."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "office", "complaint", "generalized weakness", "getting worse", "months", "not", "energy", "gets winded", "easily", "walk in", "evening", "mood", "gets together", "weekend", "teacher", "local elementary school", "used to", "frequent headaches", "pilot", "frequently", "extended periods", "time", "college", "week", "issues", "past", "hypertension", "blood pressure", "currently well-controlled", "compliant", "medication", "currently", "atorvastatin", "lisinopril", "blood pressure", "80 mm Hg", "pulse", "90 min", "temperature", "36", "98", "respirations", "min", "appears slightly pale", "lethargic", "ECG today", "normal", "recent lab", "following", "Serum creatinine", "mg/dL Estimated GFR", "mL/min Hemoglobin", "dL", "dL", "0", "Serum", "Total iron binding capacity", "3", "following", "most likely help"]}
{"question": "A 58-year-old male undergoes a surveillance colonoscopy in which a 2 cm adenoma is identified and removed. Had this adenoma not been excised, the patient would have been at risk of progression to carcinoma. Which of the following is the final mutational step in the progression from adenoma to carcinoma?", "answer": "p53 inactivation", "options": {"A": "K-ras mutation", "B": "COX-2 overexpression", "C": "p53 inactivation", "D": "APC mutation", "E": "SMAD 2/4 loss"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old male", "surveillance colonoscopy", "2", "adenoma", "identified", "removed", "adenoma not", "patient", "at risk", "progression", "carcinoma", "following", "final mutational step", "progression", "adenoma", "carcinoma"]}
{"question": "A 24-year-old man is brought to the emergency department by his roommates for aggressive and unusual behavior. His roommates state that he has been under a lot of stress lately from his final exams and has been more reclusive. They state that this evening he was very irritable and was yelling at his computer prior to breaking it, followed by him spending several hours at the gym. His temperature is 101°F (38.3°C), blood pressure is 137/98 mmHg, pulse is 120/min, respirations are 23/min, and oxygen saturation is 99% on room air. Physical exam is notable for an irritable young man. Cardiopulmonary exam is notable for tachycardia and bilateral clear breath sounds. Neurological exam reveals dilated pupils. The patient is notably diaphoretic and speaks very rapidly during the physical exam and is aggressive. He is given haloperidol, diphenhydramine, and diazepam for sedation and placed in soft restraints. His symptoms resolved over the next 10 hours in the emergency department. Which of the following is the most likely diagnosis?", "answer": "Lisdexamfetamine intoxication", "options": {"A": "Caffeine intoxication", "B": "Cocaine intoxication", "C": "Lisdexamfetamine intoxication", "D": "Phencyclidine intoxication", "E": "Schizophrenia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "aggressive", "unusual behavior", "state", "lot", "stress", "final exams", "more reclusive", "state", "evening", "very irritable", "computer", "breaking", "followed by", "spending several hours", "temperature", "blood pressure", "98 mmHg", "pulse", "min", "respirations", "23 min", "oxygen saturation", "99", "room air", "notable", "irritable young man", "Cardiopulmonary exam", "notable", "tachycardia", "bilateral clear breath sounds", "Neurological exam reveals dilated pupils", "patient", "diaphoretic", "speaks very rapidly", "aggressive", "given haloperidol", "diphenhydramine", "diazepam", "sedation", "soft restraints", "symptoms resolved", "next 10 hours", "emergency department", "following", "diagnosis"]}
{"question": "A 9-month-old boy is brought to the physician because of increased irritability, continual crying, and fever for 1 day. His mother has noticed that he refuses to lie down on his right side and keeps tugging at his right ear. One week ago, he had a runny nose that has since improved. He was born at term and has been otherwise healthy. He was exclusively breastfed until 2 months of age and is currently bottle-fed with some solid foods introduced. He has been attending a daycare center for the past 5 months. His temperature is 38.4°C (101.1°F) and pulse is 144/min. Otoscopic examination in this child is most likely to show which of the following?", "answer": "Bulging erythematous tympanic membrane", "options": {"A": "Bulging erythematous tympanic membrane", "B": "Retracted opacified tympanic membrane", "C": "Erythematous external auditory canal", "D": "Vesicles in the ear canal", "E": "Brown mass within the ear canal"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "physician", "increased irritability", "continual", "fever", "1 day", "to", "right side", "keeps tugging", "right ear", "One week", "runny nose", "since improved", "born", "term", "healthy", "breastfed", "months", "age", "currently bottle-fed", "introduced", "attending", "daycare center", "past", "months", "temperature", "pulse", "min", "Otoscopic examination", "child", "to", "following"]}
{"question": "An 11-year-old girl is brought to the office by her mother due to complaint of intermittent and severe periumbilical pain for 1 day. She does not have any significant past medical history. She provides a history of a recent school trip to the suburbs. On physical examination, there is a mild tenderness around the umbilicus without any distension or discharge. There is no rebound tenderness. Bowel sounds are normal. An abdominal imaging shows enlarged mesenteric lymph nodes, and she is diagnosed with mesenteric lymphadenitis. However, incidentally, a mass of tissue was seen joining the inferior pole of both kidneys as shown in the image. Which of the following is best describes this renal anomaly?", "answer": "Association with ureteropelvic junction obstruction (UPJO)", "options": {"A": "Fused kidneys ascend beyond superior mesenteric artery.", "B": "Increased risk of developing renal vein thrombosis", "C": "Association with ureteropelvic junction obstruction (UPJO)", "D": "Kidneys are usually non-functional.", "E": "Rapid progression to acute renal failure"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "office", "due to complaint", "intermittent", "severe periumbilical", "1 day", "not", "significant past medical history", "history", "recent school trip", "suburbs", "mild tenderness", "umbilicus", "distension", "discharge", "rebound tenderness", "Bowel sounds", "normal", "abdominal imaging", "enlarged mesenteric lymph nodes", "diagnosed", "mesenteric lymphadenitis", "mass", "tissue", "seen", "inferior pole of", "kidneys", "following", "best", "renal anomaly"]}
{"question": "A 27-year-old man presents to the clinic for his annual physical examination. He was diagnosed with a rare arrhythmia a couple of years ago following an episode of dizziness. A mutation in the gene encoding for the L-type calcium channel protein was identified by genetic testing. He feels fine today. His vitals include: blood pressure 122/89 mm Hg, pulse 90/min, respiratory rate 14/min, and temperature 36.7°C (98.0°F). The cardiac examination is unremarkable. The patient has been conducting some internet research on how the heart works and specifically asks you about his own “ventricular action potential”. Which of the following would you expect to see in this patient?", "answer": "Abnormal phase 2", "options": {"A": "Abnormal phase 1", "B": "Abnormal phase 4", "C": "Abnormal phase 3", "D": "Abnormal phase 2", "E": "Abnormal phase 0"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "clinic", "annual physical examination", "diagnosed", "rare arrhythmia", "couple", "years", "following", "episode of dizziness", "mutation", "gene", "L-type calcium channel protein", "identified", "genetic testing", "fine today", "include", "blood pressure", "mm Hg", "pulse 90 min", "respiratory rate", "min", "temperature 36", "98", "unremarkable", "patient", "internet", "heart", "about", "ventricular action potential", "following", "to see", "patient"]}
{"question": "A 27-year-old female has a history of periodic bloody diarrhea over several years. Colonoscopy shows sigmoid colon inflammation, and the patient complains of joint pain in her knees and ankles. You suspect inflammatory bowel disease. Which of the following would suggest a diagnosis of Crohn disease:", "answer": "Perianal fistula", "options": {"A": "Left lower quadrant pain", "B": "Jaundice", "C": "Loss of large bowel haustra", "D": "Mucosal and submucosal ulcerations", "E": "Perianal fistula"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old female", "history", "periodic bloody diarrhea", "several years", "Colonoscopy", "sigmoid", "patient", "joint pain", "knees", "ankles", "inflammatory bowel disease", "following", "diagnosis", "Crohn disease"]}
{"question": "A 25-year-old man is in the middle of an ascent up a mountain, at an elevation of about 4,500 meters. This is the 4th day of his expedition. His friend notices that in the last few hours, he has been coughing frequently and appears to be short of breath. He has used his albuterol inhaler twice in the past 4 hours, but it does not seem to help. Within the past hour, he has coughed up some frothy, slightly pink sputum and is now complaining of nausea and headache. Other than his asthma, which has been well-controlled on a steroid inhaler, he is healthy. Which of the following is the most likely cause of this man’s symptoms?", "answer": "Non-cardiogenic pulmonary edema", "options": {"A": "Pulmonary embolism", "B": "Non-cardiogenic pulmonary edema", "C": "Acute heart failure", "D": "An acute asthma exacerbation", "E": "Pneumothorax"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "middle", "mountain", "elevation", "500 meters", "4th day", "last", "hours", "coughing frequently", "appears to", "short of breath", "used", "albuterol inhaler twice", "past", "hours", "not", "to help", "past hour", "coughed", "frothy", "slightly pink sputum", "now", "nausea", "headache", "asthma", "well-controlled", "steroid inhaler", "healthy", "following", "most likely cause", "mans symptoms"]}
{"question": "Researchers are investigating the mechanism of cell apoptosis and host defense in mice. They have observed that mice with certain gene deletions are not able to fight the induced viral infection. They identify a cell that is able to destroy target cells infected with viruses by exocytosis of granule contents, which induces the activation of caspases. Which type of cell is responsible for this process?", "answer": "CD8+ lymphocytes", "options": {"A": "Macrophages", "B": "Neutrophils", "C": "CD8+ lymphocytes", "D": "CD4+ lymphocytes", "E": "Eosinophils"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Researchers", "investigating", "mechanism", "cell apoptosis", "host defense", "observed", "certain", "not able to", "induced viral", "cell", "able", "target cells infected", "viruses", "exocytosis", "granule", "induces", "responsible", "process"]}
{"question": "A 10-year-old boy is brought into your clinic by his mother for sunburns that have not been healing. The mother states that he easily gets sunburned. The mother admits she gave birth to him at home and has never taken him to see a doctor. The patient walks with a wide stance gait and appears unstable on his feet. He has an extensive erythematous, scaling, hyperkeratotic rash on his face, neck, arms and legs. After extensive workup, the patient is found to have a genetic disorder that results in defective absorption of an important vitamin. Which of the following is likely to be low if measured?", "answer": "Niacin", "options": {"A": "Niacin", "B": "Vitamin A", "C": "Vitamin K", "D": "Folate", "E": "Vitamin B12"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["A 10 year old boy", "brought", "clinic", "sunburns", "not", "healing", "states", "easily gets sunburned", "gave birth", "home", "never", "to see", "doctor", "patient walks", "wide", "gait", "appears unstable", "feet", "extensive erythematous", "scaling", "hyperkeratotic rash on", "face", "neck", "arms", "legs", "extensive workup", "patient", "found to", "genetic disorder", "results", "defective absorption", "important vitamin", "following", "likely to", "low", "measured"]}
{"question": "A 12-year-old boy is brought to a psychiatrist by his mother upon referral from his pediatrician. The mother describes that for the past 2 years her son has experienced episodes of repetitive blinking and sudden jerking of the arms. Additionally, she notes that he often clears his throat and occasionally makes grunting noises. These symptoms have waxed and waned in frequency, but they have persisted for the past 2 years since they first developed. The patient is otherwise healthy without any coexisting medical issues. Which of the following agents would be effective at reducing the severity and frequency of this patient's current symptoms?", "answer": "Fluphenazine", "options": {"A": "Baclofen", "B": "Valproic acid", "C": "Fluphenazine", "D": "Sertraline", "E": "Gabapentin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "psychiatrist", "pediatrician", "past", "years", "episodes of", "blinking", "sudden jerking", "arms", "notes", "often clears", "throat", "occasionally makes", "symptoms", "waxed", "frequency", "past", "years", "first", "patient", "healthy", "medical issues", "following agents", "effective", "reducing", "severity", "frequency of", "patient's current symptoms"]}
{"question": "A 63-year-old woman comes to the physician because of worsening shortness of breath, cough, and a 4-kg (8.8-lb) weight loss over the last year. She has no history of serious illness and takes no medications. She has smoked one pack of cigarettes daily for 35 years. Her temperature is 37°C (98.6°F), pulse is 92/min, respirations are 20/min, blood pressure is 124/78 mm Hg, and pulse oximetry on room air shows an oxygen saturation of 93%. Physical examination shows decreased breath sounds. A flow-volume loop obtained via pulmonary function testing is shown. Which of the following is the most likely cause of this patient's respiratory symptoms?", "answer": "Chronic obstructive pulmonary disease", "options": {"A": "Chronic obstructive pulmonary disease", "B": "Idiopathic pulmonary fibrosis", "C": "Endotracheal neoplasm", "D": "Chronic asthma", "E": "Unilateral mainstem obstruction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["63 year old woman", "physician", "of worsening shortness", "breath", "cough", "4 kg", "8.8", "weight loss", "year", "history", "serious illness", "medications", "smoked one pack", "cigarettes daily", "35 years", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "mm Hg", "pulse oximetry", "room air", "decreased breath sounds", "flow-volume loop obtained", "pulmonary function testing", "following", "most likely cause", "patient's respiratory"]}
{"question": "A 17-year-old girl presents to the gynecologist's office due to lack of menarche. She has been sexually active with 1 male lifetime partner and always uses a condom. Her mother believes that breast development started at 11 years old. On exam, she is a well-appearing, non-hirsute teenager with Tanner V breast and pubic hair development. Her pelvic exam reveals normal external genitalia, a shortened vagina, and the cervix is unable to be visualized. Initial laboratory testing for hormone levels and karyotype is normal, and imaging confirms what you suspect on exam. What is the most likely cause of her lack of menstruation?", "answer": "Müllerian agenesis", "options": {"A": "5-alpha reductase deficiency", "B": "Androgen insensitivity", "C": "Müllerian agenesis", "D": "Premature ovarian failure", "E": "Turner syndrome"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl presents", "gynecologist's office due to lack", "menarche", "sexually active", "male lifetime", "always uses", "condom", "breast development started", "years old", "exam", "a well appearing", "non hirsute teenager", "Tanner V breast", "pubic hair development", "pelvic exam reveals normal external genitalia", "shortened vagina", "cervix", "unable to", "visualized", "Initial laboratory testing", "hormone levels", "karyotype", "normal", "imaging confirms", "exam", "most likely cause of", "lack", "menstruation"]}
{"question": "A 15-year-old boy is brought to the physician with an ongoing pruritic rash for 1 week. The rash is on his right forearm (refer to the image). He has not had a similar rash in the past. He has no history of allergies, and he is not taking any medications. He frequently enjoys gardening in their backyard. They have no household pets. The physical examination reveals no other abnormalities. Given the most likely diagnosis, which of the following is the most appropriate treatment of the condition described in this case?", "answer": "Topical clotrimazole", "options": {"A": "Oral acitretin", "B": "Oral terbinafine", "C": "Topical clotrimazole", "D": "Topical hydrocortisone", "E": "Topical salicylic acid"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "pruritic rash", "1 week", "rash", "right forearm", "refer", "not", "similar rash", "past", "history of allergies", "not", "medications", "frequently", "backyard", "reveals", "abnormalities", "Given", "diagnosis", "following", "most appropriate treatment", "condition", "case"]}
{"question": "A 17-year-old girl comes to the emergency department with a 5-day history of severe abdominal pain, cramping, nausea, and vomiting. She also has pain with urination. She is sexually active with one male partner, and they use condoms inconsistently. She experienced a burning pain when she last had sexual intercourse 3 days ago. Menses occur at regular 28-day intervals and last 5 days. Her last menstrual period was 3 weeks ago. Her temperature is 38.5°C (101.3°F), pulse is 83/min, and blood pressure is 110/70 mm Hg. Physical examination shows abdominal tenderness in the lower quadrants. Pelvic examination shows cervical motion tenderness and purulent cervical discharge. Laboratory studies show a leukocyte count of 15,000/mm3 and an erythrocyte sedimentation rate of 100 mm/h. Which of the following is the most likely diagnosis?", "answer": "Pelvic inflammatory disease", "options": {"A": "Pyelonephritis", "B": "Ectopic pregnancy", "C": "Ovarian cyst rupture", "D": "Appendicitis", "E": "Pelvic inflammatory disease"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "emergency department", "5-day history", "severe abdominal", "cramping", "nausea", "vomiting", "pain", "urination", "sexually active", "one male", "use condoms", "burning pain", "last", "sexual intercourse", "days", "Menses occur", "regular", "day intervals", "last 5 days", "last menstrual period", "3 weeks", "temperature", "pulse", "83 min", "blood pressure", "70 mm Hg", "abdominal tenderness", "lower quadrants", "Pelvic examination", "cervical motion tenderness", "purulent cervical", "Laboratory studies", "leukocyte count", "mm3", "erythrocyte sedimentation rate", "100 mm/h", "following", "diagnosis"]}
{"question": "A 30-year-old African American woman comes to the physician because of a 3-month history of increasing shortness of breath, cough, and intermittent fever. She works in a local factory that manufactures components for airplanes. She drinks 2–3 glasses of wine daily and has smoked half a pack of cigarettes daily for the past 5 years. Physical examination shows a purple rash on her cheeks and nose. An x-ray of the chest shows bilateral hilar adenopathy and a calcified nodule in the left lower lobe. A bronchoalveolar lavage shows a CD4:CD8 T-lymphocyte ratio of 10:1 (N=2:1). A biopsy of the nodule shows a noncaseating granuloma. Which of the following is the strongest predisposing factor for the development of this patient's condition?", "answer": "Race", "options": {"A": "Race", "B": "Exposure to beryllium", "C": "Alcohol consumption", "D": "Smoking", "E": "Exposure to acid-fast bacilli\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old", "woman", "physician", "of", "3 month history", "increasing shortness", "breath", "cough", "intermittent fever", "local factory", "components", "airplanes", "23 glasses", "daily", "smoked half", "pack", "cigarettes daily", "past", "years", "purple rash", "cheeks", "nose", "x-ray of", "chest", "bilateral hilar adenopathy", "calcified nodule", "left lower lobe", "bronchoalveolar lavage", "CD4", "ratio", "10 1", "N", "1", "biopsy", "nodule", "noncaseating granuloma", "following", "strongest predisposing factor", "development", "patient's condition"]}
{"question": "A 32-year-old woman visits her primary care provider with the results of a recent colonoscopy, which was ordered after 3 episodes of rectal bleeding in the last month. Her grandmother, mother, and sister all have been diagnosed with nonpolyposis colorectal cancer, at ages 65, 50, and 40 years, respectively. Colonoscopy for this patient revealed a large, flat, right-sided adenoma. Histopathological examination of the lesion showed villous histology and high-grade dysplasia. Which of the following helps explain the condition of this patient?", "answer": "Microsatellite instability", "options": {"A": "Chromosomal instability", "B": "Microsatellite instability", "C": "DNA hypermethylation", "D": "Chemical carcinogenicity", "E": "Environmental carcinogenicity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "primary care provider", "results", "recent colonoscopy", "ordered", "episodes of rectal bleeding", "last month", "diagnosed", "colorectal cancer", "ages 65", "50", "40 years", "Colonoscopy", "patient revealed", "large", "flat", "right-sided adenoma", "Histopathological examination", "lesion", "villous histology", "high-grade dysplasia", "following helps", "condition", "patient"]}
{"question": "Two days after admission to the hospital, a 74-year-old man develops confusion and headache. He has also been vomiting over the past hour. His temperature is 36.7°C (98°F), pulse is 98/min, respirations are 22/min, and blood pressure is 140/80 mm Hg. He is lethargic and oriented only to person. Examination shows flushed skin. Fundoscopic examination shows bright red retinal veins. Serum studies show:\nNa+ 138 mEq/L\nK+ 3.5 mEq/L\nCl- 100 mEq/L\nHCO3- 17 mEq/L\nCreatinine 1.2 mg/dL\nUrea nitrogen 19 mg/dL\nLactate 8.0 mEq/L (N = 0.5 - 2.2 mEq/L)\nGlucose 75 mg/dL\nArterial blood gas analysis on room air shows a pH of 7.13. This patient's current presentation is most likely due to treatment for which of the following conditions?\"", "answer": "Hypertensive crisis", "options": {"A": "Alzheimer disease", "B": "Hypertensive crisis", "C": "Tension headache", "D": "Major depressive disorder", "E": "Acute dystonia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two days", "hospital", "74 year old man", "confusion", "headache", "vomiting", "past hour", "temperature", "36", "pulse", "98 min", "respirations", "min", "blood pressure", "80 mm Hg", "lethargic", "oriented only", "flushed skin", "Fundoscopic", "bright red retinal veins", "Serum studies", "Na", "mEq", "5", "HCO3", "Creatinine", "mg", "Urea nitrogen", "Lactate", "N", "mEq/L", "Glucose", "mg/dL Arterial blood gas analysis", "room air", "pH", "7", "patient", "urrent ", "ue to  reatment ", "ollowing  onditions?"]}
{"question": "A 24-year-old Turkish female presents to your office for a routine examination. She recently started a new job and has been tired most of the time. She does not have any dizziness and has not lost consciousness. She follows a well-balanced diet and is not vegetarian. She recalls that other family members have had similar symptoms in the past. On physical exam her temperature is 99°F (37.2°C), blood pressure is 115/78 mmHg, pulse is 100/min, respirations are 22/min, and pulse oximetry is 99% on room air. On physical exam, you notice conjunctival pallor. Labs are obtained and the results are shown below:\n\nHemoglobin: 10.2 g/dL\nHematocrit: 34%\nLeukocyte count: 5,000 cells/mm^3 with normal differential\nPlatelet count: 252,000/mm^3\nMean corpuscular hemoglobin concentration: 20.4%\nMean corpuscular volume: 65 µm^3\n\nPeripheral blood smear is shown in the image provided. The cause of her anemia is most likely associated with which of the following?", "answer": "Point mutation on chromosome 11", "options": {"A": "Point mutation on chromosome 11", "B": "X-linked defect in ALA synthase", "C": "Inhibition of ALA dehydratase", "D": "Blood loss", "E": "Malnutrition"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "female presents", "office", "routine", "recently started", "new job", "tired most of the time", "not", "dizziness", "not lost consciousness", "follows", "well balanced diet", "not", "similar symptoms", "past", "temperature", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "min", "pulse oximetry", "99", "room air", "conjunctival pallor", "Labs", "obtained", "results", "Hemoglobin", "10", "g/dL Hematocrit", "Leukocyte count", "5", "cells mm", "normal differential Platelet count", "mm", "Mean corpuscular hemoglobin concentration", "20", "Mean corpuscular volume", "65 m", "Peripheral blood smear", "cause", "anemia", "most likely associated with"]}
{"question": "A 43-year-old man is brought to the emergency department by his wife because of a 1-hour history of confusion and strange behavior. She reports that he started behaving in an agitated manner shortly after eating some wild berries that they had picked during their camping trip. His temperature is 38.7°C (101.7°F). Physical examination shows warm, dry skin and dry mucous membranes. His pupils are dilated and minimally reactive to light. His bowel sounds are decreased. The patient is admitted and pharmacotherapy is initiated with a drug that eventually results in complete resolution of all of his symptoms. This patient was most likely administered which of the following drugs?", "answer": "Physostigmine", "options": {"A": "Scopolamine", "B": "Rivastigmine", "C": "Atropine", "D": "Physostigmine", "E": "Neostigmine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "of", "hour history", "confusion", "strange behavior", "reports", "started", "agitated", "eating", "trip", "temperature", "warm", "dry", "dry mucous membranes", "pupils", "dilated", "reactive to light", "bowel sounds", "decreased", "patient", "pharmacotherapy", "initiated", "drug", "results", "complete resolution", "symptoms", "patient", "most likely administered", "following drugs"]}
{"question": "A 35-year-old G1 is brought to the emergency department because of sharp pains in her abdomen. She is at 30 weeks gestation based on ultrasound. She complains of  feeling a little uneasy during the last 3 weeks of her pregnancy. She mentions that her abdomen has not been enlarging as expected and her baby is not moving as much as during the earlier part of the pregnancy. If anything, she noticed her abdomen has decreased in size. While she is giving her history, the emergency medicine physician notices that she is restless and is sweating profusely. An ultrasound is performed and her blood is sent for type and match. The blood pressure is 90/60 mm Hg, the pulse is 120/min, and the respiratory rate  is 18/min. The fetal ultrasound is significant for no fetal heart motion or fetal movement. Her blood work shows the following: hemoglobin, 10.3 g/dL; platelet count, 1.1*10(5)/ml; bleeding time, 10 minutes; PT, 25 seconds; and PTT, 45 seconds. Which of the following would be the best immediate course of management for this patient?", "answer": "IV fluids", "options": {"A": "IV fluids", "B": "Initiation of labor", "C": "D-dimer assay", "D": "Fresh frozen plasma", "E": "Low-molecular-weight heparin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old G1", "brought", "emergency department", "of sharp", "abdomen", "30 weeks gestation based", "ultrasound", "little uneasy", "weeks", "pregnancy", "abdomen", "not", "enlarging", "baby", "not moving", "much", "earlier part of", "pregnancy", "abdomen", "decreased", "size", "giving", "history", "emergency physician", "restless", "sweating", "ultrasound", "performed", "blood", "sent", "type", "match", "blood pressure", "90 60 mm Hg", "pulse", "min", "respiratory rate", "min", "fetal ultrasound", "significant", "fetal", "fetal movement", "blood", "following", "hemoglobin", "10.3 g dL", "platelet count", "1.1 10 5", "ml", "bleeding time", "10 minutes", "PT", "seconds", "PTT", "seconds", "following", "best immediate course", "patient"]}
{"question": "A 21-year-old G1P0 woman presents to the labor and delivery ward at 39 weeks gestation for elective induction of labor. She requests a labor epidural. An epidural catheter is secured at the L4-L5 space. She exhibits no hemodynamic reaction to lidocaine 1.5% with epinephrine 1:200,000. A continuous infusion of bupivacaine 0.0625% is started. After 5 minutes, the nurse informs the anesthesiologist that the patient is hypotensive to 80/50 mmHg with a heart rate increase from 90 bpm to 120 bpm. The patient is asymptomatic and fetal heart rate has not changed significantly from baseline. She says that her legs feel heavy but is still able to move them. What is the most likely cause of the hemodynamic change?", "answer": "Sympathetic blockade", "options": {"A": "Bainbridge reflex", "B": "Intrathecal infiltration of local anesthetic", "C": "Local anesthetic systemic toxicity", "D": "Spinal anesthesia", "E": "Sympathetic blockade"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["21-year-old", "woman presents", "labor", "delivery ward", "weeks gestation", "elective induction of labor", "labor epidural", "epidural catheter", "secured", "L4 L5 space", "hemodynamic reaction", "lidocaine", "epinephrine", "200", "continuous infusion", "bupivacaine 0", "started", "5 minutes", "nurse informs", "anesthesiologist", "patient", "hypotensive", "80 50 mmHg", "heart rate increase", "90", "patient", "asymptomatic", "fetal heart rate", "not changed", "baseline", "legs", "heavy", "able to move", "most likely cause", "hemodynamic change"]}
{"question": "A 39-year-old woman presents to her gynecologist for a routine visit. She has no complaints during this visit. She had an abnormal pap test 6 years ago that showed atypical squamous cells of undetermined significance. The sample was negative for human papillomavirus. On her follow-up Pap test 3 years later, there was no abnormality. The latest pap test results show atypical glandular cells with reactive changes in the cervical epithelium. The gynecologist decides to perform a colposcopy, and some changes are noted in this study of the cervical epithelium. The biopsy shows dysplastic changes in the epithelial cells. Which of the following is the next best step in the management of this patient?", "answer": "Cold knife conization", "options": {"A": "Loop electrosurgical excision procedure", "B": "Cold knife conization", "C": "Follow-up pap smear in one year", "D": "Follow-up pap smear in 3 years", "E": "Repeat colposcopy in 6 months"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "gynecologist", "routine", "complaints", "abnormal pap test", "years", "negative", "human papillomavirus", "follow-up Pap test", "years later", "abnormality", "latest pap test results", "atypical", "changes", "cervical epithelium", "gynecologist", "to perform", "colposcopy", "changes", "noted", "study", "cervical epithelium", "biopsy", "changes", "following", "next best step", "patient"]}
{"question": "A 64-year-old nulliparous woman comes to the physician because of fatigue and an increase in abdominal girth despite a 5-kg (11.0-lb) weight loss over the past 6 months. Her last Pap smear 2 years ago showed atypical squamous cells of undetermined significance; subsequent HPV testing was negative at that time. Menarche was at the age of 10 years and her last menstrual period was 6 years ago. Abdominal examination shows shifting dullness. There is tenderness to palpation of the left lower quadrant but no guarding or rebound. Bimanual palpation shows a small uterus and a left 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 beta-hCG level", "B": "Proliferation of endometrial glands", "C": "Chocolate cyst of the left ovary", "D": "Elevated serum CA-125 level", "E": "Cervical dysplasia on cervical smear"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["64 year old nulliparous woman", "physician", "fatigue", "increase", "abdominal", "5 kg", "0", "weight loss", "past 6 months", "last Pap smear", "years", "subsequent HPV testing", "negative", "time", "Menarche", "age", "10 years", "last menstrual period", "years", "Abdominal", "shifting dullness", "tenderness", "palpation", "left lower quadrant", "guarding", "Bimanual palpation", "small uterus", "left adnexal mass", "Further", "to", "following findings"]}
{"question": "A 17-year-old boy comes to the emergency department following an injury during football practice. He fell and landed on the lateral aspect of his right shoulder. He is holding his right arm supported by his left arm, with his right arm adducted against his side. He is tender to palpation directly over the middle third of his clavicle. Radiographs reveal a non-displaced fracture of the middle third of the clavicle. Which of the following is the most appropriate treatment at this time?", "answer": "Figure-of-eight splinting", "options": {"A": "Open reduction and internal fixation with a compression plate", "B": "Open reduction and internal fixation with an intramedullary nail", "C": "Open reduction and internal fixation with lag screws", "D": "Figure-of-eight splinting", "E": "Mobilization"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "emergency department following", "injury", "football", "fell", "landed", "lateral aspect", "right", "holding", "right arm", "left arm", "right arm", "side", "tender", "palpation directly", "middle third of", "clavicle", "Radiographs reveal", "non-displaced fracture of", "middle third", "clavicle", "following", "most appropriate treatment", "time"]}
{"question": "A 34-year-old man comes to the physician for a routine health maintenance examination. He was diagnosed with HIV 8 years ago. He is currently receiving triple antiretroviral therapy. He is sexually active and uses condoms consistently. He is planning a trip to Thailand with his partner to celebrate his 35th birthday in 6 weeks. His last tetanus and diphtheria booster was given 4 years ago. He received three vaccinations against hepatitis B 5 years ago. He had chickenpox as a child. Other immunization records are unknown. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Leukocyte count shows 8,700/mm3, and CD4+ T-lymphocyte count is 480 cells/mm3 (Normal ≥ 500); anti-HBs is 150 mIU/mL. Which of the following recommendations is most appropriate at this time?", "answer": "Measles, mumps, rubella vaccine", "options": {"A": "Hepatitis B vaccine", "B": "Bacillus Calmette Guerin vaccine", "C": "Measles, mumps, rubella vaccine", "D": "Yellow fever vaccine", "E": "No vaccination"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "routine", "diagnosed", "HIV", "years", "currently receiving triple antiretroviral therapy", "sexually active", "uses condoms", "planning", "trip", "Thailand", "to", "weeks", "last tetanus", "diphtheria booster", "given 4 years", "received three vaccinations", "hepatitis B", "years", "chickenpox", "child", "unknown", "Vital signs", "normal limits", "Cardiopulmonary", "abnormalities", "Leukocyte count", "700 mm3", "CD4", "lymphocyte count", "480 cells/mm3", "Normal", "500", "anti-HBs", "mIU/mL", "following", "most appropriate", "time"]}
{"question": "A 37-year-old man comes to the emergency department for severe eye pain. The patient reports that he is a construction worker and was drilling metal beams when he suddenly felt a sharp pain in his right eye. Since then, the vision in his right eye has seemed blurry and his eye “has not stopped tearing.” The patient’s medical history is significant for type II diabetes mellitus and hypertension. His medications include metformin, captopril, and lovastatin. He has a mother with glaucoma, and both his brother and father have coronary artery disease. Upon physical examination, there is conjunctival injection present in the right eye with no obvious lacerations to the eyelids or defects in extraocular eye movements. Pupils are equal and reactive to light. No afferent pupillary defect is appreciated. The unaffected eye has 20/20 visual acuity. The patient refuses to participate in the visual acuity exam of the right eye due to pain. Which of the following is the best initial step in management?", "answer": "Fluorescein stain", "options": {"A": "Fluorescein stain", "B": "Orbital magnetic resonance imaging", "C": "Patching", "D": "Tonometry", "E": "Topical corticosteroids"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "emergency department", "severe eye pain", "patient reports", "construction worker", "drilling", "beams", "sharp pain in", "right eye", "then", "vision", "right", "blurry", "eye", "not stopped tearing", "patients medical history", "significant", "type II diabetes mellitus", "hypertension", "medications include metformin", "captopril", "lovastatin", "glaucoma", "coronary artery disease", "conjunctival present", "right eye", "lacerations", "eyelids", "defects", "extraocular eye movements", "Pupils", "equal", "reactive to light", "afferent pupillary defect", "eye", "20/20 visual acuity", "patient", "to", "visual acuity exam", "right eye", "pain", "following", "best initial step"]}
{"question": "A 49-year-old man comes to the hospital for a 10-day history of cough and worsening shortness of breath. He has sharp right-sided chest pain that worsens on inspiration and coughing. Two weeks ago, the patient was admitted to the hospital after passing out on the street from alcohol intoxication but he left against medical advice. He has coronary artery disease and hypertension, and he does not take any medications. He drinks 4 cans of beer daily and has smoked 2 packs of cigarettes daily for 20 years. His temperature is 38.5°C (101.3° F), pulse is 110/min, respirations are 29/min, and blood pressure is 110/65 mmHg. Examination shows poor dentition. There is dullness to percussion at the base of the right lung. Crackles and markedly decreased breath sounds are heard over the right middle and lower lung fields. An x-ray of the chest shows a right-sided loculated pleural effusion and consolidation of the surrounding lung with visible air bronchogram; there are no rib fractures. Thoracocentesis is performed. Examination of this patient's pleural fluid is most likely to show which of the following findings?", "answer": "Glucose of 30 mg/dL", "options": {"A": "Amylase of 200 U/L", "B": "Lymphocytosis of > 90%", "C": "Pleural fluid LDH/serum LDH ratio of 0.5", "D": "Lactate dehydrogenase of 45 U/L", "E": "Glucose of 30 mg/dL"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "hospital", "a 10 day history", "cough", "worsening shortness of breath", "sharp right-sided chest pain", "worsens", "inspiration", "coughing", "Two weeks", "patient", "out", "street", "alcohol intoxication", "left against medical advice", "coronary artery disease", "hypertension", "not", "medications", "4 cans", "daily", "smoked 2 packs", "cigarettes daily", "20 years", "temperature", "F", "pulse", "min", "respirations", "29 min", "blood pressure", "65 mmHg", "poor dentition", "dullness", "percussion", "base of", "right lung", "Crackles", "markedly decreased breath sounds", "heard", "right middle", "lower lung fields", "x-ray of", "chest", "right-sided loculated pleural effusion", "consolidation of", "surrounding lung", "visible air bronchogram", "rib fractures", "performed", "pleural fluid", "to", "following findings"]}
{"question": "A 70-year-old Caucasian women presents to the emergency department complaining of abdominal pain. She is oriented to person but is slow to answer questions and cannot name her location. She is afebrile on exam and endorses mild suprapubic tenderness. Her urine culture was positive for leukocyte esterase and nitrites. She was prescribed appropriate treatments. On follow-up, she complains of a new rash. In the past few days she has noticed that her skin becomes very red and more easily sunburns. Per the patient, her symptoms have resolved and her initial infection has cleared. Which of the following antibiotics was most likely prescribed to this patient?", "answer": "Trimethoprim-sulfamethoxazole", "options": {"A": "Nitrofurantoin", "B": "Cephalexin", "C": "Azithromycin", "D": "Trimethoprim-sulfamethoxazole", "E": "Ceftriaxone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old", "presents", "emergency department", "abdominal pain", "oriented to person", "slow to", "name", "location", "afebrile", "exam", "mild suprapubic tenderness", "urine culture", "positive", "leukocyte esterase", "appropriate treatments", "follow-up", "new rash", "past", "days", "skin", "very red", "more easily sunburns", "patient", "symptoms", "resolved", "initial infection", "cleared", "following", "most likely", "patient"]}
{"question": "A previously healthy 26-year-old man is brought to the emergency department because of extreme agitation and confusion. He is unable to give a clear history. His mother says he returned from a hiking trip 4 weeks ago on which he also explored caves. Over the past few days, he has had generalized fever and malaise with a sore throat. He has refused to drink any liquids for the last day. His immunizations are up-to-date. His temperature is 100.6°F (38.1°C), pulse is 92/min, respirations are 18/min, and blood pressure is 110/75 mm Hg. His pupils are 6 mm wide and reactive to light. He has a moderate amount of drool. Muscle tone is greatly increased in both the upper and lower extremities. The remainder of the examination is not performed because the patient becomes combative and refuses further assessment. Serum and urine toxicology screens are negative. Which of the following is most likely to have prevented this patient's condition?", "answer": "Immunoglobulin and vaccination administration", "options": {"A": "Corticosteroid therapy", "B": "Plasmapheresis", "C": "Antifungal therapy", "D": "Antiviral therapy", "E": "Immunoglobulin and vaccination administration"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department", "extreme agitation", "confusion", "unable to give", "clear history", "returned", "trip", "weeks", "caves", "past", "days", "generalized fever", "malaise", "sore throat", "to", "day", "immunizations", "date", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "75 mm Hg", "pupils", "6 mm wide", "reactive to light", "moderate amount", "drool", "Muscle tone", "greatly increased", "upper", "lower extremities", "not performed", "patient", "combative", "further", "Serum", "urine toxicology screens", "negative", "following", "to", "prevented", "patient's condition"]}
{"question": "A 22-year-old woman with a history of bipolar disorder presents to her psychiatrist’s office for a follow-up appointment. She says she is doing better on the new drug she was prescribed. However, she recently noticed that she is drinking a lot of water and urinates more frequently throughout the day. She also says there are moments recently when she feels confused and agitated. Her vitals include: blood pressure 122/89 mm Hg, temperature 36.7°C (98.0°F), pulse 88/min and respirations 18/min. Her physical examination is within normal limits. Which of the following drugs was she most likely prescribed?", "answer": "Lithium", "options": {"A": "Lithium", "B": "Amitriptyline", "C": "Valproic acid", "D": "Carbamazepine", "E": "Chlorpromazine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "history of bipolar disorder presents", "psychiatrists office", "follow-up appointment", "better", "new drug", "recently", "drinking", "lot", "water", "more frequently", "day", "recently", "confused", "agitated", "include", "blood pressure", "mm Hg", "temperature 36", "98", "pulse 88 min", "respirations", "min", "normal limits", "following drugs", "most likely"]}
{"question": "A 21-year-old man presents to the physician with complaint of fever and non-bloody diarrhea for the past 3 days, after a week of constipation. He and his family recently returned from a summer spent in New Delhi, India visiting relatives. Physical examination reveals abdominal tenderness and a pink macular rash extending from his trunk to his upper arms. His vital signs are as follows: temperature is 99.7°F (37.6°C), blood pressure is 120/72 mmHg, pulse is 85/min, and respirations are 16/min. Which of the following drugs would be most effective in treating this patient’s condition?", "answer": "Ciprofloxacin", "options": {"A": "Ciprofloxacin", "B": "Metronidazole", "C": "Oral rehydration solution", "D": "Oral vancomycin", "E": "Penicillin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["21-year-old man presents", "physician", "complaint", "fever", "non bloody diarrhea", "past 3 days", "week", "constipation", "recently returned", "summer spent", "New", "India", "reveals abdominal tenderness", "pink macular rash extending", "trunk", "upper arms", "vital signs", "follows", "temperature", "99", "blood pressure", "72 mmHg", "pulse", "85 min", "respirations", "min", "following drugs", "most effective", "treating", "patients condition"]}
{"question": "A 13-year-old boy is brought to his pediatrician for evaluation of leg pain. Specifically, he has been having pain around his right knee that has gotten progressively worse over the last several months. On presentation, he has swelling and tenderness over his right distal femur. Radiographs are obtained and the results are shown in figure A. His family history is significant in that several family members also had this disorder and others had pathology in the eye near birth. The patient is referred for a genetic consult, and a mutation is found on a certain chromosome. The chromosome that is most likely affected also contains a gene that is associated with which of the following pathologies?", "answer": "Breast cancer", "options": {"A": "Breast cancer", "B": "Colorectal cancer", "C": "Neurofibromas", "D": "Pancreatic cancers", "E": "Soft tissue sarcomas"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "pediatrician", "evaluation", "leg", "pain", "right", "gotten", "worse", "months", "swelling", "tenderness", "right distal femur", "Radiographs", "obtained", "results", "family history", "significant", "disorder", "others", "pathology", "eye", "birth", "patient", "referred", "genetic", "mutation", "found", "certain chromosome", "chromosome", "most likely affected", "contains", "gene", "associated with", "following pathologies"]}
{"question": "A 2-month-old Middle Eastern female infant from a consanguinous marriage presents with seizures, anorexia, failure to thrive, developmental delay, and vomiting and fatigue after eating. Blood work demonstrated levels of methylmalonic acid nearly 500 times normal levels. A carbon-14 propionate incorporation assay was performed on the fibroblasts of the patient and compared to a healthy, normal individual. Little to none of the radiolabeled carbons of the propionate appeared in any of the intermediates of the Krebs cycle. Which of the following reactions is not taking place in this individual?", "answer": "Methylmalonyl-CoA --> Succinyl-CoA", "options": {"A": "Propionyl-CoA --> Methylmalonyl-CoA", "B": "Acetyl-CoA + CO2 --> Malonyl-CoA", "C": "Methylmalonyl-CoA --> Succinyl-CoA", "D": "Pyruvate --> acetyl-CoA", "E": "Acetyl-CoA + Oxaloacetate --> Citrate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["2 month old Middle Eastern female infant", "presents", "seizures", "anorexia", "failure to thrive", "developmental delay", "vomiting", "fatigue", "eating", "Blood", "levels of methylmalonic acid nearly 500 times normal", "propionate incorporation assay", "performed", "patient", "healthy", "normal", "Little", "radiolabeled carbons", "propionate appeared", "intermediates", "following reactions", "not", "place"]}
{"question": "A 25-year-old woman with a history of polycystic ovarian syndrome, depression, and chronic bilateral ear infections presents to the otolaryngologist's clinic 12 weeks after right ear tympanoplasty. Her audiology report one week prior showed that her hearing improved as expected by 20 decibels. However, she reports that she has occasional shooting pain with eating and when she wears earrings. She states that she has a stressful job as a cashier at the local department store and often sleeps poorly. She denies any neck pain or tenderness when she washes her face. On physical exam, no tenderness is elicited with preauricular or mandibular palpation bilaterally. No jaw clicking is heard. Right postauricular tapping causes tenderness in her right tonsillar area. Her molar teeth appear even and symmetric bilaterally. Her uvula is midline and her gag reflex is intact. What is the most likely diagnosis?", "answer": "Glossopharyngeal neuralgia", "options": {"A": "Atypical migraine", "B": "Bruxism", "C": "Cluster headache", "D": "Glossopharyngeal neuralgia", "E": "Trigeminal neuralgia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "history", "polycystic ovarian syndrome", "depression", "chronic bilateral ear infections presents", "otolaryngologist's clinic", "weeks", "right ear tympanoplasty", "audiology report one week prior", "hearing improved", "20 decibels", "reports", "occasional shooting pain with eating", "states", "stressful job", "local department store", "often sleeps poorly", "neck pain", "tenderness", "face", "tenderness", "elicited", "preauricular", "mandibular palpation", "jaw", "heard", "Right postauricular", "causes tenderness", "right tonsillar area", "molar teeth appear", "symmetric", "uvula", "midline", "gag reflex", "intact", "diagnosis"]}
{"question": "A 14-month-old boy is brought in by his parents with an 8-month history of diarrhea, abdominal tenderness and concomitant failure to thrive. The pediatric attending physician believes that Crohn’s disease is the best explanation of this patient’s symptoms. Based on the pediatric attending physician’s experience, the pretest probability of this diagnosis is estimated at 40%. According to Fagan nomogram (see image). If the likelihood ratio of a negative test result (LR-) for Crohn’s disease is 0.04, what is the chance that this is the correct diagnosis in this patient with a negative test result?", "answer": "2.5%", "options": {"A": "2.5%", "B": "25%", "C": "40%", "D": "75%", "E": "97.5%"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "month history", "diarrhea", "abdominal tenderness", "concomitant failure to thrive", "pediatric attending physician", "Crohns disease", "best", "patients symptoms", "Based", "pediatric attending physicians", "probability", "diagnosis", "estimated", "40", "see", "likelihood ratio", "negative test result", "LR", "Crohns disease", "0.04", "chance", "correct diagnosis", "patient", "negative test result"]}
{"question": "A 48-year-old woman with a history of osteoarthritis and hypertension presents to the office complaining of persistent abdominal pain for the last 2 months. She describes the pain as 'burning and achy' that is worse when she eats, which has lead to a weight loss of 4.5 kg (10.0 lb). The patient is currently taking lisinopril and atenolol for her blood pressure and ibuprofen as needed for her osteoarthritis. Her temperature is 37.1°C (98.7°F), heart rate is 75/min, and blood pressure is 120/80 mm Hg. An endoscopy is performed and a gastric ulcer is visualized and biopsied. The biopsy reveals H. pylori infection. Which of the following is the most likely predisposing factor to this patient’s diagnosis?", "answer": "Chronic NSAID use", "options": {"A": "Chronic NSAID use", "B": "Longstanding GERD", "C": "Adverse effect of beta-blockers", "D": "Age and gender", "E": "A congenital diverticulum"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["48 year old woman", "history of osteoarthritis", "hypertension presents", "office", "persistent abdominal pain", "last", "months", "pain", "burning", "achy", "worse", "eats", "weight loss of", "kg", "10 0", "patient", "currently", "lisinopril", "atenolol", "blood pressure", "ibuprofen as needed", "osteoarthritis", "temperature", "98", "heart rate", "75 min", "blood pressure", "80 mm Hg", "endoscopy", "performed", "gastric ulcer", "visualized", "biopsied", "biopsy reveals H", "pylori infection", "following", "predisposing factor", "patients diagnosis"]}
{"question": "A 52-year-old male patient with chronic alcoholism presents to an ambulatory medical clinic, where the hepatologist elects to perform comprehensive hepatitis B screening, in addition to several other screening and preventative measures. Given the following choices, which serologic marker, if positive, would indicate the patient’s immunity to the hepatitis B virus?", "answer": "HBsAb", "options": {"A": "HBsAg", "B": "HBsAb", "C": "HBcAb", "D": "HBeAg", "E": "HBeAb"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male patient", "chronic alcoholism presents", "ambulatory medical clinic", "hepatologist", "to perform comprehensive hepatitis B screening", "several", "screening", "preventative measures", "Given", "following", "serologic marker", "positive", "patients immunity"]}
{"question": "A 24-year-old man comes to the physician because of chronic fatigue and generalized weakness after exertion. His legs feel stiff after walking long distances and he has leg cramps after climbing stairs. His symptoms are always relieved by rest. Urine dipstick shows 3+ blood and urinalysis is negative for RBCs. Baseline venous lactate and serum ammonia levels are collected, after which a blood pressure cuff is attached to the upper right arm. The patient is asked to continuously pump his right arm with the cuff inflated and additional venous samples are collected at 2-minute intervals. Analysis of the venous blood samples shows that, over time, serum ammonia levels increase and venous lactate levels remain stable. A biopsy of the right gastrocnemius muscle will most likely show which of the following?", "answer": "Subsarcolemmal acid–Schiff-positive deposits", "options": {"A": "Intrafascicular CD8+ lymphocytic infiltration", "B": "Endomysial fibrosis with absent dystrophin", "C": "Intermyofibrillar proliferation of mitochondria", "D": "Subsarcolemmal acid–Schiff-positive deposits", "E": "Perivascular CD4+ lymphocytic infiltrate"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "chronic fatigue", "generalized weakness", "exertion", "legs", "stiff", "walking long distances", "leg cramps", "symptoms", "always relieved by", "Urine dipstick", "3", "blood", "urinalysis", "negative", "Baseline venous lactate", "serum ammonia levels", "collected", "blood pressure cuff", "upper right arm", "patient", "to", "pump", "right arm", "cuff", "additional venous samples", "collected at", "minute intervals", "Analysis", "venous blood samples", "time", "serum ammonia levels increase", "venous lactate levels", "stable", "biopsy of", "right gastrocnemius muscle", "most likely", "following"]}
{"question": "A 59-year-old man comes to the physician because of a painful, burning red rash on his face and hands, which developed 30 minutes after going outside to do garden work. He 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 he does not apply sunscreen. The patient was diagnosed with small cell lung carcinoma 2 months ago and is currently undergoing chemotherapy. He is currently taking demeclocycline for malignancy-associated hyponatremia and amoxicillin for sinusitis. He has also had occasional back pain. He takes zolpidem and drinks 1–2 glasses of brandy before going to sleep every night. He has smoked a pack of cigarettes daily for 20 years. His pulse is 72/min and his blood pressure is 120/75 mm Hg. Physical examination shows prominent erythema on his forehead, cheeks, and neck. Erythema and papular eruptions are seen on the dorsum of both hands. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Use of demeclocycline", "options": {"A": "Adverse reaction to amoxicillin", "B": "Uroporphyrin accumulation", "C": "Systemic lupus erythematosus", "D": "Use of demeclocycline", "E": "Normal sunburn reaction\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["59 year old man", "physician", "painful", "burning red rash on", "face", "hands", "30 minutes", "outside", "garden", "long sleeved shirt", "exposed to direct", "10 minutes", "patient", "light skinned", "history", "occasional sunburns", "not apply", "patient", "diagnosed", "small cell lung carcinoma", "months", "currently", "chemotherapy", "currently", "demeclocycline", "malignancy associated hyponatremia", "amoxicillin", "sinusitis", "occasional back pain", "zolpidem", "glasses", "to sleep", "night", "smoked", "pack", "cigarettes daily", "20 years", "pulse", "72 min", "blood pressure", "75 mm Hg", "prominent erythema", "forehead", "cheeks", "neck", "Erythema", "papular eruptions", "seen", "dorsum of", "hands", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the cervical spine", "options": {"A": "X-ray of the chest", "B": "X-ray of the neck", "C": "CT scan of the cervical spine", "D": "Focused Assessment with Sonography in Trauma", "E": "X-ray of the right wrist\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "minutes", "falling", "roof", "house", "roof", "fell", "not", "consciousness", "not", "nausea", "arrival", "alert", "oriented", "cervical", "neck", "pulse", "96 min", "respirations", "min", "blood pressure", "mm Hg", "multiple bruises", "forehead", "right cheek", "pupils", "equal", "reactive to light", "2 cm laceration", "right ear", "Bilateral", "canals", "abnormalities", "right wrist", "swollen", "tender", "range of motion", "limited", "pain", "lungs", "clear", "auscultation", "midline cervical spine tenderness", "tenderness", "2nd", "3rd ribs on", "right side", "abdomen", "soft", "nontender", "Neurologic examination", "focal findings", "Two peripheral venous catheters", "following", "most appropriate next step"]}
{"question": "A 63-year-old man presents to his primary care physician because he has been having headaches and hearing loss. In addition, he says that he has been having difficulty opening his jaw to eat and recurrent middle ear infections. Physical exam reveals enlarged neck lymph nodes and a mass in the nasopharynx. Biopsy of the mass reveals undifferentiated squamous epithelial cells. The organism that is most likely associated with this patient's disease is also associated with which of the following disorders?", "answer": "Burkitt lymphoma", "options": {"A": "Adult T-cell lymphoma", "B": "Burkitt lymphoma", "C": "Heptaocellular carcinoma", "D": "Kaposi sarcoma", "E": "Vulvar carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old man presents", "primary care physician", "headaches", "hearing loss", "addition", "difficulty opening", "jaw", "eat", "recurrent middle ear infections", "reveals enlarged neck lymph nodes", "mass", "nasopharynx", "Biopsy", "reveals undifferentiated squamous epithelial cells", "most likely associated with", "patient's disease", "associated", "following disorders"]}
{"question": "A 26-year-old nurse presents 12 hours after she accidentally stuck herself with a blood-contaminated needle. She reported the accident appropriately and now seeks post-exposure prophylaxis. She does not have any complaints at the moment of presentation. Her vital signs include: blood pressure 125/80 mm Hg, heart rate 71/min, respiratory rate 15/min, and temperature 36.5℃ (97.7℉). Physical examination is unremarkable. The nurse has prescribed a post-exposure prophylaxis regimen which includes tenofovir, emtricitabine, and raltegravir. How will tenofovir change the maximum reaction rate (Vm) and Michaelis constant (Km) of the viral reverse transcriptase?", "answer": "Vm will stay the same, Km will increase", "options": {"A": "Vm will decrease, Km will stay the same", "B": "Vm and Km will both decrease", "C": "Vm will decrease, Km will increase", "D": "Vm will stay the same, Km will increase", "E": "Vm and Km will both increase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old nurse presents 12 hours", "stuck", "blood contaminated needle", "reported", "now", "post-exposure prophylaxis", "not", "complaints", "vital signs include", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "unremarkable", "nurse", "post-exposure prophylaxis regimen", "includes tenofovir", "emtricitabine", "raltegravir", "tenofovir change", "maximum reaction rate", "Vm", "constant", "viral reverse transcriptase"]}
{"question": "A 55-year-old man, who underwent a kidney transplant 2 years ago, presents in septic shock. He is compliant with his immunosuppressive therapy. He does not use any drugs and is sexually active with one male partner. His complete blood count returns as follows: Hemoglobin: 13.7 g/dL, white blood cell count: 4000 cells/microliter, platelets 250,000 cells/microliter. Of note, from his differential: neutrophils: 10%, lymphocytes: 45%, and monocytes: 7%. His basic metabolic profile is notable for a creatinine remaining at his baseline of 0.9 mg/dL. The patient is started on broad spectrum antibiotics, but his condition does not improve. Fungal blood cultures are obtained and grow Candida species. Which of the following was the most-likely predisposing factor?", "answer": "Decreased phagocytic cell count", "options": {"A": "Defective IL-2 receptor", "B": "Decreased phagocytic cell count", "C": "HIV infection", "D": "Failure to take suppressive trimethoprim/sulfamethoxazole therapy", "E": "Renal failure"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "kidney transplant", "years", "presents", "septic shock", "compliant", "immunosuppressive therapy", "not use", "drugs", "sexually active", "one male", "complete blood count returns", "follows", "Hemoglobin", "g/dL", "white blood cell count", "4000 cells/microliter", "platelets", "cells/microliter", "note", "differential", "10", "lymphocytes", "basic metabolic profile", "notable", "creatinine remaining", "baseline", "0.9 mg/dL", "patient", "started", "broad spectrum", "condition", "not", "Fungal blood cultures", "obtained", "following", "predisposing factor"]}
{"question": "One day after doctors helped a 28-year-old primigravid woman deliver a 4700 g (10 lb 6 oz) boy, he has bluish discoloration of his lips and fingernails. Oxygen saturation on room air is 81%. Examination shows central cyanosis. A continuous machine-like murmur is heard over the left upper sternal border. A single S2 heart sound is present. Supplemental oxygen does not improve the cyanosis. Echocardiography shows the pulmonary artery arising from the posterior left ventricle and the aorta arising from the right ventricle with active blood flow between the right and left ventricles. Further evaluation of the mother is most likely to show which of the following?", "answer": "Elevated fasting blood glucose", "options": {"A": "Elevated fasting blood glucose", "B": "Positive rapid plasma reagin test", "C": "Prenatal alcohol use", "D": "Prenatal lithium intake", "E": "Prenatal phenytoin intake"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["One day", "doctors helped", "year old primigravid woman deliver", "g", "10", "6 oz", "boy", "discoloration", "lips", "fingernails", "Oxygen saturation", "room air", "81", "central cyanosis", "continuous machine", "murmur", "heard", "left upper sternal border", "single S2 heart sound", "present", "Supplemental oxygen", "not", "cyanosis", "Echocardiography", "pulmonary artery arising", "posterior left ventricle", "aorta arising", "right", "active blood flow", "right", "left ventricles", "Further", "to", "following"]}
{"question": "A 65-year-old man with chronic obstructive lung disease, depression, and type 2 diabetes mellitus comes to the physician with fever, chills, dyspnea, and a productive cough for 5 days. His temperature is 38.8°C (101.8°F) and respirations are 30/min. An x-ray of the chest shows a right lower lobe infiltrate, and sputum culture grows bacteria that are sensitive to fluoroquinolone antibiotics. Pharmacotherapy with oral moxifloxacin is initiated. Three days later, the patient continues to have symptoms despite being compliant with the antibiotic. Serum moxifloxacin levels are undetectable. The lack of response to antibiotic therapy in this patient is most likely due to the concurrent ingestion of which of the following medications?", "answer": "Multivitamin", "options": {"A": "Amitryptyline", "B": "Multivitamin", "C": "Glimepiride", "D": "Theophylline", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65-year-old man", "chronic obstructive lung disease", "depression", "type 2 diabetes mellitus", "physician", "fever", "chills", "dyspnea", "productive cough", "5 days", "temperature", "respirations", "30/min", "x-ray of", "chest", "right lower lobe infiltrate", "sputum culture", "bacteria", "sensitive to fluoroquinolone antibiotics", "Pharmacotherapy", "oral moxifloxacin", "initiated", "Three days later", "patient", "to", "symptoms", "compliant", "antibiotic", "Serum moxifloxacin levels", "undetectable", "lack", "response", "antibiotic therapy", "patient", "due to", "concurrent", "following medications"]}
{"question": "A 75-year-old over-weight gentleman with a long history of uncontrolled hypertension, diabetes, smoking and obesity is presenting to his primary care physician with a chief complaint of increased difficulty climbing stairs and the need to sleep propped up by an increasing number of pillows at night. On physical examination the patient has an extra heart sound just before S1 heard best over the cardiac apex and clear lung fields. The EKG and chest x-ray are attached (Figures A and B respectively). What is the largest contributor to this patient's symptoms?", "answer": "Uncontrolled Hypertension", "options": {"A": "Long-term smoking", "B": "Uncontrolled Hypertension", "C": "Obesity", "D": "Sleep Apnea", "E": "Acute Myocardial Infarction"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old over-weight", "long history of uncontrolled hypertension", "diabetes", "smoking", "obesity", "primary care physician", "chief complaint", "increased difficulty climbing stairs", "need to sleep", "increasing number", "pillows", "night", "patient", "extra heart sound", "S1 heard best", "cardiac apex", "clear lung fields", "EKG", "chest x-ray", "largest", "patient's symptoms"]}
{"question": "An 18-month-old boy presents to the pediatrician by his mother for a routine check-up. The mother has no concerns, although she asks about the \"hole in his heart\" that the patient had at birth. The patient has no history of cyanosis or heart failure; however, a holosystolic, harsh murmur was noted at the 3- and 6-month check-ups. On examination, the patient is playful and alert. He has met all developmental milestones. The cardiac examination reveals a regular rate and rhythm with persistence of the holosystolic, harsh murmur. What is the most likely cause of the murmur in this child?", "answer": "Defect of the membranous interventricular septum", "options": {"A": "Defect of muscular interventricular septum", "B": "Patent foramen ovale", "C": "Defect of the membranous interventricular septum", "D": "Defective dynein functioning", "E": "Failure of endocardial cushion to form"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy presents", "pediatrician", "routine check-up", "hole", "heart", "patient", "birth", "patient", "history", "cyanosis", "heart failure", "holosystolic", "harsh murmur", "noted", "month check-ups", "patient", "playful", "alert", "met", "reveals", "regular rate", "rhythm", "holosystolic", "harsh murmur", "most likely cause", "murmur", "child"]}
{"question": "A 4-month-old boy is brought to his pediatrician for a well-child visit. His parents have noticed that he has had poor growth compared to his older siblings. The boy was delivered vaginally after a normal pregnancy. His temperature is 98.8°F (37.1°C), blood pressure is 98/68 mmHg, pulse is 88/min, and respirations are 20/min. On exam, his abdomen appears protuberant, and the boy appears to have abnormally enlarged cheeks. A finger stick reveals that the patient’s fasting blood glucose is 50 mg/dL. On further laboratory testing, the patient is found to have elevated blood lactate levels, as well as no response to a glucagon stimulation test. What enzymatic defect is most likely present?", "answer": "Glucose-6-phosphatase", "options": {"A": "Alpha-1,4-glucosidase", "B": "Alpha-1,6-glucosidase", "C": "Glucose-6-phosphatase", "D": "Glycogen phosphorylase", "E": "Glycogen synthase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 month old boy", "brought", "pediatrician", "poor growth", "boy", "delivered", "normal pregnancy", "temperature", "98", "blood pressure", "98", "mmHg", "pulse", "88 min", "respirations", "20 min", "exam", "abdomen appears protuberant", "boy appears to", "enlarged cheeks", "finger stick reveals", "patients fasting blood glucose", "50 mg/dL", "further laboratory testing", "patient", "found to", "elevated blood lactate levels", "response to", "glucagon stimulation test", "enzymatic defect", "present"]}
{"question": "A 10-month-old boy is brought to the clinic with a history of recurrent episodes of stridor and wheezing. His mother reports that his wheezing is exacerbated by crying, feeding, and flexion of the neck, and is relieved by extension of the neck. Occasionally he vomits after feeding. What is the most likely diagnosis?", "answer": "Double aortic arch", "options": {"A": "Gastroesophageal reflux disease", "B": "Laryngomalacia", "C": "Double aortic arch", "D": "Congenital subglottic stenosis", "E": "Recurrent viral wheeze"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A 10 month old boy", "brought", "clinic", "history of recurrent episodes", "stridor", "wheezing", "reports", "wheezing", "exacerbated", "flexion", "neck", "relieved by extension of", "neck", "Occasionally", "vomits", "diagnosis"]}
{"question": "A 25-year-old nulliparous woman presents to her gynecologist complaining of recurrent menstrual pain. She reports a 4-month history of pelvic pain that occurs during her periods. It is more severe than her typical menstrual cramps and sometimes occurs when she is not on her period. She also complains of pain during intercourse. Her periods occur every 28-30 days. Her past medical history is notable for kyphoscoliosis requiring spinal fusion and severe acne rosacea. She takes trans-tretinoin and has a copper intra-uterine device. Her family history is notable for ovarian cancer in her mother and endometrial cancer in her paternal grandmother. Her temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 16/min. On exam, she appears healthy and is in no acute distress. A bimanual examination demonstrates a normal sized uterus and a tender right adnexal mass. Her intrauterine device is well-positioned. What is the underlying cause of this patient’s condition?", "answer": "Endometrial glands and stroma within the peritoneal cavity", "options": {"A": "Benign proliferation of uterine myometrium", "B": "Chronic inflammation of the uterine endometrium", "C": "Endometrial glands and stroma within the peritoneal cavity", "D": "Endometrial glands and stroma within the uterine myometrium", "E": "Excess androgen production"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old nulliparous woman presents", "gynecologist", "recurrent menstrual pain", "reports", "4 month history", "pelvic pain", "occurs", "periods", "more severe", "typical menstrual cramps", "sometimes occurs", "not", "period", "pain", "intercourse", "periods occur", "30 days", "past medical history", "notable", "kyphoscoliosis", "spinal fusion", "severe acne rosacea", "trans tretinoin", "copper intra-uterine device", "family history", "notable", "ovarian cancer", "endometrial cancer", "temperature", "blood pressure", "85 mmHg", "pulse", "90 min", "respirations", "min", "exam", "appears healthy", "acute distress", "bimanual examination", "normal sized uterus", "tender right adnexal mass", "intrauterine device", "well positioned", "underlying cause", "patients condition"]}
{"question": "Urinalysis shows:\nProtein 1+\nLeukocyte esterase positive\nNitrite positive\nRBC 2/hpf\nWBC 90/hpf\nWBC casts numerous\nWhich of the following is the most appropriate next step in management?\"", "answer": "Treat on an outpatient basis with ciprofloxacin", "options": {"A": "Treat on an outpatient basis with nitrofurantoin", "B": "Admit the patient and perform an CT scan of the abdomen", "C": "Treat on an outpatient basis with ciprofloxacin", "D": "Admit the patient and treat with intravenous levofloxacin", "E": "Wait for culture results and treat accordingly"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Urinalysis", "Protein 1", "Leukocyte esterase positive Nitrite", "RBC", "hpf WBC 90", "casts numerous", "following", "most appropriate next step"]}
{"question": "Two days after hospitalization for urgent chemotherapy to treat Burkitt’s lymphoma, a 7-year-old boy develops dyspnea and reduced urine output. He also feels a tingling sensation in his fingers and toes. Blood pressure is 100/65 mm Hg, respirations are 28/min, pulse is 100/min, and temperature is 36.2°C (97.2°F). The lungs are clear to auscultation. He has excreted 20 mL of urine in the last 6 hours. Laboratory studies show:\nHemoglobin 15 g/dL\nLeukocyte count 6,000/mm3 with a normal differential serum\nK+ 6.5 mEq/L\nCa+ 7.6 mg/dL\nPhosphorus 5.4 mg/dL\nHCO3− 15 mEq/L\nUric acid 12 mg/dL\nUrea nitrogen 44 mg/dL\nCreatinine 2.4 mg/dL\nArterial blood gas analysis on room air:\npH 7.30\nPCO2 30 mm Hg\nO2 saturation 95%\nWhich of the following is most likely to have prevented this patient’s condition?", "answer": "Allopurinol", "options": {"A": "Allopurinol", "B": "Ciprofloxacin", "C": "Pneumococcal polysaccharide vaccine", "D": "Sodium bicarbonate", "E": "No prevention would have been effective"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Two days", "urgent chemotherapy to treat Burkitts lymphoma", "year old boy", "dyspnea", "reduced urine output", "tingling sensation in", "fingers", "toes", "Blood pressure", "100 65 mm Hg", "respirations", "min", "pulse", "100 min", "temperature", "36", "97", "lungs", "clear", "auscultation", "excreted 20 mL", "urine", "last", "hours", "Laboratory studies", "Hemoglobin", "g Leukocyte 6", "mm3", "normal differential serum", "mEq", "dL Phosphorus", "HCO3", "Arterial blood gas analysis", "room air", "pH 7 30 PCO2", "mm Hg O2 saturation 95", "following", "to", "prevented", "patients condition"]}
{"question": "A 26-year-old woman comes to the emergency room because she had difficulty breathing during an exercise session. She also has a cough and end-expiratory wheezing. Besides these symptoms, she has a normal physical appearance. She has experienced similar breathing problems during exercise in the past, but never during rest. She is afebrile. What is the best treatment in this case?", "answer": "Short acting β2-agonists", "options": {"A": "Systemic corticosteroids", "B": "Short acting β2-agonists", "C": "Aminophylline", "D": "No therapy, only avoidance of exercise", "E": "Long acting β2-agonists"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency room", "difficulty", "exercise", "cough", "end", "symptoms", "normal physical", "similar breathing", "exercise", "past", "never", "afebrile", "best treatment", "case"]}
{"question": "A 27-year-old man comes to the physician because of a 1-day history of right-sided facial weakness and sound intolerance. Three days ago, he hit the right side of his head in a motor vehicle collision. He neither lost consciousness nor sought medical attention. Physical examination shows drooping of the mouth and ptosis on the right side. Sensation over the face is not impaired. Impedance audiometry shows an absence of the acoustic reflex in the right ear. Which of the following muscles is most likely paralyzed in this patient?", "answer": "Stylohyoid", "options": {"A": "Tensor tympani", "B": "Stylopharyngeus", "C": "Cricothyroid", "D": "Anterior belly of the digastric", "E": "Stylohyoid"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old man", "physician", "1-day history", "right-sided facial weakness", "sound intolerance", "Three days", "hit", "right side of", "head", "motor vehicle collision", "lost consciousness", "drooping", "mouth", "ptosis", "right side", "Sensation", "face", "not impaired", "Impedance audiometry", "absence of", "acoustic reflex", "right ear", "following muscles", "most likely", "patient"]}
{"question": "A 3-year-old boy is brought to the emergency department by his mother for the evaluation of abdominal pain for one hour after drinking a bottle of toilet bowl cleaner. The mother reports that he vomited once on the way to the hospital and his vomit was non-bloody. The patient has pain with swallowing. He appears uncomfortable. Pulse oximetry shows an oxygen saturation of 82%. Examination shows heavy salivation. Oral examination shows mild oral erythema and in the area of the epiglottis, but no burns. An x-ray of the chest shows no abnormalities. The patient is admitted to the intensive care unit. He is intubated and oxygenation and intravenous fluid resuscitation are begun. All contaminated clothes are removed. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Obtain upper endoscopy", "options": {"A": "Obtain upper endoscopy", "B": "Perform gastric lavage", "C": "Dilute the ingested agent", "D": "Obtain barium upper gastrointestinal series", "E": "Administer activated charcoal"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "evaluation", "abdominal", "one hour", "drinking", "bottle", "toilet", "cleaner", "reports", "vomited", "hospital", "vomit", "non bloody", "patient", "pain with swallowing", "appears", "Pulse oximetry", "oxygen saturation", "heavy salivation", "mild oral erythema", "area", "epiglottis", "burns", "x-ray of", "chest", "abnormalities", "patient", "intubated", "oxygenation", "intravenous fluid resuscitation", "begun", "contaminated clothes", "removed", "following", "most appropriate next step", "patient"]}
{"question": "A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?", "answer": "Start progestin-only therapy", "options": {"A": "Total abdominal hysterectomy with bilateral salpingoopherectomy", "B": "Partial, cervix-sparing hysterectomy", "C": "Start combination estrogen and progestin therapy", "D": "Start progestin-only therapy", "E": "Observation with annual endometrial biopsies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old female presents", "gynecologist", "spotting between periods", "reports", "menses began", "age", "never", "spotting prior to", "three months", "medical history", "significant", "estrogen-receptor positive intraductal carcinoma of the breast", "treated with tamoxifen", "endometrial biopsy", "performed", "endometrial hyperplasia with atypia", "reports", "currently", "to", "children", "next best step"]}
{"question": "A 22-year-old man comes to the physician because of generalized fatigue for the past 3 months. During this time, his grades have declined in his college courses because he has had difficulty focusing on assignments and sometimes sleeps in class. He no longer plays the drums for his band and has stopped attending family events. His temperature is 37°C (98.6°F), pulse is 60/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he describes his mood as “ok.” He has a flat affect. There is no evidence of suicidal ideation. His speech is slow in rate and monotone in rhythm, and his thought process is organized. He has no delusions or hallucinations. Which of the following is the most appropriate next step in treatment?", "answer": "Escitalopram therapy", "options": {"A": "Escitalopram therapy", "B": "Reassurance", "C": "Phenelzine therapy", "D": "Diazepam therapy", "E": "Amitriptyline therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "of generalized fatigue", "past 3 months", "time", "college courses", "difficulty focusing", "assignments", "sometimes sleeps", "longer plays", "drums", "band", "stopped attending", "temperature", "98", "pulse", "60 min", "blood pressure", "80 mm Hg", "abnormalities", "mental status", "mood", "flat affect", "suicidal ideation", "speech", "slow", "rate", "rhythm", "organized", "delusions", "hallucinations", "following", "most appropriate next step", "treatment"]}
{"question": "A 67-year-old African American woman visits the clinic with a complaint of progressive fatigue. These symptoms started gradually and slowly became worse over the past 4 months. She is short of breath after walking a few blocks and has difficulty climbing stairs. She denies having chest pain, leg swelling, or a cough. Her past medical history is significant for osteoporosis and gastroesophageal reflux disease. She takes omeprazole as needed and daily baby aspirin. She is a retired accountant and is a lifetime nonsmoker but she drinks a small glass of red wine every night before bed. Her diet is varied. Today, her blood pressure is 128/72 mm Hg, heart rate is 105/min, respiratory rate is 22/min, temperature 37.0°C (98.6°F) and oxygen saturation is 94% on room air. On physical examination, she has marked conjunctival pallor. Cardiac auscultation reveals a rapid heartbeat with a regular rhythm and a 2/6 systolic murmur over the right upper sternal border. Lungs are clear to auscultation bilaterally and abdominal examination was within normal limits. Peripheral blood smear shows microcytic, hypochromic red blood cells. The following laboratory values are obtained:\nHematocrit 29%\nHemoglobin 9.8 mg/dL\nMean red blood cell volume 78 fL\nPlatelets 240,000/mm3\nWhich of the following will most likely be present in this patient?", "answer": "A decrease in her reticulocyte count", "options": {"A": "An increase in her reticulocyte count", "B": "A decrease in her reticulocyte count", "C": "A decrease in erythropoietin levels ", "D": "Increased white blood cell count", "E": "Thrombocytopenia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["67 year old", "woman", "clinic", "complaint", "progressive fatigue", "symptoms started", "slowly", "worse", "past", "months", "short of breath", "few blocks", "difficulty climbing stairs", "chest pain", "leg swelling", "cough", "past medical history", "significant", "osteoporosis", "gastroesophageal reflux disease", "omeprazole as needed", "daily baby aspirin", "retired accountant", "lifetime nonsmoker", "small glass", "night", "bed", "diet", "Today", "blood pressure", "72 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "oxygen saturation", "room air", "marked conjunctival pallor", "Cardiac auscultation reveals", "rapid heartbeat", "regular rhythm", "2/6 systolic murmur", "right upper sternal border", "Lungs", "clear", "auscultation", "abdominal", "normal limits", "Peripheral blood smear", "following laboratory values", "obtained", "Hematocrit", "Hemoglobin", "mg", "red blood cell volume", "Platelets", "mm3", "following", "most likely", "present", "patient"]}
{"question": "A 2-day old male newborn delivered vaginally at 36 weeks to a 29-year-old woman, gravida 3, para 2, has generalized convulsions lasting 2 minutes. Previous to the event, he had difficulty feeding and was lethargic. Pregnancy and delivery were uncomplicated. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Pregnancy and delivery of the mother's first 2 children were also uncomplicated. Medications of the mother include folic acid and a multivitamin. The mother's immunizations are up-to-date. The infant appears icteric. His vital signs are within normal limits. The infant's weight and length are at the 5th percentile, and his head circumference at the 99th percentile for gestational age. There are several purpura of the skin. Ocular examination shows posterior uveitis. The patient does not pass his auditory screening tests. Cranial ultrasonography shows ventricular dilatation, as well as hyperechoic foci within the cortex, basal ganglia, and periventricular region. Which of the following is the most likely diagnosis?", "answer": "Congenital toxoplasmosis", "options": {"A": "Congenital toxoplasmosis", "B": "Congenital rubella infection", "C": "Congenital syphilis infection", "D": "Congenital parvovirus infection", "E": "Congenital varicella infection\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2-day old male newborn delivered", "36 weeks", "29 year old woman", "gravida 3", "para 2", "generalized convulsions lasting 2 minutes", "event", "difficulty feeding", "lethargic", "Pregnancy", "delivery", "uncomplicated", "Apgar scores", "8", "1", "5 minutes", "Pregnancy", "delivery", "first", "uncomplicated", "Medications", "include folic acid", "multivitamin", "immunizations", "date", "infant appears icteric", "vital signs", "normal limits", "infant's weight", "length", "5th percentile", "head circumference", "99th percentile", "gestational age", "several purpura", "skin", "Ocular examination", "posterior uveitis", "patient", "not pass", "auditory screening tests", "Cranial ultrasonography", "ventricular dilatation", "hyperechoic foci", "cortex", "basal ganglia", "periventricular region", "following", "diagnosis"]}
{"question": "A 34-year-old woman makes an appointment with her gynecologist because she has been having foul smelling vaginal discharge. She says that the symptoms started about a week ago, but she can't think of any particular trigger associated with the onset of symptoms. She says that otherwise she has not experienced any pain or discomfort associated with these discharges. She has never been pregnant and currently has multiple sexual partners with whom she uses protection consistently. She has no other medical history though she says that her family has a history of reproductive system malignancy. Physical exam reveals a normal appearing vulva, and a sample of the vaginal discharge reveals gray fluid. Which of the following characteristics is associated with the most likely cause of this patient's disorder?", "answer": "Oxidase-negative, facultative anaerobe", "options": {"A": "Cervicovaginal friability", "B": "Dimorphic fungus", "C": "Overgrowth of abnormal cervical cells", "D": "Oxidase-negative, facultative anaerobe", "E": "Flagellated, pear-like-shaped trophozoites"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman makes", "appointment", "gynecologist", "foul smelling vaginal discharge", "symptoms started", "week", "trigger associated with", "onset", "symptoms", "not", "pain", "discomfort associated with", "discharges", "never", "pregnant", "currently", "multiple sexual partners", "uses protection", "medical history", "history", "reproductive malignancy", "reveals", "normal appearing vulva", "sample", "vaginal reveals gray fluid", "following characteristics", "associated with", "likely cause", "patient's"]}
{"question": "A previously healthy 2-year-old girl is brought to the physician by her mother after she noticed multiple painless, nonpruritic papules on her abdomen. The child attends daycare three times per week, and this past week one child was reported to have similar lesions. Her immunizations are up-to-date. Her brother had chickenpox one month ago. She is at the 50th percentile for height and the 60th percentile for weight. Vital signs are within normal limits. Examination shows several skin-colored, nontender, pearly papules with central umbilication on the abdomen and extremities. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Molluscum contagiosum", "options": {"A": "Insect bites", "B": "Molluscum contagiosum", "C": "Cutaneuous lichen planus", "D": "Verruca vulgaris", "E": "Chickenpox\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old girl", "brought", "physician", "multiple painless", "nonpruritic papules", "abdomen", "child attends daycare three times per week", "past week one child", "reported to", "similar lesions", "immunizations", "date", "chickenpox one month", "50th percentile", "height", "percentile", "weight", "Vital signs", "normal limits", "several skin colored", "nontender", "papules", "central", "abdomen", "extremities", "abnormalities", "following", "diagnosis"]}
{"question": "A 28-year-old man presents with fever, chills, and malaise which began 5 days ago. He also mentions that the back of his right upper arm feels itchy. He says he works as a forest guide and recently came back from a forest expedition. Upon asking, he reports that the forest where he works is infested with ticks. His temperature is 38.3°C (100.9°F), the pulse is 87/min, the respiratory rate is 15/min, and the blood pressure is 122/90 mm Hg. On physical examination, there is a rash present on the posterior aspect of his upper right arm which is shown in the image. Which of the following medications is the best course of treatment for this patient?", "answer": "Doxycycline", "options": {"A": "Azithromycin", "B": "Clindamycin", "C": "Doxycycline", "D": "Fluconazole", "E": "Trimethoprim-sulfamethoxazole"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "fever", "chills", "malaise", "began 5 days", "back of", "right upper arm", "itchy", "guide", "recently", "back", "reports", "temperature", "100 9F", "pulse", "87 min", "respiratory rate", "min", "blood pressure", "90 mm Hg", "rash present", "posterior aspect", "upper arm", "following medications", "best course", "treatment", "patient"]}
{"question": "A 23-year-old woman is brought to the emergency department by her boyfriend because of a 4-month history of feeling sad. Her boyfriend says that, during this period, she has slept and eaten very little and has been unable to focus at work. She says that she feels “empty inside” and has been hearing voices telling her that she is worthless. She first heard these voices 7 months ago when they started to make fun of her. She does not drink alcohol or use illicit drugs. Physical and neurological examinations show no abnormalities. On mental status examination, her speech is slow and monotonous; she abruptly stops talking in the middle of sentences and does not finish them. She occasionally directs her attention to the ceiling as if she were listening to someone. Which of the following is the most likely diagnosis?", "answer": "Schizoaffective disorder", "options": {"A": "Schizophrenia", "B": "Schizophreniform disorder", "C": "Schizoaffective disorder", "D": "Mood disorder with psychotic features", "E": "Schizotypal personality disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "brought", "emergency department", "month history", "feeling sad", "period", "slept", "eaten very little", "unable to focus", "empty", "hearing voices", "worthless", "first heard", "voices", "months", "started to make", "not", "alcohol", "use illicit", "Physical", "neurological examinations", "abnormalities", "mental status", "speech", "slow", "stops talking", "middle", "not finish", "occasionally directs", "listening", "following", "diagnosis"]}
{"question": "Blood cultures are sent to the laboratory and empiric treatment with intravenous vancomycin is started. Blood cultures grow gram-negative bacilli identified as Cardiobacterium hominis. Which of the following is the most appropriate next step in management?", "answer": "Switch to intravenous ceftriaxone", "options": {"A": "Switch to intravenous ampicillin", "B": "Switch to intravenous ceftriaxone", "C": "Switch to intravenous cefazolin", "D": "Switch to intravenous gentamicin", "E": "Add intravenous rifampin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Blood cultures", "sent", "laboratory", "empiric", "intravenous vancomycin", "started", "Blood cultures", "identified", "following", "most appropriate next step"]}
{"question": "A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?", "answer": "Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3", "options": {"A": "Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3", "B": "Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3", "C": "Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3", "D": "Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3", "E": "Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old man", "brought", "emergency department", "patient", "head", "collision", "15 minutes", "currently unresponsive", "temperature", "99", "blood pressure", "60", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "95", "room air", "FAST exam", "fluid", "pouch", "Laboratory values", "sent", "patient", "started", "initial trauma survey", "started", "Twenty minutes later", "blood pressure", "95 65 mmHg", "pulse", "min", "patient", "further stabilized", "scheduled", "emergency", "following best", "patients", "likely", "laboratory"]}
{"question": "A 65-year-old alcoholic male had been taken to the emergency room after he was found unconscious covered in vomitus. After regaining consciousness, he complained of a constant productive cough with foul-smelling sputum for the past few weeks. A chest x-ray(Image A) was taken and the patient was treated accordingly. The patient comes to you today complaining of watery diarrhea. Which best describes the pathogen causing diarrhea?", "answer": "Gram-positive bacilli, motile, spore-forming, obligate anaerobe", "options": {"A": "Gram-positive bacilli, motile, spore-forming, obligate anaerobe", "B": "Gram-negative bacilli, lactose non-fermenter, glucose fermenter, oxidase positive", "C": "Gram-positive bacilli, non-motile spore-forming, aerobe", "D": "Gram-negative bacilli, lactose non-fermenter, oxidase negative, and hydrogen sulfide producer", "E": "Gram-negative bacilli, lactose non-fermenter, oxidase negative, and does not produce hydrogen sulfide"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old alcoholic male", "emergency room", "found unconscious covered", "vomitus", "consciousness", "constant productive cough", "foul-smelling sputum", "past", "weeks", "chest x-ray", "patient", "treated", "patient", "today", "watery diarrhea", "best", "causing diarrhea"]}
{"question": "A 45-year-old African American woman presents to her family physician for a routine examination. Past medical history is positive for amyloidosis and non-rhythm-based cardiac abnormalities secondary to the amyloidosis. Which of the following cardiac parameters would be expected in this patient?", "answer": "Preserved ejection fraction and decreased compliance", "options": {"A": "Preserved ejection fraction and increased compliance", "B": "Preserved ejection fraction and decreased compliance", "C": "Decreased ejection fraction and increased compliance", "D": "Decreased ejection fraction and decreased compliance", "E": "Increased ejection fraction and decreased compliance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "woman presents", "family physician", "routine", "Past medical history", "positive", "amyloidosis", "non rhythm based cardiac abnormalities secondary", "amyloidosis", "following cardiac parameters", "patient"]}
{"question": "A 26-year-old healthy woman presents with lightheadedness, palpitations, and sweating, which started suddenly after she was frightened by her neighbor’s dog. The patient’s blood pressure is 135/80 mm Hg, the heart rate is 150/min, the respiratory rate is 15/min, and the temperature is 36.6℃ (97.9℉). Her ECG is shown in the exhibit. What is the preferred agent for pharmacologic management of this condition?", "answer": "Adenosine", "options": {"A": "Verapamil", "B": "Metoprolol", "C": "Amiodarone", "D": "Adenosine", "E": "Propafenone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old healthy woman presents", "lightheadedness", "palpitations", "sweating", "started", "patients blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "ECG", "preferred agent", "pharmacologic management", "condition"]}
{"question": "A 68-year-old female presents to the emergency room with acute onset of dyspnea and hemoptysis. Her past medical history is unremarkable and she has had no prior surgeries. A ventilation-perfusion scan demonstrates a large perfusion defect that is not matched by a ventilation defect in the left lower lobe. Which of the following would you also expect to find in this patient:", "answer": "Pleuritic chest pain", "options": {"A": "Pleuritic chest pain", "B": "Bradycardia", "C": "Aortic dilation", "D": "Claudication", "E": "Increased inspiratory capacity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female presents", "emergency room", "acute", "dyspnea", "hemoptysis", "past medical history", "unremarkable", "prior surgeries", "ventilation-perfusion scan", "large perfusion defect", "not matched", "ventilation defect", "left lower lobe", "following", "to find", "patient"]}
{"question": "In patients with chronic obstructive pulmonary disease, stimulation of muscarinic acetylcholine receptors results in an increase in mucus secretion, smooth muscle contraction and bronchoconstriction. The end result is an increase in airway resistance. Which of the following pharmacologic agents interferes directly with this pathway?", "answer": "Ipratropium", "options": {"A": "Epinephrine", "B": "Theophylline", "C": "Ipratropium", "D": "Albuterol", "E": "Metoprolol"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["patients", "chronic obstructive pulmonary disease", "stimulation", "muscarinic acetylcholine receptors results", "increase", "mucus secretion", "smooth muscle contraction", "bronchoconstriction", "end result", "increase", "airway resistance", "following pharmacologic agents interferes directly"]}
{"question": "A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?", "answer": "Perform ultrasonography", "options": {"A": "Perform ultrasonography", "B": "Perform external cephalic version", "C": "Administer misoprostol", "D": "Administer oxytocin", "E": "Perform Mauriceau-Smellie-Veit maneuver"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old primigravid woman", "weeks", "gestation", "emergency department", "of frequent contractions", "hours", "pregnancy", "complicated", "hyperemesis gravidarum", "second trimester", "contractions occur", "minutes", "increasing", "intensity", "duration", "onset", "temperature", "98", "pulse", "min", "blood pressure", "85 mm Hg", "Uterine contractions", "palpation", "Pelvic examination", "vagina", "cervix", "50", "3", "dilated", "4 hours", "cervix", "80", "dilated", "Pelvic examination", "inconclusive", "position of", "fetal head", "fetal heart rate", "following", "most appropriate next step"]}
{"question": "A 55-year-old man presents with sudden onset palpitations for the past couple of hours. He denies any chest pain. Past medical history is significant for unknown kidney disease. Current medications are amiloride and daily aspirin. His blood pressure is 123/87 mm Hg and pulse is 45/min. Physical examination is unremarkable. An ECG shows tall peaked T waves with sinus bradycardia. Laboratory findings are significant for serum potassium of 6.1 mEq/L. Which of the following therapies may worsen this patient’s condition?\n   ", "answer": "Administering a β-antagonist", "options": {"A": " 50 mL of 50% glucose solution with 10 units of soluble insulin by intravenous infusion", "B": "50 ml of Sodium bicarbonate (8.4%) ", "C": "Stopping amiloride", "D": "Calcium resonium", "E": "Administering a β-antagonist"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "sudden onset palpitations", "past couple", "hours", "chest pain", "Past medical history", "significant", "unknown kidney disease", "Current medications", "amiloride", "daily aspirin", "blood pressure", "87 mm Hg", "pulse", "min", "unremarkable", "ECG", "tall peaked T waves", "sinus bradycardia", "Laboratory findings", "significant", "serum potassium", "mEq/L", "following therapies", "worsen", "patients condition"]}
{"question": "A 12-year-old boy is brought by his mother to the emergency room because of a swollen, hot, and tender knee that he sustained after falling on his way home. He has never had a swollen joint before; however, he has had frequent nosebleeds throughout his life. His mother is worried because they live with her parents who are currently on blood thinners. Every morning she puts the blood thinner pill in the boy's grandfather's milk and was concerned that she may have switched it this morning. Family history reveals a number of uncles who have had bleeding disorders; however, the mother does not know the exact disorder suffered by these relatives. A hematologic panel reveals the following findings:\n\nBleeding time: Increased\nProthrombin time: 12 seconds\nPartial thromboplastin time (PTT): 55 seconds\nPTT after factor mixing study: 37 seconds\n\nWhich of the following most likely explains the abnormal partial thromboplastin time in this patient?", "answer": "Mutation in carrying protein", "options": {"A": "Activation of inhibitory factors", "B": "Antibodies to factor VIII", "C": "Inhibition of reductase enzyme", "D": "Mutation in carrying protein", "E": "Mutation in factor VIII"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency room", "swollen", "hot", "tender knee", "sustained", "falling", "home", "never", "swollen joint", "frequent nosebleeds", "worried", "live", "currently", "blood thinners", "morning", "blood thinner pill", "boy's", "milk", "switched", "morning", "Family history reveals", "number", "bleeding disorders", "not", "exact disorder suffered", "hematologic panel reveals", "following findings", "Bleeding time", "Increased Prothrombin time", "seconds Partial thromboplastin time", "seconds PTT", "factor mixing study", "seconds", "following most likely", "abnormal partial thromboplastin time", "patient"]}
{"question": "A 6-year-old girl is brought to the physician because of increasing swelling around her eyes for the past 3 days. Her vital signs are within normal limits. Physical examination shows periorbital edema and abdominal distention with shifting dullness. Laboratory studies show a serum albumin of 2 g/dL and a serum cholesterol concentration of 290 mg/dL. Urinalysis shows 4+ proteinuria and fatty casts. Histological examination of a kidney biopsy specimen is most likely to show which of the following findings?", "answer": "Normal glomeruli on light microscopy", "options": {"A": "Granular subepithelial deposits of IgG, IgM, and C3 on immunofluorescence", "B": "Mesangial proliferation on light microscopy", "C": "Deposits of IgG and C3 at the glomerular basement membrane on immunofluoresence", "D": "Subepithelial dense deposits on electron microscopy", "E": "Normal glomeruli on light microscopy"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "of increasing swelling around", "eyes", "past", "days", "vital signs", "normal", "Physical examination", "periorbital edema", "abdominal distention", "shifting dullness", "Laboratory studies", "serum albumin", "g", "serum concentration", "mg/dL", "Urinalysis", "4", "proteinuria", "casts", "Histological examination of", "kidney biopsy specimen", "to", "following findings"]}
{"question": "A 58-year-old right-handed man is brought to the emergency department after he was found unconscious in his living room by his wife. She reports that he has never had a similar episode before. The patient has hypertension and consumes multiple alcoholic drinks per day. On arrival, he is confused and oriented only to person. He cannot recall what happened. He has difficulty speaking and his words are slurred. He reports a diffuse headache and muscle pain and appears fatigued. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 14/min, and blood pressure is 135/70 mm Hg. Examination shows a 2-cm bruise on his right shoulder. Strength is 5/5 throughout, except for 1/5 in the left arm. The remainder of the physical examination shows no abnormalities. An ECG shows left ventricular hypertrophy. A CT scan of the head without contrast shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Seizure", "options": {"A": "Stroke", "B": "Transient ischemic attack", "C": "Migraine", "D": "Syncope", "E": "Seizure"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old right-handed man", "brought", "emergency department", "found unconscious", "living room", "reports", "never", "similar episode", "patient", "hypertension", "multiple alcoholic drinks per day", "arrival", "confused", "oriented only", "difficulty speaking", "slurred", "reports", "diffuse headache", "muscle pain", "appears fatigued", "temperature", "98", "pulse", "85 min", "respirations", "min", "blood pressure", "70 mm Hg", "2 cm bruise", "right shoulder", "Strength", "5/5", "except for", "left arm", "abnormalities", "ECG", "left ventricular hypertrophy", "CT scan of", "head", "contrast", "abnormalities", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 42-year-old man comes to the physician for a health maintenance examination. He has had generalized fatigue and muscle aches since his previous visit 6 months ago. He has hypertension and gastroesophageal reflux disease. Current medications include amlodipine and omeprazole. His temperature is 37.1°C (98.1°F), pulse is 88/min and blood pressure is 156/102 mm Hg. Physical examination shows no abnormalities. Serum studies show:\nNa+ 143 mEq/L\nK+ 2.3 mEq/L\nCl- 100 mEq/L\nHCO3- 31 mEq/L\nUrea nitrogen 14 mg/dL\nCreatinine 1 mg/dL\nHis blood pressure medication is discontinued. One week later his plasma aldosterone concentration is 35 ng/dL (N=3.6 - 24.0 ng/dL) and plasma renin activity is 0.4 ng/mL/h (N=0.3 to 4.2 ng/mL/h). An oral sodium loading test over 3 days fails to reduce aldosterone. A contrast-enhanced CT scan of the abdomen and pelvis shows a 3-cm, homogenous, right-sided adrenal mass with rapid contrast washout. He is counseled about his treatment options and chooses to pursue surgery. Which of the following is the most appropriate next step in management?\"", "answer": "Adrenal vein sampling", "options": {"A": "Spironolactone therapy", "B": "Right adrenalectomy", "C": "Fludrocortisone suppression test", "D": "Adrenal vein sampling", "E": "Bilateral adrenalectomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "generalized fatigue", "muscle aches", "previous", "months", "hypertension", "gastroesophageal reflux disease", "Current medications include amlodipine", "omeprazole", "temperature", "98", "pulse", "88 min", "blood pressure", "mm Hg", "abnormalities", "Serum studies", "Na", "mEq", "K", "HCO3", "31", "Urea nitrogen", "mg dL Creatinine", "dL", "blood medication", "discontinued", "One week later", "plasma aldosterone concentration", "35 ng/dL", "N 3", "24 0 ng/dL", "plasma renin activity", "ng/mL/h", "ng/mL/h", "oral sodium", "test", "3 days fails to", "aldosterone", "contrast-enhanced CT scan", "abdomen", "pelvis", "3", "homogenous", "right-sided adrenal mass", "rapid contrast washout", "counseled", "treatment options", "surgery", "following", "most appropriate next step"]}
{"question": "An otherwise healthy, exclusively breastfed 4-day-old neonate is brought to the physician because of yellowing of his skin and eyes. His urine has been clear and stools have been normal. He was born at term by vacuum-assisted delivery and weighed 4000 g (8 lb 8 oz). Pregnancy was complicated by gestational diabetes mellitus. His older sibling had jaundice in the neonatal period. Vital signs are within normal limits. He appears alert and comfortable. Physical examination shows jaundice of the skin and sclerae. The liver is palpated 1 cm below the right costal margin. Laboratory studies show:\nHemoglobin 17 g/dl\nReticulocyte count 0.5 %\nTotal bilirubin 21.2 mg/dl\nDirect bilirubin 2 mg/dl\nIndirect bilirubin 19.1 mg/dl\nCoombs test Negative\nWhich of the following is the most appropriate next step in management?\"", "answer": "Phototherapy", "options": {"A": "Intravenous immunoglobulin", "B": "Increase frequency of breast feeds", "C": "Replace breast feeding with formula feeds", "D": "MRI of the brain", "E": "Phototherapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy", "breastfed 4 day old neonate", "brought", "physician", "yellowing", "skin", "eyes", "urine", "clear", "stools", "normal", "born", "term", "vacuum assisted", "4000", "oz", "Pregnancy", "complicated", "gestational", "jaundice", "neonatal", "Vital signs", "normal limits", "appears alert", "jaundice", "skin", "sclerae", "liver", "1 cm", "right costal margin", "Laboratory studies", "Hemoglobin", "Reticulocyte count 0.5", "Total", "Direct", "Indirect bilirubin", "Coombs test Negative", "following", "most appropriate next step"]}
{"question": "A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?", "answer": "Improper supplementation of steroids", "options": {"A": "Infection involving the suture line", "B": "Loss of fluids during the procedure", "C": "Bleeding profusely through the surgical site", "D": "Improper supplementation of steroids", "E": "High doses of anesthetic drugs"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "recovering", "post-operative unit following", "laparoscopic procedure", "chronic endometriosis", "initially", "complaints", "painful menstrual", "kept", "bedridden", "day", "gynecologist", "diagnosed", "endometriosis", "years", "not find", "medication", "therapeutic measure", "helped", "medical history", "significant", "surgery", "years", "to remove tumors", "kidneys", "hydrocortisone", "hour", "laparoscopic procedure", "calls", "nurse", "difficulty breathing", "nurse records", "vital signs include", "blood pressure 85", "mm Hg", "respirations 20 min", "pulse", "min", "patient", "consciousness", "started immediately", "gains consciousness", "blood pressure", "unchanged", "following", "most likely cause", "hypotension"]}
{"question": "A 23-year-old female presents to the emergency department with right lower abdominal pain that began suddenly one hour ago. She is writhing in discomfort and has vomited twice since arrival. She has no chronic medical conditions, but states she has had chlamydia two or three times in the past. Her abdomen is firm, and she is guarding. Pelvic exam reveals blood pooling in the vagina and right adnexal tenderness. Her last menstrual period was 7 weeks ago. A pregnancy test is positive.\n\nWhich of the following is an appropriate next step in diagnosis?", "answer": "Transvaginal ultrasound", "options": {"A": "Transabdominal ultrasound.", "B": "Dilation and curettage", "C": "Transvaginal ultrasound", "D": "Methotrexate and discharge with strict follow-up instructions.", "E": "Exploratory laparotomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old female presents", "emergency department", "right lower abdominal pain", "began", "one hour", "discomfort", "vomited twice", "arrival", "chronic medical conditions", "states", "two", "three times", "past", "abdomen", "firm", "guarding", "Pelvic exam reveals blood pooling in", "vagina", "right adnexal tenderness", "last menstrual period", "weeks", "pregnancy test", "positive", "following", "appropriate next step", "diagnosis"]}
{"question": "A 47-year-old woman comes to the physician because of a 1-month history of progressive weakness. She has had increased difficulty climbing stairs and standing from a seated position. She takes no medications. Neurologic examination shows weakness of the proximal muscles. Skin examination shows diffuse erythema of the upper back, posterior neck, and shoulders. A photograph of the patient's eye is shown. Antibodies against which of the following are most likely to be present in this patient?", "answer": "Mi-2 protein", "options": {"A": "Centromeres", "B": "La protein", "C": "Scl-70 protein", "D": "Mi-2 protein", "E": "Histones"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history", "progressive weakness", "increased difficulty climbing stairs", "standing", "seated", "medications", "Neurologic examination", "weakness", "proximal muscles", "Skin examination", "diffuse erythema of", "upper back", "posterior neck", "shoulders", "photograph of", "patient's eye", "Antibodies", "following", "to", "present", "patient"]}
{"question": "A 78-year-old man presents to the emergency department because of confusion that started 2 hours ago. The patient’s daughter says that he has had blurred vision for several days. His right leg became weak 10 days ago, and he couldn’t walk for a few days before recovering. He was diagnosed with monoclonal gammopathy of undetermined significance 2 years ago. His temperature is 36.2°C (97.2°F), pulse is 75/min, respirations are 13/min, and blood pressure is 125/70 mm Hg. He also has gingival bleeding. Cervical lymphadenopathy is palpated on physical exam. Both the liver and spleen are palpated 5 cm below the costal margins. The serum protein electrophoresis with immunofixation is shown. Urine electrophoresis shows no abnormalities. A skeletal survey shows no abnormalities. Which of the following best explains these findings?", "answer": "Waldenstrom’s macroglobulinemia", "options": {"A": "Chronic lymphocytic leukemia", "B": "Diffuse large B-cell lymphoma", "C": "Monoclonal gammopathy of undetermined significance", "D": "Multiple myeloma", "E": "Waldenstrom’s macroglobulinemia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "confusion", "started 2 hours", "patients", "blurred vision", "days", "right leg", "weak 10 days", "days", "recovering", "diagnosed", "monoclonal gammopathy of undetermined significance", "years", "temperature", "36", "97", "pulse", "75 min", "respirations", "min", "blood pressure", "70 mm Hg", "gingival bleeding", "Cervical lymphadenopathy", "liver", "spleen", "5", "costal margins", "serum electrophoresis", "immunofixation", "Urine electrophoresis", "abnormalities", "skeletal survey", "abnormalities", "following best", "findings"]}
{"question": "A 17-year-old girl is being evaluated for primary amenorrhea. A pelvic ultrasound shows no uterus, fallopian tubes, or ovaries, despite having normal external sexual organs. On physical examination, there is no axillary or pubic hair, and breast development is normal. The laboratory tests show evidence of increased serum testosterone with normal conversion to dihydrotestosterone (DHT) and increased luteinizing hormone (LH). What is the karyotype of this patient?", "answer": "46, XY", "options": {"A": "46, XX", "B": "47, XXX", "C": "47, XXY", "D": "46, XY", "E": "45, X0"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl", "primary amenorrhea", "pelvic ultrasound", "uterus", "fallopian tubes", "ovaries", "normal external sexual organs", "axillary", "pubic hair", "breast development", "normal", "laboratory tests", "increased serum", "normal conversion", "dihydrotestosterone", "increased luteinizing hormone", "karyotype", "patient"]}
{"question": "A 41-year-old male with a history of pneumocystis jiroveci pneumonia is found to have multiple ring-enhancing lesions on brain CT. Which of the following is most likely responsible for this patient's abnormal scan?", "answer": "Protozoa", "options": {"A": "Neoplasm", "B": "Bacteria", "C": "Virus", "D": "Prion", "E": "Protozoa"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old male", "history of pneumocystis jiroveci pneumonia", "found to", "multiple ring enhancing lesions", "brain CT", "following", "responsible", "patient's abnormal scan"]}
{"question": "A 13-year-old boy presents to the emergency department with severe abdominal pain. His parents state that he has been complaining of abdominal pain that became increasingly severe this evening. They also state he has been eating much more lately yet still has been losing weight. The patient's past medical history is unremarkable and he is not currently on any medications. His temperature is 99.5°F (37.5°C), blood pressure is 90/58 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 98% on room air. Physical exam is notable for diffuse abdominal tenderness and tachycardia. Laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 6,500/mm^3 with normal differential\nPlatelet count: 197,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nBUN: 20 mg/dL\nGlucose: 599 mg/dL\nCreatinine: 1.1 mg/dL\nAST: 12 U/L\nALT: 10 U/L\n\nWhich of the following laboratory changes best reflects this patient's physiology as compared to his baseline?", "answer": "C", "options": {"A": "A", "B": "B", "C": "C", "D": "D", "E": "E"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "emergency department", "severe abdominal", "state", "abdominal pain", "severe", "evening", "state", "eating much", "weight", "patient's past", "unremarkable", "not currently", "medications", "temperature", "99", "blood pressure", "90 58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "diffuse abdominal tenderness", "tachycardia", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "6 500 mm 3", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4", "mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "1.1 mg/dL AST", "U/L ALT", "10 U/L", "following laboratory changes best", "patient's physiology", "baseline"]}
{"question": "A 51-year-old man is bitten by a cottonmouth viper and is successfully treated with sheep hyperimmune Fab antivenom. Three days later, the patient develops an abdominal itchy rash and re-presents to the emergency department for medical care. His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type II, and multiple basal cell carcinomas on his face and neck. He currently smokes 1 pack of cigarettes per day, drinks a 6-pack of beer per day, and denies any current illicit drug use. His vital signs include: temperature 40.0°C (104.0°F), blood pressure 126/74 mm Hg, heart rate 111/min, and respiratory rate 23/min. On physical examination, his gait is limited by diffuse arthralgias, lung sounds are clear bilaterally, and he has normal heart sounds. The patient has a pruritic periumbilical serpiginous macular rash that has spread to involve the back, upper trunk, and extremities. Of the following options, which is the next best step in patient management?", "answer": "Glucocorticoid taper with antihistamines", "options": {"A": "Dialysis", "B": "Glucocorticoid taper with antihistamines", "C": "Antihistamines", "D": "NSAIDs", "E": "Plasmapheresis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "bitten", "treated with", "antivenom", "Three days later", "patient", "abdominal itchy", "re presents", "emergency department", "medical care", "medical history", "significant", "gout", "hypertension", "hypercholesterolemia", "diabetes mellitus type II", "multiple basal cell carcinomas", "face", "neck", "currently smokes 1 pack", "cigarettes", "day", "6-pack", "day", "current illicit drug use", "vital signs include", "temperature 40", "blood pressure", "74 mm Hg", "heart rate", "min", "respiratory rate 23 min", "gait", "limited", "diffuse arthralgias", "lung sounds", "clear", "normal heart sounds", "patient", "periumbilical", "macular rash", "spread to", "back", "upper trunk", "extremities", "following options", "next best step", "patient"]}
{"question": "A 47-year-old man presents to the clinic for an evaluation of intense itching of his right thigh region for the past few days. He states some ‘red bumps’ just began to form. The patient mentions that he was recently at a business conference in Miami. He has a past medical history of hypertension, diabetes type 2, and hyperlipidemia. He takes enalapril, metformin, and atorvastatin. He does not smoke or drink. His vitals are within normal limits today. On physical examination, a linear line with 3 red papules is present along the medial aspect of his right thigh. Additionally, there are small rows of bumps on his left leg and right forearm. Excoriations are also apparent in the same region. Which of the following is the most likely diagnosis?", "answer": "Bed bug bite", "options": {"A": "Scabies", "B": "Cutaneous larva migrans", "C": "Bed bug bite", "D": "Spider bite", "E": "Flea bite"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "clinic", "of intense itching", "right thigh region", "past", "days", "states", "red", "began to form", "patient", "recently", "business", "past medical", "diabetes type 2", "hyperlipidemia", "enalapril", "metformin", "atorvastatin", "not smoke", "normal limits today", "linear line", "3 red papules", "present", "medial aspect of", "right thigh", "small", "left leg", "right forearm", "Excoriations", "same region", "following", "diagnosis"]}
{"question": "A 24-year-old woman presents to her primary care doctor with a lesion on her labia. She first noticed the lesion 2 days ago. It is not painful. She denies vaginal discharge or dysuria. She has no past medical history and takes no medications. She has had 4 sexual partners in the past 8 months and uses the pull-out method as contraception. She drinks 12-16 alcoholic beverages per week and is a law student. Her temperature is 97.8°F (36.6°C), blood pressure is 121/81 mmHg, pulse is 70/min, and respirations are 16/min. On exam, she has an indurated non-tender ulcer on the left labia majora. There is no appreciable inguinal lymphadenopathy. Multiple tests are ordered and pending. This patient's condition is most likely caused by a pathogen with which of the following characteristics on histologic imaging?", "answer": "Motile and helical-shaped bacteria", "options": {"A": "Gram-negative coccobacillus with a \"school of fish\" appearance", "B": "Gram-negative diplococci", "C": "Motile and helical-shaped bacteria", "D": "Rod-shaped organisms in phagocyte cytoplasm", "E": "Vaginal epithelial cells covered with bacteria"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care doctor", "lesion", "labia", "first", "lesion", "days", "not painful", "vaginal discharge", "dysuria", "past medical history", "medications", "4", "past 8 months", "uses", "pull out method", "contraception", "week", "law", "temperature", "97", "36", "blood pressure", "81 mmHg", "pulse", "70 min", "respirations", "min", "exam", "indurated non-tender ulcer", "left labia majora", "inguinal lymphadenopathy", "Multiple tests", "ordered", "patient's condition", "most likely caused", "following characteristics", "histologic imaging"]}
{"question": "A 70-year-old man presents with fever, headache, and vomiting. He says that symptoms onset acutely 2 days ago and have not improved. He also reports associated weakness and chills. Past medical history is significant for occasional heartburn. His temperature is 39.4°C (103.0°F), the pulse rate is 124/min, the blood pressure is 130/84 mm Hg, and the respiratory rate is 22/min. On physical examination, there is significant nuchal rigidity. No signs of raised intracranial pressure are present. A lumbar puncture is performed and cerebrospinal fluid (CSF) analysis shows lymphocyte-dominant pleocytosis with increased CSF protein levels. Bacteriological culture of the CSF reveals the growth of Listeria monocytogenes. Which of the following antibiotics is the best choice for the treatment of this patient?", "answer": "Ampicillin", "options": {"A": "Ampicillin", "B": "Ceftriaxone", "C": "Chloramphenicol", "D": "Ciprofloxacin", "E": "Vancomycin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["70 year old man presents", "fever", "headache", "vomiting", "symptoms onset", "days", "not improved", "reports associated weakness", "chills", "Past medical history", "significant", "occasional heartburn", "temperature", "pulse rate", "min", "blood pressure", "84 mm Hg", "respiratory rate", "min", "significant nuchal rigidity", "signs", "raised intracranial pressure", "present", "lumbar puncture", "performed", "cerebrospinal fluid", "analysis", "dominant pleocytosis with increased CSF protein levels", "Bacteriological culture", "reveals", "growth", "following", "best choice", "treatment", "patient"]}
{"question": "A 15-year-old girl presents to her primary care physician, accompanied by her mother, for 4 days of abdominal pain. She describes the pain as diffuse, dull, and constant. She also endorses constipation over this time. The patient's mother says the patient has become increasingly self-conscious of her appearance since starting high school this year and has increasingly isolated herself to her room, rarely spending time with or eating meals with the rest of the family. Her temperature is 98.0°F (36.7°C), blood pressure is 100/70 mmHg, pulse is 55/min, and respirations are 19/min. Body mass index (BMI) is at the 4th percentile for age and gender. Physical exam reveals dental caries, mild abdominal distension, and diffuse, fine body hair. Basic labs are most likely to reveal which of the following?", "answer": "Hypokalemia", "options": {"A": "Hypocalcemia", "B": "Hypokalemia", "C": "Hypercalcemia", "D": "Hyperkalemia", "E": "Hyperphosphatemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "primary care physician", "4 days", "abdominal pain", "pain", "diffuse", "dull", "constant", "constipation", "time", "patient's", "patient", "appearance", "starting high school", "year", "isolated", "room", "rarely spending time", "eating meals", "temperature", "98", "36", "blood pressure", "100 70 mmHg", "pulse", "min", "respirations", "min", "Body mass index", "4th percentile", "age", "gender", "reveals dental caries", "mild abdominal distension", "diffuse", "fine body", "Basic labs", "to reveal", "following"]}
{"question": "A 66-year-old white man comes to the physician because of a 10-day history of fatigue and lower leg swelling. Over the past 6 months, he has had a 3.6-kg (8-lb) weight loss. He has chronic bronchitis and uses an albuterol inhaler as needed. He has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. His temperature is 37°C (98.6°F), pulse is 88/min, and blood pressure is 120/75 mm Hg. He appears thin. Examination shows 2+ pretibial edema bilaterally. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:\nHemoglobin 11.2 g/dL\nLeukocyte count 8500/mm3\nPlatelet count 130,000/mm3\nSerum\nUrea nitrogen 23 mg/dL\nGlucose 77 mg/dL\nCreatinine 1.6 mg/dL\nAlbumin 1.8 mg/dL\nTotal cholesterol 475 mg/dL\nUrine\nBlood negative\nGlucose negative\nProtein 4+\nWBC 0–1/hpf\nFatty casts numerous\nAn x-ray of the chest shows a right upper lobe density. A CT scan of the chest shows a 2.5 x 3.5 x 2-cm right upper lobe mass. Which of the following is the most likely diagnosis?\"", "answer": "Membranous nephropathy", "options": {"A": "Focal segmental glomerulosclerosis", "B": "Granulomatosis with polyangiitis", "C": "Membranous nephropathy", "D": "Rapidly progressive glomerulonephritis", "E": "Thin basement membrane disease\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["66 year old white man", "physician", "a 10 day history", "fatigue", "lower leg swelling", "past 6 months", "3.6 kg", "weight loss", "chronic bronchitis", "uses", "albuterol inhaler as needed", "smoked one pack", "cigarettes daily", "years", "one", "daily", "temperature", "98", "pulse", "88 min", "blood pressure", "75 mm Hg", "appears thin", "2", "edema", "Cardiopulmonary", "abnormalities", "Laboratory studies", "Hemoglobin", "g", "Leukocyte", "mm3 Platelet count 130", "mg", "mg", "Creatinine 1 6", "Total", "Urine", "negative", "WBC", "hpf", "casts numerous", "x-ray of", "chest", "right upper lobe density", "CT scan of", "chest", "2", "right upper lobe mass", "following", "diagnosis"]}
{"question": "An 80-year-old male with known metastatic prostate cancer presents to your office with vague complaints of \"achy bones.\" Strangely, he refers to you using the name of another physician. On physical exam, he is afebrile, but mildly tachycardic at 100 beats/min. Mucous membranes are dry. Cardiac exam shows regular rhythm and no murmurs. The patient has diffuse, nonfocal abdominal pain. He cannot articulate the correct date. You check the patient's serum calcium level, which is found to be 15.3 mg/dL. What is the best next step in management?", "answer": "Intravenous normal saline", "options": {"A": "Pamidronate", "B": "Intravenous normal saline", "C": "Calcitonin", "D": "Furosemide", "E": "Hemodialysis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["80 year old male", "known metastatic prostate cancer presents", "office", "vague complaints", "achy bones", "refers", "using", "name", "physician", "afebrile", "mildly tachycardic", "100 beats/min", "Mucous membranes", "dry", "regular rhythm", "murmurs", "patient", "diffuse", "nonfocal abdominal", "correct date", "check", "patient", "erum calcium level,", "ound  o ", "g/dL.", "est  ext  tep "]}
{"question": "A new drug is designed to treat asthma by inhibiting bronchoconstriction. Experimental assays show that treated animals had markedly reduced acetylcholine binding to muscarinic receptors relative to untreated controls. The drug is most similar to which of the following:", "answer": "Ipratropium", "options": {"A": "Theophylline", "B": "Cromolyn", "C": "Zafirlukast", "D": "Prednisone", "E": "Ipratropium"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["new drug", "to treat asthma", "bronchoconstriction", "Experimental assays", "treated animals", "markedly reduced", "untreated controls", "drug", "most similar", "following"]}
{"question": "A 34-year-old man presents to the outpatient clinic with a complaint of right-sided jaw pain. The onset of pain was approx. 1 month ago and he is experiencing symptoms 2–3 times a day. Each episode of pain lasts for about 30 seconds. He describes the pain as severe (9 out of 10) with an electric and sharp quality. He denies having tear production or conjunctival injection on the affected side during attacks. What is the mechanism of action for the drug that will best treat this patient’s condition?", "answer": "Prevention of Na+ influx", "options": {"A": "Prevention of Na+ influx", "B": "Decrease the excitatory effects of glutamic acid", "C": "Increase the frequency of Cl- channel opening", "D": "Increase the time of Cl- channel opening", "E": "Decrease in the Ca2+ influx"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "outpatient clinic", "complaint of right-sided jaw pain", "onset", "pain", "month", "symptoms 23 times", "day", "episode of pain", "about 30 seconds", "pain", "severe", "out", "10", "sharp quality", "tear production", "conjunctival injection", "affected side", "attacks", "mechanism of action", "drug", "best treat", "patients condition"]}
{"question": "A 17-year-old African-American male presents to his family physician after noticing red-tinged urine the week before, when he was suffering from a cold. The patient states that he had experienced that before. His father is with him and says that this happens to him on occasion as well. What is the most likely diagnosis for this patient?", "answer": "Sickle cell trait", "options": {"A": "Acute cystitis", "B": "Acute interstitial nephritis", "C": "Sickle cell trait", "D": "Acute glomerulonephritis", "E": "Hemophilia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "male presents", "family physician", "red tinged urine", "week", "suffering", "cold", "patient states", "before", "occasion", "well", "diagnosis", "patient"]}
{"question": "A 4-year-old boy is brought to the physician by his mother for a well-child examination. At the visit, the mother says that she is worried about the child's vision because of an “eye condition that runs in the family.” She says that the child is doing well in all activities at his preschool, except one in which he is required to sort different colored balls into baskets of a corresponding color. A pedigree chart of the family, with the patient identified by a red arrow, is shown. The most likely cause of these changes in the patient's vision involves which of the following modes of inheritance?", "answer": "X-linked recessive", "options": {"A": "Mitochondrial inheritance", "B": "Autosomal recessive", "C": "Y-linked dominant", "D": "X-linked recessive", "E": "Autosomal dominant"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "brought", "physician", "well", "worried", "child's vision", "eye condition", "runs in", "child", "well", "preschool", "one", "required to sort different colored balls", "color", "chart", "patient identified", "red arrow", "most likely cause", "changes", "patient's vision", "following"]}
{"question": "A 71-year-old African American man with a history of prostatic adenocarcinoma presents to his oncologist with low back pain. He was diagnosed with non-resectable prostatic adenocarcinoma 4 years ago. He has undergone radiation therapy and chemotherapy. Over the past 3 months, he has developed constant mild non-radiating low back pain that occasionally wakes him up from sleep. He denies any recent falls or trauma. His past medical history is notable for hypertension, diabetes mellitus, coronary artery disease, and gout. He also has a history of thyroid cancer and underwent thyroidectomy 5 years ago. He takes lisinopril, metoprolol, aspirin, metformin, and allopurinol. He has a 40-pack-year smoking history and drinks alcohol socially. His temperature is 99.2°F (37.3°C), blood pressure is 150/85 mmHg, pulse is 84/min, and respirations are 18/min. On exam, he is well-appearing and in no acute distress. He is mildly tender to palpation along the lumbar vertebral spinous processes. A computerized tomography (CT) scan of the lumbar spine demonstrates a blastic and sclerotic lesion in the L5 vertebral body. Which of the following findings would most likely be seen on a serum study of this patient?", "answer": "Normal calcium, normal phosphate, increased alkaline phosphatase, and normal parathyroid hormone", "options": {"A": "Decreased calcium, decreased phosphate, increased alkaline phosphatase, and increased parathyroid hormone", "B": "Decreased calcium, increased phosphate, increased alkaline phosphatase, and increased parathyroid hormone", "C": "Increased calcium, decreased phosphate, increased alkaline phosphatase, and increased parathyroid hormone", "D": "Normal calcium, normal phosphate, increased alkaline phosphatase, and normal parathyroid hormone", "E": "Normal calcium, normal phosphate, normal alkaline phosphatase, and normal parathyroid hormone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "man", "history of prostatic adenocarcinoma presents", "oncologist", "low back pain", "diagnosed", "non-resectable prostatic adenocarcinoma", "years", "radiation therapy", "chemotherapy", "past 3 months", "non radiating low back pain", "occasionally wakes", "sleep", "recent falls", "trauma", "past medical history", "notable", "hypertension", "diabetes mellitus", "coronary artery disease", "gout", "history cancer", "thyroidectomy", "years", "lisinopril", "metoprolol", "aspirin", "metformin", "allopurinol", "40", "smoking history", "alcohol", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "84 min", "respirations", "min", "exam", "well appearing", "acute distress", "mildly tender", "palpation", "lumbar vertebral", "processes", "computerized tomography", "scan", "lumbar spine", "blastic", "sclerotic lesion", "L5 vertebral body", "following findings", "most likely", "seen", "serum study of", "patient"]}
{"question": "A 44-year-old Caucasian male presents with a fever, recent weight loss, and a cough productive of bloody sputum. A chest X-ray and CT scan were performed, revealing cavities near the apex of his lungs. The patient is started on rifampin, isoniazid, ethambutol and pyrazinamide. Formation of the cavities in the patient's lungs is mainly mediated by:", "answer": "TH1 cells", "options": {"A": "TH1 cells", "B": "Toxin secretion by the bacterium", "C": "B-cells", "D": "NK cells", "E": "Apoptosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male presents", "fever", "recent weight loss", "cough productive of bloody sputum", "chest X-ray", "CT scan", "performed", "revealing cavities", "the apex of", "lungs", "patient", "started", "rifampin", "isoniazid", "ethambutol", "pyrazinamide", "Formation", "cavities", "patient's lungs", "mediated"]}
{"question": "A 48-year-old man presents to his primary care physician with a 6-month history of increasing joint pain and stiffness. He says that the pain is primarily located in his knees and occurs in sharp bursts that are accompanied by redness and warmth. His past medical history is significant for diabetes though he is not currently taking any medications. He also suffers from occasional diarrhea with fatty stools. Physical exam reveals mild swelling and redness in his knees bilaterally. Furthermore, he is found to be very tan despite the fact that he says he stays out of the sun. He notes that he has always been significantly more tan than anyone else in his family. This patient is most likely predisposed to which of the following diseases?", "answer": "Hepatocellular carcinoma", "options": {"A": "Basal cell carcinoma", "B": "Hepatocellular carcinoma", "C": "Osteosarcoma", "D": "Pancreatic adenocarcinoma", "E": "Squamous cell skin carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old man presents", "primary care physician", "month history", "increasing joint pain", "stiffness", "pain", "knees", "occurs", "sharp bursts", "redness", "warmth", "past medical history", "significant", "diabetes", "not currently", "medications", "suffers", "occasional diarrhea", "fatty stools", "reveals mild swelling", "redness", "knees", "found to", "very tan", "fact", "out", "sun", "notes", "always", "tan", "else", "patient", "most likely predisposed", "following diseases"]}
{"question": "A 58-year-old chronic smoker known to have chronic bronchitis for the last 20 years presents to his physician for a scheduled follow-up visit. He mentions that over the last month he has been having difficulty breathing, especially after climbing stairs. He also says that he has had similar episodes in the past, which were relieved with the use of inhaled bronchodilators, but recently the breathlessness has ceased to respond to them. He also mentions frequent pain in the right upper quadrant of the abdomen. On physical examination, his temperature is 37°C (98.6°F), the pulse is 96/min, the blood pressure is 124/82 mm Hg, and the respirations are 26/min. Auscultation of the chest reveals wheezing bilaterally and a loud pulmonic component of the second heart sound. Two-dimensional echocardiography shows a dilated right ventricle with increased wall thickness. Right heart catheterization is performed, which indicates a pulmonary artery pressure of 30 mm Hg and a pulmonary capillary wedge pressure of 13 mm Hg. There is a significant drop in pulmonary artery pressure after the administration of inhaled nitric oxide. In addition to continued appropriate management of chronic bronchitis, which of the following medications is most likely to improve symptoms in the patient?", "answer": "Diltiazem", "options": {"A": "Captopril", "B": "Diltiazem", "C": "Hydralazine", "D": "Isosorbide mononitrate", "E": "Losartan"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old chronic smoker known to", "chronic bronchitis", "20 years presents", "physician", "scheduled", "last month", "difficulty breathing", "similar episodes", "past", "relieved", "use of inhaled bronchodilators", "recently", "breathlessness", "ceased to", "frequent pain", "right upper quadrant", "abdomen", "temperature", "98", "pulse", "96 min", "blood pressure", "mm Hg", "respirations", "min", "Auscultation", "chest reveals wheezing", "loud pulmonic component of", "second heart sound", "Two-dimensional echocardiography", "dilated right ventricle", "increased wall thickness", "heart catheterization", "performed", "pulmonary artery pressure", "30 mm Hg", "pulmonary capillary wedge pressure", "mm Hg", "significant drop", "pulmonary artery pressure", "administration of inhaled nitric oxide", "In addition to", "appropriate", "chronic bronchitis", "following medications", "to", "symptoms", "patient"]}
{"question": "A 70-year-old man presents to the clinic with right-sided chest pain and difficulty breathing for the past 10 days. When it began, the pain was mild, but as time went on, it increased to a level at which the man found it difficult to breathe. Two years ago, he was diagnosed with clear cell carcinoma of the kidney. Vital signs include: pulse rate is 72/min, blood pressure is 122/80 mm Hg, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). On physical examination, the trachea appears to have deviated to the left, respiratory movements are diminished, there is decreased resonance on percussion, and there is an absence of breath sounds over the right hemithorax. Which of the following is the most likely clinical diagnosis in this patient?", "answer": "Pleural effusion", "options": {"A": "Pneumonia", "B": "Atelectasis", "C": "Pneumothorax", "D": "Pulmonary embolism", "E": "Pleural effusion"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["70 year old man presents", "clinic", "right-sided chest pain", "difficulty breathing", "past 10 days", "began", "pain", "mild", "time", "increased", "level", "man found", "difficult to", "Two years", "diagnosed", "clear cell carcinoma of the kidney", "Vital signs include", "pulse rate", "72 min", "blood pressure", "80 mm Hg", "respiratory rate", "min", "temperature", "98", "trachea appears to", "deviated", "left", "respiratory movements", "diminished", "decreased resonance", "percussion", "absence", "breath sounds", "right hemithorax", "following", "clinical diagnosis", "patient"]}
{"question": "A 1-month-old boy is brought in by his mother for episodes of “not breathing.” She reports noticing that the patient will occasionally stop breathing while he’s sleeping, and that these episodes have been occurring more frequently. The patient was born at 32 weeks due to placental insufficiency. He was in the neonatal intensive care unit for 1 day to be placed on a respirator. During prenatal testing, it was revealed that the mother was not immune to rubella, but she otherwise had an uncomplicated pregnancy. She has no medical conditions and took only prenatal vitamins. The patient has a 3-year-old sister who is healthy. His father has a “heart condition.” The patient’s temperature is 98°F (36.7°C), blood pressure is 91/55 mmHg, pulse is 207/min, and respirations are 50/min with an oxygen saturation of 97% on room air. Physical examination is notable for pale conjunctiva. Labs are obtained, as shown below:\n\nLeukocyte count: 10,000/mm^3 with normal differential\nHemoglobin: 8.2 g/dL\nHematocrit: 28%\nMean corpuscular volume (MCV): 100 um^3\nPlatelet count: 300,000/mm^3\nReticulocyte count: 0.8% (normal range: 2-6%)\nLactate dehydrogenase: 120 U/L (normal range: 100-250 U/L)\n\nA peripheral smear reveals normocytic and normochromic red blood cells. Which of the following is a mechanism for the patient’s most likely diagnosis?", "answer": "Impaired erythropoietin production", "options": {"A": "Congenital infection", "B": "Hemoglobinopathy", "C": "Impaired erythropoietin production", "D": "Minor blood group incompatibility", "E": "Red blood cell membrane defect"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "episodes of not breathing", "reports", "patient", "occasionally stop breathing", "sleeping", "episodes", "occurring more frequently", "patient", "born", "weeks", "placental insufficiency", "neonatal intensive care unit", "1 day to", "respirator", "revealed", "not immune", "rubella", "uncomplicated pregnancy", "medical conditions", "only prenatal vitamins", "patient", "3 year old", "healthy", "heart condition", "patients temperature", "36", "blood pressure", "mmHg", "pulse", "min", "respirations", "50 min", "oxygen saturation", "97", "room air", "notable", "pale conjunctiva", "Labs", "obtained", "Leukocyte count", "10", "mm 3", "normal differential Hemoglobin", "g/dL Hematocrit", "Mean corpuscular volume", "100", "Platelet count", "300", "mm", "Reticulocyte count", "0.8", "normal range", "2-6", "Lactate dehydrogenase", "U/L", "normal range", "100", "U/L", "peripheral smear reveals normocytic", "normochromic red blood cells", "following", "mechanism", "patients", "likely diagnosis"]}
{"question": "A 63-year-old man presents to his family physician with limited movement in his left shoulder that has progressed gradually over the past 6 years. He previously had pain when moving his shoulder, but the pain subsided a year ago and now he experiences the inability to fully flex, abduct, and rotate his left arm. He had an injury to his left shoulder 10 years ago when he fell onto his arms and ‘stretched ligaments’. He did not seek medical care and managed the pain with NSAIDs and rest. He has diabetes mellitus that is well controlled with Metformin. His blood pressure is 130/80 mm Hg, the heart rate is 81/min, the respiratory rate is 15/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals limitations of both active and passive abduction and external rotation in the left arm. The range of motion in the right glenohumeral joint is normal. The muscles of the left shoulder look less bulky than those of the right shoulder. There is no change in shoulder muscle power bilaterally. The reflexes and sensation on the upper extremities are normal. Which of the following is the next best step for this patient?", "answer": "Physical therapy", "options": {"A": "No interventions are required at this stage", "B": "NSAID prescription for 1–2 weeks", "C": "Physical therapy", "D": "Corticosteroid injections", "E": "Arthroscopic capsular release"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["63 year old man presents", "family physician", "limited movement", "left shoulder", "progressed", "past", "years", "pain", "moving", "shoulder", "pain", "year", "now", "rotate", "left arm", "injury", "left", "fell", "arms", "stretched ligaments", "not", "medical care", "pain", "NSAIDs", "diabetes mellitus", "well controlled", "Metformin", "blood pressure", "80 mm Hg", "heart rate", "81 min", "respiratory rate", "min", "temperature", "36", "97 9F", "reveals limitations", "active", "passive abduction", "external rotation", "left arm", "range of motion", "right", "joint", "normal", "muscles of", "left shoulder look less bulky than", "right shoulder", "change", "shoulder", "reflexes", "sensation", "upper extremities", "normal", "following", "next best step", "patient"]}
{"question": "A 32-year-old man comes to the emergency department because of sharp chest pain for 3 days. The pain is retrosternal, 8 out of 10 in intensity, increases with respiration, and decreases while sitting upright and leaning forward. He has nausea and myalgia. He has not had fever or a cough. He has asthma and was treated for bronchitis 6 months ago with azithromycin. His mother has hypertension. He uses an over-the-counter inhaler. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Breath sounds are normal. Cardiac examination shows a high-pitched grating sound between S1 and S2. The remainder of the examination shows no abnormalities. Serum studies show:\nUrea nitrogen 16 mg/dl\nGlucose 103 mg/dL\nCreatinine 0.7 mg/dL\nTroponin I 0.230 ng/mL (N < 0.1 ng/mL)\nAn ECG shows diffuse ST elevations in all leads. The patient is at increased risk for which of the following conditions?\"", "answer": "Cardiac tamponade", "options": {"A": "Papillary muscle rupture", "B": "Pulmonary infarction", "C": "Mediastinitis", "D": "Cardiac tamponade", "E": "Ventricular aneurysm"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency department", "of sharp chest pain", "3 days", "pain", "retrosternal", "8 out", "10", "intensity", "increases", "respiration", "decreases", "sitting upright", "forward", "nausea", "myalgia", "not", "fever", "cough", "asthma", "treated", "bronchitis", "months", "azithromycin", "hypertension", "uses", "over-the-counter inhaler", "temperature", "99", "pulse", "min", "blood pressure", "84 mm Hg", "Breath sounds", "normal", "high-pitched", "sound", "S1", "S2", "abnormalities", "Serum studies", "Urea nitrogen", "mg/dl Glucose", "Creatinine 0.7", "Troponin I", "ng/mL", "N", "0.1 ng/mL", "ECG", "diffuse ST elevations", "leads", "patient", "increased risk", "following conditions"]}
{"question": "A 48-year-old man comes to the physician because of a 2-day history of an itchy rash. He has no history of skin problems. He had an upper respiratory infection 4 days ago that resolved with acetaminophen and over-the-counter cold medication. He has type I diabetes mellitus well-controlled with insulin. He was also diagnosed with hypertension 3 weeks ago and treatment with captopril was initiated. His temperature is 36.8°C (98.2°F), pulse is 68/min, respirations are 18/min, and blood pressure is 120/85 mm Hg. Examination shows rashes at the waistline, trunk, and over the forearms. A photograph of the right forearm is shown. The rashes are nontender and blanch on pressure. There is no lymphadenopathy or hepatosplenomegaly. Which of the following is the most likely explanation for this patient's skin findings?", "answer": "Cutaneous mast cell activation", "options": {"A": "Epidermal keratinocyte hyperproliferation", "B": "Cutaneous Trichophyton rubrum infection", "C": "Cutaneous cytotoxic reaction", "D": "Impaired bradykinin degradation", "E": "Cutaneous mast cell activation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["48 year old man", "physician", "2-day history", "itchy rash", "history", "skin problems", "upper respiratory infection", "days", "resolved", "acetaminophen", "over-the-counter cold medication", "type I diabetes mellitus well-controlled", "insulin", "diagnosed", "hypertension", "weeks", "treatment", "captopril", "initiated", "temperature", "36", "98", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "rashes", "trunk", "forearms", "photograph", "right forearm", "rashes", "nontender", "blanch", "pressure", "lymphadenopathy", "hepatosplenomegaly", "following", "explanation", "patient's skin findings"]}
{"question": "A 56-year-old man comes to the clinic complaining of back pain for the past 1 month. The pain is described as a dull ache that intensifies intermittently to an 8/10 in severity about 1-2 times a day. It intensified about 2 weeks ago following a fall during a ski trip. He reports that he noticed some pain at his buttocks and lower back following the fall but he wasn’t bothered by it. Hot packs and Tylenol seem to alleviate the pain somewhat. He denies lower extremity weakness, loss of sensation, fever, incontinence, or prior cancers; however, he reveals that his cousin was recently diagnosed with prostate cancer. Physical examination demonstrates normal range of motion and diffuse tenderness at the L4/L5 region with no point tenderness or vertebral step-offs. What is the next best step in the management of this patient?", "answer": "Exercise therapy with NSAIDs/acetaminophen", "options": {"A": "Back bracing", "B": "Best rest with return to activity in 1 week", "C": "Exercise therapy with NSAIDs/acetaminophen", "D": "Morphine as needed", "E": "Radiograph of lumbar spine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "clinic", "of back pain", "past", "month", "pain", "dull ache", "8/10", "severity", "2 times", "day", "2 weeks", "following", "fall", "ski trip", "reports", "pain", "buttocks", "lower back following", "fall", "Hot packs", "Tylenol", "to", "pain somewhat", "lower extremity weakness", "loss of sensation", "fever", "incontinence", "prior cancers", "reveals", "recently diagnosed", "prostate cancer", "normal range of motion", "diffuse tenderness", "L4 L5 region", "point tenderness", "vertebral step", "next best step", "patient"]}
{"question": "A 75-year-old man is brought to the emergency department 20 minutes after an episode of being unconscious. He was playing with his 3-year-old granddaughter when he suddenly fell down and was unresponsive for 1-minute. He responded normally after regaining consciousness. He has had episodes of mild chest pain and abdominal discomfort for the past 2 months, especially while working on his car. He has hypertension treated with hydrochlorothiazide. He appears alert. His temperature is 37.1°C (98.8°F), pulse is 89/min and regular, and blood pressure is 110/88 mm Hg. Examination shows a 3/6 late systolic murmur at the right sternal border that radiates to the carotids. There is no swelling or erythema of the lower extremities. Neurologic examination shows no focal findings. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Calcification of the aortic valve", "options": {"A": "Rupture of the chordae tendineae", "B": "Fibrosis of the sinus node", "C": "Asymmetric septal hypertrophy", "D": "Calcification of the aortic valve", "E": "Embolus in the pulmonary artery"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["75 year old man", "brought", "emergency department 20 minutes", "episode of", "unconscious", "playing", "year old", "fell", "unresponsive", "minute", "consciousness", "episodes of mild chest pain", "abdominal discomfort", "past", "months", "car", "hypertension treated with hydrochlorothiazide", "appears alert", "temperature", "98", "pulse", "min", "regular", "blood pressure", "88 mm Hg", "3/6 late systolic murmur", "right sternal border", "radiates", "carotids", "swelling", "erythema of the lower extremities", "Neurologic examination", "focal findings", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 37-year-old male presents to general medical clinic reporting sleeping difficulties. He states that he has daytime sleepiness, having fallen asleep several times while driving his car recently. He sometimes experiences very vivid dreams just before awakening. You ask the patient's wife if she has witnessed any episodes where her husband lost all muscle tone and fell to the ground, and she confirms that he has not had this symptom. The patient notes that this condition runs in his family, and he desperately asks for treatment. You begin him on a first-line medication for this illness, which works by which mechanism of action?", "answer": "Enhances release of norepinephrine vesicles", "options": {"A": "Agonist at the GABA receptor", "B": "Agonist at the mu opioid receptor", "C": "Blockade of 5HT reuptake", "D": "Enhances release of norepinephrine vesicles", "E": "Alpha-2 receptor antagonist"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "general medical clinic", "sleeping difficulties", "states", "daytime sleepiness", "fallen asleep", "times", "car recently", "sometimes", "very vivid dreams", "awakening", "patient's", "episodes", "lost", "muscle tone", "fell", "confirms", "not", "symptom", "patient notes", "condition runs in", "treatment", "begin", "first line medication", "illness", "mechanism of action"]}
{"question": "A 30-year-old woman is brought to the emergency department by ambulance after being found unconscious in her bedroom by her roommate. The roommate says the patient has type 1 diabetes and takes her insulin regularly. Her pulse is 110/min, the respiratory rate is 24/min, the temperature is 36.6°C (97.9°F), and the blood pressure is 95/65 mm Hg. She is breathing heavily and gives irrelevant responses to questions. Her skin and mucous membranes appear dry. Her breath has a fruity smell to it. Tendon reflexes are slightly delayed. The laboratory findings include:\nFinger-stick glucose  530 mg/dL\n    Arterial blood gas analysis \npH 7.1\npO2 94 mm Hg\npCO2 32 mm Hg\nHCO3 17 mEq/L\n    Serum  \nSodium 136 mEq/L\nPotassium 3.2 mEq/L\nChloride 136 mEq/L\n    Blood urea nitrogen  20 mg/dL\nSerum creatinine 1.2 mg/dL\n    Urine examination \nGlucose positive\nKetones positive\nLeucocytes negative\nNitrite negative\nRBC negative\nCasts negative\nWhich of the following abnormalities accounts for her sweet smelling breath?", "answer": "Excessive mobilization of fatty acids", "options": {"A": "Diminished glucose metabolism", "B": "Excessive mobilization of fatty acids", "C": "Extrahepatic ketone production", "D": "Fermentation of excess blood sugars", "E": "Inhibition of HMG-CoA synthase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old woman", "brought", "emergency department", "ambulance", "found unconscious", "bedroom", "patient", "type 1 diabetes", "insulin", "pulse", "min", "respiratory rate", "min", "temperature", "36", "97 9F", "blood pressure", "95 65 mm Hg", "breathing", "gives", "responses", "skin", "mucous membranes appear dry", "breath", "smell", "Tendon reflexes", "slightly delayed", "laboratory findings include", "mg/dL", "pH", "positive", "RBC", "Casts negative", "following abnormalities accounts", "sweet smelling breath"]}
{"question": "A 75-year-old man presents to the physician with progressive difficulty reading over the past year. Currently, he avoids driving as he has trouble reading road signs. He has no history of a serious illness and takes no medications. The fundoscopic examination shows localized retinal elevation and drusen. A description of the patient’s visual on the Amsler grid is shown. Fluorescein angiography shows early hyperfluorescence. Which of the following is the most likely diagnosis in this patient?", "answer": "Macular degeneration", "options": {"A": "Central retinal artery occlusion", "B": "Choroidal melanoma", "C": "Macular degeneration", "D": "Open-angle glaucoma", "E": "Retinal detachment"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "physician", "progressive difficulty reading", "past year", "Currently", "road signs", "history", "serious illness", "medications", "fundoscopic", "localized retinal elevation", "drusen", "patients visual", "Amsler grid", "Fluorescein angiography", "early", "following", "diagnosis", "patient"]}
{"question": "A 44-year-old woman comes to her primary care physician with complaints of irritation and a gritty sensation in her eyes for the past few months. She denies any discharge from her eyes. She has no significant past medical or surgical history. She takes multivitamins occasionally but denies use of any other medication. On further questioning, she expresses her concerns about frequent dental caries for the past 2 years. On examination, her temperature is 37.1°C (98.8°F), blood pressure is 110/80 mm Hg, pulse rate is 74/min, and respiratory rate is 16/min. Which of the following is the most likely cause of her symptoms?", "answer": "Sjögren's syndrome", "options": {"A": "Systemic lupus erythematosus (SLE)", "B": "Sjögren's syndrome", "C": "Rheumatoid arthritis", "D": "Fibromyalgia", "E": "Scleroderma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "primary care physician", "complaints", "irritation", "gritty sensation", "eyes", "past", "months", "discharge from", "eyes", "significant past medical", "surgical history", "multivitamins occasionally", "use of", "medication", "further", "frequent dental", "past", "years", "temperature", "98", "blood pressure", "80 mm Hg", "pulse rate", "74 min", "respiratory rate", "min", "following", "most likely cause", "symptoms"]}
{"question": "The medical student on the pediatric cardiology team is examining a 9-year-old girl who was referred by her primary care physician for unexplained hypertension. She is accompanied by her mother who reveals that the child is generally well but has been significantly less active than her peers for the past year. On exam, the medical student notes a thin girl in no apparent distress appearing slightly younger than stated age. Vital signs reveal a BP is 160/80, HR 80, RR 16. Physical exam is notable only for a clicking sound is noted around the time of systole but otherwise the cardiac exam is normal. Pedal pulses could not be palpated. Which of the following physical exam findings was most likely missed by both the medical student and primary care physician?", "answer": "Webbed neck", "options": {"A": "Cleft palate", "B": "Prominent occiput", "C": "Long philtrum", "D": "Webbed neck", "E": "Single palmar crease"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["medical student", "pediatric cardiology", "examining", "year old girl", "referred by", "primary care physician", "unexplained hypertension", "reveals", "child", "well", "active", "past year", "exam", "medical student notes", "thin girl", "distress appearing slightly younger", "stated age", "Vital signs reveal", "BP", "80", "80", "RR", "notable only", "sound", "noted", "time", "systole", "normal", "Pedal", "not", "following physical exam findings", "most likely missed", "medical student", "primary care physician"]}
{"question": "A 45-year-old woman comes to the emergency department complaining of abdominal pain for the past day. The pain is situated in the right upper quadrant, colicky, 8/10, and radiates to the tip of the right shoulder with no aggravating or relieving factors. The pain is associated with nausea but no vomiting. She tried to take over-the-counter antacids which relieved her pain to a certain extent, but not entirely. She does not smoke cigarettes or drink alcohol. She has no past medical illness. Her father died of pancreatic cancer at the age of 75, and her mother has diabetes controlled with medications. Temperature is 38°C (100.4°F), blood pressure is 125/89 mm Hg, pulse is 104/min, respiratory rate is 20/min, and BMI is 29 kg/m2. On abdominal examination, her abdomen is tender to shallow and deep palpation of the right upper quadrant.\nLaboratory test\nComplete blood count\nHemoglobin 13 g/dL\nWBC 15,500/mm3\nPlatelets 145,000/mm3\nBasic metabolic panel\nSerum Na+   137 mEq/L\nSerum K+ 3.6 mEq/L\nSerum Cl-   95 mEq/L\nSerum HCO3- 25 mEq/L\nBUN   10 mg/dL\nSerum creatinine        0.8 mg/dL\nLiver function test\nTotal bilirubin   1.3 mg/dL\nAST   52 U/L\nALT 60 U/L\nUltrasonography of the abdomen shows normal findings. What is the best next step in management of this patient?", "answer": "Cholescintigraphy", "options": {"A": "Emergency cholecystectomy", "B": "Percutaneous cholecystostomy", "C": "Cholescintigraphy", "D": "CT scan", "E": "Reassurance and close follow up"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "emergency department", "abdominal pain", "past day", "pain", "right upper quadrant", "colicky", "10", "radiates", "tip", "right shoulder", "aggravating", "relieving factors", "pain", "associated with nausea", "vomiting", "to", "counter antacids", "relieved", "pain", "certain extent", "not", "not smoke cigarettes", "past medical illness", "died of pancreatic cancer", "age", "75", "diabetes controlled with medications", "Temperature", "100", "blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "20 min", "BMI", "29 kg/m2", "abdominal", "abdomen", "tender", "shallow", "deep palpation", "blood", "Hemoglobin 13 g dL WBC", "Serum Na", "137 mEq L", "6", "Cl", "mg dL", "0", "function", "Total", "1", "52", "ALT", "Ultrasonography", "abdomen", "normal findings", "best next step", "patient"]}
{"question": "A 4-year-old girl is brought to the physician because of a 3-week history of generalized fatigue and easy bruising. During the past week, she has also had fever and severe leg pain that wakes her up at night. Her temperature is 38.3°C (100.9°F), pulse is 120/min, and respirations are 30/min. Examination shows cervical and axillary lymphadenopathy. The abdomen is soft and nontender; the liver is palpated 3 cm below the right costal margin, and the spleen is palpated 2 cm below the left costal margin. Laboratory studies show:\nHemoglobin 10.1 g/dL\nLeukocyte count 63,000/mm3\nPlatelet count 27,000/mm3\nA bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT. Which of the following is the most likely diagnosis?\"", "answer": "Acute lymphoblastic leukemia", "options": {"A": "Hodgkin lymphoma", "B": "Hairy cell leukemia", "C": "Aplastic anemia", "D": "Acute myeloid leukemia", "E": "Acute lymphoblastic leukemia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old girl", "brought", "physician", "3 week history", "generalized fatigue", "easy bruising", "past week", "fever", "severe leg", "wakes", "night", "temperature", "100 9F", "pulse", "min", "respirations", "30/min", "cervical", "axillary lymphadenopathy", "abdomen", "soft", "nontender", "liver", "3 cm", "right costal margin", "spleen", "2 cm", "left costal margin", "Laboratory studies", "Hemoglobin 10", "g Leukocyte count 63", "mm3 Platelet count 27", "bone marrow aspirate", "immature cells", "positive", "CD10", "CD19", "TdT", "following", "diagnosis"]}
{"question": "A 25-year-old woman comes to the physician because of a 2-day history of a burning sensation when urinating and increased urinary frequency. She is concerned about having contracted a sexually transmitted disease. Physical examination shows suprapubic tenderness. Urinalysis shows a negative nitrite test and positive leukocyte esterases. Urine culture grows organisms that show resistance to novobiocin on susceptibility testing. Which of the following is the most likely causal organism of this patient's symptoms?", "answer": "Staphylococcus saprophyticus", "options": {"A": "Staphylococcus epidermidis", "B": "Pseudomonas aeruginosa", "C": "Klebsiella pneumoniae", "D": "Proteus mirabilis", "E": "Staphylococcus saprophyticus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "of", "2-day history", "burning sensation", "increased urinary frequency", "contracted", "sexually transmitted disease", "suprapubic tenderness", "Urinalysis", "negative nitrite test", "positive leukocyte esterases", "Urine culture", "resistance to novobiocin", "susceptibility testing", "following", "causal", "patient's symptoms"]}
{"question": "A 2-day-old male infant is brought to the emergency department by ambulance after his parents noticed that he was convulsing and unresponsive. He was born at home and appeared well initially; however, within 24 hours he became increasingly irritable and lethargic. Furthermore, he stopped feeding and began to experience worsening tachypnea. This continued for about 6 hours, at which point his parents noticed the convulsions and called for an ambulance. Laboratories are obtained with the following results:\n\nOrotic acid: 9.2 mmol/mol creatinine (normal: 1.4-5.3 mmol/mol creatinine)\nAmmonia: 135 µmol/L (normal: < 50 µmol/L)\nCitrulline: 2 µmol/L (normal: 10-45 µmol/L)\n\nWhich of the following treatments would most likely be beneficial to this patient?", "answer": "Benzoate administration", "options": {"A": "Aspartame avoidance", "B": "Benzoate administration", "C": "Fructose avoidance", "D": "Galactose avoidance", "E": "Uridine administration"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2-day old male infant", "brought", "emergency department", "ambulance", "convulsing", "unresponsive", "born at home", "appeared well initially", "24 hours", "irritable", "lethargic", "stopped", "began to", "worsening tachypnea", "hours", "point", "convulsions", "called", "ambulance", "Laboratories", "obtained", "following results", "Orotic acid", "mmol/mol creatinine", "normal", "1", "mmol/mol creatinine", "Ammonia", "mol/L", "normal", "50 mol/L", "Citrulline", "2 mol/L", "normal", "10", "mol/L", "following treatments", "most likely", "patient"]}
{"question": "A 33-year-old man presents to his physician with a 3-year history of gradually worsening tics and difficulty walking. He was last seen by the physician 5 years ago for anxiety, and he has been buying anti-anxiety medications from an internet website without a prescription as he cannot afford to pay for doctor’s visits. Now, the patient notes that his anxiety is somewhat controlled, but motor difficulties are making it difficult for him to work and socialize. Family history is unobtainable as his parents died in an accident when he was an infant. He grew up in foster care and was always a bright child. An MRI of the brain is ordered; it shows prominent atrophy of the caudate nucleus. Repeats of which of the following trinucleotides are most likely responsible for this patient’s disorder?", "answer": "CAG", "options": {"A": "CCG", "B": "CGG", "C": "GAA", "D": "CAG", "E": "CTG"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "physician", "3 year history", "worsening tics", "difficulty walking", "last seen by", "physician", "years", "anxiety", "anti-anxiety medications", "to pay", "doctors", "Now", "patient notes", "anxiety", "somewhat controlled", "motor difficulties", "making", "difficult", "to", "Family history", "died", "infant", "always", "bright child", "MRI of", "brain", "ordered", "prominent atrophy of the caudate nucleus", "Repeats", "following trinucleotides", "responsible", "patients disorder"]}
{"question": "A 32-year-old man who recently emigrated from Somalia comes to the physician because of a 4-week history of fever, cough, and chest pain. He has had a 5-kg (11-lb) weight loss over the last 3 months despite no changes in appetite. His temperature is 38.1°C (100.6°F). Physical examination shows enlarged cervical lymph nodes. The lungs are clear to auscultation. The results of an interferon-γ release assay are positive. An x-ray of the chest shows bilateral mediastinal lymphadenopathy. A transbronchial needle aspiration biopsy of a mediastinal lymph node is performed; a photomicrograph of the specimen is shown. The structure indicated by the arrow is most likely comprised of which of the following types of cells?", "answer": "Macrophages", "options": {"A": "Macrophages", "B": "Neutrophils", "C": "Fibroblasts", "D": "Natural killer cells", "E": "B cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "recently", "Somalia", "physician", "4 week history", "fever", "cough", "chest pain", "5 kg", "weight loss", "months", "changes in appetite", "temperature", "100", "enlarged cervical lymph nodes", "lungs", "clear", "auscultation", "results", "interferon", "release assay", "positive", "x-ray of", "chest", "bilateral mediastinal lymphadenopathy", "transbronchial needle aspiration biopsy of", "mediastinal lymph node", "performed", "photomicrograph", "structure indicated", "arrow", "most likely", "following"]}
{"question": "A 1-year-old immigrant girl presents to her pediatrician for a routine well-child check. She has not received any recommended vaccines since birth. She attends daycare and remains healthy despite her daily association with several other children for the past 3 months at a home daycare facility. Which of the following phenomena explains why she has not contracted any vaccine-preventable diseases such as measles, diphtheria, or pertussis?", "answer": "Herd immunity", "options": {"A": "Herd immunity", "B": "Genetic drift", "C": "Genetic shift", "D": "Tolerance", "E": "Immune evasion"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "girl presents", "pediatrician", "routine well-child check", "not received", "vaccines", "birth", "attends daycare", "healthy", "daily association", "several", "children", "past 3 months", "home daycare facility", "following", "not contracted", "vaccine preventable diseases", "measles", "diphtheria", "pertussis"]}
{"question": "A pharmaceutical company has modified one of its existing antibiotics to have an improved toxicity profile. The new antibiotic blocks protein synthesis by first entering the cell and then binding to active ribosomes. The antibiotic mimics the structure of aminoacyl-tRNA. The drug is covalently bonded to the existing growing peptide chain via peptidyl transferase, thereby impairing the rest of protein synthesis and leading to early polypeptide truncation. Where is the most likely site that this process occurs?", "answer": "P site", "options": {"A": "30S small subunit", "B": "40S small subunit", "C": "A site", "D": "E site", "E": "P site"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["modified one", "to", "improved toxicity profile", "new", "blocks", "first entering", "cell", "then", "active", "mimics", "structure", "aminoacyl-tRNA", "drug", "chain", "peptidyl transferase", "impairing", "leading", "early polypeptide truncation", "site", "process occurs"]}
{"question": "A previously healthy 22-year-old man comes to the physician because of multiple nodules on his hands that first appeared a few months ago. He works as a computer game programmer. His father died of a myocardial infarction at 37 years of age, and his mother has rheumatoid arthritis. A photograph of the lesions is shown. The nodules are firm, mobile, and nontender. Which of the following is the most likely mechanism underlying this patient's skin findings?", "answer": "Extravasation of lipoproteins", "options": {"A": "Deposition of triglycerides", "B": "Fibrinoid necrosis", "C": "Crystallization of monosodium urate", "D": "Uncontrolled adipocyte growth", "E": "Extravasation of lipoproteins"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old man", "physician", "of multiple nodules", "hands", "first appeared", "few months", "computer programmer", "died", "myocardial infarction", "years", "age", "rheumatoid arthritis", "photograph", "lesions", "nodules", "firm", "mobile", "nontender", "following", "mechanism", "patient's skin findings"]}
{"question": "A previously healthy 25-year-old man is brought to the emergency department 30 minutes after collapsing during soccer practice. His father died of sudden cardiac arrest at the age of 36 years. The patient appears well. His pulse is 73/min and blood pressure is 125/78 mm Hg. Cardiac examination is shown. An ECG shows large R waves in the lateral leads and deep S waves in V1 and V2. Further evaluation is most likely to show which of the following?", "answer": "Asymmetric septal hypertrophy", "options": {"A": "Monoclonal light chain deposition in the myocardium", "B": "Aortic root dilatation", "C": "Eccentric left ventricular dilation", "D": "Asymmetric septal hypertrophy", "E": "Mitral valve fibrinoid necrosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department 30 minutes", "collapsing", "died", "sudden cardiac arrest", "age", "36 years", "patient appears well", "pulse", "min", "blood pressure", "mm Hg", "ECG", "large R waves", "lateral leads", "deep S waves", "V1", "V2", "Further", "to", "following"]}
{"question": "A 45-year-old man presents with a 3-day history of right-sided flank pain due to a lodged ureteral stone. What changes would be expected to be seen at the level of glomerular filtration?", "answer": "Increase in Bowman's space hydrostatic pressure", "options": {"A": "Increase in glomerular capillary oncotic pressure", "B": "Increase in Bowman's space capillary oncotic pressure", "C": "Increase in Bowman's space hydrostatic pressure", "D": "Increase in filtration fraction", "E": "No change in filtration fraction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "3-day history", "right-sided flank pain", "ureteral stone", "changes", "to", "seen", "level", "glomerular filtration"]}
{"question": "A 23-year-old man is brought to the emergency department by police at 2:00 AM. They picked him up from a local nightclub, where he was yelling and threatening to fight the staff. A review of his medical record is unremarkable. At the hospital, his behavior continues to be agitated and bizarre. His temperature is 37.0°C (98.6°F), the blood pressure is 162/98 mm Hg, the heart rate is 120/min, the respiratory rate is 18/min, and the oxygen saturation is 99% on room air. The physical exam is notable for agitation, but otherwise, he appears healthy. His thin nasal mucosa oozes blood and his pupils are 2mm, equal, and reactive to light. His speech is pressured and bizarre. He insists the hospital should let him go because “I am in the FBI”. Urine toxicology is sent to the laboratory for analysis. Which of the following is the most likely cause of this patient's presentation?", "answer": "Cocaine intoxication", "options": {"A": "Acute manic episode", "B": "Cocaine intoxication", "C": "Phencyclidine (PCP) intoxication", "D": "Tetrahydrocannabinol (THC) intoxication", "E": "Thyrotoxicosis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old man", "brought", "emergency department", "police", "local nightclub", "to", "staff", "unremarkable", "hospital", "behavior", "to", "agitated", "temperature", "98", "blood pressure", "98 mm Hg", "heart rate", "min", "respiratory rate", "min", "oxygen saturation", "99", "room air", "notable", "agitation", "appears healthy", "thin nasal mucosa", "blood", "pupils", "equal", "reactive to light", "speech", "pressured", "hospital", "let", "go", "I", "Urine toxicology", "sent", "laboratory", "analysis", "following", "most likely cause", "patient's"]}
{"question": "A 33-year-old man presents to a physician with a 3-year history of gradually worsening tics and difficulty walking. He was last seen by the physician 5 years ago for anxiety and has been purchasing anti-anxiety medications from an internet website without a prescription because he cannot afford to pay for the office visits. Now he says his anxiety is somewhat controlled, but the motor difficulties are making it difficult for him to work and socialize. His family history is unknown because his parents died in an automobile accident when he was an infant. He grew up in foster care and was always a bright child. An MRI of the brain is ordered, which shows prominent atrophy of the caudate nucleus. Repeats of which of the following trinucleotides are most likely responsible for this patient’s disorder?", "answer": "CAG", "options": {"A": "CCG", "B": "CGG", "C": "GAA", "D": "CAG", "E": "CTG"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "physician", "3 year history", "worsening tics", "difficulty walking", "last seen by", "physician", "years", "anxiety", "anti-anxiety medications", "to pay", "Now", "anxiety", "somewhat controlled", "motor difficulties", "making", "difficult", "to", "family history", "unknown", "died", "automobile accident", "infant", "always", "bright child", "MRI of", "brain", "ordered", "prominent atrophy of the caudate nucleus", "Repeats", "following trinucleotides", "responsible", "patients disorder"]}
{"question": "A 25-year-old woman comes to the physician because of sadness that started 6 weeks after her 9-month-old daughter was born. Since then, she has not returned to work. Her daughter usually sleeps through the night, but the patient still has difficulty staying asleep. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Major depressive disorder", "options": {"A": "Disruptive mood dysregulation disorder", "B": "Adjustment disorder", "C": "Depression with peripartum-onset", "D": "Major depressive disorder", "E": "Normal behavior"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "started 6 weeks", "9 month old", "born", "Since then", "not returned to", "usually sleeps", "night", "patient", "difficulty staying asleep", "easily", "normal", "used", "only orders delivery", "out now", "always", "exhausted to", "not", "hungry", "pregnancy", "patient's child", "complicated", "gestational diabetes", "child", "born", "36 weeks", "gestation", "medical issues", "patient", "contact with", "not sexually active", "not smoke", "use illicit", "5 ft", "tall", "kg", "BMI", "20 kg/m2", "Vital signs", "normal limits", "alert", "makes little", "abnormalities", "following", "diagnosis"]}
{"question": "A 34-year-old woman comes to the physician because of a 3-month history of pain in her right thumb and wrist that radiates to her elbow. It is worse when she holds her infant son and improves with the use of an ice pack. Six months ago, she slipped on a wet floor and fell on her right outstretched hand. Her mother takes methotrexate for chronic joint pain. The patient takes ibuprofen as needed for her current symptoms. Examination of the right hand shows tenderness over the radial styloid with swelling but no redness. There is no crepitus. Grasping her right thumb and exerting longitudinal traction toward the ulnar side elicits pain. Range of motion of the finger joints is normal. There is no swelling, redness, or tenderness of any other joints. Which of the following is the most likely diagnosis?", "answer": "De Quervain tenosynovitis", "options": {"A": "De Quervain tenosynovitis", "B": "Swan neck deformity", "C": "Mallet finger", "D": "Carpal tunnel syndrome", "E": "Stenosing tenosynovitis\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "3 month history", "pain", "right thumb", "wrist", "radiates", "elbow", "worse", "holds", "infant", "improves", "use of", "ice pack", "Six months", "wet floor", "fell", "right", "hand", "methotrexate", "chronic joint pain", "patient", "ibuprofen as needed", "current symptoms", "Examination of", "right hand", "tenderness", "swelling", "redness", "crepitus", "Grasping", "right thumb", "exerting longitudinal traction", "ulnar side elicits pain", "Range of motion of", "finger joints", "normal", "swelling", "redness", "tenderness", "joints", "following", "diagnosis"]}
{"question": "A 24-year-old woman comes to the physician because of bothersome hair growth on her face and abdomen over the past 8 years. She does not take any medications. She is 163 cm (5 ft 4 in) tall and weighs 85 kg (187 lb); BMI is 32 kg/m2. Physical examination shows coarse dark hair on the upper lip and periumbilical and periareolar skin. Her external genitalia appear normal. Her serum follicle-stimulating hormone, luteinizing hormone, and testosterone are within the reference range. A urine pregnancy test is negative. Which of the following is the most appropriate pharmacotherapy for this patient's condition at this time?", "answer": "Oral contraceptive", "options": {"A": "Prednisone", "B": "Leuprolide", "C": "Ketoconazole", "D": "Oral contraceptive", "E": "Metformin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "of", "hair growth", "face", "abdomen", "past", "years", "not", "medications", "5 ft 4", "tall", "85 kg", "BMI", "kg/m2", "coarse dark hair", "upper lip", "periumbilical", "periareolar skin", "external genitalia appear normal", "serum follicle-stimulating hormone", "luteinizing hormone", "testosterone", "reference range", "urine pregnancy test", "negative", "following", "most appropriate pharmacotherapy", "patient's condition", "time"]}
{"question": "A 45-year-old man is brought to the emergency department 20 minutes after being rescued from a fire in his apartment complex. He thinks he might have briefly lost consciousness while he was trapped in a smoke-filled room before firefighters were able to free him 20 minutes later. He reports headache, dizziness, and occasional cough. He has no difficulty breathing, speaking, or swallowing. He appears mildly uncomfortable and agitated. His temperature is 36.4°C (97.5°F), pulse is 90/min, respirations are 16/min, and blood pressure is 155/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Breath sounds are coarse. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows :\npH 7.30\nPCO2 38 mm Hg\nPO2 70 mm Hg\nHCO3- 18 mEq/L\nCOHb 2% (N < 3)\nIn addition to oxygen supplementation with a non-rebreather mask, which of the following is the most appropriate next step in management?\"", "answer": "Administration of intravenous hydroxycobalamin", "options": {"A": "Administration of intravenous dimercaprol", "B": "Hyperbaric oxygen therapy", "C": "Administration of methylene blue", "D": "Administration of intravenous hydroxycobalamin", "E": "Administration of N-acetylcysteine\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department 20 minutes", "fire", "apartment complex", "lost consciousness", "smoke", "room", "able", "free", "20 minutes later", "reports headache", "dizziness", "occasional cough", "difficulty breathing", "swallowing", "appears mildly", "agitated", "temperature", "36", "97", "pulse", "90 min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "Breath sounds", "coarse", "abnormalities", "Arterial blood gas analysis", "room air", "pH 7 30 PCO2", "mm", "PO2 70", "HCO3", "mEq/L COHb", "N", "3", "In addition to oxygen supplementation", "non-rebreather mask", "following", "most appropriate next step"]}
{"question": "A 33-year-old man is brought to the emergency department by his mother because of erratic behavior over the past 6 months. He spends most of his time alone in his room because he believes he is being followed by the Secret Service. He was fired from his job 3 months ago after threatening a colleague. He appears suspicious of his surroundings and asks the doctor questions about “the security of the hospital.” The patient exhibits a flat affect. During physical examination, he tells the doctor that he has a gun at home and plans to shoot his neighbor, whom he thinks is working for the Secret Service. Which of the following is the most appropriate action by the doctor?", "answer": "Warn the person at risk and inform law enforcement", "options": {"A": "Administer haloperidol and request a psychiatric consultation", "B": "Discuss the diagnosis and therapy plan with the patient's mother", "C": "Inform security and law enforcement", "D": "Warn the person at risk and inform law enforcement", "E": "Request a court order to override the patient's right to confidentiality"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "past 6 months", "spends most of", "time alone", "room", "followed by", "Secret Service", "fired", "job 3 months", "appears suspicious", "surroundings", "doctor", "security", "hospital", "patient", "flat affect", "doctor", "gun at home", "plans to", "Secret Service", "following", "most appropriate action", "doctor"]}
{"question": "A 59-year-old man with a history of congestive heart failure presents to his cardiologist for a follow-up visit. His past medical history is notable for diabetes mellitus, hypertension, and obesity. He takes metformin, glyburide, aspirin, lisinopril, and metoprolol. He has a 40 pack-year smoking history and drinks alcohol socially. His temperature is 99.1°F (37.2°C), blood pressure is 150/65 mmHg, pulse is 75/min, and respirations are 20/min. Physical examination reveals bilateral rales at the lung bases and 1+ edema in the bilateral legs. The physician decides to start the patient on an additional diuretic but warns the patient about an increased risk of breast enlargement. Which of the following is the most immediate physiologic effect of the medication in question?", "answer": "Decreased sodium reabsorption in the collecting duct", "options": {"A": "Decreased bicarbonate reabsorption in the proximal convoluted tubule", "B": "Decreased sodium reabsorption in the thick ascending limb", "C": "Decreased sodium reabsorption in the distal convoluted tubule", "D": "Decreased sodium reabsorption in the collecting duct", "E": "Decreased renin enzyme activity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["59 year old man", "history of congestive heart failure presents", "cardiologist", "past medical history", "notable", "diabetes mellitus", "hypertension", "obesity", "metformin", "glyburide", "aspirin", "lisinopril", "metoprolol", "40", "smoking history", "alcohol", "temperature", "99", "blood pressure", "65 mmHg", "pulse", "75 min", "respirations", "20 min", "reveals bilateral rales", "lung bases", "1", "edema", "bilateral legs", "physician", "to start", "patient", "additional diuretic", "patient", "increased risk", "breast enlargement", "following", "most immediate physiologic effect", "medication"]}
{"question": "A 3-year-old girl is brought to the emergency department for 2 days of abdominal pain and watery diarrhea. This morning her stool had a red tint. She and her parents visited a circus 1 week ago. The patient attends daycare. Her immunizations are up-to-date. Her temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg. Abdominal examination shows soft abdomen that is tender to palpation in the right lower quadrant with rebound. Stool culture grows Yersinia enterocolitica. Exposure to which of the following was the likely cause of this patient's condition?", "answer": "Undercooked pork", "options": {"A": "Undercooked pork", "B": "Undercooked poultry", "C": "Home-canned food", "D": "Unwashed vegetables", "E": "Deli meats"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "emergency department", "2 days", "abdominal pain", "watery diarrhea", "morning", "stool", "red", "circus", "week", "patient attends daycare", "immunizations", "date", "temperature", "100", "pulse", "min", "blood pressure", "80", "mm Hg", "Abdominal", "soft abdomen", "tender", "palpation", "right lower quadrant", "Stool culture", "Exposure to", "following", "likely cause", "patient's condition"]}
{"question": "A 50-year-old man is brought in by ambulance to the emergency department with difficulty breathing and speaking. His wife reports that he might have swallowed a fishbone. While taking his history the patient develops a paroxysmal cough. Visualization of his oropharynx and larynx shows a fishbone lodged in the right piriform recess. After successfully removing the fishbone the patient feels comfortable, but he is not able to cough like before. Damage to which of the following nerves is responsible for the impaired cough reflex in this patient?", "answer": "Internal laryngeal nerve", "options": {"A": "External laryngeal nerve", "B": "Internal laryngeal nerve", "C": "Recurrent laryngeal nerve", "D": "Inferior laryngeal nerve", "E": "Superior laryngeal nerve"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old man", "brought", "ambulance", "emergency department", "difficulty breathing", "reports", "swallowed", "history", "patient", "paroxysmal cough", "Visualization", "oropharynx", "larynx", "right piriform recess", "removing", "patient", "not able to cough", "Damage", "following nerves", "responsible", "impaired cough reflex", "patient"]}
{"question": "A 61-year-old male presents to the ER with abdominal discomfort and malaise over the past 2 weeks. He states he is married and monogamous. He has a temperature of 39.4°C (102.9°F) and complains of night sweats as well. On physical exam, he has an enlarged spleen with mild tenderness and pale nail beds. There is mild tonsillar erythema and the pulmonary exam demonstrates scattered crackles. A complete blood count demonstrates anemia, thrombocytopenia, and leukocytosis with lymphocytic predominance. A bone marrow aspiration is scheduled the next morning based on the peripheral blood smear findings but was inconclusive due to a low yield. The patient was admitted to the hospital due to the anemia and given a transfusion of packed red blood cells and wide spectrum antibiotics. He is released home the next day with instructions for primary care follow-up. Which of the following laboratory findings is most reliably positive for the primary cause of this illness?", "answer": "Tartrate-resistant acid phosphatase (TRAP)", "options": {"A": "Rapid streptococcal antigen", "B": "Quantiferon Gold", "C": "Monospot", "D": "Tartrate-resistant acid phosphatase (TRAP)", "E": "CD 25"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old male presents", "ER", "abdominal discomfort", "malaise", "past 2 weeks", "states", "married", "temperature", "9F", "night sweats", "well", "enlarged", "mild tenderness", "pale nail beds", "mild tonsillar erythema", "pulmonary exam", "scattered crackles", "complete blood count", "anemia", "thrombocytopenia", "leukocytosis", "lymphocytic predominance", "bone marrow aspiration", "scheduled", "next morning based", "peripheral blood smear findings", "inconclusive due to", "low", "patient", "anemia", "given", "transfusion of packed red blood cells", "wide spectrum", "released home", "next day", "instructions", "follow-up", "following laboratory findings", "most", "positive", "primary cause", "illness"]}
{"question": "A 38-year-old man comes to the emergency department because of epigastric pain and multiple episodes of vomiting for 4 hours. Initially, the vomit was yellowish in color, but after the first couple of episodes it was streaked with blood. He had 2 episodes of vomiting that contained streaks of frank blood on the way to the hospital. He has been hospitalized twice in the past year for acute pancreatitis. He drinks 2 pints of vodka daily but had over 4 pints during the past 12 hours. He takes naproxen for his 'hangovers.' He appears uncomfortable. His temperature is 37°C (99.1°F), pulse is 105/min, and blood pressure is 110/68 mm Hg. Examination shows dry mucous membranes and a tremor of his hands. The abdomen is soft and shows tenderness to palpation in the epigastric region; there is no organomegaly. Cardiopulmonary examination shows no abnormalities. Rectal examination is unremarkable. His hemoglobin concentration is 11.3 g/dL and hematocrit concentration is 40%. Which of the following is the most likely cause of this patient's findings?", "answer": "Mucosal tear at the gastroesophageal junction", "options": {"A": "Transmural tear of the lower esophagus", "B": "Pseudoaneurysm of the gastroduodenal artery", "C": "Inflammation of the esophageal wall", "D": "Mucosal tear at the gastroesophageal junction", "E": "Neoplastic growth at the gastroesophageal junction"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency department", "epigastric pain", "multiple episodes of vomiting", "4 hours", "Initially", "vomit", "color", "first couple of episodes", "blood", "2 episodes of vomiting", "contained", "frank blood", "hospital", "hospitalized twice", "past year", "acute pancreatitis", "2 pints", "daily", "over 4 pints", "past 12 hours", "naproxen", "his", "hangovers", "appears", "temperature", "99", "pulse", "min", "blood pressure", "mm Hg", "dry mucous membranes", "tremor of", "hands", "abdomen", "soft", "tenderness", "palpation", "epigastric region", "organomegaly", "Cardiopulmonary", "abnormalities", "Rectal examination", "unremarkable", "hemoglobin concentration", "g/dL", "hematocrit concentration", "40", "following", "most likely cause", "patient's findings"]}
{"question": "A 16-year-old girl comes to the physician because of a 3-week history of nausea, increased urinary frequency, and breast tenderness. She has never had a menstrual period. She is actively involved in her school's track and field team. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2. Her breast and pubic hair development are at Tanner stage 5. Which of the following serum assays is the most appropriate next step in the diagnosis of this patient's condition?", "answer": "Human chorionic gonadotropin", "options": {"A": "Estriol", "B": "Thyrotropin", "C": "Human chorionic gonadotropin", "D": "Luteinizing hormone", "E": "Prolactin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "3 week history", "nausea", "increased urinary frequency", "breast tenderness", "never", "menstrual period", "involved", "school's", "5 ft 8", "tall", "54 kg", "BMI", "kg/m2", "breast", "pubic hair development", "Tanner stage", "following serum assays", "most appropriate next step", "diagnosis", "patient's condition"]}
{"question": "A 28-year-old man presents to his primary care provider complaining of intermittent stomach pain, non-bloody diarrhea, and weight loss for the last 3 months. He has occasional abdominal pain and fever. This condition makes studying difficult. He has tried omeprazole and dietary changes with no improvement. Past medical history is significant for occasional pain in the wrists and knees for several years. He takes ibuprofen for pain relief. His temperature is 38°C (100.4°F). On mental status examination, short-term memory is impaired. Attention and concentration are reduced. Examination shows no abnormalities or tenderness of the wrists or knees. There are no abnormalities on heart and lung examinations. Abdominal examination is normal. Upper endoscopy shows normal stomach mucosa but in the duodenum, there is pale yellow mucosa with erythema and ulcerations. Biopsies show infiltration of the lamina propria with periodic acid-Schiff (PAS)-positive macrophages. Which of the following best explains these findings?", "answer": "Whipple’s disease", "options": {"A": "Celiac disease", "B": "Crohn’s disease", "C": "Giardia lamblia infection", "D": "Whipple’s disease", "E": "Wilson’s disease"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care provider", "intermittent stomach", "non bloody diarrhea", "weight loss", "months", "occasional abdominal pain", "fever", "condition makes studying difficult", "omeprazole", "dietary changes", "Past medical history", "significant", "occasional pain", "wrists", "knees", "years", "ibuprofen", "pain relief", "temperature", "100", "mental status", "impaired", "concentration", "reduced", "abnormalities", "tenderness", "wrists", "knees", "abnormalities", "heart", "lung", "Abdominal", "normal", "Upper endoscopy", "normal stomach mucosa", "duodenum", "pale yellow mucosa", "erythema", "ulcerations", "Biopsies", "infiltration", "lamina propria", "periodic acid-Schiff", "positive macrophages", "following best", "findings"]}
{"question": "A 60-year-old woman is brought to the emergency department by her husband because of worsening shortness of breath over the past 2 days. Last week, she had a sore throat and a low-grade fever. She has coughed up white sputum each morning for the past 2 years. She has hypertension and type 2 diabetes mellitus. She has smoked 2 packs of cigarettes daily for 35 years. Current medications include metformin and lisinopril. On examination, she occasionally has to catch her breath between sentences. Her temperature is 38.1°C (100.6°F), pulse is 85/min, respirations are 16/min, and blood pressure is 140/70 mm Hg. Expiratory wheezes with a prolonged expiratory phase are heard over both lung fields. Arterial blood gas analysis on room air shows:\npH 7.33\nPCO2 53 mm Hg\nPO2 68 mm Hg\nAn x-ray of the chest shows hyperinflation of bilateral lung fields and flattening of the diaphragm. Which of the following additional findings is most likely in this patient?\"", "answer": "Decreased urinary bicarbonate excretion", "options": {"A": "Increased urine osmolar gap", "B": "Decreased urinary bicarbonate excretion", "C": "Increased urinary pH", "D": "Increased serum anion gap", "E": "Decreased urinary chloride concentration"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old woman", "brought", "emergency department", "of worsening shortness", "breath", "past 2 days", "Last week", "sore throat", "low-grade fever", "coughed", "white sputum", "morning", "past", "years", "hypertension", "type 2 diabetes mellitus", "smoked 2 packs", "cigarettes daily", "35 years", "Current medications include metformin", "lisinopril", "occasionally", "to catch", "breath", "temperature", "100", "pulse", "85 min", "respirations", "min", "blood pressure", "70 mm Hg", "Expiratory wheezes", "prolonged", "phase", "heard", "lung fields", "Arterial blood gas analysis", "room air", "pH 7", "PCO2", "mm Hg PO2", "x-ray of", "chest", "hyperinflation of bilateral lung fields", "flattening", "diaphragm", "following additional findings", "patient"]}
{"question": "A 32-year-old nulliparous woman with polycystic ovary syndrome comes to the physician for a pelvic examination and Pap smear. Last year she had a progestin-releasing intrauterine device placed. Menarche occurred at the age of 10 years. She became sexually active at the age of 14 years. Her mother had breast cancer at the age of 51 years. She is 165 cm (5 ft 5 in) tall and weighs 79 kg (174 lb); BMI is 29 kg/m2. Examination shows mild facial acne. A Pap smear shows high-grade cervical intraepithelial neoplasia. Which of the following is this patient's strongest predisposing factor for developing this condition?", "answer": "Early onset of sexual activity", "options": {"A": "Early onset of sexual activity", "B": "Obesity", "C": "Early menarche", "D": "Family history of cancer", "E": "Polycystic ovary syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old nulliparous woman", "polycystic ovary syndrome", "physician", "pelvic examination", "Pap smear", "year", "progestin releasing intrauterine device", "Menarche", "age", "10 years", "sexually active", "age", "years", "breast cancer", "the age of", "years", "5 ft 5", "tall", "kg", "BMI", "29 kg/m2", "mild facial acne", "Pap smear", "high-grade cervical intraepithelial neoplasia", "following", "patient's strongest predisposing factor", "condition"]}
{"question": "A 17-year-old girl comes to the physician for a scheduled colonoscopy. She was diagnosed with familial adenomatous polyposis at the age of 13 years. Last year, her flexible sigmoidoscopy showed 12 adenomatous polyps (< 6 mm) that were removed endoscopically. Her father and her paternal grandmother were diagnosed with colon cancer at the age of 37 and 39 years, respectively. The patient appears nervous but otherwise well. Her vital signs are within normal limits. Examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. A colonoscopy shows hundreds of diffuse 4–9 mm adenomatous polyps covering the colon and > 30 rectal adenomas. Which of the following is the most appropriate next step in management?", "answer": "Proctocolectomy with ileoanal anastomosis", "options": {"A": "Repeat colonoscopy in 6 months", "B": "Endoscopic biopsy of polyps", "C": "Proctocolectomy with ileoanal anastomosis", "D": "Folinic acid (leucovorin) + 5-Fluorouracil + oxaliplatin therapy", "E": "CT scan of the abdomen with contrast"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "scheduled colonoscopy", "diagnosed", "familial adenomatous polyposis", "age", "years", "flexible sigmoidoscopy", "adenomatous polyps", "6 mm", "removed", "diagnosed", "colon cancer", "age", "years", "patient appears nervous", "well", "vital signs", "normal limits", "abnormalities", "complete blood count", "serum", "electrolytes", "urea nitrogen", "creatinine", "reference range", "colonoscopy", "diffuse", "mm adenomatous polyps covering", "colon", "30 rectal adenomas", "following", "most appropriate next step"]}
{"question": "A codon is an mRNA sequence consisting of 3 nucleotides that codes for an amino acid. Each position can be made up of any 4 nucleotides (A, U, G, C); therefore, there are a total of 64 (4 x 4 x 4) different codons that can be created but they only code for 20 amino acids. This is explained by the wobble phenomenon. One codon for leucine is CUU, which of the following can be another codon coding for leucine?", "answer": "CUA", "options": {"A": "AUG", "B": "UAA", "C": "CCC", "D": "CCA", "E": "CUA"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["mRNA sequence consisting", "amino acid", "position", "made", "U", "G", "total", "64", "4", "4", "different", "created", "only", "20 amino acids", "One", "leucine", "following", "leucine"]}
{"question": "A researcher is conducting a study to compare fracture risk in male patients above the age of 65 who received annual DEXA screening to peers who did not receive screening. He conducts a randomized controlled trial in 900 patients, with half of participants assigned to each experimental group. The researcher ultimately finds similar rates of fractures in the two groups. He then notices that he had forgotten to include 400 patients in his analysis. Including the additional participants in his analysis would most likely affect the study's results in which of the following ways?", "answer": "Increased probability of rejecting the null hypothesis when it is truly false", "options": {"A": "Decreased significance level of results", "B": "Wider confidence intervals of results", "C": "Increased probability of committing a type II error", "D": "Increased probability of rejecting the null hypothesis when it is truly false", "E": "Increased external validity of results"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["researcher", "study to", "fracture", "male patients", "age", "65", "received annual DEXA screening", "not receive screening", "900 patients", "half", "assigned", "experimental group", "researcher", "finds similar rates", "fractures", "two groups", "then", "forgotten to include 400 patients", "analysis", "Including", "additional", "analysis", "most likely", "study's results", "following"]}
{"question": "A 25-year-old woman with bipolar disorder and schizophrenia presents to the emergency room stating that she is pregnant. She says that she has been pregnant since she was 20 years old and is expecting a baby now that she is breathing much harder and feeling more faint with chest pain caused by deep breaths. Her hospital medical record shows multiple negative pregnancy tests over the past 5 years. The patient has a 20 pack-year smoking history. Her temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 28/min, and oxygen saturation is 90% on room air. Her fingerstick glucose is 100 mg/dL. She has a large abdominal pannus which is soft and nontender. Her legs are symmetric and non-tender. Oxygen is provided via nasal cannula. Her urine pregnancy test comes back positive and an initial chest radiograph is unremarkable. What is the next best step in diagnosis?", "answer": "Ventilation-perfusion scan", "options": {"A": "CT angiogram", "B": "D-dimer", "C": "Psychiatry consult for pseudocyesis", "D": "Ultrasound", "E": "Ventilation-perfusion scan"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "bipolar disorder", "schizophrenia presents", "emergency room stating", "pregnant", "pregnant", "20 years old", "baby now", "breathing", "harder", "more faint", "chest pain caused", "deep breaths", "hospital medical record", "multiple negative pregnancy tests", "past", "years", "patient", "20 year smoking history", "temperature", "blood pressure", "100 60 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "90", "room air", "fingerstick glucose", "100 mg/dL", "large abdominal pannus", "soft", "nontender", "legs", "symmetric", "non-tender", "Oxygen", "nasal cannula", "urine pregnancy test", "back positive", "initial chest radiograph", "unremarkable", "next best step", "diagnosis"]}
{"question": "A 71-year-old man comes to the physician because of a 2-week history of fatigue and a cough productive of a blood-tinged phlegm. Over the past month, he has had a 5.0-kg (11-lb) weight loss. He has hypertension and type 2 diabetes mellitus. Eight months ago, he underwent a kidney transplantation. The patient does not smoke. His current medications include lisinopril, insulin, prednisone, and mycophenolate mofetil. His temperature is 38.9°C (102.1°F), pulse is 88/min, and blood pressure is 152/92 mm Hg. Rhonchi are heard at the right lower lobe of the lung on auscultation. There is a small ulceration on the left forearm. An x-ray of the chest shows a right lung mass with lobar consolidation. Antibiotic therapy with levofloxacin is started. Three days later, the patient has a seizure and difficulty coordinating movements with his left hand. An MRI of the brain shows an intraparenchymal lesion with peripheral ring enhancement. Bronchoscopy with bronchoalveolar lavage yields weakly acid-fast, gram-positive bacteria with branching, filamentous shapes. Which of the following is the most appropriate initial pharmacotherapy?", "answer": "Trimethoprim/sulfamethoxazole", "options": {"A": "Rifampin, isoniazid, pyrazinamide, and ethambutol", "B": "Vancomycin", "C": "Piperacillin/tazobactam", "D": "Trimethoprim/sulfamethoxazole", "E": "Erythromycin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "2-week history", "fatigue", "cough productive of", "blood tinged phlegm", "past month", "5 0 kg", "weight loss", "hypertension", "type 2 diabetes mellitus", "Eight months", "kidney transplantation", "patient", "not smoke", "current medications include lisinopril", "insulin", "prednisone", "mycophenolate mofetil", "temperature", "pulse", "88 min", "blood pressure", "mm Hg", "Rhonchi", "heard", "the right lower lobe of", "lung", "auscultation", "small ulceration", "left forearm", "x-ray of", "chest", "right", "lobar consolidation", "Antibiotic therapy", "levofloxacin", "started", "Three days later", "patient", "seizure", "difficulty coordinating movements", "left hand", "MRI of", "brain", "intraparenchymal lesion", "peripheral ring enhancement", "Bronchoscopy", "bronchoalveolar lavage", "weakly", "gram positive bacteria", "branching", "filamentous shapes", "following", "most appropriate initial pharmacotherapy"]}
{"question": "A 61-year-old-male underwent deceased donor liver transplantation 3 weeks ago. During his follow up visit he complains of nausea and abdominal pain. He has been taking all of his medications as prescribed. He has a history of alcohol abuse and his last drink was one year ago. He does not smoke cigarettes and lives at home with his wife. On physical examination temperature is 98.6°F (37°C), blood pressure is 115/80 mmHg, pulse is 90/min, respirations are 18/min, and pulse oximetry is 99% on room air. He has scleral icterus and a positive fluid wave. Liver function tests are as follows:\n\nAlkaline phosphatase: 110 U/L\nAspartate aminotransferase (AST, GOT): 100 U/L\nAlanine aminotransferase (ALT, GPT): 120 U/L\nBilirubin total: 2.2 mg/dL\n\nLiver biopsy shows mixed dense interstitial lymphocytic infiltrates in the portal triad. What is the mechanism of this reaction?", "answer": "CD8+ T lymphocytes reacting against donor MHCs", "options": {"A": "CD8+ T lymphocytes reacting against donor MHCs", "B": "CD4+ T lymphocytes reacting against recipient APCs", "C": "Pre-existing recipient antibodies", "D": "Acute viral infection", "E": "Grafted T lymphocytes reacting against host"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["61 year old male", "deceased donor liver transplantation", "weeks", "nausea", "abdominal pain", "medications", "history of alcohol abuse", "last", "one year ago", "not smoke cigarettes", "lives at home", "temperature", "98", "blood pressure", "80 mmHg", "pulse", "90 min", "respirations", "min", "pulse oximetry", "99", "room air", "scleral icterus", "positive fluid wave", "Liver function tests", "follows", "Alkaline phosphatase", "U/L Aspartate aminotransferase", "AST", "100 U/L Alanine aminotransferase", "ALT", "GPT", "U/L Bilirubin total", "2.2 mg/dL", "Liver biopsy", "mixed dense interstitial lymphocytic", "portal triad", "mechanism", "reaction"]}
{"question": "A 45-year-old male patient with a history of recurrent nephrolithiasis and chronic lower back pain presents to the ER with severe, sudden-onset, upper abdominal pain. The patient is febrile, hypotensive, and tachycardic, and is rushed to the OR for exploratory laporotomy. Surgery reveals that the patient has a perforated gastric ulcer. Despite appropriate therapy, the patient expires, and subsequent autopsy reveals multiple ulcers in the stomach, duodenum, and jejunum. The patient had been complaining of abdominal pain and diarrhea for several months but had only been taking ibuprofen for his lower back pain for the past 3 weeks. What is the most likely cause of the patient's presentation?", "answer": "A gastrin-secreting tumor of the pancreas", "options": {"A": "A gastrin-secreting tumor of the pancreas", "B": "A vasoactive-intestinal-peptide (VIP) secreting tumor of the pancreas", "C": "Cytomegalovirus infection", "D": "H. pylori infection", "E": "Chronic NSAID use"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male patient", "history of recurrent nephrolithiasis", "chronic lower back pain presents", "ER", "severe", "sudden-onset", "upper abdominal pain", "patient", "febrile", "hypotensive", "tachycardic", "rushed", "exploratory", "Surgery reveals", "patient", "perforated gastric ulcer", "appropriate therapy", "patient", "subsequent autopsy reveals multiple ulcers", "stomach", "duodenum", "jejunum", "patient", "abdominal pain", "diarrhea", "months", "only", "ibuprofen", "lower back pain", "past", "weeks", "most likely cause", "patient's"]}
{"question": "A 32-year-old woman comes to the physician because of pain and stiffness in both of her hands for the past 3 weeks. The pain is most severe early in the day and does not respond to ibuprofen. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Examination shows swelling and tenderness of the wrists and metacarpophalangeal joints bilaterally. Range of motion is decreased due to pain. There are subcutaneous, nontender, firm, mobile nodules on the extensor surface of the forearm. Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?", "answer": "Prednisone", "options": {"A": "Methotrexate", "B": "Adalimumab", "C": "Colchicine", "D": "Sulfasalazine", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "pain", "stiffness", "hands", "past", "weeks", "pain", "most severe early", "day", "not", "ibuprofen", "history", "serious illness", "medications", "Vital signs", "normal limits", "swelling", "tenderness", "wrists", "joints", "Range of motion", "decreased due to pain", "subcutaneous", "nontender", "firm", "mobile nodules", "extensor surface of", "forearm", "following", "most appropriate pharmacotherapy", "patient's current symptoms"]}
{"question": "A peripheral artery is found to have 50% stenosis. Therefore, compared to a normal artery with no stenosis, by what factor has the flow of blood been decreased?", "answer": "16", "options": {"A": "2", "B": "4", "C": "8", "D": "16", "E": "32"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["peripheral artery", "found to", "50", "stenosis", "normal artery", "stenosis", "factor", "flow", "blood", "decreased"]}
{"question": "A 23-year-old woman presents to her physician requesting the chickenpox vaccine. She is also complaining of nausea, malaise, and moderate weight gain. She developed these symptoms gradually over the past 2 weeks. She reports no respiratory or cardiovascular disorders. Her last menstruation was about 6 weeks ago. She has one sexual partner and uses a natural planning method for contraception. Her vital signs include: blood pressure 110/70 mm Hg, heart rate 92/min, respiratory rate 14/min, and temperature 37.2℃ (99℉). The physical examination shows non-painful breast engorgement and nipple hyperpigmentation. There is no neck enlargement and no palpable nodules in the thyroid gland. The urine beta-hCG is positive. What is the proper recommendation regarding chickenpox vaccination in this patient?", "answer": "Confirm pregnancy with serum beta-hCG and if positive, postpone administration of the vaccine until after completion of the pregnancy.", "options": {"A": "Schedule the vaccination.", "B": "Perform varicella viral load and schedule the vaccine based on these results.", "C": "Confirm pregnancy with serum beta-hCG and if positive, schedule the patient for pregnancy termination.", "D": "Confirm pregnancy with serum beta-hCG and if positive, postpone administration of the vaccine until after completion of the pregnancy.", "E": "Confirm pregnancy with serum beta-hCG and if positive delay administration of the vaccine until the third trimester."}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old woman presents", "physician", "chickenpox vaccine", "nausea", "malaise", "moderate weight gain", "symptoms", "past 2 weeks", "reports", "respiratory", "cardiovascular disorders", "last menstruation", "about", "weeks", "one", "uses", "natural planning method", "contraception", "vital signs include", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "non painful", "nipple hyperpigmentation", "neck enlargement", "palpable nodules", "thyroid gland", "urine beta-hCG", "positive", "chickenpox vaccination", "patient"]}
{"question": "A 20-year-old Caucasian male presents with recurrent nosebleeds. Complete history reveals his father died in his 40's after an intracranial hemorrhage and two of his father's five siblings have also had recurrent nosebleeds. Which of the following would you expect to find in this patient?", "answer": "Mucosal arteriovenous malformations", "options": {"A": "Retinal hemangioblastoma", "B": "Renal cell carcinoma", "C": "Mucosal arteriovenous malformations", "D": "Vestibular schwannoma", "E": "Cafe-au-lait spots"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old", "male presents", "recurrent nosebleeds", "Complete history reveals", "died", "40's", "intracranial hemorrhage", "two", "five", "recurrent nosebleeds", "following", "to find", "patient"]}
{"question": "A 55-year-old man presents with a bilateral lower leg edema. The patient reports it developed gradually over the past 4 months. The edema is worse in the evening and improves after sleeping at night or napping during the day. There are no associated pain or sensitivity changes. The patient also notes dyspnea on usual exertion such as working at his garden. The patient has a history of a STEMI myocardial infarction 9 months ago treated with thrombolysis with an unremarkable postprocedural course. His current medications include atorvastatin 10 mg, aspirin 81 mg, and metoprolol 50 mg daily. He works as a barber at a barbershop, has a 16-pack-year history of smoking, and consumes alcohol in moderation. The vital signs include: blood pressure 130/80 mm Hg, heart rate 63/min, respiratory rate 14/min, and temperature 36.8℃ (98.2℉). The lungs are clear to auscultation. Cardiac examination shows dubious S3 and a soft grade 1/6 systolic murmur best heard at the apex of the heart. Abdominal examination reveals hepatic margin 1 cm below the costal margin. There is a 2+ bilateral pitting lower leg edema. The skin over the edema is pale with no signs of any lesions. There is no facial or flank edema. The thyroid gland is not enlarged. Which of the following tests is most likely to reveal the cause of the patient’s symptoms?", "answer": "Echocardiography", "options": {"A": "Doppler color ultrasound of the lower extremity", "B": "D-dimer measurement", "C": "Soft tissue ultrasound of the lower extremities", "D": "T4 and thyroid-stimulating hormone assessment", "E": "Echocardiography"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "bilateral lower leg edema", "patient reports", "past", "months", "edema", "worse", "evening", "improves", "sleeping", "night", "napping", "day", "associated pain", "sensitivity changes", "patient", "notes dyspnea on usual exertion", "as", "garden", "patient", "history of", "STEMI myocardial infarction", "months", "treated with thrombolysis", "unremarkable", "course", "current medications include", "metoprolol 50 mg daily", "barber", "history of smoking", "alcohol", "moderation", "vital signs include", "blood pressure", "80 mm Hg", "heart rate 63 min", "respiratory rate", "min", "temperature 36", "98", "lungs", "clear", "auscultation", "S3", "soft grade 1", "systolic murmur", "heard", "the apex of", "heart", "Abdominal", "reveals hepatic margin", "costal", "2", "bilateral pitting lower leg edema", "skin", "edema", "pale", "signs", "lesions", "facial", "flank edema", "thyroid gland", "not enlarged", "following tests", "to reveal", "cause", "patients symptoms"]}
{"question": "A 39-year-old G3P0 woman presents for preconception counseling and evaluation. The patient’s past medical history reveals hypertension and type 1 diabetes. She is currently on an insulin pump and medications for hypertension including labetalol. Her blood pressure is 130/85 mm Hg; pulse, 76/min; and BMI, 26 kg/m2. Her most recent HbA1c is 6.5%. Her previous pregnancies ended in spontaneous abortion during the 1st trimester despite adequate prenatal care. The patient intends to have a healthy pregnancy and desires to learn more about the risk factors that potentially trigger miscarriage. Which of the following maternal risk factors is most likely associated with early pregnancy loss?", "answer": "Age", "options": {"A": "Chronic hypertension", "B": "Diabetes", "C": "Infection", "D": "Age", "E": "Hypercoagulable state"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "patients past medical history reveals hypertension", "type 1 diabetes", "currently", "insulin pump", "medications", "hypertension including labetalol", "blood pressure", "85 mm Hg", "pulse", "76 min", "BMI", "kg/m2", "most recent", "6.5", "previous pregnancies ended", "spontaneous abortion", "1st trimester", "adequate", "patient", "to", "healthy pregnancy", "to", "more", "risk factors", "trigger miscarriage", "following maternal risk factors", "most likely associated with early pregnancy loss"]}
{"question": "A 71-year-old woman comes to the physician because of palpitations and shortness of breath that started 3 days ago. She has hypertension and congestive heart failure. Her pulse is 124/min, and blood pressure is 130/85 mm Hg. Cardiac examination shows an irregularly irregular rhythm without any murmurs. An ECG shows a narrow-complex tachycardia without P waves. The patient is prescribed a prophylactic medication that can be reversed with idarucizumab. The expected beneficial effect of the prescribed drug is most likely due to which of the following effects?", "answer": "Direct inhibition of thrombin", "options": {"A": "Induction of conformational change in antithrombin III", "B": "Inhibition of thrombocyte phosphodiesterase III", "C": "Irreversible inhibition of GPIIb/IIIa complex", "D": "Direct inhibition of factor Xa", "E": "Direct inhibition of thrombin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "palpitations", "shortness of breath", "started 3 days", "hypertension", "congestive heart failure", "pulse", "min", "blood pressure", "85 mm Hg", "irregular rhythm", "murmurs", "ECG", "narrow complex tachycardia", "P waves", "patient", "prophylactic medication", "reversed", "idarucizumab", "due to", "following effects"]}
{"question": "A 5-year-old African American female has experienced recurrent respiratory infections. To determine how well her cell-mediated immunity is performing, a Candida skin injection is administered. After 48 hours, there is no evidence of induration at the injection site. Of the following cell types, which one would have mediated the reaction?", "answer": "T-cells", "options": {"A": "Plasma cells", "B": "Basophils", "C": "T-cells", "D": "Mast cells", "E": "Fibroblasts"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old", "female", "recurrent respiratory infections", "To", "well", "cell-mediated immunity", "performing", "Candida skin injection", "administered", "48 hours", "induration", "injection site", "following", "one", "mediated", "reaction"]}
{"question": "A 62-year-old man comes to the physician for an annual health maintenance examination. He has a history of stable angina, gout, and hypertension. His medications include lisinopril and aspirin. He has smoked a pack of cigarettes daily for 20 years. He drinks 5–6 beers on the weekends. His blood pressure is 150/85 mm Hg. Laboratory studies show a total cholesterol of 276 mg/dL with an elevated low-density lipoprotein (LDL) concentration and low high-density lipoprotein (HDL) concentration. Administration of which of the following agents is the most appropriate next step in management?", "answer": "HMG-CoA reductase inhibitor", "options": {"A": "HMG-CoA reductase inhibitor", "B": "Peroxisome proliferator-activated receptor alpha activator", "C": "Cholesterol absorption inhibitor", "D": "Proprotein convertase subtilisin kexin 9 inhibitor", "E": "Bile acid resin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old man", "physician", "annual health maintenance examination", "history", "stable angina", "gout", "hypertension", "medications include lisinopril", "aspirin", "smoked", "pack", "cigarettes daily", "20 years", "weekends", "blood pressure", "85 mm Hg", "Laboratory studies", "total cholesterol", "mg/dL", "elevated low-density lipoprotein", "concentration", "low high-density lipoprotein", "concentration", "following", "most appropriate next step"]}
{"question": "A 45-year-old woman comes to the pediatrician’s office with her 17-year-old daughter. She tells the physician that she developed Sjögren’s syndrome when she was her daughter’s age, and that she is concerned about her daughter developing the same condition. The girl appears to be in good health, with no signs or symptoms of the disease or pathology. Which of the following antibodies will most likely be positive if the woman’s daughter were to develop Sjögren’s syndrome?", "answer": "Anti-SS-B (anti-La) antibodies", "options": {"A": "Anti-cyclic citrullinated antibodies", "B": "Anti-dsDNA antibodies", "C": "Anti-SS-B (anti-La) antibodies", "D": "Anti-histone antibodies", "E": "Anti-topoisomerase (anti-Scl 70) antibodies"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "pediatricians office", "year old", "physician", "syndrome", "age", "same condition", "girl appears to", "signs", "symptoms", "disease", "pathology", "following antibodies", "most likely", "positive", "to", "syndrome"]}
{"question": "A 40-year-old male presents to his primary care physician complaining of upper abdominal pain. He reports a four-month history of crampy epigastric pain that improves with meals. His past medical history is significant for hypertension that has been well controlled by lisinopril. He does not smoke and drinks alcohol occasionally. His family history is notable for a maternal uncle with acromegaly and a maternal grandfather with parathyroid adenoma requiring surgical resection. Based on clinical suspicion laboratory serum analysis is obtained and shows abnormal elevation of a peptide. This patient most likely has a mutation in which of the following chromosomes?", "answer": "11", "options": {"A": "5", "B": "10", "C": "11", "D": "13", "E": "17"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old male presents", "primary care physician", "upper abdominal pain", "reports", "four month history", "crampy epigastric pain", "improves", "meals", "past medical history", "significant", "hypertension", "well controlled by lisinopril", "not smoke", "alcohol occasionally", "family history", "notable", "acromegaly", "parathyroid adenoma", "surgical resection", "Based", "clinical", "laboratory serum analysis", "obtained", "abnormal elevation", "peptide", "patient", "likely", "mutation", "following chromosomes"]}
{"question": "A group of microbiological investigators is studying bacterial DNA replication in E. coli colonies. While the cells are actively proliferating, the investigators stop the bacterial cell cycle during S phase and isolate an enzyme involved in DNA replication. An assay of the enzyme's exonuclease activity determines that it is active on both intact and demethylated thymine nucleotides. Which of the following enzymes have the investigators most likely isolated?", "answer": "DNA polymerase I", "options": {"A": "DNA ligase", "B": "Telomerase", "C": "DNA polymerase I", "D": "DNA topoisomerase", "E": "Primase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigators", "studying bacterial", "replication", "colonies", "cells", "proliferating", "investigators stop", "bacterial cell cycle", "phase", "isolate", "enzyme involved", "DNA replication", "assay", "enzyme's", "active", "intact", "following enzymes", "investigators", "likely isolated"]}
{"question": "A 33-year-old woman comes to the physician because of a 3-week history of fatigue and worsening shortness of breath on exertion. There is no family history of serious illness. She does not smoke. She takes diethylpropion to control her appetite and, as a result, has had a 4.5-kg (10-lb) weight loss during the past 5 months. She is 163 cm (5 ft 4 in) tall and weighs 115 kg (254 lb); BMI is 44 kg/m2. Her pulse is 83/min and blood pressure is 125/85 mm Hg. Cardiac examination shows a loud pulmonary component of the S2. Abdominal examination shows no abnormalities. Which of the following is the most likely underlying cause of this patient's shortness of breath?", "answer": "Hyperplasia of pulmonary vascular walls", "options": {"A": "Hypertrophy of interventricular septum", "B": "Hyperplasia of pulmonary vascular walls", "C": "Blockade of the right bundle branch", "D": "Fibrosis of pulmonary interstitium", "E": "Calcification of the pulmonary valve"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "3 week history", "fatigue", "worsening shortness of breath", "exertion", "family history", "serious illness", "not smoke", "diethylpropion to control", "appetite", "result", "4.5 kg", "10", "weight loss", "past", "months", "5 ft 4", "tall", "kg", "BMI", "kg/m2", "pulse", "83 min", "blood pressure", "85 mm Hg", "loud pulmonary component", "S2", "Abdominal", "abnormalities", "following", "underlying cause of", "patient's shortness", "breath"]}
{"question": "An investigator is studying the outcomes of a malaria outbreak in an endemic region of Africa. 500 men and 500 women with known malaria exposure are selected to participate in the study. Participants with G6PD deficiency are excluded from the study. The clinical records of the study subjects are reviewed and their peripheral blood smears are evaluated for the presence of Plasmodium trophozoites. Results show that 9% of the exposed population does not have clinical or laboratory evidence of malaria infection. Which of the following best explains the absence of infection seen in this subset of participants?", "answer": "Glutamic acid substitution in the β-globin chain", "options": {"A": "Translocation of c-myc gene", "B": "Inherited defect in erythrocyte membrane ankyrin protein", "C": "Defective X-linked ALA synthase gene", "D": "Inherited mutation affecting ribosome synthesis", "E": "Glutamic acid substitution in the β-globin chain"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "outcomes", "malaria", "region", "Africa", "500", "500", "known malaria exposure", "to", "G6PD deficiency", "excluded", "study", "clinical", "study", "reviewed", "peripheral blood smears", "presence", "Results", "not", "clinical", "laboratory", "malaria infection", "following best", "absence", "infection seen"]}
{"question": "A 45-year-old man comes to his primary care provider for a routine visit. The patient mentions that while he was cooking 5 days ago, he accidentally cut himself with a meat cleaver and lost the skin at the tip of his finger. After applying pressure and ice, the bleeding stopped and he did not seek treatment. The patient is otherwise healthy and does not take any daily medications. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 114/72 mmHg, pulse is 60/min, and respirations are 12/min. On exam, the patient demonstrates a 0.5 x 0.3 cm wound on the tip of his left third finger. No bone is involved, and the wound is red, soft, and painless. There are no signs of infection. Which of the following can be expected on histopathological examination of the wounded area?", "answer": "Deposition of type III collagen", "options": {"A": "Deposition of type I collagen", "B": "Deposition of type III collagen", "C": "Epithelial cell migration from the wound borders", "D": "Neutrophil migration into the wound", "E": "Platelet aggregates"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "primary care provider", "routine", "patient", "5 days", "cut", "lost", "skin", "tip", "finger", "applying pressure", "ice", "bleeding stopped", "not", "treatment", "patient", "healthy", "not", "daily medications", "patients temperature", "98", "36", "blood pressure", "72 mmHg", "pulse", "60 min", "respirations", "min", "exam", "patient", "0.5", "3", "wound", "tip of", "left third finger", "bone", "involved", "wound", "red", "soft", "painless", "signs", "infection", "following", "histopathological examination of", "wounded area"]}
{"question": "An otherwise healthy 56-year-old woman comes to the physician because of a 3-year history of intermittent upper abdominal pain. She has had no nausea, vomiting, or change in weight. Physical examination shows no abnormalities. Laboratory studies are within normal limits. Abdominal ultrasonography shows a hyperechogenic rim-like calcification of the gallbladder wall. The finding in this patient's ultrasonography increases the risk of which of the following conditions?", "answer": "Gallbladder carcinoma", "options": {"A": "Hepatocellular carcinoma", "B": "Gallbladder empyema", "C": "Pyogenic liver abscess", "D": "Gallbladder carcinoma", "E": "Acute pancreatitis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old woman", "physician", "3 year history", "intermittent upper", "nausea", "vomiting", "change in weight", "abnormalities", "Laboratory studies", "normal limits", "Abdominal ultrasonography", "rim", "calcification of", "gallbladder wall", "finding", "patient's ultrasonography increases", "following conditions"]}
{"question": "An excisional biopsy is performed and the diagnosis of superficial spreading melanoma is confirmed. The lesion is 1.1 mm thick. Which of the following is the most appropriate next step in management?", "answer": "Surgical excision with 1-2 cm safety margins and sentinel lymph node study", "options": {"A": "Surgical excision with 0.5-1 cm safety margins only", "B": "Surgical excision with 1-2 cm safety margins only", "C": "Surgical excision with 1-2 cm safety margins and sentinel lymph node study", "D": "Surgical excision with 0.5-1 cm safety margins and sentinel lymph node study", "E": "Surgical excision with 1 cm safety margins only\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["excisional biopsy", "performed", "diagnosis", "superficial spreading melanoma", "confirmed", "lesion", "1", "mm thick", "following", "most appropriate next step"]}
{"question": "A 52-year-old man comes to the physician for a routine health maintenance examination. He has not seen a physician for 10 years. He works as a telemarketer and does not exercise. Cardiac examination shows a dull, low-pitched sound during late diastole that is best heard at the apex. The sound is loudest in the left lateral decubitus position and during end-expiration. Which of the following is the most likely cause of this finding?", "answer": "Concentric left ventricular hypertrophy", "options": {"A": "Concentric left ventricular hypertrophy", "B": "Dilation of both ventricles", "C": "Fusion of mitral valve leaflets", "D": "Right bundle branch block", "E": "Aortic root dilatation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "routine", "not seen", "physician", "not exercise", "dull", "low-pitched sound", "late", "best heard", "apex", "sound", "loudest", "left lateral decubitus position", "end-expiration", "following", "most likely cause", "finding"]}
{"question": "A 42-year-old woman comes to the physician because of vaginal discharge for 3 days. She has no dysuria, dyspareunia, pruritus, or burning. The patient is sexually active with two male partners and uses condoms inconsistently. She often douches between sexual intercourse. Pelvic examination shows thin and off-white vaginal discharge. The pH of the discharge is 5.1. Wet mount exam shows a quarter of her vaginal epithelial cells are covered with small coccobacilli. Which of the following is the most appropriate next step in management?", "answer": "Treat the patient with metronidazole", "options": {"A": "Treat the patient with ceftriaxone and azithromycin", "B": "Treat the patient and partners with metronidazole", "C": "Reassurance and follow-up in one week", "D": "Treat the patient with metronidazole", "E": "Treat patient and partners with topical ketoconazole"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "of vaginal discharge", "3 days", "dysuria", "dyspareunia", "pruritus", "burning", "patient", "sexually active", "two male", "uses condoms", "often douches", "sexual intercourse", "Pelvic examination", "thin", "off white vaginal discharge", "pH", "discharge", "5", "Wet mount exam", "quarter", "covered", "small", "following", "most appropriate next step"]}
{"question": "A 31-year-old man comes to the physician because of a 2-day history of nausea, abdominal discomfort, and yellow discoloration of the eyes. Six weeks ago, he had an episode of fever, joint pain, swollen lymph nodes, and an itchy rash on his trunk and extremities that persisted for 1 to 2 days. He returned from a backpacking trip to Colombia two months ago. His temperature is 39°C (101.8°F). Physical examination shows scleral icterus. Infection with which of the following agents is the most likely cause of this patient's findings?", "answer": "Hepatitis B", "options": {"A": "Hepatitis B", "B": "Enterotoxigenic E. coli", "C": "Borrelia burgdorferi", "D": "Hepatitis A", "E": "Campylobacter jejuni"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old man", "physician", "2-day history", "nausea", "abdominal discomfort", "yellow", "eyes", "Six weeks", "episode of fever", "joint pain", "swollen lymph nodes", "itchy", "trunk", "extremities", "2 days", "returned", "trip", "Colombia two months", "temperature", "scleral icterus", "following", "most likely cause", "patient's findings"]}
{"question": "A 49-year-old woman comes to the physician because of difficulty walking and dizziness for the past 2 weeks. She has also had fatigue, heartburn, and diarrhea for 4 months. The stools are foul-smelling and do not flush easily. Over the past 4 months, she has had a 2.2-kg (5-lb) weight loss. Her only medication is an over-the-counter antacid. Her mother has autoimmune thyroid disease and Crohn disease. She is 150 cm (4 ft 11 in) tall and weighs 43 kg (95 lb); BMI is 19.1 kg/m2. Vital signs are within normal limits. Examination shows a wide-based gait. Muscle strength and tone are normal in all extremities. Rapid alternating movement of the hands is impaired. The abdomen is soft and there is mild tenderness to palpation in the epigastric area. Her hemoglobin concentration is 11.1 mg/dL, and levels of vitamin E and vitamin D are decreased. Upper endoscopy shows several ulcers in the gastric antrum and the descending duodenum. Which of the following is the most likely underlying mechanism of this patient's symptoms?", "answer": "Inactivation of pancreatic enzymes", "options": {"A": "Autoantibodies against the intestinal mucosa", "B": "Inactivation of pancreatic enzymes", "C": "T. whipplei infiltration of intestinal villi", "D": "Intestinal inflammatory reaction to gluten", "E": "Small intestine bacterial overgrowth"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "difficulty walking", "dizziness", "past 2 weeks", "fatigue", "heartburn", "diarrhea", "months", "stools", "smelling", "not flush easily", "past", "months", "2.2 kg", "5", "weight loss", "only medication", "over-the-counter antacid", "autoimmune thyroid disease", "Crohn disease", "4 ft", "tall", "kg", "95", "BMI", "kg/m2", "Vital signs", "normal limits", "wide-based gait", "Muscle strength", "tone", "normal", "extremities", "Rapid alternating movement", "hands", "impaired", "abdomen", "soft", "mild tenderness", "palpation", "epigastric area", "hemoglobin concentration", "mg/dL", "levels", "vitamin", "vitamin D", "decreased", "Upper endoscopy", "several ulcers", "gastric antrum", "descending duodenum", "following", "underlying mechanism", "patient's symptoms"]}
{"question": "A 58-year-old woman is brought to the emergency department 30 minutes after developing acute confusion, severe headache, and vomiting. Physical examination shows left-sided numbness. A CT scan of her head shows a large intraparenchymal hemorrhage. Despite appropriate treatment, the patient dies. Autopsy shows multiple small aneurysms of the lenticulostriate arteries of the brain and bilateral hyperplasia of the adrenal glands, limited to the zona glomerulosa. The patient's adrenal condition was most likely associated with which of the following symptoms?", "answer": "Muscle weakness", "options": {"A": "Paroxysmal diaphoresis", "B": "Abdominal striae", "C": "Muscle weakness", "D": "Hirsutism", "E": "Peripheral edema"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old woman", "brought", "emergency department 30 minutes", "acute confusion", "severe headache", "vomiting", "left-sided numbness", "CT scan of", "head", "large intraparenchymal hemorrhage", "appropriate treatment", "patient", "Autopsy", "multiple small aneurysms of", "arteries", "brain", "bilateral", "adrenal", "limited", "zona glomerulosa", "patient's", "condition", "most likely associated", "following symptoms"]}
{"question": "A 13-year-old African American boy with sickle cell disease is brought to the emergency department with complaints of abdominal pain over the last 24 hours. The pain is situated in the right upper quadrant and is sharp in nature with a score of 8/10 and radiates to tip of the right scapula. He also complains of anorexia and nausea over the past 2 days. He has been admitted into the hospital several times for pain episodes involving his legs, hands, thighs, lower back, and abdomen. His last hospital admission was 4 months ago for acute chest pain, and he was treated with antibiotics, analgesics, and intravenous fluid. He takes hydroxyurea with occasional red blood cell exchange. Both of his parents are in good health. Temperature is 38°C (100.4°F), blood pressure is 133/88 mm Hg, pulse is 102/min, respiratory rate is 20/min, and BMI is 18 kg/m2. On examination, he is in pain with a tender abdomen with painful inspiration. Soft palpation of the right upper quadrant causes the patient to cry out in pain.\nLaboratory test\nComplete blood count\nHemoglobin 8.5 g/dL\nMCV 82 fl\nLeukocytes 13,500/mm3\nPlatelets 145,000/mm3\nBasic metabolic panel\nSerum Na+ 135 mEq/L\nSerum K+ 3.9 mEq/L\nSerum Cl- 101 mEq/L\nSerum HCO3- 23 mEq/L\nLiver function test\nSerum bilirubin 2.8 mg/dL\nDirect bilirubin 0.8 mg/dL\nAST\n30 U/L\nALT 35 U/L\nSerum haptoglobin 23 mg/dL (41–165 mg/dL)\nUltrasonography of abdomen shows the following image. What is the pathogenesis of this ultrasound finding?", "answer": "Chronic hemolysis", "options": {"A": "Increased cholesterol secretion", "B": "Impaired gallbladder emptying", "C": "Decreased bile salt absorption", "D": "Bacterial infection", "E": "Chronic hemolysis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "boy", "sickle cell disease", "brought", "emergency department", "complaints", "abdominal pain", "last 24 hours", "pain", "right upper quadrant", "sharp", "nature", "score", "8/10", "radiates to tip", "right scapula", "anorexia", "nausea", "past 2 days", "times", "pain episodes involving", "legs", "hands", "thighs", "lower back", "abdomen", "last", "4 months", "acute chest pain", "treated with", "analgesics", "hydroxyurea", "occasional", "exchange", "Temperature", "100", "blood pressure", "88 mm Hg", "pulse", "min", "respiratory rate", "20 min", "BMI", "kg/m2", "pain", "tender abdomen", "painful inspiration", "Soft palpation of", "right upper quadrant causes", "patient", "out", "blood", "Serum", "bilirubin", "0", "35", "mg/dL", "Ultrasonography of abdomen", "following", "pathogenesis", "ultrasound finding"]}
{"question": "A 21-year-old woman presents with irregular menses, acne, and increased body hair growth. She says her average menstrual cycle lasts 36 days and states that she has heavy menstrual bleeding. She had her menarche at the age of 13 years. Her blood pressure is 125/80 mm Hg, heart rate is 79/min, respiratory rate is 14/min, and temperature is 36.7°C (98.1°F). Her body weight is 101.0 kg (222.7 lb) and height is 170 cm (5 ft 7 in). Physical examination shows papular acne on her forehead and cheeks. There are dark hairs present on her upper lip, periareolar region, linea alba, and hips, as well as darkening of the skin on the axilla and posterior neck. Which of the following endocrine abnormalities would also most likely be found in this patient?", "answer": "Insulin resistance", "options": {"A": "Hypothyroidism", "B": "Insulin resistance", "C": "Aldosterone hyperproduction", "D": "Adrenaline hypersecretion", "E": "Hypoestrogenism"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old woman presents", "irregular menses", "acne", "increased hair", "average menstrual cycle", "36 days", "states", "heavy menstrual bleeding", "menarche at", "age", "years", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "body weight", "0 kg", "height", "5 ft", "papular acne", "forehead", "cheeks", "dark hairs present", "upper lip", "periareolar region", "linea alba", "hips", "darkening", "skin", "axilla", "posterior neck", "following endocrine abnormalities", "likely", "found", "patient"]}
{"question": "A 70-year-old man is brought to the emergency department by his wife because of progressive confusion for the past 2 weeks. He has also had a 4.5-kg (10-lb) weight loss and fatigue during the last 6 months. Physical examination shows enlarged lymph nodes in the right axilla and faint expiratory wheezing in the right middle lung field. He is only oriented to person. Serum studies show a sodium concentration of 125 mEq/L and increased antidiuretic hormone concentration. An x-ray of the chest shows a right-sided hilar mass with mediastinal fullness. A biopsy of the hilar mass is most likely to show cells that stain positive for which of the following?", "answer": "Neuron-specific enolase", "options": {"A": "Desmin", "B": "Neurofilament", "C": "Napsin A", "D": "S-100", "E": "Neuron-specific enolase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["70 year old man", "brought", "emergency department", "progressive confusion", "past 2 weeks", "4.5 kg", "10", "weight loss", "fatigue", "months", "enlarged lymph nodes", "right axilla", "faint expiratory wheezing", "right middle lung field", "only oriented to person", "Serum studies", "sodium concentration", "mEq/L", "increased antidiuretic hormone concentration", "x-ray of", "chest", "right-sided hilar", "mediastinal fullness", "biopsy", "hilar mass", "to", "cells", "positive"]}
{"question": "An otherwise healthy 17-year-old girl comes to the physician because of multiple patches on her face, hands, abdomen, and feet that are lighter than the rest of her skin. The patches began to appear 3 years ago and have been gradually increasing in size since. There is no associated itchiness, redness, numbness, or pain. She emigrated from India 2 years ago. An image of the lesions on her face is shown. Which of the following is most likely involved in the pathogenesis of this patient's skin findings?", "answer": "Autoimmune destruction of melanocytes", "options": {"A": "Absence of tyrosinase activity", "B": "Infection with Mycobacterium leprae", "C": "Infection with Malassezia globosa", "D": "Defective tuberin protein", "E": "Autoimmune destruction of melanocytes"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old girl", "physician", "of multiple patches", "face", "hands", "abdomen", "feet", "lighter", "skin", "patches began to appear 3 years", "increasing in size", "associated itchiness", "redness", "numbness", "pain", "India", "years", "lesions", "face", "following", "most likely involved", "pathogenesis", "patient's skin findings"]}
{"question": "A 9-year-old boy is brought to the emergency department by his parents after a 2-day history of fever, productive cough, and severe dyspnea. The parents report that the boy had no health problems at birth but developed respiratory problems as an infant that have continued throughout his life, including recurrent pulmonary infections. Vital signs include: temperature of 37.5ºC (99.5ºF), pulse of 105/min, respiratory rate of 34/min, and SpO2 of 87%. Physical examination shows digital clubbing and cyanosis. Chest X-rays show hyperinflation of the lungs and chronic interstitial changes. The boy’s FEV1/FVC ratio is decreased, and his FRC is increased. The resident reviewing his case is studying new gene therapies for this boy’s condition that will reintroduce the gene for which this boy is defective. An important component of this therapy is identifying a vector for the selective introduction of the replacement gene into the human body. Which of the following would be the best vector to provide gene therapy for this boy’s respiratory symptoms?", "answer": "Adenovirus", "options": {"A": "Adenovirus", "B": "Rhinovirus", "C": "Human immunodeficiency virus-1", "D": "Rabies virus", "E": "Coxsackie A virus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "2-day history", "fever", "productive cough", "severe dyspnea", "report", "boy", "problems", "birth", "respiratory problems", "infant", "including recurrent pulmonary infections", "Vital signs include", "temperature", "99", "pulse", "min", "respiratory rate", "min", "87", "digital clubbing", "cyanosis", "Chest X-rays", "hyperinflation of", "lungs", "chronic interstitial changes", "boys FEV1/FVC ratio", "decreased", "FRC", "increased", "resident reviewing", "case", "studying new gene therapies", "boys condition", "gene", "boy", "defective", "important component", "therapy", "vector", "introduction", "replacement gene", "human body", "following", "best vector to", "gene therapy", "boys respiratory symptoms"]}
{"question": "A 56-year-old woman presents to the emergency department with severe pain in her legs. She has had these pains in the past but access to a doctor was not readily available in her remote village back home. She and her family have recently moved to the United States. She is seen walking to her stretcher with a broad-based gait. Ophthalmic examination shows an absent pupillary light reflex, and pupillary constriction with accommodation and convergence. What other sign or symptom is most likely present in this patient?", "answer": "Loss of vibration sensation", "options": {"A": "Negative Romberg sign", "B": "Deep tendon hyperreflexia", "C": "Painless ulcerated papules", "D": "Bell's Palsy", "E": "Loss of vibration sensation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency department", "severe pain in", "legs", "pains", "past", "access", "doctor", "not", "available", "remote village back home", "recently moved to", "United States", "seen", "stretcher", "broad-based gait", "Ophthalmic examination", "absent light", "pupillary constriction", "accommodation", "convergence", "sign", "symptom", "most likely present", "patient"]}
{"question": "A 26-year-old man comes to the physician for a follow-up examination. Two weeks ago, he was treated in the emergency department for head trauma after being hit by a bicycle while crossing the street. Neurological examination shows decreased taste on the right anterior tongue. This patient's condition is most likely caused by damage to a cranial nerve that is also responsible for which of the following?", "answer": "Eyelid closure", "options": {"A": "Uvula movement", "B": "Facial sensation", "C": "Eyelid closure", "D": "Tongue protrusion", "E": "Parotid gland salivation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "follow-up examination", "Two weeks", "treated", "emergency department", "head trauma", "hit", "bicycle", "street", "Neurological examination", "decreased taste", "right", "patient's condition", "most likely caused", "damage", "cranial nerve", "responsible"]}
{"question": "A 45-year-old male presents to his primary care physician complaining of drainage from his left great toe. He has had an ulcer on his left great toe for over eight months. He noticed increasing drainage from the ulcer over the past week. His past medical history is notable for diabetes mellitus on insulin complicated by peripheral neuropathy and retinopathy. His most recent hemoglobin A1c was 9.4%. He has a 25 pack-year smoking history. He has multiple sexual partners and does not use condoms. His temperature is 100.8°F (38.2°C), blood pressure is 150/70 mmHg, pulse is 100/min, and respirations are 18/min. Physical examination reveals a 1 cm ulcer on the plantar aspect of the left great toe surrounded by an edematous and erythematous ring. Exposed bone can be palpated with a probe. There are multiple small cuts and bruises on both feet. A bone biopsy reveals abundant gram-negative rods that do not ferment lactose. The pathogen most likely responsible for this patient’s current condition is also strongly associated with which of the following conditions?", "answer": "Otitis externa", "options": {"A": "Otitis externa", "B": "Gastroenteritis", "C": "Waterhouse-Friedrichsen syndrome", "D": "Rheumatic fever", "E": "Toxic shock syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "primary care physician", "drainage", "left great toe", "ulcer", "left great toe", "over eight months", "increasing drainage", "ulcer", "past week", "past medical history", "notable", "diabetes mellitus", "insulin complicated", "peripheral neuropathy", "retinopathy", "most recent hemoglobin A1c", "smoking history", "multiple sexual partners", "not use condoms", "temperature", "100", "blood pressure", "70 mmHg", "pulse", "100 min", "respirations", "min", "reveals", "ulcer", "plantar of", "left great surrounded", "edematous", "erythematous ring", "Exposed bone", "probe", "multiple small cuts", "bruises", "feet", "bone biopsy reveals abundant", "not ferment lactose", "pathogen", "likely responsible", "patients current condition", "associated", "following conditions"]}
{"question": "A 69-year-old woman comes to the physician because of a 4-month history of cough with blood-tinged sputum and a 4.5-kg (10-lb) weight loss. She has smoked one pack of cigarettes daily for 38 years. Auscultation of the lungs shows wheezing in the right lung field. An x-ray of the chest shows an irregular lesion with a central cavity in the proximal right lung. A lung biopsy shows malignant cells that express desmoglein and stain positive for cytokeratin. Which of the following findings confers the worst prognosis in this patient?", "answer": "Mediastinal invasion", "options": {"A": "High mitotic activity", "B": "High nucleus to cytoplasmic ratio", "C": "Presence of necrosis", "D": "Mediastinal invasion", "E": "Poor cellular differentiation\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["69 year old woman", "physician", "4 month history", "cough", "blood-tinged sputum", "4.5 kg", "10", "weight loss", "smoked one pack", "cigarettes daily", "years", "Auscultation", "lungs", "wheezing", "right lung field", "x-ray of", "chest", "irregular lesion", "central cavity", "proximal right lung", "lung biopsy", "malignant cells", "desmoglein", "positive", "cytokeratin", "following findings", "worst", "patient"]}
{"question": "A 44-year-old woman presents to the emergency department with confusion starting this morning. Her husband states that she initially complained of abdominal pain, diarrhea, and fatigue after eating. She has vomited 3 times and progressively became more confused. Her past medical history is notable for morbid obesity, diabetes, hypertension, dyslipidemia, a sleeve gastrectomy 1 month ago, and depression with multiple suicide attempts. Her temperature is 98.0°F (36.7°C), blood pressure is 104/54 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Her physical exam is notable for generalized confusion. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 24 mEq/L\nBUN: 22 mg/dL\nGlucose: 41 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\nC-peptide level: normal\n\nWhich of the following is the most likely diagnosis?", "answer": "Dumping syndrome", "options": {"A": "Dumping syndrome", "B": "Glipizide overdose", "C": "Insulin overdose", "D": "Malnutrition", "E": "Propranolol overdose"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "confusion starting", "morning", "states", "initially", "abdominal pain", "diarrhea", "fatigue", "eating", "vomited 3 times", "more confused", "past medical history", "notable", "morbid obesity", "diabetes", "hypertension", "dyslipidemia", "sleeve gastrectomy", "month", "depression", "multiple suicide attempts", "temperature", "98", "36", "blood pressure", "54 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "generalized confusion", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L", "100 mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL C-peptide level", "normal", "following", "diagnosis"]}
{"question": "A 69-year-old man is brought to the emergency department because of severe epigastric pain and vomiting that started 30 minutes ago while gardening. His pulse is 55/min, respirations are 30/min, and blood pressure is 90/50 mm Hg. Physical examination shows diaphoresis and jugular venous distention. Crackles are heard in both lower lung fields. An ECG shows P waves independent of QRS complexes and ST segment elevation in leads II, III, and aVF. Coronary angiography is most likely to show narrowing of which of the following vessels?", "answer": "Proximal right coronary artery", "options": {"A": "Left coronary artery", "B": "Proximal right coronary artery", "C": "Left circumflex artery", "D": "Left anterior descending artery", "E": "Posterior interventricular artery"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["69 year old man", "brought", "emergency department", "severe epigastric", "vomiting", "started 30 minutes", "pulse", "min", "respirations", "30/min", "blood pressure", "90 50 mm Hg", "diaphoresis", "jugular venous distention", "Crackles", "heard", "lower lung fields", "ECG", "P waves independent of QRS complexes", "ST segment elevation", "leads", "III", "aVF", "Coronary angiography", "to", "narrowing", "following vessels"]}
{"question": "An HIV-positive patient with a CD4+ count of 45 is receiving recommended first-line treatment for a case of cytomegalovirus retinitis. Coadministration with which of the following agents would be most likely to precipitate a deficiency of neutrophils in this patient?", "answer": "Zidovudine", "options": {"A": "Foscarnet", "B": "Zidovudine", "C": "Efavirenz", "D": "Ritonavir", "E": "Raltegravir"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["HIV-positive patient", "CD4", "count", "receiving", "first-line treatment", "case", "cytomegalovirus retinitis", "following agents", "to precipitate", "deficiency", "patient"]}
{"question": "An investigator studying the immunologic profile of various cells notices that the blood of a test subject agglutinates upon addition of a serum containing antibodies against P blood group antigens. Infection with which of the following pathogens would most likely be prevented by these antibodies?", "answer": "Parvovirus B19", "options": {"A": "Parvovirus B19", "B": "Babesia microti", "C": "Plasmodium vivax", "D": "Epstein Barr virus", "E": "Influenza virus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator studying", "profile", "various", "blood", "test subject", "addition", "serum containing antibodies", "blood group", "Infection", "of the following", "most likely", "prevented", "antibodies"]}
{"question": "A 3-month-old boy is brought to the physician by his parents for the evaluation of a rash on his scalp and forehead. The parents report that the rash has been present for several weeks. They state that the rash is sometimes red and scaly, especially when it is cold. The patient was born at 36 weeks' gestation and has generally been healthy since. His father has psoriasis. The patient appears comfortable. Examination shows several erythematous patches on the scalp, forehead, and along the hairline. Some patches are covered by greasy yellow scales. Which of the following is the most likely diagnosis?", "answer": "Seborrheic dermatitis", "options": {"A": "Atopic dermatitis", "B": "Erythroderma", "C": "Seborrheic keratosis", "D": "Allergic contact dermatitis", "E": "Seborrheic dermatitis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["3 month old boy", "brought", "physician", "rash", "scalp", "forehead", "report", "rash", "present", "weeks", "state", "rash", "sometimes red", "scaly", "cold", "patient", "born", "36 weeks", "gestation", "healthy", "psoriasis", "patient appears", "several erythematous patches", "scalp", "forehead", "hairline", "patches", "covered", "greasy yellow scales", "following", "diagnosis"]}
{"question": "A 25-year-old woman has dysuria, pyuria, increased frequency of urination, and fever of 1-day duration. She is sexually active. Urine cultures show gram-positive bacteria in clusters that are catalase-positive and coagulase-negative. The patient is started on trimethoprim-sulfamethoxazole. Which of the following characteristics is used to identify the offending organism?", "answer": "Resistance to novobiocin", "options": {"A": "Beta hemolysis", "B": "Resistance to bacitracin", "C": "Sensitivity to novobiocin", "D": "Sensitivity to bacitracin", "E": "Resistance to novobiocin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "dysuria", "pyuria", "increased frequency of urination", "fever", "1-day duration", "sexually active", "Urine cultures", "clusters", "catalase positive", "coagulase negative", "patient", "started", "trimethoprim-sulfamethoxazole", "following characteristics", "used to"]}
{"question": "A 27-year-old man presents to the emergency department with dizziness. He states he has experienced a sustained sensation of the room spinning that is low grade and constant since this morning. The patient occasionally feels nauseous and has been taking diphenydramine to sleep which helps with his symptoms. The patient is generally healthy, has no other medical conditions, and only endorses eating more garlic recently to get over a cold he had a few days ago. His temperature is 98.7°F (37.1°C), blood pressure is 122/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for a healthy man. The patient is sat upright, his head is turned slightly to the right, and he is laid back flat rapidly. This does not provoke any symptoms even when repeated on the left side. A nystagmus is notable on cranial nerve exam as well as bilateral decreased hearing. The patient’s tandem gait is unstable; however, his baseline gait appears unremarkable despite the patient stating he has a sustained sensation of imbalance. Which of the following is the most likely diagnosis?", "answer": "Labyrinthitis", "options": {"A": "Benign paroxysmal positional vertigo", "B": "Labyrinthitis", "C": "Meniere disease", "D": "Vertebrobasilar stroke", "E": "Vestibular neuritis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old man presents", "emergency department", "dizziness", "states", "sustained sensation", "room", "low grade", "constant", "morning", "patient occasionally", "nauseous", "to sleep", "helps", "symptoms", "patient", "healthy", "medical conditions", "only", "eating more garlic recently to get", "cold", "few days", "temperature", "98", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "healthy man", "patient", "sat upright", "head", "turned slightly", "right", "back flat rapidly", "not", "symptoms", "repeated", "left side", "nystagmus", "notable", "cranial nerve exam", "bilateral decreased hearing", "patients tandem gait", "unstable", "baseline gait appears unremarkable", "patient stating", "sustained sensation", "imbalance", "following", "diagnosis"]}
{"question": "A 72-year-old man presents to his primary care physician complaining of increasing difficulty sleeping over the last 3 months. He reports waking up frequently during the night because he feels an urge to move his legs, and he has a similar feeling when watching television before bed. The urge is relieved by walking around or rubbing his legs. The patient’s wife also notes that she sometimes sees him moving his legs in his sleep and is sometimes awoken by him. Due to his recent sleep troubles, the patient has started to drink more coffee throughout the day to stay awake and reports having up to 3 cups daily. The patient has a past medical history of hypertension and obesity but states that he has lost 10 pounds in the last 3 months without changing his lifestyle. He is currently on hydrochlorothiazide and a multivitamin. His last colonoscopy was when he turned 50, and he has a family history of type II diabetes and dementia. At this visit, his temperature is 99.1°F (37.3°C), blood pressure is 134/81 mmHg, pulse is 82/min, and respirations are 14/min. On exam, his sclerae are slightly pale. Cardiovascular and pulmonary exams are normal, and his abdomen is soft and nontender. Neurologic exam reveals 2+ reflexes in the bilateral patellae and 5/5 strength in all extremities. Which of the following is most likely to identify the underlying etiology of this patient's symptoms?", "answer": "Colonoscopy", "options": {"A": "Dopamine uptake scan of the brain", "B": "Trial of iron supplementation", "C": "Colonoscopy", "D": "Trial of reduction in caffeine intake", "E": "Trial of pramipexole"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "primary care physician", "increasing difficulty sleeping", "last", "months", "reports waking", "frequently", "night", "to move", "legs", "similar", "television", "bed", "relieved by", "legs", "patients", "notes", "sometimes sees", "moving", "legs", "sleep", "sometimes awoken", "recent sleep", "patient", "started to", "more", "day to", "awake", "reports", "up to", "cups daily", "patient", "past medical", "obesity", "states", "lost 10 pounds", "months", "changing", "currently", "hydrochlorothiazide", "multivitamin", "last colonoscopy", "turned 50", "family history of type II diabetes", "dementia", "temperature", "99", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "exam", "sclerae", "slightly pale", "Cardiovascular", "pulmonary exams", "normal", "abdomen", "soft", "nontender", "Neurologic exam reveals 2", "reflexes", "bilateral patellae", "5/5 strength", "extremities", "following", "to", "underlying etiology", "patient's symptoms"]}
{"question": "A 38-year-old man comes to the physician because of upper abdominal discomfort for 2 weeks. He has had 3–4 episodes of vomiting during this period. Over the last year, he has had frequent episodes of abdominal pain at night that were relieved by eating. He underwent a right shoulder surgery 6 weeks ago. He has no history of serious illness. He has smoked one pack of cigarettes daily for 14 years. He drinks one to two beers daily. He has a history of illicit drug use, but has not used for the past 15 years. He is sexually active with three female partners and uses condoms inconsistently. His only medication is daily naproxen. He returned from a 2-week vacation to Mexico one month ago. He appears uncomfortable. His temperature is 39.5°C (103.1°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the right upper quadrant. Bowel sounds are normal. Rectal examination is unremarkable. Test of the stool for occult blood is positive. His hemoglobin concentration is 13.1 g/dL, leukocyte count is 23,100/mm3, and platelet count is 230,000/mm3. Abdominal ultrasound shows a 2-cm hypoechoic lesion with some internal echoes in an otherwise normal looking liver. Which of the following is the most likely cause for the sonographic findings?", "answer": "Penetrating duodenal ulcer", "options": {"A": "Penetrating duodenal ulcer", "B": "Acute pancreatitis", "C": "Echinococcus granulosus", "D": "Liver cancer", "E": "Entamoeba histolytica"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "of upper abdominal discomfort", "2 weeks", "episodes of vomiting", "period", "last year", "episodes", "abdominal", "night", "relieved by eating", "right", "weeks", "history", "serious illness", "smoked one pack", "cigarettes daily", "years", "one", "two", "daily", "history", "illicit drug use", "not used", "past", "years", "sexually active", "three female", "uses condoms", "only medication", "daily naproxen", "returned", "2-week", "Mexico one month", "appears", "temperature", "pulse", "90 min", "blood pressure", "70 mm Hg", "soft abdomen", "mild tenderness", "palpation", "right upper", "Bowel sounds", "normal", "Rectal examination", "unremarkable", "Test", "stool", "occult blood", "positive", "hemoglobin concentration", "g/dL", "leukocyte count", "23 100 mm3", "platelet count", "mm3", "Abdominal ultrasound", "2", "lesion", "internal echoes", "normal looking liver", "following", "most likely cause", "sonographic findings"]}
{"question": "A 22-year-old primigravid woman comes to the physician for her initial prenatal visit at 12 weeks' gestation. She has had generalized fatigue and shortness of breath over the past 2 months. She has also had a tingling sensation in her toes for the past month. Three years ago, she was treated for gonorrhea. She follows a strict vegan diet since the age of 13 years. Her temperature is 37°C (98.6°F), pulse is 111/min, and blood pressure is 122/80 mm Hg. Examination shows pale conjunctivae and a shiny tongue. Muscle tone and strength is normal. Deep tendon reflexes are 2+ bilaterally. Sensation to vibration and position is decreased over the upper and lower extremities. When asked to stand, hold her arms in front of her, and close her eyes, she loses her balance and takes a step backward. Which of the following is most likely to have prevented this patient's condition?", "answer": "Vitamin B12 supplementation", "options": {"A": "Calcium supplementation", "B": "Vitamin B12 supplementation", "C": "Thyroxine supplementation", "D": "Penicillin G therapy", "E": "Iron supplementation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old primigravid woman", "physician", "weeks", "gestation", "generalized fatigue", "shortness of breath", "past", "months", "tingling sensation", "toes", "past month", "Three years", "treated", "gonorrhea", "follows", "vegan diet", "age", "years", "temperature", "98", "pulse", "min", "blood pressure", "80 mm Hg", "pale conjunctivae", "shiny tongue", "Muscle tone", "strength", "normal", "Deep tendon reflexes", "2", "Sensation", "vibration", "position", "decreased", "upper", "lower extremities", "to stand", "hold", "arms", "front", "close", "eyes", "balance", "step backward", "following", "to", "prevented", "patient's condition"]}
{"question": "A 36-year-old woman comes to the physician to discuss contraceptive options. She is currently sexually active with one male partner, and they have not been using any contraception. She has no significant past medical history and takes no medications. She has smoked one pack of cigarettes daily for 15 years. She is allergic to latex and copper. A urine pregnancy test is negative. Which of the following contraceptive methods is contraindicated in this patient?", "answer": "Combined oral contraceptive pill", "options": {"A": "Diaphragm with spermicide", "B": "Progestin-only pill", "C": "Intrauterine device", "D": "Condoms", "E": "Combined oral contraceptive pill"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old woman", "physician to", "contraceptive options", "currently sexually active", "one male", "not", "using", "contraception", "significant past medical history", "medications", "smoked one pack", "cigarettes daily", "years", "allergic", "latex", "copper", "urine pregnancy test", "negative", "following contraceptive methods", "contraindicated", "patient"]}
{"question": "A 68-year-old man is brought to the emergency department because of a severe headache, nausea, and vomiting for 30 minutes. Forty-five minutes ago, he fell and struck his head, resulting in loss of consciousness for 1 minute. After regaining consciousness, he felt well for 15 minutes before the headache began. On arrival, the patient becomes rigid and his eyes deviate to the right; he is incontinent of urine. Intravenous lorazepam is administered and the rigidity resolves. Which of the following is the most likely cause of the patient's condition?", "answer": "Bleeding between dura mater and skull", "options": {"A": "Intracerebral hemorrhage", "B": "Cerebrospinal fluid production/absorption mismatch", "C": "Rupture of bridging veins", "D": "Acute insufficiency of cerebral blood flow", "E": "Bleeding between dura mater and skull"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "severe headache", "nausea", "vomiting", "30 minutes", "Forty-five", "fell", "struck", "head", "resulting in loss of consciousness", "1 minute", "consciousness", "well", "15 minutes", "headache began", "arrival", "patient", "rigid", "eyes deviate", "right", "incontinent of urine", "Intravenous lorazepam", "administered", "rigidity", "following", "most likely cause", "patient's condition"]}
{"question": "Three days after undergoing coronary bypass surgery, a 67-year-old man becomes unresponsive and hypotensive. He is intubated, mechanically ventilated, and a central line is inserted. Vasopressin and noradrenaline infusions are begun. A Foley catheter is placed. Six days later, he has high unrelenting fevers. He is currently receiving noradrenaline via an infusion pump. His temperature is 39.6° (102.3°F), pulse is 113/min, and blood pressure is 90/50 mm Hg. Examination shows a sternal wound with surrounding erythema; there is no discharge from the wound. Crackles are heard at both lung bases. Cardiac examination shows an S3 gallop. Abdominal examination shows no abnormalities. A Foley catheter is present. His hemoglobin concentration is 10.8 g/dL, leukocyte count is 21,700/mm3, and platelet count is 165,000/mm3. Samples for blood culture are drawn simultaneously from the central line and peripheral IV line. Blood cultures from the central line show coagulase-negative cocci in clusters on the 8th postoperative day, and those from the peripheral venous line show coagulase-negative cocci in clusters on the 10th postoperative day. Which of the following is the most likely diagnosis in this patient?", "answer": "Central line-associated blood stream infection", "options": {"A": "Central line-associated blood stream infection", "B": "Ventilator-associated pneumonia", "C": "Catheter-associated urinary tract infection", "D": "Bowel ischemia", "E": "Surgical site infection"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Three days", "coronary bypass surgery", "67 year old man", "unresponsive", "hypotensive", "intubated", "ventilated", "central line", "Vasopressin", "noradrenaline infusions", "begun", "Foley catheter", "Six days later", "high", "fevers", "currently receiving noradrenaline", "infusion pump", "temperature", "pulse", "min", "blood pressure", "90 50 mm Hg", "sternal wound", "surrounding erythema", "discharge from", "wound", "Crackles", "heard", "lung bases", "S3 gallop", "Abdominal", "abnormalities", "Foley catheter", "present", "hemoglobin concentration", "10.8 g/dL", "leukocyte count", "700 mm3", "platelet count", "mm3", "for blood culture", "simultaneously", "central line", "peripheral IV line", "Blood cultures", "central", "coagulase negative", "clusters", "postoperative day", "peripheral venous line", "coagulase negative", "clusters", "postoperative day", "following", "diagnosis", "patient"]}
{"question": "A 7-year-old boy is brought to the physician because of spells of unresponsiveness and upward rolling of the eyes for 2 months. The episodes start abruptly and last a few seconds. During that time he does not hear anyone’s voice or make any purposeful movements. When the episodes end, he continues what he was doing before the spell. He does not lose his posture or fall to the ground. Episodes occur multiple times during the day. Physical examination shows no abnormal findings. An EEG following hyperventilation shows 3 Hz spike-and-slow-wave discharges. Which of the following is the most appropriate pharmacotherapy at this time?", "answer": "Ethosuximide", "options": {"A": "Ethosuximide", "B": "Lamotrigine", "C": "Oxcarbazepine", "D": "Sodium valproate", "E": "No pharmacotherapy at this time"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "spells", "unresponsiveness", "upward rolling of", "eyes", "2 months", "episodes start", "last", "few seconds", "time", "not hear", "voice", "make", "purposeful movements", "episodes end", "spell", "not", "posture", "fall", "Episodes occur multiple times", "day", "Physical examination", "abnormal findings", "EEG following hyperventilation", "3 Hz", "slow-wave discharges", "following", "most appropriate pharmacotherapy", "time"]}
{"question": "A 59-year-old woman comes to the physician because of progressively worsening coordination and involuntary movements in her left hand for the past 6 months. Her husband also reports that she has been withdrawn and apathetic during this period. She is oriented to time, place, and person. Examination shows a bimanual, rhythmic, low-frequency tremor that is more prominent in the left hand. There is normal range of motion in the arms and legs; active movements are very slow. Muscle strength is normal, and there is increased resistance to passive flexion and extension in the limbs. She walks with a shuffling gait and takes small steps. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Neuronal degeneration due to α-synuclein protein misfolding", "options": {"A": "Accumulation of neurotoxic metabolites secondary to hepatocyte damage", "B": "Copper accumulation due to mutations in hepatocyte copper-transporting ATPase", "C": "Neuronal degeneration due to α-synuclein protein misfolding", "D": "Cerebellar ischemia due to chronic hypertension", "E": "Proliferation of beta-adrenergic receptors from excessive circulating T4"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["59 year old woman", "physician", "worsening coordination", "involuntary movements", "left hand", "past 6 months", "reports", "withdrawn", "apathetic", "period", "oriented to time", "place", "bimanual", "rhythmic", "low-frequency tremor", "more prominent", "left hand", "normal range of motion", "arms", "legs", "active movements", "very slow", "Muscle strength", "normal", "increased resistance to passive flexion", "extension", "limbs", "walks", "shuffling gait", "small steps", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 25-year-old man is brought to the emergency department 3 hours after rescuing babies and puppies from a burning daycare center. He says that he complains of headache and nausea attributed to running. He is breathing comfortably. What is another likely finding in this patient?", "answer": "Oxygen saturation of 99% on pulse oximetry", "options": {"A": "Oxygen saturation of 86% on pulse oximetry", "B": "Arterial oxygen partial pressure of 20 mmHg", "C": "Oxygen saturation of 99% on pulse oximetry", "D": "Cherry red facial appearance", "E": "Low blood lactate levels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "hours", "babies", "burning daycare center", "headache", "nausea attributed", "breathing", "likely finding", "patient"]}
{"question": "A 47-year-old woman comes to the physician because of a 2-week history of gradually worsening facial and lower extremity swelling. She has had a 4-kg (8.8-lb) weight gain during this time. Her blood pressure is 150/88 mm Hg. Examination shows periorbital edema and 2+ pretibial edema bilaterally. A 24-hour collection of urine shows 4.0 g of proteinuria. Microscopic examination of a kidney biopsy specimen shows thickening of the glomerular basement membrane. Electron microscopy shows dense subepithelial deposits. Further evaluation is most likely to show which of the following?", "answer": "Anti-phospholipase A2 receptor antibodies", "options": {"A": "Anti-phospholipase A2 receptor antibodies", "B": "Anti-myeloperoxidase antibodies", "C": "Anti-streptolysin O antibodies", "D": "Anti-C3 convertase antibodies", "E": "Anti-collagen type IV antibodies"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "2-week history", "worsening facial", "lower extremity swelling", "4 kg", "8.8", "weight gain", "time", "blood pressure", "88 mm Hg", "periorbital edema", "2", "edema", "24-hour collection", "urine", "4.0 g of proteinuria", "Microscopic", "kidney", "thickening of the glomerular basement membrane", "Electron microscopy", "dense", "deposits", "Further", "to", "following"]}
{"question": "A 7-year-old boy is brought to the physician for the evaluation of sore throat for the past 2 days. During this period, he has had intermittent nausea and has vomited once. The patient has no cough, hoarseness, or rhinorrhea. He had similar symptoms at the age of 5 years that resolved spontaneously. He is otherwise healthy. His temperature is 37.9°C (100.2°F), pulse is 85/min, and blood pressure is 108/70 mm Hg. Head and neck examination shows an erythematous pharynx with grayish exudates overlying the palatine tonsils. There is no lymphadenopathy. Rapid antigen detection test for group A streptococci is negative. Which of the following is most appropriate next step in the management of this patient?", "answer": "Obtain throat culture\n\"", "options": {"A": "Measurement of antistreptolysin O titer", "B": "Reassurance and follow-up in two weeks", "C": "Measurement of antiviral capsid antigen IgM antibody", "D": "Penicillin V therapy", "E": "Obtain throat culture\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "sore throat", "past 2 days", "period", "intermittent nausea", "vomited", "patient", "cough", "hoarseness", "rhinorrhea", "similar symptoms", "age", "years", "resolved", "healthy", "temperature", "100", "pulse", "85 min", "blood pressure", "70 mm Hg", "Head and neck", "erythematous pharynx", "grayish exudates", "palatine tonsils", "lymphadenopathy", "Rapid antigen detection test", "negative", "following", "most appropriate next step", "patient"]}
{"question": "A 60-year-old man with known history of chronic obstructive pulmonary disease is brought by ambulance to the emergency department due to shortness of breath. He is out of breath and cannot string a sentence together. The emergency technician suggests that the man tried his tiotropium inhaler multiple times without success. The patient's vitals are as follows: afebrile, BP 90/60, HR 120, RR 24. Oxygen saturation is 90%. An EKG is obtained that shows narrow-complex tachycardia with irregular P waves preceding each QRS complex and irregular PR intervals. What is the best next step in management?", "answer": "Give oxygen immediately", "options": {"A": "Obtain chemistries and complete blood count and observe", "B": "Give labetalol immediately and observe in emergency room", "C": "Give verapamil immediately and admit to floor", "D": "Give oxygen immediately", "E": "Intubate and admit to intensive care uint"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year", "man", "known history of chronic obstructive pulmonary disease", "brought", "ambulance to", "emergency department due", "shortness of breath", "out of breath", "string", "together", "emergency technician", "man", "tiotropium inhaler multiple times", "patient's", "follows", "afebrile", "BP 90 60", "RR", "Oxygen saturation", "90", "EKG", "obtained", "narrow complex tachycardia", "irregular P waves preceding", "QRS complex", "irregular PR intervals", "best next step"]}
{"question": "A 2-year-old girl is brought to the physician by her parents because of clumsiness and difficulty walking. She began to walk at 12 months and continues to have difficulty standing still without support. She also appears to have difficulty grabbing objects in front of her. Over the past year, she has had 5 episodes of sinusitis requiring antibiotic treatment and was hospitalized twice for bacterial pneumonia. Physical examination shows an unstable, narrow-based gait and several hyperpigmented skin patches. Serum studies show decreased levels of IgA and IgG and an increased level of alpha-fetoprotein. Over the next 5 years, which of the following complications is this patient most likely to develop?", "answer": "Conjunctival telangiectasias", "options": {"A": "Chronic eczema", "B": "Conjunctival telangiectasias", "C": "Pes cavus", "D": "Cardiac rhabdomyoma", "E": "Chronic lymphocytic leukemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 year old girl", "brought", "physician", "clumsiness", "difficulty walking", "began to", "12 months", "to", "difficulty standing", "support", "appears to", "difficulty grabbing", "front", "past year", "5 episodes of sinusitis", "antibiotic treatment", "hospitalized twice", "bacterial pneumonia", "unstable", "narrow based gait", "several hyperpigmented skin patches", "Serum studies", "decreased levels", "IgA", "increased level", "alpha-fetoprotein", "next", "years", "following complications", "patient", "to"]}
{"question": "A 42-year-old woman presents to her primary care physician with fatigue. She reports that over the past 2 months, she has felt increasingly tired despite no changes in her diet or exercise. Her past medical history is notable for obesity, seasonal allergies, and hypertension. She takes ranitidine as needed and hydrochlorothiazide daily. Her family history is notable for colorectal cancer in her mother and maternal uncle, endometrial cancer in her maternal aunt, and ovarian cancer in her maternal grandmother. Her temperature is 98.8°F (37.1°C), blood pressure is 132/71 mmHg, pulse is 89/min, and respirations are 17/min. On exam, she has conjunctival pallor. A stool sample is hemoccult positive. A colonoscopy reveals a fungating hemorrhagic mass in the ascending colon. Which of the following processes is likely impaired in this patient?", "answer": "Mismatch repair", "options": {"A": "Base excision repair", "B": "Homologous recombination", "C": "Mismatch repair", "D": "Non-homologous end joining", "E": "Nucleotide excision repair"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "fatigue", "reports", "past", "months", "tired", "changes", "diet", "exercise", "past medical history", "notable", "obesity", "seasonal allergies", "hypertension", "ranitidine as needed", "hydrochlorothiazide daily", "family history", "notable", "colorectal cancer", "endometrial cancer", "ovarian cancer", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "exam", "conjunctival pallor", "stool sample", "hemoccult positive", "colonoscopy reveals", "fungating hemorrhagic mass", "ascending colon", "following processes", "likely impaired", "patient"]}
{"question": "A 32-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician for a prenatal visit. She reports that she has had frequent headaches and dizziness recently. Pregnancy and delivery of her first child were uncomplicated. There is no personal or family history of serious illness. Medications include folic acid and a multivitamin. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 170/100 mm Hg. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Physical examination shows 2+ edema in the lower extremities. Laboratory studies show:\nHematocrit 37%\nLeukocyte count 9000/mm3\nPlatelet count 60,000/mm3\nSerum\nNa+ 140 mEq/L\nCl- 104 mEq/L\nK+ 4.4 mEq/L\nCreatinine 1.0 mg/dL\nAspartate aminotransferase 20 U/L\nAlanine aminotransferase 20 U/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Magnesium sulfate and labetalol therapy", "options": {"A": "Magnesium sulfate and labetalol therapy", "B": "Platelet transfusion", "C": "Lisinopril therapy", "D": "Admit the patient to the ICU", "E": "Perform C-section\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "estation ", "hysician ", "eports ", "requent headaches ", "izziness  ecently.", "regnancy ", "elivery ", "irst  hild ", "ncomplicated.", "ersonal ", "amily history ", "erious  llness.", "edications  nclude  olic acid ", "ultivitamin.", "emperature ", "8.", "ulse ", "0/ in,", "lood pressure ", "00  m Hg.", "elvic examination ", "terus ", "ize ", "eek gestation.", "+", "dema ", "ower extremities.", "aboratory studies ", "ematocrit ", "eukocyte  000/ m3  latelet count  0,", "erum ", "Eq/ l-", "+", ".", ".   g/ spartate  0  /", "lanine aminotransferase  0 ", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "Positron emission tomography is conducted and indicates a malignant nodule. Bronchoscopy with transbronchial biopsy is performed and a specimen sample of the nodule is sent for frozen section analysis. The tissue sample is most likely to show which of the following pathohistological findings?", "answer": "Squamous cell carcinoma", "options": {"A": "Large cell carcinoma", "B": "Carcinoid tumor", "C": "Squamous cell carcinoma", "D": "Small cell lung carcinoma", "E": "Metastasis of colorectal cancer"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Positron emission tomography", "malignant nodule", "Bronchoscopy with transbronchial biopsy", "performed", "nodule", "sent", "frozen section analysis", "tissue sample", "to", "following", "findings"]}
{"question": "A 43-year-old woman comes to the physician for a 3-month history of redness and itching in both eyes. She has also had swelling and pain in the index and middle fingers of both hands and wrist joints over the past 5 months. She has had multiple dental treatments for oral infections over the past year. She has type 2 diabetes mellitus and eczema. Her sister has vitiligo. Current medications include metformin and a daily multivitamin. Vital signs are within normal limits. Examination shows lichenified lesions over her wrists and knees. Bilateral wrist and first metacarpophalengeal joints show swelling and tenderness; range of motion is limited by pain. Oropharyngeal examination shows dry mucous membranes and multiple dental caries. Ophthalmologic examination is slightly decreased in both eyes. There are multiple corneal punctate spots on fluorescein staining. Laboratory studies show:\nHemoglobin 10.7 g/dL\nLeukocyte count 4,100/mm3\nPlatelet count 155,000/mm3\nErythrocyte sedimentation rate 48 mm/h\nSerum\nCreatinine 1.0 mg/dL\nAnti-nuclear antibody positive\nRheumatoid factor positive\nUrinalysis is within normal limits. This patient's condition is most likely associated with which of the following antibodies?\"", "answer": "Anti-Ro antibodies", "options": {"A": "Anti-U1 RNP antibodies", "B": "Anti-topoisomerase I antibodies", "C": "Anti-Jo1 antibodies", "D": "Anti-Ro antibodies", "E": "Anti-dsDNA antibodies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "3 month history", "redness", "itching", "eyes", "swelling", "pain", "index", "middle fingers of", "hands", "wrist joints", "past", "months", "multiple dental", "oral", "past year", "type 2 diabetes mellitus", "eczema", "vitiligo", "Current medications include metformin", "daily multivitamin", "Vital signs", "normal limits", "lichenified lesions", "wrists", "knees", "Bilateral wrist", "first", "joints", "swelling", "tenderness", "range of motion", "limited", "pain", "Oropharyngeal", "dry mucous membranes", "multiple dental caries", "Ophthalmologic examination", "slightly decreased", "eyes", "multiple corneal punctate spots", "fluorescein staining", "Laboratory studies", "Hemoglobin 10", "count 4 100 mm3 Platelet count", "Erythrocyte sedimentation rate 48", "h Serum Creatinine", "0", "Anti-nuclear antibody positive Rheumatoid factor", "Urinalysis", "normal limits", "patient", "ondition ", "ost  ikely  ssociated with ", "ollowing  ntibodies?"]}
{"question": "A 65-year-old man presents with facial weakness. He says he noticed that his face appeared twisted when he looked in the bathroom mirror this morning. He is otherwise well and does not have any other complaints. He denies any facial pain or paresthesia. No significant past medical history. The patient is afebrile and vital signs are within normal limits. Neurological examination reveals difficulty shutting the right eye tight and inability to bring up the right corner of his mouth when asked to smile. Remainder of the exam, including the left side of the face, is unremarkable. Which of the following is the most likely diagnosis in this patient?", "answer": "Idiopathic facial paralysis", "options": {"A": "Facial nerve schwannoma", "B": "Idiopathic facial paralysis", "C": "Right hemisphere stroke", "D": "Acoustic neuroma", "E": "Left middle cerebral artery stroke"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "facial", "face appeared twisted", "looked", "bathroom mirror", "morning", "well", "not", "complaints", "facial pain", "paresthesia", "significant past medical history", "patient", "afebrile", "vital signs", "normal limits", "Neurological examination reveals difficulty", "right eye tight", "to", "right corner of", "mouth", "smile", "exam", "including", "left side of", "face", "unremarkable", "following", "diagnosis", "patient"]}
{"question": "A 32-year-old woman, gravida 2, para 1, at 14-weeks' gestation comes to the physician for a prenatal visit. Routine first trimester screening shows increased nuchal translucency, decreased β-hCG concentration, and decreased levels of pregnancy-associated plasma protein A. Amniocentesis shows trisomy of chromosome 13. This fetus is at increased risk for which of the following?", "answer": "Cutis aplasia", "options": {"A": "Optic glioma", "B": "Cutis aplasia", "C": "Duodenal atresia", "D": "Cystic hygroma", "E": "Prominent occiput"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "gestation", "physician", "Routine first trimester screening", "increased nuchal translucency", "decreased", "hCG concentration", "decreased levels", "pregnancy-associated plasma protein A", "Amniocentesis", "trisomy", "chromosome 13", "fetus", "increased risk", "following"]}
{"question": "A 39-year-old man presents with painless swelling of the right testes and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. Which of the following group of lymph nodes are most likely involved?", "answer": "Para-aortic lymph nodes", "options": {"A": "Para-aortic lymph nodes", "B": "Superficial inguinal lymph nodes (medial group)", "C": "Deep inguinal lymph nodes", "D": "Superficial inguinal lymph nodes (lateral group)", "E": "Para-rectal lymph nodes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "painless swelling of", "right testes", "sensation", "heaviness", "revealed", "intra testicular solid mass", "not", "testis", "diagnosed", "testicular seminoma", "following group", "lymph nodes", "most likely involved"]}
{"question": "A 54-year-old man comes to the physician for a health maintenance examination. He feels well. He is 173 cm (5 ft 8 in) tall and weighs 84 kg (185 lb); BMI is 28 kg/m2. His vital signs are within normal limits. Physical examination shows no abnormalities. Serum lipid studies show:\nTotal cholesterol 280 mg/dL\nHDL-cholesterol 30 mg/dL\nLDL-cholesterol 195 mg/dL\nTriglycerides 275 mg/dL\nTreatment with atorvastatin and cholestyramine is initiated. Which of the following changes is most likely induced by both agents?\"", "answer": "Increased LDL receptor expression", "options": {"A": "Increased lipoprotein lipase activity", "B": "Increased LDL receptor expression", "C": "Increased hepatic bile salt synthesis", "D": "Decreased hepatic de novo cholesterol synthesis", "E": "Increased cholesterol levels in hepatocytes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["54 year old man", "physician", "well", "5 ft 8", "tall", "84 kg", "BMI", "kg/m2", "vital signs", "normal limits", "abnormalities", "Serum lipid studies", "Total cholesterol", "mg", "HDL", "Triglycerides", "Treatment", "atorvastatin", "cholestyramine", "initiated", "following changes", "most likely induced", "agents"]}
{"question": "A 55-year-old man comes to the physician because of fever, fatigue, dry cough, headache, and myalgia over the past week. Two days ago, he developed several painful oral lesions and difficulty swallowing. He underwent kidney transplantation 3 years ago. His temperature is 38.2°C (100.7°F). Physical examination shows bilateral rales, hepatosplenomegaly, and multiple 1–2 cm ulcerative lesions with raised borders in the oral mucosa. A photomicrograph of a liver biopsy specimen is shown. Which of the following is the most likely causal pathogen?", "answer": "Histoplasma capsulatum", "options": {"A": "Aspergillus fumigatus", "B": "Blastomyces dermatitidis", "C": "Histoplasma capsulatum", "D": "Paracoccidioides brasiliensis", "E": "Coccidioides immitis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "fever", "fatigue", "dry cough", "headache", "myalgia", "past week", "Two days", "several painful oral", "difficulty swallowing", "kidney transplantation", "years", "temperature", "100", "bilateral rales", "hepatosplenomegaly", "multiple", "ulcerative lesions", "raised borders", "oral mucosa", "photomicrograph of", "liver biopsy", "following", "causal"]}
{"question": "A 30-year-old woman presents to her primary care provider complaining of numbness and tingling sensations all over her body. After a meticulous history and physical, he found that the patient had recently been on vacation and tried a new sunscreen purchased overseas. The sunscreen contained several chemicals that he was unfamiliar with and after extensive research and consultation with several of his colleagues determined that this was a novel reaction. With the patient’s permission, he decided to write an article that described the main symptoms observed and other findings, how he treated the patient and the follow-up care. His manuscript was published in a peer-reviewed scientific journal. The physician’s publication can be described as which of the following?", "answer": "Case report", "options": {"A": "Case report", "B": "Case series", "C": "Case scenario", "D": "Case definition", "E": "Case control study"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "primary care provider", "numbness", "tingling sensations", "body", "history", "physical", "found", "patient", "recently", "new", "contained several", "extensive", "novel reaction", "patients permission", "to write", "main symptoms observed", "findings", "treated", "patient", "manuscript", "journal", "physicians publication"]}
{"question": "A 5-day-old male newborn is brought to the physician by his mother because of yellowish discoloration of the skin for 1 day. The discoloration first appeared on his face and then spread to his trunk. There have been no changes in his bowel habits or urination. He was born at 38 weeks’ gestation via uncomplicated vaginal delivery. He is exclusively breastfed every 2–3 hours. Examination shows scleral icterus and jaundice of the face, chest, and abdomen. Laboratory studies show:\nHemoglobin 17.6 g/dL\nReticulocytes 0.3%\nMaternal blood group A, Rh-negative\nFetal blood group 0, Rh-positive\nSerum\nBilirubin, total 7 mg/dL\nDirect 0.6 mg/dL\nFree T4 7 μg/dL\nWhich of the following is the most likely diagnosis?\"", "answer": "Physiological neonatal jaundice", "options": {"A": "Congenital hypothyroidism", "B": "Rhesus incompatibility", "C": "Dubin-Johnson syndrome", "D": "Physiological neonatal jaundice", "E": "Biliary atresia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 day old male newborn", "brought", "physician", "of", "discoloration", "skin", "1 day", "discoloration first appeared", "face", "then spread", "trunk", "changes in", "bowel habits", "urination", "born", "weeks gestation", "uncomplicated vaginal", "breastfed", "23 hours", "scleral icterus", "jaundice", "face", "chest", "abdomen", "Laboratory studies", "Hemoglobin", "g/dL", "0.3", "Maternal blood group A", "Fetal", "Rh-positive Serum Bilirubin", "total", "mg/dL Direct 0.6 mg dL Free T4", "g dL", "following", "diagnosis"]}
{"question": "A 57-year-old woman with type 2 diabetes mellitus comes to the physician for a follow-up examination. She previously had been compliant with her diet and medication but has had a 5-kg (11-lb) weight gain since the last visit 6 months ago. She reports that she often misses doses of her metformin. Her hemoglobin A1c is 9.8%. Which of the following is the most appropriate course of action?", "answer": "Schedule more frequent follow-up visits", "options": {"A": "Refer the patient to a dietician", "B": "Schedule more frequent follow-up visits", "C": "Refer the patient to an endocrinologist", "D": "Add glyburide to the medication regimen", "E": "Stop metformin and begin an insulin regimen"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["57 year old woman", "type 2 diabetes mellitus", "physician", "follow-up examination", "medication", "5 kg", "weight gain", "last", "months", "reports", "often misses doses", "metformin", "hemoglobin A1c", "following", "most appropriate course", "action"]}
{"question": "A 43-year-old man presents to his primary care physician for his yearly check-up exam. He has no new concerns but wants to make sure that his hypertension and diabetes are properly controlled. His past medical history is otherwise unremarkable and his only medications are metformin and lisinopril. He has smoked a pack of cigarettes per day since he was 16 years of age and drinks 3 beers per night. Physical exam is remarkable for a murmur best heard in the 5th intercostal space at the left mid-clavicular line. The murmur is high-pitched and blowing in character and can be heard throughout systole. Which of the following properties is characteristic of this patient's most likely disorder?", "answer": "Radiation of murmur to the axilla", "options": {"A": "Presents with an opening snap", "B": "Radiation of murmur to the axilla", "C": "Radiation of murmur to the neck", "D": "Radiation of murmur to the right sternal border", "E": "Results in mixing of blood between left and right ventricles"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "yearly check-up exam", "new", "to make sure", "hypertension", "diabetes", "controlled", "past medical history", "unremarkable", "only medications", "metformin", "lisinopril", "smoked", "pack", "cigarettes", "day", "years", "age", "3", "night", "murmur best heard", "5th intercostal space", "left", "clavicular line", "murmur", "high-pitched", "blowing", "character", "heard", "systole", "following properties", "characteristic", "patient's", "likely disorder"]}
{"question": "A 55-year-old man is brought to the physician because of inappropriate behavior for the past 6 months. He has been making inappropriate comments and jokes while talking to friends and family members. He was arrested 3 weeks ago while trying to kiss strangers on the street. He has no interest in talking to his daughter or playing with his grandchildren. During this period, he has developed a strong desire for chocolate pudding and potato chips and has gained 10 kg (22 lb). He appears unkempt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination shows apathy and a blunt affect. He avoids answering questions and instead comments on the individuals he saw in the waiting room. Mini-Mental State Examination score is 28/30. A complete blood count and serum concentrations of glucose, creatine, and electrolytes are within the reference range. Which of the following is the most likely diagnosis?", "answer": "Frontotemporal dementia", "options": {"A": "Parkinson disease", "B": "Amyotrophic lateral sclerosis", "C": "Normal pressure hydrocephalus", "D": "Wilson disease", "E": "Frontotemporal dementia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "physician", "of inappropriate behavior", "past 6 months", "making inappropriate", "talking", "arrested 3 weeks", "street", "talking", "playing", "period", "strong", "chocolate pudding", "gained 10 kg", "appears unkempt", "Vital signs", "normal", "Physical examination", "unremarkable", "Mental status examination", "apathy", "blunt", "saw", "waiting room", "Mini-Mental State Examination score", "30", "complete blood count", "serum", "glucose", "creatine", "electrolytes", "reference range", "following", "diagnosis"]}
{"question": "A 22-year-old woman comes to the physician because of hearing loss and unsteadiness while standing and walking for the past 2 months. She needs support from a wall to prevent herself from falling. She has not had any recent injuries and has no history of serious illness. Vital signs are within normal limits. Examination shows an unsteady gait. She sways when asked to stand upright with her feet together. She is unable to hear fingers rubbing next to her ears or repeat words whispered in her ears bilaterally. An MRI of the brain shows a 3-cm tumor in the right cerebellopontine angle and a 4.5-cm tumor in the left cerebellopontine angle. This patient is most likely to develop which of the following in the future?", "answer": "Meningioma", "options": {"A": "Renal cell carcinoma", "B": "Telangiectasias", "C": "Optic glioma", "D": "Meningioma", "E": "Astrocytoma\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "hearing loss", "unsteadiness", "standing", "past", "months", "needs support", "wall to prevent", "falling", "not", "recent injuries", "history", "serious", "Vital", "normal limits", "unsteady gait", "to stand upright", "feet together", "unable", "hear fingers rubbing next to", "ears", "repeat words", "ears", "MRI of", "brain", "3", "tumor", "right cerebellopontine angle", "4.5 cm tumor", "left cerebellopontine angle", "patient", "to", "following", "future"]}
{"question": "A study is funded by the tobacco industry to examine the association between smoking and lung cancer. They design a study with a prospective cohort of 1,000 smokers between the ages of 20-30. The length of the study is five years. After the study period ends, they conclude that there is no relationship between smoking and lung cancer. Which of the following study features is the most likely reason for the failure of the study to note an association between tobacco use and cancer?", "answer": "Latency period", "options": {"A": "Effect modification", "B": "Latency period", "C": "Pygmalion effect", "D": "Late-look bias", "E": "Confounding"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["study", "funded", "to", "association", "smoking", "lung cancer", "smokers", "ages", "20-30", "five years", "study period ends", "conclude", "relationship", "smoking", "lung cancer", "following", "most likely reason for", "failure", "study to note", "association", "tobacco use", "cancer"]}
{"question": "A 58-year-old obese male has noticed the gradual development of a soft bulge on his right groin that has been present over the past year and occasionally becomes very tender. He notices that it comes out when he coughs and strains during bowel movements. He is able to push the bulge back in without issue. After examination, you realize that he has an inguinal hernia and recommend open repair with mesh placement. After surgery, the patient returns to clinic and complains of numbness and tingling in the upper part of the scrotum and base of the penis. What nerve was most likely injured during the procedure?", "answer": "Ilioinguinal nerve", "options": {"A": "Iliohypogastric nerve", "B": "Genitofemoral nerve", "C": "Ilioinguinal nerve", "D": "Lateral femoral cutaneous nerve", "E": "Obturator nerve"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old obese male", "gradual development", "soft bulge", "right groin", "present", "past year", "occasionally", "very tender", "out", "coughs", "strains during bowel movements", "able to push", "bulge back", "issue", "inguinal hernia", "open repair", "mesh placement", "surgery", "patient returns", "clinic", "numbness", "tingling", "upper part of", "scrotum", "base of", "penis", "nerve", "most likely injured", "procedure"]}
{"question": "A 70-year-old woman comes to the physician for the evaluation of loss of urine for the last several months. She loses small amounts of urine without warning after coughing or sneezing. She also sometimes forgets the names of her relatives. She is retired and lives at an assisted-living facility. She has type 2 diabetes mellitus and hypertension. Her older sister recently received a ventriculoperitoneal shunt. She does not smoke or drink alcohol. Medications include metformin and enalapril. Vital signs are within normal limits. She walks without any problems. Sensation to pinprick and light touch is normal. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Urethral hypermobility", "options": {"A": "Detrusor overactivity", "B": "Loss of sphincter control", "C": "Urethral hypermobility", "D": "Bacterial infection of the urinary tract", "E": "Decreased cerebrospinal fluid absorption"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old woman", "physician", "loss", "urine", "last", "months", "small amounts", "urine", "coughing", "sneezing", "sometimes forgets", "names", "retired", "lives", "assisted-living facility", "type 2 diabetes mellitus", "hypertension", "recently received", "ventriculoperitoneal shunt", "not smoke", "Medications include metformin", "enalapril", "Vital signs", "normal limits", "walks", "Sensation", "pinprick", "light touch", "normal", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 78-year-old man is brought to the emergency department because of a 3-week history of productive cough, swelling of the legs and feet, and fatigue. He has had progressive dyspnea on exertion for the past 2 months. Twelve years ago, he received a porcine valve replacement for severe mitral valve regurgitation. He has coronary artery disease, type 2 diabetes mellitus, and hypertension. He has smoked one pack of cigarettes daily for 60 years and drinks one beer daily. Current medications include aspirin, simvastatin, ramipril, metoprolol, metformin, and hydrochlorothiazide. He appears pale. He is 179 cm (5 ft 9 in) tall and weighs 127 kg (279.9 lb); BMI is 41.3 kg/m2. His temperature is 37.1°C (98.9°F), respirations are 22/min, pulse is 96/min, and blood pressure is 146/94 mm Hg. Bilateral basilar rales are heard on auscultation of the lungs. Cardiac examination shows a laterally displaced apical heartbeat. A grade 3/6, decrescendo-crescendo diastolic murmur is heard over the apex. There is bilateral pitting edema of the feet and ankles. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Valve degeneration", "options": {"A": "Infective endocarditis", "B": "Chronic obstructive pulmonary disease", "C": "Pneumonia", "D": "Valve degeneration", "E": "Pulmonary embolism"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "3 week history", "productive cough", "swelling of", "legs", "feet", "fatigue", "progressive dyspnea on exertion", "past", "months", "Twelve years", "received", "porcine valve replacement", "severe mitral", "regurgitation", "coronary artery disease", "type 2 diabetes mellitus", "hypertension", "smoked one pack", "cigarettes daily", "60 years", "one", "daily", "Current medications include aspirin", "simvastatin", "ramipril", "metoprolol", "metformin", "hydrochlorothiazide", "appears pale", "5 ft 9", "tall", "kg", "BMI", "kg/m2", "temperature", "98 9F", "respirations", "min", "pulse", "96 min", "blood pressure", "mm Hg", "Bilateral basilar rales", "heard", "auscultation", "lungs", "Cardiac examination", "displaced apical heartbeat", "decrescendo crescendo diastolic murmur", "heard", "apex", "bilateral pitting edema of", "feet", "ankles", "abnormalities", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 16-year-old girl presents with a sore throat. The patient says symptoms onset acutely 3 days ago and have progressively worsened. She denies any history of cough, nasal congestion or rhinorrhea. No significant past medical history or current medications. The vital signs include: temperature 37.7°C (99.9°F), blood pressure 110/70 mm Hg, pulse 74/min, respiratory rate 20/min, and oxygen saturation 99% on room air. Physical examination is significant for anterior cervical lymphadenopathy. There is edema of the oropharynx and tonsillar swelling but no tonsillar exudate. Which of the following is the next best step in management?", "answer": "Rapid strep test", "options": {"A": "Reassurance", "B": "Rapid strep test", "C": "Ultrasound of the anterior cervical lymph nodes", "D": "Empiric treatment with antibiotics", "E": "Empiric treatment with antivirals"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "sore throat", "patient", "symptoms onset", "days", "worsened", "history", "cough", "nasal congestion", "rhinorrhea", "significant past medical history", "current medications", "vital signs include", "temperature", "99 9F", "blood pressure", "70 mm Hg", "pulse 74 min", "respiratory rate 20 min", "oxygen saturation 99", "room air", "significant", "anterior cervical lymphadenopathy", "edema", "oropharynx", "tonsillar swelling", "tonsillar exudate", "following", "next best step"]}
{"question": "A 65-year-old woman comes to the physician because of a 2-month history of intermittent bleeding from her vagina. She has no history of serious illness and takes no medications. Pelvic ultrasound shows a thickened endometrial stripe and a left adnexal mass. Endometrial biopsy shows a well-differentiated adenocarcinoma. Laboratory studies show increased levels of inhibin B. Which of the following is the most likely diagnosis?", "answer": "Granulosa cell tumor", "options": {"A": "Yolk sac tumor", "B": "Granulosa cell tumor", "C": "Immature teratoma", "D": "Serous cystadenocarcinoma", "E": "Dysgerminoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old woman", "physician", "2 month history", "intermittent bleeding", "vagina", "history", "serious illness", "medications", "Pelvic ultrasound", "thickened endometrial stripe", "left adnexal mass", "Endometrial biopsy", "well-differentiated adenocarcinoma", "Laboratory studies", "increased levels", "inhibin B", "following", "diagnosis"]}
{"question": "A 32-year-old man comes into your office because of pain in his right knee, left elbow, and left wrist. It started about a week ago but has particularly localized to his wrist. The patient states that he has 2 sexual partners. He states he has also had some white discharge from his penis with pruritis and pain during urination. His temperature is 97.6°F (36.4°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals pain upon palpation of the patient's left wrist which also appears erythematous and swollen. What is the best next step in management for this patient?", "answer": "Arthrocentesis", "options": {"A": "Arthrocentesis", "B": "Azithromycin, ceftriaxone, and vancomycin", "C": "Ibuprofen and observation", "D": "Methotrexate", "E": "MRI"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "office", "of pain in", "right knee", "left elbow", "left wrist", "started", "week", "localized", "wrist", "patient states", "has", "states", "white discharge from", "penis", "pruritis", "pain", "urination", "temperature", "97", "36", "blood pressure", "84 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "reveals pain", "palpation of", "patient's left wrist", "appears erythematous", "swollen", "best next step", "patient"]}
{"question": "A 25-year-old college student is diagnosed with acute myelogenous leukemia after presenting with a 3-week history of fever, malaise, and fatigue. He has a history of type 1 diabetes mellitus, multiple middle ear infections as a child, and infectious mononucleosis in high school. He currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and denies any 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 17/min. On physical examination, his pulses are bounding; his complexion is pale, but breath sounds remain clear. A rapidly progressive form of leukemia is identified, and the patient is scheduled to start intravenous chemotherapy. Which of the following treatments should be given to this patient to prevent or decrease the likelihood of developing acute renal failure during treatment?", "answer": "Allopurinol", "options": {"A": "Sulfinpyrazone", "B": "Probenecid", "C": "Allopurinol", "D": "Colchicine", "E": "Indomethacin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "diagnosed", "acute myelogenous leukemia", "week history", "fever", "malaise", "fatigue", "history of type 1 diabetes mellitus", "multiple middle ear infections", "child", "infectious mononucleosis", "high school", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "illicit drug use", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 87 min", "respiratory rate", "min", "pulses", "bounding", "complexion", "pale", "breath sounds", "clear", "rapidly progressive form", "leukemia", "identified", "patient", "scheduled to start intravenous chemotherapy", "following treatments", "given", "patient to prevent", "decrease", "likelihood", "acute renal failure", "treatment"]}
{"question": "A 75-year-old woman is brought to a physician’s office by her son with complaints of diarrhea and vomiting for 1 day. Her stool is loose, watery, and yellow-colored, while her vomitus contains partially digested food particles. She denies having blood or mucus in her stools and vomitus. Since the onset of her symptoms, she has not had anything to eat and her son adds that she is unable to tolerate fluids. The past medical history is unremarkable and she does not take any medications regularly. The pulse is 115/min, the respiratory rate is 16/min, the blood pressure is 100/60 mm Hg, and the temperature is 37.0°C (98.6°F). The physical examination shows dry mucous membranes and slightly sunken eyes. The abdomen is soft and non-tender. Which of the following physiologic changes in glomerular filtration rate (GFR), renal plasma flow (RPF), and filtration fraction (FF) are expected?", "answer": "Decreased GFR, decreased RPF, increased FF", "options": {"A": "Increased GFR, increased RPF, increased FF", "B": "Decreased GFR, decreased RPF, increased FF", "C": "Decreased GFR, decreased RPF, no change in FF", "D": "Decreased GFR, decreased RPF, decreased FF", "E": "Increased GFR, decreased RPF, increased FF"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old woman", "brought", "physicians office", "complaints", "diarrhea", "vomiting", "1 day", "stool", "loose", "watery", "yellow-colored", "vomitus contains", "digested", "blood", "mucus in", "stools", "vomitus", "onset", "symptoms", "not", "to eat", "adds", "unable to", "fluids", "past medical history", "unremarkable", "not", "medications", "pulse", "min", "respiratory rate", "min", "blood pressure", "100 60 mm Hg", "temperature", "98", "dry mucous membranes", "slightly sunken eyes", "abdomen", "soft", "non-tender", "following physiologic changes", "glomerular filtration rate", "renal plasma flow", "fraction"]}
{"question": "A 60-year-old African-American female presents to your office complaining of dysuria, paresthesias, and blurry vision. Her body mass index is 37.2 kg/m2. Which of the following drugs would most significantly increase the levels of C-peptide in the blood when administered to this patient?", "answer": "Glipizide", "options": {"A": "Metformin", "B": "Insulin", "C": "Glipizide", "D": "Acarbose", "E": "NPH"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old", "female presents", "office", "dysuria", "paresthesias", "blurry vision", "body mass index", "kg/m2", "following drugs", "most", "increase", "levels", "C-peptide", "blood", "administered", "patient"]}
{"question": "A 2-year-old boy is brought to the emergency department by his mother because of progressive fatigue, abdominal pain, and loss of appetite over the past 3 days. He was treated in the emergency department once in the past year for swelling of his hands and feet. He was adopted as a baby from Sudan and his family history is unknown. He does not take any medication. He is lethargic. His temperature is 37.5°C (99.5°F), pulse is 141/min, respirations are 25/min, and blood pressure is 68/40 mm Hg. Examination shows pale, dry mucous membranes and scleral icterus. Laboratory studies show:\nHemoglobin 7.1 g/dL\nMean corpuscular volume 93 fL\nReticulocyte count 11%\nSerum\nLactate dehydrogenase 194 IU/L\nTotal bilirubin 6.4 mg/dL\nDirect bilirubin 0.5 mg/dL\nHaptoglobin 21 mg/dL (N = 41–165)\nFurther evaluation of this patient is most likely to show which of the following findings?\"", "answer": "Splenomegaly on ultrasound", "options": {"A": "Anti-erythrocyte antibodies on Coombs test", "B": "Pale stool on rectal examination", "C": "Splenomegaly on ultrasound", "D": "Hypocellular bone marrow on biopsy", "E": "Low ferritin level in serum"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["2 year old boy", "brought", "emergency department", "progressive fatigue", "abdominal pain", "loss of appetite", "past", "days", "treated", "emergency department", "past year", "swelling of", "hands", "feet", "adopted", "baby", "Sudan", "family history", "unknown", "not", "medication", "lethargic", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "40 mm Hg", "pale", "dry mucous membranes", "scleral icterus", "Laboratory studies", "Hemoglobin", "g Mean corpuscular volume", "fL Reticulocyte count", "Serum", "IU L Total", "4 mg dL Direct bilirubin 0 5 mg", "Haptoglobin 21", "N", "Further", "to", "following findings"]}
{"question": "A 51-year-old woman with Sjogren’s syndrome presents to her physician for suddenly developed palpitations. She feels more anxious than usual and has had difficulty sleeping well for the past 2 weeks. She has lost 2 kg (4.4 lb) since her last routine appointment 6 months ago. She also has had diarrhea and often feels like her heart is beating very quickly. On physical examination, her skin appears warm and moist. Her reflexes are hyperactive. Her thyroid is moderately enlarged and is non-tender. She has mild dry eyes and dry mouth. Her blood pressure is 136/88 mm Hg, pulse is 76/min, respirations are 17/min and temperature is 36.7°C (98.1°F). Which of the following pathologic findings is this patient likely to have?", "answer": "Chronic lymphocytic thyroiditis", "options": {"A": "Lymphoma", "B": "Silent thyroiditis", "C": "Chronic lymphocytic thyroiditis", "D": "Granulomatous thyroiditis", "E": "Fibrous thyroiditis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "Sjogrens syndrome presents", "physician", "palpitations", "more anxious", "usual", "difficulty sleeping well", "past 2 weeks", "lost 2 kg", "4.4", "last routine appointment", "months", "diarrhea", "often", "heart", "very", "skin appears warm", "moist", "reflexes", "hyperactive", "thyroid", "moderately enlarged", "non-tender", "mild dry eyes", "dry mouth", "blood pressure", "88 mm Hg", "pulse", "76 min", "respirations", "min", "temperature", "36", "98", "following pathologic findings", "patient likely to"]}
{"question": "A 46-year-old male presents with his wife to his primary care provider for depression and strange movements. His wife reports that her husband has not been himself for the last two months. Whereas he was previously outgoing and “the life of the party,” the patient is now irritable and withdrawn. He is a partner at an accounting firm, but his colleagues are threatening his job if he continues to perform poorly at work. The patient cannot explain the recent changes to his mood and tearfully admits he fears there is something seriously wrong with him. His wife says that she thinks he is getting worse. The patient’s past medical history is significant for hypertension, for which he takes lisinopril. His family history is unknown as he was adopted. The patient met his mother once, and never knew his father but was told he died in his 50's. He drinks a few glasses of wine per week and has never smoked. On physical exam, the patient has a flat affect with facial grimace and sudden jerky movements of his upper extremities.\n\nWhich of the following is most likely to be seen on further workup?", "answer": "Dorsal striatum atrophy on head CT", "options": {"A": "Positive 14-3-3 CSF assay", "B": "Alpha-synuclein aggregates on brain biopsy", "C": "Neurofibrillary tangles on brain biopsy", "D": "Frontotemporal atrophy on head CT", "E": "Dorsal striatum atrophy on head CT"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old male presents", "primary care provider", "depression", "movements", "reports", "not", "last two months", "patient", "now irritable", "withdrawn", "firm", "to perform poorly", "patient", "recent changes", "mood", "wrong", "getting worse", "patients past medical history", "significant", "hypertension", "lisinopril", "family history", "unknown", "adopted", "patient met", "never", "died", "50's", "few glasses", "week", "never smoked", "patient", "flat affect", "facial grimace", "sudden jerky movements", "upper extremities", "following", "to", "seen", "further workup"]}
{"question": "A 64-year-old man presents to the office for an annual physical examination. He has no complaints at this visit. His chart states that he has a history of hypertension, chronic obstructive pulmonary disease (emphysema), Raynaud’s disease, and glaucoma. He is a 30 pack-year smoker. His medications included lisinopril, tiotropium, albuterol, nifedipine, and latanoprost. The blood pressure is 139/96 mm Hg, the pulse is 86/min, the respiration rate is 16/min, and the temperature is 37.2°C (99.1°F). On physical examination, his pupils are equal, round, and reactive to light. The cardiac auscultation reveals an S4 gallop without murmur, and the lungs are clear to auscultation bilaterally. However, the inspection of the chest wall shows an enlarged anterior to posterior diameter. Which of the following is the most appropriate screening test for this patient?", "answer": "Low-dose CT", "options": {"A": "Low-dose CT", "B": "Chest radiograph", "C": "Magnetic resonance imaging", "D": "Bronchoalveolar lavage with cytology", "E": "Pulmonary function tests"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["64 year old man presents", "office", "annual physical examination", "complaints", "chart states", "history of hypertension", "chronic obstructive pulmonary disease", "emphysema", "Raynauds disease", "glaucoma", "30", "smoker", "medications included lisinopril", "tiotropium", "albuterol", "nifedipine", "latanoprost", "blood pressure", "96 mm Hg", "pulse", "min", "respiration rate", "min", "temperature", "99", "pupils", "equal", "round", "reactive to light", "cardiac auscultation reveals", "S4 gallop", "murmur", "lungs", "clear", "auscultation", "inspection", "chest wall", "enlarged anterior", "posterior diameter", "following", "most appropriate", "patient"]}
{"question": "A 46-year-old woman presents to the emergency department complaining of abdominal pain, nausea, and vomiting approximately 4 hours after a fatty meal. She reports that this has happened before, but this episode is worse. The vomit was non-bilious and did not contain any blood. She recalls frequent episodes of vague epigastric pain that often wakes her up during the night. Over the counter omeprazole and a small meal or snack would provide some relief in the past. The patient also mentions recent anorexia and early satiety. She takes over the counter ibuprofen several times a week for headaches. Blood pressure is 125/82 mm Hg, pulse is 102/min, and respiratory rate is 19/min. On physical examination, she has hypoactive bowel sounds, and her abdomen seems grossly distended and tympanic on percussion. Which of the following is most consistent with a duodenal ulcer?", "answer": "Food ingestion provides relief of the symptoms", "options": {"A": "Non-bilious vomiting", "B": "Early satiety", "C": "Ibuprofen use", "D": "Omeprazole provides relief of the symptoms", "E": "Food ingestion provides relief of the symptoms"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency department", "abdominal pain", "nausea", "vomiting approximately", "hours after", "meal", "reports", "before", "episode", "worse", "vomit", "non", "not contain", "blood", "episodes", "vague epigastric", "often wakes", "night", "Over the counter omeprazole", "small", "relief", "past", "patient", "recent anorexia", "early satiety", "over the counter ibuprofen", "times", "week", "headaches", "Blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "min", "hypoactive bowel sounds", "abdomen", "distended", "tympanic", "percussion", "following", "most", "duodenal ulcer"]}
{"question": "A 21-year-old man presents to a physician because of extreme fatigue, palpitations, fever, and weight loss. He developed these symptoms gradually over the past 3 months. His blood pressure is 110/80 mm Hg, heart rate is 109/min, respiratory rate is 17/min, and temperature is 38.1°C (100.6°F). The patient is emaciated and pale. There are conjunctival hemorrhages and several bruises noted in the inner cubital area bilaterally. There are also a few lesions on the left foot. The cardiac examination reveals a holosystolic murmur best heard at the 4th intercostal space at the left sternal edge. Two blood cultures grew Staphylococcus aureus, and echocardiography shows a tricuspid valve aneurysm. Which of the following would most likely be revealed in a detailed history from this patient?", "answer": "Chronic intravenous drug usage", "options": {"A": "Percutaneous nephrostomy for acute ureterolithiasis 5 months ago", "B": "Lung abscess evacuation 3 months ago", "C": "Catheterization of the urinary bladder", "D": "Chronic intravenous drug usage", "E": "Adenoidectomy 6 months ago"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old man presents", "physician", "extreme fatigue", "palpitations", "fever", "weight loss", "symptoms", "past 3 months", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "100", "patient", "emaciated", "pale", "conjunctival hemorrhages", "several bruises noted", "inner cubital area", "few lesions", "left foot", "reveals", "holosystolic murmur best heard", "4th intercostal space", "left sternal edge", "Two blood cultures", "Staphylococcus aureus", "echocardiography", "tricuspid valve aneurysm", "following", "most likely", "revealed", "detailed history", "patient"]}
{"question": "An 18-month-old boy of Ashkenazi-Jewish descent presents with loss of developmental milestones. On ocular exam, a cherry-red macular spot is observed. No hepatomegaly is observed on physical exam. Microscopic exam shows lysosomes with onion-skin appearance.\n\nWhat is the most likely underlying biochemical abnormality?", "answer": "Accumulation of GM2 ganglioside", "options": {"A": "Accumulation of ceramide trihexoside", "B": "Accumulation of galactocerebroside", "C": "Accumulation of sphingomyelin", "D": "Accumulation of GM2 ganglioside", "E": "Accumulation of glucocerebroside"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "descent presents", "loss of developmental milestones", "ocular exam", "cherry-red macular spot", "observed", "hepatomegaly", "observed", "physical exam", "Microscopic", "lysosomes", "onion skin appearance", "most likely", "biochemical abnormality"]}
{"question": "A 21-year-old woman presents to her primary care doctor for an initial visit. She is a Syrian refugee and arrived in the United States 2 weeks ago. She has been living in refugee camps throughout Jordan and Turkey for the past 2 years. She has a 3-year-old son and reports that she has limited her food intake in order to ensure that her son has adequate nutrition. She reports decreased vision most noticeable over the past 6 months that is worse in low-light settings. She also reports severe dry eyes that have not improved with eye drops. She has no known past medical history and takes no medications. Her body mass index is 18.1 kg/m^2. On exam, she appears lethargic but is able to respond to questions appropriately. She has dry mucous membranes and decreased skin turgor. Her conjunctiva appears dry, thickened, and wrinkled. There is a small corneal ulcer on the lateral aspect of the left eye. This patient's symptoms are most consistent with a deficiency in a vitamin that contributes to which of the following processes?", "answer": "T-cell differentiation", "options": {"A": "Collagen synthesis", "B": "T-cell differentiation", "C": "Clotting factor synthesis", "D": "Cystathionine synthesis", "E": "Methylation reactions"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old woman presents", "primary care doctor", "initial", "United States 2 weeks", "living", "refugee camps", "Jordan", "Turkey", "past", "years", "3 year old", "reports", "limited", "food intake", "order to", "adequate nutrition", "reports decreased vision most", "past 6 months", "worse", "low light settings", "reports severe dry eyes", "not improved", "eye drops", "known past medical history", "medications", "body mass index", "kg/m", "exam", "appears lethargic", "able to", "dry mucous membranes", "decreased skin turgor", "conjunctiva appears dry", "thickened", "wrinkled", "small corneal ulcer", "lateral aspect of", "left eye", "patient's symptoms", "most", "deficiency", "vitamin", "following processes"]}
{"question": "Three days after delivery, a 1100-g (2-lb 7-oz) newborn has a tonic seizure that lasts for 25 seconds. She has become increasingly lethargic over the past 18 hours. She was born at 31 weeks' gestation. Antenatal period was complicated by chorioamnionitis. Apgar scores were 3 and 6 at 1 and 5 minutes, respectively. She appears ill. Her pulse is 123/min, respirations are 50/min and irregular, and blood pressure is 60/30 mm Hg. Examination shows a tense anterior fontanelle. The pupils are equal and react sluggishly to light. Examination shows slow, conjugate back and forth movements of the eyes. Muscle tone is decreased in all extremities. The lungs are clear to auscultation. Which of the following is the most likely diagnosis?", "answer": "Intraventricular hemorrhage", "options": {"A": "Galactosemia", "B": "Spinal muscular atrophy", "C": "Phenylketonuria", "D": "Congenital hydrocephalus", "E": "Intraventricular hemorrhage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Three days", "delivery", "g", "oz", "newborn", "tonic seizure", "lasts", "seconds", "lethargic", "past 18 hours", "born", "31 weeks", "gestation", "Antenatal period", "complicated", "chorioamnionitis", "Apgar scores", "3", "5 minutes", "appears ill", "pulse", "min", "respirations", "50 min", "irregular", "blood pressure", "60 30 mm Hg", "tense anterior fontanelle", "pupils", "equal", "light", "slow", "back", "movements", "eyes", "Muscle tone", "decreased", "extremities", "lungs", "clear", "auscultation", "following", "diagnosis"]}
{"question": "A researcher is studying the ability of breast cancer cells to metastasize. Neoplastic cells obtained from 30 patients with stage IV ductal carcinoma of the breast are tagged with a fluorescent antibody. The cells are then inserted into a medium resembling normal human tissue. After 2 weeks, all samples show in vitro hematogenous invasion and migration away from the original site of insertion. Which of the following properties is most likely responsible for the ability of these neoplastic cells to metastasize?", "answer": "Release of matrix metalloproteinase", "options": {"A": "Loss of cellular polarity", "B": "Overexpression of HER2/neu", "C": "Increase in N:C ratio", "D": "Presence of fibrous tissue capsule", "E": "Release of matrix metalloproteinase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["researcher", "studying the ability of breast cancer cells to metastasize", "obtained", "30 patients", "stage IV ductal carcinoma of the breast", "tagged", "fluorescent antibody", "cells", "then", "medium", "normal human tissue", "2 weeks", "in vitro hematogenous invasion", "migration", "original site of insertion", "following properties", "responsible", "ability", "to metastasize"]}
{"question": "A newlywed couple comes to your office for genetic counseling. Both potential parents are known to be carriers of the same Cystic Fibrosis (CF) mutation. What is the probability that at least one of their next three children will have CF if they are all single births?", "answer": "37/64", "options": {"A": "0", "B": "1/64", "C": "27/64", "D": "37/64", "E": "1"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["couple", "office", "genetic counseling", "potential", "known to", "carriers", "same Cystic Fibrosis", "mutation", "probability", "one", "next three children", "CF", "single births"]}
{"question": "A 32-year-old woman makes an appointment at her physician’s office for a regular health check-up. She does not have any complaints and mentions that she has started to train for an upcoming marathon and hydrates exclusively with electrolyte solutions. She has been trying unsuccessfully to quit smoking for a few years now. She has hypercholesterolemia, which is controlled with a low-cholesterol diet. Family history is significant for hypertension in both of her parents. Her father died of myocardial infarction a few years ago. The vital signs include heart rate 55/min, respiratory rate 16/min, temperature 37.6 °C (99.68 °F), and blood pressure 120/88 mm Hg. The physical exam findings are within normal limits. A routine electrocardiogram (ECG) is done and is shown below. The abnormal wave seen on the ECG tracing represents which of the following mechanical events?", "answer": "Ventricular repolarization", "options": {"A": "Ventricular depolarization", "B": "Period between ventricular depolarization and repolarization", "C": "Ventricular repolarization", "D": "Atrial depolarization", "E": "Atrial repolarization"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman makes", "appointment", "physicians office", "regular health check-up", "not", "complaints", "started to train", "marathon", "hydrates", "electrolyte solutions", "to", "smoking", "years now", "hypercholesterolemia", "controlled", "low-cholesterol diet", "Family history", "significant", "hypertension", "died", "myocardial infarction", "few years", "vital signs include heart rate", "min", "respiratory rate", "min", "temperature", "99", "F", "blood pressure", "88 mm Hg", "physical exam findings", "normal limits", "routine electrocardiogram", "abnormal wave seen", "ECG", "following mechanical"]}
{"question": "A 21-year-old female presents to her primary care doctor for prenatal counseling before attempting to become pregnant for the first time. She is an avid runner, and the physician notes her BMI of 17.5. The patient complains of chronic fatigue, which she attributes to her busy lifestyle. The physician orders a complete blood count that reveals a Hgb 10.2 g/dL (normal 12.1 to 15.1 g/dL) with an MCV 102 µm^3 (normal 78 to 98 µm^3). A serum measurement of a catabolic derivative of methionine returns elevated. Which of the following complications is the patient at most risk for if she becomes pregnant?", "answer": "Placenta abruptio", "options": {"A": "Hyperemesis gravidarum", "B": "Gestational diabetes", "C": "Placenta previa", "D": "Placenta abruptio", "E": "Placenta accreta"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["21-year-old female presents", "primary care doctor", "prenatal counseling", "to", "pregnant", "first time", "avid", "physician notes", "BMI", "patient", "chronic fatigue", "attributes", "physician orders", "complete blood count", "reveals", "Hgb 10", "g/dL", "normal", "g/dL", "MCV", "m", "normal", "98 m", "serum measurement", "catabolic derivative", "methionine returns elevated", "following complications", "patient", "most", "pregnant"]}
{"question": "A 17-year-old girl is admitted to the emergency department with severe retrosternal chest pain. The pain began suddenly after an episode of self-induced vomiting following a large meal. The patient’s parents say that she is very restricted in the foods she eats and induces vomiting frequently after meals. Vital signs are as follows: blood pressure 100/60 mm Hg, heart rate 98/min, respiratory rate 14/min, and temperature 37.9℃ (100.2℉). The patient is pale and in severe distress. Lungs are clear to auscultation. On cardiac examination, a crunching, raspy sound is auscultated over the precordium that is synchronous with the heartbeat. The abdomen is soft and nontender. Which of the following tests would most likely confirm the diagnosis in this patient?", "answer": "Contrast esophagram", "options": {"A": "Upper endoscopy", "B": "ECG", "C": "Echocardiography", "D": "Contrast esophagram", "E": "Measurement of D-dimer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "emergency department", "severe retrosternal chest pain", "pain began", "episode of self-induced vomiting following", "large", "patients", "very restricted", "eats", "induces vomiting frequently", "meals", "Vital signs", "follows", "blood pressure 100 60 mm Hg", "heart rate 98 min", "respiratory rate", "min", "temperature", "100", "patient", "pale", "severe distress", "Lungs", "clear", "auscultation", "raspy sound", "precordium", "synchronous", "heartbeat", "abdomen", "soft", "nontender", "following tests", "most likely confirm", "diagnosis", "patient"]}
{"question": "A 47-year-old woman comes to the physician for a 2-month history of fatigue, intermittent left-sided flank pain, and diffuse extremity pain. She was treated for a prolactinoma 5 years ago and has had recurrent antral and duodenal peptic ulcers despite medical therapy. Her only medication is omeprazole. Physical examination shows a moderately distended abdomen that is diffusely tender to palpation. There is mild left-sided costovertebral angle tenderness. Serum studies show a calcium of 12 mg/dL, phosphorus of 2 mg/dL, and parathyroid hormone level of 826 pg/mL. An ultrasound of the abdomen shows multiple kidney stones in the left ureteropelvic junction. This patient is most likely to have which of the following protein abnormalities?", "answer": "Altered menin protein", "options": {"A": "Inactivation of RET proto-oncogene", "B": "Altered merlin protein expression", "C": "Altered menin protein", "D": "Mutation of VHL tumor suppressor", "E": "Mutation in C-Kit protein"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "2 month history", "fatigue", "intermittent left sided flank pain", "diffuse extremity", "treated", "prolactinoma", "years", "recurrent antral", "duodenal peptic ulcers", "medical therapy", "only medication", "omeprazole", "moderately distended abdomen", "tender", "palpation", "mild left-sided costovertebral angle tenderness", "Serum studies", "calcium", "mg/dL", "phosphorus", "2 mg dL", "parathyroid hormone level", "pg/mL", "ultrasound of", "abdomen", "multiple kidney stones in", "left ureteropelvic junction", "patient", "to", "following protein abnormalities"]}
{"question": "A 28-year-old woman comes to the physician with a history of bright red blood in her stools for 3 days. She has defecated once per day. She does not have fever, pain on defecation, or abdominal pain. She was treated for a urinary tract infection with levofloxacin around 3 months ago. Menses occur at regular intervals of 28–30 days and lasts 3–4 days. Her father died of colon cancer 4 years ago. Her only medication is an iron supplement. She is 162 cm (5 ft 4 in) tall and weighs 101.2 kg (223 lbs); BMI is 38.3 kg/m2. Her temperature is 36.5°C (97.7°F), pulse is 89/min, and blood pressure is 130/80 mm Hg. Rectal examination shows anal skin tags. Anoscopy shows multiple enlarged bluish veins above the dentate line at 7 and 11 o'clock positions. When asked to exhale through a closed nostril a mass prolapses but spontaneously reduces when breathing normally. Which of the following is the most appropriate next step in management?", "answer": "Docusate therapy", "options": {"A": "Docusate therapy", "B": "Topical diltiazem", "C": "Propranolol therapy", "D": "Infrared coagulation", "E": "Hemorrhoidectomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "history", "bright red blood", "stools", "3 days", "day", "not", "fever", "pain", "defecation", "abdominal pain", "treated", "urinary tract infection", "levofloxacin", "months", "Menses occur", "regular intervals of", "days", "lasts", "days", "died of colon cancer", "years", "only medication", "iron supplement", "5 ft 4", "tall", "kg", "lbs", "BMI", "kg/m2", "temperature", "36", "97", "pulse", "min", "blood pressure", "80 mm Hg", "Rectal examination", "anal skin tags", "multiple enlarged", "veins", "line", "11 o'clock positions", "closed nostril", "mass prolapses", "breathing", "following", "most appropriate next step"]}
{"question": "A 73-year-old female with no past medical history is hospitalized after she develops a fever associated with increasing shortness of breath. She states that 1 week prior, she had a cold which seemed to be resolving. Yesterday, however, she noticed that she started to feel feverish, measured her temperature to be 101.5°F (38.6°C), and also developed an unproductive dry cough and difficulty breathing. On exam, her temperature is 100.8°F (38.2°C), blood pressure is 110/72 mmHg, pulse is 96/min, and respirations are 16/min. Her exam demonstrates decreased breath sounds at the right lung base. The chest radiograph shows a right-sided pleural effusion with an opacity in the right lower lobe that is thought to be a bacterial pneumonia. Which of the following can be expected on a sample of the effusion fluid?", "answer": "Protein-rich fluid", "options": {"A": "Clear fluid", "B": "Hypocellular fluid", "C": "Malignant cells", "D": "Protein-rich fluid", "E": "Specific gravity of 1.010"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "past medical history", "hospitalized", "fever associated with increasing shortness of breath", "states", "1 week prior", "cold", "to", "resolving", "started to", "feverish", "measured", "temperature to", "unproductive dry", "difficulty breathing", "exam", "temperature", "100", "blood pressure", "72 mmHg", "pulse", "96 min", "respirations", "min", "exam", "decreased breath sounds", "right lung base", "chest radiograph", "right-sided pleural effusion", "opacity", "right lower lobe", "to", "bacterial pneumonia", "following", "sample", "effusion fluid"]}
{"question": "A 58-year-old man comes to the physician because of burning pain in his neck and arms for a year. He has also had paresthesias in his hands during this period. He has had increasing weakness in both hands during the past 3 months. He has type 2 diabetes mellitus, hypercholesterolemia, and hypertension. He was involved in a motor vehicle collision 3 years ago. Current medications include metformin, sitagliptin, enalapril, atorvastatin, and aspirin. He has had 7 sexual partners in his lifetime; he uses condoms inconsistently. He is oriented to time, place, and person. Vital signs are within normal limits. The pupils are equal and reactive to light. Examination of the upper extremities shows decreased muscle strength, absent reflexes, and decreased hand grip with fasciculations bilaterally. Sensation to temperature and pain is absent over the chest and bilateral upper arms. Vibration and joint position sensations are present in the upper limbs. Cranial nerve examination shows no focal findings. Examination of the lower extremities show no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Syringomyelia", "options": {"A": "Tabes dorsalis", "B": "Cervical disk prolapse", "C": "Brown-Séquard syndrome", "D": "Multiple sclerosis", "E": "Syringomyelia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old man", "physician", "of burning pain in", "neck", "arms", "year", "paresthesias", "hands", "period", "increasing weakness", "hands", "past 3 months", "type 2 diabetes mellitus", "hypercholesterolemia", "hypertension", "involved", "motor vehicle collision 3 years", "Current medications include metformin", "sitagliptin", "enalapril", "atorvastatin", "aspirin", "lifetime", "uses condoms", "oriented to time", "place", "Vital signs", "normal limits", "pupils", "equal", "reactive to light", "Examination of the upper extremities", "decreased muscle strength", "absent reflexes", "decreased hand grip", "fasciculations", "Sensation", "temperature", "pain", "absent", "chest", "bilateral upper arms", "Vibration", "joint position sensations", "present", "upper limbs", "focal findings", "Examination of the lower extremities", "abnormalities", "following", "diagnosis"]}
{"question": "A 26-year-old woman comes to the physician for evaluation of nausea and fatigue. Her last menstrual period was 8 weeks ago. She has a history of bipolar disorder controlled by a drug known to sometimes cause hypothyroidism and nephrogenic diabetes insipidus. She does not smoke cigarettes or drink alcohol. A urine pregnancy test is positive. An ultrasound of the pelvis shows a viable intrauterine pregnancy. The fetus is most likely at increased risk for which of the following anomalies?", "answer": "Atrialization of the right ventricle", "options": {"A": "Abnormal placentation", "B": "Aplasia cutis", "C": "Atrialization of the right ventricle", "D": "Neural tube defects", "E": "Hypoplastic or absent limbs"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "nausea", "fatigue", "last menstrual period", "weeks", "history of bipolar disorder", "known", "sometimes cause hypothyroidism", "nephrogenic diabetes insipidus", "not smoke cigarettes", "urine pregnancy test", "positive", "ultrasound", "pelvis", "viable intrauterine", "fetus", "increased risk", "following anomalies"]}
{"question": "A 62-year-old woman is brought to the emergency department after briefly losing consciousness while walking her dog. She spontaneously regained consciousness 20 seconds later. She has a history of atrial fibrillation. Current medications include metoprolol. She reports that she forgot to take her medication the day before and took double the dose this morning instead. A decrease in which of the following most likely contributed to this patient's episode?", "answer": "Activity of adenylyl cyclase in cardiomyocytes", "options": {"A": "Phosphorylation of myosin light chains in vascular smooth muscle cells", "B": "Activity of protein kinase C in cardiomyocytes", "C": "Activity of protein kinase A in vascular smooth muscle cells", "D": "Activity of adenylyl cyclase in cardiomyocytes", "E": "Diastolic efflux of calcium in cardiomyocytes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "brought", "emergency department", "consciousness", "consciousness 20 seconds later", "history of atrial fibrillation", "Current medications include metoprolol", "reports", "forgot to", "medication", "day", "double", "dose", "morning", "decrease", "following most likely", "patient's episode"]}
{"question": "A 27-year-old man is witnessed falling off his bicycle. The patient rode his bicycle into a curb and hit his face against a rail. The patient did not lose consciousness and is ambulatory at the scene. There is blood in the patient's mouth and one of the patient's teeth is found on the sidewalk. The patient is transferred to the local emergency department. Which of the following is the best method to transport this patient's tooth?", "answer": "Submerged in milk", "options": {"A": "Submerged in milk", "B": "Submerged in normal saline", "C": "Submerged in water", "D": "Wrapped in sterile gauze", "E": "Wrapped in gauze soaked in normal saline"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man", "falling", "bicycle", "patient", "bicycle", "curb", "hit", "face", "rail", "patient", "not", "consciousness", "ambulatory", "blood", "patient's mouth", "one", "patient's teeth", "found", "sidewalk", "patient", "transferred", "local emergency department", "following", "best method to transport", "patient's tooth"]}
{"question": "A 62-year-old man presents to his primary care physician because of abdominal pain that started after he went camping several months ago and drank from a mountain stream. This past year, he also went on a trip around the world, eating local foods at each stop. Furthermore, he has had a history of cholelithiasis and had his gallbladder removed 3 years ago. Otherwise, his medical history is significant for well-controlled hypertension and diabetes. Based on clinical suspicion, an endoscopy and biopsy was performed showing a mix of mononuclear cells and a motile, urease-positive, oxidase-positive, spiral shaped organism. The changes seen on biopsy in this patient most likely predispose him to which of the following pathologies?", "answer": "MALT lymphoma", "options": {"A": "Esophageal adenocarcinoma", "B": "Gallbladder adenocarcinoma", "C": "Colon adenocarcinoma", "D": "MALT lymphoma", "E": "Pancreatic adenocarcinoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man presents", "primary care physician", "abdominal pain", "started", "months", "mountain", "past year", "trip", "eating local", "stop", "history of cholelithiasis", "gallbladder removed 3 years", "medical history", "significant", "well", "diabetes", "Based", "clinical", "endoscopy", "biopsy", "performed", "mix", "motile", "urease positive", "oxidase positive", "spiral shaped", "changes seen", "biopsy", "patient", "likely", "following pathologies"]}
{"question": "A 46-year-old man comes to the physician because of a 1-week history of headache, muscle pain, and recurrent fever spikes that occur without a noticeable rhythm. Two weeks ago, he returned from a 5-week-long world trip during which he climbed several mountains in India, Africa, and Appalachia. Chemoprophylaxis with chloroquine was initiated one week prior to the trip. Physical examination shows jaundice. The spleen is palpated 2 cm below the left costal margin. His hemoglobin concentration is 10 g/dL. A photomicrograph of a peripheral blood smear is shown. Which of the following agents is the most likely cause of this patient's findings?", "answer": "Plasmodium falciparum", "options": {"A": "Trypanosoma cruzi", "B": "Plasmodium falciparum", "C": "Chikungunya virus", "D": "Trypanosoma brucei", "E": "Leishmania donovani"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "of", "1-week history", "headache", "muscle pain", "recurrent fever", "occur", "rhythm", "Two weeks", "returned", "5 week long", "trip", "climbed several mountains", "India", "Africa", "Appalachia", "Chemoprophylaxis", "chloroquine", "initiated one week prior to", "trip", "jaundice", "spleen", "2 cm", "left costal margin", "hemoglobin concentration", "10 g/dL", "photomicrograph", "peripheral blood smear", "following agents", "most likely cause", "patient's findings"]}
{"question": "A 27-year-old woman comes to the emergency department because of progressive numbness and weakness in her left arm and left leg for 2 days. During this period, she has also had urinary urgency and incontinence. Three months ago, she had blurry vision, difficulty distinguishing colors, and headache for one week, all of which have resolved. The patient has smoked a half pack of cigarettes daily for 10 years and drinks four glasses of wine each week. Her temperature is 37°C (98.6°F), pulse is 78/min, respirations are 14/min, and blood pressure is 110/68 mm Hg. Examination shows 3/5 strength in the left arm and leg, and 5/5 strength on the right side. Upon flexion of the neck, the patient experiences a shooting electric sensation that travels down the spine. MRI of the brain shows gadolinium-enhancing lesions in the right central sulcus, cervical spinal cord, and optic nerve. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Administer IV methylprednisolone", "options": {"A": "Administer lorazepam", "B": "Administer IV methylprednisolone", "C": "Plasmapheresis", "D": "Administer tissue plasminogen activator", "E": "Glatiramer acetate therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old woman", "emergency department", "progressive numbness", "weakness", "left", "left leg", "2 days", "period", "urinary urgency", "incontinence", "Three months", "blurry vision", "difficulty", "colors", "headache", "one week", "resolved", "patient", "smoked", "half pack", "cigarettes daily", "four glasses", "week", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "3/5 strength", "left arm", "leg", "5/5 strength", "right side", "flexion", "neck", "patient", "shooting", "sensation", "spine", "MRI of", "brain", "gadolinium-enhancing lesions", "right central sulcus", "cervical spinal cord", "optic nerve", "following", "most appropriate next step", "patient"]}
{"question": "A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?", "answer": "Patient-controlled intravenous hydromorphone", "options": {"A": "Patient-controlled intravenous hydromorphone", "B": "Transdermal bupivacaine on request", "C": "Oral acetaminophen every 6 hours", "D": "Oral gabapentin every 24 hours", "E": "Transdermal fentanyl every 72 hours"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["72 year old woman", "emergency department", "upper abdominal pain", "nausea", "past hour", "patient rates", "pain", "a 10 point scale", "episode", "vomiting", "pain started", "history of type 2 diabetes mellitus", "hypertension", "osteoporosis", "patient", "smoked 2 packs", "cigarettes daily", "40 years", "daily", "Current medications include glyburide", "lisinopril", "oral vitamin D supplements", "temperature", "pulse", "min", "blood pressure", "mm Hg", "severe epigastric tenderness", "palpation", "guarding", "Ultrasonography of", "abdomen", "diffuse enlargement", "pancreas", "gallstones", "visualized", "patient", "pain control", "intravenous hydration", "following", "most appropriate next step", "management", "patients pain"]}
{"question": "The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:\nHemoglobin 12.5 g/dL\nSerum\nNa+ 140 mEq/L\nCl- 103 mEq/L\nK+ 4.2 mEq/L\nHCO3- 26 mEq/L\nCa2+ 8.9 mg/dL\nUrea Nitrogen 12 mg/dL\nGlucose 110 mg/dL\nAlkaline Phosphatase 25 U/L\nAlanine aminotransferase (ALT) 15 U/L\nAspartate aminotransferase (AST) 13 U/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Breast-conserving therapy and sentinel lymph node biopsy", "options": {"A": "Breast-conserving therapy and sentinel lymph node biopsy", "B": "Trastuzumab therapy", "C": "Whole-body PET/CT", "D": "Bilateral mastectomy with lymph node dissection", "E": "Bone scan"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["patient", "mammogram", "sized mass", "irregular border", "spiculated margins", "subsequent core needle biopsy", "mass", "infiltrating ductal carcinoma", "HER2-positive", "estrogen negative", "progesterone negative immunohistochemistry", "Blood counts", "liver function tests", "normal", "Laboratory studies", "12.5", "Serum", "Cl", "2", "HCO3", "Ca2", "mg", "mg", "U", "Alanine aminotransferase", "ALT", "U/L Aspartate aminotransferase", "AST", "U/L", "following", "most appropriate next step"]}
{"question": "A recent study examined trends in incidence and fatality of ischemic stroke in a representative sample of Scandinavian towns. The annual incidence of ischemic stroke was calculated to be 60 per 2,000 people. The 1-year case fatality rate for ischemic stroke was found to be 20%. The health department of a town in southern Sweden with a population of 20,000 is interested in knowing the 1-year mortality conferred by ischemic stroke. Based on the study's findings, which of the following estimates the annual mortality rate for ischemic stroke per 20,000?", "answer": "120 people", "options": {"A": "12 people", "B": "120 people", "C": "400 people", "D": "60 people", "E": "600 people"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["recent study examined trends", "incidence", "fatality", "ischemic stroke", "towns", "annual incidence", "ischemic stroke", "calculated to", "60", "2", "people", "1 year case fatality rate", "ischemic stroke", "found to", "20", "town", "southern Sweden", "population", "20", "1 year mortality", "ischemic stroke", "Based", "study's findings", "following estimates", "annual mortality rate", "ischemic stroke", "20"]}
{"question": "An infectious disease chairperson of a large hospital determines that the incidence of Clostridioides difficile infections at the hospital is too high. She proposes an initiative to restrict the usage of clindamycin in the hospital to determine if that lowers the incidence of C. difficile infections. She puts in place a requirement that an infectious disease fellow needs to approve any prescription of clindamycin. After 2 months, she reviews the hospital infection data and determines that the incidence of C. difficile infections has decreased, but not to the extent that she had hoped. Consequently, she decides to include fluoroquinolone antibiotics in the antibiotic restriction and examine the data again in another 2 months. Which of the following best describes the process being used by the infectious disease chairperson?", "answer": "Plan, do, study, act cycle", "options": {"A": "High reliability organization", "B": "Root cause analysis", "C": "Failure mode and effects analysis", "D": "Plan, do, study, act cycle", "E": "Lean process improvement"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["infectious disease chairperson", "large hospital", "incidence", "infections", "hospital", "too high", "to restrict", "usage", "clindamycin", "hospital to", "lowers", "incidence", "infections", "place", "requirement", "infectious disease", "needs to approve", "clindamycin", "2 months", "hospital infection data", "incidence", "infections", "decreased", "not", "extent", "to include fluoroquinolone antibiotics", "restriction", "data", "months", "following best", "process", "used by", "infectious disease chairperson"]}
{"question": "A 72-year-old man with coronary artery disease comes to the physician because of intermittent episodes of substernal chest pain and shortness of breath. The episodes occur only when walking up stairs and resolves after resting for a few minutes. He is a delivery man and is concerned because the chest pain has impacted his ability to work. His pulse is 98/min and blood pressure is 132/77 mm Hg. Physical examination is unremarkable. An ECG shows no abnormalities. A drug that blocks which of the following receptors is most likely to prevent future episodes of chest pain from occurring?", "answer": "Beta-1 adrenergic receptors", "options": {"A": "Alpha-2 adrenergic receptors", "B": "Angiotensin II receptors", "C": "Aldosterone receptors", "D": "M2 muscarinic receptors", "E": "Beta-1 adrenergic receptors"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["72 year old man", "coronary artery disease", "physician", "of intermittent episodes", "substernal chest pain", "shortness of breath", "episodes occur only", "minutes", "delivery man", "chest pain", "impacted", "ability to", "pulse", "98 min", "blood pressure", "mm Hg", "unremarkable", "ECG", "abnormalities", "drug", "blocks", "following receptors", "to prevent future episodes of chest pain", "occurring"]}
{"question": "A previously healthy 3-month-old girl is brought to the physician because of fever, irritability, and rash for 3 days. The rash started around the mouth before spreading to the trunk and extremities. Her temperature is 38.6°C (101.5°F). Examination shows a diffuse erythematous rash with flaccid bullae on the neck, flexural creases, and buttocks. Gentle pressure across the trunk with a gloved finger creates a blister. Oropharyngeal examination shows no abnormalities. Which of the following is the most likely underlying mechanism of these skin findings?", "answer": "Toxin-induced cleavage of desmoglein", "options": {"A": "Toxin-induced cleavage of desmoglein", "B": "Bacterial production of erythrogenic toxin", "C": "Bacterial invasion of the epidermis", "D": "Autoantibody deposition in stratum spinosum", "E": "Autoantibody binding of hemidesmosomes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "month old girl", "brought", "physician", "fever", "irritability", "rash", "3 days", "rash started", "mouth", "spreading", "trunk", "extremities", "temperature", "diffuse erythematous", "flaccid bullae", "neck", "flexural", "buttocks", "Gentle pressure", "trunk", "gloved finger creates", "blister", "Oropharyngeal", "abnormalities", "following", "underlying mechanism", "skin findings"]}
{"question": "A 21-year-old man comes to the physician for a follow-up examination. Four days ago, he injured his right knee while playing soccer. Increased laxity of the right knee joint is noted when the knee is flexed to 30° and an abducting force is applied to the lower leg. The examination finding in this patient is most likely caused by damage to which of the following structures?", "answer": "Medial collateral ligament", "options": {"A": "Posterior cruciate ligament", "B": "Lateral collateral ligament", "C": "Lateral meniscus", "D": "Medial collateral ligament", "E": "Anterior cruciate ligament"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old man", "physician", "follow-up examination", "Four days", "injured", "right knee", "playing", "Increased laxity", "right knee joint", "noted", "knee", "flexed", "30", "applied", "lower leg", "examination finding", "patient", "most likely caused", "damage", "following structures"]}
{"question": "A 63-year-old woman presents to her primary care doctor with increased urinary frequency. She has noticed that over the past 6 months, she has had to urinate more often than usual. Several times per day, she develops a rapid-onset need to urinate and has occasionally been unable to reach the restroom. These symptoms have caused her a lot of distress and impacted her work as a grocery store clerk. She has tried pelvic floor exercises, decreasing her caffeine consumption, and has intentionally lost 20 pounds in an effort to alleviate her symptoms. She denies urinary hesitancy or hematuria. Her past medical history is notable for rheumatoid arthritis for which she takes methotrexate. She does not smoke or drink alcohol. Her temperature is 98.8°F (37.1°C), blood pressure is 124/68 mmHg, pulse is 89/min, and respirations are 19/min. She is well-appearing and in no acute distress. Which of the following interventions would be most appropriate in this patient?", "answer": "Oxybutynin", "options": {"A": "Intermittent catheterization", "B": "Oxybutynin", "C": "Pessary placement", "D": "Tamsulosin", "E": "Topical estrogen"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old woman presents", "primary care doctor", "increased urinary frequency", "past 6 months", "to", "more often", "usual", "times", "day", "rapid-onset need to", "occasionally", "unable to reach", "restroom", "symptoms", "caused", "lot", "distress", "impacted", "grocery store clerk", "pelvic floor exercises", "decreasing", "lost 20 pounds", "effort to", "symptoms", "urinary hesitancy", "hematuria", "past medical history", "notable", "rheumatoid arthritis", "methotrexate", "not smoke", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "well appearing", "acute distress", "following interventions", "most appropriate", "patient"]}
{"question": "A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows:\nAlcohol positive\nAmphetamine negative\nBenzodiazepine negative\nCocaine positive\nGHB negative\nKetamine negative\nLSD negative\nMarijuana negative\nOpioids negative\nPCP negative\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Illusion", "options": {"A": "Cocaine intoxication", "B": "Illusion", "C": "Visual hallucination", "D": "Delusion", "E": "Alcohol withdrawal"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "behavioral health clinic", "seeing", "shaped clouds", "form", "cats", "patient", "symptoms", "present", "2 weeks", "Past medical history", "significant", "simple partial seizures", "valproate", "not", "medication adjusted", "years", "vital signs include", "blood pressure", "76 mm Hg", "heart rate", "98 min", "respiratory rate", "min", "temperature", "98", "patient", "alert", "oriented to person", "time", "place", "not constricted", "flat", "Speech", "rapid rate", "high volume", "Pupils", "equal", "reactive", "results", "urine drug screen", "follows", "positive Amphetamine negative Benzodiazepine", "GHB", "Ketamine", "LSD", "Marijuana", "Opioids", "following", "diagnosis", "patient"]}
{"question": "A 72-year-old man presents to his primary care physician with a 1 week history of persistent dry cough and worsening shortness of breath. He says that he has also been experiencing some abdominal pain and weakness. He has never experienced these symptoms before. His past medical history is significant for persistent ventricular tachycardia, and he started a new medication to control this arrhythmia about 1 month prior to presentation. Chest radiograph reveals patchy opacification bilaterally, and computed tomography (CT) scan shows diffuse ground glass changes. The drug that is most likely responsible for this patient's symptoms has which of the following mechanisms of action?", "answer": "Potassium channel blocker", "options": {"A": "Beta-adrenergic blocker", "B": "Calcium channel blocker", "C": "Potassium channel blocker", "D": "Sodium channel blocker with prolonged refractory period", "E": "Sodium channel blocker with shortened refractory period"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "primary care physician", "1 week history", "persistent dry cough", "worsening shortness of breath", "abdominal pain", "weakness", "never", "symptoms", "past medical history", "significant", "persistent ventricular tachycardia", "started", "new medication to control", "arrhythmia", "month", "Chest radiograph reveals patchy opacification", "computed tomography", "scan", "diffuse ground glass changes", "drug", "responsible", "patient's symptoms", "of", "following mechanisms", "action"]}
{"question": "A 3-year-old boy is brought to the emergency room by his mother with fever and difficulty breathing after receiving the BCG vaccine. He has never had a reaction to a vaccine before. He has a history of 2 salmonella infections over the past 2 years. He was born at 35 weeks’ gestation and spent one day in the neonatal intensive care unit. His parents' family histories are unremarkable. His temperature is 101°F (38.3°C), blood pressure is 80/55 mmHg, pulse is 135/min, and respirations are 24/min. On examination, he appears acutely ill. He has increased work of breathing with intercostal retractions. A petechial rash is noted on his trunk and extremities. A serological analysis in this patient would most likely reveal decreased levels of which of the following cytokines?", "answer": "Interferon gamma", "options": {"A": "Interferon alpha", "B": "Interferon gamma", "C": "Interleukin 1", "D": "Interleukin 12", "E": "Tumor necrosis factor alpha"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 year old boy", "brought", "emergency room", "mother", "fever", "difficulty breathing", "receiving", "BCG vaccine", "never", "reaction", "vaccine", "history", "salmonella infections", "past", "years", "born", "35 weeks gestation", "spent one day", "neonatal intensive care unit", "family histories", "unremarkable", "temperature", "blood pressure", "80", "mmHg", "pulse", "min", "respirations", "min", "appears", "ill", "increased work of breathing", "intercostal retractions", "petechial rash", "noted", "trunk", "extremities", "serological analysis", "patient", "most likely reveal decreased levels", "following cytokines"]}
{"question": "A 54-year-old woman with metastatic breast cancer comes to the physician for a follow-up examination. She had a mastectomy 6 months ago and received chemotherapy with doxorubicin and paclitaxel. A CT scan of the chest shows new metastases in the lungs and liver. Adjuvant therapy is initiated with a drug that inhibits the formation of deoxythymidine monophosphate and results in the accumulation of deoxyuridine triphosphate. The patient is advised to avoid folic acid supplementation while receiving this drug in order to prevent the toxic effects of this drug. Which of the following drugs was most likely given?", "answer": "Capecitabine", "options": {"A": "Hydroxyurea", "B": "Leflunomide", "C": "Azathioprine", "D": "Mycophenolate mofetil", "E": "Capecitabine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["54 year old woman", "metastatic", "physician", "follow-up examination", "mastectomy", "months", "received chemotherapy", "doxorubicin", "paclitaxel", "CT scan of", "chest", "new metastases", "lungs", "liver", "Adjuvant", "initiated", "drug", "inhibits", "formation", "deoxythymidine monophosphate", "results", "accumulation", "patient", "to", "folic acid supplementation", "receiving", "drug", "order to prevent", "toxic effects", "drug", "following drugs", "most likely given"]}
{"question": "A 4-year-old boy with a history of cerebral palsy is brought to the neurology clinic by his mother with progressive tightness in the lower extremities. Although the patient has been intermittently undergoing physiotherapy for the past 2 years at a specialized center, the patient’s mother is concerned he cannot yet climb the stairs. The neurologist recommends a different treatment, which involves multiple intramuscular injections of a drug in the muscles of the lower extremities to relieve tightness. The neurologist says this treatment approach is also often used to relieve headaches and reduce facial wrinkles. Which of the following is most likely the mechanism of action of this drug?", "answer": "Blocks the release of acetylcholine", "options": {"A": "Acts as a superantigen", "B": "Stimulates adenylate cyclase", "C": "Reduces neurotransmitter GABA", "D": "Blocks the release of acetylcholine", "E": "Interferes with the 60s ribosomal subunit"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "history", "cerebral palsy", "brought", "neurology clinic", "progressive tightness", "lower extremities", "patient", "physiotherapy", "past", "years", "patients", "climb", "neurologist", "different treatment", "multiple intramuscular injections of", "drug", "muscles of", "lower extremities to relieve tightness", "neurologist", "treatment approach", "often used to relieve headaches", "facial wrinkles", "following", "mechanism of action", "drug"]}
{"question": "A 37-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the physician for a follow-up examination 2 days after an increased blood pressure measurement. She now reports having a headache and visual disturbances for the past 12 hours. Her only medication is a prenatal vitamin. Her temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 164/80 mm Hg. Her blood pressure at her first-trimester prenatal visit was 110/70 mm Hg. Physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.5 g/dL\nPlatelet count 285,000/mm3\nSerum\nCreatinine 1.0 mg/dL\nUrine\nBlood negative\nProtein negative\nWhich of the following is the most likely primary component in the pathogenesis of this patient's condition?\"", "answer": "Abnormal remodeling of spiral arteries", "options": {"A": "Vasogenic cerebral edema", "B": "Increase in circulating plasma volume", "C": "Hyperperfusion of placental tissue", "D": "Abnormal remodeling of spiral arteries", "E": "Overactivation of the coagulation cascade"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "gravida 3", "para 2", "weeks", "estation ", "hysician ", "ollow-up examination    ays ", "ncreased blood pressure  easurement.", "ow  eports ", "eadache ", "isual disturbances ", "ast  2 hours.", "nly  edication ", "renatal vitamin.", "emperature ", "6.", "8.", "ulse ", "0/ in,", "lood pressure ", "0  m Hg.", "lood pressure ", "rimester ", "0  m Hg.", "bnormalities.", "aboratory studies ", "emoglobin  2.5  / latelet count ", "m3  erum Creatinine ", "L  rine  lood  egative  rotein ", "ollowing ", "rimary component ", "athogenesis ", "atient'", "ndition?\""]}
{"question": "Five days after being admitted to the hospital for a scald wound, a 2-year-old boy is found to have a temperature of 40.2°C (104.4°F). He does not have difficulty breathing, cough, or painful urination. He initially presented one hour after spilling a pot of boiling water on his torso while his mother was cooking dinner. He was admitted for fluid resuscitation, nutritional support, pain management, and wound care, and he was progressing well until today. He has no other medical conditions. Other than analgesia during this hospital stay, he does not take any medications. He appears uncomfortable but not in acute distress. His pulse is 150/min, respirations are 41/min, and blood pressure is 90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows uneven, asymmetrical scalding covering his anterior torso in arrow-like patterns with surrounding erythema and purulent discharge. The remainder of the examination shows no abnormalities. His hemoglobin is 13.4 g/dL, platelet count is 200,000/mm3, and leukocyte count is 13,900/mm3. Which of the following is the most appropriate initial pharmacological treatment for this patient?", "answer": "Vancomycin and cefepime", "options": {"A": "Amoxicillin/clavulanic acid and ceftriaxone", "B": "Ampicillin/sulbactam and daptomycin", "C": "Piperacillin/tazobactam and cefepime", "D": "Vancomycin and metronidazole", "E": "Vancomycin and cefepime"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["scald wound", "2 year old boy", "found to", "temperature", "40", "not", "difficulty breathing", "cough", "painful urination", "initially", "one hour", "spilling", "pot", "torso", "dinner", "fluid resuscitation", "nutritional support", "pain management", "wound care", "progressing well", "today", "medical conditions", "Other", "analgesia", "hospital stay", "not", "medications", "appears", "not", "acute distress", "pulse", "min", "respirations", "min", "blood pressure", "90 50 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "99", "asymmetrical scalding covering", "anterior torso", "arrow", "patterns", "surrounding erythema", "purulent discharge", "abnormalities", "hemoglobin", "13.4 g/dL", "platelet count", "200", "mm3", "leukocyte count", "900 mm3", "following", "most appropriate initial pharmacological", "patient"]}
{"question": "A 32-year-old man comes to the physician because of severe burning with urination for the past 3 days. During this period, he has had clear urethral discharge early in the morning. He has no history of serious illness, except for a rash following treatment with erythromycin 20 years ago. The patient takes no medications. He is sexually active with one male and one female partner; they use condoms inconsistently. His younger brother was diagnosed with Crohn disease at the age of 24 years. The patient does not smoke. He drinks one to two beers on weekends. He appears well. Temperature is 36.8°C (98°F), pulse is 75/min, and blood pressure is 135/78 mm Hg. Physical examination shows no abnormalities. Gram stain of a urethral swab shows neutrophils but no organisms. Which of the following is the most likely causal pathogen?", "answer": "Chlamydia trachomatis", "options": {"A": "Neisseria gonorrhoeae", "B": "Adenovirus", "C": "Trichomonas vaginalis", "D": "Chlamydia trachomatis", "E": "Herpes simplex virus\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "of severe burning", "urination", "past", "days", "period", "clear urethral", "morning", "history", "serious illness", "rash following treatment", "erythromycin 20 years", "patient", "medications", "sexually active", "one male", "one female", "use condoms", "diagnosed", "Crohn disease", "age", "years", "patient", "not smoke", "one", "two", "weekends", "appears well", "Temperature", "36", "pulse", "75 min", "blood pressure", "mm Hg", "abnormalities", "Gram stain", "urethral swab", "following", "causal"]}
{"question": "A 62-year-old man presents to the emergency department with confusion. The patient’s wife states that her husband has become more somnolent over the past several days and now is very confused. The patient has no complaints himself, but is answering questions inappropriately. The patient has a past medical history of diabetes and hypertension. His temperature is 98.3°F (36.8°C), blood pressure is 127/85 mmHg, pulse is 138/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a confused man with dry mucous membranes. Initial laboratory studies are ordered as seen below.\n\nSerum:\nNa+: 135 mEq/L\nCl-: 100 mEq/L\nK+: 3.0 mEq/L\nHCO3-: 23 mEq/L\nBUN: 30 mg/dL\nGlucose: 1,299 mg/dL\nCreatinine: 1.5 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the most appropriate initial treatment for this patient?", "answer": "Normal saline and potassium", "options": {"A": "Insulin", "B": "Insulin and normal saline", "C": "Insulin and potassium", "D": "Insulin, normal saline, and potassium", "E": "Normal saline and potassium"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["62 year old man presents", "emergency department", "confusion", "patients", "states", "more somnolent", "past", "days", "now", "very confused", "patient", "complaints", "patient", "past medical diabetes", "hypertension", "temperature", "98", "36", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "confused man", "dry mucous membranes", "Initial laboratory studies", "ordered", "seen", "Serum", "Na", "mEq/L", "100 mEq/L K", "3 0 mEq/L HCO3", "23 mEq/L", "30 mg/dL Glucose", "1", "mg/dL Creatinine", "1.5 mg/dL Ca2", "10", "mg/dL", "following", "most appropriate initial treatment", "patient"]}
{"question": "A 24-year-old woman presents to her gynecologist complaining of mild pelvic discomfort and a frothy, yellowish discharge from her vagina for the past 2 weeks. She also complains of pain during sexual intercourse and sometimes after urination. Her past medical history is noncontributory. She takes oral contraceptives and a multivitamin daily. She has had two male sexual partners in her lifetime and uses condoms inconsistently. Today, her vitals are normal. On pelvic exam, she has vulvovaginal erythema and a 'strawberry cervix' that is tender to motion, with minimal green-yellow malodorous discharge. A swab of the vaginal wall is analyzed for pH at bedside. Vaginal pH is 5.8. Which of the following is the most likely diagnosis for this patient?", "answer": "Trichomoniasis", "options": {"A": "Vulvovaginal candidiasis", "B": "Atrophic vaginitis", "C": "Bacterial vaginosis", "D": "Chlamydia", "E": "Trichomoniasis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "gynecologist", "mild pelvic discomfort", "frothy", "discharge", "vagina", "past 2 weeks", "pain", "sexual intercourse", "sometimes", "urination", "past medical history", "oral contraceptives", "multivitamin daily", "two male", "lifetime", "uses condoms", "Today", "normal", "pelvic exam", "vulvovaginal erythema", "strawberry cervix", "tender", "minimal", "discharge", "swab", "vaginal wall", "pH", "Vaginal pH", "5.8", "following", "diagnosis", "patient"]}
{"question": "A 37-year-old African American man is brought to the emergency department by police. The patient refused to leave a petting zoo after closing. He states that he has unique ideas to revolutionize the petting zoo experience. The patient has a past medical history of multiple suicide attempts. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 100/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient's cardiac and pulmonary exams are within normal limits. He denies any nausea, vomiting, shortness of breath, or systemic symptoms. The patient struggles to answer questions, as he is constantly changing the subject and speaking at a very rapid rate. The patient is kept in the emergency department overnight and is observed to not sleep and is very talkative with the nurses. Which of the following is the best long-term therapy for this patient?", "answer": "Lithium", "options": {"A": "Lithium", "B": "Valproic acid", "C": "Risperidone", "D": "Haloperidol", "E": "Diphenhydramine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "man", "brought", "emergency department", "police", "patient", "to", "closing", "states", "unique", "to", "patient", "past medical multiple suicide attempts", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient's cardiac", "pulmonary exams", "normal limits", "nausea", "vomiting", "shortness of breath", "systemic symptoms", "patient", "to", "constantly changing", "subject", "very rapid rate", "patient", "kept", "emergency department overnight", "observed to not sleep", "very", "nurses", "following", "best long-term therapy", "patient"]}
{"question": "A 55-year-old man presents for physical and preventive health screening, specifically for prostate cancer. He has not been to the doctor in a long time. Past medical history is significant for hypertension that is well-managed. Current medication is hydrochlorothiazide. He has one uncle who died of prostate cancer. He drinks one or two alcoholic drinks on the weekends and does not smoke. Today his temperature is 37.0°C (98.6°F), blood pressure is 125/75 mm Hg, pulse is 82/min, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are no significant findings on physical examination. Which of the following would be the most appropriate recommendation for prostate cancer screening in this patient?", "answer": "Serum PSA level", "options": {"A": "No screening indicated at this time", "B": "Digital rectal examination", "C": "Serum PSA level", "D": "Transrectal ultrasound (TRUS)", "E": "Contrast CT of the abdomen and pelvis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physical", "preventive health screening", "prostate cancer", "not", "doctor", "long time", "Past medical history", "significant", "hypertension", "well", "Current medication", "hydrochlorothiazide", "one", "died of prostate cancer", "one", "two", "weekends", "not smoke", "Today", "temperature", "98", "blood pressure", "75 mm Hg", "pulse", "min", "respiratory rate", "min", "oxygen saturation", "99", "room air", "significant findings", "physical examination", "following", "most appropriate", "for prostate cancer screening", "patient"]}
{"question": "A 3-year-old male is evaluated for frequent nose bleeds. Physical examination shows diffuse petechiae on the patient’s distal extremities. Peripheral blood smear shows an absence of platelet clumping. An ELISA binding assay reveals that platelet surfaces are deficient in GpIIb/IIIa receptors. Which of the following anticoagulants pharmacologically mimics this condition?", "answer": "Abciximab", "options": {"A": "Abciximab", "B": "Aspirin", "C": "Warfarin", "D": "Clopidogrel", "E": "Cilostazol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old male", "frequent nose bleeds", "diffuse petechiae", "patients distal extremities", "Peripheral blood smear", "absence", "platelet clumping", "ELISA", "assay reveals", "surfaces", "deficient", "GpIIb/IIIa receptors", "following anticoagulants", "mimics", "condition"]}
{"question": "A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?", "answer": "Radiograph sacroiliac joint", "options": {"A": "ESR", "B": "HLA-B27", "C": "MRI sacroiliac joint", "D": "Radiograph sacroiliac joint", "E": "Slit-lamp examination"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old man", "lower back pain", "began approximately", "months", "unsure", "pain", "pain", "worse", "morning", "waking", "improves", "Ibuprofen", "significant relief", "bowel", "bladder incontinence", "erectile dysfunction", "notable", "decreased chest expansion", "decreased spinal range of motion", "strength", "lower extremities", "2", "patellar reflexes", "absence", "saddle anesthesia", "following", "most appropriate next test", "patient"]}
{"question": "A genetic population study is being conducted to find the penetrance of a certain disease. This disease is associated with impaired iron metabolism and primarily affects the liver. Patients often present with diabetes and bronze skin pigmentation. After a genetic screening of 120 inhabitants with a family history of this disease, 40 were found to have the disease-producing genotype, but only 10 presented with symptoms. What are the chances of the screened patients with said genotype developing the disease phenotype?\n ", "answer": "25%", "options": {"A": "3%", "B": "25%", "C": "4%", "D": "40%", "E": "0.4%"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["to find", "penetrance", "certain disease", "disease", "associated with impaired", "liver", "Patients often present", "diabetes", "bronze skin pigmentation", "genetic screening", "family history of", "disease", "40", "found to", "disease", "genotype", "only 10", "symptoms", "chances", "screened patients", "genotype", "disease phenotype"]}
{"question": "A previously healthy 9-year-old, Caucasian girl presents to your office with severe abdominal pain. Her mother also mentions that she has been urinating significantly less lately. History from the mother reveals that the girl suffers from acne vulgaris, mild scoliosis, and had a bout of diarrhea 3 days ago after a family barbecue. Lab work is done and is notable for a platelet count of 97,000 with a normal PT and PTT. The young girl appears dehydrated, yet her serum electrolyte levels are normal. What is the most likely etiology of this girl's urinary symptoms?", "answer": "Shiga-like toxin production from EHEC", "options": {"A": "Hypothalamic dysfucntion", "B": "Surreptitious laxative use", "C": "Toxic shock syndrome", "D": "Shiga toxin production from Shigella", "E": "Shiga-like toxin production from EHEC"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old", "girl presents", "office", "severe abdominal", "History", "mother reveals", "girl suffers", "acne vulgaris", "mild scoliosis", "bout", "diarrhea 3 days", "Lab", "notable", "platelet count", "97", "normal PT", "PTT", "young girl appears dehydrated", "serum electrolyte levels", "normal", "etiology", "girl's urinary symptoms"]}
{"question": "A 55-year-old male presents to his primary care physician with right upper quadrant pain that has progressed over the last three months with unexplained weakness and joint pains that have been \"out of the ordinary\" over the last year. On history, you note the patient lives a sedentary lifestyle, rarely leaves the house, has controlled diabetes diagnosed 15 years ago, and has documented cardiomyopathy. On physical exam the man appears non-toxic, sclera are icteric, cornea appear normal, generalized pain is elicited on palpation of the right upper quadrant, and skin appears quite bronzed on his extremities. What is this patient most at risk for ten to fifteen years later due to his underlying condition?", "answer": "Hepatocellular carcinoma", "options": {"A": "Colonic adenocarcinoma", "B": "Pulmonary fibrosis", "C": "Prostatic adenocarcinoma", "D": "Hepatocellular carcinoma", "E": "Movement disorders"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male presents", "primary care physician", "right upper quadrant pain", "progressed", "three months", "unexplained weakness", "joint pains", "last year", "history", "note", "patient lives", "sedentary lifestyle", "rarely", "house", "controlled diabetes diagnosed", "years", "cardiomyopathy", "man appears non toxic", "sclera", "icteric", "cornea appear normal", "generalized pain", "elicited", "palpation", "right upper quadrant", "skin appears", "bronzed", "extremities", "patient most", "ten", "fifteen years later due to", "underlying condition"]}
{"question": "A 6-month-old girl has a weak cry, poor suck, ptosis, and constipation. Her condition began 2 days ago with a single episode of abundant watery stool and elevated temperature. The child was born at term to a healthy 26-year-old mother with an uneventful antenatal course and puerperium. The infant was exclusively breastfed till 5 months of age, after which she began receiving grated potatoes, pumpkin, carrots, and apples, in addition to the breastfeeding. She does not receive any fluids other than breast milk. The last new food item to be introduced was homemade honey that her mother added several times to grated sour apples as a sweetener 2 weeks before the onset of symptoms. The vital signs are as follows: blood pressure 70/40 mm Hg, heart rate 98/min, respiratory rate 29/min, and temperature 36.4°C (98.2°F). On physical examination, she is lethargic and has poor head control. A neurologic examination reveals ptosis and facial muscle weakness, widespread hypotonia, and symmetrically decreased upper and lower extremity reflexes. Which of the following options is a part of the pathogenesis underlying the patient’s condition?", "answer": "Vegetative form of Clostridium botulinum spores in the patient's colon", "options": {"A": "Hypocalcemia due to a decrease in breast milk consumption", "B": "Hyperkalemia due to increased dietary intake", "C": "Vegetative form of Clostridium botulinum spores in the patient's colon", "D": "Dehydration due to the absence of additional fluid intake", "E": "Development of antibodies against the acetylcholine receptor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old girl", "weak cry", "poor suck", "ptosis", "constipation", "condition began 2 days", "single episode of abundant watery stool", "elevated temperature", "child", "born", "term", "healthy", "year old", "antenatal course", "puerperium", "infant", "breastfed", "months", "age", "began receiving", "potatoes", "pumpkin", "breastfeeding", "not receive", "fluids", "breast milk", "last new food", "to", "introduced", "added several times", "sour", "sweetener 2 weeks", "onset", "symptoms", "vital signs", "follows", "blood pressure 70 40 mm Hg", "heart rate 98 min", "respiratory rate 29 min", "temperature 36", "98", "lethargic", "poor head control", "neurologic examination reveals ptosis", "facial muscle weakness", "widespread hypotonia", "decreased upper", "lower extremity reflexes", "following options", "part of", "pathogenesis", "patients condition"]}
{"question": "A 16-year-old male comes to his doctor worried that he has not yet gone through puberty. He feels that his genitals are less developed than they should be for his age. On physical exam, you note an absence of facial hair and that his voice has not yet deepened. Your exam confirms that he is Tanner Stage 1. On a thorough review of systems, you learn that the patient has lacked a sense of smell from birth. Which of the following is implicated in the development of this patient's underlying condition?", "answer": "Failure of normal neuronal migration during development", "options": {"A": "Chromosomal duplication", "B": "Expansile suprasellar tumor", "C": "Exposure to radiation", "D": "Failure of normal neuronal migration during development", "E": "Defect in steroid production"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male", "doctor worried", "not", "puberty", "genitals", "less", "age", "note", "absence", "facial hair", "voice", "not", "exam confirms", "Tanner", "review of systems", "patient", "lacked", "sense of smell", "birth", "following", "development", "patient's", "condition"]}
{"question": "A 43-year-old woman presents to a physician with weakness and fatigue for a week. She mentions that she has been taking oral fluconazole for the last 4 weeks for the treatment of tinea capitis. She also says that she loves coffee and usually consumes 4–6 cups of coffee every day. On physical examination, her vital signs are stable and examination of all systems, including nervous system, is normal. Her laboratory evaluation reveals that her serum potassium level is 3.1 mmol/L (3.1 mEq/L). The physician orders an ECG. Which of the following findings is most likely to be present?", "answer": "Depression of ST segment", "options": {"A": "Widening of QRS complexes", "B": "Tall peaked T waves", "C": "Disappearing P waves", "D": "Depression of ST segment", "E": "Shortened QT interval"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "physician", "weakness", "fatigue", "week", "oral fluconazole", "weeks", "treatment", "tinea capitis", "usually", "cups", "day", "vital signs", "stable", "systems", "including nervous system", "normal", "laboratory", "reveals", "serum potassium level", "3.1 mmol/L", "3.1 mEq/L", "physician orders", "ECG", "following findings", "to", "present"]}
{"question": "A 4-month-old girl is brought to the physician because she has been regurgitating and vomiting 10–15 minutes after feeding for the past 3 weeks. She is breastfed and formula-fed. She was born at 38 weeks' gestation and weighed 2966 g (6 lb 9 oz). She currently weighs 5878 g (12 lb 15 oz). She appears healthy. Vital signs are within normal limits. Examination shows a soft and nontender abdomen and no organomegaly. Which of the following is the most appropriate next best step in management?", "answer": "Positioning therapy", "options": {"A": "Esophageal pH monitoring", "B": "Upper endoscopy", "C": "Ultrasound of the abdomen", "D": "Pantoprazole therapy", "E": "Positioning therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 month old girl", "brought", "physician", "regurgitating", "vomiting", "minutes", "past", "weeks", "breastfed", "formula fed", "born", "weeks", "gestation", "g", "oz", "currently", "g", "oz", "appears healthy", "Vital signs", "normal limits", "soft", "nontender abdomen", "organomegaly", "following", "most appropriate next best step"]}
{"question": "A 44-year-old man presents to his primary care physician due to a tremor. His tremor has been progressively worsening over the course of several weeks and he feels embarrassed and anxious about going to social events. He says these movements are involuntary and denies having an urge to have these movements. Medical history is significant for depression which is being treated with escitalopram. His mother is currently alive and healthy but his father committed suicide and had a history of depression. Physical examination is remarkable for impaired saccade initiation and brief, abrupt, and non-stereotyped movements involved the right arm. He also has irregular finger tapping. Which of the following is the best treatment for this patient's symptoms?", "answer": "Deutetrabenazine", "options": {"A": "Carbidopa-levodopa", "B": "Cognitive behavioral therapy", "C": "Deutetrabenazine", "D": "Switch to sertraline", "E": "Valproic acid"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care physician", "tremor", "tremor", "worsening", "course", "weeks", "embarrassed", "anxious", "movements", "to", "movements", "Medical history", "significant", "depression", "treated with escitalopram", "currently alive", "healthy", "committed suicide", "history of depression", "impaired saccade initiation", "brief", "abrupt", "non stereotyped movements involved", "right arm", "irregular finger tapping", "following", "best treatment", "patient's symptoms"]}
{"question": "A 65-year-old man presents to the emergency department by ambulance following a motor vehicle accident. He was a restrained passenger. At the hospital, he is bleeding heavily from a large wound in his left leg. A review of medical records reveals a history of atrial fibrillation for which he takes warfarin. His international normalized ratio (INR) 2 days ago was 2.6. On physical exam he is cool and clammy. The vital signs include: heart rate 130/min and blood pressure 96/54 mm Hg. Aggressive resuscitation with intravenous normal saline is begun. Which of the following is the next best step to correct this patient's underlying coagulopathy?", "answer": "Give fresh frozen plasma (FFP)", "options": {"A": "Give cryoprecipitate", "B": "Give fresh frozen plasma (FFP)", "C": "Give intravenous vitamin K", "D": "Give packed red blood cells", "E": "Give platelets"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "emergency department", "ambulance following", "motor vehicle accident", "restrained", "hospital", "bleeding", "large wound", "left leg", "reveals", "history of atrial fibrillation", "warfarin", "international normalized ratio", "days", "2.6", "cool", "clammy", "vital signs include", "heart rate", "min", "blood pressure 96 54 mm Hg", "Aggressive resuscitation", "intravenous normal", "begun", "following", "next best step to correct", "patient's", "coagulopathy"]}
{"question": "A 32-year-old woman comes to the physician because of worsening fatigue and shortness of breath. Her symptoms began 8 months ago and have progressively worsened since then. She had recurrent episodes of joint pain and fever during childhood. She does not smoke or drink alcohol. She emigrated from the Congo with her parents when she was 12 years old. Her temperature is 37.4°C (99.3°F), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 140/90 mm Hg. There is an opening snap followed by a diastolic murmur at the fifth left intercostal space in the midclavicular line. If left untreated, this patient is at greatest risk for which of the following complications?", "answer": "Esophageal compression", "options": {"A": "Nephritic syndrome", "B": "Esophageal compression", "C": "Bleeding from intestinal angiodysplasia", "D": "Left ventricular hypertrophy", "E": "Ventricular tachycardia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "worsening fatigue", "shortness of breath", "symptoms began", "months", "worsened since then", "recurrent episodes of joint pain", "fever", "childhood", "not smoke", "Congo", "years old", "temperature", "99", "pulse", "90 min", "regular", "respirations", "min", "blood pressure", "90 mm Hg", "opening snap followed by", "diastolic murmur", "fifth left intercostal space", "midclavicular line", "left untreated", "patient", "greatest", "following complications"]}
{"question": "A 2-day-old boy is evaluated in the newborn nursery after the nurse witnessed the child convulsing. The child was born at 39 weeks gestation to a healthy 32-year-old G1P0 woman. Initial examination after birth was notable for a cleft palate. The child’s temperature is 99°F (37.2°C), blood pressure is 100/60 mmHg, pulse is 115/min, and respirations are 18/min. On exam, he appears somnolent. His face demonstrates periorbital fullness, hypoplastic nares, and small dysmorphic ears. A series of labs are drawn and shown below:\n\nHemoglobin: 13.1 g/dL\nHematocrit: 40%\nLeukocyte count: 4,000/mm^3 with normal differential\nPlatelet count: 200,000/mm^3\n\nSerum:\nNa+: 140 mEq/L\nCl-: 100 mEq/L\nK+: 3.8 mEq/L\nHCO3-: 25 mEq/L\nBUN: 19 mg/dL\nGlucose: 110 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 7.9 mg/dL\nPhosphate: 4.7 mg/dL\n\nThis patient is deficient in a hormone that has which of the following functions?", "answer": "Activates 1-alpha-hydroxylase", "options": {"A": "Activates 1-alpha-hydroxylase", "B": "Activates 24-alpha-hydroxylase", "C": "Activates 25-alpha-hydroxylase", "D": "Inhibits 1-alpha-hydroxylase", "E": "Inhibits 25-alpha-hydroxylase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2-day old boy", "newborn nursery", "nurse", "child convulsing", "child", "born", "weeks gestation", "healthy", "year old", "woman", "Initial", "after birth", "notable", "cleft palate", "childs temperature", "blood pressure", "100 60 mmHg", "pulse", "min", "respirations", "min", "exam", "appears somnolent", "face", "periorbital fullness", "hypoplastic nares", "small dysmorphic ears", "series", "labs", "Hemoglobin", "g/dL Hematocrit", "40", "Leukocyte count", "4", "mm", "normal differential Platelet count", "200", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "3", "mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1 0 mg/dL Ca2", "dL Phosphate", "4", "mg/dL", "patient", "deficient", "hormone", "following functions"]}
{"question": "A 65-year-old female with chronic renal failure presents with recent onset of bone pain. Serum analysis reveals decreased levels of calcium and elevated levels of parathyroid hormone. One of the mechanisms driving the elevated PTH is most similar to that seen in:", "answer": "End stage liver failure", "options": {"A": "End stage liver failure", "B": "Insufficient Ca intake", "C": "Parathyroid adenoma", "D": "Decreased functioning of the calcium-sensing receptor (CASR)", "E": "Sarcoidosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65-year-old female", "chronic renal failure presents", "recent onset", "bone", "Serum analysis reveals decreased levels", "calcium", "elevated levels", "parathyroid hormone", "One", "mechanisms", "elevated", "most similar", "seen"]}
{"question": "A 41-year-old woman with subclinical hypothyroidism comes to the physician because of a 6-month history of progressively worsening headaches and irregular menses. Her menses had previously occurred at regular 30-day intervals with moderate flow, but her last menstrual period was 12 weeks ago. She also reports that her interest in sexual intercourse has recently decreased. Her serum prolactin level is elevated. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Bromocriptine", "options": {"A": "Bromocriptine", "B": "Estrogen", "C": "Methyldopa", "D": "Metoclopromide", "E": "L-thyroxine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "subclinical hypothyroidism", "physician", "of", "month history", "worsening headaches", "irregular menses", "menses", "regular 30 day intervals", "moderate", "last menstrual period", "weeks", "reports", "interest", "sexual", "recently decreased", "serum prolactin level", "elevated", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 17-year-old boy presents to the office with allergic rhinitis. He reports symptoms of sneezing, nasal congestion, itching, and postnasal drainage every September at the start of the school year. He has a family history of childhood asthma and eczema. He has not tried any medications for his allergies. Which of the following medications is the most appropriate next step to manage the patient's symptoms?", "answer": "Intranasal corticosteroids", "options": {"A": "Intranasal antihistamines", "B": "Intranasal cromolyn sodium", "C": "Intranasal decongestants", "D": "Intranasal corticosteroids", "E": "Oral antihistamines"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "office", "allergic rhinitis", "reports symptoms", "sneezing", "nasal congestion", "itching", "postnasal drainage", "September", "start", "school year", "family history of childhood asthma", "eczema", "not", "medications", "allergies", "following medications", "most appropriate next step to", "patient's symptoms"]}
{"question": "A 30-year-old woman comes to the emergency department because of fever, watery diarrhea, and abdominal cramping for the past 24 hours. She recently went to an international food fair. Her temperature is 39°C (102.2°F). Physical examination shows increased bowel sounds. Stool cultures grow gram-positive, spore-forming, anaerobic rods that produce alpha toxin. The responsible organism also causes which of the following physical examination findings?", "answer": "Subcutaneous crepitus", "options": {"A": "Diffuse, flaccid bullae", "B": "Facial paralysis", "C": "Subcutaneous crepitus", "D": "Rose spots", "E": "Petechial rash"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old woman", "emergency department", "fever", "watery diarrhea", "abdominal cramping", "past 24 hours", "recently", "food fair", "temperature", "increased bowel sounds", "Stool cultures", "anaerobic", "alpha toxin", "responsible", "causes", "following physical examination findings"]}
{"question": "A 24-year-old woman comes to the physician for preconceptional advice. She has been married for 2 years and would like to conceive within the next year. Menses occur at regular 30-day intervals and last 4 days with normal flow. She does not smoke or drink alcohol and follows a balanced diet. She takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 55 kg (121 lb); BMI is 21.5 kg/m2. Physical examination, including pelvic examination, shows no abnormalities. She has adequate knowledge of the fertile days of her menstrual cycle. Which of the following is most appropriate recommendation for this patient at this time?", "answer": "Begin folate supplementation", "options": {"A": "Begin folate supplementation", "B": "Begin high-dose vitamin A supplementation", "C": "Begin vitamin B12 supplementation", "D": "Begin iron supplementation", "E": "Gain 2 kg prior to conception"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "married", "years", "to", "next year", "Menses occur", "regular 30 day intervals", "last 4 days", "normal", "not smoke", "follows", "balanced diet", "medications", "5 ft", "tall", "kg", "BMI", "kg/m2", "including pelvic examination", "abnormalities", "adequate knowledge", "fertile days", "menstrual cycle", "following", "most appropriate", "patient", "time"]}
{"question": "A 34-year-old woman with a history of depression is brought to the emergency department by her husband 45 minutes after ingesting an unknown amount of a termite poison in a suicide attempt. She has abdominal pain, nausea, and vomiting. Her husband reports that she has had two episodes of watery diarrhea on the way to the emergency department. A distinct, garlic-like odor on the breath is noted on examination. An ECG shows sinus tachycardia and QTc prolongation. Administration of which of the following is most appropriate?", "answer": "Dimercaprol", "options": {"A": "N-acetylcysteine", "B": "Fomepizole", "C": "Deferoxamine", "D": "Physostigmine", "E": "Dimercaprol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "history of depression", "brought", "emergency department", "45 minutes", "unknown amount", "poison", "suicide attempt", "abdominal pain", "nausea", "vomiting", "reports", "two episodes of watery diarrhea", "emergency department", "garlic", "odor", "breath", "noted", "ECG", "sinus tachycardia", "QTc prolongation", "Administration", "following", "most appropriate"]}
{"question": "A 30-year-old patient comes to the emergency room with a chief complaint of left chest pain and a productive cough with purulent sputum for 1 week. He also complains of shortness of breath. He said he had been previously diagnosed with influenza but did not follow the doctor’s instructions. His vitals include: heart rate 70/min, respiratory rate 22/min, temperature 38.7°C (101.7°F), blood pressure 120/60 mm Hg, and SO2 80%. His hemogram and chest X-ray findings are as follows:\nHemoglobin 14 mg/dL\nHematocrit 45%\nLeukocyte count 12,000/mm3\nNeutrophils 82%\nLymphocytes 15%\nMonocytes 3%\nPlatelet count 270,000/mm3\nChest X-ray alveolar infiltrates in the left base with air bronchograms\nWhat is the most likely diagnosis?", "answer": "Pneumonia", "options": {"A": "Sarcoidosis", "B": "Pneumonia", "C": "Histoplasmosis", "D": "Lung cancer", "E": "Tuberculosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old patient", "emergency room", "chief complaint of left chest pain", "productive cough", "purulent sputum", "1 week", "of shortness", "breath", "diagnosed", "influenza", "not follow", "doctors instructions", "include", "heart rate 70 min", "respiratory rate", "min", "temperature", "blood pressure", "60 mm Hg", "SO2 80", "hemogram", "chest X-ray findings", "follows", "Hemoglobin", "mg/dL Hematocrit", "Leukocyte count", "mm3", "Lymphocytes", "Monocytes", "Chest X-ray", "infiltrates", "left base", "air bronchograms", "diagnosis"]}
{"question": "While playing in the woods with friends, a 14-year-old African-American male is bitten by an insect. Minutes later he notices swelling and redness at the site of the insect bite. Which substance has directly led to the wheal formation?", "answer": "Histamine", "options": {"A": "IFN-gamma", "B": "Histamine", "C": "IL-22", "D": "Arachidonic acid", "E": "IL-4"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["playing", "woods", "year old", "male", "bitten", "insect", "Minutes later", "swelling", "redness", "site of", "insect bite", "directly led", "wheal formation"]}
{"question": "A 76-year-old male with a history of chronic uncontrolled hypertension presents to the emergency room following an episode of syncope. He reports that he felt lightheaded and experienced chest pain while walking his dog earlier in the morning. He notes that he has experienced multiple similar episodes over the past year. A trans-esophageal echocardiogram demonstrates a thickened, calcified aortic valve with left ventricular hypertrophy. Which of the following heart sounds would likely be heard on auscultation of this patient?", "answer": "Crescendo-decrescendo murmur radiating to the carotids that is loudest at the right upper sternal border", "options": {"A": "Diastolic rumble following an opening snap with an accentuated S1", "B": "Early diastolic high-pitched blowing decrescendo murmur that is loudest at the left sternal border", "C": "Crescendo-decrescendo murmur radiating to the carotids that is loudest at the right upper sternal border", "D": "Holosystolic murmur radiating to the axilla that is loudest at the apex", "E": "Midsystolic click that is most prominent that is loudest at the apex"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["76 year old male", "history of chronic uncontrolled hypertension presents", "emergency room following", "episode of syncope", "reports", "lightheaded", "chest pain", "earlier", "morning", "notes", "multiple similar episodes", "past year", "trans-esophageal echocardiogram", "thickened", "calcified aortic valve", "left ventricular hypertrophy", "following heart sounds", "likely", "heard", "auscultation", "patient"]}
{"question": "A 43-year-old Caucasian male spent the past month on a business trip in the Caribbean. Two weeks following his return, he began experiencing diarrhea, pain in his abdomen, and a headache. He presents to the hospital and is noted to be febrile with prominent rose-colored spots on his chest and abdomen. Following recovery, the patient may become a carrier of the bacteria with the bacteria heavily localized to the:", "answer": "Gallbladder", "options": {"A": "Gallbladder", "B": "Spleen", "C": "CD4 T-helper cells", "D": "Lungs", "E": "Sensory ganglia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male spent", "past month", "business trip", "Caribbean", "Two weeks following", "return", "began", "diarrhea", "pain", "abdomen", "headache", "presents", "hospital", "noted to", "febrile", "prominent rose colored spots", "chest", "abdomen", "Following recovery", "patient", "carrier", "bacteria", "bacteria", "localized"]}
{"question": "A clinical study is studying new genetic gene-based therapies for children and adults with sickle cell disease. The patients were informed that they were divided into two age groups since younger patients suffer from different complications of the disease. The pediatric group is more likely to suffer from which of the complications?\nI. Splenic sequestration\nII. Avascular necrosis\nIII. Pulmonary hypertension\nIV. Acute chest syndrome\nV. Nephropathy", "answer": "I, IV", "options": {"A": "I, II", "B": "I, IV, V", "C": "I, II, IV", "D": "III, IV", "E": "I, IV"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["studying new genetic", "based therapies", "children", "adults", "sickle cell disease", "patients", "informed", "divided", "two age groups", "younger patients suffer", "different complications of", "disease", "pediatric group", "more likely to suffer", "complications", "I", "Splenic", "necrosis", "Pulmonary IV", "Acute chest syndrome", "Nephropathy"]}
{"question": "A 21-year-old Cambodian patient with a history of rheumatic heart disease presents to his primary care physician for a routine check-up. He reports being compliant with monthly penicillin G injections since being diagnosed with rheumatic fever at age 15. He denies any major side effects from the treatment, except for the inconvenience of organizing transportation to a physician's office every month. On exam, the patient is found to have a loud first heart sound and a mid-diastolic rumble that is best heard at the apex. Which of the following is the next best step?", "answer": "Continue intramuscular penicillin therapy", "options": {"A": "Stop penicillin therapy", "B": "Stop penicillin therapy in 4 years", "C": "Decrease frequency of injections to bimonthly", "D": "Switch to intramuscular cefotaxime, which has fewer side effects", "E": "Continue intramuscular penicillin therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["21-year-old", "patient", "history", "rheumatic heart disease presents", "primary care physician", "routine check-up", "reports", "compliant", "monthly", "diagnosed", "rheumatic fever", "age", "major side effects", "treatment", "except for", "organizing transportation", "physician's office", "month", "exam", "patient", "found to", "loud first heart sound", "mid diastolic rumble", "best heard", "apex", "following", "next best step"]}
{"question": "A 56-year-old woman presents to the emergency department with muscle weakness. She reports her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities. She also notices increased urinary frequency. Approximately 1 month ago she was diagnosed with a calcium phosphate nephrolithiasis. Medical history is significant for rheumatoid arthritis diagnosed approximately 10 years ago treated with methotrexate, and type II diabetes mellitus treated with metformin. Her temperature is 98.6°F (37°C), blood pressure is 138/92 mmHg, pulse is 92/min, and respirations are 17/min. On physical exam, there is mild tenderness to palpation of the metacarpophalangeal and proximal interphalangeal joints. There is 4/5 power throughout the lower extremity. Laboratory testing is shown.\n\nSerum:\nNa+: 137 mEq/L\nCl-: 106 mEq/L\nK+: 2.9 mEq/L\nHCO3-: 18 mEq/L\nGlucose: 115 mg/dL\nCreatinine: 1.0 mg/dL\nUrine pH: 5.6\n\nWhich of the following is the best next step in management?", "answer": "Administer intravenous sodium bicarbonate", "options": {"A": "Administer hydrochlorothiazide", "B": "Administer intravenous insulin", "C": "Administer intravenous sodium bicarbonate", "D": "Begin potassium replacement therapy with dextrose", "E": "Increase the methotrexate dose"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "muscle weakness", "reports", "symptoms", "worsened", "course", "2 weeks", "most significant", "lower extremities", "increased urinary frequency", "Approximately", "month", "diagnosed", "calcium phosphate nephrolithiasis", "Medical history", "significant", "rheumatoid arthritis diagnosed approximately", "treated with methotrexate", "type II diabetes mellitus treated with metformin", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "mild tenderness", "palpation", "proximal interphalangeal joints", "4/5 power", "lower extremity", "Laboratory testing", "Serum", "Na", "137 mEq L", "mEq/L K", "2.9 mEq/L HCO3", "mEq/L Glucose", "mg/dL Creatinine", "1 0 mg/dL Urine pH", "5.6", "following", "best next step"]}
{"question": "A 32-year-old woman comes to the office for a regular follow-up. She was diagnosed with type 2 diabetes mellitus 4 years ago. Her last blood test showed a fasting blood glucose level of 6.6 mmol/L (118.9 mg/dL) and HbA1c of 5.1%. No other significant past medical history. Current medications are metformin and a daily multivitamin. No significant family history. The physician wants to take her blood pressure measurements, but the patient states that she measures it every day in the morning and in the evening and even shows him a blood pressure diary with all the measurements being within normal limits. Which of the following statements is correct?", "answer": "The physician has to measure the patient’s blood pressure because it is a standard of care for any person with diabetes mellitus who presents for a check-up.", "options": {"A": "The physician should not measure the blood pressure in this patient and should simply make a note in a record showing the results from the patient’s diary.", "B": "The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.", "C": "The physician has to measure the patient’s blood pressure because it is a standard of care for any person with diabetes mellitus who presents for a check-up.", "D": "The physician should not measure the blood pressure in this patient because the local standards of care in the physician’s office differ from the national standards of care so measurements of this patient’s blood pressure can not be compared to diabet", "E": "Assessment of blood pressure only needs to be done at the initial visit; it is not necessary to measure blood pressure in this patient at any follow-up appointments."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "office", "regular follow-up", "diagnosed", "type 2 diabetes mellitus", "years", "last blood test", "fasting blood glucose level", "mmol", "mg/dL", "significant past medical history", "Current medications", "metformin", "daily multivitamin", "significant family history", "physician", "to", "patient states", "measures", "day", "morning", "evening", "blood pressure", "measurements", "normal limits", "following", "correct"]}
{"question": "A 72-year-old woman is brought to the emergency department for right hip pain 1 hour after she fell while walking around in her house. She has been unable to stand or walk since the fall. She has hypertension and gout. Her sister died of multiple myeloma at the age of 55 years. Current medications include amlodipine and febuxostat. She does not smoke cigarettes. She drinks a glass of wine daily. Her temperature is 37.3°C (99.1°F), pulse is 101/min, and blood pressure is 128/86 mm Hg. Examination shows right groin tenderness. Range of motion of the right hip is limited by pain. The remainder of the examination shows no abnormalities. A complete blood count and serum creatinine concentration are within the reference range. An x-ray of the hip shows a linear fracture of the right femoral neck. She is scheduled for surgery. Which of the following is the most likely underlying cause of this patient's fracture?", "answer": "Reduced osteoblastic activity", "options": {"A": "Reduced osteoblastic activity", "B": "Monoclonal antibody production", "C": "Interrupted vascular supply", "D": "Impaired bone mineralization", "E": "Defective osteoclast function"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "right hip pain", "hour", "fell", "house", "unable to stand", "fall", "hypertension", "gout", "died", "multiple myeloma", "age", "years", "Current medications include amlodipine", "febuxostat", "not smoke cigarettes", "glass", "daily", "temperature", "99", "pulse", "min", "blood pressure", "mm Hg", "right", "Range of motion", "hip", "limited", "pain", "abnormalities", "complete blood count", "serum concentration", "reference range", "x-ray", "hip", "linear fracture", "right femoral neck", "scheduled", "surgery", "following", "underlying cause", "patient's fracture"]}
{"question": "A 47-year-old man presents as a new patient at an outpatient clinic. He has never seen a physician before, but was motivated by his 40-year-old brother's recent heart attack and seeks to optimize his health. In particular, he read that uncontrolled atherosclerosis can lead to a heart attack. Which molecule is downregulated in response to the advent of atherosclerosis?", "answer": "Nitric oxide", "options": {"A": "Serotonin", "B": "Thromboxane A2", "C": "Nitric oxide", "D": "Interleukin 1", "E": "Tumor necrosis factor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "new patient", "outpatient clinic", "never seen", "physician", "40 year old", "recent heart attack", "to", "uncontrolled atherosclerosis", "lead", "heart attack", "response", "atherosclerosis"]}
{"question": "A newborn is brought to the emergency department by his parents with violent vomiting. It started about 3 days ago and has slowly gotten worse. He vomits after most feedings but seems to keep some formula down. His mother notes that he is eager to feed between episodes and seems to be putting on weight. Other than an uncomplicated course of chlamydia conjunctivitis, the infant has been healthy. He was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. The physical exam is significant for a palpable mass in the right upper quadrant. What is the first-line confirmatory diagnostic test and associated finding?", "answer": "Abdominal ultrasound; elongated pyloric channel and muscle hypertrophy", "options": {"A": "Abdominal X-ray; ‘double bubble’ sign", "B": "Barium upper GI series; GE junction and portion of the stomach in thorax", "C": "Barium upper GI series; bird beak sign and corkscrewing", "D": "Air enema; filling defect and coil spring sign", "E": "Abdominal ultrasound; elongated pyloric channel and muscle hypertrophy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["newborn", "brought", "emergency department", "parents", "violent vomiting", "started", "3 days", "slowly gotten worse", "vomits", "to keep", "formula", "notes", "to", "episodes", "to", "putting", "weight", "Other", "uncomplicated course", "chlamydia conjunctivitis", "infant", "healthy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "significant", "palpable mass", "right upper quadrant", "first line confirmatory diagnostic test", "associated finding"]}
{"question": "A 32-year-old pregnant woman presents to the clinic with complaints of cramping, abdominal pain, and severe watery diarrhea for the past 3 days. She also is nauseous and complains of fever and malaise. She was started on a 7-day course of amoxicillin after being admitted to the hospital for pyelonephritis 5 days ago. The vital signs include heart rate 98/min, respiratory rate 16/min, temperature 38.9°C (102.0°F), and blood pressure 92/56 mm Hg. Physical examination reveals abdominal distention with diffuse tenderness. Laboratory studies show a peripheral white blood cell (WBC) count of 15,000/mm3 and stool guaiac positive for occult blood. Which of the following is the best pharmacotherapy for her condition?", "answer": "Oral vancomycin", "options": {"A": "Metronidazole", "B": "Rifaximin", "C": "IV metronidazole plus oral vancomycin", "D": "Oral vancomycin", "E": "Oral nitazoxanide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "clinic", "complaints", "cramping", "abdominal pain", "severe watery diarrhea", "past 3 days", "nauseous", "fever", "malaise", "started", "7-day course", "amoxicillin", "pyelonephritis", "days", "vital signs include heart rate 98 min", "respiratory rate", "min", "temperature", "blood pressure", "mm Hg", "reveals abdominal", "diffuse tenderness", "Laboratory studies", "peripheral white", "count", "mm3", "stool guaiac positive", "occult blood", "following", "best pharmacotherapy", "condition"]}
{"question": "A 26-year-old woman (gravida 3 para 1) with no prenatal care delivers a boy at 37 weeks gestation. His Apgar score is 5 at 1 minute and 8 at 5 minutes. His weight is 2.1 kg (4.2 lb) and length is 47 cm (1 ft 7 in). The mother’s history is significant for chronic pyelonephritis, atrial fibrillation, and gastroesophageal reflux disease. She has a 5-pack-year smoking history and also reports alcohol consumption during pregnancy. Examination of the infant shows a short depressed nasal bridge, wide nose, brachydactyly, and a short neck. Ophthalmoscopy reveals bilateral cataracts. What is the most likely cause of the newborn’s symptoms?", "answer": "Warfarin", "options": {"A": "Omeprazole", "B": "Gentamicin", "C": "Alcohol", "D": "Atenolol", "E": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "gravida 3 para 1", "delivers", "boy", "weeks gestation", "Apgar score", "5", "minute", "5 minutes", "weight", "2.1 kg", "4.2", "length", "1 ft 7", "mothers history", "significant", "chronic pyelonephritis", "atrial fibrillation", "gastroesophageal reflux disease", "5 year smoking history", "reports alcohol consumption during pregnancy", "infant", "short depressed", "wide nose", "brachydactyly", "short neck", "Ophthalmoscopy reveals bilateral cataracts", "most likely cause", "newborns symptoms"]}
{"question": "An 8-year-old girl is brought to the physician because of repetitive involuntary movements, including neck twisting, grimacing, grunting, and blinking, for the past 18 months. Her symptoms seem to improve with concentration and worsen with fatigue. During the past 3 months, they have become so severe that she has missed many school days. Her mother says she also has too much anxiety about her involuntary movements to see her friends and prefers staying home in her room. Her birth and development until 18 months ago were normal. Her father suffers from bipolar disorder. Vital signs are within normal limits. Mental status examination shows intact higher mental function and thought processes. Neurological examination shows multiple motor and vocal tics. Physical examination is otherwise within normal limits. Which of the following is the most appropriate initial pharmacotherapy for this condition?", "answer": "Risperidone", "options": {"A": "Buspirone", "B": "Alprazolam", "C": "Risperidone", "D": "Fluoxetine", "E": "Chlorpromazine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "repetitive involuntary movements", "including neck twisting", "grimacing", "blinking", "past", "months", "symptoms", "to", "concentration", "worsen", "fatigue", "past 3 months", "so severe", "missed", "school days", "anxiety", "involuntary movements to see", "home", "room", "birth", "development", "months", "normal", "suffers", "bipolar disorder", "Vital signs", "normal", "Mental", "intact higher", "Neurological examination", "multiple motor", "vocal tics", "normal limits", "following", "most appropriate initial pharmacotherapy", "condition"]}
{"question": "A 55-year-old man presents to his primary care provider with increased urinary frequency. Over the past 3 months, he has been urinating 2-3 times more often than usual. He has started to feel dehydrated and has increased his water intake to compensate. He works as a bank teller. He has a 25-pack-year smoking history and drinks 8-10 beers per week. His temperature is 98°F (36.8°C), blood pressure is 114/68 mmHg, pulse is 100/min, and respirations are 18/min. Capillary refill is 3 seconds. His mucous membranes appear dry. The patient is instructed to hold all water intake. Urine specific gravity is 1.002 after 12 hours of water deprivation. The patient is given desmopressin but his urine specific gravity remains relatively unchanged. Which of the following is the most appropriate pharmacologic treatment for this patient's condition?", "answer": "Metolazone", "options": {"A": "Desmopressin", "B": "Furosemide", "C": "Mannitol", "D": "Metolazone", "E": "Spironolactone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care provider", "increased urinary frequency", "past 3 months", "2-3 times", "often", "usual", "started to", "dehydrated", "increased", "water intake to compensate", "bank teller", "smoking history", "8-10", "week", "temperature", "36", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "min", "Capillary refill", "3 seconds", "mucous membranes appear dry", "patient", "to hold", "water intake", "Urine specific gravity", "1", "12 hours of water deprivation", "patient", "given desmopressin", "urine specific gravity", "unchanged", "following", "most appropriate pharmacologic treatment", "patient's condition"]}
{"question": "A 17-year-old boy comes to the physician because of a nonpruritic rash on his chest for 1 week. He returned from a trip to Puerto Rico 10 days ago. He started using a new laundry detergent after returning. He has type 1 diabetes mellitus controlled with insulin. His mother has Hashimoto thyroiditis, and his sister has severe facial acne. Examination of the skin shows multiple, nontender, round, hypopigmented macules on the chest and trunk. There is fine scaling when the lesions are scraped with a spatula. Which of the following is the most likely underlying mechanism of this patient's symptoms?", "answer": "Increased growth of Malassezia globosa", "options": {"A": "Autoimmune destruction of melanocytes", "B": "Increased sebum production", "C": "Increased growth of Malassezia globosa", "D": "Antigen uptake by Langerhans cells", "E": "Infection with Trichophyton rubrum"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "physician", "of", "nonpruritic rash", "chest", "1 week", "returned", "trip", "Puerto Rico 10 days", "started using", "new", "returning", "type 1 diabetes mellitus controlled", "insulin", "Hashimoto thyroiditis", "severe facial acne", "Examination of", "skin", "multiple", "nontender", "round", "hypopigmented macules", "chest", "trunk", "fine scaling", "lesions", "scraped", "spatula", "following", "underlying mechanism", "patient's symptoms"]}
{"question": "A pharmaceutical company conducts a randomized clinical trial in an attempt to show that their new anticoagulant drug prevents more thrombotic events following total knee arthroplasty than the current standard of care. However, a significant number of patients are lost to follow-up or fail to complete treatment according to the study arm to which they were assigned. Several patients in the novel drug arm are also switched at a later time to a novel anticoagulant or warfarin per their primary care physician. All patients enrolled in the study are subsequently analyzed based on the initial group they were assigned to and there is a significant improvement in outcome of the new drug. What analysis most appropriately describes this trial?", "answer": "Intention to treat", "options": {"A": "As treated", "B": "Intention to treat", "C": "Modified intention to treat", "D": "Non-inferiority", "E": "Per protocol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["to", "new anticoagulant drug prevents more thrombotic", "following total knee arthroplasty", "the current standard of", "significant number of patients", "lost to follow-up", "fail to complete", "study arm", "assigned", "patients", "novel drug arm", "switched", "later time", "novel anticoagulant", "warfarin", "primary care physician", "patients enrolled", "study", "based", "initial group", "assigned", "significant", "outcome", "new drug", "analysis"]}
{"question": "A 34-year-old man comes to the physician for evaluation of a rash on the elbows for several months. A biopsy of the affected area shows a thinned stratum granulosum as well as retained nuclei and spongiotic clusters of neutrophils in the stratum corneum. This patient's skin findings are most likely associated with which of the following conditions?", "answer": "Seronegative spondylarthropathy", "options": {"A": "Seronegative spondylarthropathy", "B": "Hypersensitivity to gliadin", "C": "Infection with hepatitis C virus", "D": "Hashimoto thyroiditis", "E": "Insulin resistance"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "rash", "elbows", "months", "biopsy", "affected area", "thinned stratum granulosum", "retained nuclei", "spongiotic clusters", "stratum corneum", "patient's skin findings", "most likely associated", "following conditions"]}
{"question": "A 28-year-old woman is brought to the emergency department 1 hour after being involved in a motor vehicle collision. She was riding a bike when she lost control and hit a car on the opposite side of the road. On arrival, she is unconscious. She has a history of intravenous heroin use. Her pulse is 56/min, respirations are 8/min and irregular, and blood pressure is 196/102 mm Hg. Examination shows a 2-cm laceration over the left cheek and a 3-cm laceration over the left chest. There are multiple abrasions over her face and chest. She opens her eyes and flexes her extremities to painful stimuli. The pupils are dilated and react sluggishly to light. There are decreased breath sounds over the left lung. The trachea is central. There is no jugular venous distention. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The left knee and right ankle are swollen; range of motion is limited. Two large-bore peripheral intravenous catheters are inserted. She is intubated and mechanical ventilation is initiated. A focused assessment with sonography in trauma is negative. An occlusive dressing is applied over the left chest wound. She is scheduled for a noncontrast CT scan of the brain. Which of the following is the underlying cause of this patient's hypertension?", "answer": "Elevated sympathetic response", "options": {"A": "Elevated sympathetic response", "B": "Reduced parasympathetic response", "C": "Increased intrathoracic pressure", "D": "Brainstem compression", "E": "Posttraumatic vasospasm"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "hour", "involved", "motor vehicle collision", "bike", "lost control", "hit", "car", "opposite side", "road", "arrival", "unconscious", "history of intravenous heroin use", "pulse", "min", "respirations", "min", "irregular", "blood pressure", "mm Hg", "2 cm laceration", "left cheek", "3 cm laceration", "left chest", "multiple abrasions", "face", "chest", "opens", "eyes", "extremities", "painful", "pupils", "dilated", "light", "decreased breath sounds", "left lung", "trachea", "central", "jugular venous distention", "abnormalities", "abdomen", "soft", "nontender", "left knee", "right ankle", "swollen", "range of motion", "limited", "Two large bore peripheral intravenous catheters", "intubated", "mechanical ventilation", "initiated", "focused assessment", "sonography", "trauma", "negative", "occlusive dressing", "applied", "left chest wound", "scheduled", "CT scan", "brain", "following", "underlying cause", "patient's hypertension"]}
{"question": "A 28-year-old female presents to her primary care physician because of pain on her right foot. She says that the pain began 2 weeks ago and gets worse with weight bearing. She has been training for a marathon, and this pain has limited her training. On exam, there are no signs of inflammation or deformities on her foot. Compression of the forefoot with concomitant pressure on the interdigital space reproduces the pain on the plantar surface between the third and fourth toes and produces an audible click. What is the cause of this patient's condition?", "answer": "A benign neuroma", "options": {"A": "A bony outgrowth", "B": "Inflammation of the bursa", "C": "A benign neuroma", "D": "A metatarsal compression fracture", "E": "Inflammation and scarring of the plantar fascia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female presents", "primary care physician", "of pain", "right", "pain began 2 weeks", "gets worse", "weight bearing", "training", "marathon", "pain", "limited", "training", "exam", "signs", "inflammation", "deformities", "foot", "Compression of", "forefoot", "concomitant pressure", "interdigital space", "pain", "plantar", "third", "fourth toes", "cause", "patient's condition"]}
{"question": "A 68-year-old Caucasian male complains of severe headache and pain while chewing. Upon examination, he is found to have a left visual field deficit. Laboratory results show elevated erythrocyte sedimentation rate. Which of the following drugs would be the best choice for treatment of this patient?", "answer": "Prednisone", "options": {"A": "Propranolol", "B": "Prednisone", "C": "Sumatriptan", "D": "Pilocarpine", "E": "Clopidogrel"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "male", "severe headache", "pain", "chewing", "found to", "left visual deficit", "Laboratory results", "elevated erythrocyte sedimentation rate", "following drugs", "best choice", "treatment", "patient"]}
{"question": "A 62-year-old woman comes to the physician because of involuntary, rhythmic movements of her hands for the past 5 months. Her symptoms initially affected her left hand only, but now both hands are affected. She also reports that her symptoms are worse at rest and that performing tasks such as tying her shoelaces and writing have become more difficult. Her husband thinks that she has been more withdrawn lately. She used to drink a half a bottle of sherry every day for the past 18 years but has not consumed alcohol in the past year. She has chronic liver disease, hypertension, and peripheral artery disease. Current medications include aspirin and propanolol. She appears anxious. She is oriented to time, place, and person. Her temperature is 37°C (98.6°F), pulse is 98/min, and blood pressure is 144/82 mm Hg. Examination shows a rhythmic, low-frequency tremor that is more prominent in the left hand. Range of motion in the arms and legs is normal. Increased resistance to passive flexion and extension is present in the left upper limb. Muscle strength is 4/5 in all limbs. Sensations to pinprick and light touch are preserved. The finger-to-nose test is normal bilaterally. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Degeneration of the substantia nigra", "options": {"A": "Copper accumulation in the basal ganglia", "B": "Increased serum free T4 levels", "C": "Infarction of the red nucleus", "D": "Cerebellar infarction", "E": "Degeneration of the substantia nigra"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["62 year old woman", "physician", "rhythmic movements", "hands", "past", "months", "symptoms initially affected", "left hand only", "now", "hands", "affected", "reports", "symptoms", "worse", "tying", "more difficult", "more withdrawn", "used to", "half", "bottle", "day", "past", "years", "not", "alcohol", "past year", "chronic liver disease", "hypertension", "peripheral artery disease", "Current medications include aspirin", "propanolol", "appears anxious", "oriented to time", "place", "temperature", "98", "pulse", "98 min", "blood pressure", "mm Hg", "rhythmic", "low-frequency tremor", "more prominent", "left hand", "Range of motion", "arms", "legs", "normal", "Increased resistance to passive flexion", "extension", "present", "left upper limb", "Muscle strength", "4/5", "limbs", "Sensations", "pinprick", "light touch", "preserved", "finger-to-nose test", "normal", "following", "underlying cause", "patient's symptoms"]}
{"question": "During an experiment conducted to alter the infectivity of common viruses that affect humans, an investigator successfully increases the host range of human immunodeficiency virus (HIV). The new strain of the virus can infect fibroblast-like cells in addition to the usual target of HIV. Which of the following is the most likely explanation for the increase in the host range of the virus?", "answer": "Mutation of the gene coding for viral surface glycoproteins", "options": {"A": "Mutation of the gene coding for viral surface glycoproteins", "B": "Point mutations in the hemagglutinin gene", "C": "Increased rate of budding out of host cells", "D": "Reassortment of genetic material between segments of two viruses", "E": "Excessive activity of viral RNA polymerase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["to alter", "infectivity", "common viruses", "humans", "investigator", "increases", "human immunodeficiency virus", "new strain", "infect", "cells in addition to", "usual target", "HIV", "following", "increase", "range"]}
{"question": "A 66-year-old man with congestive heart failure presents to the emergency department complaining of worsening shortness of breath. These symptoms have worsened over the last 3 days. He has a blood pressure of 126/85 mm Hg and heart rate of 82/min. Physical examination is notable for bibasilar crackles. A chest X-ray reveals bilateral pulmonary edema. His current medications include metoprolol succinate and captopril. You wish to add an additional medication targeted towards his symptoms. Of the following, which statement is correct regarding loop diuretics?", "answer": "Loop diuretics inhibit the action of the Na+/K+/Cl- cotransporter", "options": {"A": "Loop diuretics decrease sodium, magnesium, and chloride but increase calcium", "B": "Loop diuretics inhibit the action of the Na+/K+/Cl- cotransporter", "C": "Loop diuretics can cause ammonia toxicity", "D": "Loop diuretics can cause metabolic acidosis", "E": "Loop diuretics can cause hyperlipidemia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old man", "congestive heart failure presents", "emergency department", "of worsening shortness", "breath", "symptoms", "worsened", "3 days", "blood pressure", "85 mm Hg", "min", "Physical", "notable", "crackles", "chest X-ray reveals bilateral pulmonary edema", "current medications include metoprolol succinate", "captopril", "wish to add", "additional medication targeted", "symptoms", "following", "correct", "loop diuretics"]}
{"question": "A 52-year-old man comes to the physician because his skin has been progressively yellowing for the past 4 weeks. He also reports low appetite and difficulty fitting into his pants because of his swollen legs over the past several months. There is no personal or family history of serious illness. He does not smoke and drinks 1 to 2 beers on special occasions. He used to be sexually active with multiple female partners but has lost interest in sexual intercourse recently. He is 178 cm (5 ft 10 in) tall and weighs 68 kg (150 lb); his BMI is 22 kg/m2. Vital signs are within normal limits. Physical examination shows yellowing of the skin and sclera as well as erythema of the palms. There is bilateral enlargement of breast tissue. Cardiopulmonary examinations show no abnormalities. The abdomen is distended. The liver is palpated 2 to 3 cm below the right costal margin. On percussion of the left abdomen, a thrill can be felt on the right side. Hepatojugular reflux is absent. There is bilateral edema below the knees. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Chronic viral hepatitis", "options": {"A": "Chronic viral hepatitis", "B": "Congestive hepatopathy", "C": "Primary biliary cirrhosis", "D": "Autoimmune hepatitis", "E": "Non-alcoholic steatohepatitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "skin", "yellowing", "past 4 weeks", "reports low appetite", "difficulty fitting", "pants", "of", "swollen legs", "past", "months", "personal", "family history", "serious illness", "not smoke", "1", "2", "special occasions", "used to", "sexually active", "female", "lost interest", "sexual recently", "5 ft 10", "tall", "kg", "BMI", "kg/m2", "Vital signs", "normal", "Physical examination", "yellowing of the skin", "sclera", "erythema", "palms", "bilateral enlargement of breast tissue", "Cardiopulmonary examinations", "abnormalities", "abdomen", "distended", "liver", "2", "3 cm", "right costal margin", "percussion", "left abdomen", "thrill", "right side", "Hepatojugular reflux", "absent", "bilateral edema", "knees", "following", "underlying cause", "patient's condition"]}
{"question": "A 45-year-old male presents to his primary care physician for complaints of dizziness. The patient reports he experiences room-spinning dizziness lasting several hours at a time, approximately 2-3 times a month, starting 3 months ago. Upon questioning, the patient also reports right sided diminished hearing, tinnitus, and a sensation of ear fullness. Her temperature is 99 deg F (37.2 deg C), pulse 70/min, respirations 12, blood pressure 130 mmHg/85 mmHg, SpO2 99%. You decide to order an audiometric evaluation. What is the most likely finding of the audiogram?", "answer": "Low frequency sensorineural hearing loss", "options": {"A": "Low frequency sensorineural hearing loss", "B": "High frequency sensorineural hearing loss", "C": "Low frequency conductive hearing loss", "D": "High frequency conductive hearing loss", "E": "Normal audiogram"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male presents", "primary care physician", "complaints", "dizziness", "patient reports", "room-spinning dizziness lasting several hours", "time", "approximately", "times", "month", "starting 3 months", "patient", "reports right sided diminished hearing", "tinnitus", "sensation", "ear fullness", "temperature", "99 deg F", "pulse 70 min", "respirations", "blood pressure", "mmHg 85", "99", "to order", "audiometric", "finding", "audiogram"]}
{"question": "A 32-year-old man comes to the physician for a follow-up examination 1 week after being admitted to the hospital for oral candidiasis and esophagitis. His CD4+ T lymphocyte count is 180 cells/μL. An HIV antibody test is positive. Genotypic resistance assay shows the virus to be susceptible to all antiretroviral therapy regimens and therapy with dolutegravir, tenofovir, and emtricitabine is initiated. Which of the following sets of laboratory findings would be most likely on follow-up evaluation 3 months later?\n $$$ CD4 +/CD8 ratio %%% HIV RNA %%% HIV antibody test $$$", "answer": "↑ ↓ positive", "options": {"A": "↓ ↑ negative", "B": "↑ ↑ negative", "C": "↑ ↓ positive", "D": "↓ ↑ positive", "E": "↓ ↓ negative"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "follow-up", "1 week", "oral candidiasis", "esophagitis", "CD4", "lymphocyte count", "cells/L", "HIV antibody test", "positive", "Genotypic resistance assay", "to", "susceptible", "antiretroviral therapy", "therapy", "dolutegravir", "tenofovir", "emtricitabine", "initiated", "following sets", "laboratory findings", "follow-up", "later", "CD4", "CD8 ratio", "HIV", "antibody test"]}
{"question": "A 21-year-old U.S. born first year medical student with no prior hospital or healthcare work presents to the physician for a routine physical exam. The patient is HIV negative, denies drug use, and denies sick contacts. The physician places a purified protein tuberculin test in the patient's right forearm intradermally. What is the proper time to read the test and induration diameter that would indicate a positive test result?", "answer": "72 hours and 16mm diameter", "options": {"A": "24 hours and 18mm diameter", "B": "36 hours and 7mm diameter", "C": "48 hours and 11mm diameter", "D": "72 hours and 16mm diameter", "E": "96 hours and 14mm diameter"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["A 21-year-old U", "born first", "medical student", "prior hospital", "presents", "physician", "routine physical exam", "patient", "HIV negative", "drug use", "sick", "physician places a purified protein tuberculin test", "patient's right forearm", "time to", "test", "induration diameter", "positive test result"]}
{"question": "A 3-year-old boy is brought to the emergency department for nausea and vomiting for 1 day. His maternal uncle had a seizure disorder and died in childhood. He appears fatigued. Respirations are 32/min. Examination shows diffuse weakness in the extremities. Serum studies show a low pH, elevated lactate concentration, and normal blood glucose. A metabolic condition characterized by a defect in oxidative phosphorylation is suspected. Microscopic examination of a muscle biopsy specimen of this patient is most likely to show which of the following findings?", "answer": "Subsarcolemmal accumulation of mitochondria", "options": {"A": "Fibrofatty replacement of normal muscle fibers", "B": "Muscle atrophy with perimysial inflammation", "C": "Intermyofibrillar accumulation of glycogen", "D": "Endomysial inflammation with T cell infiltration", "E": "Subsarcolemmal accumulation of mitochondria"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "nausea", "vomiting", "1 day", "seizure disorder", "died", "childhood", "appears fatigued", "Respirations", "min", "diffuse weakness", "extremities", "Serum studies", "low pH", "elevated lactate concentration", "normal blood glucose", "metabolic condition", "defect", "suspected", "Microscopic examination of", "muscle biopsy specimen", "patient", "to", "following findings"]}
{"question": "A 6-year-old boy presents to your office with loss of his peripheral vision. His mother discovered this because he was almost struck by a vehicle that \"he couldn't see at all\". In addition, he has been complaining of a headache for the last several weeks and had an episode of vomiting 2 days ago. He has a family history of migraines in his mother and grandmother. He is currently in the 80th percentile for height and weight. On physical exam his temperature is 99°F (37.2°C), blood pressure is 110/75 mmHg, pulse is 100/min, respirations are 19/min, and pulse oximetry is 99% on room air. He is uncooperative for the rest of the physical exam. During workup, a lesion is found in this patient. Which of the following would most likely be seen during histopathologic analysis?", "answer": "Cholesterol crystals and calcification", "options": {"A": "Rosettes and small blue cells", "B": "Eosinophilic, corkscrew fibers", "C": "Perivascular rosettes with rod-shaped blepharoplasts", "D": "Cholesterol crystals and calcification", "E": "Round nuclei with clear cytoplasm"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "office", "loss of", "peripheral vision", "almost struck by", "vehicle", "ee ", "ddition,", "omplaining of a headache ", "ast ", "eeks ", "pisode of  omiting   days ", "amily history of migraines ", "urrently ", "0th  ercentile ", "eight ", "eight.", "emperature ", "lood pressure ", "5  mHg,", "ulse ", "00/ in,", "espirations ", "in,", "ulse oximetry ", "9%", "oom air.", "orkup,", "esion ", "ound ", "atient.", "ollowing ", "ost  ikely ", "een ", "istopathologic  nalysis?"]}
{"question": "Researchers are experimenting with hormone levels in mice in fasting and fed states. To test hormone levels in the fed state, the mice are given an oral glucose load and various hormones are measured in a blood sample. Researchers are most interested in the hormone whose blood levels track evenly with C-peptide levels. The hormone the researchers are most interested in is responsible for which of the following actions in the body?", "answer": "Fatty acid synthesis", "options": {"A": "Fatty acid synthesis", "B": "Fatty acid breakdown", "C": "Protein catabolism", "D": "Ketogenesis", "E": "Lipolysis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Researchers", "hormone levels", "fasting", "fed states", "To test hormone levels", "fed state", "given", "oral glucose load", "various hormones", "measured", "blood sample", "Researchers", "most", "hormone", "blood levels track", "C-peptide levels", "hormone", "researchers", "most", "responsible", "following actions", "body"]}
{"question": "A 42-year-old woman presents because of a painful mass she first noticed on her neck 1 week ago (see image). The mass has grown over the last few days. She has no history of serious illness and takes no medications. On physical exam, her temperature is 38.0°C (100.4°F), pulse is 86/min, respirations are 12/min, blood pressure is 135/80 mm Hg. The mass is tender and relatively soft and mobile. The overlying skin is warm. On her right ear, there is a series of small and healing skin punctures left by the bite of her neighbor’s kitten 3 weeks ago. No other mass is detected in the neck, supraclavicular, axillary, or inguinal regions. Oral examination reveals several discolored teeth. Her lungs are clear to auscultation and heart sounds are normal. Which of the following is the most appropriate diagnostic study at this time?", "answer": "Warthin-Starry silver stain for Bartonella henselae", "options": {"A": "Culture for facultative anaerobes", "B": "Histologic evaluation for Reed-Sternburg cells", "C": "The Monospot test for Epstein-Barr virus", "D": "Toxoplasma IgG using enzyme-linked immunosorbent assay", "E": "Warthin-Starry silver stain for Bartonella henselae"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "painful mass", "first", "neck 1 week", "see", "mass", "days", "history", "serious illness", "medications", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "80 mm Hg", "mass", "tender", "soft", "mobile", "skin", "warm", "right ear", "series", "small", "healing skin punctures left", "bite", "weeks", "mass", "detected", "neck", "supraclavicular", "axillary", "inguinal regions", "reveals several discolored teeth", "lungs", "clear", "auscultation", "heart sounds", "normal", "following", "most appropriate diagnostic", "time"]}
{"question": "A 26-year-old female who is 12 weeks pregnant presents to her primary care physician because she is concerned about her acne. While she has struggled with acne for most of her adult life, the acne has become more severe in the past few months. She has used benzoyl peroxide, salicylic acid, and topical antibiotics in the past but these treatments have had little effect. The patient would like to try minocycline, which worked for a friend of hers. The physician responds that this drug cannot be given to pregnant women, and offers to start the patient on the drug after she delivers the baby. Minocycline may to toxic to the fetus through which mechanism?", "answer": "Inhibition of bone growth", "options": {"A": "Inhibition of bone growth", "B": "Formation of renal cysts", "C": "Atrialization of the ventricle", "D": "Scarring of the bile ducts", "E": "Gray coloring of the skin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "weeks pregnant presents", "primary care physician", "acne", "acne", "most", "adult", "acne", "more severe", "past", "months", "used benzoyl peroxide", "salicylic acid", "topical", "past", "treatments", "little effect", "patient", "to", "minocycline", "physician", "drug", "given", "to start", "patient", "drug", "delivers", "baby", "Minocycline", "toxic", "fetus", "mechanism"]}
{"question": "A 28-year-old man presents with a draining abscess on his left jaw. The patient states that he had a “bad tooth” a few weeks ago which has progressed to his current condition. His vital signs include: blood pressure 110/80 mm Hg, heart rate 85/min, and temperature 37.9°C (100.3°F). On physical examination, the patient has a 4 cm abscess on the left maxillary line that is draining a granulous, purulent material. Which of the following is the most likely causative organism of this abscess?", "answer": "Gram-positive, branching rod", "options": {"A": "Enveloped, double stranded DNA virus", "B": "Gram-positive cocci in clusters", "C": "Gram-positive cocci in chains", "D": "Gram-positive, branching rod", "E": "Aerobic gram-negative rod"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "draining abscess", "left jaw", "patient states", "bad tooth", "few weeks", "progressed", "current condition", "vital signs include", "blood pressure", "80 mm Hg", "heart rate 85 min", "temperature", "100", "patient", "4 cm abscess", "left maxillary line", "draining", "granulous", "purulent", "following", "abscess"]}
{"question": "A 30-year-old obese female presents with new-onset headaches, ringing in her ears, and blurry vision. Ibuprofen and avoidance of light has not relieved her symptoms. She denies a history of recent trauma, fever, chills, and fatigue. Past medical history is significant for type 2 diabetes mellitus managed with metformin. She has had 20/20 vision her whole life and wonders if she might need to get eyeglasses. She has 2 healthy school-age children. Her temperature is 36.8°C (98.2°F), heart rate is 90/min, respiratory rate is 15/min, and blood pressure is 135/80 mm Hg. Physical exam is notable for decreased lateral eye movement, and the funduscopic findings are shown in the picture. Laboratory findings are within normal limits and brain imaging is normal. Lumbar puncture demonstrates an elevated opening pressure and normal CSF composition. Which of the following is a side effect of the medication used to treat this condition?", "answer": "Kidney stones", "options": {"A": "Kidney stones", "B": "Elevated liver function tests", "C": "Rhabdomyolysis", "D": "Decreased white blood cell count", "E": "Pancreatitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old obese female presents", "new-onset headaches", "ringing in", "ears", "blurry vision", "Ibuprofen", "light", "not relieved", "symptoms", "history", "recent trauma", "fever", "chills", "fatigue", "Past medical history", "significant", "type 2 diabetes mellitus", "metformin", "20/20 vision", "whole", "need to", "eyeglasses", "has", "healthy school-age children", "temperature", "36", "98", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "notable", "decreased lateral eye movement", "funduscopic findings", "picture", "Laboratory findings", "normal limits", "brain imaging", "normal", "Lumbar puncture", "elevated opening pressure", "normal CSF composition", "following", "side effect", "medication used to treat", "condition"]}
{"question": "A 28-year-old gravida 1 para 1 woman is being seen in the hospital for breast tenderness. She reports that both breasts are swollen and tender. She is also having difficulty getting her newborn to latch. The patient gave birth 4 days ago by uncomplicated vaginal delivery. During her pregnancy, the patient developed gestational diabetes but was otherwise healthy. She took folate and insulin. She attended all her pre-natal appointments. Upon examination, the patient has a low grade fever, but all other vital signs are stable. Bilateral breasts appear engorged and are tender to palpation. There is no erythema, warmth, or induration. A lactation nurse is brought in to assist the patient and her newborn with more effective breastfeeding positions. The patient says a neighbor told her that breastmilk actually lacks in nutrients, and she asks what the best option is for the health of her newborn. Which of the following components is breastmilk a poor source of?", "answer": "Vitamin D", "options": {"A": "Immunoglobulin A", "B": "Lysozymes", "C": "Phosphorus", "D": "Vitamin D", "E": "Whey protein"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old gravida 1 para", "woman", "seen", "hospital", "breast tenderness", "reports", "breasts", "swollen", "tender", "difficulty getting", "newborn", "latch", "patient gave birth 4 days", "uncomplicated vaginal delivery", "pregnancy", "patient", "gestational diabetes", "healthy", "folate", "insulin", "attended", "pre natal appointments", "patient", "low grade fever", "vital signs", "stable", "Bilateral breasts appear engorged", "tender", "palpation", "erythema", "warmth", "induration", "lactation nurse", "brought", "assist", "patient", "newborn", "effective breastfeeding positions", "patient", "breastmilk", "lacks", "best option", "health", "newborn", "following components", "breastmilk", "poor source"]}
{"question": "A 5-month-old boy is brought to the pediatrician by his parents, who began noticing that the infant was not able to hold his head upright when sitting or in a prone position. Upon examination, the infant has a musty odor, fair skin with patches of eczema, and blue eyes. The pediatrician orders laboratory tests and prescribes a special diet. Which of the following substances should be included in this diet?", "answer": "Large neutral amino acids", "options": {"A": "Large neutral amino acids", "B": "L-carnitine", "C": "Thiamine", "D": "Malate", "E": "Arginine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 month old boy", "brought", "pediatrician", "began", "infant", "not able to hold", "head upright", "sitting", "prone position", "infant", "musty odor", "fair skin", "patches", "eczema", "blue eyes", "pediatrician", "laboratory tests", "special diet", "following", "included", "diet"]}
{"question": "A 54-year-old man comes to the emergency department because of a 3-week history of intermittent swelling of his left arm and feeling of fullness in his head that is exacerbated by lying down and bending over to tie his shoes. Physical examination shows left-sided facial edema and distention of superficial veins in the neck and left chest wall. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Apical lung tumor", "options": {"A": "Right heart failure", "B": "Cervical rib", "C": "Apical lung tumor", "D": "Subclavian steal syndrome", "E": "Mediastinal lymphoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["54 year old man", "emergency department", "of", "3 week history", "intermittent swelling", "left arm", "fullness", "head", "exacerbated", "lying", "bending", "to tie", "shoes", "left-sided facial edema", "distention of superficial veins", "neck", "left chest wall", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 45-year-old woman comes to the physician because of fatigue, irregular menses, and recurrent respiratory infections for the past 6 months. Her blood pressure is 151/82 mm Hg. Physical examination shows a round face, thinning of the skin, and multiple bruises on her arms. Further studies confirm the diagnosis of an ACTH-secreting pituitary adenoma. This patient is at greatest risk for which of the following?", "answer": "Pathologic fracture", "options": {"A": "Weight loss", "B": "Eosinophilia", "C": "Hypoglycemia", "D": "Bitemporal hemianopsia", "E": "Pathologic fracture"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "fatigue", "irregular menses", "recurrent respiratory infections", "past 6 months", "blood pressure", "mm Hg", "round face", "thinning of", "skin", "multiple bruises", "arms", "Further studies confirm the diagnosis of", "ACTH-secreting pituitary adenoma", "patient", "greatest", "following"]}
{"question": "An 8-year-old boy is brought to the pediatric emergency department by his parents with a complaint of abdominal pain and diarrhea for the past week. He states that for the past two days, he has noticed blood in his stool. His parents note that they attended a neighbor’s barbecue last weekend, but otherwise have not eaten any new foods or changed their usual diet. The patient is admitted to the hospital unit for further work-up. The provider team finds that the patient’s blood is positive for Shiga-like toxin and notes the following lab values: creatinine of 4.2 mg/dL, platelet count of 50,000/mm^3, and hemoglobin of 6.0 g/dL. Which of the following additional lab findings would be consistent with the diagnosis?", "answer": "Microthrombi within glomerular vessels on kidney biopsy", "options": {"A": "Blunting of villi on ileal biopsy", "B": "Crypt abscesses and ulcers on colonic biopsy", "C": "Microthrombi within glomerular vessels on kidney biopsy", "D": "Foamy macrophages in intestinal lamina propria on duodenal biopsy", "E": "Sickling of red blood cells on peripheral blood smear"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "pediatric emergency department", "complaint", "abdominal pain", "diarrhea", "past week", "states", "past two days", "blood in", "stool", "note", "attended", "last weekend", "not eaten", "new", "changed", "usual diet", "patient", "hospital unit", "further work-up", "provider", "finds", "patients blood", "positive", "Shiga-like toxin", "notes", "following lab values", "creatinine", "2 mg dL", "platelet count", "50", "mm", "hemoglobin", "6.0 g", "following additional lab findings", "diagnosis"]}
{"question": "A 55-year-old woman comes to the physician because of involuntary hand movements that improve with alcohol consumption. Physical examination shows bilateral hand tremors that worsen when the patient is asked to extend her arms out in front of her. The physician prescribes a medication that is associated with an increased risk of bronchospasms. This drug has which of the following immediate effects on the cardiovascular system?\n $$$ Stroke volume %%% Heart rate %%% Peripheral vascular resistance $$$", "answer": "↓ ↓ ↑", "options": {"A": "↑ ↑ ↓", "B": "↓ ↓ ↓", "C": "↓ ↑ ↑", "D": "↓ ↓ ↑", "E": "↑ ↑ ↑"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "involuntary hand movements", "bilateral hand tremors", "worsen", "patient", "to extend", "arms out", "front", "physician", "medication", "associated with", "increased risk", "bronchospasms", "drug", "following immediate effects", "cardiovascular system", "Stroke volume", "Heart rate", "Peripheral vascular resistance"]}
{"question": "A 3-year-old girl is brought to the emergency department by her parents with sudden onset shortness of breath. They tell the emergency physician that their daughter was lying on the bed watching television when she suddenly began gasping for air. They observed a bowl of peanuts lying next to her when they grabbed her up and brought her to the emergency department. Her respirations are 25/min, the pulse is 100/min and the blood pressure is 90/65 mm Hg. The physical findings as of now are apparently normal. She is started on oxygen and is sent in for a chest X-ray. Based on her history and physical exam findings, the cause of her current symptoms would be seen on the X-ray at which of the following sites?\n ", "answer": "The superior segment of the right lower lobe", "options": {"A": "The apical segment of the right upper lobe", "B": "The apical segment of the left upper lobe", "C": "The superior segment of the right lower lobe", "D": "The posterior segment of the right lower lobe", "E": "The lingula of the right lower lobe"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["3 year old girl", "brought", "emergency department", "sudden onset shortness of breath", "emergency physician", "lying", "bed", "began gasping for air", "observed", "lying next to", "grabbed", "brought", "emergency department", "respirations", "min", "pulse", "100 min", "blood pressure", "90 65 mm Hg", "physical findings", "now", "normal", "started", "oxygen", "sent", "chest X-ray", "Based", "history", "physical exam findings", "cause", "current symptoms", "seen", "X-ray", "of", "following sites"]}
{"question": "An otherwise healthy 67-year-old woman comes to your clinic after being admitted to the hospital for 2 weeks after breaking her hip. She has not regularly seen a physician for the past several years because she has been working hard at her long-time job as a schoolteacher. You wonder if she has not been taking adequate preventative measures to prevent osteoporosis and order the appropriate labs. Although she is recovering from surgery well, she is visibly upset because she is worried that her hospital bill will bankrupt her. Which of the following best describes her Medicare coverage?", "answer": "Medicare Part A will cover the majority of her hospital fees, including inpatient drugs and lab tests.", "options": {"A": "Medicare Part A will cover the majority of her hospital fees, including inpatient drugs and lab tests.", "B": "Medicare Part B will cover the majority of her hospital fees, including inpatient drugs and lab tests.", "C": "Medicare Part C will cover the majority of drug costs during her inpatient treatment.", "D": "Medicare Part D will cover the cost of drugs during her inpatient treatment.", "E": "Medicare is unlikely to cover the cost of her admission because she has not been paying her premium."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy 67 year old woman", "clinic", "2 weeks", "breaking", "hip", "not", "seen", "physician", "past", "years", "hard", "long time", "schoolteacher", "not", "adequate preventative measures to prevent osteoporosis", "order", "appropriate labs", "recovering from surgery well", "worried", "hospital bill", "following best", "Medicare coverage"]}
{"question": "A 45-year-old woman has painless abdominal distension 2 days after admission for acute pancreatitis. Her initial abdominal pain has resolved. Enteral nutrition has been initiated. She has not passed any stool since being admitted to the hospital. She has nausea but no vomiting. Her temperature is 36.7°C (98.1°F), pulse is 95/min, respiratory rate is 17/min, and blood pressure is 100/70 mm Hg. The lungs are clear to auscultation. Abdominal examination shows symmetric distention, absent bowel sounds, and tympanic percussion without tenderness. Laboratory studies show:\nSerum\nNa+ 137 mEq/L\nK+ 3.2 mEq/L\nCl− 104 mEq/L\nHCO3− 23 mEq/L\nUrea nitrogen 22 mg/dL\nCreatinine 0.8 mg/dL\nA supine abdominal X-ray is shown. Which of the following best explains these findings?", "answer": "Ileus", "options": {"A": "Ascites", "B": "Ileus", "C": "Necrotizing pancreatitis", "D": "Pancreatic fluid collection", "E": "Pancreatic pseudocyst"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "painless abdominal distension 2 days", "acute pancreatitis", "initial abdominal pain", "resolved", "Enteral nutrition", "initiated", "not passed", "stool", "nausea", "vomiting", "temperature", "36", "98", "pulse", "95 min", "respiratory rate", "min", "blood pressure", "100 70 mm Hg", "lungs", "clear", "auscultation", "Abdominal", "symmetric distention", "absent bowel sounds", "tympanic percussion", "tenderness", "Laboratory studies", "Serum", "137 mEq", "HCO3", "Urea", "mg dL Creatinine 0.8", "dL", "supine abdominal X-ray", "following best", "findings"]}
{"question": "An investigator is studying the changes that occur in the oxygen-hemoglobin dissociation curve of different types of hemoglobin under various conditions. The blood obtained from a male infant shows decreased affinity for 2,3-bisphosphoglyceric acid. Which of the following is the most likely composition of the hemoglobin molecule in this sample?", "answer": "α2γ2\n\"", "options": {"A": "β4", "B": "α2βS2", "C": "α2β2", "D": "α2δ2", "E": "α2γ2\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "changes", "occur", "oxygen", "dissociation curve", "different", "various conditions", "blood obtained", "male infant", "decreased", "3", "acid", "following", "composition", "hemoglobin"]}
{"question": "A research team is studying the effects of a novel drug that was discovered to treat type 2 diabetes. In order to learn more about its effects, they follow patients who are currently taking the drug and determine whether there are adverse effects that exceed anticipated levels and may therefore be drug-related. They discover that the drug causes an excess of sudden cardiac death in 19 patients with renal failure out of 2 million total patients that are followed. Based on these results, an additional warning about this serious adverse effect is added to the investigator brochure for the drug. Which of the following clinical phase studies does this study most likely describe?", "answer": "Phase IV", "options": {"A": "Phase I", "B": "Phase II", "C": "Phase III", "D": "Phase IV", "E": "Phase V"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["studying", "effects of", "novel drug", "to treat type 2 diabetes", "order to", "more", "effects", "follow patients", "currently", "drug", "adverse effects", "anticipated levels", "drug related", "drug causes", "excess", "sudden cardiac death", "patients", "renal failure", "2 million total patients", "followed", "Based", "results", "additional", "serious adverse effect", "added", "drug", "following clinical phase studies", "study", "likely"]}
{"question": "A 48-year-old man presents to a physician with complaints of paresthesia of the lower extremities, which he has had for the last 3 months. He has been frequently fatigued for the past 5 months and also experienced an increased frequency of urination over the last few months. There is no history of a known medical condition or of substance abuse. His physical examination does not reveal any specific abnormality, except that he is obese: his body mass index is 34.6 kg/m2. The patient’s detailed laboratory evaluation reveals a fasting plasma glucose of 160 mg/dL and 2-hour plasma glucose of 270 mg/dL. His physician tells him that his laboratory evaluation suggests a diagnosis of diabetes mellitus type 2. The patient, surprised by this news, asks his physician why he has developed diabetes mellitus even though no one else in his family has ever suffered from it. The physician explains to him that genetic factors play an important role in the development of diabetes mellitus, but that their interactions are complex. Apart from neonatal diabetes mellitus and maturity-onset diabetes of the young (MODY), the development of diabetes mellitus cannot be explained by a single genetic mutation. Which of the following options best explains the genetics of the form of diabetes mellitus from which this man is suffering?", "answer": "Polygenic inheritance", "options": {"A": "Anticipation", "B": "Genomic imprinting", "C": "Natural selection", "D": "Polygenic inheritance", "E": "Synergistic epistasis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["48 year old man presents", "physician", "complaints of paresthesia", "lower extremities", "last", "months", "frequently fatigued", "past", "months", "increased frequency of urination", "last", "months", "history of", "known medical condition", "of substance abuse", "not reveal", "specific abnormality", "except", "obese", "body mass index", "kg/m2", "patients detailed laboratory", "reveals", "fasting plasma glucose", "160 mg", "2-hour plasma glucose", "mg/dL", "physician", "laboratory", "diagnosis", "diabetes mellitus type 2", "patient", "physician", "diabetes mellitus", "no one else", "family", "suffered", "physician", "genetic factors play", "important role", "development", "diabetes mellitus", "interactions", "complex", "neonatal diabetes mellitus", "maturity-onset diabetes of the young", "development", "diabetes mellitus", "single", "following options best", "form", "man", "suffering"]}
{"question": "A 47-year-old man is brought to the emergency department 1 hour after injuring his genital area when he fell astride his backyard fence. He was trimming a tree from the fence when he lost his balance. His vital signs are within normal limits. Examination shows blood at the urethral meatus, perineal ecchymoses, and a scrotal hematoma. An x-ray of the pelvis shows swelling of the soft tissue but no other abnormalities. Which part of the urinary tract is most likely damaged in this patient?", "answer": "Bulbous urethra", "options": {"A": "Penile urethra", "B": "Anterior bladder wall", "C": "Bulbous urethra", "D": "Membranous urethra", "E": "Prostatic urethra"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "hour", "genital area", "fell", "backyard", "trimming", "tree", "lost", "balance", "vital signs", "normal limits", "blood", "urethral meatus", "perineal ecchymoses", "scrotal hematoma", "x-ray", "pelvis", "swelling", "soft tissue", "abnormalities", "part of", "urinary tract", "most likely damaged", "patient"]}
{"question": "You are working in the emergency room of a children's hospital when a 4-year-old girl is brought in by ambulance due to \"difficulty breathing.\" The patient had been eating lunch on a school field trip when she suddenly complained of abdominal pain. Shortly thereafter, she was noted to have swelling of the lips, a rapidly developing red rash and difficulty breathing. In the ambulance her blood pressure was persistently 80/50 mmHg despite intramuscular epinephrine. In the course of stabilization and work up of the patient, you note an elevated tryptase level. What is the mechanism behind this elevated tryptase level?", "answer": "Cross-linking of IgE on mast cells", "options": {"A": "IgG production by plasma cells", "B": "IgM mediated complement activation", "C": "Cross-linking of IgE on mast cells", "D": "Antibody-antigen immune complexes", "E": "Cross-linking of IgG on mast cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["emergency room", "children", "ospital ", "- ear- ld  irl ", "rought ", "mbulance  ue to ", "ifficulty breathing.", "atient ", "ating  unch ", "chool  ield  rip ", "bdominal pain.", "oted  o ", "welling of the lips,", "apidly ", "ed  ash ", "ifficulty breathing.", "mbulance ", "lood pressure ", "0/ 0  mHg ", "ntramuscular  pinephrine.", "ourse ", "tabilization ", "ote ", "levated  ryptase  evel.", "echanism ", "levated  ryptase  evel?"]}
{"question": "A 26-year-old man is brought to the emergency department by his friends because of blurred vision and slurred speech for the past 6 hours. He had some difficulty swallowing his food during lunch and has weakness in both arms. Two weeks ago, he had an upper respiratory infection that resolved spontaneously. He lives independently and returned from his grandparents' farm 2 days ago. He commonly consumes canned vegetables and fruits. He is alert and oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 88/min, respirations are 10/min and labored, and blood pressure is 110/70 mm Hg. Examination shows bilateral nystagmus and ptosis. The pupils are dilated and not reactive to light. Muscle strength of the facial muscles and bilateral upper extremities is decreased. Upper extremity deep tendon reflexes are 1+ bilaterally. Cardiopulmonary examination shows no abnormalities. Which of the following is the most likely cause for this patient's symptoms?", "answer": "Toxin that inhibits ACh release", "options": {"A": "Chemical that inhibits acetylcholinesterase", "B": "Cell-mediated focal demyelination", "C": "Autoantibodies against ACh receptors", "D": "Toxin that inhibits ACh release", "E": "Autoantibodies against myelin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "blurred vision", "slurred speech", "past", "hours", "difficulty swallowing", "food", "lunch", "weakness", "arms", "Two weeks", "upper respiratory infection", "resolved", "lives", "returned", "farm 2 days", "canned", "alert", "oriented to person", "place", "time", "temperature", "98", "pulse", "88 min", "respirations", "10/min", "labored", "blood pressure", "70 mm Hg", "bilateral nystagmus", "ptosis", "pupils", "dilated", "not reactive to light", "Muscle strength", "facial muscles", "bilateral upper extremities", "decreased", "Upper extremity deep tendon reflexes", "1", "Cardiopulmonary", "abnormalities", "following", "most likely cause", "patient's symptoms"]}
{"question": "An 8-year old boy is brought into clinic for evaluation of possible scoliosis that was newly found on a routine exam at school. On exam, he is also noted to be in the 99th percentile for height and 70th percentile for weight. He appears to have abnormally long extremities as well as an upward lens dislocation on ophthalmologic exam. A mutation leading to a defect in which of the following proteins is the most likely cause of his condition?", "answer": "Fibrillin", "options": {"A": "Type I collagen", "B": "Type IV collagen", "C": "Elastin", "D": "Fibrillin", "E": "ATP7A"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "clinic", "possible scoliosis", "found", "routine exam", "school", "exam", "noted to", "99th percentile", "height", "percentile", "weight", "appears to", "long extremities", "upward lens dislocation", "ophthalmologic exam", "mutation leading", "defect", "following proteins", "most likely cause", "condition"]}
{"question": "A 52-year-old man comes to the physician because of malaise and dark urine for the past 5 days. He has also had recurrent episodes of sinus congestion, productive cough, and fever for 3 months. Additionally, he has noticed a rash on his arms and feet. He has seasonal allergic conjunctivitis treated with ketotifen eye drops. Vital signs are within normal limits. Examination shows several erythematous and necrotic papules on his arms and feet. He has inflamed nasopharyngeal mucosa and a perforated nasal septum. The nasal bridge is collapsed. Laboratory studies show:\nHemoglobin 11.3 g/dL\nLeukocyte count 12000/mm3\nPlatelet count 270,000/mm3\nESR 55 mm/hr\nSerum\nUrea nitrogen 28 mg/dL\nCreatinine 2.9 mg/dL\nAnti-DNA antibodies negative\nAntineutrophil cytoplasmic antibodies positive\nUrine\nProtein 2+\nGlucose negative\nRBC 35–37/hpf\nRBC casts numerous\nWhich of the following biopsy findings is most likely to be observed in this patient?\"", "answer": "Granulomatous vasculitis of small and medium-sized vessels", "options": {"A": "Tissue eosinophilia with granulomatous reactions", "B": "Nongranulomatous fibrinoid necrosis with infiltration of neutrophils", "C": "Immunoglobulin and complement deposits at the dermoepidermal junction", "D": "Granulomatous vasculitis of small and medium-sized vessels", "E": "Transmural necrotizing arteritis and fibrinoid necrosis in muscles\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "malaise", "dark urine", "past 5 days", "recurrent episodes of sinus congestion", "productive cough", "fever", "months", "rash", "arms", "feet", "seasonal allergic conjunctivitis treated with ketotifen eye drops", "Vital signs", "normal limits", "several erythematous", "necrotic papules", "arms", "feet", "inflamed nasopharyngeal mucosa", "perforated nasal septum", "nasal bridge", "collapsed", "Laboratory studies", "11", "mm3 Platelet count", "hr", "9", "Anti-DNA antibodies negative", "hpf", "casts numerous", "following biopsy findings", "to", "observed", "patient"]}
{"question": "A 3-week-old boy is brought to the physician for the evaluation of poor feeding and recurrent episodes of vomiting. He was delivered at term after an uncomplicated pregnancy. He is at the 5th percentile for length and weight. Physical examination shows generalized hypotonia. Urinalysis shows increased propionic acid concentration. The finding on urinalysis is best explained by the breakdown of which of the following substances?", "answer": "Branched-chain amino acids", "options": {"A": "Even-chain fatty acids", "B": "Hexose monosaccharides", "C": "Branched-chain amino acids", "D": "Catechol-containing monoamines", "E": "Bicyclic nitrogenous bases"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 week old boy", "brought", "physician", "evaluation", "poor", "recurrent episodes of vomiting", "delivered", "term", "uncomplicated pregnancy", "5th percentile", "length", "weight", "generalized hypotonia", "Urinalysis", "increased propionic acid concentration", "finding", "urinalysis", "best", "breakdown", "following"]}
{"question": "A 59-year-old man presents to the emergency department with a sudden-onset sensation that the room is spinning causing him to experience several episodes of nausea and vomiting. Upon arriving, the patient’s symptoms have resolved. He states his symptoms occurred as he was going to bed. He has never experienced this before, but felt extremely dizzy for roughly 3 minutes. He currently feels at his baseline. The patient is otherwise healthy and only has a history of eczema. His temperature is 97.7°F (36.5°C), blood pressure is 134/85 mmHg, pulse is 85/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy man with a normal gait. The patient has a physiologic nystagmus and his cranial nerve exam is unremarkable. The patient’s head is turned to the left and he is laid back on the stretcher, which exacerbates severe symptoms with a nystagmus notable. The patient’s symptoms improve after 2 minutes of being in this position. Which of the following is the most likely diagnosis?", "answer": "Benign paroxysmal positional vertigo", "options": {"A": "Benign paroxysmal positional vertigo", "B": "Labyrinthitis", "C": "Meniere disease", "D": "Vertebrobasilar stroke", "E": "Vestibular neuritis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["59 year old man presents", "emergency department", "sudden-onset sensation", "room", "spinning causing", "to", "several episodes of nausea", "vomiting", "patients symptoms", "resolved", "states", "symptoms", "bed", "never", "before", "extremely dizzy", "minutes", "currently", "baseline", "patient", "healthy", "only", "history of eczema", "temperature", "97", "36", "blood pressure", "85 mmHg", "pulse", "85 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "healthy man", "normal gait", "patient", "physiologic nystagmus", "cranial nerve exam", "unremarkable", "patients head", "turned", "left", "back", "stretcher", "exacerbates severe", "nystagmus notable", "patients symptoms", "minutes", "position", "following", "diagnosis"]}
{"question": "A 17-year-old boy is brought to the physician because of progressive right knee pain for the past 3 months. He reports that the pain is worse at night and while doing sports at school. He has not had any trauma to the knee or any previous problems with his joints. His vital signs are within normal limits. Examination of the right knee shows mild swelling and tenderness without warmth or erythema; the range of motion is limited. He walks with an antalgic gait. Laboratory studies show an alkaline phosphatase of 180 U/L and an erythrocyte sedimentation rate of 80 mm/h. An x-ray of the right knee is shown. Which of the following is the most likely diagnosis?", "answer": "Osteosarcoma\n\"", "options": {"A": "Ewing sarcoma", "B": "Chordoma", "C": "Osteochondroma", "D": "Chondrosarcoma", "E": "Osteosarcoma\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "of progressive right", "past 3 months", "reports", "pain", "worse", "night", "not", "trauma", "knee", "previous problems", "joints", "vital signs", "normal limits", "Examination of", "right knee", "mild swelling", "tenderness", "warmth", "erythema", "range of motion", "limited", "walks", "antalgic gait", "Laboratory studies", "alkaline phosphatase", "U/L", "erythrocyte sedimentation rate", "80 mm/h", "x-ray of", "right knee", "following", "diagnosis"]}
{"question": "One hour after being admitted to the hospital for sharp, acute chest pain and diaphoresis, a 55-year-old woman with type 2 diabetes mellitus loses consciousness in the emergency department. There are no palpable pulses. Chest compressions are started. The patient has a history of breast cancer that was surgically treated 4 years ago. Prior to admission, the patient was on a long bus ride to visit her sister. Her medications include tamoxifen, atorvastatin, metoprolol, metformin, and insulin. Serum troponin levels are elevated. The cardiac rhythm is shown. Which of the following is the most appropriate next step in management?", "answer": "Intravenous epinephrine therapy", "options": {"A": "Intravenous glucagon therapy", "B": "Defibrillation", "C": "Coronary angiography", "D": "Intravenous epinephrine therapy", "E": "Intravenous dextrose therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["One hour", "sharp", "acute", "diaphoresis", "year old woman", "type 2 diabetes mellitus", "consciousness", "emergency department", "palpable pulses", "Chest compressions", "started", "patient", "history of breast cancer", "surgically treated 4 years", "patient", "long bus", "to", "medications include tamoxifen", "atorvastatin", "metoprolol", "metformin", "insulin", "Serum troponin levels", "elevated", "cardiac rhythm", "following", "most appropriate next step"]}
{"question": "A 4-year-old boy presents to the opthalmologist for a down- and inward dislocation of the lens in his left eye. On physical exam, the boy has a marfanoid habitus and mental retardation. Biochemical tests were performed to locate the exact defect in this boy. It was found that there was a significant reduction of the conversion of 5,10-methyltetrahydrofolate to 5-methyltetrahydrofolate. Which of the following is the diagnosis?", "answer": "Homocystinuria", "options": {"A": "Marfan syndrome", "B": "Homocystinuria", "C": "Alkaptonuria", "D": "Phenylketonuria", "E": "Maple syrup disease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy presents", "inward dislocation of", "lens", "left eye", "boy", "marfanoid habitus", "mental retardation", "Biochemical tests", "performed to", "exact defect", "boy", "found", "significant reduction", "conversion", "10", "5", "following", "diagnosis"]}
{"question": "A 45-year-old gravida 1, para 0 woman is brought to the hospital in labor at 39 weeks gestation. After 4 hours, she gives birth to a healthy appearing baby boy with APGAR scores of 7 at 1 minute and 9 at 5 minutes. She had limited prenatal screening but did have an ultrasound at 35 weeks that showed polyhydramnios. The next day, the neonate vomits greenish-yellow fluid after breastfeeding. This occurs 2 more times that day after feeding and several times between feedings. The next day, the neonate appears weak with difficulty latching to the breast and is dehydrated. The physician on duty is concerned and orders blood work, IV fluids, and the abdominal X-ray shown below. Which of the following disorders is most associated with the newborn’s condition?", "answer": "Trisomy 21", "options": {"A": "Trisomy 18", "B": "Trisomy 13", "C": "Trisomy 21", "D": "47 XXY", "E": "45 XO"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old gravida 1", "para 0 woman", "brought", "hospital", "labor", "weeks gestation", "4 hours", "gives birth", "healthy appearing baby boy", "APGAR scores", "at 1 minute", "5 minutes", "limited prenatal screening", "ultrasound", "35 weeks", "polyhydramnios", "next day", "neonate vomits", "yellow fluid", "breastfeeding", "occurs 2", "times", "day", "several times", "next day", "neonate appears weak", "difficulty latching", "breast", "dehydrated", "physician", "orders blood", "abdominal X-ray", "following disorders", "most associated with", "newborns condition"]}
{"question": "A 39-year-old woman presents with progressive weakness, exercise intolerance, and occasional dizziness for the past 3 months. Past medical history is unremarkable. She reports an 18-pack-year smoking history and drinks alcohol rarely. Her vital signs include: temperature 36.6°C (97.8°F), blood pressure 139/82 mm Hg, pulse 98/min. Physical examination is unremarkable. Her laboratory results are significant for the following:\nHemoglobin 9.2 g/dL\nErythrocyte count 2.1 million/mm3\nMean corpuscular volume (MCV) 88 μm3\nMean corpuscular hemoglobin (MCH) 32 pg/cell\nLeukocyte count 7,500/mm3\nWhich of the following is the best next step in the management of this patient’s condition?", "answer": "Reticulocyte count", "options": {"A": "Serum ferritin level", "B": "C-reactive protein (CRP)", "C": "Reticulocyte count", "D": "Direct antiglobulin test", "E": "Bone marrow biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "progressive weakness", "exercise intolerance", "occasional dizziness", "past 3 months", "Past medical history", "unremarkable", "reports", "smoking history", "alcohol rarely", "vital signs include", "temperature 36", "97", "blood pressure", "mm Hg", "pulse 98 min", "unremarkable", "laboratory results", "significant", "following", "Hemoglobin", "g", "Erythrocyte", "mm3 Mean corpuscular volume", "pg/cell Leukocyte", "7", "following", "best next step", "management", "patients condition"]}
{"question": "A 71-year-old woman presents to the clinic after an X-ray that revealed compression fractures of her L1 and L2 vertebral bodies due to osteoporotic changes. The patient has a history of hypertension for which she takes hydrochlorothiazide, and rheumatoid arthritis, for which she has been taking prednisone for the last 2 years. The patient states that she had a dual-energy X-ray absorptiometry (DEXA) scan 3 years ago that was normal and attributes that finding to regularly taking calcium and vitamin D supplements since then. The patient states that her pain from the fractures is stopping her from participating in her regular activities, such as exercising and gardening. Which of the following is the main cause of her osteoporosis?", "answer": "Bone depletion due to chronic corticosteroid use", "options": {"A": "Decreased estrogen levels", "B": "Hydrochlorothiazide (HCTZ) therapy", "C": "Calcium malabsorption", "D": "Bone depletion due to chronic corticosteroid use", "E": "Undiagnosed hyperparathyroidism"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic", "X-ray", "revealed compression fractures", "L1", "L2 vertebral bodies due to", "changes", "patient", "history of hypertension", "hydrochlorothiazide", "rheumatoid arthritis", "prednisone", "years", "patient states", "dual-energy X-ray absorptiometry", "scan", "years", "normal", "attributes", "finding", "calcium", "vitamin D supplements since then", "patient states", "pain", "fractures", "stopping", "participating", "regular", "exercising", "following", "main cause", "osteoporosis"]}
{"question": "A 24-year-old male is brought in by ambulance to the emergency department after he was found unresponsive at home for an unknown length of time. Upon arrival, he is found to be severely altered and unable to answer questions about his medical history. Based on clinical suspicion, a panel of basic blood tests are obtained including an arterial blood gas, which shows a pH of 7.32, a pCO2 of 70, and a sodium bicarbonate level of 30 mg/dl. Which of the following is most likely the primary disturbance leading to the values found in the ABG?", "answer": "Respiratory acidosis", "options": {"A": "Metabolic acidosis", "B": "Metabolic alkalosis", "C": "Respiratory acidosis", "D": "Respiratory alkalosis", "E": "Mixed alkalosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male", "brought", "ambulance", "emergency department", "found unresponsive", "home", "unknown length", "time", "arrival", "found to", "severely altered", "unable to", "medical history", "Based", "clinical", "panel", "basic blood tests", "obtained including", "arterial blood gas", "pH", "7", "pCO2", "70", "sodium", "30 mg/dl", "following", "primary disturbance leading", "values found", "ABG"]}
{"question": "A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Tear in the tunica intima", "options": {"A": "Tear in the tunica intima", "B": "Fibrofatty plaque in the aortic wall", "C": "Obstruction of the pulmonary arteries", "D": "Rupture of a bulla in the lung", "E": "Perforation of the esophageal wall"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65-year-old man", "hypertension", "type 2 diabetes mellitus", "brought", "emergency department 20 minutes", "onset of severe anterior chest pain", "shortness of breath", "smoked one pack", "cigarettes daily", "30 years", "appears", "pulse", "min", "respirations", "min", "blood pressure", "88 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "98", "high-pitched", "blowing", "diastolic murmur", "heard", "right upper sternal border", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 19-year-old woman comes to the physician because of worsening pain with swallowing for 3 days and a dry sensation in the mouth over the past week. She has a history of asthma controlled with inhaled fluticasone and albuterol. Physical examination shows white plaques on the dorsal surface of the tongue and buccal mucosa that bleed when scraped off. Which of the following is the most appropriate pharmacotherapy?", "answer": "Nystatin", "options": {"A": "Triamcinolone", "B": "Nystatin", "C": "Acyclovir", "D": "Griseofulvin", "E": "Amphotericin B"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of worsening pain with swallowing", "3 days", "dry sensation", "mouth", "past week", "history of asthma controlled", "inhaled fluticasone", "albuterol", "white plaques", "dorsal surface of", "tongue", "buccal mucosa", "bleed", "scraped", "following", "most appropriate pharmacotherapy"]}
{"question": "A 23-year-old woman presents with ongoing diplopia for 1 week. She has noticed that her diplopia is more prominent when she looks at objects in her periphery. It does not present when looking straight ahead. She does not have a fever, headache, ocular pain, lacrimation, blurring of vision, or changes in her color vision. She is a college student and is otherwise healthy. The neurological examination reveals that when she looks to the left, her right eye does not adduct while her left eye abducts with nystagmus. Furthermore, when she looks to the right, her left eye does not adduct while her right eye abducts with prominent nystagmus. Her pupils are bilateral, equal and reactive to light and accommodation. The convergence is normal. The rest of the cranial nerve examination is unremarkable. What is the next best step in the management of this patient?", "answer": "Magnetic resonance imaging (MRI) of the brain", "options": {"A": "Computed tomography (CT) scan of the head", "B": "Lumbar puncture", "C": "Magnetic resonance imaging (MRI) of the brain", "D": "Ophthalmology referral", "E": "Visual evoked potential"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old woman presents", "diplopia", "1 week", "diplopia", "more prominent", "looks", "periphery", "not present", "looking straight", "not", "fever", "headache", "ocular pain", "lacrimation", "blurring of vision", "changes", "color", "healthy", "neurological examination reveals", "looks", "left", "right eye", "not", "left eye", "nystagmus", "looks", "right", "left eye", "not", "right eye", "prominent nystagmus", "pupils", "bilateral", "equal", "reactive to light", "accommodation", "convergence", "normal", "unremarkable", "next best step", "patient"]}
{"question": "A 22-year-old man is brought to the physician by his mother because of concerns about his recent behavior. Three months ago, the patient first reported hearing loud voices coming from the ceiling of his room. During this time, he has also become increasingly worried that visitors to the house were placing secret surveillance cameras. Mental status examination shows tangential speech with paranoid thoughts. Treatment for this patient's condition predominantly targets which of the following dopaminergic pathways?", "answer": "Mesolimbic pathway", "options": {"A": "Mesolimbic pathway", "B": "Thalamocortical pathway", "C": "Mesocortical pathway", "D": "Corticostriatal pathway", "E": "Nigrostriatal pathway"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "physician", "mother", "concerns", "recent behavior", "Three months", "patient first reported hearing loud voices", "room", "time", "worried", "house", "placing secret surveillance cameras", "Mental status", "tangential speech", "Treatment", "patient's condition", "targets", "following dopaminergic"]}
{"question": "A 22-year-old woman at 30 weeks gestation presents to the obstetrician with the sudden onset of fever, headache, anorexia, fatigue, and malaise. She mentioned that she had eaten ice cream 3 days ago. Blood cultures show gram-positive rods that are catalase-positive and display distinctive tumbling motility in liquid medium. What is the most likely diagnosis?", "answer": "Listeriosis", "options": {"A": "Brucellosis", "B": "Influenza", "C": "Listeriosis", "D": "Legionnaires' disease", "E": "Tularaemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "30 weeks presents", "obstetrician", "sudden", "fever", "headache", "anorexia", "fatigue", "malaise", "eaten", "days", "Blood cultures", "catalase positive", "display", "liquid", "diagnosis"]}
{"question": "A 48-year-old woman presents to the emergency room because of severe back pain after a fall. She says that she was walking home from work when she slipped on a patch of ice on the sidewalk. Since she did not have anything to hold onto, she fell backwards and landed on her posterior iliac crests bilaterally. Immediately after the fall, she started experiencing back pain and tenderness that concerned her enough to call for an ambulance. Her past medical history is significant for arthritis, diabetes, and hypertension. On arrival, her temperature is 99°F (37.2°C), blood pressure is 129/86 mmHg, pulse is 112/min, respirations are 19/min. Physical exam reveals tenderness to palpation over the middle of her lower back. A drug that may have predisposed this patient to this outcome most likely has which of the following mechanisms?", "answer": "Inhibition of leukotriene and prostaglandin production", "options": {"A": "Inhibition of leukotriene and prostaglandin production", "B": "Inhibition of circulating cytokine", "C": "Inhibition of folate processing", "D": "Inhibition of prostaglandin production alone", "E": "Stimulation of adipocyte transcription factor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["48 year old woman presents", "emergency room", "of severe back pain", "fall", "home", "work", "patch", "ice", "sidewalk", "not", "to hold", "fell backwards", "landed", "posterior iliac crests", "Immediately", "fall", "started", "back pain", "tenderness", "to call", "ambulance", "past medical history", "significant", "arthritis", "diabetes", "hypertension", "arrival", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "reveals tenderness", "palpation", "middle", "lower back", "drug", "predisposed", "likely", "following mechanisms"]}
{"question": "A 32-year-old woman presents for a follow-up visit. She was diagnosed with type 2 diabetes mellitus a month ago but refused to start medications despite counseling due to her fear of gaining weight. She tried exercising and eating healthy in an attempt to ''cure'' her diabetes. She managed to lose 1.8 kg (4 lb) in a month. Today she still complains of increased urinary frequency, the same symptom that leads to her initial suspicion of diabetes. No other significant past medical history. She is happily married and plans on having kids in the next few years. The patient is a non-smoker, denies illicit drug use, and drinks socially. Her vital signs show a pulse of 80/min, a respiratory rate of 16/min, a blood pressure of 120/80 mm Hg, and a temperature of 36.9°C (98.4°F). Her BMI is 33.0 kg/m2. Physical exam findings are unremarkable. Her fingerstick glucose today is 214 mg/dL. Laboratory findings reveal the following:\nGlycated Hemoglobin (HbA1c) 7.1%\nBlood glucose (fasting) 130 mg/dL\nSerum:\nSodium 142 mEq/L\nPotassium 3.9 mEq/L\nChloride 101 mEq/L\nSerum creatinine 0.8 mg/dL\nBlood urea nitrogen 9 mg/dL\nUrinalysis shows:\nGlucose Positive\nKetones Negative\nLeukocytes Negative\nNitrites Negative\nRBCs Negative\nCasts Negative\nWhich of the following is the best treatment option for this patient?", "answer": "Start metformin.", "options": {"A": "Start insulin.", "B": "Start glipizide.", "C": "Start metformin.", "D": "Start exenatide.", "E": "Start empagliflozin."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "diagnosed", "type 2 diabetes mellitus", "month", "to start medications", "counseling due to", "gaining weight", "exercising", "eating healthy", "to", "diabetes", "to", "1.8 kg", "4", "month", "Today", "increased urinary frequency", "same symptom", "leads", "initial", "diabetes", "significant past medical history", "married", "plans", "next", "years", "patient", "non-smoker", "illicit drug use", "vital signs", "pulse", "80 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "temperature", "36", "98", "BMI", "0 kg/m2", "Physical exam findings", "unremarkable", "fingerstick glucose today", "mg/dL", "Laboratory findings reveal", "following", "Glycated Hemoglobin", "Blood glucose", "fasting", "mg/dL Serum", "Sodium", "mEq/L", "Chloride", "creatinine", "Blood urea", "Urinalysis", "Glucose Positive Ketones Negative", "Casts Negative", "following", "best treatment option", "patient"]}
{"question": "A previously healthy 30-year-old woman comes to the physician because of a 6-month history of a recurring rash that typically occurs on exposure to the sun and affects only the face. She also has noticed several nonpainful ulcers on the roof of her mouth. She is sexually active with one male partner and they use condoms inconsistently. Her mother has end-stage renal disease. The patient does not smoke or drink alcohol. Her vital signs are within normal limits. Physical examination shows an erythematous rash across the cheeks that spares the nasolabial folds. There are three small ulcers on the hard palate. Laboratory studies show:\nLeukocyte count 3,000/mm3\nPlatelet count 70,000/mm3\nErythrocyte sedimentation rate 80 mm/h\nSerum\nAntinuclear antibodies 1:320\nAnti-Smith antibodies positive\nUrine\nProtein 3+\nRBC casts negative\nRBCs none\nWBCs 10–15/hpf\nWhich of the following is the most appropriate next step in management?\"", "answer": "Renal biopsy", "options": {"A": "Skin biopsy", "B": "Renal biopsy", "C": "Administration of hydroxychloroquine", "D": "Administration of azathioprine", "E": "Pathergy skin testing"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy 30 year old woman", "physician", "month history", "recurring rash", "occurs", "exposure", "sun", "only", "face", "ulcers", "roof of", "mouth", "sexually active", "one male", "use condoms", "end-stage renal disease", "patient", "not smoke", "vital signs", "normal limits", "erythematous rash", "cheeks", "nasolabial folds", "three small ulcers", "hard palate", "Laboratory studies", "Leukocyte", "mm3 Platelet count 70", "Erythrocyte sedimentation rate 80 mm/h Serum Antinuclear antibodies 1 320 Anti-Smith antibodies positive Urine", "RBC casts negative", "WBCs", "hpf", "following", "most appropriate next step"]}
{"question": "A 59-year-old man presents to the emergency room for a fever that has persisted for over 4 days. In addition, he has been experiencing weakness and malaise. His past medical history is significant for a bicuspid aortic valve that was replaced 2 years ago. Physical exam reveals nailbed splinter hemorrhages, tender nodules on his fingers, and retinal hemorrhages. An echocardiogram shows aortic valve vegetations and culture reveals a gram-positive alpha-hemolytic organism that grows as cocci in chains. The organism is then exposed to optochin and found to be resistant. Finally, they are seen to ferment sorbitol. The most likely cause of this patient's symptoms is associated with which of the following?", "answer": "Dental procedures", "options": {"A": "Colon cancer", "B": "Dental procedures", "C": "IV drug use", "D": "Pneumonia", "E": "Sexual activity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["59 year old man presents", "emergency room", "fever", "days", "addition", "weakness", "malaise", "past medical history", "significant", "bicuspid aortic valve", "replaced 2 years", "reveals nailbed splinter hemorrhages", "tender nodules on", "fingers", "retinal hemorrhages", "echocardiogram", "aortic valve vegetations", "culture reveals", "gram positive alpha-hemolytic", "chains", "then exposed to optochin", "found to", "resistant", "seen", "ferment sorbitol", "most likely cause", "patient's symptoms", "associated with"]}
{"question": "A previously healthy 2-year-old boy is brought to the physician by his mother after 2 days of fever, runny nose, hoarseness, and severe, dry cough. He appears restless. His temperature is 38.1°C (100.5°F), and his respiratory rate is 39/min. Examination shows clear rhinorrhea and a barking cough. There is a prolonged inspiratory phase with a harsh stridor upon agitation. An x-ray of the neck shows tapering of the subglottic region. Which of the following is the most likely causal organism?", "answer": "Parainfluenza virus", "options": {"A": "Adenovirus", "B": "Streptococcus pneumoniae", "C": "Haemophilus influenzae", "D": "Parainfluenza virus", "E": "Measles morbillivirus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "mother", "2 days", "fever", "runny nose", "hoarseness", "severe", "dry cough", "appears restless", "temperature", "100", "respiratory rate", "min", "clear rhinorrhea", "barking cough", "prolonged inspiratory phase", "harsh stridor", "agitation", "x-ray", "neck", "subglottic region", "following", "causal"]}
{"question": "An 18-month-old boy is presented to the emergency department by his parents due to swelling in his right knee after playing in the park. His parents say there was no obvious injury. After questioning, the mother says that an uncle of hers had similar problems. The vital signs include heart rate 146/min, respiratory rate 26/min, temperature 37.1°C (98.8°F) and blood pressure 90/52 mm Hg. On physical examination, the swelling of the right knee is evident. The rest of the physical findings are unremarkable. The ultrasound is compatible with the hemarthrosis of the right knee. The complete blood count (CBC) results are as follows:\nHemoglobin 12.2 g/dL\nHematocrit 36%\nLeukocyte count 7,300/mm3\nNeutrophils 45%\nBands 3%\nEosinophils 1%\nBasophils 0%\nLymphocytes 44%\nMonocytes 2%\nPlatelet count 200,000/mm³\nThe coagulation test results are as follows:\nPartial thromboplastin time (activated) 52.0 s\nProthrombin time 14.0 s\nReticulocyte count 1.2%\nThrombin time < 2 seconds deviation from control\nWhat is the most likely diagnosis?", "answer": "Hemophilia A", "options": {"A": "Marfan syndrome", "B": "Von Willebrand disease", "C": "Ehler-Danlos disease", "D": "Hemophilia A", "E": "Bernard-Soulier disease"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "emergency department", "due to swelling", "right knee", "playing", "park", "injury", "similar", "vital signs include heart rate", "min", "respiratory rate", "min", "temperature", "98", "blood pressure 90", "mm Hg", "swelling of", "right knee", "physical findings", "unremarkable", "ultrasound", "compatible", "hemarthrosis of", "right knee", "complete blood count", "CBC", "results", "follows", "Hemoglobin", "g/dL Hematocrit", "count", "mm3", "Bands", "Eosinophils", "Basophils", "Lymphocytes", "Platelet count 200", "mm", "coagulation test results", "follows", "Partial thromboplastin time", "52 0", "Prothrombin time", "Reticulocyte count 1 2", "Thrombin time", "2 seconds deviation", "control", "diagnosis"]}
{"question": "A 32-year-old man presents to the clinic for follow up for treatment of latent tuberculosis. He is a healthcare worker and began isoniazid 3 months ago after a routine PPD yielded a 12-mm induration. He feels otherwise well and attributes this to his vegetarian diet that he has been following for the past 4 years. His past medical history is unremarkable, but his family history is significant for a \"liver disease,\" the specifics of which are unknown. Physical exam shows mildly reduced sensation to pinprick over the distal lower extremities. The abdomen is soft, nontender, and without hepatosplenomegaly. Laboratory studies demonstrate the following:\n\nSerum:\nHemoglobin: 9.6 g/dL\nHematocrit: 34%\nLeukocyte count: 9,200/mm^3 with normal differential\nPlatelets: 270,000/mm^3\nMean corpuscular volume: 77 µm^3\nAST: 92 U/L\nALT: 84 U/L\nFerritin: 302 ng/mL (normal 15-200 ng/mL)\nTotal iron: 273 µg/dL (normal 50-170 µg/dL)\nTIBC: 150 µg/dL (normal 250–370 µg/dL)\n\nWhich of the following is the most appropriate next step in management?", "answer": "Pyridoxine supplementation", "options": {"A": "Blood lead levels", "B": "Cobalamin supplementation", "C": "Pyridoxine supplementation", "D": "Serial phlebotomy", "E": "Stop isoniazid treatment"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "clinic", "follow up", "treatment", "latent", "healthcare worker", "began isoniazid", "months", "routine PPD", "mm induration", "well", "attributes", "vegetarian diet", "following", "past", "years", "past medical history", "unremarkable", "family history", "significant", "liver disease", "specifics", "unknown", "mildly reduced sensation", "pinprick", "distal lower extremities", "abdomen", "soft", "nontender", "hepatosplenomegaly", "Laboratory studies", "following", "Serum", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "200 mm", "normal differential Platelets", "mm", "Mean corpuscular volume", "m", "AST", "U/L ALT", "84 U/L Ferritin", "ng/mL", "normal", "200 ng/mL", "Total iron", "g/dL", "normal 50", "g/dL", "TIBC", "g/dL", "normal", "g/dL", "following", "most appropriate next step"]}
{"question": "A case-control study with a focus on risk factors that may influence the development of depression was conducted among the elderly population in one tertiary hospital in Malaysia. The study involved 150 elderly patients diagnosed with depressive illness from the psychiatry ward, as well as another group of 150 elderly patients without any history of depressive illness (but hospitalized for other reasons) at the same ward. The data were collected through questionnaires, and 2 principal investigators (who were also the patients’ attending physicians) acted as interviewers after proper training for the purposes of this study. Multivariate analyses of logistic regression with independent variables were employed to determine the adjusted odds ratio for the risk of developing depression. The study results showed that a lower level of social support, lack of education, and the presence of chronic illnesses highly correlated with depression. In order to maximally avoid bias that may stem from this kind of study design, what should the researchers have done differently to increase the validity of their results?", "answer": "Blinded the investigators", "options": {"A": "Used open-ended questions", "B": "Included more interviewers", "C": "Blinded the investigators", "D": "Used Bonferroni correction on data", "E": "Used closed testing procedures on the data"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["focus", "risk factors", "development", "depression", "population", "one tertiary hospital", "Malaysia", "study involved", "elderly patients diagnosed", "depressive illness", "psychiatry ward", "group", "elderly patients", "history", "depressive illness", "hospitalized", "same ward", "data", "collected", "2 principal investigators", "attending", "acted", "interviewers", "training", "independent variables", "employed to", "adjusted odds ratio", "depression", "study results", "lower level", "lack of education", "presence", "chronic illnesses highly correlated", "depression", "order", "stem", "kind", "researchers", "to increase", "validity of", "results"]}
{"question": "A 28-year-old woman presents with weight gain and a milky-white discharge from her breasts. Patient says she noticed herself gaining weight and a milky white discharge from her breasts. Past medical history is significant for schizophrenia, recently diagnosed and treated with risperidone. No history of headache, nausea, and vomiting. No other current medications. Her last menstrual period was 2 months ago. Review of systems is significant for decreased libido. Patient is afebrile and vital signs are within normal limits. On physical examination, patient had a weight gain of 3 kg (6.6 lb) over the past month. There is bilateral breast tenderness present. A urine pregnancy test is negative. Which of the following is the most likely etiology of this patient’s symptoms?", "answer": "Decrease in dopamine activity in tuberoinfundibular pathway", "options": {"A": "Decrease in dopamine activity in mesolimbic pathway", "B": "Increase in dopamine activity in mesolimbic pathway", "C": "Decrease in dopamine activity in tuberoinfundibular pathway", "D": "Increase in dopamine activity in tuberoinfundibular pathway", "E": "Decrease in dopamine activity in nigrostriatal pathway"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "weight gain", "milky white", "breasts", "gaining weight", "milky white discharge", "breasts", "Past medical history", "significant", "schizophrenia", "recently diagnosed", "treated with risperidone", "history of headache", "nausea", "vomiting", "current medications", "last menstrual period", "2 months", "Review of systems", "significant", "decreased libido", "Patient", "afebrile", "vital signs", "normal limits", "patient", "weight gain", "kg", "6.6", "past month", "bilateral present", "urine pregnancy test", "negative", "following", "etiology", "patients symptoms"]}
{"question": "A 55-year-old man is brought to the emergency department for the evaluation of severe chest pain for the last hour. The pain travels along the left arm and upper jaw. The patient also reports difficulty breathing and profuse sweating. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the last 35 years. His medications include enalapril and metformin. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 90/60 mm Hg. An ECG shows ST elevation in the leads II, III, and aVF. Morphine is administered and oxygen supplementation and fluid resuscitation are begun. Shortly after, the patient becomes unstable. Following emergency resuscitation and stabilization, a written advance directive provided by the patient's primary care physician shows a do-not-resuscitate (DNR) order. The patient's wife, who is the power of attorney, disagrees. Which of the following is the most appropriate next step in management of this patient?", "answer": "Supportive care only", "options": {"A": "Obtain court order to revoke written advance directive", "B": "Supportive care only", "C": "Reperform resuscitation when needed", "D": "Contact the patient's oldest child", "E": "Contact the ethics committee"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "of severe chest pain", "last hour", "pain", "left arm", "upper jaw", "patient", "reports difficulty breathing", "profuse sweating", "hypertension", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "last 35 years", "medications include enalapril", "metformin", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "90 60 mm Hg", "ECG", "ST elevation", "leads", "III", "aVF", "Morphine", "administered", "oxygen supplementation", "fluid resuscitation", "begun", "patient", "unstable", "Following emergency resuscitation", "stabilization", "written advance directive", "patient's primary care physician", "do-not-resuscitate", "patient's", "power of attorney", "disagrees", "following", "most appropriate next step", "patient"]}
{"question": "An 11-month-old boy is brought to a pediatrician by his parents for evaluation of vomiting and watery diarrhea over the last day. The mother informs the pediatrician that the boy had consumed an apple bought from a fruit vendor on the previous day, but that otherwise there has been no recent change in his diet. There is no history of blood in the stool, flatulence, irritability, or poor appetite. There is no history of recurrent or chronic diarrhea or any other gastrointestinal symptoms. On physical examination, his temperature is 37.6°C (99.6°F), pulse is 120/min, respirations are 24/min, and blood pressure is 92/60 mm Hg. General examination reveals a playful infant with normal skin turgor and no sunken eyes. The pediatrician explains to the parents that he most likely has acute gastroenteritis and that no specific medication is indicated at present. He also instructs the parents about his diet during the illness and reviews the danger signs of dehydration. He suggests a follow-up evaluation after 48 hours or earlier if any complications arise. Which of the following dietary recommendations did the pediatrician make?", "answer": "Age-appropriate diet", "options": {"A": "Age-appropriate diet", "B": "BRAT diet", "C": "Plenty of juices and carbonated sodas", "D": "Diluted formula milk", "E": "Lactose-free diet"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "pediatrician", "vomiting", "watery diarrhea", "day", "informs", "pediatrician", "boy", "apple", "vendor", "previous day", "recent change", "diet", "history", "blood", "stool", "flatulence", "irritability", "poor appetite", "history", "recurrent", "chronic diarrhea", "gastrointestinal symptoms", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "General", "reveals", "playful infant", "normal skin turgor", "sunken eyes", "pediatrician", "most likely", "acute gastroenteritis", "specific medication", "indicated", "present", "diet", "illness", "signs", "dehydration", "follow-up", "48 hours", "earlier", "complications", "following dietary", "pediatrician make"]}
{"question": "A 28-year-old female is brought to the emergency department after being found unconscious outside of a local night club by her friends. On arrival the patient is stuporous. Her temperature is 35°C (95°F), blood pressure is 105/75 mm Hg, pulse is 55/min, and respirations are 10/min. Examination shows dry mucous membranes. The pupils are small and react sluggishly to light. She does not respond to any commands, and painful stimuli cause her to withdraw all extremities. No injection marks can be found on her extremities. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of her symptoms?", "answer": "Heroin", "options": {"A": "Amitriptyline", "B": "Phencyclidine", "C": "MDMA", "D": "Heroin", "E": "Cannabis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old female", "brought", "emergency department", "found unconscious outside", "local night club", "arrival", "patient", "stuporous", "temperature", "blood pressure", "75 mm Hg", "pulse", "min", "respirations", "10/min", "dry mucous membranes", "pupils", "small", "light", "not", "painful", "cause", "to", "extremities", "injection marks", "found", "extremities", "abnormalities", "following", "most likely cause", "symptoms"]}
{"question": "A previously healthy 5-year-old boy is brought to the physician because of increasing weakness and a retroauricular rash that started 2 days ago. The rash spread rapidly and involves the trunk and extremities. Last week, he had a mild sore throat, pink eyes, and a headache. His family recently immigrated from Ethiopia. His immunization status is unknown. The patient appears severely ill. His temperature is 38.5°C (101.3°F). Examination shows tender postauricular and suboccipital lymphadenopathy. There is a nonconfluent, maculopapular rash over the torso and extremities. Infection with which of the following is the most likely cause of this patient's symptoms?", "answer": "Togavirus", "options": {"A": "Togavirus", "B": "Varicella zoster virus", "C": "Parvovirus", "D": "Human herpesvirus 6", "E": "Paramyxovirus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "increasing weakness", "rash", "started 2 days", "rash spread rapidly", "trunk", "extremities", "week", "mild sore throat", "pink eyes", "headache", "recently", "Ethiopia", "immunization status", "unknown", "patient appears severely ill", "temperature", "tender postauricular", "suboccipital lymphadenopathy", "nonconfluent", "maculopapular rash", "torso", "extremities", "Infection", "following", "most likely cause", "patient's symptoms"]}
{"question": "A previously healthy 14-year-old girl is brought to the emergency department by her mother because of abdominal pain, nausea, and vomiting for 6 hours. Over the past 6 weeks, she has also had increased frequency of urination, and she has been drinking more water than usual. She has lost 6 kg (13 lb) over the same time period despite having a good appetite. Her temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 32/min, and blood pressure is 94/58 mm Hg. She appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to show which of the following findings?", "answer": "Decreased total body potassium", "options": {"A": "Increased arterial pCO2", "B": "Increased arterial blood pH", "C": "Excess water retention", "D": "Serum glucose concentration > 800 mg/dL", "E": "Decreased total body potassium"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old girl", "brought", "emergency department", "abdominal pain", "nausea", "vomiting", "hours", "past", "weeks", "increased frequency of urination", "drinking more water", "usual", "lost", "kg", "same time period", "good appetite", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "58 mm Hg", "appears lethargic", "deep", "labored breathing", "dry mucous membranes", "abdomen", "soft", "diffuse tenderness", "palpation", "guarding", "Urine dipstick", "positive", "ketones", "glucose", "Further", "to", "following findings"]}
{"question": "A 40-year-old woman with ongoing dyspnea returns to her physician for a follow-up appointment. After an abnormal echocardiogram and pulmonary function testing revealed an isolated reduction in DLCO, a right heart catheterization was ordered to confirm the physician's clinical suspicion. She has family members with similar findings and genetic testing revealed a mutation in the BMPR2 gene. A representative lesion from lung biopsy histology is shown in figure A. Given the patient's clinical presentation and test results, which of the following pharmacologic therapies will the physician most likely provide?", "answer": "Vasodilator", "options": {"A": "Plasmapheresis", "B": "Inhibitor of nitric oxide", "C": "Bronchodilator", "D": "Immunosuppression", "E": "Vasodilator"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "dyspnea returns", "physician", "follow-up appointment", "abnormal echocardiogram", "pulmonary function testing revealed", "isolated reduction", "DLCO", "right heart catheterization", "ordered to confirm", "physician's clinical", "similar findings", "genetic testing revealed", "mutation", "BMPR2", "lesion", "lung histology", "Given", "patient's", "test results", "following pharmacologic therapies", "physician", "likely"]}
{"question": "An infant boy of unknown age and medical history is dropped off in the emergency department. The infant appears lethargic and has a large protruding tongue. Although the infant exhibits signs of neglect, he is in no apparent distress. The heart rate is 70/min, the respiratory rate is 30/min, and the temperature is 35.7°C (96.2°F). Which of the following is the most likely cause of the patient’s physical exam findings?", "answer": "Congenital agenesis of an endocrine gland in the anterior neck", "options": {"A": "Mutation in the WT2 gene", "B": "Congenital agenesis of an endocrine gland in the anterior neck", "C": "Excess growth hormone secondary to pituitary gland tumor", "D": "Type I hypersensitivity reaction", "E": "Autosomal dominant mutation in the SERPING1 gene"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["infant boy", "unknown age", "medical history", "emergency department", "infant appears lethargic", "large protruding tongue", "infant", "signs", "neglect", "distress", "heart rate", "70 min", "respiratory rate", "30/min", "temperature", "35", "96", "following", "most likely cause", "patients physical exam findings"]}
{"question": "A 55-year-old woman is brought to the emergency department because of worsening upper abdominal pain for 8 hours. She reports that the pain radiates to the 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": "Hemorrhagic fluid loss", "B": "Decreased albumin concentration", "C": "Decreased cardiac output", "D": "Increased excretion of water", "E": "Capillary leakage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "emergency department", "of worsening upper abdominal pain", "8 hours", "reports", "pain radiates", "back", "associated with nausea", "hypertension", "hyperlipidemia", "enalapril", "furosemide", "simvastatin", "temperature", "99.5 F", "blood pressure", "84 58 mm Hg", "pulse", "min", "lungs", "clear", "auscultation", "abdominal distention", "epigastric tenderness", "guarding", "Bowel sounds", "decreased", "Extremities", "warm", "Laboratory studies", "Hematocrit 48", "Leukocyte count", "800 mm3 Platelet count", "Serum", "Calcium", "0 mg/dL Urea nitrogen 32", "Amylase", "U/L", "ECG", "sinus tachycardia", "following", "underlying cause", "patient", "ital sign  bnormalities?"]}
{"question": "A 59-year-old man with a history of major depressive disorder, asthma, and erectile dysfunction presents to his family physician complaining of depressed mood, amotivation, overeating, and anhedonia. He currently takes no medications. The patient has a 3 pack-year smoking history and would like to quit but has been unsuccessful in the past. His BMI is 29 kg/m^2. The physician suggests starting an antidepressant for the patient's mood symptoms. The patient is reluctant, as he used to take sertraline, but stopped it after his erectile dysfunction worsened. Which of the following antidepressants would be most appropriate for this patient?", "answer": "Bupropion", "options": {"A": "Amitriptyline", "B": "Bupropion", "C": "Citalopram", "D": "Mirtazapine", "E": "Sertraline"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old man", "history of major depressive disorder", "asthma", "erectile dysfunction presents", "family physician", "depressed mood", "amotivation", "overeating", "anhedonia", "currently", "medications", "patient", "3 year smoking history", "to", "unsuccessful", "past", "BMI", "29 kg/m", "physician", "starting", "antidepressant", "patient's symptoms", "patient", "used to", "sertraline", "stopped", "erectile dysfunction worsened", "following antidepressants", "most appropriate", "patient"]}
{"question": "A 70-year-old woman presents with a 2-week history of severe fatigue. Over the past month, she has unintentionally lost 2 kg (4.4 lb). Three years ago, she was diagnosed with myelodysplastic syndrome. Currently, she takes no medications other than aspirin for occasional knee pain. She does not smoke or drink alcohol. Her vital signs are within the normal range. On physical examination, her conjunctivae are pale. Petechiae are present on the distal lower extremities and on the soft and hard palates. Palpation reveals bilateral painless cervical lymphadenopathy. Examination of the lungs, heart, and abdomen shows no abnormalities. Laboratory studies show:\nHemoglobin 9 g/dL\nMean corpuscular volume 90 μm3\nLeukocyte count 3000/mm3\nPlatelet count 20,000/mm3\nA Giemsa-stained peripheral blood smear is shown in the image. Which of the following best explains these findings?", "answer": "Acute myeloid leukemia", "options": {"A": "Acute myeloid leukemia", "B": "Aplastic anemia", "C": "Chronic myelogenous leukemia", "D": "Hairy cell leukemia", "E": "Primary myelofibrosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old woman presents", "2-week history", "severe fatigue", "past month", "lost 2 kg", "4.4", "Three years", "diagnosed", "myelodysplastic syndrome", "Currently", "medications", "aspirin", "occasional knee pain", "not smoke", "vital signs", "normal range", "conjunctivae", "pale", "Petechiae", "present", "distal lower extremities", "soft", "hard palates", "Palpation reveals bilateral painless cervical lymphadenopathy", "lungs", "heart", "abdomen", "abnormalities", "Laboratory studies", "Hemoglobin", "g/dL Mean corpuscular volume 90 m3 Leukocyte count 3000 mm3 Platelet count", "Giemsa-stained peripheral blood smear", "following best", "findings"]}
{"question": "A 16-year-old man with no significant past medical, surgical, or family history presents to his pediatrician with new symptoms following a recent camping trip. He notes that he went with a group of friends and 1 other group member is experiencing similar symptoms. Over the past 5 days, he endorses significant flatulence, nausea, and greasy, foul-smelling diarrhea. He denies tenesmus, urgency, and bloody diarrhea. The blood pressure is 118/74 mm Hg, heart rate is 88/min, respiratory rate is 14/min, and temperature is 37.0°C (98.6°F). Physical examination is notable for mild, diffuse abdominal tenderness. He has no blood in the rectal vault. What is the patient most likely to report about his camping activities?", "answer": "Collecting water from a stream, without boiling or chemical treatment", "options": {"A": "Collecting water from a stream, without boiling or chemical treatment", "B": "Recent antibiotic prescription", "C": "This has been going on for months.", "D": "The patient camped as a side excursion from a cruise ship.", "E": "The patient camped in Mexico."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "significant past medical", "surgical", "family history presents", "pediatrician", "new symptoms following", "recent", "trip", "notes", "1", "group member", "similar symptoms", "past", "days", "significant flatulence", "nausea", "greasy", "smelling diarrhea", "tenesmus", "urgency", "bloody diarrhea", "blood pressure", "74 mm Hg", "heart rate", "88 min", "respiratory rate", "min", "temperature", "98", "notable", "mild", "diffuse abdominal tenderness", "blood", "rectal vault", "patient", "to report"]}
{"question": "A 57-year-old woman comes to the physician because of a 1-month history of multiple swellings in both her axillae. She says they are generally painless, but are sometimes painful on the weekends. She also has increased fatigue, recurring low-grade fevers, and generalized pruritus. She does not smoke. She drinks five to six beers on the weekends. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 130/70 mm Hg. Physical examination reveals multiple firm and nontender axillary lymph nodes. A lymph node biopsy shows multinucleate giant lymphocytes with prominent nucleoli that resemble eosinophilic inclusions. Which of the following additional findings would be associated with a poor prognosis in this patient?", "answer": "Erythocyte sedimentation rate of 65 mm/h\n\"", "options": {"A": "Mediastinal tumor occupying 7% of the chest's width", "B": "Axillary tumor 6 cm across", "C": "Nodular lymphocyte predominant type tumor", "D": "Leukocyte count of 9,000/mm3", "E": "Erythocyte sedimentation rate of 65 mm/h\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["57 year old woman", "physician", "month history", "multiple swellings", "axillae", "painless", "sometimes painful", "weekends", "increased fatigue", "recurring low-grade fevers", "generalized pruritus", "not smoke", "five", "six", "weekends", "temperature", "98", "pulse", "80 min", "respirations", "min", "blood pressure", "70 mm Hg", "reveals multiple firm", "nontender axillary lymph nodes", "lymph node biopsy", "multinucleate giant lymphocytes", "prominent nucleoli", "eosinophilic inclusions", "following additional findings", "associated with", "poor prognosis", "patient"]}
{"question": "A 43-year-old man comes to the emergency room complaining of chest discomfort. He describes the feeling as \"tightness,\" and also reports weakness and palpitations for the past hour. He denies shortness of breath, diaphoresis, or lightheadedness. He has no significant past medical history, and does not smoke, drink, or use illicit drugs. His father had a myocardial infarction at age 72. He is afebrile, heart rate is 125 bpm, and his blood pressure is 120/76. He is alert and oriented to person, place, and time. His electrocardiogram is shown below. Which of the following tests should be ordered in the initial work-up of this patient's condition?", "answer": "Thyroid stimulating hormone level (TSH)", "options": {"A": "Urine free cortisol level", "B": "Blood alcohol level", "C": "Chest x-ray", "D": "Thyroid stimulating hormone level (TSH)", "E": "Urine metanephrines"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency room", "chest discomfort", "tightness", "reports weakness", "palpitations", "past hour", "shortness of breath", "diaphoresis", "lightheadedness", "significant past medical history", "not smoke", "use illicit", "myocardial infarction", "age 72", "afebrile", "heart rate", "blood pressure", "76", "alert", "oriented to person", "place", "time", "electrocardiogram", "following tests", "ordered", "initial", "ondition?"]}
{"question": "An 11-year-old African American boy is brought to your office by his parents with a 1-day history of severe left hip pain. It is too painful for him to walk without support. He took ibuprofen, which brought no relief. He has had no chills or sweats. Similar painful episodes in the past required multiple hospitalizations. He returned from a trip to Kenya with his family 2 months ago. His vaccinations are up-to-date. His temperature is 38°C (100.4° F), pulse is 100/min, blood pressure is 120/80 mm Hg. Physical examination shows pale conjunctivae. The abdomen is soft with no organomegaly. Passive movement of the hip causes severe pain. There is tenderness on palpation, but no swelling, warmth, or erythema of the hip. His laboratory studies show a hematocrit of 25% and leukocyte count of 14 000/mm3. A peripheral blood smear would most likely show which of the following?", "answer": "Howell-Jolly bodies", "options": {"A": "Trophozoites", "B": "Decreased number of thrombocytes", "C": "Decreased number of reticulocytes", "D": "Howell-Jolly bodies", "E": "Gram-negative bacilli\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "boy", "brought", "office", "1-day history", "severe left hip pain", "painful", "to", "support", "ibuprofen", "brought", "relief", "chills", "sweats", "Similar painful episodes", "past required multiple hospitalizations", "returned", "trip", "Kenya", "months", "vaccinations", "date", "temperature", "100", "F", "pulse", "100 min", "blood pressure", "80 mm Hg", "pale conjunctivae", "abdomen", "soft", "organomegaly", "Passive movement", "hip causes severe pain", "tenderness", "palpation", "swelling", "warmth", "erythema", "hip", "laboratory studies", "hematocrit", "leukocyte count", "mm3", "peripheral blood smear", "most likely", "following"]}
{"question": "A researcher is studying the brains of patients who recently died from stroke-related causes. One specimen has a large thrombus in an area of the brain that is important in relaying many modalities of sensory information from the periphery to the sensory cortex. Which of the following embryologic structures gave rise to the part of the brain in question?", "answer": "Diencephalon", "options": {"A": "Telencephalon", "B": "Diencephalon", "C": "Mesencephalon", "D": "Metencephalon", "E": "Mylencephalon"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["researcher", "studying", "brains", "patients", "recently died", "stroke related causes", "One", "large thrombus", "area", "brain", "important", "relaying", "sensory", "periphery", "sensory cortex", "following embryologic structures gave", "part of", "brain"]}
{"question": "A 33-year-old man is brought to the emergency department after being involved in a bar fight. Physical examination shows tenderness to palpation over the left side of the back. An x-ray of the chest shows a fracture of the 12th rib on the left side. Further evaluation is most likely to show which of the following injuries?", "answer": "Kidney laceration", "options": {"A": "Liver hematoma", "B": "Pneumothorax", "C": "Colon perforation", "D": "Kidney laceration", "E": "Pancreatic transection"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "involved", "tenderness", "palpation", "left side of", "back", "x-ray of", "chest", "fracture of", "rib", "left side", "Further", "to", "following injuries"]}
{"question": "A 71-year-old African American man is brought to the emergency department with a worsening productive cough and dyspnea for 2 days. He has had generalized bone pain for 2 months. He was admitted for pyelonephritis last month. He also received outpatient treatment for pneumonia almost 2 months ago. Over the past 2 months, he has been taking over-the-counter ibuprofen for pain as needed. He appears anxious. The vital signs include: temperature 38.8°C (101.8°F), pulse 95/min, respiratory rate 20/min, and blood pressure 155/90 mm Hg. The conjunctivae are pale. Crackles are heard in the right lower lobe. The cardiac examination shows no abnormalities. The laboratory studies show the following:\nHemoglobin 9 g/dL\nMean corpuscular volume 95 μm3\nLeukocyte count 13,500/mm3\nSegmented neutrophils 75%\nLymphocytes 25%\nPlatelet count 240,000/mm3\nESR 85 mm/hr\nSerum\nNa+ 135 mEq/L\nK+ 4.2 mEq/L\nCl− 113 mEq/L\nHCO3− 20 mEq/L\nCa+ 12.4 mg/dL\nAlbumin 4 g/dL\nUrea nitrogen 38 mg/dL\nCreatinine 2.2 mg/dL\nA chest X-ray shows a right lower lobe opacity and blurring of the ipsilateral diaphragmatic dome. Skull and pelvic X-rays are performed (see image). Which of the following is the most likely underlying cause of this patient’s recent infections?", "answer": "Hypogammaglobulinemia", "options": {"A": "Advanced age", "B": "Hypogammaglobulinemia", "C": "NSAID-induced chronic kidney disease", "D": "T cell dysfunction", "E": "Unresolved pneumonia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "man", "brought", "emergency department", "worsening productive cough", "dyspnea", "2 days", "generalized bone", "months", "pyelonephritis", "month", "received", "pneumonia almost", "months", "past", "months", "over-the-counter ibuprofen", "pain as needed", "appears anxious", "vital signs include", "temperature", "pulse 95 min", "respiratory rate 20 min", "blood pressure", "90 mm Hg", "conjunctivae", "pale", "Crackles", "heard", "right lower lobe", "abnormalities", "laboratory studies", "following", "g", "Mean corpuscular volume", "count", "neutrophils", "Platelet count", "hr Serum", "Cl", "Ca", "mg", "mg", "Creatinine", "chest X-ray", "right lower lobe opacity", "blurring", "ipsilateral diaphragmatic dome", "Skull", "pelvic X-rays", "performed", "see", "following", "underlying cause", "patients recent"]}
{"question": "A 35-year-old man comes to the physician because of a 4-month history of intermittent headaches. They have been getting progressively worse and no longer respond to ibuprofen. He also complains of weight gain and excessive sweating. Physical examination shows prominent supraorbital ridges, prognathism, macroglossia with thick lips, and disproportionately broad hands and feet. There is decreased peripheral vision bilaterally on visual field testing. An MRI of the brain shows a mass in the sella turcica. Genetic analysis of a biopsy specimen from the mass shows cells that overexpress adenylyl cyclase. Which of the following is the most appropriate pharmacotherapy for this condition?", "answer": "Octreotide", "options": {"A": "Methimazole", "B": "Octreotide", "C": "Leuprolide", "D": "Risperidone", "E": "Metyrapone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man", "physician", "of", "4 month history", "intermittent headaches", "getting", "worse", "longer", "ibuprofen", "weight gain", "excessive sweating", "prominent supraorbital ridges", "prognathism", "macroglossia", "thick lips", "broad hands", "feet", "decreased peripheral vision", "field testing", "MRI of", "brain", "mass", "sella turcica", "Genetic analysis", "biopsy", "mass", "cells", "adenylyl cyclase", "following", "most appropriate pharmacotherapy", "condition"]}
{"question": "A 10-year-old boy comes for a post-operative clinic visit with his ENT surgeon three months after airway reconstruction surgery and placement of a tracheostomy tube. Since the surgery, he says that he has been able to breathe better and is now getting used to tracheostomy care and tracheostomy tube changes. In addition to this surgery, he has had over twenty surgeries to implant hearing aids, reconstruct his cheekbones, and support his jaw to enable him to swallow. He was born with these abnormalities and had difficult breathing, hearing, and eating throughout his childhood. Fortunately, he is now beginning to feel better and is able to attend public school where he is one of the best students in the class. Abnormal development of which of the following structures is most likely responsible for this patient's malformations?", "answer": "First branchial arch", "options": {"A": "First branchial arch", "B": "First branchial pouch", "C": "Second branchial arch", "D": "Second branchial cleft", "E": "Third and fourth branchial pouches"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 year old boy", "post-operative clinic visit", "ENT surgeon three months", "airway reconstruction surgery", "placement", "tracheostomy tube", "surgery", "able to", "better", "now getting used", "tracheostomy tube changes", "surgery", "over twenty surgeries to implant hearing aids", "cheekbones", "support", "jaw to", "to swallow", "born", "abnormalities", "difficult breathing", "hearing", "eating", "childhood", "now beginning to", "better", "able to attend public school", "one", "best", "Abnormal development", "following structures", "responsible", "patient's malformations"]}
{"question": "A 60-year-old man presents to the emergency department with a rapid change in his behavior. The patient recently returned from a vacation in rural Mexico and recovered from several episodes of bloody diarrhea. He has had a notable and rapid decline in his memory which started this morning. His personality has also changed, has not been sleeping, and seems generally apathetic. Brief and involuntary muscle twitches have been noted as well. The patient has a past medical history of hypertension and diabetes. His temperature is 99.8°F (37.7°C), blood pressure is 152/98 mmHg, pulse is 97/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a confused and apathetic man who is not compliant with the neurological exam. The patient is admitted to the ICU; however, during his hospital course, the patient ultimately dies. Which of the following was most likely to be found in this patient upon initial presentation?", "answer": "Sharp wave complexes on EEG", "options": {"A": "Blood in the subarachnoid place", "B": "Multifocal infarction on MRI", "C": "Neurofibrillary tangles", "D": "Sharp wave complexes on EEG", "E": "Tear of a bridging vein"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["60 year old man presents", "emergency department", "rapid", "patient recently returned", "rural Mexico", "recovered", "episodes of bloody diarrhea", "notable", "rapid", "memory", "started", "morning", "personality", "changed", "not", "sleeping", "apathetic", "Brief", "involuntary muscle twitches", "noted", "well", "patient", "past medical", "diabetes", "temperature", "99", "blood pressure", "98 mmHg", "pulse", "97 min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "confused", "apathetic man", "not compliant", "neurological exam", "patient", "ICU", "hospital course", "patient", "following", "to", "found", "patient", "initial presentation"]}
{"question": "A 71-year-old woman with a past medical history of type 2 diabetes, hypercholesterolemia, and hypertension was admitted to the hospital 8 hours ago with substernal chest pain for management of acute non-ST-elevated myocardial infarction (NSTEMI). The ECG findings noted by ST-depressions and T-wave inversions on anterolateral leads, which is also accompanied by elevated cardiac enzymes. Upon diagnosis, management with inhaled oxygen therapy, beta-blockers and aspirin, and low-molecular-weight heparin therapy were initiated, and she was placed on bed rest with continuous electrocardiographic monitoring. Since admission, she required 2 doses of sublingual nitric oxide for recurrent angina, and the repeat troponin levels continued to rise. Given her risk factors, plans were made for early coronary angiography. The telemetry nurse calls the on-call physician because of her concern with the patient’s mild confusion and increasing need for supplemental oxygen. At bedside evaluation, The vital signs include: heart rate 122/min, blood pressure 89/40 mm Hg, and the pulse oximetry is 91% on 6L of oxygen by nasal cannula. The telemetry and a repeat ECG show sinus tachycardia. She is breathing rapidly, appears confused, and complains of shortness of breath. On physical exam, the skin is cool and clammy and appears pale and dull. She has diffuse bilateral pulmonary crackles, and an S3 gallop is noted on chest auscultation with no new murmurs. She has jugular venous distention to the jaw-line, rapid and faint radial pulses, and 1+ dependent edema. She is immediately transferred to the intensive care unit for respiratory support and precautions for airway security. The bedside sonography shows abnormal hypodynamic anterior wall movement and an ejection fraction of 20%, but no evidence of mitral regurgitation or ventricular shunt. The chest X-ray demonstrates cephalization of pulmonary veins and pulmonary edema. What is the most appropriate next step in the stabilization of this patient?", "answer": "Initiate dopamine therapy and diuresis", "options": {"A": "Insert two large-bore intravenous catheters and start rapid fluid resuscitation", "B": "Initiate dopamine therapy and diuresis", "C": "Start intravenous fluids and epinephrine therapy", "D": "Obtain blood cultures and start preliminary broad-spectrum antibiotics", "E": "Intubate the patient and perform an emergency cardiocentesis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "past medical history of type 2 diabetes", "hypercholesterolemia", "hypertension", "8 hours", "chest pain", "acute non-ST-elevated myocardial infarction", "ECG findings noted", "ST-depressions", "T-wave inversions", "anterolateral leads", "elevated cardiac enzymes", "diagnosis", "inhaled", "beta-blockers", "aspirin", "low-molecular-weight heparin therapy", "initiated", "bed rest", "electrocardiographic monitoring", "required 2 doses", "sublingual nitric oxide", "recurrent angina", "repeat troponin levels", "to", "Given", "risk factors", "plans", "made", "early coronary angiography", "telemetry nurse calls", "call physician", "patients mild confusion", "increasing need", "supplemental oxygen", "vital signs include", "heart rate", "min", "blood pressure", "40 mm Hg", "pulse oximetry", "oxygen", "nasal cannula", "telemetry", "repeat ECG", "sinus tachycardia", "breathing rapidly", "appears confused", "of shortness", "breath", "skin", "cool", "clammy", "appears pale", "dull", "diffuse bilateral pulmonary crackles", "S3 gallop", "noted", "chest auscultation", "new murmurs", "jugular venous distention", "jaw line", "rapid", "faint radial pulses", "1", "dependent edema", "immediately transferred", "intensive care unit", "respiratory support", "airway", "sonography", "abnormal hypodynamic anterior wall movement", "ejection fraction of 20", "mitral regurgitation", "ventricular shunt", "chest X-ray", "pulmonary veins", "pulmonary edema", "most appropriate next step", "stabilization", "patient"]}
{"question": "A 42-year-old woman is brought to the physician by her husband because of a 1-year history of abnormal behavior. During this time she has been irritable, restless, and has had multiple episodes of hearing voices. Over the past month, she has also had difficulty swallowing. She has a 2-year history of depression. She was let go by her employer 6 months ago because she could no longer handle all her tasks and often forgot about assignments. Her father committed suicide at the age of 50. The patient has smoked one pack of cigarettes daily over the past 20 years. She has a history of smoking cocaine for 8 years but stopped 1 year ago. Vital signs are within normal limits. On mental status examination, she is confused and oriented to person and place only. Neurologic examination shows a delayed return to neutral ankle position after triggering the plantar reflex. Physical examination shows irregular, nonrepetitive, and arrhythmic movements of the neck and head. The patient has poor articulation. Which of the following is the most likely diagnosis?", "answer": "Huntington disease", "options": {"A": "Sydenham chorea", "B": "Parkinson disease", "C": "Multiple sclerosis", "D": "Drug-induced chorea", "E": "Huntington disease"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "physician", "year history", "abnormal behavior", "time", "irritable", "restless", "multiple episodes of hearing voices", "past month", "difficulty swallowing", "2 year history of depression", "let go", "employer", "months", "longer", "often forgot", "assignments", "committed suicide", "age", "50", "patient", "smoked one pack", "cigarettes daily", "past 20 years", "history of smoking cocaine", "years", "stopped 1 year", "Vital signs", "normal limits", "mental status", "confused", "oriented to person", "place only", "Neurologic examination", "delayed return", "neutral ankle position", "triggering", "plantar reflex", "irregular", "arrhythmic movements of", "neck", "head", "patient", "poor articulation", "following", "diagnosis"]}
{"question": "A 64-year-old woman has progressively worsening abdominal pain 5 hours after an open valve replacement with cardiopulmonary bypass. The pain is crampy and associated with an urge to defecate. The patient reports having had 2 bloody bowel movements in the last hour. Her operation was complicated by significant intraoperative blood loss, which prolonged the operation and necessitated 2 transfusions of red blood cells. She has hypercholesterolemia and type 2 diabetes mellitus. The patient received prophylactic perioperative antibiotics and opioid pain management during recovery. Her temperature is 37.9°C (98.9°F), pulse is 95/min, and blood pressure is 115/69 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the left quadrants but no rebound tenderness or guarding. Bowel sounds are decreased. Rectal examination shows blood on the examining finger. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Decreased blood flow to the splenic flexure", "options": {"A": "Embolization of superior mesenteric artery", "B": "Decreased blood flow to the splenic flexure", "C": "Small outpouchings in the sigmoid wall", "D": "Atherosclerotic narrowing of the intestinal vessels", "E": "Infection with Clostridioides difficile"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["64 year old woman", "worsening abdominal pain", "hours", "open valve replacement", "cardiopulmonary bypass", "pain", "crampy", "associated with", "2 bloody bowel movements", "hour", "operation", "complicated", "significant intraoperative blood loss", "prolonged", "operation", "2 transfusions of red blood cells", "hypercholesterolemia", "type 2 diabetes mellitus", "patient received prophylactic perioperative antibiotics", "opioid pain management", "recovery", "temperature", "98 9F", "pulse", "95 min", "blood pressure", "69 mm Hg", "soft abdomen", "mild tenderness", "palpation", "left quadrants", "rebound tenderness", "guarding", "Bowel sounds", "decreased", "Rectal examination", "blood", "examining finger", "following", "underlying cause", "patient's symptoms"]}
{"question": "An 8-month-old boy is brought to the emergency department by his mother. She is concerned that her son has had intermittent periods of severe abdominal pain over the past several days that has been associated with emesis and \"currant jelly\" stool. Of note, the family lives in a rural part of the state, requiring a 2 hour drive to the nearest hospital. He currently appears to be in significant pain and has vomited twice in the past hour. On physical examination, a sausage-shaped mass is noted on palpation of the right upper quadrant of the abdomen. Ultrasound of the abdomen was consistent with a diagnosis of intussusception. An air-contrast barium enema was performed, which confirmed the diagnosis and also successfully reduced the intussusception. Which of the following is the next best step in the management of this patient?", "answer": "Admit to hospital for 24 hour observation for complications and/or recurrence", "options": {"A": "Discharge to home with follow-up in 3 weeks in an outpatient pediatric gastroenterology clinic", "B": "Repeat barium enema q6 hrs to monitor for recurrence", "C": "Keep patient NPO and initiate work-up to identify lead-point", "D": "Admit to hospital for 24 hour observation for complications and/or recurrence", "E": "Pursue urgent surgical reduction with resection of necrotic segments of bowel"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "emergency department", "intermittent periods", "severe abdominal pain", "past", "days", "associated with emesis", "stool", "note", "rural part of", "state", "2 hour", "nearest hospital", "currently appears to", "significant pain", "vomited twice", "past hour", "shaped mass", "noted", "palpation of", "right upper quadrant", "abdomen", "Ultrasound of", "abdomen", "diagnosis", "intussusception", "air-contrast barium enema", "performed", "confirmed", "diagnosis", "reduced", "intussusception", "following", "next best step", "patient"]}
{"question": "A 48-year-old woman presents to her primary care physician with complaints of persistent fatigue, dizziness, and weight loss for the past 3 months. She has a history of hypothyroidism and takes thyroxine replacement. Her blood pressure is 90/60 mm Hg in a supine position and 65/40 mm Hg while sitting, temperature is 36.8°C (98.2°F), and pulse is 75/min. On physical examination, there is a mild increase in thyroid size, with a rubbery consistency. Her skin shows diffuse hyperpigmentation, more pronounced in the oral mucosa and palmar creases. Which of the following best represent the etiology of this patient’s condition?", "answer": "Autoimmune destruction of the adrenal gland", "options": {"A": "Autoimmune destruction of the adrenal gland", "B": "↓ adrenocorticotropic hormone secretion from the pituitary gland", "C": "↓ corticotropin-releasing hormone secretion from the hypothalamus", "D": "Prolonged corticosteroid therapy", "E": "↑ iron absorption and deposition in the body"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["48 year old woman presents", "primary care physician", "complaints", "persistent fatigue", "dizziness", "weight loss", "past 3 months", "history of hypothyroidism", "thyroxine replacement", "blood pressure", "90 60 mm Hg", "supine position", "65 40 mm Hg", "sitting", "temperature", "36", "98", "pulse", "75 min", "mild increase in thyroid size", "rubbery consistency", "skin", "diffuse hyperpigmentation", "more", "oral mucosa", "palmar creases", "following best", "etiology", "patients condition"]}
{"question": "A 19-year-old man with a history of generalized tonic-clonic seizures comes to the physician for a routine health maintenance examination. He is a known user of intravenous cocaine. His vital signs are within normal limits. Physical examination shows multiple hyperpigmented lines along the forearms. Oral examination shows marked overgrowth of friable, ulcerated gingival mucosa. Which of the following is the most likely cause of this patient's oral examination findings?", "answer": "Phenytoin", "options": {"A": "Phenytoin", "B": "Lamotrigine", "C": "Lacosamide", "D": "Cyclosporine", "E": "Carbamazepine\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "history", "generalized tonic-clonic seizures", "physician", "routine", "known user", "intravenous cocaine", "vital signs", "normal", "Physical examination", "multiple hyperpigmented lines", "forearms", "marked overgrowth", "friable", "ulcerated gingival", "following", "most likely cause", "oral", "findings"]}
{"question": "A 62-year-old man with prostate cancer comes to the physician because of low back pain for 2 weeks and a 4.5-kg (10-lb) weight loss. Physical examination shows localized tenderness over the lumbar spine. An x-ray of the lumbar spine shows several osteoblastic lesions at the level of L2 and L4 vertebrae. Microscopic examination of a bone biopsy specimen from the L4 vertebra shows irregular bone trabeculae and star-shaped cells with long, cytoplasmic processes located deep within the lacunae. Exchange of nutrients and waste products between these cells most likely occurs through which of the following structures?", "answer": "Macula communicans", "options": {"A": "Macula adherens", "B": "Macula communicans", "C": "Zonula occludens", "D": "Hemidesmosomes", "E": "Zonula adherens"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old man", "prostate cancer", "physician", "of low back pain", "2 weeks", "4.5 kg", "10", "weight loss", "localized tenderness", "lumbar spine", "x-ray of", "lumbar spine", "several", "lesions", "level", "L2", "L4 vertebrae", "Microscopic examination of", "bone biopsy specimen", "L4 vertebra", "irregular bone trabeculae", "star shaped cells", "long", "cytoplasmic processes", "deep", "Exchange", "cells", "likely occurs", "following structures"]}
{"question": "A 2-week-old female newborn is brought to the physician because of increasing yellow discoloration of her eyes and skin for 2 days. She was born at 39 weeks' gestation and weighed 3066 g (6 lb 12 oz); she now weighs 3200 g (7 lb 1 oz). She is exclusively breastfed. Her older brother died 3 months after liver surgery. Her temperature is 37.1°C (98.8°F), pulse is 145/min, and respirations are 40/min. Examination shows yellow discoloration extending to the palms and soles. The liver is palpated 1 cm below the right costal margin. Laboratory studies show:\nHematocrit 51%\nSerum\nBilirubin\nTotal 16.1 mg/dL\nDirect 0.7 mg/dL\nAlkaline phosphatase 22 U/L\nAST 12 U/L\nALT 12 U/L\nWhich of the following is the most likely diagnosis?\"", "answer": "Breast milk jaundice", "options": {"A": "Biliary atresia", "B": "Physiologic neonatal jaundice", "C": "Isoimmune mediated hemolysis", "D": "Breast milk jaundice", "E": "Breastfeeding failure jaundice"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["2 week old female newborn", "brought", "physician", "increasing yellow", "eyes", "skin", "2 days", "born", "weeks", "estation ", " ", "z)", "ow ", " ", "  z)", "reastfed.", "ied   months ", "iver surgery.", "emperature ", "8.", "ulse ", "in,", "espirations ", "0/ in.", "ellow discoloration  xtending ", "oles.", "iver ", "  m ", "ight  ostal margin.", "aboratory studies ", "ematocrit ", "erum Bilirubin Total  6.1  g/dL  irect  .7  g/dL  lkaline phosphatase ", "/L  ST ", "LT ", "ollowing ", "iagnosis?"]}
{"question": "A researcher is trying to determine whether a newly discovered substance X can be useful in promoting wound healing after surgery. She conducts this study by enrolling the next 100 patients that will be undergoing this surgery and separating them into 2 groups. She decides which patient will be in which group by using a random number generator. Subsequently, she prepares 1 set of syringes with the novel substance X and 1 set of syringes with a saline control. Both of these sets of syringes are unlabeled and the substances inside cannot be distinguished. She gives the surgeon performing the surgery 1 of the syringes and does not inform him nor the patient which syringe was used. After the study is complete, she analyzes all the data that was collected and performs statistical analysis. This study most likely provides which level of evidence for use of substance X?", "answer": "Level 1", "options": {"A": "Level 1", "B": "Level 2", "C": "Level 3", "D": "Level 4", "E": "Level 5"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["researcher", "to", "useful", "wound healing", "surgery", "study", "next 100 patients", "surgery", "separating", "patient", "group", "using", "random number generator", "prepares 1 set", "syringes", "novel", "1 set", "syringes", "control", "sets", "syringes", "gives", "surgeon performing", "surgery 1", "syringes", "not inform", "patient", "syringe", "used", "study", "complete", "data", "collected", "performs", "study", "likely", "level of evidence", "use", "substance"]}
{"question": "A 13-year-old boy is brought to a physician with severe fevers and headaches for 3 days. The pain is constant and mainly behind the eyes. He has myalgias, nausea, vomiting, and a rash for one day. Last week, during an academic winter break, he traveled on a tour with his family to several countries, including Brazil, Panama, and Peru. They spent many evenings outdoors without any protection against insect bites. There is no history of contact with pets, serious illness, or use of medications. The temperature is 40.0℃ (104.0℉); the pulse is 110/min; the respiratory rate is 18/min, and the blood pressure is 110/60 mm Hg. A maculopapular rash is seen over the trunk and extremities. Several tender lymph nodes are palpated in the neck on both sides. A peripheral blood smear shows no organisms. Which of the following is most likely responsible for this patient’s presentation?", "answer": "Dengue fever", "options": {"A": "Babesiosis", "B": "Chagas disease", "C": "Dengue fever", "D": "Malaria", "E": "Zika virus"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "severe fevers", "headaches", "3 days", "pain", "constant", "eyes", "myalgias", "nausea", "vomiting", "rash", "one", "week", "winter break", "tour", "countries", "including Brazil", "Panama", "Peru", "spent", "evenings outdoors", "protection", "insect bites", "history", "contact", "serious illness", "use of medications", "temperature", "40 0", "0", "pulse", "min", "respiratory rate", "min", "blood pressure", "60 mm Hg", "maculopapular rash", "seen", "trunk", "extremities", "tender lymph nodes", "neck", "sides", "peripheral blood smear", "following", "responsible", "patients"]}
{"question": "A 34-year-old male comes to his family physician with complaints of joint pain that has been present for over 7 weeks. Prior to the onset of his arthritis, he recalls having a gastrointestinal infection which caused mild diarrhea and abdominal cramps. He recovered well and had no issues until his joint pain started. A prescription for naproxen was previously prescribed but he still does not feel well. He has no significant past medical or family history. On physical examination, his blood pressure is 120/78 mm Hg, respirations are 17/min, pulse is 64/min, and temperature is 36.7°C (98.0°F). Which of the following therapies is likely to be most beneficial in treating this patient’s condition?", "answer": "Sulfasalazine", "options": {"A": "Diclofenac", "B": "Sulfasalazine", "C": "Methotrexate", "D": "Ketoprofen", "E": "Ceftriaxone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male", "family physician", "complaints", "joint pain", "present", "weeks", "Prior to", "onset", "arthritis", "gastrointestinal infection", "caused mild diarrhea", "abdominal cramps", "recovered well", "issues", "joint pain started", "naproxen", "not", "well", "significant past medical", "family history", "blood pressure", "mm Hg", "respirations", "min", "pulse", "64 min", "temperature", "36", "98", "following therapies", "likely to", "treating", "patients condition"]}
{"question": "A 22-year-old man presents to the emergency department with a 2-day history of fever and altered mentation. He reports fever without chills and rigors and denies sore throat, abdominal pain, headache, loose stool, burning micturition, or seizures. He has a history of tics and is currently on a low dose of haloperidol. At the hospital, his temperature is 39.6°C (103.2°F); the blood pressure is 126/66 mm Hg, and the pulse is 116/min. He is profusely sweating and generalized rigidity is present. He is confused and disoriented. He is able to move all his limbs. Normal deep tendon reflexes are present with bilateral downgoing plantar responses. A brain MRI is unremarkable. Urine toxicology is negative. The white blood cell count is 14,700/mm3. Creatine kinase is 5600 U/L. Lumbar puncture is performed and cerebrospinal fluid (CSF) studies show:\nCSF opening pressure 22 cm H20\nCSF white blood cells 4 cells/mm3\nCSF red blood cells 0 cells/mm3\nCSF glucose 64 mg/dL\nCSF protein 48 mg/dL\nSerum glucose 96 mg/dL\nWhat is the most likely diagnosis?", "answer": "Neuroleptic malignant syndrome", "options": {"A": "Acute disseminated encephalomyelitis", "B": "Cerebral venous sinus thrombosis", "C": "Encephalitis", "D": "Meningitis", "E": "Neuroleptic malignant syndrome"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "2-day history", "fever", "altered", "reports fever", "chills", "rigors", "sore throat", "abdominal pain", "headache", "loose stool", "burning micturition", "seizures", "history", "tics", "currently", "low", "haloperidol", "hospital", "temperature", "blood pressure", "66 mm Hg", "pulse", "min", "sweating", "generalized rigidity", "present", "confused", "disoriented", "able to move", "limbs", "Normal deep tendon reflexes", "present", "bilateral", "plantar responses", "brain MRI", "unremarkable", "Urine toxicology", "negative", "white blood cell count", "700 mm3", "Creatine kinase", "5600 U/L", "Lumbar puncture", "performed", "cerebrospinal fluid", "studies", "CSF opening", "white blood cells", "0", "glucose 64 mg", "mg dL Serum", "96", "diagnosis"]}
{"question": "A 10-month-old boy is brought to the physician by his mother for evaluation of abnormal growth and skin abnormalities. His mother has also noticed that his eyes do not fully close when sleeping. He is at the 24th percentile for height, 17th percentile for weight, and 29th percentile for head circumference. Physical examination shows wrinkled skin, prominent veins on the scalp and extremities, and circumoral cyanosis. Genetic testing shows a point mutation in a gene that encodes for a scaffold protein of the inner nuclear membrane. The mutation causes a deformed and unstable nuclear membrane, which leads to premature aging. Which of the following is most likely to be the defective protein?", "answer": "Lamin", "options": {"A": "Desmin", "B": "Nesprin", "C": "Vimentin", "D": "Lamin", "E": "Plectin\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["A 10 month old boy", "brought", "physician", "abnormal growth", "skin abnormalities", "eyes", "not", "close", "sleeping", "percentile", "height", "percentile", "weight", "percentile", "head circumference", "wrinkled skin", "prominent veins", "scalp", "extremities", "circumoral cyanosis", "Genetic testing", "a point mutation", "gene", "a scaffold protein", "inner nuclear membrane", "mutation causes", "deformed", "unstable nuclear membrane", "leads", "premature aging", "following", "to", "defective protein"]}
{"question": "A 64-year-old man presents to his primary care physician because of a tremor that he has developed over the last several months. He says that the tremor is worst when he is resting but becomes better when he engages in movements such as picking up the remote for his TV. His wife also says that his movements have become slower over the last few months. Physical exam reveals increased resistance to passive motion of his extremities. Gait exam also shows trouble with starting movement and short, shuffling steps. The most likely cause of this patient's symptoms involve the degeneration of a certain subset of neurons. When the substance released by these neurons interact with a G-alpha-s coupled receptor, which of the following effects occurs?", "answer": "Inhibition of the globus pallidus internus", "options": {"A": "Inhibition of the globus pallidus externus", "B": "Inhibition of the globus pallidus internus", "C": "Stimulation of the globus pallidus externus", "D": "Stimulation of the globus pallidus internus", "E": "Stimulation of the subthalamic nucleus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["64 year old man presents", "primary care physician", "tremor", "months", "tremor", "worst", "better", "movements", "as picking", "remote", "TV", "movements", "slower", "months", "reveals increased resistance to passive motion", "exam", "starting movement", "short", "steps", "most likely cause", "patient's symptoms", "degeneration", "certain", "neurons", "released", "interact", "G-alpha", "coupled receptor", "following effects occurs"]}
{"question": "A 49-year-old woman presents to her physician with complaints of breast swelling and redness of the skin over her right breast for the past 1 month. She also mentions that the skin above her right breast appears to have thickened. She denies any pain or nipple discharge. The past medical history is significant for a total abdominal hysterectomy at 45 years of age. Her last mammogram 1 year ago was negative for any pathologic changes. On examination, the right breast was diffusely erythematous with gross edema and tenderness and appeared larger than the left breast. The right nipple was retracted and the right breast was warmer than the left breast. No localized mass was palpated. Which of the following statements best describes the patient’s most likely condition?", "answer": "The inflammation is due to obstruction of dermal lymphatic vessels.", "options": {"A": "It is a benign lesion.", "B": "The inflammation is due to obstruction of dermal lymphatic vessels.", "C": "The lesion expresses receptors for estrogen and progesterone.", "D": "The lesion is due to Streptococcal infection.", "E": "It shows predominant lymphatic spread."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "complaints of breast swelling", "redness of", "skin", "right breast", "past", "month", "skin", "right breast appears to", "thickened", "pain", "nipple discharge", "past medical history", "significant", "total abdominal hysterectomy", "years", "age", "last mammogram", "year", "negative", "pathologic changes", "right breast", "erythematous", "gross edema", "tenderness", "appeared larger", "left breast", "right nipple", "retracted", "right breast", "warmer", "left breast", "localized mass", "following", "best", "patients", "likely condition"]}
{"question": "A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management?", "answer": "Plan for oxytocin administration", "options": {"A": "Perform cesarean delivery", "B": "Plan for oxytocin administration", "C": "Administer magnesium sulfate", "D": "Perform weekly pelvic ultrasound", "E": "Perform dilation and curettage\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["36 year old primigravid woman", "weeks", "gestation", "physician", "absent fetal movements", "last 2 days", "Pregnancy", "confirmed by ultrasonography", "weeks earlier", "vaginal bleeding", "discharge", "history of type 1 diabetes mellitus controlled", "insulin", "Vital signs", "normal limits", "Pelvic examination", "soft", "2", "long cervix", "midline", "cervical os measuring 3", "uterus", "size", "weeks", "gestation", "Transvaginal ultrasonography", "fetus", "cardiac", "following", "most appropriate next step"]}
{"question": "A 63-year-old man presents to his primary care physician complaining of excessive daytime sleepiness. He explains that this problem has worsened slowly over the past few years but is now interfering with his ability to play with his grandchildren. He worked previously as an overnight train conductor, but he has been retired for the past 3 years. He sleeps approximately 8-9 hours per night and believes his sleep quality is good; however, his wife notes that he often snores loudly during sleep. He has never experienced muscle weakness or hallucinations. He has also been experiencing headaches in the morning and endorses a depressed mood. His physical exam is most notable for his large body habitus, with a BMI of 34. What is the best description of the underlying mechanism for this patient's excessive daytime sleepiness?", "answer": "Poor oropharyngeal tone", "options": {"A": "Insufficient sleep duration", "B": "Circadian rhythm sleep-wake disorder", "C": "Poor oropharyngeal tone", "D": "Deficiency of the neuropeptides, orexin-A and orexin-B", "E": "Psychiatric disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["63 year old man presents", "primary care physician", "excessive daytime sleepiness", "problem", "worsened slowly", "past", "years", "now interfering", "ability to play", "overnight train conductor", "retired", "past", "years", "sleeps approximately 8", "hours", "night", "sleep quality", "good", "notes", "often snores", "sleep", "never", "muscle weakness", "hallucinations", "headaches", "morning", "depressed mood", "most notable", "large body", "BMI", "best", "underlying mechanism", "patient's excessive daytime sleepiness"]}
{"question": "A previously healthy 5-year-old boy is brought to the physician with a recurring fever and malaise for 3 weeks. He has also had fatigue and loss of appetite. He initially presented 2 weeks ago with a maculopapular rash that has since resolved. At the time, he was given a prescription for amoxicillin-clavulanate. He denies sore throat or myalgias. He is home-schooled and has had no sick contacts. There are no pets at home, but he often visits a feline animal shelter where his mother volunteers. His temperature is 38.4°C (101.2°F). Physical examination shows a 1-cm papular lesion on the back of the right hand. He also has tender, bulky lymphadenopathy of the axillae and groin. Which of the following is the most appropriate next step in management?", "answer": "Azithromycin therapy", "options": {"A": "Doxycycline therapy", "B": "Pyrimethamine therapy", "C": "Itraconazole therapy", "D": "Azithromycin therapy", "E": "Streptomycin therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "recurring fever", "malaise", "weeks", "fatigue", "loss of appetite", "initially", "2 weeks", "maculopapular rash", "since resolved", "time", "given", "amoxicillin-clavulanate", "sore throat", "myalgias", "home-schooled", "sick", "at home", "often", "shelter", "volunteers", "temperature", "papular lesion", "back of", "right hand", "tender", "bulky lymphadenopathy", "axillae", "groin", "following", "most appropriate next step"]}
{"question": "An 8-year-old girl is brought to the physician by her parents because of difficulty sleeping. One to two times per week for the past 2 months, she has woken up frightened in the middle of the night, yelling and crying. She has not seemed confused after waking up, and she is consolable and able to fall back asleep in her parents' bed. The following day, she seems more tired than usual at school. She recalls that she had a bad dream and looks for ways to delay bedtime in the evenings. She has met all her developmental milestones to date. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Nightmare disorder", "options": {"A": "Sleep terror disorder", "B": "Post-traumatic stress disorder", "C": "Normal development", "D": "Nightmare disorder", "E": "Separation anxiety disorder\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "difficulty sleeping", "One", "two", "week", "past", "months", "woken up", "middle", "night", "not", "confused", "waking", "able to fall back asleep", "bed", "following day", "more tired", "usual", "school", "bad dream", "looks", "to delay bedtime", "evenings", "met", "date", "abnormalities", "following", "diagnosis"]}
{"question": "A 56-year-old man who underwent kidney transplantation 6 months ago, presents to the physician because of fever, dyspnea, non-productive cough, and lethargy. He is on no other medications apart from immunosuppressive therapy. On physical examination, the vital signs include: pulse 110/min, blood pressure 126/76 mm Hg, respirations 26/min, oxygen saturation 80% at room air, and temperature 37.7°C (99.9°F). Chest auscultation is normal except for occasional bilateral wheezes. An X-ray of the chest shows diffuse interstitial infiltrates. Bronchoalveolar lavage is performed and methenamine silver staining confirms a parasitic infestation. Which of the following is the most appropriate pharmacotherapy for the patient?", "answer": "Trimethoprim-sulfamethoxazole intravenously", "options": {"A": "Intravenous pentamidine", "B": "Trimethoprim-sulfamethoxazole intravenously", "C": "Trimethoprim-sulfamethoxazole orally", "D": "High-dose corticosteroids and bronchodilators", "E": "Oral dapsone + trimethoprim"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "kidney transplantation", "months", "presents", "physician", "fever", "dyspnea", "non-productive cough", "lethargy", "medications", "immunosuppressive", "vital signs include", "pulse", "min", "blood pressure", "76 mm Hg", "respirations", "min", "oxygen saturation 80", "room air", "temperature", "99 9F", "Chest auscultation", "normal", "occasional bilateral wheezes", "X-ray of", "chest", "diffuse interstitial infiltrates", "Bronchoalveolar lavage", "performed", "methenamine confirms", "parasitic infestation", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?", "answer": "Exercise and smoking cessation", "options": {"A": "Balloon angioplasty with stenting", "B": "Exercise and smoking cessation", "C": "Femoral-popliteal bypass", "D": "Lisinopril and atorvastatin", "E": "Lovenox and atorvastatin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old man presents", "clinic", "burning bilateral leg pain", "increasing", "past", "months", "worsens", "walks", "improves", "past medical", "surgical history", "significant", "hypertension", "hyperlipidemia", "diabetes", "40", "smoking history", "temperature", "99", "blood pressure", "mm Hg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "95", "room air", "lower extremities reveals palpable", "weak posterior tibial", "dorsalis pedis pulses", "following", "best initial treatment", "patient's symptoms"]}
{"question": "A 30-year-old woman, gravida 2, para 1, comes to the physician because she had a positive pregnancy test at home. During the last two weeks, she has had nausea and two episodes of non-bloody vomiting. She also reports increased urinary frequency. Her pregnancy and delivery of her first child were uncomplicated. Last year, she had two episodes of grand-mal seizure. She is sexually active with her husband and they use condoms inconsistently. She does not smoke or drink alcohol. She does not use illicit drugs. Current medications include valproic acid and a multivitamin. Her vital signs are within normal limits. Physical examination shows no abnormalities. A urine pregnancy test is positive. The child is at increased risk for requiring which of the following interventions?", "answer": "Lower spinal surgery", "options": {"A": "Cochlear implantation", "B": "Kidney transplantation", "C": "Respiratory support", "D": "Lower spinal surgery", "E": "Dental treatment"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old woman", "gravida 2", "para 1", "physician", "positive pregnancy test at home", "last two weeks", "nausea", "two episodes of non bloody vomiting", "reports increased urinary frequency", "pregnancy", "delivery", "first child", "uncomplicated", "year", "two episodes of grand-mal seizure", "sexually active", "use condoms", "not smoke", "not use illicit drugs", "Current medications include valproic acid", "multivitamin", "vital signs", "normal", "Physical examination", "abnormalities", "urine pregnancy test", "positive", "child", "increased risk", "following interventions"]}
{"question": "A 71-year-old man comes to the physician accompanied by his wife because of a 6-month history of worsening episodic upper abdominal pain and an 8-kg (17.6-lb) weight loss. The pain is dull, nonradiating, worse after eating, and occasionally associated with bloating and diarrhea. His symptoms have not improved despite 4 weeks of treatment with omeprazole. He attributes his weight loss to recently eating very small portions and avoiding fatty foods. He has hypertension and hypercholesterolemia. He underwent a coronary artery bypass graft operation for coronary artery disease 8 years ago. Current medications include lisinopril, metoprolol, atorvastatin, and aspirin. He has smoked a pack of cigarettes daily for 20 years and drinks 1–2 beers daily. His pulse is 79/min and blood pressure is 138/89 mm Hg. Examination shows a soft abdomen without tenderness to palpation or guarding. Which of the following is most likely to confirm the diagnosis?", "answer": "CT angiography of the abdomen", "options": {"A": "Serum CA 19-9", "B": "Right upper quadrant abdominal ultrasound", "C": "CT angiography of the abdomen", "D": "Endoscopic retrograde cholangiography", "E": "Upper endoscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "of", "month history", "worsening episodic upper abdominal pain", "kg", "weight loss", "pain", "dull", "worse after eating", "occasionally associated with bloating", "diarrhea", "symptoms", "not improved", "weeks", "treatment", "omeprazole", "attributes", "weight loss", "recently eating very small portions", "hypertension", "hypercholesterolemia", "coronary artery bypass graft operation", "years", "Current medications include lisinopril", "metoprolol", "atorvastatin", "aspirin", "smoked", "pack", "cigarettes daily", "20 years", "daily", "pulse", "min", "blood pressure", "mm Hg", "soft abdomen", "tenderness", "palpation", "guarding", "following", "to confirm", "diagnosis"]}
{"question": "Five days after admission into the ICU for drug-induced acute kidney injury, a 27-year-old woman develops fever. She is currently on a ventilator and sedatives. Hemodialysis is performed via a catheter placed in the right internal jugular vein. Feeding is via a nasogastric tube. An indwelling urinary catheter shows minimum output. Her blood pressure is 85/45 mm Hg, the pulse is 112/min, the respirations are 32/min, and the temperature is 39.6°C (103.3°F). The examination of the central catheter shows erythema around the insertion site with no discharge. Lung auscultation shows rhonchi. Cardiac examination shows no new findings. A chest CT scan shows bilateral pleural effusions with no lung infiltration. Empirical antibiotic therapy is initiated. Blood cultures obtained from peripheral blood and the catheter tip show S. aureus with a similar antibiogram. Urinary culture obtained from the indwelling catheter shows polymicrobial growth. Which of the following best explains this patient’s recent findings?", "answer": "Central catheter-related bacteremia", "options": {"A": "Catheter-associated urinary tract infection", "B": "Central catheter-related bacteremia", "C": "Endocarditis", "D": "Naso-gastric tube sinusitis", "E": "Ventilator-associated pneumonia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["ICU", "drug-induced acute kidney injury", "27 year old woman", "fever", "currently", "ventilator", "sedatives", "Hemodialysis", "performed", "catheter", "right internal jugular vein", "nasogastric tube", "indwelling urinary catheter", "minimum", "blood pressure", "85", "mm Hg", "pulse", "min", "respirations", "min", "temperature", "central catheter", "erythema", "insertion site", "discharge", "Lung auscultation", "rhonchi", "new findings", "chest CT scan", "bilateral pleural effusions", "lung infiltration", "Empirical antibiotic therapy", "initiated", "Blood cultures obtained", "peripheral blood", "catheter tip", "S", "aureus", "similar antibiogram", "Urinary obtained", "indwelling catheter", "growth", "following best", "patients recent findings"]}
{"question": "A 70-year-old man presents for his annual check-up. He says he feels well except for occasional abdominal pain. He describes the pain as 4/10–5/10 in intensity, diffusely localized to the periumbilical and epigastric regions, radiating to the groin. The pain occurs 1–2 times a month and always subsides on its own. The patient denies any recent history of fever, chills, nausea, vomiting, change in body weight, or change in bowel and/or bladder habits. His past medical history is significant for hypertension, hyperlipidemia, and peripheral vascular disease, managed with lisinopril and simvastatin. The patient reports a 40-pack-year smoking history and 1–2 alcoholic drinks a day. The blood pressure is 150/100 mm Hg and the pulse is 80/min. Peripheral pulses are 2+ bilaterally in all extremities. Abdominal exam reveals a bruit in the epigastric region along with mild tenderness to palpation with no rebound or guarding. There is also a pulsatile abdominal mass felt on deep palpation at the junction of the periumbilical and the suprapubic regions. The remainder of the physical exam is normal. Laboratory studies show:\nSerum total cholesterol 175 mg/dL\nSerum total bilirubin 1 mg/dL\nSerum amylase 25 U/L\nSerum alanine aminotransferase (ALT) 20 U/L\nSerum aspartate aminotransferase (AST) 16 U/L\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Abdominal aortic aneurysm", "options": {"A": "Abdominal aortic aneurysm", "B": "Acute pancreatitis", "C": "Mesenteric ischemia", "D": "Acute gastritis", "E": "Diverticulitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["70 year old man presents", "annual check-up", "well", "occasional abdominal pain", "pain", "4", "10", "intensity", "localized", "periumbilical", "epigastric regions", "radiating to", "groin", "pain occurs", "times", "month", "always", "patient", "recent history", "fever", "chills", "nausea", "vomiting", "change", "bowel", "bladder", "past medical history", "significant", "hypertension", "hyperlipidemia", "peripheral vascular disease", "lisinopril", "simvastatin", "patient reports", "40", "smoking history", "alcoholic", "day", "blood pressure", "100 mm Hg", "pulse", "80 min", "Peripheral pulses", "2", "extremities", "Abdominal exam reveals", "bruit", "epigastric region", "mild tenderness", "palpation", "guarding", "pulsatile abdominal mass", "deep palpation", "junction", "periumbilical", "suprapubic regions", "normal", "Laboratory studies", "Serum", "cholesterol", "mg", "bilirubin", "mg", "amylase", "L", "alanine aminotransferase", "ALT", "20 U/L Serum aspartate aminotransferase", "AST", "U/L", "following", "diagnosis", "patient"]}
{"question": "Six days after undergoing a left hemicolectomy for colorectal carcinoma, a 59-year-old man collapses in the hospital hallway and is unconscious for 30 seconds. Afterwards, he complains of shortness of breath and chest pain with deep inhalation. He has hypertension and hyperlipidemia. He smoked one pack of cigarettes daily for 35 years but quit prior to admission to the hospital. He does not drink alcohol. He is in distress and appears ill. His temperature is 36.5°C (97.7°F), blood pressure is 80/50 mm Hg, and pulse is 135/min and weak. Oxygen saturation is 88% on room air. Physical examination shows elevated jugular venous distention. Cardiac examination shows a regular, rapid heart rate and a holosystolic murmur that increases during inspiration. His abdomen is soft and mildly tender to palpation around the surgical site. Examination of his extremities shows pitting edema of the left leg. His skin is cold and clammy. Further examination is most likely to reveal which of the following findings?", "answer": "Dilated right ventricular cavity", "options": {"A": "Rapid, aberrant contractions of the atria", "B": "Stenosis of the carotid arteries", "C": "Dilated right ventricular cavity", "D": "Anechoic space between pericardium and epicardium", "E": "Reduced regional ventricular wall motion"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Six days", "left hemicolectomy", "colorectal carcinoma", "59 year old man", "hospital hallway", "unconscious", "30 seconds", "of shortness", "breath", "chest pain", "deep inhalation", "hypertension", "hyperlipidemia", "smoked one pack", "cigarettes daily", "35 years", "prior to", "hospital", "not", "alcohol", "distress", "appears ill", "temperature", "36", "97", "blood pressure", "80 50 mm Hg", "pulse", "min", "weak", "Oxygen saturation", "88", "room air", "elevated jugular venous distention", "regular", "rapid heart rate", "holosystolic murmur", "increases", "inspiration", "abdomen", "soft", "mildly tender", "palpation", "the surgical site", "Examination of", "extremities", "pitting edema of", "left leg", "skin", "cold", "clammy", "Further", "to reveal", "following findings"]}
{"question": "A 35-year-old woman presents to her physician with a complaint of pain and stiffness in her hands. She says that the pain began 6 weeks ago a few days after she had gotten over a minor upper respiratory infection. She admits that the pain is worse in the morning, and she occasionally notes subjective fever but has not taken her temperature. She also admits that her appetite has mildly decreased, but she denies any change in weight. The pain is partially alleviated by ibuprofen, but she has been unsatisfied with the results. She is concerned about her condition as it makes caring for her two young children very difficult. Temperature is 99.4°F (37.4°C), blood pressure is 119/73 mmHg, pulse is 75/min, and respirations are 18/min. Physical examination demonstrates swelling and tenderness over the wrists and metacarpophalangeal joints bilaterally. Bilateral radiographs of the hands demonstrate mild periarticular osteopenia around the left fifth metacarpophalangeal joint. Which of the following is the next best step in management of this patient's acute symptoms?", "answer": "Prednisone", "options": {"A": "Anakinra", "B": "Etanercept", "C": "Methotrexate", "D": "Reassurance", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old woman presents", "physician", "complaint", "pain", "stiffness", "hands", "pain began", "weeks", "few days", "gotten", "minor upper respiratory infection", "pain", "worse", "morning", "occasionally notes subjective fever", "not", "temperature", "appetite", "mildly decreased", "change in weight", "pain", "ibuprofen", "results", "condition", "makes", "two young children very difficult", "Temperature", "99", "blood pressure", "mmHg", "pulse", "75 min", "respirations", "min", "swelling", "tenderness", "wrists", "joints", "Bilateral radiographs of", "hands", "mild periarticular", "left fifth metacarpophalangeal joint", "following", "next best step", "management", "patient's acute symptoms"]}
{"question": "A 15-year-old girl is brought to the physician because of abnormal vaginal bleeding for the past 2 months. Apart from the past 2 months, she has had regular menstrual cycles. She had menarche at the age of 13. She has no personal or family history of any serious illnesses. She takes no medications. Her vital signs are within normal limits. Physical examination shows no abnormal findings. Laboratory studies show elevated serum beta-HCG and AFP levels. An abdominal ultrasound shows a predominantly solid mass in the left ovary. The right ovary and the uterus show no abnormal findings. Which of the following ovarian tumors best explains these findings?", "answer": "Embryonal carcinoma", "options": {"A": "Corpus luteum cyst", "B": "Embryonal carcinoma", "C": "Fibromas", "D": "Krukenberg tumor", "E": "Serous cystadenoma"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "of abnormal vaginal bleeding", "past", "months", "past", "months", "regular menstrual cycles", "menarche at", "age", "personal", "family history", "serious illnesses", "medications", "vital signs", "normal", "Physical examination", "abnormal findings", "Laboratory studies", "elevated serum beta-HCG", "levels", "abdominal ultrasound", "solid mass", "left ovary", "right ovary", "uterus", "abnormal findings", "of the following ovarian tumors best", "findings"]}
{"question": "A 2-year-old boy presents with a swollen face and irritability. The patient's mother reports his urine was red this morning. 3 weeks ago, he presented to this same clinic with a ‘sandpaper’ rash and a red tongue with patchy hyperplastic fungiform papillae for which he was given broad-spectrum antibiotics. Laboratory tests reveal proteinuria, elevated antistreptolysin O, and decreased serum C3. Which of the following conditions mentioned below are triggered by a similar mechanism?\nI. Arthus reaction\nII. Myasthenia gravis\nIII. Acute rheumatic fever\nIV. Polyarteritis nodosa\nV. Rheumatoid arthritis", "answer": "I, IV, V", "options": {"A": "I, II", "B": "III, IV", "C": "I, IV, V", "D": "II, III, IV", "E": "I, IV, V"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["2 year old boy presents", "swollen face", "irritability", "patient's", "reports", "urine", "red", "morning", "weeks", "same clinic", "rash", "red tongue", "patchy hyperplastic fungiform papillae", "given broad spectrum", "Laboratory tests reveal proteinuria", "elevated antistreptolysin O", "decreased serum C3", "following conditions", "triggered", "similar mechanism", "I", "Arthus reaction II", "Myasthenia gravis III", "Acute rheumatic fever IV", "Polyarteritis nodosa", "Rheumatoid arthritis"]}
{"question": "A 37-year-old woman presents to the general medical clinic with a chief complaint of anxiety. She has been having severe anxiety and fatigue for the past seven months. She has difficulty concentrating and her work has suffered, and she has also developed diarrhea from the stress. She doesn't understand why she feels so anxious and is unable to attribute it to anything specific aspect of her life right now. You decide to begin pharmacotherapy. All of the following are suitable mechanisms of drugs that can treat this illness EXCEPT:", "answer": "A drug that blocks dopamine 2 receptors", "options": {"A": "A drug that stimulates 5-HT1A receptors", "B": "A drug that blocks 5-HT reuptake", "C": "A drug that blocks both serotonin and norepinephrine reuptake", "D": "A drug that acts as a GABA agonist", "E": "A drug that blocks dopamine 2 receptors"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "general medical clinic", "chief complaint", "anxiety", "severe anxiety", "fatigue", "past seven months", "difficulty concentrating", "suffered", "diarrhea", "stress", "so anxious", "unable to attribute", "to", "specific aspect", "right now", "to begin pharmacotherapy", "following", "suitable mechanisms", "drugs", "treat", "illness"]}
{"question": "A 17-year-old female is brought to the emergency room by her parents shortly after a suicide attempt by aspirin overdose. Which of the following acid/base changes will occur FIRST in this patient?", "answer": "Respiratory alkalosis", "options": {"A": "Non-anion gap metabolic acidosis", "B": "Anion gap metabolic acidosis", "C": "Respiratory acidosis", "D": "Metabolic alkalosis", "E": "Respiratory alkalosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "brought", "emergency room", "suicide attempt", "aspirin overdose", "following acid base changes", "occur FIRST", "patient"]}
{"question": "During a humanitarian medical mission in rural Vietnam, a medical resident encounters a 50-year-old man with a year-long history of a pruritic rash on his upper body and face, along with numbness and tingling sensation of both of his palms. He mostly works on his family’s rice farm, where he also takes care of livestock. A physical examination revealed multiple erythematous macules and papules on the face, arms, chest, and back, as well as thinning of the eyebrows and loss of some eyelashes. Additional findings include hypopigmented macules around the elbows, which are insensitive to light touch, temperature, and pinprick. The grip strength is slightly diminished bilaterally with the conservation of both bicipital reflexes. What is the most likely diagnosis?", "answer": "Leprosy", "options": {"A": "Cutaneous leishmaniasis", "B": "Sporotrichosis", "C": "Tinea corporis", "D": "Leprosy", "E": "Scrofula"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["rural Vietnam", "medical resident", "50 year old man", "long history", "pruritic rash", "upper body", "face", "numbness", "tingling sensation", "mostly", "rice farm", "revealed multiple erythematous macules", "papules", "face", "arms", "chest", "back", "thinning of", "eyebrows", "loss of", "eyelashes", "Additional findings include hypopigmented macules", "elbows", "insensitive", "light touch", "temperature", "grip strength", "slightly diminished", "conservation", "bicipital reflexes", "diagnosis"]}
{"question": "A 21-year-old female is brought to the emergency department by her roommate. Her roommate says that the patient has been acting “strangely” for the past 10 days. She has noticed that the patient has been moving and talking on the phone at all hours of the night. She doesn’t think that the patient sleeps more than one to two hours a night. She also spends hours pacing up and down the apartment, talking about “trying to save the world.” She also notices that the patient has been speaking very fast. When asking the patient if anything seems different, the patient denies anything wrong, only adding that, “she’s made great progress on her plans.\" The patient said she has felt like this on one occasion 2 years ago, and she recalled being hospitalized for about 2 weeks. She denies any history of depression, although she said about a year ago she had no energy and had a hard time motivating herself to go to class and see her friends for months. She denies hearing any voices or any visual hallucinations. What is the most likely diagnosis in this patient?", "answer": "Bipolar I disorder", "options": {"A": "Schizoaffective disorder", "B": "Major depressive disorder", "C": "Bipolar I disorder", "D": "Bipolar II disorder", "E": "Dysthymic disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["21-year-old female", "brought", "emergency department", "patient", "acting", "past 10 days", "patient", "moving", "hours", "night", "patient sleeps more", "one", "two hours", "night", "spends hours", "down", "apartment", "talking", "patient", "very fast", "patient", "different", "patient", "wrong", "only adding", "shes made great progress", "plans", "patient", "one occasion", "years ago", "hospitalized", "2 weeks", "history of depression", "year", "energy", "hard time", "to go", "see", "months", "hearing", "voices", "visual hallucinations", "diagnosis", "patient"]}
{"question": "An 87-year-old woman is brought to the emergency department 30 minutes after a fall onto a hardwood floor. She landed on her left side and hit the left side of her head. She did not lose consciousness. She has a mild headache over the left temple and severe left hip pain. She has had nasal congestion, a sore throat, and a productive cough for the last 2 days. She has a history of atrial fibrillation, coronary artery disease, hypertension, and osteoporosis. She underwent two coronary artery bypass grafts 5 years ago. She had smoked one pack of cigarettes daily for 30 years but quit 30 years ago. Her current medications include aspirin, apixaban, diltiazem, omeprazole, and vitamin D supplementation. The patient is oriented to person, place, and time. There is a 2-cm ecchymosis over the left temple. Examination of the left hip shows swelling and tenderness; range of motion is limited. Intravenous morphine 2 mg is started. During further examination, the patient complains of dizziness and palpitations. She is diaphoretic and pale. Her skin is cold and clammy. Her pulse is 110/min and faint, respirations are 20/min, and blood pressure is 70/30 mm Hg. Cranial nerves are intact. Cardiac examinations shows no murmurs, rubs, or gallops. An ECG shows absent P waves and nonspecific changes of the ST segment and the T wave. Which of the following is the most likely underlying mechanism for the patient's sudden decline in her condition?", "answer": "Blood loss", "options": {"A": "Pulmonary embolism", "B": "Cardiac tamponade", "C": "Brain herniation", "D": "Sepsis", "E": "Blood loss"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["87 year old woman", "brought", "emergency department 30 minutes", "fall", "floor", "landed", "left side", "hit", "left side of", "head", "not", "consciousness", "mild headache", "left", "severe left hip pain", "nasal congestion", "sore throat", "productive cough", "2 days", "history of atrial fibrillation", "coronary artery disease", "hypertension", "osteoporosis", "two coronary artery bypass grafts", "years", "smoked one pack", "cigarettes daily", "30 years", "30 years", "current medications include aspirin", "apixaban", "diltiazem", "omeprazole", "vitamin", "supplementation", "patient", "oriented to person", "place", "time", "2 cm ecchymosis", "left temple", "Examination", "hip", "swelling", "tenderness", "range of motion", "limited", "Intravenous morphine", "mg", "started", "further", "patient", "dizziness", "palpitations", "diaphoretic", "pale", "skin", "cold", "clammy", "pulse", "min", "faint", "respirations", "20 min", "blood pressure", "70 30 mm Hg", "Cranial nerves", "intact", "murmurs", "rubs", "ECG", "absent P waves", "nonspecific changes", "ST segment", "T wave", "following", "underlying mechanism", "patient's sudden", "condition"]}
{"question": "A 27-year-old male presents with primary complaints of a palpable mass in his scrotum and mild testicular pain. Physical exam reveals an abnormal appearing scrotum around the left testis, as depicted in image A. Which of the following is the most likely etiology of this presentation?", "answer": "Compression of the left renal vein at the aortic origin of the superior mesenteric artery", "options": {"A": "Compression of the left renal vein at the aortic origin of the superior mesenteric artery", "B": "Patent processus vaginalis allowing fluid entry into the scrotum", "C": "Neisseria gonorrhoeae Infection of the left testis leading to epididymitis", "D": "Unilateral failure of the left testis to descend into the scrotum", "E": "Twisting of the spermatic cord secondary to rotation of the left testis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old male presents", "primary complaints", "palpable mass", "scrotum", "mild testicular", "reveals", "abnormal appearing scrotum", "left testis", "following", "etiology"]}
{"question": "A 30-month-old boy is brought to the emergency department by his parents. He has burns over his left hand. The mother tells the doctor that the child was playing unobserved in the kitchen and accidentally grabbed a hot spoon, which produced the burn. She also says his pediatrician had expressed concern as to the possibility of autism spectrum disorder during the last visit and had suggested regular follow-up. 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. On physical examination, his temperature is 37.0°C (98.6°F), pulse rate is 140/min, and respiratory rate is 28/min. He is irritable and crying excessively. On examination, the skin of the left hand is white-pink with small blisters over the entire dorsal aspect of the hand, but the skin of the palmar surface is undamaged. There is a sharp demarcation between healthy skin above the wrist and the injured skin of the hand. There are no burns or another injury anywhere else on the child. Which of the following is the most likely cause of the burns?", "answer": "Forced immersion in hot water", "options": {"A": "Forced immersion in hot water", "B": "Burn as a result of poor supervision", "C": "Cigarette burns", "D": "Accidental burns", "E": "Abusive burn from a hot spoon"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 month old boy", "brought", "emergency department", "burns", "left", "doctor", "child", "playing", "kitchen", "grabbed", "hot spoon", "burn", "pediatrician", "possibility", "autism spectrum disorder", "last", "regular follow-up", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "temperature", "98", "pulse rate", "min", "respiratory rate", "min", "irritable", "excessively", "skin of", "left hand", "pink", "blisters", "entire dorsal aspect", "hand", "skin of", "palmar surface", "sharp", "healthy skin", "wrist", "the injured skin of", "hand", "burns", "injury", "else", "child", "following", "most likely cause", "burns"]}
{"question": "A 75-year-old man is brought to the emergency department for a 5-day-history of worsening dyspnea, orthopnea, and lower leg swelling. He has a history of hypertension, hyperlipidemia, non-alcoholic fatty liver disease, and myocardial infarction 10 years ago. Current medications include metoprolol, lisinopril, ethacrynic acid, eplerenone, and aspirin. He drinks 1 beer daily. He has a 30-pack-year smoking history. He is allergic to sulfonamides. His temperature is 37.0°C (98.6°F), his pulse is 120/min, and his blood pressure is 120/80 mm Hg. Physical examination reveals jugular venous distention and 3+ pitting edema in his lower legs. Crackles are heard at both lung bases. The point of maximal impulse is 2 cm to the left of the midclavicular line in the 6th intercostal space. Which of the following additional findings would be most strongly associated with increased mortality?", "answer": "Decreased serum Na+", "options": {"A": "Decreased BNP levels", "B": "Decreased serum Na+", "C": "Decreased QRS complex duration", "D": "Increased VO2", "E": "Increased heart rate variability"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["75 year old man", "brought", "emergency department", "5-day history", "worsening dyspnea", "orthopnea", "lower leg swelling", "history of hypertension", "hyperlipidemia", "non-alcoholic fatty liver disease", "myocardial infarction", "Current medications include metoprolol", "lisinopril", "ethacrynic acid", "eplerenone", "aspirin", "1", "daily", "30", "smoking history", "allergic", "sulfonamides", "temperature", "98", "pulse", "min", "blood pressure", "80 mm Hg", "reveals jugular venous distention", "3", "pitting edema", "lower legs", "Crackles", "heard", "lung bases", "point", "maximal impulse", "2 cm", "left", "midclavicular", "intercostal space", "following additional findings", "most", "associated with increased mortality"]}
{"question": "You have been asked to quantify the relative risk of developing bacterial meningitis following exposure to a patient with active disease. You analyze 200 patients in total, half of which are controls. In the trial arm, 30% of exposed patients ultimately contracted bacterial meningitis. In the unexposed group, only 1% contracted the disease. Which of the following is the relative risk due to disease exposure?", "answer": "[30 / (30 + 70)] / [1 / (1 + 99)]", "options": {"A": "[30 / (30 + 70)] / [1 / (1 + 99)]", "B": "(30 * 99) / (70 * 1)", "C": "[70 / (30 + 70)] / [99 / (1 + 99)]", "D": "(70 * 1) / (39 * 99)", "E": "[1 / (1 + 99)] / 30 / (30 + 70)]"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["to quantify", "relative risk", "bacterial meningitis following exposure to", "patient", "active disease", "200 patients", "total", "half", "controls", "30", "exposed patients", "contracted bacterial meningitis", "only", "contracted", "disease", "following", "relative risk due to disease exposure"]}
{"question": "A father brings in his 7-year-old twin sons because they have a diffuse rash. They have several papules, vesicles, pustules, and crusts on their scalps, torso, and limbs. The skin lesions are pruritic. Other than that, the boys appear to be well. The father reports that several children in school have a similar rash. The family recently returned from a beach vacation but have not traveled internationally. Both boys have stable vital signs within normal limits. What is the most common complication of the infection the boys appear to have?", "answer": "Bacterial superinfection of skin lesions", "options": {"A": "Hepatitis", "B": "Bacterial superinfection of skin lesions", "C": "Pneumonia", "D": "Encephalitis", "E": "Cerebellar ataxia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old twin", "diffuse rash", "several papules", "vesicles", "pustules", "crusts", "scalps", "torso", "limbs", "skin lesions", "boys appear to", "well", "reports", "several children in school", "similar rash", "recently returned", "beach", "not", "boys", "stable vital signs", "normal limits", "most common complication", "infection", "boys appear to"]}
{"question": "A 75-year-old female comes to the physician’s office with complaints of right lower quadrant pain. She has been experiencing these symptoms for the last 6 months and they have progressively gotten worse. An ultrasound reveals a large ovarian mass and abdominal and pelvic CT reveals no metastases. Her serum levels of CA-125 are elevated and the biopsy reveals the primary neoplasm as ovarian in origin. Her cancer is characterized as invasive carcinoma without metastasis. Which of the following cellular changes is consistent with this diagnosis?", "answer": "Loss of E-cadherin", "options": {"A": "Appropriate basal to apical differentiation", "B": "Intact basement membrane", "C": "Loss of E-cadherin", "D": "Seeding via capillaries", "E": "Increased proliferation of cells with preservation of size and shape"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old female", "physicians office", "complaints", "right lower quadrant pain", "symptoms", "months", "gotten worse", "ultrasound reveals", "large ovarian", "abdominal", "pelvic CT reveals", "metastases", "serum levels", "CA-125", "elevated", "biopsy reveals", "primary", "ovarian", "origin", "cancer", "invasive carcinoma", "metastasis", "following cellular changes", "diagnosis"]}
{"question": "A 36-year-old African American woman G1P0 at 33 weeks gestation presents to the emergency department because \"her water broke.\" Her prenatal history is remarkable for proteinuria in the absence of hypertension during her third trimester check-up. She denies any smoking, alcohol use, sick contacts, abdominal pain, fever, nausea, vomiting, or diarrhea. Her temperature is 98.6°F (37°C), blood pressure is 150/90 mmHg, pulse is 120/min, and respirations are 26/min. While the on-call obstetrician is on her way to the emergency department, the following labs are obtained:\n\nHemoglobin: 11 g/dL\nHematocrit: 35 %\nLeukocyte count: 9,800/mm^3 with normal differential\nPlatelet count: 400,000/mm^3\n\nSerum:\nNa+: 137 mEq/L\nCl-: 99 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 22 mEq/L\nBUN: 35 mg/dL\nGlucose: 128 mg/dL\nCreatinine: 1.2 mg/dL\n\nUrine:\nEpithelial cells: Scant\nProtein: 2+\nGlucose: 1+\nWBC: 2/hpf\nBacterial: None\n\nWhat is the most likely finding in the neonate after delivery?", "answer": "Growth retardation", "options": {"A": "Growth retardation", "B": "Meconium aspiration", "C": "Microcephaly", "D": "Seizures", "E": "Stillbirth"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old", "woman", "weeks presents", "emergency department", "water", "prenatal history", "proteinuria", "absence of hypertension", "third trimester check-up", "smoking", "sick", "abdominal pain", "fever", "nausea", "vomiting", "diarrhea", "temperature", "98", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "call obstetrician", "emergency department", "following labs", "obtained", "Hemoglobin", "g/dL Hematocrit", "35", "Leukocyte count", "800 mm", "normal differential Platelet count", "400", "mm", "Serum", "Na", "137 mEq L", "99 mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "35 mg/dL Glucose", "mg/dL Creatinine", "1.2 mg/dL", "Urine", "Epithelial cells", "Scant Protein", "2", "Glucose", "1", "WBC", "2 hpf Bacterial", "finding", "neonate", "delivery"]}
{"question": "A 30-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital in active labor. Her first pregnancy and delivery were complicated by iron deficiency anemia and pregnancy-induced hypertension. She has had no routine prenatal care during this pregnancy but was diagnosed with oligohydramnios 4 weeks ago. The remainder of her medical history is not immediately available. A 2400-g (5.4-lb) female newborn is delivered vaginally. Examination of the newborn shows a short, mildly webbed neck and low-set ears. Ocular hypertelorism along with slanted palpebral fissures are noted. A cleft palate and hypoplasia of the nails and distal phalanges are present. There is increased coarse hair on the body and face. Which of the following best explains the clinical findings found in this newborn?", "answer": "Maternal phenytoin therapy", "options": {"A": "Maternal phenytoin therapy", "B": "Fetal posterior urethral valves", "C": "Maternal diabetes mellitus", "D": "Maternal alcohol intake", "E": "Fetal X chromosome monosomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman", "gravida 2", "para 1", "40 weeks", "gestation", "active labor", "first pregnancy", "delivery", "complicated", "iron deficiency anemia", "pregnancy-induced hypertension", "routine care", "pregnancy", "diagnosed", "oligohydramnios", "weeks", "of", "medical history", "not immediately available", "2400", "female newborn", "delivered", "Examination", "newborn", "short", "mildly webbed neck", "low-set ears", "Ocular hypertelorism", "palpebral fissures", "noted", "cleft palate", "hypoplasia", "nails", "distal phalanges", "present", "increased coarse", "body", "face", "following best", "clinical findings found", "newborn"]}
{"question": "A 32-year-old female presents to her obstetrician 3 weeks postpartum for failure to lactate. Of note, she has been unable to tolerate cold environments since the birth of her child. Review of systems is positive for fatigue, lightheadedness, and a 3-pound weight gain over the last 3 weeks. Her delivery was complicated by placenta accreta with postpartum blood loss. Her newborn infant is doing well on formula. She denies any personal or family history of thyroid disease. Physical exam is overall unremarkable. On a panel of hormone testing, which of the following levels is most likely to be normal in this patient?", "answer": "Aldosterone", "options": {"A": "Antidiuretic hormone", "B": "Aldosterone", "C": "Cortisol", "D": "Luteinizing hormone", "E": "Thyroid hormone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female presents", "obstetrician", "weeks postpartum", "failure", "lactate", "note", "unable to", "birth of", "child", "positive", "fatigue", "lightheadedness", "3 pound weight gain", "3 weeks", "delivery", "complicated", "placenta accreta", "postpartum blood loss", "newborn infant", "well", "formula", "personal", "family history of thyroid disease", "overall unremarkable", "hormone", "following levels", "to", "normal", "patient"]}
{"question": "A 44-year-old woman comes to the physician because of a 2-year history of progressive dysphagia. She initially had symptoms only when consuming solid foods, but for the past 2 months she has also had difficulty swallowing liquids. She describes a feeling of food “getting stuck” in her throat. She was diagnosed with gastroesophageal reflux disease 2 years ago and has had episodic pallor of her fingers since adolescence. She has smoked half a pack of cigarettes daily for 24 years. Her only medication is omeprazole. Her pulse is 65/min, respirations are 12/min, and blood pressure is 127/73 mm Hg. Examination shows thickening of the skin of her fingers, with small white papules on her fingertips. There are small dilated blood vessels on her face, lips, and tongue. Cardiopulmonary examination shows no abnormalities. Which of the following is the most likely cause of this patient's dysphagia?", "answer": "Esophageal smooth muscle atrophy and fibrosis", "options": {"A": "Uncoordinated contractions of the esophagus", "B": "Protrusion of thin tissue membranes into the esophagus", "C": "Esophageal smooth muscle atrophy and fibrosis", "D": "Degeneration of upper and lower motor neurons", "E": "Outpouching of the lower pharyngeal mucosa and submucosa\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "2 year history", "progressive dysphagia", "initially", "symptoms only", "past", "months", "difficulty swallowing liquids", "food getting", "throat", "diagnosed", "gastroesophageal reflux disease", "years", "episodic pallor of", "fingers", "adolescence", "smoked half", "pack", "cigarettes daily", "years", "only medication", "omeprazole", "pulse", "65 min", "respirations", "min", "blood pressure", "mm Hg", "thickening", "skin", "fingers", "papules", "fingertips", "small dilated blood vessels", "face", "lips", "tongue", "Cardiopulmonary", "abnormalities", "following", "most likely cause", "patient's dysphagia"]}
{"question": "A 14-year-old boy is brought to the emergency department by his parents for joint pain following the acute onset of a diffuse, pruritic rash for the past 24 hours. A week ago, he was diagnosed with pharyngitis after returning home from summer camp and is currently taking antibiotics. There is no family history of serious illness. His temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Physical examination shows periorbital edema, generalized lymphadenopathy, and well-circumscribed, erythematous, confluent skin lesions of variable sizes up to several centimeters in width over his entire body. There is pain on passive movement of wrists and ankle joints bilaterally. Urine dipstick shows 1+ proteinuria. There is no hematuria. Which of the following is the most appropriate next step in management?", "answer": "Discontinue antibiotic", "options": {"A": "Switch medication to doxycycline", "B": "Discontinue antibiotic", "C": "Administer prednisone", "D": "Perform allergy testing", "E": "Administer diphenhydramine\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency department", "joint pain following", "acute", "diffuse", "pruritic rash", "past 24 hours", "week", "diagnosed", "pharyngitis", "returning home", "summer camp", "currently", "family history", "serious illness", "temperature", "pulse", "90 min", "blood pressure", "70 mm Hg", "periorbital edema", "generalized lymphadenopathy", "well circumscribed", "erythematous", "confluent skin lesions of variable sizes up to", "centimeters", "width", "entire body", "pain", "passive movement", "wrists", "ankle joints", "Urine dipstick", "1", "proteinuria", "hematuria", "following", "most appropriate next step"]}
{"question": "A 61-year-old woman comes to the physician because of a 6-day history of cough, shortness of breath, and fever. She also reports that she has had 4 episodes of watery diarrhea per day for the last 3 days. She has chronic bronchitis. She has smoked one pack of cigarettes daily for the past 30 years. Her temperature is 39°C (102.2°F) and pulse is 65/min. Examination shows diffuse crackles over the left lower lung field. Laboratory studies show:\nHemoglobin 13.8 g/dL\nLeukocyte count 16,000/mm3\nPlatelet count 150,000/mm3\nSerum\nNa+ 131 mEq/L\nCl- 102 mEq/L\nK+ 4.7 mEq/L\nAn x-ray of the chest shows consolidation of the left lower lobe. A Gram stain of induced sputum shows numerous neutrophils but no organisms. Which of the following is the most appropriate pharmacotherapy?\"", "answer": "Levofloxacin", "options": {"A": "Rifampin", "B": "Amoxicillin", "C": "Vancomycin", "D": "Levofloxacin", "E": "Cotrimoxazole"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old woman", "physician", "6-day history", "cough", "shortness of breath", "fever", "reports", "4 episodes of watery diarrhea", "day", "3 days", "chronic bronchitis", "smoked one pack", "cigarettes daily", "past 30 years", "temperature", "pulse", "65 min", "diffuse crackles", "left lower", "Laboratory studies", "Hemoglobin", "g", "Leukocyte", "mm3 Platelet count", "Serum", "mEq Cl", "K", "4 7", "x-ray of", "chest", "consolidation", "left lower lobe", "Gram stain", "induced sputum", "numerous", "following", "most appropriate pharmacotherapy"]}
{"question": "A 70-year-old woman presents to the office for a yearly physical. She states she has recently started experiencing pain in her legs and her back. Last year, she experienced a fracture of her left arm while trying to lift groceries. The patient states that she does not consume any dairy and does not go outside often because of the pain in her legs and back. Of note, she takes carbamazepine for seizures. On exam, her vitals are within normal limits. You suspect the patient might have osteomalacia. Testing for which of the following is the next best step to confirm your suspicion?", "answer": "25-hydroxyvitamin D", "options": {"A": "7-dehydrocholesterol", "B": "25-hydroxyvitamin D", "C": "1,25-hydroxyvitamin D", "D": "Pre-vitamin D3", "E": "Dietary vitamin D2"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["70 year old woman presents", "office", "yearly physical", "states", "recently started", "pain in", "legs", "back", "year", "fracture of", "left arm", "lift", "patient states", "not", "dairy", "not go outside often", "pain", "legs", "back", "note", "carbamazepine", "seizures", "exam", "normal limits", "patient", "osteomalacia", "Testing", "following", "next best step to confirm"]}
{"question": "A 3-year-old boy is brought to the physician for evaluation of developmental delay. He could sit alone at 12 months and started walking with support at the age of 2 years. He can name only very few familiar objects and uses simple two-word sentences. He cannot stack more than 2 blocks. His parents report that he does not like playing with other children. He is at the 80th percentile for head circumference, 85th percentile for height, and 50th percentile for weight. He has a long and narrow face as well as large protruding ears. His thumbs can be passively flexed to the ipsilateral forearm. This patient is at increased risk of developing which of the following conditions?", "answer": "Mitral regurgitation", "options": {"A": "Acute myeloid leukemia", "B": "Aortic dissection", "C": "Type 2 diabetes mellitus", "D": "Hyperuricemia", "E": "Mitral regurgitation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "physician", "developmental delay", "sit alone", "12 months", "started walking with support", "age", "years", "name only very", "familiar", "uses simple two", "stack more", "blocks", "report", "not", "playing", "children", "80th percentile", "head circumference", "percentile", "height", "50th percentile", "weight", "long", "narrow face", "large protruding ears", "thumbs", "flexed", "ipsilateral forearm", "patient", "increased risk", "following conditions"]}
{"question": "A 25-year-old woman is brought to the emergency department because of a 1-day history of lower abdominal pain and vaginal bleeding. Her last menstrual period was 7 weeks ago. A urine pregnancy test is positive. A pelvic ultrasound shows a normal appearing uterus with an empty intrauterine cavity and a minimal amount of free pelvic fluid. Treatment with a drug is begun. Which of the following is the most likely effect of this drug?", "answer": "Increase in deoxyuridine monophosphate", "options": {"A": "Decrease in guanylate", "B": "Increase in thymidine monophosphate", "C": "Increase in deoxyuridine monophosphate", "D": "Decrease in phosphoribosyl pyrophosphate", "E": "Increase in tetrahydrofolate polyglutamate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "1-day history", "lower abdominal pain", "vaginal bleeding", "last menstrual period", "weeks", "urine pregnancy test", "positive", "pelvic ultrasound", "normal appearing uterus", "empty intrauterine cavity", "minimal amount", "free pelvic fluid", "Treatment", "drug", "begun", "following", "effect of", "drug"]}
{"question": "A 71-year-old man presents to the physician for a routine health-maintenance examination. He feels well; however, he is concerned about the need for prostate cancer screening. He has a 3-year history of benign prostatic hyperplasia. His symptoms of urinary hesitancy and terminal dribbling of urine are well controlled with tamsulosin and finasteride. He also had a percutaneous coronary angioplasty done 2 years ago following a diagnosis of unstable angina. His medication list also includes aspirin, atorvastatin, losartan, and nitroglycerin. His vital signs are within normal limits. He has never had a serum prostate-specific antigen (PSA) test or prostate ultrasonography. Which of the following is the most appropriate screening test for prostate cancer in this patient?", "answer": "No screening test is recommended", "options": {"A": "Prostate ultrasonography every year", "B": "Prostate ultrasonography every 5 years", "C": "Serum PSA every year", "D": "Serum PSA every 2-4 years", "E": "No screening test is recommended"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "physician", "routine", "well", "need", "prostate cancer screening", "3 year history of benign prostatic hyperplasia", "symptoms", "urinary", "terminal dribbling of urine", "well controlled", "tamsulosin", "finasteride", "percutaneous coronary angioplasty", "2 years", "following", "diagnosis", "unstable angina", "medication", "includes aspirin", "atorvastatin", "losartan", "nitroglycerin", "vital signs", "normal limits", "never", "serum prostate-specific antigen", "test", "prostate ultrasonography", "following", "most appropriate screening test for prostate cancer", "patient"]}
{"question": "A 47-year-old woman presents to the clinic complaining of difficulty swallowing that started 1 month ago. The patient also reports a weight loss of 10 lbs during this time, without a change in her appetite. She denies fatigue, cough, hoarseness, pain, or hemoptysis. The patient has a history of childhood lymphoma, which was treated with radiation. She takes no medications. She has smoked 1 pack of cigarettes per day since she was 25 years old. Her physical exam is notable for a palpable nodule on the right side of the thyroid. An ultrasound is performed, which confirms a 1.2 cm hyperechoic nodule in the right lobe. Thyroid function labs are drawn and shown below:\n\nSerum TSH: 0.2 mU/L\nSerum thyroxine (T4): 187 nmol/L\nSerum triiodothyronine (T3): 3.3 nmol/L\n\nWhich of the following is the next best step in management?", "answer": "Thyroid scintigraphy", "options": {"A": "Fine needle aspiration", "B": "Levothyroxine", "C": "Partial thyroidectomy", "D": "Radioactive iodine", "E": "Thyroid scintigraphy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "clinic", "difficulty swallowing", "started 1 month", "patient", "reports", "weight loss of 10 lbs", "time", "change in", "appetite", "fatigue", "cough", "hoarseness", "pain", "hemoptysis", "patient", "history of childhood lymphoma", "treated with radiation", "medications", "smoked 1 pack", "cigarettes", "day", "years old", "notable", "palpable nodule", "right side", "thyroid", "ultrasound", "performed", "confirms a", "2 cm hyperechoic nodule", "right lobe", "Thyroid function labs", "Serum", "0.2 mU/L Serum thyroxine", "nmol/L Serum triiodothyronine", "3.3 nmol/L", "following", "next best step"]}
{"question": "A 2-year-old boy is brought to the physician by his parents for the evaluation of an unusual cough, a raspy voice, and noisy breathing for the last 2 days. During this time, the symptoms have always occurred in the late evening. The parents also report that prior to the onset of these symptoms, their son had a low-grade fever and a runny nose for 2 days. He attends daycare. His immunizations are up-to-date. His temperature is 37.8°C (100°F) and respirations are 33/min. Physical examination shows supraclavicular retractions. There is a high-pitched breath sound on inspiration. Which of the following is the most likely location of the abnormality?", "answer": "Subglottic larynx", "options": {"A": "Bronchioles", "B": "Epiglottis", "C": "Supraglottic larynx", "D": "Subglottic larynx", "E": "Bronchi\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["2 year old boy", "brought", "physician", "unusual cough", "raspy voice", "noisy breathing", "2 days", "time", "symptoms", "always", "late evening", "report", "prior to", "onset", "symptoms", "low-grade fever", "runny nose", "2 days", "attends daycare", "immunizations", "date", "temperature", "respirations", "min", "supraclavicular retractions", "high-pitched breath", "inspiration", "following", "location", "abnormality"]}
{"question": "A 9-year-old boy from Eritrea is admitted to the hospital for lethargy and increased work of breathing. He has had recurrent episodes of fever, shortness of breath, and fatigue in the past 3 years. His pulse is 132/min and blood pressure is 90/66 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Auscultation of the chest shows coarse crackles in both lungs and a diastolic murmur at the cardiac apex. Despite appropriate lifesaving measures, he dies. A photomicrograph of a section of myocardium obtained at autopsy is shown. Which of the following is the most likely underlying cause of this patient's cardiac disease?", "answer": "Type II hypersensitivity reaction", "options": {"A": "Amastigote infiltration", "B": "Beta-myosin heavy chain defect", "C": "Non-caseating granulomatous inflammation", "D": "Type II hypersensitivity reaction", "E": "Exotoxin-mediated myonecrosis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "Eritrea", "lethargy", "increased work of breathing", "recurrent episodes of fever", "shortness of breath", "fatigue", "past", "years", "pulse", "min", "blood pressure", "90 66 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "Auscultation", "chest", "coarse crackles", "lungs", "diastolic murmur", "cardiac apex", "appropriate lifesaving measures", "photomicrograph", "section", "myocardium obtained", "autopsy", "following", "underlying cause", "patient's cardiac disease"]}
{"question": "A 52-year-old woman presents to her primary care physician with symptoms of heat intolerance, unintentional weight loss, feelings of anxiety, and excessive energy that hinder her from falling asleep at night. On physical exam, the patient is found to have mildly protuberant eyes bilaterally as well as discoloration and swelling of her shins. Which of the following lab results would most likely be present in this patient?", "answer": "Decreased serum TSH", "options": {"A": "Decreased anti-TSH antibodies", "B": "Decreased free T4", "C": "Decreased serum TSH", "D": "Increased anti-mitochondrial antibodies", "E": "Increased serum TSH"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "symptoms of heat intolerance", "unintentional weight loss", "anxiety", "excessive energy", "falling asleep", "night", "patient", "found to", "mildly protuberant eyes", "discoloration", "swelling", "shins", "following lab results", "most likely", "present", "patient"]}
{"question": "A 35-year-old man presents with acute-onset right flank pain. He says that his symptoms began suddenly 6 hours ago and have not improved. He describes the pain as severe, colicky, and ‘coming in waves’. It is localized to the right flank and radiates to the groin. He says he has associated nausea. He denies any fever, chills, dysuria, or hematuria. His past medical history is significant for asymptomatic nephrolithiasis, diagnosed 9 months ago on an upright abdominal radiograph, which has not yet been treated. The patient’s vital signs include: temperature 37.0°C (98.6°F), blood pressure 145/90 mm Hg, pulse 119/min, and respiratory rate 21/min. On physical examination, the patient is constantly moving and writhing with pain. There is severe right costovertebral angle tenderness. The remainder of the physical examination is unremarkable. A urine dipstick shows 2+ blood. A noncontrast CT of the abdomen and pelvis reveals a 4-mm-diameter radiopaque stone at the right ureteropelvic junction. Several nonobstructing small-diameter stones are noted in the left kidney. Mild hydronephrosis of the right kidney is noted. Intravenous fluids are started and ondansetron is administered. Which of the following is the next best step in the management of this patient?", "answer": "Hydrocodone and indomethacin", "options": {"A": "Emergency percutaneous nephrostomy", "B": "Hydrocodone and indomethacin", "C": "24-hour urine chemistry", "D": "Lithotripsy", "E": "Potassium citrate"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old man presents", "acute-onset right flank", "symptoms began", "hours", "not improved", "pain", "severe", "colicky", "localized", "right flank", "radiates", "groin", "associated nausea", "fever", "chills", "dysuria", "hematuria", "past medical history", "significant", "asymptomatic nephrolithiasis", "diagnosed", "months", "upright abdominal radiograph", "not", "treated", "patients vital signs include", "temperature", "98", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "min", "patient", "constantly moving", "pain", "severe right costovertebral angle tenderness", "unremarkable", "urine dipstick", "2", "blood", "CT of", "abdomen", "pelvis reveals", "4-mm diameter radiopaque stone", "right ureteropelvic junction", "Several", "small diameter stones", "noted", "left kidney", "Mild hydronephrosis", "right kidney", "noted", "started", "ondansetron", "administered", "following", "next best step", "patient"]}
{"question": "A 22-year-old man is brought to the emergency department by ambulance 1 hour after a motor vehicle accident. He did not require any circulatory resuscitation at the scene, but he was intubated because he was unresponsive. He has no history of serious illnesses. He is on mechanical ventilation with no sedation. His blood pressure is 121/62 mm Hg, the pulse is 68/min, and the temperature is 36.5°C (97.7°F). His Glasgow coma scale (GCS) is 3. Early laboratory studies show no abnormalities. A search of the state donor registry shows that he has registered as an organ donor. Which of the following is the most appropriate next step in evaluation?", "answer": "Evaluation of brainstem reflexes", "options": {"A": "Apnea test", "B": "Brain MRI", "C": "Cerebral angiography", "D": "Electroencephalography", "E": "Evaluation of brainstem reflexes"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "hour", "motor vehicle accident", "not", "circulatory resuscitation", "intubated", "unresponsive", "history", "serious illnesses", "mechanical ventilation", "sedation", "blood pressure", "62 mm Hg", "pulse", "min", "temperature", "36", "97", "Glasgow coma scale", "3", "Early laboratory studies", "abnormalities", "state donor", "organ donor", "following", "most appropriate next step"]}
{"question": "A 72-year-old woman with a medical history significant for chronic kidney disease stage 4, hypertension, and type 2 diabetes mellitus, presents to the office for a scheduled visit. During her last visit, the physician started discussing with her the possibility of starting her on dialysis for her chronic kidney disease. The patient has no complaints about her health and enjoys spending time with her family. At presentation, she is afebrile; the blood pressure is 139/89 mm Hg and the heart rate is 80/min. On physical examination, her pulses are bounding, the complexion is pale, she has a grade ⅙ holosystolic murmur, breath sounds remain clear, and 2+ pedal edema to the knee. The measurement of which of the following laboratory values is most appropriate to screen for renal osteodystrophy in this patient?", "answer": "Serum intact parathyroid hormone level", "options": {"A": "Erythrocyte sedimentation rate", "B": "Serum C-reactive protein level", "C": "Serum intact parathyroid hormone level", "D": "Serum thyroid-stimulating hormone level", "E": "Serum vitamin B-12 level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old woman", "medical history significant", "chronic kidney disease stage 4", "hypertension", "type 2 diabetes mellitus", "presents", "office", "scheduled", "last", "physician started", "possibility", "starting", "dialysis", "chronic kidney disease", "patient", "complaints", "spending time", "afebrile", "blood pressure", "mm Hg", "heart rate", "80 min", "pulses", "bounding", "complexion", "pale", "grade", "holosystolic murmur", "breath sounds", "clear", "2", "pedal", "knee", "following", "values", "most appropriate to screen", "renal osteodystrophy", "patient"]}
{"question": "A 44-year-old woman presents to her physician’s office for weakness. She reports having some difficulty placing books on a high shelf and getting up from a seated position. She denies muscle pain or any new rashes. She has noticed a tremor that is worse with action and has been having trouble falling asleep and staying asleep. She has lost approximately 10 pounds unintentionally over the course of 2 months. Medical history is significant for type I diabetes mellitus managed with an insulin pump. Family history is notable for systemic lupus erythematosus in her mother and panic disorder in the father. Her temperature is 98.6°F (37 °C), blood pressure is 140/85 mmHg, pulse is 102/min, and respirations are 17/min. On physical exam, she is mildly diaphoretic and restless, she has notable lid retraction, and her hair is thin. She has 4/5 strength in the proximal upper and lower extremities. Biceps and patellar tendon reflexes are 3+. Which of the following laboratory findings are most likely present in this patient?", "answer": "Decreased thyroid-stimulating hormone", "options": {"A": "Anti-Mi-2 antibody positivity", "B": "Anti-nuclear antibody positivity", "C": "Decreased thyroid-stimulating hormone", "D": "Increased erythrocyte sedimentation rate", "E": "Normal laboratory results"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physicians office", "weakness", "reports", "difficulty placing", "high", "getting", "seated position", "muscle pain", "new rashes", "tremor", "trouble falling asleep", "asleep", "lost approximately 10 pounds", "course of", "months", "Medical history", "significant", "type I diabetes mellitus", "insulin pump", "Family history", "notable", "systemic lupus erythematosus", "panic disorder", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "mildly diaphoretic", "restless", "notable lid retraction", "hair", "thin", "4/5 strength", "proximal upper", "lower extremities", "Biceps", "patellar tendon reflexes", "3", "following laboratory findings", "most likely present", "patient"]}
{"question": "A 23-year-old college senior visits the university health clinic after vomiting large amounts of blood. He has been vomiting for the past 36 hours after celebrating his team’s win at the national hockey championship with his varsity friends while consuming copious amounts of alcohol. His personal medical history is unremarkable. His blood pressure is 129/89 mm Hg while supine and 100/70 mm Hg while standing. His pulse is 98/min, strong and regular, with an oxygen saturation of 98%. His body temperature is 36.5°C (97.7°F), while the rest of the physical exam is normal. Which of the following is associated with this patient’s condition?", "answer": "Esophageal tear", "options": {"A": "Portal hypertension", "B": "Esophageal perforation", "C": "Esophageal metaplasia", "D": "Output of the esophageal mucosa", "E": "Esophageal tear"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old college", "university", "clinic", "vomiting large amounts of blood", "vomiting", "past 36 hours", "win", "copious amounts", "alcohol", "personal medical history", "unremarkable", "blood pressure", "mm Hg", "supine", "100 70 mm Hg", "standing", "pulse", "98 min", "strong", "regular", "oxygen saturation", "98", "body temperature", "36", "97", "normal", "following", "associated with", "patients condition"]}
{"question": "A 29-year-old G1P0 at 23 weeks of gestation presents to the ED for left flank pain migrating to the groin. The pain is sharp, causing her to have nausea and vomiting. She also endorses urinary frequency, but denies vaginal discharge. There have been no complications in her pregnancy thus far. Her abdominal exam is remarkable for left lower quadrant tenderness to palpation with pain radiating to the left groin, but no guarding. She also has tenderness to palpation of the left flank. Blood is visible on inspection of the perineal area.\n\nUrinalysis:\nUrine Color: Yellow\npH: 7.1\nSpecific gravity: 1.010\nBlood: 3+\nBilirubin: Negative\nGlucose: Negative\nKetones: Negative\nProtein: Negative\nNitrite: Negative\nLeukocyte esterase: Negative\nRed blood cells: 291 cells/ul\nWhite blood cells: 75 cells/ul\n\nWhich of the following is the next best step in management?", "answer": "Renal ultrasound", "options": {"A": "Renal radiograph", "B": "Intravenous pyelogram", "C": "Renal ultrasound", "D": "Noncontrast CT scan of abdomen and pelvis", "E": "Exploratory laparoscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old", "23 weeks of gestation presents", "left flank pain migrating", "groin", "pain", "sharp", "causing", "to", "nausea", "vomiting", "urinary frequency", "vaginal discharge", "complications", "pregnancy", "far", "abdominal exam", "left lower quadrant tenderness to palpation", "pain radiating", "left groin", "guarding", "tenderness", "palpation", "left", "Blood", "visible", "inspection", "perineal area", "Urinalysis", "Urine Color", "Yellow pH", "Specific gravity", "1", "Blood", "3", "Bilirubin", "Negative Glucose", "Negative Ketones", "Negative Protein", "Negative Nitrite", "Negative Leukocyte esterase", "Negative Red blood cells", "cells/ul White blood cells", "75 cells/ul", "following", "next best step"]}
{"question": "A 26-year-old female presents to her primary care physician concerned that she has contracted a sexually transmitted disease. She states that she is having severe pain whenever she urinates and seems to be urinating more frequently than normal. She reports that her symptoms started after she began having unprotected sexual intercourse with 1 partner earlier this week. The physician obtains a urinalysis which demonstrates the following, SG: 1.010, Leukocyte esterase: Positive, Nitrites: Positive, Protein: Trace, pH: 5.0, RBC: Negative. A urease test is performed which is negative. This patient has most likely been infected with which of the following organisms?", "answer": "Escherichia coli", "options": {"A": "Proteus mirabilis", "B": "Klebsiella pneumoniae", "C": "Escherichia coli", "D": "Staphylococcus saprophyticus", "E": "Enterobacter cloacae"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female presents", "primary care physician", "contracted", "sexually transmitted disease", "states", "severe pain", "to", "more frequently", "normal", "reports", "symptoms started", "began", "unprotected sexual intercourse", "earlier", "week", "physician obtains", "urinalysis", "following", "SG", "1", "Leukocyte esterase", "Positive", "Positive", "Protein", "Trace", "pH", "5 0", "Negative", "urease test", "performed", "negative", "patient", "most likely", "infected", "following"]}
{"question": "A 57-year-old woman comes to the emergency department because of severe pain around her right eye, blurred vision in the same eye, and a headache for the past 4 hours. She is nauseous but has not vomited. She can see colored bright circles when she looks at a light source. She is currently being treated for a urinary tract infection with trimethoprim-sulfamethoxazole. She appears uncomfortable. Vital signs are within normal limits. Examination shows visual acuity of 20/20 in the left eye and counting fingers at 5 feet in the right eye. The right eye shows conjunctival injection and edema of the cornea. The right pupil is dilated and fixed. Intravenous analgesia and antiemetics are administered. Which of the following is the most appropriate next step in management?", "answer": "Perform gonioscopy", "options": {"A": "Perform ultrasound biomicroscopy", "B": "Administer topical atropine", "C": "Perform gonioscopy", "D": "Perform fundoscopy", "E": "Administer topical steroids"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["57 year old woman", "emergency department", "of severe pain", "right eye", "blurred vision", "same eye", "headache", "past", "hours", "nauseous", "not vomited", "see colored bright circles", "looks", "light source", "currently", "treated", "urinary tract infection", "trimethoprim-sulfamethoxazole", "appears", "Vital signs", "normal limits", "visual acuity", "20/20", "left eye", "counting fingers", "5 feet", "right eye", "right eye", "conjunctival injection", "edema", "cornea", "right pupil", "dilated", "fixed", "Intravenous analgesia", "antiemetics", "administered", "following", "most appropriate next step"]}
{"question": "A 48-year-old Caucasian woman presents to her physician for an initial visit. She has no chronic diseases. The past medical history is significant for myomectomy performed 10 years ago for a large uterine fibroid. She had 2 uncomplicated pregnancies and 2 spontaneous vaginal deliveries. Currently, she only takes oral contraceptives. She is a former smoker with a 3-pack-year history. Her last Pap test performed 2 years ago was negative. She had a normal blood glucose measurement 3 years ago. The family history is remarkable for systolic hypertension in her mother and older brother. The blood pressure is 110/80 mm Hg, heart rate is 76/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient is afebrile. The BMI is 32 kg/m2. Her physical examination is unremarkable. Which of the following preventative tests is indicated for this patient at this time?", "answer": "Fasting blood glucose", "options": {"A": "Abdominal ultrasound", "B": "Chest CT", "C": "Pap smear", "D": "Fasting blood glucose", "E": "Colonoscopy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["48 year old", "woman presents", "physician", "initial", "chronic diseases", "past medical history", "significant", "myomectomy performed", "large uterine fibroid", "2 uncomplicated pregnancies", "2 spontaneous vaginal deliveries", "Currently", "only", "oral contraceptives", "former smoker", "history", "last Pap test performed 2 years", "negative", "normal blood glucose measurement 3 years", "family history", "systolic hypertension", "blood pressure", "80 mm Hg", "heart rate", "76 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient", "afebrile", "BMI", "kg/m2", "unremarkable", "following preventative tests", "indicated", "patient", "time"]}
{"question": "An investigator is studying a strain of bacteria that retains a blue color after crystal violet dye and acetone are applied. The bacteria are inoculated in a petri dish containing hypotonic saline. After the addition of an antibiotic, the bacteria swell and rupture. This antibiotic most likely belongs to which of the following classes?", "answer": "Cephalosporin", "options": {"A": "Macrolide", "B": "Cephalosporin", "C": "Fluoroquinolone", "D": "Sulfonamide", "E": "Tetracycline"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "strain", "bacteria", "retains", "blue color", "crystal violet", "acetone", "applied", "bacteria", "inoculated", "petri dish containing hypotonic", "addition", "bacteria swell", "rupture", "likely", "following"]}
{"question": "Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?", "answer": "Uterine fundal massage", "options": {"A": "Discontinuing oxytocin", "B": "Intramuscular carboprost", "C": "Intravenous methylergonovine", "D": "Manual exploration of the uterus", "E": "Uterine fundal massage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Immediately following prolonged delivery of", "placenta", "40 weeks gestation", "year old multiparous woman", "vaginal bleeding", "mild asthma", "patients pregnancy", "uncomplicated", "attended", "prenatal appointments", "followed", "physician's", "screening", "diseases", "laboratory testing", "diet", "exercise", "Previous pregnancies", "uncomplicated", "history", "serious illness", "currently", "intravenous infusion", "oxytocin", "temperature", "99", "blood pressure", "60 mm Hg", "pulse", "88 min", "respirations", "min", "Uterine palpation reveals", "soft enlarged fundus", "extends", "umbilicus", "Based", "birth canal", "placenta", "following options", "most appropriate initial step", "patient"]}
{"question": "A 17-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. Examination shows normal breast development. Pubic hair is coarse and extends to the inner surface of the thighs. Pelvic examination shows a blind vaginal pouch. Ultrasonography shows ovaries, but no uterus. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Müllerian duct agenesis", "options": {"A": "17-alpha-hydroxylase enzyme deficiency", "B": "Müllerian duct agenesis", "C": "Androgen insensitivity", "D": "Pure gonadal dysgenesis", "E": "Failure of Müllerian duct recanalization\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "not", "menstrual period", "personal", "family history", "serious illness", "normal", "Pubic hair", "coarse", "extends", "inner surface of", "thighs", "Pelvic examination", "blind vaginal pouch", "Ultrasonography", "ovaries", "uterus", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 32-year-old man comes to the emergency department because of abdominal pain, a runny nose, and chills for 6 hours. He has also had diarrhea and difficulty sleeping. He appears irritable. His temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/90 mm Hg. Examination shows cool, damp skin with piloerection. The pupils are 7 mm in diameter and equal in size. Cardiopulmonary examination shows no abnormalities. The abdomen is tender to palpation. Bowel sounds are hyperactive. Deep tendon reflexes are 3+ bilaterally. Withdrawal from which of the following substances is the most likely cause of this patient's symptoms?", "answer": "Heroin", "options": {"A": "Gamma-hydroxybutyric acid", "B": "Barbiturates", "C": "Cannabis", "D": "Phencyclidine", "E": "Heroin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "emergency department", "abdominal pain", "runny nose", "chills", "hours", "diarrhea", "difficulty sleeping", "appears irritable", "temperature", "98", "pulse", "min", "blood pressure", "90 mm Hg", "cool", "damp skin", "piloerection", "pupils", "7 mm", "diameter", "equal", "size", "Cardiopulmonary", "abnormalities", "abdomen", "tender", "palpation", "Bowel sounds", "hyperactive", "Deep tendon reflexes", "3", "Withdrawal", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 34-year-old G3P2 undergoes colposcopy at 15 weeks gestation due to high-grade intraepithelial lesion detected on a Pap smear. She has no history of the gynecologic disease and had normal Pap smear results prior to the current pregnancy. The pelvic examination does not reveal any cervical lesions. Colposcopy shows a non-deformed cervix with a well-visualized transformation zone. Application of acetic acid reveals an area of acetowhite epithelium 2 cm in the largest diameter located at 6 o’clock with sharp irregular borders. A punch biopsy shows irregularly shaped tongues of pleomorphic squamous epithelium cells invading the stroma to a depth of 2 mm. Which of the following describes the proper management strategy for this patient?", "answer": "Perform a diagnostic conization", "options": {"A": "Perform a diagnostic conization", "B": "Terminate the pregnancy and perform a radical hysterectomy", "C": "Observe until 34 weeks of pregnancy", "D": "Perform radical trachelectomy", "E": "Schedule a diagnostic lymphadenectomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "colposcopy", "weeks gestation", "high-grade intraepithelial lesion detected", "a Pap smear", "history of", "gynecologic disease", "normal Pap smear results prior to", "current pregnancy", "pelvic examination", "not reveal", "cervical lesions", "Colposcopy", "non deformed cervix", "well visualized transformation zone", "Application", "acetic acid reveals", "area", "epithelium 2", "largest diameter", "sharp irregular borders", "punch biopsy", "shaped tongues of pleomorphic squamous epithelium cells", "stroma", "depth", "mm", "following", "patient"]}
{"question": "A 24-year-old G1P0 presents to her obstetrician at 26 weeks’ gestation complaining of worsening headaches and blurry vision. Her past medical history is notable for hypertension and diabetes mellitus. Her temperature is 98.6°F (37°C), blood pressure is 160/95 mmHg, pulse is 100/min, and respirations are 18/min. On physical exam, she is tender to palpation in her abdomen and has mild edema in her extremities. A urine dipstick demonstrates 3+ protein. The patient is immediately started on IV magnesium sulfate, diazepam, and a medication that affects both a- and ß-adrenergic receptors. Which of the following medications is most consistent with this mechanism of action?", "answer": "Labetalol", "options": {"A": "Labetalol", "B": "Propranolol", "C": "Metoprolol", "D": "Esmolol", "E": "Pindolol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "presents", "obstetrician", "weeks gestation", "of worsening headaches", "blurry vision", "past medical history", "notable", "hypertension", "diabetes mellitus", "temperature", "98", "blood pressure", "95 mmHg", "pulse", "100 min", "respirations", "min", "tender", "palpation", "abdomen", "mild edema", "extremities", "urine dipstick", "3", "protein", "patient", "immediately started", "IV magnesium sulfate", "diazepam", "medication", "adrenergic receptors", "following medications", "most", "mechanism of action"]}
{"question": "A 24-year-old woman complains of intermittent fever and joint pain. She says that these symptoms have been present for the past month. Before that, she had no signs or symptoms and was completely healthy. She has also lost her appetite and some weight. A complete blood count (CBC) showed severe pancytopenia. What is the next best step in evaluating this patient?", "answer": "Bone marrow examination", "options": {"A": "Bone marrow examination", "B": "Treatment with antibiotics", "C": "Repeated CBCs for several weeks and reassess", "D": "Treatment with corticosteroids", "E": "Treatment for acute leukemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "intermittent fever", "joint pain", "symptoms", "present", "past month", "signs", "symptoms", "completely healthy", "lost", "appetite", "weight", "complete blood count", "CBC", "severe pancytopenia", "next best step", "patient"]}
{"question": "An 8-year-old boy presents to the emergency department with puffy eyes. The patient’s parents noticed that his eyes were very puffy this morning thus prompting his presentation. They state their son has always been very healthy and other than a rash acquired from wrestling treated with a topical antibiotic has been very healthy. His temperature is 98.3°F (36.8°C), blood pressure is 125/85 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 99% on room air. Physical exam is notable for periorbital edema but is otherwise unremarkable. Urinalysis is notable for red blood cells and an amber urine sample. Which of the following is the most likely etiology of this patient’s symptoms?", "answer": "Deposition of circulating immune complexes", "options": {"A": "Autoimmune type IV collagen destruction", "B": "Deposition of circulating immune complexes", "C": "IgA-mediated vasculitis", "D": "IgE-mediated degranulation", "E": "Increased glomerular permeability to protein only"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "emergency department", "puffy eyes", "patients", "eyes", "very puffy", "morning", "prompting", "state", "always", "very healthy", "other", "rash acquired", "treated with", "topical", "very healthy", "temperature", "98", "36", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "periorbital edema", "unremarkable", "Urinalysis", "notable", "red blood cells", "amber urine sample", "following", "etiology", "patients symptoms"]}
{"question": "A 29-year-old woman, gravida 1, para 0, at 38 weeks' gestation comes to the emergency department for sudden leakage of clear fluid from her vagina. Her pregnancy has been uncomplicated. She has largely been compliant with her prenatal care but missed some appointments. She has a history of chronic hypertension. She drinks a glass of wine once per week. Current medications include labetalol, iron, and vitamin supplements. Her temperature is 37.9°C (100.2°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Examination shows a soft and nontender abdomen on palpation. Speculum examination demonstrates clear fluid in the cervical canal. The fetal heart rate is reactive at 170/min with no decelerations. Tocometry shows no contractions. The vaginal fluid demonstrates a ferning pattern when placed onto a glass slide. Which of the following is the most likely cause of this patient's condition?", "answer": "Ascending infection", "options": {"A": "Ascending infection", "B": "Sexual intercourse during third trimester", "C": "β-blocker use", "D": "Alcohol use", "E": "Oligohydramnios"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old woman", "gravida 1", "para 0", "weeks", "gestation", "emergency department", "sudden leakage", "clear fluid", "vagina", "pregnancy", "uncomplicated", "compliant", "missed", "appointments", "history of chronic hypertension", "glass", "week", "Current medications include labetalol", "iron", "temperature", "100", "pulse", "70 min", "respirations", "min", "blood pressure", "mm Hg", "soft", "nontender abdomen", "palpation", "Speculum", "cervical canal", "fetal heart rate", "reactive", "min", "contractions", "vaginal fluid", "ferning pattern", "glass slide", "following", "most likely cause", "patient's condition"]}
{"question": "A previously healthy 44-year-old man comes to his physician because of frequent urination and increased thirst for several weeks. Physical examination shows darkened skin and a firm mass in the right upper quadrant. His blood glucose is 220 mg/dL. A photomicrograph of a specimen obtained on liver biopsy is shown. Which of the following best describes the pathogenesis of the disease process in this patient?", "answer": "Defective transferrin receptor binding", "options": {"A": "Upregulation of erythropoietin production", "B": "Absence of β-globin synthesis", "C": "Absence of a serine protease inhibitor", "D": "Defective transferrin receptor binding", "E": "Defective serum copper transportation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old man", "physician", "frequent urination", "increased thirst", "weeks", "darkened skin", "firm mass", "right upper quadrant", "blood glucose", "mg/dL", "photomicrograph", "obtained", "liver biopsy", "following best", "pathogenesis", "disease process", "patient"]}
{"question": "A 65-year-old woman comes to the clinic for an annual well-check. Her past medical history includes diabetes and hypertension, which are well-controlled with metformin and losartan, respectively. The patient reports a healthy diet consisting of mainly vegetables and lean meat. She denies smoking or alcohol use. She enjoys taking walks with her husband and sunbathing. Physical examination is unremarkable expect for a rough, scaly, sand paper-like plaque on her left dorsal hand with no tenderness or pain. What is the most likely diagnosis?", "answer": "Actinic keratosis", "options": {"A": "Actinic keratosis", "B": "Psoriasis", "C": "Rosacea", "D": "Seborrheic keratosis", "E": "Sunburn"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old woman", "clinic", "annual well check", "past medical history includes diabetes", "hypertension", "well-controlled", "metformin", "losartan", "patient reports", "healthy diet consisting", "smoking", "walks", "unremarkable", "scaly", "like plaque", "left dorsal hand", "tenderness", "pain", "diagnosis"]}
{"question": "A 65-year-old man comes to the physician for a routine health maintenance examination. He feels well. His most recent examination 2 years ago included purified protein derivative (PPD) skin testing and showed no abnormalities. He is a retired physician and recently came back from rural China where he completed a voluntary service at a local healthcare center. A PPD skin test is performed. Three days later, an induration of 12 mm is noted. An x-ray of the chest shows no abnormalities. He is started on a drug that inhibits the synthesis of mycolic acid. This patient is at greatest risk of developing which of the following adverse effects?", "answer": "Liver injury", "options": {"A": "Optic neuropathy", "B": "Liver injury", "C": "Hyperuricemia", "D": "Cytochrome P-450 induction", "E": "Nephrotoxicity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old man", "physician", "routine", "well", "most recent", "years", "included purified protein derivative", "skin testing", "abnormalities", "retired physician", "recently", "back", "rural China", "completed", "local", "center", "PPD skin test", "performed", "Three days later", "induration", "mm", "noted", "x-ray of", "chest", "abnormalities", "inhibits", "patient", "greatest", "following adverse effects"]}
{"question": "A 21-year-old gravida 1 presents to her physician’s office for an antepartum visit at 11 weeks gestation. She has complaints of malaise, occasional nausea, and changes in food preferences. Her vital signs include: blood pressure 100/70 mm Hg, heart rate 90/min, respiratory rate 14/min, and temperature 36.8℃ (98.2℉). Examination reveals a systolic ejection murmur along the left sternal border. There are no changes in skin color, nails, or hair growth. No neck enlargement is noted. Blood analysis shows the following:\nErythrocyte count 3.5 million/mm3\nHb 11.9 g/dL\nHCT 35%\nReticulocyte count 0.2%\nMCV 85 fL\nPlatelet count 21,0000/mm3\nLeukocyte count 7800/mm3\nSerum iron 17 µmol/L\nFerritin 120 µg/L\nWhat is the most likely cause of the changes in the patient’s blood count?", "answer": "Increase in plasma volume", "options": {"A": "Decreased iron transport across the intestinal wall", "B": "Increase in plasma volume", "C": "Failure of synthesis of a D-aminolevulinic acid", "D": "Insufficient iron intake", "E": "Failure of purine and thymidylate synthesis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["21-year-old gravida 1 presents", "physicians office", "antepartum", "weeks gestation", "complaints", "malaise", "occasional nausea", "changes", "food preferences", "vital signs include", "blood pressure 100 70 mm Hg", "heart rate 90 min", "respiratory rate", "min", "temperature 36", "98", "reveals", "systolic ejection murmur", "left sternal border", "changes in skin color", "nails", "hair growth", "neck enlargement", "noted", "Blood analysis", "following", "Erythrocyte count", "million mm3 Hb", "g", "HCT 35", "0", "MCV 85 fL Platelet count 21", "mm3 Leukocyte count", "Serum iron 17 mol/L Ferritin", "g", "most likely cause", "changes", "patients blood count"]}
{"question": "The study is performed in an attempt to determine whether there is an association between maternal exposure to 2nd-hand smoke and low birth weight. A total of 1,000 women who have given birth to at least 1 child are placed into 1 of 2 groups according to the birth weight of their 1st child. Each group includes 500 women whose 1st child either weighed < 2,500 g (5.5 lb) or > 2,500 g (5.5 lb). In the 1st group, 250 subjects admitted to living with or being in close proximity to a smoker. In the 2nd group, 50 subjects admitted to living with or being in close proximity to a smoker. Which of the following is the strongest measure of association that can be calculated from this study?", "answer": "Odds ratio", "options": {"A": "Odds ratio", "B": "Relative risk", "C": "Rate ratio", "D": "Absolute risk", "E": "Risk difference"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["study", "performed", "to", "association", "maternal exposure", "2nd hand smoke", "low birth weight", "total", "given birth", "child", "birth weight of", "1st child", "group includes 500", "1st child either", "500", "500", "1st group", "subjects", "living", "close proximity", "smoker", "2nd group", "50 subjects", "living", "close proximity", "smoker", "following", "strongest measure", "association", "calculated", "study"]}
{"question": "A 50-year-old woman is brought to the emergency department following a motor vehicle accident. She is awake but slow to respond. Her breath smells of alcohol. The emergency medical technician reports that her blood pressure has been dropping despite intravenous fluids. Ultrasound reveals a hypoechoic rim around the spleen, suspicious for a splenic laceration. The patient is brought into the operating room for abdominal exploration and a splenic embolization is performed. Since arriving to the hospital, the patient has received 8 units of packed red blood cells and 2 units of fresh frozen plasma. She is stabilized and admitted for observation. The next morning on rounds, the patient complains of numbness and tingling of her mouth and cramping of her hands. Her temperature is 99°F (37.2°C), blood pressure is 110/69 mmHg, and pulse is 93/min. On physical examination, her abdomen is mildly tender without distention. The surgical wound is clean, dry, and intact. Jugular venous pressure is normal. Periodic spasms of the muscles of her bilateral upper and lower extremities can be seen and tapping of the facial nerve elicits twitching of he facial muscles. Which of the following is most likely to improve the patient’s symptoms?", "answer": "Calcium gluconate", "options": {"A": "Calcium gluconate", "B": "Dextrose", "C": "Lorazepam", "D": "Thiamine", "E": "Sodium bicarbonate"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["50 year old woman", "brought", "emergency department following", "motor vehicle accident", "awake", "slow to", "breath smells of alcohol", "emergency medical technician reports", "blood pressure", "Ultrasound reveals", "rim", "spleen", "suspicious", "splenic laceration", "patient", "brought", "operating room", "abdominal exploration", "splenic embolization", "performed", "Since", "hospital", "patient", "received", "units", "packed red blood cells", "2 units", "fresh frozen plasma", "stabilized", "admitted for observation", "next", "patient", "numbness", "tingling", "mouth", "cramping", "hands", "temperature", "blood pressure", "69 mmHg", "pulse", "min", "abdomen", "mildly tender", "distention", "surgical wound", "dry", "intact", "Jugular venous pressure", "normal", "Periodic spasms of", "muscles", "bilateral upper", "lower extremities", "seen", "facial nerve elicits twitching of", "facial muscles", "following", "to", "patients symptoms"]}
{"question": "A 72-year-old man presents to the ED complaining of worsening abdominal pain over the last few hours. He also reports nausea, but denies fever, vomiting, or changes in the appearance of his bowel movements. His medical history is significant for type 2 diabetes mellitus, hypertension, coronary artery disease, stroke, atrial fibrillation, and peptic ulcer disease. Due to his recurrent bleeding peptic ulcers, he does not take warfarin. His surgical history is significant for an appendectomy as a child. His medications include metformin, lisinopril, metoprolol, and omeprazole. He has a 50-pack-year history of smoking. His temperature is 37.6 C (99.7 F), blood pressure is 146/80 mm Hg, pulse is 115/min, and respiratory rate is 20/min. On physical exam, he is in acute distress due to the pain. Pulmonary auscultation reveals scattered wheezes and decreased air entry. His heart rate is irregularly irregular, with no murmurs, rubs or gallops. Abdominal exam is significant for decreased bowel sounds and diffuse tenderness. Initial laboratory evaluation is as follows:\nNa 138 mEq/L, Cl 101 mEq/L, HCO3 12 mEq/L, BUN 21 mg/dL, Cr 0.9 mg/dL, glucose 190 mg/dL, amylase 240 U/L (normal < 65 U/L).\nWhat is the most likely diagnosis in this patient?", "answer": "Acute mesenteric ischemia", "options": {"A": "Peptic ulcer perforation", "B": "Acute cholecystitis", "C": "Acute mesenteric ischemia", "D": "Diabetic ketoacidosis", "E": "Acute pancreatitis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "worsening abdominal", "last", "hours", "reports nausea", "fever", "vomiting", "changes in", "appearance", "bowel movements", "medical history", "significant", "type 2 diabetes mellitus", "hypertension", "coronary artery disease", "stroke", "atrial fibrillation", "peptic ulcer disease", "recurrent bleeding peptic ulcers", "not", "warfarin", "surgical history", "significant", "appendectomy", "child", "medications include metformin", "lisinopril", "metoprolol", "omeprazole", "50", "history of smoking", "temperature", "99", "F", "blood pressure", "80 mm Hg", "pulse", "min", "respiratory rate", "20 min", "acute distress", "pain", "Pulmonary auscultation reveals scattered wheezes", "decreased air entry", "heart rate", "irregular", "murmurs", "rubs", "Abdominal exam", "significant", "decreased bowel sounds", "diffuse tenderness", "Initial laboratory evaluation", "follows", "Na", "mEq/L", "mEq/L", "HCO3", "mEq/L", "mg/dL", "Cr 0.9 mg/dL", "glucose", "mg/dL", "amylase", "U/L", "normal", "65 U/L", "diagnosis", "patient"]}
{"question": "A 72-year-old multiparous woman comes to the physician for the evaluation of episodes of involuntary urine leakage for the past 6 months. She loses small amounts of urine without warning after laughing or sneezing. She also sometimes forgets the names of her grandchildren and friends. She is retired and lives at an assisted-living facility. She has insulin-dependent diabetes mellitus type 2. Her mother received a ventriculoperitoneal shunt around her age. She walks without any problems. Sensation to pinprick and light touch is normal. Which of the following is the primary underlying etiology for this patient's urinary incontinence?", "answer": "Urethral hypermobility", "options": {"A": "Detrusor-sphincter dyssynergia", "B": "Urethral hypermobility", "C": "Decreased cerebrospinal fluid absorption", "D": "Impaired detrusor contractility", "E": "Loss of sphincter control"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old multiparous woman", "physician", "of episodes", "urine leakage", "past 6 months", "small amounts", "urine", "sneezing", "sometimes forgets", "names", "retired", "lives", "assisted-living facility", "insulin-dependent diabetes mellitus type 2", "received", "ventriculoperitoneal shunt", "age", "walks", "Sensation", "pinprick", "light touch", "normal", "following", "primary underlying etiology", "patient's urinary incontinence"]}
{"question": "A 45-year-old woman presents to the office complaining of fatigue and unintentional weight loss. On examination, there is a palpable firm lymph node in the cervical area. Biopsy of the lymph node reveals Hodgkin’s lymphoma. The patient agrees to start the standard chemotherapy regimen. A few months later, after the completion of 3 successful courses, the patient presents with a dry cough and progressively worsening shortness of breath. Her temperature is 37°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 72/min, and the respirations are 16/min. Pulse oximetry shows an O2 saturation of 94% on room air. On spirometry, the patient's FEV1/FVC ratio is normal. Chest CT reveals bilateral diffuse cystic airspaces in middle and lower lung fields. Which of the following is the most likely cause of this patient’s current symptoms?", "answer": "Drug-induced interstitial lung disease", "options": {"A": "Drug-induced interstitial lung disease", "B": "Metastatic spread to the lungs", "C": "Development of chronic obstructive pulmonary disease", "D": "Transfusion-related acute lung injury", "E": "Development of bacterial pneumonia due to immunocompromised state"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "office", "fatigue", "unintentional weight loss", "palpable firm lymph node", "cervical area", "Biopsy of", "reveals Hodgkins lymphoma", "patient agrees to start", "standard chemotherapy regimen", "few months later", "completion", "successful courses", "patient presents", "dry cough", "worsening shortness of breath", "temperature", "98", "blood pressure", "70 mm Hg", "pulse", "72 min", "respirations", "min", "Pulse oximetry", "O2 saturation", "room air", "spirometry", "patient's FEV1/FVC ratio", "normal", "Chest reveals bilateral diffuse cystic", "middle", "lower lung fields", "following", "most likely cause", "patients current symptoms"]}
{"question": "A 47-year-old woman comes to the emergency department after coughing up 2 cups of bright red blood. A CT angiogram of the chest shows active extravasation from the right bronchial artery. A coil embolization is planned to stop the bleeding. During this procedure, a catheter is first inserted into the right femoral artery. Which of the following represents the correct subsequent order of the catheter route?", "answer": "Thoracic aorta, right posterior intercostal artery, right bronchial artery", "options": {"A": "Thoracic aorta, brachiocephalic trunk, right subclavian artery, right internal thoracic artery, right bronchial artery", "B": "Thoracic aorta, right subclavian artery, right internal thoracic artery, right bronchial artery", "C": "Thoracic aorta, right posterior intercostal artery, right bronchial artery", "D": "Thoracic aorta, right superior epigastric artery, right bronchial artery", "E": "Thoracic aorta, left ventricle, left atrium, pulmonary artery, right bronchial artery"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "emergency department", "coughing up", "cups", "bright red blood", "CT angiogram of", "chest", "active extravasation", "right bronchial artery", "coil embolization", "planned to stop", "bleeding", "procedure", "catheter", "first", "right femoral artery", "following", "correct subsequent order", "catheter route"]}
{"question": "A 53-year-old farmer presents to the clinic for evaluation of a pigmented lesion on his arm. He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size. He otherwise does not have any complaints and is generally healthy. Which of the following findings on physical exam would suggest a malignant diagnosis?", "answer": "Different pigmentation throughout the lesion", "options": {"A": "Different pigmentation throughout the lesion", "B": "Flat lesion with symmetric hyperpigmentation", "C": "Hyperpigmented lesion with smooth borders", "D": "Symmetrical ovoid lesion", "E": "Tenderness to palpation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old farmer presents", "clinic", "pigmented lesion", "arm", "states", "first", "lesion", "year", "slowly", "size", "not", "complaints", "healthy", "following findings", "malignant diagnosis"]}
{"question": "A 72-year-old man comes to the physician because of fatigue and a 5-kg (11-lb) weight loss over the past 6 months despite a good appetite. He takes no medications. He does not smoke or use illicit drugs. Physical examination shows hepatosplenomegaly and diffuse, nontender lymphadenopathy. Laboratory studies show a hemoglobin concentration of 11 g/dL and a leukocyte count of 16,000/mm3. A direct antiglobulin (Coombs) test is positive. A photomicrograph of a peripheral blood smear is shown. Which of the following is the most likely diagnosis?", "answer": "Chronic lymphocytic leukemia", "options": {"A": "Chronic myelogenous leukemia", "B": "Acute myelogenous leukemia", "C": "Follicular lymphoma", "D": "Chronic lymphocytic leukemia", "E": "Hemophagocytic lymphohistiocytosis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old man", "physician", "fatigue", "5 kg", "weight loss", "past 6 months", "good appetite", "medications", "not smoke", "use illicit", "hepatosplenomegaly", "diffuse", "nontender lymphadenopathy", "Laboratory studies", "a hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "direct antiglobulin", "Coombs", "test", "positive", "photomicrograph", "peripheral blood smear", "following", "diagnosis"]}
{"question": "A 15-year-old adolescent presents to his pediatrician with progressive easy fatigability and exercises intolerance over the last several months. The patient was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. There is no history of palpitation, dyspnea, or lower limb edema. On physical examination his vital signs are stable. On chest auscultation, a wide fixed split in the second heart sound is detected. A medium-pitched systolic ejection murmur is present which is best heard at the left middle and upper sternal border. A short mid-diastolic rumble is also audible over the lower left sternal border, which is best heard with the bell of the stethoscope. Which of the following findings is most likely to be present on this patient’s echocardiogram?", "answer": "Anterior movement of ventricular septum during systole", "options": {"A": "Decreased right ventricular end-diastolic dimension", "B": "Anterior movement of ventricular septum during systole", "C": "Goose-neck deformity of left ventricular outflow tract", "D": "Increased left ventricular shortening fraction", "E": "Displacement of tricuspid valve leaflets inferiorly into right ventricle"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old adolescent presents", "pediatrician", "progressive easy fatigability", "exercises intolerance", "months", "patient", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "history", "palpitation", "dyspnea", "lower limb edema", "vital signs", "stable", "chest auscultation", "wide fixed split", "second heart sound", "detected", "medium-pitched systolic ejection murmur", "present", "best heard", "left middle", "upper sternal border", "short", "diastolic rumble", "lower left sternal border", "best heard", "bell", "stethoscope", "following findings", "to", "present", "patients echocardiogram"]}
{"question": "A one-week-old boy is brought to the emergency department by his mother, who recently immigrated to the United States and does not have health insurance. He was born at home, and has not received any medical care since birth. The mother states the boy has become irritable and has been feeding poorly. In the last day, she said he seems \"stiff\" and is having apparent muscle spasms. On your exam, you note the findings in figure A. Which of the following interventions might have prevented this disease?", "answer": "Toxoid vaccine given to mother pre-natally", "options": {"A": "Conjugated polysaccharide vaccine given to infant at birth", "B": "Toxoid vaccine given to mother pre-natally", "C": "Vitamin injection given to newborn at birth", "D": "Improved maternal nutrition", "E": "Genetic counseling"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["one-week old boy", "brought", "emergency department", "recently", "United States", "not", "born at home", "not received", "medical care", "birth", "states", "boy", "irritable", "poorly", "last day", "stiff", "muscle spasms", "exam", "note", "findings", "following interventions", "prevented", "disease"]}
{"question": "Given the mRNA sequence shown below, if translation were to start at the first base, what would the tRNA anticodon be for the last amino acid translated in the chain?\n5'----GCACCGGCCUGACUAUAA---3'", "answer": "3' CGG 5'", "options": {"A": "3' GCG 5'", "B": "3' CGC 5'", "C": "3' GAU 5'", "D": "5' CGG 3'", "E": "3' CGG 5'"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["Given", "mRNA sequence", "to start", "first base", "tRNA anticodon", "last amino acid", "chain", "5", "3"]}
{"question": "A 7-year-old boy is brought to a new pediatrician to establish care. He presents with a history of extensive eczema, recurrent respiratory, skin, and gastrointestinal infections, and significant thrombocytopenia. 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. Given this classic grouping of clinical symptoms in a patient of this age, which of the following represents the most likely underlying medical condition?", "answer": "Wiskott-Aldrich syndrome", "options": {"A": "Wiskott-Aldrich syndrome", "B": "Ataxia-telangiectasia", "C": "Severe combined immunodeficiency syndrome", "D": "Chediak-Higashi syndrome", "E": "Hyper-IgE disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "new pediatrician to establish", "presents", "history of extensive eczema", "recurrent respiratory", "skin", "gastrointestinal infections", "significant thrombocytopenia", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "Given", "classic grouping", "clinical symptoms", "patient", "age", "following", "most likely", "medical condition"]}
{"question": "A 9-year-old boy is brought to the physician by his mother for evaluation of diffuse bone pain in his right leg. His family immigrated to the United States 6 months ago from northern Canada. He is below the 5th percentile for height and at the 10th percentile for weight. Physical examination shows tenderness to palpation of the right distal femur. There is hepatosplenomegaly. An x-ray of right femur shows generalized trabecular thinning and several osteolytic bone lesions. Laboratory studies show:\nHemoglobin 9.2 g/dL\nLeukocyte count 7,600/mm3\nPlatelets 71,000/mm3\nA bone marrow aspirate shows mononuclear cells filled with lipid that appear like wrinkled silk. Deficiency of which of the following enzymes is the most likely cause of this patient's symptoms?\"", "answer": "Glucocerebrosidase", "options": {"A": "Sphingomyelinase", "B": "α-Galactosidase A", "C": "Arylsulfatase A", "D": "Galactocerebrosidase", "E": "Glucocerebrosidase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "evaluation", "diffuse bone", "right leg", "United States", "months", "northern Canada", "5th percentile", "height", "percentile", "weight", "tenderness", "palpation", "right distal femur", "hepatosplenomegaly", "x-ray of right femur", "generalized trabecular thinning", "several osteolytic bone lesions", "Laboratory studies", "Hemoglobin", "g Leukocyte count 7 600 mm3 Platelets", "bone marrow aspirate", "lipid", "appear", "wrinkled silk", "Deficiency", "following enzymes", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 55-year-old man comes to the physician because of intermittent palpitations that occur when he is stressed, exercising, or when he drinks alcohol. Physical examination shows an irregularly irregular pulse. An ECG shows irregular QRS complexes without any discrete P waves. Pharmacotherapy with carvedilol is initiated for his condition. Compared to treatment with propranolol, which of the following adverse effects is most likely?", "answer": "Hypotension", "options": {"A": "Hyperkalemia", "B": "Hypotension", "C": "Bradycardia", "D": "Hyperglycemia", "E": "Bronchospasm"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "intermittent palpitations", "occur", "stressed", "exercising", "alcohol", "irregular pulse", "ECG", "irregular QRS complexes", "discrete P waves", "Pharmacotherapy", "carvedilol", "initiated", "condition", "treatment", "propranolol", "following adverse effects"]}
{"question": "When hepatitis D was injected into an immunocompromised mouse, there was no detectable hepatitis D RNA in the blood at any time point during the next several months. When co-injected with hepatitis B, hepatitis D RNA was was detected in the blood. Which of the following best describes this phenomenon?", "answer": "Complementation", "options": {"A": "Recombination", "B": "Reassortment", "C": "Complementation", "D": "Phenotypic mixing", "E": "Transduction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["hepatitis D", "injected", "immunocompromised", "detectable hepatitis D RNA", "blood", "time point", "next", "months", "co injected", "hepatitis B", "hepatitis D RNA", "detected", "blood", "following best"]}
{"question": "A 33-year-old woman comes to the physician because of a 4-day history of fever, anterior neck pain, and throat swelling. She has no history of serious illness. Her temperature is 38.1°C (100.6°F) and pulse is 109/min. Physical examination shows diaphoresis and a fine tremor of the outstretched hands. The thyroid gland is enlarged, firm, and tender to palpation. Serum thyroid stimulating hormone level is 0.06 μU/mL and erythrocyte sedimentation rate is 65 mm/h. 123I scan shows an enlarged thyroid gland with diffusely decreased uptake. Histologic examination of a thyroid biopsy specimen is most likely to show which of the following findings?", "answer": "Noncaseating granulomas with multinucleated giant cells", "options": {"A": "Follicular epithelial cell hyperplasia", "B": "Undifferentiated giant cells with areas of necrosis and hemorrhage", "C": "Concentric intracellular lamellar calcifications", "D": "Lymphocytic infiltration with germinal follicle formation", "E": "Noncaseating granulomas with multinucleated giant cells"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "4-day history", "fever", "anterior neck pain", "throat swelling", "history", "serious illness", "temperature", "100", "pulse", "min", "diaphoresis", "fine tremor of", "hands", "thyroid gland", "enlarged", "firm", "tender", "palpation", "Serum thyroid stimulating hormone level", "0.06 U/mL", "erythrocyte sedimentation rate", "65 mm/h", "scan", "enlarged thyroid gland", "decreased uptake", "Histologic", "biopsy", "to", "following findings"]}
{"question": " A 43-year-old woman was admitted to the hospital for anticoagulation following a pulmonary embolism. She was found to have a deep venous thrombosis on further workup after a long plane ride coming back from visiting China. She denies any personal 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. Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and she currently denies any illicit drug use. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 111/min, and respiratory rate 23/min. On physical examination, her pulses are bounding and complexion is pale, but breath sounds remain clear. Oxygen saturation was initially 81% on room air, with a new oxygen requirement of 8 L by face mask. On day 6 of combined heparin and warfarin anticoagulation, her platelet count decreases from 182,000/mcL to 63,000/mcL. Her international normalized ratio (INR) is not yet therapeutic. What is the next best step in therapy?", "answer": "Discontinue heparin and warfarin", "options": {"A": "Continue heparin and warfarin until INR is therapeutic for 24 hours", "B": "Discontinue heparin; continue warfarin", "C": "Continue heparin; discontinue warfarin", "D": "Discontinue heparin and warfarin", "E": "Continue heparin and warfarin, and administer vitamin K"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "anticoagulation following", "pulmonary embolism", "found to", "deep venous thrombosis", "further workup", "long plane", "back", "China", "personal history", "blood clots", "past", "to", "treated", "pulmonary embolism", "recent past", "past medical history", "significant", "preeclampsia", "hypertension", "polycystic ovarian syndrome", "hypercholesterolemia", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "currently", "illicit drug use", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate", "min", "respiratory rate 23 min", "pulses", "bounding", "complexion", "pale", "breath sounds", "clear", "Oxygen saturation", "initially 81", "room air", "new oxygen requirement", "face mask", "day 6", "combined heparin", "warfarin anticoagulation", "platelet count decreases", "mcL", "63", "mcL", "international normalized ratio", "not", "therapeutic", "next best step", "therapy"]}
{"question": "A 68-year-old woman is brought to the emergency department by ambulance after she was found down by her daughter. She lives alone in her apartment so it is unclear when she began to develop symptoms. Her medical history is significant for cardiac arrhythmias, diabetes, pericarditis, and a stroke 2 years ago. On presentation her temperature is 98.1°F (36.7°C), blood pressure is 88/51 mmHg, pulse is 137/min, and respirations are 18/min. On physical exam her skin is cold and clammy. If special tests were obtained, they would reveal dramatically decreased pulmonary capillary wedge pressure, increased systemic vascular resistance, and mildly decreased cardiac output. Which of the following treatments would most directly target the cause of this patient's low blood pressure?", "answer": "Intravenous fluids", "options": {"A": "Antibiotic administration", "B": "Intravenous fluids", "C": "Intravenous ionotropes", "D": "Relieve obstruction", "E": "Vasopressors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "ambulance", "found", "lives alone", "apartment", "began to", "symptoms", "medical history", "significant", "cardiac arrhythmias", "diabetes", "pericarditis", "stroke", "years", "temperature", "98", "36", "blood pressure", "88", "mmHg", "pulse", "min", "respirations", "min", "skin", "cold", "clammy", "special tests", "obtained", "reveal", "decreased pulmonary capillary wedge pressure", "increased systemic vascular resistance", "mildly decreased cardiac output", "following treatments", "most directly target", "cause", "patient's low blood pressure"]}
{"question": "A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient?", "answer": "A transvaginal ultrasound would provide a better resolution of the suspected pathology, but a transabdominal ultrasound can still be used to assess this patient", "options": {"A": "No imaging is indicated for this patient because the diagnosis can be made on the basis of the clinical examination", "B": "A transvaginal ultrasound would provide a better resolution of the suspected pathology, but a transabdominal ultrasound can still be used to assess this patient", "C": "Increased anterior abdominal wall adiposity does not pose any problems with a full urinary bladder, so a transabdominal ultrasound will provide the same sensitivity as a transvaginal ultrasound", "D": "Transabdominal ultrasound would be better for this patient because it can detect small pelvic masses better than a transvaginal ultrasound", "E": "Pelvic MRI is warranted in this case because transvaginal ultrasound cannot be performed and transabdominal ultrasound is unlikely to provide any diagnostic information"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "gynecologist", "amenorrhea", "occasional dull right-sided lower abdominal pain", "radiates", "rectum", "menarche at", "years", "age", "regular", "day cycles", "years", "age", "menstrual cycle irregularity approximately", "years", "not", "menses", "months", "not sexually active", "not", "medications", "weight", "kg", "height", "5.4 ft", "vital signs", "normal limits", "normal growth pattern", "hair loss", "acne", "noted", "black discoloration of", "skin", "axillae", "posterior neck", "Palpation of", "abdomen reveals slight tenderness", "right lower quadrant", "masses", "reveals", "abnormalities", "hymen", "intact", "rectal examination reveals", "non-tender", "mobile", "right-sided adnexal mass", "following", "best", "patient"]}
{"question": "A 26-year-old man comes to the physician for a follow-up examination. He was diagnosed with HIV infection 2 weeks ago. His CD4+ T-lymphocyte count is 162/mm3 (N ≥ 500). An interferon-gamma release assay is negative. Prophylactic treatment against which of the following pathogens is most appropriate at this time?", "answer": "Pneumocystis jirovecii", "options": {"A": "Aspergillus fumigatus", "B": "Mycobacterium tuberculosis", "C": "Pneumocystis jirovecii", "D": "Toxoplasma gondii", "E": "Cytomegalovirus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "follow-up examination", "diagnosed", "weeks", "CD4", "lymphocyte count", "mm3", "N", "500", "interferon-gamma release assay", "negative", "Prophylactic treatment", "following", "most appropriate", "time"]}
{"question": "A 58-year-old department store manager comes to his doctor’s office complaining that he had recently been waking up in the middle of the night with abdominal pain. This has happened several nights a week in the past month. He has also been experiencing occasional discomfort in the afternoon. The patient's appetite has suffered as a result of the pain he was experiencing. His clothes hang on him loosely. The patient does not take any prescription or over the counter medications. The remainder of the patient’s history and physical exam is completely normal. The doctor refers the patient to a gastroenterologist for a stomach acid test and an upper gastrointestinal endoscopy which revealed that this patient is a heavy acid producer and has a gastric peptic ulcer. This ulcer is most likely found in which part of the stomach?", "answer": "In the pyloric channel within 3 cm of the pylorus", "options": {"A": "In the pyloric channel within 3 cm of the pylorus", "B": "Along the lesser curve at the incisura angularis", "C": "Proximal gastroesophageal ulcer near the gastroesophageal junction", "D": "In the body", "E": "Multiple sites throughout the stomach"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old department store", "doctors office", "recently", "waking up", "middle", "night", "abdominal pain", "nights", "week", "past", "occasional discomfort", "afternoon", "patient's appetite", "suffered", "result", "pain", "clothes hang", "patient", "not", "over the counter medications", "completely normal", "doctor refers", "patient", "gastroenterologist", "stomach acid test", "upper gastrointestinal endoscopy", "revealed", "patient", "heavy acid", "gastric peptic ulcer", "ulcer", "most likely found", "part", "stomach"]}
{"question": "An otherwise healthy 49-year-old man presents to his primary care physician for follow-up for a high HbA1C. 3 months ago, his HbA1c was 8.9% on routine screening. Today, after lifestyle modifications, it is 8.1% and his serum glucose is 270 mg/dL. Which of the following is the best initial therapy for this patient's condition?", "answer": "Metformin", "options": {"A": "Metformin", "B": "Metformin added to basal insulin", "C": "Metformin added to an insulin secretagogue", "D": "Metformin added to a glucagon-like peptide 1 (GLP-1) agonist", "E": "Metformin added to a dipeptidyl peptidase-4 (DPP-4) inhibitor"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old man presents", "primary care physician", "follow-up", "high", "months", "routine screening", "Today", "lifestyle modifications", "8.1", "serum glucose", "mg/dL", "following", "best initial therapy", "patient's"]}
{"question": "A 9-year-old boy is brought to the physician by his parents because of right-sided shoulder pain for 1 day. He has not had chills or sweating. Over the past year, he was treated twice in the emergency department for painful swelling of his hands and feet. He emigrated with his family from Kenya 2 years ago. His temperature is 37.4°C (99.3°F), pulse is 96/min, and blood pressure is 123/82 mm Hg. Physical examination shows no tenderness, erythema, or joint swelling of the shoulder. Laboratory studies show:\nHemoglobin 7 g/dL\nMean corpuscular volume 88 μm\nReticulocyte count 9%\nLeukocyte count 12,000/mm3\nA peripheral blood smear is most likely to show which of the following abnormalities?\"", "answer": "Nuclear remnants in erythrocytes", "options": {"A": "Ring-shaped inclusions in erythrocytes", "B": "Teardrop-shaped erythrocytes", "C": "Nuclear remnants in erythrocytes", "D": "Fragmentation of erythrocytes", "E": "Erythrocytes with no central pallor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "right-sided shoulder pain", "1 day", "not", "chills", "sweating", "past year", "treated twice", "emergency department", "painful swelling of", "hands", "feet", "Kenya", "years", "temperature", "99", "pulse", "96 min", "blood pressure", "mm Hg", "tenderness", "erythema", "joint swelling", "shoulder", "Laboratory studies", "Hemoglobin", "g", "Mean corpuscular volume 88 m Reticulocyte count", "mm3", "peripheral blood smear", "to", "following abnormalities"]}
{"question": "A 60-year-old man with a history of coronary artery disease and hyperlipidemia presents to his internist for a follow-up visit 3 weeks after visiting an urgent care center for symptoms of cough, fever, and difficulty breathing. He had been prescribed erythromycin in addition to his usual regimen of rosuvastatin and aspirin. With which potential side effect or interaction should the internist be most concerned?", "answer": "Myalgia due to decreased rosuvastatin metabolism in the presence of erythromycin", "options": {"A": "Gastric bleeding due to decreased aspirin metabolism in the presence of erythromycin", "B": "Unstable angina due to decreased rosuvastatin metabolism in the presence of erythromycin", "C": "Myalgia due to decreased rosuvastatin metabolism in the presence of erythromycin", "D": "Metabolic acidosis due to decreased aspirin metabolism in the presence of erythromycin", "E": "Tinnitus due to decreased aspirin metabolism in the presence of erythromycin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "history of coronary artery disease", "hyperlipidemia presents", "internist", "follow-up", "3 weeks", "urgent care center", "symptoms", "cough", "fever", "difficulty breathing", "erythromycin in addition to", "usual regimen", "rosuvastatin", "aspirin", "potential side effect", "interaction", "internist", "most"]}
{"question": "A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbeaing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis?", "answer": "Normal behavior", "options": {"A": "Oppositional defiant disorder", "B": "Normal behavior", "C": "Conduct disorder", "D": "Attention deficit hyperactivity disorder", "E": "Antisocial personality disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "pediatrician's office", "issues", "started high school four months", "recent", "earned", "top marks", "middle school", "never talks", "home", "patient", "exam room", "out", "room", "patient", "so", "good days", "begins to chew gum", "states", "hanging out", "girls", "physical abuse", "seen", "smoke marijuana", "football field", "not go near", "smoking cigarettes", "intention to", "others", "teachers", "not as good", "middle school teachers", "states", "best", "videos", "diagnosis"]}
{"question": "A 47-year-old alcoholic man presents to the office for a 72-hour history of intense right hemithorax pain. He also complains of fever, chills, and sweating that started 10 days ago, as well as persistent coughing with abundant malodorous sputum. Chest radiography shows a round consolidation with hydro-aerial levels in the middle third of the right hemithorax. Sputum samples for a direct exam, culture, and bradykinin (BK) are sent. What is the correct diagnosis?", "answer": "Lung abscess", "options": {"A": "Bronchiectasis", "B": "Bronchopulmonary sequestration", "C": "Lung abscess", "D": "Tuberculosis", "E": "Lung cancer"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old alcoholic man presents", "office", "72-hour history", "intense right hemithorax pain", "fever", "chills", "sweating", "started 10 days", "persistent", "abundant", "sputum", "Chest radiography", "round consolidation", "levels", "middle third", "right hemithorax", "Sputum samples", "direct exam", "culture", "bradykinin", "sent", "correct diagnosis"]}
{"question": "A 9-year-old boy is brought to the clinic by his parents for an annual wellness examination. He is a relatively healthy boy who was born at term via vaginal delivery. He is meeting his developmental milestones and growth curves and is up-to-date on his immunizations. The father complains that he is picky with his food and would rather eat pizza. The patient denies any trouble at school, fevers, pain, or other concerns. A physical examination demonstrates a healthy boy with a grade 3 midsystolic ejection murmur at the second intercostal space that does not disappear when he sits up. What is the most likely explanation for this patient’s findings?", "answer": "Defect of the septum secundum", "options": {"A": "Defect of the septum secundum", "B": "Failure of the septum primum to fuse with the endocardial cushions", "C": "Inflammation of the visceral and parietal pericardium", "D": "Physiologic conditions outside the heart", "E": "Prolonged patency of the ductus arteriosus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "clinic", "annual", "boy", "born", "term", "vaginal delivery", "growth curves", "date", "immunizations", "food", "rather eat", "patient", "trouble at school", "fevers", "pain", "healthy boy", "grade 3 midsystolic ejection murmur", "second intercostal space", "not", "sits up", "explanation", "patients findings"]}
{"question": "A 24-year-old woman presents to the emergency department with palpitations for the last hour. This is her 3rd emergency department visit in the last 8 weeks due to the same complaint. She denies fever, shortness of breath, nasal discharge, bowel changes, weight loss, and heat intolerance. She has asthma that is poorly controlled despite regular inhaler use. She drinks a cup of coffee each morning, and she is physically active and jogs for at least 30 minutes daily. She is in a monogamous relationship with her boyfriend and regularly uses barrier contraceptives. Her last menses was 1 week ago. Physical examination reveals: blood pressure 104/70 mm Hg, pulse 194 /min that is regular, and respiratory rate 18/min. Her ECG is shown in the image. A gentle massage over the carotid artery for 5–10 seconds did not terminate her palpitations. What is the most appropriate next step in the management of this patient?", "answer": "Verapamil", "options": {"A": "Adenosine", "B": "Amiodarone", "C": "Digoxin", "D": "Propranolol", "E": "Verapamil"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency department", "palpitations", "hour", "3rd emergency department", "weeks", "same complaint", "fever", "shortness of breath", "nasal discharge", "bowel changes", "weight loss", "heat intolerance", "asthma", "poorly controlled", "regular inhaler use", "cup", "morning", "physically active", "at least 30 minutes daily", "relationship", "uses barrier contraceptives", "last menses", "1 week", "reveals", "blood pressure", "70 mm Hg", "pulse", "min", "regular", "respiratory rate", "min", "ECG", "gentle massage", "carotid artery", "510 seconds", "not terminate", "palpitations", "most appropriate next step", "patient"]}
{"question": "One day after a 4700-g (10-lb 6-oz) male newborn is delivered to a 28-year-old primigravid woman, he has bluish discoloration of his lips and fingernails. Oxygen saturation on room air is 81%. Examination shows central cyanosis. A continuous machine-like murmur is heard over the left upper sternal border. A single S2 heart sound is present. Supplemental oxygen does not improve cyanosis. Echocardiography shows the pulmonary artery arising from the posterior left ventricle and aorta arising from the right ventricle with active blood flow between the right and left ventricles. Further evaluation of the mother is most likely to show which of the following?", "answer": "Elevated fasting blood glucose", "options": {"A": "Prenatal lithium intake", "B": "Elevated serum TSH", "C": "Prenatal phenytoin intake", "D": "Positive rapid plasma reagin test", "E": "Elevated fasting blood glucose"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["One", "One day", "g", "10", "6 oz", "male newborn", "delivered", "year old primigravid woman", "discoloration", "lips", "fingernails", "Oxygen saturation", "room air", "81", "central cyanosis", "continuous machine", "murmur", "heard", "left upper sternal border", "single S2 heart sound", "present", "Supplemental oxygen", "not", "cyanosis", "Echocardiography", "pulmonary artery arising", "posterior left ventricle", "aorta arising", "right", "active blood flow", "right", "left ventricles", "Further", "to", "following"]}
{"question": "A 16-year-old boy with a history of severe, persistent asthma presents to the emergency department with severe shortness of breath and cough. He states that he was outside playing basketball with his friends, forgot to take his inhaler, and began to have severe difficulty breathing. On exam, he is in clear respiratory distress with decreased air movement throughout all lung fields. He is immediately treated with beta-agonists which markedly improve his symptoms. Prior to treatment, which of the following was most likely observed in this patient?", "answer": "Pulsus paradoxus", "options": {"A": "Inspiratory stridor", "B": "Increased breath sounds", "C": "Friction rub", "D": "Kussmaul's sign", "E": "Pulsus paradoxus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "history of severe", "persistent asthma presents", "emergency department", "cough", "states", "outside playing basketball", "forgot to", "inhaler", "began to", "severe difficulty breathing", "exam", "clear respiratory distress", "decreased", "lung fields", "immediately treated with beta agonists", "markedly", "symptoms", "treatment", "following", "most likely observed", "patient"]}
{"question": "A 3670-g (8 lb 1 oz) male newborn is delivered to a 26-year-old primigravid woman. She received adequate prenatal care and labor was uncomplicated. She has chronic hepatitis B infection and gastroesophageal reflux disease. Her only medication is ranitidine. She admits to smoking cannabis and one half-pack of cigarettes daily. She drinks two beers on the weekend. The mother is apprehensive about taking care of her baby and requests for some information regarding breastfeeding. Which of the following is a contraindication to breastfeeding?", "answer": "Cannabis use", "options": {"A": "Ranitidine use", "B": "Hepatitis B infection", "C": "Seropositive for cytomegalovirus", "D": "Cannabis use", "E": "Smoking\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["g", "1 oz", "male newborn", "delivered", "year old primigravid woman", "received adequate", "labor", "uncomplicated", "chronic", "gastroesophageal reflux disease", "only medication", "ranitidine", "one half pack", "cigarettes daily", "two", "weekend", "apprehensive", "breastfeeding", "following", "contraindication", "breastfeeding"]}
{"question": "A 35-year-old male is picked up by paramedics presenting with respiratory depression, pupillary constriction, and seizures. Within a few minutes, the male dies. On autopsy, fresh tracks marks are seen on both arms. Administration of which of the following medications would have been appropriate for this patient?", "answer": "Naloxone", "options": {"A": "Methadone", "B": "Naloxone", "C": "Diazepam", "D": "Flumazenil", "E": "Buproprion"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old male", "paramedics", "respiratory depression", "pupillary constriction", "seizures", "few minutes", "male", "autopsy", "fresh tracks marks", "seen", "arms", "Administration of", "following medications", "appropriate", "patient"]}
{"question": "A 3900-g (8.6-lb) newborn is delivered at 38 week' gestation to a 27-year-old woman, gravida 3, para 2, via spontaneous vaginal delivery. Immediately after delivery, he spontaneously cries, grimaces, and moves all four extremities. Over the next five minutes, he becomes cyanotic, dyspneic, and tachypneic. Mask ventilation with 100% oxygen is begun, but ten minutes after delivery the baby continues to appear cyanotic. His temperature is 37.2°C (99.0°F), pulse is 155/min, respirations are 65/min, and blood pressure is 90/60 mm Hg. Pulse oximetry on 100% oxygen mask ventilation shows an oxygen saturation of 83%. Breath sounds are normal on the right and absent on the left. Heart sounds are best heard in the right midclavicular line. The abdomen appears concave. An x-ray of the chest is shown below. Which of the following is the most appropriate initial step in the management of this patient?", "answer": "Intubation and mechanical ventilation\n\"", "options": {"A": "Extracorporeal life support", "B": "Surfactant administration", "C": "Surgical repair", "D": "Chest tube placement", "E": "Intubation and mechanical ventilation\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["newborn", "delivered", "week", "gestation", "27 year old woman", "gravida 3", "para 2", "spontaneous vaginal delivery", "Immediately", "delivery", "grimaces", "moves", "four extremities", "next five minutes", "cyanotic", "dyspneic", "tachypneic", "Mask ventilation", "100", "oxygen", "begun", "ten minutes", "delivery", "baby", "to appear cyanotic", "temperature", "99", "pulse", "min", "respirations", "65 min", "blood pressure", "90 60 mm Hg", "Pulse oximetry", "100", "oxygen mask ventilation", "oxygen saturation", "83", "Breath sounds", "normal", "right", "absent", "left", "Heart sounds", "best heard", "right midclavicular line", "abdomen appears concave", "x-ray of", "chest", "following", "most appropriate initial step", "patient"]}
{"question": "A 17-year-old boy is being seen by student health for a sports physical. He denies any recent injuries. He reports that he is doing well in his classes. He fractured his left collar bone 3 years ago, which required open reduction and internal fixation. He has not had any other surgeries. He takes no medications. His father and his paternal grandfather have hypertension. When asked about his mother, the patient tears up and he quickly begins talkig about how excited he is for baseball tryouts. He has a chance this year to be in the starting lineup if, “I just stay focused.” From previous records, the patient’s mother died of ovarian cancer 6 months ago. Which of the following defense mechanisms is the patient exhibiting?", "answer": "Suppression", "options": {"A": "Denial", "B": "Displacement", "C": "Rationalization", "D": "Repression", "E": "Suppression"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "seen", "physical", "recent injuries", "reports", "well", "fractured", "left collar bone", "years", "required open reduction", "internal fixation", "not", "surgeries", "medications", "hypertension", "patient tears", "begins", "excited", "baseball", "chance", "year to", "starting", "I", "focused", "previous records", "patients", "died of ovarian cancer", "months", "following", "patient"]}
{"question": "A 5-year-old boy is brought to the emergency department by his parents with complaints of severe muscle cramping and abdominal pain. They live in Virginia. The parents state that about 2 hours before, the child was playing in their outdoor shed when he suddenly ran inside crying, saying he was bitten by a bug. One hour following the bite, the child developed the symptoms of cramping and pain. He has no known medical history and takes no medications. His blood pressure is 132/86 mm Hg, the heart rate is 116/min, and the respiratory rate is 20/min. Vital signs reveal tachycardia and hypertension. On exam, there is a 1 cm area of erythema to the dorsum of his right hand without any further dermatologic findings. Palpation of his abdomen reveals firm rigidity but no discernable rebound tenderness. What arthropod is most likely responsible for his symptoms?", "answer": "Black widow", "options": {"A": "Brown recluse", "B": "Black widow", "C": "Bark scorpion", "D": "Cryptopid centipede", "E": "Tick"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "complaints", "severe muscle", "abdominal pain", "live", "Virginia", "state", "2 hours", "child", "playing", "ran", "bitten", "bug", "One hour following", "bite", "child", "symptoms", "cramping", "pain", "known medical history", "medications", "blood pressure", "mm Hg", "heart rate", "min", "respiratory rate", "20 min", "Vital signs reveal tachycardia", "hypertension", "exam", "1", "area", "erythema", "dorsum of", "right hand", "further dermatologic findings", "Palpation of", "abdomen reveals firm rigidity", "discernable rebound tenderness", "responsible", "symptoms"]}
{"question": "A 59-year-old man presents to his primary care provider complaining of bilateral calf cramping with walking for the past 7 months. His pain goes away when he stops walking; however, his condition affects his work as a mail carrier. His medical history is remarkable for type 2 diabetes mellitus, hyperlipidemia, and 25-pack-year smoking history. His ankle-brachial index (ABI) is found to be 0.70. The patient is diagnosed with mild to moderate peripheral artery disease. A supervised exercise program for 3 months, aspirin, and cilostazol are started. Which of the following is the best next step if the patient has no improvement?", "answer": "Revascularization", "options": {"A": "Heparin", "B": "Pentoxifylline", "C": "Revascularization", "D": "Amputation", "E": "Surgical decompression"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old man presents", "primary care provider", "bilateral calf cramping", "past", "months", "pain", "stops", "condition", "mail carrier", "medical history", "type 2 diabetes mellitus", "hyperlipidemia", "smoking history", "ankle-brachial index", "found to", "0 70", "patient", "diagnosed", "mild to moderate peripheral artery disease", "exercise program", "months", "aspirin", "cilostazol", "started", "following", "best next step", "patient"]}
{"question": "A 66-year-old female with hypertension and a recent history of acute ST-elevation myocardial infarction (STEMI) 6 days previous, treated with percutaneous transluminal angioplasty (PTA), presents with sudden onset chest pain, shortness of breath, diaphoresis, and syncope. Vitals are temperature 37°C (98.6°F), blood pressure 80/50 mm Hg, pulse 125/min, respirations 12/min, and oxygen saturation 92% on room air. On physical examination, the patient is pale and unresponsive. Cardiac exam reveals tachycardia and a pronounced holosystolic murmur loudest at the apex and radiates to the back. Lungs are clear to auscultation. Chest X-ray shows cardiomegaly with clear lung fields. ECG is significant for ST elevations in the precordial leads (V2-V4) and low-voltage QRS complexes. Emergency transthoracic echocardiography shows a left ventricular wall motion abnormality along with a significant pericardial effusion. The patient is intubated, and aggressive fluid resuscitation is initiated. What is the next best step in management?", "answer": "Immediate transfer to the operating room", "options": {"A": "Intra-aortic balloon counterpulsation", "B": "Administer dobutamine 70 mcg/min IV", "C": "Emergency pericardiocentesis", "D": "Immediate transfer to the operating room", "E": "Immediate cardiac catheterization"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["66 year old female", "hypertension", "recent history of acute ST-elevation myocardial infarction", "days previous", "treated with percutaneous transluminal angioplasty", "presents", "sudden onset chest pain", "shortness of breath", "diaphoresis", "syncope", "temperature", "98", "blood pressure 80 50 mm Hg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "patient", "pale", "unresponsive", "reveals tachycardia", "holosystolic murmur loudest", "apex", "radiates", "back", "Lungs", "clear", "auscultation", "Chest X-ray", "cardiomegaly", "clear lung fields", "ECG", "significant", "ST elevations", "precordial leads", "V2", "low voltage QRS complexes", "Emergency transthoracic echocardiography", "left ventricular wall motion abnormality", "significant pericardial effusion", "patient", "intubated", "aggressive fluid resuscitation", "initiated", "next best step"]}
{"question": "A 5-year-old boy is brought to the physician because of a 5-week history of pain in his left thigh. The mother reports that her son fell from a ladder while playing with friends about a month and a half ago. He had a runny nose 3 weeks ago. He has no history of serious illness. He has reached all developmental milestones for his age. His immunizations are up-to-date. His 7-year-old brother has asthma. He is at 60th percentile for height and 65th percentile for weight. He appears healthy. His temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 17/min, and blood pressure is 110/70 mm Hg. Examination shows a mild left-sided antalgic gait. The left groin is tender to palpation; abduction and internal rotation are limited by pain. The remainder of the physical examination shows no abnormalities. His hemoglobin concentration is 13.3 g/dL, leukocyte count is 8,800/mm3, and platelet count is 230,000/mm3. An x-ray of the pelvis shows a left femoral epiphysis that is smaller than the right with widening of the medial joint space on the left. The femoral head shows little discernible damage. Which of the following is the most appropriate next step in management?", "answer": "Limited weight bearing and physical therapy", "options": {"A": "Femoral osteotomy", "B": "Oral hydroxyurea", "C": "Casting and bracing", "D": "Femoral head pinning", "E": "Limited weight bearing and physical therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["5 year old boy", "brought", "physician", "5 week history", "pain", "left thigh", "reports", "fell from", "ladder", "playing", "month", "half", "runny nose", "weeks", "history", "serious illness", "reached", "age", "immunizations", "date", "year old", "asthma", "percentile", "height", "percentile", "weight", "appears healthy", "temperature", "98", "pulse", "88 min", "respirations", "min", "blood pressure", "70 mm Hg", "mild left-sided antalgic gait", "left groin", "tender", "palpation", "abduction", "internal rotation", "limited", "pain", "abnormalities", "hemoglobin concentration", "g/dL", "leukocyte count", "800 mm3", "platelet count", "mm3", "x-ray", "pelvis", "left femoral epiphysis", "smaller", "right", "widening", "medial joint space", "left", "femoral head", "little discernible damage", "following", "most appropriate next step"]}
{"question": "A 69-year-old man presents for a general follow up appointment. He states that he is doing well and wants to be sure he is healthy. The patient’s past medical history is significant for type II diabetes mellitus, peripheral vascular disease, and hypertension. His current medications include metformin, glyburide, lisinopril, metoprolol and hydrochlorothiazide. His blood pressure is 130/90 mmHg and pulse is 80/min. A fasting lipid panel was performed last week demonstrating an LDL of 85 mg/dL and triglycerides of 160 mg/dL. The patient states that he has not experienced any symptoms since his last visit. The patient’s blood glucose at this visit is 100 mg/dL. Which of the following is recommended in this patient?", "answer": "Begin statin therapy", "options": {"A": "Increase lisinopril dose", "B": "Increase HCTZ dose", "C": "Increase metformin dose", "D": "Begin statin therapy", "E": "Discontinue metoprolol and start propranolol"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old man presents", "general follow up appointment", "states", "well", "to", "sure", "healthy", "patients past medical history", "significant", "type II diabetes mellitus", "peripheral vascular disease", "hypertension", "current medications include metformin", "glyburide", "lisinopril", "metoprolol", "hydrochlorothiazide", "blood pressure", "90 mmHg", "pulse", "80 min", "fasting lipid panel", "performed last week", "85 mg/dL", "triglycerides", "160 mg dL", "patient states", "not", "symptoms", "last", "blood glucose", "100 mg/dL", "following", "patient"]}
{"question": "A 27-year-old man presents to the emergency department with loss of consciousness. The patient was brought in 20 minutes ago by the supervisor at a homeless shelter who found him passed out next to a bottle of acetaminophen. The patient has a past medical history of HIV, hepatitis C, IV drug abuse, alcohol abuse, suicide attempt, and constipation. He takes methadone daily but is notably non-compliant with his anti-retroviral therapy. His temperature is 104°F (40°C), blood pressure is 85/40 mmHg, pulse is 180/min, respirations are 18/min, and oxygen saturation is 90% on room air. The patient is started on IV fluids, N-acetylcysteine, and 100% oxygen. Blood cultures are obtained, and lab work is sent off. The patient is then started on broad spectrum antibiotics and given norepinephrine. Repeat vitals demonstrate hypotension and tachycardia. Serum toxicology returns and is positive for alcohol. The patient is transferred to the medicine floor and managed further. Two days later, the patient's vitals have improved. Repeat lab values are ordered and return as follows:\n\nHemoglobin: 11 g/dL\nHematocrit: 30%\nLeukocyte count: 6,500 cells/mm^3 with normal differential\nPlatelet count: 245,000/mm^3\n\nSerum:\nNa+: 138 mEq/L\nCl-: 100 mEq/L\nK+: 4.1 mEq/L\nHCO3-: 22 mEq/L\nBUN: 30 mg/dL\nGlucose: 145 mg/dL\nCreatinine: 1.4 mg/dL\nCa2+: 9.6 mg/dL\nAST: 1,440 U/L\nALT: 1,350 U/L\n\nWhich of the following is the best explanation for this patient’s laboratory abnormalities?", "answer": "Previous hypotension", "options": {"A": "Alcohol abuse", "B": "Antibiotic use", "C": "Chronic viral infection", "D": "Previous hypotension", "E": "Toxic liver metabolite"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "emergency department", "loss of consciousness", "patient", "brought", "20 minutes", "supervisor", "homeless shelter", "found", "passed out next to", "bottle", "acetaminophen", "patient", "past medical HIV", "hepatitis C", "IV drug abuse", "alcohol abuse", "suicide attempt", "constipation", "methadone daily", "non-compliant", "anti-retroviral therapy", "temperature", "blood pressure", "85 40 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "90", "room air", "patient", "started", "N-acetylcysteine", "100", "oxygen", "Blood cultures", "obtained", "lab", "sent", "patient", "then started", "broad spectrum", "given norepinephrine", "Repeat", "hypotension", "tachycardia", "Serum toxicology returns", "positive", "alcohol", "patient", "transferred", "medicine floor", "further", "Two days later", "patient's", "improved", "Repeat lab values", "ordered", "return", "follows", "Hemoglobin", "g/dL Hematocrit", "30", "Leukocyte count", "6 500 cells mm 3", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4.1 mEq/L HCO3", "mEq/L", "30 mg/dL Glucose", "mg/dL Creatinine", "1.4 mg/dL Ca2", "dL AST", "1 440 U/L ALT", "1 350 U/L", "following", "best explanation", "patients laboratory abnormalities"]}
{"question": "A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process?", "answer": "Hydrocele", "options": {"A": "Femoral hernia", "B": "Hydrocele", "C": "Varicocele", "D": "Diaphragmatic hernia", "E": "Testicular torsion"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["1-year-old", "pediatrician's office", "routine appointment", "states", "well", "intermittent bulge", "right side", "groin", "strains", "bowel movement", "unremarkable", "physician", "condition", "caused", "incomplete obliteration", "processus vaginalis", "condition", "caused", "same defective process"]}
{"question": "A 42-year-old man comes to the physician because of a 3-week history of rash that began on his right ankle and gradually progressed up his calf. The rash is itchy and mildly painful. He has type 2 diabetes mellitus and hypertension. He does not smoke or drink alcohol. His current medications include metformin, glipizide, and enalapril. He returned from a trip to Nigeria around 5 weeks ago. He works on a fishing trawler. His temperature is 37°C (98.6°F), pulse is 65/min, and blood pressure is 150/86 mm Hg. Other than the rash on his calf, the examination shows no abnormalities. A picture of the rash is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Cutaneous larva migrans", "options": {"A": "Contact dermatitis", "B": "Cutaneous larva migrans", "C": "Tinea", "D": "Superficial thrombophlebitis", "E": "Swimmer's itch"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "3 week history", "rash", "began", "right ankle", "progressed", "calf", "rash", "itchy", "mildly painful", "type 2 diabetes mellitus", "hypertension", "not smoke", "current medications include metformin", "glipizide", "enalapril", "returned", "trip", "Nigeria", "weeks", "temperature", "98", "pulse", "65 min", "blood pressure", "mm Hg", "Other", "rash", "calf", "abnormalities", "picture", "rash", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 64-year-old woman comes to the emergency room because of a sudden weakness in her right arm and leg. She has atrial fibrillation, tinea unguium, gastroesophageal reflux disease, hypertension, and hypercholesterolemia. Current medications include warfarin, enalapril, simvastatin, lansoprazole, hydrochlorothiazide, griseofulvin, and ginkgo biloba. Two weeks ago, she had an appointment with her podiatrist. Physical examination shows sagging of her right lower face and decreased muscle strength in her right upper and lower extremity. Babinski sign is positive on the right. Her prothrombin time is 14 seconds (INR = 1.5). Which of the following drugs is the most likely underlying cause of this patient's current condition?", "answer": "Griseofulvin", "options": {"A": "Ginkgo biloba", "B": "Simvastatin", "C": "Enalapril", "D": "Lansoprazole", "E": "Griseofulvin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["64 year old woman", "emergency room", "of", "sudden weakness", "right arm", "leg", "atrial fibrillation", "tinea unguium", "gastroesophageal reflux disease", "hypertension", "hypercholesterolemia", "Current medications include warfarin", "enalapril", "simvastatin", "lansoprazole", "hydrochlorothiazide", "griseofulvin", "ginkgo biloba", "Two weeks", "appointment", "podiatrist", "sagging", "right lower face", "decreased muscle strength", "right upper", "lower extremity", "Babinski sign", "positive", "right", "prothrombin time", "seconds", "INR", "1.5", "following drugs", "underlying cause", "patient's current condition"]}
{"question": "A 70-year-old man is accompanied by his wife to the primary care clinic for hand tremors. He states that he first noticed the tremor of his left hand 1 year ago. Since then, the tremor has been worsening and now he can hardly relax when trying to read. His wife says that she is also worried about his memory. She had to take over the finances several weeks ago after learning that he had forgotten to pay the bills for the past few months. The patient’s medical history is significant for hypertension. He takes aspirin and amlodipine. His mother had schizophrenia. The patient drinks 1-2 beers a night and is a former cigar smoker. On physical examination, he speaks softly and has reduced facial expressions. He has a resting tremor that is worse on the left, and he resists manipulation of his bilateral upper extremities. Which of the following is the most likely diagnosis?", "answer": "Parkinson disease", "options": {"A": "Essential tremor", "B": "Dementia with Lewy bodies", "C": "Parkinson disease", "D": "Progressive supranuclear palsy", "E": "Tardive dyskinesia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man", "primary care clinic", "hand tremors", "states", "first", "tremor of", "left hand", "year", "then", "tremor", "worsening", "now", "relax", "to", "worried", "memory", "to", "finances", "weeks", "forgotten to pay", "bills", "past", "months", "patients medical history", "significant", "hypertension", "aspirin", "amlodipine", "schizophrenia", "patient", "1-2", "night", "former cigar smoker", "speaks softly", "reduced facial expressions", "resting tremor", "worse", "left", "manipulation", "bilateral upper extremities", "following", "diagnosis"]}
{"question": "A 69-year-old woman comes to the physician because of a 3-week history of headache and worsening vision. Ophthalmologic examination shows a visual acuity of 20/120 in the right eye and 20/80 in the left eye. Physical examination shows no other abnormalities. Laboratory studies show a hemoglobin of 14.2 g/dL and total serum calcium of 9.9 mg/dL. A photomicrograph of a peripheral blood smear is shown. Serum electrophoresis shows increased concentration of a pentameric immunoglobulin. Which of the following is the most likely diagnosis?", "answer": "Waldenstrom macroglobulinemia", "options": {"A": "Multiple myeloma", "B": "Hyper IgM syndrome", "C": "Essential thrombocythemia", "D": "Waldenstrom macroglobulinemia", "E": "Giant cell arteritis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["69 year old woman", "physician", "of", "3 week history", "headache", "worsening vision", "Ophthalmologic examination", "visual acuity", "20/120", "right eye", "20/80", "left eye", "Physical examination", "abnormalities", "Laboratory studies", "a hemoglobin", "g", "total serum calcium", "mg dL", "photomicrograph", "peripheral blood smear", "Serum electrophoresis", "increased concentration", "a", "immunoglobulin", "following", "diagnosis"]}
{"question": "A 55-year-old male bodybuilder presents to the emergency department with weakness of his right arm. The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea. The patient has a past medical history of diabetes. He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25. The patient admits to using anabolic steroids. He has lost 17 pounds since he last came to the emergency department 1 month ago. His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm. The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam. Which of the following is the most likely diagnosis?", "answer": "Apical lung tumor", "options": {"A": "Apical lung tumor", "B": "Brachial plexopathy", "C": "Cerebral infarction", "D": "Scalenus anticus syndrome", "E": "Subclavian steal syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male", "presents", "emergency department", "weakness of", "right arm", "patient states", "symptoms", "weeks", "today", "hand", "so weak", "cup", "patient", "past medical diabetes", "2-7 alcoholic drinks per day", "smoked 2 packs", "cigarettes", "day", "patient", "using anabolic steroids", "lost", "pounds", "last", "emergency department", "month", "temperature", "99", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "reveals decreased sensation", "right arm", "2/5 strength", "right arm", "5/5 strength", "left arm", "patient states", "dull aching", "burning pain in", "right arm", "exam", "following", "diagnosis"]}
{"question": "A 24-year-old woman comes to the emergency department because of abdominal pain, fever, nausea, and vomiting for 12 hours. Her abdominal pain was initially dull and diffuse but has progressed to a sharp pain on the lower right side. Two years ago she had to undergo right salpingo-oophorectomy after an ectopic pregnancy. Her temperature is 38.7°C (101.7°F). Physical examination shows severe right lower quadrant tenderness with rebound tenderness; bowel sounds are decreased. Laboratory studies show leukocytosis with left shift. An abdominal CT scan shows a distended, edematous appendix. The patient is taken to the operating room for an appendectomy. During the surgery, the adhesions from the patient's previous surgery make it difficult for the resident physician to identify the appendix. Her attending mentions that she should use a certain structure for guidance to locate the appendix. The attending is most likely referring to which of the following structures?", "answer": "Teniae coli", "options": {"A": "Deep inguinal ring", "B": "Teniae coli", "C": "Ileocolic artery", "D": "Right ureter", "E": "Epiploic appendages"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "abdominal pain", "fever", "nausea", "vomiting", "12 hours", "abdominal pain", "initially dull", "diffuse", "progressed", "sharp pain", "lower right side", "Two years", "to", "right salpingo-oophorectomy", "ectopic pregnancy", "temperature", "severe right lower quadrant tenderness", "rebound", "bowel sounds", "decreased", "Laboratory studies", "leukocytosis", "left shift", "abdominal CT", "distended", "edematous appendix", "patient", "operating room", "appendectomy", "surgery", "adhesions", "patient's previous surgery make", "difficult", "resident physician to", "appendix", "attending", "use", "certain structure", "guidance to", "appendix", "attending", "referring", "following structures"]}
{"question": "A 25-year-old man presents to the emergency department after a car accident. He was the front seat restrained driver in a head-on collision. He has no significant past medical history. The patient’s vitals are stabilized and he is ultimately discharged with his injuries appropriately treated. At the patient’s follow up primary care appointment, he complains of being unable to lift his left foot. He otherwise states that he feels well and is not in pain. His vitals are within normal limits. Physical exam is notable for 1/5 strength upon dorsiflexion of the patient’s left foot, and 5/5 plantarflexion of the same foot. Which of the following initial injuries most likely occurred in this patient?", "answer": "Fibular neck fracture", "options": {"A": "Calcaneal fracture", "B": "Distal femur fracture", "C": "Fibular neck fracture", "D": "Lisfranc fracture", "E": "Tibial plateau fracture"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "car accident", "front", "restrained driver", "head", "collision", "significant past medical history", "patients", "stabilized", "discharged", "injuries", "treated", "primary", "unable to lift", "left foot", "states", "well", "not", "pain", "normal limits", "notable", "strength", "dorsiflexion of", "patients left foot", "5/5 plantarflexion of", "same foot", "following initial injuries", "likely", "patient"]}
{"question": "A 25-year-old man with no significant past medical history is brought in by ambulance after a witnessed seizure at home. On physical exam, temperature is 102.3 deg F (39.1 deg C), blood pressure is 90/62 mmHg, pulse is 118/min, and respirations are 25/min. He is unable to touch his chin to his chest and spontaneously flexes his hips with passive neck flexion. Appropriate empiric treatment is begun. CT head is unremarkable, and a lumbar puncture sample is obtained. Gram stain of the cerebrospinal fluid (CSF) reveals gram-positive diplococci. Which of the following would you expect to see on CSF studies?", "answer": "Elevated opening pressure, elevated protein, low glucose", "options": {"A": "Elevated opening pressure, elevated protein, elevated glucose", "B": "Elevated opening pressure, elevated protein, normal glucose", "C": "Elevated opening pressure, elevated protein, low glucose", "D": "Normal opening pressure, elevated protein, normal glucose", "E": "Normal opening pressure, normal protein, normal glucose"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "significant past medical history", "brought", "ambulance", "seizure at home", "temperature", "deg F", "blood pressure", "90 62 mmHg", "pulse", "min", "respirations", "min", "unable to touch", "chin", "chest", "hips", "passive neck flexion", "Appropriate empiric", "begun", "CT head", "unremarkable", "lumbar puncture", "obtained", "Gram stain", "cerebrospinal fluid", "reveals", "following", "to see", "CSF studies"]}
{"question": "A 25-year-old G1P0 woman at 33 weeks gestation presents to the obstetrician for an episode of postcoital spotting. The patient’s pregnancy is complicated by diet-controlled gestational diabetes. She has no other medical conditions. She takes prenatal vitamins. She denies tobacco, alcohol, or recreational drug use. She is currently sexually active with her boyfriend of 1 year, but prior to her current relationship, she states she had multiple male partners. On physical examination, no vaginal bleeding is appreciated. The cervix is closed, and there is no leakage of fluid or contractions. Fetal movement is normal. Fundal height is 33 cm. Fetal pulse is 138/min. The patient’s temperature is 37.0 °C (98.6°F), blood pressure is 112/75 mm Hg, and pulse is 76/min. A urine dipstick is negative for glucose and protein. Chlamydia trachomatis nucleic acid amplification testing is positive. Which of the following is the mechanism behind the first-line treatment for this patient’s condition?", "answer": "Inhibits the 50S ribosome subunit", "options": {"A": "Disrupts peptidoglycan cross-linking", "B": "Inhibits DNA gyrase", "C": "Inhibits the 30S ribosome subunit", "D": "Inhibits the 50S ribosome subunit", "E": "Inhibits transpeptidase and cell wall synthesis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "woman", "weeks presents", "obstetrician", "episode of", "spotting", "patients pregnancy", "complicated by diet controlled gestational diabetes", "medical conditions", "prenatal vitamins", "tobacco", "alcohol", "recreational drug use", "currently sexually active", "year", "prior to", "current relationship", "states", "male", "vaginal bleeding", "cervix", "closed", "leakage", "fluid", "contractions", "Fetal movement", "normal", "Fundal height", "Fetal pulse", "min", "patients temperature", "0", "98", "blood pressure", "75 mm Hg", "pulse", "76 min", "urine dipstick", "negative", "glucose", "protein", "nucleic acid amplification testing", "positive", "following", "mechanism", "first-line treatment", "patients condition"]}
{"question": "A 27-year-old woman comes to the physician because of a 2-day history of severe burning pain with urination, and urinary frequency. She has no history of serious illness. The patient and her husband are currently trying to conceive a child. Her only medication is a prenatal multivitamin. Her temperature is 36.5°C (97.7°F), pulse is 75/min, and blood pressure is 125/78 mm Hg. Examination shows mild tenderness to palpation over the suprapubic region. There is no costovertebral angle tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 14.8 g/dL\nLeukocyte count 8,200/mm3\nPlatelet count 230,000/mm3\nUrine\npH 7\nWBC 52/hpf\nRBC 17/hpf\nProtein negative\nNitrites positive\nLeukocyte esterase positive\nA urine pregnancy test is negative. Which of the following is the most appropriate next step in management?\"", "answer": "Oral fosfomycin", "options": {"A": "Oral ciprofloxacin", "B": "Reassurance and follow-up in 2 weeks", "C": "Urinary catheterization", "D": "Oral fosfomycin", "E": "Urine culture\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old woman", "physician", "of", "2-day history", "severe burning pain", "urination", "urinary frequency", "history", "serious illness", "patient", "currently", "to", "child", "only medication", "prenatal multivitamin", "temperature", "36", "97", "pulse", "75 min", "blood pressure", "mm Hg", "mild tenderness", "palpation", "suprapubic region", "costovertebral angle tenderness", "abnormalities", "Laboratory studies", "Hemoglobin", "g", "Leukocyte", "200 mm3 Platelet count", "pH", "WBC", "hpf", "positive", "esterase", "urine pregnancy test", "negative", "following", "most appropriate next step"]}
{"question": "A 60-year-old man comes to the physician because of a 2-day history of blood in his urine, lower abdominal pain, and a burning sensation while micturating. Five months ago, he was diagnosed with high-grade non-Hodgkin lymphoma and a deep vein thrombosis of his right popliteal vein. His medications include polychemotherapy every 3 weeks and a daily subcutaneous dose of low molecular weight heparin. The last cycle of chemotherapy was 2 weeks ago. His temperature is 37°C (98.6°F), pulse is 94/min, and blood pressure is 110/76 mm Hg. Examination shows bilateral axillary and inguinal lymphadenopathy, hepatosplenomegaly, and mild suprapubic tenderness. Laboratory studies show:\nHemoglobin 10.2 g/dL\nLeukocytes 4,300/mm3\nPlatelet count 145,000/mm3\nPartial thromboplastin time 55 seconds\nProthrombin time 11 seconds (INR=1)\nUrine\nRBCs 50–55/hpf\nRBC casts negative\nWBCs 7/hpf\nEpithelial cells 5/hpf\nBacteria occasional\nAdministration of which of the following is most likely to have prevented this patient's current condition?\"", "answer": "Mercaptoethane sulfonate", "options": {"A": "Protamine sulfate", "B": "Mercaptoethane sulfonate", "C": "Palifermin", "D": "Ciprofloxacin", "E": "Dexrazoxane"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old man", "physician", "2-day history", "blood", "urine", "lower abdominal pain", "burning sensation", "Five months", "diagnosed", "high-grade non-Hodgkin lymphoma", "deep vein", "right popliteal", "medications include polychemotherapy", "3 weeks", "daily subcutaneous dose", "low molecular weight heparin", "last cycle", "chemotherapy", "2 weeks", "temperature", "98", "pulse", "min", "blood pressure", "76 mm Hg", "bilateral axillary", "inguinal lymphadenopathy", "hepatosplenomegaly", "mild suprapubic tenderness", "Laboratory studies", "Hemoglobin 10.2 g Leukocytes", "mm3 Platelet count", "Partial thromboplastin time", "seconds Prothrombin time 11", "INR 1", "Urine", "hpf", "casts negative WBCs", "hpf Epithelial cells", "Bacteria occasional Administration", "following", "to", "prevented", "patient", "urrent  ondition?"]}
{"question": "A 47-year-old woman is upset with her neighbor for playing music too loudly late at night. Rather than confront her neighbor directly, the woman makes a habit of parking her car in a manner that makes it difficult for her neighbor to park in his spot. Which of the following defense mechanisms is this woman demonstrating?", "answer": "Passive aggression", "options": {"A": "Sublimation", "B": "Regression", "C": "Acting out", "D": "Displacement", "E": "Passive aggression"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "playing", "too", "late", "night", "directly", "woman makes", "parking", "car", "makes", "difficult", "to park", "spot", "following", "woman"]}
{"question": "A 54-year-old man presents with feelings of sadness and low mood on most days of the week for the past month. He reports an inability to concentrate and also finds it hard to develop an interest in his daily activities. He goes on to tell his physician that he struggles to get sleep at night, and, in the morning, he doesn’t have the energy to get out of bed. He says he feels like a loser since he hasn’t accomplished all that he had set out to do and feels guilty for being unable to provide for his family. He says he doesn’t have the will to live anymore but denies any plans to commit suicide. Past medical history is significant for erectile dysfunction which was diagnosed about a year ago. Which of the following medications should be avoided in the treatment of this patient’s depression?", "answer": "Fluoxetine", "options": {"A": "Vortioxetine", "B": "Fluoxetine", "C": "Bupropion", "D": "Mirtazapine", "E": "Vilazodone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["54 year old man presents", "low mood", "days of the week", "past month", "reports", "to concentrate", "finds", "hard to", "physician", "to", "sleep", "night", "morning", "energy to get out", "bed", "hasnt", "set out", "unable to", "to live", "plans to commit suicide", "Past medical history", "significant", "erectile dysfunction", "diagnosed", "year", "following medications", "depression"]}
{"question": "A 40-year-old woman residing at an iodine-deficient endemic area presents to the physician with a painless and gradually progressive anterior neck mass. She has occasional dysphagia, but has no history of prior head and neck irradiation. The examination shows a mass that moves with deglutition, suggesting a thyroid mass. An ultrasound of the neck reveals a 3 cm x 3 cm (1.2 in x 1.2 in) mass in the right thyroid lobe with punctate microcalcifications, hypoechogenicity, irregular margins, and enhanced vascularity. There is no cervical lymphadenopathy. Her serum TSH is 3.3 mU/L, serum T3 is 2.2 nmol/L, and serum T4 is 111 nmol/L. An FNAC of the nodule shows abundant follicular cells suspicious of follicular neoplasm. A right lobectomy with isthmectomy is performed. Which of the following histopathological finding is diagnostic?", "answer": "Follicular cells that lack nuclear atypia, with capsular and vascular invasion", "options": {"A": "Presence of Psammoma bodies", "B": "Well-differentiated follicular cells without vascular invasion", "C": "Follicular cells that lack nuclear atypia, with capsular and vascular invasion", "D": "Hyperplastic parafollicular C cells", "E": "Highly undifferentiated malignant cells with areas of necrosis and inflammation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old woman", "iodine deficient", "area presents", "physician", "painless", "progressive anterior", "occasional dysphagia", "history of prior head and neck irradiation", "mass", "moves", "deglutition", "thyroid mass", "ultrasound of the neck reveals", "3", "3", "1.2", "mass", "right thyroid lobe", "punctate microcalcifications", "irregular margins", "vascularity", "cervical lymphadenopathy", "serum", "3.3 mU/L", "serum", "2.2 nmol/L", "serum T4", "nmol/L", "nodule", "abundant follicular cells suspicious", "follicular neoplasm", "right lobectomy", "isthmectomy", "performed", "following histopathological finding", "diagnostic"]}
{"question": "A 15-year-old girl is brought to the physician because she has not yet had her first menstrual period. She reports that she frequently experiences cramping and pain in her legs during school sports. The patient is at the 20th percentile for height and 50th percentile for weight. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 155/90 mm Hg. Examination shows a high-arched palate with maloccluded teeth and a low posterior hairline. The patient has a broad chest with widely spaced nipples. Pelvic examination shows normal external female genitalia. There is scant pubic hair. Without appropriate treatment, this patient is at the greatest risk of developing which of the following complications?", "answer": "Pathologic fractures", "options": {"A": "Obsessive-compulsive disorder", "B": "Pathologic fractures", "C": "Pulmonary stenosis", "D": "Severe acne", "E": "Ectopia lentis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "not", "first menstrual period", "reports", "frequently", "cramping", "pain in", "legs", "patient", "percentile", "height", "50th percentile", "weight", "temperature", "98", "pulse", "70 min", "blood pressure", "90 mm Hg", "high-arched palate", "teeth", "low posterior hairline", "patient", "broad chest", "widely spaced nipples", "Pelvic examination", "normal", "scant pubic hair", "appropriate treatment", "patient", "greatest", "following complications"]}
{"question": "A 55-year-old man presents to the urgent clinic complaining of pain in his right foot. He reported that the pain is intense that he had to remove his shoe and sock, and rates the pain level as 6 out of 10. He does not report trauma or recent infection. The past medical history includes hypertension. The medications include hydrochlorothiazide, enalapril, and a daily multivitamin. The family history is noncontributory. He consumes alcohol in moderation. His diet mostly consists of red meat and white rice. The blood pressure is 137/85 mm Hg, heart rate is 74/min, respiratory rate is 12/min, and the temperature is 36.9°C (98.4°F). The physical examination demonstrates swelling, redness, and tenderness to palpation in the first metatarsophalangeal joint of his right foot. There are no skin lesions. The rest of the patient’s examination is normal. An arthrocentesis procedure is scheduled. Which of the following is the most likely pharmacological treatment for the presented patient?", "answer": "Diclofenac alone", "options": {"A": "Probenecid alone", "B": "Oral methylprednisolone and meloxicam", "C": "Allopurinol alone", "D": "Colchicine and celecoxib", "E": "Diclofenac alone"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "urgent clinic", "pain", "right foot", "reported", "pain", "intense", "to remove", "shoe", "sock", "rates", "pain level", "10", "not report trauma", "recent infection", "past medical history includes hypertension", "medications include hydrochlorothiazide", "enalapril", "daily multivitamin", "family history", "alcohol", "moderation", "diet mostly consists", "white rice", "blood pressure", "85 mm Hg", "heart rate", "74 min", "respiratory rate", "min", "temperature", "36", "98", "swelling", "redness", "tenderness", "palpation", "first metatarsophalangeal joint of", "right foot", "skin lesions", "normal", "arthrocentesis procedure", "scheduled", "following", "pharmacological", "patient"]}
{"question": "A 37-year-old man presents to the emergency department for a persistent fever. The patient states he has felt unwell for the past week and has felt subjectively febrile. The patient has a past medical history of a suicide attempt and alcohol abuse. He is not currently taking any medications. The patient admits to using heroin and cocaine and drinking 5-8 alcoholic drinks per day. His temperature is 103°F (39.4°C), blood pressure is 92/59 mmHg, pulse is 110/min, respirations are 20/min, and oxygen saturation is 96% on room air. Cardiopulmonary exam is notable for a systolic murmur heard best along the left sternal border. Dermatologic exam reveals scarring in the antecubital fossa. Which of the following is the next best step in management?", "answer": "Blood cultures", "options": {"A": "Blood cultures", "B": "Chest radiograph", "C": "CT scan", "D": "Ultrasound", "E": "Vancomycin and gentamicin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "persistent fever", "patient states", "unwell", "past week", "febrile", "patient", "past medical", "suicide attempt", "alcohol abuse", "not currently", "medications", "patient", "using heroin", "cocaine", "drinking 5-8 alcoholic drinks per day", "temperature", "blood pressure", "59 mmHg", "pulse", "min", "respirations", "20 min", "oxygen saturation", "96", "room", "Cardiopulmonary exam", "notable", "systolic murmur heard best", "left sternal border", "Dermatologic exam reveals scarring", "antecubital fossa", "following", "next best step"]}
{"question": "A 63-year-old man comes to the physician for evaluation of fever and a nonproductive cough for the past 2 weeks. During this period, he has also had fatigue, myalgia, and difficulty breathing. Five weeks ago, he underwent an aortic prosthetic valve replacement due to high-grade aortic stenosis. The patient has a history of hypertension, asthma, and type 2 diabetes mellitus. A colonoscopy 2 years ago was normal. The patient has smoked one pack of cigarettes daily for the past 40 years. He has never used illicit drugs. Current medications include aspirin, warfarin, lisinopril, metformin, inhaled albuterol, and a multivitamin. The patient appears lethargic. Temperature is 38.6°C (101.5°F), pulse is 105/min, and blood pressure is 140/60 mm Hg. Rales are heard on auscultation of the lungs. A grade 2/6, diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. A photograph of his right index finger is shown. Laboratory studies show a leukocyte count of 13,800/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Which of the following is the most likely causal organism?", "answer": "Staphylococcus epidermidis", "options": {"A": "Streptococcus gallolyticus", "B": "Staphylococcus epidermidis", "C": "Enterococcus faecalis", "D": "Viridans streptococci", "E": "Streptococcus pyogenes"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old man", "physician", "fever", "cough", "past 2 weeks", "period", "fatigue", "myalgia", "difficulty breathing", "Five weeks", "aortic prosthetic valve replacement due to high-grade", "stenosis", "patient", "history of hypertension", "asthma", "type 2 diabetes mellitus", "colonoscopy", "years", "normal", "patient", "smoked one pack", "cigarettes daily", "past 40 years", "never used illicit drugs", "Current medications include aspirin", "warfarin", "lisinopril", "metformin", "inhaled albuterol", "multivitamin", "patient appears lethargic", "Temperature", "pulse", "min", "blood pressure", "60 mm Hg", "Rales", "heard", "auscultation", "lungs", "diastolic blowing murmur", "heard", "left sternal border", "radiates", "right sternal border", "photograph", "right index finger", "Laboratory studies", "leukocyte count", "800 mm3", "erythrocyte sedimentation rate", "48 mm/h", "following", "causal"]}
{"question": "A 42-year-old man presents to his primary care provider complaining of insomnia. He describes 3 months of frequent nighttime awakenings and nightmares. Per chart review, he is a combat veteran and was on a military tour in Afghanistan 4 months ago when a car bomb exploded, injuring him and killing his friend; however, when the physician asks about this, the patient states that he “does not talk about that” and changes the subject. He reports anxiety, irritability and feeling detached from his friends and family, which he believes is harming his relationships. Physical exam reveals an overweight, anxious appearing man with normal vital signs and an exaggerated startle response. Which of the following medications might have helped prevent this patient’s current disorder?", "answer": "Propanolol", "options": {"A": "Buspirone", "B": "Prazosin", "C": "Propanolol", "D": "Sertraline", "E": "Zolpidem"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider complaining of insomnia", "3 months", "frequent nighttime awakenings", "nightmares", "military tour", "Afghanistan", "months", "car bomb", "physician", "patient states", "not talk", "changes", "subject", "reports anxiety", "irritability", "feeling detached", "relationships", "reveals", "overweight", "anxious appearing man", "normal vital signs", "exaggerated startle response", "following medications", "helped prevent", "patients current disorder"]}
{"question": "A 38-year-old man presents with fatigue and weight loss for the past 4 months. He feels tired all the time. He also no longer feels interested in his work. He says he has lost weight and says, \"I just don’t want to eat.\" No significant past medical history. No current medications. Physical examination is unremarkable. The patient is started on sertraline. He returns for follow-up after 2 weeks and says that he has been compliant with his medications. He says that he is now getting a full night’s sleep with no early morning awakenings. Despite regaining his appetite, he hasn’t regained any lost weight, and he still feels fatigued. He believes that the medication is not working well and asks to be started on something else. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Continue sertraline", "options": {"A": "Replace sertraline with fluoxetine", "B": "Discontinue sertraline", "C": "Continue sertraline", "D": "Add fluoxetine to sertraline", "E": "Add amitriptyline to sertraline"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "fatigue", "weight loss", "past", "months", "tired", "time", "longer", "lost weight", "I", "to eat", "significant past medical history", "current medications", "unremarkable", "patient", "started", "sertraline", "returns", "follow-up", "2 weeks", "compliant", "medications", "now getting", "full nights sleep", "early morning awakenings", "appetite", "hasnt", "lost weight", "fatigued", "medication", "not", "well", "to", "started", "else", "following", "most appropriate next step", "patient"]}
{"question": "A 68-year-old man presents to the physician with fever, cough, weakness, night sweats, and poor appetite for the past 6 months. Medical records suggest that he has lost 7.5 kg (16.5 lb) of weight during this period. There is no history of breathlessness, nasal discharge, nasal obstruction, palpitations, chest pain, or symptoms related to digestion. He was released from prison 9 months ago after serving a 2-year sentence. His temperature is 38.1°C (100.6°F), pulse is 84/min, respirations are 16/min, and blood pressure is 122/80 mm Hg. Physical examination shows hepatomegaly and generalized lymphadenopathy, and auscultation of the chest reveals diffuse crackles throughout the lung fields bilaterally. On direct ophthalmoscopy, three discrete, yellow-colored, 0.5 mm to 1.0 mm lesions with indistinct borders are seen in the posterior pole. A chest X-ray is shown in the image. Tuberculin skin test with purified protein derivative is negative. What is the most likely diagnosis?", "answer": "Tuberculosis", "options": {"A": "Sarcoidosis", "B": "Chronic histoplasmosis", "C": "Langerhans cell histiocytosis", "D": "Tuberculosis", "E": "Bronchoalveolar carcinoma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "physician", "fever", "cough", "weakness", "night sweats", "poor appetite", "past 6 months", "Medical records", "lost 7.5 kg", "weight", "period", "history", "breathlessness", "nasal discharge", "nasal obstruction", "palpitations", "chest pain", "symptoms related", "digestion", "released from prison", "months", "serving", "2 year", "temperature", "100", "pulse", "84 min", "respirations", "min", "blood pressure", "80 mm Hg", "hepatomegaly", "generalized lymphadenopathy", "auscultation", "chest reveals diffuse crackles", "lung fields", "direct ophthalmoscopy", "three discrete", "yellow-colored", "0.5 mm", "1", "lesions", "indistinct borders", "seen", "posterior pole", "chest X-ray", "Tuberculin skin test", "purified protein derivative", "negative", "diagnosis"]}
{"question": "A 53-year-old man seeks evaluation from his physician with concerns about his blood pressure. He was recently told at a local health fair that he has high blood pressure. He has not seen a physician since leaving college because he never felt the need for medical attention. Although he feels fine, he is concerned because his father had hypertension and died due to a heart attack at 61 years of age. He does not smoke cigarettes but drinks alcohol occasionally. The blood pressure is 150/90 mm Hg today. The physical examination is unremarkable. Labs are ordered and he is asked to monitor his blood pressure at home before the follow-up visit. Two weeks later, the blood pressure is 140/90 mm Hg. The blood pressure measurements at home ranged from 130/90 to 155/95 mm Hg. An electrocardiogram (ECG) is normal. Lab tests show the following:\nSerum glucose (fasting) 88 mg/dL\n    Serum 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 mEq/L\nHDL-cholesterol 35 mEq/L\nLDL-cholesterol 186 mg/dL\nTriglycerides 250 mg/dL\n    Urinalysis:  \nGlucose negative\nKetones negative\nLeucocytes negative\nNitrite negative\nRBC negative\nCasts negative\nRegular exercise and a 'heart healthy diet' are advised. He is started on lisinopril for hypertension. Which of the following medications should be added to this patient?", "answer": "Atorvastatin", "options": {"A": "Atorvastatin", "B": "Niacin", "C": "Gemfibrozil", "D": "Orlistat", "E": "Cholestyramine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "blood pressure", "recently", "local", "fair", "high blood pressure", "not seen", "physician", "college", "never", "need", "medical", "fine", "hypertension", "died due to", "heart attack", "61 years", "age", "not smoke cigarettes", "alcohol occasionally", "blood pressure", "90 mm Hg today", "unremarkable", "Labs", "ordered", "to monitor", "blood pressure at home", "Two weeks later", "blood pressure", "90 mm Hg", "at home ranged", "90", "95 mm Hg", "electrocardiogram", "normal", "Lab tests", "following", "Serum glucose", "fasting", "88 mg/dL", "Serum electrolytes", "mEq/L Potassium", "Chloride", "Serum creatinine 0.8", "urea nitrogen", "Cholesterol", "total", "mEq", "HDL-cholesterol", "LDL-cholesterol", "mg Triglycerides", "Urinalysis", "Glucose negative Ketones", "Nitrite", "Casts negative", "heart healthy diet", "started", "lisinopril", "hypertension", "following medications", "added", "patient"]}
{"question": "A 19-year-old woman comes to the physician for a routine examination. She has one sexual partner, with whom she had unprotected sexual intercourse 3 days ago. She does not desire a pregnancy and is interested in a reliable and long-term contraceptive method. She has read in detail about the reliability, adverse-effects, health risks, and effective duration of intrauterine devices (IUD) as a birth control method. She requests the physician to prescribe and place an IUD for her. The physician feels that providing contraception would be a violation of her religious beliefs. Which of the following responses by the physician is most appropriate?", "answer": "“I can understand your need for the IUD, but I cannot place it for you due to my religious beliefs. I would be happy to refer you to a colleague who could do it.”", "options": {"A": "“Prescribing any means of contraception is against my religious beliefs, but as a doctor, I am obliged to place the IUD for you.”", "B": "“I need to discuss this with my pastor before I decide whether to insert an IUD, as this is against my religious beliefs.”", "C": "“I can understand your need for the IUD, but I cannot place it for you due to my religious beliefs. I would be happy to refer you to a colleague who could do it.”", "D": "“I understand your concerns, but I cannot place the IUD for you due to my religious beliefs. I recommend you use condoms instead.", "E": "“First, I would like to perform an STD panel since you are sexually active.”"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "routine", "one", "unprotected sexual intercourse", "days", "not", "pregnancy", "long-term contraceptive method", "detail", "reliability", "adverse-effects", "effective duration", "intrauterine devices", "birth control method", "physician", "place", "IUD", "physician", "contraception", "following responses", "physician", "most appropriate"]}
{"question": "A 30-year-old woman was found lying down and unresponsive by her parents 2 hours ago. She has no significant medical history. Two years ago, the woman discovered that her husband of 8 years was having an extramarital affair; this revelation subsequently resulted in a drawn-out divorce. After the separation, she moved back in with her parents, who note that she stays in her room, sleeps a lot, and rarely eats. A physical exam shows obtundation. Her temperature is 37.1ºC (98.7ºF), pulse is 110/min, respirations are 24/min, and blood pressure is 126/78 mm Hg. The patient’s admission labs are as follows:\nTSH  3.2 µU/mL\nMorning cortisol  8 µg/dL\nProlactin 15 ng/mL\nFSH 7 mIU/mL\nLH 6 mIU/mL\nGlucose 22 mg/dL\nC-peptide not detected\nBeta-hydroxybutyrate  ≤ 2.7 mmol/L\nWhich of the following is most true of the cell type that is likely involved in the production of the molecule causing this patient’s symptoms?", "answer": "Gram-negative enteric bacillus; catalase-positive, oxidase-negative, turns pink on MacConkey agar", "options": {"A": "Contains M3 receptors that stimulate Gq in response to parasympathetic innervation", "B": "Gram-negative enteric bacillus; catalase-positive, oxidase-negative, turns pink on MacConkey agar", "C": "Located in the periphery of islets of Langerhans", "D": "Located in zona fasciculata of the adrenal cortex", "E": "Gram-negative enteric bacillus; urease-positive, oxidase-positive, can be identified by silver stain"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old woman", "found lying", "unresponsive", "hours", "significant medical history", "Two years", "woman", "years", "resulted", "out divorce", "separation", "moved back", "note", "room", "sleeps", "lot", "rarely eats", "obtundation", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "labs", "follows", "U/mL Morning cortisol", "8 g/dL Prolactin", "mIU", "LH 6", "Glucose", "C-peptide not detected Beta-hydroxybutyrate", "mmol/L", "following", "most true", "likely involved", "causing", "patients symptoms"]}
{"question": "A 46-year-old female is brought to the emergency department by her husband 1 hour after the onset of chest palpitations. Her symptoms began suddenly while she was drinking coffee and have persisted since then. She has not had shortness of breath, chest pain, dizziness, or loss of consciousness. She has experienced these palpitations before, but they typically resolve spontaneously within a few minutes. She has no history of serious illness and takes no medications. Her temperature is 36.8°C (98.2°F), pulse is 155/min, respirations are 18/min, and blood pressure is 130/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Physical examination shows no abnormalities other than tachycardia. An ECG is shown. Repeated, forceful exhalation against a closed glottis while supine fails to relieve her symptoms. Which of the following is the most appropriate next step in management?", "answer": "Administer adenosine intravenously", "options": {"A": "Administer adenosine intravenously", "B": "Administer verapamil intravenously", "C": "Electrical cardioversion", "D": "Administer digoxin intravenously", "E": "Administer diltiazem intravenously"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old female", "brought", "emergency department", "hour", "onset", "chest palpitations", "symptoms began", "drinking", "since then", "not", "shortness of breath", "chest pain", "dizziness", "loss of consciousness", "palpitations", "minutes", "history", "serious illness", "medications", "temperature", "36", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "97", "abnormalities", "tachycardia", "ECG", "Repeated", "exhalation", "closed glottis", "supine fails to relieve", "symptoms", "following", "most appropriate next step"]}
{"question": "A 15-year-old boy is brought to the office by his mother with complaints of facial puffiness and smoky urine. The mother noticed puffiness on her son’s face a week ago, and it has been progressively worsening since then. She also states that her son had a sore throat 3 weeks ago. The patient does not have fever/chills, changes in urinary frequency, or abdominal discomfort. On physical examination, facial edema is noted. The vital signs include: blood pressure 145/85 mm Hg, pulse 96/min, temperature 36.7°C (98.1°F), and respiratory rate 20/min.\nA complete blood count report shows:\nHemoglobin 10.1 g/dL\nRBC 4.9 million cells/µL\nHematocrit 46%\nTotal leukocyte count 6,800 cells/µL\nNeutrophils 70%\nLymphocytes 26%\nMonocytes 3%\nEosinophil 1%\nBasophils 0%\nPlatelets 210,000 cells/µL\nESR 18 mm (1st hour)\nUrinalysis shows:\npH 6.4\nColor dark brown\nRBC plenty\nWBC 3–4/HPF\nProtein absent\nCast RBC and granular casts\nGlucose absent\nCrystal none\nKetone absent\nNitrite absent\nWhich of the following laboratory findings can be expected in this patient?", "answer": "Positive streptozyme test", "options": {"A": "Normal erythrocyte sedimentation rate", "B": "Decreased serum creatinine", "C": "Positive streptozyme test", "D": "Increased C3 level", "E": "Negative antistreptolysin O (ASO) titer"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "office", "complaints", "facial puffiness", "smoky urine", "puffiness", "face", "week", "worsening since then", "states", "sore throat", "weeks", "patient", "not", "fever/chills", "changes", "urinary frequency", "abdominal discomfort", "facial edema", "noted", "vital signs include", "blood pressure", "85 mm Hg", "pulse 96 min", "temperature 36", "98", "respiratory rate 20 min", "complete blood count report", "Hemoglobin 10", "g/dL", "9", "cells/L Hematocrit", "Total leukocyte count", "Neutrophils", "Lymphocytes", "Monocytes", "Eosinophil", "Basophils 0", "Platelets", "ESR 18 mm", "1st hour", "Urinalysis", "pH", "4 Color dark brown RBC", "WBC", "HPF Protein absent Cast", "granular casts Glucose absent Crystal", "Ketone absent Nitrite absent", "following laboratory findings", "patient"]}
{"question": "A 32-year-old African American man presents to the office for a routine examination. He has no complaints at this time. Records show that his systolic blood pressure was in the 130–138 range and diastolic blood pressure in the 88–95 range despite counseling on lifestyle modification. He admits that he was not compliant with this advice. He takes no medications and works at home as a web designer. He does not drink alcohol but smokes marijuana on a weekly basis. Temperature is 37°C (98.6°F), blood pressure is 138/90 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 29.8 kg/m2. Physical examination is normal except for truncal obesity, with a waist circumference of 44 inches. Fasting laboratory results are as follows:\nBlood glucose 117 mg/dL\nTotal cholesterol 210 mg/dL\nLDL cholesterol  120 mg/dL\nHDL cholesterol  38 mg/dL\nTriglycerides  240 mg/dL\n Which of the following mechanisms contribute to this patient’s condition?", "answer": "Insulin receptor resistance", "options": {"A": "Granulomatous inflammation in medium-sized vessels", "B": "Autoimmune destruction of pancreatic beta cells", "C": "Insulin receptor resistance", "D": "LDL receptor gene mutation", "E": "Excessive cortisol secretion and activity"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "man presents", "office", "routine", "complaints", "time", "Records", "systolic blood pressure", "range", "diastolic blood pressure", "range", "counseling", "lifestyle modification", "not compliant", "medications", "at home", "web", "not", "alcohol", "smokes marijuana", "weekly basis", "Temperature", "98", "blood pressure", "90 mm Hg", "pulse", "76 min", "respirations", "min", "BMI", "29", "kg/m2", "normal", "truncal obesity", "waist circumference", "inches", "Fasting laboratory results", "follows", "Blood glucose", "mg", "Total cholesterol", "LDL", "HDL", "Triglycerides", "following mechanisms", "patients condition"]}
{"question": "A 45-year-old man is brought by his wife with a complaint of an ongoing progressive history of memory problems for 6 months. He is an accountant by profession. He has difficulty remembering things and events, which has affected his job. He began using a diary to aid with remembering his agenda. His wife also says that he has wet his pants multiple times in the past 2 months and he avoids going out. He has been smoking 1 pack of cigarettes daily for the past 20 years. His past medical history is unremarkable. The vital signs include: blood pressure of 134/76 mm Hg, a pulse of 70 per minute, and a temperature of 37.0°C (98.6°F). His mini-mental state examination (MMSE) result is 22/30. His extraocular movements are normal. The muscle tone and strength are normal in all 4 limbs. The sensory examination is unremarkable. He has an absent Romberg’s sign. He walks slowly, taking small steps, with feet wide apart as if his feet are stuck to the floor. The CT scan of the head is shown in the image. What is the most likely diagnosis of the patient?", "answer": "Normal-pressure hydrocephalus", "options": {"A": "Early-onset Alzheimer’s disease", "B": "Frontotemporal dementia", "C": "Normal-pressure hydrocephalus", "D": "Parkinson’s disease", "E": "Progressive supranuclear palsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "complaint", "progressive history", "memory problems", "months", "accountant", "difficulty", "affected", "began using", "to aid", "wet", "pants multiple times", "past 2 months", "out", "smoking 1 pack", "cigarettes daily", "past 20 years", "past medical history", "unremarkable", "vital signs include", "blood pressure", "76 mm Hg", "pulse", "70", "minute", "temperature", "98", "mini-mental state examination", "result", "30", "extraocular movements", "normal", "muscle tone", "strength", "normal", "limbs", "sensory", "unremarkable", "absent Rombergs sign", "walks slowly", "small steps", "feet wide", "feet", "stuck", "floor", "CT scan of", "head", "diagnosis", "patient"]}
{"question": "A 69-year-old man presents with granulomatosis with polyangiitis diagnosed about 8 months ago. He was treated appropriately and states that his symptoms are well controlled. He is presenting today for a general follow up visit. His temperature is 99.0°F (37.2°C), blood pressure is 184/104 mmHg, pulse is 88/min, respirations are 12/min, and oxygen saturation is 98% on room air. His physical examination is notable for the findings in Figures A and B. Which of the following would be found in this patient on serum laboratory studies?", "answer": "Hypokalemia and metabolic alkalosis", "options": {"A": "Hyperkalemia and metabolic acidosis", "B": "Hyperkalemia and metabolic alkalosis", "C": "Hypokalemia and metabolic acidosis", "D": "Hypokalemia and metabolic alkalosis", "E": "Hypokalemia and normal acid-base status"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old man presents", "granulomatosis", "polyangiitis diagnosed", "months", "treated", "states", "symptoms", "well controlled", "today", "general", "temperature", "99", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "findings", "following", "found", "patient", "serum laboratory studies"]}
{"question": "A 55-year-old man comes to the emergency department because of left-sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST-elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures?", "answer": "Left coronary artery → left circumflex artery", "options": {"A": "Left coronary artery → left circumflex artery", "B": "Right coronary artery → right marginal artery", "C": "Left coronary artery → posterior descending artery", "D": "Right coronary artery → posterior descending artery", "E": "Left coronary artery → left anterior descending artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "emergency department", "left-sided chest pain", "difficulty breathing", "past 30 minutes", "pulse", "88 min", "pale", "anxious", "Serum studies", "increased cardiac enzymes", "ECG", "ST-elevations", "leads I", "aVL", "V6", "percutaneous coronary intervention", "performed", "order to localize", "site of", "lesion", "catheter", "pass", "following structures"]}
{"question": "A 28-year-old woman, gravida 1, para 0, at 20 weeks' gestation comes to the physician for genetic counseling. Her brother and maternal uncle both have anemia that worsens after taking certain medications. Based on the pedigree shown, what is the probability that her son will be affected by the disease?", "answer": "25%", "options": {"A": "25%", "B": "0%", "C": "100%", "D": "12.5%", "E": "50%\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "20 weeks", "gestation", "physician", "genetic counseling", "anemia", "worsens", "certain", "Based", "probability", "affected", "disease"]}
{"question": "A 75-year-old woman with late-onset autoimmune diabetes mellitus, rheumatoid arthritis, coronary artery disease, and idiopathic pulmonary fibrosis presents to the ship medic with altered mental status. While on her current cruise to the Caribbean islands, she experienced nausea, vomiting, and diarrhea. She takes aspirin, simvastatin, low-dose prednisone, glargine, and aspart. She is allergic to amoxicillin and shellfish. She works as a greeter at a warehouse and smokes 5 packs/day. Her temperature is 100.5°F (38.1°C), blood pressure is 90/55 mmHg, pulse is 130/min, and respirations are 30/min. Her pupils are equal and reactive to light bilaterally. Her lungs are clear to auscultation bilaterally, but her breath has a fruity odor. She has an early systolic murmur best appreciated at the left upper sternal border. She has reproducible peri-umbilical tenderness. Which of the following will most likely be present in this patient?", "answer": "Respiratory alkalosis and anion-gap metabolic acidosis", "options": {"A": "Respiratory acidosis and contraction metabolic alkalosis", "B": "Respiratory alkalosis and non-contraction metabolic alkalosis", "C": "Respiratory alkalosis and anion-gap metabolic acidosis", "D": "Respiratory alkalosis and non anion-gap metabolic acidosis", "E": "Respiratory acidosis and anion-gap metabolic acidosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old woman", "late-onset autoimmune diabetes mellitus", "rheumatoid arthritis", "coronary artery disease", "idiopathic pulmonary fibrosis presents", "ship", "altered mental status", "current", "Caribbean islands", "nausea", "vomiting", "diarrhea", "aspirin", "simvastatin", "low-dose prednisone", "glargine", "aspart", "allergic", "amoxicillin", "warehouse", "packs/day", "temperature", "100", "blood pressure", "90", "mmHg", "pulse", "min", "respirations", "30/min", "pupils", "equal", "reactive to light", "lungs", "clear", "auscultation", "breath", "early systolic murmur best", "left upper sternal border", "reproducible peri umbilical tenderness", "following", "most likely", "present", "patient"]}
{"question": "A 31-year-old man is referred to a neurologist due to his gradually increasing eccentric behavior and involuntary movements, especially the movements of his arms and hands. He also has difficulty with his short-term memory. Past medical history is otherwise noncontributory. His father had similar symptoms before he died but those symptoms started at the age of 33. His blood pressure is 125/92 mm Hg, pulse is 90/min, respiratory rate 12/min, and temperature is 36.6°C (97.9°F). Physical exam reveals involuntary writhing movements of hands, slow eye movements, and sporadic rigidity. The physician explains that this is an inherited disorder where the symptoms occur progressively at an earlier age than the parent and often with increased severity in the future generations. Which of the following is the most likely diagnosis of this patient?", "answer": "Huntington's disease", "options": {"A": "Huntington's disease", "B": "Friedreich ataxia", "C": "Myotonic dystrophy", "D": "Wilson's disease", "E": "Neurofibromatosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old man", "referred", "neurologist", "increasing eccentric behavior", "involuntary movements", "movements", "arms", "hands", "difficulty", "Past medical history", "similar symptoms", "died", "symptoms started", "age", "blood pressure", "mm Hg", "pulse", "90 min", "respiratory rate", "min", "temperature", "36", "97 9F", "reveals involuntary writhing movements", "hands", "slow eye movements", "sporadic rigidity", "physician", "inherited disorder", "symptoms occur", "earlier age", "often", "increased severity", "following", "diagnosis", "patient"]}
{"question": "A 55-year-old man comes to the physician for evaluation prior to parathyroidectomy. A Tc99m-sestamibi scan shows two spots of increased uptake in the superior mediastinum. These spots represent structures that are most likely derived from which of the following embryological precursors?", "answer": "3rd branchial pouch", "options": {"A": "4th branchial pouch", "B": "3rd branchial pouch", "C": "2nd branchial arch", "D": "4th branchial arch", "E": "3rd branchial arch"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "prior to parathyroidectomy", "scan", "two spots", "increased uptake", "superior mediastinum", "spots", "structures", "most likely derived", "following embryological"]}
{"question": "A 45-year-old obese man presents to his primary care provider for an annual physical. The patient states that he has noticed increased sleepiness during the day at work over the past 6 months in addition to difficulty concentrating and worsening memory. He denies recent weight loss, and is not sure if he snores because he sleeps by himself. His past medical history is significant for hypertension and type II diabetes. Vital signs are T 98.6 F, HR 75 bpm, BP 140/90 mm Hg, RR 18/min. Physical exam reveals a 350 pound man. Jugular venous distension is difficult to evaluate due to excess tissue in the neck. There is no peripheral edema. Lung exam is normal. Routine CBC shows WBC count of 5000 cells/ml, platelet count of 350,000/mcL, hemoglobin of 18 gm/dL, and hematocrit of 54%. What is the most likely cause of his abnormal lab results?", "answer": "Sleep apnea", "options": {"A": "Cor pulmonale", "B": "Malignancy", "C": "Diuretic overuse", "D": "JAK2 mutation", "E": "Sleep apnea"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old obese man presents", "primary care provider", "annual physical", "patient states", "increased sleepiness", "day", "past 6 months", "difficulty concentrating", "worsening memory", "recent weight loss", "not sure", "snores", "sleeps", "past medical history", "significant", "hypertension", "type II diabetes", "Vital signs", "T 98", "F", "75", "BP", "90 mm Hg", "RR", "min", "reveals", "350 pound man", "Jugular venous distension", "difficult to", "due to excess tissue", "neck", "peripheral", "Lung exam", "normal", "Routine CBC", "WBC count", "5000 cells/ml", "platelet count", "350", "mcL", "hemoglobin", "gm dL", "hematocrit", "54", "most likely cause", "abnormal lab results"]}
{"question": "A new assay for Lyme disease has been developed. While the assay has been tested extensively in Maine, a group of inventors are planning to test it in Southern California. In comparison to the assay's performance in Maine, testing the assay in Southern California would affect the performance of the assay in which of the following ways?", "answer": "Greater likelihood that an individual with a negative test will truly not have Lyme disease\n\"", "options": {"A": "Decrease negative likelihood ratio of the Lyme disease assay", "B": "Lower likelihood that a patient without Lyme disease truly has a negative test", "C": "Greater likelihood that an individual with a positive test will truly have Lyme disease", "D": "Decreased positive likelihood ratio of the Lyme disease assay", "E": "Greater likelihood that an individual with a negative test will truly not have Lyme disease\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["new assay", "Lyme disease", "assay", "Maine", "inventors", "planning to test", "Southern California", "assay's", "Maine", "testing", "assay", "Southern California", "assay", "following"]}
{"question": "A 68-year-old male is brought to the emergency department by his wife. An hour earlier, he dropped to the floor and began to violently shake his extremities. He urinated on the carpet and seemed confused for several minutes after. He is now feeling better. He has never experienced an episode like this before, nor does he think anyone in his family has. He and his wife are concerned that he has unintentionally lost 22.6 kg (50 lb) in the past 6 months. He has also been experiencing chest pain and has coughed up blood on a few occasions. He has a 50-pack-year smoking history and quit 2 years ago. His temperature is 36.8°C (98.2°F), heart rate is 98/min, respiratory rate is 15/min, blood pressure is 100/75 mm Hg, and he is O2 saturation is 100% on room air. The physical exam, including a full neurologic and cardiac assessment, demonstrates no abnormal findings. Edema, ascites, and skin tenting are notably absent. A brain MRI does not indicate areas of infarction or metastatic lesions. ECG is normal. Urine toxicology screen is negative. EEG is pending. Laboratory findings are shown below:\nBUN 15 mg/dL N: 7 to 20 mg/dL\npCO2 40 mm Hg N: 35-45 mm Hg\nCreatinine 0.8 mg/dL N: 0.8 to 1.4 mg/dL\nGlucose 95 mg/dL N: 64 to 128 mg/dL\nSerum chloride 103 mmol/L N: 101 to 111 mmol/L\nSerum potassium 3.9 mEq/L N: 3.7 to 5.2 mEq/L\nSerum sodium 115 mEq/L N: 136 to 144 mEq/L\nTotal calcium 2.3 mmol/L N: 2-2.6 mmol/L\nMagnesium 1.7 mEq/L N: 1.5-2 mEq/L\nPhosphate 0.9 mmol/L N: 0.8-1.5 mmol/L\nHemoglobin 14 g/dL N: 13-17 g/dL (men), 12-15 g/dL (women)\nGlycosylated hemoglobin 5.5% N: 4%-6%\nTotal cholesterol 4 mmol/L N: 3-5.5 mmol/L\nBicarbonate (HCO3) 19 mmol/L N: 18-22 mmol/L\nWhat is indicated first?", "answer": "Hypertonic saline", "options": {"A": "Phenytoin", "B": "Valproic acid", "C": "Diazepam", "D": "Hypertonic saline", "E": "Chemotherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male", "brought", "emergency department", "hour earlier", "floor", "began to", "shake", "extremities", "carpet", "confused", "minutes", "now", "better", "never", "episode", "lost", "kg", "50", "past 6 months", "chest pain", "coughed up blood", "few occasions", "50", "smoking history", "years", "temperature", "36", "98", "heart rate", "98 min", "respiratory rate", "min", "blood pressure", "100 75 mm Hg", "O2 saturation", "100", "room air", "including", "full neurologic", "abnormal findings", "Edema", "ascites", "skin tenting", "absent", "brain MRI", "not", "areas", "infarction", "metastatic lesions", "ECG", "normal", "Urine toxicology", "negative", "EEG", "Laboratory findings", "mg/dL", "7", "20 mg/dL pCO2 40 mm Hg", "35", "mm Hg Creatinine 0.8 mg/dL", "8", "1", "dL", "95", "64", "mg dL Serum chloride", "mmol/L", "mmol", "Serum potassium", "mEq", "3", "2 mEq/L Serum sodium", "mEq", "mmol", "mmol/L Magnesium", "mEq", "mEq", "Phosphate", "mmol", "0 8-1 5 mmol L Hemoglobin", "g/dL N", "g/dL", "g/dL", "hemoglobin", "N", "4", "Total cholesterol 4 mmol/L", "3-5", "mmol/L Bicarbonate", "HCO3", "mmol/L", "18-22 mmol/L", "indicated first"]}
{"question": "One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show:\nHemoglobin 12.5 g/dL\nLeukocyte count 18,600/mm3\nPlatelet count 228,000/mm3\nErythrocyte sedimentation rate 120 mm/h\nSerum\nNa+ 134 mEq/L\nK+ 3.5 mEq/L\nCl- 98 mEq/L\nHCO3- 22 mEq/L\nGlucose 200 mg/dL\nUrea nitrogen 60 mg/dL\nCreatinine 3.2 mg/dL\nCreatine kinase 750 U/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Surgical debridement", "options": {"A": "X-ray of the abdomen and pelvis", "B": "Vacuum-assisted wound closure device", "C": "Surgical debridement", "D": "CT scan of abdomen", "E": "Intravenous clindamycin therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["One day", "open colectomy", "65-year-old man", "colon cancer", "shivers", "procedure", "scheduled to", "persistent bleeding", "conversion", "operation", "Five years", "renal transplantation", "cystic disease", "prednisolone", "then", "history", "allergy", "sulfonamides", "appears", "ill", "temperature", "pulse", "min", "respirations", "23 min", "blood pressure", "90 62 mm Hg", "Abdominal", "midline incision extending", "xiphisternum", "pubic symphysis", "5", "2", "area", "discoloration", "margin", "incision", "lower abdomen", "Palpation of", "abdomen", "severe pain", "crackling", "heard", "Laboratory studies", "Hemoglobin", "Platelet count", "Erythrocyte sedimentation rate", "Serum Na", "L", "Cl", "mg", "Urea nitrogen", "mg", "Creatinine", "2", "U", "following", "most appropriate next step"]}
{"question": "A 2-year-old boy is brought to the physician by his mother because of fever and left ear pain for the past 3 days. He has also been frequently rubbing his left ear since he woke up in the morning. He has a history of atopic dermatitis, and his mother is concerned that his symptoms may be caused by him itching at night. She says that he has not been having many flare-ups lately; the latest flare-up subsided in time for his second birthday party, which he celebrated at a swimming pool 1 week ago. Six months ago, he had an episode of urticaria following antibiotic treatment for pharyngitis. He takes no medications. His temperature is 38.5°C (101.3°F), pulse is 110/min, respirations are 25/min, and blood pressure is 90/50 mm Hg. Otoscopy shows an opaque, bulging tympanic membrane. Which of the following is the most appropriate next step in management?", "answer": "Oral azithromycin", "options": {"A": "Topical hydrocortisone and gentamicin eardrops", "B": "Oral azithromycin", "C": "Tympanostomy tube placement", "D": "Otic ofloxacin therapy", "E": "Tympanocentesis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "brought", "physician", "mother", "fever", "left ear pain", "past 3 days", "frequently rubbing", "left ear", "woke up", "morning", "history", "atopic dermatitis", "symptoms", "caused", "itching", "night", "not", "flare-ups", "latest flare-up", "time", "second", "swimming pool 1 week", "Six months", "episode of urticaria following antibiotic treatment", "pharyngitis", "medications", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "90 50 mm Hg", "Otoscopy", "opaque", "bulging tympanic membrane", "following", "most appropriate next step"]}
{"question": "A 75-year-old Caucasian man presents to the emergency department with abdominal pain. The patient states he was at home eating dinner when he began to experience severe abdominal pain. The patient has a past medical history of diabetes, hypertension, and atherosclerosis. He lives at home alone, smokes cigarettes, and drinks 1 to 2 alcoholic drinks per day. The patient is given IV morphine and an ultrasound is obtained demonstrating a dilated abdominal aorta. The patient states that his father died of a similar finding and is concerned about his prognosis. Which of the following is the greatest risk factor for this patient's presentation?", "answer": "Cigarette smoking", "options": {"A": "Atherosclerosis", "B": "Caucasian race", "C": "Cigarette smoking", "D": "Family history", "E": "Male gender and age"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old", "man presents", "emergency department", "abdominal pain", "patient states", "at home eating dinner", "began to", "severe abdominal", "patient", "past medical diabetes", "hypertension", "atherosclerosis", "lives at home alone", "smokes cigarettes", "1", "2 alcoholic drinks", "day", "patient", "given IV morphine", "ultrasound", "obtained", "dilated abdominal aorta", "patient states", "died", "similar finding", "prognosis", "following", "greatest risk factor", "patient's"]}
{"question": "A 74-year-old gentleman presents to his family practitioner with the complaint of an inability to open his left eye since this morning. He also complains of intermittent pain and numbness in his left arm that has been present for the last few days. He denies ocular pain, difficulty swallowing, fatigability, or diplopia. His symptoms remain constant without fluctuation. He has a history of diabetes mellitus type 2, hypertension, and hypercholesterolemia. Further history reveals that he has lost 5.4 kg (12 lb) of weight in the past 4 months. He is a chronic smoker with a 72 pack-year smoking history. His blood pressure is 142/76 mm Hg, the heart rate is 76/min, the respiratory rate is 12/min, the temperature is 36.8°C (98.4°F), and BMI is the 18.2 kg/m2. The patient is awake, alert, and oriented to person, place, and time. He has partial drooping of the left eyelid while the right eyelid appears normal. The left pupil is 1 mm and the right pupil is 3 mm in diameter. Extraocular muscle movements are normal. What additional clinical feature would most likely be present in this patient?", "answer": "Loss of hemifacial sweating", "options": {"A": "Facial asymmetry", "B": "Ipsilateral loss of touch sensations on the face", "C": "Loss of hemifacial sweating", "D": "Tongue deviation to the left side", "E": "Urinary retention"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old", "presents", "practitioner", "complaint", "to open", "left eye", "morning", "intermittent pain", "numbness", "left arm", "present", "days", "ocular pain", "difficulty swallowing", "fatigability", "diplopia", "symptoms", "constant", "fluctuation", "history of diabetes mellitus type 2", "hypertension", "hypercholesterolemia", "Further history reveals", "lost 5.4 kg", "weight", "past", "months", "chronic smoker", "72", "smoking history", "blood pressure", "76 mm Hg", "heart rate", "76 min", "respiratory rate", "min", "temperature", "36", "98", "BMI", "kg/m2", "patient", "awake", "alert", "oriented to person", "place", "time", "partial drooping", "left eyelid", "right eyelid appears normal", "left pupil", "1 mm", "right pupil", "3 mm", "diameter", "Extraocular", "normal", "additional clinical feature", "most likely", "present", "patient"]}
{"question": "A 65-year-old female patient with a past medical history of diabetes mellitus and an allergy to penicillin develops an infected abscess positive for MRSA on the third day of her hospital stay. She is started on an IV infusion of vancomycin at a dose of 1000 mg every 12 hours. Vancomycin is eliminated by first-order kinetics and has a half life of 6 hours. The volume of distribution of vancomycin is 0.5 L/kg. Assuming no loading dose is given, how long will it take for the drug to reach 94% of its plasma steady state concentration?", "answer": "24 hours", "options": {"A": "6 hours", "B": "12 hours", "C": "18 hours", "D": "24 hours", "E": "30 hours"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65-year-old female patient", "past medical history of diabetes mellitus", "allergy to penicillin", "infected abscess positive", "MRSA", "third day", "hospital", "started", "IV infusion of vancomycin", "dose", "mg", "12 hours", "Vancomycin", "eliminated", "first-order", "half", "hours", "volume of distribution", "vancomycin", "0.5 L kg", "loading dose", "given", "long", "drug to reach", "plasma", "concentration"]}
{"question": "A 27-year-old man presents to his primary care physician with concerns about poor sleep quality. The patient states that he often has trouble falling asleep and that it is negatively affecting his studies. He is nervous that he is going to fail out of graduate school. He states that he recently performed poorly at a lab meeting where he had to present his research. This has been a recurrent issue for the patient any time he has had to present in front of groups. Additionally, the patient is concerned that his girlfriend is going to leave him and feels the relationship is failing. The patient has a past medical history of irritable bowel syndrome for which he takes fiber supplements. His temperature is 98.9°F (37.2°C), blood pressure is 117/68 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is within normal limits. Which of the following is the best initial step in management?", "answer": "Cognitive behavioral therapy", "options": {"A": "Alprazolam during presentations", "B": "Cognitive behavioral therapy", "C": "Duloxetine", "D": "Fluoxetine", "E": "Propranolol during presentations"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old man presents", "primary care physician", "poor", "patient states", "often", "trouble falling asleep", "affecting", "studies", "nervous", "to fail out", "graduate school", "states", "recently performed poorly", "lab", "to present", "recurrent issue", "patient", "time", "to present", "front", "groups", "patient", "to", "relationship", "failing", "patient", "past medical history of irritable bowel syndrome", "fiber supplements", "temperature", "98 9F", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "normal limits", "following", "best initial step"]}
{"question": "A 56-year-old woman presents to the emergency department with a 1-hour history of persistent nasal bleeding. The bleeding started spontaneously. The patient experienced a similar episode last year. Currently, she has hypertension and takes hydrochlorothiazide and losartan. She is anxious. Her blood pressure is 175/88 mm Hg. During the examination, the patient holds a blood-stained gauze against her right nostril. Upon removal of the gauze, blood slowly drips down from her right nostril. Examination of the left nostril reveals no abnormalities. Squeezing the nostrils for 20 minutes fails to control bleeding. Which of the following interventions is the most appropriate next step in the management of this patient?", "answer": "Nasal oxymetazoline", "options": {"A": "Anterior nasal packing with topical antibiotics", "B": "Intravenous infusion of nitroglycerin", "C": "Nasal oxymetazoline", "D": "Oral captopril", "E": "Silver nitrate cauterization of the bleeding vessel"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "hour history", "persistent nasal bleeding", "bleeding started", "patient", "similar episode", "year", "Currently", "hypertension", "hydrochlorothiazide", "losartan", "anxious", "blood pressure", "88 mm Hg", "patient holds", "blood-stained gauze", "right nostril", "removal", "gauze", "blood slowly drips", "right nostril", "left", "reveals", "abnormalities", "Squeezing", "nostrils", "20 minutes fails to control bleeding", "following interventions", "most appropriate next step", "patient"]}
{"question": "A professional musician visits his physician after a morning concert. He complains of painless swelling in his right cheek when he plays his tuba. Physical examination of the patient reveals slight facial asymmetry due to minor swelling on the right side of the face. The skin over the swelling is smooth without any secondary changes. Palpation reveals a soft and non-tender swelling. The oral opening is normal without any trismus. Further examination reveals swelling of the left buccal mucosa extending from the first to the third molar. Bedside ultrasound shows small areas of high echogenicity consistent with pneumoparotid. Which nerve is associated with motor function to prevent air from entering the affected duct in this patient?", "answer": "CN VII – Buccal branch", "options": {"A": "V2 – Maxillary nerve", "B": "V3 – Mandibular nerve", "C": "CN VII – Zygomatic branch", "D": "CN VII – Buccal branch", "E": "CN VII – Marginal mandibular branch"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["musician", "physician", "morning", "painless swelling", "right cheek", "plays", "tuba", "Physical examination", "patient reveals slight facial due to minor swelling", "right side of", "face", "skin", "swelling", "smooth", "secondary changes", "Palpation reveals", "soft", "non-tender swelling", "oral opening", "normal", "trismus", "Further", "reveals swelling of", "left buccal mucosa extending", "first", "third", "ultrasound", "small areas", "high echogenicity", "pneumoparotid", "nerve", "associated with", "to prevent air", "entering", "affected duct", "patient"]}
{"question": "A 67-year-old man comes to the emergency department for evaluation of progressively worsening edema and decreased urine output over the past few days. He has a history of chronic sinus infections and was hospitalized last year for a suspected pneumonia with hemoptysis. Physical exam shows bilateral pitting edema of the lower extremities. Serum studies show a creatinine of 3.4 mg/dL and blood urea nitrogen of 35 mg/dL. Urine dipstick shows 3+ blood. A kidney biopsy is performed and light microscopy shows crescent-shaped glomeruli. Immunofluorescent microscopy of the tissue sample is most likely to show which of the following findings?", "answer": "No deposits", "options": {"A": "Subendothelial deposits", "B": "Intramembranous deposits", "C": "Mesangial deposits", "D": "Subepithelial deposits", "E": "No deposits"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["67 year old man", "emergency department", "worsening edema", "decreased urine output", "past", "days", "history of chronic sinus infections", "hospitalized last year", "suspected pneumonia", "hemoptysis", "bilateral pitting edema of", "lower extremities", "Serum studies", "creatinine", "mg/dL", "blood urea nitrogen", "mg/dL", "Urine dipstick", "3", "blood", "kidney biopsy", "performed", "light microscopy", "crescent shaped glomeruli", "microscopy", "tissue", "to", "following findings"]}
{"question": "A 51-year-old man alcoholic presents to the emergency department with persistent vomiting. He was found vomiting forcefully next to an empty bottle of vodka. His medical history is significant for Lyme disease, currently being treated with doxycycline. After a prolonged episode of retching, the patient begins choking and coughing forcefully in between bouts of chest pain in the ER. At this point, the patient is unable to communicate. The patient appears toxic. His temperature is 37°C (98.6°F), respiratory rate is 15/min, pulse is 107/min, and blood pressure is 90/68 mm Hg. A quick physical exam reveals fullness at the base of the neck and a crunching, rasping sound on auscultation of the chest. The attending physician orders an upright chest X-ray, showing free mediastinal air. What is the most likely diagnosis?", "answer": "Boerhaave syndrome", "options": {"A": "Esophageal candidiasis", "B": "Dieulafoy's lesion", "C": "Pill esophagitis", "D": "Boerhaave syndrome", "E": "Mallory Weiss tear"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man alcoholic presents", "emergency department", "persistent vomiting", "found vomiting", "next to", "empty bottle", "medical history", "significant", "Lyme disease", "currently", "treated with doxycycline", "prolonged episode of retching", "patient begins choking", "coughing", "bouts of chest pain", "ER", "point", "patient", "unable", "communicate", "patient appears toxic", "temperature", "98", "respiratory rate", "min", "pulse", "min", "blood pressure", "90", "mm Hg", "quick", "reveals fullness", "base of", "neck", "rasping sound", "auscultation", "chest", "attending physician orders", "upright chest X-ray", "free mediastinal air", "diagnosis"]}
{"question": "An 85-year-old woman presents to her physician with complaints of significant weakness and weight loss. She recently has been diagnosed with stage IV breast cancer for which she currently is receiving treatment. She mentions that, despite taking a diet rich in protein and calories, she continues to lose weight. On physical examination, her vital signs are stable, but muscle wasting is clearly evident in her upper limbs, lower limbs, and face. The physician explains to her that her advanced cancer is the most important cause for the weight loss and muscle wasting. This cachexia is mediated by the proteolysis-inducing factor released from cancer cells. Which of the following effects is produced by this factor?", "answer": "Activation of NF-κB", "options": {"A": "Activation of hormone-sensitive lipase in adipose tissue", "B": "Increased release of tumor necrosis factor (TNF) from macrophages", "C": "Stimulation of apoptosis", "D": "Activation of NF-κB", "E": "Suppression of the appetite center in the hypothalamus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["85 year old woman presents", "physician", "complaints", "significant weakness", "weight loss", "recently", "diagnosed", "stage IV breast cancer", "currently", "receiving treatment", "diet rich", "protein", "calories", "to", "weight", "vital signs", "stable", "muscle wasting", "upper limbs", "lower limbs", "face", "physician", "advanced cancer", "most important cause", "weight loss", "muscle wasting", "cachexia", "mediated", "proteolysis-inducing factor released", "following effects", "factor"]}
{"question": "A 74-year-old man is brought to the emergency department because of lower abdominal pain for 3 hours. The pain is sharp, constant, and does not radiate. He has not urinated for 24 hours and he has not passed stool for over 3 days. He was diagnosed with herpes zoster 3 weeks ago and has been taking amitriptyline for post-herpetic neuralgia for 1 week. Last year he was diagnosed with nephrolithiasis and was treated with lithotripsy. He has a history of hypertension, benign prostatic hyperplasia, and coronary artery disease. His other medications include amlodipine, metoprolol, tamsulosin, aspirin, and simvastatin. He appears uncomfortable. His temperature is 37.3°C (99.1°F), pulse is 102/min, and blood pressure is 140/90 mm Hg. Abdominal examination shows a palpable lower midline abdominal mass that is tender to palpation. Bowel sounds are hypoactive. The remainder of the examination shows no abnormalities. A pelvic ultrasound shows an anechoic mass in the lower abdomen. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Transurethral catheterization", "options": {"A": "CT scan of the abdomen and pelvis", "B": "Observation and NSAIDs administration", "C": "Transurethral catheterization", "D": "Finasteride administration", "E": "IV pyelography"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old man", "brought", "emergency department", "of lower abdominal pain", "hours", "pain", "sharp", "constant", "not radiate", "not", "24 hours", "not passed stool", "3 days", "diagnosed", "herpes zoster", "weeks", "amitriptyline", "post-herpetic neuralgia", "1 week", "year", "diagnosed", "nephrolithiasis", "treated with lithotripsy", "history of hypertension", "benign prostatic hyperplasia", "coronary artery disease", "medications include amlodipine", "metoprolol", "tamsulosin", "aspirin", "simvastatin", "appears", "temperature", "99", "pulse", "min", "blood pressure", "90 mm Hg", "Abdominal", "palpable lower midline abdominal mass", "tender", "palpation", "Bowel sounds", "hypoactive", "abnormalities", "pelvic ultrasound", "mass", "lower abdomen", "following", "most appropriate next step", "patient"]}
{"question": "A 57-year-old man presents with a large wound on his right lower leg that has been present for 6 months as shown in the picture. He has had chronically swollen legs for over 10 years. His mother and brother had similar problems with their legs. He had a documented deep vein thrombosis (DVT) in the affected leg 5 years earlier, but has no other past medical history. He has a blood pressure of 126/84 and heart rate of 62/min. Which of the following is the most likely diagnosis?", "answer": "Chronic venous insufficiency", "options": {"A": "Arterial ulcer", "B": "Marjolin ulcer", "C": "Chronic venous insufficiency", "D": "Lymphedema", "E": "Kaposi sarcoma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["57 year old man presents", "large wound", "right lower leg", "present", "months", "picture", "swollen legs", "similar", "legs", "deep vein thrombosis", "affected leg", "years earlier", "past medical history", "blood pressure", "84", "heart rate", "62 min", "following", "diagnosis"]}
{"question": "A 15-year-old girl is brought into the clinic for a second opinion by her mother. She was recently diagnosed with alopecia areata after having presented to her family doctor with a 2-month history of noticeable bald patches. The mother was concerned because the treatment involved topical steroids. The patient is noted to have started high school earlier this year and has an attention-deficit/ hyperactivity disorder that is treated with methylphenidate. The patient is afebrile and her vital signs are within normal limits. Physical examination reveals a moderately distressed young female playing with her hair. She has very short nails on both hands and patches of hair loss on the scalp. Which of the following is the most appropriate initial management for this patient’s condition?", "answer": "Behavioral therapy", "options": {"A": "Behavioral therapy", "B": "Selective serotonin reuptake inhibitors", "C": "Antipsychotics", "D": "Lithium", "E": "Psychodynamic therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "clinic", "recently diagnosed", "alopecia areata", "family doctor", "2 month history", "bald patches", "treatment involved topical steroids", "patient", "noted to", "started high school earlier", "year", "attention-deficit", "hyperactivity disorder", "treated with methylphenidate", "patient", "afebrile", "vital signs", "normal", "Physical examination reveals", "moderately", "young female playing", "hair", "very", "hands", "patches of hair loss", "scalp", "following", "most appropriate initial management", "patients condition"]}
{"question": "Seven hours after undergoing left hip arthroplasty for chronic hip pain, a 67-year-old woman reports a prickling sensation in her left anteromedial thigh and lower leg. Neurologic examination shows left leg strength 3/5 on hip flexion and 2/5 on knee extension. Patellar reflex is decreased on the left. Sensation to pinprick and light touch are decreased on the anteromedial left thigh as well as medial lower leg. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Femoral nerve injury", "options": {"A": "Sural nerve injury", "B": "Femoral nerve injury", "C": "Fibular nerve injury", "D": "S1 radiculopathy", "E": "L5 radiculopathy\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Seven hours", "left", "chronic hip pain", "67 year old woman reports", "prickling sensation", "left anteromedial thigh", "lower leg", "Neurologic examination", "left leg strength", "hip flexion", "2/5", "knee extension", "Patellar", "decreased", "left", "Sensation", "pinprick", "light touch", "decreased", "anteromedial left thigh", "medial lower leg", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 61-year-old man comes to the physician because of a 3-month history of worsening exertional dyspnea and a persistent dry cough. For 37 years he has worked in a naval shipyard. He has smoked 1 pack of cigarettes daily for the past 40 years. Pulmonary examination shows fine bibasilar end-expiratory crackles. An x-ray of the chest shows diffuse bilateral infiltrates predominantly in the lower lobes and pleural reticulonodular opacities. A CT scan of the chest shows pleural plaques and subpleural linear opacities. The patient is most likely to develop which of the following conditions?", "answer": "Bronchogenic carcinoma", "options": {"A": "Bronchogenic carcinoma", "B": "Aspergilloma", "C": "Mycobacterial Infection", "D": "Malignant mesothelioma", "E": "Spontaneous pneumothorax"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["61 year old man", "physician", "3 month history", "worsening exertional dyspnea", "persistent dry cough", "years", "smoked 1 pack", "cigarettes daily", "past 40 years", "Pulmonary", "fine", "end-expiratory crackles", "x-ray of", "chest", "diffuse bilateral infiltrates", "lower lobes", "pleural", "opacities", "CT scan of", "chest", "pleural plaques", "linear opacities", "patient", "to", "following conditions"]}
{"question": "A previously healthy 28-year-old woman comes to the physician because of lower abdominal pain and purulent vaginal discharge for the past 5 days. Menses occur at irregular 20 to 40-day intervals and last 4 to 8 days. She is sexually active with a new partner that she met 2 months ago and they use condoms inconsistently. She had a normal pap smear 5 months ago. She drinks 2 beers every other day. Her temperature is 39°C (102.2°F), pulse is 85/min, and blood pressure is 108/75 mm Hg. Examination shows lower abdominal tenderness and bilateral inguinal lymphadenopathy. Pelvic examination is notable for uterine and adnexal tenderness as well as small amounts of bloody cervical discharge. A spot urine pregnancy test is negative. Laboratory studies show a leukocyte count of 14,500/mm3 and an erythrocyte sedimentation rate of 90 mm/h. Nucleic acid amplification confirms the suspected diagnosis. The patient is started on ceftriaxone and doxycycline. Which of the following is the most appropriate next step in management?", "answer": "HIV test", "options": {"A": "CT scan of the abdomen", "B": "Tzanck smear", "C": "Colposcopy", "D": "Pap smear", "E": "HIV test"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy", "year old woman", "physician", "lower abdominal pain", "purulent vaginal discharge", "past 5 days", "Menses occur", "irregular 20", "40 day intervals", "last 4", "days", "sexually active", "new", "met 2 months", "use condoms", "normal pap smear", "months", "2", "day", "temperature", "pulse", "85 min", "blood pressure", "75 mm Hg", "lower abdominal tenderness", "bilateral inguinal lymphadenopathy", "Pelvic examination", "notable", "uterine", "adnexal tenderness", "small amounts", "bloody cervical discharge", "spot urine pregnancy test", "negative", "Laboratory studies", "leukocyte count", "14 500 mm3", "erythrocyte sedimentation rate", "90 mm/h", "Nucleic acid amplification confirms", "suspected diagnosis", "patient", "started", "ceftriaxone", "doxycycline", "following", "most appropriate next step"]}
{"question": "Scientists are developing a new non-steroidal anti-inflammatory drug for osteoarthritis. Their hope is that the new drug will have a higher potency but the same efficacy as ibuprofen in the hope of minimizing gastrointestinal side effects. If ibuprofen is curve C in the figure provided, which of the following would be the curve for the new drug based on the scientists’ specifications? The desired therapeutic effect in patients is represented by the dashed line Y.", "answer": "Curve A", "options": {"A": "Curve A", "B": "Curve B", "C": "Curve C", "D": "Curve D", "E": "Curve E"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Scientists", "new non-steroidal anti-inflammatory drug", "osteoarthritis", "new drug", "higher potency", "same efficacy", "ibuprofen", "gastrointestinal side effects", "ibuprofen", "curve", "following", "curve", "new drug based", "scientists", "therapeutic effect", "patients", "line"]}
{"question": "A 48-year-old man presents to the emergency department with shortness of breath. He reports that 6 months ago he was able to walk several miles without stopping. Yesterday, he became short of breath walking from his bed to the bathroom. He also endorses worsening abdominal distension and leg swelling, which he reports is new from several months ago. The patient has a past medical history of hypertension and hyperlipidemia. On physical exam, the patient has moderate abdominal distension and pitting edema to the knee. Crackles are present at the bilateral bases. Laboratory testing reveals the following:\n\nHemoglobin: 13.4 g/dL\nMean corpuscular volume (MCV): 102 um^3\nLeukocyte count: 11,200 /mm^3 with normal differential\nPlatelet count: 256,000/mm^3\n\nSerum:\nNa+: 137 mEq/L\nCl-: 100 mEq/L\nK+: 4.2 mEq/L\nHCO3-: 25 mEq/L\nBUN: 18 mg/dL\nGlucose: 126 mg/dL\nCreatinine: 0.9 mg/dL\nAlkaline phosphatase: 88 U/L\nAspartate aminotransferase (AST): 212 U/L\nAlanine aminotransferase (ALT): 104 U/L\n\nWhich of the following is the best next step in management?", "answer": "Alcohol cessation", "options": {"A": "Alcohol cessation", "B": "Antiviral therapy", "C": "Hormone replacement", "D": "Immunosuppressive therapy", "E": "Vitamin repletion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["48 year old man presents", "emergency department", "shortness of breath", "reports", "months", "able to", "several miles", "stopping", "short of breath", "bed", "bathroom", "worsening abdominal distension", "leg swelling", "reports", "new", "months", "patient", "past medical", "hyperlipidemia", "patient", "moderate abdominal distension", "pitting", "knee", "Crackles", "present", "bilateral bases", "Laboratory testing reveals", "following", "Hemoglobin", "13.4 g/dL Mean corpuscular volume", "Leukocyte count", "200", "mm", "normal differential Platelet count", "mm", "Serum", "Na", "137 mEq L", "100 mEq/L K", "4.2 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "0.9 mg/dL Alkaline phosphatase", "88 U/L Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "U/L", "following", "best next step"]}
{"question": "A 28-year-old patient comes to the physician’s office with complaints of headaches and difficulty seeing out of the corner of her eye. She gave birth to her son 1 year ago. Further visual testing reveals the patient has bitemporal hemianopsia. The patient undergoes brain MRI which shows an anterior pituitary mass, likely adenoma. The patient has her blood tested to see if the adenoma is secreting extra hormone. The patient is found to have a slight excess of a hormone that uptakes a basophilic stain. Which of the following is most likely to be the hormone detected in her blood?", "answer": "Thyroid stimulating hormone", "options": {"A": "Prolactin", "B": "Oxytocin", "C": "Growth hormone", "D": "Antidiuretic hormone", "E": "Thyroid stimulating hormone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old patient", "physicians office", "complaints", "headaches", "difficulty out", "corner", "eye", "gave birth", "year", "Further visual testing reveals", "patient", "bitemporal hemianopsia", "patient", "brain MRI", "anterior", "likely adenoma", "patient", "blood", "to see", "adenoma", "secreting extra hormone", "patient", "found to", "slight excess", "hormone", "uptakes", "basophilic", "following", "to", "hormone detected", "blood"]}
{"question": "Several weeks following a kidney transplantation, a 50-year-old Caucasian female presents for evaluation of the transplanted organ. Biopsy shows inflammation involving the endothelial cells of the kidney vasculature and the presence of mononuclear cells in the interstitium. Which cells are most likely responsible for this presentation?", "answer": "Recipient T-cells", "options": {"A": "Donor T-cells", "B": "Recipient T-cells", "C": "Preformed recipient antibodies", "D": "Donor antibodies", "E": "Deposition of antibody immune complexes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Several weeks following", "kidney transplantation", "50 year old", "female presents", "transplanted organ", "Biopsy", "inflammation involving", "endothelial", "kidney vasculature", "presence of mononuclear cells", "interstitium", "cells", "responsible"]}
{"question": "A 64-year-old woman comes to the physician for her routine health maintenance examination. She feels well. She had cervical cancer and received radiotherapy 8 years ago. Her vital signs are within normal limits. On percussion, the spleen size is 15 cm. Otherwise, the physical examination shows no abnormalities. The laboratory test results are as follows:\nHemoglobin 10 g/dL\nMean corpuscular volume 88 μm3\nLeukocyte count 65,000/mm3\nPlatelet count 500,000/mm3\nTwo images of the peripheral blood smear are shown on the image. Which of the following is the most appropriate next step in management?", "answer": "Dasatinib", "options": {"A": "Allogeneic stem cell transplantation", "B": "Dasatinib", "C": "Phlebotomy", "D": "Rituximab", "E": "Watchful waiting"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["64 year old woman", "physician", "routine", "well", "cervical cancer", "received radiotherapy", "years", "vital signs", "normal limits", "percussion", "spleen size", "abnormalities", "laboratory test results", "follows", "Hemoglobin", "g", "Mean corpuscular volume 88 m3 Leukocyte count 65", "mm3 Platelet count", "Two", "peripheral blood smear", "following", "most appropriate next step"]}
{"question": "A 17-year-old boy is brought to the emergency department after being stabbed with a knife during an altercation. Physical examination shows a 4-cm stab wound on the right lateral border of the T1 spinous process. An MRI of the spinal cord shows damage to the area of the right lateral corticospinal tract at the level of T1. Further evaluation will most likely show which of the following findings?", "answer": "Absence of right-sided motor function below T1", "options": {"A": "Absence of left-sided proprioception below T1", "B": "Absence of right-sided temperature sensation below T1", "C": "Presence of left-sided Babinski sign", "D": "Absence of left-sided fine touch sensation below T1", "E": "Absence of right-sided motor function below T1"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "emergency department", "stabbed", "knife", "4 cm stab wound", "right lateral border", "T1 spinous process", "MRI of", "spinal cord", "damage to the area", "right lateral corticospinal tract", "level", "T1", "Further", "most likely", "following findings"]}
{"question": "A 24-year-old man with type 1 diabetes mellitus is brought to the emergency department because of weakness, abdominal pain, nausea, and one episode of vomiting for 1 day. He has not taken his insulin for 3 days. His pulse is 125/min and respirations are 29/min. Examination shows dry mucous membranes. His breath has a fruity odor. Which of the following sets of laboratory values is most likely on evaluation of urine obtained before treatment?\n $$$ pH %%% HCO3- %%% NH4+ %%% K+ $$$", "answer": "↓ ↓ ↑ ↑", "options": {"A": "↓ ↓ ↑ ↑", "B": "↓ normal ↓ ↓", "C": "↓ ↑ normal ↑", "D": "↑ ↑ normal ↑", "E": "↓ ↓ ↑ ↓"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "type 1 diabetes mellitus", "brought", "emergency department", "weakness", "abdominal pain", "nausea", "one episode of vomiting", "1 day", "not", "insulin", "3 days", "pulse", "min", "respirations", "29 min", "dry mucous membranes", "breath", "following sets", "laboratory values", "urine obtained", "treatment", "pH", "HCO3"]}
{"question": "A group of researchers is looking to study the effect of body weight on blood pressure in the elderly. Previous work measuring body weight and blood pressure at 2-time points in a large group of healthy individuals revealed that a 10% increase in body weight was accompanied by a 7 mm Hg increase in blood pressure. If the researchers want to determine if there is a linear relationship between body weight and blood pressure in a subgroup of elderly individuals in this study, which of the following statistical methods would best be employed to answer this question?", "answer": "Pearson’s correlation", "options": {"A": "One-way analysis of variance (ANOVA)", "B": "Two-way analysis of variance (ANOVA)", "C": "Pearson’s correlation", "D": "Spearman’s correlation", "E": "Wilcoxon signed-rank test"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["researchers", "looking to study", "effect", "body weight", "blood pressure", "Previous", "measuring body weight", "blood pressure", "time points in", "group", "revealed", "a 10", "increase", "body weight", "mm Hg increase", "blood pressure", "researchers", "to", "linear relationship", "body weight", "blood pressure", "study", "following", "best", "employed to"]}
{"question": "A 80-year-old man is brought to the emergency department with complaints that he \"can’t control his left leg”. His symptoms started a few hours ago. He was outside taking a walk with his wife when suddenly his leg shot out and kicked her. His past medical history is notable for diabetes, hypertension, and a myocardial infarction 5 years ago. He smokes 1-2 cigarettes/day. He does not use alcohol or illicit drugs. On exam, the patient has intermittent wide, flinging movements that affect his proximal left arm. Which of the following parts of his brain is most likely damaged?", "answer": "Right subthalamic nucleus", "options": {"A": "Left internal capsule", "B": "Right internal capsule", "C": "Left subthalamic nucleus", "D": "Right subthalamic nucleus", "E": "Ventral posterior thalamic nucleus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["80 year old man", "brought", "emergency department", "complaints", "cant control", "left leg", "symptoms started", "few hours", "outside", "leg shot out", "past medical history", "notable", "diabetes", "hypertension", "myocardial infarction", "years", "smokes 1-2 cigarettes day", "not use alcohol", "illicit drugs", "exam", "patient", "intermittent wide", "movements", "proximal left arm", "of", "following parts", "brain", "most likely damaged"]}
{"question": "A 23-year-old college student presents with his parents for a follow-up appointment. He was recently diagnosed with schizophrenia and was started on risperidone approx. 2 months ago. He reports a significant improvement since the start of treatment. His parents report that their son’s symptoms of delusions, hallucinations, and paranoid behavior have been ameliorated. On physical examination, the patient seems uncomfortable. He frequently fidgets and repeatedly crosses and uncrosses his legs. When asked if something is troubling him, he gets up and starts pacing. He says, “It’s always like this. I cannot sit still. It is frustrating.” What is the most likely diagnosis?", "answer": "Akathisia", "options": {"A": "Ataxia", "B": "Akathisia", "C": "Generalized anxiety disorder", "D": "Restless legs syndrome", "E": "Tardive dyskinesia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old", "presents", "follow-up appointment", "recently diagnosed", "schizophrenia", "started", "risperidone", "months", "reports", "significant", "start", "treatment", "report", "symptoms", "delusions", "hallucinations", "patient", "frequently fidgets", "repeatedly", "legs", "gets", "starts", "always", "I", "sit", "diagnosis"]}
{"question": "A 53-year-old woman with type 2 diabetes mellitus is admitted for evaluation of recurrent episodes of nausea, tremors, and excessive sweating. She works as a nurse and reports self-measured blood glucose levels below 50 mg/dL on several occasions. Her family history is positive for borderline personality disorder. The only medication listed in her history is metformin. Which of the following is the most appropriate next step in management?", "answer": "Ask the patient if she is taking any medications other than metformin", "options": {"A": "Report the patient to her employer", "B": "Ask the patient if she is taking any medications other than metformin", "C": "Search the patient's belongings for insulin", "D": "Measure glycated hemoglobin concentration", "E": "Measure serum C-peptide concentration"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "type 2 diabetes mellitus", "of recurrent episodes", "nausea", "tremors", "excessive sweating", "nurse", "reports", "measured blood glucose levels", "50 mg/dL", "several occasions", "family history", "positive", "borderline personality disorder", "only medication", "history", "metformin", "following", "most appropriate next step"]}
{"question": "A 25-year old Caucasian female presents with symptoms of Graves' disease. Her doctor prescribes medications and sends the patient home. After two months of therapy, the patient returns upset that her exophthalmos has not gone away. Which of the following drugs should the physician have prescribed to treat the exophthalmos?", "answer": "Corticosteroids", "options": {"A": "Propanolol", "B": "Metropolol", "C": "PTU", "D": "Corticosteroids", "E": "No treatment as this will resolve naturally"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "female presents", "symptoms", "Graves", "disease", "doctor", "medications", "sends", "patient home", "two months", "therapy", "patient returns", "exophthalmos", "not", "following drugs", "physician", "to treat", "exophthalmos"]}
{"question": "A 42-year-old woman is brought to the emergency department because of intermittent sharp right upper quadrant abdominal pain and nausea for the past 10 hours. She vomited three times. There is no associated fever, chills, diarrhea, or urinary symptoms. She has two children who both attend high school. She appears uncomfortable. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2. Her temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 140/90 mm Hg. She has mild scleral icterus. The abdomen is soft and nondistended, with tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. Laboratory studies show:\nHemoglobin count 14 g/dL\nLeukocyte count 9,000 mm3\nPlatelet count 160,000 mm3\nSerum\nAlkaline phosphatase 238 U/L\nAspartate aminotransferase 60 U/L\nBilirubin\nTotal 2.8 mg/dL\nDirect 2.1 mg/dL\nWhich of the following is the most appropriate next step in diagnosis?\"", "answer": "Transabdominal ultrasonography", "options": {"A": "CT scan of the abdomen", "B": "Transabdominal ultrasonography", "C": "Endoscopic retrograde cholangiopancreatography", "D": "HIDA scan of the biliary tract", "E": "Upper gastrointestinal series"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "intermittent sharp right upper quadrant abdominal pain", "nausea", "past 10 hours", "vomited three times", "associated fever", "chills", "diarrhea", "urinary symptoms", "two children", "attend high school", "appears", "5 ft 5", "tall", "kg", "BMI", "kg/m2", "temperature", "98", "pulse", "100 min", "blood pressure", "90 mm Hg", "mild scleral icterus", "abdomen", "soft", "tenderness", "palpation", "right upper quadrant", "guarding", "Bowel sounds", "normal", "Laboratory studies", "Hemoglobin count", "g dL Leukocyte", "mm3 Platelet count", "Alkaline phosphatase", "Aspartate aminotransferase 60", "Total 2", "dL Direct 2.1 mg/dL", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 12-month-old girl is brought to her pediatrician for a checkup and vaccines. The patient’s mother wants to send her to daycare but is worried about exposure to unvaccinated children and other potential sources of infection. The toddler was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines. She does not walk yet but stands in place and can say a few words. The toddler drinks formula and eats a mixture of soft vegetables and pureed meals. She has no current medications. On physical exam, the vital signs include: temperature 37.0°C (98.6°F), blood pressure 95/50 mm Hg, pulse 130/min, and respiratory rate 28/min. The patient is alert and responsive. The remainder of the exam is unremarkable. Which of the following is most appropriate for this patient at this visit?", "answer": "MMR vaccine", "options": {"A": "Referral for speech pathology", "B": "MMR vaccine", "C": "Rotavirus vaccine", "D": "Meningococcal vaccine", "E": "Gross motor workup and evaluation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old girl", "brought", "pediatrician", "checkup", "vaccines", "patients", "to send", "to daycare", "worried", "exposure", "children", "potential sources of infection", "toddler", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "not", "stands", "place", "few", "toddler", "formula", "eats", "soft", "meals", "current medications", "vital signs include", "temperature", "98", "blood pressure 95 50 mm Hg", "pulse", "min", "respiratory rate", "min", "patient", "alert", "responsive", "exam", "unremarkable", "following", "most appropriate", "patient"]}
{"question": "A 72-year-old patient is referred to an ophthalmologist because he has noticed some mild discomfort in his eyes though his vision remains unchanged. He cannot recall when this feeling started. His past medical history is significant for diabetes mellitus and two myocardial infarctions that have led to significant cardiac dysfunction. Specifically, he has dyspnea and peripheral edema and occasionally decompensates into more severe pulmonary edema requiring hospitalization. Testing reveals increased intra-ocular pressure so the ophthalmologist prescribes several medications. The medication for this disorder that is most likely to be contraindicated in this patient has which of the following characteristics?", "answer": "It decreases intracellular cyclic AMP levels", "options": {"A": "It alters bicarbonate metabolism", "B": "It decreases intracellular cyclic AMP levels", "C": "It increases intracellular calcium levels", "D": "It increases adenylyl cyclase activity", "E": "It is produced by cyclooxygenase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old patient", "referred", "ophthalmologist", "mild discomfort", "eyes", "vision", "unchanged", "started", "past medical history", "significant", "diabetes mellitus", "two myocardial infarctions", "led", "significant cardiac dysfunction", "dyspnea", "peripheral edema", "occasionally decompensates", "severe pulmonary", "Testing reveals increased intra-ocular pressure", "ophthalmologist", "several medications", "medication", "disorder", "to", "contraindicated", "patient", "following characteristics"]}
{"question": "A baby is born after the 32nd gestational week by cesarean delivery. The mother suffered from gestational diabetes; however, she had no other pregnancy-related diseases and was otherwise healthy. The baby has a blood pressure of 100/58 mm Hg, heart rate of 104/min, and oxygen saturation of 88%. The child has tachypnea, subcostal and intercostal retractions, nasal flaring, and cyanosis. The cyanosis is responding well to initial administration of oxygen. The nasogastric tube was positioned without problems. Which of the following is the most likely diagnosis?", "answer": "Neonatal respiratory distress syndrome (NRDS)", "options": {"A": "Neonatal respiratory distress syndrome (NRDS)", "B": "Sepsis", "C": "Tracheoesophageal fistula", "D": "Pneumonia", "E": "Congenital heart anomaly with right-to-left shunt"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["baby", "born", "gestational week", "cesarean delivery", "suffered", "gestational diabetes", "pregnancy diseases", "healthy", "baby", "blood pressure", "100 58 mm Hg", "heart rate", "min", "oxygen saturation", "88", "child", "tachypnea", "subcostal", "intercostal retractions", "nasal flaring", "cyanosis", "cyanosis", "well", "initial administration", "oxygen", "nasogastric tube", "positioned", "problems", "following", "diagnosis"]}
{"question": "Eight days after sigmoid resection for acute diverticulitis, a 61-year-old man has left-sided flank pain. He has been on bowel rest since admission. Other than multiple admissions for alcohol withdrawal, he has no history of serious illness. Current medications include intravenous cefepime and morphine. His temperature is 36.9°C (98.4°F), pulse is 89/min, and blood pressure is 118/75 mm Hg. Abdominal exam shows a well-healing incision with minimal serous drainage. Examination of the skin shows scattered spider angiomas, a large hematoma on the left flank, and numerous bruises over the abdomen and extremities. He complains of pain when his left hip is extended. Laboratory studies show:\nHemoglobin 8.4 g/dL\nMean corpuscular volume 102 μm3\nLeukocyte count 8,200/mm3\nPlatelet count 170,000/mm3\nSerum\nBleeding time 4 minutes\nProthrombin time 26 seconds\nPartial thromboplastin time (activated) 39 seconds\nWhich of the following is the most likely underlying cause of this patient's current symptoms?\"", "answer": "Impaired activation of factor VII", "options": {"A": "Resistance of Factor V inactivation", "B": "Impaired activation of factor VII", "C": "Administration of heparin", "D": "Decreased synthesis of thrombopoietin", "E": "Deficiency of folic acid"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Eight days", "sigmoid resection", "acute diverticulitis", "61 year old man", "left sided flank pain", "bowel", "Other", "multiple", "alcohol withdrawal", "history", "serious illness", "Current medications include intravenous cefepime", "morphine", "temperature", "36", "98", "pulse", "min", "blood pressure", "75 mm Hg", "Abdominal exam", "well healing", "minimal serous drainage", "Examination of", "skin", "scattered spider angiomas", "large hematoma", "left flank", "numerous bruises", "abdomen", "extremities", "pain", "left hip", "extended", "Laboratory studies", "Hemoglobin 8 g Mean corpuscular volume", "m3 Leukocyte count 8 200 mm3 Platelet count", "Serum Bleeding time", "minutes Prothrombin time 26 seconds Partial thromboplastin time", "seconds", "following", "underlying cause", "patient", "urrent  ymptoms?"]}
{"question": "An otherwise healthy 14-year-old girl is brought to the emergency room by her father because of excessive thirst, excessive urination, and weight loss. Her symptoms started acutely 5 days ago. Vital signs reveal a temperature of 36.6°C (97.8°F), blood pressure of 100/65 mm Hg, and pulse of 105/min. Physical examination shows a thin girl with dry mucous membranes but normal skin turgor. Laboratory results are shown:\nRandom blood sugar 410 mg/dL\nC-peptide     undetectable\nSerum beta-hydroxybutyrate negative\nWhich of the following is the best initial therapy for this patient?", "answer": "Basal-bolus insulin", "options": {"A": "Metformin", "B": "Glimepiride", "C": "Intravenous fluids, insulin infusion, and correction of electrolytes", "D": "Basal-bolus insulin", "E": "Pramlintide"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old girl", "brought", "emergency room", "excessive thirst", "excessive urination", "weight loss", "symptoms started", "days", "Vital signs reveal", "temperature", "36", "97", "blood pressure", "100 65 mm Hg", "pulse", "min", "thin girl", "dry mucous membranes", "normal", "Laboratory results", "Random blood sugar", "mg/dL C-peptide", "Serum beta-hydroxybutyrate negative", "following", "best initial therapy", "patient"]}
{"question": "An 8-year old boy is brought to the emergency department because he has been lethargic and has had several episodes of nausea and vomiting for the past day. He has also had increased thirst over the past two months. He has lost 5.4 kg (11.9 lbs) during this time. He is otherwise healthy and has no history of serious illness. His temperature is 37.5 °C (99.5 °F), blood pressure is 95/68 mm Hg, pulse is 110/min, and respirations are 30/min. He is somnolent and slightly confused. His mucous membranes are dry. Laboratory studies show:\nHemoglobin 16.2 g/dL\nLeukocyte count 9,500/mm3\nPlatelet count 380,000/mm3\nSerum\nNa+ 130 mEq/L\nK+ 5.5 mEq/L\nCl- 99 mEq/L\nHCO3- 16 mEq/L\nCreatinine 1.2 mg/dL\nGlucose 570 mg/dL\nKetones positive\nBlood gases, arterial\npH 7.25\npCO2 21 mm Hg\nWhich of the following is the most appropriate next step in management?\"", "answer": "Intravenous hydration with 0.9% normal saline and insulin", "options": {"A": "Intravenous hydration with 0.9% normal saline and insulin", "B": "Intravenous hydration with 5% dextrose solution and 0.45% normal saline", "C": "Intravenous hydration with 0.45% normal saline and insulin", "D": "Intravenous hydration with 0.9% normal saline and potassium chloride", "E": "Intravenous sodium bicarbonate\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "lethargic", "several episodes of nausea", "vomiting", "past day", "increased thirst", "past two months", "lost 5.4 kg", "lbs", "time", "healthy", "history", "serious illness", "temperature", "99.5 F", "blood pressure", "95", "mm Hg", "pulse", "min", "respirations", "30/min", "somnolent", "slightly confused", "mucous membranes", "dry", "Laboratory studies", "Hemoglobin", "g", "Leukocyte count", "mm3 Platelet count", "130", "L", "HCO3", "mg", "mg", "positive Blood gases", "arterial pH 7", "pCO2", "mm Hg", "following", "most appropriate next step"]}
{"question": "A 27-year-old woman presents with a history of repeated episodes of discoloration of the fingers over the last 3 years. She mentions that the episodes are usually triggered by exposure to cold, which leads to a sequential white, blue, and red discoloration of her fingers, followed by resolution of the symptoms. During an episode, she experiences pain and numbness in the affected fingers. The episodes are usually of short duration and do not interfere with her life, so she did not seek medical advice till now. Which of the following additional clinical features in this patient would most likely support the most likely diagnosis?", "answer": "Bilateral symmetrical involvement of the extremities", "options": {"A": "Calcinosis on the dorsal surface of the forearm", "B": "Generalized pruritus", "C": "Photosensitive skin rash", "D": "Telangiectasia over face", "E": "Bilateral symmetrical involvement of the extremities"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old woman presents", "history of repeated episodes", "discoloration", "fingers", "last", "years", "episodes", "usually triggered by exposure", "cold", "leads", "sequential white", "blue", "red discoloration", "fingers", "followed by resolution", "symptoms", "episode", "pain", "numbness in", "affected fingers", "episodes", "usually", "short duration", "not interfere", "not", "medical advice", "now", "following additional clinical features", "patient", "most likely support", "diagnosis"]}
{"question": "A 4-month-old boy is brought to the physician by his parents for a well-child examination. He has cystic fibrosis diagnosed by newborn screening. His parents report frequent feedings and large-volume and greasy stools. His 4-year-old brother has autism. Current medications include bronchodilators, pancreatic enzyme supplements, and fat-soluble vitamins. He is at the 18th percentile for height and 15th percentile for weight. Scattered wheezes are heard throughout both lung fields. Examination shows a distended and tympanic abdomen with no tenderness or guarding. Which of the following is a contraindication for administering one or more routine vaccinations in this patient at this time?", "answer": "History of intussusception", "options": {"A": "Fever of 38.2°C (100.7°F) following previous vaccinations", "B": "History of cystic fibrosis", "C": "Allergy to egg protein", "D": "History of febrile seizures", "E": "History of intussusception"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 month old boy", "brought", "physician", "well", "cystic fibrosis diagnosed", "newborn screening", "report frequent", "large volume", "greasy stools", "4 year old", "autism", "Current medications include bronchodilators", "pancreatic enzyme supplements", "fat-soluble vitamins", "percentile", "height", "percentile", "weight", "Scattered wheezes", "heard", "lung fields", "distended", "tympanic abdomen", "tenderness", "guarding", "following", "contraindication", "administering one", "more routine vaccinations", "patient", "time"]}
{"question": "A 50-year-old woman comes to the physician because of blisters on her forearm that appeared 3 days ago. She also reports pain in her left cheek when eating and pain during sexual intercourse for the past week. She has not been sick for the past 6 months. She has started hiking in the woods on the weekends with her son a couple months ago but has been careful to avoid poison ivy. She has a history of hypertension and osteoarthritis. She recently started taking captopril and stopped taking meloxicam 2 weeks ago. She has a family history of pernicious anemia and Graves' disease. The patient's vital signs are within normal limits. Examination reveals multiple, flaccid blisters on the volar surface of the forearm and ulcers on the buccal, gingival, and vulvar mucosa. The epidermis on the forearm separates when the skin is lightly stroked. The total body surface area involvement of the blisters is estimated to be 10%. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Pemphigus vulgaris", "options": {"A": "Lichen planus", "B": "Toxic epidermal necrolysis", "C": "Dermatitis herpetiformis", "D": "Bullous pemphigoid", "E": "Pemphigus vulgaris"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["50 year old woman", "physician", "of blisters", "forearm", "appeared 3 days", "reports pain in", "left cheek", "eating", "pain", "sexual intercourse", "past week", "not", "sick", "past 6 months", "started", "woods", "weekends", "couple months", "to", "history of hypertension", "osteoarthritis", "recently started", "captopril", "stopped", "meloxicam", "weeks", "family history of pernicious anemia", "Graves", "disease", "patient's vital signs", "normal limits", "reveals multiple", "flaccid blisters", "volar surface of", "forearm", "ulcers", "buccal", "gingival", "vulvar mucosa", "epidermis", "forearm separates", "skin", "lightly stroked", "total body surface area involvement of", "blisters", "estimated to", "10", "abnormalities", "following", "diagnosis"]}
{"question": "A 30-year-old man presents to his primary care physician for pain in his left ankle. The patient states that he was at karate practice when he suddenly felt severe pain in his ankle forcing him to stop. The patient has a past medical history notable for type I diabetes and is currently being treated for an episode of acute bacterial sinusitis with moxifloxacin. The patient recently had to have his insulin dose increased secondary to poorly controlled blood glucose levels. Otherwise, the patient takes ibuprofen for headaches and loratadine for seasonal allergies. Physical exam reveals a young healthy man in no acute distress. Pain is elicited over the Achilles tendon with dorsiflexion of the left foot. Pain is also elicited with plantar flexion of the left foot against resistance. Which of the following is the best next step in management?", "answer": "Change antibiotics and refrain from athletic activities", "options": {"A": "Change antibiotics and refrain from athletic activities", "B": "Ibuprofen and rest", "C": "Orthopedic ankle brace", "D": "Refrain from athletic activities for 1 to 2 weeks", "E": "Rehabilitation exercises and activity as tolerated"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old man presents", "primary care physician", "pain in", "left ankle", "patient states", "severe pain in", "ankle forcing", "to stop", "patient", "past medical history notable", "type I diabetes", "currently", "treated", "episode of acute bacterial sinusitis", "moxifloxacin", "patient recently", "to", "insulin dose increased secondary to poorly controlled blood glucose levels", "patient", "ibuprofen", "headaches", "loratadine", "seasonal allergies", "reveals", "young healthy man", "acute distress", "Pain", "elicited", "Achilles tendon", "dorsiflexion of", "left foot", "Pain", "elicited", "plantar flexion of", "left foot", "resistance", "following", "best next step"]}
{"question": "An investigator is studying the replication of a virus in denucleated embryonic fibroblasts. After the fibroblasts are infected with the virus, viral proteins are directly translated from the virion's genetic material using fibroblast ribosomes. The resultant large polypeptides are then cleaved into smaller peptides by viral proteases to generate mature viral proteins. Finally, the virion's genetic material is replicated using a protein translated from the virion's genetic material. Which of the following is the most likely virus being evaluated in this study?", "answer": "Coxsackievirus", "options": {"A": "Human immunodeficiency virus", "B": "Parvovirus", "C": "Molluscum contagiosum virus", "D": "Measles virus", "E": "Coxsackievirus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "replication", "virus", "embryonic", "infected", "viral proteins", "directly", "virion's genetic material using", "ribosomes", "large polypeptides", "then", "peptides", "viral proteases to", "mature viral proteins", "virion's genetic material", "replicated using a protein", "virion's genetic material", "following", "study"]}
{"question": "A 35-year-old man with a past medical history of HIV is hospitalized with a disseminated zoster infection and treated with IV acyclovir. His course of illness worsens on the 4th day after admission and his creatinine level increases to 4.2 mg/dL. Urinalysis shows birefringent needle-shaped crystals. What could have prevented this deterioration in the patient's renal function?", "answer": "Adequate initial hydration", "options": {"A": "Initial administration of glucocorticoids", "B": "Monitoring of drug levels", "C": "Obtaining a thorough history of patient allergies", "D": "Adequate initial hydration", "E": "Initial administration of allopurinol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old man", "past medical HIV", "hospitalized", "disseminated zoster infection", "treated with IV acyclovir", "course of illness worsens", "4th day", "creatinine level increases", "2 mg dL", "Urinalysis", "needle-shaped crystals", "prevented", "patient's renal function"]}
{"question": "A 81-year-old man presents to his primary care physician with a 4-month history of shortness of breath. He says that he has slowly lost the ability to do things due to fatigue and now gets winded after walking around the house. He also says that his cough has been getting worse and seems to be producing more sputum. He has gained about 5 pounds over the last 6 months. His past medical history is significant for hypertension and diabetes. He has a 40 pack-year smoking history and drinks about 3 drinks per week. Physical exam reveals a cyanotic appearing man with 1+ edema in his legs bilaterally. He also has wheezing on lung auscultation with a prolonged expiratory phase. Which of the following would most likely be seen on a chest radiograph in this patient?", "answer": "Cardiomegaly and increased bronchial markings", "options": {"A": "Calcified pleural plaques surrounding the diaphragm", "B": "Cardiomegaly and increased bronchial markings", "C": "Hyperinflated lungs and loss of lung markings", "D": "Perihilar mass with unilateral hilar enlargement", "E": "Subpleural cystic enlargement"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["81 year old man presents", "primary care physician", "4 month history of shortness", "breath", "slowly lost", "ability to", "due", "fatigue", "now gets winded", "house", "cough", "getting worse", "to", "more sputum", "gained", "pounds", "last", "months", "past medical history", "significant", "hypertension", "diabetes", "40", "smoking history", "week", "reveals", "cyanotic appearing man", "1", "edema", "legs", "wheezing", "lung auscultation", "prolonged expiratory phase", "following", "most likely", "seen", "chest radiograph", "patient"]}
{"question": "A 72-year-old man presents to his primary care physician because he feels like his vision has been changing over the last 6 months. In particular, he feels that he cannot see as well out of his right eye as previously. His past medical history is significant for myocardial infarction as well as Lyme disease. On presentation, he is found to have a droopy right eyelid as well as persistent constriction of his right pupil. Additionally, the skin on his right half of his face is found to be cracked and dry. Which of the following is most likely associated with this patient's symptoms?", "answer": "Pancoast tumor", "options": {"A": "Drug use", "B": "Facial nerve damage", "C": "Oculomotor nerve damage", "D": "Pancoast tumor", "E": "Syphilis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old man presents", "primary care physician", "vision", "changing", "months", "see", "well", "right eye", "past medical history", "significant", "myocardial infarction", "Lyme disease", "found to", "droopy right eyelid", "persistent constriction", "right", "the skin", "right half of", "face", "found to", "cracked", "dry", "following", "most likely associated with", "patient's symptoms"]}
{"question": "A 5-year-old boy is brought to the emergency department after he fell on the playground in kindergarten and was unable to get up. His right leg was found to be bent abnormally at the femur, and he was splinted on site by first responders. His past medical history is significant for multiple prior fractures in his left humerus and femur. Otherwise, he has been hitting normal developmental milestones and appears to be excelling in kindergarten. Physical exam also reveals the finding shown in figure A. Which of the following is the most likely cause of this patient's multiple fractures?", "answer": "Increased adenylyl cyclase activity", "options": {"A": "Abnormal collagen production", "B": "Decreased collagen hydroxylation", "C": "Increased adenylyl cyclase activity", "D": "Mutation in neurofibromin", "E": "Non-accidental trauma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "fell", "playground", "kindergarten", "unable to get", "right leg", "found to", "bent", "femur", "splinted on site", "first responders", "past medical history", "significant", "multiple prior fractures", "left humerus", "femur", "hitting normal", "appears to", "excelling", "kindergarten", "reveals", "finding", "following", "most likely cause", "patient's multiple fractures"]}
{"question": "A 32-year-old woman is brought to the emergency department after she started convulsing in the office. She has no previous history of seizures and recovers by the time she arrives at the emergency department. She says that over the last 2 days she has also experienced insomnia, abdominal pain, and dark urine. Her past medical history is significant for asthma; however, she says that she has not experienced any of these symptoms previously. She smokes 1 pack of cigarettes per day, drinks a glass of wine with dinner every night, and is currently taking oral contraceptive pills (OCPs). On presentation, her temperature is 99°F (37.2°C), blood pressure is 140/98 mmHg, pulse is 112/min, and respirations are 11/min. Which of the following enzymes is most likely to be defective in this patient?", "answer": "Porphobilinogen deaminase", "options": {"A": "Aminolevulinate dehydratase", "B": "Aminolevulinate synthase", "C": "Ferrochelatase", "D": "Porphobilinogen deaminase", "E": "Uroporphyrinogen decarboxylase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "started convulsing", "office", "previous history", "seizures", "recovers", "time", "emergency department", "last 2 days", "insomnia", "abdominal pain", "dark urine", "past medical history", "significant", "asthma", "not", "symptoms", "smokes 1 pack", "cigarettes", "day", "glass", "dinner", "night", "currently", "oral contraceptive pills", "temperature", "blood pressure", "98 mmHg", "pulse", "min", "respirations", "min", "following enzymes", "to", "defective", "patient"]}
{"question": "A 3-year-old is brought to the pediatrician by his mother because she is concerned about recent changes to his behavior. She states that he has seemed to regress in his motor development and has been having occasional brief episodes of uncontrollable shaking. During the subsequent work up, a muscle biopsy is obtained which demonstrates red ragged fibers and a presumptive diagnosis of a genetic disease made. The mother asks if her other son will be affected. What should be the physician's response?", "answer": "There is a 100% he will be affected, but the severity may be different", "options": {"A": "There is a 100% he will be affected, but the severity may be different", "B": "There is a 25% chance he will be affected", "C": "He will be unaffected", "D": "There is a 100% he will be affected, and the severity will be the same", "E": "There is a 50% chance he will be affected"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old", "brought", "pediatrician", "recent changes", "behavior", "states", "to regress", "motor development", "occasional brief episodes of", "shaking", "subsequent work up", "muscle biopsy", "obtained", "red", "fibers", "presumptive diagnosis", "genetic disease made", "affected", "physician's response"]}
{"question": "A group of researchers studying the relationship between major depressive disorder and unprovoked seizures identified 36 patients via chart review who had been rehospitalized for unprovoked seizures following discharge from an inpatient psychiatric unit and 105 patients recently discharged from the same unit who did not experience unprovoked seizures. The results of the study show:\nUnprovoked seizure No seizure\nMajor depressive disorder 20 35\nNo major depressive disorder 16 70\nBased on this information, which of the following is the most appropriate measure of association between history of major depressive disorder (MDD) and unprovoked seizures?\"", "answer": "2.5", "options": {"A": "0.36", "B": "1.95", "C": "0.19", "D": "2.5", "E": "0.17"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["researchers studying", "relationship", "major depressive disorder", "seizures identified 36 patients", "seizures following discharge", "inpatient", "patients recently", "same unit", "not", "seizures", "results", "study", "seizure", "seizure Major depressive disorder 20 35", "major depressive disorder", "70 Based", "following", "most appropriate measure", "association", "history of major depressive disorder", "seizures"]}
{"question": "A 56-year-old man of Nepalese origin presents to a clinic complaining of skin rashes that have been troubling him for years. On examination, there are numerous poorly demarcated skin lesions present on all parts of the body. There is also evidence of significant facial thickening, eyebrow loss, and symmetrical sensory neuropathy in a ‘glove and stocking’ distribution. An examination of the hands reveals bilateral weakness. A skin biopsy is taken from one of the lesions, and the culture is positive for acid-fast bacilli. Which of the following pharmacological therapies is involved in the treatment of this condition?", "answer": "Dapsone", "options": {"A": "Dapsone", "B": "Flucloxacillin", "C": "Isoniazid", "D": "Ketoconazole", "E": "Prednisone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "origin presents", "a clinic complaining of skin rashes", "years", "numerous poorly demarcated skin lesions present", "parts", "body", "significant facial thickening", "eyebrow loss", "symmetrical sensory neuropathy", "glove", "stocking distribution", "examination of", "hands reveals bilateral weakness", "skin biopsy", "one", "lesions", "culture", "positive", "acid-fast", "following pharmacological therapies", "involved", "treatment", "condition"]}
{"question": "A 16-year-old girl comes to the physician because of episodic lower abdominal pain for 5 months. The pain starts to occur a few hours before her menses and lasts for 2–3 days. Ibuprofen helped reduce the pain in the first months but has no effect now. She has missed a couple of days at school because of severe pain. Menarche was at the age of 14 years, and menses occur at regular 29-day intervals. She is sexually active with one male partner and uses condoms inconsistently. Her temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 110/70 mm Hg. Physical and pelvic examination show no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?", "answer": "Oral contraceptive pill", "options": {"A": "Diagnostic laparoscopy", "B": "Ceftriaxone and doxycycline therapy", "C": "Pelvic ultrasonography", "D": "Oral contraceptive pill", "E": "Urinalysis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "physician", "episodic lower abdominal pain", "months", "pain starts to occur", "few hours", "menses", "lasts", "23 days", "Ibuprofen helped", "pain", "first months", "no effect now", "missed", "couple", "days", "school", "severe pain", "Menarche", "age", "years", "menses occur", "regular 29 day intervals", "sexually active", "one male", "uses condoms", "temperature", "98", "pulse", "88 min", "blood pressure", "70 mm Hg", "Physical", "pelvic examination", "abnormalities", "urine pregnancy test", "negative", "following", "most appropriate next step"]}
{"question": "A medical examiner was called to investigate the death of a 75-year-old type 1 diabetic Caucasian male who was a retired physician. His caretaker discovered his body in the bedroom with an empty syringe and a small bottle of lispro lying on the nightstand. She explains that his wife of 50 years passed away six months ago and that he had no children or family. He had become extremely depressed and did not want to live anymore. Which of the following would be most consistent with his blood chemistry if a blood sample were taken?", "answer": "Glucose: 25 mg/dL, high insulin and absent C-peptide levels", "options": {"A": "Glucose: 25 mg/dL, high insulin and high C-peptide levels", "B": "Glucose: 25 mg/dL, high insulin and normal C-peptide levels", "C": "Glucose: 25 mg/dL, high insulin and absent C-peptide levels", "D": "Glucose: 95 mg/dL, low insulin and low C-peptide levels", "E": "Glucose: 95 mg/dL, high insulin and C-peptide levels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["medical examiner", "called to investigate", "death", "75 year old type 1 diabetic", "male", "retired physician", "caretaker", "body", "bedroom", "empty syringe", "small bottle", "lispro lying", "50 years passed", "six months", "children", "extremely depressed", "not", "to live", "following", "most", "blood chemistry", "blood sample"]}
{"question": "A 52-year-old woman makes a follow-up appointment with her primary care physician for evaluation of her diabetes medications. Specifically, she complains that she has been experiencing flushing, nausea, and palpitations after drinking a glass of wine with dinner after she started the latest regimen for her diabetes. She was warned that this was a side-effect of one of her medications but she did not understand the severity of the reaction. Given this experience, she asks to be placed on an alternative regimen that does not involve the medication that caused this reaction. Her physician therefore replaces the medication with another one that interacts with the same target though at a different binding site. Which of the following is a side-effect of the new medication?", "answer": "Weight gain", "options": {"A": "Hepatotoxicity", "B": "Lactic acidosis", "C": "Pancreatitis", "D": "Urinary tract infection", "E": "Weight gain"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman makes", "follow-up appointment", "primary care physician", "diabetes", "flushing", "nausea", "palpitations", "drinking", "glass", "dinner", "started", "latest regimen", "diabetes", "side-effect", "one", "medications", "not", "severity", "reaction", "Given", "to", "regimen", "not", "medication", "caused", "reaction", "physician", "replaces", "medication", "one", "same target", "different", "following", "side-effect", "new medication"]}
{"question": "A 3-year-old girl is brought to the physician by her mother two days after the sudden onset of a rash. The mother says that the rash developed an hour after she bathed the child in lukewarm water. Two weeks ago, the patient was diagnosed with a skin infection and was treated with penicillin V. She has been otherwise healthy but has missed several well-child examinations. She lives with her single mother, who recently lost her job and is now dependent on social assistance. The patient's mother has major depressive disorder and her maternal aunt has systemic lupus erythematosus. The girl's temperature is 36.8°C (98.2°F), pulse is 112/min, and blood pressure is 108/62 mm Hg. She has poor eye contact. Physical examination shows sharply delineated erythema on the lower extremities up to the umbilicus with sparing of the knees and flexor surfaces. Further evaluation is most likely to reveal which of the following?", "answer": "Multiple injuries in different stages of healing", "options": {"A": "Multiple injuries in different stages of healing", "B": "Dermatographism", "C": "Positive Nikolsky's sign", "D": "Malar rash with sparing of the nasolabial folds", "E": "Ulcers of the oral mucosa\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "physician", "two days", "sudden onset", "rash", "rash", "hour", "bathed", "child", "water", "Two weeks", "patient", "diagnosed", "skin infection", "treated with penicillin V", "healthy", "missed", "well-child", "lives with", "single mother", "recently lost", "now dependent", "social assistance", "patient's", "major depressive disorder", "systemic lupus erythematosus", "girl's temperature", "36", "98", "pulse", "min", "blood pressure", "62 mm Hg", "poor eye contact", "delineated erythema", "lower extremities up to", "umbilicus", "knees", "flexor surfaces", "Further", "to reveal", "following"]}
{"question": "An 2-year-old girl with a history of SS-hemoglobin is brought to her pediatrician by her mother, who noted an abdominal mass. On exam, the girl's spleen is palpably enlarged, and her palms and conjunctiva are noted to be extremely pale. Serum haptoglobin levels are normal. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Extravascular hemolysis", "options": {"A": "Decreased red blood cell production", "B": "Extravascular hemolysis", "C": "Intravascular hemolysis", "D": "Complement-mediated hemolysis", "E": "Hemolytic uremic syndrome"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year old girl", "a history", "SS hemoglobin", "brought", "pediatrician", "noted", "abdominal mass", "exam", "girl's spleen", "enlarged", "conjunctiva", "noted to", "extremely pale", "Serum haptoglobin levels", "normal", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 19-year-old woman comes to the physician because of a delayed menstrual period. She has had regular menses since menarche at age 11. Her last menstrual period was 7 weeks ago. She is sexually active with two male partners. A urine pregnancy test is positive. An ultrasound of the pelvis shows a viable intrauterine pregnancy with an estimated gestational age of 6 weeks and 5 days. She does not wish to continue with the pregnancy. After carefully weighing the options with her physician, she is prescribed two medications, one of which is mifepristone. Which of the following is this drug's primary mechanism of action?", "answer": "Blockage of progesterone receptor", "options": {"A": "Inhibition of dihydrofolate reductase", "B": "Blockage of progesterone receptor", "C": "Activation of prostaglandin E1 receptors", "D": "Antagonist at gonadotropin-releasing hormone receptors", "E": "Agonist at oxytocin receptors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "delayed menstrual", "regular menses", "menarche at age", "last menstrual period", "weeks", "sexually active", "two male", "urine pregnancy test", "positive", "ultrasound", "pelvis", "viable intrauterine pregnancy", "estimated gestational age", "6 weeks", "5 days", "not wish to", "pregnancy", "options", "physician", "two medications", "one", "mifepristone", "following", "drug's primary mechanism of action"]}
{"question": "A 97-year-old man visits the urology clinic 5 days after experiencing urinary retention at an emergency department visit. The patient has a history of hypertension, type II diabetes mellitus, stroke, dyslipidemia, a past myocardial infarction, and severe osteoarthritis in his right hip. He is not compliant with his medications and his multiple comorbidities are poorly managed. In the hospital, the patient’s urinary retention was treated with Foley catheterization. At clinic, the patient’s serum-specific prostate-specific antigen (PSA) is 6.0 ng/mL (normal is < 4 ng/mL). Digital rectal examination (DRE) demonstrates a nontender prostate with several rock hard nodules. The patient's Foley is removed and he is able to urinate on his own. Which is the most appropriate next step in management?", "answer": "Reassurance", "options": {"A": "CT abdomen and pelvis", "B": "Cystourethroscopy", "C": "Transrectal prostate biopsy", "D": "Reassurance", "E": "Repeat PSA test"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["97 year old man", "urology clinic 5 days", "urinary retention", "emergency department", "patient", "history of hypertension", "type II diabetes mellitus", "stroke", "dyslipidemia", "past myocardial infarction", "severe osteoarthritis", "right", "not compliant", "medications", "multiple comorbidities", "poorly", "hospital", "patients urinary retention", "treated with Foley catheterization", "clinic", "patients serum specific prostate-specific antigen", "0 ng/mL", "normal", "4 ng/mL", "Digital rectal examination", "nontender prostate", "rock hard nodules", "patient's", "removed", "able to", "most appropriate next step"]}
{"question": "A 66-year-old woman presents to the emergency department with lower extremity pain. She reports that she has had worsening pain in her left calf over the past year while walking. The pain improves with rest, but the patient notes that she now has to stop walking more frequently than in the past to relieve the pain. The patient’s past medical history is otherwise notable for hypertension and coronary artery disease. Her home medications include hydrochlorothiazide and lisinopril. Her family history is significant for diabetes mellitus in her father. On physical exam, her left lower extremity is slightly cool to the touch with palpable distal pulses. The skin of the left lower extremity appears smooth and shiny below the mid-calf. Laboratory testing is performed and reveals the following:\n\n\n\nSerum:\n\nHigh-density lipoprotein (HDL): 60 mg/dL\n\nLow-density lipoprotein (LDL): 96 mg/dL\n\nTriglycerides: 140 mg/dL\n\n\n\nThis patient should be started on which of the following medication regimens?", "answer": "Aspirin and atorvastatin", "options": {"A": "Aspirin only", "B": "Aspirin and atorvastatin", "C": "Aspirin and cilostazol", "D": "Atorvastatin only", "E": "Atorvastatin and cilostazol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old woman presents", "emergency department", "lower extremity pain", "reports", "worsening pain in", "left calf", "past year", "pain improves", "patient notes", "now", "to stop", "more frequently", "past to relieve", "pain", "patients past medical history", "notable", "hypertension", "coronary artery disease", "home medications include hydrochlorothiazide", "lisinopril", "family history", "significant", "diabetes mellitus", "left lower extremity", "slightly cool", "touch", "palpable distal pulses", "skin of", "left lower extremity appears smooth", "shiny", "calf", "Laboratory testing", "performed", "reveals", "following", "Serum", "High-density lipoprotein", "60 mg/dL", "Low-density lipoprotein", "96 mg/dL", "Triglycerides", "mg/dL", "patient", "started", "following medication"]}
{"question": "A 50-year-old man comes to the emergency department for evaluation of right-sided facial weakness that he noticed after waking up. One month ago, he also experienced right-sided neck pain and headache that began after returning from a hunting trip to New Hampshire the week before. He took ibuprofen to relieve symptoms, which subsided a week later. He has a 5-year history of hypertension controlled with drug therapy. He has smoked one pack of cigarettes daily for 35 years and he drinks two beers daily. His vital signs are within the normal range. Physical examination shows right-sided drooping of the upper and lower half of the face. The patient has difficulties smiling and he is unable to close his right eye. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?", "answer": "Enzyme‑linked immunosorbent assay", "options": {"A": "Western blot", "B": "Polymerase chain reaction of the facial skin", "C": "Cerebrospinal fluid analysis", "D": "Enzyme‑linked immunosorbent assay", "E": "Noncontrast CT"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["50 year old man", "emergency department", "right-sided facial weakness", "waking", "One month", "right-sided neck pain", "headache", "began", "returning", "trip", "New Hampshire", "week", "ibuprofen to relieve symptoms", "week later", "5 year history of hypertension controlled", "drug therapy", "smoked one pack", "cigarettes daily", "35 years", "two", "daily", "vital signs", "normal range", "right-sided", "upper", "lower half", "face", "patient", "difficulties", "unable to close", "right eye", "abnormalities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 5-year-old boy is brought to the physician because of a 10-day history of intermittent fevers and painful swelling of the right ankle. He has not had trauma to the ankle. He has a history of sickle cell disease and had an episode of dactylitis of his left index finger 3 years ago. Current medications include hydroxyurea and acetaminophen as needed for the ankle pain. His temperature is 38°C (100.4°F), blood pressure is 125/68 mm Hg, pulse is 105/min, and respirations are 14/min. Examination shows a tender, swollen, and erythematous right ankle with point tenderness over the medial malleolus. X-ray of the right ankle demonstrates marked periosteal thickening and elevation, as well as a central sclerotic lesion with a lucent rim over the right lateral malleolus. A bone biopsy culture confirms the diagnosis. Which of the following is the most likely causal organism?", "answer": "Salmonella enterica", "options": {"A": "Streptococcus pneumoniae", "B": "Escherichia coli", "C": "Streptococcus pyogenes", "D": "Salmonella enterica", "E": "Pseudomonas aeruginosa"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["5 year old boy", "brought", "physician", "a 10 day history", "intermittent fevers", "painful swelling", "right", "not", "trauma", "ankle", "history of", "disease", "episode of dactylitis", "left index finger 3 years", "Current medications include hydroxyurea", "acetaminophen as needed", "ankle pain", "temperature", "100", "blood pressure", "mm Hg", "pulse", "min", "respirations", "min", "tender", "swollen", "erythematous right ankle", "point tenderness", "medial malleolus", "X-ray of", "right ankle", "marked periosteal thickening", "elevation", "central sclerotic lesion", "rim", "right lateral malleolus", "bone confirms", "diagnosis", "following", "causal"]}
{"question": "A 34-year-old woman presents to the emergency department with moderate right wrist pain after falling on her outstretched hand. She has numbness in the 3 medial digits. The patient has no known previous medical conditions. Her family history is not pertinent, and she currently takes no medications. Physical examination shows her blood pressure is 134/82 mm Hg, the respirations are 14/min, the pulse is 87/min, and the temperature is 36.7°C (98.0°F). When asked to make a fist, the patient is able to flex only the lateral 2 digits. Tapping the anterior portion of her wrist elicits tingling in the medial 3 digits. The patient is taken to get an X-ray. Which of the following is the most likely diagnosis for this patient’s injury?", "answer": "Lunate dislocation", "options": {"A": "Scaphoid fracture", "B": "Lunate dislocation", "C": "Fracture of distal radius", "D": "Palmar aponeurosis tear", "E": "Interosseous ligament rupture"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "moderate right wrist pain", "falling", "hand", "numbness in", "medial digits", "patient", "known previous medical conditions", "family history", "not", "currently", "medications", "blood pressure", "mm Hg", "respirations", "min", "pulse", "87 min", "temperature", "36", "98", "to make", "fist", "patient", "able", "only", "lateral", "digits", "Tapping", "anterior portion", "wrist elicits tingling in", "medial", "digits", "patient", "to", "X-ray", "following", "diagnosis", "patients injury"]}
{"question": "A 28-year-old woman visits the clinic expressing a desire to become pregnant. She was seen for depressed mood and disinterest in her usual leisure activities a few months ago. She also had decreased sleep and appetite and was not able to concentrate at work. She was started on fluoxetine and has been compliant for the last 6 months despite experiencing some of the side effects. She now feels significantly better and would like to stop the medication because she plans to become pregnant and thinks it is unnecessary now. Which of the following statements is correct regarding this patient’s current antidepressant therapy?", "answer": "It can cause anorgasmia.", "options": {"A": "It can cause anorgasmia.", "B": "It has the shortest half-life of any drugs in the same class.", "C": "It is unsafe to take during pregnancy.", "D": "It decreases levels of concurrent neuroleptics.", "E": "Most side effects persist throughout therapy."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "clinic", "to", "pregnant", "seen", "depressed mood", "usual", "few months", "decreased sleep", "appetite", "not able to concentrate", "started", "fluoxetine", "compliant", "months", "side effects", "now", "better", "to stop", "medication", "plans to", "pregnant", "now", "following", "correct", "patients current antidepressant"]}
{"question": "A 67-year-old man presents to his primary care provider because of fatigue and loss of appetite. He is also concerned that his legs are swollen below the knee. He has had type 2 diabetes for 35 years, for which he takes metformin and glyburide. Today his temperature is 36.5°C (97.7°F), the blood pressure is 165/82 mm Hg, and the pulse is 88/min. Presence of which of the following would make diabetic kidney disease less likely in this patient?", "answer": "Cellular casts in urinalysis", "options": {"A": "Nephrotic range proteinuria", "B": "Diabetic retinopathy", "C": "Cellular casts in urinalysis", "D": "Gradual reduction of glomerular filtration rate (GFR)", "E": "Normal-to-large kidneys on ultrasound"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "primary care provider", "fatigue", "loss of appetite", "legs", "swollen", "knee", "type 2 diabetes", "35 years", "metformin", "glyburide", "Today", "temperature", "36", "97", "blood pressure", "mm Hg", "pulse", "88 min", "Presence", "following", "make diabetic kidney disease", "likely", "patient"]}
{"question": "A 33-year-old woman presents to the clinic complaining of yellowish discoloration of her skin and eyes, mild fever, and body aches. She has had this problem for 6 months, but it has become worse over the past few weeks. She also complains of repeated bouts of bloody diarrhea and abdominal pain. The past medical history is noncontributory. She takes no medication. Both of her parents are alive with no significant disease. She works as a dental hygienist and drinks wine occasionally on weekends. Today, the vital signs include blood pressure 110/60 mm Hg, pulse rate 90/min, respiratory rate 19/min, and temperature 36.6°C (97.8°F). On physical examination, she appears uncomfortable. The skin and sclera are jaundiced. The heart has a regular rate and rhythm, and the lungs are clear to auscultation bilaterally. The abdomen is soft with mild hepatosplenomegaly. There is no tenderness or rebound tenderness. The digital rectal examination reveals blood and mucus in the rectal vault. Laboratory studies show:\nSerum sodium 140 mEq/L\nSerum potassium 3.8 mEq/L\n  Alanine aminotransferase (ALT) 250 U/L\nAspartate aminotransferase (AST) 170 U/L\nAlkaline phosphatase (ALP) 120 U/L\nWhich of the following antibodies would you expect to find in this patient?", "answer": "Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA)", "options": {"A": "Anti-mitochondrial antibody", "B": "Anti-endomysial IgA", "C": "Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA)", "D": "Anti-cyclic citrullinated peptide (anti-CCP)", "E": "Anti-double stranded DNA (anti-dsDNA)"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "clinic", "of", "discoloration", "skin", "eyes", "mild fever", "body aches", "problem", "months", "worse", "past", "weeks", "repeated bouts", "bloody diarrhea", "abdominal pain", "past medical history", "medication", "alive", "significant disease", "dental hygienist", "occasionally", "weekends", "Today", "vital signs include blood pressure", "60 mm Hg", "pulse rate 90 min", "respiratory rate", "min", "temperature 36", "97", "appears", "skin", "sclera", "jaundiced", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "abdomen", "soft", "mild hepatosplenomegaly", "tenderness", "rebound tenderness", "digital rectal examination reveals blood", "mucus", "rectal vault", "Laboratory studies", "Serum sodium", "mEq", "potassium", "Alanine aminotransferase", "ALT", "U/L Aspartate aminotransferase", "AST", "U/L Alkaline phosphatase", "following antibodies", "to find", "patient"]}
{"question": "An 11-year-old male presents to the pediatrician with his mother for evaluation of difficulty walking. His mother reports that the patient was walking normally until about a year ago, when he started to complain of weakness in his legs. He seems to be less steady on his feet than before, and he has fallen twice at home. Prior to a year ago, the patient had no difficulty walking and was active on his school’s soccer team. He has no other past medical history. The patient is an only child, and his mother denies any family history of neurological disease. On physical examination, the patient has mildly slurred speech. He has a wide-based gait with symmetric weakness and decreased sensation in his lower extremities. The patient also has the physical exam findings seen in Figures A and B. Which of the following is the most likely etiology of this patient’s presentation?", "answer": "Trinucleotide (GAA) repeat expansion on chromosome 9", "options": {"A": "Genetic mutation on chromosome 11q22", "B": "Infection with gram-negative rods", "C": "Trinucleotide (CGG) repeat expansion on chromosome X", "D": "Trinucleotide (CTG) repeat expansion on chromosome 19", "E": "Trinucleotide (GAA) repeat expansion on chromosome 9"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old male presents", "pediatrician", "difficulty walking", "reports", "patient", "year", "started to", "weakness", "legs", "to", "less steady", "feet", "before", "twice", "year", "patient", "difficulty walking", "active", "schools", "past medical history", "patient", "family history of neurological disease", "patient", "mildly slurred speech", "wide-based gait", "symmetric weakness", "decreased sensation in", "lower extremities", "patient", "physical exam findings seen", "following", "etiology", "patients"]}
{"question": "A 4-month-old girl is brought to the physician by her mother because of a 4-day history of vomiting, poor feeding, and more frequent napping. She appears lethargic. Her vital signs are within normal limits. Physical examination shows a bulging, tense anterior fontanelle. Fundoscopic exam shows bilateral retinal hemorrhage. A complete blood count shows a leukocyte count of 8,000/mm3. An x-ray of the chest shows healing fractures of the 4th and 5th left ribs. Which of the following is the most likely cause of the patient's condition?", "answer": "Shearing head injury", "options": {"A": "Malnutrition", "B": "Shearing head injury", "C": "Inherited connective tissue disorder", "D": "Bleeding from the germinal matrix", "E": "Epidural hematoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 month old girl", "brought", "physician", "mother", "4-day history", "vomiting", "poor feeding", "more frequent napping", "appears lethargic", "vital signs", "normal", "Physical examination", "bulging", "tense anterior fontanelle", "Fundoscopic exam", "bilateral retinal hemorrhage", "complete blood count", "leukocyte count", "mm3", "x-ray of", "chest", "healing fractures", "4th", "5th left ribs", "following", "most likely cause", "patient's condition"]}
{"question": "A 27-year-old G1P0 at 12 weeks estimated gestational age presents for prenatal care. The patient says she has occasional nausea and vomiting and a few episodes of palpitations and diarrhea this last week. Physical examination is unremarkable, except for a heart rate of 145/min. Basic thyroid function tests are shown in the table below. Which of the following additional laboratory tests would be most useful is assessing this patient’s condition?\nThyroid-stimulating hormone (TSH) \n0.28 mIU/L (0.3–4.5 mIU/L)\nTotal T4\n12 µg/dL (5.4–11.5 µg/dL)", "answer": "Free thyroxine (T4) levels", "options": {"A": "Total triiodothyronine (T3) levels", "B": "Free thyroxine (T4) levels", "C": "Thyroxine-binding globulin (TBG) levels", "D": "Thyroid peroxidase (TPO) antibodies", "E": "Thyrotropin receptor antibodies (TRAb)"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old", "weeks estimated gestational age presents", "patient", "occasional nausea", "vomiting", "few episodes of palpitations", "diarrhea", "last week", "unremarkable", "except for", "heart rate of", "min", "Basic thyroid function tests", "table", "following additional laboratory tests", "most useful", "patients", "Thyroid-stimulating hormone", "0 28 mIU/L", "5", "Total T4", "g/dL", "5", "5 g/dL"]}
{"question": "A 1-year-old girl is brought to the physician for follow-up examination 1 week after admission to the hospital for bacterial pneumonia. She has had multiple episodes of purulent otitis media and infectious diarrhea since the age of 6 months. She underwent treatment for oral thrush 1 month ago. There is no family history of serious illness. Her height and weight are both below the 10th percentile. Physical examination shows no visible tonsils and slightly decreased breath sounds in the left lower lobe. Laboratory studies show increased deoxyadenosine concentration in both the serum and urine. An x-ray of the chest shows an absent thymic shadow. Which of the following additional findings is most likely in this patient?", "answer": "Decreased circulating T cells", "options": {"A": "Decreased circulating parathyroid hormone", "B": "Increased circulating IgE", "C": "Decreased circulating T cells", "D": "Decreased circulating platelets", "E": "Increased circulating neutrophils"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "follow-up", "1 week", "hospital", "bacterial pneumonia", "multiple episodes of purulent otitis media", "infectious diarrhea", "age", "months", "treatment", "oral", "month", "family history", "serious illness", "height", "weight", "percentile", "visible tonsils", "slightly decreased breath sounds", "left lower lobe", "Laboratory studies", "increased", "concentration", "serum", "urine", "x-ray of", "chest", "absent thymic shadow", "following additional findings", "patient"]}
{"question": "A 30-year-old man presents to his primary care doctor for a 2 month follow-up appointment. He had recently separated from his male partner of 10 years and has been struggling to maintain his weight and the rigors of work in a new start-up company. At his initial visit, he was prescribed escitalopram. 2 weeks later, the patient was instructed to continue taking the medication despite feeling more depressed. After expressing increased desire to carry out suicidal thoughts, he was hospitalized for a brief course. During this visit, he reports that he is feeling much better, but he has an elective inguinal hernia repair scheduled for the end of the week. \"The surgeon said to not take anything before the surgery. Besides, I'm feeling better and don't feel like taking escitalopram everyday.\" What is the most appropriate response?", "answer": "Continue escitalopram on day of surgery and continue afterwards for 4 more months", "options": {"A": "Continue escitalopram on day of surgery and continue afterwards for 4 more months", "B": "Continue escitalopram until surgery and discontinue afterwards", "C": "Discontinue escitalopram", "D": "Hold escitalopram the day before surgery and continue afterwards for 4 more months", "E": "Hold escitalopram the day of surgery and continue afterwards for 4 more months"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old man presents", "primary care doctor", "2 month follow-up appointment", "recently separated", "male", "to", "weight", "rigors", "new", "company", "initial", "escitalopram", "2 weeks later", "patient", "to", "medication", "more depressed", "increased", "to carry out suicidal thoughts", "hospitalized", "brief course", "reports", "much better", "elective inguinal hernia repair scheduled", "end", "week", "surgeon", "to not", "before", "surgery", "I", " ", "etter ", "citalopram e eryday.\"", "st a propriate r sponse?"]}
{"question": "A 66-year-old man comes to the physician because of difficulty walking for the past year. He reports that his gait has become slower and that initiating steps has become more challenging. During the past 6 months, his family has noticed that he is starting to forget important family meetings and holidays. On a number of occasions, he has not been able to get to the bathroom in time in order to urinate. He has hypertension treated with hydrochlorothiazide. His father died of Parkinson's disease at the age of 63 years. The patient had smoked one pack of cigarettes daily for 40 years, but quit 10 years ago. His vital signs are within normal limits. On mental status examination, he is confused and has short-term memory deficits. He has a wide-based, shuffling gait. Muscle strength is normal. Deep tendon reflexes are 2+ bilaterally. An MRI of the head is shown. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Decreased cerebrospinal fluid absorption", "options": {"A": "Normal changes associated with aging", "B": "Increased cerebrospinal fluid production", "C": "Decreased cerebrospinal fluid absorption", "D": "Obstructed passage of cerebrospinal fluid", "E": "Degeneration of cholinergic neurons in the temporal lobe"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["66 year old man", "physician", "of difficulty walking", "past year", "reports", "gait", "slower", "initiating steps", "more challenging", "past 6 months", "starting", "forget important", "number", "occasions", "not", "able to get", "bathroom", "time", "order to", "hypertension treated with hydrochlorothiazide", "died", "Parkinson's disease", "age", "63 years", "patient", "smoked one pack", "cigarettes daily", "40 years", "vital signs", "normal limits", "mental status", "confused", "deficits", "wide-based", "gait", "Muscle strength", "normal", "Deep tendon reflexes", "2", "MRI of", "head", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 67-year-old woman presents with right leg pain and swelling of 5 days’ duration. She has a history of hypertension for 15 years and had a recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize and walk, the right leg became painful and swollen. Her temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 75/min. On physical examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Dilated superficial veins are present on the right foot and the right leg is slightly redder than the left. There is some tenderness on palpation in the popliteal fossa behind the knee. Which of the following is the best initial step in the management of this patient’s condition?", "answer": "Wells’ clinical probability tool", "options": {"A": "Wells’ clinical probability tool", "B": "Computerized tomography (CT) with contrast", "C": "International randomized ratio (INR)", "D": "Thrombophilia screen", "E": "Activated partial thromboplastin time (aPTT)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old woman presents", "right leg pain", "swelling", "5 days duration", "history of hypertension", "years", "recent", "pneumonia", "at home", "beginning to mobilize", "right leg", "painful", "swollen", "temperature", "98", "blood pressure", "80 mm Hg", "pulse", "75 min", "right calf", "4", "greater", "circumference", "left", "measured 10", "tibial tuberosity", "Dilated superficial", "present", "right foot", "right leg", "slightly redder", "left", "tenderness", "palpation", "popliteal fossa", "knee", "following", "best initial step", "management", "patients condition"]}
{"question": "A 71-year-old man with Hodgkin lymphoma is admitted to the hospital with lower back pain and no urine output over the last 12 hours. Physical examination shows inguinal lymphadenopathy. There is no suprapubic fullness or tenderness. Serum creatinine is elevated compared to 1 week prior. A contrast-enhanced CT scan of the abdomen shows retroperitoneal fibrosis, bilateral hydronephrosis, and a collapsed bladder. Which of the following is the next appropriate step in management of this patient?", "answer": "Perform ureteral stenting", "options": {"A": "Place a urethral catheter", "B": "Perform ureteral stenting", "C": "Initiate oxybutynin therapy", "D": "Place a suprapubic catheter", "E": "Initiate tamsulosin therapy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "Hodgkin lymphoma", "lower back pain", "urine output", "12 hours", "inguinal lymphadenopathy", "suprapubic fullness", "tenderness", "Serum creatinine", "elevated", "1 week prior", "contrast-enhanced CT scan", "abdomen", "retroperitoneal fibrosis", "bilateral hydronephrosis", "collapsed bladder", "following", "next appropriate step", "patient"]}
{"question": "A 30-year-old African-American woman comes to the physician for a routine checkup. She feels well. She has a history of type 2 diabetes mellitus that is well-controlled with metformin. Her mother died of a progressive lung disease at the age of 50 years. The patient is sexually active with her husband, and they use condoms consistently. She has smoked one pack of cigarettes daily for the past 10 years. She drinks one to two glasses of wine per day. She does not use illicit drugs. Vital signs are within normal limits. Examination, including ophthalmologic evaluation, shows no abnormalities. Laboratory studies, including serum creatinine and calcium concentrations, are within normal limits. An ECG shows no abnormalities. A tuberculin skin test is negative. A chest x-ray is shown. Which of the following is the most appropriate next step in management?", "answer": "Monitoring", "options": {"A": "ANCA testing", "B": "Lung biopsy", "C": "Oral methotrexate therapy", "D": "Monitoring", "E": "Oral isoniazid monotherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old", "woman", "physician", "routine checkup", "well", "history of type 2 diabetes mellitus", "well-controlled", "metformin", "died of", "progressive lung disease", "age", "50 years", "patient", "sexually active", "use condoms", "smoked one pack", "cigarettes daily", "past", "one", "two glasses", "day", "not use illicit drugs", "Vital signs", "normal limits", "including ophthalmologic", "abnormalities", "Laboratory studies", "including serum creatinine", "calcium", "normal limits", "ECG", "abnormalities", "tuberculin skin test", "negative", "chest x-ray", "following", "most appropriate next step"]}
{"question": "A research scientist attempts to understand the influence of carbon dioxide content in blood on its oxygen binding. The scientist adds carbon dioxide to dog blood and measures the uptake of oxygen in the blood versus oxygen pressure in the peripheral tissue. He notes in one dog that with the addition of carbon dioxide with a pressure of 90 mmHg, the oxygen pressure in the peripheral tissue rose from 26 to 33 mmHg. How can this phenomenon be explained?", "answer": "High partial pressure of CO2 in tissues facilitates O2 unloading in peripheral tissues", "options": {"A": "Binding of O2 to hemoglobin in lungs drives release of CO2 from hemoglobin", "B": "The sum of the partial pressures of CO2 and O2 cannot exceed a known threshold in blood", "C": "High partial pressure of CO2 in tissues facilitates O2 unloading in peripheral tissues", "D": "High partial pressure of CO2 in tissues decreases peripheral blood volume", "E": "High partial pressure of CO2 in tissues causes alkalemia, which is necessary for O2 unloading"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["scientist", "to", "carbon dioxide content", "blood", "scientist adds carbon dioxide", "blood", "measures", "uptake", "oxygen", "blood", "oxygen pressure", "peripheral tissue", "notes", "one", "addition", "carbon dioxide", "pressure", "90 mmHg", "oxygen pressure", "peripheral tissue rose", "mmHg"]}
{"question": "A young man about to leave for his freshman year of college visits his physician in order to ensure that his immunizations are up-to-date. Because he is living in a college dormitory, his physician gives him a vaccine that prevents meningococcal disease. What type of vaccine did this patient likely receive?", "answer": "Conjugated polysaccharide", "options": {"A": "Live, attenuated", "B": "Killed, inactivated", "C": "Toxoid", "D": "Conjugated polysaccharide", "E": "Killed, attenuated"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["young man", "to", "physician", "order to", "immunizations", "date", "living", "college dormitory", "physician gives", "vaccine", "prevents meningococcal disease", "type", "vaccine", "patient likely receive"]}
{"question": "A 29-year-old woman comes to the military physician because of a 2-day history of fever, joint pain, dry cough, chest pain, and a painful red rash on her lower legs. Two weeks ago, she returned from military training in Southern California. She appears ill. Her temperature is 39°C (102.1°F). Physical examination shows diffuse inspiratory crackles over all lung fields and multiple tender erythematous nodules over the anterior aspect of both legs. A biopsy specimen of this patient's lungs is most likely to show which of the following?", "answer": "Spherules filled with endospores", "options": {"A": "Spherules filled with endospores", "B": "Broad-based budding yeast", "C": "Oval, budding yeast with pseudohyphae", "D": "Septate hyphae with acute-angle branching", "E": "Round yeast surrounded by budding yeast cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old woman", "military physician", "2-day history", "fever", "joint pain", "dry cough", "chest pain", "painful red rash", "lower legs", "Two weeks", "returned", "military training", "Southern California", "appears ill", "temperature", "diffuse inspiratory crackles over", "lung fields", "multiple tender erythematous nodules", "anterior aspect", "legs", "biopsy specimen", "patient's lungs", "to", "following"]}
{"question": "a 34-year-old G2P2 woman presents to her obstetrician because of new onset discharge from her breast. She first noticed it in her bra a few days ago, but now she notes that at times she's soaking through to her blouse, which is mortifying. She was also concerned about being pregnant because she has not gotten her period in 3 months. In the office ß-HCG is negative. The patient's nipple discharge is guaiac negative. Which of the following therapies is most appropriate?", "answer": "Cabergoline", "options": {"A": "Tamoxifine", "B": "Leuprolide", "C": "Haloperidol", "D": "Cabergoline", "E": "Carbidopa-levodopa"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "obstetrician", "of new onset discharge", "breast", "first", "bra", "few days", "now", "notes", "times she", "soaking", "blouse", "pregnant", "not gotten", "period", "months", "office", "HCG", "negative", "patient's nipple", "guaiac negative", "following therapies", "most appropriate"]}
{"question": "A 65-year-old woman returns to the outpatient oncology clinic to follow up on her recently diagnosed breast cancer. A few months ago, she noticed a lump during a breast self-exam that was shown to be breast cancer. A lumpectomy revealed invasive ductal carcinoma that was estrogen- and progesterone receptor-positive with nodal metastases. She is following up to discuss treatment options. She had her last menstrual period 10 years ago and has not had any spotting since that time. Her mother had breast cancer and she remembered her taking chemotherapy and had a poor quality of life, thus she asks not to be treated similarly. Which of the following is the mechanism of action of the best treatment option for this patient?", "answer": "Inhibit peripheral conversion of androgens to estrogen", "options": {"A": "Antagonist for estrogen receptors in the breast", "B": "Cell cycle arrest", "C": "Antagonist for estrogen receptors in the hypothalamus", "D": "Inhibit peripheral conversion of androgens to estrogen", "E": "Estrogen receptors downregulation in the breast"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65-year-old woman returns", "outpatient oncology clinic to follow up", "recently diagnosed breast cancer", "few months", "lump", "breast self-exam", "to", "breast cancer", "lumpectomy revealed invasive ductal carcinoma", "estrogen", "progesterone receptor-positive", "nodal metastases", "following up", "treatment options", "last menstrual period", "not", "spotting", "time", "breast cancer", "chemotherapy", "poor quality of life", "not to", "treated", "following", "mechanism of action", "best treatment option", "patient"]}
{"question": "A 17-year-old girl comes to the emergency department because of numbness around her mouth and uncontrolled twitching of the mouth for the past 30 minutes. Her symptoms began while she was at a concert. Her temperature is 37°C (98.6°F), pulse is 69/min, and respirations are 28/min. When the blood pressure cuff is inflated, painful contractions of the hand muscles occur. Arterial blood gas shows a pH of 7.53, pO2 of 100 mm Hg, and a pCO2 of 29 mm Hg. Which of the following additional findings is most likely in this patient?", "answer": "Decreased cerebral blood flow", "options": {"A": "Decreased cerebral blood flow", "B": "Increased peripheral oxygen unloading from hemoglobin", "C": "Decreased total serum calcium concentration", "D": "Increased serum potassium concentration", "E": "Increased serum phosphate concentration"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "emergency department", "of numbness", "mouth", "uncontrolled twitching", "mouth", "past 30 minutes", "symptoms began", "temperature", "98", "pulse", "69 min", "respirations", "min", "blood pressure cuff", "painful contractions of", "hand muscles occur", "Arterial blood gas", "pH", "7", "pO2", "100 mm Hg", "pCO2", "29 mm Hg", "following additional findings", "patient"]}
{"question": "A 68-year-old woman is brought to the emergency department after being found unresponsive in her bedroom in a nursing home facility. Her past medical history is relevant for hypertension, diagnosed 5 years ago, for which she has been prescribed a calcium channel blocker and a thiazide diuretic. Upon admission, she is found with a blood pressure of 200/116 mm Hg, a heart rate of 70/min, a respiratory rate of 15 /min, and a temperature of 36.5°C (97.7°F). Her cardiopulmonary auscultation is unremarkable, except for the identification of a 4th heart sound. Neurological examination reveals the patient is stuporous, with eye-opening response reacting only to pain, no verbal response, and flexion withdrawal to pain. Both pupils are symmetric, with the sluggish pupillary response to light. 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": "Charcot-Bouchard aneurysm rupture", "options": {"A": "Charcot-Bouchard aneurysm rupture", "B": "Arteriovenous malformation rupture", "C": "Dural arteriovenous fistula", "D": "Venous sinus thrombosis", "E": "Hemorrhagic transformation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "found unresponsive", "bedroom", "nursing facility", "past medical history", "relevant", "hypertension", "diagnosed", "calcium channel blocker", "thiazide diuretic", "found", "blood pressure", "200", "mm Hg", "heart rate", "70 min", "respiratory rate", "min", "temperature", "36", "97", "cardiopulmonary auscultation", "unremarkable", "except for", "identification", "4th", "sound", "Neurological", "reveals", "patient", "stuporous", "eye opening response reacting only", "pain", "verbal response", "flexion withdrawal to pain", "pupils", "symmetric", "sluggish pupillary response to light", "CT of", "head", "performed", "following", "etiology", "patients condition"]}
{"question": "An 11-year-old boy presents to his pediatrician with muscle cramps and fatigue that have progressively worsened over the past year. His mom says that he has always had occasional symptoms including abdominal pain, muscle weakness, and mild paresthesias; however, since starting middle school these symptoms have started interfering with his daily activities. In addition, the boy complains that he has been needing to use the restroom a lot, which is annoying since he has to ask for permission to leave class every time. Labs are obtained showing hypokalemia, hypochloremia, metabolic alkalosis, hypomagnesemia, and hypocalciuria. The most likely cause of this patient's symptoms involves a protein that binds which of the following drugs?", "answer": "Hydrochlorothiazide", "options": {"A": "Amiloride", "B": "Furosemide", "C": "Hydrochlorothiazide", "D": "Mannitol", "E": "Spironolactone"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "pediatrician", "muscle cramps", "fatigue", "worsened", "past year", "mom", "always", "occasional symptoms including abdominal pain", "muscle weakness", "mild paresthesias", "starting middle school", "symptoms", "started interfering", "addition", "boy", "needing to use", "restroom", "lot", "to", "permission to", "time", "Labs", "obtained", "hypokalemia", "hypochloremia", "metabolic alkalosis", "hypomagnesemia", "hypocalciuria", "most likely cause", "patient's symptoms", "a protein", "following drugs"]}
{"question": "A 67-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. His temperature is 97.5°F (36.4°C), blood pressure is 182/112 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 95% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. The patient is started on anti-hypertensive medications including a beta-blocker, a thiazide diuretic, and a calcium channel blocker. He returns 1 month later with no change in his blood pressure. Which of the following is the best next step in management?", "answer": "Renal ultrasound with Doppler", "options": {"A": "CT abdomen/pelvis", "B": "Increase dose of current blood pressure medications", "C": "Lisinopril", "D": "Renal ultrasound with Doppler", "E": "Surgical revascularization"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man", "smoking history", "diabetes type II", "hyperlipidemia presents", "primary care clinic", "annual exam", "complaints", "reports", "blood glucose", "tight control", "not smoked", "cigarette", "past", "months", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "85 min", "respirations", "min", "oxygen saturation", "95", "room air", "notable", "bruits", "lateral", "midline", "umbilicus", "patient", "started", "anti-hypertensive medications including", "beta-blocker", "thiazide diuretic", "calcium channel blocker", "returns 1 month later", "change", "blood pressure", "following", "best next step"]}
{"question": "A 7-year-old girl presents to a new pediatrician with fever, shortness of breath, and productive cough. She had similar symptoms a few weeks ago. The girl was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines and is meeting all developmental milestones. A further review of her history reveals seizures, upper respiratory infections, and cellulitis. On physical examination, the patient is pale with white-blonde hair and pale blue eyes. Which of the following would you expect to see on a peripheral blood smear for this patient?", "answer": "Polymorphonuclear leukocytes containing giant inclusion bodies", "options": {"A": "Predominance of band leukocytes", "B": "Stippled eosinophils", "C": "Downey cells", "D": "Polymorphonuclear leukocytes containing giant inclusion bodies", "E": "Significant basophil predominance"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "new pediatrician", "fever", "shortness of breath", "productive cough", "similar symptoms", "few weeks", "girl", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "further", "reveals seizures", "upper respiratory infections", "cellulitis", "patient", "pale", "white-blonde hair", "pale blue eyes", "following", "to see", "peripheral blood smear", "patient"]}
{"question": "A 16-year-old female presents to her pediatrician's office requesting to be started on an oral contraceptive pill. She has no significant past medical history and is not currently taking any medications. The physician is a devout member of the Roman Catholic church and is strongly opposed to the use of any type of artificial contraception. Which of the following is the most appropriate response to this patient's request?", "answer": "Explain that he will refer the patient to one of his partners who can fulfill this request", "options": {"A": "The physician is obligated to prescribe the oral contraceptives regardless of his personal beliefs", "B": "Refuse to prescribe the oral contraceptive", "C": "Suggest that the patient remain abstinent or, if necessary, use an alternative means of birth control", "D": "Explain that he will refer the patient to one of his partners who can fulfill this request", "E": "Tell the patient that he is unable to prescribe this medication without parental consent"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female presents", "pediatrician's office", "to", "started", "oral contraceptive pill", "significant past medical history", "not currently", "medications", "physician", "member", "Roman Catholic church", "use of", "type", "artificial contraception", "following", "most appropriate response", "patient's request"]}
{"question": "A 14-year-old boy presents to the emergency department with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. The patient is otherwise healthy and has no history of trauma or hereditary bleeding disorders. His temperature is 98.9°F (37.2°C), blood pressure is 120/64 mmHg, pulse is 85/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple clots in the nares which, when dislodged, are followed by bleeding. Which of the following location is the most likely etiology of this patient's symptoms?", "answer": "Kiesselbach plexus", "options": {"A": "Carotid artery", "B": "Ethmoidal artery", "C": "Kiesselbach plexus", "D": "Septal hematoma", "E": "Sphenopalatine artery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "emergency department", "intractable nosebleed", "Pinching", "nose", "failed to stop", "bleed", "patient", "healthy", "history", "trauma", "hereditary bleeding disorders", "temperature", "98 9F", "blood pressure", "64 mmHg", "pulse", "85 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "multiple clots", "nares", "followed by bleeding", "following location", "etiology", "patient's symptoms"]}
{"question": "A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation?", "answer": "15 mmHg decrease in systolic blood pressure with inspiration", "options": {"A": "Decrease in the patient's heart rate by 15 beats per minute with inspiration", "B": "Elevated blood pressure to 170/110", "C": "Steadily decreasing heart rate to 60 beats per minute", "D": "15 mmHg decrease in systolic blood pressure with inspiration", "E": "Decrease in central venous pressure by 5 mmHg with inspiration"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old male", "emergency department", "stab wound", "precordial chest wall", "patient", "distress", "cold", "sweaty", "pale", "Initial", "significant", "heart sounds", "distended neck", "3 cm stab wound", "left sternal border", "Breath sounds", "present", "of tracheal deviation", "following additional findings", "further"]}
{"question": "A 51-year-old woman comes to the physician because of a 3-day history of worsening shortness of breath, nonproductive cough, and sharp substernal chest pain. The chest pain worsens on inspiration and on lying down. The patient was diagnosed with breast cancer 2 months ago and was treated with mastectomy followed by adjuvant radiation therapy. She has hypertension and hyperlipidemia. Current medications include tamoxifen, valsartan, and pitavastatin. She has smoked a pack of cigarettes daily for 15 years but quit after being diagnosed with breast cancer. Her pulse is 95/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. Cardiac examination shows a scratching sound best heard at the left lower sternal border. An ECG shows sinus tachycardia and ST segment elevations in leads I, II, avF, and V1–6. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Neutrophilic infiltration of the pericardium", "options": {"A": "Dystrophic calcification of the mitral valve", "B": "Embolic occlusion of a pulmonary artery", "C": "Neutrophilic infiltration of the pericardium", "D": "Subendothelial fibrosis of coronary arteries", "E": "Fibrotic thickening of the pericardium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "of", "3-day history", "worsening shortness", "breath", "nonproductive cough", "sharp", "chest pain", "chest pain worsens", "inspiration", "lying", "patient", "diagnosed", "breast cancer", "months", "treated with mastectomy followed by adjuvant radiation therapy", "hypertension", "hyperlipidemia", "Current medications include tamoxifen", "valsartan", "pitavastatin", "smoked", "pack", "cigarettes daily", "years", "diagnosed", "breast cancer", "pulse", "95 min", "respirations", "20 min", "blood pressure", "60 mm Hg", "sound best heard", "left lower sternal border", "ECG", "sinus tachycardia", "ST segment elevations", "leads I", "avF", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 45-year-old man is brought into the clinic by his wife. She reports that her husband has been feeling down since he lost a big project at work 2 months ago. The patient says he feels unmotivated to work or do things around the house. He also says he is not eating or sleeping as usual and spends most of his day pacing about his room. He feels guilty for losing such a project this late in his career and feels overwhelming fear about the future of his company and his family’s well-being. During the interview, he appears to be in mild distress and is wringing his hands. The patient is prescribed citalopram and buspirone. Which of the following side effects is most commonly seen with buspirone?", "answer": "Lightheadedness", "options": {"A": "Lightheadedness", "B": "Dry mouth", "C": "Respiratory depression", "D": "Anterograde amnesia", "E": "Sleepwalking"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "clinic", "reports", "lost", "big", "2 months", "patient", "to", "house", "not eating", "sleeping", "usual", "spends most", "day", "room", "late", "company", "appears to", "mild distress", "hands", "patient", "citalopram", "buspirone", "following side effects", "most", "seen", "buspirone"]}
{"question": "A 35-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient?", "answer": "Pain relieved by sitting up and leaning forward", "options": {"A": "Pain improves with inspiration", "B": "Pain relieved by sitting up and leaning forward", "C": "High-pitched diastolic murmur", "D": "Fixed and split S2", "E": "Mid-systolic click"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old", "female presents", "emergency room", "of chest pain", "recent onset arthritis", "increased photosensitivity", "reveals bilateral facial rash", "following", "to", "observed", "patient"]}
{"question": "A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient’s husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient’s condition would most likely benefit from which of the following medications?", "answer": "Rivastigmine", "options": {"A": "Bromocriptine", "B": "Levodopa", "C": "Reserpine", "D": "Rivastigmine", "E": "Selegiline"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old woman presents", "primary care doctor", "reports", "not acting", "gotten lost", "several times", "past 2 months", "appears to", "talking", "frequently", "note", "patients", "died", "stroke", "months", "causing", "appetite", "decreased", "died", "oriented to person", "place", "time", "inattentive", "speech", "shakes", "hand", "exam", "gait", "slow", "appears unstable", "patients condition", "most likely benefit", "following medications"]}
{"question": "A 32-year-old female with Crohn's disease diagnosed in her early 20s comes to your office for a follow-up appointment. She is complaining of headaches and fatigue. Which of the following arterial blood findings might you expect?", "answer": "Normal Pa02, normal 02 saturation (Sa02), low 02 content (Ca02)", "options": {"A": "Normal Pa02, normal 02 saturation (Sa02), normal 02 content (Ca02)", "B": "Low Pa02, low 02 saturation (Sa02), low 02 content (Ca02)", "C": "Low Pa02, normal 02 saturation (Sa02), normal 02 content (Ca02)", "D": "Normal Pa02, normal 02 saturation (Sa02), low 02 content (Ca02)", "E": "High Pa02, normal 02 saturation (Sa02), normal 02 content (Ca02)"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "Crohn's disease diagnosed", "early 20s", "office", "follow-up appointment", "headaches", "fatigue", "following arterial blood findings"]}
{"question": "Four days into hospitalization for severe pneumonia, a 76-year-old woman suddenly becomes unresponsive. She has no history of heart disease. She is on clarithromycin and ceftriaxone. Her carotid pulse is not detected. A single-lead ECG strip is shown. Previous ECG shows QT prolongation. Laboratory studies show:\nSerum\nNa+ 145 mEq/L\nK+ 6.1 mEq/L\nCa2+ 10.5 mEq/L\nMg2+ 1.8 mEq/L\nThyroid-stimulating hormone 0.1 μU/mL\nCardiopulmonary resuscitation has been initiated. Which of the following is the most likely underlying cause of this patient’s recent condition?", "answer": "Clarithromycin", "options": {"A": "Hypercalcemia", "B": "Thyrotoxicosis", "C": "Hyperkalemia", "D": "Clarithromycin", "E": "Septic shock"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Four days", "severe pneumonia", "76 year old woman", "unresponsive", "history of heart disease", "clarithromycin", "ceftriaxone", "carotid pulse", "not detected", "single lead ECG strip", "Previous ECG", "QT prolongation", "Laboratory studies", "Serum", "mEq", "10", "8", "Thyroid-stimulating hormone", "mL Cardiopulmonary resuscitation", "initiated", "following", "underlying cause", "patients recent condition"]}
{"question": "A 42-year-old woman comes to the physician for a routine health maintenance examination. She is doing well. She is 168 cm (5 ft 6 in) tall and weighs 75 kg (165 lb); BMI is 27 kg/m2. Her BMI had previously been stable at 24 kg/m2. The patient states that she has had decreased appetite over the past month. The patient's change in appetite is most likely mediated by which of the following?", "answer": "Decreased hypothalamic neuropeptide Y", "options": {"A": "Increased hepatic somatomedin C secretion", "B": "Decreased hypothalamic neuropeptide Y", "C": "Potentiation of cholecystokinin", "D": "Increased fatty acid oxidation", "E": "Inhibition of proopiomelanocortin neurons"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "routine", "well", "5 ft 6", "tall", "75 kg", "BMI", "27 kg/m2", "BMI", "stable", "kg/m2", "patient states", "decreased appetite", "past month", "patient's change in appetite", "most likely mediated"]}
{"question": "A 35-year-old man is brought to the emergency department after experiencing a seizure. According to his girlfriend, he has had fatigue for the last 3 days and became confused this morning, after which he started having uncontrollable convulsions throughout his entire body. He was unconscious throughout the episode, which lasted about 4 minutes. He has not visited a physician for over 10 years. He has smoked one pack of cigarettes daily for 12 years. His girlfriend admits they occasionally use heroin together with their friends. His temperature is 38.8°C (101.8°F), pulse is 93/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. The lungs are clear to auscultation and examination shows normal heart sounds and no carotid or femoral bruits. He appears emaciated and somnolent. There are multiple track marks on both his arms. He is unable to cooperate for a neurological exam. Laboratory studies show a leukocyte count of 3,000/mm3, a hematocrit of 34%, a platelet count of 354,000/mm3, and an erythrocyte sedimentation rate of 27 mm/h. His CD4+ T-lymphocyte count is 84/mm3 (normal ≥ 500). A CT scan of the head is shown. Which of the following is the most appropriate next step considering this patient's CT scan findings?", "answer": "Pyrimethamine, sulfadiazine, and leucovorin", "options": {"A": "Pyrimethamine, sulfadiazine, and leucovorin", "B": "Trimethoprim-sulfamethoxazole", "C": "CT-guided stereotactic aspiration", "D": "Albendazole", "E": "Glucocorticoids"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old man", "brought", "emergency department", "seizure", "fatigue", "3 days", "confused", "morning", "started", "convulsions", "entire body", "unconscious", "episode", "lasted", "minutes", "not", "physician", "smoked one pack", "cigarettes daily", "years", "occasionally use heroin together", "temperature", "pulse", "min", "respirations", "20 min", "blood pressure", "70 mm Hg", "lungs", "clear", "auscultation", "normal heart sounds", "carotid", "femoral bruits", "appears emaciated", "somnolent", "multiple track marks", "arms", "unable to", "neurological exam", "Laboratory studies", "leukocyte count", "mm3", "hematocrit", "platelet count", "mm3", "erythrocyte sedimentation rate", "27 mm/h", "CD4", "lymphocyte count", "84 mm3", "normal", "500", "CT scan of", "head", "following", "most appropriate next step", "patient's CT scan findings"]}
{"question": "A 55-year-old woman presents with fatigue and flu-like symptoms. She says her symptoms started 5 days ago with a low-grade fever and myalgia, which have not improved. For the past 4 days, she has also had chills, sore throat, and rhinorrhea. She works as a kindergarten teacher and says several children in her class have had similar symptoms. Her past medical history is significant for depression managed with escitalopram, and dysmenorrhea. A review of systems is significant for general fatigue for the past 5 months. Her vital signs include: temperature 38.5°C (101.3°F), pulse 99/min, blood pressure 115/75 mm Hg, and respiratory rate 22/min. Physical examination reveals pallor of the mucous membranes. Initial laboratory findings are significant for the following:\nHematocrit 24.5%\nHemoglobin 11.0 g/dL\nPlatelet Count 215,000/mm3\nMean corpuscular volume (MCV) 82 fL\nRed cell distribution width (RDW) 10.5%\nWhich of the following is the best next diagnostic test in this patient?", "answer": "Reticulocyte count", "options": {"A": "Reticulocyte count", "B": "Serum folate level", "C": "Serum ferritin level", "D": "Serum iron level", "E": "Hemoglobin electrophoresis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "fatigue", "flu-like symptoms", "symptoms started 5 days", "low-grade fever", "myalgia", "not improved", "past", "days", "chills", "sore throat", "rhinorrhea", "kindergarten teacher", "several children", "similar symptoms", "past medical history", "significant", "depression", "escitalopram", "dysmenorrhea", "review of systems", "significant", "general fatigue", "past", "months", "vital signs include", "temperature", "pulse 99 min", "blood pressure", "75 mm Hg", "respiratory rate", "min", "reveals pallor", "mucous membranes", "Initial laboratory findings", "significant", "following", "Hematocrit", "Hemoglobin", "g", "Platelet", "volume", "Red cell distribution width", "following", "best next diagnostic test", "patient"]}
{"question": "An investigator is studying collagen synthesis in human fibroblast cells. Using a fluorescent tag, α-collagen chains are identified and then monitored as they travel through the rough endoplasmic reticulum, the Golgi apparatus, and eventually into the extracellular space. Which of the following steps in collagen synthesis occurs extracellularly?", "answer": "Cleavage of procollagen C- and N-terminals", "options": {"A": "Glycosylation of pro-α chains", "B": "Hydroxylation of proline and lysine", "C": "Cleavage of procollagen C- and N-terminals", "D": "Triple-helix formation", "E": "Translation of pro-α chains"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying", "human", "cells", "Using", "fluorescent tag", "collagen chains", "identified", "then monitored", "rough endoplasmic reticulum", "Golgi apparatus", "extracellular space", "following steps", "occurs"]}
{"question": "An 8-year-old boy is brought in by his mother due to complaints of a headache with diminished vision of his temporal field. It has been previously recorded that the patient has poor growth velocity. On imaging, a cystic calcified mass is noted above the sella turcica. From which of the following is this mass most likely derived?", "answer": "Oral ectoderm", "options": {"A": "Oral ectoderm", "B": "Cholesterol", "C": "Neuroectoderm", "D": "Neurohypophysis", "E": "Paraxial mesoderm"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "due to complaints", "headache", "diminished vision of", "temporal field", "recorded", "patient", "poor growth velocity", "imaging", "cystic calcified mass", "noted", "sella turcica", "following", "mass", "likely derived"]}
{"question": "A 65-year-old man comes to the physician because of a 10-month history of crampy left lower extremity pain that is exacerbated by walking and relieved by rest. The pain is especially severe when he walks on an incline. He has a 20-year history of type 2 diabetes mellitus, for which he takes metformin. He has smoked 1 pack of cigarettes daily for 40 years. His blood pressure is 140/92 mm Hg. Physical examination shows dry and hairless skin over the left foot. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Intimal plaque in the posterior tibial artery", "options": {"A": "Osteophytic compression of the lumbar spinal canal", "B": "Thrombosing vasculitis of the popliteal artery", "C": "Intimal plaque in the posterior tibial artery", "D": "Fibrin clot in the left popliteal vein", "E": "Systemic hyperplastic arteriolosclerosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old man", "physician", "a 10 month history", "crampy left", "exacerbated", "relieved by", "pain", "severe", "walks", "20 year history of type 2 diabetes mellitus", "metformin", "smoked 1 pack", "cigarettes daily", "40 years", "blood pressure", "mm Hg", "dry", "skin", "left foot", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 65-year-old African-American man comes to the physician for a follow-up examination after presenting with elevated blood pressure readings during his last visit. He has no history of major medical illness and takes no medications. He is 180 cm (5 ft 9 in) tall and weighs 68 kg (150 lb); BMI is 22 kg/m2. His pulse is 80/min and blood pressure is 155/90 mm Hg. Laboratory studies show no abnormalities. Which of the following is the most appropriate initial pharmacotherapy for this patient?", "answer": "Chlorthalidone", "options": {"A": "Valsartan", "B": "Metoprolol", "C": "Chlorthalidone", "D": "Aliskiren", "E": "Captopril"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old", "man", "physician", "follow-up examination", "elevated blood pressure", "history of major medical illness", "medications", "5 ft 9", "tall", "kg", "BMI", "kg/m2", "pulse", "80 min", "blood pressure", "90 mm Hg", "Laboratory studies", "abnormalities", "following", "most appropriate initial pharmacotherapy", "patient"]}
{"question": "A 7-month-old boy is brought in to his pediatrician’s office due to concern for recurrent infections. The parents state that over the last 3-4 months, the boy has had multiple viral respiratory infections, along with a fungal pneumonia requiring hospitalization. Currently he is without complaints; however, the parents are concerned that he continues to have loose stools and is falling off of his growth curve. Newborn screening is not recorded in the patient’s chart. On exam, the patient’s temperature is 98.4°F (36.9°C), blood pressure is 108/68 mmHg, pulse is 90/min, and respirations are 12/min. The patient is engaging appropriately and is able to grasp, sit, and is beginning to crawl. However, the patient is at the 20th percentile for length and weight, when he was previously at the 50th percentile at 3 months of age. Further screening suggests that the patient has an autosomal recessive immunodeficiency associated with absent T-cells. Which of the following is also associated with this disease?", "answer": "Accumulation of deoxyadenosine", "options": {"A": "Accumulation of deoxyadenosine", "B": "Dysfunctional cell chemotaxis", "C": "Mutation in ATM DNA repair gene", "D": "Negative nitroblue-tetrazolium test", "E": "Nonfunctional common gamma chain"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "pediatricians office due to", "recurrent infections", "state", "last", "months", "boy", "multiple viral", "fungal pneumonia", "Currently", "complaints", "to", "loose stools", "falling", "growth curve", "Newborn screening", "not", "chart", "exam", "patients temperature", "98", "36", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "patient", "engaging", "able", "grasp", "sit", "beginning", "crawl", "patient", "percentile", "length", "weight", "50th percentile", "3", "age", "Further screening", "patient", "immunodeficiency associated with absent T-cells", "following", "associated", "disease"]}
{"question": "A 51-year-old woman with a history of palpitations is being evaluated by a surgeon for epigastric pain. It is discovered that she has an epigastric hernia that needs repair. During her preoperative evaluation, she is ordered to receive lab testing, an electrocardiogram (ECG), and a chest X-ray. These screening studies are unremarkable except for her chest X-ray, which shows a 2 cm isolated pulmonary nodule in the middle lobe of the right lung. The nodule has poorly defined margins, and it shows a dense, irregular pattern of calcification. The patient is immediately referred to a pulmonologist for evaluation of the lesion. The patient denies any recent illnesses and states that she has not traveled outside of the country since she was a child. She has had no sick contacts or respiratory symptoms, and she does not currently take any medications. She does, however, admit to a 20-pack-year history of smoking. Which of the following is the most appropriate next step in evaluating this patient’s diagnosis with regard to the pulmonary nodule?", "answer": "Try to obtain previous chest radiographs for comparison", "options": {"A": "Obtain a contrast-enhanced CT scan of the chest", "B": "Send sputum for cytology", "C": "Order a positron emission tomography scan of the chest", "D": "Perform a flexible bronchoscopy with biopsy", "E": "Try to obtain previous chest radiographs for comparison"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "history of palpitations", "surgeon", "epigastric pain", "epigastric hernia", "needs repair", "preoperative evaluation", "ordered to receive lab testing", "electrocardiogram", "chest X-ray", "unremarkable", "chest X-ray", "2", "isolated pulmonary nodule", "the middle lobe of", "right lung", "nodule", "poorly", "margins", "dense", "irregular pattern", "calcification", "patient", "immediately referred", "pulmonologist", "lesion", "patient", "recent illnesses", "states", "not", "outside", "country", "child", "sick", "respiratory symptoms", "not currently", "medications", "20 year history of smoking", "following", "most appropriate next step", "patients diagnosis", "pulmonary nodule"]}
{"question": "You are currently employed as a clinical researcher working on clinical trials of a new drug to be used for the treatment of Parkinson's disease. Currently, you have already determined the safe clinical dose of the drug in a healthy patient. You are in the phase of drug development where the drug is studied in patients with the target disease to determine its efficacy. Which of the following phases is this new drug currently in?", "answer": "Phase 2", "options": {"A": "Phase 1", "B": "Phase 2", "C": "Phase 3", "D": "Phase 4", "E": "Phase 0"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["currently employed", "clinical researcher", "new", "to", "used", "treatment of Parkinson's disease", "Currently", "clinical dose", "drug", "healthy patient", "phase", "drug development", "drug", "studied", "patients", "target disease to", "efficacy", "following phases", "new drug currently"]}
{"question": "A 37-year-old man is presented to the emergency department by paramedics after being involved in a serious 3-car collision on an interstate highway while he was driving his motorcycle. On physical examination, he is responsive only to painful stimuli and his pupils are not reactive to light. His upper extremities are involuntarily flexed with hands clenched into fists. The vital signs include temperature 36.1°C (97.0°F), blood pressure 80/60 mm Hg, and pulse 102/min. A non-contrast computed tomography (CT) scan of the head shows a massive intracerebral hemorrhage with a midline shift. Arterial blood gas (ABG) analysis shows partial pressure of carbon dioxide in arterial blood (PaCO2) of 68 mm Hg, and the patient is put on mechanical ventilation. His condition continues to decline while in the emergency department and it is suspected that this patient is brain dead. Which of the following results can be used to confirm brain death and legally remove this patient from the ventilator?", "answer": "CT scan", "options": {"A": "Electrocardiogram", "B": "More than a 30% decrease in pulse oximetry", "C": "Lumbar puncture and CSF culture", "D": "Electromyography with nerve conduction studies", "E": "CT scan"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "emergency department", "paramedics", "involved", "serious", "car collision", "highway", "motorcycle", "responsive only", "painful", "pupils", "not reactive to light", "upper extremities", "flexed", "hands clenched", "fists", "vital signs include temperature 36", "97", "blood pressure 80 60 mm Hg", "pulse", "min", "non contrast computed tomography", "scan of", "head", "massive intracerebral", "midline shift", "Arterial blood gas", "analysis", "partial pressure", "carbon dioxide", "arterial blood", "mm Hg", "patient", "mechanical ventilation", "condition", "to", "emergency department", "suspected", "patient", "brain dead", "following results", "used to confirm brain death", "remove", "patient", "ventilator"]}
{"question": "A 45-year-old male presents to his primary care provider with an abnormal gait. He was hospitalized one week prior for acute cholecystitis and underwent a laparoscopic cholecystectomy. He received post-operative antibiotics via intramuscular injection. He recovered well and he was discharged on post-operative day #3. However, since he started walking after the operation, he noticed a limp that has not improved. On exam, his left hip drops every time he raises his left foot to take a step. In which of the following locations did this patient likely receive the intramuscular injection?", "answer": "Superomedial quadrant of the buttock", "options": {"A": "Anteromedial thigh", "B": "Superomedial quadrant of the buttock", "C": "Superolateral quadrant of the buttock", "D": "Inferomedial quadrant of the buttock", "E": "Inferolateral quadrant of the buttock"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "primary care provider", "abnormal gait", "hospitalized one week prior", "acute cholecystitis", "laparoscopic cholecystectomy", "received post-operative antibiotics", "intramuscular", "recovered well", "post-operative day", "3", "started", "operation", "limp", "not improved", "exam", "left hip drops", "time", "left foot to", "step", "following locations", "patient likely receive", "intramuscular injection"]}
{"question": "A 22-year-old woman in the intensive care unit has had persistent oozing from the margins of wounds for 2 hours that is not controlled by pressure bandages. She was admitted to the hospital 13 hours ago following a high-speed motor vehicle collision. Initial focused assessment with sonography for trauma was negative. An x-ray survey showed opacification of the right lung field and fractures of multiple ribs, the tibia, fibula, calcaneus, right acetabulum, and bilateral pubic rami. Laboratory studies showed a hemoglobin concentration of 14.8 g/dL, leukocyte count of 10,300/mm3, platelet count of 175,000/mm3, and blood glucose concentration of 77 mg/dL. Infusion of 0.9% saline was begun. Multiple lacerations on the forehead and extremities were sutured, and fractures were stabilized. Repeat laboratory studies now show a hemoglobin concentration of 12.4 g/dL, platelet count of 102,000/mm3, prothrombin time of 26 seconds (INR=1.8), and activated partial thromboplastin time of 63 seconds. Which of the following is the next best step in management?", "answer": "Transfuse packed RBC, fresh frozen plasma, and platelet concentrate in a 1:1:1 ratio", "options": {"A": "Transfuse packed RBC, fresh frozen plasma, and platelet concentrate in a 1:1:1 ratio", "B": "Transfuse whole blood and administer vitamin K", "C": "Transfuse fresh frozen plasma and platelet concentrate in a 1:1 ratio", "D": "Transfuse packed RBC", "E": "Transfuse packed RBC and fresh frozen plasma in a 1:1 ratio"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "intensive care unit", "persistent oozing", "margins", "wounds", "2 hours", "not controlled by pressure bandages", "hours", "following", "high speed motor vehicle", "Initial focused assessment", "sonography", "trauma", "negative", "x-ray survey", "opacification", "right lung field", "fractures of multiple ribs", "tibia", "fibula", "calcaneus", "right acetabulum", "bilateral pubic rami", "Laboratory studies", "a hemoglobin concentration", "dL", "leukocyte count", "10 300 mm3", "platelet count", "mm3", "blood glucose concentration", "mg/dL", "Infusion", "0.9", "saline", "begun", "Multiple lacerations", "forehead", "extremities", "sutured", "fractures", "stabilized", "Repeat laboratory studies now", "a hemoglobin concentration", "12.4 g/dL", "platelet count", "mm3", "prothrombin time", "seconds", "INR 1.8", "activated partial thromboplastin time", "63 seconds", "following", "next best step"]}
{"question": "A 13-month-old boy with sickle cell anemia is brought to the emergency department because of continuous crying and severe left-hand swelling. His condition started 2 hours earlier without any preceding trauma. The child was given diclofenac syrup at home with no relief. The temperature is 37°C (98.6°F), blood pressure is 100/60 mm Hg, and pulse is 100/min. The physical examination reveals swelling and tenderness to palpation of the left hand. The hemoglobin level is 10.4 g/dL. Which of the following is the best initial step in management of this patient condition?", "answer": "Intravenous morphine", "options": {"A": "Intravenous morphine", "B": "Intravenous meperidine", "C": "Joint aspiration", "D": "Incentive spirometry", "E": "Magnetic resonance imaging (MRI) of the affected joint"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy", "sickle cell anemia", "brought", "emergency department", "severe left-hand swelling", "condition started 2 hours earlier", "preceding trauma", "child", "given diclofenac", "at home", "relief", "temperature", "98", "blood pressure", "100 60 mm Hg", "pulse", "100 min", "reveals swelling", "tenderness", "palpation", "left hand", "hemoglobin level", "10.4 g/dL", "following", "best initial step", "management", "patient"]}
{"question": "A 31-year-old male comedian presents to your mental health clinic for a psychotherapy appointment. He is undergoing psychodynamic psychotherapy for depressive symptoms. During the therapy session, you discuss his job as a successful comedian and identify ways that he channels his emotions about his abusive childhood into comedy routines. Though he enjoys his job overall and idolizes some of his coworkers, he complains about most of them being “totally incompetent.” When you attempt to shift the discussion back to his childhood, he avoids eye contact and he tells you he “doesn’t want to talk about it anymore.” Which of the following is an immature defense mechanism exhibited by this patient?", "answer": "Splitting", "options": {"A": "Denial", "B": "Humor", "C": "Reaction formation", "D": "Splitting", "E": "Suppression"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old male comedian presents", "mental health clinic", "psychotherapy appointment", "psychodynamic psychotherapy", "depressive symptoms", "therapy", "successful comedian", "channels", "childhood", "routines", "overall", "totally incompetent", "to shift", "discussion back", "childhood", "to talk", "following", "immature", "patient"]}
{"question": "An investigator is studying the physiological response during congestive heart failure exacerbations in patients with systolic heart failure. A hormone released by ventricular cardiomyocytes in response to increased wall stress is isolated from a patient's blood sample. The intracellular mechanism by which this hormone acts is most similar to the effect of which of the following substances?", "answer": "Nitric oxide", "options": {"A": "Nitric oxide", "B": "Human chorionic gonadotropin", "C": "Aldosterone", "D": "Angiotensin II", "E": "Platelet-derived growth factor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying", "physiological response", "congestive heart failure exacerbations", "patients", "systolic heart failure", "hormone released", "ventricular", "response to increased wall stress", "isolated", "patient's blood sample", "intracellular mechanism", "hormone acts", "most similar", "effect", "following"]}
{"question": "An asymptomatic 15-year-old high school wrestler with no family history of renal disease is completing his preseason physical exam. He submits a urine sample for a dipstick examination, which tests positive for protein. What is the next appropriate step in management?", "answer": "Repeat dipstick on a separate occasion", "options": {"A": "Repeat dipstick on a separate occasion", "B": "Urine culture", "C": "Renal ultrasound", "D": "24 hour urine collection", "E": "Spot urine-protein-to-creatinine ratio"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["asymptomatic", "high school", "family history of disease", "completing", "submits", "urine", "dipstick", "tests positive", "protein", "next appropriate step"]}
{"question": "A 44-year-old man is brought to the emergency department by his daughter for a 1-week history of right leg weakness, unsteady gait, and multiple falls. During the past 6 months, he has become more forgetful and has sometimes lost his way along familiar routes. He has been having difficulties operating simple kitchen appliances such as the dishwasher and the coffee maker. He has recently become increasingly paranoid, agitated, and restless. He has HIV, hypertension, and type 2 diabetes mellitus. His last visit to a physician was more than 2 years ago, and he has been noncompliant with his medications. His temperature is 37.2 °C (99.0 °F), blood pressure is 152/68 mm Hg, pulse is 98/min, and respirations are 14/min. He is somnolent and slightly confused. He is oriented to person, but not place or time. There is mild lymphadenopathy in the cervical, axillary, and inguinal areas. Neurological examination shows right lower extremity weakness with normal tone and no other focal deficits. Laboratory studies show:\nHemoglobin 9.2 g/dL\nLeukocyte count 3600/mm3\nPlatelet count 140,000/mm3\nCD4+ count 56/μL\nHIV viral load > 100,000 copies/mL\nSerum\nCryptococcal antigen negative\nToxoplasma gondii IgG positive\nAn MRI of the brain shows disseminated, nonenhancing white matter lesions with no mass effect. Which of the following is the most likely diagnosis?\"", "answer": "Progressive multifocal leukoencephalopathy", "options": {"A": "Vascular dementia", "B": "Neurocysticercosis", "C": "Progressive multifocal leukoencephalopathy", "D": "Primary CNS lymphoma", "E": "Cerebral toxoplasmosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "1-week history of right leg weakness", "unsteady gait", "multiple falls", "past 6 months", "more forgetful", "sometimes lost", "familiar routes", "difficulties operating simple kitchen appliances", "maker", "recently", "agitated", "restless", "HIV", "hypertension", "type 2 diabetes mellitus", "last", "more", "years", "noncompliant", "medications", "temperature", "99 0 F", "blood pressure", "mm Hg", "pulse", "98 min", "respirations", "min", "somnolent", "slightly confused", "oriented to person", "not place", "time", "mild lymphadenopathy", "cervical", "axillary", "inguinal areas", "Neurological examination", "right lower extremity weakness", "normal tone", "focal deficits", "Laboratory studies", "Hemoglobin", "g Leukocyte count", "mm3 Platelet count", "CD4", "L HIV viral load", "100", "copies/mL Serum", "negative Toxoplasma gondii IgG positive", "MRI of", "brain", "disseminated", "nonenhancing white matter lesions", "mass effect", "following", "diagnosis"]}
{"question": "A 70 year-old man comes to the emergency department for sudden loss of vision in the right eye over the last 24 hours. He has noticed progressive bilateral loss of central vision over the last year. He has had difficulty reading his newspaper and watching his television. He has smoked 1 pack daily for 50 years. Ophthalmologic examination shows visual acuity of 20/60 in the left eye and 20/200 in the right eye. The pupils are equal and reactive to light. Tonometry reveals an intraocular pressure of 18 mm Hg in the right eye and 20 mm Hg in the left eye. Anterior segment exam is unremarkable. Slit-lamp examination shows subretinal fluid and small hemorrhage with grayish-green discoloration in the macular area in the right eye, and multiple drusen in the left eye with retinal pigment epithelial changes. Which of the following is the most appropriate initial treatment for the patient's illness?", "answer": "Ranibizumab", "options": {"A": "Etanercept", "B": "Thermal laser photocoagulation", "C": "Ranibizumab", "D": "Macular translocation surgery", "E": "Photodynamic therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man", "emergency department", "sudden loss of vision", "right eye", "24 hours", "progressive bilateral loss of central vision", "last year", "difficulty reading", "newspaper", "television", "smoked 1", "daily", "50", "Ophthalmologic examination", "visual acuity", "20/60", "left eye", "20/200", "right eye", "pupils", "equal", "reactive to light", "Tonometry reveals", "intraocular pressure", "mm Hg", "right eye", "20 mm Hg", "left eye", "Anterior segment exam", "unremarkable", "Slit-lamp examination", "subretinal fluid", "small hemorrhage", "grayish green discoloration", "macular area", "right eye", "multiple drusen", "left eye", "retinal pigment epithelial changes", "following", "most appropriate initial treatment", "patient's illness"]}
{"question": "A 67-year-old man presents to the emergency department with confusion. The patient is generally healthy, but his wife noticed him becoming progressively more confused as the day went on. The patient is not currently taking any medications and has no recent falls or trauma. His temperature is 102°F (38.9°C), blood pressure is 126/64 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a confused man who cannot participate in a neurological exam secondary to his confusion. No symptoms are elicited with flexion of the neck and jolt accentuation of headache is negative. Initial laboratory values are unremarkable and the patient's chest radiograph and urinalysis are within normal limits. An initial CT scan of the head is unremarkable. Which of the following is the best next step in management?", "answer": "Acyclovir", "options": {"A": "Acyclovir", "B": "CT angiogram of the head and neck", "C": "MRI of the head", "D": "PCR of the cerebrospinal fluid", "E": "Vancomycin, ceftriaxone, ampicillin, and dexamethasone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man presents", "emergency department", "confusion", "patient", "healthy", "more confused", "day", "patient", "not currently", "medications", "recent falls", "trauma", "temperature", "blood pressure", "64 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "confused man", "neurological exam secondary to", "confusion", "symptoms", "elicited", "flexion", "neck", "headache", "negative", "laboratory", "unremarkable", "patient's chest radiograph", "urinalysis", "normal limits", "initial CT scan of", "head", "unremarkable", "following", "best next step"]}
{"question": "A 70-year-old man presents to his primary care physician for ear pain. The patient states he has had ear pain for the past several days that seems to be worsening. The patient lives in a retirement home and previously worked as a banker. The patient currently is active, swims every day, and drinks 3 to 4 glasses of whiskey at night. There have been multiple cases of the common cold at his retirement community. The patient has a past medical history of myocardial infarction, Alzheimer dementia, diabetes, hypertension, vascular claudication, and anxiety. His current medications include insulin, metformin, aspirin, metoprolol, lisinopril, and buspirone. His temperature is 99.5°F (37.5°C), blood pressure is 167/108 mmHg, pulse is 102/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. HEENT exam is notable for tenderness over the left mastoid process. Abdominal and musculoskeletal exam are within normal limits. Which of the following is the best management for this patient's condition?", "answer": "Ciprofloxacin", "options": {"A": "Acetic acid drops", "B": "Amoxicillin", "C": "Amoxicillin/clavulanic acid", "D": "Ciprofloxacin", "E": "Observation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["70 year old man presents", "primary care physician", "ear pain", "patient states", "ear pain", "past", "days", "to", "worsening", "patient lives", "retirement home", "patient currently", "active", "day", "3", "4 glasses of", "night", "multiple cases", "common cold", "retirement community", "patient", "past medical history of myocardial infarction", "Alzheimer dementia", "diabetes", "hypertension", "vascular claudication", "anxiety", "current medications include insulin", "metformin", "aspirin", "metoprolol", "lisinopril", "buspirone", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room", "Cardiopulmonary exam", "normal limits", "HEENT exam", "notable", "tenderness", "left mastoid process", "Abdominal", "musculoskeletal exam", "normal limits", "following", "best management", "patient's"]}
{"question": "A 53-year-old woman with endometriosis comes to the physician because of bilateral flank pain and decreased urine output for 1-week. She has not had any fevers, chills, or dysuria. Physical examination shows several surgical scars on her abdomen. Laboratory studies show a serum creatinine concentration of 3.5 mg/dL. A CT scan of the abdomen shows numerous intra-abdominal adhesions, as well as dilatation of the renal pelvis and proximal ureters bilaterally. An increase in which of following is the most likely underlying mechanism of this patient's renal dysfunction?", "answer": "Hydrostatic pressure in the tubules", "options": {"A": "Hydrostatic pressure in the tubules", "B": "Osmotic pressure in the glomeruli", "C": "Hydrostatic pressure in the efferent arteriole", "D": "Osmotic pressure in the afferent arteriole", "E": "Osmotic pressure in the tubules"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "endometriosis", "physician", "bilateral flank pain", "decreased urine output", "1-week", "not", "fevers", "chills", "dysuria", "several surgical scars", "abdomen", "Laboratory studies", "serum creatinine concentration", "mg dL", "CT scan", "abdomen", "numerous intra-abdominal adhesions", "dilatation of the renal pelvis", "proximal ureters", "increase", "underlying mechanism", "patient's renal dysfunction"]}
{"question": "A 43-year-old male visits the emergency room around 4 weeks after getting bitten by a bat during a cave diving trip. After cleansing the wound with water, the patient reports that he felt well enough not to seek medical attention immediately following his trip. He does endorse feeling feverish in the past week but a new onset of photophobia and irritability led him to seek help today. What would the post-mortem pathology report show if the patient succumbs to this infection?", "answer": "Negri bodies", "options": {"A": "Psammoma bodies", "B": "Pick bodies", "C": "Heinz bodies", "D": "Negri bodies", "E": "Howell-Jolly bodies"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male", "emergency room", "weeks", "getting bitten", "cave", "trip", "wound", "water", "patient reports", "well", "not to", "medical", "immediately following", "trip", "feeling feverish", "past week", "new onset", "photophobia", "irritability led", "to", "help today", "post-mortem pathology", "patient", "infection"]}
{"question": "A 65-year-old woman is brought to the emergency department by her husband who found her lying unconscious at home. He says that the patient has been complaining of progressively worsening weakness and confusion for the past week. Her past medical history is significant for hypertension, systemic lupus erythematosus, and trigeminal neuralgia. Her medications include metoprolol, valsartan, prednisone, and carbamazepine. On admission, blood pressure is 130/70 mm Hg, pulse rate is 100 /min, respiratory rate is 17/min, and temperature is 36.5°C (97.7ºF). She regained consciousness while on the way to the hospital but is still drowsy and disoriented. Physical examination is normal. Finger-stick glucose level is 110 mg/dl. Other laboratory studies show:\nNa+ 120 mEq/L (136—145 mEq/L)\nK+ 3.5 mEq/L (3.5—5.0 mEq/L)\nCI- 107 mEq/L (95—105 mEq/L)\nCreatinine 0.8 mg/dL (0.6—1.2 mg/dL)\nSerum osmolality 250 mOsm/kg (275—295 mOsm/kg)\nUrine Na+ 70 mEq/L  \nUrine osmolality 105 mOsm/kg  \nShe is admitted to the hospital for further management. Which of the following is the next best step in the management of this patient’s condition?", "answer": "Fluid restriction", "options": {"A": "Fluid restriction", "B": "Rapid resuscitation with hypertonic saline", "C": "Desmopressin", "D": "Lithium", "E": "Tolvaptan"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old woman", "brought", "emergency department", "found", "lying unconscious", "home", "patient", "worsening weakness", "confusion", "past week", "past medical history", "significant", "hypertension", "systemic lupus erythematosus", "trigeminal neuralgia", "medications include metoprolol", "valsartan", "prednisone", "carbamazepine", "On admission", "blood pressure", "70 mm Hg", "pulse rate", "100", "min", "respiratory rate", "min", "temperature", "36", "97", "consciousness", "hospital", "drowsy", "disoriented", "normal", "Finger-stick glucose level", "mg/dl", "laboratory studies", "Na", "mEq/L", "mEq/L", "mEq/L", "3", "0 mEq/L", "CI", "mEq", "mEq/L", "Creatinine 0.8 mg/dL", "0 61 mg/dL", "Serum osmolality", "mOsm/kg", "mOsm/kg", "Urine Na", "70 mEq/L", "osmolality", "mOsm/kg", "further", "following", "next best step", "management", "patients condition"]}
{"question": "A 22-year-old primigravid woman at 12 weeks' gestation comes to the physician because of several hours of abdominal cramping and passing of large vaginal blood clots. Her temperature is 36.8°C (98.3°F), pulse is 75/min, and blood pressure is 110/65 mmHg. The uterus is consistent in size with a 12-week gestation. Speculum exam shows an open cervical os and blood clots within the vaginal vault. Transvaginal ultrasound shows an empty gestational sac. The patient is worried about undergoing invasive procedures. Which of the following is the most appropriate next step in management?", "answer": "Expectant management", "options": {"A": "Dilation and curettage", "B": "Expectant management", "C": "Methotrexate therapy", "D": "Serial beta-hCG measurement", "E": "Oxytocin therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old primigravid woman", "weeks", "gestation", "physician", "several hours", "abdominal cramping", "large vaginal blood clots", "temperature", "36", "98", "pulse", "75 min", "blood pressure", "65 mmHg", "uterus", "size", "week gestation", "Speculum exam", "open cervical os", "blood clots", "vaginal vault", "Transvaginal ultrasound", "empty gestational sac", "patient", "worried", "invasive procedures", "following", "most appropriate next step"]}
{"question": "A surgeon is interested in studying how different surgical techniques impact the healing of tendon injuries. In particular, he will compare 3 different types of suture repairs biomechanically in order to determine the maximum load before failure of the tendon 2 weeks after repair. He collects data on maximum load for 90 different repaired tendons from an animal model. Thirty tendons were repaired using each of the different suture techniques. Which of the following statistical measures is most appropriate for analyzing the results of this study?", "answer": "ANOVA", "options": {"A": "ANOVA", "B": "Chi-squared", "C": "Pearson r coefficient", "D": "Student t-test", "E": "Wilcoxon rank sum"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["surgeon", "studying", "different surgical techniques impact", "healing of tendon injuries", "3 different types of suture repairs", "order to", "maximum load", "failure", "tendon 2 weeks", "repair", "collects data", "maximum load", "90 different repaired tendons", "Thirty", "repaired using", "different suture techniques", "following", "measures", "most appropriate", "results", "study"]}
{"question": "A 67-year-old man comes to the physician because of a 2-month history of generalized fatigue. On examination, he appears pale. He also has multiple pinpoint, red, nonblanching spots on his extremities. His spleen is significantly enlarged. Laboratory studies show a hemoglobin concentration of 8.3 g/dL, a leukocyte count of 81,000/mm3, and a platelet count of 35,600/mm3. A peripheral blood smear shows immature cells with large, prominent nucleoli and pink, elongated, needle-shaped cytoplasmic inclusions. Which of the following is the most likely diagnosis?", "answer": "Acute myelogenous leukemia", "options": {"A": "Myelodysplastic syndrome", "B": "Acute lymphoblastic leukemia", "C": "Acute myelogenous leukemia", "D": "Chronic myelogenous leukemia", "E": "Hairy cell leukemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "physician", "2 month history", "generalized fatigue", "appears pale", "multiple pinpoint", "red", "spots", "extremities", "spleen", "enlarged", "Laboratory studies", "a hemoglobin concentration", "3 g/dL", "leukocyte count", "81", "mm3", "platelet count", "35 600 mm3", "peripheral blood smear", "immature cells", "large", "prominent nucleoli", "pink", "elongated", "needle-shaped cytoplasmic inclusions", "following", "diagnosis"]}
{"question": "An investigator is studying the effect that mutations in different parts of the respiratory tract have on susceptibility to infection. A mutation in the gene encoding for the CD21 protein is induced in a sample of cells obtained from the nasopharyngeal epithelium. This mutation is most likely to prevent infection with which of the following viruses?", "answer": "Epstein-Barr virus", "options": {"A": "Rhinovirus", "B": "Epstein-Barr virus", "C": "Human immunodeficiency virus", "D": "Cytomegalovirus", "E": "Parvovirus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "effect", "different parts of", "respiratory tract", "susceptibility", "infection", "mutation", "gene", "CD21 protein", "induced", "cells obtained", "nasopharyngeal epithelium", "mutation", "to prevent infection", "following viruses"]}
{"question": "A 33-year-old woman presents to her primary care physician for gradually worsening pain in both wrists that began several months ago. The pain originally did not bother her, but it has recently begun to affect her daily functioning. She states that the early morning stiffness in her hands is severe and has made it difficult to tend to her rose garden. She occasionally takes ibuprofen for the pain, but she says this does not really help. Her medical history is significant for diabetes mellitus and major depressive disorder. She is currently taking insulin, sertraline, and a daily multivitamin. The vital signs include: blood pressure 126/84 mm Hg, heart rate 82/min, and temperature 37.0°C (98.6°F). On physical exam, her wrists and metacarpophalangeal joints are swollen, tender, erythematous, and warm to the touch. There are no nodules or vasculitic lesions. Which of the following antibodies would be most specific to this patient’s condition?", "answer": "Anti-cyclic citrullinated peptide", "options": {"A": "Anti-Ro", "B": "Rheumatoid factor", "C": "Anti-Scl-70", "D": "c-ANCA", "E": "Anti-cyclic citrullinated peptide"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care physician", "worsening pain in", "wrists", "began several months", "pain", "not", "recently begun to", "daily functioning", "states", "early morning", "hands", "severe", "made", "difficult to", "rose garden", "occasionally", "ibuprofen", "pain", "not", "help", "medical history", "significant", "diabetes mellitus", "major depressive disorder", "currently", "insulin", "sertraline", "daily multivitamin", "vital signs include", "blood pressure", "84 mm Hg", "heart rate", "min", "temperature", "98", "wrists", "metacarpophalangeal joints", "swollen", "tender", "erythematous", "warm", "touch", "nodules", "vasculitic lesions", "following antibodies", "most specific", "patients condition"]}
{"question": "A 22-year-old man comes to the physician for a follow-up evaluation for chronic lower back pain. He has back stiffness that lasts all morning and slowly improves throughout the day. He has tried multiple over-the-counter medications, including ibuprofen, without any improvement in his symptoms. Physical examination shows tenderness over the iliac crest bilaterally and limited range of motion of the lumbar spine with forward flexion. The results of HLA-B27 testing are positive. An x-ray of the lumbar spine shows fusion of the lumbar vertebrae and sacroiliac joints. The physician plans to prescribe a new medication but first orders a tuberculin skin test to assess for the risk of latent tuberculosis reactivation. Inhibition of which of the following is the most likely primary mechanism of action of this drug?", "answer": "TNF-α", "options": {"A": "Inosine monophosphate dehydrogenase", "B": "TNF-α", "C": "NF-κB", "D": "Calcineurin", "E": "mTOR kinase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "follow-up", "chronic lower back pain", "back stiffness", "lasts", "morning", "slowly improves", "day", "multiple over-the-counter medications", "including ibuprofen", "symptoms", "Physical", "tenderness", "iliac crest", "limited range of motion", "lumbar spine", "forward flexion", "results", "HLA B27 testing", "positive", "x-ray of", "lumbar spine", "fusion", "lumbar vertebrae", "sacroiliac joints", "physician plans to", "new medication", "first orders", "tuberculin skin test to", "tuberculosis reactivation", "following", "primary mechanism of action", "drug"]}
{"question": "A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the NSA is spying on him and controlling his mind. His wife reports that the patient has become withdrawn and at times depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an invention that will block people from being able to control his mind. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?", "answer": "Schizophreniform disorder", "options": {"A": "Delusional disorder", "B": "Schizophreniform disorder", "C": "Schizophrenia", "D": "Brief psychotic disorder", "E": "Schizotypal personality disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "agitated behavior", "weeks", "controlling", "reports", "patient", "withdrawn", "times depressed", "past 3 months", "lost", "stopped", "to", "4 weeks", "then", "block", "able to control", "Physical", "neurologic examinations", "abnormalities", "mental status", "confused", "suspicious", "marked psychomotor agitation", "speech", "following", "diagnosis"]}
{"question": "A 28-year-old man presents to his primary care provider because of shortness of breath, cough, and wheezing. He reports that in high school, he occasionally had shortness of breath and would wheeze after running. His symptoms have progressively worsened over the past 6 months and are now occurring daily. He also finds himself being woken up from sleep by his wheeze approximately 3 times a week. His medical history is unremarkable. He denies tobacco use or excessive alcohol consumption. His temperature is 37.1°C (98.8°F), blood pressure is 121/82 mm Hg, and heart rate is 82/min. Physical examination is remarkable for expiratory wheezing bilaterally. Spirometry shows an FEV1 of 73% of predicted, which improves by 19% with albuterol. In addition to a short-acting beta-agonist as needed, which of the following is the most appropriate therapy for this patient?", "answer": "A low-dose inhaled corticosteroid and a long-acting beta-agonist", "options": {"A": "A low-dose inhaled corticosteroid alone", "B": "A long-acting beta-agonist alone", "C": "A low-dose inhaled corticosteroid and a long-acting beta-agonist", "D": "A medium-dose inhaled corticosteroid and a long-acting beta-agonist", "E": "A high-dose inhaled corticosteroid and a long-acting beta-agonist"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider", "of shortness", "breath", "cough", "wheezing", "reports", "high school", "occasionally", "shortness of breath", "wheeze", "symptoms", "worsened", "past 6 months", "now occurring daily", "finds", "woken up", "sleep", "wheeze approximately", "times", "week", "medical history", "unremarkable", "tobacco use", "excessive alcohol consumption", "temperature", "98", "blood pressure", "mm Hg", "heart rate", "min", "expiratory wheezing", "Spirometry", "FEV1", "predicted", "improves", "albuterol", "short acting beta agonist as needed", "following", "most appropriate therapy", "patient"]}
{"question": "A 35-year-old woman comes to the physician because of a dry cough and worsening shortness of breath with exertion for the past 6 months. She used to go running three times each week but had to stop because of decreased exercise tolerance and pain in the bilateral ankles. Two months ago, she was in Nigeria for several weeks to visit her family. She is allergic to cats and pollen. She has smoked one pack of cigarettes daily for the past 17 years. Her vital signs are within normal limits. Examination shows multiple 1.5- to 2-cm, nontender lymph nodes in the axillae. A few crackles are heard on auscultation of the chest. Her serum calcium concentration is 11.7 mg/dL. An x-ray of the chest shows enlarged hilar lymph nodes bilaterally and reticular opacities in both lungs. Which of the following is the most likely cause of these findings?", "answer": "Granulomatous inflammation", "options": {"A": "Necrotizing inflammation", "B": "Granulomatous inflammation", "C": "Neoplastic transformation", "D": "Viral infection", "E": "Air trapping"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old woman", "physician", "dry cough", "worsening shortness of breath", "exertion", "past 6 months", "used to go", "three times", "week", "to stop", "decreased exercise tolerance", "pain in", "bilateral ankles", "Two months", "Nigeria", "several weeks to", "allergic to cats", "pollen", "smoked one pack", "cigarettes daily", "past", "years", "vital signs", "normal limits", "multiple", "2", "nontender lymph nodes", "axillae", "few crackles", "heard", "auscultation", "chest", "serum concentration", "mg/dL", "x-ray of", "chest", "enlarged hilar", "reticular opacities", "lungs", "following", "most likely cause", "findings"]}
{"question": "A 78-year-old male presents to the emergency department after passing out. His wife reports that she and the patient were walking their dog when he suddenly lost consciousness. On physical exam, he has a loud crescendo-decrescendo systolic murmur and is subsequently diagnosed with severe aortic stenosis. The patient undergoes open aortic valve replacement and has an uncomplicated postoperative course. His sternal wound drain is pulled for low output on post-operative day three. On post-operative day five, the patient complains of pain during deep inspiration and retrosternal chest pain. His temperature is 101.7°F (38.7°C), blood pressure is 125/81 mmHg, pulse is 104/min, and respirations are 18/min. On physical exam, the patient is tender to palpation around his sternal wound, and there is erythema around the incision without dehiscence. His chest radiograph shows a widened mediastinum with a small pleural effusion on the left. CT angiography shows stranding in the subcutaneous tissue and a fluid collection below the sternum.\n\nWhich of the following is the best next step in management?", "answer": "Intravenous antibiotics and debridement of surgical wound", "options": {"A": "Placement of a left-sided chest tube", "B": "Surgical repair of esophageal perforation", "C": "Surgical repair of aortic injury", "D": "Intravenous antibiotics and observation", "E": "Intravenous antibiotics and debridement of surgical wound"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old male presents", "emergency department", "out", "reports", "patient", "lost consciousness", "loud crescendo-decrescendo systolic murmur", "diagnosed", "severe aortic stenosis", "patient", "open aortic valve replacement", "uncomplicated postoperative course", "sternal", "pulled", "low", "post-operative day three", "post-operative day five", "patient", "pain", "deep inspiration", "retrosternal chest pain", "temperature", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "patient", "tender", "palpation", "sternal wound", "erythema", "incision", "dehiscence", "chest radiograph", "widened mediastinum", "small pleural effusion", "left", "CT angiography", "stranding", "subcutaneous tissue", "fluid collection", "sternum", "following", "best next step"]}
{"question": "A 66-year-old G3P3 presents with an 8-year-history of back pain, perineal discomfort, difficulty urinating, recurrent malaise, and low-grade fevers. These symptoms have recurred regularly for the past 5–6 years. She also says that there are times when she experiences a feeling of having a foreign body in her vagina. With the onset of symptoms, she was evaluated by a physician who prescribed her medications after a thorough examination and recommended a vaginal pessary, but she was non-compliant. She had 3 vaginal deliveries She has been menopausal since 51 years of age. She does not have a history of malignancies or cardiovascular disease. She has type 2 diabetes mellitus that is controlled with diet and metformin. Her vital signs include: blood pressure 110/60 mm Hg, heart rate 91/min, respiratory rate 13/min, and temperature 37.4℃ (99.3℉). On physical examination, there is bilateral costovertebral angle tenderness. The urinary bladder is non-palpable. The gynecologic examination reveals descent of the cervix to the level of the introitus. A Valsalva maneuver elicits uterine procidentia. Which pathology is most likely to be revealed by imaging in this patient?", "answer": "Hydronephrosis", "options": {"A": "Renal tumor", "B": "Hydronephrosis", "C": "Urinary bladder polyp", "D": "Renal calculi", "E": "Renal cyst"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old", "presents", "year history of back pain", "perineal discomfort", "difficulty urinating", "recurrent malaise", "low-grade fevers", "symptoms", "past", "years", "times", "foreign body in", "vagina", "onset", "symptoms", "physician", "medications", "vaginal pessary", "non-compliant", "3 vaginal deliveries", "menopausal", "years", "age", "not", "history", "malignancies", "cardiovascular disease", "type 2 diabetes mellitus", "controlled", "diet", "metformin", "vital signs include", "blood pressure", "60 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "bilateral costovertebral angle tenderness", "urinary bladder", "non-palpable", "reveals descent", "cervix", "level", "introitus", "Valsalva maneuver elicits uterine procidentia", "pathology", "to", "revealed", "imaging", "patient"]}
{"question": "A 9-year-old boy is brought to the emergency department for the evaluation of diarrhea and vomiting for the last 2 days. During this period, he has had about 12 watery, non-bloody bowel movements and has vomited three times. He came back from a trip to India 3 days ago, where he and his family were visiting relatives. He has not been able to eat anything since the symptoms started. The patient has not urinated since yesterday. He appears pale. His temperature is 38°C (100.4°F), pulse is 106/min, and blood pressure is 96/60 mm Hg. Examination shows dry mucous membranes. The abdomen is soft with no organomegaly. Bowel sounds are hyperactive. Laboratory studies show:\nHemoglobin 13 g/dL\nSerum\nNa+ 148 mEq/L\nCl- 103 mEq/L\nK+ 3.7 mEq/L\nHCO3- 19 mEq/L\nUrea nitrogen 80 mg/dL\nGlucose 90 mg/dL\nCreatinine 2 mg/dL\nIntravenous fluid resuscitation is begun. Which of the following is the most likely cause of this patient's abnormal renal laboratory findings?\"", "answer": "Decreased renal perfusion", "options": {"A": "Decreased renal perfusion", "B": "Renal artery stenosis", "C": "IgA complex deposition", "D": "Glomerulonephritis", "E": "Urinary tract obstruction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "diarrhea", "vomiting", "2 days", "period", "about", "non bloody", "vomited three times", "back", "trip", "India", "days", "not", "able to eat", "since", "symptoms started", "patient", "not", "appears pale", "temperature", "100", "pulse", "min", "blood pressure", "96 60 mm Hg", "dry mucous membranes", "abdomen", "soft", "organomegaly", "Bowel sounds", "hyperactive", "Laboratory studies", "13", "Serum", "K", "HCO3", "Urea nitrogen", "mg", "mg", "Creatinine", "fluid resuscitation", "begun", "following", "most likely cause", "patient", "bnormal  enal  aboratory findings?"]}
{"question": "A previously healthy 25-year-old man comes to the physician because of a 4-day history of fever, joint and body pain, diffuse headache, and pain behind the eyes. This morning he noticed that his gums bled when he brushed his teeth. He returned from a backpacking trip to the Philippines 4 days ago. His temperature is 39.4°C (103.0°F). Physical examination shows a diffuse maculopapular rash. His leukocyte count is 3,200/mm3 and platelet count is 89,000/mm3. Further evaluation shows increased serum levels of a flavivirus. Which of the following is the most likely causal pathogen?", "answer": "Dengue virus", "options": {"A": "Chikungunya virus", "B": "Ebola virus", "C": "Hanta virus", "D": "Lassa virus", "E": "Dengue virus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old man", "physician", "4-day history", "fever", "joint", "body pain", "diffuse headache", "pain", "eyes", "morning", "gums bled", "brushed", "teeth", "returned", "trip", "Philippines", "days", "temperature", "diffuse maculopapular rash", "leukocyte count", "3 200 mm3", "platelet count", "mm3", "Further", "increased serum levels", "following", "causal"]}
{"question": "You are reviewing the protocol for a retrospective case-control study investigating risk factors for mesothelioma among retired factory workers. 100 cases of mesothelioma and 100 age and sex matched controls are to be recruited and interviewed about their exposure to industrial grade fiberglass by blinded interviewers. The investigators' primary hypothesis is that cases of mesothelioma will be more likely to have been exposed to industrial grade fiberglass. The design of this study is most concerning for which type of bias?", "answer": "Recall bias", "options": {"A": "Interviewer bias", "B": "Recall bias", "C": "Observer bias", "D": "Lead-time bias", "E": "This study design is free of potential bias"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["reviewing", "protocol", "retrospective", "risk factors", "mesothelioma", "retired factory workers", "100 cases", "mesothelioma", "100 age", "sex matched controls", "to", "exposure", "grade", "interviewers", "investigators", "primary", "cases", "mesothelioma", "more likely to", "exposed", "grade", "most", "type"]}
{"question": "A 40-year-old man presents to his primary care provider complaining of abdominal pain. The patient reports a dull pain that has been present for 4 weeks now. The patient states that the pain is located to his right upper quadrant and does not change with eating. The patient denies any alcohol or illicit substance use, stating that he is meticulous about eating healthy since he is a professional bodybuilder. The patient reports no history of malignancy. On exam, the patient's temperature is 98.2°F (36.8°C), blood pressure is 130/86 mmHg, pulse is 60/min, and respirations are 12/min. The patient has an athletic build, and his exam is unremarkable for any palpable mass or abdominal tenderness. On further questioning, the patient does endorse a 5-year history of using anabolic steroids for bodybuilding. Imaging demonstrates an enhancing liver nodule. Which of the following is the most likely histopathologic finding of this patient’s disease?", "answer": "Sheets of normal hepatocytes without portal tracts or central veins", "options": {"A": "Columnar cells with acinar structures", "B": "Hemorrhagic nests with atypical endothelial cells", "C": "Hypervascular lesion lined by normal endothelial cells", "D": "Multifocal tumor with multiple layers of hepatocytes with hemorrhage and necrosis", "E": "Sheets of normal hepatocytes without portal tracts or central veins"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["40 year old man presents", "primary care provider", "abdominal pain", "patient reports", "dull pain", "present", "weeks now", "patient states", "pain", "right upper quadrant", "not change", "eating", "patient", "alcohol", "illicit substance use", "stating", "eating healthy", "professional", "patient reports", "history", "malignancy", "exam", "patient's temperature", "98", "36", "blood pressure", "mmHg", "pulse", "60 min", "respirations", "min", "patient", "exam", "unremarkable", "palpable mass", "abdominal tenderness", "further", "patient", "5 year history", "using anabolic steroids", "bodybuilding", "Imaging", "liver nodule", "following", "histopathologic finding", "patients disease"]}
{"question": "A 48-year-old man comes to the physician because of a 3-month history of worsening shortness of breath and cough productive of frothy, whitish sputum. One year ago, he had a similar episode lasting 6 months. He has smoked a pack of cigarettes daily for 25 years. Physical examination shows bluish discoloration of the tongue and lips. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Increased serum hematocrit", "options": {"A": "Increased pulmonary capillary wedge pressure", "B": "Normal FEV1", "C": "Increased FEV1/FVC ratio", "D": "Increased serum hematocrit", "E": "Increased diffusing capacity for carbon monoxide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["48 year old man", "physician", "of", "3 month history", "worsening shortness", "breath", "cough productive", "frothy", "sputum", "One year ago", "similar episode lasting", "months", "smoked", "pack", "cigarettes daily", "years", "discoloration", "tongue", "lips", "Scattered expiratory wheezing", "rhonchi", "heard", "lung fields", "Further", "to", "following findings"]}
{"question": "A 24-year-old woman presents to the emergency department after she was found agitated and screaming for help in the middle of the street. She says she also has dizziness and tingling in the lips and hands. Her past medical history is relevant for general anxiety disorder, managed medically with paroxetine. At admission, her pulse is 125/min, respiratory rate is 25/min, and body temperature is 36.5°C (97.7°C). Physical examination is unremarkable. An arterial blood gas sample is taken. Which of the following results would you most likely expect to see in this patient?", "answer": "pH: increased, HCO3- : decreased, Pco2: decreased", "options": {"A": "pH: increased, HCO3- : decreased, Pco2: decreased", "B": "pH: decreased, HCO3- : decreased, Pco2: decreased", "C": "pH: decreased, HCO3- : increased, Pco2: increased", "D": "pH: increased, HCO3- : increased, Pco2: increased", "E": "pH: normal, HCO3- : increased, Pco2: increased"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "found agitated", "help", "middle", "street", "dizziness", "tingling", "lips", "hands", "past medical history", "relevant", "general anxiety disorder", "paroxetine", "pulse", "min", "respiratory rate", "min", "body temperature", "36", "97", "unremarkable", "arterial blood sample", "following results", "most likely", "to see", "patient"]}
{"question": "A 42-year-old woman presents to a medical office with complaints of fatigue, weight loss, and low-grade fever for 1 week. She noticed bleeding spots on her feet this morning. The past medical history is significant for a recent dental appointment. She is a non-smoker and does not drink alcohol. She does not currently take any medications. On examination, the vital signs include temperature 37.8°C (100.0°F), blood pressure 138/90 mm Hg, respirations 21/min, and pulse 87/min. Cardiac auscultation reveals a pansystolic murmur in the mitral area with radiation to the right axilla. Laboratory studies show hemoglobin levels of 17.2 g/dL, erythrocyte sedimentation rate (ESR) of 25 mm/h, and a white blood cell (WBC) count of 12,000 cells/mm3. An echocardiogram (ECG) reveals valvular vegetations on the mitral valve with mild regurgitation. Blood samples are sent for bacterial culture. Empiric antibiotic therapy is initiated with ceftriaxone and vancomycin. The blood cultures most likely will yield the growth of which of the following organisms?", "answer": "Streptococcus viridans", "options": {"A": "Staphylococcus aureus", "B": "Actinomyces israelii", "C": "Streptococcus viridans", "D": "Group B Streptococcus", "E": "Coxiella burnetii"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "medical office", "complaints", "fatigue", "weight loss", "low-grade fever", "1 week", "bleeding spots", "feet", "morning", "past medical history", "significant", "recent dental appointment", "non-smoker", "not", "alcohol", "not currently", "medications", "vital signs include temperature", "100", "blood pressure", "90 mm Hg", "respirations", "min", "pulse 87 min", "Cardiac auscultation reveals", "pansystolic murmur", "mitral area", "radiation", "right axilla", "Laboratory studies", "hemoglobin levels", "g dL", "erythrocyte sedimentation rate", "25 mm h", "white blood cell", "count", "cells/mm3", "echocardiogram", "reveals valvular vegetations", "mitral valve", "mild regurgitation", "Blood samples", "sent for bacterial culture", "Empiric antibiotic therapy", "initiated", "ceftriaxone", "vancomycin", "blood cultures", "likely", "growth", "following organisms"]}
{"question": "A 38-year-old G2P2 presents to her gynecologist to discuss the results of her diagnostic tests. She has no  current complaints or concurrent diseases. She underwent a tubal ligation after her last pregnancy. Her last Pap smear showed a high-grade squamous intraepithelial lesion and a reflex HPV test was positive. Colposcopic examination reveals areas of thin acetowhite epithelium with diffuse borders and fine punctation. The biopsy obtained from the suspicious areas shows CIN 1. Which of the following is an appropriate next step in the management of this patient?", "answer": "Loop electrosurgical excision procedure", "options": {"A": "Cryoablation", "B": "Loop electrosurgical excision procedure", "C": "Cold-knife conization", "D": "Test for type 16 and 18 HPV", "E": "Repeat cytology and HPV co-testing in 6 months"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "presents", "gynecologist to", "results", "diagnostic tests", "current complaints", "concurrent diseases", "tubal", "pregnancy", "last Pap smear", "high-grade squamous intraepithelial lesion", "HPV", "positive", "Colposcopic", "reveals areas", "thin", "epithelium", "diffuse borders", "fine punctation", "biopsy obtained", "suspicious areas", "CIN 1", "following", "appropriate next step", "patient"]}
{"question": "A 62-year-old man comes to the physician for a follow-up examination after having been diagnosed with stage II adenocarcinoma of the left lower lung lobe without evidence of distant metastases 1 week ago following an evaluation for a chronic cough. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 40 years. His current medications include metformin, sitagliptin, and enalapril. He is 177 cm (5 ft 10 in) tall and weighs 65 kg (143 lb); BMI is 20.7 kg/m2. He appears lethargic. Vital signs are within normal limits. Pulse oximetry shows an oxygen saturation of 98%. Examination shows inspiratory wheezing at the left lung base. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, glucose, and liver enzymes are within the reference range. Spirometry shows an FEV1 of 1.6 L. The diffusing lung capacity for carbon monoxide (DLCO) is 66% of predicted. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Schedule lobectomy", "options": {"A": "Schedule lobectomy", "B": "Radiation therapy", "C": "Schedule a wedge resection", "D": "Administer cisplatin and etoposide", "E": "Administer cisplatin and vinorelbine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man", "physician", "follow-up examination", "diagnosed", "adenocarcinoma of the left lower lung lobe", "1 week", "following", "chronic cough", "hypertension", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "past 40 years", "current medications include metformin", "sitagliptin", "enalapril", "5 ft 10", "tall", "65 kg", "BMI", "20", "kg/m2", "appears lethargic", "Vital signs", "normal limits", "Pulse oximetry", "oxygen saturation", "98", "inspiratory wheezing", "left", "abnormalities", "complete blood count", "serum", "electrolytes", "creatinine", "glucose", "liver enzymes", "reference range", "Spirometry", "FEV1", "diffusing lung capacity", "carbon monoxide", "DLCO", "66", "predicted", "following", "most appropriate next step", "patient"]}
{"question": "An otherwise healthy 23-year-old man comes to the physician because of a 3-day history of mild persistent bleeding from the site of a tooth extraction. He has no prior history of medical procedures or surgeries and no history of easy bruising. He appears well. Vital signs are within normal limits. Laboratory studies show:\nHemoglobin 12.4 g/dL\nPlatelets 200,000/mm3\nSerum\nProthrombin time 25 seconds\nPartial thromboplastin time (activated) 35 seconds\nDeficiency of which of the following coagulation factors is the most likely cause of this patient’s condition?\"", "answer": "Factor VII", "options": {"A": "Factor VII", "B": "Factor V", "C": "Factor II", "D": "Factor XIII", "E": "Factor X"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy 23 year old man", "physician", "3-day history", "mild persistent bleeding", "site of", "tooth extraction", "prior history of medical procedures", "surgeries", "history", "easy bruising", "appears well", "Vital signs", "normal limits", "Laboratory studies", "Hemoglobin 12.4 g Platelets 200", "mm3 Serum Prothrombin time", "seconds Partial thromboplastin time", "35 seconds Deficiency of", "following coagulation factors", "most likely cause", "patients condition"]}
{"question": "A 64-year-old man presents to his primary care clinic for a regular checkup. He reports feeling depressed since his wife left him 6 months prior and is unable to recall why she left him. He denies any sleep disturbance, change in his eating habits, guilt, or suicidal ideation. His past medical history is notable for hypertension, gout, and a myocardial infarction five years ago. He takes lisinopril, aspirin, metoprolol, and allopurinol. He has a 50 pack-year smoking history and was previously a heroin addict but has not used in over 20 years. He drinks at least 6 beers per day. His temperature is 98.6°F (37°C), blood pressure is 155/95 mmHg, pulse is 100/min, and respirations are 18/min. He appears somewhat disheveled, inattentive, and smells of alcohol. During his prior visits, he has been well-groomed and attentive. When asked what year it is and who the president is, he confidently replies “1999” and “Jimmy Carter.” He says his son’s name is “Peter” when it is actually “Jake.” This patient likely has a lesion in which of the following brain regions?", "answer": "Anterior pillars of the fornix", "options": {"A": "Anterior pillars of the fornix", "B": "Arcuate fasciculus", "C": "Dorsal hippocampus", "D": "Parahippocampal gyrus", "E": "Posterior pillars of the fornix"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["64 year old man presents", "primary care clinic", "regular checkup", "reports", "depressed", "left", "months prior", "unable to", "left", "sleep disturbance", "change in", "eating habits", "suicidal ideation", "past medical history", "notable", "hypertension", "gout", "myocardial infarction five years", "lisinopril", "aspirin", "metoprolol", "allopurinol", "50", "smoking history", "heroin addict", "not used", "20 years", "6", "day", "temperature", "98", "blood pressure", "95 mmHg", "pulse", "100 min", "respirations", "min", "appears somewhat", "inattentive", "smells", "alcohol", "prior", "well groomed", "year", "name", "patient likely", "lesion", "of", "following brain regions"]}
{"question": "A 21-year-old man comes to the physician's office due to a 3-week history of fatigue and a rash, along with the recent development of joint pain that has moved from his knee to his elbows. The patient reports going camping last month but denies having been bitten by a tick. His past medical history is significant for asthma treated with an albuterol inhaler. His pulse is 54/min and blood pressure is 110/72. Physical examination reveals multiple circular red rings with central clearings on the right arm and chest. There is a normal range of motion in all joints and 5/5 strength bilaterally in the upper and lower extremities. Without proper treatment, the patient is at highest risk for which of the following complications?", "answer": "Cranial nerve palsy", "options": {"A": "Cranial nerve palsy", "B": "Glomerular damage", "C": "Heart valve stenosis", "D": "Bone marrow failure", "E": "Liver capsule inflammation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["21-year-old man", "physician's office due to", "week history", "fatigue", "rash", "recent development", "joint pain", "moved from", "knee", "elbows", "month", "bitten", "tick", "past medical history", "significant", "asthma treated with", "albuterol inhaler", "pulse", "54 min", "blood pressure", "72", "reveals multiple circular red rings", "central", "right arm", "chest", "normal range of motion", "joints", "5/5 strength", "upper", "lower extremities", "treatment", "patient", "highest risk", "following complications"]}
{"question": "A 58-year-old man presents to the emergency department with severe chest pain and uneasiness. He says that symptoms onset acutely half an hour ago while he was watching television. He describes the pain as being 8/10 in intensity, sharp in character, localized to the center of the chest and retrosternal, and radiating to the back and shoulders. The patient denies any associated change in the pain with breathing or body position. He says he has associated nausea but denies any vomiting. He denies any recent history of fever, chills, or chronic cough. His past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus for which he takes lisinopril, hydrochlorothiazide, simvastatin, and metformin. He reports a 30-pack-year smoking history and has 1–2 alcoholic drinks during the weekend. Family history is significant for hypertension, hyperlipidemia, and an ST elevation myocardial infarction in his father and paternal uncle. His blood pressure is 220/110 mm Hg in the right arm and 180/100 mm Hg in the left arm. On physical examination, the patient is diaphoretic. Cardiac exam reveals a grade 2/6 diastolic decrescendo murmur loudest over the left sternal border. Remainder of the physical examination is normal. The chest radiograph shows a widened mediastinum. The electrocardiogram (ECG) reveals non-specific ST segment and T wave changes. Intravenous morphine and beta-blockers are started. Which of the following is the most likely diagnosis in this patient?", "answer": "Aortic dissection", "options": {"A": "Aortic dissection", "B": "Pulmonary embolism", "C": "Acute myocardial infarction", "D": "Myocarditis", "E": "Aortic regurgitation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old man presents", "emergency department", "severe chest", "uneasiness", "symptoms onset", "half", "hour", "pain", "8/10", "intensity", "sharp", "character", "localized", "center", "chest", "retrosternal", "radiating to", "back", "shoulders", "patient", "associated change", "pain", "breathing", "body position", "associated nausea", "vomiting", "recent history", "fever", "chills", "chronic cough", "past medical history", "significant", "hypertension", "hyperlipidemia", "diabetes mellitus", "lisinopril", "hydrochlorothiazide", "simvastatin", "metformin", "reports", "30", "smoking history", "weekend", "Family history", "significant", "hypertension", "hyperlipidemia", "ST elevation myocardial infarction", "blood pressure", "mm Hg", "right arm", "100 mm Hg", "left arm", "patient", "diaphoretic", "reveals", "diastolic", "murmur loudest", "left sternal border", "normal", "chest radiograph", "widened mediastinum", "electrocardiogram", "reveals non-specific ST segment", "T wave changes", "Intravenous morphine", "beta-blockers", "started", "following", "diagnosis", "patient"]}
{"question": "A study on cholesterol levels is performed. There are 1000 participants. It is determined that in this population, the mean LDL is 200 mg/dL with a standard deviation of 50 mg/dL. If the population has a normal distribution, how many people have a cholesterol less than 300 mg/dL?", "answer": "975", "options": {"A": "680", "B": "840", "C": "950", "D": "975", "E": "997"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["study", "cholesterol levels", "performed", "population", "mean", "200 mg dL", "standard deviation", "50", "dL", "population", "normal distribution", "cholesterol", "300 mg/dL"]}
{"question": "A 2-year-old boy is brought to the physician by his mother for evaluation of recurrent infections and easy bruising. He has been hospitalized 3 times for severe skin and respiratory infections, which responded to treatment with antibiotics. Examination shows sparse silvery hair. The skin is hypopigmented and there are diffuse petechiae. Laboratory studies show a hemoglobin concentration of 8 g/dL, leukocyte count of 3000/mm3, and platelet count of 45,000/mm3. A peripheral blood smear shows giant cytoplasmic granules in granulocytes and platelets. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Defective lysosomal trafficking regulator gene", "options": {"A": "Defective CD40 ligand", "B": "Defective tyrosine kinase gene", "C": "WAS gene mutation", "D": "Defective NADPH oxidase", "E": "Defective lysosomal trafficking regulator gene"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 year old boy", "brought", "physician", "recurrent infections", "easy bruising", "hospitalized 3", "severe skin", "respiratory infections", "treatment", "sparse silvery hair", "skin", "hypopigmented", "diffuse petechiae", "Laboratory studies", "a hemoglobin concentration", "dL", "leukocyte count", "3000 mm3", "platelet count", "mm3", "peripheral blood smear", "giant cytoplasmic granules", "granulocytes", "platelets", "following", "underlying cause", "patient's symptoms"]}
{"question": "To protect against a potentially deadly infection, a 19-year-old female receives a vaccine containing capsular polysaccharide. This vaccine will stimulate her immune system to produce antibodies against which organism?", "answer": "Neisseria meningitidis", "options": {"A": "Measles", "B": "Smallpox", "C": "Neisseria meningitidis", "D": "Corynebacterium diphtheriae", "E": "Clostridium tetani"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["To", "infection", "year old female receives", "vaccine containing capsular polysaccharide", "vaccine", "immune system to", "antibodies"]}
{"question": "A 6-year-old African American boy presents with fever, jaundice, normochromic normocytic anemia and generalized bone pain. He has a history of similar recurrent bone pain in the past which was partially relieved by analgesics. His vital signs include: blood pressure 120/70 mm Hg, pulse 105/min, respiratory rate 40/min, temperature 37.7℃ (99.9℉), and oxygen saturation 98% in room air. On physical examination, the patient is in severe distress due to pain. He is pale, icteric and dehydrated. His abdomen is full, tense and some degree of guarding is present. Musculoskeletal examination reveals diffuse tenderness of the legs and arms. A complete blood count reveals the following:\nHb 6.5g/dL\nHct 18%\nMCV 82.3 fL\nPlatelet 465,000/µL\nWBC 9800/µL\nReticulocyte 7%\nTotal bilirubin 84 g/dL\nA peripheral blood smear shows target cells, elongated cells, and erythrocytes with nuclear remnants. Results from Hb electrophoresis are shown in the exhibit (see image). Which of the following is the most likely cause of this patient’s condition?", "answer": "Sickle cell disease", "options": {"A": "Sickle cell trait", "B": "Sickle cell disease", "C": "Von-Gierke’s disease", "D": "G6PD deficiency", "E": "HbC"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "boy presents", "fever", "jaundice", "normochromic normocytic anemia", "generalized bone", "history", "similar recurrent bone pain", "past", "relieved by analgesics", "vital signs include", "blood pressure", "70 mm Hg", "pulse", "min", "respiratory rate 40 min", "temperature", "99.9", "oxygen saturation 98", "room air", "patient", "severe distress", "pain", "pale", "icteric", "dehydrated", "abdomen", "full", "tense", "degree", "guarding", "present", "reveals diffuse tenderness", "legs", "arms", "complete blood count reveals", "following", "Hb", "dL Hct", "MCV", "fL", "WBC", "Total bilirubin 84 g dL", "peripheral blood smear", "target cells", "elongated cells", "erythrocytes", "nuclear remnants", "Results", "Hb electrophoresis", "see", "following", "most likely cause", "patients condition"]}
{"question": "A 69-year-old woman is admitted to the hospital with substernal, crushing chest pain. She is emergently moved to the cardiac catheterization lab where she undergoes cardiac angiography. Angiography reveals that the diameter of her left anterior descending artery (LAD) is 50% of normal. If her blood pressure, LAD length, and blood viscosity have not changed, which of the following represents the most likely change in LAD flow from baseline?", "answer": "Decreased by 93.75%", "options": {"A": "Increased by 6.25%", "B": "Increased by 25%", "C": "Decreased by 93.75%", "D": "Decreased by 87.5%", "E": "Decreased by 25%"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["69 year old woman", "crushing chest pain", "moved to", "cardiac catheterization lab", "cardiac angiography", "reveals", "diameter", "left anterior descending artery", "50", "normal", "blood pressure", "LAD length", "blood viscosity", "not changed", "following", "most likely change", "LAD", "baseline"]}
{"question": "A 63-year-old man comes to the physician because of generalized fatigue and malaise for 2 months. He has been unable to engage in his daily activities. Three months ago, he was treated for a urinary tract infection with trimethoprim-sulfamethoxazole. He has hypertension, asthma, and chronic lower back pain. Current medications include hydrochlorothiazide, an albuterol inhaler, naproxen, and an aspirin-caffeine combination. Vital signs are within normal limits. Examination shows conjunctival pallor. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 9.1 g/dL\nLeukocyte count 8,900/mm3\nErythrocyte sedimentation rate 13 mm/h\nSerum\nNa+ 136 mEq/L\nK+ 4.8 mEq/L\nCl- 102 mEq/L\nUrea nitrogen 41 mg/dL\nGlucose 70 mg/dL\nCreatinine 2.4 mg/dL\nCalcium 9.8 mg/dL\nUrine\nProtein 1+\nBlood 1+\nRBCs none\nWBCs 8–9/hpf\nBacteria none\nUrine cultures are negative. Ultrasound shows shrunken kidneys with irregular contours and papillary calcifications. Which of the following is the most likely underlying mechanism of this patient's renal failure?\"", "answer": "Inhibition of prostacyclin production", "options": {"A": "Inhibition of prostacyclin production", "B": "Excess amount of light chain production", "C": "Precipitation of drugs within the renal tubules", "D": "MUC1 gene mutation", "E": "Hypersensitivity reaction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man", "physician", "generalized fatigue", "malaise", "months", "unable", "Three months", "treated", "urinary tract infection", "trimethoprim-sulfamethoxazole", "hypertension", "asthma", "chronic lower back pain", "Current medications include hydrochlorothiazide", "albuterol inhaler", "naproxen", "aspirin-caffeine combination", "Vital signs", "normal limits", "conjunctival pallor", "abnormalities", "Laboratory studies", "8", "8", "Urine", "RBCs", "WBCs", "hpf Bacteria", "Urine cultures", "negative", "Ultrasound", "shrunken kidneys", "irregular contours", "papillary calcifications", "following", "underlying mechanism", "patient", "enal failure?"]}
{"question": "A 60-year-old woman presents to the clinic with a 3-month history of shortness of breath that worsens on exertion. She also complains of chronic cough that has lasted for 10 years. Her symptoms are worsened even with light activities like climbing up a flight of stairs. She denies any weight loss, lightheadedness, or fever. Her medical history is significant for hypertension, for which she takes amlodipine daily. She has a 70-pack-year history of cigarette smoking and drinks 3–4 alcoholic beverages per week. Her blood pressure today is 128/84 mm Hg. A chest X-ray shows flattening of the diaphragm bilaterally. Physical examination is notable for coarse wheezing bilaterally. Which of the following is likely to be seen with pulmonary function testing?", "answer": "Decreased FEV1: FVC and increased total lung capacity", "options": {"A": "Increased FEV1: FVC and decreased total lung capacity", "B": "Decreased FEV1: FVC and increased total lung capacity", "C": "Increased FEV1: FVC and normal total lung capacity", "D": "Decreased FEV1: FVC and decreased total lung capacity", "E": "Normal FEV1: FVC and decreased total lung capacity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old woman presents", "clinic", "3 month history of shortness", "breath", "worsens", "exertion", "chronic cough", "lasted", "symptoms", "worsened", "weight loss", "lightheadedness", "fever", "medical history", "significant", "hypertension", "amlodipine daily", "70", "history of cigarette smoking", "week", "blood pressure today", "84 mm Hg", "chest X-ray", "flattening", "diaphragm", "notable", "coarse wheezing", "following", "likely to", "seen", "pulmonary function testing"]}
{"question": "A 54-year-old male presents to clinic complaining that he is not sleeping well because he has to get up from bed to urinate multiple times throughout the night. He says that he strains to void, has terminal dribbling, and has urinary urgency. Past medical history is significant for orthostatic hypotension. On digital rectal exam, you note symmetric firm enlargement of the prostate. Free Prostate-Specific-Antigen (PSA) level is 4.6 ng/mL. Before you finish your physical exam, the patient asks if there is anything you can do for his male-pattern baldness. What is the mechanism of action of the drug that would pharmacologically treat this patient’s urinary issues and his male-pattern baldness?", "answer": "5-alpha reductase inhibition", "options": {"A": "Phosphodiesterase-5 inhibition", "B": "Alpha-1 blockade", "C": "Squalene epoxidase inhibition", "D": "5-alpha reductase inhibition", "E": "17,20-desmolase inhibition"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["54 year old male presents", "clinic", "not sleeping well", "to get", "bed to", "multiple times", "night", "strains to void", "terminal dribbling", "urinary urgency", "Past medical history", "significant", "orthostatic hypotension", "digital rectal exam", "note symmetric firm enlargement of", "prostate", "Free", "Specific-Antigen", "level", "4.6 ng/mL", "finish", "patient", "male-pattern baldness", "mechanism of action", "drug", "treat", "patients urinary issues", "male-pattern baldness"]}
{"question": "A 75-year-old man presents to the emergency department after an episode of syncope while walking outside with his wife. His wife states that he suddenly appeared pale and collapsed to the ground. She says he remained unconscious for 1 minute. He says noticed a fluttering in his chest and excessive sweating before the episode. He has type 2 diabetes mellitus, essential hypertension, and chronic stable angina. He has not started any new medications in the past few months. Vital signs reveal: temperature 37.0°C (98.6°F), blood pressure 135/72 mm Hg, and pulse 72/min. Physical examination is unremarkable. ECG shows an old bifascicular block. Echocardiogram and 24-hour Holter monitoring are normal. Which of the following is the best next step in the evaluation of this patient’s condition?", "answer": "Continuous loop recorder", "options": {"A": "Electroencephalography (EEG)", "B": "Tilt-table test", "C": "Continuous loop recorder", "D": "Valsalva maneuver", "E": "Cardiac enzymes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "emergency department", "episode of syncope", "outside", "states", "appeared pale", "collapsed", "unconscious", "minute", "fluttering", "chest", "excessive sweating", "episode", "type 2 diabetes mellitus", "essential hypertension", "chronic stable angina", "not started", "new medications", "past", "months", "Vital signs reveal", "temperature", "98", "blood pressure", "72 mm Hg", "pulse 72 min", "unremarkable", "ECG", "old bifascicular block", "Echocardiogram", "hour Holter monitoring", "normal", "following", "best next step", "condition"]}
{"question": "Two days after undergoing emergency cardiac catherization for myocardial infarction, a 68-year-old woman has pain in her toes. During the intervention, she was found to have an occluded left anterior descending artery and 3 stents were placed. She has hypertension, hypercholesterolemia, and coronary artery disease. Prior to admission, her medications were metoprolol, enalapril, atorvastatin, and aspirin. Her temperature is 37.3°C (99.1°F), pulse is 93/min, and blood pressure is 115/78 mm Hg. Examination shows discoloration of the toes of both feet. A photograph of the right foot is shown. The lesions are cool and tender to palpation. The rest of the skin on the feet is warm; femoral and pedal pulses are palpable bilaterally. This patient is at increased risk for which of the following conditions?", "answer": "Acute kidney injury", "options": {"A": "Acute kidney injury", "B": "Lipodermatosclerosis", "C": "Basophilia", "D": "Permanent flexion contracture", "E": "Migratory thrombophlebitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Two days", "emergency cardiac", "myocardial infarction", "year old woman", "pain in", "toes", "intervention", "found to", "occluded left anterior descending artery", "3 stents", "hypertension", "hypercholesterolemia", "coronary artery disease", "medications", "metoprolol", "enalapril", "atorvastatin", "aspirin", "temperature", "99", "pulse", "min", "blood pressure", "mm Hg", "discoloration", "toes", "feet", "photograph", "right foot", "lesions", "cool", "tender", "palpation", "skin", "feet", "warm", "femoral", "pedal pulses", "palpable", "patient", "increased risk", "following conditions"]}
{"question": "A novel PET radiotracer is being evaluated for its ability to aid in the diagnosis of Alzheimer’s disease (AD). The study decides to use a sample size of 1,000 patients, and half of the patients enrolled have AD. In the group of patients with AD, 400 are found positive on the novel type of PET imaging examination. In the control group, 50 are found positive. What is the PPV of this novel exam?", "answer": "400 / (400+50)", "options": {"A": "400 / (400+100)", "B": "450 / (450 + 50)", "C": "400 / (400+50)", "D": "400 / (400 + 150)", "E": "450 / (450 + 100)"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["novel", "ability to aid", "diagnosis", "Alzheimers disease", "study", "to use", "sample size", "patients", "half", "patients enrolled", "AD", "group", "patients", "AD", "400", "found positive", "novel type", "PET imaging", "50", "found positive", "PPV", "novel exam"]}
{"question": "A 17-year-old girl is brought in by her mother due to rapid weight loss over the past month. The patient says she has been having episodes of diarrhea, which she attributes to laxatives she takes regularly to keep her weight down. She also says she has not had her period yet. The patient’s mother adds that the patient has been underperforming at school and acting very strangely at home. Her current BMI is 16.8 kg/m2. On physical examination, the skin on her limbs and around her neck is inflamed and erythematous. Her tongue is bright red and smooth. She states that over the last 2 weeks, she has been eating nothing but small portions of fruit. She is diagnosed with a vitamin deficiency. Which of the following statements is true about the vitamin most likely deficient in this patient?", "answer": "Synthesis requires vitamin B2 and B6", "options": {"A": "It is derived from tyrosine", "B": "Synthesis requires vitamin B1 and B6", "C": "It is used to treat hypertension", "D": "Synthesis requires vitamin B2 and B6", "E": "It increases the GI absorption of iron"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "due to rapid weight loss", "past month", "patient", "episodes of diarrhea", "attributes to laxatives", "to keep", "weight", "not", "period", "patients", "adds", "patient", "school", "acting very", "home", "current BMI", "kg/m2", "skin", "limbs", "neck", "inflamed", "erythematous", "tongue", "bright red", "smooth", "states", "last 2 weeks", "eating", "small portions", "diagnosed", "a vitamin deficiency", "following", "true", "vitamin", "likely deficient", "patient"]}
{"question": "A 57-year-old man is admitted to the burn unit after he was brought to the emergency room following an accidental fire in his house. His past medical history is unknown due to his current clinical condition. Currently, his blood pressure is 75/40 mmHg, pulse rate is 140/min, and respiratory rate is 17/min. The patient is subsequently intubated and started on aggressive fluid resuscitation. A Swan-Ganz catheter is inserted to clarify his volume status. Which of the following hemodynamic parameters would you expect to see in this patient?", "answer": "Cardiac output: ↓, systemic vascular resistance: ↑, pulmonary artery wedge pressure: ↓", "options": {"A": "Cardiac output: ↓, systemic vascular resistance: ↔, pulmonary artery wedge pressure: ↔", "B": "Cardiac output: ↑, systemic vascular resistance: ↑, pulmonary artery wedge pressure: ↔", "C": "Cardiac output: ↓, systemic vascular resistance: ↑, pulmonary artery wedge pressure: ↓", "D": "Cardiac output: ↑, systemic vascular resistance: ↓, pulmonary artery wedge pressure: ↔", "E": "Cardiac output: ↔, systemic vascular resistance: ↔, pulmonary artery wedge pressure: ↔"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["57 year old man", "burn unit", "brought", "emergency room following", "accidental fire", "house", "past medical history", "unknown due to", "current clinical condition", "Currently", "blood pressure", "75 40 mmHg", "pulse rate", "min", "respiratory rate", "min", "patient", "intubated", "started", "aggressive fluid resuscitation", "Swan-Ganz catheter", "to", "volume status", "following hemodynamic parameters", "to see", "patient"]}
{"question": "A 35-year-old woman volunteers for a study on respiratory physiology. Pressure probes A and B are placed as follows:\nProbe A: between the parietal and visceral pleura\nProbe B: within the cavity of an alveoli\nThe probes provide a pressure reading relative to atmospheric pressure. To obtain a baseline reading, she is asked to sit comfortably and breathe normally. Which of the following sets of values will most likely be seen at the end of inspiration?", "answer": "Probe A: -6 mm Hg; Probe B: 0 mm Hg", "options": {"A": "Probe A: 0 mm Hg; Probe B: -1 mm Hg", "B": "Probe A: -4 mm Hg; Probe B: 0 mm Hg", "C": "Probe A: -4 mm Hg; Probe B: -1 mm Hg", "D": "Probe A: -6 mm Hg; Probe B: 0 mm Hg", "E": "Probe A: -6 mm Hg; Probe B: -1 mm Hg"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman volunteers", "study", "respiratory physiology", "Pressure probes", "follows", "Probe", "parietal", "visceral pleura Probe", "cavity", "alveoli", "probes", "pressure", "atmospheric pressure", "To obtain", "baseline", "to sit", "following sets", "values", "most likely", "seen", "end", "inspiration"]}
{"question": "A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?", "answer": "Testicular torsion", "options": {"A": "Appendicitis", "B": "Epididymitis", "C": "Seminoma", "D": "Testicular torsion", "E": "Traumatic urethral injury"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "2-hour history", "sudden abdominal", "playing football", "symptoms started", "patients past medical history", "notable only", "asthma", "Social history", "notable", "4", "past month", "temperature", "99", "blood pressure", "88 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "noted", "non-tender abdomen", "Testicular exam reveals", "right testicle", "elevated", "horizontal", "scrotum", "swollen", "discolored", "following", "diagnosis"]}
{"question": "Please refer to the summary above to answer this question\nWhich of the following is the most appropriate next step in management?\"\n\"Patient Information\nAge: 23 years\nGender: F, self-identified\nEthnicity: unspecified\nSite of Care: office\nHistory\nReason for Visit/Chief Concern: “I can't run anymore because my knee hurts.”\nHistory of Present Illness:\n2-day history of right knee pain\npain is localized “somewhere under the kneecap”\npain is achy; rated 5/10; increases to 8/10 with prolonged sitting\nreports an occasional “popping” sound and sensation when she rises from a seated position\nno history of trauma to the knee\nPast Medical History:\nright clavicular fracture 2 years ago, treated with a shoulder sling\nMedications:\nmultivitamin\nAllergies:\nno known drug allergies\nPsychosocial History:\ndoes not smoke\ndrinks up to three glasses of wine weekly\nPhysical Examination\nTemp Pulse Resp BP O2 Sat Ht Wt BMI\n37°C\n(98.6°F)\n65/min 15/min 108/62 mm Hg –\n173 cm\n(5 ft 8 in)\n54 kg\n(119 lb)\n18 kg/m2\nAppearance: no acute distress\nPulmonary: clear to auscultation\nCardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops\nAbdominal: thin; no tenderness, guarding, masses, bruits, or hepatosplenomegaly\nExtremities: no joint erythema, edema, or warmth; dorsalis pedis, radial, and femoral pulses intact\nMusculoskeletal: diffuse tenderness to palpation over the right anterior knee, worse with full extension of the knee; no associated effusion or erythema; full, symmetric strength of quadriceps, hip abductors, and hip external rotators; crepitus with knee range of motion; antalgic gait\nNeurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits\"", "answer": "Pain control and rest", "options": {"A": "Pain control and rest", "B": "Physical therapy", "C": "Arthroscopy of the knee", "D": "Synovial fluid analysis", "E": "Intraarticular steroid injection"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["refer", "above to", "following", "most appropriate next step", "Patient Age", "23 years Gender", "F", "identified Ethnicity", "unspecified Site of Care", "office History Reason for Visit", "I", "un ", "nee ", "istory of Present Illness:", "-day  istory ", "ight ", "ocalized ", "neecap  ain ", "chy;", "/10;", "ncreases ", "/10 ", "rolonged  itting  eports ", "ccasional  opping  ound ", "ensation ", "eated position ", "istory ", "rauma ", "nee  ast Medical History:", "ight  lavicular fracture ", "ears ", "reated with ", "houlder  ling  edications:", "ultivitamin  llergies:", "nown  rug allergies  sychosocial  istory:", "ot  moke ", "hree  lasses  f ", "eekly  hysical  xamination  emp  ulse  esp  P  2  at  t  t  MI ", "8.", "5/ in ", "2  m Hg ", "  t   ", "4  g ", "g/m2  ppearance:", "cute  istress  ulmonary:", "lear  o  uscultation  ardiac:", "egular  ate ", "hythm;", "ormal  1 ", "2;", "urmurs,", "ubs,", "bdominal:", "hin;", "enderness,", "uarding,", "asses,", "ruits,", "epatosplenomegaly  xtremities:", "oint erythema,", "dema,", "armth;", "emoral pulses  ntact  usculoskeletal:", "iffuse  enderness ", "alpation ", "ight  nee,", "orse ", "ull  xtension ", "nee;", "ssociated  ffusion ", "rythema;", "ull,", "ymmetric  trength ", "uadriceps,", "ip ", "ip  xternal  otators;", "repitus ", "nee  ange of motion;", "ntalgic gait  eurologic:", "lert ", "riented;", "ranial nerves ", "ntact;", "ocal neurologic deficits\""]}
{"question": "A 12-month-old boy is brought to the physician by his parents for a 4-week history of fever, malaise, cough, and difficulty breathing. He has had recurrent episodes of gastroenteritis since birth. Cardiopulmonary examination shows subcostal retractions and crackles bilaterally. There is enlargement of the cervical, axillary, and inguinal lymph nodes. An x-ray of the chest shows bilateral consolidations. A sputum culture shows colonies of Burkholderia cepacia. A blood sample is obtained and after the addition of nitroblue tetrazolium to the sample, neutrophils remain colorless. A defect in which of the following is the most likely cause of this patient's condition?", "answer": "NADPH oxidase complex", "options": {"A": "B cell maturation", "B": "Microtubule polymerization", "C": "T cell CD40 ligand", "D": "Actin filament assembly", "E": "NADPH oxidase complex"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old boy", "brought", "physician", "week history", "fever", "malaise", "cough", "difficulty breathing", "recurrent episodes of gastroenteritis", "birth", "Cardiopulmonary examination", "subcostal retractions", "crackles", "enlargement", "cervical", "axillary", "inguinal lymph nodes", "x-ray of", "chest", "bilateral consolidations", "sputum culture", "colonies", "Burkholderia cepacia", "blood sample", "obtained", "addition", "nitroblue tetrazolium", "colorless", "defect", "following", "most likely cause", "patient's condition"]}
{"question": "A 4-year-old boy is brought to the pediatrician by his mother who is concerned about progressive leg weakness. His mother reports that the patient used to play outside with their neighbors for hours, but for the past few months she has seen him sitting on the sidewalk after 15 minutes because he’s too tired. The patient says his legs are “sleepy.” The patient’s mother has also had to remove the carpets from the house because the patient kept tripping over the edges. The mother reports that the patient is shy but cooperates well with his siblings and other children. He can say his first and last name and just started counting. His mother states he learned to fully walk by 15 months of age. He was hospitalized for bronchiolitis at 12 months of age, which resolved with supportive care. He had an uncomplicated orchiopexy surgery for undescended testes at 7 months of age. He has no other chronic medical conditions and takes no medications. He is up to date on his vaccinations including a flu vaccine 2 weeks ago. The patient’s mother has systemic lupus erythematous and his paternal uncle has dermatomyositis. On physical examination, bilateral calves are large in circumference compared to the thighs. Strength is 3/5 in bilateral quadriceps and 4/5 in bilateral calves. Sensation is intact. Achilles tendon reflexes are 1+ bilaterally. The patient can hop on one leg, but gets tired after 10 jumps. He has a slight waddling gait. Which of the following is the most appropriate test to confirm the diagnosis?", "answer": "Genetic testing", "options": {"A": "Acetylcholine receptor antibody level", "B": "Creatine kinase level", "C": "Genetic testing", "D": "Muscle biopsy", "E": "Nerve conduction study"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "pediatrician", "progressive leg weakness", "reports", "patient used to play outside", "hours", "past", "months", "seen", "sitting", "sidewalk", "15 minutes", "tired", "patient", "legs", "sleepy", "patients", "to remove", "carpets", "house", "patient kept", "edges", "reports", "patient", "shy", "well", "children", "first", "started counting", "states", "to", "months", "age", "hospitalized", "bronchiolitis", "months", "age", "resolved", "supportive care", "uncomplicated orchiopexy surgery", "undescended testes", "months", "age", "chronic medical conditions", "medications", "date", "vaccinations including", "flu vaccine", "weeks", "patients", "systemic lupus erythematous", "dermatomyositis", "bilateral calves", "large", "circumference", "thighs", "Strength", "3/5", "bilateral quadriceps", "4/5", "bilateral calves", "Sensation", "intact", "Achilles tendon reflexes", "1", "patient", "hop", "one leg", "gets tired", "10 jumps", "slight waddling gait", "following", "most appropriate test to confirm", "diagnosis"]}
{"question": "A 22-year-old female is brought to the emergency department by her friends. She was supposed to attend her first job interview in a few hours when she started having palpitations. Her past medical history is insignificant, and she currently takes no medications. Her vitals show the following: pulse rate is 90/min, respiratory rate is 28/min, and blood pressure is 136/86 mm Hg. Her ECG is normal. What will be the patient’s approximate alveolar carbon dioxide pressure (PACO2) given her normal respiratory rate is 14/min and PACO2 is 36 mm Hg? Ignore dead space and assume carbon dioxide production is constant.", "answer": "18 mm Hg", "options": {"A": "18 mm Hg", "B": "27 mm Hg", "C": "36 mm Hg", "D": "44 mm Hg", "E": "72 mm Hg"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "brought", "emergency department", "to attend", "first", "hours", "started", "palpitations", "past medical history", "currently", "medications", "following", "pulse rate", "90 min", "respiratory rate", "min", "blood pressure", "mm Hg", "ECG", "normal", "patients approximate alveolar carbon dioxide pressure", "given", "normal respiratory rate", "min", "36 mm Hg", "dead space", "carbon dioxide production", "constant"]}
{"question": "A 68-year-old man with hypertension comes to the physician because of fatigue and difficulty initiating urination. He wakes up several times a night to urinate. He does not take any medications. His blood pressure is 166/82 mm Hg. Digital rectal examination shows a firm, non-tender, and uniformly enlarged prostate. Which of the following is the most appropriate pharmacotherapy?", "answer": "Terazosin", "options": {"A": "Finasteride", "B": "Phenoxybenzamine", "C": "Tamsulosin", "D": "Terazosin", "E": "α-Methyldopa"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "hypertension", "physician", "fatigue", "difficulty initiating urination", "wakes up", "times", "night to", "not", "medications", "blood pressure", "mm Hg", "Digital rectal examination", "firm", "non-tender", "enlarged prostate", "following", "most appropriate pharmacotherapy"]}
{"question": "A 51-year-old woman comes to the physician because of numbness of her legs and toes for 3 months. She has also had fatigue and occasional shortness of breath for the past 5 months. She is a painter. Examination shows pale conjunctivae. Sensation to vibration and position is absent over the lower extremities. She has a broad-based gait. The patient sways when she stands with her feet together and closes her eyes. Which of the following laboratory findings is most likely to be seen in this patient?", "answer": "Elevated methylmalonic acid levels\n\"", "options": {"A": "Poliovirus RNA in cerebrospinal fluid", "B": "Basophilic stippling on peripheral smear", "C": "Oligoclonal bands in cerebrospinal fluid", "D": "Positive rapid plasma reagin test", "E": "Elevated methylmalonic acid levels\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "numbness", "legs", "toes", "months", "fatigue", "occasional shortness of breath", "past", "months", "painter", "pale conjunctivae", "Sensation", "vibration", "position", "absent", "lower extremities", "broad-based gait", "patient", "stands", "feet together", "closes", "eyes", "following laboratory findings", "to", "seen", "patient"]}
{"question": "A 38-year-old woman makes an appointment with her family physician for a routine check-up after being away due to travel for 1 year. She recently had a screening Pap smear, which was negative for malignancy. Her past medical history is significant for a Pap smear 2 years ago that reported a low-grade squamous intraepithelial lesion (LSIL). A subsequent colposcopy diagnosed low-grade cervical intraepithelial neoplasia (CIN2). The patient is surprised by the differences in her diagnostic tests. You explain to her the basis for the difference and reassure her. With this in mind, which of the following HPV serotypes is most likely to be present in the patient?", "answer": "HPV 6", "options": {"A": "HPV 18", "B": "HPV 6", "C": "HPV 31", "D": "HPV 16", "E": "HPV 33"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman makes", "appointment", "family physician", "routine check-up", "due to", "1 year", "recently", "screening Pap smear", "negative", "malignancy", "past medical history", "significant", "a Pap smear", "years", "reported", "low-grade squamous intraepithelial lesion", "subsequent colposcopy diagnosed low-grade cervical intraepithelial neoplasia", "patient", "differences", "diagnostic tests", "basis", "difference", "following HPV", "to", "present", "patient"]}
{"question": "A 19-year-old collegiate football player sustains an injury to his left knee during a game. He was running with the ball when he dodged a defensive player and fell, twisting his left knee. He felt a “pop” as he fell. When he attempts to bear weight on his left knee, it feels unstable, and \"gives way.\" He needs assistance to walk off the field. The pain is localized diffusely over the knee and is non-radiating. His past medical history is notable for asthma. He uses an albuterol inhaler as needed. He does not smoke or drink alcohol. On exam, he has a notable suprapatellar effusion. Range of motion is limited in the extremes of flexion. When the proximal tibia is pulled anteriorly while the knee is flexed and the patient is supine, there is 1.5 centimeter of anterior translation. The contralateral knee translates 0.5 centimeters with a similar force. The injured structure in this patient originates on which of the following bony landmarks?", "answer": "Posteromedial aspect of the lateral femoral condyle", "options": {"A": "Lateral aspect of the lateral femoral condyle", "B": "Lateral aspect of the medial femoral condyle", "C": "Medial aspect of the medial femoral condyle", "D": "Posteromedial aspect of the lateral femoral condyle", "E": "Tibial tubercle"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old collegiate football", "sustains", "injury", "left knee", "ball", "fell", "twisting", "left knee", "fell", "to", "weight", "left knee", "unstable", "gives", "needs assistance to", "field", "pain", "localized", "knee", "non radiating", "past medical history", "notable", "asthma", "uses", "albuterol inhaler as needed", "not smoke", "exam", "notable", "effusion", "Range of motion", "limited", "extremes", "flexion", "proximal tibia", "pulled", "knee", "flexed", "patient", "supine", "1.5 centimeter of anterior", "contralateral knee", "0.5 centimeters", "similar", "injured structure", "patient", "following bony"]}
{"question": "A 65-year-old woman is brought to the emergency department by her husband due to difficulty speaking and confusion for 1 hour. She was gardening when she suddenly developed these symptoms. She is not able to respond to the questions despite multiple repetitions. She also appears unsteady with her gait and is able to walk with support. The past medical history includes type 2 diabetes mellitus, dyslipidemia, and osteoarthritis. The medicine list includes aspirin, atorvastatin, metformin, and chondroitin sulfate. The vital signs include: blood pressure 174/88 mm Hg, heart rate 154/min and irregular, respiratory rate 12/min, and oxygen saturation 96% on room air. She is awake, but not following commands. The pupils are equal bilaterally and reactive to light. There is mild facial droop on the right side. The forehead wrinkles are preserved. When the soles of her feet are stimulated with a blunt instrument, the right-sided big toe goes upward, while the left-sided big toe goes downward. The ECG shows variable R-R intervals and absent of P waves. What is the next step in the management of this patient?", "answer": "CT scan of the head", "options": {"A": "Amiodarone", "B": "Aspirin", "C": "CT scan of the head", "D": "Echocardiography", "E": "MRI of the head"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old woman", "brought", "emergency department", "due to difficulty speaking", "confusion", "hour", "symptoms", "not able to", "multiple repetitions", "appears unsteady", "gait", "able to", "support", "past medical history includes type 2 diabetes mellitus", "dyslipidemia", "osteoarthritis", "medicine", "includes aspirin", "atorvastatin", "metformin", "chondroitin sulfate", "vital signs include", "blood pressure", "88 mm Hg", "heart rate", "min", "irregular", "respiratory rate", "min", "oxygen saturation 96", "room air", "awake", "not following", "pupils", "equal", "reactive to light", "mild facial droop", "right side", "forehead wrinkles", "preserved", "soles of", "feet", "right sided big toe", "upward", "left sided big toe", "downward", "ECG", "variable R-R intervals", "absent", "P waves", "next step", "patient"]}
{"question": "A 45-year-old man presents to the physician with a complaint of recurrent chest pain for the last 2 weeks. He mentions that the pain is not present at rest, but when he walks for some distance, he feels pain like a pressure over the retrosternal region. The pain disappears within a few minutes of stopping the physical activity. He is an otherwise healthy man with no known medical disorder. He does not smoke or have any known dependence. There is no family history of ischemic heart disease or vascular disorder. On physical examination, his vital signs, including blood pressure, are normal. The diagnosis of coronary artery disease due to atherosclerosis is made. Which of the following is known to be an infection associated with this patient’s condition?", "answer": "Chlamydophila pneumoniae", "options": {"A": "Chlamydophila pneumoniae", "B": "Coxiella burnetii", "C": "Legionella pneumophilia", "D": "Mycoplasma pneumoniae", "E": "Rickettsia rickettsii"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "physician", "complaint of recurrent", "last", "weeks", "pain", "not present", "walks", "distance", "pain", "pressure", "retrosternal region", "pain", "minutes", "stopping", "man", "known medical", "not smoke", "known dependence", "family history of ischemic heart disease", "vascular disorder", "vital signs", "including blood pressure", "normal", "diagnosis of coronary artery disease", "atherosclerosis", "made", "following", "known to", "infection associated with", "patients condition"]}
{"question": "An investigator is studying cellular repair mechanisms in various tissues. One of the samples being reviewed is from the anterior horn of the spinal cord of a patient who was involved in a snowboard accident. Pathologic examination of the biopsy specimen shows dispersion of the Nissl bodies, swelling of the neuronal body, and a displacement of the nucleus to the periphery in numerous cells. Which of the following is the most likely explanation for the observed findings?", "answer": "Central chromatolysis", "options": {"A": "Neurodegenerative changes", "B": "Wallerian degeneration", "C": "Central chromatolysis", "D": "Reactive astrogliosis", "E": "Neuronal aging"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying cellular repair mechanisms", "various tissues", "One", "samples", "reviewed", "anterior horn", "spinal cord", "patient", "involved", "snowboard", "Pathologic examination", "biopsy specimen", "dispersion", "Nissl bodies", "swelling", "neuronal body", "displacement", "nucleus", "periphery", "numerous cells", "following", "observed findings"]}
{"question": "Fertilization begins when sperm binds to the corona radiata of the egg. Once the sperm enters the cytoplasm, a cortical reaction occurs which prevents other sperm from entering the oocyte. The oocyte then undergoes an important reaction. What is the next reaction that is necessary for fertilization to continue?", "answer": "The second meiotic division", "options": {"A": "Release of a polar body", "B": "Degeneration of the sperm tail", "C": "Acrosome reaction", "D": "The second meiotic division", "E": "Formation of the spindle apparatus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Fertilization begins", "corona radiata", "egg", "enters", "cytoplasm", "cortical reaction occurs", "prevents", "entering", "then", "important reaction", "next reaction", "fertilization to"]}
{"question": "A 67-year-old man presents to his primary care provider with bloody urine. He first noticed the blood 1 week ago. He otherwise feels healthy. His past medical history is significant for type 2 diabetes mellitus for 18 years, for which he takes insulin injections. He has smoked 30–40 cigarettes per day for the past 29 years and drinks alcohol socially. Today his vital signs include: temperature 36.6°C (97.8°F), blood pressure 135/82 mm Hg, and heart rate 105/min. There are no findings on physical examination. Urinalysis shows 15–20 red cells/high power field. Which of the following is the next best test to evaluate this patient’s condition?", "answer": "Contrast-enhanced CT", "options": {"A": "Urine cytology", "B": "Contrast-enhanced CT", "C": "Prostate-specific antigen", "D": "Biopsy", "E": "Urinary markers"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old man presents", "primary care provider", "bloody urine", "first", "blood", "week", "healthy", "past medical history", "significant", "type 2 diabetes mellitus", "years", "insulin injections", "smoked", "cigarettes", "day", "past 29 years", "alcohol", "Today", "vital signs include", "temperature 36", "97", "blood pressure", "mm Hg", "heart rate", "min", "findings", "physical examination", "Urinalysis", "red cells/high power field", "following", "next best test to", "patients condition"]}
{"question": "A previously healthy 19-year-old woman comes to the physician because of vaginal discharge for 3 days. She describes the discharge as yellow and mucopurulent with a foul odor. She has also noticed vaginal bleeding after sexual activity. She has not had any itching or irritation. Her last menstrual period was 2 weeks ago. She is sexually active with one male partner, and they use condoms inconsistently. A rapid urine hCG test is negative. Her temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 108/62 mm Hg. Pelvic examination shows a friable cervix. Speculum examination is unremarkable. A wet mount shows no abnormalities. Which of the following is the most appropriate diagnostic test?", "answer": "Nucleic acid amplification test\n\"", "options": {"A": "Tzanck smear", "B": "Gram stain of cervical swab", "C": "Colposcopy", "D": "Pap smear", "E": "Nucleic acid amplification test\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy", "year old woman", "physician", "of vaginal discharge", "3 days", "discharge", "yellow", "mucopurulent", "foul odor", "vaginal bleeding", "not", "itching", "irritation", "last menstrual period", "2 weeks", "sexually active", "one male", "use condoms", "rapid urine hCG test", "negative", "temperature", "99", "pulse", "88 min", "blood pressure", "62 mm Hg", "Pelvic examination", "friable cervix", "Speculum", "unremarkable", "wet mount", "abnormalities", "following", "most appropriate diagnostic test"]}
{"question": "A 35-year-old man with no past medical history presents to his primary care physician with complaints of fatigue. He states that his life has been hectic lately and that everything seems to be falling apart. He is scared that he will lose his job, that his wife will leave him, and that his children will not be able to afford to go to college. His worries are severe enough that they have began to interfere with his daily activities. His wife is also present and states that he has a very secure job and that they are well off financially. She says that he has always worried about something since she met him years ago. What medication would benefit this patient long term?", "answer": "Escitalopram", "options": {"A": "Escitalopram", "B": "Diazepam", "C": "Risperidone", "D": "Lithium", "E": "No treatment recommended"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old man", "past medical history presents", "primary care physician", "complaints", "fatigue", "states", "to", "falling", "children", "not", "able", "to go", "college", "worries", "severe", "began to interfere", "present", "states", "very secure", "well", "always worried", "since", "met", "years", "medication", "benefit", "patient long term"]}
{"question": "A 34-year-old man comes to the physician because of blurry vision and fatigue for 2 months. During this period, he has also had occasional bleeding from his gums after brushing his teeth. One month ago, he was diagnosed with deep vein thrombosis after returning from an overseas business meeting. His pulse is 118/min, respirations are 19/min, and blood pressure is 149/91 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows bluish discoloration of the lips. The tip of the spleen is palpable 1 cm below the left costal margin. Sensory examination of the hands shows paresthesia. Hemoglobin concentration is 18 g/dL, hematocrit is 65%, leukocytes are 15,000/μL, and platelets are 470,000/μL. His serum erythropoietin concentration is decreased. Activation of which of the following is the most likely underlying cause of this patient's condition?", "answer": "Nonreceptor tyrosine kinase", "options": {"A": "Cytokine receptor", "B": "Transcription factor", "C": "Antiapoptotic molecule", "D": "Nonreceptor tyrosine kinase", "E": "Serine/threonine kinase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "blurry vision", "fatigue", "months", "period", "occasional bleeding", "gums", "brushing", "teeth", "One month", "diagnosed", "deep vein thrombosis", "returning", "business", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "97", "discoloration", "lips", "tip", "spleen", "palpable 1 cm", "left costal margin", "Sensory examination of", "hands", "paresthesia", "Hemoglobin concentration", "g/dL", "hematocrit", "65", "platelets", "serum erythropoietin concentration", "decreased", "Activation", "following", "underlying cause", "patient's condition"]}
{"question": "A 23-year-old woman is brought to the emergency department by emergency medical services. She was found trying to hang herself in her kitchen. The patient has a past medical history of drug abuse, alcoholism, anxiety, mania, irritable bowel syndrome, and hypertension. Her current medications include naltrexone, sodium docusate, and clonazepam as needed. Her temperature is 99.5°F (37.5°C), blood pressure is 100/65 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note a teary young woman. There are multiple bilateral superficial cuts along her wrists. The patient's cardiac and pulmonary exams are within normal limits. Neurological exam reveals a patient who is alert and oriented. The patient claims that you cannot send her home because if you do she will kill herself. Laboratory values are ordered and return as below.\n\nHemoglobin: 15 g/dL\nHematocrit: 40%\nLeukocyte count: 4,500 cells/mm^3 with normal differential\nPlatelet count: 197,500/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 102 mEq/L\nK+: 4.4 mEq/L\nHCO3-: 24 mEq/L\nBUN: 20 mg/dL\nGlucose: 90 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.2 mg/dL\nAST: 12 U/L\nALT: 10 U/L\n\nThe patient is transferred to the crisis intervention unit. Which of the following is the best next step in management?", "answer": "Lamotrigine", "options": {"A": "Haloperidol", "B": "Lamotrigine", "C": "Fluoxetine", "D": "Escitalopram", "E": "Diazepam"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "brought", "emergency department", "found", "hang", "kitchen", "patient", "past medical history of drug abuse", "alcoholism", "anxiety", "mania", "irritable bowel syndrome", "hypertension", "current medications include naltrexone", "sodium docusate", "clonazepam as needed", "temperature", "99", "blood pressure", "100 65 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "note", "teary young woman", "multiple bilateral superficial cuts", "wrists", "patient's cardiac", "pulmonary exams", "normal limits", "Neurological exam reveals", "patient", "alert", "oriented", "patient", "send", "home", "kill", "Laboratory values", "ordered", "return", "Hemoglobin", "g/dL Hematocrit", "40", "Leukocyte count", "4 500 cells mm", "normal differential Platelet count", "500 mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.4 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "90 mg/dL Creatinine", "1 0 mg/dL Ca2", "10", "mg/dL AST", "U/L ALT", "10 U/L", "patient", "transferred", "crisis intervention unit", "following", "best next step"]}
{"question": "A 6-year-old girl is brought to the physician because of a 4-day history of irritation and redness in both eyes. Her symptoms initially started in the left eye and progressed to involve both eyes within 24 hours. She presents with profuse tearing and reports that her eyes are sticky and difficult to open in the morning. She was diagnosed with asthma 2 years ago and has been admitted to the hospital for acute exacerbations 3 times since then. Current medications include inhaled beclomethasone, inhaled albuterol, and montelukast. Her temperature is 38.2 °C (100.8°F). Physical examination reveals a tender left preauricular lymph node. There is chemosis and diffuse erythema of the bulbar conjunctiva bilaterally. Slit lamp examination reveals a follicular reaction in both palpebral conjunctivae and diffuse, fine epithelial keratitis of both corneas. Corneal sensation is normal. Which of the following is the most appropriate next step in management?", "answer": "Supportive therapy", "options": {"A": "Supportive therapy", "B": "Oral cetirizine", "C": "Topical prednisolone acetate", "D": "Topical natamycin", "E": "Topical erythromycin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "physician", "4-day history", "irritation", "redness", "eyes", "symptoms initially started", "left eye", "progressed to", "eyes", "24 hours", "presents", "tearing", "reports", "eyes", "difficult to open", "morning", "diagnosed", "asthma", "years", "acute exacerbations", "times", "then", "Current medications include inhaled beclomethasone", "inhaled albuterol", "montelukast", "temperature", "100", "reveals", "tender left preauricular lymph node", "chemosis", "diffuse erythema", "bulbar", "Slit lamp", "reveals", "follicular reaction", "palpebral conjunctivae", "diffuse", "fine epithelial keratitis", "corneas", "sensation", "normal", "following", "most appropriate next step"]}
{"question": "A 55-year-old woman comes to the physician because of a 4-month history of a painless lump on her neck. Examination shows a hard nodule on the left side of her neck. A fine-needle aspiration biopsy shows well-differentiated cuboidal cells arranged spherically around colloid. She undergoes thyroidectomy. Histopathological examination of the surgical specimen shows invasion of the thyroid capsule and blood vessels. Which of the following cellular events is most likely involved in the pathogenesis of this patient's condition?", "answer": "PAX8-PPAR gamma gene rearrangement", "options": {"A": "TSH receptor gene mutation", "B": "Activation mutation in the BRAF gene", "C": "p53 tumor suppressor gene inactivation", "D": "Mutation in the RET proto-oncogene", "E": "PAX8-PPAR gamma gene rearrangement"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "4 month history", "painless lump", "neck", "Examination", "hard nodule", "left side of", "neck", "fine-needle aspiration biopsy", "well-differentiated", "colloid", "thyroidectomy", "Histopathological examination", "surgical specimen", "invasion", "thyroid capsule", "blood vessels", "following cellular", "most likely involved", "pathogenesis", "patient's condition"]}
{"question": "A 61-year-old man sustains an intracranial injury to a nerve that also passes through the parotid gland. Which of the following is a possible consequence of this injury?", "answer": "Changes in hearing", "options": {"A": "Loss of taste from posterior 1/3 of tongue", "B": "Loss of general sensation in anterior 2/3 of tongue", "C": "Paralysis of lateral rectus muscle", "D": "Changes in hearing", "E": "Horner's syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old man sustains", "intracranial injury to", "nerve", "passes", "parotid gland", "following", "possible consequence of", "injury"]}
{"question": "A 10-month-old boy is admitted to the pediatric intensive care ward because of progressive dyspnea and fever. For the past 2 weeks, he was unsuccessfully treated for an upper respiratory tract infection with ampicillin. He has a history of neonatal sepsis, frequent respiratory tract infections since the age of 3 months, and recurrent otitis media. He was born full-term vaginally to a consanguineous couple from an uncomplicated pregnancy. He received routine immunizations until 6 months of age. The patient’s vital signs are as follows: blood pressure is 70/40 mm Hg, heart rate is 138/min, respiratory rate is 39/min, and temperature is 39.5℃ (103.1 ℉). Physical examination reveals cyanosis, nasal flare, intercostal retractions, and bilaterally decreased breath sounds with crackles heard over the lower lobes on auscultation. The chest X-ray confirms bilateral lower lobe pneumonia. The blood count shows the following findings:\nErythrocytes 4.1 x 106/mm3\nHgb 13 g/dL\nTotal leukocyte count  41,100/mm3\nNeutrophils 74%\nLymphocytes 14%\nEosinophils 2%\nMonocytes 10%\nBasophils 0%\nPlatelet count 210,000/mm3\nThe patient is diagnosed with bilateral community-acquired lower lobe pneumonia and prescribed antibiotics. An immunological workup is performed to assess the patient’s immunity:\nMeasurement Result Normal range\nAntibodies\nTotal serum IgG 22.0 mg/dL  231–1,411 mg/dL \nSerum IgA 59.3 mg/dL 0–83 mg/dL\nSerum IgM 111.9 mg/dL 0–145 mg/dL\nLymphocyte flow cytometry\nCD3+ cells 2.2% 60–85%\nCD19+ cells 95.1% 8–20%\nCD16/CD56+ cells  0.1% 3–30%\nWhich of the following procedures is the option of choice for the further management of this patient?", "answer": "Bone marrow transplantation", "options": {"A": "Periodical prophylactic antibiotic administration", "B": "Periodical intravenous immune globulin administration", "C": "Thymectomy", "D": "Bone marrow transplantation", "E": "Chemotherapy"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["A 10 month old boy", "pediatric intensive care ward", "progressive dyspnea", "fever", "past 2 weeks", "treated", "upper respiratory tract infection", "ampicillin", "history of neonatal sepsis", "frequent infections", "age", "months", "recurrent otitis media", "born full-term", "consanguineous couple", "uncomplicated pregnancy", "received routine immunizations", "months", "age", "patients vital signs", "follows", "blood pressure", "70 40 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "reveals cyanosis", "nasal flare", "intercostal retractions", "decreased breath sounds", "crackles heard", "lower lobes", "auscultation", "chest X-ray confirms bilateral lower lobe pneumonia", "blood count", "following findings", "Erythrocytes", "mm3 Hgb", "g/dL Total leukocyte", "100", "Neutrophils 74", "Lymphocytes 14", "10", "Basophils 0", "Platelet count", "patient", "diagnosed", "bilateral community-acquired lower lobe pneumonia", "immunological workup", "performed to", "patients immunity", "Measurement Result Normal range Antibodies Total serum IgG", "0 mg/dL", "mg", "Serum IgA", "mg", "IgM", "flow cytometry CD3", "following procedures", "option", "further", "patient"]}
{"question": "A 50-year-old man arrives to the clinic complaining of progressive weakness. He explains that for 3 months he has had difficulty climbing the stairs, which has now progressed to difficulty getting out of a chair. He denies diplopia, dysphagia, dyspnea, muscle aches, or joint pains. He denies weight loss, weight gain, change in appetite, or heat or cold intolerance. He reports intermittent low-grade fevers. He has a medical history significant for hypertension and hyperlipidemia. He has taken simvastatin and losartan daily for the past 6 years. His temperature is 99.0°F (37.2°C), blood pressure is 135/82 mmHg, and pulse is 76/min. Cardiopulmonary examination is normal. The abdomen is soft, non-tender, non-distended, and without hepatosplenomegaly. Muscle strength is 3/5 in the hip flexors and 4/5 in the deltoids, biceps, triceps, patellar, and Achilles tendon reflexes are 2+ and symmetric. Sensation to pain, light touch, and vibration are intact. Gait is cautious, but grossly normal. There is mild muscle tenderness of his thighs and upper extremities. There is no joint swelling or erythema and no skin rashes. A complete metabolic panel is within normal limits. Additional lab work is obtained as shown below:\n\nSerum:\nNa+: 141 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 23 mEq/L\nUrea nitrogen: 18 mg/dL\nGlucose: 128 mg/dL\nCreatinine: 1.0 mg/dL\nAlkaline phosphatase: 69 U/L\nAspartate aminotransferase (AST): 302 U/L\nAlanine aminotransferase (ALT): 210 U/L\nTSH: 6.9 uU/mL\nThyroxine (T4): 5.8 ug/dL\nCreatine kinase: 4300 U/L\nC-reactive protein: 11.9 mg/L\nErythrocyte sedimentation rate: 37 mm/h\n\nWhich of the following is the most accurate diagnostic test?", "answer": "Muscle biopsy", "options": {"A": "Autoantibodies", "B": "Electromyography", "C": "Fine needle aspiration", "D": "Muscle biopsy", "E": "Statin cessation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["50 year old man", "clinic", "progressive weakness", "3 months", "difficulty climbing", "now progressed", "difficulty getting", "chair", "diplopia", "dysphagia", "dyspnea", "muscle aches", "joint pains", "weight loss", "weight gain", "change in appetite", "cold intolerance", "reports intermittent low-grade fevers", "medical history significant", "hypertension", "hyperlipidemia", "simvastatin", "losartan daily", "past", "years", "temperature", "99", "blood pressure", "mmHg", "pulse", "76 min", "Cardiopulmonary", "normal", "abdomen", "soft", "non-tender", "distended", "hepatosplenomegaly", "Muscle strength", "3/5", "hip flexors", "4/5", "deltoids", "biceps", "triceps", "patellar", "Achilles tendon reflexes", "2", "symmetric", "Sensation", "pain", "light touch", "vibration", "intact", "Gait", "normal", "mild muscle tenderness of", "thighs", "upper extremities", "joint swelling", "erythema", "skin rashes", "complete metabolic panel", "normal limits", "Additional lab", "obtained", "Serum", "Na", "mEq/L", "100 mEq/L K", "4", "mEq/L HCO3", "23 mEq/L Urea nitrogen", "mg/dL Glucose", "mg/dL Creatinine", "1 0 mg/dL Alkaline phosphatase", "69 U/L Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "U/L", "6.9 uU/mL Thyroxine", "5.8 ug/dL Creatine kinase", "U/L C-reactive protein", "mg/L Erythrocyte sedimentation rate", "mm/h", "following", "most accurate diagnostic test"]}
{"question": "A 40-year-old man presents with an episode of rectal bleeding. He is concerned because his mother died of colorectal cancer at 50 years of age. He has no further information about his family history. Physical examination and digital rectal examination are normal. He undergoes a colonoscopy and is found to have innumerable adenomas in the left side of the colon ranging in size from 4–15 mm. Which of the following is the most likely underlying mechanism of this patient illness?", "answer": "Mutations of the APC gene", "options": {"A": "Mutation in DNA mismatch repair genes", "B": "Alterations in STK11 gene", "C": "Mutations of the APC gene", "D": "Inactivation of RB1 gene", "E": "Inactivation of BRCA1 and BRCA2 genes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old man presents", "episode of rectal bleeding", "died", "colorectal cancer", "50 years", "age", "further", "history", "Physical examination", "digital rectal examination", "normal", "colonoscopy", "found to", "adenomas", "the left side of", "colon ranging", "size", "415 mm", "following", "underlying mechanism", "patient illness"]}
{"question": "A 28-year-old man presents to his physician with a history of excessive thirst and excessive urination over the last 3 weeks. He mentions that he has to wake up multiple times at night to urinate. A detailed history reveals that he has a known case of bipolar mood disorder and has been taking lithium carbonate for 5 years. His urinary specific gravity is 1.003, and his urinary osmolality is 150 mOsm/kg H2O. Which of the following Darrow-Yannet diagrams best describes the status of volumes and osmolality of this man’s body fluids?", "answer": "Image 2", "options": {"A": "Image 1", "B": "Image 2", "C": "Image 3", "D": "Image 4", "E": "IMage 5"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "physician", "history", "excessive thirst", "excessive urination", "weeks", "to wake up multiple times", "night to", "detailed history reveals", "known case", "bipolar mood disorder", "carbonate", "years", "urinary specific gravity", "1", "urinary osmolality", "mOsm/kg H2O", "following", "best", "status", "volumes", "osmolality of", "mans body fluids"]}
{"question": "An 8-year-old African American girl is brought to the clinic by her mother for her regular blood exchange. They come in every 2–3 months for the procedure. The child is in good health with no symptoms. Her last trip to the emergency department was 6 months ago due to bone pain. She was treated with morphine and oxygen and a blood transfusion. She takes hydroxyurea and a multivitamin with iron every day. She has an uncle that also has to get blood exchanges. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 37.0°C (98.6°F). She calmly waits for the machine to be set up and catheters inserted into both of her arms. She watches a movie as her blood is slowly replaced with 6 L of red blood cells. Based on this history, which of the following mechanisms most likely explains this patient’s condition?", "answer": "Amino acid substitution", "options": {"A": "Amino acid deletion", "B": "Amino acid substitution", "C": "Enzyme deficiency", "D": "Trinucleotide repeat", "E": "Nonsense mutation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "girl", "brought", "clinic", "regular blood exchange", "23 months", "procedure", "child", "symptoms", "last trip", "emergency department", "months", "due to bone pain", "treated with morphine", "oxygen", "blood transfusion", "hydroxyurea", "multivitamin with iron", "day", "to", "blood", "Today", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "98", "waits", "machine to", "catheters", "arms", "movie", "blood", "slowly replaced", "red blood cells", "Based", "history", "following mechanisms", "likely", "patients condition"]}
{"question": "A 75-year-old woman presents to the emergency department because of a brief loss of consciousness, slurred speech, and facial numbness. Family members report that she complained about feeling chest pain and shortness of breath while on her morning walk. Medical history is noncontributory. Physical examination shows decreased pupil reactivity to light and hemiplegic gait. Her pulse is 120/min, respirations are 26/min, temperature is 36.7°C (98.0°F), and blood pressure is 160/80 mm Hg. On heart auscultation, S1 is loud, widely split, and there is a diastolic murmur. Transthoracic echocardiography in a 4-chamber apical view revealed a large oval-shaped and sessile left atrial mass. Which of the following is the most likely complication of this patient's condition?", "answer": "Mitral valve obstruction", "options": {"A": "Atrial fibrillation", "B": "Atrioventricular block", "C": "Congestive heart failure", "D": "Mitral valve obstruction", "E": "Pericarditis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["75 year old woman presents", "emergency department", "of", "brief loss", "consciousness", "slurred speech", "facial numbness", "report", "about", "chest pain", "shortness of breath", "morning", "Medical history", "decreased pupil reactivity to light", "hemiplegic gait", "pulse", "min", "respirations", "min", "temperature", "36", "98", "blood pressure", "80 mm Hg", "heart auscultation", "S1", "loud", "split", "diastolic murmur", "Transthoracic echocardiography", "4-chamber apical view revealed", "large oval-shaped", "sessile left atrial mass", "following", "complication", "patient's condition"]}
{"question": "A 40-year-old man presents to the office with complaints of fatigue and difficulty breathing for the past few weeks. He also complains of early morning stiffness of his metatarsophalangeal and metacarpophalangeal joints on both sides that lasts for 2 hours. He feels better only after a warm water tub bath every day in the morning. He denies noticing any kind of rash on his body. He has been working in the shipbuilding industry for 20 years. He loves skin tanning and hunting in summer. He smokes 2 packs of cigarettes every day and has been doing so for the past 15 years. His pulmonary function test shows reduced forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio with a reduction of both FEV1 and FEV1 and decreased diffusing capacity of the lungs for carbon monoxide (DLCO). His chest X-ray shows multiple nodules with calcification. Which of the following antibodies will most likely be present in this patient that is very specific to the condition he has?", "answer": "Anti-CCP", "options": {"A": "Anti-CCP", "B": "Anti-Scl 70", "C": "Anti-Ro", "D": "Anti-ds-DNA", "E": "Anti-Jo1"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old man presents", "office", "complaints", "fatigue", "difficulty breathing", "past", "weeks", "early morning stiffness", "metacarpophalangeal joints", "sides", "lasts", "hours", "better only", "warm water tub bath", "day", "morning", "kind", "rash", "body", "20 years", "skin tanning", "summer", "smokes 2 packs", "cigarettes", "day", "so", "past", "years", "pulmonary function test", "reduced forced expiratory volume in 1 second", "vital capacity", "ratio", "reduction", "FEV1", "FEV1", "decreased", "capacity", "lungs", "carbon monoxide", "DLCO", "chest X-ray", "multiple nodules", "calcification", "following antibodies", "most likely", "present", "patient", "very specific", "condition"]}
{"question": "A 29-year-old man presents to clinic with a complaint of fatigue that has developed over the past 6 months. Upon questioning, he endorses abdominal pain, non-bloody diarrhea, and decreased appetite over the past year. He denies recent travel outside of the country or eating uncooked meats. On exam, his temperature is 99.0°F (37.2°C), blood pressure is 126/78 mmHg, pulse is 93/min, and respirations are 12/min. Notably, the abdominal exam is unremarkable aside from some tenderness to palpation near the umbilicus. His colonoscopy demonstrates perianal inflammation with a normal rectum, and biopsies of suspicious lesions in the transverse colon reveal transmural inflammation. Which one of the following is most strongly associated with the patient’s condition?", "answer": "Kidney stones", "options": {"A": "Colorectal cancer", "B": "Endocarditis", "C": "Hemolytic anemia", "D": "Kidney stones", "E": "Positive serum transglutaminase antibodies"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old man presents", "clinic", "complaint", "fatigue", "past 6 months", "abdominal pain", "non bloody diarrhea", "decreased appetite", "past year", "recent", "outside", "country", "eating", "exam", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "abdominal exam", "unremarkable", "tenderness", "palpation", "umbilicus", "colonoscopy", "perianal inflammation", "normal rectum", "biopsies", "suspicious lesions", "transverse colon reveal transmural inflammation", "one", "following", "most", "associated with", "patients condition"]}
{"question": "A 37-year-old male presents to your clinic with shortness of breath and lower extremity edema. He was born in Southeast Asia and emigrated to America ten years prior. Examination demonstrates 2+ pitting edema to the level of his knees, ascites, and bibasilar crackles, as well as an opening snap followed by a mid-to-late diastolic murmur. The patient undergoes a right heart catheterization that demonstrates a pulmonary capillary wedge pressure (PCWP) of 24 mmHg. The patient is most likely to have which of the following?", "answer": "Normal or decreased left ventricular end diastolic pressure (LVEDP)", "options": {"A": "Increased pulmonary vascular compliance", "B": "Decreased pulmonary artery systolic pressure (PASP)", "C": "Increased left ventricular end diastolic pressure (LVEDP)", "D": "Normal or decreased left ventricular end diastolic pressure (LVEDP)", "E": "Decreased transmitral gradient"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "clinic", "shortness of breath", "lower extremity edema", "born", "Southeast Asia", "to America ten years prior", "2", "pitting", "level of", "knees", "ascites", "crackles", "opening snap followed by", "late diastolic murmur", "patient", "right heart catheterization", "pulmonary capillary wedge pressure", "mmHg", "patient", "to", "following"]}
{"question": "A 67-year-old man comes to the physician for a follow-up examination after he was diagnosed with mantle cell lymphoma. The physician recommends a chemotherapeutic regimen containing bortezomib. Which of the following best describes the effect of this drug?", "answer": "Accumulation of ubiquitinated proteins", "options": {"A": "Stabilization of tubulin polymers", "B": "Accumulation of ubiquitinated proteins", "C": "Crosslinking of purine bases", "D": "Preventing the relaxation of DNA supercoils", "E": "Inhibition of tyrosine kinase receptors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["67 year old man", "physician", "follow-up examination", "diagnosed", "mantle cell lymphoma", "physician", "chemotherapeutic regimen containing bortezomib", "following best", "effect of", "drug"]}
{"question": "A 57-year-old man presents for his yearly wellness visit. He says he has been feeling well and has no complaints. No significant past medical history or current medications. The patient reports a 35-pack-year smoking history but says he quit 5 years ago. His family history is significant for lung cancer in his father who died at age 67. His vital signs include: temperature 36.8°C (98.2°F), pulse 95/min, respiratory rate 16/min, blood pressure 100/75 mm Hg. Physical examination is unremarkable. Laboratory findings are significant for the following:\nSerum potassium 3.9 mEq/L\nSerum sodium 140 mEq/L\nSerum chloride 103 mEq/L\nSerum calcium 2.5 mmol/L\nBUN 15 mg/dL\nCreatinine 0.8 mg/dL\nGlucose 95 mg/dL\nMagnesium 1.7 mEq/L\nPhosphate 1.1 mmol/L\nHemoglobin 14 g/dL\nBicarbonate (HCO3-) 25 mEq/L\nBilirubin, total 0.9 mg/dL\nBilirubin, indirect 0.4 mg/dL\nAST 10 U/L  \nALT 19 U/L  \nAlkaline phosphatase 40 U/L\nAlbumin 3.6 g/dL\nWhich of the following preventative screening tests is recommended for this patient at this time?", "answer": "Low-dose CT scan (LDCT) of the chest", "options": {"A": "Chest X-ray", "B": "Abdominal ultrasound", "C": "ECG", "D": "Low-dose CT scan (LDCT) of the chest", "E": "No screening indicated"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["57 year old man presents", "yearly", "well", "complaints", "significant past medical history", "current medications", "patient reports", "35", "smoking history", "family history", "significant", "lung cancer", "died", "age 67", "vital signs include", "temperature 36", "98", "pulse 95 min", "respiratory rate", "min", "blood pressure 100 75 mm Hg", "unremarkable", "Laboratory findings", "significant", "following", "Serum", "mEq", "chloride", "calcium 2", "mmol", "mg dL Creatinine", "mg dL", "95", "mmol", "g", "Bicarbonate", "HCO3", "mEq/L Bilirubin", "total 0.9 mg/dL Bilirubin", "0.4 mg dL", "U", "Alkaline phosphatase", "Albumin", "g dL", "following preventative", "patient", "time"]}
{"question": "A 49-year-old woman presents to her physician with a fever accompanied by chills and burning micturition since the past 5 days. She is an otherwise healthy woman with no significant past medical history and has an active sexual life. On physical examination, her temperature is 39.4°C (103.0°F), pulse rate is 90/min, blood pressure is 122/80 mm Hg, and respiratory rate is 14/min. Examination of the abdomen and genitourinary region do not reveal any specific positive findings. The physician orders a urinalysis of fresh unspun urine for this patient which shows 25 WBCs/mL of urine. The physician prescribes an empirical antibiotic and other medications for symptom relief. He also orders a bacteriological culture of her urine. After 48 hours of treatment, the woman returns to the physician to report that her symptoms have not improved. The bacteriological culture report indicates the growth of gram-negative bacilli which are lactose-negative and indole-negative, which produce a substance that hydrolyzes urea to produce ammonia. Which of the following bacteria is the most likely cause of infection in the woman?", "answer": "Proteus mirabilis", "options": {"A": "Citrobacter freundii", "B": "Escherichia coli", "C": "Enterobacter cloacae", "D": "Klebsiella pneumoniae", "E": "Proteus mirabilis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "physician", "fever", "chills", "burning micturition", "past", "days", "healthy woman", "significant past medical history", "active", "temperature", "pulse rate", "90 min", "blood pressure", "80 mm Hg", "respiratory rate", "min", "Examination of", "abdomen", "genitourinary region", "not reveal", "specific positive findings", "physician orders", "urinalysis", "fresh", "urine", "patient", "WBCs mL", "urine", "physician", "empirical", "medications", "orders", "bacteriological culture", "urine", "48 hours", "treatment", "woman returns", "physician to report", "symptoms", "not improved", "bacteriological culture report", "growth", "lactose negative", "indole negative", "urea to", "ammonia", "following bacteria", "most likely cause", "infection", "woman"]}
{"question": "A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 14/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?", "answer": "Cochlear hair cell degeneration", "options": {"A": "Accumulation of desquamated keratin debri", "B": "Eustachian tube obstruction secondary to nasopharyngeal inflammatory edema", "C": "Stapedial abnormal bone growth", "D": "Cochlear hair cell degeneration", "E": "Endolymphatic hydrops"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["72 year old man presents", "primary care physician", "worsening hearing loss", "states", "hearing began approximately", "years", "able", "hear", "difficulty", "current symptoms", "reports", "steady ringing in", "ears", "times", "dizziness", "Medical history", "significant", "three prior episodes of acute otitis media", "history", "notable", "diagnosed", "cholesteatoma", "temperature", "98", "blood pressure", "88 mmHg", "pulse", "min", "respirations", "min", "tuning fork", "middle", "patient's forehead", "sound", "ears", "tuning fork", "external auditory canal", "mastoid process", "air conduction", "greater than bone conduction", "following", "cause", "patient's symptoms"]}
{"question": "An investigator is studying the molecular structure of various proteinogenic L-amino acids. The structure of one of the amino acids being studied is shown. The derivative of this amino acid is most likely to cause which of the following effects in the human body?", "answer": "Peripheral vasodilation", "options": {"A": "Ketotic acidosis", "B": "Skin pigmentation", "C": "Pupillary dilation", "D": "Peripheral vasodilation", "E": "Respiratory depression"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "various", "amino acids", "structure", "one", "amino acids", "studied", "derivative", "amino acid", "to cause", "following effects", "human body"]}
{"question": "A 68-year-old man presents to his primary care physician with a 4-week history of back pain. He says that the pain does not appear to be associated with activity and is somewhat relieved by taking an NSAID. Furthermore, he says that he has had increasing difficulty trying to urinate. His past medical history is significant for kidney stones and a 30-pack-year smoking history. Radiographs reveal osteoblastic lesions in the spine. Which of the following drugs would most likely be effective in treating this patient's disease?", "answer": "Continuous leuprolide", "options": {"A": "Continuous leuprolide", "B": "Imatinib", "C": "Pulsatile leuprolide", "D": "Rituximab", "E": "Tamsulosin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "4 week history of back pain", "pain", "not appear to", "associated with activity", "somewhat relieved by", "NSAID", "increasing difficulty", "to", "past medical history", "significant", "kidney stones", "30", "smoking history", "Radiographs reveal", "lesions", "spine", "following drugs", "most likely", "effective", "treating", "patient's disease"]}
{"question": "A 29-year-old woman presents with skin lesions on her elbows and forearms. She notes that they first started appearing 2 months ago and have not improved. She describes the lesions as painless and rarely itchy. She denies any similar symptoms in the past, and has no other significant past medical history. Review of systems is significant for recent joint pain, conjunctivitis, and corneal dryness. The patient is afebrile and vital signs are within normal limits. Non-tender, raised, inflamed, white-silver maculopapular lesions are present. Which of the following are the most likely histopathologic findings in this patient's skin biopsy?", "answer": "Basal cell hyperplasia, proliferation of subepidermal vasculature, and keratinization", "options": {"A": "Intracellular edema with detachment at basal level", "B": "Subepidermal blister (detachment at suprabasal level)", "C": "Cytoplasmic vacuolation", "D": "Basal cell hyperplasia, proliferation of subepidermal vasculature, and keratinization", "E": "Nuclear atypia, cellular pleomorphism, and a disorganized structure of cells from basal to apical layers of the tissue"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "skin lesions", "elbows", "forearms", "notes", "first started appearing 2 months", "not improved", "lesions", "painless", "rarely itchy", "similar symptoms", "past", "past medical history", "Review of systems", "significant", "recent joint pain", "conjunctivitis", "corneal dryness", "patient", "afebrile", "vital signs", "normal limits", "Non-tender", "raised", "inflamed", "white silver maculopapular lesions", "present", "following", "histopathologic findings", "patient's skin"]}
{"question": "Two days after delivery, a newborn develops a red, irritated eye with yellow discharge. She was born at 39 weeks' gestation to a 28-year-old woman, gravida 1, para 1. Pregnancy and delivery were uncomplicated. The mother had not seen her gynecologist since her first prenatal visit. The newborn's temperature is 37.2°C (99.0°F), pulse is 140/min, respirations are 42/min, and blood pressure is 73/53 mm Hg. Ophthalmic examination shows eyelid edema, conjunctival injection, and copious yellow mucopurulent discharge from the right eye. There is no corneal ulceration or evidence of keratitis. Funduscopic examination is normal. The diagnosis is confirmed and appropriate treatment is administered. Which of the following is most likely to have prevented this patient's condition?", "answer": "Topical erythromycin administered to the infant", "options": {"A": "Oral erythromycin administered to the infant", "B": "IV ceftriaxone administered to the infant", "C": "Topical erythromycin administered to the infant", "D": "Oral doxycycline administered to the mother", "E": "Oral amoxicillin administered to the mother"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Two days", "delivery", "newborn", "red", "eye", "yellow discharge", "born", "weeks", "gestation", "year old woman", "gravida 1", "para 1", "Pregnancy", "delivery", "uncomplicated", "not seen", "gynecologist", "newborn's temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Ophthalmic examination", "eyelid edema", "conjunctival injection", "copious yellow mucopurulent discharge from", "right eye", "corneal ulceration", "keratitis", "Funduscopic", "normal", "diagnosis", "confirmed", "appropriate treatment", "administered", "following", "to", "prevented", "patient's condition"]}
{"question": "A 16-year-old boy is brought to the emergency department after losing consciousness. He had no preceding chest pain or palpitations. His father has cataracts and had frontal balding in his twenties but has no history of cardiac disease. His paternal grandfather also had early-onset balding. His pulse is 43/min. Physical examination shows frontal hair loss, temporal muscle wasting, and testicular atrophy. Neurologic examination shows bilateral foot drop and weakness of the intrinsic hand muscles. An ECG shows bradycardia with third-degree atrioventricular block. The severity of this patient's symptoms compared to that of his father is most likely due to which of the following genetic properties?", "answer": "Anticipation", "options": {"A": "Pleiotropy", "B": "Loss of heterozygosity", "C": "Codominance", "D": "Penetrance", "E": "Anticipation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "emergency department", "consciousness", "preceding chest pain", "palpitations", "cataracts", "frontal balding", "twenties", "history of cardiac disease", "early balding", "pulse", "min", "frontal hair loss", "temporal", "testicular atrophy", "Neurologic examination", "bilateral foot drop", "weakness of the intrinsic hand muscles", "ECG", "bradycardia", "third-degree atrioventricular block", "severity of", "patient's symptoms", "due to", "following genetic properties"]}
{"question": "A 32-year-old primigravida at 35 weeks gestation seeks evaluation at the emergency department for swelling and redness of the left calf, which started 2 hours ago. She reports that the pain has worsened since the onset. The patient denies a history of insect bites or trauma. She has never experienced something like this in the past. Her pregnancy has been uneventful so far. She does not use alcohol, tobacco, or any illicit drugs. She does not take any medications other than prenatal vitamins. Her temperature is 36.8℃ (98.2℉), the blood pressure is 105/60 mm Hg, the pulse is 110/min, and the respirations are 15/min. The left calf is edematous with the presence of erythema. The skin feels warm and pain is elicited with passive dorsiflexion of the foot. The femoral, popliteal, and pedal pulses are palpable bilaterally. An abdominal examination reveals a fundal height consistent with the gestational age. The lungs are clear to auscultation bilaterally. The patient is admitted to the hospital and appropriate treatment is initiated. Which of the following hormones is most likely implicated in the development of this patient’s condition?", "answer": "Estriol", "options": {"A": "Estriol", "B": "Progesterone", "C": "Human chorionic gonadotropin", "D": "Human placental lactogen", "E": "Prolactin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old primigravida", "35 weeks gestation", "emergency department", "swelling", "redness", "left calf", "started 2 hours", "reports", "pain", "worsened", "onset", "patient", "history", "insect bites", "trauma", "never", "past", "pregnancy", "far", "not use alcohol", "tobacco", "illicit drugs", "not", "medications", "prenatal vitamins", "temperature", "36", "98", "blood pressure", "60 mm Hg", "pulse", "min", "respirations", "min", "left calf", "edematous", "presence", "erythema", "skin", "warm", "pain", "elicited", "passive dorsiflexion of", "foot", "femoral", "popliteal", "pedal pulses", "palpable", "abdominal", "reveals", "fundal height", "gestational age", "lungs", "clear", "auscultation", "patient", "appropriate treatment", "initiated", "following hormones", "most likely", "development", "patients condition"]}
{"question": "A 26-year-old nurse at 8 weeks of gestation presents to the physician with low-grade fever and body ache for the past 2 days. She also complains of a fine pink and itchy rash that appeared 2 nights ago. The rash 1st appeared on her face and spread to her neck. Past medical history is noncontributory. She takes prenatal vitamins with folate every day. She has had many sick contacts while working in the hospital. Additionally, her daughter has had several colds over the last few months. On examination, the temperature is 38.3°C (100.9°F), she has a fine macular rash on her face and neck with focal macules on her chest. Palpation of the neck reveals lymphadenopathy in the posterior auricular nodes. What is the most appropriate next step in the management of this patient?", "answer": "Test for rubella antibodies in her blood", "options": {"A": "Administer anti-rubella antibodies", "B": "Admit the patient and place her in isolation", "C": "Administer rubella vaccine", "D": "Test for rubella antibodies in her blood", "E": "Termination of pregnancy"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old nurse", "weeks of gestation presents", "physician", "low-grade fever", "body ache", "past 2 days", "fine pink", "itchy rash", "appeared 2 nights", "rash 1st appeared", "face", "spread", "neck", "Past medical history", "prenatal vitamins", "folate", "day", "sick", "hospital", "several colds", "months", "temperature", "100 9F", "fine macular rash on", "face", "neck", "focal macules", "chest", "Palpation", "neck reveals lymphadenopathy", "posterior auricular nodes", "most appropriate next step", "patient"]}
{"question": "A 55-year-old man with a history of fatigue and exertional dyspnea presents to the urgent care clinic following an acute upper respiratory illness. On physical examination, his pulses are bounding, his complexion is very pale, and scleral icterus is apparent. The spleen is moderately enlarged. Oxygen saturation is 79% at rest, with a new oxygen requirement of 9 L by a non-rebreather mask. Laboratory analysis results show a hemoglobin level of 6.8 g/dL. Of the following options, which hypersensitivity reaction does this condition represent?", "answer": "Type II–cytotoxic hypersensitivity reaction", "options": {"A": "Type I–anaphylactic hypersensitivity reaction", "B": "Type II–cytotoxic hypersensitivity reaction", "C": "Type III–immune complex-mediated hypersensitivity reaction", "D": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "E": "Type II and II–mixed cytotoxic and immune complex hypersensitivity reaction"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "history", "fatigue", "exertional dyspnea presents", "urgent care clinic following", "acute upper respiratory illness", "pulses", "bounding", "complexion", "very pale", "scleral icterus", "spleen", "moderately enlarged", "Oxygen saturation", "new oxygen requirement", "non-rebreather mask", "Laboratory analysis results", "a hemoglobin level", "6.8 g/dL", "following options", "hypersensitivity reaction", "condition"]}
{"question": "A 57-year-old HIV-positive male with a history of intravenous drug abuse presents to the emergency room complaining of arm swelling. He reports that he developed progressively worsening swelling and tenderness over the right antecubital fossa three days prior. He recently returned from a trip to Nicaragua. His past medical history is notable for an anaphylactoid reaction to vancomycin. His temperature is 101.4°F (38.6°C), blood pressure is 140/70 mmHg, pulse is 110/min, and respirations are 20/min. Physical examination reveals an erythematous, fluctuant, and tender mass overlying the right antecubital fossa. Multiple injection marks are noted across both upper extremities. He undergoes incision and drainage and is started on an antibiotic that targets the 50S ribosome. He is discharged with plans to follow up in one week. However, five days later he presents to the same emergency room complaining of abdominal cramps and watery diarrhea. Which of the following classes of pathogens is most likely responsible for this patient’s current symptoms?", "answer": "Gram-positive bacillus", "options": {"A": "Gram-negative curved bacillus", "B": "Gram-negative bacillus", "C": "Anaerobic flagellated protozoan", "D": "Gram-positive coccus", "E": "Gram-positive bacillus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["HIV-positive male", "history of intravenous drug abuse presents", "emergency room", "of arm swelling", "reports", "worsening swelling", "tenderness", "right antecubital fossa three days prior", "recently returned", "trip", "Nicaragua", "past medical history", "notable", "anaphylactoid reaction", "vancomycin", "temperature", "blood pressure", "70 mmHg", "pulse", "min", "respirations", "20 min", "reveals", "erythematous", "fluctuant", "tender mass", "right antecubital fossa", "Multiple injection marks", "noted", "upper extremities", "incision", "drainage", "started", "targets", "ribosome", "to follow up", "one week", "later", "presents", "same emergency room", "abdominal cramps", "watery diarrhea", "following", "responsible", "patients current symptoms"]}
{"question": "A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below:\n\nSerum:\nNa+: 130 mEq/L\nK+: 3.7 mEq/L\nCl-: 100 mEq/L\nHCO3-: 24 mEq/L\nUrea nitrogen: 7 mg/dL\nGlucose: 70 mg/dL\nCreatinine: 0.9 mg/dL\nCa2+: 9.7 mg/dL\n\nUrine:\nAppearance: dark\nGlucose: negative\nWBC: 0/hpf\nBacterial: none\nNa+: 320 mEq/L/24 hours\n\nHis temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?", "answer": "Fluid restriction", "options": {"A": "Fluid restriction", "B": "Oral salt tablets", "C": "Demeclocycline", "D": "Conivaptan", "E": "Continue conservative management"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["69 year old male presents", "emergency department", "slurred speech", "to use", "right arm", "eating dinner", "patient", "emergency department", "one hour", "CT scan", "performed", "head", "not reveal", "signs", "hemorrhage", "patient", "given thrombolytics", "then", "neurology floor", "Three days later", "patient", "recovering", "stable", "depressed", "well", "symptoms", "improving", "initial presentation", "patient", "of neck pain", "worsened slowly", "past", "days", "given ibuprofen", "Laboratory values", "ordered", "return", "indicated", "Serum", "Na", "mEq/L K", "3", "mEq/L", "100 mEq/L HCO3", "mEq/L Urea nitrogen", "mg/dL Glucose", "70 mg/dL Creatinine", "0.9 mg/dL Ca2", "dL", "Urine", "Appearance", "dark Glucose", "negative WBC", "0 hpf Bacterial", "Na", "320 mEq/L 24 hours", "temperature", "99", "pulse", "95 min", "blood pressure", "70 mmHg", "respirations", "10/min", "oxygen saturation", "98", "room air", "following", "best next step"]}
{"question": "A 70-year-old man with a 2 year history of Alzheimer disease presents is brought in from his nursing facility with altered mental status and recurrent falls during the past few days. Current medications include donepezil and galantamine. His vital signs are as follows: temperature 36.0°C (96.8°F), blood pressure 90/60 mm Hg, heart rate 102/min, respiratory rate 22/min. Physical examination reveals several lacerations on his head and extremities. He is oriented only to the person. Urine and blood cultures are positive for E. coli. The patient is admitted and initial treatment with IV fluids, antibiotics, and subcutaneous prophylactic heparin. On the second day of hospitalization, diffuse bleeding from venipuncture sites and wounds is observed. His blood test results show thrombocytopenia, prolonged PT and PTT, and a positive D-dimer. Which of the following is the most appropriate next step in the management of this patient’s condition?", "answer": "Cryoprecipitate, FFP and low dose SC heparin", "options": {"A": "Immediately cease heparin therapy and prescribe an alternative anticoagulant", "B": "Start prednisone therapy", "C": "Cryoprecipitate, FFP and low dose SC heparin", "D": "Urgent plasma exchange", "E": "Splenectomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man", "2", "history", "Alzheimer disease presents", "brought", "nursing facility", "altered mental status", "recurrent falls", "past", "days", "Current medications include donepezil", "galantamine", "vital signs", "follows", "temperature 36", "96", "blood pressure 90 60 mm Hg", "heart rate", "min", "respiratory rate", "min", "reveals several", "head", "extremities", "oriented only", "Urine", "blood cultures", "positive", "patient", "initial treatment", "subcutaneous prophylactic heparin", "second day", "diffuse bleeding", "venipuncture sites", "wounds", "observed", "blood test results", "thrombocytopenia", "prolonged PT", "PTT", "positive", "following", "most appropriate next step", "management", "patients condition"]}
{"question": "A 59-year-old woman is brought to the emergency department for the confusion. She was in her usual state of health until about 2 hours ago when she was found trying to cook a frozen pizza in her medicine cabinet. She also complained to her husband that she had a terrible headache. Her past medical history is notable for hypertension, which has been difficult to control on multiple medications. Her temperature is 37.1°C (98.8°F), the pulse is 75/min, and the blood pressure is 202/128 mm Hg. On physical exam, she is alert and oriented only to self. The physical exam is otherwise unremarkable and the neurologic exam shows no focal neurological deficits. Noncontrast CT head imaging is unremarkable; a T2-weighted image from the patient’s MRI brain scan is shown. Which of the following is the next best step in management for this patient?", "answer": "IV nicardipine", "options": {"A": "IV lorazepam", "B": "IV nicardipine", "C": "IV phenytoin", "D": "IV tissue plasminogen activator (tPA)", "E": "IV vancomycin, ceftriaxone, and ampicillin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old woman", "brought", "emergency department", "confusion", "usual state of health", "about", "hours", "found", "to cook", "frozen", "medicine cabinet", "terrible headache", "past medical history", "notable", "hypertension", "difficult", "multiple", "temperature", "98", "pulse", "75 min", "blood pressure", "mm Hg", "alert", "oriented only", "unremarkable", "neurologic exam", "focal neurological deficits", "CT head imaging", "unremarkable", "weighted", "patients MRI brain scan", "following", "next best step", "patient"]}
{"question": "A 22-year-old man is brought to the emergency department by his father because he is having bizarre thoughts. The patient says that he is being haunted by aliens from outer space. The father is worried as his son has had these symptoms for the past 7 months and lately, it seems to be getting worse. He has become more self-obsessed and does not seem to have any interest in his favorite activities. He has no plans to harm himself or others but spends a lot of time and energy building ‘defenses’ in and around his room as he is absolutely sure that aliens will come to get him soon. His blood pressure is 121/79 mm Hg, pulse 86/min, respiratory rate 15/min, temperature 36.8°C (98.2°F). Which of the following is correct regarding the patient’s symptoms?", "answer": "He has a fixed false belief.", "options": {"A": "It would benefit from psychosurgery.", "B": "He has a fixed false belief.", "C": "It is a negative symptom.", "D": "It falls under the disorganized thinking domain.", "E": "It is amenable to cognitive behavioral therapy."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "bizarre thoughts", "patient", "outer space", "worried", "symptoms", "past", "months", "to", "getting worse", "more", "not", "to", "plans to", "others", "spends", "lot", "time", "energy building", "room", "to", "blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "min", "temperature 36", "98", "following", "correct", "patients symptoms"]}
{"question": "A family doctor in a rural area is treating a patient for dyspepsia. The patient had chronic heartburn and abdominal pain for the last 2 months and peptic ulcer disease due to a suspected H. pylori infection. For reasons relating to affordability and accessibility, the doctor decides to perform a diagnostic test in the office that is less invasive and more convenient. Which of the following is the most likely test used?", "answer": "Serology (ELISA testing)", "options": {"A": "Detection of the breakdown products of urea in biopsy", "B": "Steiner's stain", "C": "Stool antigen test", "D": "Culture of organisms from gastric specimen", "E": "Serology (ELISA testing)"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["family doctor", "rural area", "treating", "patient", "dyspepsia", "patient", "chronic heartburn", "abdominal pain", "months", "peptic ulcer disease due to a suspected H", "pylori infection", "relating", "affordability", "accessibility", "doctor", "to perform", "diagnostic test", "office", "less invasive", "more convenient", "following", "most likely test used"]}
{"question": "A 32-year-old man comes to the physician with difficulty swallowing for several weeks. Examination of the oropharynx shows lesions on palate and tongue that can be easily scraped off. An image of the lesions is shown. Which of the following is a risk factor for this patient's findings?", "answer": "Decline in CD4+ T-cells", "options": {"A": "Decline in CD4+ T-cells", "B": "Inhalation of salbutamol", "C": "Missed childhood vaccination", "D": "Chronic nicotine abuse", "E": "Epstein-Barr virus infection"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "difficulty swallowing", "weeks", "oropharynx", "lesions", "palate", "tongue", "easily scraped", "lesions", "following", "a", "factor", "patient's findings"]}
{"question": "A 7-year-old boy presents with difficult left eye-opening in the morning, eye discharge, and irritation. These symptoms developed gradually over the past week. He attends a primary school where recently an outbreak of tonsillitis took place. He had otitis media 2 weeks ago treated with ampicillin. At the presentation, the patient’s vital signs are within normal limits. Eye examination reveals bulbar conjunctival injection, mild eyelid edema, and a moderate mucopurulent discharge with crusts on the lower eyelid. There is no corneal or eyelid ulceration. No lymphadenopathy is noted. Which of the following investigations should be performed to establish a diagnosis before the treatment?", "answer": "No investigations are required in this case", "options": {"A": "Bacterial culture of the discharge", "B": "No investigations are required in this case", "C": "Rapid viral test", "D": "Scrapings with Gram staining", "E": "Polymerase chain reaction"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "difficult left opening", "morning", "eye discharge", "irritation", "symptoms", "past week", "attends", "primary school", "recently", "tonsillitis", "place", "otitis media", "weeks", "treated with ampicillin", "patients vital signs", "normal limits", "Eye examination reveals bulbar conjunctival injection", "mild eyelid edema", "moderate mucopurulent discharge", "crusts", "lower eyelid", "corneal", "eyelid ulceration", "lymphadenopathy", "noted", "following", "performed to establish", "diagnosis", "treatment"]}
{"question": "A 32 year-old African American man with a past medical history of sickle cell anemia presents to his primary care physician for a routine check-up. He has no complaints. His physician notes that he likely has an increased susceptibility to infections with certain organisms. Which of the following patient groups has a similar pattern of increased susceptibility?", "answer": "C3 complement deficiency", "options": {"A": "C5-9 complement deficiency", "B": "T-cell deficiency", "C": "C3 complement deficiency", "D": "Hemophilia A", "E": "Hemophilia B"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year", "man", "past medical history of sickle cell anemia presents", "primary care physician", "routine check-up", "complaints", "physician notes", "likely", "increased susceptibility to infections", "certain", "following patient groups", "similar pattern", "increased susceptibility"]}
{"question": "A 3175-g (7-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old primigravid woman following a spontaneous vaginal delivery. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. Cardiac examination in the delivery room shows a continuous machine-like murmur. An echocardiogram shows a structure with blood flow between the pulmonary artery and the aorta. This structure is most likely a derivate of which of the following?", "answer": "6th aortic arch", "options": {"A": "4th aortic arch", "B": "2nd aortic arch", "C": "6th aortic arch", "D": "1st aortic arch", "E": "3rd aortic arch"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["g", "male newborn", "delivered", "weeks", "gestation", "29 year old primigravid woman following", "spontaneous vaginal delivery", "Apgar scores", "5 minutes", "delivery room", "continuous machine", "murmur", "echocardiogram", "structure", "blood flow", "pulmonary artery", "aorta", "structure"]}
{"question": "A 27-year-old man with a past medical history of type I diabetes mellitus presents to the emergency department with altered mental status. The patient was noted as becoming more lethargic and confused over the past day, prompting his roommates to bring him in. His temperature is 99.0°F (37.2°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 144 mEq/L\nCl-: 100 mEq/L\nK+: 6.3 mEq/L\nHCO3-: 16 mEq/L\nBUN: 20 mg/dL\nGlucose: 599 mg/dL\nCreatinine: 1.4 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the appropriate endpoint of treatment for this patient?", "answer": "Normal anion gap", "options": {"A": "Clinically asymptomatic", "B": "Normal anion gap", "C": "Normal glucose", "D": "Normal potassium", "E": "Vitals stable"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year", "man", "past", "history of type I diabetes mellitus presents", "emergency department", "altered mental status", "patient", "noted", "more lethargic", "confused", "past day", "prompting", "to", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L", "100 mEq/L K", "6.3 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "1.4 mg/dL Ca2", "10", "mg/dL", "following", "appropriate endpoint", "treatment", "patient"]}
{"question": "The drug cilostazol is known for its ability to relax vascular smooth muscle and therefore cause vasodilation through its inhibition of phosphodiesterase 3. Given this mechanism of action, what other effect would be expected?", "answer": "Positive inotropy", "options": {"A": "Increased left ventricular end-diastolic volume", "B": "Positive inotropy", "C": "Negative chronotropy", "D": "Angioedema", "E": "Antiarrhythmic action"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["drug cilostazol", "known", "ability", "relax vascular smooth muscle", "cause vasodilation", "inhibition", "phosphodiesterase", "Given", "mechanism of action", "effect"]}
{"question": "A 43-year-old woman presents to her primary care provider with shortness of breath. She reports a 4-month history of progressively worsening difficulty breathing with associated occasional chest pain. She is a long-distance runner but has had trouble running recently due to her breathing difficulties. Her past medical history is notable for well-controlled hypertension for which she takes hydrochlorothiazide. She had a tibial osteosarcoma lesion with pulmonary metastases as a child and successfully underwent chemotherapy and surgical resection. She has a 10 pack-year smoking history but quit 15 years ago. She drinks a glass of wine 3 times per week. Her temperature is 98.6°F (37°C), blood pressure is 140/85 mmHg, pulse is 82/min, and respirations are 18/min. On exam, she has increased work of breathing with a normal S1 and loud P2. An echocardiogram in this patient would most likely reveal which of the following?", "answer": "Right ventricular hypertrophy with a dilated pulmonary artery", "options": {"A": "Biventricular dilatation with a decreased ejection fraction", "B": "Left atrial dilatation with mitral valve stenosis", "C": "Left ventricular dilatation with an incompetent aortic valve", "D": "Left ventricular hypertrophy with a bicuspid aortic valve", "E": "Right ventricular hypertrophy with a dilated pulmonary artery"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care provider", "shortness of breath", "reports", "4 month history", "worsening difficulty breathing with associated occasional chest pain", "long distance", "trouble", "recently due to", "breathing difficulties", "past medical history", "notable", "well", "hydrochlorothiazide", "tibial osteosarcoma lesion", "pulmonary metastases", "child", "chemotherapy", "surgical resection", "a 10", "smoking history", "years", "glass", "times", "week", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "exam", "increased work of breathing", "normal S1", "loud P2", "echocardiogram", "patient", "most likely reveal", "following"]}
{"question": "A 23-year-old man presents to the physician with nausea, vomiting, constipation, and abdominal pain for the past 24 hours. He has also developed difficulty in swallowing and blurring of vision. He also complains of significant dryness of his mouth and throat. When asked about his diet, he reports that he has been saving money by eating dented and old canned goods. On physical examination, his vital signs are stable. His neurologic examination reveals bilateral fixed dilated pupils, weakness of extraocular muscles, and weak gag reflex, while sensations and gait are normal. Laboratory evaluation of his stool isolates a toxin produced by gram-positive, anaerobic, spore-forming bacilli. Which of the following mechanisms best explains the action of the toxin?", "answer": "Blockade of release of acetylcholine at neuromuscular junctions", "options": {"A": "Blockade of voltage-gated fast sodium channels in motor neurons", "B": "Blockade of release of acetylcholine at neuromuscular junctions", "C": "Inactivation of acetylcholinesterase at neuromuscular junctions", "D": "Competitive antagonism of acetylcholine at postsynaptic receptors", "E": "Prolonged depolarization of NM receptors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old man presents", "physician", "nausea", "vomiting", "constipation", "abdominal pain", "past 24 hours", "difficulty in swallowing", "blurring of vision", "significant dryness", "mouth", "throat", "diet", "reports", "money", "eating dented", "old canned goods", "vital signs", "stable", "neurologic examination reveals bilateral fixed dilated pupils", "weakness", "extraocular muscles", "weak gag reflex", "sensations", "gait", "normal", "Laboratory", "stool isolates", "toxin", "following mechanisms best", "action", "toxin"]}
{"question": "A 55-year-old woman comes to the physician because of involuntary rhythmic shaking of both hands for several months. More recently, she also noticed involuntary head nodding movements. The shaking seems to improve after having one or two glasses of wine. Her father had similar symptoms starting at the age of 60. Neurologic examination shows a symmetric hand tremor that worsens with voluntary movement of the respective extremity. The most appropriate pharmacotherapy for this patient's symptoms is also recommended for the treatment of which of the following conditions?", "answer": "Hyperthyroidism", "options": {"A": "Motion sickness", "B": "Restless legs syndrome", "C": "Sleepwalking", "D": "Hyperthyroidism", "E": "Malignant hyperthermia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "involuntary rhythmic shaking", "hands", "months", "recently", "involuntary head nodding movements", "shaking", "to", "one", "two glasses", "similar symptoms starting", "age of 60", "Neurologic examination", "symmetric hand tremor", "worsens", "voluntary movement", "extremity", "most appropriate pharmacotherapy", "patient's symptoms", "treatment", "following conditions"]}
{"question": "A 72-year-old woman is brought to the emergency department 4 hours after the sudden onset of shortness of breath and dizziness. Her blood pressure is 88/56 mm Hg. Examination shows crackles at both lung bases and an S3 gallop. The extremities are cold to the touch. Serum studies show a urea nitrogen concentration of 15 mg/dL, a creatinine concentration of 1.0 mg/dL, and a lactic acid concentration of 6.4 mmol/L (N < 2). Arterial blood gas analysis on room air shows:\npH 7.27\npCO2 36 mm Hg\nHCO3- 15 mEq/L\nAn ECG shows ST-segment elevation in the precordial leads. Which of the following is the most likely explanation for this patient's laboratory changes?\"", "answer": "Accumulation of NADH", "options": {"A": "Catecholamine stimulation of glycolysis", "B": "Decreased reabsorption of HCO3-", "C": "Increased activity of HMG-CoA lyase", "D": "Defective mitochondrial oxygen utilization", "E": "Accumulation of NADH"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "hours", "sudden onset of shortness", "breath", "dizziness", "blood pressure", "88", "mm Hg", "crackles", "lung bases", "S3 gallop", "extremities", "cold to", "touch", "Serum studies", "urea", "concentration", "mg/dL", "creatinine concentration", "1.0 mg/dL", "lactic acid concentration", "mmol/L", "N", "Arterial blood gas analysis", "room air", "pH 7 27 pCO2 36 mm Hg HCO3", "mEq/L", "ECG", "ST-segment elevation", "precordial leads", "following", "explanation", "patient", "aboratory  hanges?"]}
{"question": "A previously healthy 24-year-old woman comes to the physician because of fever, headache, myalgia, photophobia, and a nonproductive cough for 2 days. Three weeks ago, she received a parrot as a birthday present. Her temperature is 38.5°C (101.3°F). Pulmonary examination shows crackles at both lung bases. Her leukocyte count is 8,000/mm3. An x-ray of the chest shows diffuse patchy infiltrates that are most prominent in the lower lobes. Which of the following is the most likely causal organism?", "answer": "Chlamydophila psittaci", "options": {"A": "Chlamydophila psittaci", "B": "Cryptococcus neoformans", "C": "Leptospira interrogans", "D": "Babesia microti", "E": "Francisella tularensis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old woman", "physician", "fever", "headache", "myalgia", "photophobia", "nonproductive cough", "2 days", "Three weeks", "received", "present", "temperature", "Pulmonary", "crackles", "lung bases", "leukocyte count", "mm3", "x-ray of", "chest", "diffuse patchy infiltrates", "most prominent", "lower lobes", "following", "causal"]}
{"question": "A 71-year-old woman presents to the emergency department with a headache for the past 30 minutes. She says that this is the worst headache of her life and that it came on suddenly after she hit her head. She says that she has also been experiencing visual problems with double vision when she looks to the left or the right. Visual examination reveals that her right eye cannot move right past the midline and her left eye cannot move left past the midline. Which of the following is most likely responsible for this patient's visual defects?", "answer": "Central herniation", "options": {"A": "Bilateral uncal herniation", "B": "Central herniation", "C": "Subfalcine herniation", "D": "Tonsillar herniation", "E": "Unilateral uncal herniation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "headache", "past 30 minutes", "worst headache", "hit", "head", "visual problems", "double", "looks", "left", "right", "Visual examination reveals", "right eye", "move right past", "midline", "left eye", "move left past", "midline", "following", "responsible", "patient's visual defects"]}
{"question": "A 58-year-old man comes to the physician because of intermittent throbbing headaches over the past year. The headaches are worse when he wakes up and are not accompanied by other symptoms. The patient also reports trouble concentrating on daily tasks at work. His wife has been complaining lately about his snoring during sleep, which he attributes to his chronic sinusitis. He has a history of hypertension and an allergy to dust mites. He has smoked a pack of cigarettes daily for 14 years. His pulse is 72/min and blood pressure is 150/95 mm Hg. He is 178 cm (5 ft 10 in) tall and weighs 120 kg (265 lb); BMI is 37.9 kg/m2. Neurological and cutaneous examination shows no abnormalities. Which of the following is the most likely cause of this patient's hypertension?", "answer": "Nocturnal upper airway obstruction", "options": {"A": "Low circulating free thyroxine levels", "B": "Nocturnal upper airway obstruction", "C": "Hypophyseal neoplasm", "D": "Hypersecretion of aldosterone", "E": "Low synaptic serotonin levels"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old man", "physician", "of intermittent throbbing headaches", "past year", "headaches", "worse", "wakes up", "not", "symptoms", "patient", "reports", "snoring", "sleep", "attributes", "chronic sinusitis", "history of hypertension", "allergy", "dust mites", "smoked", "pack", "cigarettes daily", "years", "pulse", "72 min", "blood pressure", "95 mm Hg", "5 ft 10", "tall", "kg", "BMI", "kg/m2", "Neurological", "cutaneous examination", "abnormalities", "following", "most likely cause", "patient's hypertension"]}
{"question": "A 75-year-old man presents to the emergency department for abdominal pain. The patient states the pain started this morning and has been worsening steadily. He decided to come to the emergency department when he began vomiting. The patient has a past medical history of obesity, diabetes, alcohol abuse, and hypertension. His current medications include captopril, insulin, metformin, sodium docusate, and ibuprofen. His temperature is 104.0°F (40°C), blood pressure is 160/97 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Abdominal exam reveals left lower quadrant tenderness. Cardiac exam reveals a crescendo systolic murmur heard best by the right upper sternal border. Lab values are ordered and return as below.\n\nHemoglobin: 15 g/dL\nHematocrit: 42%\nLeukocyte count: 19,500 cells/mm^3 with normal differential\nPlatelet count: 226,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 101 mEq/L\nK+: 4.4 mEq/L\nHCO3-: 24 mEq/L\nBUN: 22 mg/dL\nGlucose: 144 mg/dL\nCreatinine: 1.2 mg/dL\nCa2+: 9.8 mg/dL\n\nWhich of the following is the most accurate test for this patient's condition?", "answer": "CT scan", "options": {"A": "Amylase and lipase levels", "B": "Barium enema", "C": "Colonoscopy", "D": "CT scan", "E": "Sigmoidoscopy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["75 year old man presents", "emergency department", "abdominal pain", "patient states", "pain started", "morning", "worsening", "to", "emergency department", "began vomiting", "patient", "past medical", "diabetes", "alcohol abuse", "hypertension", "current medications include captopril", "insulin", "metformin", "sodium docusate", "ibuprofen", "temperature", "blood pressure", "97 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room", "Abdominal exam reveals left lower quadrant tenderness", "reveals", "crescendo systolic murmur heard best", "right upper sternal border", "Lab values", "ordered", "return", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "500 cells mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.4 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1.2 mg/dL Ca2", "mg/dL", "following", "most accurate test", "patient's condition"]}
{"question": "A 24-year-old man is brought to the emergency department by his brother because of a 3-hour history of lethargy and confusion. The brother says that 2 days ago, the patient ate several large-capped mushrooms he had foraged in the woods. After eating the mushrooms, he developed severe, bloody diarrhea that has since resolved. His pulse is 140/min, respirations are 26/min, and blood pressure is 98/62 mm Hg. Examination shows dry mucous membranes and tenderness to deep palpation in the right upper quadrant. Serum studies show a serum AST concentration of 2335 U/L and ALT concentration of 2294 U/L. Inhibition of which of the following processes is the most likely cause of this patient's condition?", "answer": "Messenger RNA synthesis", "options": {"A": "Messenger RNA synthesis", "B": "ATP production", "C": "Microtubule polymerization", "D": "Parasympathetic activation", "E": "Cell depolarization"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "hour history", "lethargy", "confusion", "2 days", "patient ate", "large capped", "woods", "eating", "severe", "bloody", "since resolved", "pulse", "min", "respirations", "min", "blood pressure", "98 62 mm Hg", "dry mucous membranes", "tenderness", "deep palpation", "right upper quadrant", "Serum studies", "serum concentration", "U/L", "ALT concentration", "U/L", "Inhibition", "following processes", "most likely cause", "patient's condition"]}
{"question": "A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?", "answer": "Listen to the patient’s wife’s wishes and withdraw care", "options": {"A": "Listen to the patient’s wife’s wishes and withdraw care", "B": "Listen to the patient’s daughter’s wishes and continue all care", "C": "Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated", "D": "Consult the hospital ethics committee and continue all care until a decision is reached", "E": "Call other family members and consult them for their opinions"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["76 year old man", "brought", "hospital", "stroke", "Head CT", "done", "emergency department", "intracranial hemorrhage", "arrival", "non responsive", "only", "pain", "not open", "eyes", "medical", "further", "intubated", "airway protection", "second day", "ICU", "blood pressure", "measured", "54 mmHg", "pulse", "min", "given fluids", "progresses", "renal failure", "mental status deteriorates", "physicians", "ICU", "patients", "wishes", "patient", "appropriate", "not", "living will", "withdrawn", "to", "point", "patients", "disagrees", "best", "patient", "to", "Based", "best course", "action", "physician"]}
{"question": "A 43-year-old woman walks into the clinic for an annual check-up appointment with her family physician. When asked about any changes in her life, she states that she lost her job about 6 months ago. Since then, she has lived with her boyfriend who is also unemployed. She frequently uses laxatives and takes some over the counter medications to help her sleep. Her blood pressure is 129/87 mm Hg, respirations are 12/min, pulse is 58/min, and temperature is 36.7°C (98.1°F). Her physical exam is mostly benign. Her pupils appear mildly constricted and she appears drowsy and subdued. The physician suspects that the physical findings in this patient are caused by a substance she is likely abusing. Which of the following is the substance?", "answer": "Codeine", "options": {"A": "Ketamine", "B": "Cocaine", "C": "Codeine", "D": "Alprazolam", "E": "Clonazepam"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman walks", "clinic", "annual check-up appointment", "family physician", "changes", "life", "states", "lost", "job", "6 months", "then", "lived", "unemployed", "frequently uses laxatives", "over the counter medications to help", "sleep", "blood pressure", "87 mm Hg", "respirations", "min", "pulse", "58 min", "temperature", "36", "98", "mostly benign", "pupils appear mildly constricted", "appears drowsy", "physician", "physical findings", "patient", "caused", "likely abusing", "following"]}
{"question": "A 42-year-old woman comes to the clinic with a complaint of a severely itchy and painful rash on her hands and legs for a day. On further questioning, she revealed that she loves nature and goes on trekking to the woods frequently. She just returned from a similar trip, 2 days ago. On physical examination, a prominent rash along with multiple blisters is noted on the ventral aspect of her right forearm. A photograph of the rash is shown. Which of the following is the most likely reaction that the patient is experiencing?", "answer": "Type IV hypersensitivity reaction", "options": {"A": "Type IV hypersensitivity reaction", "B": "Type III hypersensitivity reaction", "C": "Bullous pemphigoid", "D": "Type I hypersensitivity reaction", "E": "Type II hypersensitivity reaction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "clinic", "complaint", "severely itchy", "painful rash", "hands", "legs", "day", "further", "revealed", "nature", "trekking", "woods frequently", "returned", "similar trip", "2 days", "prominent rash", "multiple blisters", "noted", "ventral aspect", "right forearm", "photograph", "rash", "following", "reaction", "patient"]}
{"question": "A 6-year-old boy presents to his primary care physician with hip pain that started this morning. The patient claims the pain is severe and is stopping him from skateboarding. The patient recently recovered from a upper respiratory infection that he caught from his siblings but has otherwise been healthy. The patient has a past medical history of obesity. His temperature is 98.1°F (36.7°C), blood pressure is 100/55 mmHg, pulse is 90/min, respirations are 22/min, and oxygen saturation is 98% on room air. On physical exam, you note an obese boy in no acute distress. Cardiopulmonary exam is within normal limits. Inspection of the hip reveals no abnormalities or swelling. The hip exhibits a normal range of motion and physical exam only elicits minor pain. The patient's gait appears normal and pain is elicited when the patient jumps or runs. Which of the following is the best next step in management for this patient's most likely diagnosis?", "answer": "Ibuprofen and rest", "options": {"A": "Radiography", "B": "CT scan", "C": "MRI", "D": "Aspiration and broad spectrum antibiotics", "E": "Ibuprofen and rest"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy presents", "primary care physician", "hip pain", "started", "morning", "patient", "pain", "severe", "stopping", "patient recently recovered", "upper respiratory infection", "caught", "healthy", "patient", "past medical", "temperature", "98", "36", "blood pressure", "100", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "note", "obese boy", "acute distress", "Cardiopulmonary exam", "normal limits", "Inspection", "hip reveals", "abnormalities", "swelling", "hip", "normal range of motion", "only elicits minor pain", "patient's gait appears normal", "pain", "elicited", "patient jumps", "runs", "following", "best next step", "patient's", "likely diagnosis"]}
{"question": "An investigator is studying the incidence of sickle cell trait in African American infants. To identify the trait, polymerase chain reaction testing is performed on venous blood samples obtained from the infants. Which of the following is required for this laboratory technique?", "answer": "Initial sequence of the 3' end of a DNA strand", "options": {"A": "RNA-dependent DNA polymerase", "B": "Ligation of Okazaki fragments", "C": "Initial sequence of the 3' end of a DNA strand", "D": "Complete genome DNA sequence", "E": "Single-stranded binding proteins"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying", "incidence", "sickle cell trait", "infants", "To", "trait", "polymerase chain reaction testing", "performed", "venous blood samples obtained", "infants", "following", "required"]}
{"question": "A previously healthy 20-year-old woman comes to the physician because of recurrent abdominal cramps, bloating, and diarrhea for 4 months. She describes her stools as greasy, foul-smelling, and difficult to flush. During this time she has had a 6-kg (13.2-lb) weight loss. She has no personal or family history of serious illness. Physical examination shows pallor and cheilitis. Laboratory studies show a hemoglobin concentration of 11 g/dL. Serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Test of the stool for occult blood is negative and stool microscopy reveals no pathogens and no leukocytes. Analysis of a 24-hour stool sample shows 12 g of fat. The patient is asked to consume 25 g of d-xylose. Five hours later, its concentration is measured in urine at 2 g (N = > 4 g/5 h). The test is repeated after a two-week course of rifaximin, but the urinary concentration of d-xylose remains the same. Which of the following is the most likely diagnosis?", "answer": "Hypersensitivity to gliadin\n\"", "options": {"A": "Lactose intolerance", "B": "Exocrine pancreatic insufficiency", "C": "Tropheryma whipplei infection", "D": "Bacterial overgrowth in the small intestine", "E": "Hypersensitivity to gliadin\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy 20 year old woman", "physician", "recurrent abdominal cramps", "bloating", "diarrhea", "months", "stools", "greasy", "foul-smelling", "difficult to flush", "time", "kg", "weight loss", "personal", "family history", "serious illness", "pallor", "cheilitis", "Laboratory studies", "a hemoglobin concentration", "g/dL", "Serum", "electrolytes", "urea nitrogen", "creatinine", "reference range", "Test", "stool", "occult blood", "negative", "stool microscopy reveals", "leukocytes", "Analysis", "hour stool", "g", "fat", "patient", "g", "xylose", "Five hours later", "concentration", "measured", "urine", "g", "4 g 5 h", "test", "repeated", "two week course", "rifaximin", "urinary concentration", "xylose", "same", "following", "diagnosis"]}
{"question": "A 27-year-old man presents to the emergency room complaining of shortness of breath and productive cough for a few days. He says that his sputum is mostly yellow with tiny red specks. He denies fever, chills, recent weight loss, or joint pain. He has no history of recent travel or sick contacts.  His medical history is unremarkable. He smokes a pack of cigarettes daily. He has had 3 sexual partners in the past year. His temperature is 37°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respirations are 20/min. On physical examination, the patient is in mild respiratory distress. Cardiopulmonary auscultation reveals diffuse bilateral rales. An HIV test is negative. His laboratory results are as follow:\nComplete blood count\nHemoglobin 12 gm/dL\nSerum chemistry\nSodium 143 mEq/L\nPotassium 4.1 mEq/L\nChloride 98 mEq/L\nBicarbonate  22 mEq/L\nBlood urea nitrogen 26 mg/dL\nCreatinine 2.3 mg/dL\nGlucose  86 mg/dL\nUrine dipstick\nProtein trace\nBlood positive\nLeukocytes negative\nNitrates negative\nWhich of the following is the most likely cause of his current condition?", "answer": "Basement membrane antibodies", "options": {"A": "Pneumocystis pneumonia", "B": "Pulmonary embolism", "C": "Heart failure", "D": "Basement membrane antibodies", "E": "Ruptured alveolar bleb"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "emergency room", "of shortness", "breath", "productive cough", "days", "sputum", "mostly yellow", "red", "fever", "chills", "recent weight loss", "joint pain", "history of recent travel", "sick", "medical history", "unremarkable", "smokes", "pack", "cigarettes daily", "3", "past year", "temperature", "98", "blood pressure", "70 mm Hg", "pulse", "98 min", "respirations", "20 min", "patient", "mild respiratory distress", "Cardiopulmonary auscultation reveals diffuse bilateral rales", "HIV test", "negative", "laboratory results", "follow", "blood", "Urine", "trace", "positive", "negative", "following", "most likely cause", "current condition"]}
{"question": "An investigator is studying the clearance of respiratory particles in healthy non-smokers. An aerosol containing radio-labeled particles that are small enough to reach the alveoli is administered to the subjects via a non-rebreather mask. A gamma scanner is then used to evaluate the rate of particle clearance from the lungs. The primary mechanism of particle clearance most likely involves which of the following cell types?", "answer": "Macrophages", "options": {"A": "Goblet cells", "B": "Club cells", "C": "Type I pneumocytes", "D": "Macrophages", "E": "Neutrophils"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "clearance", "respiratory", "healthy non-smokers", "aerosol containing radio labeled", "small", "to reach", "alveoli", "administered", "subjects", "non-rebreather mask", "gamma scanner", "then used to", "rate", "particle clearance", "lungs", "primary mechanism", "particle clearance", "likely", "following"]}
{"question": "A 35-year-old woman, gravida 4, para 3, at 34 weeks' gestation comes to the physician for a prenatal visit. She feels well. She does not note any contractions or fluid from her vagina. Her third child was delivered spontaneously at 35 weeks' gestation; pregnancy and delivery of her other two children were uncomplicated. Vital signs are normal. The abdomen is nontender and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 34-weeks' gestation. Ultrasonography shows the fetus in a breech presentation. The fetal heart rate is 148/min. Which of the following is the most appropriate next step in management?", "answer": "Observation", "options": {"A": "Internal cephalic version", "B": "Cesarean section", "C": "External cephalic version", "D": "Observation", "E": "Intravenous penicillin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "gravida 4", "para 3", "weeks", "gestation", "physician", "well", "not note", "contractions", "fluid", "vagina", "third child", "delivered", "35 weeks", "gestation", "pregnancy", "delivery", "two children", "uncomplicated", "Vital signs", "normal", "abdomen", "nontender", "contractions", "Pelvic examination", "uterus", "size", "weeks", "gestation", "Ultrasonography", "fetus", "breech presentation", "fetal heart rate", "min", "following", "most appropriate next step"]}
{"question": "A 25-year-old woman gives birth to a male child at 30 weeks of gestation. Pregnancy was complicated by polyhydramnios diagnosed on ultrasonography at 26 weeks of gestation. The baby is born vaginally weighing 1.2 kg (2.64 lb). Because he does not cry immediately after birth, endotracheal intubation is attempted to secure the airway. However, the vocal cords cannot be visualized because there is only a single opening corresponding to the esophagus. He is transferred to the NICU under bag and mask ventilation, where intubation is attempted once again by passing the endotracheal tube in the visualized opening, after which his oxygen saturation begins to improve. His temperature is 37.0ºC (98.6°F), pulse is 120/min, and respiratory rate is 42/min. On physical examination, no abnormalities are noted. Chest radiography is suggestive of respiratory distress syndrome. Which of the following most likely failed to develop in this patient?", "answer": "Fourth and sixth branchial arches", "options": {"A": "First branchial arch", "B": "Second branchial arch", "C": "Third branchial arch", "D": "Fourth and sixth branchial arches", "E": "Mesonephric duct"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman gives birth", "male", "30 weeks of gestation", "Pregnancy", "complicated", "polyhydramnios diagnosed", "ultrasonography", "weeks of gestation", "baby", "born", "1.2 kg", "2 64", "not", "immediately", "birth", "endotracheal intubation", "to secure", "airway", "vocal cords", "visualized", "only", "single opening", "esophagus", "transferred", "NICU", "bag", "mask ventilation", "intubation", "once", "by passing", "endotracheal tube", "visualized opening", "oxygen saturation begins to", "temperature", "98", "pulse", "min", "respiratory rate", "min", "abnormalities", "noted", "Chest radiography", "suggestive of respiratory distress syndrome", "following most likely failed to", "patient"]}
{"question": "An 19-year-old woman presents to her primary care physician because she has been feeling increasingly lethargic over the last 6 months. Specifically, she says that she feels tired easily and has been cold even though she is wearing lots of layers. Her medical history is significant for seasonal allergies but is otherwise unremarkable. When prompted, she also says that she has a hard time swallowing food though she has no difficulty drinking liquids. Physical exam reveals a midline mass in her neck. Which of the following structures would most likely be seen if this patient's mass was biopsied?", "answer": "Follicles with colloid", "options": {"A": "Blood vessels", "B": "Follicles with colloid", "C": "Hollow epithelial duct", "D": "Lymphatic ducts", "E": "Neutrophilic invasion"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "lethargic", "months", "tired easily", "cold", "lots", "layers", "medical history", "significant", "seasonal allergies", "unremarkable", "prompted", "hard time swallowing", "difficulty drinking", "reveals", "midline mass", "neck", "following structures", "most likely", "seen", "patient's mass", "biopsied"]}
{"question": "A 72-year-old man arrives at the emergency department 30 minutes after developing rapid onset right-sided weakness and decreased sensation on the right side of his body. The patient’s wife also reports that he has had difficulty forming sentences. His wife adds that these symptoms were at their maximum within a few minutes of the incident and began to resolve almost instantaneously. The patient says he had a related episode of painless visual loss in his left eye that resolved after about 10–20 minutes about 3 months ago. His past medical history includes diabetes mellitus type 2 and essential hypertension. The patient reports a 50 pack-year smoking history. His blood pressure is 140/60 mm Hg, and his temperature is 36.5°C (97.7°F). Neurological examination is significant for a subtle weakness of the right hand. A noncontrast CT scan of the head is unremarkable, and a carotid Doppler ultrasound shows 10% stenosis of the right internal carotid artery and 50% stenosis of the left internal carotid artery. Which of the following is the expected change in resistance to blood flow through the stenotic artery most likely responsible for this patient’s current symptoms?", "answer": "It will be 16 times greater", "options": {"A": "It will double", "B": "It will be 4 times greater", "C": "It will be 8 times greater", "D": "It will be 16 times greater", "E": "No change"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old man", "emergency department 30 minutes", "rapid onset right-sided weakness", "decreased sensation", "right side of", "body", "patients", "reports", "difficulty forming", "adds", "symptoms", "maximum", "few minutes", "began to", "almost", "patient", "related episode of painless visual loss", "left eye", "resolved", "about", "minutes", "months", "past medical history includes diabetes mellitus type 2", "essential hypertension", "patient reports", "50", "smoking history", "blood pressure", "60 mm Hg", "temperature", "36", "97", "Neurological examination", "significant", "subtle weakness of", "right hand", "CT scan of", "head", "unremarkable", "carotid Doppler ultrasound", "10", "stenosis", "right", "50", "stenosis", "left", "following", "change", "resistance to blood flow", "stenotic artery", "likely responsible", "patients current symptoms"]}
{"question": "A 39-year-old African American woman is admitted to the hospital following a seizure with a severe post-ictal headache. She was diagnosed with breast cancer 1 year ago when she presented with a hard, rock-like, immobile mass with irregular borders accompanied by changes in the breast skin, including erythema and dimpling. She had ipsilateral mobile axillary lymphadenopathy at that time. A biopsy confirmed the diagnosis of stage 2B invasive breast cancer. Her mother died at 42 years of age due to the same type of breast cancer. A CT scan done during this admission reveals multiple metastatic lesions in the brain and liver, along with the involvement of supra- and infra-clavicular lymph nodes. Which of the following molecular profile most likely characterizes this patient?", "answer": "ER, PR, HER2 negative", "options": {"A": "Progesterone receptor (PR) positive", "B": "ER, PR, HER2 negative", "C": "Estrogen receptor (ER) positive", "D": "PR, ER, HER2 positive", "E": "HER2 positive"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "woman", "following", "seizure", "severe post ictal headache", "diagnosed", "breast cancer", "year", "hard", "rock", "immobile mass", "irregular borders", "changes", "breast skin", "including erythema", "dimpling", "ipsilateral mobile axillary lymphadenopathy", "time", "biopsy confirmed the diagnosis of", "invasive breast cancer", "died", "years", "age due to the same type of breast cancer", "CT scan done", "reveals multiple metastatic lesions", "brain", "liver", "with", "involvement", "supra", "infra clavicular lymph nodes", "following molecular profile", "likely", "patient"]}
{"question": "A 13-year-old boy is brought to the physician because of a 1-month history of progressive difficulty breathing through his nose and a 2-week history of recurrent severe nosebleeds. When he holds the right nostril shut, he is unable to breathe nasally and his sense of smell is reduced. He has a 6-year history of asthma, which is well controlled with inhaled albuterol. Vital signs are within normal limits. Nasal inspection shows a pink, lobulated mass filling the left nasal cavity. The septum is deviated to the right side. The mass bleeds on touch. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?", "answer": "CT scan of head with contrast", "options": {"A": "Coagulation tests", "B": "Sweat chloride test", "C": "Punch biopsy of the mass", "D": "Genetic analysis of dynein genes", "E": "CT scan of head with contrast"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "month history", "progressive difficulty breathing", "nose", "2-week history", "recurrent severe nosebleeds", "holds", "right nostril", "unable to", "sense of smell", "reduced", "year history of asthma", "well controlled", "inhaled albuterol", "Vital signs", "normal limits", "Nasal inspection", "pink", "mass", "left nasal cavity", "septum", "deviated", "right side", "mass bleeds", "touch", "abnormalities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 20-year-old man comes to the emergency room because of palpitations and mild dyspnea for the last 2 hours. He has had similar episodes in the past that resolved within 20 minutes, but they have been worsening since he started training for his first marathon 1 month ago. Ten years ago, he was treated for streptococcal pharyngitis with a 10-day course of penicillin. His maternal uncle passed away unexpectedly from a heart condition at age 40. He is 180 cm (5 ft 11 in) tall and weighs 85 kg (187 lb); BMI is 26.2 kg/m2. His temperature is 36.5°C (97.7°F), pulse is 70/min, respirations are 18/min, and blood pressure is 132/60 mm Hg. On examination, there is a decrescendo early diastolic murmur heard best along the left sternal border. His head slightly bobs about every second. The remainder of the examination shows no abnormalities. Which of the following is most likely to be present?", "answer": "Bicuspid aortic valve", "options": {"A": "Asymmetric septal hypertrophy", "B": "Antistreptolysin O antibodies", "C": "Myxomatous degeneration", "D": "Bicuspid aortic valve", "E": "Valve vegetation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["20 year old man", "emergency room", "palpitations", "mild dyspnea", "hours", "similar episodes", "past", "resolved", "20 minutes", "worsening", "started training", "first marathon", "month", "Ten years", "treated", "streptococcal pharyngitis", "a 10 day course", "penicillin", "passed", "heart condition", "age 40", "5 ft", "tall", "85 kg", "BMI", "kg/m2", "temperature", "36", "97", "pulse", "70 min", "respirations", "min", "blood pressure", "60 mm Hg", "decrescendo early diastolic murmur heard best", "left sternal border", "head slightly bobs", "second", "abnormalities", "following", "to", "present"]}
{"question": "A 71-year-old man comes to the physician for a routine health maintenance examination. He feels well. He goes for a 30-minute walk three times a week and does not experience any shortness of breath or chest or leg pain on exertion. He has not had any weakness, numbness, or vision disturbance. He has diabetes that is well controlled with insulin injections. He had smoked one pack of cigarettes every day for 40 years but quit 5 years ago. He appears healthy and well nourished. His temperature is 36.3°C (97.3°F), pulse is 75/min, and blood pressure is 136/78 mm Hg. Physical examination shows normal heart sounds. There are systolic bruits over the neck bilaterally. Physical and neurologic examinations show no other abnormalities. Fasting serum studies show:\nTotal cholesterol 210 mg/dL\nHDL cholesterol 28 mg/dL\nLDL cholesterol 154 mg/dL\nTriglycerides 140 mg/dL\nGlucose 102 mg/dL\nDuplex ultrasonography of the carotid arteries shows a 85% stenosis on the left and a 55% stenosis on the right side. Which of the following is the most appropriate next step in management?\"", "answer": "Left carotid endarterectomy", "options": {"A": "Aspirin therapy only", "B": "Left carotid endarterectomy", "C": "Reassurance", "D": "Carotid artery stenting", "E": "Bilateral carotid endarterectomy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "routine", "well", "30-minute", "three times", "week", "not", "shortness of breath", "chest", "leg pain", "exertion", "not", "weakness", "numbness", "vision disturbance", "diabetes", "well controlled", "insulin injections", "smoked one pack", "cigarettes", "day", "40 years", "years", "appears healthy", "well nourished", "temperature", "36", "97", "pulse", "75 min", "blood pressure", "mm Hg", "normal heart sounds", "systolic bruits", "neck", "Physical", "neurologic examinations", "abnormalities", "Fasting serum studies", "Total cholesterol", "mg/dL HDL", "Triglycerides", "Glucose", "Duplex ultrasonography", "carotid arteries", "85", "stenosis", "left", "stenosis", "right side", "following", "most appropriate next step"]}
{"question": "A 28-year-old woman is brought to the emergency department after being resuscitated in the field. Her husband is with her and recalls seeing pills beside her when he was in the bathroom. He reveals she has a past medical history of depression and was recently given a prescription for smoking cessation. On physical exam, you notice a right-sided scalp hematoma and a deep laceration to her tongue. She has a poor EEG waveform indicating limited to no cerebral blood flow and failed both her apnea test and reflexes. She is found to be in a persistent vegetative state, and the health care team starts to initiate the end of life discussion. The husband states that the patient had no advance directives other than to have told her husband she did not want to be kept alive with machines. The parents want all heroic measures to be taken. Which of the following is the most accurate statement with regards to this situation?", "answer": "The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.", "options": {"A": "The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.", "B": "The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.", "C": "The patient’s adult daughter may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.", "D": "The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.", "E": "An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "resuscitated in the field", "seeing pills", "bathroom", "reveals", "past medical history of depression", "recently given", "smoking cessation", "right-sided scalp hematoma", "deep", "tongue", "poor EEG", "limited", "cerebral blood flow", "failed", "apnea test", "reflexes", "found to", "persistent vegetative state", "starts to initiate", "end", "discussion", "states", "patient", "advance directives", "to", "not", "to", "kept alive", "machines", "measures to", "following", "most accurate"]}
{"question": "An 8-year-old girl is brought to the emergency department because of a 2-day history of low-grade fever, itchy rash, and generalized joint pain. The rash initially started in the antecubital and popliteal fossae and then spread to her trunk and distal extremities. One week ago, she was diagnosed with acute sinusitis and was started on amoxicillin. She has no history of adverse drug reactions and immunizations are up-to-date. Her temperature is 37.5°C (99.5°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Physical examination shows periorbital edema and multiple erythematous, annular plaques of variable sizes over her entire body. One of the lesions in the right popliteal fossa has an area of central clearing and the patient's mother reports that it has been present for over 24 hours. Urinalysis is normal. Which of the following is the most likely diagnosis?", "answer": "Serum sickness-like reaction", "options": {"A": "Serum sickness-like reaction", "B": "Stevens-Johnson syndrome", "C": "Pemphigus vulgaris", "D": "Drug reaction with eosinophilia and systemic symptoms", "E": "IgA vasculitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "emergency department", "2-day history", "low-grade fever", "itchy rash", "generalized joint", "rash initially started", "antecubital", "popliteal fossae", "then spread", "trunk", "distal extremities", "One week", "diagnosed", "acute sinusitis", "started", "amoxicillin", "history", "adverse drug reactions", "immunizations", "date", "temperature", "99", "pulse", "90 min", "blood pressure", "70 mm Hg", "periorbital edema", "multiple erythematous", "annular plaques", "variable sizes", "entire body", "One", "lesions", "right popliteal fossa", "area", "central", "patient's", "reports", "present", "24 hours", "Urinalysis", "normal", "following", "diagnosis"]}
{"question": "A 7-year-old boy presents to the clinic with his mother, who notes that the way in which he plays has changed and that he has been limping, favoring his left leg. When asked, the patient states that his left knee hurts. He is afebrile and vital signs are stable. The patient is well nourished and meeting all developmental milestones. On physical examination, the knee has a full range of motion; however, passive motion elicits pain in the left hip. An X-ray is performed and reveals a flattened left femoral head. Which of the following is the most likely diagnosis?", "answer": "Legg-Calvé-Perthes disease (LCPD)", "options": {"A": "Septic arthritis", "B": "Rickets", "C": "Legg-Calvé-Perthes disease (LCPD)", "D": "Slipped capital femoral epiphysis", "E": "Juvenile idiopathic arthritis (JIA)"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "clinic", "notes", "plays", "changed", "limping", "favoring", "left leg", "patient states", "left knee", "afebrile", "vital signs", "stable", "patient", "well nourished", "knee", "full range of motion", "passive motion elicits pain in", "left hip", "X-ray", "performed", "reveals", "flattened left", "following", "diagnosis"]}
{"question": "A 57-year-old man presents to the clinic for a chronic cough over the past 4 months. The patient reports a productive yellow/green cough that is worse at night. He denies any significant precipitating event prior to his symptoms. He denies fever, chest pain, palpitations, weight changes, or abdominal pain, but endorses some difficulty breathing that waxes and wanes. He denies alcohol usage but endorses a 35 pack-year smoking history. A physical examination demonstrates mild wheezes, bibasilar crackles, and mild clubbing of his fingertips. A pulmonary function test is subsequently ordered, and partial results are shown below:\n\nTidal volume: 500 mL\nResidual volume: 1700 mL\nExpiratory reserve volume: 1500 mL\nInspiratory reserve volume: 3000 mL\n\nWhat is the functional residual capacity of this patient?", "answer": "3200 mL", "options": {"A": "2000 mL", "B": "2200 mL", "C": "3200 mL", "D": "3500 mL", "E": "4500 mL"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["57 year old man presents", "clinic", "chronic cough", "past", "months", "patient reports", "productive", "cough", "worse", "night", "significant precipitating event prior to", "symptoms", "fever", "chest pain", "palpitations", "weight changes", "abdominal pain", "difficulty breathing", "waxes", "alcohol usage", "35", "smoking history", "mild wheezes", "crackles", "mild clubbing", "fingertips", "pulmonary function test", "ordered", "Tidal volume", "500 mL Residual volume", "mL Expiratory reserve volume", "1500 mL Inspiratory reserve volume", "3000 mL", "functional residual capacity", "patient"]}
{"question": "A 17-year-old man presents to his primary care physician concerned about excessive sleepiness that has persisted his entire life. He notes that he has been having difficulty with his job as a waiter because he often falls asleep suddenly during the day. He also experiences a sensation of dreaming as he goes to sleep even though he still feels awake. He sleeps about 10 hours per day and still feels tired throughout the day. The patient has even reported driving into a tree once as he fell asleep while driving. The patient often stays up late at night working on the computer. Physical exam demonstrates an obese young man who appears tired. His oropharynx demonstrates high palatal ridges and good dental hygiene. Which of the following is the best next step in management?", "answer": "Begin inhibitor of dopamine reuptake", "options": {"A": "Continuous positive airway pressure at night", "B": "Begin inhibitor of dopamine reuptake", "C": "Recommend scheduling regular naps and more time for sleep at night", "D": "Recommend to abstain from activities at night that expose the patient to blue light", "E": "Start a selective serotonin reuptake inhibitor"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "excessive sleepiness", "entire life", "notes", "difficulty", "waiter", "often falls asleep", "day", "sensation", "to sleep", "awake", "sleeps", "10", "day", "tired", "day", "patient", "reported", "tree", "fell asleep", "patient often", "late", "night", "computer", "obese young man", "appears tired", "oropharynx", "high palatal ridges", "good dental hygiene", "following", "best next step"]}
{"question": "A 38-year-old woman presents to her primary care physician for a new patient appointment. She states that she feels well and has no current complaints. The patient recently started seeing a specialist for treatment for another medical condition but otherwise has had no medical problems. The patient lives alone and drinks 2 alcoholic beverages every night. She has had 3 sexual partners in her lifetime, uses oral contraceptive pills for contraception, and has never been pregnant. Physical exam reveals a pleasant, obese woman with normal S1 and S2 on cardiac exam. Musculoskeletal exam reveals swelling of the MCP and PIP joints of the hands as well as ulnar deviation of the fingers. Laboratory tests are ordered and results are 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\nAST: 95 U/L\nALT: 68 U/L\n\nWhich of the following best explains this patient's abnormal laboratory values?", "answer": "Medication", "options": {"A": "Alcohol", "B": "Bacterial infection", "C": "Medication", "D": "Obesity", "E": "Viral infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "new", "states", "well", "current complaints", "patient recently started seeing", "specialist", "treatment", "medical condition", "medical problems", "patient lives alone", "2", "night", "3", "lifetime", "uses oral contraceptive pills", "contraception", "never", "pregnant", "reveals", "obese woman", "normal S1", "S2", "Musculoskeletal", "reveals swelling", "MCP", "PIP joints of", "hands", "ulnar deviation of the fingers", "Laboratory tests", "ordered", "results", "Serum", "Na", "mEq/L", "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 AST", "95 U/L ALT", "U/L", "following best", "patient's abnormal laboratory values"]}
{"question": "A 67-year-old woman is brought to the emergency department by her husband because of a 1-hour history of severe groin pain, nausea, and vomiting. She has had a groin swelling that worsens with standing, coughing, and straining for the past 3 months. Her pulse is 120/min. Examination shows pallor; there is swelling, erythema, and tenderness to palpation of the right groin that is centered below the inguinal ligament. The most likely cause of this patient's condition is entrapment of an organ between which of the following structures?", "answer": "Lacunar ligament and femoral vein", "options": {"A": "Linea alba and conjoint tendon", "B": "Inferior epigastric artery and rectus sheath", "C": "Conjoint tendon and inguinal ligament", "D": "Medial and median umbilical ligaments", "E": "Lacunar ligament and femoral vein"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["67 year old woman", "brought", "emergency department", "hour history", "severe groin", "nausea", "vomiting", "groin swelling", "worsens", "standing", "coughing", "straining", "past 3 months", "pulse", "min", "pallor", "swelling", "erythema", "tenderness", "palpation", "right", "centered", "inguinal ligament", "most likely cause", "patient's condition", "entrapment", "organ", "following structures"]}
{"question": "A 35-year-old woman presents to her dermatologist with complaints of discoloration of the skin on her hands and wrists. She says her symptoms started about 6-months ago. Around this time, she recalls moving into her new house with her husband and children. She had to quit her job to relocate and says she is having difficulty maintaining a clean and happy household. She admits to being stressed most of the time. She was previously in good health. No significant past medical history.  The patient is afebrile and vital signs are within normal limits. Physical examination reveals patchy red, scaly skin on both hands. Upon further questioning, the patient admits to having to continuously wash her hands because she has this irrational idea that her hands are dirty. She tries her best to ignore these thoughts but eventually succumbs to wash her hands over and over to ease the anxiety. Which of the following statements is correct concerning this patient’s most likely condition?", "answer": "Symptoms are ego-dystonic", "options": {"A": "Symptoms are ego-dystonic", "B": "Patients generally lack insight", "C": "The condition is readily treatable", "D": "The condition is associated with early onset dementia", "E": "The condition rarely affects daily functioning"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old woman presents", "dermatologist", "complaints of discoloration", "skin", "hands", "wrists", "symptoms started", "months", "time", "moving", "new house", "children", "to", "difficulty", "to", "stressed most of the time", "significant past medical history", "patient", "afebrile", "vital signs", "normal", "Physical examination reveals patchy red", "scaly skin", "hands", "further", "patient", "to", "hands", "irrational idea", "hands", "best to", "to", "hands", "over to", "anxiety", "following", "correct", "patients", "likely condition"]}
{"question": "A 2800-g (6-lb 3-oz) male newborn is born at 39 weeks’ gestation to a 22-year-old woman, gravida 2, para 2, after an uncomplicated labor and delivery. The mother did not receive prenatal care. She traveled to Brazil to visit relatives during the first trimester of her pregnancy. She has bipolar disorder treated with lithium. The newborn is at the 50th percentile for height, 25th percentile for weight, and 2nd percentile for head circumference. Neurologic examination shows spasticity of the upper and lower extremities. The wrists are fixed in flexion bilaterally. Deep tendon reflexes are 4+ and symmetric. Ophthalmoscopic examination shows focal pigmentary retinal mottling. Testing for otoacoustic emissions is negative. Which of the following measures during the mother’s pregnancy is most likely to have prevented this newborn's condition?", "answer": "Use of mosquito repellant", "options": {"A": "Avoid consumption of undercooked meat", "B": "Use of mosquito repellant", "C": "Administration of antibiotic therapy", "D": "Daily intake of prenatal vitamins", "E": "Discontinuation of mood stabilizer"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2800 g", "oz", "male newborn", "born", "weeks gestation", "year old woman", "gravida 2", "para 2", "uncomplicated labor", "delivery", "not receive", "Brazil to", "first trimester", "pregnancy", "bipolar disorder treated with lithium", "newborn", "50th percentile", "height", "percentile", "weight", "2nd percentile", "head circumference", "Neurologic examination", "spasticity", "upper", "lower extremities", "wrists", "fixed in flexion", "Deep tendon reflexes", "4", "symmetric", "Ophthalmoscopic examination", "focal pigmentary retinal mottling", "Testing", "otoacoustic emissions", "negative", "following measures", "pregnancy", "to", "prevented", "newborn's condition"]}
{"question": "An otherwise healthy 47-year-old woman comes to the physician for the evaluation of a 4-month history of worsening fatigue and constipation. She has also noticed that her cheeks appear fuller and her voice has become hoarse. Her temperature is 36.3°C (97.3°F) and pulse is 59/min. Examination of the neck shows a painless, mildly enlarged thyroid gland. Her skin is dry and cool and her nails appear brittle. Serum studies show antibodies against thyroid peroxidase. A biopsy of the thyroid gland is most likely to show which of the following?", "answer": "Lymphocytic infiltration, Hürthle cells, and germinal centers", "options": {"A": "Large, irregular nuclei, nuclear grooves, and Psammoma bodies", "B": "Tall follicular cells, scalloped colloid, and vascular congestion", "C": "Spindle cells, pleomorphic giant cells, and mitotic figures", "D": "Multinucleated giant cells, macrophages, and degenerated follicular cells", "E": "Lymphocytic infiltration, Hürthle cells, and germinal centers"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old woman", "physician", "month history", "worsening fatigue", "constipation", "cheeks appear", "voice", "hoarse", "temperature", "36", "97", "pulse", "59 min", "Examination of", "neck", "painless", "mildly enlarged thyroid gland", "skin", "dry", "cool", "nails appear brittle", "Serum studies", "antibodies", "thyroid peroxidase", "biopsy of", "thyroid gland", "to", "following"]}
{"question": "A 62-year-old woman presents with abdominal pain and blood in her urine. Since the acute onset of symptoms 3 days ago, there has been no improvement. She describes the pain as moderate, sharp and burning in character, non-radiating, and localized to the suprapubic region. She also has noted some mild urinary frequency and urgency for the past 5 days, which has been getting progressively worse. She denies any flank pain, fever, chills, night sweats, dysuria, or pain on urination. The patient has a history of an abdominal leiomyosarcoma, which was diagnosed 6 months ago. The course of her disease is complicated by hepatic metastases, for which she recently started receiving a new therapy. The patient reports a 15-pack-year smoking history, but no alcohol or recreational drug use. Her temperature is 37.0℃ (98.6℉), pulse is 84/min, respiratory rate is 18/min, and blood pressure is 110/75 mm Hg. On physical examination, there is some mild suprapubic tenderness to palpation. The remainder of the exam is unremarkable. Laboratory findings include a mild leukopenia of 3,000/mm3. A urine dipstick reveals 3+ blood. Which of the following best describes the medication that could have prevented this patient’s symptoms?", "answer": "A thiol given concurrently with an antineoplastic agent to help reduce inflammation of the transitional epithelium of the bladder", "options": {"A": "Serine protease inhibitor that reduces the action of plasmin", "B": "Agent that binds to an intracellular receptor and results in the transactivation of genes that promote gluconeogenesis and has anti-inflammatory effects", "C": "A thiol given concurrently with an antineoplastic agent to help reduce inflammation of the transitional epithelium of the bladder", "D": "Monoclonal antibody that inhibits bcr-abl tyrosine kinase, blocking cell proliferation and inducing apoptosis", "E": "Antifolate that inhibits dihydrofolate reductase, inhibiting purine production necessary for cell synthesis and division"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["62 year old woman presents", "abdominal pain", "blood in", "urine", "acute onset of symptoms 3 days", "pain", "moderate", "sharp", "burning", "character", "non radiating", "localized", "suprapubic region", "noted", "mild urinary frequency", "urgency", "past 5 days", "getting", "worse", "flank pain", "fever", "chills", "night sweats", "dysuria", "pain", "urination", "patient", "history", "abdominal leiomyosarcoma", "diagnosed", "months", "course of", "disease", "complicated", "hepatic metastases", "recently started receiving", "new therapy", "patient reports", "smoking history", "alcohol", "recreational drug use", "temperature", "0", "98", "pulse", "84 min", "respiratory rate", "min", "blood pressure", "75 mm Hg", "mild suprapubic tenderness", "palpation", "exam", "unremarkable", "Laboratory findings include", "mild leukopenia", "mm3", "urine dipstick reveals 3", "blood", "following best", "medication", "prevented", "patients symptoms"]}
{"question": "A 5-year-old boy is brought to the physician by his parents because of a 6-week history of increased tiredness, irritability, and worsening leg pain. His parents report that he has been reluctant to walk recently because of the pain in his legs. Examination shows conjunctival pallor and diffuse petechiae. There are palpable, nontender posterior cervical and axillary lymph nodes. His hemoglobin concentration is 8.9 g/dL, leukocyte count is 45,750/mm3, and platelet count is 25,000/mm3. A bone marrow aspiration shows numerous immature cells that stain positive for CD10, CD19, and terminal deoxynucleotidyl transferase (TdT). Which of the following translocations is associated with a favorable prognosis for this patient's condition?", "answer": "t(12;21)", "options": {"A": "t(12;21)", "B": "t(15;17)", "C": "t(8;14)", "D": "t(14;18)", "E": "t(9;22)"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 year old boy", "brought", "physician", "week history", "increased tiredness", "irritability", "worsening leg pain", "report", "to", "recently", "pain", "legs", "conjunctival pallor", "diffuse petechiae", "palpable", "nontender posterior cervical", "axillary lymph nodes", "hemoglobin concentration", "g/dL", "leukocyte count", "750 mm3", "platelet count", "mm3", "bone marrow aspiration", "numerous immature cells", "positive", "CD10", "CD19", "terminal deoxynucleotidyl transferase", "TdT", "following translocations", "associated with", "favorable prognosis", "patient's condition"]}
{"question": "A 37-year-old man comes to the physician because of fever, night sweats, malaise, dyspnea, and a productive cough with bloody sputum for 4 days. He was diagnosed with HIV infection 15 years ago and has not been compliant with his medication regimen. Physical examination shows diminished breath sounds over the left lung fields. An x-ray of the chest shows an ill-defined lesion in the upper lobe of the left lung. A CT-guided biopsy of the lesion is performed; a photomicrograph of the biopsy specimen stained with mucicarmine is shown. Which of the following is the most likely causal organism?", "answer": "Cryptococcus neoformans", "options": {"A": "Cocciodioides immitis", "B": "Candida albicans", "C": "Histoplasma capsulatum", "D": "Blastomyces dermatitidis", "E": "Cryptococcus neoformans"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "fever", "night sweats", "malaise", "dyspnea", "productive cough", "bloody sputum", "4 days", "diagnosed", "HIV infection", "years", "not", "compliant", "medication regimen", "diminished breath sounds", "left lung fields", "x-ray of", "chest", "ill", "lesion", "the upper lobe of", "left lung", "CT-guided biopsy", "lesion", "performed", "photomicrograph", "biopsy specimen stained", "mucicarmine", "following", "causal"]}
{"question": "A 47-year-old man presents with a history of a frequent unpleasant crawling sensation in both of his legs accompanied by an urge to move his legs for the last 6 months. He continuously moves his legs to provide him with partial relief from the unpleasant feelings in his legs. The symptoms are especially severe during the night or while lying down in bed after returning from work. These symptoms occur 3–5 days per week. He also complains of significant daytime fatigue and sleep disturbances on most days of the week. He is advised to take a polysomnography test, which reveals periodic limb movements (PLMs) during his sleep. Which of the following conditions is most associated with secondary restless legs syndrome?", "answer": "Iron deficiency anemia", "options": {"A": "Iron deficiency anemia", "B": "Pulmonary tuberculosis", "C": "Zinc deficiency", "D": "Vitamin B3 deficiency", "E": "Liver failure"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "history", "frequent", "crawling sensation", "legs", "to move", "legs", "months", "moves", "legs to", "partial relief", "legs", "symptoms", "severe", "night", "lying", "bed", "returning", "work", "symptoms occur 35 days per week", "significant daytime fatigue", "sleep disturbances", "days of the week", "to", "polysomnography test", "reveals periodic limb", "sleep", "following conditions", "most associated with secondary restless legs syndrome"]}
{"question": "A 4-year-old girl is brought to the physician because of worsening jaundice that started 8 days ago. She has had similar episodes in the past. Her father underwent a splenectomy during adolescence. Physical examination shows mild splenomegaly. Laboratory studies show:\nHemoglobin 10.1 g/dL\nWBC count 7200/mm3\nMean corpuscular volume 81 μm3\nMean corpuscular hemoglobin concentration 41% Hb/cell\nPlatelet count 250,000/mm3\nRed cell distribution width 16% (N=13%–15%)\nReticulocytes 11%\nErythrocyte sedimentation rate 10 mm/h\nSerum\nNa+ 139 mEq/L\nK+ 4.2 mEq/L\nCl- 100 mEq/L\nUrea nitrogen 16 mg/dL\nA peripheral blood smear shows red blood cells that appear round, smaller, and without central pallor. Which of the following is the most sensitive test for confirming this patient's condition?\"", "answer": "Eosin-5-maleimide binding test", "options": {"A": "Osmotic fragility test", "B": "Coombs test", "C": "Eosin-5-maleimide binding test", "D": "Hemoglobin electrophoresis", "E": "Serum ferritin level\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old girl", "brought", "physician", "worsening jaundice", "started", "days", "similar episodes", "past", "splenectomy", "adolescence", "mild splenomegaly", "Laboratory studies", "Hemoglobin", "g", "WBC", "Mean corpuscular volume", "concentration", "Hb cell", "Red cell distribution width", "N", "Erythrocyte sedimentation rate 10 mm/h Serum", "mEq/L K", "4", "Urea nitrogen 16 mg/dL", "peripheral blood smear", "red blood cells", "appear round", "smaller", "central pallor", "following", "most sensitive test", "confirming", "patient", "ondition?"]}
{"question": "A 72-year-old obese man presents as a new patient to his primary care physician because he has been feeling tired and short of breath after recently moving to Denver. He is a former 50 pack-year smoker and has previously had deep venous thrombosis. Furthermore, he previously had a lobe of the lung removed due to lung cancer. Finally, he has a family history of a progressive restrictive lung disease. Laboratory values are obtained as follows:\n\nOxygen tension in inspired air = 130 mmHg\nAlveolar carbon dioxide tension = 48 mmHg\nArterial oxygen tension = 58 mmHg\nRespiratory exchange ratio = 0.80\nRespiratory rate = 20/min\nTidal volume = 500 mL\n\nWhich of the following mechanisms is consistent with these values?", "answer": "High altitude", "options": {"A": "High altitude", "B": "Hypoventilation", "C": "Pulmonary fibrosis", "D": "Shunt physiology", "E": "V/Q mismatch"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old obese man presents", "new patient", "primary care physician", "tired", "short of breath", "recently moving", "former 50", "smoker", "deep venous thrombosis", "lobe of", "lung removed due to lung cancer", "family history of", "progressive", "lung disease", "Laboratory values", "obtained", "follows", "Oxygen tension", "inspired air", "mmHg Alveolar carbon dioxide tension", "48 mmHg Arterial oxygen tension", "58 mmHg Respiratory exchange ratio", "0 80 Respiratory rate", "20 min Tidal volume", "500 mL", "following mechanisms", "values"]}
{"question": "A 27-year old gentleman presents to the primary care physician with the chief complaint of \"feeling down\" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything \"feels slower\" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him?", "answer": "Electroconvulsive therapy", "options": {"A": "Psychotherapy", "B": "Citalopram", "C": "Paroxetine", "D": "Electroconvulsive therapy", "E": "Sertraline"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old", "presents", "primary care physician", "chief complaint", "last", "weeks", "trouble falling asleep", "night", "decreased appetite", "recent", "intense", "state", "slower", "used to", "similar four week period", "year", "self-harm", "others", "racing thoughts", "delusions of grandeur", "following", "INAPPROPRIATE first line treatment"]}
{"question": "A 27-year-old man presents to the emergency department after being hit by a car while riding his bike. The patient was brought in with his airway intact, vitals stable, and with a C-collar on. Physical exam is notable for bruising over the patient’s head and a confused man with a Glasgow coma scale of 11. It is noticed that the patient has a very irregular pattern of breathing. Repeat vitals demonstrate his temperature is 97.5°F (36.4°C), blood pressure is 172/102 mmHg, pulse is 55/min, respirations are 22/min and irregular, and oxygen saturation is 94% on room air. Which of the following interventions are most likely to improve this patient's vital signs?", "answer": "Head elevation, sedation, mannitol, hyperventilation", "options": {"A": "Head elevation, norepinephrine, mannitol, hyperventilation", "B": "Head elevation, sedation, hypertonic saline, hypoventilation", "C": "Head elevation, sedation, mannitol, hyperventilation", "D": "Lower head, sedation, hypertonic saline, hyperventilation", "E": "Lower head, sedation, hypertonic saline, hypoventilation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old man presents", "emergency department", "hit by", "car", "bike", "patient", "brought", "airway intact", "stable", "collar", "notable", "bruising", "patients head", "confused man", "Glasgow coma scale", "11", "patient", "very irregular pattern", "breathing", "Repeat", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "irregular", "oxygen saturation", "room air", "following interventions", "to", "patient's vital signs"]}
{"question": "A 27-year-old G0P0 female presents to her OB/GYN for a preconception visit to seek advice before becoming pregnant. A detailed history reveals no prior medical or surgical history, and she appears to be in good health currently. Her vaccination history is up-to-date. She denies tobacco or recreational drug use and admits to drinking 2 glasses of wine per week. She states that she is looking to start trying to become pregnant within the next month, hopefully by the end of January. Which of the following is NOT recommended as a next step for this patient's preconception care?", "answer": "Administer measles, mumps, rubella (MMR) vaccination", "options": {"A": "Begin 400 mcg folic acid supplementation", "B": "Recommend inactivated influenza vaccination", "C": "Obtain rubella titer", "D": "Administer measles, mumps, rubella (MMR) vaccination", "E": "Obtain varicella zoster titer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old", "female presents", "OB/GYN", "preconception", "to", "pregnant", "detailed history reveals", "prior medical", "surgical history", "appears to", "currently", "vaccination history", "date", "tobacco", "recreational drug use", "drinking", "glasses", "wine", "week", "states", "looking to start", "to", "pregnant", "next month", "end", "January", "following", "NOT", "next step", "patient's preconception"]}
{"question": "A 22-year-old female college student presents to the emergency department due to severe pain in her stomach after an evening of heavy drinking with her friends. The pain is located in the upper half of the abdomen, is severe in intensity, and has an acute onset. She claims to have consumed a dozen alcoholic drinks. Her past medical history is unremarkable. She has recently completed an extremely low-calorie diet which resulted in her losing 10 kg (22 lb) of body weight. Her pulse is 130/min, respirations are 26/min, and blood pressure is 130/86 mm Hg. Examination reveals a visibly distressed young female with periumbilical tenderness. Her BMI is 23 kg/m2. Laboratory tests show:\nArterial blood gas analysis\npH 7.54\nPo2 100 mm Hg\nPco2 23 mm Hg\nHCO3- 22 mEq/L\nSerum\nSodium 140 mEq/L\nPotassium 3.9 mEq/L\nChloride 100 mEq/L\nWhich of the following most likely caused her elevated pH?", "answer": "Anxiety induced hyperventilation", "options": {"A": "Alcohol induced respiratory depression", "B": "Anxiety induced hyperventilation", "C": "Pain induced hypoventilation", "D": "Renal failure induced electrolyte imbalance", "E": "Weight loss induced electrolyte imbalance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female", "presents", "emergency department due to severe pain in", "stomach", "evening", "heavy drinking", "pain", "upper half", "abdomen", "severe", "intensity", "acute onset", "to", "past medical history", "unremarkable", "recently completed", "extremely low-calorie diet", "resulted", "10 kg", "body weight", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "reveals", "young female", "periumbilical tenderness", "BMI", "23 kg/m2", "Laboratory tests", "Arterial blood gas analysis pH", "54", "100 mm Hg", "23", "HCO3", "mEq/L Serum Sodium", "Chloride", "following most likely caused", "elevated pH"]}
{"question": "A 16-year-old boy presents with shortness of breath after prolonged exposure to cold air during a recent hike with his friends. Past medical history is significant for asthma, untreated because he doesn't like using medications. The patient says he is a non-smoker and occasionally drinks alcohol. On physical examination, his temperature is 37.0°C (98.6°F), pulse rate is 120/min, blood pressure is 114/76 mm Hg, and respiratory rate is 32/min. Auscultation of the chest reveals bilateral wheezing. Nebulized ipratropium bromide results in significant clinical improvement. Which of the following second messenger systems is affected by this drug?", "answer": "Phosphoinositol system", "options": {"A": "Cyclic adenosine monophosphate (cAMP) system", "B": "Cyclic guanosine monophosphate (cGMP) system", "C": "Arachidonic acid system", "D": "Phosphoinositol system", "E": "Tyrosine kinase system"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "shortness of breath", "prolonged exposure to cold air", "recent", "Past medical history", "significant", "asthma", "untreated", "using medications", "patient", "non-smoker", "occasionally", "alcohol", "temperature", "98", "pulse rate", "min", "blood pressure", "76 mm Hg", "respiratory rate", "min", "Auscultation", "chest reveals bilateral wheezing", "Nebulized ipratropium bromide results", "significant clinical", "following", "affected", "drug"]}
{"question": "A multicentric, ambidirectional cohort study (i.e. a study that combines elements of both prospective and retrospective cohort studies) was designed in order to evaluate the relationship between nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) and exposure to patients in intensive-care units of several tertiary hospital centers. The sample included 1,000 physicians who worked in the hospital environment and who willingly underwent swabbing of their nasal vestibule and nasopharynx for active surveillance. Data of their working location was obtained from hospital administrative services. Of those who worked in the intensive care unit, 350 were colonized with MRSA, while 250 were not. Whereas in those that worked in other hospital wards, 100 were colonized with MRSA, and 300 were not. What is the relative risk of MRSA colonization in relation to working in the intensive-care unit?", "answer": "2.33", "options": {"A": "0.18", "B": "0.43", "C": "1.66", "D": "2.33", "E": "3.22"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["multicentric", "cohort study", "i.e", "study", "combines", "order to", "relationship", "nasal colonization", "methicillin-resistant Staphylococcus aureus", "exposure to patients", "intensive-care units", "tertiary hospital centers", "included 1", "physicians", "hospital environment", "nasal vestibule", "nasopharynx", "Data", "working location", "obtained", "administrative", "intensive care unit", "350", "MRSA", "not", "100", "MRSA", "300", "not", "relative risk", "MRSA colonization", "intensive-care unit"]}
{"question": "A 45-year-old man presents to the emergency department with abdominal distension. The patient states he has had gradually worsening abdominal distension with undulating pain, nausea, and vomiting for the past several months. The patient does not see a physician typically and has no known past medical history. He works as a farmer and interacts with livestock and also breeds dogs. His temperature is 98.7°F (37.1°C), blood pressure is 159/90 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for mild abdominal distension and discomfort to palpation of the upper abdominal quadrants. Laboratory values are ordered and are notable for a mild eosinophilia. A CT scan of the abdomen demonstrates multiple small eggshell calcifications within the right lobe of the liver. Which of the following is the most likely etiology of this patients symptoms?", "answer": "Echinococcus granulosus", "options": {"A": "Echinococcus granulosus", "B": "Enterobius vermicularis", "C": "Necator americanus", "D": "Taenia saginata", "E": "Taenia solium"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "abdominal distension", "patient states", "worsening abdominal", "pain", "nausea", "vomiting", "past", "months", "patient", "not see", "physician", "known past medical history", "farmer", "breeds", "temperature", "98", "blood pressure", "90 mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "99", "room air", "notable", "mild abdominal distension", "discomfort", "palpation", "upper abdominal quadrants", "Laboratory values", "ordered", "notable", "mild eosinophilia", "CT scan", "abdomen", "multiple small eggshell calcifications", "the right lobe of", "liver", "following", "etiology", "patients symptoms"]}
{"question": "A 49-year-old man presents to his physician complaining of weakness and fatigue. On exam, you note significant peripheral edema. Transthoracic echocardiogram is performed and reveals a preserved ejection fraction with impaired diastolic relaxation. A representative still image is shown in Image A. Which of the following is likely the cause of this patient's symptoms?", "answer": "Hemochromatosis", "options": {"A": "Previous treatment with doxorubicin", "B": "Hemochromatosis", "C": "Heavy, long-term alcohol consumption", "D": "History of myocardial infarction", "E": "History of a recent viral infection"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "physician", "weakness", "fatigue", "exam", "note significant peripheral edema", "Transthoracic echocardiogram", "performed", "reveals", "preserved ejection fraction", "impaired diastolic", "following", "likely", "cause", "patient's symptoms"]}
{"question": "A 65-year-old male prisoner goes on a hunger strike to protest the conditions of his detainment. After 5 days without food, he suffers a seizure for which he is taken into a medical facility. On physical examination, he looks pale and diaphoretic. His blood glucose level is 50 mg/dL. In order to keep a constant supply of energy to his brain, which of the following molecules is his liver releasing into the bloodstream?", "answer": "ß-hydroxybutyric acid", "options": {"A": "ß-hydroxybutyric acid", "B": "Fatty acids", "C": "Glucose-1-phosphate", "D": "Glucose-6-phosphate", "E": "Glycogen"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65-year-old male", "hunger", "to", "conditions", "5 days", "food", "suffers", "seizure", "medical facility", "looks pale", "diaphoretic", "blood glucose level", "50 mg/dL", "order to keep", "constant supply", "energy", "brain", "following", "liver releasing", "bloodstream"]}
{"question": "A 67-year-old patient comes to the physician because of a 4-month history of weight loss, chest pain, dry cough, and shortness of breath on exertion. He worked as a shipbuilder for 45 years and is now retired. Since the death of his wife 2 years ago, he has lived with his daughter. He has never smoked. His temperature is 38.1°C (100.6°F), pulse is 85/min, and blood pressure is 134/82 mm Hg. Fine, end-inspiratory rales are heard at the left lung base; breath sounds are absent at the right lung base. A CT scan of the chest shows pleural thickening and a right hemothorax. Thoracocentesis confirms the diagnosis of mesothelioma. The patient and his family are informed about the poor prognosis of this condition and that the mean survival time is 1 year. The patient states that he wishes to receive radiation. He would also like to receive home hospice care but is unsure whether his health insurance would cover the costs. The patient's son, who has been assigned power of attorney, does not agree with this decision. The patient does not have a living will but states that if his heart stops beating, he wants to receive cardiopulmonary resuscitation. Which of the following disqualifies the patient from receiving hospice care?", "answer": "His life expectancy\n\"", "options": {"A": "Lack of living will", "B": "Wish for cardiopulmonary resuscitation", "C": "Uncertain coverage by health insurance", "D": "The son's objection", "E": "His life expectancy\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["67 year old patient", "physician", "of", "4 month history", "weight loss", "chest pain", "dry cough", "shortness of breath", "exertion", "years", "now retired", "death", "years", "lived", "never smoked", "temperature", "100", "pulse", "85 min", "blood pressure", "mm Hg", "Fine", "end inspiratory", "heard", "left lung base", "breath sounds", "absent", "right lung base", "CT scan of", "chest", "pleural thickening", "right hemothorax", "confirms", "diagnosis", "mesothelioma", "patient", "informed", "poor prognosis", "condition", "mean survival time", "1 year", "patient states", "wishes to receive radiation", "to receive home hospice", "unsure", "cover", "costs", "patient's", "assigned power of attorney", "not agree", "patient", "not", "living will", "states", "heart stops", "to receive cardiopulmonary resuscitation", "following", "patient", "receiving hospice"]}
{"question": "An 8-month-old boy is brought to his pediatrician by his parents with a 12-hour history of fever and coughing. He has also been experiencing intermittent diarrhea and skin abscesses since birth. Otherwise, he has been meeting developmental milestones as expected. Analysis of this patient's sputum reveals acute angle branching fungi, and culture shows gram-positive cocci in clusters. A flow cytometry reduction test was obtained that confirmed the diagnosis. Which of the following processes is most likely defective in this patient?", "answer": "Transforming oxygen into superoxide radicals", "options": {"A": "Actin polymerization", "B": "Leukocyte migration", "C": "Maturation of B-cells", "D": "Transforming oxygen into superoxide radicals", "E": "Transforming superoxide radicals into hydrogen peroxide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "pediatrician", "12-hour history", "fever", "coughing", "intermittent diarrhea", "skin abscesses", "birth", "Analysis", "patient's sputum reveals acute angle branching fungi", "culture", "flow cytometry reduction test", "obtained", "confirmed", "diagnosis", "following processes", "defective", "patient"]}
{"question": "A 25-year-old man with a genetic disorder presents for genetic counseling because he is concerned about the risk that any children he has will have the same disease as himself. Specifically, since childhood he has had difficulty breathing requiring bronchodilators, inhaled corticosteroids, and chest physiotherapy. He has also had diarrhea and malabsorption requiring enzyme replacement therapy. If his wife comes from a population where 1 in 10,000 people are affected by this same disorder, which of the following best represents the likelihood a child would be affected as well?", "answer": "1%", "options": {"A": "0.01%", "B": "0.5%", "C": "1%", "D": "2%", "E": "50%"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "genetic disorder presents", "genetic counseling", "children", "same disease", "childhood", "difficulty breathing", "bronchodilators", "inhaled corticosteroids", "chest physiotherapy", "diarrhea", "malabsorption", "enzyme replacement therapy", "population", "10", "affected", "same disorder", "following best", "likelihood", "child", "affected", "well"]}
{"question": "A medical research study is evaluating an investigational novel drug (medication 1) as 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 relative risk of death from a cardiac cause? (Round to the nearest whole number.)", "answer": "64%", "options": {"A": "36%", "B": "42%", "C": "57%", "D": "64%", "E": "72%"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["medical", "study", "investigational novel drug", "medication 1", "medication 2", "patients", "emergency department", "myocardial infarction", "study enrolled", "total", "subjects", "1 500", "study arm", "Follow-up", "days post-MI", "following", "results", "Endpoints Medication", "2 P-Value Primary", "death", "cardiac", "0.03 Secondary", "hyperkalemia 57 70 0.4", "relative", "of death", "cardiac cause", "Round", "nearest whole number"]}
{"question": "A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids.\n\nWhat is the next best step in management?", "answer": "100% oxygen, hydroxycobalamin, and sodium thiosulfate", "options": {"A": "Methylene blue", "B": "Hyperbaric oxygen", "C": "Intravenous epinephrine", "D": "Sodium thiosulfate and sodium nitrite", "E": "100% oxygen, hydroxycobalamin, and sodium thiosulfate"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old male", "fluctuating levels of consciousness", "brought", "emergency department", "ambulance due to", "fire", "home", "currently opens", "eyes to voice", "localizes painful", "asked questions", "disoriented", "patients temperature", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "97", "O2", "room air", "patients nose", "mouth", "burns", "airway obstruction", "accessory muscle use", "blood lactate", "mmol/L", "patient", "started", "next best step"]}
{"question": "A 75-year-old man presents to the emergency department because of pain in his left thigh and left calf for the past 3 months. The pain occurs at rest, increases with walking, and is mildly improved by hanging the foot off the bed. He has had hypertension for 25 years and type 2 diabetes mellitus for 30 years. He has smoked 30–40 cigarettes per day for the past 45 years. On examination, femoral, popliteal, and dorsalis pedis pulses are faint on both sides. The patient’s foot is shown in the image. Resting ankle-brachial index (ABI) is found to be 0.30. Antiplatelet therapy and aggressive risk factors modifications are initiated. Which of the following is the best next step for this patient?", "answer": "Urgent assessment for revascularization", "options": {"A": "Systemic anticoagulation with heparin", "B": "Cilostazol", "C": "Urgent assessment for revascularization", "D": "Exercise therapy", "E": "Amputation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "emergency department", "of pain", "left thigh", "left calf", "past 3 months", "pain occurs", "increases", "mildly improved", "hanging", "foot", "bed", "hypertension", "years", "type 2 diabetes mellitus", "30 years", "smoked", "cigarettes", "day", "past", "years", "femoral", "popliteal", "dorsalis pedis pulses", "faint", "sides", "patients foot", "ankle-brachial index", "found to", "0 30", "Antiplatelet therapy", "aggressive risk factors modifications", "initiated", "following", "best next step", "patient"]}
{"question": "A 72-year-old man presents to the emergency department because of difficulty breathing and sharp chest pain. The chest pain increases in intensity with lying down, and it radiates to the scapular ridge. Approximately 3 weeks ago, he had an anterior ST-elevation myocardial infarction, which was treated with intravenous alteplase. He was discharged home in a stable condition. Current vital signs include a temperature of 38.1 (100.5°F), blood pressure of 131/91 mm Hg, and pulse of 99/min. On examination, heart sounds are distant and a scratching sound is heard on the left sternal border. ECG reveals widespread concave ST elevations in the precordial leads and PR depressions in leads V2-V6. Which of the following is the most likely cause of this patient condition?", "answer": "Dressler’s syndrome", "options": {"A": "Myocarditis", "B": "Ventricular aneurysm", "C": "Recurrent infarction", "D": "Aortic dissection", "E": "Dressler’s syndrome"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["72 year old man presents", "emergency department", "difficulty breathing", "sharp chest pain", "chest pain increases", "intensity", "lying", "radiates", "scapular ridge", "Approximately", "weeks", "anterior ST-elevation myocardial infarction", "treated with intravenous alteplase", "home", "stable condition", "Current vital signs include", "temperature", "100", "blood pressure", "mm Hg", "pulse", "99 min", "heart sounds", "distant", "sound", "heard", "left sternal border", "ECG reveals widespread concave ST elevations", "precordial leads", "PR depressions", "leads V2 V6", "following", "most likely cause", "patient condition"]}
{"question": "A 2-year-old girl is brought to the emergency department after swallowing a button battery that was lying on the table 1 hour ago. She has no shortness of breath or chest discomfort. Her pulse is 112/min and respirations are 30/min. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination shows no abnormalities. An x-ray of the chest shows the battery lodged in the esophagus at the level of T2. Which of the following is the most appropriate next step in management?", "answer": "Endoscopic removal of the battery", "options": {"A": "Administer syrup of ipecac", "B": "Removal of the battery with magnet and nasogastric tube", "C": "Reassurance and observation", "D": "Administer chelation therapy", "E": "Endoscopic removal of the battery"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["2 year old girl", "brought", "emergency department", "swallowing", "button battery", "lying", "table", "hour", "shortness of breath", "chest discomfort", "pulse", "min", "respirations", "30/min", "Pulse oximetry", "room air", "oxygen saturation", "98", "abnormalities", "x-ray of", "chest", "battery", "esophagus", "level", "T2", "following", "most appropriate next step"]}
{"question": "A 4-week-old male presents with his parents to the pediatrician for a well-child visit. The patient’s mother reports that the patient was eating well until about one week ago, when he began vomiting after breastfeeding. His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse. The patient now vomits after every feed. His mother states the vomitus looks like breastmilk. The patient’s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs. Two weeks ago, the patient was in the 75th percentile for weight and 70th for height. He is now in the 60th percentile for weight and 68th percentile for height. On physical exam, the patient has dry mucous membranes. His abdomen is soft and non-distended.\n\nWhich of the following is the best next step in management?", "answer": "Abdominal ultrasound", "options": {"A": "Abdominal ultrasound", "B": "Abdominal radiograph", "C": "Supplement breastfeeding with formula", "D": "Trial of cow's milk-free diet", "E": "Trial of empiric proton pump inhibitor"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["4 week old male presents", "pediatrician", "patients", "reports", "patient", "eating well", "about one week", "began vomiting", "breastfeeding", "increasing", "frequency", "feeds", "decreasing", "amount", "vomiting", "to", "getting worse", "patient now vomits", "states", "vomitus looks", "breastmilk", "patients", "breastfeeding", "not to switch", "formula", "worries", "patient", "not getting", "nutrition", "needs", "Two weeks", "patient", "percentile", "weight", "height", "now", "percentile", "weight", "percentile", "height", "patient", "dry mucous membranes", "abdomen", "soft", "non distended", "following", "best next step"]}
{"question": "A 72-year-old man being treated for benign prostatic hyperplasia (BPH) is admitted to the emergency department for 1 week of dysuria, nocturia, urge incontinence, and difficulty initiating micturition. His medical history is relevant for hypertension, active tobacco use, chronic obstructive pulmonary disease, and BPH with multiple urinary tract infections. Upon admission, he is found with a heart rate of 130/min, respiratory rate of 19/min, body temperature of 39.0°C (102.2°F), and blood pressure of 80/50 mm Hg. Additional findings during the physical examination include decreased breath sounds, wheezes, crackles at the lung bases, and intense right flank pain. A complete blood count shows leukocytosis and neutrophilia with a left shift. A sample for arterial blood gas analysis (ABG) was taken, which is shown below.\nLaboratory test\nSerum Na+ 140 mEq/L\nSerum Cl- 102 mEq/L\nSerum K+ 4.8 mEq/L\nSerum creatinine (SCr)  2.3 mg/dL\n    Arterial blood gas  \npH 7.12\nPo2 82 mm Hg\nPco2 60 mm Hg\nSO2% 92%\nHCO3- 12.0 mEq/L\nWhich of the following best explains the patient’s condition?", "answer": "Metabolic acidosis complicated by respiratory acidosis", "options": {"A": "Metabolic acidosis complicated by respiratory acidosis", "B": "Metabolic acidosis complicated by respiratory alkalosis", "C": "Respiratory alkalosis complicated by metabolic acidosis", "D": "Respiratory acidosis complicated by metabolic alkalosis", "E": "Non-anion gap metabolic acidosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old man", "treated", "benign prostatic hyperplasia", "emergency department", "1 week", "dysuria", "nocturia", "urge incontinence", "difficulty initiating micturition", "medical history", "relevant", "hypertension", "active tobacco use", "chronic obstructive pulmonary disease", "BPH", "multiple urinary tract infections", "found", "heart rate", "min", "respiratory rate", "min", "body temperature", "blood pressure", "80 50 mm Hg", "Additional findings", "include decreased breath sounds", "wheezes", "crackles", "lung bases", "intense right flank pain", "complete blood count", "leukocytosis", "neutrophilia", "left shift", "arterial blood gas analysis", "ABG", "Laboratory Serum", "mEq", "Cl", "K", "4", "creatinine", "mg", "Arterial blood gas", "pH 7", "mm Hg", "HCO3", "L", "following best", "patients condition"]}
{"question": "A 22-year-old male varsity athlete visits the on-campus health services for shortness of breath, fatigue, and lower limb edema with onset 1 week after mild upper respiratory tract infection. Upon physical examination, his blood pressure is 100/68 mm Hg, heart rate is 120/min, respiratory rate is 23/min, and temperature is 36.4°C (97.5°F). He is referred to the nearest hospital, where his systolic pressure drops below 90 mm Hg with an S3 gallop, and he needs inotropic support in the critical care unit. A chest radiograph shows an enlarged heart, clear lungs, and effacement of the right costodiaphragmatic angle. A subsequent esophageal echocardiogram reveals severe dilation of all heart cavities, an ejection fraction of 23%, and mitral regurgitation. His family and personal history are unremarkable; therefore, an endomyocardial biopsy (EMB) is ordered. Which of the following microscopic findings would you expect in this specimen?", "answer": "Infiltration with lymphocytes", "options": {"A": "Infiltration with lymphocytes", "B": "Infiltration with eosinophils", "C": "Infiltration with giant cells", "D": "Infiltration with neutrophils", "E": "Infiltration with granulomas"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male", "athlete", "shortness of breath", "fatigue", "lower limb edema", "onset 1 week", "mild upper respiratory tract infection", "blood pressure", "100", "mm Hg", "heart rate", "min", "respiratory rate", "23 min", "temperature", "36", "97", "nearest", "systolic pressure drops", "90 mm Hg", "S3 gallop", "needs", "support", "critical care unit", "chest radiograph", "enlarged heart", "clear lungs", "effacement", "right", "angle", "subsequent esophageal echocardiogram reveals severe dilation", "heart cavities", "ejection fraction of 23", "mitral regurgitation", "personal history", "unremarkable", "endomyocardial biopsy", "ordered", "following"]}
{"question": "A 72-year-old man presents to the outpatient clinic today. He has New York Heart Association class III heart failure. His current medications include captopril 20 mg, furosemide 40 mg, potassium chloride 10 mg twice daily, rosuvastatin 20 mg, and aspirin 81 mg. He reports that he generally feels well and has not had any recent worsening of his symptoms. His blood pressure is 132/85 mm Hg and heart rate is 84/min. Physical examination is unremarkable except for trace pitting edema of the bilateral lower extremities. What other medication should be added to his heart failure regimen?", "answer": "Metoprolol succinate ", "options": {"A": "Losartan", "B": "Metoprolol tartrate", "C": "Metoprolol succinate ", "D": "Isosorbide dinitrate/hydralazine ", "E": "Digoxin "}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "outpatient clinic today", "New York Heart Association class III", "failure", "current medications include captopril 20 mg", "potassium chloride 10 mg twice daily", "rosuvastatin 20 mg", "reports", "well", "not", "recent worsening", "symptoms", "blood pressure", "85 mm Hg", "heart rate", "84 min", "unremarkable", "trace pitting edema of", "bilateral lower extremities", "medication", "added", "heart failure regimen"]}
{"question": "A 40-year-old, gravida 2, nulliparous woman, at 14 weeks' gestation comes to the physician because of a 6-hour history of light vaginal bleeding and lower abdominal discomfort. Eight months ago she had a spontaneous abortion at 10 weeks' gestation. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. Abdominal examination shows no tenderness or masses; bowel sounds are normal. On pelvic examination, there is old blood in the vaginal vault and at the closed cervical os. The uterus is larger than expected for the length of gestation and there are bilateral adnexal masses. Serum β-hCG concentration is 120,000 mIU/ml. Which of the following is the most appropriate next step in management?", "answer": "Transvaginal ultrasound", "options": {"A": "Transvaginal ultrasound", "B": "Chorionic villus sampling", "C": "Thyroid function tests", "D": "Fetal blood sampling", "E": "Fetal Doppler ultrasound"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["40 year old", "gravida 2", "nulliparous woman", "weeks", "gestation", "physician", "6-hour history", "light vaginal bleeding", "lower abdominal discomfort", "Eight months", "spontaneous abortion", "10 weeks", "gestation", "pulse", "min", "respirations", "min", "blood pressure", "76 mm Hg", "Abdominal", "tenderness", "masses", "bowel sounds", "normal", "pelvic examination", "old blood", "vaginal vault", "closed cervical os", "uterus", "larger", "length of gestation", "bilateral adnexal masses", "Serum", "hCG concentration", "mIU/ml", "following", "most appropriate next step"]}
{"question": "A 34-year-old business executive presents to her primary care provider because of difficulty falling asleep on her trips. She makes 4–5 business trips from California to China every month. Her typical direct Los Angeles to Hong Kong flight leaves Los Angeles at 12:30 a.m. and reaches Hong Kong at 7:00 p.m. (local time) the next day. She complains of difficulty falling asleep at night and feeling sleepy the next morning. On arriving back in Los Angeles 2–3 days later, she feels extremely weak, has muscle soreness, and abdominal distension, all of which self-resolve in a few days. She is otherwise healthy and does not take any medications. Physical examination is unremarkable. After discussing general sleep hygiene recommendations, which of the following is the best next step for this patient’s condition?", "answer": "Melatonin", "options": {"A": "Polysomnography", "B": "Escitalopram", "C": "Temazepam", "D": "Zolpidem", "E": "Melatonin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old business executive presents", "primary care provider", "of difficulty falling asleep", "makes", "business", "California", "China", "month", "typical direct Los Angeles", "Hong Kong", "Los Angeles", "30", "m", "reaches Hong Kong", "m", "local time", "next day", "difficulty falling asleep", "night", "sleepy", "next morning", "back", "Los Angeles 23 days later", "extremely weak", "muscle soreness", "abdominal distension", "days", "healthy", "not", "medications", "unremarkable", "general", "following", "best next step", "patients condition"]}
{"question": "A 5-week-old infant boy presents to the pediatrician with intermittent vomiting for the last 2 weeks. The mother reports that the vomiting is non-bilious and immediately follows feeding. After vomiting, the baby is hungry and wants to feed again. The frequency of vomiting has been increasing progressively over 2 weeks. The vital signs are within normal limits. The examination of the abdomen reveals the presence of a firm mass of approx. 2 cm in length, above and to the right of the umbilicus. The mass is movable, olive-shaped, and hard on palpation. Which of the following is the most likely surgical treatment for this infant’s condition?", "answer": "Pyloromyotomy", "options": {"A": "Surgical ligation of the fistula and primary end-to-end anastomosis of the esophagus", "B": "Pyloromyotomy", "C": "Duodenoduodenostomy", "D": "Diverticulectomy", "E": "Endorectal pull-through procedure"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 week old infant boy presents", "pediatrician", "intermittent vomiting", "2 weeks", "reports", "vomiting", "non", "immediately follows", "vomiting", "baby", "hungry", "to", "frequency of vomiting", "increasing", "weeks", "vital signs", "normal limits", "examination of", "abdomen reveals", "presence", "firm mass", "length", "above", "right", "umbilicus", "mass", "movable", "olive shaped", "hard", "palpation", "following", "surgical treatment", "infants condition"]}
{"question": "A 32-year-old woman with bipolar disorder visits her gynecologist because she believes she is pregnant. A urine pregnancy test is performed which confirms she is pregnant. She has mild bipolar disorder for which she takes lithium and admits that she has been taking it ‘on and off’ for 2 years now but has never had any symptoms or episodes of relapse. She says that she had not made contact with her psychiatrist for the past several months because she ‘couldn’t find any time.’ Which of the following is the next best step in the management of this patient?", "answer": "Taper lithium and provide a prescription for clonazepam as needed", "options": {"A": "Continue lithium administration through pregnancy", "B": "Taper lithium and administer valproate", "C": "Continue lithium administration through pregnancy and add lamotrigine", "D": "Taper lithium and administer carbamazepine", "E": "Taper lithium and provide a prescription for clonazepam as needed"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "bipolar disorder", "gynecologist", "pregnant", "urine pregnancy test", "performed", "confirms", "pregnant", "mild bipolar disorder", "lithium", "years now", "never", "symptoms", "episodes of relapse", "not made contact with", "psychiatrist", "past", "months", "find", "time", "following", "next best step", "patient"]}
{"question": "A 4-year-old male is brought by his mother to the emergency room with dyspnea and fever. His mother reports a two-day history of progressive shortness of breath, malaise, and a fever with a maximum temperature of 101.6°F (38.7°C). The child has visited the emergency room three times over the past two years for pneumonia and otitis media. His family history is notable for sarcoidosis in his mother, diabetes in his father, and an early childhood death in his maternal uncle. His temperature is 101.2°F (38.4°C), blood pressure is 110/90 mmHg, pulse is 110/min, and respirations are 24/min. Physical examination reveals scant lymphoid tissue. A serological analysis reveals decreased levels of IgA, IgG, and IgM. This patient most likely has a defect in a protein that is active in which of the following cellular stages?", "answer": "Pre-B-cell", "options": {"A": "Pro-B-cell", "B": "Pre-B-cell", "C": "Immature B-cell", "D": "Mature B-cell", "E": "Plasma cell"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old male", "brought", "emergency room", "dyspnea", "fever", "reports", "two day history of progressive shortness", "breath", "malaise", "fever", "maximum temperature", "child", "emergency room three times", "past two years", "pneumonia", "otitis media", "family history", "notable", "sarcoidosis", "diabetes", "early childhood death in", "temperature", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "reveals scant lymphoid tissue", "serological analysis reveals decreased levels", "IgA", "IgM", "patient", "likely", "a defect", "protein", "active", "following cellular stages"]}
{"question": "A 4-month-old boy is brought to the physician for a well-child examination. He was born at 36 weeks' gestation. The mother has had no prenatal care. His 6-year-old sister has a history of osteosarcoma. He is exclusively breast fed. He is at the 60th percentile for height and weight. Vital signs are within normal limits. Examination shows inward deviation of the right eye. Indirect ophthalmoscopy shows a white reflex in the right eye and a red reflex in the left eye. Which of the following is the most appropriate next step in management?", "answer": "Fundus examination", "options": {"A": "Screen for galactosemia", "B": "Visual training exercises", "C": "CT scan of the eye", "D": "Fundus examination", "E": "Serum rubella titers"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["4 month old boy", "brought", "physician", "well", "born", "36 weeks", "gestation", "year old", "history of osteosarcoma", "breast fed", "percentile", "height", "weight", "Vital signs", "normal limits", "inward deviation", "right", "Indirect ophthalmoscopy", "white reflex", "right", "red reflex", "left eye", "following", "most appropriate next step"]}
{"question": "A 38-year-old woman with a history of Crohn’s disease presents with a 3-week history of weight gain. The patient also presents with a 1-month history of abdominal pain, cramping, and bloody diarrhea consistent with worsening of her inflammatory bowel disease. Past medical history is significant for Crohn’s disease diagnosed 2 years ago for which she currently takes an oral medication daily and intermittently receives intravenous medication she cannot recall the name of. Her temperature is 37.0°C (98.6°F), blood pressure is 120/90 mm Hg, pulse is 68/min, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination reveals significant truncal weight gain. The patient has excessive facial hair in addition to purplish striae on her abdomen. Which of the following laboratory findings would most likely be found in this patient?", "answer": "Hypokalemia", "options": {"A": "Hyperkalemia", "B": "Normal random blood glucose levels", "C": "Metabolic acidosis", "D": "Hypoglycemia", "E": "Hypokalemia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "history of Crohns disease presents", "week history", "weight gain", "patient", "presents", "month history", "abdominal pain", "cramping", "bloody diarrhea", "of", "inflammatory bowel disease", "medical history", "significant", "Crohns disease diagnosed 2 years", "currently", "oral medication daily", "receives intravenous medication", "name", "temperature", "98", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "min", "oxygen saturation", "99", "room air", "reveals significant truncal weight gain", "patient", "excessive facial hair in addition to purplish striae", "abdomen", "following laboratory findings", "most likely", "found", "patient"]}
{"question": "A 22-year-old man comes to the physician because of a 2-week history of cough and decreased urination. The cough was initially nonproductive, but in the last few days he has coughed up small amounts of blood-tinged sputum with clots. He has not had any fevers, chills, or weight loss. He has smoked one pack of cigarettes daily for 5 years. Pulse is 115/min and blood pressure is 125/66 mm Hg. Physical examination shows dried blood around the lips. Serum studies show a creatinine of 2.9 mg/dL. Results of a serum antineutrophil cytoplasm antibody test are negative. A biopsy specimen of the kidney is most likely to show which of the following light microscopy findings?", "answer": "Fibrin crescents in Bowman space", "options": {"A": "Neutrophilic infiltration of the capillaries", "B": "Expansion of the mesangial matrix", "C": "Thinning of the basement membrane", "D": "Fibrin crescents in Bowman space", "E": "Enlarged and hypercellular glomeruli"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "2-week history", "cough", "decreased urination", "cough", "initially", "last", "days", "coughed up small amounts", "blood tinged sputum", "clots", "not", "fevers", "chills", "weight loss", "smoked one pack", "cigarettes daily", "Pulse", "min", "blood pressure", "66 mm Hg", "dried blood", "lips", "Serum studies", "creatinine", "Results", "serum antineutrophil cytoplasm antibody test", "negative", "biopsy specimen", "kidney", "to", "following light microscopy findings"]}
{"question": "A 27-year-old man is brought to the emergency department after a motorcycle accident 30 minutes ago. He was found at the scene of the accident with a major injury to the anterior chest by a metallic object that was not removed during transport to the hospital. The medical history could not be obtained. His blood pressure is 80/50 mm Hg, pulse is 130/min, and respiratory rate is 40/min. Evaluation upon arrival to the emergency department reveals a sharp metal object penetrating through the anterior chest to the right of the sternum at the 4th intercostal space. The patient is taken to the operating room immediately, where it is shown the heart has sustained a major injury. Which of the following arteries supplies the part of the heart most likely injured in this patient?", "answer": "Right marginal artery", "options": {"A": "Right marginal artery", "B": "Left circumflex coronary artery", "C": "Left anterior descending artery", "D": "Posterior descending artery", "E": "Left coronary artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old man", "brought", "emergency department", "motorcycle accident 30 minutes", "found", "major injury to", "anterior chest", "metallic", "not removed", "transport", "hospital", "medical history", "not", "obtained", "blood pressure", "80 50 mm Hg", "pulse", "min", "respiratory rate", "40 min", "arrival", "emergency department reveals", "sharp", "penetrating", "anterior chest", "right", "sternum", "4th intercostal space", "patient", "operating room immediately", "heart", "sustained", "major injury", "following arteries supplies", "part", "heart", "likely injured", "patient"]}
{"question": "A 32-year-old man comes to the physician because of a 2 month history of difficulty sleeping and worsening fatigue. During this time, he has also had difficulty concentrating and remembering tasks at work as well as diminished interest in his hobbies. He has no suicidal or homicidal ideation. He does not have auditory or visual hallucinations. Vital signs are normal. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect with slowed thinking and speech. The physician prescribes sertraline. Three weeks later, the patient comes to the physician again with only minor improvements in his symptoms. Which of the following is the most appropriate next step in management?", "answer": "Continue sertraline for 3 more weeks\n\"", "options": {"A": "Provide electroconvulsive therapy", "B": "Change medication to duloxetine", "C": "Augment with phenelzine and continue sertraline", "D": "Augment with aripiprazole and continue sertraline", "E": "Continue sertraline for 3 more weeks\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "2 month history", "difficulty sleeping", "worsening fatigue", "time", "difficulty concentrating", "diminished interest", "suicidal", "homicidal ideation", "not", "auditory", "visual hallucinations", "Vital signs", "normal", "abnormalities", "Mental status", "depressed mood", "flat affect", "slowed", "speech", "physician", "sertraline", "Three weeks later", "patient", "physician", "only minor", "symptoms", "following", "most appropriate next step"]}
{"question": "A 50-year-old man presents with severe chest pain for a week. His pain increases with breathing and is localized to the right. He has tried over-the-counter medications at home, but they did not help. The patient has a 20-pack-year smoking history and currently smokes 2 pack of cigarettes daily, and he drinks 3 to 4 cans of beer daily before dinner. His temperature is 39.1°C (102.3°F), blood pressure is 127/85 mm Hg, pulse is 109/min, and respirations are 20/min. Respiratory examination shows dullness to percussion from the 7th rib inferiorly at the right midaxillary line, decreased vocal tactile fremitus, and diminished breath sounds in the same area. Chest radiograph is shown in the image. The patient is prepared for thoracocentesis. Which of the following locations would be the most appropriate for insertion of a chest tube?", "answer": "Above the superior border of the 8th rib in the midaxillary line", "options": {"A": "Above the superior border of the 7th rib in the midclavicular line", "B": "Above the superior border of the 5th rib in the midclavicular line", "C": "Below the inferior border of the 5th rib in the midaxillary line", "D": "Above the superior border of the 8th rib in the midaxillary line", "E": "Below the inferior border of the 7th rib in the midaxillary line"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old man presents", "severe chest", "week", "pain increases", "breathing", "localized", "right", "over-the-counter medications at home", "not help", "patient", "20 year smoking history", "currently smokes 2 pack", "cigarettes daily", "3", "4 cans of", "daily", "dinner", "temperature", "blood pressure", "85 mm Hg", "pulse", "min", "respirations", "20 min", "Respiratory examination", "dullness", "percussion", "rib", "right midaxillary line", "decreased vocal tactile", "diminished breath sounds", "same area", "Chest radiograph", "patient", "prepared", "following locations", "most appropriate", "insertion of", "chest tube"]}
{"question": "A previously healthy 13-year-old girl is brought to the physician by her mother because of a change in behavior. The mother reports that over the past 6 months, her daughter has had frequent mood swings. Sometimes, she is irritable for several days and loses her temper easily. In between these episodes, she behaves “normal,” spends time with her friends, and participates in gymnastics training twice a week. The mother has also noticed that her daughter needs more time than usual to get ready for school. Sometimes, she puts on excessive make-up. One month ago, her teacher had informed the parents that their daughter had skipped school and was seen at the local mall with one of her classmates instead. The patient reports that she often feels tired, especially when she has to wake up early for school. On the weekends, she sleeps until 1 pm. Menses have occurred at 15- to 45-day intervals since menarche at the age of 12 years; they are not associated with abdominal discomfort or functional impairment. Physical examination shows no abnormalities. Which of the following is the most likely explanation for the patient's behavior?", "answer": "Normal behavior", "options": {"A": "Borderline personality disorder", "B": "Normal behavior", "C": "Major depressive disorder", "D": "Premenstrual syndrome", "E": "Bipolar disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old girl", "brought", "physician", "change", "behavior", "reports", "past 6 months", "frequent mood swings", "Sometimes", "irritable", "days", "easily", "episodes", "normal", "spends time", "training twice", "week", "needs more time", "usual to", "Sometimes", "excessive make", "One month", "teacher", "informed", "skipped school", "seen", "local mall", "one", "patient reports", "often", "tired", "to wake up early", "school", "weekends", "sleeps", "Menses", "day intervals", "menarche at", "age", "years", "not associated with abdominal discomfort", "functional impairment", "abnormalities", "following", "explanation", "patient's behavior"]}
{"question": "A 44-year-old woman with recurrent urinary tract infections is brought to the emergency department by ambulance after sudden onset of severe headache 30 minutes ago. She has a history of occasional, mild headaches in the morning. There is no other history of serious illness. Both her father and her paternal grandmother died of chronic kidney disease. Her temperature is 37.2°C (99.1°F) and blood pressure is 145/90 mm Hg. Physical examination shows neck stiffness. When her hip is flexed, she is unable to fully extend her knee because of pain. Lumbar puncture performed 12 hours after headache onset yields 10 mL of yellow-colored fluid with no leukocytes. Which of the following is the most likely predisposing factor for this patient's current condition?", "answer": "Saccular aneurysm\n\"", "options": {"A": "Arterial atherosclerosis", "B": "Bacterial infection", "C": "Hypercoagulable state", "D": "Cerebral atrophy", "E": "Saccular aneurysm\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "recurrent urinary tract infections", "brought", "emergency department", "ambulance", "sudden onset", "severe headache 30 minutes", "history of occasional", "mild headaches", "morning", "history", "serious illness", "died of chronic kidney disease", "temperature", "99", "blood pressure", "90 mm Hg", "neck stiffness", "hip", "flexed", "unable", "extend", "knee", "pain", "Lumbar performed 12 hours", "headache onset", "10 mL of yellow colored fluid", "following", "predisposing factor", "patient's current condition"]}
{"question": "A 56-year-old man presents to the family medicine office since he has been having difficulty keeping his blood pressure under control for the past month. He has a significant medical history of hypertension, coronary artery disease, and diabetes mellitus. He has a prescription for losartan, atenolol, and metformin. The blood pressure is 178/100 mm Hg, the heart rate is 92/min, and the respiratory rate is 16/min. The physical examination is positive for a grade II holosystolic murmur at the left sternal border. He also has diminished sensation in his toes. Which of the following statements is the most effective means of communication between the doctor and the patient?", "answer": "“What is causing your blood pressure to be elevated?”", "options": {"A": "“Have you been taking your medications as prescribed?”", "B": "“Why are you not taking your medication?”", "C": "“What is causing your blood pressure to be elevated?”", "D": "“You are taking your medications as prescribed, aren’t you?”", "E": "“Would you like us to consider trying a different medication for your blood pressure?”"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "family medicine office", "difficulty keeping", "blood pressure", "control", "past month", "significant medical", "coronary artery disease", "diabetes mellitus", "losartan", "atenolol", "metformin", "blood pressure", "100 mm Hg", "heart rate", "min", "respiratory rate", "min", "positive", "holosystolic murmur", "left sternal border", "diminished sensation", "toes", "following", "most effective means of communication", "doctor", "patient"]}
{"question": "Twenty minutes after delivery by lower segment cesarean section at 38 weeks' gestation, a 4630-g (10-lb 3-oz) male newborn has respiratory distress. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Pregnancy was complicated by gestational diabetes mellitus. His temperature is 36.9°C (98.4°F), pulse is 155/min and respirations are 72/min. Pulse oximetry on room air shows an oxygen saturation of 88%. Grunting and moderate intercostal and subcostal retractions are present. Diffuse crackles are heard on auscultation of the chest. An x-ray of the chest shows increased lung volume and fluid within the interlobar fissures. Which of the following is the most appropriate next step in management?", "answer": "Supportive care", "options": {"A": "Supportive care", "B": "Broad-spectrum antibiotic therapy", "C": "Continuous positive airway pressure", "D": "Surfactant therapy", "E": "Nitric oxide therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Twenty minutes", "delivery", "lower segment cesarean section", "weeks", "gestation", "g", "10", "3 oz", "male newborn", "respiratory distress", "Apgar scores", "8", "1", "5 minutes", "Pregnancy", "complicated", "gestational", "temperature", "36", "98", "pulse", "min", "respirations", "72 min", "Pulse oximetry", "room air", "oxygen saturation", "88", "moderate", "subcostal retractions", "present", "Diffuse crackles", "heard", "auscultation", "chest", "x-ray of", "chest", "increased lung volume", "fluid", "interlobar fissures", "following", "most appropriate next step"]}
{"question": "A 27-year-old gravida 2, para 1 presents to her physician at 21 weeks gestation with decreased sensitivity, tingling, and pain in her right hand that is worse at night and is partially relieved by shaking her hand. She developed these symptoms gradually over the past month. She does not report any trauma to her extremities, neck, or spine. The physical examination shows a normal range of motion of the neck, spine, and extremities. On neurologic examination, the patient has 2+ biceps and triceps reflexes. She has decreased pressure and temperature sensitivity over the palmar surface of the 1st, 2nd, and 3rd fingers. Wrist flexion and tapping the skin over the flexor retinaculum trigger exacerbation of the symptoms. Which of the following statements about the patient’s condition is correct?", "answer": "Immobilization (for example, splinting) should improve the reported outcome in this patient.", "options": {"A": "This is a fairly uncommon condition in pregnant women.", "B": "Pre-pregnancy obesity increases risk of developing this condition during pregnancy.", "C": "Corticosteroid injections are contraindicated in pregnant women for management of this condition.", "D": "If this condition has occurred in the second or third trimester of pregnancy, it is unlikely to resolve after the completion of pregnancy.", "E": "Immobilization (for example, splinting) should improve the reported outcome in this patient."}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["27 year old gravida 2", "para 1 presents", "physician", "weeks gestation", "decreased sensitivity", "tingling", "pain in", "right hand", "worse", "night", "relieved by shaking", "hand", "symptoms", "past month", "not report", "trauma", "extremities", "neck", "spine", "normal range of motion", "neck", "spine", "extremities", "neurologic examination", "patient", "biceps", "triceps reflexes", "decreased pressure", "temperature sensitivity", "palmar surface of", "1st", "2nd", "3rd fingers", "Wrist flexion", "skin", "flexor retinaculum trigger exacerbation", "symptoms", "following", "patients condition", "correct"]}
{"question": "A 15-year-old female is brought to the emergency room with high fever and confusion. She complains of chills and myalgias, and physical examination reveals a petechial rash. Petechial biopsy reveals a Gram-negative diplococcus. The patient is at greatest risk for which of the following?", "answer": "Bilateral adrenal destruction", "options": {"A": "Bilateral adrenal destruction", "B": "Pelvic inflammatory disease", "C": "Septic arthritis", "D": "Osteomyelitis", "E": "Acute endocarditis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "brought", "emergency room", "high fever", "confusion", "chills", "myalgias", "reveals", "petechial rash", "biopsy reveals", "patient", "greatest", "following"]}
{"question": "A 65-year-old man with a history of diabetes, hypertension, hyperlipidemia, and obesity is transferred from the cardiac catheterization lab to the cardiac critical care unit after sustaining a massive myocardial infarction. He received a bare metal stent and has now stabilized. However, shortly after being transferred, he reports palpitations. EKG reveals ventricular tachycardia. Your attending wishes to start an anti-arrhythmic drug with a high selectivity for ischemic cardiac myocytes. You call the nurse and ask her to begin intravenous:", "answer": "Lidocaine", "options": {"A": "Quinidine", "B": "Lidocaine", "C": "Dofetilide", "D": "Procainamide", "E": "Flecainide"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65-year-old man", "history", "diabetes", "hypertension", "hyperlipidemia", "obesity", "transferred", "cardiac catheterization lab", "cardiac critical care unit", "sustaining", "massive myocardial infarction", "received", "bare metal stent", "now stabilized", "transferred", "reports palpitations", "EKG reveals ventricular tachycardia", "attending wishes to start", "anti-arrhythmic drug", "high", "ischemic", "call", "nurse", "to begin intravenous"]}
{"question": "A 13-year-old girl is brought to the physician by her father because of a worsening pruritic rash for 2 days. Five weeks ago, she was diagnosed with juvenile myoclonic epilepsy and treatment with lamotrigine was begun. Her immunizations are up-to-date. Her temperature is 38.8°C (101.8°F). Physical examination shows facial edema and a partially confluent morbilliform rash over the face, trunk, and extremities. There is swelling of the cervical and inguinal lymph nodes and hepatomegaly. Further evaluation is most likely to show which of the following?", "answer": "Increased absolute eosinophil count", "options": {"A": "Fragmented red blood cells", "B": "Increased absolute eosinophil count", "C": "Positive heterophile antibody test", "D": "Anti-measles IgM antibodies", "E": "Elevated antistreptolysin-O titer"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "worsening pruritic rash", "2", "Five weeks", "diagnosed", "juvenile myoclonic epilepsy", "treatment", "lamotrigine", "begun", "immunizations", "date", "temperature", "facial edema", "confluent morbilliform", "face", "trunk", "extremities", "swelling", "cervical", "inguinal lymph nodes", "hepatomegaly", "Further", "to", "following"]}
{"question": "A 9-year-old boy is brought to his physician for behavioral problems in school. The patient’s parents have noted that he often will “shake his hands” abnormally at times and does so on his own without provocation. This has persisted for the past year. Additionally, the child has made loud grunting sounds in school that disturb the other students and the teacher. The patient has a past medical history of asthma and atopic dermatitis, and his current medications include ibuprofen, albuterol, and topical corticosteroids during flares. On physical exam, you note an active young child who is playing with toys in the office. You observe the grunting sounds he makes at this office visit. The child seems mistrustful, does not reply to your questions, and does not look you in the eyes. Which of the following is most likely also found in this patient?", "answer": "Excessive hand washing", "options": {"A": "Auditory hallucinations", "B": "Cough that occurs only at night", "C": "Excessive hand washing", "D": "Mental retardation", "E": "Poor communication skills"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "behavioral problems in school", "patients", "noted", "often", "shake", "hands", "times", "so", "past year", "child", "made loud", "in school", "teacher", "patient", "past medical", "atopic dermatitis", "current medications include ibuprofen", "albuterol", "topical corticosteroids", "flares", "note", "active young child", "playing", "toys", "office", "observe", "makes", "child", "not", "not look", "eyes", "following", "found", "patient"]}
{"question": "A 52-year-old man presents to the Emergency Department because of bilateral leg swelling and puffiness of both eyes in the morning. His symptoms started about 2 weeks ago. He denies smoking or alcohol use and his family history is noncontributory. Today, his vital signs include a temperature of 36.8°C (98.2°F), blood pressure of 162/87 mm Hg, and a pulse of 85/min. On physical examination, he is jaundiced and there is hepatosplenomegaly and 2+ lower extremity edema up to the mid-thigh. Laboratory results are shown:\nAnti-HCV\nreactive\nSerum albumin\n3 g/dL\nUrine dipstick\n3+ protein\nUrinalysis\n10–15 red blood cells/high power field and red cell casts\nWhich of the following is a feature of this patient’s condition?", "answer": "Subendothelial immune complex deposits", "options": {"A": "Subendothelial immune complex deposits", "B": "Phospholipase A2 receptor antibodies", "C": "Normal complement level", "D": "Renal vasoconstriction and altered autoregulation", "E": "Few immune complex deposits"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "Emergency Department", "bilateral leg swelling", "puffiness", "eyes", "morning", "symptoms started", "2 weeks", "smoking", "family history", "Today", "vital signs include", "temperature", "36", "98", "blood pressure", "87 mm Hg", "pulse", "85 min", "jaundiced", "hepatosplenomegaly", "2", "lower extremity edema", "thigh", "Laboratory results", "Anti-HCV reactive Serum albumin", "g/dL", "protein", "cells/high power field", "red cell casts", "following", "feature", "patients"]}
{"question": "A 61-year-old woman presents to her primary care physician complaining of left-sided facial pain that started yesterday. She describes the pain as stinging, burning, and constant. It does not worsen with jaw movement or chewing. Her past medical history includes hyperlipidemia and multiple sclerosis (MS), and she had chickenpox as a child but received a shingles vaccination last year. Medications include simvastatin and glatiramer acetate. The patient’s last MS flare was 5 weeks ago, at which time she received a prednisone burst with taper. At this visit, her temperature is 99.9 °F (37.7°C), blood pressure is 139/87 mmHg, pulse is 82/min, and respirations are 14/min. On exam, there is no rash or skin change on either side of the patient’s face. Gentle palpation of the left cheek and mandible produce significant pain, but there is full range of motion in the jaw. Which of the following medications is the most likely to prevent long-term persistence of this patient’s pain?", "answer": "Oral acyclovir", "options": {"A": "Carbamazepine", "B": "Amitriptyline", "C": "Oral acyclovir", "D": "Topical corticosteroids", "E": "Gabapentin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["61 year old woman presents", "primary care physician", "left-sided facial pain", "started", "pain", "stinging", "burning", "constant", "not worsen", "jaw movement", "chewing", "past medical history includes hyperlipidemia", "multiple sclerosis", "chickenpox", "child", "received", "shingles vaccination", "year", "Medications include simvastatin", "glatiramer acetate", "patients last MS flare", "5 weeks", "time", "received", "prednisone burst", "temperature", "99.9 F", "blood pressure", "87 mmHg", "pulse", "min", "respirations", "min", "exam", "rash", "skin change", "side", "patients face", "Gentle palpation", "left cheek", "mandible", "significant pain", "full range of motion", "jaw", "following medications", "to prevent long-term", "patients pain"]}
{"question": "A 38-year-old woman comes to the physician because of a 2-day history of a red, itchy, burning rash on her vulva. She has had three similar episodes over the last two years that have all self-resolved. Genitourinary examination shows a small area of erythema with an overlying cluster of vesicles on the inside surface of the vulva. Latent infection of which of the following is most likely responsible for this patient's recurrent symptoms?", "answer": "Sensory neurons", "options": {"A": "Macrophages", "B": "Sensory neurons", "C": "Monocytes", "D": "Astrocytes", "E": "T cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "2-day history", "red", "itchy", "burning rash", "vulva", "three similar episodes", "two years", "self resolved", "Genitourinary", "small area", "erythema", "cluster", "vesicles", "surface", "vulva", "Latent infection", "following", "responsible", "patient's recurrent symptoms"]}
{"question": "A researcher is studying gamete production and oogenesis. For her experiment, she decides to cultivate primary oocytes just prior to ovulation and secondary oocytes just prior to fertilization. When she examines these gametes, she will find that the primary oocytes and secondary oocytes are arrested in which phases of meiosis, respectively?", "answer": "Prophase I; metaphase II", "options": {"A": "Interphase I; prophase II", "B": "Metaphase I; metaphase II", "C": "Metaphase I; prophase II", "D": "Anaphase I; anaphase II", "E": "Prophase I; metaphase II"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["researcher", "studying", "oogenesis", "to", "prior to ovulation", "prior to fertilization", "find", "arrested", "phases", "meiosis"]}
{"question": "A 51-year-old woman presents to the primary care clinic complaining of trouble sleeping. She reports that she has episodes of “overheating” and “sweating” during the day and at night. The nightly episodes keep her from staying asleep. She also explains how embarrassing it is when she suddenly becomes hot and flushed during work meetings. The patient becomes visibly upset and states that she is worried about her marriage as well. She says she has been fighting with her husband about not going out because she is “too tired.” They have not been able to have sex the past several months because “it hurts.” Labs are drawn, as shown below:\n\nFollicle stimulating hormone (FSH): 62 mIU/mL\nEstridiol: 34 pg/mL\nProgesterone: 0.1 ng/mL\nLuteinizing hormone (LH): 46 mIU/mL\nFree testosterone: 2.1 ng/dL\n\nWhich of the following contributes most to the production of estrogen in this patient?", "answer": "Adipose tissue", "options": {"A": "Adipose tissue", "B": "Adrenal glands", "C": "Bartholin glands", "D": "Mammary glands", "E": "Ovaries"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care clinic", "trouble sleeping", "reports", "episodes of overheating", "sweating", "day", "night", "episodes keep", "asleep", "embarrassing", "hot", "flushed", "patient", "states", "worried", "marriage", "well", "not", "out", "tired", "not", "able to", "sex", "past", "months", "Labs", "Follicle stimulating hormone", "62 mIU/mL", "pg/mL Progesterone", "0.1 ng/mL Luteinizing hormone", "mIU/mL Free testosterone", "2.1 ng/dL", "following", "most", "estrogen", "patient"]}
{"question": "A 67-year-old man comes to the physician because of progressive burning pain and intermittent “electrical shocks” in his right chest for 3 months. Over the last 2 weeks, the pain has increased to an extent that he can no longer tolerate clothing on the affected area. Three months ago, he had a rash around his right nipple and axilla that resolved a week later. The patient had a myocardial infarction 2 years ago. He has smoked one packs of cigarettes daily for 47 years. Current medications include aspirin, simvastatin, metoprolol, and ramipril. His temperature is 36.9°C (97.9°F), pulse is 92/min, and blood pressure is 150/95 mm Hg. Examination shows increased sensation to light touch over the right chest. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Oral gabapentin", "options": {"A": "Sublingual nitrates", "B": "Oral tricyclic antidepressants", "C": "Oral famciclovir", "D": "Intrathecal glucocorticoids", "E": "Oral gabapentin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["67 year old man", "physician", "progressive burning pain", "intermittent electrical", "right chest", "3 months", "last", "weeks", "pain", "increased", "extent", "longer", "clothing", "affected area", "Three months", "rash", "right", "axilla", "resolved", "week later", "patient", "myocardial infarction", "years", "smoked one packs", "cigarettes daily", "years", "Current medications include aspirin", "simvastatin", "metoprolol", "ramipril", "temperature", "36", "97 9F", "pulse", "min", "blood pressure", "95 mm Hg", "increased sensation", "light touch", "right chest", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 51-year-old woman is brought to the emergency department because of an aggressive cough with copious amounts of thick, foamy, yellow-green sputum. She says she has had this cough for about 11 years with exacerbations similar to her presentation today. She also reports that her cough is worse in the morning. She was evaluated multiple times in the past because of recurrent bouts of bronchitis that have required treatment with antibiotics. She is a non-smoker. On physical examination, the blood pressure is 125/78 mm Hg, pulse rate is 80/min, respiratory rate is 16/min, and temperature is 36.7°C (98.0°F). Chest auscultation reveals crackles and wheezing over the right middle lobe and the rest of her physical examinations are normal. The chest X-ray shows irregular opacities in the right middle lobe and diffuse airway thickening. Based on this history and physical examination, which of the following is the most likely diagnosis?", "answer": "Bronchiectasis", "options": {"A": "Tuberculosis", "B": "Alpha-1-antitrypsin deficiency", "C": "Bronchiectasis", "D": "Chronic obstructive pulmonary disease", "E": "Chronic bronchitis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "aggressive cough", "copious amounts", "thick", "foamy", "sputum", "cough", "years", "exacerbations similar", "today", "reports", "cough", "worse", "morning", "multiple times", "past", "recurrent bouts", "bronchitis", "required", "antibiotics", "non-smoker", "blood pressure", "mm Hg", "pulse rate", "80 min", "respiratory rate", "min", "temperature", "36", "98", "Chest auscultation reveals crackles", "wheezing", "right middle lobe", "normal", "chest X-ray", "irregular opacities", "right middle lobe", "diffuse airway thickening", "Based", "history", "following", "diagnosis"]}
{"question": "A 30-year-old woman presents to her primary care provider complaining of intermittent fever and loss of appetite for the past 2 weeks. She is also concerned about painful genital lesions. Past medical history is noncontributory. She takes oral contraceptives and a multivitamin daily. She has had two male sexual partners in her lifetime and uses condoms inconsistently. She admits to being sexually active with 2 partners in the last 3 months and only using condoms on occasion. Today, her vitals are normal. On pelvic exam, there are red-rimmed, fluid-filled blisters over the labia minora (as seen in the photograph below) with swollen and tender inguinal lymph nodes. Which of the following is the most likely diagnosis of this patient?", "answer": "Genital herpes", "options": {"A": "Syphilis", "B": "Condyloma acuminata", "C": "Gonorrhea", "D": "Genital herpes", "E": "Trichomoniasis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["30 year old woman presents", "primary care provider", "intermittent fever", "loss of appetite", "past 2 weeks", "painful genital lesions", "Past medical history", "oral contraceptives", "multivitamin daily", "two male", "lifetime", "uses condoms", "to", "sexually active", "last", "months", "only using condoms", "occasion", "Today", "normal", "pelvic exam", "red rimmed", "fluid", "blisters", "labia minora", "seen", "photograph", "swollen", "tender inguinal lymph nodes", "following", "diagnosis", "patient"]}
{"question": "A 23-year-old woman comes to the emergency department because of increasing abdominal pain with associated nausea and vomiting. The symptoms began suddenly after having intercourse with her partner six hours ago. There is no associated fever, diarrhea, vaginal bleeding, or discharge. Menarche was at the age of 13 years and her last menstrual period was 4 weeks ago. She uses combination contraceptive pills. She had an appendectomy at the age of 12. Her temperature is 37.5°C (99.5°F), pulse is 100/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows severe right lower quadrant tenderness with associated rebound and guarding. Pelvic examination shows scant, clear vaginal discharge and right adnexal tenderness. There is no cervical wall motion tenderness. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 9,000/mm3, and platelet count is 250,000/mm3. A urine pregnancy test is negative. Which of the following imaging findings is most likely?", "answer": "Decreased ovarian blood flow on doppler", "options": {"A": "Echogenic tubal ring", "B": "Decreased ovarian blood flow on doppler", "C": "Complex, echogenic intrauterine mass", "D": "Distended fallopian tube with incomplete septations", "E": "Increased ovarian blood flow on doppler"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "emergency department", "of increasing abdominal pain with associated nausea", "vomiting", "symptoms began", "intercourse", "six hours", "associated fever", "diarrhea", "vaginal bleeding", "discharge", "Menarche", "age", "years", "last menstrual period", "4 weeks", "uses combination contraceptive pills", "appendectomy", "age", "temperature", "99", "pulse", "100 min", "respirations", "min", "blood pressure", "70 mm Hg", "Abdominal", "severe right lower quadrant tenderness with associated rebound", "guarding", "Pelvic examination", "scant", "clear vaginal discharge", "right adnexal tenderness", "cervical wall motion tenderness", "hemoglobin concentration", "10.5 g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "urine pregnancy test", "negative", "following imaging findings"]}
{"question": "A 17-year-old girl presents with significant weight loss over the last few months. There is a positive family history of Hodgkin lymphoma and hyperthyroidism. Her blood pressure is 100/65 mm Hg, pulse rate is 60/min, and respiratory rate is 17/min. Her weight is 41 kg and height is 165 cm. On physical examination, the patient is ill-appearing. Her skin is dry, and there are several patches of thin hair on her arm. No parotid gland enlargement is noted and her knuckles show no signs of trauma. Laboratory findings are significant for the following:\nHemoglobin  10.1 g/dL\nHematocrit 37.7%\nLeukocyte count  5,500/mm³\nNeutrophils 65% \nLymphocytes  30%\nMonocytes 5%\nMean corpuscular volume  65.2 µm³\nPlatelet count 190,000/mm³\nErythrocyte sedimentation rate  10 mm/h\nWhich of the following findings is associated with this patient’s most likely condition?", "answer": "Amenorrhea", "options": {"A": "Amenorrhea", "B": "Dental caries", "C": "Diarrhea", "D": "Abdominal striae", "E": "Parotid gland enlargement"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl presents", "significant weight loss", "last", "months", "positive family history of Hodgkin lymphoma", "hyperthyroidism", "blood pressure", "100 65 mm Hg", "pulse rate", "60 min", "respiratory rate", "min", "weight", "kg", "height", "patient", "ill appearing", "skin", "dry", "several patches", "thin hair", "arm", "parotid gland enlargement", "noted", "knuckles", "signs", "trauma", "Laboratory findings", "significant", "following", "Hemoglobin", "count", "500", "65", "30", "Mean corpuscular volume", "Platelet count", "rate", "h", "following findings", "associated with", "patients", "likely condition"]}
{"question": "A 61-year-old woman comes to the emergency department because of a 2-hour history of headache, nausea, blurred vision, and pain in the left eye. She has had similar symptoms in the past. Her vital signs are within normal limits. The left eye is red and is hard on palpation. The left pupil is mid-dilated and nonreactive to light. Administration of which of the following drugs should be avoided in this patient?", "answer": "Epinephrine", "options": {"A": "Acetazolamide", "B": "Epinephrine", "C": "Pilocarpine", "D": "Apraclonidine", "E": "Timolol"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old woman", "emergency department", "of", "2-hour history", "headache", "nausea", "blurred vision", "pain in", "left eye", "similar symptoms", "past", "vital signs", "normal limits", "left eye", "red", "hard", "palpation", "left pupil", "dilated", "nonreactive", "light", "Administration", "following drugs", "patient"]}
{"question": "Two hours after undergoing a left femoral artery embolectomy, an obese 63-year-old woman has severe pain, numbness, and tingling of the left leg. The surgery was without complication and peripheral pulses were weakly palpable postprocedure. She has type 2 diabetes mellitus, peripheral artery disease, hypertension, and hypercholesterolemia. Prior to admission, her medications included insulin, enalapril, carvedilol, aspirin, and rosuvastatin. She appears uncomfortable. Her temperature is 37.1°C (99.3°F), pulse is 98/min, and blood pressure is 132/90 mm Hg. Examination shows a left groin surgical incision. The left lower extremity is swollen, stiff, and tender on palpation. Dorsiflexion of her left foot causes severe pain in her calf. Femoral pulses are palpated bilaterally. Pedal pulses are weaker on the left side as compared to the right side. Laboratory studies show:\nHemoglobin 12.1\nLeukocyte count 11,300/mm3\nPlatelet count 189,000/mm3\nSerum\nGlucose 222 mg/dL\nCreatinine 1.1 mg/dL\nUrinalysis is within normal limits. Which of the following is the most likely cause of these findings?\"", "answer": "Reperfusion injury", "options": {"A": "Deep vein thrombosis", "B": "Reperfusion injury", "C": "Rhabdomyolysis", "D": "Cholesterol embolism", "E": "Cellulitis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two hours", "left", "obese 63 year old woman", "severe pain", "numbness", "tingling", "left leg", "surgery", "complication", "peripheral pulses", "palpable postprocedure", "type 2 diabetes mellitus", "peripheral artery disease", "hypertension", "hypercholesterolemia", "medications included insulin", "enalapril", "carvedilol", "aspirin", "rosuvastatin", "appears", "temperature", "99", "pulse", "98 min", "blood pressure", "90 mm Hg", "left groin surgical incision", "left lower extremity", "swollen", "stiff", "tender", "palpation", "Dorsiflexion of", "left foot causes severe pain in", "calf", "Femoral pulses", "Pedal pulses", "weaker", "left side", "right side", "Laboratory studies", "Hemoglobin", "Leukocyte count", "mm3 Platelet count", "Serum", "mg/dL Creatinine", "Urinalysis", "normal limits", "following", "most likely cause", "findings"]}
{"question": "A regional academic medical center has 10 cases of adenovirus in the span of a week among its ICU patients. A committee is formed to investigate this outbreak. They are tasked with identifying the patients and interviewing the care providers to understand how adenovirus could have been spread from patient to patient. This committee will review charts, talk to the care provider teams, and investigate current patient safety and sanitation measures in the ICU. The goal of the committee is to identify weaknesses in the current system and to put in place a plan to help prevent this sort of outbreak from reoccurring in the future. The committee is most likely using what type of analysis?", "answer": "Root cause analysis", "options": {"A": "Failure mode and effects analysis", "B": "Root cause analysis", "C": "Algorithmic analysis", "D": "Simulation", "E": "Heuristic analysis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["regional academic medical center", "10 cases", "adenovirus", "span", "week", "ICU patients", "formed to investigate", "patients", "providers to", "adenovirus", "spread", "patient", "patient", "talk", "care provider teams", "investigate current", "measures", "ICU", "to", "weaknesses", "current system", "to", "place", "plan to help prevent", "sort", "future", "most likely using", "type", "analysis"]}
{"question": "A 9-year-old boy who recently emigrated from sub-Saharan Africa is brought to the physician because of a 2-day history of fever, chills, and productive cough. His mother reports that he has had several episodes of painful swelling of his fingers during infancy that resolved with pain medication. His immunization status is unknown. His temperature is 39.8°C (103.6°F). Examination shows pale conjunctivae and yellow sclerae. There are decreased breath sounds and inspiratory crackles over the left lower lung fields. His hemoglobin concentration is 7 g/dL. Blood cultures grow optochin-sensitive, gram-positive diplococci. A deficiency in which of the following most likely contributed to this patient's infection?", "answer": "Bacterial clearance", "options": {"A": "Bacterial clearance", "B": "Immunoglobulin A action", "C": "Respiratory burst", "D": "Complement production", "E": "T cell differentiation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "recently", "sub-Saharan Africa", "brought", "physician", "2-day history", "fever", "chills", "productive cough", "reports", "several episodes of painful swelling", "fingers", "infancy", "resolved", "pain medication", "immunization status", "unknown", "temperature", "pale conjunctivae", "yellow sclerae", "decreased breath sounds", "inspiratory crackles", "left lower", "hemoglobin concentration", "g/dL", "Blood cultures", "optochin sensitive", "deficiency", "following most likely", "patient's infection"]}
{"question": "A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?", "answer": "Donepezil", "options": {"A": "Donepezil", "B": "Thiamine", "C": "Acetazolamide", "D": "Sertraline", "E": "Memantine\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "physician", "follow-up examination", "more forgetful", "withdrawn", "year", "frequently", "car", "forgets", "names", "known", "30 years", "difficulty", "recently", "episode of urinary", "fecal incontinence", "week", "found", "parking lot", "grocery store", "hypertension", "hyperlipidemia", "smoked one pack", "cigarettes daily", "40 years", "years", "current medications include hydrochlorothiazide", "atorvastatin", "appears healthy", "BMI", "23 kg/m2", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "Mini-mental state examination score", "30", "not", "Cranial nerves", "intact", "5/5 strength", "full sensation", "light touch", "extremities", "patellar", "Achilles", "biceps reflexes", "2", "gait", "steady", "MRI scan of", "brain", "ventriculomegaly", "prominent", "sulci", "following", "most appropriate pharmacotherapy"]}
{"question": "A 45-year-old man with a 5-year history worsening shortness of breath and cough comes to the physician for a follow-up examination. He has never smoked. His pulse is 75/min, blood pressure is 130/65 mm Hg, and respirations are 25/min. Examination shows an increased anteroposterior diameter of the chest. Diminished breath sounds and wheezing are heard on auscultation of the chest. An x-ray of the chest shows widened intercostal spaces, a flattened diaphragm, and basilar-predominant bullous changes of the lungs. This patient is at increased risk for which of the following complications?", "answer": "Hepatocellular carcinoma", "options": {"A": "Hepatocellular carcinoma", "B": "Churg-Strauss syndrome", "C": "Pulmonary fibrosis", "D": "Bronchogenic carcinoma", "E": "Bronchiolitis obliterans"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "history worsening shortness of breath", "cough", "physician", "follow-up examination", "never smoked", "pulse", "75 min", "blood pressure", "65 mm Hg", "respirations", "min", "increased anteroposterior diameter of", "chest", "Diminished", "wheezing", "heard", "auscultation", "chest", "x-ray of", "chest", "widened intercostal spaces", "flattened diaphragm", "basilar predominant bullous changes", "lungs", "patient", "increased risk", "following complications"]}
{"question": "A 61-year-old obese man with recently diagnosed hypertension returns to his primary care provider for a follow-up appointment and blood pressure check. He reports feeling well with no changes to since starting his new blood pressure medication 1 week ago. His past medical history is noncontributory. Besides his blood pressure medication, he takes atorvastatin and a daily multivitamin. The patient reports a 25-pack-year smoking history and is a social drinker on weekends. Today his physical exam is normal. Vital signs and laboratory results are provided in the table.\nLaboratory test\n2 weeks ago Today\nBlood pressure 159/87 mm Hg Blood pressure 164/90 mm Hg\nHeart rate 90/min Heart rate 92/min\nSodium 140 mE/L Sodium 142 mE/L\nPotassium 3.1 mE/L Potassium 4.3 mE/L\nChloride 105 mE/L Chloride 103 mE/L\nCarbon dioxide 23 mE/L Carbon dioxide 22 mE/L\nBUN 15 mg/dL BUN 22 mg/dL\nCreatinine 0.80 mg/dL Creatinine 1.8 mg/dL\nMagnetic resonance angiography (MRA) shows a bilateral narrowing of renal arteries. Which of the following is most likely this patient’s new medication that caused his acute renal failure?", "answer": "Captopril", "options": {"A": "Verapamil", "B": "Hydralazine", "C": "Clonidine", "D": "Captopril", "E": "Hydrochlorothiazide"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["61 year old obese man", "recently diagnosed hypertension returns", "primary care provider", "follow-up appointment", "blood pressure check", "reports", "well", "changes", "since starting", "new blood pressure medication 1 week", "past medical history", "blood medication", "atorvastatin", "daily multivitamin", "patient reports", "smoking history", "social drinker", "weekends", "Today", "normal", "Vital signs", "laboratory results", "Laboratory", "Blood", "mm Hg", "Heart", "Sodium", "L Sodium", "L Potassium 3 1", "L Potassium", "3", "L", "105", "L", "103", "L Carbon dioxide 23", "L", "dioxide", "L", "mg dL", "mg", "Creatinine", "1", "Magnetic resonance angiography", "bilateral narrowing of renal arteries", "following", "patients new medication", "caused", "acute renal failure"]}
{"question": "A startup is working on a novel project in which they claim they can replicate the organelle that is defective in MELAS syndrome. Which of the following metabolic processes must they be able to replicate if their project is to mimic the metabolic processes of this organelle?", "answer": "Fatty acid (beta) oxidation", "options": {"A": "Glycolysis", "B": "Fatty acid synthesis", "C": "Fatty acid (beta) oxidation", "D": "Hexose monophaste shunt", "E": "Cholesterol synthesis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["novel", "replicate", "organelle", "defective", "MELAS syndrome", "following metabolic processes", "able to replicate", "to", "metabolic processes", "organelle"]}
{"question": "A 53-year-old man with a history of hypertension, hyperlipidemia, and obesity presents to you in clinic for a yearly physical. His current medication regimen includes a beta blocker, angiotensin converting enzyme inhibitor, and a statin. You review his recent lab work and note that despite being on a maximum statin dose, his LDL cholesterol remains elevated. You decide to prescribe another medication to improve his lipid profile. One month later, you receive a telephone call from your patient; he complains of turning bright red and feeling \"scorching hot\" every time he takes his medications. You decide to prescribe the which of the following medications to alleviate his symptoms:", "answer": "Aspirin", "options": {"A": "Diphenhydramine", "B": "Aspirin", "C": "Coenzyme Q10", "D": "Hydroxyzine", "E": "Acetaminophen"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "history of hypertension", "hyperlipidemia", "obesity presents", "clinic", "yearly physical", "current medication regimen includes", "beta blocker", "angiotensin converting enzyme inhibitor", "statin", "recent lab", "note", "maximum statin dose", "LDL cholesterol", "elevated", "to", "medication to", "lipid profile", "One month later", "receive", "telephone call", "patient", "turning bright red", "hot", "time", "medications", "to", "following medications to", "symptoms"]}
{"question": "A 2-week-old newborn is brought to the physician for a follow-up examination. He was born at term and the pregnancy was uncomplicated. His mother says he has been feeding well and passing adequate amounts of urine. He appears healthy. He is at the 60th percentile for length and 40th percentile for weight. His temperature is 37.3°C (99.1°F), pulse is 130/min, respirations are 49/min and blood pressure is 62/40 mm Hg. A thrill is present over the third left intercostal space. A 5/6 holosystolic murmur is heard over the left lower sternal border. An echocardiography shows a 3-mm membranous ventricular septal defect. Which of the following is the most appropriate next step in management?", "answer": "Outpatient follow-up", "options": {"A": "Amoxicillin therapy", "B": "Prostaglandin E1 therapy", "C": "Outpatient follow-up", "D": "Indomethacin therapy", "E": "Cardiac catheterization"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["2 week old newborn", "brought", "physician", "follow-up examination", "born", "term", "pregnancy", "uncomplicated", "well", "passing adequate amounts", "urine", "appears healthy", "percentile", "length", "percentile", "weight", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "62 40 mm Hg", "thrill", "present", "third left intercostal space", "5/6 holosystolic murmur", "heard", "left lower sternal border", "echocardiography", "3-mm membranous ventricular septal defect", "following", "most appropriate next step"]}
{"question": "A 55-year-old man comes to the emergency department because of severe chest pain for the past hour. The patient describes the pain as located in the middle of his chest, tearing in quality, and radiating to his back. He has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has smoked a pack of cigarettes daily for the past 30 years. He drinks 2–3 beers daily. He used cocaine in his 30s, but he has not used any illicit drugs for the past 15 years. Medications include enalapril, atorvastatin, and metformin. He says that he has not been taking his medications on a regular basis. He is 174 cm (5 ft 9 in) tall and weighs 98 kg (216 lb); BMI is 32 kg/m2. His pulse is 80/min, and blood pressure is 150/90 mm Hg in his right arm and 180/100 mm Hg in his left arm. Cardiac examination shows a high-pitched, blowing, decrescendo early diastolic murmur. An ECG shows no abnormalities. An x-ray of the chest shows a widened mediastinum. Which of the following is the strongest predisposing factor for this patient's condition?", "answer": "Hypertension", "options": {"A": "Diabetes mellitus", "B": "Age", "C": "Hyperlipidemia", "D": "Hypertension", "E": "History of smoking"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency department", "of severe chest pain", "past hour", "patient", "pain", "middle", "chest", "tearing", "quality", "radiating to", "back", "history of hypertension", "hyperlipidemia", "type 2 diabetes mellitus", "smoked", "pack", "cigarettes daily", "past 30 years", "23", "daily", "used cocaine", "30s", "not used", "illicit drugs", "past", "years", "Medications include enalapril", "atorvastatin", "metformin", "not", "medications", "regular basis", "5 ft 9", "tall", "98 kg", "BMI", "kg/m2", "pulse", "80 min", "blood pressure", "90 mm Hg", "right arm", "100 mm Hg", "left arm", "high-pitched", "blowing", "early diastolic murmur", "ECG", "abnormalities", "x-ray of", "chest", "widened mediastinum", "following", "strongest predisposing factor", "patient's condition"]}
{"question": "An 8-year-old boy is brought to the pediatrician because his mother is concerned about recent behavioral changes. His mother states that she has started to notice that he is slurring his speech and seems to be falling more than normal. On exam, the pediatrician observes the boy has pes cavus, hammer toes, and kyposcoliosis. Based on these findings, the pediatrician is concerned the child has a trinucleotide repeat disease. Which of the following trinucleotide repeats is this child most likely to possess?", "answer": "GAA", "options": {"A": "CGG", "B": "GAA", "C": "CAG", "D": "CTG", "E": "GCC"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "recent behavioral changes", "states", "started to", "slurring", "speech", "to", "falling more", "normal", "exam", "pediatrician observes", "boy", "pes cavus", "hammer toes", "Based", "findings", "pediatrician", "child", "trinucleotide repeat disease", "following trinucleotide repeats", "child", "to possess"]}
{"question": "A 32-year-old woman presents to her primary care physician for recent onset headaches, weight loss, and restlessness. Her symptoms started yesterday, and since then she has felt sweaty and generally uncomfortable. The patient’s past medical history is unremarkable except for a recent viral respiratory infection which resolved on its own. The patient is not currently on any medications. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 110/min, respirations are 14/min, and oxygen saturation is 98% on room air. On physical exam, you see a sweaty and uncomfortable woman who has a rapid pulse. The patient demonstrates no abnormalities on HEENT exam. The patient’s laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 8,500/mm^3 with normal differential\nPlatelet count: 195,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 102 mEq/L\nK+: 4.4 mEq/L\nHCO3-: 24 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.2 mg/dL\nTSH: .03 mIU/L\nAST: 12 U/L\nALT: 10 U/L\n\nThe patient is prescribed propranolol and proplythiouracil. She returns 1 week later complaining of severe fatigue. Laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 8,500/mm^3 with normal differential\nPlatelet count: 195,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 102 mEq/L\nK+: 4.4 mEq/L\nHCO3-: 24 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.2 mg/dL\nTSH: 6.0 mIU/L\nAST: 12 U/L\nALT: 10 U/L\n\nWhich of the following is the best next step in management?", "answer": "Discontinue current medications", "options": {"A": "Decrease dose of current medications", "B": "Discontinue current medications and add ibuprofen", "C": "Discontinue current medications and add T4", "D": "Discontinue medications and add T3", "E": "Discontinue current medications"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care physician", "recent onset headaches", "weight loss", "restlessness", "symptoms started", "since then", "sweaty", "patients past medical history", "unremarkable", "recent infection", "resolved", "patient", "not currently", "medications", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "see", "sweaty", "woman", "rapid pulse", "patient", "abnormalities", "HEENT exam", "patients laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.4 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1 0 mg/dL Ca2", "10", "mg/dL", "mIU/L AST", "U/L ALT", "10 U/L", "patient", "propranolol", "returns 1 week later", "severe fatigue", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.4 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1 0 mg/dL Ca2", "10", "mg/dL", "0 mIU/L AST", "U/L ALT", "10 U/L", "following", "best next step"]}
{"question": "A 26-year-old woman comes to the physician because of recurrent thoughts that cause her severe distress. She describes these thoughts as gory images of violent people entering her flat with criminal intent. She has had tremors and palpitations while experiencing these thoughts and must get up twenty to thirty times at night to check that the door and windows have been locked. She says that neither the thoughts nor her actions are consistent with her “normal self”. She has a history of general anxiety disorder and major depressive disorder. She drinks 1–2 alcoholic beverages weekly and does not smoke or use illicit drugs. She takes no medications. She appears healthy and well nourished. Her vital signs are within normal limits. On mental status examination, she is calm, alert and oriented to person, place, and time. She describes her mood as \"\"good.\"\"; her speech is organized, logical, and coherent. Which of the following is the most appropriate next step in management?\"", "answer": "Sertraline", "options": {"A": "Olanzapine", "B": "Venlafaxine", "C": "Risperidone", "D": "Phenelzine", "E": "Sertraline"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "recurrent", "cause", "severe distress", "thoughts", "of violent", "entering", "flat", "tremors", "palpitations", "get", "twenty", "thirty times", "night to check", "door", "windows", "locked", "actions", "normal", "history of general anxiety disorder", "major depressive disorder", "weekly", "not smoke", "use illicit", "medications", "appears healthy", "well nourished", "vital signs", "normal limits", "mental status", "alert", "oriented to person", "place", "time", "mood", "good", "speech", "organized", "coherent", "following", "most appropriate next step"]}
{"question": "A 41-year-old man presents to a New Mexico emergency department with a 12 hour history of shortness of breath and a nonproductive cough. He says that last week he experienced fevers, chills, fatigue, and myalgias but assumed that he simply had a cold. The symptoms went away after 3 days and he felt fine for several days afterward until he started experiencing shortness of breath even at rest. He works as an exterminator and recently had a job in a rodent infested home. Physical exam reveals a thin, tachypneic man with diffuse rales bilaterally. The most likely cause of this patient's symptoms is associated with which of the following?", "answer": "Decreased serum albumin level", "options": {"A": "Binding to sialic acid residues in human cells", "B": "Cerebral spinal fluid pleocytosis", "C": "Decreased serum albumin level", "D": "Safety pin-shaped organisms on peripheral blood smear", "E": "Widened mediastinum on chest radiograph"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "New Mexico emergency department", "12 hour history of shortness", "breath", "nonproductive cough", "last week", "fevers", "chills", "fatigue", "myalgias", "cold", "symptoms", "3 days", "fine", "days", "started", "shortness of breath", "recently", "home", "reveals", "thin", "tachypneic man", "diffuse rales", "most likely cause", "patient's symptoms", "associated with"]}
{"question": "A 62-year-old woman with a history of subarachnoid hemorrhage is brought to the emergency department because of shortness of breath and sharp chest pain that worsens on inspiration. She underwent surgery for a hip fracture 3 weeks ago. Her pulse is 110/min, respirations are 20/min, and blood pressure is 112/74 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. The lungs are clear to auscultation and there is no jugular venous distention. A ventilation and perfusion scan shows a small perfusion defect in the left lower lung. A drug with which of the following mechanisms of action is most appropriate for this patient?", "answer": "Activation of antithrombin III", "options": {"A": "Inhibition of vitamin K epoxide reductase", "B": "Inhibition of cyclooxygenase", "C": "Inhibition of adenosine diphosphate receptors", "D": "Activation of plasminogen", "E": "Activation of antithrombin III"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["62 year old woman", "history of subarachnoid hemorrhage", "brought", "emergency department", "of shortness", "breath", "sharp chest pain", "worsens", "inspiration", "surgery", "hip fracture 3 weeks", "pulse", "min", "respirations", "20 min", "blood pressure", "74 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "lungs", "clear", "auscultation", "jugular venous distention", "ventilation", "perfusion scan", "small perfusion defect", "left lower lung", "drug", "of", "following mechanisms", "action", "most appropriate", "patient"]}
{"question": "A 17-year-old girl is brought to the emergency department by her friends who were at a party with her and found her unconscious in the bathroom. They admit that alcohol was present at the party. The patient's blood pressure is 118/78 mm Hg, pulse is 40/min, respiratory rate is 16/min, and temperature is 36.7°C (98.1°F). On physical examination, she is unresponsive to verbal commands but does respond to noxious stimuli. Her pupils are pinpoint and her mucous membranes are moist. Her heart is bradycardic without murmurs, and her respiratory rate is slowed but clear to auscultation. What is the most likely cause of her symptoms?", "answer": "Overdose of heroin", "options": {"A": "Alcohol poisoning", "B": "Overdose of heroin", "C": "Ethylene glycol ingestion", "D": "Overdose of cocaine", "E": "3,4-methylenedioxy-methamphetamine (MDMA) ingestion"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "emergency department", "found", "unconscious", "bathroom", "alcohol", "present", "patient's blood pressure", "mm Hg", "pulse", "40 min", "respiratory rate", "min", "temperature", "36", "98", "unresponsive", "verbal", "pupils", "pinpoint", "mucous membranes", "moist", "heart", "bradycardic", "murmurs", "respiratory rate", "slowed", "clear", "auscultation", "most likely cause", "symptoms"]}
{"question": "A 44-year-old woman presents with increased thirst and frequent urination that started 6 months ago and have progressively worsened. Recently, she also notes occasional edema of the face. She has no significant past medical history or current medications. The patient is afebrile and the rest of the vital signs include: blood pressure is 120/80 mm Hg, heart rate is 61/min, respiratory rate is 14/min, and temperature is 36.6°C (97.8°F). The BMI is 35.2 kg/m2. On physical exam, there is 2+ pitting edema of the lower extremities and 1+ edema in the face. There is generalized increased deposition of adipose tissue present that is worse in the posterior neck, upper back, and shoulders. There is hyperpigmentation of the axilla and inguinal areas. The laboratory tests show the following findings:\nBlood\nErythrocyte count 4.1 million/mm3\nHgb 12.9 mg/dL\nLeukocyte count 7,200/mm3\nPlatelet count 167,000/mm3\nFasting blood glucose 141 mg/dL (7.8 mmol/L)\nCreatinine 1.23 mg/dL (108.7 µmol/L)\nUrea nitrogen 19 mg/dL (6.78 mmol/L)\nUrine dipstick\nGlucose +++\nProtein ++\nBacteria Negative\nThe 24-hour urine protein is 0.36 g. Which of the following medications is the best treatment for this patient’s condition?", "answer": "Enalapril", "options": {"A": "Enalapril", "B": "Insulin", "C": "Metoprolol", "D": "Furosemide", "E": "Mannitol"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "increased thirst", "frequent urination", "started", "months", "worsened", "Recently", "notes occasional edema of the face", "significant past medical history", "current medications", "patient", "afebrile", "vital signs include", "blood pressure", "80 mm Hg", "heart rate", "61 min", "respiratory rate", "min", "temperature", "36", "97", "BMI", "35", "kg/m2", "2", "pitting edema of", "lower extremities", "1", "edema", "face", "generalized increased deposition", "adipose tissue present", "worse", "posterior neck", "upper back", "shoulders", "hyperpigmentation", "axilla", "inguinal areas", "laboratory tests", "following findings", "Blood Erythrocyte count", "million mm3 Hgb", "dL Leukocyte count", "200", "Fasting blood glucose", "dL", "mmol/L", "Creatinine", "23 mg/dL", "mol/L", "Urea", "mg/dL", "mmol/L", "Urine dipstick Glucose", "Protein", "Bacteria Negative", "24-hour urine protein", "0.36 g", "following medications", "best", "condition"]}
{"question": "A 3-week-old newborn is brought to the pediatrician by his mother. His mother is concerned about her son’s irritability and vomiting, particularly after breastfeeding him. The infant was born at 39 weeks via spontaneous vaginal delivery. His initial physical was benign. Today the newborn appears mildly jaundiced with palpable hepatomegaly, and his eyes appear cloudy, consistent with the development of cataracts. The newborn is also in the lower weight-age percentile. The physician considers a hereditary enzyme deficiency and orders blood work and a urinalysis to confirm his diagnosis. He recommends that milk and foods high in galactose and/or lactose be eliminated from the diet. Which of the following is the most likely deficient enzyme in this metabolic disorder?", "answer": "Galactose-1-phosphate uridyl transferase", "options": {"A": "Galactokinase", "B": "Galactose-1-phosphate uridyl transferase", "C": "Aldose reductase", "D": "UDP-galactose-4-epimerase", "E": "Glucose-6-phosphate dehydrogenase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 week old newborn", "brought", "pediatrician", "irritability", "vomiting", "breastfeeding", "infant", "born", "weeks", "spontaneous vaginal delivery", "initial physical", "benign", "Today", "newborn appears mildly jaundiced", "palpable hepatomegaly", "eyes appear cloudy", "development", "cataracts", "newborn", "lower weight age percentile", "physician", "hereditary enzyme deficiency", "orders blood", "urinalysis to confirm", "diagnosis", "milk", "high", "galactose", "lactose", "eliminated", "diet", "following", "deficient enzyme", "metabolic"]}
{"question": "A 43-year-old man visits his physician’s office for a routine check-up. He tells his physician that he is otherwise healthy, except for persistent headaches that he gets every morning. Upon further questioning, he reveals that he has been changing glove sizes quite frequently over the past couple of years. His wedding ring doesn’t fit him anymore. He thought this was probably due to some extra weight that he has put on. Vital signs include: blood pressure 160/90 mm Hg, heart rate 82/min, and respiratory rate 21/min. His current physical appearance is cataloged in the image. His past medical history is significant for diabetes for which he has been receiving treatment for the past 2 years. Which of the following organs most likely has a structural abnormality that has resulted in this patient’s current presentation?", "answer": "Anterior pituitary gland", "options": {"A": "Anterior pituitary gland", "B": "Posterior pituitary gland", "C": "Pancreas", "D": "Liver", "E": "Lungs"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physicians office", "routine check-up", "physician", "healthy", "persistent headaches", "gets", "morning", "further", "reveals", "changing glove sizes", "frequently", "past couple", "years", "ring", "fit", "due to", "extra weight", "Vital signs include", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "current physical appearance", "past medical history", "significant", "diabetes", "receiving treatment", "past", "years", "following organs", "likely", "structural abnormality", "current"]}
{"question": "Two days after being admitted for acute myocardial infarction, a 61-year-old man has sharp, substernal chest pain that worsens with inspiration and improves when leaning forward. Cardiac examination shows a scratchy sound best heard over the left sternal border. Histopathological examination of the affected tissue is most likely to show which of the following findings?", "answer": "Neutrophilic infiltration", "options": {"A": "Neutrophilic infiltration", "B": "Normal myocardium", "C": "Coagulative necrosis", "D": "Collagenous scar tissue", "E": "Granulation tissue with macrophages"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Two days", "acute myocardial infarction", "61 year old man", "sharp", "chest pain", "worsens", "inspiration", "improves", "forward", "scratchy sound best heard", "left sternal border", "Histopathological examination", "affected tissue", "to", "following findings"]}
{"question": "A 42-year-old man comes to the physician because of a 6-week history of intermittent fever, abdominal pain, bloody diarrhea, and sensation of incomplete rectal emptying. He also has had a 4.5-kg (10-lb) weight loss over the past 3 months. Abdominal examination shows diffuse tenderness. Colonoscopy shows circumferential erythematous lesions that extend without interruption from the anal verge to the cecum. A biopsy specimen taken from the rectum shows mucosal and submucosal inflammation with crypt abscesses. This patient is most likely at risk of developing colon cancer with which of the following characteristics?", "answer": "Non-polypoid dysplasia", "options": {"A": "Unifocal lesion", "B": "Late p53 mutation", "C": "Non-polypoid dysplasia", "D": "Low-grade lesion", "E": "Early APC mutation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "week history", "intermittent fever", "abdominal pain", "bloody diarrhea", "sensation", "incomplete rectal", "4.5 kg", "10", "Abdominal", "diffuse tenderness", "Colonoscopy", "circumferential erythematous lesions", "extend", "interruption", "anal verge", "cecum", "biopsy specimen", "rectum", "mucosal", "submucosal inflammation", "crypt abscesses", "patient", "of", "colon cancer", "following characteristics"]}
{"question": "A 5-year-old boy presents to his pediatrician along with his parents due to episodes of “staring into space.” This symptom occurs several times a day and lasts only a few seconds. During these episodes, the boy does not respond to verbal or physical stimulation, and his parents deny him falling down or shaking. After the episode, the boy returns to his normal activity and is not confused. The parents deny any history of head trauma, recent medication use, or infection. Neurological exam is unremarkable. His episode is precipitated as he blows at a pinwheel. An EEG is performed, which shows 3-Hz spike and waveform. Which of the following is the best treatment option for this patient?", "answer": "Ethosuximide", "options": {"A": "Ethosuximide", "B": "Levetiracetam", "C": "Lamotrigine", "D": "Valproic acid", "E": "Zonisamide"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["5 year old boy presents", "pediatrician", "due to episodes of staring", "space", "symptom occurs several times", "day", "lasts only", "few seconds", "episodes", "boy", "not", "verbal", "falling", "shaking", "episode", "boy returns", "normal activity", "not confused", "history", "head trauma", "recent medication use", "infection", "Neurological exam", "unremarkable", "episode", "precipitated", "blows", "pinwheel", "EEG", "performed", "3 Hz", "following", "best treatment option", "patient"]}
{"question": "A 45 year-old gentleman presents to his primary care physician complaining of wrist pain and is diagnosed with carpal tunnel syndrome. Upon further questioning, the patient admits that he has recently been outgrowing his gloves and shoes and has had to purchase a new hat as well due to increased head size. Upon exam, he is found to have new mild hypertension and on basic labs he is found to be hyperglycemic. Which of the following is the best blood test to diagnose his suspected disorder?", "answer": "IGF-1 level", "options": {"A": "Hydroxyproline level", "B": "Alkaline Phosphatase level", "C": "Cortisol level", "D": "Growth Hormone level", "E": "IGF-1 level"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "presents", "primary care physician", "wrist pain", "diagnosed", "carpal tunnel syndrome", "further", "patient", "recently", "gloves", "shoes", "to", "new hat", "well", "increased head", "exam", "found to", "new mild hypertension", "basic labs", "found to", "following", "best blood test to diagnose", "suspected disorder"]}
{"question": "A 59-year-old male with a history of hypertension presents with chest pain and hoarseness. Patient reports that his hoarseness onset gradually approximately 2 weeks ago and has steadily worsened. He states that approximately 2 hours ago he had sudden onset chest pain which has not improved. The patient describes the chest pain as severe, sharp in character, localized to the midline and radiating to the back. Past medical history is significant for hypertension diagnosed 10 years previously, which was being managed medically, although patient admits he stopped taking his medication and has not been to his doctor in the last couple of years. No current medications. Patient admits to a 20-pack-year smoking history.\nVital signs are temperature 37 °C (98.6 °F), blood pressure 169/100 mm Hg, pulse 85/min, respiration rate 19/min, and oxygen saturation 98% on room air. On physical exam, patient is diaphoretic and in distress. Cardiac exam is significant for an early diastolic murmur. Lungs are clear to auscultation. Remainder of physical exam is normal. While performing the exam, the patient suddenly grips his chest and has a syncopal episode. He cannot be roused. Repeat vital signs show blood pressure 85/50 mm Hg, pulse 145/min, respiration rate 25/min, and oxygen saturation 92% on room air. Extremities are pale and cool.\nPatient is intubated. High flow supplemental oxygen and aggressive fluid resuscitation are initiated. Type and crossmatch are ordered. Which of the following is the next best step in management?", "answer": "Transthoracic echocardiography", "options": {"A": "Chest X-ray", "B": "EKG", "C": "Transthoracic echocardiography", "D": "Cardiac troponins", "E": "Emergency surgery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old male", "history of hypertension presents", "chest pain", "hoarseness", "Patient reports", "hoarseness onset", "approximately", "weeks", "worsened", "states", "approximately", "hours", "sudden onset chest pain", "not improved", "patient", "chest pain", "severe", "sharp", "character", "localized", "midline", "radiating to", "back", "Past medical history", "significant", "hypertension diagnosed", "patient", "stopped", "medication", "not", "doctor", "last couple", "years", "current medications", "Patient", "20 year smoking history", "Vital signs", "temperature", "98", "F", "blood pressure", "100 mm Hg", "pulse 85 min", "respiration rate", "min", "oxygen saturation 98", "room air", "patient", "diaphoretic", "distress", "significant", "early diastolic murmur", "Lungs", "clear", "auscultation", "normal", "performing", "exam", "patient", "grips", "chest", "syncopal episode", "Repeat vital signs", "blood pressure 85 50 mm Hg", "pulse", "min", "respiration rate", "min", "oxygen saturation", "room air", "Extremities", "pale", "cool", "Patient", "intubated", "High", "supplemental oxygen", "aggressive fluid resuscitation", "initiated", "Type", "crossmatch", "ordered", "following", "next best step"]}
{"question": "A 25-year-old G1P0 woman at an estimated gestational age of 9 weeks presents for her first prenatal visit following a positive home pregnancy test. She says she missed 2 periods but assumed it was due to stress at work. She has decided to continue with the pregnancy. Her past medical history is significant for migraine headaches, seizures, and asthma. She takes multiple medications for her condition. Physical examination is unremarkable. An ultrasound confirms a 9-week-old intrauterine pregnancy. Which of these following medications poses the greatest risk to the fetus?", "answer": "Valproic acid", "options": {"A": "Acetaminophen", "B": "Sumatriptan", "C": "Valproic acid", "D": "Albuterol", "E": "Budesonide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "woman", "estimated gestational age", "weeks presents", "following", "positive home", "missed 2 periods", "due to stress", "to", "pregnancy", "past medical history", "significant", "migraine headaches", "seizures", "asthma", "multiple medications", "condition", "unremarkable", "ultrasound confirms", "week old intrauterine", "following medications", "greatest risk", "fetus"]}
{"question": "A 4-day-old newborn is brought to the physician because of a generalized rash for 1 day. He was born at term. The mother had no prenatal care and has a history of gonorrhea, which was treated 4 years ago. The newborn is at the 50th percentile for head circumference, 60th percentile for length, and 55th percentile for weight. His temperature is 36.8°C (98.2°F), pulse is 152/min, and respirations are 51/min. Examination shows an erythematous maculopapular rash and pustules with an erythematous base over the trunk and extremities, sparing the palms and soles. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Erythema toxicum", "options": {"A": "Acropustulosis", "B": "Erythema toxicum", "C": "Milia", "D": "Pustular melanosis", "E": "Congenital syphilis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 day old newborn", "brought", "physician", "of", "generalized rash", "1 day", "born", "term", "history", "gonorrhea", "treated 4 years", "newborn", "50th percentile", "head circumference", "percentile", "length", "percentile", "weight", "temperature", "36", "98", "pulse", "min", "respirations", "min", "erythematous maculopapular rash", "pustules", "erythematous base", "trunk", "extremities", "soles", "abnormalities", "following", "diagnosis"]}
{"question": "A hospitalized 45-year-old man has had mild flank pain since awakening 3 hours ago. He also reports a new generalized rash. Two weeks ago, he was diagnosed with pulmonary tuberculosis. Current medications include isoniazid, pyrazinamide, rifampin, ethambutol, and pyridoxine. His temperature is 38.3°C (100.9°F), pulse is 74/min, and blood pressure is 128/72 mm Hg. Examination of the skin shows diffuse erythema with confluent papules. There is no costovertebral angle tenderness. Laboratory studies show:\nLeukocyte count 9,800/mm3\nSegmented neutrophils 59%\nBands 3%\nEosinophils 4%\nLymphocytes 29%\nMonocytes 5%\nSerum\nUrea nitrogen 25 mg/dL\nCreatinine 1.9 mg/dL\nUrine\nWBC 8–10/hpf\nEosinophils numerous\nRBC 5–6/hpf\nRBC casts negative\nWBC casts numerous\nIn addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in management?\"", "answer": "Discontinue rifampin", "options": {"A": "Initiate hemodialysis", "B": "Administer ciprofloxacin", "C": "Discontinue rifampin", "D": "Perform serum protein electrophoresis", "E": "Perform renal biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["hospitalized", "year old man", "mild flank", "awakening 3 hours", "reports", "new generalized rash", "Two weeks", "diagnosed", "pulmonary tuberculosis", "Current medications include isoniazid", "pyrazinamide", "rifampin", "ethambutol", "pyridoxine", "temperature", "100 9F", "pulse", "74 min", "blood pressure", "72 mm Hg", "Examination of", "skin", "diffuse erythema", "confluent papules", "costovertebral angle tenderness", "Laboratory studies", "Leukocyte count", "800 mm3 Segmented neutrophils 59", "Bands", "Eosinophils 4", "29", "mg/dL", "WBC", "hpf", "numerous RBC", "casts negative WBC casts numerous In addition to intravenous fluid resuscitation", "following", "most appropriate next step"]}
{"question": "A 26-year-old woman comes to the emergency department with fever, abdominal pain, and nausea for the past 7 hours. The pain started in the right lower abdomen but has now progressed to diffuse abdominal pain. Her temperature is 39.5°C (103.1°F). Physical examination shows generalized abdominal tenderness with rebound, guarding, and decreased bowel sounds. She is taken for an emergency exploratory laparoscopy, which shows a perforated appendix with an adjacent abscess and peritoneal inflammation. Cultures from the abscess fluid grow catalase-producing, anaerobic, gram-negative rods that have the ability to grow in bile. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Ampicillin and sulbactam", "options": {"A": "Vancomycin and azithromycin", "B": "Piperacillin", "C": "Cefazolin and doxycycline", "D": "Ampicillin and sulbactam", "E": "Aztreonam"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "emergency department", "fever", "abdominal pain", "nausea", "past", "hours", "pain started", "right lower abdomen", "now progressed to diffuse abdominal pain", "temperature", "generalized abdominal tenderness", "guarding", "decreased bowel sounds", "emergency exploratory laparoscopy", "perforated", "adjacent abscess", "peritoneal inflammation", "Cultures", "abscess fluid", "catalase", "anaerobic", "ability to", "bile", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 67-year-old male presents to his primary care physician for evaluation of fever and an unintended weight loss of 25 pounds over the last 4 months. He also has decreased appetite and complains of abdominal pain located in the right upper quadrant. The patient has not noticed any changes in stool or urine. He emigrated from Malaysia to the United States one year prior. Social history reveals that he smokes half a pack per day and has 5-7 drinks of alcohol per day. The patient is up to date on all of his vaccinations. Physical exam findings include mild jaundice as well as an enlarged liver edge that is tender to palpation. Based on clinical suspicion, biomarker labs are sent and show polycythemia and an elevated alpha fetoprotein level but a normal CA 19-9 level. Surface antigen for hepatitis B is negative. Ultrasound reveals a normal sized gallbladder. Given this presentation, which of the following organisms was most likely associated with the development of disease in this patient?", "answer": "Acute angle branching fungus", "options": {"A": "Acute angle branching fungus", "B": "Curved gram-negative bacteria", "C": "Enveloped DNA virus", "D": "Naked DNA virus", "E": "Trematode from undercooked fish"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old male presents", "primary care physician", "fever", "unintended weight loss of 25 pounds", "last", "months", "decreased appetite", "abdominal pain", "right upper quadrant", "patient", "not", "changes in stool", "urine", "Malaysia", "United States one year prior", "Social history reveals", "smokes half", "pack", "day", "5", "day", "patient", "date", "of", "vaccinations", "Physical exam findings include mild jaundice", "enlarged", "tender", "palpation", "Based", "clinical", "biomarker labs", "sent", "polycythemia", "elevated", "normal CA 19-9 level", "Surface antigen", "hepatitis B", "negative", "Ultrasound reveals", "normal sized gallbladder", "Given", "following", "most likely associated with", "development", "disease", "patient"]}
{"question": "A 24-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained driver. On arrival, he is alert and oriented. His pulse is 112/min, respirations are 29/min, and blood pressure is 100/60 mm Hg. The pupils are equal and reactive to light. There is a 3-cm laceration over the forehead and multiple bruises over the trunk. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The right knee is swollen and tender; range of motion is limited by pain. Infusion of 0.9% saline is begun and intravenous acetaminophen is administered. Two hours later, blood-tinged fluid spontaneously drains from both nostrils, and is made worse by leaning forward. On a piece of gauze, it shows up as a rapidly-expanding clear ring of fluid surrounding blood. Further evaluation of this patient is most likely to show which of the following?", "answer": "Bilateral periorbital ecchymosis", "options": {"A": "Cranial nerve XII palsy", "B": "Bilateral periorbital ecchymosis", "C": "Numbness of upper cheek area", "D": "Carotid artery dissection", "E": "Retroauricular ecchymosis\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department 30 minutes", "involved", "high speed motor vehicle collision", "restrained driver", "arrival", "alert", "oriented", "pulse", "min", "respirations", "29 min", "blood pressure", "100 60 mm Hg", "pupils", "equal", "reactive to light", "3", "laceration", "forehead", "multiple bruises", "trunk", "lungs", "clear", "auscultation", "Cardiac examination", "abnormalities", "abdomen", "soft", "nontender", "right knee", "swollen", "tender", "range of motion", "limited", "pain", "Infusion", "0.9", "saline", "begun", "intravenous acetaminophen", "administered", "Two hours later", "blood-tinged fluid", "drains", "nostrils", "made worse", "forward", "piece", "gauze", "rapidly expanding", "ring", "surrounding blood", "Further evaluation", "patient", "to", "following"]}
{"question": "A 30-year-old man comes to the physician after receiving a high blood pressure reading of 160/90 mm Hg at an annual employee health check-up. During the past few months, the patient has had occasional headaches and mild abdominal pain, both of which were relieved with ibuprofen. He has also had several episodes of heart palpitations. He has no history of serious illness. His mother and father both have hypertension. He has smoked one pack of cigarettes daily for the past 10 years and drinks one glass of wine daily. He occasionally smokes marijuana. He appears pale. His temperature is 36.8°C (98.2°F), pulse is 103/min, and blood pressure is 164/102 mm Hg. Physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 15.3 g/dL\nLeukocyte count 7,900/mm3\nPlatelet count 223,000/mm3\nSerum\nNa+ 138 mEq/L\nK+ 4.6 mEq/L\nCl- 103 mEq/L\nUrea nitrogen 14 mg/dL\nGlucose 90 mg/dL\nCreatinine 0.9 mg/dL\nPlasma metanephrines 1.2 nmol/L (N < 0.5 nmol/L)\nUrine toxicology screening is positive for tetrahydrocannabinol (THC). Renal doppler shows no abnormalities. A CT scan of the abdomen shows a mass in the left adrenal gland. Which of the following is the most appropriate next step in management of this patient?\"", "answer": "Phenoxybenzamine", "options": {"A": "MIBG therapy", "B": "Phenoxybenzamine", "C": "Resection of adrenal mass", "D": "Propranolol", "E": "Metoprolol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old man", "physician", "receiving", "high blood pressure", "90 mm Hg", "annual", "check-up", "past", "months", "patient", "occasional headaches", "mild abdominal", "relieved", "ibuprofen", "several episodes of heart palpitations", "history", "serious illness", "hypertension", "smoked one pack", "cigarettes daily", "past", "one glass", "daily", "occasionally smokes marijuana", "appears pale", "temperature", "36", "98", "pulse", "min", "blood pressure", "mm Hg", "abnormalities", "Laboratory studies", "Hemoglobin", "Leukocyte 7", "Platelet count", "Serum Na", "L K", "Cl", "Urea", "mg", "mg", "Creatinine 0", "Plasma", "1 2", "N", "0.5 nmol L", "Urine toxicology", "positive", "tetrahydrocannabinol", "Renal doppler", "abnormalities", "CT scan", "abdomen", "mass", "left", "following", "most appropriate next step", "patient"]}
{"question": "A 35-year-old man is brought to the emergency department 40 minutes after spilling hot oil over himself in a kitchen accident. Examination shows multiple tense blisters over the abdomen, anterior chest, and anterior and posterior aspects of the right upper extremity and right thigh. On deroofing the blisters, the skin underneath is tender, mottled, and does not blanch with pressure. The skin over the left thigh is tender, erythematous, and shows quick capillary refill after blanching with pressure. Which of the following most closely approximates the body surface area affected by 2nd-degree burns in this patient?", "answer": "36%", "options": {"A": "9%", "B": "18%", "C": "45%", "D": "54%", "E": "36%"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old man", "brought", "emergency department 40 minutes", "spilling hot oil", "kitchen", "multiple tense blisters", "abdomen", "anterior chest", "anterior", "posterior aspects", "right upper extremity", "right thigh", "blisters", "skin", "tender", "mottled", "not blanch", "pressure", "skin", "left thigh", "tender", "erythematous", "quick capillary refill", "blanching", "pressure", "following most", "approximates", "body surface area affected", "2nd degree burns", "patient"]}
{"question": "A 36-year-old man is brought to the emergency department by his girlfriend because of increasing confusion for the past 6 hours. He drinks large amounts of alcohol daily and occasionally uses illicit drugs. He is lethargic and oriented only to person. Physical examination shows jaundice, hepatomegaly, and scattered petechiae over the trunk and back. Neurologic examination shows normal, reactive pupils and a flapping tremor when the wrists are extended. A drug with which of the following mechanism of action would be most appropriate for this patient's condition?", "answer": "Excretion of NH4", "options": {"A": "Inhibition of D2 receptors", "B": "Excretion of NH4", "C": "Excretion of free iron", "D": "Activation of GABA receptors", "E": "Production of NH3"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["36 year old man", "brought", "emergency department", "increasing confusion", "past", "hours", "large amounts", "alcohol daily", "occasionally uses illicit drugs", "lethargic", "oriented only", "jaundice", "hepatomegaly", "scattered petechiae", "trunk", "back", "Neurologic examination", "normal", "reactive pupils", "flapping tremor", "wrists", "extended", "drug", "of", "following mechanism", "action", "most appropriate", "patient's condition"]}
{"question": "A 48-year-old homeless male presents to the ED because he hasn’t felt well recently. He states that he has been feeling nauseous and extremely weak over the past few days. He has several previous admissions for alcohol intoxication and uses heroin occasionally. His temperature is 100.9°F (38.3°C), blood pressure is 127/89 mmHg, and pulse is 101/min. His physical examination is notable for palmar erythema, tender hepatomegaly, and gynecomastia. His laboratory findings are notable for:\n\nAST: 170 U/L\nALT: 60 U/L\nGGT: 400 (normal range: 0-45 U/L)\nAlkaline phosphatase: 150 IU/L\nDirect bilirubin: 0.2 mg/dL\nTotal bilirubin: 0.8 mg/dL\nWBC: 10,500\nSerum iron: 100 µg/dL\nTIBC: 300 µg/dL (normal range: 250–370 µg/dL)\nSerum acetaminophen screen: Negative\nSerum AFP: 6 ng/mL (normal range: < 10ng/mL)\n\nWhich of the following is the most likely cause of this patient’s symptoms?", "answer": "Alcoholic hepatitis", "options": {"A": "Acute cholangitis", "B": "Hepatocellular carcinoma", "C": "Alcoholic hepatitis", "D": "Acute viral hepatitis", "E": "Hereditary hemochromatosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["48 year old homeless male presents", "hasnt", "well recently", "states", "nauseous", "extremely weak", "past", "days", "several previous", "alcohol intoxication", "uses heroin occasionally", "temperature", "100 9F", "blood pressure", "mmHg", "pulse", "min", "notable", "palmar erythema", "tender hepatomegaly", "gynecomastia", "laboratory findings", "notable", "AST", "U/L ALT", "60 U/L GGT", "400", "normal range", "0-45 U/L", "Alkaline phosphatase", "IU/L Direct bilirubin", "0.2 mg/dL Total bilirubin", "0.8 mg/dL WBC", "10 500 Serum iron", "100 g/dL TIBC", "300 g/dL", "normal range", "g/dL", "Serum acetaminophen screen", "Negative Serum", "ng/mL", "normal range", "mL", "following", "most likely cause", "patients symptoms"]}
{"question": "A 23-year-old woman presents to your office for a gynecological exam. She says that she has been in good health and has no complaints. She has been in a steady monogamous relationship for the past year. Physical examination was unremarkable. Screening tests are performed and return positive for gonorrhea. You treat her with an intramuscular injection of ceftriaxone and 7 day course of doxycycline. What else is recommended for this case?", "answer": "Treat her partner for gonorrhea and chlamydia", "options": {"A": "Treatment with penicillin G for potential co-infection with syphilis", "B": "Treat her partner for gonorrhea and chlamydia", "C": "Recheck her in 1 week for gonorrhea and chlamydia", "D": "Inform her that her partner is likely cheating on her", "E": "Perform an abdominal ultrasonography in order to rule out pelvic inflammatory disease"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman presents", "office", "complaints", "steady", "relationship", "past year", "unremarkable", "performed", "return positive", "gonorrhea", "treat", "intramuscular", "ceftriaxone", "7 day course", "doxycycline", "else", "case"]}
{"question": "A 63-year-old man with high blood pressure, dyslipidemia, and diabetes presents to the clinic for routine follow-up. He has no current complaints and has been compliant with his chronic medications. His blood pressure is 132/87 mm Hg and his pulse is 75/min and regular. On physical examination, you notice that he has xanthelasmas on both of his eyelids. He currently uses a statin to lower his LDL but has not reached the LDL goal you have set for him. You would like to add an additional medication for LDL control. Of the following, which statement regarding fibrates is true?", "answer": "Fibrates can potentiate the risk of myositis when given with statins", "options": {"A": "The primary effect of fibrates is to lower LDL", "B": "Fibrates can cause significant skin flushing and pruritus", "C": "Fibrates can potentiate the risk of myositis when given with statins", "D": "Fibrates can increase the risk of cataracts", "E": "Fibrates inhibit the rate-limiting step in cholesterol synthesis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["63 year old man", "high blood pressure", "dyslipidemia", "diabetes presents", "clinic", "routine follow-up", "current complaints", "compliant", "chronic medications", "blood pressure", "87 mm Hg", "pulse", "75 min", "regular", "xanthelasmas", "of", "eyelids", "currently uses", "statin to lower", "not reached", "set", "to add", "additional", "following", "fibrates", "true"]}
{"question": "A 61-year-old woman comes to the physician for a follow-up examination 1 week after undergoing right-sided radical mastectomy and axillary lymph node dissection for breast cancer. She says that she has been unable to comb her hair with her right hand since the surgery. Physical examination shows shoulder asymmetry. She is unable to abduct her right arm above 90 degrees. When she pushes against a wall, there is protrusion of the medial aspect of the right scapula. Injury to which of the following nerves is the most likely cause of this patient's condition?", "answer": "Long thoracic nerve", "options": {"A": "Upper trunk of the brachial plexus", "B": "Axillary nerve", "C": "Long thoracic nerve", "D": "Suprascapular nerve", "E": "Thoracodorsal nerve"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["61 year old woman", "physician", "follow-up", "1 week", "right sided radical mastectomy", "axillary lymph node dissection", "breast cancer", "unable to comb", "hair", "right hand", "surgery", "shoulder asymmetry", "unable to", "right arm", "90 degrees", "pushes", "wall", "protrusion", "medial aspect", "right scapula", "Injury", "following nerves", "most likely cause", "patient's condition"]}
{"question": "A 53-year-old woman comes to the physician because of intermittent heaviness and paresthesia of the right arm for the past 2 months. She has also had multiple episodes of lightheadedness while painting a mural for the past 2 weeks. During these episodes, she was nauseated and had blurred vision. Her symptoms resolved after she drank some juice. She has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Current medications include metformin, glipizide, enalapril, and atorvastatin. She appears anxious. Examination shows decreased radial and brachial pulses on the right upper extremity. The skin over the right upper extremity is cooler than the left. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Reversed blood flow in the right vertebral artery", "options": {"A": "Adverse effect of medications", "B": "Reversed blood flow in the right vertebral artery", "C": "Non-enzymatic glycosylation of peripheral nerve", "D": "Compression of neurovascular structures in the neck", "E": "Infarction of the middle cerebral artery"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "intermittent heaviness", "paresthesia of", "right arm", "past", "months", "multiple episodes of lightheadedness", "painting", "mural", "past 2 weeks", "episodes", "nauseated", "blurred vision", "symptoms resolved", "hypertension", "type 2 diabetes mellitus", "hypercholesterolemia", "Current medications include metformin", "glipizide", "enalapril", "atorvastatin", "appears anxious", "decreased", "brachial pulses", "right upper extremity", "skin", "right", "cooler", "left", "Cardiopulmonary", "abnormalities", "Neurologic examination", "focal findings", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 31-year-old physician notices that her senior colleague has been arriving late for work for the past 2 weeks. The colleague recently lost his wife to cancer and has been taking care of his 4 young children. Following the death of his wife, the department chair offered him extended time off, but he declined. Resident physicians have noted and discussed some recent changes in this colleague, such as missed clinic appointments, 2 intra-operative errors, and the smell of alcohol on his breath on 3 different occasions. Which of the following is the most appropriate action by the physician regarding her colleague?", "answer": "Inform the local Physician Health Program", "options": {"A": "Advise resident physicians to report future misconduct to the department chair", "B": "Alert the State Licensing Board", "C": "Confront the colleague in private", "D": "Contact the colleague's friends and family", "E": "Inform the local Physician Health Program"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["31 year old physician", "late", "past 2 weeks", "recently lost", "cancer", "young", "Following", "death", "chair offered", "extended time", "Resident physicians", "noted", "recent changes", "missed clinic appointments", "2 intra-operative errors", "smell", "alcohol", "breath", "different occasions", "following", "most appropriate action", "physician"]}
{"question": "A 42-year-old woman comes to the physician because of a 10-month history of joint pain and stiffness in her wrists and fingers. The symptoms are worse in the morning and improve with activity. Physical examination shows swelling and warmth over the MCP and wrist joints in both hands. An x-ray of the hands is shown. Synovial biopsy from an affected joint would most likely show which of the following?", "answer": "Proliferation of granulation tissue", "options": {"A": "Noninflammatory superficial fibrin deposits", "B": "Monosodium urate crystals", "C": "Calcium pyrophosphate crystals", "D": "Noncaseating granulomas", "E": "Proliferation of granulation tissue"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "a 10 month history", "joint pain", "stiffness", "wrists", "fingers", "symptoms", "worse", "morning", "swelling", "warmth", "MCP", "wrist joints", "hands", "x-ray", "hands", "Synovial", "affected joint", "most likely", "following"]}
{"question": "A 26-year-old female presents to your office due to one week of “feeling unwell.” She complains of a headache and non-productive cough over the last several days, which have both worsened today. She does not have any history of serious infection and is not currently taking any medication. On physical exam, her temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 98% on room air. She has diffuse rhonchi bilaterally. You decide to order a chest radiograph, shown in image A. The pathogen responsible for her current presentation most likely belongs to which of the following categories?", "answer": "Non-gram staining bacteria", "options": {"A": "Gram-positive organism", "B": "Gram-negative organism", "C": "Non-gram staining bacteria", "D": "DNA virus", "E": "RNA virus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female presents", "office due to one week", "unwell", "headache", "non-productive cough", "days", "worsened today", "not", "history", "serious infection", "not currently", "medication", "temperature", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "pulse oximetry", "98", "room air", "diffuse rhonchi", "to order", "chest radiograph", "responsible", "current", "likely", "following"]}
{"question": "A 61-year-old man comes to the physician because of several episodes of dark urine over the past 2 weeks. He does not have dysuria or flank pain. He works in a factory that produces dyes. Since an accident at work 5 years ago, he has had moderate hearing loss bilaterally. He takes no medications. He has smoked a pack of cigarettes daily for 29 years and drinks one alcoholic beverage daily. Vital signs are within normal limits. Physical examination shows no abnormalities. His urine is pink; urinalysis shows 80 RBC/hpf but no WBCs. Cystoscopy shows a 3-cm mass in the bladder mucosa. The mass is resected. Pathologic examination shows an urothelial carcinoma with penetration into the muscular layer. An x-ray of the chest and a CT scan of the abdomen and pelvis with contrast show a normal upper urinary tract and normal lymph nodes. Which of the following is the most appropriate next step in management?", "answer": "Radical cystectomy", "options": {"A": "Transurethral resection of tumor with intravesical chemotherapy", "B": "Radiation therapy", "C": "Transurethral resection of tumor with intravesical BCG instillation", "D": "Radical cystectomy", "E": "Palliative polychemotherapy\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["61 year old man", "physician", "of several episodes", "dark urine", "past 2 weeks", "not", "dysuria", "flank pain", "factory", "dyes", "accident at work", "years", "moderate hearing loss", "medications", "smoked", "pack", "cigarettes daily", "29 years", "one", "daily", "Vital signs", "normal", "Physical examination", "abnormalities", "urine", "pink", "urinalysis", "80 RBC/hpf", "WBCs", "Cystoscopy", "3", "mass", "bladder", "mass", "resected", "Pathologic examination", "urothelial carcinoma", "penetration", "muscular layer", "x-ray of", "chest", "CT scan", "abdomen", "pelvis", "contrast", "normal upper urinary tract", "normal lymph nodes", "following", "most appropriate next step"]}
{"question": "An 8-year-old boy is brought to the physician by his parents because of fever for 3 days. During the period, he has had fatigue, severe burning with urination, and increased urination. The mother reports that his urine has red streaks and a “strange” odor. He has taken acetaminophen twice a day for the past two days with no improvement in his symptoms. He has had multiple ear infections in the past but has been healthy in the past year. His immunizations are up-to-date. He appears uncomfortable. His temperature is 39°C (102.2°F). Examination shows right-sided costovertebral angle tenderness. Laboratory studies show a leukocyte count of 16,000/cm3 and an erythrocyte sedimentation rate of 40 mm/hr. Urine dipstick shows leukocyte esterase and nitrites. Urinalysis shows:\nBlood 2+\nProtein 2+\nWBC 24/hpf\nRBC 50/hpf\nRBC casts none\nWBC casts numerous\nGranular casts none\nUrine cultures are sent to the laboratory. Damage to which of the following structures is the most likely cause of this patient's hematuria?\"", "answer": "Renal papilla", "options": {"A": "Renal tubules", "B": "Renal papilla", "C": "Urethral epithelium", "D": "Renal interstitium", "E": "Mucosa of the bladder\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "fever", "3 days", "period", "fatigue", "severe burning", "urination", "increased urination", "reports", "urine", "red", "acetaminophen twice a day", "past two days", "symptoms", "multiple ear infections", "past", "healthy", "past year", "immunizations", "date", "appears", "temperature", "right-sided costovertebral angle tenderness", "Laboratory studies", "leukocyte count", "cm3", "erythrocyte sedimentation rate", "40 mm", "Urine dipstick", "leukocyte esterase", "Urinalysis", "Blood", "Protein", "WBC", "hpf", "50", "casts", "WBC casts numerous Granular casts", "Urine cultures", "sent", "laboratory", "Damage", "following structures", "most likely cause", "patient", "ematuria?"]}
{"question": "A 27-year-old woman presents to her primary care physician for a concern about her pregnancy. This is her first pregnancy, and she is currently at 33 weeks gestation. She states that she has experienced diffuse swelling of her ankles and legs and is concerned that it is abnormal. Otherwise, she has no concerns. The patient has a past medical history of obesity and diabetes. Her temperature is 98.5°F (36.9°C), blood pressure is 147/92 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam reveals bilateral edema of the lower extremities. Which of the following is the best next step in management?", "answer": "Spot protein to creatinine ratio", "options": {"A": "A 24 hour urine protein", "B": "Echocardiography", "C": "Reassurance and followup in 1 week", "D": "Spot protein to creatinine ratio", "E": "Urinalysis and urine protein"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old woman presents", "primary care physician", "pregnancy", "first pregnancy", "currently", "weeks gestation", "states", "diffuse swelling", "ankles", "legs", "abnormal", "patient", "past medical", "diabetes", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "97", "room air", "reveals bilateral edema of", "lower extremities", "following", "best next step"]}
{"question": "A 72-year-old woman is brought to the emergency department with fever, myalgia, and cough for 3 days. She lives in an assisted living facility and several of her neighbors have had similar symptoms. She has hypertension treated with lisinopril. She has not been vaccinated against influenza. Her temperature is 38.9°C (102.2°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/62 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Her leukocyte count is 10,500/mm3, serum creatinine is 0.9 mg/dL, and serum procalcitonin level is 0.05 μg/L (N < 0.06). An x-ray of the chest shows reticulonodular opacities in the lower lobes bilaterally. Blood and sputum cultures are negative. The patient is admitted to the hospital and empirical treatment with ceftriaxone and azithromycin is begun. Two days after admission, her temperature is 37.6°C (99.7°F) and pulse oximetry shows an oxygen saturation of 96% on room air. Her serum procalcitonin level is 0.04 μg/L. Which of the following is the most appropriate next step in management?", "answer": "Discontinue ceftriaxone and azithromycin", "options": {"A": "Start treatment with oseltamivir", "B": "Discontinue ceftriaxone and azithromycin", "C": "Discontinue ceftriaxone and continue azithromycin to complete 7-day course", "D": "Repeat sputum culture", "E": "Repeat x-ray of the chest\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "fever", "myalgia", "cough", "3 days", "lives in", "assisted living facility", "several", "similar symptoms", "hypertension treated with lisinopril", "not", "vaccinated", "influenza", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "62 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "leukocyte count", "10 500 mm3", "serum creatinine", "0.9 mg/dL", "serum procalcitonin level", "0.05 g/L", "N", "0.06", "x-ray of", "chest", "opacities", "lower lobes", "Blood", "sputum cultures", "negative", "patient", "empirical treatment", "ceftriaxone", "azithromycin", "begun", "Two days", "temperature", "99", "pulse oximetry", "oxygen saturation", "96", "room air", "serum procalcitonin level", "0.04 g/L", "following", "most appropriate next step"]}
{"question": "A 32-year-old male presents presents for a new patient visit. He states that he is in good health but has had decreasing exercise tolerance and increased levels of shortness of breath over the past 5 years. He believed that it was due to aging; he has not seen a doctor in 10 years. On auscultation, you note an early diastolic decrescendo blowing murmur that radiates along the left sternal border. In the United States, what is the most likely cause of this patient's condition?", "answer": "Congenital bicuspid aortic valve", "options": {"A": "Rheumatic heart disease", "B": "Syphilis", "C": "Connective tissue disease", "D": "Myxomatous degeneration", "E": "Congenital bicuspid aortic valve"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old male presents presents", "new", "states", "decreasing exercise tolerance", "increased levels of shortness", "breath", "past", "years", "due to aging", "not seen", "doctor", "auscultation", "note", "early diastolic", "blowing murmur", "radiates", "left sternal border", "United States", "most likely cause", "patient's condition"]}
{"question": "A 56-year-old woman presents to the emergency department with several episodes in which she felt \"dizzy.\" She has had these symptoms on and off for the past year and can recall no clear exacerbating factor or time of day when her symptoms occur. She has a perpetual sensation of fullness in her ear but otherwise has no symptoms currently. Her temperature is 97.6°F (36.4°C), blood pressure is 122/77 mmHg, pulse is 85/min, respirations are 13/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is unremarkable. The patient's gait is stable. Which of the following is also likely to be found in this patient?", "answer": "Sensorineural hearing loss", "options": {"A": "Conductive hearing loss", "B": "Gradually improving symptoms", "C": "Positional vertigo", "D": "Sensorineural hearing loss", "E": "Vertical nystagmus"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "several episodes", "dizzy", "symptoms", "past year", "clear exacerbating factor", "time of day", "symptoms occur", "sensation", "fullness", "ear", "symptoms currently", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "85 min", "respirations", "min", "oxygen saturation", "98", "room air", "Cardiopulmonary exam", "unremarkable", "patient", "ait ", "table.", "ollowing ", "ikely  o ", "ound ", "atient?"]}
{"question": "A 3-year-old recent immigrant is diagnosed with primary tuberculosis. Her body produces T cells that do not have IL-12 receptors on their surface, and she is noted to have impaired development of Th1 T-helper cells. Which of the following cytokines would benefit this patient?", "answer": "Interferon-gamma", "options": {"A": "IL-4", "B": "IL-17", "C": "IL-22", "D": "Interferon-gamma", "E": "TGF-beta"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["3 year old recent immigrant", "diagnosed", "primary tuberculosis", "body", "not", "IL-12 receptors", "surface", "noted to", "impaired development", "Th1 T-helper cells", "following cytokines", "benefit", "patient"]}
{"question": "A 33-year-old woman presents to the emergency department with weakness. She states that at the end of the day she feels so fatigued and weak that she can hardly care for herself. She currently feels this way. The patient has had multiple illnesses recently and has been traveling, hiking, and camping. Her temperature is 98.0°F (36.7°C), blood pressure is 124/84 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for 2/5 strength of the upper extremities and 4/5 strength of the lower extremities. Visual exam is notable for mild diplopia. Which of the following is the most likely diagnosis?", "answer": "Myasthenia gravis", "options": {"A": "Amyotrophic lateral sclerosis", "B": "Guillain-Barre syndrome", "C": "Lambert-Eaton syndrome", "D": "Myasthenia gravis", "E": "Tick paralysis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "weakness", "states", "end", "day", "so fatigued", "weak", "currently", "patient", "multiple illnesses recently", "temperature", "98", "36", "blood pressure", "84 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "strength", "upper extremities", "4/5 strength of", "lower extremities", "Visual exam", "notable", "mild diplopia", "following", "diagnosis"]}
{"question": "A 35-year-old patient with no significant past medical history arrives to the ED with abdominal cramps, nausea, and vomiting. He has had no recent travel or chemical exposures; however, three other members of his family also arrived concurrently to the ED with abdominal cramps, nausea, and vomiting. When asked about their recent activities, they recall that they had shared a lunch of leftover fried rice and soft boiled eggs about 5 hours earlier. The patients are otherwise afebrile and deny any history of diarrhea. Which of the following toxins is the most likely to have caused these symptoms?", "answer": "Cereulide", "options": {"A": "Exotoxin A", "B": "Cereulide", "C": "Toxin B", "D": "Shiga toxin", "E": "Endotoxin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old patient", "significant past", "abdominal cramps", "nausea", "vomiting", "recent", "chemical exposures", "three", "abdominal cramps", "nausea", "vomiting", "recent", "shared", "lunch", "fried rice", "soft", "hours earlier", "patients", "afebrile", "history", "diarrhea", "following toxins", "to", "caused", "symptoms"]}
{"question": "Please refer to the summary above to answer this question\nWhich of the following is the most likely diagnosis?\"\n\"Patient Information\nAge: 66 years\nGender: M, self-identified\nEthnicity: African-American\nSite of Care: office\nHistory\nReason for Visit/Chief Concern: “I need to go to the bathroom all the time.”\nHistory of Present Illness:\n1-year history of frequent urination\nurinates every 2–3 hours during the day and wakes up at least 3 times at night to urinate\nhas had 2 episodes of cystitis treated with antibiotics in the past 4 months\nhas a weak urinary stream\nhas not noticed any blood in the urine\ndoes not have any pain with urination or ejaculatory dysfunction\nPast Medical History:\ntype 2 diabetes mellitus\nnephrolithiasis, treated with percutaneous nephrolithotomy\nessential tremor\nMedications:\nmetformin, canagliflozin, propranolol\nAllergies:\nsulfa drugs\nSocial History:\nsexually active with his wife; does not use condoms consistently\nhas smoked one pack of cigarettes daily for 50 years\ndrinks one to two glasses of beer weekly\nPhysical Examination\nTemp Pulse Resp BP O2 Sat Ht Wt BMI\n37°C\n(98.6°F)\n72/min 16/min 134/81 mm Hg –\n183 cm\n(6 ft)\n105 kg\n(231 lb)\n31 kg/m2\nAppearance: no acute distress\nPulmonary: clear to auscultation\nCardiac: regular rate and rhythm; normal S1, S2; S4 gallop\nAbdominal: overweight; no tenderness, guarding, masses, bruits, or hepatosplenomegaly\nExtremities: no joint erythema, edema, or warmth; dorsalis pedis, radial, and femoral pulses intact\nGenitourinary: no lesions or discharge\nRectal: slightly enlarged, smooth, nontender prostate\nNeurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits\"", "answer": "Benign prostatic hyperplasia", "options": {"A": "Neurogenic bladder", "B": "Acute prostatitis", "C": "Prostate cancer", "D": "Urethral stricture", "E": "Benign prostatic hyperplasia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["refer", "above to", "following", "diagnosis", "Patient Age", "66 years Gender", "M", "identified Ethnicity", "Site of Care", "office History Reason for Visit", "I need to go", "bathroom", "time", "History of Present Illness", "1 year history of frequent urination", "23 hours", "day", "wakes up", "times", "night to", "2 episodes of cystitis treated with", "past", "months", "weak urinary stream", "not", "blood in", "urine", "not", "pain", "urination", "ejaculatory dysfunction Past Medical History", "type 2 diabetes mellitus nephrolithiasis", "treated with percutaneous nephrolithotomy essential Medications", "metformin", "canagliflozin", "propranolol Allergies", "sulfa drugs Social History", "sexually active", "not use condoms", "smoked one pack", "cigarettes daily", "50 years", "one", "two glasses of", "weekly Physical Examination Temp Pulse Resp BP O2 Sat Ht Wt BMI", "98", "72 min", "81 mm Hg", "ft", "kg", "31 kg/m2 Appearance", "acute distress Pulmonary", "clear to auscultation Cardiac", "regular rate", "rhythm", "normal S1", "S2", "S4", "Abdominal", "overweight", "tenderness", "guarding", "masses", "bruits", "hepatosplenomegaly Extremities", "joint erythema", "edema", "warmth", "femoral pulses intact Genitourinary", "lesions", "discharge Rectal", "slightly enlarged", "smooth", "nontender prostate Neurologic", "alert", "oriented", "cranial nerves", "intact", "focal neurologic deficits"]}
{"question": "A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?", "answer": "Chorionic villi attaching to the myometrium", "options": {"A": "Chorionic villi attaching to the decidua basalis", "B": "Chorionic villi attaching to the myometrium", "C": "Chorionic villi invading into the myometrium", "D": "Chorionic villi invading into the serosa", "E": "Placental implantation over internal cervical os"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["29 year old", "female gives birth", "healthy baby boy", "weeks of gestation", "vaginal delivery", "Immediately", "of", "placenta", "vaginal hemorrhage", "prior", "history", "notable", "emergency cesarean section", "first pregnancy", "not receive", "prenatal", "pregnancy", "past medical history", "notable", "obesity", "diabetes mellitus", "well controlled", "metformin", "temperature", "99", "blood pressure", "95 50 mmHg", "pulse", "min", "respirations", "min", "patient", "moderate distress", "extremities", "pale", "cool", "clammy", "Capillary refill", "delayed", "following", "most likely cause", "patients bleeding"]}
{"question": "A 35-year-old woman is started on a new experimental intravenous drug X. In order to make sure that she is able to take this drug safely, the physician in charge of her care calculates the appropriate doses to give to this patient. Data on the properties of drug X from a subject with a similar body composition to the patient is provided below:\n\nWeight: 100 kg\nDose provided: 1500 mg\nSerum concentration 15 mg/dL\nBioavailability: 1\n\nIf the patient has a weight of 60 kg and the target serum concentration is 10 mg/dL, which of the following best represents the loading dose of drug X that should be given to this patient?", "answer": "600 mg", "options": {"A": "150 mg", "B": "300mg", "C": "450 mg", "D": "600 mg", "E": "1000 mg"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "started", "new experimental intravenous", "order to make sure", "able to", "drug", "physician", "charge", "appropriate doses to give", "patient", "drug", "subject", "similar body composition", "patient", "Weight", "100 kg Dose", "1500 mg Serum concentration", "dL Bioavailability", "1", "patient", "weight", "60 kg", "target serum concentration", "10 mg/dL", "following best", "loading dose", "drug", "given", "patient"]}
{"question": "A 4-year-old Caucasian boy is brought by his mother to the pediatrician with a red and swollen elbow. He was playing outside a few days prior to presentation when he fell and lightly scraped his elbow on the sidewalk. He was born at 34 weeks’ gestation and was in the neonatal ICU for 2 days. He has a history of easy bruising and bleeding gums. His temperature is 102.1°F (38.9°C), blood pressure is 105/65 mmHg, pulse is 110/min, and respirations are 20/min. On exam, he has a swollen, erythematous, fluctuant, and exquisitely tender mass on his right elbow. There is expressible purulence coming from his wound. A peripheral blood smear in this patient would most likely reveal which of the following findings?", "answer": "Neutrophils with abundant peroxidase-positive granules", "options": {"A": "Absence of dark blue cytoplasmic staining upon nitroblue tetrazolium administration", "B": "Macrocytic erythrocytes and acanthocytes", "C": "Neutrophils with abundant peroxidase-positive granules", "D": "Neutrophils with peroxidase-negative granules", "E": "Neutrophils with pale cytoplasm without granules"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old", "boy", "brought", "pediatrician", "red", "swollen elbow", "playing outside", "few days prior to", "fell", "lightly scraped", "elbow", "sidewalk", "born", "weeks gestation", "neonatal ICU", "2 days", "history", "easy bruising", "bleeding gums", "temperature", "blood pressure", "65 mmHg", "pulse", "min", "respirations", "20 min", "exam", "swollen", "erythematous", "fluctuant", "tender mass", "right elbow", "purulence", "wound", "peripheral blood smear", "patient", "most likely reveal", "following findings"]}
{"question": "A 16-year-old boy is brought to the physician because of a lesion that has been growing on his jaw over the past several months. He recently immigrated to the USA from Kenya with his family. Physical examination shows a 3-cm solid mass located above the left mandible. There is cervical lymphadenopathy. Biopsy of the mass shows sheets of lymphocytes and interspersed reactive histiocytes with abundant, clear cytoplasm and phagocytosed debris. Which of the following mechanisms is most likely directly responsible for the malignant transformation of this patient's cells?", "answer": "Activation of transcription", "options": {"A": "Activation of transcription", "B": "Defect in DNA repair", "C": "Impairment of receptor function", "D": "Inhibition of cell cycle arrest", "E": "Integration of viral DNA\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "lesion", "jaw", "past", "months", "recently", "USA", "Kenya", "3", "solid mass", "left mandible", "cervical", "Biopsy", "mass", "sheets", "lymphocytes", "reactive", "abundant", "clear cytoplasm", "phagocytosed", "following mechanisms", "directly responsible", "malignant transformation", "patient's cells"]}
{"question": "A scientist is studying the mechanism by which the gastrointestinal system coordinates the process of food digestion. Specifically, she is interested in how distension of the lower esophagus by a bolus of food changes responses in the downstream segments of the digestive system. She observes that there is a resulting relaxation and opening of the lower esophageal (cardiac) sphincter after the introduction of a food bolus. She also observes a simultaneous relaxation of the orad stomach during this time. Which of the following substances is most likely involved in the process being observed here?", "answer": "Vasoactive intestinal polypeptide", "options": {"A": "Ghrelin", "B": "Motilin", "C": "Neuropeptide-Y", "D": "Secretin", "E": "Vasoactive intestinal polypeptide"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["scientist", "studying", "mechanism", "gastrointestinal system coordinates", "digestion", "distension", "lower esophagus", "bolus of food changes responses", "downstream segments", "digestive system", "observes", "resulting", "opening", "lower esophageal", "cardiac", "sphincter", "introduction of", "food bolus", "observes", "simultaneous", "stomach", "time", "following", "most likely involved", "process", "observed"]}
{"question": "An 18-year-old male is seen for a routine physical prior to starting college. He will be moving from Ohio to California, away from his family for the first time. His temperature is 36.8 deg C (98.2 deg F), pulse is 74/min, and blood pressure is 122/68 mmHg. BMI is 24. On questioning, he reveals that he has a habit of binge eating during times of stress, particularly during exams. He then feels guilty about his behavior and attempts to compensate by going to the gym, sometimes for 4+ hours per day. He is disturbed by this behavior and feels out of control. He denies ever vomiting as a means of loosing weight. What is the most likely diagnosis?", "answer": "Bulimia nervosa", "options": {"A": "Anorexia nervosa", "B": "Bulimia nervosa", "C": "Normal behavior variant", "D": "Hypomania", "E": "Body dysmorphic disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "seen", "routine physical", "starting college", "moving", "Ohio", "California", "first time", "temperature", "36", "deg", "98", "deg F", "pulse", "74 min", "blood pressure", "mmHg", "BMI", "reveals", "binge", "times", "stress", "exams", "then", "behavior", "to compensate", "sometimes", "hours", "day", "behavior", "out", "control", "vomiting", "loosing weight", "diagnosis"]}
{"question": "A 4-year-old boy is brought to the physician because of a progressive headache and neck pain for 2 weeks. During this period, he has had multiple episodes of dizziness and tingling sensations in his arms and hands. A year ago, he underwent closed reduction of a dislocated shoulder that he suffered after a fall. He underwent surgical removal of a sac-like protuberance on his lower back, soon after being born. His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 100/80 mm Hg. His neck is supple. Neurological examination shows sensorineural hearing loss bilaterally and normal gross motor function. Fundoscopy reveals bilateral optic disk swelling. An MRI of the brain is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Chiari II malformation", "options": {"A": "Medulloblastoma", "B": "Intraventricular hemorrhage", "C": "Chiari II malformation", "D": "Vestibular schwannoma", "E": "Brachial plexus injury"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "physician", "progressive headache", "neck pain", "2 weeks", "period", "multiple episodes of dizziness", "tingling sensations", "arms", "hands", "year", "closed reduction", "dislocated shoulder", "suffered", "fall", "surgical removal", "sac", "protuberance", "lower back", "born", "temperature", "36", "pulse", "80 min", "blood pressure", "100 80 mm Hg", "neck", "supple", "Neurological examination", "sensorineural hearing loss", "normal gross motor function", "Fundoscopy reveals bilateral optic disk swelling", "MRI of", "brain", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 16-year-old boy is brought to the physician by his host parents for evaluation of a progressively pruritic rash over his shoulders and buttocks for the past 6 months. He recently came to the United States from Nigeria to attend a year of high school. He reports that it has been increasingly difficult for him to read the whiteboard during classes. Physical examination shows symmetrically distributed papules 4–8 mm in diameter, excoriation marks, and patchy hyperpigmentation over his shoulders, waist, and buttocks. There is nontender inguinal lymphadenopathy and several firm, nontender subcutaneous nodules along the right iliac crest. Six skin snip biopsies are taken from the pelvic girdle, buttocks, and thigh, and are then incubated in saline. After 24 hours, microscopic examination shows motile microfilariae. Which of the following is the most likely diagnosis?", "answer": "Onchocerciasis", "options": {"A": "Lymphatic filariasis", "B": "Onchocerciasis", "C": "Trichuriasis", "D": "Cysticercosis", "E": "Cutaneous larva migrans"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "pruritic rash", "shoulders", "buttocks", "past 6 months", "recently", "United States", "Nigeria to attend", "year", "high school", "reports", "difficult", "to", "distributed papules 48 mm", "diameter", "excoriation marks", "patchy hyperpigmentation", "shoulders", "waist", "buttocks", "nontender inguinal lymphadenopathy", "several firm", "nontender subcutaneous nodules", "right iliac crest", "Six skin snip biopsies", "pelvic girdle", "buttocks", "thigh", "then incubated", "24 hours", "microscopic examination", "motile", "following", "diagnosis"]}
{"question": "A study is designed to assess the functions of immune components. The investigator obtains a lymph node biopsy from a healthy subject and observes it under a microscope. A photomicrograph of the cross-section of this lymph node is shown. Which of the following immunologic processes most likely occurs in the region labeled with an arrow?", "answer": "Isotype switching", "options": {"A": "T cell activation", "B": "Macrophage activation", "C": "Negative selection", "D": "V(D)J recombination", "E": "Isotype switching"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["study", "to", "functions", "immune components", "investigator obtains", "lymph node biopsy", "observes", "microscope", "photomicrograph", "cross-section", "lymph node", "following immunologic processes", "likely occurs", "region labeled", "arrow"]}
{"question": "A 45-year-old man presents to the physician with complaints of fever with rigors, headache, malaise, muscle pains, nausea, vomiting, and decreased appetite for the past 3 days. He informs the physician that he had been backpacking on the Appalachian Trail in the woods of Georgia in the month of June, 2 weeks ago, and had been bitten by a tick there. His temperature is 39.0°C (102.3°F), pulse is 94/min, respirations are 18/min, and blood pressure is 126/82 mm Hg. His physical exam does not reveal any significant abnormality except for mild splenomegaly. Laboratory studies show:\nTotal white blood cell count 3,700/mm3 (3.7 x 109/L)\nDifferential count  \nNeutrophils 85%\nLymphocytes 12%\nMonocytes 2%\nEosinophils 1%\nBasophils 0%\nPlatelet count 88,000/mm3 (95 x 109/L)\nSerum alanine aminotransferase 140 IU/L\nSerum aspartate aminotransferase 80 IU/L\nMicroscopic examination of a peripheral blood smear stained with Wright-Giemsa stain shows the presence of morulae in the cytoplasm of leukocytes. In addition to drugs for symptomatic relief, what is the most appropriate initial step in the treatment of this patient?", "answer": "Doxycycline", "options": {"A": "Daptomycin", "B": "Ceftriaxone", "C": "Doxycycline", "D": "Ciprofloxacin", "E": "Rifampin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "complaints", "fever", "rigors", "headache", "malaise", "muscle pains", "nausea", "vomiting", "decreased appetite", "past 3 days", "informs", "physician", "Appalachian Trail", "woods", "Georgia", "month", "June", "2 weeks", "bitten", "tick", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "not reveal", "significant abnormality", "mild", "Laboratory studies", "Total white blood cell count", "700 mm3", "3", "Differential count", "Neutrophils 85", "Eosinophils", "Basophils 0", "Platelet count 88", "mm3", "95", "Serum alanine aminotransferase", "IU", "aspartate aminotransferase 80", "Microscopic examination", "peripheral blood smear stained", "Wright-Giemsa stain", "presence", "morulae", "cytoplasm", "In addition to drugs", "most appropriate initial step"]}
{"question": "A 72-year-old woman is brought to the emergency department by her son after he noticed that she was slurring her speech. He also noticed that she appeared to have difficulty using her fork about halfway through dinner when the speech problems started. He brought her to the emergency department immediately and he estimates that only 1 hour has passed since the beginning of the symptoms. An immediate exam is conducted. A medication is administered to ameliorate the effects of this patient's condition that would not be available for use if the patient had presented significantly later. An hour later the patient's condition becomes significantly worse and new deficits are found. Which of the following agents should be used at this point?", "answer": "Aminocaproic acid", "options": {"A": "Aminocaproic acid", "B": "Antivenin", "C": "Plasma transfusion", "D": "Protamine sulfate", "E": "Vitamin K"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "slurring", "speech", "appeared to", "difficulty using", "fork", "dinner", "speech problems started", "brought", "emergency department immediately", "estimates", "only", "hour", "passed", "beginning", "symptoms", "immediate exam", "medication", "administered to", "effects", "patient's condition", "not", "available", "use", "patient", "later", "hour later", "patient's condition", "worse", "new deficits", "found", "following agents", "used", "point"]}
{"question": "A 10-year-old boy is brought to the pediatric clinic because of persistent sinus infections. For the past 5 years, he has had multiple sinus and upper respiratory infections. He has also had recurrent diarrhea throughout childhood. His temperature is 37.0°C (98.6°F), the heart rate is 90/min, the respirations are 16/min, and the blood pressure is 125/75 mm Hg. Laboratory studies show abnormally low levels of one immunoglobulin isotype but normal levels of others. Which of the following is the most likely diagnosis?", "answer": "Selective IgA deficiency", "options": {"A": "Chediak-Higashi syndrome", "B": "Common variable immunodeficiency", "C": "Drug-induced IgA deficiency", "D": "Selective IgA deficiency", "E": "Transient hypogammaglobulinemia of infancy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["A 10 year old boy", "brought", "pediatric clinic", "persistent sinus infections", "past", "years", "multiple sinus", "upper respiratory infections", "recurrent", "childhood", "temperature", "98", "heart rate", "90 min", "respirations", "min", "blood pressure", "75 mm Hg", "Laboratory studies", "abnormally low levels", "one immunoglobulin", "normal levels", "others", "following", "diagnosis"]}
{"question": "A 22-year-old male presents to the physician with a 9-year history of recurring acne on his face. He has tried a number of over-the-counter face wash, gels, and supplements over the past few years with temporary relief but no significant lasting effects. The acne has gotten worse over time and now he is especially concerned about his appearance. A physical examination reveals numerous nodulocystic lesions over the face and neck. Scarring is present interspersed between the pustules. There are some lesions on the shoulders and upper back as well. Which of the following is the most appropriate treatment option for this patient at this time?", "answer": "Oral isotretinoin", "options": {"A": "Oral erythromycin", "B": "Oral doxycycline", "C": "Oral isotretinoin", "D": "Topical isotretinoin", "E": "Topical salicylic acid"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male presents", "physician", "year history", "recurring acne", "face", "number", "over-the-counter face", "gels", "supplements", "past", "years", "temporary relief", "significant", "effects", "acne", "gotten worse", "time", "now", "concerned about", "appearance", "reveals numerous", "lesions", "face", "neck", "Scarring", "present", "pustules", "lesions", "shoulders", "upper back", "well", "following", "most appropriate", "patient", "time"]}
{"question": "A 72-year-old man presents with shortness of breath and right-sided chest pain. Physical exam reveals decreased breath sounds and dull percussion at the right lung base. Chest X-ray reveals a right-sided pleural effusion. A thoracentesis was performed, removing 450 mL of light pink fluid. Pleural fluid analysis reveals:\nPleural fluid to serum protein ratio: 0.35\nPleural fluid to serum LDH ratio: 0.49 \nLactate dehydrogenase (LDH): 105 IU (serum LDH Reference: 100–190)\nWhich of the following disorders is most likely in this patient?", "answer": "Congestive heart failure", "options": {"A": "Pancreatitis", "B": "Chylothorax", "C": "Uremia", "D": "Sarcoidosis", "E": "Congestive heart failure"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["72 year old man presents", "shortness of breath", "right-sided chest pain", "reveals decreased breath sounds", "dull percussion", "right lung base", "Chest X-ray reveals", "right-sided pleural effusion", "performed", "removing 450 mL", "light pink fluid", "Pleural fluid analysis reveals", "Pleural fluid", "serum protein ratio", "0.35 Pleural fluid", "serum LDH ratio", "0", "Lactate dehydrogenase", "IU", "serum LDH", "following disorders", "patient"]}
{"question": "A 63-year-old man presents to the clinic with fever accompanied by shortness of breath. The symptoms developed a week ago and have been progressively worsening over the last 2 days. He reports his cough is productive of thick, yellow sputum. He was diagnosed with chronic obstructive pulmonary disease 3 years ago and has been on treatment ever since. He quit smoking 10 years ago but occasionally experiences shortness of breath along with chest tightness that improves with the use of an inhaler. However, this time the symptoms seem to be more severe and unrelenting. His temperature is 38.6°C (101.4°F), the respirations are 21/min, the blood pressure is 100/60 mm Hg, and the pulse is 105/min. Auscultation reveals bilateral crackles and expiratory wheezes. His oxygen saturation is 95% on room air. According to this patient’s history, which of the following should be the next step in the management of this patient?", "answer": "Chest X-ray", "options": {"A": "Chest X-ray", "B": "CT scan", "C": "Bronchoscopy", "D": "Arterial blood gases", "E": "Bronchoprovocation test"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man presents", "clinic", "fever", "shortness of breath", "symptoms", "week", "worsening", "2 days", "reports", "cough", "productive", "thick", "yellow", "diagnosed", "chronic obstructive pulmonary disease", "years", "on treatment ever", "smoking", "occasionally", "shortness of breath", "chest tightness", "improves", "use of", "inhaler", "time", "symptoms", "to", "more severe", "temperature", "respirations", "min", "blood pressure", "100 60 mm Hg", "pulse", "min", "Auscultation reveals bilateral crackles", "expiratory wheezes", "oxygen saturation", "95", "room air", "patients history", "following", "next step", "patient"]}
{"question": "A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1–2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management?", "answer": "Colonoscopy", "options": {"A": "Colonoscopy", "B": "Flexible sigmoidoscopy", "C": "D-xylose absorption test", "D": "CT scan of the abdomen and pelvis with contrast", "E": "Capsule endoscopy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old white man", "physician", "of increasing generalized fatigue", "months", "unable", "work out", "period", "cramping lower abdominal pain", "diarrhea", "past", "weeks", "occasionally bloody", "diagnosed", "colon cancer", "age", "65", "smoked half", "pack", "cigarettes daily", "past", "social occasions", "temperature", "99", "pulse", "88 min", "blood pressure", "74 mm Hg", "dry mucous membranes", "abdomen", "soft", "slight tenderness", "palpation", "lower quadrants", "Rectal", "stool mixed", "blood", "hemoglobin concentration", "g/dL", "leukocyte count", "500 mm3", "platelet count", "480", "mm3", "Urinalysis", "normal limits", "following", "most appropriate next step"]}
{"question": "A 47-year-old presents to the clinic with a 3-day history of severe mid-epigastric abdominal pain radiating to the back. The patient has hypertension, diabetes mellitus, and hypertriglyceridemia. Prescription medications include enalapril, metformin, sitagliptin, glargine, lispro, and fenofibrate. The patient has not had a cigarette in more than 35 years, and reports only having 1 or 2 drinks during special occasions such as weddings and family reunions. The blood pressure is 146/90 mm Hg, the heart rate is 88/min, the respiratory rate is 10/min, and the temperature is 37.8°C (100.0°F). On physical examination, the patient appears uncomfortable but alert. The visualization of the sclera is negative for jaundice. The neck is supple and non-tender without nodules. There are no heart murmurs. The lungs are clear to auscultation bilaterally. The palpation of the abdomen elicits pain in the epigastric region. The liver is palpable along the costal margin, and the Murphy’s sign is negative. The laboratory results are as follows:\nNa+ 138 mEq/L\nK+ 4.2 mEq/L\nCl- 108 mmol/L\nHCO-3 20 mmol/L\nBUN 178 mg/dL\nCr 1.0 mg/dL\nGlucose  154 mg/dL\nLDL 117 mg/dL\nHDL 48 mg/dL\nTG 942 mg/dL\nAST 45 IU/L\nALT 48 IU/L\nGGT 27 IU/L\nAmylase  110 U/L\nLipase 250 U/L\nAccording to the clinical vignette, which of the following is the most likely diagnosis of the patient?", "answer": "Acute pancreatitis", "options": {"A": "Mallory-Weiss tear", "B": "Duodenal ulcer", "C": "Superior mesenteric artery embolism", "D": "Acute pancreatitis", "E": "Abdominal aortic aneurysm"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old presents", "clinic", "3 history", "severe", "epigastric abdominal pain radiating", "back", "patient", "hypertension", "diabetes mellitus", "hypertriglyceridemia", "Prescription medications include enalapril", "metformin", "sitagliptin", "glargine", "lispro", "fenofibrate", "patient", "not", "cigarette", "35 years", "reports only", "1", "2", "special occasions", "reunions", "blood pressure", "90 mm Hg", "heart rate", "88 min", "respiratory rate", "10/min", "temperature", "100", "patient appears", "alert", "visualization", "sclera", "negative", "jaundice", "neck", "supple", "non-tender", "nodules", "heart murmurs", "lungs", "clear", "auscultation", "palpation of", "abdomen elicits pain", "epigastric", "liver", "palpable", "costal margin", "Murphys sign", "negative", "laboratory results", "follows", "Na", "mEq K", "4", "mmol", "20 mmol", "mg dL Cr 1 0", "Glucose", "HDL 48", "TG", "AST 45 IU", "GGT", "Amylase", "U", "Lipase", "clinical", "following", "diagnosis", "patient"]}
{"question": "An investigator is studying the effects of an antihypertensive drug during pregnancy. Follow-up studies show that the drug can adversely affect differentiation of the ureteric bud into its direct derivatives in fetuses exposed during the first trimester. Which of the following structures is most likely to develop incorrectly in the affected fetus?", "answer": "Collecting ducts", "options": {"A": "Distal convoluted tubule", "B": "Collecting ducts", "C": "Bladder", "D": "Loop of Henle", "E": "Proximal convoluted tubule"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "effects", "antihypertensive drug", "pregnancy", "drug", "differentiation", "ureteric bud", "direct", "fetuses exposed", "first trimester", "following structures", "to", "affected fetus"]}
{"question": "A 56-year-old woman presents to the ER with 12 hours of right colic pain that travels from her groin down her inner thigh. The patient complains of dysuria, hematuria, and reports of “passing gravel” when urinating. She was diagnosed with gout and hypertension 5 years ago. Physical examination is unremarkable. The emergency department team orders urinalysis and a CT scan that shows a mild dilation of the right ureter associated with multiple small stones of low Hounsfield unit values (HU). Which of the following findings is most likely to appear in the urinalysis of this patient?", "answer": "Acidic urine", "options": {"A": "Low specific gravity", "B": "Alkaline urine", "C": "Positive leukocyte esterase", "D": "Nitrites", "E": "Acidic urine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "ER", "12 hours", "right colic pain", "groin", "inner thigh", "patient", "dysuria", "hematuria", "reports", "diagnosed", "gout", "hypertension", "years", "unremarkable", "emergency department", "orders urinalysis", "CT scan", "mild dilation of", "right ureter associated with multiple small stones", "low Hounsfield unit values", "following findings", "to appear", "urinalysis", "patient"]}
{"question": "A new mother expresses her concerns because her 1-day-old newborn has been having feeding difficulties. The child vomits after every feeding and has had a continuous cough since shortly after birth. The mother denies any greenish coloration of the vomit and says that it is only composed of whitish milk that the baby just had. The child exhibits these coughing spells during the exam, at which time the physician notices the child’s skin becoming cyanotic. The mother states that the child was born vaginally with no complications, although her records show that she had polyhydramnios during her last ultrasound before the delivery. Which of the following is the most likely cause of the patient’s symptoms?", "answer": "Defective formation of the esophagus with gastric connection to the trachea", "options": {"A": "Obstruction due to failure of rotation of pancreatic tissue", "B": "Hypertrophy of the pyloric sphincter", "C": "Failure of neural crest cells to migrate into the myenteric plexus", "D": "Failure of recanalization of duodenum", "E": "Defective formation of the esophagus with gastric connection to the trachea"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["new", "1-day old newborn", "feeding difficulties", "child vomits", "cough", "birth", "coloration", "vomit", "only", "milk", "baby", "child", "coughing spells", "exam", "time", "physician", "childs skin", "cyanotic", "states", "child", "born", "complications", "records", "polyhydramnios", "ultrasound", "delivery", "following", "most likely cause", "patients symptoms"]}
{"question": "An 18-year-old man comes to the physician with his parents for a routine health maintenance examination. He noticed a swelling on his back 7 months ago. He has a history of using intravenous heroin but has not used illicit drugs for the past 2 months. There is no personal or family history of serious illness. Vital signs are within normal limits. Examination shows a 2-cm soft, lobulated, mobile swelling on the right side of his upper back. The mass slips away from the fingers when its edges are palpated. Healed track marks are present in the bilateral cubital fossae. The patient is told that the mass on his back is most likely a lipoma, a benign mass consisting of fat tissue that does not require any further treatment. He is aware of the diagnosis and informs you that he wants it removed for cosmetic reasons. Four months ago, he had asked another physician to remove it but the physician refused to perform the procedure since he did not consider it necessary. The patient is counseled regarding the potential benefits and risks of the excision and that there is a chance of recurrence. His parents ask the physician not to perform the excision. However, the patient insists on undergoing the procedure. Which of the following is the most appropriate next step in management?", "answer": "Perform the excision", "options": {"A": "Ask the patient to follow up in 6 months", "B": "Perform the excision", "C": "Refer to the hospital ethics committee", "D": "Refer him to a methadone clinic", "E": "Request parental consent\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "routine", "swelling", "back", "months", "history", "using intravenous heroin", "not used illicit drugs", "past 2 months", "personal", "family history", "serious", "Vital", "normal limits", "2", "soft", "mobile swelling", "right side of", "upper back", "mass", "fingers", "edges", "Healed track marks", "present", "bilateral cubital fossae", "patient", "mass", "back", "lipoma", "benign mass consisting", "fat tissue", "not", "further treatment", "aware of", "diagnosis", "informs", "removed", "cosmetic", "Four months", "physician to remove", "physician", "to perform", "procedure", "not", "patient", "counseled", "potential benefits", "excision", "chance", "recurrence", "physician not to perform", "excision", "patient", "procedure", "following", "most appropriate next step"]}
{"question": "A 41-year-old woman is brought to the emergency department with the acute-onset of severe abdominal pain for the past 2 hours. She has a history of frequent episodes of vague abdominal pain, but they have never been this severe. Every time she has had pain, it would resolve after eating a meal. Her past medical history is otherwise insignificant. Her vital signs include: blood pressure 121/77 mm Hg, pulse 91/min, respiratory rate 21/min, and temperature 37°C (98.6°F). On examination, her abdomen is flat and rigid. Which of the following is the next best step in evaluating this patient’s discomfort and stomach pain by physical exam?", "answer": "Auscultate the abdomen", "options": {"A": "Elicit shifting dullness of the abdomen", "B": "Percuss the point of maximal pain", "C": "Perform light palpation at the point of maximal pain", "D": "Attempt to perform a deep, slow palpation with quick release", "E": "Auscultate the abdomen"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "emergency department", "acute-onset", "severe abdominal pain", "past", "hours", "history", "episodes", "vague abdominal", "never", "severe", "time", "pain", "eating", "past medical history", "vital signs include", "blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "min", "temperature", "98", "abdomen", "flat", "rigid", "following", "next best step", "patients discomfort", "stomach pain"]}
{"question": "A group of scientists is verifying previous research on DNA replication. In the picture is the theoretical structure for tRNA. Where is the binding site for an amino acid?", "answer": "A", "options": {"A": "A", "B": "B", "C": "C", "D": "D", "E": "E"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["scientists", "previous", "DNA replication", "picture", "structure", "tRNA", "site"]}
{"question": "A 20-year-old college student is brought to the ED after a motor vehicle accident. Primary and secondary surveys reveal no significant compromise to his airway, his cardiovascular system, or to his motor function. However, his conjunctiva appear injected and he maintains combative behavior towards staff. What test will confirm potential substance use?", "answer": "Gas chromatography / mass spectrometry (GC/MS)", "options": {"A": "Polymerase chain reaction", "B": "Urine immunoassay", "C": "Western blot", "D": "Gas chromatography / mass spectrometry (GC/MS)", "E": "Breath alcohol test"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["20 year old", "brought", "motor vehicle accident", "Primary", "secondary", "reveal", "significant compromise", "airway", "cardiovascular system", "conjunctiva appear injected", "combative behavior", "staff", "test", "confirm potential substance use"]}
{"question": "A 52-year-old G3P3 presents to her gynecologist complaining of painful intercourse. She reports a 6-month history of intermittent dryness, itching, and burning during intercourse. Upon further questioning, she also reports poor sleep and occasional periods during which she feels very warm and sweats profusely. Her past medical history is significant for poorly controlled hypertension and a 10 pack-year smoking history. She takes hydrochlorothiazide and enalapril. Her temperature is 99.3°F (37.4°C), blood pressure is 135/85 mmHg, pulse is 90/min, and respirations are 18/min. On examination, she is a healthy female in no distress. Pelvic examination reveals no adnexal or cervical motion tenderness. Which of the following sets of hormone levels are most likely to be found in this patient?", "answer": "Decreased estrogen, increased FSH, increased LH, increased GnRH", "options": {"A": "Decreased estrogen, decreased FSH, decreased LH, decreased GnRH", "B": "Increased estrogen, decreased FSH, decreased LH, decreased GnRH", "C": "Decreased estrogen, decreased FSH, decreased LH, increased GnRH", "D": "Decreased estrogen, increased FSH, increased LH, increased GnRH", "E": "Normal estrogen, normal FSH, normal LH, normal GnRH"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "gynecologist", "painful intercourse", "reports", "month history", "intermittent dryness", "itching", "burning", "intercourse", "further", "reports poor sleep", "occasional periods", "very warm", "sweats", "past medical history", "significant", "poorly controlled hypertension", "a 10", "smoking history", "hydrochlorothiazide", "enalapril", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "90 min", "respirations", "min", "healthy", "distress", "Pelvic examination reveals", "adnexal", "cervical motion tenderness", "following sets", "hormone levels", "to", "found", "patient"]}
{"question": "An otherwise healthy 28-year-old woman comes to the physician because of a 14-day history of a painful red nodules on her legs associated with malaise and mild joint pains. She reports that the nodules were initially smaller and distinct but some have fused together over the past 3–4 days and now appear like bruises. There is no preceding history of fever, trauma, or insect bites. Her vital signs are within normal limits. A photograph of the tender lesions on her shins is shown. The remainder of the examination shows no abnormalities. Complete blood count and antistreptolysin O (ASO) titers are within the reference range. Erythrocyte sedimentation rate is 30 mm/h. Which of the following is the most appropriate next step in management ?", "answer": "X-ray of the chest", "options": {"A": "Oral amoxicillin", "B": "Oral isoniazid", "C": "X-ray of the chest", "D": "Stool culture", "E": "Skin biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy", "year old woman", "physician", "day history", "painful red nodules", "legs associated with malaise", "mild joint pains", "reports", "nodules", "initially smaller", "fused together", "past", "days", "now appear", "bruises", "preceding history", "fever", "trauma", "insect bites", "vital signs", "normal limits", "photograph", "tender lesions", "shins", "abnormalities", "Complete blood count", "antistreptolysin O", "titers", "reference range", "Erythrocyte sedimentation rate", "30 mm/h", "following", "most appropriate next step"]}
{"question": "A 2-year-old boy is brought to his pediatrician’s office with complaints of watery diarrhea for the past 2 weeks. He has had a couple of episodes of watery diarrhea in the past, but this is the first time it failed to subside over the course of a few days. His father tells the doctor that the child has frothy stools with a distinct foul odor. Other than diarrhea, his parents also mention that he has had several bouts of the flu over the past 2 years and has also been hospitalized twice with pneumonia. On examination, the child is underweight and seems to be pale and dehydrated. His blood pressure is 80/50 mm Hg, the pulse rate of 110/min, and the respiratory rate is 18/min. Auscultation of the lungs reveals rhonchi. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Faulty transmembrane ion channel", "options": {"A": "Faulty transmembrane ion channel", "B": "Defect in the lysosomal trafficking regulator", "C": "Primary ciliary dyskinesia", "D": "Accumulation of branched chain amino acids", "E": "Dysfunction of phenylalanine hydroxylase"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2 year old boy", "brought", "pediatricians office", "complaints", "watery diarrhea", "past 2 weeks", "couple of episodes", "watery diarrhea", "past", "first time", "failed to", "course", "days", "doctor", "child", "frothy stools", "foul odor", "diarrhea", "several bouts", "flu", "past", "years", "hospitalized twice", "pneumonia", "child", "underweight", "to", "pale", "dehydrated", "blood pressure", "80 50 mm Hg", "pulse rate", "min", "respiratory rate", "min", "Auscultation", "lungs reveals rhonchi", "following", "most likely cause", "patients symptoms"]}
{"question": "A 21-year-old primigravida woman visits the clinic in her 22nd week of gestation as part of her antenatal care. She has no complaints. Past medical history is unremarkable. Her only medication is a prenatal vitamin. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse rate is 78/min, and respiration rate is 20/min. Physical examination is consistent with the gestational age of her pregnancy with no abnormalities noted. Urine dipstick is normal. Which of the following is the current primary location for fetal myelopoiesis at this stage of development?", "answer": "Liver", "options": {"A": "Yolk sac", "B": "Liver", "C": "Thymus", "D": "Aorta-gonad-mesonephros region", "E": "Spleen"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old primigravida woman", "clinic", "week", "gestation", "part of", "complaints", "Past medical history", "unremarkable", "only medication", "prenatal vitamin", "temperature", "98", "blood pressure", "70 mm Hg", "pulse rate", "min", "respiration rate", "20 min", "gestational", "pregnancy", "abnormalities noted", "Urine dipstick", "normal", "following", "current primary location", "fetal myelopoiesis", "stage", "development"]}
{"question": "A 73-year-old man presents to the outpatient clinic complaining of chest pain with exertion. He states that resting for a few minutes usually resolves the chest pain. Currently, he takes 81 mg of aspirin daily. He has a blood pressure of 127/85 mm Hg and heart rate of 75/min. Physical examination reveals regular heart sounds and clear lung sounds bilateral. Which medication regimen below should be added?", "answer": "Metoprolol and a statin daily. Sublingual nitroglycerin as needed.", "options": {"A": "Amlodipine daily. Sublingual nitroglycerin as needed.", "B": "Metoprolol and a statin daily. Sublingual nitroglycerin as needed.", "C": "Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.", "D": "Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.", "E": "Amlodipine and a statin daily. Sublingual nitroglycerin as needed."}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "outpatient clinic", "chest pain", "exertion", "states", "minutes usually", "chest pain", "Currently", "daily", "blood pressure", "85 mm Hg", "75 min", "Physical", "reveals regular heart sounds", "clear lung sounds bilateral", "medication regimen", "added"]}
{"question": "An 8-year-old African-American boy is brought to the emergency room with severe pain in both hands. His mother says that the patient had a fever with a cough a couple of days ago. Family history is positive for an uncle who died from a blood disease. A peripheral blood smear of this patient is shown in the image. Which of the following is the most likely mechanism for this patient’s disease?", "answer": "Missense mutation", "options": {"A": "Nonsense mutation", "B": "Frameshift mutation", "C": "Mismatch repair", "D": "Silent mutation", "E": "Missense mutation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "boy", "brought", "emergency room", "severe", "hands", "patient", "fever", "cough", "couple", "days", "Family history", "positive", "died", "blood disease", "peripheral blood smear", "patient", "following", "mechanism", "patients disease"]}
{"question": "A 65-year-old Caucasian man visits the nephrology outpatient clinic for a follow-up appointment. He was previously diagnosed with stage G3a chronic kidney disease (CKD) and albuminuria stage A2. He follows strict dietary recommendations and takes enalapril. He has a history of benign prostatic hyperplasia which has been complicated by urinary tract obstruction. His vitals are stable, and his blood pressure is within the recommended limits. His most recent laboratory studies are as follows:\nSerum sodium 140 mEq/L\nSerum potassium 5.8 mEq/L\nSerum chloride 102 mEq/L\nSerum phosphate 4.0 mg/dL\nHemoglobin 11.5 mg/dL\nAlbumin excretion rate (AER) 280 mg/day\nWhich of the following is the best strategy in the management of this patient?", "answer": "Addition of patiromer", "options": {"A": "Removal of enalapril", "B": "Addition of furosemide", "C": "Observation", "D": "Addition of patiromer", "E": "Addition of sevelamer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old", "man", "nephrology outpatient clinic", "follow-up appointment", "diagnosed", "stage G3a chronic kidney disease", "albuminuria", "follows", "dietary", "enalapril", "history of benign prostatic hyperplasia", "complicated", "urinary tract obstruction", "stable", "blood pressure", "limits", "most recent laboratory studies", "follows", "mEq", "chloride", "mg dL Hemoglobin", "mg dL", "excretion rate", "day", "following", "best", "patient"]}
{"question": "A 5-year-old girl is brought to a medical office for evaluation of persistent abdominal pain that has worsened over the past 24 hours. The mother states that the girl often has constipation which has worsened over the last 3 days. The mother denies that the girl has had bloody stools. The girl has not had a bowel movement or passed flatulence in 72 hours. She has vomited 3 times since last night and refuses to eat. She has no significant medical history, including no history of surgeries. On exam, there are no abdominal masses; however, the upper abdomen is distended and tympanic. What is the most likely underlying cause of the girl’s symptoms?", "answer": "Malrotation of the gut", "options": {"A": "Volvulus", "B": "Malrotation of the gut", "C": "Pyloric stenosis", "D": "Duodenal atresia", "E": "Meckel’s diverticulum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["5 year old girl", "brought", "medical office", "evaluation", "persistent abdominal", "worsened", "past 24 hours", "states", "girl often", "constipation", "worsened", "3 days", "girl", "bloody stools", "girl", "not", "bowel movement", "passed flatulence", "72 hours", "vomited 3", "night", "to eat", "significant medical history", "including", "history of surgeries", "exam", "abdominal masses", "upper abdomen", "distended", "tympanic", "underlying cause", "girls symptoms"]}
{"question": "A 53-year old man presents for a well physical examination. He reports his diet is suboptimal, but otherwise reports a healthy lifestyle. He has no past medical history and only takes a multivitamin. He has a blood pressure of 116/74 mm Hg and a pulse of 76/min. On physical examination, he is in no acute distress, has no cardiac murmurs, and his lung sounds are clear to auscultation bilaterally. You order a lipid panel that returns as follows: LDL 203, HDL 37, TG 292. Of the following, which medication should be initiated?", "answer": "Atorvastatin 40 mg", "options": {"A": "Simvastatin 10 mg daily", "B": "Ezetimibe 10 mg daily", "C": "Fenofibrate 145 mg daily", "D": "Atorvastatin 40 mg", "E": "Colesevelam 3.75 grams daily"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "well", "reports", "diet", "suboptimal", "reports", "past medical history", "only", "multivitamin", "blood pressure", "74 mm Hg", "pulse", "76 min", "acute distress", "cardiac murmurs", "lung sounds", "clear", "auscultation", "order", "lipid panel", "returns", "follows", "HDL", "TG", "following", "medication", "initiated"]}
{"question": "A 45-year-old man presents to the emergency department with complaints of right-sided weakness and slurring of speech for 1 hour. There is no history of head trauma, myocardial infarction, recent surgery, gastrointestinal or urinary bleeding. He has hypertension, chronic atrial fibrillation, and a 20 pack-year cigarette smoking history. The medication list includes valsartan and rivaroxaban. The vital signs include: blood pressure 180/92 mm Hg, pulse 144/min and irregular, and temperature 37.2°C (99.0°F). On physical examination, there is a facial asymmetry with a deviation of angle of mouth to the left side on smiling. Muscle strength is reduced in both upper and lower limbs on the right side while on the left side it’s normal. Random blood glucose is 104 mg/dL. A complete blood count is normal. A CT scan of the head is shown in the image. What is the most appropriate next step in the management of this patient?", "answer": "Aspirin", "options": {"A": "Amiodarone", "B": "Aspirin", "C": "Heparin", "D": "Metoprolol", "E": "Tissue plasminogen activator"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "complaints", "right-sided weakness", "slurring", "speech", "1 hour", "history", "head trauma", "myocardial infarction", "recent surgery", "gastrointestinal", "urinary bleeding", "hypertension", "chronic atrial fibrillation", "20 year cigarette smoking history", "includes valsartan", "rivaroxaban", "vital signs include", "blood pressure", "mm Hg", "pulse", "min", "irregular", "temperature", "99", "facial asymmetry", "deviation of angle", "mouth", "left side", "Muscle strength", "reduced", "upper", "lower limbs", "right side", "left side", "normal", "Random blood glucose", "mg/dL", "complete blood count", "normal", "CT scan of", "head", "most appropriate next step", "patient"]}
{"question": "An 18-month-old girl is brought to the pediatrician’s office for failure to thrive and developmental delay. The patient’s mother says she has not started speaking and is just now starting to pull herself up to standing position. Furthermore, her movement appears to be restricted. Physical examination reveals coarse facial features and restricted joint mobility. Laboratory studies show increased plasma levels of several enzymes. Which of the following is the underlying biochemical defect in this patient?", "answer": "Failure of mannose phosphorylation", "options": {"A": "Failure of mannose phosphorylation", "B": "Inappropriate degradation of lysosomal enzymes", "C": "Congenital lack of lysosomal formation", "D": "Inappropriate protein targeting to endoplasmic reticulum", "E": "Misfolding of nuclear proteins"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old girl", "brought", "pediatricians office", "failure to thrive", "developmental delay", "patients", "not started", "now starting", "pull", "up to standing position", "movement appears to", "restricted", "reveals coarse facial features", "restricted joint", "Laboratory studies", "increased plasma levels", "enzymes", "following", "underlying biochemical defect", "patient"]}
{"question": "A 29-year-old man presents to the emergency department with chest pain and fatigue for the past week. The patient is homeless and his medical history is not known. His temperature is 103°F (39.4°C), blood pressure is 97/58 mmHg, pulse is 140/min, respirations are 25/min, and oxygen saturation is 95% on room air. Physical exam is notable for scars in the antecubital fossa and a murmur over the left sternal border. The patient is admitted to the intensive care unit and is treated appropriately. On day 3 of his hospital stay, the patient presents with right-sided weakness in his arm and leg and dysarthric speech. Which of the following is the most likely etiology of his current symptoms?", "answer": "Septic emboli", "options": {"A": "Bacterial meningitis", "B": "Septic emboli", "C": "Herpes simplex virus encephalitis", "D": "Intracranial hemorrhage", "E": "Thromboembolic stroke"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old man presents", "emergency department", "chest pain", "fatigue", "past week", "patient", "homeless", "medical history", "not known", "temperature", "blood pressure", "97 58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "95", "room air", "notable", "scars", "antecubital fossa", "murmur", "left sternal border", "patient", "treated", "day", "hospital", "patient presents", "right-sided weakness", "arm", "leg", "dysarthric speech", "following", "etiology", "current symptoms"]}
{"question": "A 69-year-old man comes to the physician because of a 3-month history of urinary urgency, nocturia, and progressive pain in his lower back. The pain is worse at night and does not respond to ibuprofen. Rectal examination shows an enlarged, asymmetric prostate with a nodular surface. Prostate-specific antigen concentration is 11 ng/ml (N < 4). A biopsy of the prostate shows a high-grade adenocarcinoma. A CT scan of the pelvis shows multiple osteoblastic lesions of the lumbar spine. The patient is started on a drug that competes with androgens for interaction with the testosterone receptors. Treatment with which of the following drugs was most likely initiated in this patient?", "answer": "Flutamide", "options": {"A": "Leuprolide", "B": "Flutamide", "C": "Degarelix", "D": "Docetaxel", "E": "Finasteride"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["69 year old man", "physician", "3 month history", "urinary urgency", "nocturia", "progressive pain in", "lower back", "pain", "worse", "night", "not", "ibuprofen", "Rectal examination", "enlarged", "asymmetric prostate", "nodular surface", "specific antigen concentration", "ng/ml", "N", "4", "biopsy of", "prostate", "high-grade adenocarcinoma", "CT scan of", "pelvis", "multiple", "lesions of", "lumbar spine", "patient", "androgens", "interaction", "testosterone receptors", "Treatment", "following drugs", "most likely initiated", "patient"]}
{"question": "A 49-year-old man presents with an 11-month history of progressive fatigue. He denies any night sweats, weight loss, abdominal pain, nausea, vomiting, change in bowel habits, or bleeding. He has no significant past medical history. His vital signs include: temperature 37.0°C (98.6°F), blood pressure 119/81 mm Hg, pulse 83/min, and respiratory rate 19/min. On physical examination, mild splenomegaly is noted on abdominal percussion. Laboratory findings are significant for a leukocyte count of 16,700/mm3 and a low serum leukocyte alkaline phosphatase (LAP) score. A bone marrow biopsy is performed, which shows marked hypercellularity with a clear dominance of granulocytes. Cytogenetic analysis is positive for the Ph1 gene. Which of the following is the best course of treatment for this patient?", "answer": "Imatinib", "options": {"A": "Hydroxyurea", "B": "Interferon-α-2b", "C": "Rituximab", "D": "Cytarabine", "E": "Imatinib"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "month history", "progressive fatigue", "night sweats", "weight loss", "abdominal pain", "nausea", "vomiting", "change in bowel habits", "bleeding", "significant past medical history", "vital signs include", "temperature", "98", "blood pressure", "81 mm Hg", "pulse 83 min", "respiratory rate", "min", "mild splenomegaly", "noted", "abdominal percussion", "Laboratory findings", "significant", "leukocyte count", "16 700 mm3", "low serum leukocyte alkaline phosphatase", "score", "bone marrow biopsy", "performed", "marked hypercellularity", "clear", "granulocytes", "positive", "Ph1 gene", "following", "best course", "treatment", "patient"]}
{"question": "A 32-year-old woman is brought to the emergency department by her neighbors 30 minutes after they found her unconscious in her yard. Her neighbors report that she has been spending more time at home by herself because she recently lost her job. On arrival, she is unable to provide a history. She appears anxious. Her pulse is 76/min, respirations are 13/min, and blood pressure is 114/72 mm Hg. Examination shows significant weakness of the left upper and lower extremities. She is unable to plantarflex the ankle while supine. She is able to stand on her toes. Her gait is unsteady. Deep tendon reflexes are 3+ and symmetric. A CT scan of the head shows no abnormalities. An MRI of the brain and MR angiography show no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Conversion disorder", "options": {"A": "Conversion disorder", "B": "Malingering", "C": "Somatic symptom disorder", "D": "Acute stress disorder", "E": "Acute hemorrhagic stroke"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "30 minutes", "found", "unconscious", "yard", "report", "spending more time at home", "recently lost", "arrival", "unable to", "history", "appears anxious", "pulse", "76 min", "respirations", "min", "blood pressure", "72 mm Hg", "significant weakness", "left upper", "lower extremities", "unable to", "ankle", "supine", "able to stand", "toes", "gait", "unsteady", "Deep tendon reflexes", "3", "symmetric", "CT scan of", "head", "abnormalities", "MRI of", "brain", "MR angiography", "abnormalities", "following", "diagnosis"]}
{"question": "A 12-year-old boy is brought to the physician because of difficulty in walking for 5 months. His mother reports that he has trouble keeping his balance and walking without support. Over the past year, he has started to have difficulty seeing in the dark and his hearing has been impaired. Examination shows marked scaling of the skin on the face and feet and a shortened 4th toe. Muscle strength is 3/5 in the lower extremities and 4/5 in the upper extremities. Sensation to pinprick is symmetrically decreased over the legs. Fundoscopy shows peripheral pigment deposits and retinal atrophy. His serum phytanic acid concentration is markedly elevated. The patient's condition is most likely caused by a defect in which of the following cellular structures?", "answer": "Peroxisomes", "options": {"A": "Peroxisomes", "B": "Mitochondria", "C": "Smooth endoplasmic reticulum", "D": "Myofilaments", "E": "Proteasomes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "of difficulty in walking", "5 months", "reports", "keeping", "balance", "support", "past year", "started to", "difficulty seeing", "dark", "hearing", "impaired", "marked scaling of the skin", "face", "feet", "shortened 4th toe", "Muscle", "3/5", "lower extremities", "4/5", "upper extremities", "Sensation", "pinprick", "decreased", "legs", "Fundoscopy", "peripheral pigment deposits", "retinal atrophy", "serum phytanic acid concentration", "markedly elevated", "patient's condition", "most likely caused", "defect", "following cellular structures"]}
{"question": "A 40-year-old man presents with a rash, oral lesions, and vision problems for 5 days. He says the rash started as a burning feeling on his face and the upper part of his torso, but soon red spots appeared in that same distribution. The spots grew in size and spread to his upper extremities. The patient says the spots are painful but denies any associated pruritus. He says the painful oral lesions appeared about the same time as the rash. For the past 3 days, he also says he has been having double vision and dry, itchy eyes. He reports that he had a mild upper respiratory infection for a few days that preceded his current symptoms. The patient denies any chills, hematuria, abdominal or chest pain, or similar symptoms in the past. Past medical history is significant for a severe urinary tract infection diagnosed 3 weeks ago for which he has been taking trimethoprim-sulfamethoxazole. The vital signs include: temperature 38.3℃ (101.0℉), blood pressure 110/60 mm Hg, respiratory rate 20/min, and pulse 108/min. On physical examination, the patient has severe painful erosions of the oral mucosa. There are multiple fluid-filled vesicles and bullae averaging 3 mm in diameter with a surrounding erythematous ring that involve only the upper torso and extensor surfaces of upper extremities. Several of the lesions have ruptured, resulting in sloughing off of the epidermal layer. There is a prominent conjunctival injection present. Ophthalmic examination reveals mild bilateral corneal abrasions without any evidence of frank ulceration. Laboratory findings are significant for the following:\nWhite blood cell (WBC) count 8,500/mm3\nRed blood cell (RBC) count 4.20 x 106/mm3\nHematocrit 41.5%\nHemoglobin 14.0 g/dL\nPlatelet count 215,000/mm3\nC-reactive protein (CRP) 86 mg/L\nUrine and blood cultures are pending. Which of the following would confirm the most likely diagnosis in this patient?\n ", "answer": "Biopsy and histopathologic analysis of skin lesions", "options": {"A": "Gram stain and culture of skin sample", "B": "Biopsy and histopathologic analysis of skin lesions", "C": "Direct immunofluorescence analysis of perilesional skin biopsy", "D": "Urine collection (24-hour)", "E": "Flow cytometry"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["40 year old man presents", "rash", "oral lesions", "vision problems", "5 days", "rash started", "burning", "face", "upper part of", "torso", "red spots appeared", "same distribution", "spots", "size", "spread", "upper extremities", "patient", "spots", "painful", "associated pruritus", "painful oral lesions appeared", "same time", "rash", "past", "days", "double vision", "dry", "itchy", "reports", "mild upper respiratory infection", "days", "preceded", "current symptoms", "patient", "chills", "hematuria", "abdominal", "chest pain", "similar symptoms", "past", "Past medical history", "significant", "severe urinary tract infection diagnosed 3 weeks", "trimethoprim-sulfamethoxazole", "vital signs include", "temperature", "0", "blood pressure", "60 mm Hg", "respiratory rate 20 min", "pulse", "min", "patient", "severe painful erosions of", "oral mucosa", "multiple fluid", "vesicles", "bullae averaging 3 mm", "diameter", "surrounding erythematous ring", "only", "upper torso", "extensor surfaces", "upper extremities", "Several", "lesions", "ruptured", "resulting in sloughing", "epidermal layer", "prominent conjunctival injection present", "Ophthalmic examination reveals mild bilateral corneal", "ulceration", "Laboratory findings", "significant", "following", "blood cell", "count", "mm3 Red", "Hemoglobin", "g", "protein", "Urine", "blood cultures", "following", "confirm", "diagnosis", "patient"]}
{"question": "A 2-year-old boy is brought to the physician for the evaluation of fever, difficulty breathing, and coughing for the past week. In the past year, he has had four sinus infections, three upper respiratory tract infections, and an episode of severe bronchiolitis requiring hospitalization. Since birth, he has had multiple episodes of oral thrush treated with nystatin, as well as chronic diarrhea and failure to thrive. His temperature is 38.0°C (100.4°F), pulse is 130/min, respirations are 38/min, and blood pressure is 106/63 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Auscultation of the lungs show bilateral crackles and wheezing. Examination shows a prominent nasal bridge, hypoplastic wing of the nose, a shortened chin, and dysplastic ears. An x-ray of the chest shows hyperinflation of the lungs, interstitial infiltrates, and atelectasis. A nasopharyngeal aspirate test for respiratory syncytial virus (RSV) is positive. This patient most likely has a deficiency of which of the following?", "answer": "T cells", "options": {"A": "B cells", "B": "T cells", "C": "Interleukin-12 receptor", "D": "B and T cells", "E": "Leukocyte adhesion\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "brought", "physician", "fever", "difficulty breathing", "coughing", "past week", "past year", "four sinus infections", "three upper respiratory tract infections", "episode of severe bronchiolitis", "birth", "multiple episodes of oral thrush treated with nystatin", "chronic diarrhea", "failure to thrive", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "63 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "88", "Auscultation", "lungs", "bilateral crackles", "wheezing", "prominent nasal bridge", "hypoplastic wing of the nose", "shortened chin", "dysplastic ears", "x-ray of", "chest", "hyperinflation of", "lungs", "interstitial infiltrates", "atelectasis", "nasopharyngeal aspirate test", "positive", "patient", "likely", "deficiency"]}
{"question": "A morbidly obese 43-year-old man presents for elective bariatric surgery after previously failing several non-surgical weight loss plans. After discussing the risks and benefits of several different procedures, a sleeve gastrectomy is performed. During the surgery, the surgeon begins by incising into the right half of the greater curvature of the stomach. Which of the following arteries most likely directly provides the blood supply to this region of the stomach?", "answer": "Right gastroepiploic artery", "options": {"A": "Short gastric arteries", "B": "Splenic artery", "C": "Right gastric artery", "D": "Right gastroepiploic artery", "E": "Right gastroduodenal artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["obese", "year old man presents", "elective bariatric surgery", "failing several non-surgical weight loss plans", "benefits", "different procedures", "sleeve gastrectomy", "performed", "surgery", "surgeon begins", "the right half of", "greater curvature", "stomach", "following arteries", "likely directly", "blood supply", "region of", "stomach"]}
{"question": "A 5-year-old boy is brought in by his parents for recurrent abdominal pain. The child has been taken out of class 5 times this past week for abdominal pain that resulted in him being sent home. The mother reports that her son's stools have remained unchanged during this time and are brown in color, without blood, and with normal consistency and scent. She also notes that while at home he seems to be his usual self and does not complain of any symptoms. Of note she presents to you that she has been preparing her son's lunches which consist of couscous, vegetables, fried rice, and chicken. The patient denies difficulty with producing stool and does not complain of any functional pain. The child's vitals and labs including BMP and CBC are unremarkable and within normal limits. An abdominal exam is performed and there is no tenderness upon palpation, and the abdomen is soft and non-distended. After a conversation with the child exploring his symptoms, which of the following is the next step in management for this child?", "answer": "Begin cognitive behavioral therapy", "options": {"A": "Increase oral hydration and fiber intake", "B": "Check the stool for fecal red blood cells and leukocytes", "C": "Perform a stool culture", "D": "Begin treatment with ciprofloxacin", "E": "Begin cognitive behavioral therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["5 year old boy", "brought", "recurrent abdominal pain", "child", "past week", "abdominal pain", "resulted", "sent home", "reports", "stools", "unchanged", "time", "brown", "color", "blood", "normal consistency", "scent", "notes", "at home", "to", "usual", "not", "symptoms", "note", "presents", "lunches", "consist", "fried rice", "patient", "difficulty", "stool", "not", "functional pain", "child's", "labs including BMP", "CBC", "unremarkable", "normal limits", "abdominal exam", "performed", "tenderness", "palpation", "abdomen", "soft", "non distended", "child", "symptoms", "following", "next"]}
{"question": "A 40-year-old woman comes to the physician for the evaluation of a 4-month history of reddening of the nose and cheeks. She has no itching or pain. She first noticed the redness while on a recent holiday in Spain, where she stayed at the beach and did daily wine tastings. She has tried several brands of sunscreen, stopped going outside in the middle of the day, and has not drunk alcohol since her trip, but the facial redness persists. She has no history of serious illness. Her younger sister has acne vulgaris, and her mother has systemic lupus erythematosus. The patient reports that she has had a lot of stress lately due to relationship problems with her husband. She does not smoke. Her vital signs are within normal limits. Examination shows erythema of the nose, chin, and medial cheeks with scant papules and telangiectasias. There are no comedones or blisters. The remainder of the examination shows no abnormalities. In addition to behavioral modifications, which of the following is the most appropriate initial treatment?", "answer": "Topical metronidazole", "options": {"A": "Topical corticosteroids", "B": "Topical benzoyl peroxide", "C": "Oral isotretinoin", "D": "Oral hydroxychloroquine", "E": "Topical metronidazole"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "physician", "month history", "nose", "cheeks", "itching", "pain", "first", "redness", "recent", "Spain", "beach", "daily", "stopped", "outside", "middle", "day", "not drunk alcohol", "trip", "facial redness", "history", "serious illness", "acne vulgaris", "systemic lupus erythematosus", "patient reports", "lot", "stress", "due to relationship problems", "not smoke", "vital signs", "normal limits", "erythema", "nose", "chin", "medial cheeks", "scant papules", "telangiectasias", "comedones", "blisters", "abnormalities", "behavioral modifications", "following", "most appropriate initial treatment"]}
{"question": "A 25-year-old previously healthy woman presents to her PCP reporting cessation of menses for the past 6 months. Previously, her period occurred regularly, every 30 days. She also complains of decreased peripheral vision, most noticeably when she is driving her car. She denies any recent sexual activity and a pregnancy test is negative. Upon further work-up, what other physical findings may be discovered?", "answer": "Decreased bone density", "options": {"A": "Pregnancy", "B": "Breast mass", "C": "Decreased bone density", "D": "Enlarged thyroid", "E": "Renal failure"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "healthy woman presents", "PCP", "cessation of menses", "past 6 months", "period", "30 days", "decreased peripheral vision", "most", "car", "recent", "pregnancy test", "negative", "further work-up", "physical findings"]}
{"question": "A 13-year-old boy is brought to the physician because of bleeding from his lips earlier that day. He has a history of recurrent nosebleeds since childhood. His father has a similar history of recurrent nosebleeds. He is at the 60th percentile for height and weight. Examination shows multiple, small dilated capillaries over the lips, nose, and fingers. The remainder of the examination shows no abnormalities. Which of the following conditions is this patient at increased risk for?", "answer": "High-output cardiac failure", "options": {"A": "Glaucoma", "B": "Acute leukemia", "C": "Renal cell carcinoma", "D": "High-output cardiac failure", "E": "Gastrointestinal polyps"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "of bleeding", "lips earlier", "day", "history", "recurrent nosebleeds", "childhood", "similar history", "recurrent nosebleeds", "percentile", "height", "weight", "multiple", "small dilated capillaries", "lips", "nose", "fingers", "abnormalities", "following conditions", "patient", "increased risk"]}
{"question": "A 22-year-old G1P1 has an uncomplicated vaginal delivery and delivers a newborn boy at 39 + 1 weeks. The APGAR scores are 8 and 9 at 1 and 5 minutes, respectively. Shortly after the delivery, the child is put on his mother’s chest for skin-to-skin and the mother is encouraged to initiate breastfeeding. Which of the following cels produces the hormone responsible for establishing lactation during this process?", "answer": "Lactotropes", "options": {"A": "Gonadotropes", "B": "Thyrotropes", "C": "Lactotropes", "D": "Corticotropes", "E": "Somatotropes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old G1P1", "uncomplicated vaginal", "delivers", "newborn boy", "1 weeks", "APGAR scores", "5 minutes", "delivery", "child", "chest", "skin", "to initiate breastfeeding", "following cels", "hormone responsible", "establishing lactation", "process"]}
{"question": "A 28-year-old man presents to the physician because of dizziness and palpitations for the past 12 hours and fever, malaise, headache, and myalgias for the past week. The patient traveled into the woods of Massachusetts 4 weeks ago. He has no known chronic medical conditions, and there is no history of substance use. His temperature is 38.3°C (100.9°F), pulse is 52/min, respirations are 16/min, and blood pressure is 126/84 mm Hg. His physical examination shows a single, 10-cm, round, erythematous lesion with a bull’s-eye pattern in the right popliteal fossa. His electrocardiogram shows Mobitz I second-degree atrioventricular (AV) block. The complete blood cell count and serum electrolyte levels are normal, but the erythrocyte sedimentation rate is 35 mm/hour. What is the most likely cause of the patient’s cardiac symptoms?", "answer": " Spirochete infection", "options": {"A": "Mycoplasma infection", "B": " Spirochete infection", "C": "Systemic fungal infection", "D": "Viral infection transmitted by Aedes aegypti mosquito bite", "E": "Sexually transmitted bacterial infection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "physician", "dizziness", "palpitations", "past 12 hours", "fever", "malaise", "headache", "myalgias", "past week", "patient", "woods", "Massachusetts", "weeks", "known chronic medical conditions", "history of", "use", "temperature", "100 9F", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "single", "10", "round", "erythematous lesion", "bulls-eye pattern", "right popliteal fossa", "electrocardiogram", "Mobitz I second-degree", "block", "complete blood cell count", "serum electrolyte levels", "normal", "erythrocyte sedimentation rate", "35 mm hour", "most likely cause", "patients"]}
{"question": "A 4-year-old boy is presented to the clinic by his mother due to a peeling erythematous rash on his face, back, and buttocks which started this morning. Two days ago, the patient’s mother says his skin was extremely tender and within 24 hours progressed to desquamation. She also says that, for the past few weeks, he was very irritable and cried more than usual during diaper changes. The patient is up to date on his vaccinations and has been meeting all developmental milestones. No significant family history. On physical examination, the temperature is 38.4°C (101.1°F) and the pulse is 70/min. The epidermis separates from the dermis by gentle lateral stroking of the skin. Systemic antibiotics are prescribed, and adequate fluid replacement is provided. Which of the following microorganisms most likely caused this patient’s condition?", "answer": "Staphylococcus aureus", "options": {"A": "Neisseria meningitidis", "B": "Bacillus anthracis", "C": "Clostridium sp.", "D": "Streptococcus sp.", "E": "Staphylococcus aureus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["4 year old boy", "clinic", "due to", "peeling erythematous rash", "face", "back", "buttocks", "started", "morning", "Two days", "patients", "skin", "extremely tender", "24 hours progressed", "desquamation", "past", "weeks", "very irritable", "more", "usual", "diaper changes", "patient", "date", "vaccinations", "significant family history", "temperature", "pulse", "70 min", "epidermis separates", "dermis", "gentle lateral stroking", "Systemic", "adequate fluid replacement", "following", "likely caused", "patients condition"]}
{"question": "A 12-month-old boy presents for a routine checkup. The patient immigrated from the Philippines with his parents a few months ago. No prior immunization records are available. The patient’s mother claims that he had a series of shots at 6 months of age which gave him a severe allergic reaction with swelling of the tongue and the face. She also remembers that he had the same reaction when she introduced solid foods to his diet, including carrots, eggs, and bananas. Which of the following vaccinations are not recommended for this patient?", "answer": "Intramuscular influenza vaccine", "options": {"A": "Measles, mumps, and rubella (MMR) vaccine", "B": "Intramuscular influenza vaccine", "C": "Varicella vaccine", "D": "Intranasal influenza vaccine", "E": "Hepatitis B vaccine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old boy presents", "routine checkup", "patient", "Philippines", "few months", "prior", "available", "patients", "series", "shots", "months", "age", "gave", "severe allergic", "swelling of", "tongue", "face", "same reaction", "introduced solid", "including", "following vaccinations", "not", "patient"]}
{"question": "A 37-year-old man is brought to the emergency department by a friend after he was found lying unconscious outside his front door. The friend reports that they were “pretty drunk” the previous night, and she had dropped her friend off at his home and driven off. When she came back in the morning, she found him passed out on the ground next to the doorstep. On arrival, he is conscious and cooperative. He reports feeling cold, with severe pain in his hands and face. He remembers having lost his gloves last night. His rectal temperature is 35.2°C (95.3°F), pulse is 86/min, respirations are 17/min, and blood pressure is 124/58 mm Hg. Examination shows decreased sensations over the distal fingers, which are cold to touch. The skin over the distal phalanges is cyanotic, hard, waxy, and tender, with surrounding edema. Laboratory studies are within the reference range. An x-ray of the chest and ECG show no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Immersion of affected extremities in warm water", "options": {"A": "Debridement of the affected tissue", "B": "Intra-arterial administration of tissue plasminogen activator", "C": "Intravenous administration of warmed crystalloid", "D": "Intravenous administration of antibiotics", "E": "Immersion of affected extremities in warm water"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "found lying unconscious outside", "front door", "reports", "drunk", "previous night", "home", "back", "morning", "found", "passed out", "next to", "arrival", "reports feeling cold", "severe", "hands", "face", "lost", "gloves last night", "rectal temperature", "35", "95", "pulse", "min", "respirations", "min", "blood pressure", "58 mm Hg", "decreased sensations", "distal fingers", "cold to touch", "skin", "distal phalanges", "cyanotic", "hard", "waxy", "tender", "surrounding edema", "Laboratory studies", "reference range", "x-ray of", "chest", "ECG", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 16-year-old woman presents to the emergency department for evaluation of acute vomiting and abdominal pain. Onset was roughly 3 hours ago while she was sleeping. She has no known past medical history. Her family history is positive for hypothyroidism and diabetes mellitus in her maternal grandmother. On examination, she is found to have fruity breath and poor skin turgor. She appears fatigued and her consciousness is slightly altered. Laboratory results show a blood glucose level of 691 mg/dL, sodium of 125 mg/dL, and elevated serum ketones. Of the following, which is the next best step in patient management?", "answer": "Administer IV fluids and insulin", "options": {"A": "Administer IV fluids and insulin", "B": "Discontinue metformin; initiate basal-bolus insulin", "C": "Discontinue metformin; initiate insulin aspart at mealtimes", "D": "Discontinue sitagliptin; initiate basal-bolus insulin", "E": "Discontinue metformin; initiate insulin glargine 10 units at bedtime"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "acute vomiting", "abdominal", "Onset", "hours", "sleeping", "known past medical history", "family history", "positive", "hypothyroidism", "diabetes mellitus", "found to", "fruity breath", "poor skin turgor", "appears fatigued", "consciousness", "slightly altered", "Laboratory results", "blood glucose level", "mg/dL", "sodium", "mg/dL", "elevated serum ketones", "following", "next best step", "patient"]}
{"question": "A 4-year-old African-American girl is brought to the physician because of multiple episodes of bilateral leg pain for 4 months. The pain is crampy in nature, lasts up to an hour, and occurs primarily before her bedtime. Occasionally, she has woken up crying because of severe pain. The pain is reduced when her mother massages her legs. She has no pain while attending school or playing. Her mother has rheumatoid arthritis. The patient's temperature is 37°C (98.6°F), pulse is 90/min and blood pressure is 94/60 mm Hg. Physical examination shows no abnormalities. Her hemoglobin concentration is 12.1 g/dL, leukocyte count is 10,900/mm3 and platelet count is 230,000/mm3. Which of the following is the most appropriate next best step in management?", "answer": "Reassurance", "options": {"A": "Antinuclear antibody", "B": "Pramipexole therapy", "C": "Nafcillin therapy", "D": "X-ray of the lower extremities", "E": "Reassurance"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old", "girl", "brought", "physician", "of multiple episodes", "bilateral leg pain", "4 months", "pain", "crampy", "nature", "lasts", "hour", "occurs", "bedtime", "Occasionally", "woken up", "severe pain", "pain", "reduced", "massages", "legs", "pain", "attending school", "playing", "rheumatoid arthritis", "patient's temperature", "98", "pulse", "90 min", "blood pressure", "60 mm Hg", "abnormalities", "hemoglobin concentration", "g/dL", "leukocyte count", "10 900 mm3", "platelet count", "mm3", "following", "most appropriate next best step"]}
{"question": "A 37-year-old man makes an appointment with his primary care physician because he has been feeling tired and is no longer able to play on a recreational soccer team. He also says his coworkers have commented that he appears pale though he has not noticed any changes himself. He says that he has been generally healthy and that the only notable event that happened in the last year is that he went backpacking all over the world. Based on clinical suspicion, a series of blood tests are performed with partial results presented below:\n\nHemoglobin: 9.8 g/dL\nPlatelet count: 174,000/mm^3\nMean corpuscular volume: 72 µm^3 (normal: 80-100 µm^3)\nIron: 22 µg/dL (normal: 50-170 µg/dL)\nFerritin: 8 ng/mL (normal: 15-200 ng/mL)\nLactate dehydrogenase: 57 U/L (normal: 45-90 U/L)\nUrine hemoglobin: absent\n\nInfection with which of the following types of organisms could lead to this pattern of findings?", "answer": "Nematode", "options": {"A": "Double-stranded virus", "B": "Nematode", "C": "Mosquito-born protozoa", "D": "Single-stranded virus", "E": "Tick-born protozoa"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man makes", "appointment", "primary care physician", "tired", "longer able to play", "appears pale", "not", "changes", "healthy", "only notable event", "year", "Based", "clinical", "series", "blood tests", "performed", "Hemoglobin", "g/dL Platelet count", "mm", "Mean corpuscular volume", "72 m", "normal", "80 100 m", "Iron", "g/dL", "normal", "50", "g/dL", "Ferritin", "ng/mL", "normal", "200 ng/mL", "Lactate dehydrogenase", "57 U/L", "normal", "90 U/L", "Urine hemoglobin", "absent", "Infection", "following types", "organisms", "lead", "pattern", "findings"]}
{"question": "A 53-year-old male presents to your office for a regularly scheduled check-up. The patient was diagnosed with type II diabetes mellitus two years ago. To date, diet, exercise, and metformin have failed to control his elevated blood glucose. Past medical history is also significant for hypertension. The patient does not smoke or use cigarettes. Laboratory values show a hemoglobin A1c (HbA1c) of 8.5%. You decide to add sitagliptin to the patient’s medication regimen. Which of the following is the direct mechanism of action of sitagliptin?", "answer": "Inhibits degradation of endogenous incretins", "options": {"A": "Inhibits degradation of endogenous incretins", "B": "Inhibits alpha-glucosidases at the intestinal brush border", "C": "Activates transcription of PPARs to increase peripheral sensitivity to insulin", "D": "Depolarizes potassium channels in pancreatic beta cells", "E": "Increases secretion of insulin in response to oral glucose loads and delays gastric emptying"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "office", "scheduled check-up", "patient", "diagnosed", "type II diabetes mellitus two years", "date", "diet", "exercise", "metformin", "failed to control", "elevated blood glucose", "Past medical history", "significant", "hypertension", "patient", "not smoke", "use cigarettes", "Laboratory values", "a hemoglobin A1c", "8.5", "to add sitagliptin", "patients medication regimen", "following", "direct mechanism of action", "sitagliptin"]}
{"question": "A 67-year-old woman presents with her husband because of left leg pain and swelling of 3 days’ duration. He has a history of type 2 diabetes mellitus and recent hospitalization for congestive heart failure exacerbation. On physical examination, the left calf is 4 cm greater in circumference than the right. Pitting edema is present on the left leg and there are superficial dilated veins. Venous duplex ultrasound shows an inability to fully compress the lumen of the profunda femoris vein. Which of the following is the most likely diagnosis?", "answer": "Deep venous thrombosis", "options": {"A": "Superficial venous thrombophlebitis", "B": "Erythema nodosum", "C": "Lymphangitis", "D": "Deep venous thrombosis", "E": "Ruptured popliteal cyst"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old woman presents", "left leg pain", "swelling", "3 days duration", "history of type 2 diabetes mellitus", "recent hospitalization", "congestive exacerbation", "left calf", "4", "greater", "circumference", "right", "Pitting edema", "present", "left leg", "superficial dilated", "duplex ultrasound", "compress", "lumen of", "profunda femoris vein", "following", "diagnosis"]}
{"question": "A 52-year-old woman presents to the emergency room complaining of chest pain. She reports a 4-hour history of dull substernal pain radiating to her jaw. Her history is notable for hypertension, diabetes mellitus, and alcohol abuse. She has a 30 pack-year smoking history and takes lisinopril and metformin but has an allergy to aspirin. Her temperature is 99.1°F (37.3°C), blood pressure is 150/90 mmHg, pulse is 120/min, and respirations are 22/min. Physical examination reveals a diaphoretic and distressed woman. An electrocardiogram reveals ST elevations in leads I, aVL, and V5-6. She is admitted with plans for immediate transport to the catheterization lab for stent placement. What is the mechanism of the next medication that should be given to this patient?", "answer": "ADP receptor inhibitor", "options": {"A": "Thrombin inhibitor", "B": "Phosphodiesterase activator", "C": "Vitamin K epoxide reductase inhibitor", "D": "ADP receptor inhibitor", "E": "Cyclooxygenase activator"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency room", "of chest pain", "reports", "4-hour history", "dull substernal pain radiating", "jaw", "history", "notable", "hypertension", "diabetes mellitus", "alcohol abuse", "30", "smoking history", "lisinopril", "metformin", "allergy", "aspirin", "temperature", "99", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "reveals", "diaphoretic", "woman", "electrocardiogram reveals ST elevations", "leads I", "aVL", "plans", "immediate transport", "catheterization lab", "stent placement", "mechanism", "next medication", "given", "patient"]}
{"question": "A 72-year-old woman presents with left lower limb swelling. She first noticed her left leg was swollen about 2 weeks ago. She denies any pain and initially thought the swelling would subside on its own. Past medical history is significant for hypertension and hyperlipidemia. She is a smoker with a 35 pack-year history and an occasional drinker. She takes chlorthalidone, lisinopril, atorvastatin and a multivitamin. On physical examination, her left leg appears larger than her right with 2+ pitting edema up to her knee. She also has a few distended superficial veins along the posterior aspect of her left leg. Lower extremities have 2+ pulses bilaterally. The ultrasound of her left lower thigh and leg shows an obstructing thrombosis of the distal portion of the femoral vein. Which of the following veins help to prevent this patient’s condition from happening?", "answer": "Perforator veins", "options": {"A": "Giacomini vein", "B": "Perforator veins", "C": "Accessory saphenous vein", "D": "Deep femoral vein", "E": "Fibular vein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old woman presents", "left lower limb swelling", "first", "left leg", "swollen", "2 weeks", "pain", "initially", "swelling", "Past medical history", "significant", "hypertension", "hyperlipidemia", "smoker", "35", "history", "occasional drinker", "chlorthalidone", "lisinopril", "atorvastatin", "multivitamin", "left leg appears larger", "right", "2", "pitting edema", "knee", "few distended superficial veins", "posterior", "of", "left leg", "Lower extremities", "2", "pulses", "ultrasound of", "left lower thigh", "leg", "obstructing thrombosis of", "distal portion", "femoral vein", "following veins help to prevent", "patients condition"]}
{"question": "A 22-year-old man comes to the physician because of headaches and blurry vision for the past 6 months. He also reports frequent episodes of vomiting over the last month. His father has died of renal cell carcinoma at the age of 37 years. Examination shows 20/40 vision bilaterally. Fundoscopic examination shows bilateral optic disc swelling and growth of capillary vessels in the temporal peripheral retina. An MRI of the brain shows an infratentorial mass. The patient undergoes surgical resection of the mass. A photomicrograph of the resected specimen is shown. Which of the following is the most likely diagnosis?", "answer": "Hemangioblastoma", "options": {"A": "Medulloblastoma", "B": "Glioblastoma", "C": "Oligodendroglioma", "D": "Hemangioblastoma", "E": "Ependymoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "headaches", "blurry vision", "past 6 months", "reports frequent episodes of vomiting", "last month", "died", "renal cell carcinoma", "age", "years", "20/40 vision", "Fundoscopic examination", "bilateral optic disc swelling", "growth", "capillary vessels", "temporal peripheral retina", "MRI of", "brain", "infratentorial mass", "patient", "surgical", "mass", "photomicrograph", "resected", "following", "diagnosis"]}
{"question": "A 30-year-old man presents to his psychiatrist for a follow-up visit. He was diagnosed with schizophrenia 6 months ago and has been taking fluphenazine. He says that his symptoms are well controlled by the medication, and he no longer has auditory hallucinations. The psychiatrist also notes that his delusions and other psychotic symptoms have improved significantly. However, the psychiatrist notices something while talking to the patient that prompts him to say, “I know the drug has effectively controlled your symptoms but I think you should discontinue it now otherwise this side effect is likely to be irreversible.” Which of the following did the psychiatrist most likely notice in this patient?", "answer": "Choreoathetoid movements of face", "options": {"A": "Resting tremors", "B": "Crossing and uncrossing legs constantly", "C": "Reduced spontaneous movements while walking ", "D": "Involuntary sustained twisting of neck", "E": "Choreoathetoid movements of face"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["30 year old man presents", "psychiatrist", "diagnosed", "schizophrenia 6 months", "fluphenazine", "symptoms", "well controlled by", "medication", "longer", "auditory hallucinations", "psychiatrist", "notes", "delusions", "psychotic symptoms", "improved", "psychiatrist", "prompts", "to", "I", "drug", "controlled", "symptoms", "I", "discontinue", "now", "side effect", "likely to", "following", "psychiatrist", "likely", "patient"]}
{"question": "An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?", "answer": "Amputate the child’s arm at the elbow joint", "options": {"A": "Amputate the child’s arm at the elbow joint", "B": "Wait for the child to gain consciousness to obtain his consent to amputate his arm", "C": "Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm", "D": "Find the child’s parents to obtain consent to amputate the child’s arm", "E": "Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "year old", "brought", "emergency department", "severe injuries caused", "motor vehicle accident", "child", "wheeled", "pediatric intensive care unit", "severe injury", "right", "external", "internal injuries", "hemorrhaging", "found to", "unstable", "transfusion", "surgery", "currently unconscious", "pediatric trauma", "childs arm", "need to", "amputated", "elbow", "following", "most appropriate course", "action to", "amputation"]}
{"question": "A 55-year-old man comes to the physician because of difficulties achieving an erection for the past year. A medication is prescribed that inhibits cyclic GMP phosphodiesterase type 5. Which of the following is the most likely site of action of the prescribed drug?", "answer": "Corpus cavernosum", "options": {"A": "Corpus cavernosum", "B": "Prostate smooth muscle", "C": "Corpus spongiosum", "D": "Pelvic splanchnic nerves", "E": "Pudendal nerve"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "difficulties", "erection", "past year", "medication", "inhibits cyclic GMP phosphodiesterase type 5", "following", "site of action", "drug"]}
{"question": "A 65-year-old woman undergoes an abdominal hysterectomy. She develops pain and discharge at the incision site on the fourth postoperative day. The past medical history is significant for diabetes of 12 years duration, which is well-controlled on insulin. Pus from the incision site is sent for culture on MacConkey agar, which shows white-colorless colonies. On blood agar, the colonies were green. Biochemical tests reveal an oxidase-positive organism. Which of the following is the most likely pathogen?", "answer": "Pseudomonas aeruginosa", "options": {"A": "Staphylococcus aureus", "B": "Staphylococcus epidermidis", "C": "Enterococcus faecalis", "D": "Streptococcus pyogenes", "E": "Pseudomonas aeruginosa"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["65 year old woman", "abdominal hysterectomy", "pain", "discharge", "incision site", "fourth postoperative day", "past medical history", "significant", "diabetes", "years duration", "well-controlled", "insulin", "Pus", "incision site", "sent", "culture", "MacConkey agar", "white colorless colonies", "colonies", "green", "Biochemical tests reveal", "oxidase positive", "following"]}
{"question": "A 40-year-old woman comes to the emergency department because of difficulty walking for the past 4 hours. She first noticed her symptoms after getting up this morning and her foot dragging while walking. She feels tired. She has a history of chronic sinusitis. Six months ago, she was diagnosed with asthma. Current medications include an albuterol inhaler and inhaled corticosteroids. Her temperature is 38.9°C (102°F), pulse is 80/min, and her blood pressure is 140/90 mm Hg. Auscultation of her lungs shows diffuse wheezing over bilateral lung fields. Physical examination shows tender subcutaneous nodules on the extensor surfaces of the elbows. There are palpable, non-blanching erythematous lesions on both shins. Dorsiflexion of the right foot is impaired. Sensation to pinprick, light touch, and vibration is decreased over the ulnar aspect of the left forearm. Laboratory studies show:\nHemoglobin 11.3 g/dL\nLeukocyte count 24,500\nSegmented neutrophils 48%\nEosinophils 29%\nLymphocytes 19%\nMonocytes 4%\nPlatelet count 290,000/mm3\nSerum\nUrea nitrogen 32 mg/dL\nCreatinine 1.85 mg/dL\nUrine\nBlood 2+\nProtein 3+\nWhich of the following is the most likely diagnosis in this patient?\"", "answer": "Eosinophilic granulomatosis with polyangiitis\n\"", "options": {"A": "Granulomatosis with polyangiitis", "B": "Goodpasture syndrome", "C": "Henoch-Schönlein purpura", "D": "Excessive glucocorticoid use", "E": "Eosinophilic granulomatosis with polyangiitis\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "emergency department", "of difficulty walking", "past", "hours", "first", "symptoms", "getting", "morning", "foot dragging", "tired", "history", "chronic sinusitis", "Six months", "diagnosed", "asthma", "Current medications include", "albuterol inhaler", "inhaled corticosteroids", "temperature", "pulse", "80 min", "blood pressure", "90 mm Hg", "Auscultation", "lungs", "diffuse wheezing", "bilateral lung fields", "tender subcutaneous nodules", "extensor surfaces of", "elbows", "palpable", "non blanching erythematous lesions", "shins", "Dorsiflexion", "right foot", "impaired", "Sensation", "light touch", "vibration", "decreased", "ulnar aspect", "left forearm", "Laboratory studies", "g dL Leukocyte count", "500", "neutrophils", "29", "19", "Platelet count", "mm3", "mg dL", "Protein", "following", "diagnosis", "patient"]}
{"question": "A 21-year-old medical student is studying different types of necrosis and tissue injuries. In the pathology laboratory, he observes different dead tissues under the microscope and notices the changes that are occurring as a function of time. After serial observations, he deduced that coagulation necrosis is...?", "answer": "Characterized by the preservation of cellular shape", "options": {"A": "The result of denaturation of glucose", "B": "The result of hydrolytic enzymes", "C": "Characterized by the preservation of cellular shape", "D": "Characteristic of brain ischemia", "E": "Commonly associated with acute pancreatic necrosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["21-year-old medical student", "studying", "necrosis", "tissue injuries", "pathology laboratory", "observes different dead tissues", "microscope", "changes", "occurring", "function", "time", "serial observations", "coagulation necrosis"]}
{"question": "A 35-year-old male presents to the emergency room with difficulty breathing. He is accompanied by his wife who reports that they were eating peanuts while lying in bed on their backs when he suddenly started coughing profusely. He has a significant cough and has some trouble breathing. His past medical history is notable for obesity, obstructive sleep apnea, seasonal allergies, and alcohol abuse. He uses a continuous positive airway pressure machine nightly. His medications include cetirizine and fish oil. He has a 10 pack-year smoking history. His temperature is 98.6°F (37°C), blood pressure is 125/30 mmHg, pulse is 110/min, and respirations are 23/min. Which of the following lung segments is most likely affected in this patient?", "answer": "Superior segment of right inferior lobe", "options": {"A": "Inferior segment of left inferior lobe", "B": "Anterior segment of right superior lobe", "C": "Inferior segment of right inferior lobe", "D": "Superior segment of right inferior lobe", "E": "Posterior segment of right superior lobe"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old male presents", "emergency room", "difficulty breathing", "reports", "eating", "lying in bed", "backs", "started coughing", "significant cough", "trouble breathing", "past medical history", "notable", "obesity", "obstructive sleep apnea", "seasonal allergies", "alcohol abuse", "uses", "continuous positive airway pressure machine", "medications include cetirizine", "fish oil", "a 10", "smoking history", "temperature", "98", "blood pressure", "30 mmHg", "pulse", "min", "respirations", "23 min", "of", "following lung segments", "most likely affected", "patient"]}
{"question": "A 28-year-old woman, gravida 1, para 0, at 10 weeks gestation comes to the physician for her first prenatal visit. Today, she feels well. She has no history of serious illness. Her pulse is 75/min and blood pressure is 110/74 mm Hg. Examination shows no abnormalities. Ultrasonography shows a pregnancy consistent in size with a 10-week gestation. Serum studies in this patient are most likely to show which of the following sets of laboratory values?\n $$$ Thyroid-binding globulin %%% Free Triiodothyronine (T3) %%% Free Thyroxine (T4) %%% Total T3+T4 $$$", "answer": "↑ normal normal ↑", "options": {"A": "↑ normal normal ↑", "B": "↓ normal normal ↓", "C": "Normal normal normal normal", "D": "Normal ↑ ↑ ↑", "E": "↓ ↓ normal ↓"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "10 weeks gestation", "physician", "Today", "well", "history", "serious illness", "pulse", "75 min", "blood pressure", "74 mm Hg", "abnormalities", "Ultrasonography", "pregnancy", "size", "a 10 week gestation", "Serum studies", "patient", "to", "following sets", "laboratory values", "Thyroid", "globulin", "Free Triiodothyronine", "Free Thyroxine", "Total T3"]}
{"question": "A 4-day-old boy is monitored in the well baby nursery. He was born to a G1P1 mother at 36 weeks gestation. The child is doing well, and the mother is recovering from vaginal delivery. On physical exam, there is an arousable infant who is crying vigorously and is mildly cyanotic. A red reflex is noted bilaterally on ophthalmologic exam. The infant's fontanelle is soft, and his sucking reflex is present. A positive Babinski sign is noted on physical exam bilaterally. A continuous murmur is auscultated on cardiac exam. Which of the following would most likely have prevented the abnormal finding in this infant?", "answer": "Indomethacin", "options": {"A": "Betamethasone", "B": "Delivery at 40 weeks gestation", "C": "Folic acid", "D": "Indomethacin", "E": "Prostaglandins"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["4 day old boy", "monitored", "well baby nursery", "born", "G1P1", "36 weeks gestation", "child", "well", "recovering from vaginal delivery", "infant", "vigorously", "mildly cyanotic", "red reflex", "noted", "ophthalmologic exam", "infant's fontanelle", "soft", "sucking reflex", "present", "positive Babinski sign", "noted", "continuous murmur", "following", "most likely", "prevented", "abnormal finding", "infant"]}
{"question": "A 17-year-old girl is brought to the physician for the evaluation of fatigue for the past 6 months. During this period, she has had a 5-kg (11-lbs) weight loss. She states that she has no friends. When she is not in school, she spends most of her time in bed. She has no history of serious illness. Her mother has major depressive disorder. She appears pale and thin. She is at 25th percentile for height, 10th percentile for weight, and 20th percentile for BMI; her BMI is 19.0. Her temperature is 37°C (98.6°F), pulse is 65/min, and blood pressure is 110/70 mm Hg. Examination shows dry skin, brittle nails, and calluses on the knuckles. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.3 g/dL\nSerum\nNa+ 133 mEq/L\nCl- 90 mEq/L\nK+ 3.2 mEq/L\nHCO3- 30 mEq/L\nCa+2 7.8 mg/dL\nWhich of the following is the most likely diagnosis?\"", "answer": "Bulimia nervosa", "options": {"A": "Anemia", "B": "Milk-alkali syndrome", "C": "Anorexia nervosa", "D": "Major depressive disorder", "E": "Bulimia nervosa"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "fatigue", "past 6 months", "period", "5 kg", "lbs", "weight loss", "states", "not", "school", "spends most of", "time", "bed", "history", "serious illness", "major depressive disorder", "appears pale", "thin", "percentile", "height", "percentile", "weight", "percentile", "BMI", "BMI", "0", "temperature", "98", "pulse", "65 min", "blood pressure", "70 mm Hg", "dry skin", "brittle nails", "calluses", "knuckles", "abnormalities", "Laboratory studies", "Hemoglobin", "g dL Serum", "mEq/L Cl", "90", "HCO3", "mg dL", "following", "diagnosis"]}
{"question": "A study is performed to determine the prevalence of a particular rare fungal pneumonia. A sample population of 100 subjects is monitored for 4 months. Every month, the entire population is screened and the number of new cases is recorded for the group. The data from the study are given in the table below:\nTime point New cases of fungal pneumonia\nt = 0 months 10\nt = 1 months 4\nt = 2 months 2\nt = 3 months 5\nt = 4 months 4\nWhich of the following is correct regarding the prevalence of this rare genetic condition in this sample population?", "answer": "The prevalence at the conclusion of the study is 25%.", "options": {"A": "The prevalence at time point 2 months is 2%.", "B": "The prevalence at time point 3 months is 11%.", "C": "The prevalence at the conclusion of the study is 15%.", "D": "The prevalence and the incidence at time point 2 months are equal.", "E": "The prevalence at the conclusion of the study is 25%."}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["study", "performed to", "prevalence", "rare fungal pneumonia", "population", "100 subjects", "monitored", "months", "month", "entire population", "screened", "number", "new cases", "recorded", "group", "given", "table", "Time point New cases", "fungal pneumonia", "0 months 10", "5", "following", "correct", "prevalence", "rare genetic", "population"]}
{"question": "A 53-year-old woman comes to the physician because of a 3-year history of increasing weakness of her extremities and neck pain that is worse on coughing or sneezing. She first noticed weakness of her right upper extremity 3 years ago, which progressed to her right lower extremity 2 years ago, her left lower extremity 1 year ago, and her left upper extremity 6 months ago. She has had difficulty swallowing and speaking for the past 5 months. Vital signs are within normal limits. Examination shows an ataxic gait. Speech is dysarthritic. Muscular examination shows spasticity and muscle strength is decreased in all extremities. There is bilateral atrophy of the sternocleidomastoid and trapezius muscles. Deep tendon reflexes are 4+ bilaterally. Plantar response shows an extensor response bilaterally. Sensation is decreased below the C5 dermatome bilaterally. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Foramen magnum meningioma", "options": {"A": "Foramen magnum meningioma", "B": "Cerebellar astrocytoma", "C": "Amyotrophic lateral sclerosis", "D": "Multiple sclerosis", "E": "Cerebral glioblastoma multiforme\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "3 year history", "increasing weakness", "extremities", "neck pain", "worse", "coughing", "sneezing", "first", "weakness", "right upper extremity", "years", "progressed", "right lower extremity", "years", "left lower extremity", "year", "left upper extremity", "months", "difficulty swallowing", "past", "months", "Vital signs", "normal limits", "ataxic gait", "Speech", "Muscular", "spasticity", "muscle strength", "decreased", "extremities", "bilateral atrophy", "sternocleidomastoid", "trapezius muscles", "Deep tendon reflexes", "4", "Plantar response", "extensor response", "Sensation", "decreased", "C5 dermatome", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 3-year-old girl is brought to her pediatrician because of a nosebleed that will not stop. Her parents say that she started having a nosebleed about 1 hour prior to presentation. Since then they have not been able to stop the bleeding. Her past medical history is remarkable for asthma, and she has a cousin who has been diagnosed with hemophilia. Physical exam reveals diffuse petechiae and purpura. A panel of bleeding tests are obtained with the following results:\n\nBleeding time: 11 minutes\nProthrombin time: 14 seconds\nPartial thromboplastin time: 32 seconds\nPlatelet count: 195,000/mm^3\n\nPeripheral blood smear shows normal cell morphology. Which of the following characteristics is most likely true about this patient?", "answer": "Mutation in glycoprotein IIb/IIIa", "options": {"A": "Decreased levels of von Willebrand factor", "B": "Mutation in glycoprotein Ib", "C": "Mutation in glycoprotein IIb/IIIa", "D": "Production of anti platelet antibodies", "E": "Production of antibodies against ADAMTS13"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old girl", "brought", "pediatrician", "nosebleed", "not stop", "started", "nosebleed", "hour", "Since then", "not", "able to stop", "bleeding", "past medical history", "asthma", "diagnosed", "hemophilia", "reveals diffuse petechiae", "purpura", "panel", "bleeding tests", "obtained", "following results", "Bleeding time", "minutes Prothrombin time", "seconds Partial thromboplastin time", "seconds Platelet count", "mm", "Peripheral blood smear", "normal cell morphology", "following characteristics", "true", "patient"]}
{"question": "A 57-year-old man presents to his primary care physician with a 2-month history of right upper and lower extremity weakness. He noticed the weakness when he started falling far more frequently while running errands. Since then, he has had increasing difficulty with walking and lifting objects. His past medical history is significant only for well-controlled hypertension, but he says that some members of his family have had musculoskeletal problems. His right upper extremity shows forearm atrophy and depressed reflexes while his right lower extremity is hypertonic with a positive Babinski sign. Which of the following is most likely associated with the cause of this patient's symptoms?", "answer": "Mutation in SOD1", "options": {"A": "HLA-B8 haplotype", "B": "HLA-DR2 haplotype", "C": "Mutation in SOD1", "D": "Mutation in SMN1", "E": "Viral infection"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["57 year old man presents", "primary care physician", "2 month history", "right upper", "lower extremity weakness", "weakness", "started falling far", "frequently", "then", "increasing difficulty", "walking", "past medical history", "significant only", "well", "musculoskeletal problems", "right upper extremity", "forearm atrophy", "depressed reflexes", "right lower extremity", "positive Babinski sign", "following", "most likely associated", "cause", "patient's symptoms"]}
{"question": "A 56-year-old African American presents to the emergency department due to abdominal pain, fatigue, and weight loss over the past 3 months. He has a long-standing history of chronic hepatitis B virus infection complicated by cirrhosis. On examination, he has jaundice, leg edema, and a palpable mass in the right upper abdominal quadrant. Abdominal ultrasound shows a 3-cm liver mass with poorly defined margins and coarse, irregular internal echoes. Lab results are shown:\nAspartate aminotransferase (AST) 90 U/L\nAlanine aminotransferase (ALT) 50 U/L\nTotal bilirubin 2 mg/dL\nAlbumin 3 g/dL\nAlkaline phosphatase 100 U/L\nAlpha fetoprotein 600 micrograms/L\nWhich of the following is a feature of this patient's condition?", "answer": "It arises from hepatocytes", "options": {"A": "Liver biopsy is required for diagnosis in a majority of patients", "B": "It arises from the bile duct epithelium", "C": "It arises from hepatocytes", "D": "Daughter cysts are usually present on abdominal ultrasound", "E": "Doppler blood flow shows venous pattern"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "presents", "emergency department", "abdominal pain", "fatigue", "a long standing history of", "hepatitis B virus infection complicated", "cirrhosis", "jaundice", "leg edema", "palpable mass", "right upper abdominal quadrant", "ultrasound", "3", "liver mass", "poorly", "margins", "coarse", "irregular internal echoes", "Lab results", "Aspartate aminotransferase", "AST", "90 U/L Alanine aminotransferase", "ALT", "U/L Total bilirubin", "mg/dL Albumin", "phosphatase", "Alpha fetoprotein", "following", "feature", "patient's"]}
{"question": "A 6-year-old boy presents to the office to establish care after recently being assigned to a shelter run by the local child protective services authority. The nurse who performed the vitals and intake says that, when offered an age-appropriate book to read while waiting for the physician, the patient said that he has never attended a school of any sort and is unable to read. He answers questions with short responses and avoids eye contact for most of the visit. His father suffers from alcoholism and physically abused the patient’s mother. Physical examination is negative for any abnormal findings, including signs of fracture or bruising. Which of the following types of abuse has the child most likely experienced?", "answer": "Child neglect", "options": {"A": "Corrupting", "B": "Child neglect", "C": "No abuse", "D": "Active abuse", "E": "Passive abuse"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "office to establish", "recently", "assigned", "shelter run", "local", "nurse", "performed", "intake", "offered", "age appropriate", "to", "waiting", "physician", "patient", "never attended", "school", "sort", "unable to", "short responses", "suffers", "alcoholism", "abused", "patients", "Physical examination", "negative", "abnormal", "including signs", "fracture", "bruising", "following types", "abuse", "child", "likely"]}
{"question": "Researchers are investigating oncogenes, specifically the KRAS gene that is associated with colon, lung, and pancreatic cancer. They have established that the gain-of-function mutation in this gene increases the chance of cancer development. They are also working to advance the research further to study tumor suppressor genes. Which of the genes below is considered a tumor suppressor gene?", "answer": "Rb", "options": {"A": "JAK2", "B": "Her2/neu", "C": "Rb", "D": "BRAF", "E": "BCL-2"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Researchers", "investigating oncogenes", "KRAS gene", "associated with colon", "lung", "pancreatic cancer", "established", "gene increases", "chance", "cancer development", "to advance", "further to study tumor suppressor genes", "genes", "tumor suppressor gene"]}
{"question": "The success of a new treatment designed to deter people from smoking was evaluated by a team of researchers. However, the heaviest and most committed smokers in the study group were less interested in quitting and subsequently dropped out of the study. Nonetheless, the researchers continued with their research (disregarding those who dropped out), which resulted in a false conclusion that the treatment was more successful than the results would have shown under ideal study conditions. The smokers who were confirmed as quitters were actually the ones who were more interested in giving up smoking, which is why they remained in the study. Which of the following is the bias that invalidates the researchers’ conclusion in this example?", "answer": "Attrition bias", "options": {"A": "Ascertainment bias", "B": "Non-response bias", "C": "Exclusion bias", "D": "Detection bias", "E": "Attrition bias"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["success", "new treatment", "to", "smoking", "researchers", "heaviest", "committed smokers", "less", "out", "study", "researchers", "out", "resulted", "false", "treatment", "more successful", "results", "ideal study conditions", "smokers", "confirmed", "ones", "more", "study", "following", "researchers"]}
{"question": "A 45-year-old man presents to the emergency department with complaint off dizziness and nausea for the past hour. He says that he can feel his heartbeat racing. He also reports of generalized weakness that began in the morning. He was diagnosed with end-stage renal disease 2 years ago and currently on dialysis, but he missed his last dialysis session. He has also been diabetic for the past 15 years and managed with insulin, and was also diagnosed with celiac disease 8 years ago. He does not smoke or drink alcohol. The family history is insignificant. The temperature is 36.7°C (98.0°F), blood pressure is 145/90 mm Hg, pulse is 87/min, and respiratory rate is 14/min. On physical examination, the patient looks fatigued and exhausted. The muscle strength in the lower limbs is 4/5 bilaterally. An ECG is ordered which shows peaked and narrow T waves and prolongation of PR interval. The lab test results are as follows:\nSerum Sodium 132 mEq/L\nSerum Potassium 8 mEq/L\nSerum Creatinine 5 mg/dL\nBlood urea nitrogen (BUN) 25 mg/dL\nWhat is the mechanism of action of the most likely initial treatment for the patient’s condition?\n ", "answer": "Antagonizes the membrane action of hyperkalemia", "options": {"A": "Blocks Na+/K+ ATPase", "B": "Antagonizes the membrane action of hyperkalemia", "C": "Blocks B adrenergic receptors", "D": "Prevents platelet aggregation", "E": "Increase potassium loss from the gastrointestinal tract"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "complaint", "dizziness", "nausea", "past hour", "heartbeat", "reports", "generalized weakness", "began", "morning", "diagnosed", "end-stage renal disease", "years", "currently", "dialysis", "missed", "last dialysis", "diabetic", "past", "years", "insulin", "diagnosed", "celiac disease", "years", "not smoke", "family history", "temperature", "36", "98", "blood pressure", "90 mm Hg", "pulse", "87 min", "respiratory rate", "min", "patient looks fatigued", "exhausted", "muscle strength", "lower limbs", "4/5", "ECG", "ordered", "peaked", "narrow T waves", "prolongation", "PR interval", "lab test results", "follows", "Sodium", "mEq/L", "Creatinine", "dL Blood urea nitrogen", "dL", "mechanism of action", "likely initial treatment", "patients condition"]}
{"question": "A 38-year-old G1P0 woman presents to her obstetrician for a prenatal visit. She reports feeling well and has no acute concerns. She is currently at 28 weeks gestation previously confirmed by ultrasound. She takes her folate supplements daily. On physical exam, the uterus is soft and globular. The top of the uterine fundus is found around the level of the umbilicus. A fetal ultrasound demonstrates a reduced liver volume and subcutaneous fat with relative sparing of the head. Which of the following is most likely the cause of this patient's ultrasound findings?", "answer": "Cigarette smoking", "options": {"A": "Aneuploidy", "B": "Cigarette smoking", "C": "Fetal congenital heart disease", "D": "Fetal infection", "E": "Neural tube defect"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "woman presents", "obstetrician", "reports", "well", "acute", "currently", "weeks gestation", "confirmed by ultrasound", "folate supplements daily", "uterus", "soft", "globular", "top of", "uterine fundus", "found", "level", "umbilicus", "fetal ultrasound", "reduced liver volume", "subcutaneous fat", "relative", "head", "following", "cause", "patient's ultrasound findings"]}
{"question": "A 7-day-old female newborn is brought to the physician because of lethargy, vomiting, poor feeding, and diarrhea for 4 days. She was born at 39 weeks' gestation. Vital signs are within normal limits. Bilateral cataracts and icterus are present. Examination shows jaundice of the skin, and the liver is palpated 5-cm below the right costal margin. Muscle tone is decreased in all extremities. Serum glucose concentration is 40 mg/dL. Which of the following metabolites is most likely to be increased in this patient?", "answer": "Galactose-1-phosphate", "options": {"A": "Sphingomyelin", "B": "Uric acid", "C": "Branched-chain amino acids", "D": "Galactose-1-phosphate", "E": "Limit dextrins"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["day old female newborn", "brought", "physician", "lethargy", "vomiting", "poor feeding", "diarrhea", "4 days", "born", "weeks", "gestation", "Vital signs", "normal limits", "Bilateral cataracts", "icterus", "present", "jaundice", "skin", "liver", "5 cm", "right costal margin", "Muscle tone", "decreased", "extremities", "Serum", "40 mg/dL", "following metabolites", "to", "increased", "patient"]}
{"question": "An 82-year-old man is brought to the emergency department after he was found down by his daughter. On presentation, he is alert and oriented with no obvious signs of trauma. He says that he felt lightheaded shortly before passing out and that he has been feeling extremely fatigued over the last few weeks. He has a known diagnosis of colorectal adenocarcinoma and had it surgically removed 2 months ago; however, recently he has been feeling increasingly short of breath. He has a 60-pack-year smoking history and drinks 2-3 beers a night. He worked as an insulation technician and shipyard laborer for 40 years prior to retiring at age 65. Radiographs reveal approximately a dozen new nodules scattered throughout his lungs bilaterally. Biopsy of these lesions would most likely reveal which of the following?", "answer": "Mucin-producing glands with squamous components", "options": {"A": "Flat cells with keratin pearls and intercellular bridges", "B": "Mucin-producing glands with squamous components", "C": "Pleomorphic giant cells", "D": "Psammoma bodies", "E": "Small dark blue cells that stain for chromogranin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "found", "alert", "oriented", "signs", "trauma", "lightheaded", "before passing out", "extremely fatigued", "weeks", "known diagnosis", "colorectal adenocarcinoma", "surgically removed 2 months", "recently", "short of breath", "60", "smoking history", "night", "insulation technician", "laborer", "40 years prior to retiring", "age 65", "Radiographs reveal approximately", "new nodules scattered", "lungs", "Biopsy of", "lesions", "most likely reveal", "following"]}
{"question": "A 54-year-old woman comes to the physician because of lower back pain, night sweats, and a 5-kg (11-lb) weight loss during the past 4 weeks. She has rheumatoid arthritis treated with adalimumab. Her temperature is 38°C (100.4°F). Physical examination shows tenderness over the T10 and L1 spinous processes. Passive extension of the right hip causes pain in the right lower quadrant. The patient's symptoms are most likely caused by an organism with which of the following virulence factors?", "answer": "Surface glycolipids that prevent phagolysosome fusion", "options": {"A": "Polysaccharide capsule that prevents phagocytosis", "B": "Surface glycolipids that prevent phagolysosome fusion", "C": "Polypeptides that inactivate elongation factor 2", "D": "Proteins that bind to the Fc region of immunoglobulin G", "E": "Protease that cleaves immunoglobulin A"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["54 year old woman", "physician", "lower back pain", "night sweats", "5 kg", "weight loss", "past 4 weeks", "rheumatoid arthritis treated with adalimumab", "temperature", "100", "tenderness", "T10", "L1 spinous processes", "Passive extension", "right hip causes pain", "right lower quadrant", "patient's symptoms", "most likely caused", "following virulence factors"]}
{"question": "A 48-year-old woman presents to her primary care physician for a wellness visit. She states she is generally healthy and currently has no complaints. She drinks 1 alcoholic beverage daily and is currently sexually active. Her last menstrual period was 1 week ago and it is regular. She smokes 1 pack of cigarettes per day and would like to quit. She describes her mood as being a bit down in the winter months but otherwise feels well. Her family history is notable for diabetes in all of her uncles and colon cancer in her mother and father at age 72 and 81, respectively. She has been trying to lose weight and requests help with this as well. Her diet consists of mostly packaged foods. His temperature is 98.0°F (36.7°C), blood pressure is 122/82 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Her BMI is 23 kg/m^2. Physical exam reveals a healthy woman with no abnormal findings. Which of the following is the most appropriate initial intervention for this patient?", "answer": "Varenicline and nicotine gum", "options": {"A": "Alcohol cessation", "B": "Bupropion", "C": "Colonoscopy", "D": "Varenicline and nicotine gum", "E": "Weight loss, exercise, and nutrition consultation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["48 year old woman presents", "primary care physician", "states", "healthy", "currently", "complaints", "1", "daily", "currently sexually active", "last menstrual period", "1 week", "regular", "smokes 1 pack", "cigarettes", "day", "to", "mood", "bit", "winter months", "well", "family history", "notable", "diabetes", "colon cancer", "age 72", "81", "to", "weight", "help", "well", "diet consists", "mostly", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "BMI", "23 kg/m", "reveals", "healthy woman", "abnormal findings", "following", "most appropriate initial intervention", "patient"]}
{"question": "A 55-year-old male presents to his primary care physician complaining of right hip pain for the past eight months. He also reports progressive loss of hearing over the same time period. Radiographic imaging reveals multiple areas of expanded bony cortices and coarsened trabeculae in his right hip and skull. Laboratory analysis reveals an isolated elevation in alkaline phosphatase with normal levels of serum calcium and phosphate. Which of the following histologic findings is most likely to be seen if one of the lesions were biopsied?", "answer": "Immature woven bone with collagen fibers arranged irregularly", "options": {"A": "Immature woven bone with collagen fibers arranged irregularly", "B": "Mature lamellar bone with collagen fibers arranged in lamellae", "C": "Chondroblasts and chondrocytes forming a cartilaginous matrix", "D": "Large pleomorphic cells with numerous atypical mitotic figures and “lacey” osteoid formation", "E": "Sheets of monotonous round blue cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "primary care physician", "right hip pain", "past eight months", "reports progressive loss of hearing", "same time period", "Radiographic imaging reveals multiple areas of expanded bony cortices", "coarsened trabeculae", "right hip", "skull", "Laboratory analysis reveals", "isolated elevation", "alkaline phosphatase", "normal levels", "serum calcium", "phosphate", "following histologic findings", "to", "seen", "one", "lesions", "biopsied"]}
{"question": "A 28-year-old woman comes to the physician because she has not had a menstrual period for 3 months. Menarche occurred at the age of 12 years and menses occurred at regular 30-day intervals until they became irregular 1 year ago. She is 160 cm (5 ft 3 in) tall and weighs 85 kg (187 lb); BMI is 33.2 kg/m2. Physical exam shows nodules and pustules along the jaw line and dark hair growth around the umbilicus. Pelvic examination shows a normal-sized, retroverted uterus. A urine pregnancy test is negative. Without treatment, this patient is at greatest risk for which of the following?", "answer": "Endometrial carcinoma", "options": {"A": "Endometrioma", "B": "Cervical carcinoma", "C": "Choriocarcinoma", "D": "Mature cystic teratoma", "E": "Endometrial carcinoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "not", "menstrual period", "months", "Menarche", "age", "years", "menses", "regular 30 day intervals", "irregular", "year", "5 ft", "tall", "85 kg", "BMI", "kg/m2", "nodules", "pustules", "jaw line", "dark hair growth", "umbilicus", "Pelvic examination", "normal-sized", "uterus", "urine pregnancy test", "negative", "treatment", "patient", "greatest", "following"]}
{"question": "A 33-year-old woman with Crohn’s disease colitis presents to her physician after 2 days of photophobia and blurred vision. She has had no similar episodes in the past. She has no abdominal pain or diarrhea and takes mesalazine, azathioprine, and prednisone as maintenance therapy. Her vital signs are within normal range. Examination of the eyes shows conjunctival injection. The physical examination is otherwise normal. Slit-lamp examination by an ophthalmologist shows evidence of inflammation in the anterior chamber. Which of the following is the most appropriate modification to this patient’s medication at this time?", "answer": "Increasing dose of prednisone", "options": {"A": "Adding infliximab", "B": "Decreasing dose of azathioprine", "C": "Discontinuing sulfasalazine", "D": "Increasing dose of prednisone", "E": "No modification of therapy at this time"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "Crohns disease colitis presents", "physician", "2 days", "photophobia", "blurred vision", "similar episodes", "past", "abdominal pain", "diarrhea", "mesalazine", "azathioprine", "prednisone", "maintenance therapy", "vital signs", "normal range", "Examination of", "eyes", "conjunctival injection", "normal", "Slit-lamp examination", "ophthalmologist", "inflammation", "anterior chamber", "following", "most appropriate modification", "patients medication", "time"]}
{"question": "A 55-year-old woman with type 2 diabetes mellitus is admitted to the hospital because of a 2-day history of fever, breathlessness, and cough productive of large quantities of green sputum. She drinks 8 beers daily. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 28/min, and blood pressure is 100/60 mm Hg. Blood and sputum cultures grow gram-negative, catalase-positive, capsulated bacilli. Which of the following components of the causal organism is the most likely cause of this patient's hypotension?", "answer": "Lipid A", "options": {"A": "Lecithinase", "B": "Lipooligosaccharide", "C": "Poly-D-glutamate", "D": "Teichoic acid", "E": "Lipid A"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "type 2 diabetes mellitus", "2-day history", "fever", "breathlessness", "cough productive", "large quantities", "green sputum", "daily", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "100 60 mm Hg", "Blood", "sputum cultures", "gram negative", "catalase positive", "following components", "causal", "most likely cause", "patient's hypotension"]}
{"question": "A 6-month-old male presents for a routine visit to his pediatrician. Two months ago, the patient was seen for tachypnea and wheezing, and diagnosed with severe respiratory syncytial virus (RSV) bronchiolitis. After admission to the hospital and supportive care, the patient recovered and currently is not experiencing any trouble breathing. Regarding the possible of future reactive airway disease, which of the following statements is most accurate?", "answer": "“Your child has a greater than 20% chance of developing asthma”", "options": {"A": "“Your child’s risk of asthma is the same as the general population.”", "B": "“There is no clear relationship between RSV and the development of asthma.”", "C": "“Your child has a less than 5% chance of developing asthma”", "D": "“Your child has a greater than 20% chance of developing asthma”", "E": "“Your child’s risk of asthma is less than the general population.”"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old male presents", "routine", "pediatrician", "Two months", "patient", "seen", "tachypnea", "wheezing", "diagnosed", "severe respiratory syncytial virus", "bronchiolitis", "supportive care", "patient recovered", "currently", "not", "trouble breathing", "possible", "future reactive airway disease", "following", "most accurate"]}
{"question": "A 12-year-old boy is brought to an outpatient clinic by his mother, who noticed that her son’s urine has been dark for the past 4 days. She initially attributed this to inadequate hydration, so she monitored her son’s fluid intake and encouraged him to drink more water. However, she noticed that the color of the urine kept getting darker until it began to resemble cola. The boy’s medical history is significant for a sore throat approx. 2 weeks ago, which resolved without medication or treatment. The boy has also been complaining of pain in his ankles, which he first noticed shortly after soccer practice 1 week ago. He has had no pain during urination or urethral discharge, however, and does not have any history of previous episodes of cola-colored urine or passage of blood in the urine. However, the boy has been experiencing intermittent episodes of abdominal pain for the past 3 days. The boy also has wheals on his torso, legs, and buttocks, which his mother attributes to seasonal allergies. Physical examination reveals an alert child who is not in obvious distress but who has a mild conjunctival pallor. Vital signs include: respiratory rate is 22/min, temperature is 36.7°C (98.0°F), and blood pressure is 130/90 mm Hg. Examination of the musculoskeletal system reveals multiple skin lesions (see image). Which of the following laboratory findings is most likely associated with this patient’s clinical presentation?", "answer": "Elevated level of serum IgA", "options": {"A": "24-hour urinary protein of more than 4 g", "B": "Low C-reactive protein level", "C": "Elevated level of serum IgA", "D": "Elevated IgM-IgG immune complex rheumatoid factor", "E": "Elevated levels of serum IgG and C3 protein"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "outpatient clinic", "urine", "dark", "past 4 days", "initially attributed", "inadequate hydration", "monitored", "fluid intake", "to", "more water", "color of", "urine kept getting darker", "began to", "cola", "boys medical history", "significant", "sore throat", "2 weeks", "resolved", "medication", "treatment", "boy", "pain", "ankles", "first", "week", "pain", "urination", "urethral discharge", "not", "history of previous episodes", "cola colored urine", "passage", "blood", "urine", "boy", "intermittent episodes of abdominal pain", "past", "days", "boy", "wheals", "torso", "legs", "buttocks", "attributes", "seasonal allergies", "reveals", "alert child", "not", "distress", "mild conjunctival pallor", "Vital signs include", "respiratory rate", "min", "temperature", "36", "98", "blood pressure", "90 mm Hg", "reveals multiple skin lesions", "see", "following laboratory findings", "most likely associated with", "patients"]}
{"question": "A 7-month-old boy is brought to the ED by his mother because of abdominal pain. Two weeks ago, she noticed he had a fever and looser stools, but both resolved after a few days. One week ago, he began to experience periodic episodes during which he would curl up into a ball, scream, and cry. The episodes lasted a few minutes, and were occasionally followed by vomiting. Between events, he was completely normal. She says the episodes have become more frequent over time, and this morning, she noticed blood in his diaper. In the ED, his vitals are within normal ranges, and his physical exam is normal. After confirming the diagnosis with an abdominal ultrasound, what is the next step in management?", "answer": "Air contrast enema", "options": {"A": "Supportive care", "B": "Air contrast enema", "C": "Abdominal laparotomy", "D": "Abdominal CT scan", "E": "Broad-spectrum antibiotics"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "abdominal pain", "Two weeks", "fever", "looser stools", "resolved", "days", "One", "began to", "periodic episodes", "curl", "ball", "episodes lasted", "few minutes", "occasionally followed by vomiting", "completely normal", "episodes", "more frequent", "time", "morning", "blood", "diaper", "normal ranges", "normal", "confirming", "diagnosis", "abdominal", "next step"]}
{"question": "A 25-year-old man visits a local clinic while volunteering abroad to rebuild homes after a natural disaster. He reports that he has been experiencing an intermittent rash on his feet for several weeks that is associated with occasional itching and burning. He states that he has been working in wet conditions in work boots and often does not get a chance to remove them until just before going to bed. On physical exam, there is diffuse erythema and maceration of the webspaces between his toes. He starts taking a medication. Two days later, he experiences severe nausea and vomiting after drinking alcohol. Which of the following is the mechanism of action of the drug most likely prescribed in this case?", "answer": "Cell arrest at metaphase", "options": {"A": "Cell arrest at metaphase", "B": "Disruption of fungal cell membrane", "C": "Inhibition of cell wall synthesis", "D": "Inhibition of DNA synthesis", "E": "Inhibition of steroid synthesis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "local clinic", "volunteering", "to", "homes", "reports", "intermittent rash", "feet", "several weeks", "associated with occasional itching", "burning", "states", "conditions", "boots", "often", "not", "chance to remove", "before", "bed", "diffuse erythema", "maceration", "toes", "starts", "medication", "Two days later", "severe nausea", "vomiting", "drinking alcohol", "following", "mechanism of action", "drug", "likely", "case"]}
{"question": "A 58-year-old male presents to his primary care doctor with the complaint of vision changes over the last several months. The patient's past medical history is notable for schizophrenia which has been well-controlled for the last 25 years on chlorpromazine. Which of the following is likely to be seen on ophthalmoscopy?", "answer": "Corneal deposits", "options": {"A": "Retinitis pigmentosa", "B": "Macular degeneration", "C": "Glaucoma", "D": "Retinal hemorrhage", "E": "Corneal deposits"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old male presents", "primary care doctor", "complaint", "vision changes", "months", "patient's past", "notable", "schizophrenia", "well-controlled", "years", "chlorpromazine", "following", "likely to", "seen", "ophthalmoscopy"]}
{"question": "A 40-year-old woman presents with a ‘tingling’ feeling in the toes of both feet that started 5 days ago. She says that the feeling varies in intensity but has been there ever since she recovered from a stomach flu last week. Over the last 2 days, the tingling sensation has started to spread up her legs. She also reports feeling weak in the legs for the past 2 days. Her past medical history is unremarkable, and she currently takes no medications. Which of the following diagnostic tests would most likely be abnormal in this patient?", "answer": "Nerve conduction studies", "options": {"A": "Noncontrast CT of the head", "B": "Transthoracic echocardiography", "C": "Serum hemoglobin concentration", "D": "Nerve conduction studies", "E": "Serum calcium concentration"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["40 year old woman presents", "tingling", "toes", "feet", "started 5 days", "intensity", "ever", "recovered", "stomach flu", "week", "last 2 days", "tingling sensation", "started to spread up", "legs", "reports feeling weak", "legs", "past 2 days", "past medical history", "unremarkable", "currently", "medications", "following diagnostic tests", "most likely", "abnormal", "patient"]}
{"question": "А 60-уеаr-old Ніѕраnіс mаn рrеѕеntѕ to thе offісе for а rеgulаr hеаlth сhесkuр. Не hаѕ bееn wаіtіng for his hір rерlасеmеnt ѕurgеrу for osteoarthritis, whісh he was diagnosed for the past 5 уеаrѕ. Не admits to having taken high doses of painkillers for hip pain management, but now they don’t provide any pain relief. Ніѕ vіtаl ѕigns include: blood рrеѕѕurе 110/70 mm Нg, рulѕе 78/mіn, tеmреrаturе 36.7°C (98.1°F), and rеѕріrаtorу rаtе 10/mіn. Оn physical ехаmіnаtіon, thеrе іѕ а lіmіtеd rаngе of motіon of hіѕ rіght hір.\nThe laboratory results are as follows:\nHemoglobin 12 g/dL\nRed blood cell 5.1 million cells/µL\nHematocrit 45%\nTotal leukocyte count 6,500 cells/µL\nNeutrophils 71%\nLymphocyte 14%\nMonocytes 4%\nEosinophil 11%\nBasophils 0%\nPlatelets 240,000 cells/µL\nUrinalysis shows:\npH 6.2\nColor light yellow\nRBC 7–8/ HPF\nWBC 10-12 /HPF\nProtein 1+\nCast none\nGlucose absent\nCrystal none\nKetone absent\nNitrite negative\n24-hr urine protein excretion 0.9 g\nUrine for culture No growth noted after 48 hours of inoculation at 37.0°C (98.6°F)\nWhat is the most likely diagnosis?", "answer": "Analgesic nephropathy", "options": {"A": "Chronic pyelonephritis", "B": "Diffuse cortical necrosis", "C": "Acute tubular necrosis", "D": "Membranous nephropathy", "E": "Analgesic nephropathy"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": [" 60 r old n mn", "th", "h bn", "h", "osteoarthritis", "diagnosed", "past", "r", "high doses", "painkillers", "hip", "now", "pain relief", "include", "blood", "70 mm g", "ul", "mn", "36", "98", "rt 10 mn", "physical", "thr", "h", "laboratory results", "follows", "g/dL", "cell", "million cells", "leukocyte", "14", "4", "Urinalysis", "pH", "Color light yellow RBC", "HPF WBC 10", "Protein 1", "Cast", "Glucose absent Crystal", "Ketone absent Nitrite negative", "hr urine protein excretion 0.9 g", "culture", "growth noted", "48 hours", "inoculation", "98", "diagnosis"]}
{"question": "A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?", "answer": "Borderline personality disorder", "options": {"A": "Major depressive disorder (MDD)", "B": "Bipolar I disorder", "C": "Borderline personality disorder", "D": "Histrionic personality disorder", "E": "Factitious disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "hospitalized due to depression", "suicidal ideation", "5 year history", "relationships", "last only", "few short weeks", "months", "relationship", "left", "abandoned", "empty", "extremely", "periods", "patient", "shopping", "making big", "impulse", "gets bored easily", "moves", "to", "next", "patient", "changes in appetite", "energy level", "concentration", "multiple linear lacerations", "phases", "healing", "noted", "forearms", "trunk", "Following", "physicians to", "best", "planet", "nurse", "blood", "stated", "nurses", "incompetent", "cruel", "following", "diagnosis"]}
{"question": "A 63-year-old man is brought to the emergency department by his wife because she is concerned he is having another stroke. The patient says he woke up with right-sided facial weakness and drooping. Past medical history is significant for a recent case of shingles treated with acyclovir, and a stroke, diagnosed 10 years ago, from which he recovered with no residual functional deficits. On physical examination, there is weakness and drooping of the entire right side of the face. Sensation is intact. The remainder of the physical examination is unremarkable. Which of the following additional findings would also most likely be seen in this patient?", "answer": "Decreased salivation", "options": {"A": "Decreased salivation", "B": "Partial hearing loss", "C": "Complete loss of taste to the tongue", "D": "Wrinkled forehead", "E": "Expressive aphasia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["63 year old man", "brought", "emergency department", "stroke", "patient", "woke up", "right-sided facial weakness", "Past medical history", "recent", "shingles treated with acyclovir", "stroke", "diagnosed", "recovered", "residual functional deficits", "weakness", "drooping", "entire right side", "face", "Sensation", "intact", "unremarkable", "following additional findings", "likely", "seen", "patient"]}
{"question": "A 65-year-old male with diffuse large B cell lymphoma is treated with a chemotherapy regimen including 6-mercaptopurine. Administration of which of the following agents would increase this patient’s risk for mercaptopurine toxicity?", "answer": "Allopurinol", "options": {"A": "Leucovorin", "B": "Dexrazoxane", "C": "Mesna", "D": "Allopurinol", "E": "Amifostine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65-year-old male", "diffuse large B cell lymphoma", "treated with", "chemotherapy regimen including 6-mercaptopurine", "following", "increase", "patients", "mercaptopurine"]}
{"question": "A 55-year-old man comes to the physician because of weight loss and increased urinary frequency for the past month. He has also noticed blood in the urine, usually towards the end of voiding. He emigrated to the U.S. from Kenya 5 years ago. He has smoked one pack of cigarettes daily for 35 years. Physical examination shows a palpable liver edge and splenomegaly. Laboratory studies show a hemoglobin concentration of 9.5 mg/dL and a urine dipstick is strongly positive for blood. A CT scan of the abdomen shows bladder wall thickening and fibrosis. A biopsy specimen of the bladder shows squamous cell carcinoma. Which of the following additional findings is most likely in this patient?", "answer": "Elevated mean pulmonary artery pressure", "options": {"A": "Calcified cysts in the liver", "B": "Dilation of right and left ventricles", "C": "Elevated mean pulmonary artery pressure", "D": "Atrophy of the retina with sclerosing keratitis", "E": "Peripheral nonpitting edema"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "weight loss", "increased urinary frequency", "past month", "blood in", "urine", "usually", "end", "voiding", "emigrated", "U", "Kenya", "years", "smoked one pack", "cigarettes daily", "35 years", "palpable", "splenomegaly", "Laboratory studies", "a hemoglobin concentration", "9.5 mg/dL", "urine dipstick", "positive", "blood", "CT scan", "abdomen", "bladder wall thickening", "fibrosis", "biopsy specimen", "bladder", "squamous cell carcinoma", "following additional findings", "patient"]}
{"question": "A 62-year-old woman is brought to the emergency department because of sudden loss of vision in her right eye that occurred 50 minutes ago. She does not have eye pain. She had several episodes of loss of vision in the past, but her vision improved following treatment with glucocorticoids. She has coronary artery disease, hypertension, type 2 diabetes mellitus, and multiple sclerosis. She underwent a left carotid endarterectomy 3 years ago. She had a myocardial infarction 5 years ago. Current medications include aspirin, metoprolol, lisinopril, atorvastatin, metformin, glipizide, and weekly intramuscular beta-interferon injections. Her temperature is 36.8°C (98.2°F), pulse is 80/min, and blood pressure is 155/88 mm Hg. Examination shows 20/50 vision in the left eye and no perception of light in the right eye. The direct pupillary reflex is brisk in the left eye and absent in the right eye. The indirect pupillary reflex is brisk in the right eye but absent in the left eye. Intraocular pressure is 18 mm Hg in the right eye and 16 mm Hg in the left eye. A white, 1-mm ring is seen around the circumference of the cornea in both eyes. Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula. The optic disc appears normal. Fundoscopic examination of the left eye shows a few soft and hard exudates in the superior and nasal retinal quadrants. The optic disc and macula appear normal. Which of the following is the most likely diagnosis?", "answer": "Central retinal artery occlusion", "options": {"A": "Central serous retinopathy", "B": "Acute angle-closure glaucoma", "C": "Central retinal vein occlusion", "D": "Vitreous hemorrhage", "E": "Central retinal artery occlusion"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["62 year old woman", "brought", "emergency department", "of sudden loss", "vision", "right eye", "50 minutes", "not", "eye pain", "several episodes of loss", "vision", "past", "vision improved following treatment", "glucocorticoids", "coronary artery disease", "hypertension", "type 2 diabetes mellitus", "multiple sclerosis", "left carotid endarterectomy", "years", "myocardial infarction", "years", "Current medications include aspirin", "metoprolol", "lisinopril", "atorvastatin", "metformin", "glipizide", "weekly intramuscular beta-interferon injections", "temperature", "36", "98", "pulse", "80 min", "blood pressure", "88 mm Hg", "20/50 vision", "left", "perception of light", "right eye", "direct pupillary reflex", "brisk", "left eye", "absent", "right eye", "indirect pupillary reflex", "brisk", "right eye", "absent", "left eye", "Intraocular pressure", "mm Hg", "right eye", "mm Hg", "left eye", "white", "1-mm ring", "seen", "circumference", "cornea", "eyes", "Fundoscopic examination of", "right eye", "pale", "white retina", "bright red area", "macula", "optic disc appears normal", "Fundoscopic examination of", "left eye", "few soft", "hard exudates", "superior", "nasal retinal quadrants", "optic disc", "macula appear normal", "following", "diagnosis"]}
{"question": "A male child is presented at the pediatric clinic for a well-child visit by his mother who reports previously normal developmental milestones. The child was born at 40 weeks with no complications during pregnancy or birth. The mother notes that the child is able to sit momentarily propped up with his hand. The infant is able to sit without support. He is able to feed himself crackers and pureed food. He is constantly shaking his toy teddy bear but is able to stop when the mother says ‘no’. Which of the following indicate the most likely language milestone the child presents with?", "answer": "Babbling", "options": {"A": "Able to say his first and last name", "B": "Babbling", "C": "Cooing", "D": "Saying words such as apple and cat, though limited to around 4 different words", "E": "Two-word combinations"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["male child", "pediatric clinic", "reports", "normal", "child", "born", "40 weeks", "complications", "pregnancy", "birth", "notes", "child", "able to sit", "hand", "infant", "able to sit", "support", "able to", "constantly shaking", "toy", "able to stop", "following", "child presents"]}
{"question": "A 14-year-old boy is brought to a child psychiatry office by his father, who is concerned about his grades and teachers’ comments that he has “problems focusing.” He has a B- average. The boy's teachers in math, social studies, and English say that he often appears to not be listening in class, instead talking to classmates, making jokes, and blurting out incorrect answers. He typically turns in his homework late or not at all. During other classes (band and science, which he enjoys), none of these behaviors are observed. At home, he enjoys playing chess and reads comic and fiction books for hours without pause. His father describes him as calm and organized at home. Formal testing reveals an intelligence quotient (IQ) of 102. Which of the following is the most likely explanation for this patient’s grades?", "answer": "Reduced interest", "options": {"A": "Absence seizures", "B": "Attention deficit hyperactivity disorder (ADHD)", "C": "Intellectual disability", "D": "Mood disorder", "E": "Reduced interest"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "child psychiatry office", "teachers", "focusing", "a B", "average", "boy's teachers", "often appears to not", "listening", "talking", "making", "out incorrect", "turns", "late", "not at all", "band", "behaviors", "observed", "home", "playing", "hours", "pause", "organized at home", "Formal testing reveals", "intelligence quotient", "following", "explanation", "patients grades"]}
{"question": "A 65-year-old male who is being treated for depression visits your emergency room complaining of being unable to urinate. In addition, the patient complains of tachycardia and dry mouth. He has no history of benign prostatic hyperplasia and reports of only being on one psychiatric medication. What type of psychiatric medication would cause such a side effect profile?", "answer": "Tricyclic antidepressant", "options": {"A": "Monoamine oxidase inhibitor", "B": "Serotonin norepinephrine receptor inhibitor", "C": "Aminoketone", "D": "Selective serotonin reuptake inhibitor", "E": "Tricyclic antidepressant"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["65 year old male", "treated", "depression", "emergency room", "unable to", "addition", "patient", "tachycardia", "dry mouth", "history of benign prostatic hyperplasia", "reports", "only", "one psychiatric medication", "type", "psychiatric", "cause", "side effect profile"]}
{"question": "A previously healthy 5-year-old boy is brought to the emergency department because of a 1-day history of high fever. His temperature prior to arrival was 40.0°C (104°F). There is no family history of serious illness. Development has been appropriate for his age. He is administered rectal acetaminophen. While in the waiting room, he becomes unresponsive and starts jerking his arms and legs back and forth. A fingerstick blood glucose concentration is 86 mg/dL. After 5 minutes, he continues having jerky movements and is unresponsive to verbal and painful stimuli. Which of the following is the most appropriate next step in management?", "answer": "Intravenous administration of lorazepam", "options": {"A": "Intravenous administration of valproate", "B": "Intravenous administration of lorazepam", "C": "Intravenous administration of phenobarbital", "D": "Obtain blood cultures", "E": "Intravenous administration of fosphenytoin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "1-day history", "high fever", "temperature prior to arrival", "40", "family history", "serious illness", "Development", "appropriate", "age", "administered rectal acetaminophen", "waiting room", "unresponsive", "starts jerking", "arms", "legs back", "fingerstick blood glucose concentration", "mg/dL", "5 minutes", "jerky movements", "unresponsive", "verbal", "painful", "following", "most appropriate next step"]}
{"question": "A 21-year-old man with a recent history of traumatic right femur fracture status post open reduction and internal fixation presents for follow-up. The patient says his pain is controlled with the oxycodone but he says he has been severely constipated the past 4 days. No other past medical history. Current medications are oxycodone and ibuprofen. The patient is afebrile and vital signs are within normal limits. On physical examination, surgical incision is healing well. Which of the following is correct regarding the likely role of opiates in this patient’s constipation?", "answer": "Opiates increase fluid absorption from the lumen leading to hard stools", "options": {"A": "Opiates cause rapid gastrointestinal transit", "B": "Opiates increase the production and secretion of pancreatic digestive enzymes", "C": "Opiates increase fluid absorption from the lumen leading to hard stools", "D": "Opiates decrease the sympathetic activity of the gut wall", "E": "Opiates activate the excitatory neural pathways in the gut"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["21-year-old man", "recent history of traumatic right femur fracture", "open reduction", "internal fixation presents", "follow-up", "patient", "pain", "controlled", "oxycodone", "severely constipated", "past", "days", "past medical history", "Current medications", "oxycodone", "ibuprofen", "patient", "afebrile", "vital signs", "normal limits", "surgical incision", "healing well", "following", "correct", "likely role", "opiates", "patients constipation"]}
{"question": "A 48-year-old man presents to an urgent care center with epigastric discomfort following meals and an occasional dry cough worse in the morning, both of which have increased in frequency over the past several months. He is otherwise healthy and has no additional complaints. Past medical history is significant for major depressive disease, anxiety, and hypothyroidism. Physical exam is unremarkable. Given the following options, what is the most appropriate next step in patient management?", "answer": "Lifestyle modifications", "options": {"A": "Electrocardiogram", "B": "Lifestyle modifications", "C": "Begin Omeprazole therapy", "D": "EGD with esophageal biopsy", "E": "Fluoroscopic barium swallow"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old man presents", "urgent care center", "epigastric discomfort following meals", "occasional dry cough worse", "morning", "increased", "frequency", "past", "months", "healthy", "additional complaints", "Past medical history", "significant", "major depressive disease", "anxiety", "hypothyroidism", "unremarkable", "Given", "following options", "most appropriate next step", "patient"]}
{"question": "A 66-year-old man comes to the physician because of a 3-month history of constipation and streaks of blood in his stool. He has had a 10-kg (22-lb) weight loss during this period. Colonoscopy shows an exophytic tumor in the sigmoid colon. A CT scan of the abdomen shows liver metastases and enlarged mesenteric and para-aortic lymph nodes. A diagnosis of stage IV colorectal cancer is made, and palliative chemotherapy is initiated. The chemotherapy regimen includes a monoclonal antibody that inhibits tumor growth by preventing ligand binding to a protein directly responsible for epithelial cell proliferation and organogenesis. Which of the following proteins is most likely inhibited by this drug?", "answer": "EGFR", "options": {"A": "ALK", "B": "EGFR", "C": "TNF-α", "D": "VEGF", "E": "CD52"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["66 year old man", "physician", "3 month history", "constipation", "blood", "stool", "a 10 kg", "weight loss", "period", "Colonoscopy", "exophytic tumor", "sigmoid colon", "CT scan", "abdomen", "liver metastases", "enlarged mesenteric", "para-aortic lymph nodes", "diagnosis", "stage IV colorectal cancer", "made", "palliative chemotherapy", "initiated", "chemotherapy regimen includes", "monoclonal antibody", "inhibits tumor growth", "preventing", "a protein directly responsible", "epithelial cell proliferation", "following proteins", "most likely inhibited", "drug"]}
{"question": "A 9-year-old girl is brought to the physician because her parents are concerned about their daughter's physical changes. She recently started wearing a bra and uses a facial scrub for oily skin. The parents have also noticed increasing body odor. The patient has a history of migraine headaches controlled with propranolol. She is at the 55th percentile for height and 60th percentile for weight. Examination shows separation of areola and breast contours; the nipple and areola form a secondary mound. Coarse dark axillary hair and sparse pubic hair are present. Which of the following is the most likely cause of these findings?", "answer": "Physiological development", "options": {"A": "Tumor of the pineal gland", "B": "Hamartoma of the hypothalamus", "C": "Physiological development", "D": "Mosaic G-protein mutation", "E": "Functioning follicular ovarian cyst"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "physical changes", "recently started", "bra", "uses", "facial", "oily", "increasing body odor", "patient", "history of migraine headaches controlled", "propranolol", "percentile", "height", "percentile", "weight", "separation", "areola", "breast contours", "nipple", "areola form", "secondary", "Coarse dark axillary", "sparse pubic hair", "present", "following", "most likely cause", "findings"]}
{"question": "A 31-year-old woman presents to her gynecologist to be evaluated for her inability to conceive. She is G1P0 who has a 28-day cycle and no menstrual abnormalities. Her single pregnancy terminated early with an elective abortion at the patient’s request. She had several sexual partners before meeting her husband 5 years ago. They have intercourse regularly without the use of contraception and have been tracking her ovulation cycle to try to become pregnant for at least 1 year. She reports a history of occasional malodorous vaginal discharge and mild lower abdominal pain after menses and sexual intercourse, but she notes no such symptoms recently. Her husband’s spermogram was normal. Her weight is 65 kg (143 lb) and the height is 160 cm (5 ft, 3 in). On examination, the patient’s vital signs are within normal limits. The physical examination is unremarkable. On pelvic examination, the adnexa are slightly tender to palpation bilaterally. Which of the following tests is the most reasonable to be performed next in this patient?", "answer": "Hysterosalpingography", "options": {"A": "Post-coital testing of cervical mucus", "B": "Test for anti-Mullerian hormone", "C": "Exploratory laparoscopy", "D": "Hysterosalpingography", "E": "Pelvic MRI"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old woman presents", "gynecologist to", "to", "day cycle", "menstrual abnormalities", "single pregnancy terminated early", "elective", "patients request", "several sexual partners", "years", "intercourse", "use of contraception", "tracking", "ovulation cycle to", "to", "pregnant", "1 year", "reports", "history", "occasional", "vaginal discharge", "mild lower abdominal pain", "menses", "sexual intercourse", "notes", "symptoms recently", "normal", "weight", "65 kg", "height", "5 ft", "3", "patients vital signs", "normal limits", "unremarkable", "pelvic examination", "adnexa", "slightly tender", "palpation", "following tests", "most", "to", "performed next", "patient"]}
{"question": "A 10-day-old male infant is brought to the emergency room for abdominal distension for the past day. His mother reports that he has been refusing feeds for about 1 day and appears more lethargic than usual. While changing his diaper today, she noticed that the baby felt warm. He has about 1-2 wet diapers a day and has 1-2 seedy stools a day. The mother reports an uncomplicated vaginal delivery. His past medical history is significant for moderate respiratory distress following birth that has since resolved. His temperature is 101°F (38.3°C), blood pressure is 98/69 mmHg, pulse is 174/min, respirations are 47/min, and oxygen saturation is 99% on room air. A physical examination demonstrates a baby in moderate distress with abdominal distension. What is the best initial step in the management of this patient?", "answer": "Urinary catheterization", "options": {"A": "Cystoscopy", "B": "Radionuclide scan", "C": "Renal ultrasound", "D": "Urinary catheterization", "E": "Voiding cystourethrogram"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["A 10 day old male infant", "brought", "emergency room", "abdominal distension", "past day", "reports", "feeds", "1 day", "appears more lethargic", "usual", "changing", "diaper today", "baby", "warm", "about", "wet diapers", "day", "has", "seedy stools", "day", "reports", "uncomplicated vaginal", "past medical history", "significant", "moderate respiratory distress following birth", "since resolved", "temperature", "blood pressure", "98 69 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "baby", "moderate distress", "abdominal distension", "best initial step", "patient"]}
{"question": "A 66-year-old male with a history of deep venous thrombosis is admitted to the hospital with shortness of breath and pleuritic chest pain. He is treated with an anticoagulant, but he develops significant hematochezia. His BP is now 105/60 and HR is 117; both were within normal limits on admission. The effects of the anticoagulant are virtually completely reversed with the administration of protamine. Which of the following was the anticoagulant most likely administered to this patient?", "answer": "Heparin", "options": {"A": "Warfarin", "B": "Enoxaparin", "C": "Heparin", "D": "Bivalirudin", "E": "Dabigatran"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["66 year old male", "history of deep venous thrombosis", "shortness of breath", "pleuritic chest pain", "treated with", "anticoagulant", "significant hematochezia", "BP", "now", "60", "normal limits on admission", "effects", "anticoagulant", "completely reversed", "administration", "protamine", "following", "anticoagulant", "likely administered", "patient"]}
{"question": "A 4-day-old boy is brought to the physician because of somnolence, poor feeding, and vomiting after his first few breast feedings. He appears lethargic. His respiratory rate is 73/min. Serum ammonia is markedly increased. Genetic analysis shows deficiency in N-acetylglutamate synthase. The activity of which of the following enzymes is most likely directly affected by this genetic defect?", "answer": "Carbamoyl phosphate synthetase I", "options": {"A": "Carbamoyl phosphate synthetase I", "B": "Ornithine translocase", "C": "Argininosuccinate synthetase", "D": "Argininosuccinase", "E": "Arginase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["4 day old boy", "brought", "physician", "somnolence", "poor feeding", "vomiting", "first", "breast feedings", "appears lethargic", "respiratory rate", "min", "Serum ammonia", "markedly increased", "Genetic analysis", "deficiency", "synthase", "following", "directly affected", "genetic defect"]}
{"question": "During the selection of subjects for a study on infantile vitamin deficiencies, a child is examined by the lead investigator. She is at the 75th percentile for head circumference and the 80th percentile for length and weight. She can lift her chest and shoulders up when in a prone position, but cannot roll over from a prone position. Her eyes follow objects past the midline. She coos and makes gurgling sounds. When the investigator strokes the sole of her foot, her big toe curls upward and there is fanning of her other toes. She makes a stepping motion when she is held upright and her feet are in contact with the examination table. Which of the following additional skills or behaviors would be expected in a healthy patient of this developmental age?", "answer": "Smiles at her mother", "options": {"A": "Reaches out for objects", "B": "Responds to calling of own name", "C": "Cries when separated from her mother", "D": "Rolls over from her back", "E": "Smiles at her mother"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["a study", "infantile vitamin deficiencies", "child", "examined", "lead investigator", "percentile", "head circumference", "80th percentile", "length", "weight", "lift", "chest", "shoulders", "prone position", "roll over", "prone position", "eyes follow", "past", "midline", "makes gurgling sounds", "investigator strokes", "sole of", "foot", "big toe curls upward", "fanning", "toes", "makes", "stepping", "held upright", "feet", "in contact with", "examination table", "following additional", "behaviors", "healthy patient", "developmental"]}
{"question": "Two viruses, X and Y, infect the same cell and begin to reproduce within the cell. As a result of the co-infection, some viruses are produced where the genome of Y is surrounded by the nucleocapsid of X and vice versa with the genome of X and nucleocapsid of Y. When the virus containing genome X surrounded by the nucleocapsid of Y infects another cell, what is the most likely outcome?", "answer": "Virions containing genome X and nucleocapsid X will be produced", "options": {"A": "Virions containing genome X and nucleocapsid Y will be produced", "B": "Virions containing genome X and nucleocapsid X will be produced", "C": "Virions containing genome Y and nucleocapsid Y will be produced", "D": "Virions containing genome Y and nucleocapsid X will be produced", "E": "No virions will be produced"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Two viruses", "infect", "same cell", "begin to", "cell", "result", "co-infection", "viruses", "genome", "surrounded", "nucleocapsid", "genome", "nucleocapsid", "virus containing genome", "surrounded", "nucleocapsid", "infects", "cell", "most likely outcome"]}
{"question": "A 56-year-old Caucasian male presents to the clinic to establish care. He has never seen a physician and denies any known medical problems. Physical examination is notable for central obesity, but the patient has regular heart and lung sounds. He has a blood pressure of 157/95 mm Hg and heart rate of 92/min. He follows up 2 weeks later, and his blood pressure continues to be elevated. At this time, you diagnose him with essential hypertension and decide to initiate antihypertensive therapy. Per the Joint National Committee 8 guidelines for treatment of high blood pressure, of the following combinations of drugs, which can be considered for first-line treatment of high blood pressure in the Caucasian population?", "answer": "ACE inhibitor, ARB, CCB, or thiazide", "options": {"A": "ACE inhibitor, angiotensin receptor blocker (ARB), beta-blocker (BB), or thiazide", "B": "ACE inhibitor, ARB, CCB, or thiazide", "C": "ACE inhibitor, ARB, CCB or loop diuretic", "D": "ACE inhibitor, ARB, alpha-blocker, or loop diuretic", "E": "ACE inhibitor, ARB, alpha-blocker, or direct vasodilator"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "male presents", "clinic to establish", "never seen", "physician", "known", "notable", "central obesity", "patient", "regular heart", "lung sounds", "blood pressure", "95 mm Hg", "heart rate", "min", "follows up 2 weeks later", "blood pressure", "to", "elevated", "time", "diagnose", "essential hypertension", "to initiate antihypertensive therapy", "guidelines", "treatment", "combinations", "drugs", "first", "high blood pressure", "population"]}
{"question": "A 50-year-old woman returns from a family trip to the Caribbean with three days of fever, watery diarrhea, and vomiting. She states that she tried to avoid uncooked food and unpeeled fruits on her vacation. Of note, her grandson had caught a cold from daycare prior to the trip, and she had been in close contact with the infant throughout the trip. She denies rhinorrhea or coughing. On exam, her temperature is 99.1°F (37.3°C), blood pressure is 110/68 mmHg, pulse is 113/min, and respirations are 12/min. Her stool culture is negative for bacteria. Which of the following describes the most likely cause?", "answer": "(+) ssRNA virus", "options": {"A": "Linear dsDNA virus", "B": "Linear dsRNA virus", "C": "ssDNA virus", "D": "(+) ssRNA virus", "E": "(-) ssRNA virus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old woman returns", "trip", "Caribbean", "three days", "fever", "watery diarrhea", "vomiting", "states", "to", "note", "caught", "cold", "daycare", "trip", "close contact", "infant", "trip", "rhinorrhea", "coughing", "exam", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "stool culture", "negative", "bacteria", "following", "cause"]}
{"question": "An 18-year-old high school student is brought to the emergency department after collapsing during her cheerleading practice session. She was brought to the hospital even though she regained consciousness within seconds. Her mother informs the doctor that she had a similar episode last month at a party, but they thought it was due to stress and exhaustion. Both incidents occurred in a loud and crowded environment. Her past medical history is insignificant. Her blood pressure is 120/80 mm Hg and the pulse is 77/min and regular. Physical examination findings are within normal limits. A set of tests are ordered along with a 12-lead ECG. The ECG tracing obtained is shown. What is the best treatment option for this patient?", "answer": "Nadolol", "options": {"A": "Epinephrine", "B": "Erythromycin", "C": "Furosemide", "D": "Nadolol", "E": "Quinidine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "brought", "emergency department", "collapsing", "brought", "hospital", "consciousness", "seconds", "informs", "doctor", "similar episode", "month", "due to stress", "exhaustion", "loud", "environment", "past medical history", "blood pressure", "80 mm Hg", "pulse", "min", "regular", "Physical examination findings", "normal limits", "set", "tests", "ordered", "12-lead ECG", "ECG", "obtained", "best treatment option", "patient"]}
{"question": "A 58-year-old man comes to the physician because of severe muscle aches and fatigue for 3 days. Last week he was diagnosed with atypical pneumonia and treated with clarithromycin. He has hyperlipidemia for which he takes lovastatin. Physical examination shows generalized tenderness of the proximal muscles in the upper and lower extremities. Serum studies show an elevated creatinine kinase concentration. This patient's current symptoms are most likely caused by inhibition of which of the following hepatic enzymes?", "answer": "CYP3A4", "options": {"A": "CYP2E1", "B": "CYP3A4", "C": "CYP2C9", "D": "CYP1A2", "E": "CYP2C19"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old man", "physician", "severe muscle aches", "fatigue", "days", "week", "diagnosed", "atypical pneumonia", "treated with clarithromycin", "hyperlipidemia", "lovastatin", "generalized tenderness", "proximal", "upper", "lower extremities", "Serum studies", "elevated creatinine kinase concentration", "patient's current symptoms", "most likely", "inhibition", "following", "enzymes"]}
{"question": "A 58-year-old woman presents to the physician for a routine health maintenance examination. She has a history of dyslipidemia and chronic hypertension. Her medications include atorvastatin, hydrochlorothiazide, and lisinopril. She exercises every day and follows a healthy diet. She does not smoke. There is no family history of chronic disease. Her blood pressure is 130/80 mm Hg, which is confirmed on repeat measurement. Her BMI is 22 kg/m2. The physical examination shows no abnormal findings. The laboratory test results show:\nSerum  \nTotal cholesterol 193 mg/dL\nLow-density lipoprotein (LDL-C) 124 mg/dL\nHigh-density lipoprotein (HDL-C) 40 mg/dL\nTriglycerides 148 mg/dL\nThe patient's 10-year risk of cardiovascular disease (CVD) is 4.6%. Which of the following is the most appropriate next step in pharmacotherapy?", "answer": "Ezetimibe", "options": {"A": "Ezetimibe", "B": "Fenofibrate", "C": "Niacin", "D": "Fish oils", "E": "No additional pharmacotherapy at this time"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old woman presents", "physician", "routine", "history", "dyslipidemia", "chronic hypertension", "medications include atorvastatin", "hydrochlorothiazide", "lisinopril", "exercises", "day", "follows", "healthy diet", "not smoke", "family history of chronic disease", "blood pressure", "80 mm Hg", "confirmed", "repeat measurement", "BMI", "kg/m2", "abnormal findings", "laboratory test results", "Serum", "Total cholesterol", "mg/dL Low-density lipoprotein", "mg/dL High-density lipoprotein", "40", "Triglycerides", "patient's 10 year risk", "cardiovascular disease", "4.6", "following", "most appropriate next step", "pharmacotherapy"]}
{"question": "A 30-year-old woman presents to her new doctor at 27 weeks' gestation with her second pregnancy. Her blood type is B- and the father of the child is B+. Her first child had an Apgar score of 7 at 1 minute and 9 at 5 minutes and has a B+ blood type. The fetus has a heart rate of 130/min and blood pressure of 100/58 mm Hg. There is a concern that the fetus may develop erythroblastosis fetalis (EF). Which of the following statements is true about erythroblastosis fetalis?", "answer": "Can occur with an Rh-negative mother and Rh-positive father.", "options": {"A": "Can occur with an Rh-negative mother and Rh-positive father.", "B": "Rho(D) immune globulin should be administered during the first trimester.", "C": "The first child will always be affected, as well as all subsequent pregnancies.", "D": "The combination of an Rh-positive mother and an Rh-negative fetus will cause the condition.", "E": "In EF, IgM crosses the placenta and causes erythrocyte hemolysis in the fetus."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "new doctor", "27 weeks", "gestation", "second", "blood type", "first child", "Apgar score", "at 1 minute", "5 minutes", "a B", "blood type", "fetus", "heart rate", "min", "blood pressure", "100 58 mm Hg", "fetus", "erythroblastosis fetalis", "following", "true", "erythroblastosis fetalis"]}
{"question": "Five days after undergoing right hemicolectomy for colon cancer, a 62-year-old man has fever, abdominal pain, nausea, and urinary frequency. The surgery was uncomplicated. An indwelling urinary catheter was placed intraoperatively. His temperature is 39.4°C (102.9°F), pulse is 91/min, and blood pressure is 118/83 mm Hg. There is tenderness to palpation of the costovertebral angle. The urine collected in the catheter bag appears cloudy. Which of the following measures is most likely to have prevented this patient's current condition?", "answer": "Early removal of catheter", "options": {"A": "Urinary antiseptics", "B": "Early removal of catheter", "C": "Antimicrobial prophylaxis", "D": "Periurethral care", "E": "Daily catheter replacement"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["right hemicolectomy", "colon cancer", "62 year old man", "fever", "abdominal pain", "nausea", "urinary frequency", "surgery", "uncomplicated", "indwelling urinary catheter", "temperature", "9F", "pulse", "min", "blood pressure", "83 mm Hg", "tenderness", "palpation", "costovertebral angle", "urine collected", "catheter bag appears cloudy", "following measures", "to", "prevented", "patient's current condition"]}
{"question": "A previously healthy 42-year-old man comes to the emergency room with constipation and diffuse, worsening abdominal pain for 2 days. He has no history of major medical illness. His father died in a car accident at the age of 32 years, and his mother has type 2 diabetes mellitus. A diagnosis of bowel obstruction is suspected and he is taken to the operating room for exploratory laparotomy. A partial resection of the colon is performed. The gross appearance of the patient's colonic tissue is shown. Microscopic examination shows tubular, tubulovillous, and villous adenomas. Assuming the patient's partner is not a carrier of the condition, which of the following is the likelihood that this patient’s children will develop this condition?", "answer": "50%", "options": {"A": "100%", "B": "25%", "C": "75%", "D": "50%", "E": "0%"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old man", "emergency room", "constipation", "diffuse", "worsening abdominal pain", "2 days", "history of major medical illness", "died", "car accident", "age", "years", "type 2 diabetes mellitus", "diagnosis", "bowel obstruction", "suspected", "operating room", "exploratory laparotomy", "partial resection of", "colon", "performed", "gross appearance", "patient's colonic tissue", "Microscopic examination", "tubular", "villous adenomas", "patient's", "not", "carrier", "condition", "following", "likelihood", "patients children", "condition"]}
{"question": "A 64-year-old man is brought to the emergency department by his wife with a 2-hour history of diarrhea and vomiting. He says that he felt fine in the morning, but noticed that he was salivating, sweating, and feeling nauseated on the way home from his work as a landscaper. The diarrhea and vomiting then started about 10 minutes after he got home. His past medical history is significant for depression and drug abuse. His wife says that he has also been more confused lately and is afraid he may have ingested something unusual. Physical exam reveals miosis, rhinorrhea, wheezing, and tongue fasciculations. Which of the following treatments would most likely be effective for this patient?", "answer": "Atropine", "options": {"A": "Ammonium chloride", "B": "Atropine", "C": "Fomepizole", "D": "Naloxone", "E": "Sodium bicarbonate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["64 year old man", "brought", "emergency department", "hour history", "diarrhea", "vomiting", "fine", "morning", "salivating", "sweating", "nauseated", "home", "diarrhea", "vomiting then started", "10 minutes", "got home", "past medical history", "significant", "depression", "drug abuse", "more confused", "unusual", "reveals miosis", "rhinorrhea", "wheezing", "tongue fasciculations", "following treatments", "most likely", "effective", "patient"]}
{"question": "A 36-year-old female presents to clinic inquiring about the meaning of a previous negative test result from a new HIV screening test. The efficacy of this new screening test for HIV has been assessed by comparison against existing gold standard detection of HIV RNA via PCR. The study includes 1000 patients, with 850 HIV-negative patients (by PCR) receiving a negative test result, 30 HIV-negative patients receiving a positive test result, 100 HIV positive patients receiving a positive test result, and 20 HIV positive patients receiving a negative test result. Which of the following is most likely to increase the negative predictive value for this test?", "answer": "Decreased prevalence of HIV in the tested population", "options": {"A": "Increased prevalence of HIV in the tested population", "B": "Decreased prevalence of HIV in the tested population", "C": "Increased number of false positive test results", "D": "Increased number of false negative test results", "E": "Decreased number of false positive test results"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["36 year old female presents", "clinic", "previous negative test result", "new HIV screening test", "efficacy", "new", "HIV", "gold standard detection", "PCR", "study includes", "patients", "850 HIV-negative patients", "PCR", "receiving", "negative test result", "30 HIV-negative patients receiving", "positive test result", "100 HIV positive patients receiving", "positive test result", "20 HIV positive patients receiving", "negative test result", "following", "to increase", "negative predictive value", "test"]}
{"question": "A 58-year-old woman is brought to the emergency room by her husband complaining, “I can’t see out of my right eye.” She was watching television last night when she covered her left eye due to an itch and discovered that she could not see. The patient denies any precipitating event, pain, swelling, flashes, floaters, or headaches. Her past medical history is significant for uncontrolled hypertension and angina. Her medications include hydrochlorothiazide, lisinopril, atorvastatin, and nitroglycerin as needed. Her physical examination is unremarkable. Fundus examination demonstrates generalized pallor and slight disc edema with no hemorrhages. What is the most likely explanation for this patient’s symptoms?", "answer": "Occlusion of the ophthalmic artery by embolus", "options": {"A": "Acute increase in pressure of the eye", "B": "Detachment of the retina", "C": "Inflammation of the temporal artery", "D": "Occlusion of the ophthalmic artery by embolus", "E": "Optic neuritis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old woman", "brought", "emergency room", "I cant see out", "right eye", "night", "covered", "left due to", "itch", "not see", "patient", "precipitating event", "pain", "swelling", "flashes", "floaters", "headaches", "past medical history", "significant", "uncontrolled hypertension", "angina", "medications include hydrochlorothiazide", "lisinopril", "atorvastatin", "nitroglycerin as needed", "unremarkable", "Fundus examination", "generalized pallor", "slight disc edema", "hemorrhages", "patients symptoms"]}
{"question": "A 28-year-old man is brought to the emergency department with shortness of breath and chest pain, 35 minutes after he was involved in a high-speed motor vehicle collision. He was the helmeted driver of a scooter hit by a truck. On arrival, he is alert and oriented with a Glasgow Coma Scale rating of 14. His temperature is 37.3°C (99.1°F), pulse is 103/min, respirations are 33/min and blood pressure is 132/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Examination shows multiple abrasions over his abdomen and extremities. There is a 2.5-cm (1-in) laceration on the left side of the chest. There are decreased breath sounds over the left base. Cardiac examination shows no abnormalities. The abdomen is soft and there is tenderness to palpation over the left upper quadrant. Bowel sounds are normal. His hemoglobin concentration is 13.6 g/dL, leukocyte count is 9,110/mm3, and platelet count is 190,000/mm3. A chest x-ray is shown. Which of the following is the most likely diagnosis?", "answer": "Diaphragmatic rupture", "options": {"A": "Diaphragmatic rupture", "B": "Esophageal perforation", "C": "Diaphragmatic eventration", "D": "Pneumothorax", "E": "Phrenic nerve palsy\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "shortness of breath", "chest pain", "35 minutes", "involved", "high speed motor vehicle collision", "helmeted driver", "hit", "truck", "arrival", "alert", "oriented", "Glasgow Coma Scale", "14", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "88 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "multiple abrasions", "abdomen", "extremities", "2.5", "1", "laceration", "left side of", "chest", "decreased breath sounds", "left base", "Cardiac", "abnormalities", "abdomen", "soft", "tenderness", "palpation", "left upper quadrant", "Bowel sounds", "normal", "hemoglobin concentration", "13.6 g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "chest x-ray", "following", "diagnosis"]}
{"question": "A 72-year-old man has been recently diagnosed with stage 3 squamous cell carcinoma of the oral cavity. After the necessary laboratory workup, concurrent chemoradiation therapy has been planned. Radiation therapy is planned to take place over 7 weeks and he will receive radiation doses daily, Monday–Friday, in 2.0 Gy fractions. For concurrent chemotherapy, he will receive intravenous cisplatin at a dosage of 50 mg/m2 weekly for 7 weeks. Which of the following best explains the mechanism of action of the antineoplastic drug that the patient will receive?", "answer": "Formation of interstrand DNA cross-links", "options": {"A": "Inhibition of polymerization of tubulin", "B": "Inhibition of topoisomerase 2", "C": "Formation of interstrand DNA cross-links", "D": "Inhibition of topoisomerase 1", "E": "Free radical-mediated lipid peroxidation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man", "recently diagnosed", "squamous cell carcinoma of the oral cavity", "laboratory workup", "concurrent therapy", "planned", "Radiation therapy", "planned to", "place", "weeks", "receive radiation doses daily", "2 0 Gy fractions", "concurrent chemotherapy", "receive intravenous", "dosage", "m2 weekly", "weeks", "following best", "mechanism of action", "antineoplastic drug", "patient", "receive"]}
{"question": "A 52-year-old woman presents to her primary care provider with shortness of breath. She reports a 3-month history of difficulty breathing with exertion that has progressed to affect her at rest. She swims 45 minutes every day but has had trouble swimming recently due to her breathing difficulties. Her past medical history is notable for well-controlled mild intermittent asthma and generalized anxiety disorder. She has a 15 pack-year smoking history but quit 15 years ago. She does not drink alcohol. Her mother died at the age of 60 from heart failure and was a lifetime non-smoker. Her temperature is 99°F (37.2°C), blood pressure is 135/85 mmHg, pulse is 85/min, and respirations are 22/min. Her BMI is 23 kg/m^2. On exam, she has slightly increased work of breathing. Cardiac auscultation reveals a normal S1 and loud P2. An echocardiogram is performed demonstrating right ventricular hypertrophy. Her pulmonary artery pressure is 24 mmHg at rest and 40 mmHg with exercise. This patient’s condition is associated with a mutation in a gene that does which of the following?", "answer": "Inhibits smooth muscle proliferation", "options": {"A": "Degrades proteases", "B": "Inhibits free radical formation", "C": "Inhibits smooth muscle proliferation", "D": "Internalizes low-density lipoprotein", "E": "Promotes intracellular chloride transport"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care provider", "shortness of breath", "reports", "3 month history", "difficulty breathing", "exertion", "progressed to", "45 minutes", "day", "trouble", "recently due to", "breathing difficulties", "past medical history", "notable", "well-controlled mild intermittent asthma", "generalized anxiety disorder", "smoking history", "years", "not", "alcohol", "died", "age", "60", "heart failure", "lifetime non-smoker", "temperature", "blood pressure", "85 mmHg", "pulse", "85 min", "respirations", "min", "BMI", "23 kg/m", "exam", "slightly increased work of breathing", "Cardiac auscultation reveals", "normal S1", "loud P2", "echocardiogram", "performed", "right ventricular hypertrophy", "pulmonary artery pressure", "mmHg", "40 mmHg", "exercise", "patients condition", "associated with", "mutation", "gene", "following"]}
{"question": "A 20-year-old man presents to the family medicine clinic with left knee pain. He is the star running back for his college football team with a promising future in the sport. He states he injured his knee 2 days ago during the final game of the season while making a cutting move, where his foot was planted and rotated outward and his knee buckled inward. He admits to feeling a ‘pop’ and having immediate pain. He denies any locking, clicking, or giving way since the event. Physical examination reveals an antalgic gait with avoidance of active knee extension. His left knee demonstrates moderate, diffuse swelling and is very tender to palpation along the joint line. Which of the following structures is most likely damaged in this patient?", "answer": "Anterior cruciate ligament", "options": {"A": "Anterior cruciate ligament", "B": "Lateral meniscus", "C": "Medial collateral ligament", "D": "Medial meniscus", "E": "Posterior cruciate ligament"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["20 year old man presents", "family medicine clinic", "left", "star", "back", "college football", "future", "states", "injured", "knee 2 days", "final", "season", "making", "cutting move", "foot", "rotated outward", "knee buckled inward", "immediate pain", "locking", "giving", "event", "reveals", "antalgic gait", "active knee extension", "left knee", "moderate", "diffuse swelling", "very tender", "palpation", "joint line", "following structures", "most likely damaged", "patient"]}
{"question": "A 9-year-old girl is brought to the pediatrician by her parents because of unremitting cough, fevers, night sweats, anorexia, and weight loss for 4 weeks. Her vaccinations are up to date. When asked about recent exposure to an ill person, the parents mention that she is frequently under the care of a middle-aged woman who recently immigrated from a small rural community in north India. Her temperature is 39.0°C (102.2°F), respiratory rate is 30/min, and heart rate is 120/min. Her weight is 2 standard deviations below normal for her age. Chest auscultation shows fine crackles in both lung fields.  The patient is referred to a nearby children’s hospital where her clinical condition rapidly worsens over several weeks. A chest radiograph is shown. Microbiological evaluation of a bronchial aspirate reveals an organism with a cell wall that is impervious to Gram stain. Which of the following best describes the cell wall of the causative agent?", "answer": "High mycolic acid content", "options": {"A": "Low muramic acid content", "B": "High mycolic acid content", "C": "High ergosterol content", "D": "Absence of cellular wall", "E": "Teichoic acid-rich cellular wall"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "pediatrician", "cough", "fevers", "night sweats", "anorexia", "weight loss", "weeks", "vaccinations", "date", "recent exposure", "ill", "frequently", "care of", "middle aged woman", "recently", "small", "north India", "temperature", "respiratory rate", "30/min", "heart rate", "min", "weight", "2 standard", "normal", "age", "Chest auscultation", "fine crackles", "lung fields", "patient", "clinical condition rapidly worsens", "weeks", "chest radiograph", "bronchial aspirate reveals", "cell wall", "Gram stain", "following best", "cell wall", "causative agent"]}
{"question": "A 70-year-old man is brought to the emergency room with complaints of severe substernal chest pain for the last hour. The pain started suddenly, and the patient describes the pain as “going into the shoulder”. The patient took aspirin at home and has been given multiple doses of sublingual nitroglycerin, but the pain has not subsided. He has a blood pressure of 112/84 mm Hg, the pulse is 63/min, the respiratory rate is 18/min, and the temperature is 36.9°C (98.0°F). Cardiac auscultation reveals normal S1 and S2 sounds, however, an additional S4 sound is heard. The patient is sweating profusely, and the lungs are clear to auscultation. No jugular venous distension or pedal edema is observed. His initial ECG shows ST elevation in leads II, III, and aVF. Which of the following will likely have the most benefit in this patient?", "answer": "Percutaneous coronary intervention", "options": {"A": "Antiarrhythmics", "B": "Beta blockers", "C": "Clopidogrel", "D": "Thrombolytics", "E": "Percutaneous coronary intervention"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["70 year old man", "brought", "emergency room", "complaints", "severe substernal chest pain", "last hour", "pain started", "patient", "pain", "shoulder", "patient", "aspirin at home", "given multiple doses", "sublingual nitroglycerin", "pain", "not", "blood pressure", "84 mm Hg", "pulse", "63 min", "respiratory rate", "min", "temperature", "36", "98", "Cardiac auscultation reveals normal S1", "S2", "additional S4 sound", "heard", "patient", "sweating", "lungs", "clear", "auscultation", "jugular venous distension", "pedal edema", "observed", "initial ECG", "ST elevation", "leads", "III", "aVF", "following", "likely", "most benefit", "patient"]}
{"question": "A 24-year-old female comes to the physician for evaluation of a delayed menstrual period and intermittent lower abdominal pain for 2 days. Menarche occurred at the age of 12 years, and menses have occurred at regular 28-day intervals. Her last menstrual period was 7 weeks ago. Two years ago, she was treated for chlamydia infection. Pelvic examination shows a soft, mildly enlarged uterus. Endometrial biopsy shows decidualization of the endometrium without chorionic villi. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Fertilized ovum outside the uterus", "options": {"A": "Benign proliferation of myometrial smooth muscle", "B": "Ectopic endometrial tissue", "C": "Fertilized ovum outside the uterus", "D": "Endometrial infiltration by plasma cells", "E": "Empty ovum fertilized by two sperm"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female", "physician", "delayed menstrual", "intermittent lower abdominal pain", "2 days", "Menarche", "age", "years", "menses", "regular", "day intervals", "last menstrual period", "weeks", "Two years", "treated", "chlamydia infection", "Pelvic", "soft", "mildly enlarged", "Endometrial biopsy", "decidualization", "endometrium", "chorionic villi", "Further", "to", "following findings"]}
{"question": "A 10-year-old girl with previously diagnosed sickle cell anemia presents to the emergency room with a low-grade fever, malaise, petechiae on her arms, and a rash on her face. She regularly takes hydroxyurea and receives blood transfusions to treat her condition. Her blood tests show a hemoglobin of 4.0 g/dL, MCV of 87 fl, and 2% reticulocyte count. An attempted bone marrow biopsy was  a dry, empty tap. What is the most likely diagnosis?", "answer": "Aplastic crisis", "options": {"A": "Aplastic crisis", "B": "Gastrointestinal bleeding", "C": "Anemia of chronic disease", "D": "Reaction to the blood transfusions", "E": "Sequestration crisis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 year old girl", "diagnosed sickle cell anemia presents", "emergency room", "low-grade fever", "malaise", "petechiae", "arms", "rash on", "face", "hydroxyurea", "receives blood transfusions to treat", "condition", "blood tests", "a hemoglobin", "0 g/dL", "MCV", "87 fl", "2", "reticulocyte count", "bone marrow biopsy", "dry", "empty", "diagnosis"]}
{"question": "A 55-year-old man comes to the physician because of progressive daytime sleepiness and exertional dyspnea for the past 6 months. Physical examination shows conjunctival pallor and several subcutaneous purple spots on his legs. His hemoglobin concentration is 8.5 g/dL, leukocyte count is 3,000/mm3, and platelet count is 16,000/mm3. Which of the following laboratory values is most likely to be increased in this patient?", "answer": "Erythropoietin concentration", "options": {"A": "Haptoglobin concentration", "B": "Transferrin concentration", "C": "Reticulocyte count", "D": "Erythropoietin concentration", "E": "Lactate dehydrogenase concentration"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "progressive daytime sleepiness", "exertional dyspnea", "past 6 months", "conjunctival pallor", "several subcutaneous purple spots", "legs", "hemoglobin concentration", "8.5 g/dL", "leukocyte count", "3", "mm3", "platelet count", "mm3", "following laboratory values", "to", "increased", "patient"]}
{"question": "A 35-year-old man is referred to a physical therapist due to limitation of movement in the wrist and fingers of his left hand. He cannot hold objects or perform daily activities with his left hand. He broke his left arm at the humerus one month ago. The break was simple and treatment involved a cast for one month. Then he lost his health insurance and could not return for follow up. Only after removing the cast did he notice the movement issues in his left hand and wrist. His past medical history is otherwise insignificant, and vital signs are within normal limits. On examination, the patient’s left hand is pale and flexed in a claw-like position. It is firm and tender to palpation. Right radial pulse is 2+ and left radial pulse is 1+. The patient is unable to actively extend his fingers and wrist, and passive extension is difficult and painful. Which of the following is a proper treatment for the presented patient?", "answer": "Surgical release", "options": {"A": "Surgical release", "B": "Needle fasciotomy", "C": "Corticosteroid injections", "D": "Collagenase injections", "E": "Botulinum toxin injections"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old man", "referred", "physical therapist due to limitation", "movement", "wrist", "fingers of", "left hand", "hold", "perform", "left hand", "broke", "left", "humerus one month", "break", "simple", "treatment involved", "cast", "one month", "Then", "lost", "not return", "follow up", "Only", "removing", "cast", "movement issues", "left hand", "wrist", "past medical history", "vital signs", "normal limits", "patients left hand", "pale", "flexed", "claw", "position", "firm", "tender", "palpation", "Right radial pulse", "2", "left radial pulse", "1", "patient", "unable", "extend", "fingers", "wrist", "passive extension", "difficult", "painful", "following"]}
{"question": "A 22-year-old man is brought to the emergency department because of progressive left-sided scrotal pain for 4 hours. He describes the pain as throbbing in nature and 6 out of 10 in intensity. He has vomited once on the way to the hospital. He has had pain during urination for the past 4 days. He has been sexually active with 2 female partners over the past year and uses condoms inconsistently. His father was diagnosed with testicular cancer at the age of 51 years. He appears anxious. His temperature is 36.9°C (98.42°F), pulse is 94/min, and blood pressure is 124/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Examination shows a tender, swollen left testicle and an erythematous left hemiscrotum. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Which of the following is the most appropriate next step in management?", "answer": "Scrotal ultrasonography", "options": {"A": "Measurement of serum α-fetoprotein level", "B": "CT scan of the abdomen and pelvis", "C": "Surgical exploration", "D": "Scrotal ultrasonography", "E": "Measurement of serum mumps IgG titer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "of progressive left-sided scrotal pain", "hours", "pain", "throbbing", "nature", "6 out", "10", "intensity", "vomited", "hospital", "pain", "urination", "past", "days", "sexually active", "female", "past year", "uses condoms", "diagnosed", "testicular cancer", "age", "years", "appears anxious", "temperature", "36", "98", "pulse", "min", "blood pressure", "mm Hg", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "tender", "swollen left testicle", "erythematous left hemiscrotum", "Urine dipstick", "leukocyte esterase", "urinalysis", "WBCs", "following", "most appropriate next step"]}
{"question": "A 4-month-old boy is brought to the physician because of a lesion on his right thigh. Yesterday, he was administered all scheduled childhood immunizations. His vital signs are within normal limits. Physical examination shows a 2-cm sized ulcer with surrounding induration over the right anterolateral thigh. Which of the following is the most likely cause of his symptoms?", "answer": "Immune complex deposition", "options": {"A": "Dermal mast cell activation", "B": "Immune complex deposition", "C": "Intradermal acantholysis", "D": "Infective dermal inflammation", "E": "T lymphocyte mediated hypersensitivity"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 month old boy", "brought", "physician", "of", "lesion", "right thigh", "administered", "scheduled childhood immunizations", "vital signs", "normal", "Physical examination", "2", "sized ulcer", "surrounding induration", "right anterolateral thigh", "following", "most likely cause", "symptoms"]}
{"question": "A 5-year-old boy presents to a pediatric orthopedic surgeon for evaluation of spinal curvature. His primary care physician noticed during an annual checkup that the boy's shoulders were uneven, and radiograph revealed early onset scoliosis. His past medical history is significant for multiple fractures as well as short stature. Based on the early presentation of scoliosis and the unusual history of fractures, the surgeon orders further workup and discovers a genetic mutation in an extracellular protein. This protein exists in two different forms. The first is an insoluble dimer that is linked by disulfide bonds and links integrins to the extracellular matrix. The second is a soluble protein that assists with clotting. Based on these descriptions, which of the following proteins is most likely mutated in this patient?", "answer": "Fibronectin", "options": {"A": "Dermatan sulfate", "B": "Fibrillin", "C": "Fibronectin", "D": "Type 1 collagen", "E": "Type 3 collagen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy presents", "pediatric orthopedic", "spinal curvature", "primary care physician", "annual checkup", "boy's shoulders", "radiograph revealed early onset scoliosis", "past medical history", "significant", "multiple fractures", "short stature", "Based", "early", "scoliosis", "unusual history of fractures", "surgeon orders further workup", "genetic mutation", "extracellular protein", "protein", "two different forms", "first", "integrins", "extracellular matrix", "second", "soluble protein", "assists", "clotting", "Based", "following proteins", "most likely mutated", "patient"]}
{"question": "An 80-year-old woman is brought to the physician by her 2 daughters for worsening memory loss. They report that their mother is increasingly forgetful about recent conversations and events. She is unable to remember her appointments and commitments she has made. 3 years ago, the patient was moved into an elder care facility because she was often getting lost on her way home and forgetting to take her medications. The patient reports that she is very socially active at her new home and has long conversations with the other residents about her adventures as an air hostess during her youth. Which of the following cerebral pathologies is most likely present in this patient?", "answer": "Neurofibrillary tangles", "options": {"A": "Demyelination", "B": "Intracytoplasmic vacuoles", "C": "Lacunar infarcts", "D": "Lewy bodies", "E": "Neurofibrillary tangles"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["80 year old woman", "brought", "physician", "her 2", "worsening memory loss", "report", "forgetful", "recent", "unable to", "appointments", "made", "years", "patient", "moved", "facility", "often getting lost", "home", "forgetting to", "medications", "patient reports", "very", "active", "new home", "long", "residents", "air", "youth", "following", "pathologies", "most likely present", "patient"]}
{"question": "An experimental new drug (SD27C) is being studied. This novel drug delivers insulin via the intranasal route. Consent is obtained from participants who are diabetic and are taking insulin as their current treatment regimen to participate in a clinical trial. 500 patients consent and are divided into 2 groups, and a double-blind clinical trial was conducted. One group received the new formulation (SD27C), while the second group received regular insulin via subcutaneous injection. The results showed that the treatment outcomes in both groups are the same. SD27C is currently under investigation in which phase of the clinical trial?", "answer": "Phase III", "options": {"A": "Phase IV", "B": "Phase III", "C": "Post-market surveillance", "D": "Phase II", "E": "Phase I"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["experimental new drug", "studied", "novel drug delivers insulin", "intranasal route", "Consent", "obtained", "diabetic", "taking insulin", "current to", "500 patients consent", "divided", "One group received", "new", "received regular", "subcutaneous", "results", "treatment outcomes", "groups", "same", "currently"]}
{"question": "A 65-year-old woman presents with progressive gait difficulty, neck pain, and bladder incontinence. She also complains of urinary urgency. Past medical history is significant for uncontrolled diabetes mellitus with a previous hemoglobin A1c of 10.8%. Physical examination reveals slightly increased muscle tone in all limbs with brisk tendon reflexes. Sensory examination reveals a decrease of all sensations in a stocking and glove distribution. Her gait is significantly impaired. She walks slowly with small steps and has difficulty turning while walking. She scores 23 out of 30 on a mini-mental state examination (MMSE). A brain MRI reveals dilated ventricles with a callosal angle of 60 degrees and mild cortical atrophy. What is the most appropriate next step in the management of this patient?", "answer": "Large-volume lumbar tap", "options": {"A": "Acetazolamide", "B": "Donepezil", "C": "Large-volume lumbar tap", "D": "Levodopa", "E": "Ventriculoperitoneal shunt"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old woman presents", "progressive gait difficulty", "neck pain", "bladder incontinence", "of urinary urgency", "Past medical", "significant", "uncontrolled diabetes mellitus", "a previous hemoglobin A1c", "10.8", "reveals slightly increased muscle tone", "limbs", "brisk tendon reflexes", "Sensory", "reveals", "decrease", "sensations", "stocking", "glove distribution", "gait", "impaired", "walks slowly", "small steps", "difficulty turning", "scores 23 out", "30", "mini-mental state examination", "brain MRI reveals dilated ventricles", "callosal angle", "60 degrees", "mild cortical atrophy", "most appropriate next step", "patient"]}
{"question": "A 48-year-old woman presents to the emergency department because of increasingly severe right upper abdominal pain, fever, and non-bloody vomiting for the last 5 hours. The pain is dull, intermittent, and radiates to her right shoulder. During the past 3 months, she has had recurring abdominal discomfort after meals. The patient underwent an appendectomy more than 30 years ago. She has hypertension, diabetes mellitus type 2, and chronic back pain. She takes bisoprolol, metformin, and ibuprofen daily. She is 171 cm (5 ft 6 in) tall and weighs 99 kg (218 lb). Her BMI is 35.2 kg/m2. She appears uncomfortable and is clutching her abdomen. Her temperature is 38.5°C (101.3°F), pulse is 108/min, and blood pressure is 150/82 mm Hg. Abdominal examination shows right upper quadrant abdominal tenderness and guarding. Upon deep palpation of the right upper quadrant, the patient pauses during inspiration. Laboratory studies show the following:\nBlood\nHemoglobin 13.1 g/dL\nLeukocyte count 10,900/mm3\nPlatelet count 236,000/mm3\nMean corpuscular volume 89/µm3\nSerum\nUrea nitrogen 28 mg/dL\nGlucose 89 mg/dL\nCreatinine 0.7 mg/dL\nBilirubin  \nTotal 1.6 mg/dL\nDirect 1.1 mg/dL\nAlkaline phosphatase 79 U/L\nAlanine aminotransferase (ALT, GPT) 28 U/L\nAspartate aminotransferase (AST, GOT) 32 U/L\nAn X-ray of the abdomen shows no abnormalities. Further evaluation of the patient is most likely to reveal which of the following?", "answer": "History of multiple past pregnancies", "options": {"A": "Elevated carbohydrate-deficient transferrin", "B": "Frequent, high-pitched bowel sounds on auscultation", "C": "History of multiple past pregnancies", "D": "History of recent travel to Indonesia", "E": "History of recurrent sexually transmitted infections"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old woman presents", "emergency department", "severe right upper", "fever", "non bloody vomiting", "hours", "pain", "dull", "intermittent", "radiates", "right shoulder", "past 3 months", "recurring abdominal discomfort", "meals", "patient", "appendectomy", "30 years", "hypertension", "diabetes mellitus type 2", "chronic back pain", "bisoprolol", "metformin", "ibuprofen daily", "5 ft 6", "tall", "99 kg", "BMI", "35", "kg/m2", "appears", "abdomen", "temperature", "pulse", "min", "blood pressure", "mm Hg", "Abdominal", "right upper quadrant abdominal tenderness", "guarding", "deep palpation", "right upper quadrant", "patient pauses", "inspiration", "Laboratory studies", "following", "Blood", "900 mm3 Platelet", "volume", "28 mg", "mg", "Creatinine 0", "6", "Direct 1.1 mg/dL Alkaline phosphatase", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L Aspartate aminotransferase", "AST", "U/L", "X-ray of", "abdomen", "abnormalities", "Further", "to reveal", "following"]}
{"question": "A 24-year-old man is running a marathon (42.2 km) on a hot summer day and collapses about halfway through the run. Emergency personnel are called and find him having a seizure. As the seizure subsides, the runner exhibits confusion, dry lips and decreased skin turgor. On the way to the emergency department, he denies taking medication or having a history of seizures. He reports that he drank water, but he admits that it was probably not enough. Which of the following would be the next best step in the management of this patient?", "answer": "3% NaCl", "options": {"A": "Indapamide", "B": "Relcovaptan", "C": "3% NaCl", "D": "0.9% NaCl", "E": "Furosemide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "marathon", "hot summer day", "run", "Emergency personnel", "called", "find", "seizure", "seizure", "confusion", "dry lips", "decreased skin turgor", "emergency department", "medication", "history", "seizures", "reports", "water", "not", "following", "next best step", "patient"]}
{"question": "A 40-year-old woman comes to the physician for a 2-month history of chest pain and heartburn after meals. The patient reports that the pain is worse at night and especially when lying down. She has a history of Raynaud's disease treated with nifedipine. There is no family history of serious illness. She emigrated to the US from Nigeria 5 years ago. She does not smoke or drink alcohol. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Thickening and hardening of the skin is seen on the hands and face. There are several firm, white nodules on the elbows and fingertips. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Anticentromere antibodies", "options": {"A": "Anti-RNA polymerase III antibodies", "B": "Anti-U1 RNP antibodies", "C": "Anticentromere antibodies", "D": "Anti-Scl-70 antibodies", "E": "Anti-dsDNA antibodies"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old woman", "physician", "2 month history of chest pain", "heartburn", "meals", "patient reports", "pain", "worse", "night", "lying", "history of Raynaud's disease treated with nifedipine", "family history", "serious illness", "Nigeria", "years", "not smoke", "Vital signs", "normal limits", "Cardiopulmonary", "abnormalities", "Thickening", "hardening", "skin", "seen", "hands", "face", "several firm", "white nodules", "elbows", "fingertips", "Further", "to", "following findings"]}
{"question": "A 55-year-old man is evaluated in the clinic for several episodes of diarrhea during the past 2 months. He denies having fever or abdominal pain and states that his diarrhea has been getting worse despite the use of over-the-counter loperamide and bismuth compounds. Upon further questioning, he recalls having multiple episodes of a burning sensation in his neck and upper chest, associated with redness and flushing of his face, which lasted for a few seconds. Because of his hypertension and dyslipidemia, the man is taking amlodipine and following a low-calorie diet. Physical examination shows that the blood pressure is 129/89 mm Hg, the pulse rate is 78/min, the respiratory rate is 14/min, and the temperature is 36.6°C (98.0°F). His abdomen is lax with no tenderness or rigidity, and rectal examination shows no blood in the rectal vault. Cardiac auscultation reveals a 3/6 holosystolic murmur in the tricuspid area, which increases in intensity with inspiration. Altered metabolism of which of the following amino acids is most likely the explanation for this patient’s presentation?", "answer": "Tryptophan", "options": {"A": "Phenylalanine", "B": "Tryptophan", "C": "Homocysteine", "D": "Arginine", "E": "Glycine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "clinic", "several episodes of diarrhea", "past", "months", "fever", "abdominal pain", "states", "diarrhea", "getting worse", "the use of over", "counter loperamide", "further", "multiple episodes of", "burning sensation", "neck", "upper chest", "associated with redness", "flushing of", "face", "lasted", "seconds", "hypertension", "dyslipidemia", "man", "amlodipine", "following", "low-calorie diet", "blood pressure", "mm Hg", "pulse rate", "min", "respiratory rate", "min", "temperature", "36", "98", "abdomen", "lax", "tenderness", "rigidity", "rectal examination", "blood", "rectal vault", "Cardiac auscultation reveals", "3/6 holosystolic murmur", "tricuspid area", "increases", "intensity", "inspiration", "following", "explanation", "patients"]}
{"question": "A 15-month-old girl is brought to the emergency department shortly after a 2-minute episode of rhythmic eye blinking and uncontrolled shaking of all limbs. She was unresponsive during the episode. For the past few days, the girl has had a fever and mild nasal congestion. Her immunizations are up-to-date. Her temperature is 39.2°C (102.6°F), pulse is 110/min, respirations are 28/min, and blood pressure is 88/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. She is sleepy but opens her eyes when her name is called. Examination shows moist mucous membranes. Neurologic examination shows no abnormalities. The neck is supple with normal range of motion. An oral dose of acetaminophen is administered. On re-evaluation, the girl is alert and playing with toys in the examination room. Which of the following is the most appropriate next step in management?", "answer": "Discharge the patient", "options": {"A": "Perform an EEG", "B": "Perform a CT scan of the head", "C": "Observe the patient for 24 hours", "D": "Discharge the patient", "E": "Administer lorazepam"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old girl", "brought", "emergency department", "2 minute episode of rhythmic eye blinking", "uncontrolled shaking", "limbs", "unresponsive", "episode", "past", "days", "girl", "fever", "mild nasal congestion", "immunizations", "date", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "88", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "100", "sleepy", "opens", "eyes", "name", "called", "moist mucous membranes", "Neurologic examination", "abnormalities", "neck", "supple", "normal range of motion", "oral dose", "acetaminophen", "administered", "girl", "alert", "playing", "toys", "following", "most appropriate next step"]}
{"question": "A 4-year-old boy presents with involuntary jerks seen in his upper extremities. The patient’s mother says that “his eyes move in different directions every now and then”. Last winter, the patient had chickenpox but otherwise has always been healthy. His vital signs are a blood pressure of 100/90 mm Hg, temperature of 36.8°C (98.2°F), and respiratory rate of 17/min. On physical examination, the patient’s eyes move chaotically in all directions. Laboratory tests are unremarkable, except for a random urinary vanillylmandelic acid (VMA) level of 18 mg/g creatinine (reference range for children aged 2–4 years: < 13 mg/g creatinine). An abdominal ultrasound shows a 2 cm x 3 cm x 5 cm mass in the left adrenal gland. A biopsy of the mass reveals neuroblasts arranged in a rosette pattern. Which of the following oncogenes is most commonly associated with this condition?", "answer": "MYCN", "options": {"A": "MYCN", "B": "KRAS", "C": "ALK", "D": "JAK2", "E": "RET"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["4 year old boy presents", "jerks seen", "upper extremities", "patients", "eyes move", "different directions", "now", "then", "Last winter", "patient", "chickenpox", "always", "healthy", "vital signs", "blood pressure", "100/90 mm Hg", "temperature", "36", "98", "respiratory rate", "min", "patients eyes move", "directions", "Laboratory tests", "unremarkable", "except for", "random urinary vanillylmandelic acid", "level", "mg/g creatinine", "reference range", "children aged", "years", "mg/g creatinine", "abdominal ultrasound", "2 cm", "3", "mass", "left", "biopsy", "mass reveals", "rosette pattern", "following oncogenes", "most", "associated", "condition"]}
{"question": "A 36-year-old man undergoes surgical intervention due to a right upper quadrant stab wound. His gallbladder was found to be lacerated and is removed. It is sent for histological evaluation. The pathologist examines the slide shown in the exhibit and identifies several structures numbered the image. Which of the following statements is correct?", "answer": "This section is taken from the site which does not adjoin liver", "options": {"A": "The function of the cells in area 1 is to secrete bile", "B": "The cells in area 3 are inactivated by cholecystokinin", "C": "The cells in area 2 belong to muscularis propria", "D": "This section is taken from the site which does not adjoin liver", "E": "Normally, there should be goblet cells among the cells in area 1"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old man", "surgical intervention due to", "right upper quadrant stab wound", "gallbladder", "found to", "lacerated", "removed", "sent", "histological", "pathologist", "slide", "several structures numbered", "following", "correct"]}
{"question": "A 25-year-old man presents to the emergency department for a fever and abdominal pain. The patient states that his pain has been worsening over the past week in the setting of a fever. He has a past medical history of IV drug abuse and multiple admissions for septic shock. His temperature is 102°F (38.9°C), blood pressure is 94/54 mmHg, pulse is 133/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for a murmur over the left upper sternal border. Abdominal exam reveals left upper quadrant tenderness. Laboratory values are ordered as seen below.\n\nHemoglobin: 15 g/dL\nHematocrit: 44%\nLeukocyte count: 16,700/mm^3\nPlatelet count: 299,000/mm^3\n\nWhich of the following is the most likely diagnosis?", "answer": "Splenic abscess", "options": {"A": "Appendicitis", "B": "Diverticulitis", "C": "Hepatic abscess", "D": "Mesenteric ischemia", "E": "Splenic abscess"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "fever", "abdominal pain", "patient states", "pain", "worsening", "past week", "setting", "fever", "past medical history of IV drug abuse", "multiple", "septic shock", "temperature", "blood pressure", "54 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "100", "room air", "notable", "murmur", "left upper sternal border", "Abdominal exam reveals left upper quadrant tenderness", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "700 mm", "Platelet count", "mm", "following", "diagnosis"]}
{"question": "A 62-year-old man is brought to the emergency department from a senior-care facility after he was found with a decreased level of consciousness and fever. His personal history is relevant for colorectal cancer that was managed with surgical excision of the tumor. Upon admission, he is found to have a blood pressure of 130/80 mm Hg, a pulse of 102/min, a respiratory rate of 20/min, and a body temperature 38.8°C (101.8°F). There is no rash on physical examination; he is found to have neck rigidity, confusion, and photophobia. There are no focal neurological deficits. A head CT is normal without mass or hydrocephalus. A lumbar puncture was performed and cerebrospinal fluid (CSF) is sent to analysis while ceftriaxone and vancomycin are started. Which of the following additional antimicrobials should be added in the management of this patient?", "answer": "Ampicillin", "options": {"A": "Ampicillin", "B": "Amphotericin", "C": "Clindamycin", "D": "Trimethoprim-sulfamethoxazole (TMP-SMX)", "E": "Meropenem"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man", "brought", "emergency department", "facility", "found", "decreased level of consciousness", "fever", "personal history", "relevant", "colorectal cancer", "surgical", "tumor", "found to", "blood pressure", "80 mm Hg", "pulse", "min", "respiratory rate", "20 min", "body temperature", "rash", "found to", "neck rigidity", "confusion", "photophobia", "focal neurological deficits", "head CT", "normal", "mass", "hydrocephalus", "lumbar puncture", "performed", "cerebrospinal fluid", "sent", "analysis", "ceftriaxone", "vancomycin", "started", "following additional antimicrobials", "added", "patient"]}
{"question": "A 13-year-old boy re-presents to his pediatrician with a new onset rash that began a few days after his initial visit. He initially presented with complaints of sore throat but was found to have a negative strep test. His mother demanded that he be placed on antibiotics, but this was refused by his pediatrician. The boy's father, a neurologist, therefore, started him on penicillin. Shortly after starting the drug, the boy developed a fever and a rash. The patient is admitted and his symptoms worsen. His skin begins to slough off, and the rash covers over 30% of his body. His oropharynx and corneal membranes are also affected. You examine him at the bedside and note a positive Nikolsky's sign. What is the most likely diagnosis?", "answer": "Toxic Epidermal Necrolysis", "options": {"A": "Erythema Multiforme", "B": "Stevens-Johnson Syndrome", "C": "Toxic Epidermal Necrolysis", "D": "Rocky Mounted Spotted Fever", "E": "Pemphigus Vulgaris"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy re presents", "pediatrician", "new onset rash", "began", "few days", "initial visit", "initially presented", "complaints", "sore throat", "found to", "negative strep test", "demanded", "pediatrician", "boy's", "neurologist", "started", "penicillin", "starting", "drug", "boy", "fever", "rash", "patient", "symptoms worsen", "skin begins", "slough", "rash covers", "30", "body", "oropharynx", "corneal membranes", "affected", "note", "positive Nikolsky's sign", "diagnosis"]}
{"question": "A 16-year-old girl who recently immigrated to the United States from Bolivia presents to her primary care physician with a chief complaint of inattentiveness in school. The patient's teacher describes her as occasionally \"day-dreaming\" for periods of time during which the patient does not respond or participate in school activities. Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment. The patient has no other complaints herself. The only other concern that the patient's mother has is that upon awakening she notices that sometimes the patient's arm will jerk back and forth. The patient states she is not doing this intentionally. The patient has an unknown past medical history and is currently not on any medications. On physical exam you note a young, healthy girl whose neurological exam is within normal limits. Which of the following is the best initial treatment?", "answer": "Valproic acid", "options": {"A": "Carbamazepine", "B": "Ethosuximide", "C": "Valproic acid", "D": "Lamotrigine", "E": "Cognitive behavioral therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "recently", "United States", "Bolivia presents", "primary care physician", "chief complaint", "inattentiveness in school", "patient", "eacher ", "ccasionally ", "eriods ", "ime ", "atient ", "ot ", "n  chool ", "elped ", "atient  hange ", "ehavior,", "ncluding ", "eacher ", "atient ", "omplaints ", "nly ", "atient'", "akening s", "metimes t", "tient's", " wi", "k ba k an", "ient st tes sh", " do", "ient ha", "nown pa t medical history an", "rently no  on", "ications. O", "e a ", "ng, h", "lthy gi l wh", "rological exam is", "mal limits. W", "lowing is", "t in tial tr atment?"]}
{"question": "A 29-year-old man is brought to the emergency room 6 hours after the onset of severe epigastric pain and vomiting. His heart rate is 110/min and blood pressure is 98/72 mm Hg. He is diagnosed with acute pancreatitis, and fluid resuscitation with normal saline is initiated. Which of the following is the most likely immediate effect of fluid resuscitation in this patient?", "answer": "Increase in myocardial oxygen demand", "options": {"A": "Increase in cardiac afterload", "B": "Increase in volume of distribution", "C": "Increase in myocardial oxygen demand", "D": "Increase in plasma oncotic pressure", "E": "Increase in glomerular filtration fraction\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old man", "brought", "emergency room", "hours", "onset", "severe epigastric", "vomiting", "heart rate", "min", "blood pressure", "98 72 mm Hg", "diagnosed", "acute pancreatitis", "fluid resuscitation", "normal saline", "initiated", "following", "immediate effect", "fluid resuscitation", "patient"]}
{"question": "A 25-year-old woman presents with abdominal pain and discomfort for the past 3 days. She was diagnosed with irritable bowel syndrome (IBS) a couple of years ago, managed until recently with imipramine, psyllium, and loperamide. 5 days ago, because she had developed alternating diarrhea and constipation, bloating, and abdominal pain on her medication, she was started on alosetron. Her current temperature is 39.0°C (102.2°F), the heart rate is 115/min, the blood pressure is 90/60 mm Hg and the respiratory rate is 22/min. Abdominal examination shows diffuse tenderness to palpation with guarding but no rebound. Bowel sounds are hypoactive on auscultation. A fecal occult blood test is positive and laboratory tests show her white cell count to be 15,800/µL. Arterial blood gas (ABG) analysis reveals a metabolic acidosis Which of the following is the most likely diagnosis in this patient?", "answer": "Ischemic colitis", "options": {"A": "Pseudomembranous colitis", "B": "Crohn’s disease", "C": "Perforated duodenal ulcer", "D": "Appendicitis", "E": "Ischemic colitis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "abdominal pain", "discomfort", "past 3 days", "diagnosed", "irritable bowel syndrome", "couple", "years", "recently", "imipramine", "psyllium", "loperamide", "days", "alternating diarrhea", "constipation", "bloating", "abdominal pain", "medication", "started", "alosetron", "current temperature", "heart rate", "min", "blood pressure", "90 60 mm Hg", "respiratory rate", "min", "Abdominal", "diffuse tenderness", "palpation", "guarding", "Bowel sounds", "hypoactive", "auscultation", "fecal occult blood test", "positive", "laboratory tests", "white cell count to", "800", "Arterial blood gas", "analysis reveals", "metabolic acidosis", "following", "diagnosis", "patient"]}
{"question": "A 34-year-old patient with a history of anxiety, chronic constipation, chronic headaches, and chronic hypertension presents to the emergency room with severe right flank pain radiating to his scrotum. A urinalysis with stone analysis is performed and the results are shown in figure A. Prior to discharge, it is noted that the patients BP is still 170/110 mmHg. Furthermore, his calcium and PTH levels were both found to be increased. Which of the following representative histology slides of thyroid tissue represents a potential complication of the patients condition?", "answer": "Medullary thyroid cancer", "options": {"A": "Anaplastic thyroid cancer", "B": "Medullary thyroid cancer", "C": "Papillary thyroid cancer", "D": "Lymphoma", "E": "Follicular thyroid cancer"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old patient", "history", "anxiety", "chronic constipation", "chronic headaches", "chronic hypertension presents", "emergency room", "severe right flank pain radiating to", "scrotum", "urinalysis", "stone analysis", "performed", "results", "discharge", "noted", "patients BP", "mmHg", "calcium", "levels", "found to", "increased", "following", "histology slides", "thyroid tissue", "potential complication", "patients condition"]}
{"question": "A 10-year-old boy presents with a painful rash for 1 day. He says that the reddish, purple rash started on his forearm but has now spread to his abdomen. He says there is a burning pain in the area where the rash is located. He also says he has had a stuffy nose for several days. Past medical history is significant for asthma and epilepsy, medically managed. Current medications are a daily chewable multivitamin, albuterol, budesonide, and lamotrigine. On physical examination, there is a red-purple maculopapular rash present on upper extremities and torso. There are some blisters present over the rash, as shown in the image, which is also present in the oral mucosa. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Lamotrigine", "options": {"A": "Budesonide", "B": "Infection", "C": "Lamotrigine", "D": "Multivitamin", "E": "Albuterol"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A 10 year old boy presents", "painful rash", "1 day", "purple rash started", "forearm", "now spread", "abdomen", "burning pain", "area", "rash", "stuffy nose", "days", "Past medical history", "significant", "asthma", "epilepsy", "Current medications", "daily", "multivitamin", "albuterol", "budesonide", "lamotrigine", "red purple maculopapular rash present", "upper", "torso", "blisters present", "rash", "present", "oral mucosa", "following", "most likely cause", "patients symptoms"]}
{"question": "A 38-year-old man presents to the endocrinologist with complaints of increased shoe size and headaches in the morning. These symptoms have developed gradually over the past year but have become especially concerning because he can no longer wear his normal-sized boots. He denies any other symptoms, including visual changes. He was recently started on lisinopril by his primary care physician for high blood pressure. His vital signs are within normal limits and stable. On exam, the endocrinologist notes the findings shown in Figures A and B. These facial features are especially striking when contrasted with his drivers license from 10 years prior, when his jaw was much less prominent. The endocrinologist sends a screening blood test to work-up the likely diagnosis. Which of the following organs or glands produces the molecule being tested in this screening?", "answer": "Liver", "options": {"A": "Anterior pituitary gland", "B": "Liver", "C": "Posterior pituitary gland", "D": "Pancreas", "E": "Kidney"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "endocrinologist", "complaints", "increased shoe", "headaches", "morning", "symptoms", "past year", "longer", "normal-sized boots", "symptoms", "including visual changes", "recently started", "lisinopril", "primary care physician", "high blood pressure", "vital signs", "normal limits", "stable", "exam", "endocrinologist notes", "findings", "facial features", "contrasted", "drivers", "prior", "jaw", "much", "prominent", "endocrinologist sends", "screening blood", "work-up", "likely diagnosis", "following organs", "glands"]}
{"question": "A 64-year-old man is brought to the emergency department because of dull lower abdominal pain for 3 hours. He has not urinated for 24 hours and has not passed stool for over 3 days. He was diagnosed with herpes zoster 4 weeks ago and continues to have pain even after his rash resolved. He has hypertension, benign prostatic hyperplasia, and coronary artery disease. Physical examination shows a tender, palpable suprapubic mass. Bowel sounds are hypoactive. Abdominal ultrasound shows a large anechoic mass in the pelvis. Which of the following drugs most likely accounts for this patient's current symptoms?", "answer": "Desipramine", "options": {"A": "Simvastatin", "B": "Pregabalin", "C": "Amlodipine", "D": "Valproate", "E": "Desipramine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["64 year old man", "brought", "emergency department", "dull lower abdominal pain", "hours", "not", "24 hours", "not passed stool", "3 days", "diagnosed", "herpes zoster", "weeks", "to", "pain", "rash resolved", "hypertension", "benign prostatic hyperplasia", "coronary artery disease", "tender", "palpable suprapubic mass", "Bowel sounds", "hypoactive", "Abdominal ultrasound", "large", "mass", "pelvis", "following drugs", "likely accounts", "patient's current symptoms"]}
{"question": "A 12-year-old girl presents to the pediatric dermatologist with an expanding, but otherwise asymptomatic erythematous patch on her right shoulder, which she first noticed 3 days ago. The girl states the rash started as a small red bump but has gradually progressed to its current size. No similar lesions were observed elsewhere by her or her mother. She has felt ill and her mother has detected intermittent low-grade fevers. During the skin examination, a target-like erythematous patch, approximately 7 cm in diameter, was noted on the left shoulder (as shown in the image). Another notable finding was axillary lymphadenopathy. On further questioning it was revealed that the patient went camping with her grandfather approximately 11 days ago; however, she does not recall any insect bites or exposure to animals. The family has a pet cat living in their household. Based on the history and physical examination results, what is the most likely diagnosis?", "answer": "Lyme disease", "options": {"A": "Tinea corporis", "B": "Lyme disease", "C": "Granuloma anulare", "D": "Pityriasis rosea", "E": "Hansen’s disease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "pediatric dermatologist", "expanding", "asymptomatic erythematous patch", "right shoulder", "first", "3 days", "girl states", "rash started", "small red", "progressed", "current size", "similar lesions", "observed", "ill", "detected intermittent low-grade fevers", "skin examination", "target", "erythematous patch", "approximately", "diameter", "noted", "left shoulder", "notable finding", "axillary lymphadenopathy", "further", "revealed", "patient", "approximately", "days", "not", "insect bites", "exposure to animals", "cat living", "Based", "history", "physical examination results", "diagnosis"]}
{"question": "A 75-year-old man with a 35-pack-year history of smoking is found to be lethargic three days being admitted with a femur fracture following a motor vehicle accident. His recovery has been progressing well thus far, though pain continued to be present. On exam, the patient minimally responsive with pinpoint pupils. Vital signs are blood pressure of 115/65 mmHg, HR 80/min, respiratory rate 6/min, and oxygen saturation of 87% on room air. Arterial blood gas (ABG) shows a pH of 7.24 (Normal: 7.35-7.45), PaCO2 of 60mm Hg (normal 35-45mm Hg), a HCO3 of 23 mEq/L (normal 21-28 mEq/L) and a Pa02 of 60 mmHg (normal 80-100 mmHg). Which of the following is the most appropriate therapy at this time?", "answer": "Naloxone", "options": {"A": "Repeat catheterization", "B": "Glucocorticoids", "C": "Heparin", "D": "Naloxone", "E": "Emergent cardiac surgery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["75 year old man", "35", "history of smoking", "found to", "lethargic three days", "femur fracture following", "motor vehicle accident", "recovery", "progressing well", "far", "pain", "to", "present", "exam", "patient", "responsive", "pinpoint pupils", "Vital signs", "blood pressure", "65 mmHg", "80 min", "respiratory rate", "min", "oxygen saturation", "87", "room air", "Arterial blood gas", "pH", "7", "Normal", "7 35 7", "Hg", "normal 35", "Hg", "HCO3", "23 mEq/L", "normal", "mEq/L", "60 mmHg", "normal 80 100 mmHg", "following", "most appropriate therapy", "time"]}
{"question": "A 27-year-old woman comes to the physician for the evaluation of infertility. She has been unable to conceive for the past 2 years. Menses occur at 45 to 80-day intervals. She is 168 cm (5 ft 6 in) tall and weighs 77 kg (170 lb); BMI is 27.4 kg/m2. Physical examination shows facial acne and pigmented hair on the upper lip. Serum studies show elevated levels of testosterone and an LH:FSH ratio of 4:1. Treatment with the appropriate drug for this patient's infertility is begun. Which of the following is the primary mechanism of action of this drug?", "answer": "Inhibition of hypothalamic estrogen receptors", "options": {"A": "Activation of pituitary dopamine receptors", "B": "Inhibition of endometrial progesterone receptors", "C": "Activation of ovarian luteinizing hormone receptors", "D": "Activation of granulosa cell aromatase", "E": "Inhibition of hypothalamic estrogen receptors"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old woman", "physician", "infertility", "unable to", "past", "years", "Menses occur", "80 day intervals", "5 ft 6", "tall", "kg", "BMI", "27", "kg/m2", "facial acne", "pigmented hair", "upper lip", "Serum studies", "elevated levels", "testosterone", "LH", "ratio", "1", "Treatment", "appropriate drug", "patient's infertility", "begun", "following", "primary mechanism of action", "drug"]}
{"question": "A six-year-old male presents to the pediatrician for a well child visit. The patient’s parents report that they are struggling to manage his temper tantrums, which happen as frequently as several times per day. They usually occur in the morning before school and during mealtimes, when his parents try to limit how much he eats. The patient often returns for second or third helpings at meals and snacks throughout the day. The patient’s parents have begun limiting the patient’s food intake because he has been gaining weight. They also report that the patient recently began first grade but still struggles with counting objects and naming letters consistently. The patient sat without support at 11 months of age and walked at 17 months of age. He is in the 99th percentile for weight and 5th percentile for height. On physical exam, he has almond-shaped eyes and a downturned mouth. He has poor muscle tone.\n\nWhich of the following additional findings would most likely be seen in this patient?", "answer": "Hypogonadism", "options": {"A": "Ataxia", "B": "Hemihyperplasia", "C": "Hypogonadism", "D": "Macroorchidism", "E": "Webbed neck"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["six year old male presents", "pediatrician", "patients", "report", "to", "temper tantrums", "frequently", "times", "day", "usually occur", "morning", "school", "mealtimes", "to limit", "eats", "patient often returns", "second", "third", "meals", "day", "patients", "begun limiting", "patients food intake", "gaining weight", "report", "patient recently began first grade", "counting", "patient sat", "support", "months", "age", "months", "age", "99th percentile", "weight", "5th percentile", "height", "almond-shaped eyes", "downturned mouth", "poor muscle tone", "following additional findings", "most likely", "seen", "patient"]}
{"question": "A 72-year-old and his caregiver present for a follow-up after a transthoracic needle biopsy of one of the large lesions in his chest was reported as non-small cell carcinoma of the lung. Previously, a chest CT revealed numerous nodules in the lungs bilaterally. The chest CT was ordered after the patient experienced a persistent cough with hemoptysis and a history of multiple episodes of pneumonia over the past year. The patient has a history of dementia and is a poor historian. The caregiver states that the patient has no history of smoking and that he was a lawyer before he retired, 10 years ago. The caregiver can only provide a limited medical history, but states that the patient sees another doctor “to monitor his prostate”. Which of the following is true regarding the pathogenesis of the nodules seen in this patient?", "answer": "Tumors seeded via the pulmonary arteries", "options": {"A": "Aspergillus infection leading to a formation of a 'fungus ball'", "B": "Malignant transformation of neuroendocrine cells", "C": "Infection of the lung parenchyma with a gram-negative bacteria grown on charcoal yeast agar", "D": "Proliferation of cells that contain glands that produce mucin", "E": "Tumors seeded via the pulmonary arteries"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["72 year old", "caregiver present", "follow-up", "transthoracic needle biopsy", "one", "large lesions", "chest", "reported", "non-small cell carcinoma of the lung", "chest CT revealed numerous nodules", "lungs", "chest CT", "ordered", "patient", "persistent cough", "hemoptysis", "history of multiple episodes", "pneumonia", "past year", "patient", "history of dementia", "poor historian", "caregiver states", "patient", "history of smoking", "lawyer", "retired", "caregiver", "only", "limited medical history", "states", "patient sees", "doctor to monitor", "prostate", "following", "true", "pathogenesis", "nodules seen", "patient"]}
{"question": "A 21-year-old African American female presents to her primary care physician reporting a history of excess hair growth. She has to shave her face and chest on a regular basis. She is sexually active and uses condoms for protection. Her last period was two months ago and she reports having 5-6 menstrual periods per year at irregular intervals. She has no past medical history and takes no medications. She drinks socially and does not smoke. Her family history is notable for heart disease in her father and endometrial cancer in her mother. Her temperature is 98.6°F (37°C), blood pressure is 125/85 mmHg, pulse is 95/min, and respirations are 16/min. The physician considers starting the patient on a medication that is also indicated in the treatment of histoplasmosis. This medication primary acts by inhibiting which of the following proteins?", "answer": "Desmolase", "options": {"A": "Squalene epoxidase", "B": "Desmolase", "C": "Aromatase", "D": "5-alpha-reductase", "E": "1,3-beta-glucan synthase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old", "female presents", "primary care physician", "history of excess hair growth", "to shave", "face", "chest", "regular basis", "sexually active", "uses condoms", "protection", "last period", "two months", "reports", "5-6 menstrual periods", "year", "irregular intervals", "past medical history", "medications", "not smoke", "family history", "notable", "heart disease", "endometrial cancer", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "95 min", "respirations", "min", "physician", "starting", "patient", "medication", "indicated", "treatment", "histoplasmosis", "medication primary acts", "inhibiting", "following proteins"]}
{"question": "A previously healthy 18-year-old woman comes to the emergency department for evaluation of intractable vomiting and uterine cramping. Her last menstrual period was 7 weeks ago. Serum β-human chorionic gonadotropin concentration is 170,000 mIU/mL. A transvaginal ultrasound shows a complex intrauterine mass with numerous anechoic spaces and multiple ovarian cysts. The patient undergoes dilation and curettage, which shows hydropic villi with diffuse, circumferential trophoblastic proliferation. Karyotype analysis of the specimen is most likely to show which of the following?", "answer": "46,XX of paternal origin only", "options": {"A": "46,XX of maternal origin only", "B": "69,XXY of paternal origin only", "C": "46,XX of paternal origin only", "D": "46,XY of both maternal and paternal origin", "E": "69,XYY of both maternal and paternal origin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old woman", "emergency department", "intractable vomiting", "uterine cramping", "last menstrual period", "weeks", "Serum", "human chorionic gonadotropin concentration", "mIU/mL", "transvaginal ultrasound", "complex intrauterine mass", "numerous", "spaces", "multiple ovarian", "patient", "dilation", "curettage", "hydropic villi", "diffuse", "circumferential trophoblastic proliferation", "Karyotype analysis", "specimen", "to", "following"]}
{"question": "A 45-year-old man presents to the emergency department for sudden pain in his foot. The patient states that when he woke up, he experienced severe pain in his right great toe. The patient’s wife immediately brought him to the emergency department. The patient has a past medical history of diabetes mellitus, obesity, and hypertension and is currently taking insulin, metformin, lisinopril, and ibuprofen. The patient is a current smoker and smokes 2 packs per day. He also drinks 3 glasses of whiskey every night. The patient is started on IV fluids and corticosteroids. His blood pressure, taken at the end of this visit, is 175/95 mmHg. As the patient’s symptoms improve, he asks how he can avoid having these symptoms again in the future. Which of the following is the best initial intervention in preventing a future episode of this patient’s condition?", "answer": "Lifestyle measures", "options": {"A": "Allopurinol", "B": "Hydrochlorothiazide", "C": "Lifestyle measures", "D": "Niacin", "E": "Probenecid"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "sudden pain in", "foot", "patient states", "woke up", "severe pain", "right great toe", "patients", "immediately brought", "emergency department", "patient", "past medical history of diabetes mellitus", "obesity", "hypertension", "currently", "insulin", "metformin", "lisinopril", "ibuprofen", "patient", "current smoker", "packs per day", "3 glasses", "night", "patient", "started", "corticosteroids", "blood pressure", "end", "95 mmHg", "patients symptoms", "symptoms", "future", "following", "best initial intervention", "preventing", "future episode of", "patients condition"]}
{"question": "A 14-year-old girl is brought to the physician for a follow-up examination. She has had frequent falls over the past two years. During the past six months, the patient has been unable to walk or stand without assistance and she now uses a wheelchair. Her mother was diagnosed with a vestibular schwannoma at age 52. Her vital signs are within normal limits. Her speech is slow and unclear. Neurological examination shows nystagmus in both eyes. Her gait is wide-based with irregular and uneven steps. Her proprioception and vibration sense are absent. Muscle strength is decreased especially in the lower extremities. Deep tendon reflexes are 1+ bilaterally. The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes. This patient is most likely to die from which of the following complications?", "answer": "Heart failure", "options": {"A": "Posterior fossa tumors", "B": "Renal cell carcinoma", "C": "Heart failure", "D": "Leukemia", "E": "Aspiration pneumonia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "follow-up examination", "frequent falls", "past two years", "past six months", "patient", "unable to", "stand", "assistance", "now uses", "wheelchair", "diagnosed", "vestibular schwannoma", "age", "vital signs", "normal limits", "speech", "slow", "Neurological examination", "nystagmus", "eyes", "gait", "wide based", "irregular", "steps", "vibration sense", "absent", "Muscle", "decreased", "lower extremities", "Deep tendon reflexes", "1", "kyphoscoliosis", "foot inversion", "hammer toes", "patient", "to die", "following complications"]}
{"question": "A drug discovery team is conducting research to observe the characteristics of a novel drug under different experimental conditions. The drug is converted into the inactive metabolites by an action of an enzyme E. After multiple experiments, the team concludes that as compared to physiologic pH, the affinity of the enzyme E for the drug decreases markedly in acidic pH. Co-administration of an antioxidant A increases the value of Michaelis-Menten constant (Km) for the enzyme reaction, while co-administration of a drug B decreases the value of Km. Assume the metabolism of the novel drug follows Michaelis-Menten kinetics at the therapeutic dose, and that the effects of different factors on the metabolism of the drug are first-order linear. For which of the following conditions will the metabolism of the drug be the slowest?", "answer": "Acidic pH, co-administration of antioxidant A, no administration of drug B", "options": {"A": "Physiologic pH, co-administration of antioxidant A, no administration of drug B", "B": "Acidic pH, co-administration of antioxidant A, no administration of drug B", "C": "Acidic pH, co-administration of antioxidant A and of drug B", "D": "Acidic pH, co-administration of drug B, no administration of antioxidant A", "E": "Acidic pH, without administration of antioxidant A or drug B"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["to observe", "characteristics", "novel drug", "different experimental conditions", "drug", "inactive metabolites", "multiple", "concludes", "physiologic pH", "enzyme", "drug decreases markedly", "pH", "antioxidant", "increases", "value", "constant", "co administration", "drug", "decreases", "value", "novel", "follows", "therapeutic dose", "effects", "different factors", "first order linear", "following conditions", "slowest"]}
{"question": "A 35-year-old woman is brought to the emergency department 30 minutes after the onset of severe dyspnea. On arrival, she is unresponsive. Her pulse is 160/min, respirations are 32/min, and blood pressure is 60/30 mm Hg. CT angiography of the chest shows extensive pulmonary embolism in both lungs. She is given a drug that inhibits both thrombin and factor Xa. Which of the following medications was most likely administered?", "answer": "Unfractioned heparin", "options": {"A": "Ticagrelor", "B": "Apixaban", "C": "Unfractioned heparin", "D": "Fondaparinux", "E": "Tenecteplase\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old woman", "brought", "emergency department 30 minutes", "onset", "severe dyspnea", "arrival", "unresponsive", "pulse", "min", "respirations", "min", "blood pressure", "60 30 mm Hg", "CT angiography of", "chest", "extensive pulmonary embolism", "lungs", "given", "drug", "inhibits", "thrombin", "factor Xa", "following medications", "most likely administered"]}
{"question": "A 58-year-old man is brought to the emergency department because of confusion, weight loss, and anuria. He has chronic kidney disease, hypertension, and type 2 diabetes mellitus. He was diagnosed with acute lymphoblastic leukemia at the age of 8 years and was treated with an allogeneic stem cell transplantation. He is HIV-positive and has active hepatitis C virus infection. He drinks around 8 cans of beer every week. His current medications include tenofovir, emtricitabine, atazanavir, daclatasvir, sofosbuvir, insulin, amlodipine, and enalapril. He appears lethargic. His temperature is 36°C (96.8°F), pulse is 130/min, respirations are 26/min, and blood pressure is 145/90 mm Hg. Examination shows severe edema in his legs and generalized muscular weakness. Auscultation of the lung shows crepitant rales. Laboratory studies show positive HCV antibody and positive HCV RNA. His HIV viral load is undetectable and his CD4+ T-lymphocyte count is 589/μL. Six months ago, his CD4+ T-lymphocyte count was 618/μL. An ECG of the heart shows arrhythmia with frequent premature ventricular contractions. Arterial blood gas analysis on room air shows:\npH 7.23\nPCO2 31 mm Hg\nHCO3- 13 mEq/L\nBase excess -12 mEq/L\nThe patient states he would like to donate organs or tissues in the case of his death. Which of the following is an absolute contraindication for organ donation in this patient?\"", "answer": "No absolute contraindications", "options": {"A": "HIV infection", "B": "Childhood leukemia", "C": "Acute kidney injury", "D": "Alcoholism", "E": "No absolute contraindications"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old man", "brought", "emergency department", "confusion", "weight loss", "anuria", "chronic kidney disease", "hypertension", "type 2 diabetes mellitus", "diagnosed", "acute lymphoblastic leukemia", "age", "years", "treated with", "allogeneic stem cell transplantation", "HIV-positive", "active hepatitis C virus infection", "cans", "week", "current medications include tenofovir", "emtricitabine", "atazanavir", "daclatasvir", "sofosbuvir", "insulin", "amlodipine", "enalapril", "appears lethargic", "temperature", "96", "pulse", "min", "respirations", "min", "blood pressure", "90 mm Hg", "severe", "legs", "generalized muscular weakness", "Auscultation", "lung", "crepitant rales", "Laboratory studies", "positive HCV antibody", "positive", "RNA", "HIV viral load", "undetectable", "CD4", "lymphocyte count", "Six months", "CD4", "lymphocyte count", "ECG", "heart", "arrhythmia", "frequent premature ventricular contractions", "Arterial blood gas analysis", "room air", "pH 7 23 PCO2 31 mm Hg HCO3", "mEq/L Base excess", "patient states", "to", "organs", "tissues", "case", "death", "following", "absolute contraindication", "organ donation", "patient"]}
{"question": "A 27-year-old G1P0 presents to her obstetrician for her normal 30-week obstetric appointment. She reports that she feels well and has no complaints. Her past medical history is notable for intermittent asthma. Her only medications are prenatal vitamins. She has gained 10 pounds, more than expected given her current stage of pregnancy. Abdominal ultrasound reveals the presence of twins with separate amniotic sacs that share a common chorion and placenta. During which time interval following fertilization did the morula divide into two in this mother?", "answer": "Days 4-8", "options": {"A": "Days 1-3", "B": "Days 4-8", "C": "Days 9-12", "D": "Days 13-15", "E": "Day 16+"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old", "presents", "obstetrician", "normal 30 week obstetric appointment", "reports", "well", "complaints", "past medical history", "notable", "intermittent asthma", "only medications", "prenatal vitamins", "gained 10 pounds", "more", "given", "current stage of pregnancy", "Abdominal ultrasound reveals", "presence", "separate amniotic sacs", "common chorion", "placenta", "time interval following fertilization", "morula divide", "two"]}
{"question": "A 2-month-old girl is brought to the physician by her father for a routine well-child examination. She is given a vaccine that contains polyribosylribitol phosphate conjugated to a toxoid carrier. The vaccine is most likely to provide immunity against which of the following pathogens?", "answer": "Haemophilus influenzae", "options": {"A": "Streptococcus pneumoniae", "B": "Corynebacterium diphtheriae", "C": "Neisseria meningitidis", "D": "Haemophilus influenzae", "E": "Bordetella pertussis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["2 month old girl", "brought", "physician", "routine well", "given", "vaccine", "contains polyribosylribitol phosphate conjugated", "toxoid carrier", "vaccine", "to", "immunity", "following"]}
{"question": "A research group designed a study to investigate the epidemiology of syphilis in the United States. The investigators examined per capita income and rates of syphilis in New York City, Los Angeles, Chicago, and Houston. Data on city-wide syphilis rates was provided by each city's health agency. The investigators ultimately found that the number of new cases of syphilis was higher in low-income neighborhoods. This study is best described as which of the following?", "answer": "Ecological study", "options": {"A": "Prospective cohort study", "B": "Case-control study", "C": "Ecological study", "D": "Case series", "E": "Double-blind clinical trial"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["group", "study to investigate", "epidemiology", "syphilis", "United States", "investigators examined", "capita income", "rates", "syphilis", "New York City", "Los Angeles", "Chicago", "Data", "city wide syphilis rates", "city's", "investigators", "found", "number", "new cases", "syphilis", "higher", "low-income neighborhoods", "study", "best"]}
{"question": "A 7-year-old girl is brought to her pediatrician complaining of painful urination over the last 5 days. She describes it as a burning and itching when she uses the bathroom and has never had a feeling like this before. She was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines and is meeting all developmental milestones. Detailed history reveals that the parents have observed significant behavior changes in their daughter over the last 6 months such as social withdrawal and increased fearfulness. They have not identified a cause for these sudden behavioral changes. The pediatrician performs a complete physical examination. Upon genital examination, the girl becomes very nervous and begins to cry. After an examination of the vagina, the physician is concerned about a sexually transmitted disease. She orders testing and connects the family to child protective services for further investigation and counseling. Which of the following findings on physical examination of the vaginal region justifies the pediatrician’s suspicion?", "answer": "Yellow mucopurulent discharge", "options": {"A": "Erythematous and greasy yellowish scaling", "B": "Crusty weepy lesions accompanied by erythema and severe itching", "C": "Well-demarcated erythematous plaques with silvery-white scaling and mild pruritus", "D": "Linear pruritic rash with papules and vesicles", "E": "Yellow mucopurulent discharge"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "pediatrician", "painful urination", "last", "days", "burning", "itching", "uses", "bathroom", "never", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "Detailed history reveals", "observed significant behavior changes", "last", "months", "social withdrawal", "increased fearfulness", "not identified", "cause", "sudden behavioral changes", "pediatrician performs", "genital examination", "girl", "very nervous", "begins", "examination of", "vagina", "physician", "sexually transmitted disease", "orders testing", "further", "counseling", "following findings", "physical examination", "vaginal region justifies", "pediatricians"]}
{"question": "A 9-month-old girl is brought in by her father for a scheduled check-up with her pediatrician. He states that over the past 4-5 months she has had multiple ear infections. She was also hospitalized for an upper respiratory infection 2 months ago. Since then she has been well. She has started to pull herself up to walk. Additionally, the patient’s medical history is significant for eczema and allergic rhinitis. The father denies any family history of immunodeficiencies. There are no notable findings on physical exam. Labs are remarkable for low IgG levels with normal IgA, IgE, and IgM levels. Which of the following is the most likely etiology for the patient’s presentation?", "answer": "Delayed onset of normal immunoglobulins", "options": {"A": "Adenosine deaminase deficiency", "B": "Defect in Bruton tyrosine kinase", "C": "Delayed onset of normal immunoglobulins", "D": "Failure of B-cell differentiation", "E": "Impaired T cell signaling"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old girl", "brought", "scheduled check-up", "pediatrician", "states", "past", "months", "multiple ear infections", "hospitalized", "upper respiratory infection", "months", "then", "well", "started to pull", "up to", "patients medical history", "significant", "eczema", "allergic rhinitis", "family history of immunodeficiencies", "notable findings", "physical exam", "Labs", "normal IgA", "IgM levels", "following", "etiology", "patients"]}
{"question": "A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. The patient’s temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% O2 on room air. During the physical exam, the patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the best initial therapy?", "answer": "Lorazepam", "options": {"A": "Benztropine", "B": "Cyproheptadine", "C": "Electroconvulsive therapy", "D": "Haloperidol", "E": "Lorazepam"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old woman", "inpatient", "reported", "talk", "patients", "states", "home", "work", "found", "patient sitting", "bed staring", "wall", "name", "waved", "hand", "front of", "not", "to move", "position", "patients temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "O2", "room air", "patient", "lying", "bed", "left arm raised", "pointing", "to change", "position", "patient", "mute", "external", "patients medical history", "significant", "depression", "recently switched", "phenelzine", "fluoxetine", "following", "best initial therapy"]}
{"question": "An 8-year-old girl is brought to the emergency room for a 6-hour history of fever, sore throat, and difficulty swallowing. Physical examination shows pooling of oral secretions and inspiratory stridor. Lateral x-ray of the neck shows thickening of the epiglottis and aryepiglottic folds. Throat culture with chocolate agar shows small, gram-negative coccobacilli. The patient's brother is started on the recommended antibiotic for chemoprophylaxis. Which of the following is the primary mechanism of action of this drug?", "answer": "Inhibition of DNA-dependent RNA-polymerase", "options": {"A": "Inhibition of DNA-dependent RNA-polymerase", "B": "Inhibition of the 50S ribosomal subunit", "C": "Inhibition of prokaryotic topoisomerase II", "D": "Inhibition of the 30S ribosomal subunit", "E": "Inhibition of peptidoglycan crosslinking"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "emergency room", "6-hour history", "fever", "sore throat", "difficulty swallowing", "pooling", "oral secretions", "inspiratory stridor", "Lateral x-ray", "neck", "thickening", "epiglottis", "aryepiglottic folds", "Throat culture", "small", "patient's", "started", "chemoprophylaxis", "following", "primary mechanism of action", "drug"]}
{"question": "A group of medical students is studying bacteria and their pathogenesis. They have identified that a substantial number of bacteria cause human disease by producing exotoxins. Exotoxins are typically proteins, but they have different mechanisms of action and act at different sites. The following is a list of exotoxins together with mechanisms of action. Which of the following pairs is correctly matched?", "answer": "Cholera toxin - ADP-ribosylates Gs, keeping adenylate cyclase active and ↑ [cAMP]", "options": {"A": "Diphtheria toxin - cleaves synaptobrevin, blocking vesicle formation and the release of acetylcholine", "B": "Tetanospasmin - binds 60S ribosome subunit and inhibits protein synthesis", "C": "Cholera toxin - ADP-ribosylates Gs, keeping adenylate cyclase active and ↑ [cAMP]", "D": "Botulinum toxin - cleaves synaptobrevin, blocking vesicle formation and the release of the inhibitory neurotransmitters GABA and glycine", "E": "Anthrax toxin - ADP-ribosylates elongation factor - 2 (EF-2) and inhibits protein synthesis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["medical students", "studying bacteria", "pathogenesis", "identified", "number", "bacteria cause human disease", "exotoxins", "proteins", "different mechanisms of action", "act", "different sites", "following", "exotoxins together", "mechanisms of action", "following pairs", "matched"]}
{"question": "A previously healthy 52-year-old woman comes to the physician because of a 3-month history of chest pain on exertion. She takes no medications. Cardiopulmonary examination shows no abnormalities. Cardiac stress ECG shows inducible ST-segment depressions in the precordial leads that coincide with the patient's report of chest pain and resolve upon cessation of exercise. Pharmacotherapy with verapamil is initiated. This drug is most likely to have which of the following sets of effects?\n $$$ End-diastolic volume (EDV) %%% Blood pressure (BP) %%% Contractility %%% Heart rate (HR) $$$", "answer": "↑ ↓ ↓ ↓", "options": {"A": "↓ ↓ ↓ ↑", "B": "No change no change no change no change", "C": "↓ ↓ ↓ no change", "D": "↓ ↓ no change ↑", "E": "↑ ↓ ↓ ↓"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old woman", "physician", "of", "3 month history", "chest pain", "exertion", "medications", "Cardiopulmonary", "abnormalities", "Cardiac stress ECG", "inducible ST-segment depressions", "precordial leads", "of chest pain", "exercise", "Pharmacotherapy", "verapamil", "initiated", "drug", "to", "following sets", "End-diastolic volume", "Blood", "Contractility", "Heart rate"]}
{"question": "A 17-year-old boy is brought to the physician by his parents who are concerned about his bizarre behavior. Over the past three months, he has become withdrawn from his friends and less interested in his classes and extracurricular activities. On several occasions, he has torn apart rooms in their home looking for “bugs” and states that the President is spying on him because aliens have told the government that he is a threat. Although he has always been quite clean in the past, his father notes that the patient’s room is now malodorous with clothes and dishes strewn about haphazardly. He also says that sometimes he can hear the devil speaking to him from inside his head. He has no medical problems, does not drink alcohol or use any drugs. Physical examination of the boy reveals no abnormalities. On mental status examination, the boy is oriented to person, place and time. He avoids eye contact and replies mostly with monosyllabic responses. He appears distracted, and confirms that he is hearing whispering voices in his head. What is the most appropriate diagnosis for this patient?", "answer": "Schizophreniform disorder", "options": {"A": "Brief psychotic disorder", "B": "Schizoid personality type", "C": "Schizoaffective disorder", "D": "Schizophreniform disorder", "E": "Schizophrenia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "bizarre behavior", "past three months", "withdrawn", "less", "several occasions", "torn", "rooms", "home looking", "bugs", "states", "always", "past", "notes", "patients room", "now", "clothes", "dishes", "about", "sometimes", "hear", "head", "medical problems", "not", "alcohol", "use", "drugs", "boy reveals", "abnormalities", "mental status", "boy", "oriented to person", "place", "time", "mostly", "responses", "appears distracted", "confirms", "hearing whispering voices", "head", "most appropriate diagnosis", "patient"]}
{"question": "A 59-year-old female presents to the emergency department after a fall. She reports severe pain in her right hip and an inability to move her right leg. Her past medical history is notable for osteoporosis, rheumatoid arthritis, and has never undergone surgery before. The patient was adopted, and her family history is unknown. She has never smoked and drinks alcohol socially. Her temperature is 98.8°F (37.1°C), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 22/min. Her right leg is shortened, abducted, and externally rotated. A radiograph demonstrates a displaced femoral neck fracture. She is admitted and eventually brought to the operating room to undergo right hip arthroplasty. While undergoing induction anesthesia with inhaled sevoflurane, she develops severe muscle contractions. Her temperature is 103.4°F (39.7°C). A medication with which of the following mechanisms of action is indicated in the acute management of this patient’s condition?", "answer": "Ryanodine receptor antagonist", "options": {"A": "Ryanodine receptor antagonist", "B": "GABA agonist", "C": "Serotonin 1B/1D agonist", "D": "NMDA receptor antagonist", "E": "Acetylcholine receptor agonist"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old female presents", "emergency department", "fall", "reports severe pain in", "right hip", "to move", "right leg", "past medical history", "notable", "osteoporosis", "rheumatoid arthritis", "never", "surgery", "patient", "adopted", "family history", "unknown", "never smoked", "alcohol", "temperature", "98", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "right leg", "shortened", "externally rotated", "radiograph", "displaced femoral neck fracture", "brought", "operating room to", "right", "induction anesthesia", "inhaled sevoflurane", "severe muscle contractions", "temperature", "medication", "of", "following mechanisms", "action", "indicated", "acute management", "patients condition"]}
{"question": "Recently, clarithromycin was found to have an increased risk of cardiac death in a Danish study. This study analyzed patients who were previously treated with clarithromycin or another antibiotic, and then they were followed over time to ascertain if cardiac death resulted. What type of study design does this represent?", "answer": "Cohort study", "options": {"A": "Randomized controlled trial", "B": "Cohort study", "C": "Cross-sectional study", "D": "Case control study", "E": "Non-inferiority trial"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Recently", "clarithromycin", "found to", "increased risk", "cardiac death", "study", "study", "patients", "treated with clarithromycin", "then", "followed", "time to", "cardiac death resulted", "type"]}
{"question": "A 21-year-old male college student is brought to the emergency department by the campus police after he was found yelling at a bookshelf in the library. His roommate does not know of any prior episodes similar to this. His vital signs are within normal limits. The patient appears unkempt. On mental status examination, he talks very fast with occasional abrupt interruptions. He is agitated. He is disoriented to time and repeatedly tells the physician, “I hear the sun telling me that I was chosen to save the universe.” Urine toxicology screen is negative. Which of the following is the most appropriate pharmacotherapy?", "answer": "Ziprasidone", "options": {"A": "Haloperidol", "B": "Alprazolam", "C": "Dexmedetomidine", "D": "Valproic acid", "E": "Ziprasidone"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["21-year-old male", "brought", "emergency department", "police", "found", "library", "not", "of", "prior episodes similar", "vital signs", "normal limits", "patient appears unkempt", "mental status", "talks very fast", "occasional abrupt interruptions", "agitated", "disoriented", "time", "repeatedly", "physician", "I hear", "sun", "I", "to", "universe", "Urine toxicology screen", "negative", "following", "most appropriate pharmacotherapy"]}
{"question": "A 62-year-old female presents to her primary care physician complaining of bloody stool. She reports several episodes of bloody stools over the past two months as well as a feeling of a mass near her anus. She has one to two non-painful bowel movements per day. She has a history of alcohol abuse and hypertension. Anoscopy reveals engorged vessels. Which of the following vessels most likely drains blood from the affected region?", "answer": "Superior rectal vein", "options": {"A": "Superior rectal vein", "B": "Inferior rectal vein", "C": "Internal pudendal vein", "D": "Middle rectal vein", "E": "Left colic vein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old female presents", "primary care physician", "bloody stool", "reports several episodes of bloody stools", "past two months", "mass", "anus", "one", "two non painful bowel movements per day", "history of alcohol abuse", "hypertension", "reveals engorged vessels", "following vessels", "likely drains blood", "affected region"]}
{"question": "Three weeks after delivering a healthy boy, a 28-year-old woman, gravida 1, para 1, comes to the physician for a postpartum check-up. Labor and delivery were uncomplicated. Two days after delivery she was diagnosed with postpartum endometritis and received intravenous clindamycin plus gentamicin for 2 days. She had painful swelling of the breasts at the beginning of lactation, but frequent breastfeeding and warm compresses prior to breastfeeding improved her symptoms. Physical examination shows no abnormalities. The patient asks about a reliable contraceptive method. Which of the following is the most appropriate recommendation?", "answer": "Progestin-only contraceptive pills", "options": {"A": "Spermicide", "B": "Basal body temperature method", "C": "Progestin-only contraceptive pills", "D": "Combined oral contraceptives", "E": "No contraception needed while lactating"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Three weeks", "delivering", "healthy boy", "year old woman", "gravida 1", "para 1", "physician", "postpartum check-up", "Labor", "delivery", "uncomplicated", "Two days", "delivery", "diagnosed", "postpartum endometritis", "received intravenous clindamycin plus gentamicin", "2 days", "painful swelling of", "breasts", "beginning", "lactation", "frequent breastfeeding", "warm compresses prior to breastfeeding improved", "symptoms", "abnormalities", "patient", "contraceptive method", "following", "most appropriate"]}
{"question": "An 83-year-old man is being seen in the hospital for confusion. The patient was admitted 4 days ago for pneumonia. He has been improving on ceftriaxone and azithromycin. Then 2 nights ago he had an episode of confusion. He was unsure where he was and attempted to leave. He was calmed down by nurses with redirection. He had a chest radiograph that was stable from admission, a normal EKG, and a normal urinalysis. This morning he was alert and oriented. Then this evening he became confused and agitated again. The patient has a history of benign prostatic hyperplasia, severe dementia, and osteoarthritis. He takes tamsulosin in addition to the newly started antibiotics. Upon physical examination, the patient is alert but orientated only to name. He tries to get up, falls back onto the bed, and grabs his right knee. He states, “I need to get to work. My boss is waiting, but my knee hurts.” He tries to walk again, threatens the nurse who stops him, and throws a plate at the wall. In addition to reorientation, which of the following is the next best step in management?", "answer": "Haloperidol", "options": {"A": "Haloperidol", "B": "Lorazepam", "C": "Morphine", "D": "Physical restraints", "E": "Rivastigmine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["83 year old man", "seen", "hospital", "confusion", "patient", "4 days", "pneumonia", "improving", "ceftriaxone", "azithromycin", "Then", "nights", "episode of confusion", "unsure", "to", "nurses", "chest radiograph", "stable", "normal EKG", "normal urinalysis", "morning", "alert", "oriented", "Then", "evening", "confused", "agitated", "patient", "history of benign prostatic hyperplasia", "severe dementia", "osteoarthritis", "tamsulosin in addition to", "started", "patient", "alert", "orientated only to name", "to get", "falls back", "bed", "grabs", "right knee", "states", "I need to", "to", "boss", "waiting", "knee", "to", "nurse", "stops", "throws", "plate", "wall", "reorientation", "following", "next best step"]}
{"question": "A 61-year-old woman presents to her physician with foot tingling, numbness, and pain. She describes her pain as constant and burning and gives it 5 out of 10 on the visual analog pain scale. She also recalls several falls due to the numbness in her feet. She was diagnosed with diabetes mellitus and diabetic retinopathy 5 years ago. Since then, she takes metformin 1000 mg twice daily and had no follow-up visits to adjust her therapy. Her weight is 110 kg (242.5 lb), and her height is 176 cm (5 ft. 7 in). The vital signs are as follows: blood pressure is 150/90 mm Hg, heart rate is 72/min, respiratory rate is 12/min, and the temperature is 36.6°C (97.9°F). The patient has increased adiposity in the abdominal region with stretch marks. The respiratory examination is within normal limits. The cardiovascular exam is significant for a bilateral carotid bruit. The neurological examination shows bilateral decreased ankle reflex, symmetrically decreased touch sensation and absent vibration sensation in both feet up to the ankle. The gait is mildly ataxic. The Romberg test is positive with a tendency to fall to both sides, and significant worsening on eye closure. Which of the following medications should be used to manage the patient’s pain?", "answer": "Nortriptyline", "options": {"A": "Diclofenac", "B": "Morphine", "C": "Tramadol", "D": "Topiramate", "E": "Nortriptyline"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["61 year old woman presents", "physician", "foot tingling", "numbness", "pain", "pain", "constant", "burning", "gives", "5 out", "10", "visual analog pain scale", "several falls due to", "numbness", "feet", "diagnosed", "diabetes mellitus", "diabetic retinopathy", "years", "Since then", "metformin", "mg twice daily", "to", "therapy", "weight", "kg", "height", "5 ft", "vital signs", "follows", "blood pressure", "90 mm Hg", "heart rate", "72 min", "respiratory rate", "min", "temperature", "36", "97 9F", "patient", "increased adiposity", "abdominal", "stretch marks", "respiratory examination", "normal limits", "cardiovascular exam", "significant", "bilateral carotid bruit", "neurological examination", "bilateral decreased ankle", "decreased touch sensation", "absent vibration sensation", "feet", "ankle", "gait", "mildly ataxic", "Romberg test", "positive", "to fall", "sides", "significant worsening", "eye closure", "following medications", "used to", "patients pain"]}
{"question": "A 4-year-old boy is brought to the pediatrician in the month of January with a one-week history of a cough and somnolence. He developed a fever and cough and stated that his legs hurt ‘really bad’ 3–4 days prior to his symptoms. He has asthma but no other significant past medical history. He takes albuterol and his mom administered acetaminophen because he was feeling ‘hot’. The blood pressure is 92/66 mm Hg, the heart rate is 118/min, the respiratory rate is 40/min, and the temperature is 39.2°C (102.6°F). On physical examination, the visualization of the pharynx shows mild erythema without purulence. Auscultation of the lungs reveals crackles over the right lung base. The rapid strep test is negative. A chest X-ray shows homogenous opacity in the lower lobe of the right lung. Which of the following best describes the vaccine that could have prevented the boy from acquiring this infection?", "answer": "Inactivated vaccine", "options": {"A": "Live attenuated vaccine", "B": "Inactivated vaccine", "C": "Subunit vaccine", "D": "Conjugate vaccine", "E": "Toxoid vaccine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "pediatrician", "month", "January", "one-week history", "cough", "somnolence", "fever", "cough", "stated", "legs", "bad", "days prior to", "symptoms", "asthma", "significant past medical history", "albuterol", "mom administered acetaminophen", "hot", "blood pressure", "66 mm Hg", "heart rate", "min", "respiratory rate", "40 min", "temperature", "visualization", "pharynx", "mild erythema", "purulence", "Auscultation", "lungs reveals crackles", "right lung base", "rapid strep test", "negative", "chest X-ray", "homogenous opacity", "the lower lobe of", "right lung", "following best", "vaccine", "prevented", "boy", "acquiring", "infection"]}
{"question": "A 3-month-old African American infant presents to the hospital with 2 days of fever, \"coke\"-colored urine, and jaundice. The pregnancy was uneventful except the infant was found to have hyperbilirubinemia that was treated with phototherapy. The mother explains that she breastfeeds her child and recently was treated herself for a UTI with trimethoprim-sulfamethoxazole (TMP-SMX). Which of the following diseases is similarly inherited as the disease experienced by the child?", "answer": "Hemophilia A", "options": {"A": "Marfan syndrome", "B": "Sickle cell anemia", "C": "Hemophilia A", "D": "Beta thalassemia", "E": "Rett syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 month old", "infant presents", "hospital", "2 days", "fever", "coke", "colored urine", "jaundice", "pregnancy", "infant", "found to", "hyperbilirubinemia", "treated with phototherapy", "breastfeeds", "child", "recently", "treated", "UTI", "trimethoprim-sulfamethoxazole", "following diseases", "inherited", "disease", "child"]}
{"question": "An 83-year-old male presents with dyspnea, orthopnea, and a chest radiograph demonstrating pulmonary edema. A diagnosis of congestive heart failure is considered. The following clinical measurements are obtained: 100 bpm heart rate, 0.2 mL O2/mL systemic blood arterial oxygen content, 0.1 mL O2/mL pulmonary arterial oxygen content, and 400 mL O2/min oxygen consumption. Using the above information, which of the following values represents this patient's cardiac stroke volume?", "answer": "40 mL/beat", "options": {"A": "30 mL/beat", "B": "40 mL/beat", "C": "50 mL/beat", "D": "60 mL/beat", "E": "70 mL/beat"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["83 year old male presents", "dyspnea", "orthopnea", "chest radiograph", "pulmonary edema", "diagnosis", "congestive heart failure", "following", "obtained", "100", "heart rate", "0.2 mL O2 mL systemic blood oxygen content", "0.1 mL O2 mL pulmonary arterial oxygen content", "400 mL O2 min oxygen consumption", "Using", "above", "following values", "patient's cardiac stroke volume"]}
{"question": "A 67-year-old man presents with an excruciatingly painful tongue lesion. He says the lesion was preceded by an intermittent headache for the past month that localized unilaterally to the left temple and occasionally radiates to the right eye. The tongue lesion onset acutely and has been present for a few days. The pain is constant. His past medical history is relevant for hypertension and recurrent migraines. Current medications include captopril. On physical examination, multiple knot-like swellings are seen on the left temple. Findings from an inspection of the oral cavity are shown in the exhibit (see image). Laboratory findings are significant for the following:\nHemoglobin 12.9 g/dL\nHematocrit 40.7%\nLeukocyte count 5500/mm3\nNeutrophils 65%\nLymphocytes 30%\nMonocytes 5%\nMean corpuscular volume 88.2 μm3\nPlatelet count 190,000/mm3\nErythrocyte sedimentation rate 45 mm/h\nWhich of the following is the next best step in the management of this patient?", "answer": "High-dose systemic corticosteroids", "options": {"A": "Temporal artery biopsy", "B": "CT", "C": "Lysis therapy", "D": "High-dose systemic corticosteroids", "E": "Paracetamol"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man presents", "painful", "lesion", "preceded", "intermittent headache", "past month", "localized", "left temple", "occasionally radiates", "right eye", "tongue lesion onset", "present", "days", "pain", "constant", "past medical history", "relevant", "hypertension", "recurrent migraines", "Current medications include captopril", "multiple knot", "swellings", "seen", "left temple", "Findings", "inspection", "oral cavity", "see", "Laboratory findings", "significant", "following", "Hemoglobin", "40", "count", "mm3", "65", "30", "Mean corpuscular volume", "Platelet count", "rate", "h", "following", "next best step", "patient"]}
{"question": "A 67-year-old man presents to his primary care physician for a wellness checkup. The patient states he has been doing well and currently has no concerns. The patient's daughter states that she feels he is abnormally fatigued and has complained of light-headedness whenever he gardens. He also admits that he fainted once. The patient has a past medical history of type II diabetes, hypertension, and constipation. He recently had a \"throat cold\" that he recovered from with rest and fluids. His temperature is 98.9°F (37.2°C), blood pressure is 167/98 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air. Physical exam reveals a systolic murmur heard best along the right upper sternal border. An ECG is performed and demonstrates no signs of ST elevation. Cardiac troponins are negative. Which of the following is the most likely diagnosis?", "answer": "Calcification of valve leaflets", "options": {"A": "Autoimmune valve destruction", "B": "Bicuspid valve", "C": "Calcification of valve leaflets", "D": "Incompetent valve", "E": "Outflow tract obstruction"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "primary care physician", "checkup", "patient states", "well", "currently", "patient", "tates ", "atigued ", "ight-headedness ", "ardens.", "ainted ", "atient ", "ast  edical ", "I  iabetes,", "ypertension,", "onstipation.", "ecently ", "hroat  old\"", "ecovered ", "luids.", "emperature ", "8. F ", "lood pressure ", "8  mHg,", "ulse ", "0/ in,", "espirations ", "in,", "xygen saturation ", "9%", "oom air.", "eveals ", "ystolic murmur  eard  est ", "ight  pper  ternal border.", "CG ", "erformed ", "igns ", "T elevation.", "ardiac troponins ", "egative.", "ollowing ", "iagnosis?"]}
{"question": "A 55-year-old woman presents to the office complaining of leg ulcers for the past 6 months. She has a chronic history of severe rheumatoid arthritis controlled with methotrexate. She does not drink alcohol or smoke cigarettes. Her vitals are normal. Her lungs are clear to auscultation. The abdomen is soft and non-tender with a palpable spleen tip on inspiration. Skin examination shows scattered ulcers on the legs in various stages of healing. Additionally, metacarpophalangeal and proximal interphalangeal joints are tender. Varicose veins are not observed. Laboratory results are as follows:\nHemoglobin  10.5 g/dL\nMCV 74 fl\nPlatelets 226,000/mm3\nWhite blood cells 2500 /mm3\nNeutrophils 20%\nAlanine 36/UL\nAminotransaminase aspartate 39/UL\nAminotransaminase creatinine 1.0 mg/dL\nHIV test is negative. Which of the following is the most likely cause of this patient’s condition?", "answer": "Felty syndrome", "options": {"A": "Venous stasis and valve insufficiency", "B": "Felty syndrome", "C": "Drug toxicity", "D": "Vitamin deficiency", "E": "Caplan syndrome"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "office", "of leg ulcers", "past 6 months", "chronic history of severe rheumatoid arthritis controlled", "methotrexate", "not", "alcohol", "smoke cigarettes", "normal", "lungs", "clear", "auscultation", "abdomen", "soft", "non-tender", "palpable spleen tip", "inspiration", "Skin examination", "scattered ulcers", "legs", "various stages", "healing", "proximal interphalangeal joints", "tender", "Varicose veins", "not observed", "Laboratory results", "follows", "Hemoglobin", "g", "MCV 74 fl", "White blood cells 2500", "20", "36", "aspartate", "creatinine", "0", "test", "negative", "following", "most likely cause", "patients condition"]}
{"question": "A previously healthy 10-day-old infant is brought to the emergency department by his mother because of episodes of weakness and spasms for the past 12 hours. His mother states that he has also had difficulty feeding and a weak suck. He has not had fever, cough, diarrhea, or vomiting. He was born at 39 weeks' gestation via uncomplicated vaginal delivery at home. Pregnancy was uncomplicated. The mother refused antenatal vaccines out of concern they would cause side effects. She is worried his symptoms may be from some raw honey his older sister maybe inadvertently fed him 5 days ago. He appears irritable. His temperature is 37.1°C (98.8°F). Examination shows generalized muscle stiffness and twitches. His fontanelles are soft and flat. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal organism?", "answer": "Clostridium tetani", "options": {"A": "Clostridium botulinum", "B": "Clostridium tetani", "C": "Neisseria meningitidis", "D": "Listeria monocytogenes", "E": "Escherichia coli\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy 10 day old infant", "brought", "emergency department", "of episodes", "weakness", "spasms", "past 12 hours", "states", "difficulty feeding", "weak suck", "not", "fever", "cough", "diarrhea", "vomiting", "born", "weeks", "gestation", "uncomplicated vaginal at home", "Pregnancy", "uncomplicated", "antenatal vaccines out", "cause side effects", "worried", "symptoms", "raw", "maybe", "fed", "5 days", "appears irritable", "temperature", "98", "generalized muscle stiffness", "twitches", "fontanelles", "soft", "flat", "abnormalities", "following", "causal"]}
{"question": "A 4-year-old girl is brought to the clinic by her parents, who are concerned about an abdominal swelling that they noticed 2 days ago. The family immigrated from Bangladesh to the United States recently. The mother mentions that the girl has never been as active as other children of the same age but has no medical conditions either. Her appetite has declined, and she vomited a few times last week. On physical examination, slight prominence of frontal bosses at the forehead is noticeable with malar prominence and massive splenomegaly. Slight beading at the end of her ribs is evident. She has a dusky complexion, sclerae are anicteric, and oral mucosa is pale. Laboratory results are pending. Which of the following is the most likely explanation for the findings seen in this patient?", "answer": "Extramedullary hematopoiesis due to thalassemia", "options": {"A": "Glycogen storage disease", "B": "Graves disease", "C": "Renal failure", "D": "Extramedullary hematopoiesis due to thalassemia", "E": "Lymphoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old girl", "brought", "clinic", "abdominal swelling", "2 days", "Bangladesh", "United States recently", "girl", "never", "active", "children", "same age", "medical conditions", "appetite", "vomited", "few times last week", "slight prominence", "frontal", "forehead", "malar prominence", "massive", "Slight beading", "end of", "ribs", "dusky complexion", "sclerae", "anicteric", "oral mucosa", "pale", "Laboratory results", "following", "findings seen", "patient"]}
{"question": "A 14-year-old boy presents to his pediatrician with a 5-day history of abdominal pain and bloody stool. He denies having a fever and says that he has not experienced any other symptoms associated with the abdominal pain. He has no past medical history and does not take any medications or supplements. His family history is significant for a grandfather who developed Alzheimer disease at age 80 and a cousin who died at age 21 from colon cancer. Physical exam is unremarkable. Based on clinical suspicion a colonoscopy is obtained showing hundreds of small polyps in the colon. A mutation of a gene on which of the following chromosomes is most likely responsible for this patient's symptoms?", "answer": "5", "options": {"A": "5", "B": "7", "C": "17", "D": "19", "E": "X"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "pediatrician", "5-day history", "abdominal pain", "bloody stool", "fever", "not", "symptoms associated with", "abdominal pain", "past medical history", "not", "medications", "supplements", "family history", "significant", "Alzheimer disease", "age 80", "died", "age", "colon cancer", "unremarkable", "Based", "clinical", "colonoscopy", "obtained", "small polyps", "colon", "mutation", "gene", "following chromosomes", "responsible", "patient's symptoms"]}
{"question": "A 31-year-old man comes to the physician because of pain, tingling, and numbness in his right hand that started 3 months ago. It is worse at night and frequently wakes him up. The symptoms can be relieved by shaking his hands but soon recur. He reports weakness of his right hand, especially when grasping objects. He has type 2 diabetes mellitus. His current medications are metformin and sitagliptin. Four months ago he went on a camping trip. He has been working as a hardscaper for 8 years. His temperature is 37.5°C (99.5°F), pulse is 86/min, and blood pressure is 110/70 mm Hg. Examination shows reproduction of his symptoms when his right hand is held above his head for 2 minutes. Laboratory studies show:\nHemoglobin 13.2 g/dL\nLeukocyte count 7,600/mm3\nHemoglobin A1C 6.3%\nErythrocyte sedimentation rate 13 mm/h\nWhich of the following is most likely to confirm the diagnosis?\"", "answer": "Nerve conduction studies", "options": {"A": "ELISA for B. burgdorferi antibodies", "B": "CT scan of cervical spine", "C": "Nerve conduction studies", "D": "MRI of the head", "E": "Arterial Doppler ultrasonography\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["31 year old man", "physician", "pain", "tingling", "numbness", "right", "started 3 months", "worse", "night", "frequently wakes", "symptoms", "relieved by shaking", "hands", "reports weakness of", "right hand", "grasping", "type 2 diabetes mellitus", "current medications", "metformin", "sitagliptin", "Four months", "trip", "years", "temperature", "99", "pulse", "min", "blood pressure", "70 mm Hg", "reproduction", "symptoms", "right hand", "held", "head", "2 minutes", "Laboratory studies", "Hemoglobin", "g", "mm3", "Erythrocyte sedimentation rate", "h", "following", "to confirm", "diagnosis"]}
{"question": "A 64-year-old man comes to the physician because of fatigue and decreased urinary frequency for 6 months. His pulse is 86/min and blood pressure is 150/90 mm Hg. Examination shows 1+ edema on bilateral ankles. His serum creatinine is 2 mg/dL and blood urea nitrogen is 28 mg/dL. Urinalysis shows proteinuria. A photomicrograph of a biopsy specimen from the patient's kidney is shown. Which of the following is the most likely explanation for the patient’s biopsy findings?", "answer": "Chronic hyperglycemia", "options": {"A": "HIV infection", "B": "Amyloidosis", "C": "Chronic hyperglycemia", "D": "Recurrent kidney infections", "E": "Systemic lupus erythematosus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["64 year old man", "physician", "fatigue", "decreased urinary frequency", "months", "pulse", "min", "blood pressure", "90 mm Hg", "1", "edema", "bilateral ankles", "serum creatinine", "2 mg/dL", "blood urea nitrogen", "dL", "Urinalysis", "proteinuria", "photomicrograph", "biopsy specimen", "patient's kidney", "following", "explanation", "patients biopsy findings"]}
{"question": "A 50-year-old woman comes to the physician for a routine health maintenance examination. She has no personal or family history of serious illness. She smoked one pack of cigarettes daily for 5 years during her 20s. Her pulse is 70/min, and blood pressure is 120/78 mm Hg. Serum lipid studies and glucose concentration are within the reference ranges. Which of the following health maintenance recommendations is most appropriate at this time?", "answer": "Perform colonoscopy", "options": {"A": "Perform DEXA scan", "B": "Perform colonoscopy", "C": "Perform 24-hour ECG", "D": "Perform BRCA gene test", "E": "Perform abdominal ultrasound"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old woman", "physician", "routine", "personal", "family history", "serious illness", "smoked one pack", "cigarettes daily", "20s", "pulse", "70 min", "blood pressure", "mm Hg", "Serum lipid studies", "glucose concentration", "reference ranges", "following", "most appropriate", "time"]}
{"question": "A 72-year-old man presents to the emergency department when he discovered a large volume of blood in his stool. He states that he was going to the bathroom when he saw a large amount of bright red blood in the toilet bowl. He was surprised because he did not feel pain and felt it was a normal bowel movement. The patient has a past medical history of diabetes, obesity, hypertension, anxiety, fibromyalgia, diabetic nephropathy, and schizotypal personality disorder. His current medications include atorvastatin, lisinopril, metformin, insulin, clonazepam, gabapentin, sodium docusate, polyethylene glycol, fiber supplements, and ibuprofen. His temperature is 99.5°F (37.5°C), blood pressure is 132/84 mmHg, pulse is 80/min, respirations are 11/min, and oxygen saturation is 96% on room air. On physical exam, the patient's cardiac exam reveals a normal rate and rhythm, and his pulmonary exam is clear to auscultation bilaterally. Abdominal exam is notable for an obese abdomen without tenderness to palpation. Which of the following is an appropriate treatment for this patient's condition?", "answer": "IV fluids and NPO", "options": {"A": "Cautery of an arteriovenous malformation", "B": "IV fluids and NPO", "C": "NPO, ciprofloxacin, and metronidazole", "D": "Surgical excision of poorly differentiated tissue", "E": "Surgical resection of a blood vessel"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old man presents", "emergency department", "large volume of blood", "stool", "states", "bathroom", "saw", "large amount", "bright red blood", "toilet", "not", "pain", "normal bowel movement", "patient", "past medical diabetes", "obesity", "hypertension", "anxiety", "fibromyalgia", "diabetic nephropathy", "schizotypal personality disorder", "current medications include atorvastatin", "lisinopril", "metformin", "insulin", "clonazepam", "gabapentin", "sodium docusate", "polyethylene glycol", "fiber supplements", "ibuprofen", "temperature", "99", "blood pressure", "84 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "96", "room air", "patient's", "reveals", "normal rate", "rhythm", "pulmonary exam", "clear", "auscultation", "Abdominal exam", "notable", "obese abdomen", "tenderness", "palpation", "following", "appropriate treatment", "patient's condition"]}
{"question": "A popular news outlet recently published an article that discussed the size of low-density lipoprotein (LDL) cholesterol particles: type A and type B. Type B is thought to be more harmful to arterial walls. A group of researchers wants to determine whether patients who have an elevated level of type B LDL cholesterol are more likely to develop cardiovascular events. A study is designed with 3418 adult participants. Initial levels of type B LDL are obtained and participants are separated into normal and elevated levels of type B LDL. Socio-demographics including age, gender, education level, and smoking status are also recorded. The primary outcome is incidence of cardiovascular events over 10 years. Secondary outcomes include all-cause death, death by cardiovascular events, stroke, and hospitalizations. For this study, which of the following analyses would be the most appropriate measure to determine the association between type B LDL and cardiovascular events?", "answer": "Relative risk", "options": {"A": "Analysis of covariance", "B": "Fisher’s exact test", "C": "Likelihood ratios", "D": "Odds ratio", "E": "Relative risk"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["outlet recently", "size", "low-density lipoprotein", "cholesterol", "type", "Type", "to", "more", "arterial walls", "researchers", "to", "patients", "elevated level", "type", "LDL cholesterol", "more likely to", "cardiovascular events", "study", "adult", "Initial levels", "type", "obtained", "separated", "normal", "elevated levels", "type", "including age", "gender", "education level", "smoking status", "recorded", "primary outcome", "incidence", "cardiovascular events", "Secondary outcomes include", "cause death", "death", "cardiovascular events", "stroke", "study", "following analyses", "most appropriate measure to", "cardiovascular events"]}
{"question": "A 36-year-old man comes to the emergency department for the evaluation of recurrent bloody diarrhea for 4 weeks. During this time, he has also had intermittent abdominal pain. His symptoms have worsened over the past 2 days and he has also had fever and several episodes of nonbloody vomiting. He was diagnosed with ulcerative colitis three years ago but has had difficulty complying with his drug regimen. His temperature is 38.8°C (100.9°F), pulse is 112/min and regular, and blood pressure is 90/50 mm Hg. Abdominal examination shows a distended abdomen with no guarding or rebound; bowel sounds are hypoactive. Hemoglobin concentration is 10.1 g/dL, leukocyte count is 15,000/mm3, and erythrocyte sedimentation rate is 50 mm/h. Fluid resuscitation is initiated. In addition to complete bowel rest, which of the following is the most appropriate next step in the management of this patient?", "answer": "Abdominal x-ray", "options": {"A": "Topical sulfasalazine and oral prednisolone", "B": "Abdominal x-ray", "C": "IV metronidazole and rectal vancomycin", "D": "Double-contrast barium enema", "E": "Colonoscopy\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["36 year old man", "emergency department", "recurrent bloody", "4 weeks", "time", "intermittent abdominal pain", "symptoms", "worsened", "past 2 days", "fever", "several episodes of", "vomiting", "diagnosed", "ulcerative colitis three years", "difficulty complying", "drug regimen", "temperature", "100 9F", "pulse", "min", "regular", "blood pressure", "90 50 mm Hg", "Abdominal", "distended abdomen", "guarding", "bowel sounds", "hypoactive", "Hemoglobin concentration", "10", "g/dL", "leukocyte count", "mm3", "erythrocyte sedimentation rate", "50 mm/h", "Fluid resuscitation", "initiated", "complete bowel", "following", "most appropriate next step", "patient"]}
{"question": "A 19-year-old woman, gravida 1, para 0, at 21 weeks’ gestation comes to the physician for a follow-up prenatal visit. At her previous appointment, her serum α-fetoprotein concentration was elevated. She had smoked 1 pack of cigarettes daily for 3 years but quit at 6 weeks' gestation. Examination shows a uterus consistent in size with a 21-week gestation. Ultrasonography shows fetal viscera suspended freely into the amniotic cavity. Which of the following is the most likely diagnosis?", "answer": "Gastroschisis", "options": {"A": "Diaphragmatic hernia", "B": "Umbilical hernia", "C": "Vesicourachal diverticulum", "D": "Gastroschisis", "E": "Omphalocele"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "weeks gestation", "physician", "prenatal", "previous appointment", "serum", "fetoprotein concentration", "elevated", "smoked 1 pack", "cigarettes daily", "3 years", "6 weeks", "gestation", "uterus", "size", "week gestation", "Ultrasonography", "fetal viscera suspended freely", "amniotic cavity", "following", "diagnosis"]}
{"question": "A mother brings her 10 month-old boy to the pediatrician for a check-up. His birth was without complications and his development to-date has been progressing normally. He currently crawls, pulls himself up to standing, says 'mama' and 'dada' nonspecifically, and responds when called by his name. However, his mother is concerned, as she has noted over the past several weeks that he has periods where he stops breathing when he gets frightened or upset. These episodes last for 20-30 seconds and are accompanied by his lips and face become bluish. His breathing has always resumed normally within 45 seconds after the start of the episode, and he acts normally afterwards. One instance resulted in the child passing out for a 5-10 seconds before a spontaneous recovery. Which of the following is the most appropriate management of this patient's condition?", "answer": "Education and reassurance of the mother", "options": {"A": "Education and reassurance of the mother", "B": "Echocardiogram", "C": "Electroencephalogram", "D": "Basic metabolic panel", "E": "Lung spirometry"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["10 month old boy", "pediatrician", "check-up", "birth", "complications", "development", "date", "progressing", "currently crawls", "pulls", "up", "standing", "called", "name", "noted", "past", "weeks", "periods", "stops breathing", "gets", "episodes last", "20", "lips", "face", "breathing", "always resumed", "seconds", "start of", "episode", "acts", "One", "resulted", "child passing out", "5-10 seconds", "spontaneous recovery", "following", "most appropriate management", "patient's"]}
{"question": "  An outbreak of diphtheria has occurred for the third time in a decade in a small village in South Africa. Diphtheria is endemic to the area with many healthy villagers colonized with different bacterial strains. Vaccine distribution in this area is difficult due to treacherous terrain. A team of doctors is sent to the region to conduct a health campaign. Toxigenic strains of C. diphtheria are isolated from symptomatic patients. Which of the following best explains the initial emergence of a pathogenic strain causing such outbreaks?", "answer": "Lysogenic conversion", "options": {"A": "Presence of naked DNA in the environment", "B": "Infection with a lytic phage", "C": "Lysogenic conversion", "D": "Suppression of lysogenic cycle", "E": "Conjugation between the toxigenic and non-toxigenic strains of C. diphtheriae"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["diphtheria", "third time", "decade", "small village", "South Africa", "Diphtheria", "area", "healthy", "different bacterial strains", "Vaccine distribution", "area", "difficult due to", "doctors", "sent", "region to", "strains", "diphtheria", "isolated", "symptomatic patients", "following best", "initial", "pathogenic strain causing", "outbreaks"]}
{"question": "A 39-year-old man presents to the emergency department for severe abdominal pain. His pain is located in the epigastric region of his abdomen, which he describes as sharp and persistent. His symptoms began approximately 2 days prior to presentation, and he has tried acetaminophen and ibuprofen, which did not improve his symptoms. He feels nauseated and has had 2 episodes of non-bloody, non-bilious emesis. He has a medical history of hypertension and hyperlipidemia for which he is on chlorthalidone and simvastatin. He has smoked 1 pack of cigarettes per day for the last 20 years and drinks 1 pint of vodka per day. On physical exam, there is tenderness to palpation of the upper abdomen, and the patient is noted to have tender hepatomegaly. Serum studies demonstrate:\n\nAmylase: 350 U/L (25-125 U/L)\nLipase: 150 U/L (12-53 U/L)\nAST: 305 U/L (8-20 U/L)\nALT: 152 U/L (8-20 U/L)\n\nHe is admitted to the hospital and started on intravenous fluids and morphine. Approximately 18 hours after admission the patient reports to feeling anxious, tremulous, and having trouble falling asleep. His blood pressure is 165/105 mmHg and pulse is 140/min. On exam, the patient appears restless and diaphoretic. Which of the following will most likely improve this patient's symptoms?", "answer": "Lorazepam", "options": {"A": "Chlordiazepoxide", "B": "Haloperidol", "C": "Lorazepam", "D": "Risperidone", "E": "Thiamine"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "severe abdominal", "pain", "epigastric region of", "abdomen", "sharp", "persistent", "symptoms began approximately 2 days prior to", "acetaminophen", "ibuprofen", "not", "symptoms", "nauseated", "2 episodes of non bloody", "bilious emesis", "medical", "hyperlipidemia", "chlorthalidone", "simvastatin", "smoked 1 pack", "cigarettes", "day", "20 years", "1 pint", "day", "tenderness", "palpation of", "upper abdomen", "patient", "noted to", "tender hepatomegaly", "Serum studies", "Amylase", "350 U/L", "U/L", "Lipase", "U/L", "U/L", "AST", "305 U/L", "20 U/L", "ALT", "U/L", "20 U/L", "started", "morphine", "Approximately 18 hours", "patient reports", "anxious", "tremulous", "trouble falling asleep", "blood pressure", "mmHg", "pulse", "min", "exam", "patient appears restless", "diaphoretic", "following", "most likely", "patient's symptoms"]}
{"question": "A 41-year-old African American man presents to his primary care physician a few months after being found to have a blood pressure of 152/95 mmHg. The patient denies any current symptoms, having any past medical history, or prior hospitalizations. He does not take any medications but takes one multivitamin daily. His blood pressures on three separate occasions have been 151/93 mmHg, 150/90 mmHg, and 155/97 mmHg. In today’s visit, his blood pressure is 149/91 mmHg despite exercise and dietary modifications. Physical examination is unremarkable. After extensive work-up he is started on appropriate monotherapy for his hypertension. Which of the following laboratory abnormalities may be found on follow-up testing?", "answer": "Hypercalcemia", "options": {"A": "Hypercalcemia", "B": "Hyperkalemia", "C": "Hypermagnesemia", "D": "Hypolipidemia", "E": "Hypouricemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "man presents", "primary care physician", "few months", "found to", "blood pressure", "95 mmHg", "patient", "current symptoms", "past medical history", "prior", "not", "medications", "one multivitamin daily", "blood pressures", "three separate occasions", "mmHg", "90 mmHg", "97 mmHg", "todays", "blood pressure", "mmHg", "exercise", "dietary modifications", "unremarkable", "extensive work-up", "started", "appropriate", "hypertension", "following laboratory abnormalities", "found", "follow-up testing"]}
{"question": "An 11-year-old boy presents to the emergency department with heavy drooling. The patient was being watched by his babysitter when she found him in this manner. His temperature is 99.1°F (37.3°C), blood pressure is 107/58 mmHg, pulse is 119/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a young boy in acute distress who is drooling. The boy states he is in pain and can’t swallow. The patient’s tongue seems abnormally enlarged and erythematous. Which of the following is the most likely diagnosis?", "answer": "Caustic ingestion", "options": {"A": "Aspirin overdose", "B": "Caustic ingestion", "C": "Diphenhydramine ingestion", "D": "Insecticide exposure", "E": "Iron overdose"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "emergency department", "heavy drooling", "patient", "found", "temperature", "99", "blood pressure", "58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "young boy", "acute distress", "drooling", "boy states", "pain", "cant swallow", "patients tongue", "enlarged", "erythematous", "following", "diagnosis"]}
{"question": "A 66-year-old man is brought to the emergency department because of shortness of breath and confusion. His pulse is 98/min, and blood pressure is 109/73 mm Hg. He is oriented to person but not time or place. A graph of his breathing pattern and oxygen saturation is shown. Which of the following additional findings is most likely present in this patient?", "answer": "Ventricular gallop", "options": {"A": "Ventricular gallop", "B": "Rib fracture", "C": "Miotic pupils", "D": "Barrel chest", "E": "Fruity breath odor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old man", "brought", "emergency department", "of shortness", "breath", "confusion", "pulse", "98 min", "blood pressure", "mm Hg", "oriented to person", "not time", "place", "breathing pattern", "oxygen saturation", "following additional findings", "most likely present", "patient"]}
{"question": "A patient in the neonatal intensive care unit develops severe cyanosis. Cardiac exam reveals a single loud S2 with a right ventricular heave. Echocardiography reveals an aorta lying anterior and right of the pulmonary artery. Which of the following processes failed during fetal development?", "answer": "Aorticopulmonary septum to spiral", "options": {"A": "Fusion of the membranous ventricular septum", "B": "Aorticopulmonary septum to spiral", "C": "Ectopic ductal tissue tightening", "D": "Reentry of viscera from yolk sac", "E": "Fusion of septum primum and septum secondum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["patient", "neonatal", "severe cyanosis", "reveals", "single loud S2", "right ventricular heave", "Echocardiography reveals", "aorta lying anterior", "right", "pulmonary artery", "following processes failed", "fetal development"]}
{"question": "A 12-year-old boy is brought to the emergency department late at night by his worried mother. She says he has not been feeling well since this morning after breakfast. He skipped both lunch and dinner. He complains of abdominal pain as he points towards his lower abdomen but says that the pain initially started at the center of his belly. His mother adds that he vomited once on the way to the hospital. His past medical history is noncontributory and his vaccinations are up to date. His temperature is 38.1°C (100.6°F), pulse is 98/min, respirations are 20/min, and blood pressure is 110/75 mm Hg. Physical examination reveals right lower quadrant tenderness. The patient is prepared for laparoscopic abdominal surgery. Which of the following structures is most likely to aid the surgeons in finding the source of this patient's pain and fever?", "answer": "Teniae coli", "options": {"A": "Teniae coli", "B": "McBurney's point", "C": "Transumbilical plane", "D": "Linea Semilunaris", "E": "Arcuate line"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department late", "night", "worried", "not", "well", "morning", "breakfast", "skipped", "lunch", "dinner", "abdominal pain", "points", "lower abdomen", "pain initially started", "center", "belly", "adds", "vomited", "hospital", "past medical history", "vaccinations", "date", "temperature", "100", "pulse", "98 min", "respirations", "20 min", "blood pressure", "75 mm Hg", "reveals right lower quadrant tenderness", "patient", "prepared", "laparoscopic abdominal surgery", "following structures", "to aid", "surgeons", "finding", "source", "patient's pain", "fever"]}
{"question": "A 58-year-old woman is followed in the nephrology clinic for longstanding chronic kidney disease (CKD) secondary to uncontrolled hypertension. Her glomerular filtration rate (GFR) continues to decline, and she is approaching initiation of hemodialysis. Plans are made to obtain vascular access at the appropriate time, and the patient undergoes the requisite screening to be enrolled as an end stage renal disease (ESRD) patient. Among patients on chronic hemodialysis, which of the following is the most common cause of death?", "answer": "Cardiovascular disease", "options": {"A": "Stroke", "B": "Hyperkalemia", "C": "Infection", "D": "Cardiovascular disease", "E": "Cancer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["58 year old woman", "followed", "nephrology clinic", "chronic kidney disease", "secondary to uncontrolled hypertension", "glomerular filtration rate", "to", "approaching initiation", "hemodialysis", "Plans", "made to obtain vascular access", "appropriate time", "patient", "requisite screening to", "enrolled", "end stage renal disease", "patient", "patients", "chronic hemodialysis", "following", "most common cause of death"]}
{"question": "A 48-year-old woman is brought to her primary care physician by her sister who is concerned about a deterioration in the patient’s general status. The patient was diagnosed with HIV 7 years ago. She says that her last T cell count was \"good enough\", so she has been been skipping every other dose of her antiretroviral medications and trimethoprim-sulfamethoxazole. Her sister has had to drive her home from work several times this month because she has become disoriented and confused about her surroundings. Motor strength is 4/5 on the right and 3/5 on the left. She is able to walk unassisted, but her gait appears mildly uncoordinated. There is diplopia when the right eye is covered. Her CD4 count is 75 cells/µL. MRI shows numerous asymmetric, hyperintense, non-enhancing lesions bilaterally without mass effect. Brain biopsy shows demyelination and atypical astrocytes. Which of the following is most likely responsible for this patient's current condition?", "answer": "John Cunningham virus (JC virus)", "options": {"A": "Autoimmune demyelination", "B": "HIV associated neurocognitive disorder (HAND)", "C": "John Cunningham virus (JC virus)", "D": "Primary CNS lymphoma (PCNSL)", "E": "Toxoplasma gondii"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old woman", "brought", "primary care physician", "patients general status", "patient", "diagnosed", "HIV", "years", "last T cell count", "good", "skipping", "dose", "antiretroviral medications", "trimethoprim-sulfamethoxazole", "to", "home", "work", "times", "month", "disoriented", "confused", "surroundings", "Motor strength", "4/5", "right", "3/5", "left", "able to", "gait appears mildly uncoordinated", "diplopia", "right eye", "covered", "CD4 count", "75 cells/L", "MRI", "numerous asymmetric", "non-enhancing lesions", "mass effect", "Brain biopsy", "demyelination", "atypical", "following", "responsible", "patient", "urrent  ondition?"]}
{"question": "A 30-year-old forest landscape specialist is brought to the emergency department with hematemesis and confusion. One week ago, she was diagnosed with influenza when she had fevers, severe headaches, myalgias, hip and shoulder pain, and a maculopapular rash. After a day of relative remission, she developed abdominal pain, vomiting, and diarrhea. A single episode of hematemesis occurred prior to admission. Two weeks ago she visited rainforests and caves in western Africa where she had direct contact with animals, including apes. She has no history of serious illnesses or use of medications. She is restless and her temperature is 38.0°C (100.4°F); pulse, 95/min; respirations, 20/min; and supine and upright blood pressure, 130/70 mm Hg and 100/65 mm Hg, respectively. Conjunctival suffusion is seen. Ecchymoses are observed on the lower extremities. She is bleeding from one of her intravenous lines. The peripheral blood smear is negative for organisms. The laboratory studies show the following:\nHemoglobin 10 g/dL\nLeukocyte count 1,000/mm3\nSegmented neutrophils 65%\nLymphocytes 20%\nPlatelet count 50,000/mm3\nPartial thromboplastin time (activated) 60 seconds\nProthrombin time 25 seconds\nFibrin split products positive\nSerum  \nAlanine aminotransferase (ALT) 85 U/L\nAspartate aminotransferase (AST) 120 U/L\nγ-Glutamyltransferase (GGT) 83 U/L (N = 5–50 U/L)\nCreatinine 2 mg/dL\nWhich of the following is the most likely causal pathogen?", "answer": "Ebola virus", "options": {"A": "Ebola virus", "B": "Babesia microti", "C": "Plasmodium falciparum", "D": "Yersinia pestis", "E": "Zika virus"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old", "landscape specialist", "brought", "emergency department", "hematemesis", "confusion", "One week", "diagnosed", "influenza", "fevers", "severe headaches", "myalgias", "hip", "shoulder pain", "maculopapular rash", "day", "relative remission", "abdominal pain", "vomiting", "diarrhea", "single episode of hematemesis", "prior to", "Two weeks", "caves in western Africa", "direct contact with animals", "including", "history", "serious illnesses", "use of medications", "restless", "temperature", "100", "pulse", "95 min", "respirations", "20 min", "supine", "upright blood pressure", "70 mm Hg", "100 65 mm Hg", "Conjunctival", "seen", "Ecchymoses", "observed", "lower extremities", "bleeding", "one", "intravenous lines", "peripheral blood smear", "negative", "laboratory studies", "following", "Hemoglobin", "g Leukocyte 1", "mm3 Segmented neutrophils 65", "Lymphocytes 20", "Platelet count 50", "Partial thromboplastin time", "seconds Prothrombin time", "Fibrin split products positive Serum", "Alanine aminotransferase", "ALT", "85 U/L Aspartate aminotransferase", "AST", "U/L", "Glutamyltransferase", "GGT", "83 U/L", "N", "550 U/L", "Creatinine", "mg/dL", "following", "causal"]}
{"question": "A 10-year-old child is sent to the school psychologist in May because he refuses to comply with the class rules. His teacher says this has been going on since school started back in August. He gets upset at the teacher regularly when he is told to complete a homework assignment in class. Sometimes he refuses to complete them altogether. Several of his teachers have reported that he intentionally creates noises in class to interrupt the class. He tells the psychologist that the teacher and his classmates are at fault. What is the most appropriate treatment?", "answer": "Cognitive-behavioral therapy", "options": {"A": "Administration of clozapine", "B": "Administration of lithium", "C": "Cognitive-behavioral therapy", "D": "Interpersonal therapy", "E": "Motivational interviewing"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["A 10 year", "sent", "school psychologist", "May", "to comply", "teacher", "school started back", "August", "gets", "teacher", "to complete", "assignment", "Sometimes", "to complete", "teachers", "reported", "creates", "to interrupt", "psychologist", "teacher", "fault", "most appropriate treatment"]}
{"question": "A 5-year-old boy is brought to the physician by his parents for the evaluation of an episode of loss of consciousness while he was playing soccer earlier that morning. He was unconscious for about 15 seconds and did not shake, bite his tongue, or lose bowel or bladder control. He has been healthy except for 1 episode of simple febrile seizure. His father died suddenly at the age of 34 of an unknown heart condition. The patient does not take any medications. He is alert and oriented. His temperature is 37°C (98.6°F), pulse is 95/min and regular, and blood pressure is 90/60 mm Hg. Physical examination shows no abnormalities. Laboratory studies are within normal limits. An ECG shows sinus rhythm and a QT interval corrected for heart rate (QTc) of 470 milliseconds. Which of the following is the most appropriate next step in treatment?", "answer": "Propranolol", "options": {"A": "Propranolol", "B": "Implantable cardioverter defibrillator", "C": "Procainamide", "D": "Magnesium sulfate", "E": "Amiodarone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["5 year old boy", "brought", "physician", "of", "episode", "loss", "consciousness", "playing", "earlier", "morning", "unconscious", "seconds", "not shake", "bite", "tongue", "bowel", "bladder control", "healthy", "episode of simple febrile seizure", "died", "age", "unknown heart condition", "patient", "not", "medications", "alert", "oriented", "temperature", "98", "pulse", "95 min", "regular", "blood pressure", "90 60 mm Hg", "abnormalities", "Laboratory studies", "normal limits", "ECG", "sinus rhythm", "QT interval corrected for heart rate", "milliseconds", "following", "most appropriate next step", "treatment"]}
{"question": "A 9-year-old boy is brought to the emergency department by his mother because of painful swelling in his right knee that started after he collided with another player during a soccer game. He has no history of serious illness except for an episode of prolonged bleeding following a tooth extraction a few months ago. Physical examination shows marked tenderness and swelling of the right knee joint. There are multiple bruises on the lower extremities in various stages of healing. Laboratory studies show a platelet count of 235,000/mm3, partial thromboplastin time of 78 seconds, prothrombin time of 14 seconds, and bleeding time of 4 minutes. The plasma concentration of which of the following is most likely to be decreased in this patient?", "answer": "Thrombin", "options": {"A": "Protein C", "B": "Plasmin", "C": "Thrombin", "D": "Von Willebrand factor", "E": "Factor VII"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "emergency department", "painful swelling", "right knee", "started", "history", "serious illness except for", "episode of prolonged bleeding following", "tooth extraction", "few months", "marked tenderness", "swelling of", "right knee joint", "multiple bruises", "lower extremities", "various stages", "healing", "Laboratory studies", "platelet count", "mm3", "partial thromboplastin time", "seconds", "prothrombin time", "seconds", "bleeding time of", "minutes", "plasma concentration", "following", "to", "decreased", "patient"]}
{"question": "A 38-year-old woman presents with dysphagia. She says the dysphagia is worse for solids than liquids and is progressive. She also complains of associated weakness, fatigue, and dyspnea. The patient denies any recent history of weight loss. Laboratory findings are significant for a hemoglobin of 8.7 g/dL. A peripheral blood smear shows evidence of microcytic hypochromic anemia. Which of the following is the most likely cause of her dysphagia?", "answer": "Upper esophageal web", "options": {"A": "Lower esophageal ring", "B": "Failure of the relaxation of lower esophageal sphincter", "C": "Upper esophageal web", "D": "Lower esophageal spasm", "E": "Esophageal carcinoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "dysphagia", "dysphagia", "worse", "solids", "progressive", "associated weakness", "fatigue", "dyspnea", "patient", "recent history of weight loss", "Laboratory", "significant", "a hemoglobin", "dL", "peripheral blood smear", "microcytic hypochromic anemia", "following", "most likely cause", "dysphagia"]}
{"question": "A 16-year-old girl is brought to the physician because of a 1-month history of fever, headaches, and profound fatigue. Her temperature is 38.2°C (100.8°F). Examination shows splenomegaly. Laboratory studies show:\nLeukocyte count 13,000/mm3 (15% atypical lymphocytes)\nSerum\nAlanine aminotransferase (ALT) 60 U/L\nAspartate aminotransferase (AST) 40 U/L\nHeterophile antibody assay negative\nEBV viral capsid antigen (VCA) antibodies negative\nHIV antibody negative\nIn an immunocompromised host, the causal organism of this patient's symptoms would most likely cause which of the following conditions?\"", "answer": "Linear ulcers near the lower esophageal sphincter", "options": {"A": "Multiple cerebral abscesses with surrounding edema", "B": "Diffuse pulmonary infiltrates with pneumatoceles", "C": "Purplish skin nodules on the distal extremities", "D": "Non-scrapable white patches on the lateral tongue", "E": "Linear ulcers near the lower esophageal sphincter"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "month history", "fever", "headaches", "profound fatigue", "temperature", "100", "splenomegaly", "Laboratory studies", "Leukocyte count", "mm3", "atypical lymphocytes", "Serum Alanine aminotransferase", "ALT", "60 U/L Aspartate aminotransferase", "AST", "U/L Heterophile antibody assay negative", "viral capsid", "antibodies", "HIV antibody", "immunocompromised host", "causal", "patient", "ymptoms ", "ause ", "ollowing  onditions?"]}
{"question": "A 33-year-old African American woman presents to her primary care physician for a wellness checkup. She states that she has lost 20 pounds over the past 2 months yet has experienced an increased appetite during this period. She endorses hyperhidrosis and increased urinary volume and frequency. Physical exam is notable for an anxious woman and a regular and tachycardic pulse. 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\nCa2+: 12.2 mg/dL\n\nThe patient's urine calcium level is elevated. Which of the following is the most likely diagnosis?", "answer": "Hyperthyroidism", "options": {"A": "Familial hypercalcemic hypocalciuria", "B": "Hyperparathyroidism", "C": "Hyperthyroidism", "D": "Malignancy", "E": "Sarcoidosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "woman presents", "primary care physician", "checkup", "states", "lost 20 pounds", "past", "months", "increased appetite", "period", "hyperhidrosis", "increased urinary volume", "frequency", "notable", "anxious woman", "regular", "tachycardic pulse", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L Ca2", "mg/dL", "patient's urine calcium level", "elevated", "following", "diagnosis"]}
{"question": "A 57-year-old woman comes to the emergency department because of dizziness, nausea, and vomiting for 4 days. Her temperature is 37.3°C (99.1°F), pulse is 100/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Arterial blood gas analysis on room air shows:\npH 7.58\nPCO2 43 mm Hg\nPO2 96 mm Hg\nHCO3- 32 mEq/L\nThe most appropriate next step in diagnosis is measurement of which of the following?\"", "answer": "Urine chloride", "options": {"A": "Urine albumin to creatinine ratio", "B": "Serum osmolal gap", "C": "Urine chloride", "D": "Urine anion gap", "E": "Serum anion gap"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["57 year old woman", "emergency department", "dizziness", "nausea", "vomiting", "4 days", "temperature", "99", "pulse", "100 min", "respirations", "20 min", "blood pressure", "70 mm Hg", "abnormalities", "Arterial blood gas analysis", "room air", "pH 7 58 PCO2", "mm Hg PO2 96", "HCO3", "mEq/L", "most appropriate next step", "diagnosis", "measurement"]}
{"question": "A 32-year-old man comes to the physician because of low-grade fever and progressive painful lumps in his right groin for 6 days. The lumps have been discharging purulent fluid since the evening of the previous day. He had a shallow, painless lesion on his penis 3 weeks ago, but was too embarrassed to seek medical attention; it has resolved in the meantime. There is no personal or family history of serious illness. He has smoked one pack of cigarettes daily for 12 years. He is sexually active with multiple male partners and uses condoms inconsistently. His temperature is 38.0°C (100.4°F). Examination of his groin shows multiple masses discharging pus. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal organism?", "answer": "Chlamydia trachomatis", "options": {"A": "Haemophilus ducreyi", "B": "Yersinia pestis", "C": "Herpes simplex virus 2", "D": "Klebsiella granulomatis", "E": "Chlamydia trachomatis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "low-grade fever", "progressive painful lumps", "right", "6 days", "lumps", "discharging purulent fluid", "evening", "previous day", "shallow", "painless lesion", "penis", "weeks", "embarrassed to", "medical", "resolved", "personal", "family history", "serious illness", "smoked one pack", "cigarettes daily", "years", "sexually active", "male", "uses condoms", "temperature", "100", "groin", "multiple masses discharging pus", "abnormalities", "following", "causal"]}
{"question": "A 45-year-old woman comes to the physician for the evaluation of persistent headaches for the last 2 months. The symptoms started insidiously. Menses had previously occurred at regular 28-day intervals with moderate flow. Her last menstrual period was 12 weeks ago. She is sexually active with her husband but reports decreased interest in sexual intercourse over the past few months. The patient does not smoke or drink alcohol. She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. She appears uncomfortable. Vital signs are within normal limits. A urine pregnancy test is negative. A pelvic ultrasound shows atrophic endometrium. A cranial MRI with contrast shows a 2-cm intrasellar mass. A hormone assay is performed and is positive. Which of the following is the most appropriate next step in the management?", "answer": "Cabergoline therapy", "options": {"A": "Cabergoline therapy", "B": "Radiotherapy", "C": "Observation and outpatient follow-up", "D": "Biopsy of intrasellar mass", "E": "Temozolomide therapy\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "persistent headaches", "last", "months", "symptoms started", "Menses", "regular", "day intervals", "moderate", "last menstrual period", "weeks", "sexually active", "reports decreased interest", "sexual intercourse", "past", "months", "patient", "not smoke", "5 ft 6", "tall", "kg", "BMI", "kg/m2", "appears", "Vital signs", "normal limits", "urine pregnancy test", "negative", "pelvic ultrasound", "atrophic endometrium", "cranial MRI with contrast", "2", "mass", "hormone assay", "performed", "positive", "following", "most appropriate next step"]}
{"question": "A 69-year-old man presents to his primary care physician after 2 episodes of dizziness while watching television. On further questioning, he admits to progressive fatigue and shortness of breath on exertion for the past few weeks. His medical history is significant for hypertension for the past 25 years and congestive heart failure for the past 2 years, for which he is on multiple medications. His blood pressure is 100/50 mm Hg, the heart rate is 50/min, and the temperature is 36.6°C (97.8°F). The physical examination is within normal limits. A 12-lead ECG is obtained and the results are shown in the picture. Which of the following is the best initial step for the management of this patient?", "answer": "Check the patient's medication profile", "options": {"A": "Observation and repeat ECG if symptoms recur", "B": "Temporary cardiac pacing", "C": "External defibrillation", "D": "Check the patient's medication profile", "E": "Glucagon"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old man presents", "primary care physician", "2 episodes of dizziness", "television", "further", "progressive fatigue", "shortness of breath", "exertion", "past", "weeks", "medical history", "significant", "hypertension", "past", "years", "congestive heart failure", "past", "years", "multiple medications", "blood pressure", "100 50 mm Hg", "heart rate", "50 min", "temperature", "36", "97", "normal limits", "12-lead ECG", "obtained", "results", "picture", "following", "best initial step", "patient"]}
{"question": "A 28-year-old woman comes to the physician because of increasingly frequent episodes of double vision for 2 days. She was seen in the emergency department for an episode of imbalance and decreased sensation in her right arm 3 months ago. Examination shows impaired adduction of the right eye with left lateral gaze but normal convergence of both eyes. Deep tendon reflexes are 4+ in all extremities. The Romberg test is positive. An MRI of the brain shows hyperintense oval plaques in the periventricular region and a plaque in the midbrain on T2-weighted images. Microscopic examination of material from the midbrain plaque would most likely show which of the following?", "answer": "Demyelination with partial preservation of axons\n\"", "options": {"A": "Eosinophilic intracytoplasmic inclusion bodies", "B": "Loss of axons and atrophy of oligodendrocytes", "C": "Lymphocytic infiltration of the endoneurium", "D": "Extracellular deposits of amyloid peptides", "E": "Demyelination with partial preservation of axons\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "of", "frequent episodes", "double vision", "2 days", "seen in", "emergency department", "episode of imbalance", "decreased sensation", "right arm", "months", "impaired adduction", "right eye", "left gaze", "normal convergence", "eyes", "Deep tendon reflexes", "4", "extremities", "Romberg test", "positive", "MRI of", "brain", "oval plaques", "periventricular region", "plaque", "midbrain", "weighted", "Microscopic examination", "midbrain plaque", "most likely", "following"]}
{"question": "A 37-year-old woman is brought to the emergency department by police after being found naked outside a government building. She is accompanied by her husband who reports that she has been having “crazy” ideas. The patient’s speech is pressured and she switches topics quickly from how she is going to be president one day to how she is going to learn 20 languages fluently by the end of the year. Upon further questioning, it is revealed that she has struggled with at least 2 depressive episodes in the past year. Her medical history is significant for hypertension, hyperlipidemia, gout, and chronic migraines. She was recently diagnosed with a urinary tract infection and given nitrofurantoin. She has also been taking indomethacin for an acute gout flare. Her other medications include atorvastatin, allopurinol, metoprolol, and acetazolamide. She is prescribed lithium and instructed to follow-up with a primary care physician. At a follow-up appointment, she complains of nausea, vomiting, and increased urinary frequency. On examination, she has a coarse tremor and diffuse hyperreflexia. Which of the following medications is most likely is responsible for the patient’s current presentation?", "answer": "Indomethacin", "options": {"A": "Acetazolamide", "B": "Atorvastatin", "C": "Indomethacin", "D": "Metoprolol", "E": "Nitrofurantoin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "police", "found naked outside", "government building", "reports", "pressured", "switches topics", "to", "one day", "to", "20", "end", "year", "further", "revealed", "depressive episodes", "past year", "medical history", "significant", "hypertension", "hyperlipidemia", "gout", "chronic migraines", "recently diagnosed", "urinary tract infection", "given nitrofurantoin", "indomethacin", "acute gout flare", "medications include atorvastatin", "allopurinol", "metoprolol", "acetazolamide", "lithium", "to follow-up", "primary", "follow-up appointment", "nausea", "vomiting", "increased urinary frequency", "coarse tremor", "diffuse hyperreflexia", "following medications", "most likely", "responsible", "patients current"]}
{"question": "A 58-year-old Caucasian woman visits her primary care physician for an annual check-up. She has a history of type 2 diabetes mellitus and stage 3A chronic kidney disease. Her estimated glomerular filtration rate has not changed since her last visit. Today, her parathyroid levels are moderately elevated. She lives at home with her husband and 2 children and works as a bank clerk. Her vitals are normal, and her physical examination is unremarkable. Which of the following explains this new finding?", "answer": "Phosphate retention", "options": {"A": "Phosphate retention", "B": "Hyperuricemia", "C": "Acidemia", "D": "Hypercalcemia", "E": "Uremia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old", "woman", "primary care physician", "annual check-up", "history of type 2 diabetes mellitus", "chronic kidney disease", "estimated glomerular filtration rate", "not changed", "last", "Today", "parathyroid levels", "moderately elevated", "lives at home", "2 children", "bank clerk", "normal", "unremarkable", "following", "new finding"]}
{"question": "A 32-year-old woman presents with a severe headache and neck pain for the past 60 minutes. She says the headache was severe and onset suddenly like a ‘thunderclap’. She reports associated nausea, vomiting, neck pain, and stiffness. She denies any recent head trauma, loss of consciousness, visual disturbances, or focal neurologic deficits. Her past medical history is significant for hypertension, managed with hydrochlorothiazide. She denies any history of smoking, alcohol use, or recreational drug use. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 165/95 mm Hg, pulse 92/min, and respiratory rate 15/min. On physical examination, there is mild nuchal rigidity noted with limited flexion at the neck. An ophthalmic examination of the retina shows mild papilledema. A noncontrast computed tomography (CT) scan of the head is performed and shown in the exhibit (see image). Which of the following is the next best step in the management of this patient?", "answer": "Labetalol", "options": {"A": "Mannitol", "B": "Lumbar puncture", "C": "Nitroprusside", "D": "Dexamethasone", "E": "Labetalol"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "severe headache", "neck pain", "past 60 minutes", "headache", "severe", "onset", "reports associated nausea", "vomiting", "neck pain", "stiffness", "recent head", "loss of consciousness", "visual disturbances", "focal neurologic deficits", "past medical history", "significant", "hypertension", "hydrochlorothiazide", "history of smoking", "recreational drug use", "vital signs include", "temperature", "98", "blood pressure", "95 mm Hg", "pulse", "min", "respiratory rate", "min", "mild nuchal rigidity noted", "limited flexion", "neck", "ophthalmic", "retina", "mild papilledema", "computed tomography", "scan of", "head", "performed", "see", "following", "next best step", "patient"]}
{"question": "A 26-year-old primigravida presents to her physician’s office at 35 weeks gestation with new onset lower leg edema. The course of her pregnancy was uneventful up to the time of presentation and she has been compliant with the recommended  prenatal care. She reports a 4 pack-year history of smoking prior to her pregnancy. She also used oral contraceptives for birth control before considering the pregnancy. Prior to pregnancy, she weighed 52 kg (114.6 lb). She gained 11 kg (24.3 lb) during the pregnancy thus far, and  2 kg (4.4 lb) during the last 2 weeks. Her height is 169 cm (5 ft 7 in). She has a family history of hypertension in her mother (diagnosed at 46 years of age) and aunt (diagnosed at 51 years of age). The blood pressure is 145/90 mm Hg, the heart rate is 91/min, the respiratory rate is 15/min, and the temperature is 36.6℃ (97.9℉). The blood pressure is unchanged 15 minutes and 4 hours after the initial measurement. The fetal heart rate is 144/min. The examination is remarkable for 2+ pitting lower leg edema. The neurologic examination shows no focality. A urine dipstick test shows 2+ proteinuria. Which of the following factors is a risk factor for her condition?", "answer": "Primigravida", "options": {"A": "Smoking prior to pregnancy", "B": "Oral contraceptives intake", "C": "Primigravida", "D": "BMI < 18.5 kg/m2 prior to pregnancy", "E": "Family history of hypertension"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old primigravida presents", "physicians office", "35 weeks gestation", "new onset lower leg edema", "course", "pregnancy", "time", "compliant", "reports", "4 year history of smoking", "pregnancy", "used oral contraceptives", "birth control", "pregnancy", "pregnancy", "kg", "gained", "kg", "pregnancy", "far", "2 kg", "4.4", "last", "weeks", "height", "5 ft", "family history of hypertension", "diagnosed", "years", "age", "diagnosed", "years", "age", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "blood pressure", "unchanged 15 minutes", "4", "initial measurement", "fetal heart rate", "min", "2", "pitting lower leg edema", "neurologic examination", "focality", "urine dipstick test", "2", "proteinuria", "following factors", "a", "factor", "condition"]}
{"question": "A 46-year-old African American woman presents to her primary care doctor complaining of muscle aches and weakness. She reports a 3 month history of gradually worsening upper and lower extremity pain. She is having trouble keeping up with her children and feels tired for most of the day. A review of systems reveals mild constipation. Her past medical history is notable for hypertension, diabetes, rheumatoid arthritis, and obesity. She takes lisinopril, metformin, and methotrexate. Her family history is notable for chronic lymphocytic leukemia in her mother and prostate cancer in her father. Her temperature is 99°F (37.2°C), blood pressure is 145/95 mmHg, pulse is 80/min, and respirations are 17/min. On exam, she appears well and in no acute distress. Muscle strength is 4/5 in her upper and lower extremities bilaterally. Patellar and brachioradialis reflexes are 2+ bilaterally. A serum analysis in this patient would most likely reveal which of the following?", "answer": "Increased PTH, decreased phosphate, and increased calcium", "options": {"A": "Decreased PTH, decreased phosphate, and increased calcium", "B": "Decreased PTH, increased phosphate, and decreased calcium", "C": "Increased PTH, decreased phosphate, and increased calcium", "D": "Increased PTH, increased phosphate, and decreased calcium", "E": "Increased PTH, increased phosphate, and increased calcium"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "woman presents", "primary care doctor", "muscle aches", "weakness", "reports", "3 month history", "worsening upper", "lower extremity pain", "keeping", "children", "tired", "day", "review of systems reveals mild constipation", "past medical history", "notable", "hypertension", "diabetes", "rheumatoid arthritis", "obesity", "lisinopril", "metformin", "methotrexate", "family history", "notable", "chronic lymphocytic leukemia", "prostate cancer", "temperature", "blood pressure", "95 mmHg", "pulse", "80 min", "respirations", "min", "exam", "appears well", "acute distress", "Muscle strength", "4/5", "upper", "lower extremities", "Patellar", "brachioradialis reflexes", "2", "serum analysis", "patient", "most likely reveal", "following"]}
{"question": "A 14-year-old girl presents to her pediatrician with complaints of repeated jerking of her neck for the past 2 years. Initially, her parents considered it a sign of discomfort in her neck, but later they noticed that the jerking was more frequent when she was under emotional stress or when she was fatigued. The patient says she can voluntarily control the jerking in some social situations, but when she is under stress, she feels the urge to jerk her neck and she feels better after that. The parents also report that during the past year, there have even been a few weeks when the frequency of the neck jerking had decreased drastically, only to increase again afterwards. On physical examination, she is a physically healthy female with normal vital signs. Her neurologic examination is normal. The pediatrician also notes that when he makes certain movements, the patient partially imitates these movements. The parents are very much concerned about her abnormal movements and insist on a complete diagnostic work-up. After a detailed history, physical examination, and laboratory investigations, the pediatrician confirms the diagnosis of Tourette syndrome. The presence of which of the following findings is most likely to confirm the pediatrician’s diagnosis?", "answer": "History of repeated bouts of unprovoked obscene speech over the past year", "options": {"A": "History of repeated bouts of unprovoked obscene speech over the past year", "B": "Rigidity and bradykinesia", "C": "Low serum ceruloplasmin level", "D": "Decreased caudate volumes in magnetic resonance imaging (MRI) of the brain", "E": "Increased activity in frontal subcortical regions in positron-emission tomography (PET) study"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl presents", "pediatrician", "complaints", "repeated jerking", "neck", "past", "years", "Initially", "sign", "discomfort", "neck", "later", "jerking", "more frequent", "emotional stress", "fatigued", "patient", "control", "jerking", "stress", "to jerk", "neck", "better", "report", "past year", "few weeks", "frequency", "neck jerking", "decreased", "only to increase", "healthy", "normal vital signs", "neurologic examination", "normal", "pediatrician", "notes", "makes certain movements", "patient", "movements", "very much", "abnormal movements", "complete diagnostic work-up", "detailed history", "laboratory", "pediatrician confirms", "diagnosis", "Tourette syndrome", "presence", "following findings", "to confirm", "pediatricians diagnosis"]}
{"question": "The division chief of general internal medicine at an academic medical center is interested in reducing 30-day readmissions for diabetic ketoacidosis (DKA) in elderly patients. Her research team decided to follow 587 patients over the age of 65 who have recently been admitted to the hospital for DKA for a 30-day period. At the end of 30 days, she identified 100 patients who were readmitted to the hospital and examined risk factors associated with readmission. The main results of her study are summarized in the table below.\nRR (95% CI) P-value\nEpisodes of DKA in the past 3 years < 0.001\nNone Reference\n1–2\n1.23 (1.04–1.36)\n3–4 1.48 (1.38–1.59)\n5+ 2.20 (1.83–2.51)\nWhich of the following aspects of the results would support a causal relationship between a history of DKA and 30-day readmission risk for DKA?\"", "answer": "Dose-response relationship", "options": {"A": "Low p-value", "B": "Confidence intervals that do not cross 1.0", "C": "Case-control study design", "D": "High odds ratio", "E": "Dose-response relationship"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["division", "general internal", "academic medical center", "reducing", "diabetic ketoacidosis", "DKA", "elderly patients", "to follow", "patients", "age", "65", "recently", "DKA", "30 day period", "end", "30 days", "identified 100 patients", "hospital", "examined risk factors associated with", "main results", "study", "table", "95", "CI", "P-value Episodes of DKA", "past", "years", "0.001", "23", "1", "36", "48", "1 381 59", "5", "2 20", "1", "following aspects", "results", "support", "causal relationship", "history", "DKA", "DKA"]}
{"question": "A 74-year-old man is brought from a nursing home to the emergency room for progressive confusion. The patient has a history of stroke 3 years ago, which rendered him wheelchair-bound. He was recently started on clozapine for schizothymia disorder. Vital signs reveal a temperature of 38.7°C (101.66°F), a blood pressure of 100/72 mm Hg, and a pulse of 105/minute. On physical examination, he is disoriented to place and time. Initial lab work-up results are shown:\nSerum glucose: 945 mg/dL\nSerum sodium: 120 mEq/L\nSerum urea: 58 mg/dL\nSerum creatinine: 2.2 mg/dL\nSerum osmolality: 338 mOsm/kg\nSerum beta-hydroxybutyrate: negative\nUrinalysis reveals: numerous white blood cells and trace ketones\nWhich of the following manifestations is more likely to be present in this patient?", "answer": "Seizures", "options": {"A": "Fruity odor of the breath", "B": "Abdominal pain", "C": "Seizures", "D": "Nausea or vomiting", "E": "Rapid deep breathing"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old man", "brought", "nursing home", "emergency room", "progressive confusion", "patient", "history", "stroke", "years", "wheelchair-bound", "recently started", "clozapine", "disorder", "Vital signs reveal", "temperature", "blood pressure", "100 72 mm Hg", "pulse", "minute", "disoriented to place", "time", "Initial lab", "results", "Serum glucose", "945 mg/dL Serum sodium", "mEq/L Serum urea", "58 mg dL Serum creatinine", "2.2 mg/dL Serum osmolality", "mOsm/kg Serum beta-hydroxybutyrate", "negative Urinalysis reveals", "numerous white blood cells", "trace ketones", "of", "following manifestations", "more likely to", "present", "patient"]}
{"question": "A 54-year-old male presents to the emergency department with nasal congestion and sore throat. He also endorses ten days of fatigue, rhinorrhea and cough, which he reports are getting worse. For the last four days, he has also had facial pain and thicker nasal drainage. The patient’s past medical history includes obesity, type II diabetes mellitus, and mild intermittent asthma. His home medications include metformin and an albuterol inhaler as needed. The patient has a 40 pack-year smoking history and drinks 6-12 beers per week. His temperature is 102.8°F (39.3°C), blood pressure is 145/96 mmHg, pulse is 105/min, and respirations are 16/min. On physical exam, he has poor dentition. Purulent mucus is draining from his nares, and his oropharynx is erythematous. His maxillary sinuses are tender to palpation.\n\nWhich one of the following is the most common risk factor for this condition?", "answer": "Viral infection", "options": {"A": "Asthma", "B": "Diabetes mellitus", "C": "Poor dentition", "D": "Tobacco use", "E": "Viral infection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["54 year old male presents", "emergency department", "nasal congestion", "sore throat", "fatigue", "rhinorrhea", "cough", "reports", "getting worse", "last four days", "facial pain", "thicker nasal drainage", "patients past medical history includes obesity", "type II diabetes mellitus", "mild intermittent asthma", "home medications include metformin", "albuterol inhaler as needed", "patient", "40", "smoking history", "6-12", "week", "temperature", "blood pressure", "96 mmHg", "pulse", "min", "respirations", "min", "poor dentition", "Purulent mucus", "draining", "nares", "oropharynx", "erythematous", "maxillary sinuses", "tender", "palpation", "one", "following", "most common risk factor", "condition"]}
{"question": "A 72-year-old man presents to the emergency department with severe respiratory distress. He was diagnosed with metastatic pancreatic cancer 6 months ago and underwent 2 rounds of chemotherapy. He says that he has had a cough and flu-like symptoms for the past week. During the interview, he is having progressive difficulty answering questions and suddenly becomes obtunded with decreased motor reflexes. His temperature is 38.8°C (102.0°F), blood pressure is 90/60 mm Hg, pulse is 94/min, and respirations are 22/min. Pulse oximetry is 82% on room air. The patient’s medical record contains an advanced directive stating that he would like all interventions except for cardiopulmonary resuscitation. Which of the following is the most appropriate next step in management?", "answer": "Intubate and administer intravenous antibiotics.", "options": {"A": "Observe and monitor vital signs for improvement.", "B": "Administer intravenous fluids.", "C": "Intubate and administer intravenous antibiotics.", "D": "Administer intravenous antibiotics and draw blood for testing.", "E": "Intubate only."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "emergency department", "severe respiratory distress", "diagnosed", "metastatic pancreatic cancer", "months", "2", "chemotherapy", "cough", "flu-like symptoms", "past week", "progressive difficulty answering questions", "obtunded", "decreased motor reflexes", "temperature", "blood pressure", "90 60 mm Hg", "pulse", "min", "respirations", "min", "Pulse oximetry", "room air", "patients", "contains", "advanced directive stating", "interventions", "cardiopulmonary resuscitation", "following", "most appropriate next step"]}
{"question": "A 32-year-old woman presents to clinic complaining of pelvic pain and heavy menstrual bleeding for the past 2 years. The patient reports that her last menstrual period was 1 week ago and she soaked through 1 tampon every 1-2 hours during that time. She does not take any medications and denies alcohol and cigarette use. She is currently trying to have a child with her husband. She works as a school teacher and exercises regularly. Her temperature is 97.0°F (36.1°C), blood pressure is 122/80 mmHg, pulse is 93/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical examination reveals an enlarged, irregularly-shaped uterus palpable at the level of the umbilicus. Laboratory studies are ordered as seen below.\n\nHemoglobin: 9.0 g/dL\nHematocrit: 29%\nMCV: 70 fL\nLeukocyte count: 4,500/mm^3 with normal differential\nPlatelet count: 188,000/mm^3\n\nUrine:\nhCG: Negative\nBlood: Negative\nLeukocytes: Negative\nBacteria: Negative\n\nWhich of the following is the most effective treatment for this patient?", "answer": "Myomectomy", "options": {"A": "Folate", "B": "Hysterectomy", "C": "Iron", "D": "Myomectomy", "E": "Oral contraceptive pills"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic complaining of pelvic pain", "heavy menstrual bleeding", "past", "years", "patient reports", "last menstrual period", "1 week", "soaked", "tampon", "1", "hours", "time", "not", "medications", "alcohol", "currently", "to", "child", "school teacher", "exercises", "temperature", "97", "36", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "reveals", "enlarged", "shaped uterus palpable", "level", "umbilicus", "Laboratory studies", "ordered", "seen", "Hemoglobin", "0 g/dL Hematocrit", "29", "MCV", "70 fL Leukocyte count", "4 500 mm", "normal differential Platelet count", "mm", "Urine", "hCG", "Negative Blood", "Negative", "Negative Bacteria", "Negative", "following", "most effective", "patient"]}
{"question": "A 25-year-old man is brought to the emergency department by ambulance after a motor vehicle accident. His car was rear-ended by a drunk driver while he was stopped at a traffic light. At the scene, he was noted to have multiple small lacerations over his upper extremities from broken glass. He has otherwise been healthy, does not smoke, and drinks 5 beers per night. He notes that he recently started trying out a vegan diet and moved to an apartment located in a historic neighborhood that was built in the 1870s. Physical exam reveals several small lacerations on his arms bilaterally but is otherwise unremarkable. A complete blood workup is sent and some of the notable findings are shown below:\n\nHemoglobin: 12.1 g/dL (normal: 13.5-17.5 g/dL)\nPlatelet count: 261,000/mm^3 (normal: 150,000-400,000/mm^3)\nMean corpuscular volume: 74 µm^3 (normal: 80-100 µm^3)\n\nFurther testing using serum hemoglobin electrophoresis reveals:\nHemoglobin A1 92% (normal 95-98%)\nHemoglobin A2: 6% (normal: 1.5-3.1%)\n\nWhich of the following cell morphologies would most likely be seen on blood smear in this patient?", "answer": "Codocytes", "options": {"A": "All cells appear normal", "B": "Codocytes", "C": "Megaloblasts", "D": "Sideroblasts", "E": "Schistocytes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "motor vehicle accident", "car", "rear-ended", "stopped", "traffic light", "noted to", "multiple small lacerations", "upper extremities", "glass", "healthy", "not smoke", "5", "night", "notes", "recently started", "out", "vegan diet", "moved to", "apartment", "historic neighborhood", "1870s", "reveals several small lacerations", "arms", "unremarkable", "complete blood workup", "sent", "notable findings", "Hemoglobin", "g/dL", "normal", "g/dL", "Platelet count", "mm", "normal", "400", "mm", "Mean corpuscular volume", "74 m", "normal", "80 100 m", "Further testing using serum hemoglobin electrophoresis reveals", "Hemoglobin A1", "normal 95 98", "Hemoglobin A2", "normal", "1", "1", "following cell morphologies", "most likely", "seen", "blood smear", "patient"]}
{"question": "A 35-year-old woman comes to the physician because of a 3-month history of worsening fatigue. She has difficulty concentrating at work despite sleeping well most nights. Three years ago, she was diagnosed with Crohn disease. She has about 7 non-bloody, mildly painful bowel movements daily. Her current medications include 5-aminosalicylic acid and topical budesonide. She does not smoke or drink alcohol. She appears pale. Her temperature is 37.9°C (100.2°F), pulse is 92/min, and blood pressure is 110/65 mmHg. The abdomen is diffusely tender to palpation, with no guarding. Laboratory results show:\nHemoglobin 10.5 g/dL\nMean corpuscular volume 83 μm3\nReticulocytes 0.2 %\nPlatelets 189,000/mm3\nSerum\nIron 21 μg/dL\nTotal iron binding capacity 176 μg/dL (N=240–450)\nA blood smear shows anisocytosis. Which of the following is the most appropriate next step in treatment?\"", "answer": "Oral prednisone therapy", "options": {"A": "Oral prednisone therapy", "B": "Subcutaneous erythropoietin injection", "C": "Red blood cell transfusion", "D": "Intravenous metronidazole therapy", "E": "Oral vitamin B12 supplementation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "physician", "3 month history", "worsening fatigue", "difficulty concentrating", "sleeping well", "nights", "Three years", "diagnosed", "Crohn disease", "about", "non bloody", "mildly painful bowel movements daily", "current medications include 5-aminosalicylic acid", "topical budesonide", "not smoke", "appears pale", "temperature", "100", "pulse", "min", "blood pressure", "65 mmHg", "abdomen", "tender", "palpation", "guarding", "Laboratory results", "Hemoglobin", "g", "volume 83", "2", "Platelets", "Serum", "Total iron binding capacity", "N", "blood smear", "anisocytosis", "following", "most appropriate next step", "treatment"]}
{"question": "A 10-year-old girl with a rash is brought to the clinic by her mother. The patient’s mother says that the onset of the rash occurred 2 days ago. The rash was itchy, red, and initially localized to the cheeks with circumoral pallor, and it gradually spread to the arms and trunk. The patient’s mother also says her daughter had been reporting a high fever of 39.4°C (102.9°F), headaches, myalgia, and flu-like symptoms about a week ago, which resolved in 2 days with acetaminophen. The patient has no significant past medical history. Her vital signs include: temperature 37.0°C (98.6°F), pulse 90/min, blood pressure 125/85 mm Hg, respiratory rate 20/min. Physical examination shows a symmetric erythematous maculopapular rash on both cheeks with circumoral pallor, which extends to the patient’s trunk, arms, and buttocks. The remainder of the exam is unremarkable. Laboratory findings are significant for a leukocyte count of 7,100/mm3 and platelet count of 325,000/mm3. Which of the following is the next best step in the management of this patient?", "answer": "Discharge home, saying that the patient may immediately return to school", "options": {"A": "Administer intravenous immunoglobulin (IVIG)", "B": "Transfuse with whole blood", "C": "Discharge home, saying that the patient may immediately return to school", "D": "Discharge home, saying that the patient may return to school after the disappearance of the rash", "E": "Discharge home with instructions for strict isolation from pregnant women until disappearance of the rash"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["10 year old girl", "rash", "brought", "clinic", "patients", "onset", "rash", "2 days", "rash", "itchy", "red", "initially localized", "cheeks", "circumoral pallor", "spread", "arms", "trunk", "patients", "high fever", "9F", "headaches", "myalgia", "flu-like symptoms", "week", "resolved", "2 days", "acetaminophen", "patient", "significant past medical history", "vital signs include", "temperature", "98", "pulse 90 min", "blood pressure", "85 mm Hg", "respiratory rate 20 min", "symmetric erythematous maculopapular rash", "cheeks", "circumoral pallor", "extends", "patients trunk", "arms", "buttocks", "exam", "unremarkable", "Laboratory findings", "significant", "leukocyte count", "7 100 mm3", "platelet count", "325", "mm3", "following", "next best step", "patient"]}
{"question": "A 54-year-old male presents to the emergency department after an episode of bloody vomiting. He is a chronic alcoholic with a history of cirrhosis, and this is the third time he is presenting with this complaint. His first two episodes of hematemesis required endoscopic management of bleeding esophageal varices. His hemoglobin on admission laboratory evaluation was 11.2 g/dL. The patient is stabilized, and upper endoscopy is performed with successful banding of bleeding varices. Follow-up lab-work shows hemoglobin levels of 10.9 g/dL and 11.1 g/dL on days 1 and 2 after admission. Which of the following is the best next step in the management of this patient?", "answer": "Discuss with the patient the option of a transjugular intrahepatic portosystemic stent (TIPS)", "options": {"A": "Monitor stability and discharge with continuation of endoscopic surveillance at regular 3 month intervals", "B": "Discuss with the patient the option of a transjugular intrahepatic portosystemic stent (TIPS)", "C": "Balloon tamponade of bleeding varices", "D": "Begin long-term octreotide and a 4-week course of prophylactic antibiotics", "E": "Give 2 units packed RBCs"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["54 year old male presents", "emergency department", "episode of bloody vomiting", "chronic alcoholic", "history", "cirrhosis", "third time", "presenting", "complaint", "first two episodes of hematemesis required endoscopic", "bleeding esophageal varices", "hemoglobin", "laboratory", "g/dL", "patient", "stabilized", "upper endoscopy", "performed", "successful banding", "bleeding varices", "Follow lab work", "hemoglobin levels", "10.9 g dL", "1", "days", "2", "following", "best next step", "patient"]}
{"question": "A 45-year-old man is brought into the emergency department after he was hit by a car. The patient was intoxicated and walked into oncoming traffic. He is currently unconscious and has a Glasgow coma scale score of 3. The patient has been admitted multiple times for alcohol intoxication and pancreatitis. The patient is resuscitated with fluid and blood products. An initial trauma survey reveals minor scrapes and abrasions and pelvic instability. The patient’s pelvis is placed in a binder. After further resuscitation the patient becomes responsive and states he is in pain. He is given medications and further resuscitation ensues. One hour later, the patient complains of numbness surrounding his mouth and in his extremities. Which of the following is the most likely explanation of this patient’s current symptoms?", "answer": "Transfusion complication", "options": {"A": "Hypokalemia", "B": "Late-onset edema surrounding the spinal cord", "C": "Medication complication", "D": "Transfusion complication", "E": "Trauma to the spinal cord"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "hit by", "car", "patient", "traffic", "currently unconscious", "Glasgow coma scale score", "3", "patient", "multiple times", "alcohol intoxication", "pancreatitis", "patient", "resuscitated", "fluid", "blood products", "initial trauma survey reveals minor scrapes", "abrasions", "pelvic instability", "patients pelvis", "binder", "further resuscitation", "patient", "responsive", "states", "pain", "given medications", "further resuscitation", "One hour later", "patient", "numbness surrounding", "mouth", "extremities", "following", "patients current symptoms"]}
{"question": "A 57-year-old woman is admitted to the intensive care unit for management of shock. Her pulse is feeble and blood pressure is 86/45 mm Hg. The patient undergoes pulmonary artery catheterization which shows an elevated pulmonary capillary wedge pressure and increased systemic vascular resistance. Which of the following additional findings is most likely in this patient?", "answer": "Confusion due to decreased stroke volume", "options": {"A": "Cold skin due to loss of intravascular fluid volume", "B": "Bradycardia due to neurologic dysfunction", "C": "Bronchospasm due to excessive histamine release", "D": "Mottled skin due to release of endotoxins", "E": "Confusion due to decreased stroke volume"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["57 year old woman", "management", "shock", "pulse", "blood pressure", "mm Hg", "patient", "pulmonary artery catheterization", "elevated pulmonary capillary wedge pressure", "increased systemic", "following additional findings", "patient"]}
{"question": "A 65-year-old Caucasian man presents to the emergency room with chest pain. Coronary angiography reveals significant stenosis of the left anterior descending (LAD) artery. Which of the following represents a plausible clinical predictor of myocardial necrosis in this patient?", "answer": "Rate of plaque formation", "options": {"A": "Cholesterol crystal presence", "B": "Rate of plaque formation", "C": "Calcium content", "D": "Presence of cytokines", "E": "Amount of foam cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old", "man presents", "emergency room", "chest pain", "Coronary angiography reveals significant stenosis", "left anterior descending", "artery", "following", "clinical", "myocardial necrosis", "patient"]}
{"question": "A 30-year-old woman comes to the physician because of a 1-month history of intermittent abdominal pain, flatulence, and watery diarrhea. The episodes typically occur 2–3 hours after meals, particularly following ingestion of ice cream, cheese, and pizza. She is administered 50 g of lactose orally. Which of the following changes is most likely to be observed in this patient?", "answer": "Increased stool osmotic gap", "options": {"A": "Decreased urinary D-xylose concentration", "B": "Increased serum glucose concentration", "C": "Increased stool osmotic gap", "D": "Decreased fecal fat content", "E": "Decreased breath hydrogen content"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old woman", "physician", "month history", "intermittent abdominal pain", "flatulence", "watery diarrhea", "episodes", "occur 23 hours after meals", "following", "administered 50 g", "lactose orally", "following changes", "to", "observed", "patient"]}
{"question": "A 70-year-old male with a 10-year history of COPD visits his pulmonologist for a checkup. Physical examination reveals cyanosis, digital clubbing, and bilateral lung wheezes are heard upon auscultation. The patient has a cough productive of thick yellow sputum. Which of the following findings is most likely present in this patient?", "answer": "Increased pulmonary arterial resistance", "options": {"A": "Decreased arterial carbon dioxide content", "B": "Increased pulmonary arterial resistance", "C": "Increased pH of the arterial blood", "D": "Increased cerebral vascular resistance", "E": "Increased right ventricle compliance"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["70 year old male", "10", "history", "COPD", "pulmonologist", "Physical", "reveals cyanosis", "digital clubbing", "bilateral lung wheezes", "heard", "auscultation", "patient", "cough productive", "thick yellow", "following findings", "most likely present", "patient"]}
{"question": "Background and Methods:\nAldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1,663 patients who had severe heart failure, a left ventricular ejection fraction of no more than 35 percent, and were being treated with an angiotensin-converting-enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily and 841 to receive placebo. The primary endpoint was death from all causes.\nResults:\nThe trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46%) and 284 in the spironolactone group (35%; relative risk of death, 0.70; 95% confidence interval, 0.60 to 0.82; p<0.001). This 30 percent reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from progressive heart failure and sudden death from cardiac causes. The frequency of hospitalization for worsening heart failure was 35% lower in the spironolactone group than in the placebo group (relative risk of hospitalization, 0.65; 95% confidence interval, 0.54 to 0.77; p<0.001). In addition, patients who received spironolactone had a significant improvement in the symptoms of heart failure, as assessed on the basis of the New York Heart Association functional class (p<0.001). Gynecomastia was reported in 10% of men who were treated with spironolactone, as compared with 1% of men in the placebo group (p<0.001). The incidence of serious hyperkalemia was minimal in both groups of patients.\nWhich of the following statements represents the most accurate interpretation of the results from the aforementioned clinical trial?", "answer": "Spironolactone, in addition to standard therapy, substantially reduces the risk of morbidity and death in patients with severe heart failure", "options": {"A": "Spironolactone, in addition to standard therapy, substantially reduces the risk of morbidity and death in patients with severe heart failure", "B": "The addition of spironolactone significant improved symptoms of heart failure, but not overall mortality", "C": "Spironolactone did not improve all-cause morbidity and mortality in patients with severe heart failure", "D": "The incidence of both gynecomastia and hyperkalemia was elevated in patients treated with spironolactone", "E": "Given the large sample size of this clinical trial, the results are likelily generalizable to all patient with heart failure"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Methods", "Aldosterone", "important", "pathophysiology", "heart", "enrolled 1", "patients", "severe heart failure", "left ventricular ejection fraction", "35 percent", "treated with", "angiotensin-converting-enzyme inhibitor", "loop diuretic", "cases digoxin", "total", "patients", "assigned to receive", "daily", "to receive placebo", "death", "causes", "Results", "discontinued early", "mean follow-up period", "months", "interim analysis", "spironolactone", "efficacious", "deaths", "placebo group", "spironolactone group", "relative", "of death", "0 70", "95", "confidence interval", "0 60", "82", "p 0.001", "30 percent", "death", "patients", "spironolactone group", "attributed", "lower risk", "death", "progressive heart failure", "sudden death", "cardiac causes", "frequency", "worsening heart failure", "35", "lower", "spironolactone group", "placebo group", "relative risk", "0.65", "95", "confidence interval", "0 54", "77", "p 0.001", "addition", "patients", "received spironolactone", "significant", "symptoms", "heart failure", "basis", "New York Heart Association functional class", "p 0.001", "Gynecomastia", "reported", "10", "treated with spironolactone", "1", "men", "placebo group", "p 0.001", "incidence", "serious hyperkalemia", "minimal", "groups", "patients", "following", "most accurate interpretation", "results"]}
{"question": "During an experiment, an investigator attempts to determine the rates of apoptosis in various tissue samples. Injecting cytotoxic T cells into the cell culture of one of the samples causes the tissue cells to undergo apoptosis. Apoptosis is most likely due to secretion of which of the following substances in this case?", "answer": "Granzyme B", "options": {"A": "Cytochrome C", "B": "Bcl-2", "C": "TNF-α", "D": "Granzyme B", "E": "Caspases"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "to", "rates", "apoptosis", "various tissue samples", "Injecting", "culture", "one", "samples causes", "tissue cells to", "apoptosis", "due to secretion", "following", "case"]}
{"question": "Which of the following situations calls for treatment with alprazolam?", "answer": "A 35-year-old male that gets tachycardic, tachypnic, and diaphoretic every time he rides a plane", "options": {"A": "A 28-year-old female that gets irritated or worried about everyday things out of proportion to the actual source of worry", "B": "A 35-year-old male that gets tachycardic, tachypnic, and diaphoretic every time he rides a plane", "C": "A 42-year-old female with extreme mood changes ranging from mania to severe depression", "D": "A 19-year-old male that saw his sibling murdered, and has had flashbacks and hypervigilance for more than one month", "E": "A 65-year-old male with narrow angle glaucoma that complains of excessive worry, rumination, and uneasiness about future uncertainties"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["following", "calls", "treatment", "alprazolam"]}
{"question": "A 30-year-old woman is brought to the clinic at her husband's insistence for sleep disturbances. Most nights of the week she repeatedly gets out of bed to pace around their apartment before returning to bed. The woman says that while she's lying in bed, she becomes overwhelmed by a \"creepy-crawly\" feeling in her legs that she can only relieve by getting out of bed. Past medical history is noncontributory and physical exam is unremarkable. Which of the following laboratory studies is most likely abnormal in this patient?", "answer": "Complete blood count", "options": {"A": "Complete blood count", "B": "Hemoglobin A1c", "C": "Liver function tests", "D": "Lumbar puncture", "E": "Nerve conduction studies"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman", "brought", "clinic", "leep disturbances.", "ights ", "eek ", "epeatedly  ets  ut ", "ed ", "ace ", "partment ", "eturning ", "ed.", "oman ", "he'", "ing in bed, ", "gs t", "ly r lieve by g tting o", "d. ", "st medical history i", "remarkable. ", "llowing l boratory studies i", "normal i", "tient?"]}
{"question": "A 40-year-old woman presents with ongoing heartburn despite being on treatment for the last few months. She describes a burning sensation in her chest even after small meals. She has stopped eating fatty and spicy foods as they aggravate her heartburn significantly. She has also stopped drinking alcohol but is unable to quit smoking. Her attempts to lose weight have failed. Three months ago, she was started on omeprazole and ranitidine, but she still is having symptoms. She had previously used oral antacids but had to stop because of intolerable constipation. Past medical history is significant for a mild cough for the past several years. Her vital signs are pulse 90/min, blood pressure 120/67 mm Hg, respiratory rate 14/min, and temperature of 36.7°C (98.0°F). Her current BMI is 26 kg/m2. Her teeth are yellow-stained, but the physical examination is otherwise unremarkable. What is the next best step in her management?", "answer": "Start metoclopramide.", "options": {"A": "Prescribe a nicotine patch.", "B": "Abdominal radiographs", "C": "Start metoclopramide.", "D": "Endoscopic evaluation", "E": "Refer for bariatric surgery."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old woman presents", "heartburn", "on treatment", "months", "burning sensation", "chest", "small meals", "stopped eating", "aggravate", "heartburn", "stopped drinking alcohol", "unable to", "smoking", "to", "weight", "failed", "Three months", "started", "omeprazole", "ranitidine", "symptoms", "used oral antacids", "to stop", "constipation", "Past medical history", "significant", "mild cough", "past", "years", "vital signs", "pulse 90 min", "blood pressure", "67 mm Hg", "respiratory rate", "min", "temperature", "36", "98", "current BMI", "kg/m2", "teeth", "yellow stained", "unremarkable", "next best step"]}
{"question": "A 17-year-old girl presents to the emergency department with a severe headache. The patient has had headaches in the past, but she describes this as the worst headache of her life. Her symptoms started yesterday and have been getting progressively worse. The patient states that the pain is mostly on one side of her head. There has been a recent outbreak of measles at the patient’s school, and the patient’s mother has been trying to give her daughter medicine to prevent her from getting sick, but the mother fears that her daughter may have caught the measles. On physical exam, you note an obese young girl who is clutching her head with the light in the room turned off. Her neurological exam is within normal limits. Fundoscopic exam reveals mild bilateral papilledema. A MRI of the head is obtained and reveals cerebral edema. A lumbar puncture reveals an increased opening pressure with a normal glucose level. Which of the following is the most likely diagnosis?", "answer": "Fat-soluble vitamin overuse", "options": {"A": "Viral meningitis", "B": "Bacterial meningitis", "C": "Subarachnoid hemorrhage", "D": "Migraine headache", "E": "Fat-soluble vitamin overuse"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl presents", "emergency department", "severe headache", "patient", "headaches", "past", "worst headache", "symptoms started", "getting", "worse", "patient states", "pain", "mostly", "one side of", "head", "recent", "measles", "patients school", "patients", "to give", "medicine to prevent", "getting sick", "caught", "measles", "note", "obese young girl", "head", "light", "room turned", "neurological exam", "normal limits", "Fundoscopic exam reveals mild bilateral papilledema", "MRI of", "head", "obtained", "reveals cerebral edema", "lumbar puncture reveals", "increased opening pressure", "normal glucose level", "following", "diagnosis"]}
{"question": "A previously healthy 1-year-old boy is brought to the emergency department because of irritability and fever for 2 days. His symptoms began shortly after returning from a family trip to Canada. He was born at term. His immunizations are up-to-date. His 6-year-old brother is healthy and there is no family history of serious illness. The boy appears weak and lethargic. He is at the 50th percentile for height and 75th percentile for weight. His temperature is 39.2°C (102.5°F), pulse is 110/min, respirations are 28/min, and blood pressure is 92/55 mm Hg. Physical examination shows several purple spots over the trunk and extremities that are 1 mm in diameter. Capillary refill time is 4 seconds. The remainder of the examination shows no abnormalities. His hemoglobin concentration is 12 g/dL, leukocyte count is 19,000/mm3, and platelet count is 225,000/mm3. A lumbar puncture is done; cerebrospinal fluid (CSF) analysis shows abundant segmented neutrophils, decreased glucose concentration, and an increased protein concentration. Which of the following is the most appropriate next step in management?", "answer": "Ceftriaxone and vancomycin therapy for the patient and rifampin prophylaxis for close contacts", "options": {"A": "Ampicillin therapy for the patient and ciprofloxacin prophylaxis for close contacts", "B": "Cefotaxime and vancomycin therapy for the patient and doxycycline prophylaxis for close contacts", "C": "Vancomycin therapy for the patient and rifampin prophylaxis for close contacts", "D": "Ceftriaxone and vancomycin therapy for the patient and rifampin prophylaxis for close contacts", "E": "Cefotaxime and vancomycin therapy for the patient and no prophylaxis for close contacts\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "irritability", "fever", "2 days", "symptoms began", "returning", "trip", "Canada", "born", "term", "immunizations", "date", "year old", "healthy", "family history", "serious illness", "boy appears weak", "lethargic", "50th percentile", "height", "percentile", "weight", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "several purple spots", "trunk", "extremities", "1 mm", "diameter", "Capillary refill time", "4 seconds", "abnormalities", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "lumbar puncture", "cerebrospinal fluid", "analysis", "abundant segmented neutrophils", "decreased", "increased protein concentration", "following", "most appropriate next step"]}
{"question": "A 62-year-old woman is brought to the emergency room at a nearby hospital after being involved in a roadside accident in which she sustained severe chest trauma. Enroute to the hospital, morphine is administered for pain control. Upon arrival, the patient rapidly develops respiratory failure and requires intubation and mechanical ventilation. She is administered pancuronium in preparation for intubation but suddenly develops severe bronchospasm and wheezing. Her blood pressure also quickly falls from 120/80 mm Hg to 100/60 mm Hg. Which of the following best explains the most likely etiology of this complication?", "answer": "Histamine release", "options": {"A": "Autonomic stimulation", "B": "Drug interaction", "C": "Histamine release", "D": "Skeletal muscle paralysis", "E": "Underlying neuromuscular disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman", "brought", "emergency room", "nearby hospital", "involved", "sustained severe chest trauma", "hospital", "morphine", "administered", "pain control", "arrival", "patient rapidly", "respiratory failure", "intubation", "mechanical ventilation", "administered pancuronium", "preparation", "intubation", "severe bronchospasm", "wheezing", "blood pressure", "falls", "80 mm Hg", "100 60 mm Hg", "following best", "etiology", "complication"]}
{"question": "An investigator is studying intracellular processes in muscle tissue after denervation. A biopsy specimen is obtained from the biceps femoris muscle of an 82-year-old woman who sustained sciatic nerve injury. Investigation of the tissue specimen shows shrunken cells with dense eosinophilic cytoplasm, nuclear shrinkage, and plasma membrane blebbing. Which of the following best explains the muscle biopsy findings?", "answer": "Release of mitochondrial cytochrome c", "options": {"A": "Release of mitochondrial cytochrome c", "B": "Degradation of Bcl-2-associated X protein", "C": "Denaturation of cytoplasmic proteins", "D": "Deactivation of caspases", "E": "Inhibition of Fas/FasL interaction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying intracellular processes", "muscle tissue", "denervation", "biopsy specimen", "obtained", "biceps femoris muscle", "year old woman", "sustained sciatic nerve injury", "of", "tissue specimen", "shrunken", "dense", "cytoplasm", "nuclear shrinkage", "plasma membrane blebbing", "following best", "muscle"]}
{"question": "A 15-year-old girl is brought to the physician by her mother because of lower abdominal pain for the past 5 days. The pain is constant and she describes it as 7 out of 10 in intensity. Over the past 7 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days. She has not yet attained menarche. Examination shows suprapubic tenderness to palpation. Pubic hair and breast development are Tanner stage 4. Examination of the external genitalia shows no abnormalities. Pelvic examination shows bulging, bluish vaginal tissue. Rectal examination shows an anterior tender mass. Which of the following is the most effective intervention for this patient's condition?", "answer": "Perform hymenotomy", "options": {"A": "Administer oral contraceptives pills", "B": "Perform vaginal dilation", "C": "Administer ibuprofen", "D": "Perform hymenotomy", "E": "Administer gonadotropin-releasing hormone agonist therapy\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "lower abdominal pain", "past", "days", "pain", "constant", "out", "10", "intensity", "past", "months", "multiple similar episodes of abdominal pain", "lasting", "days", "not", "menarche", "suprapubic tenderness", "palpation", "Pubic hair", "breast development", "Tanner stage 4", "Examination", "external genitalia", "abnormalities", "Pelvic examination", "bulging", "vaginal tissue", "Rectal", "anterior tender mass", "following", "most effective intervention", "patient's condition"]}
{"question": "A 46-year-old woman comes to the physician for a cognitive evaluation. She is an office manager. She has had increasing difficulties with multitasking and reports that her job performance has declined over the past 1 year. On mental status examination, short-term memory is impaired and long-term memory is intact. Laboratory studies, including thyroid-stimulating hormone and vitamin B12, are within the reference range. An MRI of the brain shows generalized atrophy, most pronounced in the bilateral medial temporal lobes and hippocampi. If this patient's condition has a genetic etiology, which of the following alterations is most likely to be found on genetic testing?", "answer": "Mutation in presenilin 1", "options": {"A": "Noncoding hexanucleotide repeats", "B": "Deletion of chromosome 21q", "C": "Mutation in presenilin 1", "D": "Expansion of CAG trinucleotide repeat", "E": "Presence of ApoE ε4 allele"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "cognitive evaluation", "office manager", "increasing difficulties", "reports", "job performance", "past", "year", "mental status", "impaired", "intact", "Laboratory studies", "including thyroid-stimulating hormone", "vitamin B12", "reference range", "MRI of", "brain", "generalized atrophy", "most", "bilateral medial temporal lobes", "hippocampi", "patient's condition", "genetic etiology", "following", "to", "found", "genetic testing"]}
{"question": "An investigator, studying learning in primates, gives an experimental chimpanzee a series of puzzles to solve. The chimpanzee solves the puzzle when he is able to place a set of wooden blocks sequentially inside the next biggest block. When a puzzle is solved successfully, a 30-second audio clip of a pop song plays. 15 seconds after that, a tangerine drops into the chimpanzee's room. After 2 days of this regimen, the chimpanzee undergoes functional magnetic resonance imaging (fMRI) of his brain while hearing the audio clip, which shows markedly elevated neurotransmission in the ventral tegmental area and substantia nigra. Which of the following best explains the finding on fMRI?", "answer": "Classical conditioning", "options": {"A": "Positive reinforcement", "B": "Negative reinforcement", "C": "Displacement", "D": "Classical conditioning", "E": "Extinction"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "gives", "experimental", "series", "to", "able to place", "set", "wooden blocks", "next biggest block", "30 second audio clip", "plays", "seconds", "tangerine drops", "room", "2 days", "regimen", "functional magnetic resonance imaging", "brain", "hearing", "audio clip", "markedly elevated neurotransmission", "ventral tegmental area", "substantia nigra", "following best", "finding", "fMRI"]}
{"question": "A 15-year-old male adolescent presents to the pediatrician with his parents complaining that he is shorter than his peers. His past medical history does not suggest any specific recurrent or chronic disease. There is no history of weight gain, weight loss, constipation, dry skin, headache. Both his parents are of normal height. On physical examination, he is a well-fed, well-developed male and his vital signs are within normal range. His physical examination is completely normal. His sexual development corresponds to Tanner stage 2. Analysis of his growth charts suggests that his height and weight at birth were within normal range. After the age of six months, his height and weight curves drifted further from average and approached the 5th percentile. An X-ray of the patient’s left hand reveals delayed bone age. Which of the following is the most likely cause of short stature in the boy?", "answer": "Constitutional growth delay", "options": {"A": "Constitutional growth delay", "B": "Familial short stature", "C": "Congenital adrenal hyperplasia", "D": "Growth hormone deficiency", "E": "Hypothyroidism"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male adolescent presents", "pediatrician", "shorter", "past medical history", "not", "specific recurrent", "chronic disease", "history", "weight gain", "weight loss", "constipation", "dry skin", "headache", "normal height", "well fed", "male", "vital signs", "normal range", "completely normal", "sexual development", "Tanner", "Analysis", "height", "weight", "birth", "normal range", "age", "six", "height", "weight curves", "further", "average", "approached", "5th percentile", "X-ray", "patients left hand reveals delayed bone age", "following", "most likely cause", "short stature", "boy"]}
{"question": "A 53-year-old female visits her physician with watery diarrhea and episodic flushing. The patient reports that she is often short of breath, and a pulmonary exam reveals bilateral wheezing. A CT scan shows a mass in the terminal ileum. 24-hour urine collection shows abnormally elevated 5-hydroxyindoleacetic acid (HIAA) levels. Ultrasound demonstrates a tricuspid valve with signs of fibrosis with a normal mitral valve. A metastatic disease to which organ is most commonly associated with the patient's syndrome?", "answer": "Liver", "options": {"A": "Lung", "B": "Kidney", "C": "Brain", "D": "Liver", "E": "Pancreas"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "physician", "watery diarrhea", "episodic flushing", "patient reports", "often short of breath", "pulmonary exam reveals bilateral wheezing", "CT scan", "mass", "terminal ileum", "24-hour urine collection", "elevated 5-hydroxyindoleacetic acid", "levels", "Ultrasound", "tricuspid valve", "signs", "fibrosis", "normal mitral valve", "metastatic disease to", "organ", "most", "associated with", "patient's syndrome"]}
{"question": "A patient weighing 70 kg (154 lb) requires intravenous antibiotics for a calcified abscess. The desired target plasma concentration of the antibiotic is 4.5 mg/L. The patient is estimated to have a volume of distribution of 30 L and a clearance rate of 60 mL/min. How many milligrams of the drug should be administered for the initial dose to reach the desired target plasma concentration?", "answer": "135 mg", "options": {"A": "135 mg", "B": "270 mg", "C": "35 mg", "D": "200 mg", "E": "70 mg"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["patient", "70 kg", "intravenous", "calcified abscess", "target plasma concentration", "4.5 mg/L", "patient", "estimated to", "volume of distribution", "30 L", "clearance rate", "60 mL min", "milligrams", "drug", "administered", "initial dose to reach", "target plasma concentration"]}
{"question": "An 82-year-old man with alcohol use disorder is brought to the emergency department from his assisted living facility because of fever and cough for 1 week. The cough is productive of thick, mucoid, blood-tinged sputum. His temperature is 38.5°C (101.3°F) and respirations are 20/min. Physical examination shows coarse inspiratory crackles over the right lung field. Sputum cultures grow gram-negative, encapsulated bacilli that are resistant to amoxicillin, ceftriaxone, and aztreonam. Which of the following infection control measures is most appropriate for preventing transmission of this organism to other patients in the hospital?", "answer": "Isolate patient to a single-occupancy room", "options": {"A": "Require all staff and visitors to wear droplet masks", "B": "Transfer patient to a positive pressure room", "C": "Require autoclave sterilization of all medical instruments", "D": "Isolate patient to a single-occupancy room", "E": "Transfer patient to a negative pressure room"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "alcohol use disorder", "brought", "emergency department", "assisted living facility", "fever", "cough", "1 week", "cough", "productive", "thick", "mucoid", "blood-tinged sputum", "temperature", "respirations", "20 min", "coarse inspiratory crackles", "right lung field", "Sputum cultures", "encapsulated", "resistant to amoxicillin", "ceftriaxone", "aztreonam", "following", "measures", "most appropriate", "preventing transmission", "patients in", "hospital"]}
{"question": "A 4-year-old boy presents to the Emergency Department with wheezing and shortness of breath after playing with the new family pet. Which of the following immunological factors is most involved in generating the antibodies necessary for mast cell Fc-receptor cross-linking and degranulation?", "answer": "IL-4", "options": {"A": "IL-2", "B": "IL-4", "C": "IL-5", "D": "IL-10", "E": "IL-13"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy presents", "Emergency Department", "wheezing", "shortness of breath", "playing", "new", "following", "most involved", "antibodies", "Fc-receptor cross-linking", "degranulation"]}
{"question": "A 35-year-old man is brought to his psychiatrist by his wife. The patient’s wife says his last visit was 3 years ago for an episode of depression. At that time, he was prescribed fluoxetine, which he did not take because he believed that his symptoms would subside on their own. A few months later, his wife says that he suddenly came out of his feelings of ‘depression’ and began to be more excitable and show pressured speech. She observed that he slept very little but had a heightened interest in sexual activity. This lasted for a few weeks, and he went back to his depressed state. He has continued to experience feelings of sadness and shows a lack of concentration at work. She often finds him crying, and he also expresses feelings of guilt for all the wrongs he allegedly did to her and to the family. There was a week where he had a brief time of excitability and was considering donating all their savings to a local charity. She is highly perturbed by his behavior and often finds it hard to predict what his mood will be like next. The patient denies any suicidal or homicidal ideations. A urine toxicology screen is negative. All laboratory tests, including thyroid hormone levels, are normal. Which of the following is the most appropriate diagnosis in this patient?", "answer": "Cyclothymia", "options": {"A": "Major depressive disorder", "B": "Dysthymia", "C": "Cyclothymia", "D": "Bipolar disorder, type I", "E": "Schizoaffective disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old man", "brought", "psychiatrist", "patients", "last", "3 years", "episode of depression", "time", "fluoxetine", "not", "symptoms", "few months later", "out", "feelings", "depression", "began to", "more excitable", "pressured speech", "observed", "slept very little", "heightened", "sexual activity", "lasted", "weeks", "back", "depressed state", "to", "lack of concentration", "often finds", "wrongs", "week", "brief time", "excitability", "savings", "local", "highly", "behavior", "often finds", "hard to", "mood", "next", "patient", "suicidal", "homicidal ideations", "urine toxicology", "negative", "laboratory tests", "including thyroid", "normal", "following", "most appropriate diagnosis", "patient"]}
{"question": "A previously healthy 56-year-old woman comes to the family physician for a 1-month history of sleep disturbance and sadness. The symptoms have been occurring since her husband died in a car accident. Before eventually falling asleep, she stays awake for multiple hours and has crying spells. Several times she has been woken up by the sound of her husband calling her name. She has lost 3 kg (6.6 lb) over the past month. She has 3 children with whom she still keeps regular contact and regularly attends church services with her friends. She expresses feeling a great feeling of loss over the death of her husband. She has no suicidal ideation. She is alert and oriented. Neurological exam shows no abnormalities. Which of the following is the most likely diagnosis for this patient's symptoms?", "answer": "Normal bereavement", "options": {"A": "Schizoaffective disorder", "B": "Normal bereavement", "C": "Acute stress disorder", "D": "Major depressive disorder", "E": "Adjustment disorder with depressed mood"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old woman", "family physician", "month history", "sleep disturbance", "symptoms", "occurring", "died", "car accident", "falling asleep", "awake", "multiple hours", "spells", "times", "woken up", "sound", "calling", "name", "lost 3 kg", "6.6", "past month", "keeps regular contact", "attends church", "great feeling of loss", "death", "suicidal ideation", "alert", "oriented", "Neurological exam", "abnormalities", "following", "diagnosis", "patient's symptoms"]}
{"question": "A 75-year-old man comes to the physician because of a 2-month history of intermittent bright red blood in his stool, progressive fatigue, and a 5-kg (11-lb) weight loss. He appears thin and fatigued. Physical examination shows conjunctival pallor. Hemoglobin concentration is 7.5 g/dL and MCV is 77 μm3. Results of fecal occult blood testing are positive. A colonoscopy shows a large, friable mass in the anal canal proximal to the pectinate line. Primary metastasis to which of the following lymph nodes is most likely in this patient?", "answer": "Internal iliac", "options": {"A": "Inferior mesenteric", "B": "Internal iliac", "C": "External iliac", "D": "Para-aortic", "E": "Deep inguinal"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old man", "physician", "2 month history", "intermittent bright red blood", "stool", "progressive fatigue", "5 kg", "weight loss", "appears thin", "fatigued", "conjunctival pallor", "Hemoglobin concentration", "7.5 g/dL", "MCV", "m3", "Results", "fecal occult blood testing", "positive", "colonoscopy", "large", "friable mass", "anal canal proximal to", "pectinate line", "Primary metastasis", "following lymph nodes", "patient"]}
{"question": "A 33-year-old woman presents with weight gain and marks on her abdomen (as seen in the image below). She does not have any significant past medical history. She is a nonsmoker and denies any alcohol use. Her blood pressure is 160/110 mm Hg and pulse is 77/min. A T1/T2 MRI of the head shows evidence of a pituitary adenoma, and she undergoes surgical resection of the tumor. Which of the following therapies is indicated in this patient to ensure normal functioning of her hypothalamic-pituitary-adrenal (HPA) axis?", "answer": "Hydrocortisone", "options": {"A": "Bilateral adrenalectomy", "B": "Fludrocortisone", "C": "Hydrocortisone", "D": "Mometasone", "E": "Methotrexate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "weight gain", "marks", "abdomen", "seen", "not", "significant past medical history", "nonsmoker", "blood pressure", "mm Hg", "pulse", "min", "T1", "MRI of", "head", "of", "pituitary adenoma", "surgical resection", "tumor", "following therapies", "indicated", "patient to", "normal functioning", "hypothalamic-pituitary-adrenal", "axis"]}
{"question": "A 58-year-old man presents with a sudden-onset severe headache and vomiting for the past 2 hours. Past medical history is significant for poorly controlled hypertension, managed with multiple medications. His blood pressure is 188/87 mm Hg and pulse is 110/min. A non-contrast CT of the head is unremarkable and cerebrospinal fluid analysis is within normal limits, except for an RBC count of 5.58 x 106/mm3. Labetalol IV is administered. Which of the following medications should also be added to this patient’s management?", "answer": "Nimodipine", "options": {"A": "Nifedipine", "B": "Verapamil", "C": "Furosemide", "D": "Nimodipine", "E": "Ecosprin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old man presents", "sudden-onset severe headache", "vomiting", "past", "hours", "medical history", "significant", "poorly controlled hypertension", "multiple medications", "blood pressure", "87 mm Hg", "pulse", "min", "non contrast CT", "head", "unremarkable", "cerebrospinal fluid analysis", "normal limits", "except for", "RBC count", "58", "mm3", "Labetalol IV", "administered", "following medications", "added", "patients"]}
{"question": "A 25-year-old patient comes to the physician with complaints of dysuria and white urethral discharge. He is sexually active with 4 partners and does not use condoms. The physician is concerned for a sexually transmitted infection and decides to analyze the nucleic acid sequences present in the discharge to aid in diagnosis via DNA amplification. Which of the following is responsible for the creation of the nucleic acid copies during the elongation phase of the technique most likely used in this case?", "answer": "Heat-resistant DNA polymerase", "options": {"A": "DNA primers", "B": "Nucleotide sequence of the target gene", "C": "Amino acid sequence of the target gene", "D": "Heat-sensitive DNA polymerase", "E": "Heat-resistant DNA polymerase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old patient", "physician", "complaints", "dysuria", "white urethral discharge", "sexually active", "not use condoms", "physician", "sexually transmitted infection", "to", "present", "discharge to aid", "diagnosis", "following", "responsible", "creation", "nucleic acid copies", "phase", "technique", "likely"]}
{"question": "A 61-year-old man is brought to the emergency department by his wife because of increasing confusion over the past 12 hours. His wife reports that he has a history of type 1 diabetes mellitus. His temperature is 38.8°C (101.8°F). He is confused and oriented only to person. Examination shows left periorbital swelling that is tender to palpation, mucopurulent rhinorrhea, and a black necrotic spot over the nose. There is discharge of the left eye with associated proptosis. A photomicrograph of a specimen obtained on biopsy of the left maxillary sinus is shown. Which of the following is the most likely causal organism?", "answer": "Rhizopus microsporus", "options": {"A": "Pseudomonas aeruginosa", "B": "Rhizopus microsporus", "C": "Aspergillus fumigatus", "D": "Blastomyces dermatitidis", "E": "Pneumocystis jirovecii"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old man", "brought", "emergency department", "increasing confusion", "past 12 hours", "reports", "history of type 1 diabetes mellitus", "temperature", "confused", "oriented only", "left periorbital swelling", "tender", "palpation", "mucopurulent rhinorrhea", "black necrotic spot", "nose", "discharge of", "left eye", "associated proptosis", "photomicrograph", "obtained", "biopsy", "left maxillary sinus", "following", "causal"]}
{"question": "A 57-year-old woman comes to the physician because of a 6-month history of tinnitus and progressive hearing loss in the left ear. She has type 2 diabetes mellitus and Raynaud syndrome. Her current medications include metformin, nifedipine, and a multivitamin. She appears well. Vital signs are within normal limits. Physical examination shows no abnormalities. A vibrating tuning fork is placed on the left mastoid process. Immediately after the patient does not hear a tone, the tuning fork is held over the left ear and she reports hearing the tuning fork again. The same test is repeated on the right side and shows the same pattern. The vibration tuning fork is then placed on the middle of the forehead and the patient hears the sound louder in the right ear. Which of the following is the most likely diagnosis?", "answer": "Acoustic neuroma", "options": {"A": "Meningioma", "B": "Presbycusis", "C": "Acoustic neuroma", "D": "Cerumen impaction", "E": "Ménière disease\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["57 year old woman", "physician", "month history", "tinnitus", "progressive hearing loss in", "left ear", "type 2 diabetes mellitus", "Raynaud syndrome", "current medications include metformin", "nifedipine", "multivitamin", "appears well", "Vital signs", "normal", "Physical examination", "abnormalities", "tuning fork", "left mastoid process", "Immediately", "patient", "not hear", "tone", "tuning fork", "held", "left ear", "reports hearing", "tuning fork", "same test", "repeated", "right side", "same pattern", "vibration tuning fork", "then", "middle", "forehead", "patient hears", "sound louder", "right ear", "following", "diagnosis"]}
{"question": "A 4-week-old boy is brought to the emergency department with a 2-day history of projectile vomiting after feeding. His parents state that he is their firstborn child and that he was born healthy. He developed normally for several weeks but started to eat less 1 week ago. Physical exam reveals a small, round mass in the right upper quadrant of the abdomen close to the midline. The infant throws up in the emergency department, and the vomitus is observed to be watery with no traces of bile. Which of the following is associated with the most likely cause of this patient's symptoms?", "answer": "Nitric oxide synthase deficiency", "options": {"A": "Chloride transport defect", "B": "Failure of neural crest migration", "C": "Nitric oxide synthase deficiency", "D": "Recanalization defect", "E": "Vascular accident"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 week old boy", "brought", "emergency department", "2-day history", "projectile vomiting", "state", "firstborn child", "born healthy", "weeks", "started to eat less", "week", "reveals", "small", "round mass", "right upper quadrant of", "abdomen close", "midline", "infant throws", "emergency department", "vomitus", "observed to", "watery", "traces", "bile", "following", "associated with", "likely cause", "patient's symptoms"]}
{"question": "A 49-year-old woman is brought in to the emergency department by ambulance after developing crushing chest pain and palpitations. Past medical history is significant for hypertension, hyperlipidemia, and obesity. She takes chlorthalidone, lisinopril, atorvastatin, metformin, and an oral contraceptive every day. She works as a lawyer and her job is stressful. She drinks wine with dinner every night and smokes 10 cigarettes a day. Emergency personnel stabilized her and administered oxygen while on the way to the hospital. Upon arrival, the vital signs include: blood pressure 120/80 mm Hg, heart rate 120/min, respiratory rate 22/min, and temperature 37.7°C (99.9°F). On physical exam, she is an obese woman in acute distress. She is diaphoretic and has difficulty catching her breath. A bedside electrocardiogram (ECG) is performed which reveals ST-segment elevation in leads II, III, and aVF. Which of the following is the most probable diagnosis?", "answer": "Inferior wall myocardial infarction ", "options": {"A": "Inferior wall myocardial infarction ", "B": "Lateral wall myocardial infarction", "C": "Posterior wall myocardial infarction", "D": "Anteroseptal myocardial infarction", "E": "Right ventricular myocardial infarction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "ambulance", "crushing chest pain", "palpitations", "Past medical history", "significant", "hypertension", "hyperlipidemia", "obesity", "chlorthalidone", "lisinopril", "atorvastatin", "metformin", "oral contraceptive", "day", "lawyer", "stressful", "dinner", "night", "smokes 10 cigarettes", "day", "Emergency personnel stabilized", "administered oxygen", "hospital", "arrival", "vital signs include", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99 9F", "obese woman", "acute distress", "diaphoretic", "difficulty catching", "breath", "electrocardiogram", "performed", "reveals ST-segment elevation", "leads", "III", "aVF", "following"]}
{"question": "A 60-year-old woman presents for an evaluation for snoring. According to her husband, her snoring has increased over the last year, and he can’t tolerate it anymore. He has also noticed that she wakes up at night regularly for a few seconds but then falls back asleep. During the day, the patient says she is sleepy most of the time and complains of headaches and poor concentration. Past medical history is significant for hypertension and hyperlipidemia. Her temperature is 36.6°C (97.9°F), blood pressure is 156/98 mm Hg, pulse is 90/min and respirations are 20/min. Her body mass index (BMI) is 38 kg/m2. A polysomnographic study is ordered, and the result is shown below. While counseling the patient about her condition and available treatment options, she is asked if she wants to try a new therapy in which a device stimulates one of her cranial nerves. Which of the following muscles would most likely be stimulated by this method?", "answer": "Genioglossus muscle", "options": {"A": "Genioglossus muscle", "B": "Digastric muscle", "C": "Hyoglossus muscle", "D": "Palatoglossus muscle", "E": "Intercostal muscles"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["60 year old woman presents", "snoring", "snoring", "increased", "year", "cant", "wakes up", "night", "seconds", "then falls back asleep", "day", "patient", "sleepy", "time", "headaches", "poor concentration", "Past medical history", "significant", "hypertension", "hyperlipidemia", "temperature", "36", "97 9F", "blood pressure", "98 mm Hg", "pulse", "90 min", "respirations", "20 min", "body mass index", "kg/m2", "study", "ordered", "result", "counseling", "patient", "condition", "available treatment options", "to", "new therapy", "device", "one", "cranial nerves", "following muscles", "most likely", "method"]}
{"question": "A 4-week-old male infant is brought to the physician because of a 1-week history of refusing to finish all his bottle feeds and becoming irritable shortly after feeding. He has also spit up sour-smelling milk after most feeds. Pregnancy and delivery were uncomplicated, with the exception of a positive vaginal swab for group B streptococci 6 weeks ago, for which the mother received one dose of intravenous penicillin. The baby is at the 70th percentile for length and 50th percentile for weight. His temperature is 36.6°C (98°F), pulse is 180/min, respirations are 30/min, and blood pressure is 85/55 mm Hg. He appears lethargic. Examination shows sunken fontanelles and a strong rooting reflex. The abdomen is soft with a 1.5-cm (0.6-inch) nontender epigastric mass. Examination of the genitals shows a normally pigmented scrotum, retractile testicles that can be pulled into the scrotum, a normal-appearing penis, and a patent anus. Which of the following interventions would have been most likely to decrease the patient's risk of developing his condition?", "answer": "Breastfeeding only", "options": {"A": "Feeding of soy milk formula", "B": "Breastfeeding only", "C": "Avoiding penicillin administration to the mother", "D": "Treating the infant with glucocorticoids", "E": "Performing cesarean section\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 week old male infant", "brought", "physician", "1-week history", "to finish", "bottle feeds", "irritable", "spit", "sour smelling milk", "feeds", "Pregnancy", "delivery", "uncomplicated", "positive vaginal swab", "weeks", "received one dose", "intravenous penicillin", "baby", "percentile", "length", "50th percentile", "weight", "temperature", "36", "pulse", "min", "respirations", "30/min", "blood pressure", "85", "mm Hg", "appears lethargic", "sunken fontanelles", "strong rooting reflex", "abdomen", "soft", "0.6 inch", "nontender epigastric mass", "genitals", "pigmented scrotum", "retractile testicles", "pulled", "scrotum", "normal appearing penis", "patent anus", "following interventions", "to decrease", "patient's", "condition"]}
{"question": "A 52-year-old woman status-post liver transplant presents to her transplant surgeon because she has noticed increased urination over the last 3 weeks. Six months ago she received a liver transplant because of fulminant liver failure after viral hepatitis. Since then, she has noticed that she has been drinking more water and urinating more. Her husband has also noticed that she has been eating a lot more. She says that she never had these symptoms prior to her transplant and has been taking her medications on time. After confirmatory tests, she is started on a medication that binds to an ATP-gated potassium channel. The drug that increases the risk of the complication experienced by this patient most likely has which of the following mechanisms of action?", "answer": "Binding to FKBP-12 to inhibit calcineurin", "options": {"A": "Binding to cyclophilin D to inhibit calcineurin", "B": "Binding to FKBP-12 to inhibit calcineurin", "C": "Inosine monophosphate dehydrogenase inhibitor", "D": "Conversion into 6-mecaptopurine", "E": "Targeting the a-chain of the IL-2 receptor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman status-post liver transplant presents", "transplant", "increased urination", "weeks", "Six months", "received", "liver transplant", "failure", "viral hepatitis", "then", "drinking more water", "eating", "lot", "never", "symptoms prior to", "transplant", "medications on time", "confirmatory tests", "started", "medication", "ATP gated potassium channel", "drug", "increases", "complication", "patient", "likely", "of", "following mechanisms", "action"]}
{"question": "A 47-year-old woman with a history of recent gastric bypass surgery presents for a follow-up visit. 8 months ago, she underwent gastric bypass surgery because she was struggling with maintaining her BMI below 42 kg/m². She previously weighed 120 kg (265 lb), and now she weighs 74.8 kg (165 lb). She says that she has low energy and is easily fatigued. These symptoms have become progressively worse over the past month. She is struggling to get through the day and sometimes has to nap before she can continue with her work. She has also recently noticed that she gets cramps in her legs, especially after a long day. The patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Her hemoglobin is 9.5 mg/dL with an MCV of 75 fl. Her peripheral smear is shown in the exhibit. Which of the following supplements would most likely improve this patient’s symptoms?", "answer": "Iron", "options": {"A": "Calcium", "B": "Pyridoxine", "C": "Retinoids", "D": "Methylcobalamin", "E": "Iron"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "history of recent gastric bypass surgery presents", "months", "gastric bypass surgery", "BMI", "kg/m", "kg", "now", "74", "kg", "easily fatigued", "symptoms", "worse", "past month", "to get", "day", "sometimes", "nap", "recently", "gets cramps in", "legs", "long day", "patient", "afebrile", "vital signs", "normal", "Physical examination", "unremarkable", "hemoglobin", "9.5 mg/dL", "MCV", "75 fl", "peripheral smear", "following supplements", "most likely", "patients symptoms"]}
{"question": "A 19-year-old woman comes to the physician for a routine health maintenance examination. She appears well. Her vital signs are within normal limits. Cardiac auscultation shows a mid-systolic click and a grade 3/6, late-systolic, crescendo murmur that is best heard at the cardiac apex in the left lateral recumbent position. After the patient stands up suddenly, the click is heard during early systole and the intensity of the murmur increases. Which of the following is the most likely underlying cause of this patient's examination findings?", "answer": "Dermatan sulfate deposition", "options": {"A": "Myosin heavy chain defect", "B": "Dermatan sulfate deposition", "C": "Congenital valvular fusion", "D": "Congenital interventricular communication", "E": "Dystrophic valvular calcification\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "routine", "appears well", "vital signs", "normal limits", "Cardiac auscultation", "mid-systolic click", "late-systolic", "crescendo murmur", "best heard", "cardiac apex", "left lateral recumbent position", "patient stands up", "heard", "early systole", "intensity", "murmur increases", "following", "underlying cause", "findings"]}
{"question": "A 60-year-old woman with ovarian cancer comes to the physician with a 5-day history of fever, chills, and dyspnea. She has a right subclavian chemoport in which she last received chemotherapy 2 weeks ago. Her temperature is 39.5°C (103.1°F), blood pressure is 110/80 mm Hg, and pulse is 115/min. Cardiopulmonary examination shows jugular venous distention and a new, soft holosystolic murmur heard best in the left parasternal region. Crackles are heard at both lung bases. Echocardiography shows a vegetation on the tricuspid valve. Peripheral blood cultures taken from this patient is most likely to show which of the following findings?", "answer": "Gram-positive, catalase-positive, coagulase-positive cocci in clusters", "options": {"A": "Gram-positive, catalase-negative, α-hemolytic, optochin-resistant cocci in chains", "B": "Gram-positive, catalase-positive, coagulase-negative, novobiocin-resistant cocci in clusters", "C": "Gram-positive, catalase-positive, coagulase-positive cocci in clusters", "D": "Gram-positive, catalase-negative, nonhemolytic, salt-sensitive cocci in chains", "E": "Gram-positive, catalase-negative, β-hemolytic, bacitracin-resistant cocci in chains"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old woman", "ovarian cancer", "physician", "5-day history", "fever", "chills", "dyspnea", "right subclavian", "last received chemotherapy", "weeks", "temperature", "blood pressure", "80 mm Hg", "pulse", "min", "Cardiopulmonary", "jugular venous distention", "new", "soft holosystolic murmur heard best", "left parasternal region", "Crackles", "heard", "lung bases", "Echocardiography", "vegetation", "tricuspid valve", "Peripheral blood cultures", "patient", "to", "following findings"]}
{"question": "A 28-year-old woman at 28 weeks gestation seeks evaluation at her obstetrician’s office with complaints of a severe headache, blurred vision, and vomiting for the past 2 days. Her pregnancy has been otherwise uneventful. The past medical history is unremarkable. The blood pressure is 195/150 mm Hg and the pulse is 88/min. On examination, moderate pitting edema is present in her ankles. The urinalysis is normal except for 3+ proteinuria. The obstetrician orders a complete blood count (CBC), liver function tests (LFTs), creatinine, and a coagulation profile. The obstetrician transfers her to the hospital by ambulance for expectant management. Which of the following medications would be most helpful for this patient?", "answer": "Nifedipine", "options": {"A": "Hydrochlorothiazide", "B": "Lisinopril", "C": "Metoprolol", "D": "Olmesartan", "E": "Nifedipine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "weeks", "obstetricians office", "complaints", "severe headache", "blurred vision", "vomiting", "past 2 days", "pregnancy", "past medical history", "unremarkable", "blood pressure", "mm Hg", "pulse", "88 min", "moderate pitting edema", "present", "ankles", "urinalysis", "normal", "proteinuria", "obstetrician orders", "complete blood count", "CBC", "liver function tests", "creatinine", "coagulation profile", "obstetrician transfers", "hospital", "ambulance", "following medications", "most helpful", "patient"]}
{"question": "A 35-year-old G0P0000 presents to her gynecologist with complaints of irregular menstruation. She has had only two periods in the last year. She also endorses feeling flushed without provocation and experiencing occasional dyspareunia with post-coital spotting. In addition, she has also had more frequent headaches than usual. The patient has a past medical history of Hashimoto’s thyroiditis and takes levothyroxine daily. Her mother has type I diabetes mellitus. At this visit, the patient’s temperature is 98.5°F (36.9°C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are unremarkable. The patient has Tanner V breasts and pubic hair. Pelvic exam reveals a normal cervix, anteverted uterus without tenderness, and no adnexal masses. The following laboratory studies are performed:\n\nSerum:\nThyroid stimulating hormone (TSH): 28 µIU/mL (9-30 µIU/mL)\nCycle day 3 follicle stimulating hormone (FSH): 49 mIU/mL (4.7-21.5 mIU/mL)\nCycle day 3 estradiol: 8 pg/mL (27-123 pg/mL)\nProlactin: 14 ng/mL (4-23 ng/mL)\nTestosterone: 42 ng/dL (15-70 ng/dL)\n\nWhich of the following is the best next step in management?", "answer": "Estradiol patch with oral medroxyprogesterone", "options": {"A": "Vaginal estradiol gel", "B": "Increase levothyroxine dose", "C": "Estradiol patch with oral medroxyprogesterone", "D": "Brain MRI", "E": "Combined oral contraceptive"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old", "presents", "gynecologist", "complaints", "irregular menstruation", "only two periods", "year", "flushed", "occasional dyspareunia", "post-coital spotting", "addition", "more frequent headaches", "usual", "patient", "past medical Hashimotos thyroiditis", "levothyroxine daily", "type I diabetes mellitus", "patients temperature", "98", "36", "pulse", "70 min", "blood pressure", "76 mmHg", "respirations", "min", "Cardiopulmonary", "abdominal exams", "unremarkable", "patient", "Tanner V breasts", "pubic hair", "Pelvic exam reveals", "normal cervix", "anteverted uterus", "tenderness", "adnexal masses", "following laboratory studies", "performed", "Serum", "Thyroid stimulating hormone", "IU/mL", "30 IU/mL", "Cycle day 3 follicle stimulating hormone", "mIU mL", "mL", "Cycle day 3 estradiol", "pg/mL", "27", "pg/mL", "Prolactin", "ng/mL", "4 23 ng/mL", "Testosterone", "ng/dL", "70 ng/dL", "following", "best next step"]}
{"question": "A 45-year-old man comes to the clinic complaining of yellow skin and eyes, loss of appetite, and severe nausea over the last month or so. He drinks 2–3 beers everyday and about 5–6 on the weekend. He does not take any over-the-counter medications. He has smoked one pack of cigarettes every day for the last 20 years but does not use illicit drugs. Additionally, he reports no history of vomiting, abdominal pain, altered bowel habits, or unintentional weight loss. His temperature is 37°C (98.6°F), blood pressure is 135/85 mm Hg, pulse is 78/ min, respiratory rate is 14/ min, and BMI is 19 kg/m2. On physical examination his skin and sclera are icteric, and his abdomen is tender with a mildly enlarged liver. On laboratory investigations:\nComplete blood count\nHemoglobin 11 g/dL\nMCV 105 µm3\nWhite blood cell 14,000/mm3\nPlatelets 110,000/mm3\nWhich of the following liver function analyses is expected in this patient?", "answer": "Alanine aminotransferase (ALT): 120 / Aspartate aminotransferase (AST): 256 / AST/ALT: 2.1", "options": {"A": "Alanine aminotransferase (ALT): 38/ Aspartate aminotransferase (AST): 30 / AST/ALT: 0.79", "B": "Alanine aminotransferase (ALT): 1,500 / Aspartate aminotransferase (AST): 1,089 / AST/ALT: 0.73", "C": "Alanine aminotransferase (ALT): 120 / Aspartate aminotransferase (AST): 256 / AST/ALT: 2.1", "D": "Alanine aminotransferase (ALT): 83 / Aspartate aminotransferase (AST): 72 / AST/ALT: 0.87", "E": "Alanine aminotransferase (ALT): 2,521 / Aspartate aminotransferase (AST): 2,222 / AST/ALT: 0.88"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "clinic", "yellow skin", "eyes", "loss of appetite", "severe nausea", "month", "so", "23", "everyday", "about", "weekend", "not", "over-the-counter medications", "smoked one pack", "cigarettes", "day", "20 years", "not use illicit drugs", "reports", "history", "vomiting", "abdominal pain", "altered bowel habits", "unintentional weight loss", "temperature", "98", "blood pressure", "85 mm Hg", "pulse", "min", "respiratory rate", "min", "BMI", "kg/m2", "skin", "sclera", "icteric", "abdomen", "tender", "mildly enlarged", "laboratory", "Complete blood count Hemoglobin", "g", "MCV", "m3", "mm3 Platelets", "following liver function analyses", "patient"]}
{"question": "A 24-year-old man comes to the physician because of 2 episodes of bleeding from the rectum over the past month. The patient’s father died of colon cancer at the age of 42. The patient has no history of any serious illness and takes no medications. He does not smoke. His vital signs are within normal limits. Physical examination shows a small hard mass over the right mandible that is nontender and fixed to the underlying bone. A similarly hard and painless 5 × 5 mass is palpated over the rectus abdominis muscle. On examination of the rectum, a polypoid mass is palpated at fingertip. Proctosigmoidoscopy shows numerous polyps. Which of the following best explains these findings?", "answer": "Gardner’s syndrome", "options": {"A": "Familial polyposis of the colon", "B": "Gardner’s syndrome", "C": "Lynch’s syndrome", "D": "Peutz-Jeghers syndrome", "E": "Turcot’s syndrome"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "2 episodes", "bleeding", "rectum", "past month", "patients", "died of colon cancer", "age", "patient", "history", "serious illness", "medications", "not smoke", "vital signs", "normal", "Physical examination", "small hard mass", "right", "nontender", "fixed", "underlying bone", "hard", "painless", "mass", "rectus abdominis muscle", "examination", "rectum", "polypoid mass", "fingertip", "Proctosigmoidoscopy", "numerous polyps", "following best", "findings"]}
{"question": "A 56-year-old man is brought to the emergency department after falling 16 feet from a ladder. He has severe pain in both his legs and his right arm. He appears pale and diaphoretic. His temperature is 37.5°C (99.5°F), pulse is 120/min and weak, respirations are 26/min, and blood pressure is 80/50 mm Hg. He opens his eyes and withdraws in response to painful stimuli and makes incomprehensible sounds. The abdomen is soft and nontender. All extremities are cold, with 1+ pulses distally. Arterial blood gas analysis on room air shows:\npH 7.29\nPCO2 33 mm Hg\nPO2 65 mm Hg\nHCO3- 15 mEq/L\nA CT scan shows displaced fractures of the pelvic ring, as well as fractures of both tibiae, the right distal radius, and right proximal humerus. The patient undergoes emergent open reduction and is admitted to the intensive care unit. Which of the following best indicates inadequate fluid resuscitation?\"", "answer": "Urine output of 25 mL in 3 hours", "options": {"A": "High pulse pressure", "B": "Urine output of 25 mL in 3 hours", "C": "Glasgow coma score of 8", "D": "Capillary refill time of 3 seconds", "E": "Base deficit of 1 mmol/L\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "falling", "feet", "ladder", "severe pain", "legs", "right arm", "appears pale", "diaphoretic", "temperature", "99", "pulse", "min", "weak", "respirations", "min", "blood pressure", "80 50 mm Hg", "opens", "eyes", "response", "painful", "makes incomprehensible sounds", "abdomen", "soft", "nontender", "extremities", "cold", "1", "pulses", "Arterial blood gas analysis", "room air", "pH 7", "PCO2", "mm Hg PO2 65", "HCO3", "mEq/L", "CT scan", "displaced", "pelvic ring", "fractures of", "tibiae", "right distal", "right proximal", "patient", "open reduction", "following best", "inadequate fluid resuscitation"]}
{"question": "A 2-year-old boy is brought to the pediatrician for recurrent nosebleeds. The boy was adopted two months ago and the parents have no record of his medical or family history. They report that the child has had frequent prolonged nosebleeds several times per week. Despite them applying pressure on the distal aspect of the nares and keeping his head elevated, the bleeding generally continues for hours. On exam, the boy appears pale and lethargic. A blood sample is obtained but the child bleeds through multiple pieces of gauze. No agglutination is observed when ristocetin is added to the patient’s blood. The addition of normal plasma to the sample still does not lead to agglutination. This patient has a condition that is most consistent with which of the following modes of transmission?", "answer": "Autosomal recessive", "options": {"A": "Autosomal dominant", "B": "Autosomal recessive", "C": "Mitochondrial", "D": "X-linked dominant", "E": "X-linked recessive"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "brought", "pediatrician", "recurrent nosebleeds", "boy", "adopted two months", "family history", "report", "child", "frequent prolonged nosebleeds", "times per week", "applying pressure", "distal aspect", "nares", "keeping", "head elevated", "bleeding", "hours", "exam", "boy appears pale", "lethargic", "blood sample", "obtained", "child bleeds", "multiple pieces", "gauze", "agglutination", "observed", "ristocetin", "added", "patients blood", "addition", "normal plasma", "not lead", "agglutination", "patient", "condition", "most", "of", "following modes", "transmission"]}
{"question": "A 72-year-old man comes to the physician with his son for a follow-up examination. The son reports that his father's mental status has declined since the previous visit when he was diagnosed with Alzheimer dementia. The patient often begins tasks and forgets what he was doing. He has increased trouble remembering events that occurred the day before and sometimes forgets names of common household objects. He has hypertension and hyperlipidemia. His current medications include lisinopril, hydrochlorothiazide, atorvastatin, and donepezil. He is confused and oriented only to person. He is unable to count serial sevens backward from 100. He is able to register 3 items but unable to recall them 5 minutes later. Which of the following is the most appropriate pharmacotherapy?", "answer": "Memantine", "options": {"A": "Risperidone", "B": "Ginkgo biloba", "C": "Citalopram", "D": "Memantine", "E": "Vitamin E"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["72 year old man", "physician", "follow-up examination", "reports", "mental status", "previous", "diagnosed", "Alzheimer dementia", "patient often begins", "forgets", "increased", "day", "sometimes forgets", "hypertension", "hyperlipidemia", "current medications include lisinopril", "hydrochlorothiazide", "atorvastatin", "donepezil", "confused", "oriented only", "unable to count serial", "backward", "100", "able to", "3", "unable to", "5 minutes later", "following", "most appropriate pharmacotherapy"]}
{"question": "A 35-year-old female presents to her gynecologist complaining of vaginal discomfort. She reports that over the past two weeks, she has developed dyspareunia and feels as if there is a mass on the external aspect of her vagina. She is sexually active in a monogamous relationship. On physical examination, there is a 2 cm unilateral erythematous swelling on the right side of the posterolateral labia minora. Which of the following embryologic precursors gives rise to the affected tissue in this patient?", "answer": "Urogenital sinus", "options": {"A": "Paramesonephric duct", "B": "Genital tubercle", "C": "Urogenital sinus", "D": "Urogenital fold", "E": "Labioscrotal swelling"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old female presents", "gynecologist", "vaginal discomfort", "reports", "past two weeks", "dyspareunia", "mass", "external aspect of", "vagina", "sexually active", "relationship", "2", "unilateral erythematous swelling", "the right side of", "posterolateral labia", "following embryologic", "gives", "affected tissue", "patient"]}
{"question": "A 34-year-old woman comes to the emergency department complaining of severe headache and anxiety, diaphoresis, and palpitations for the last 30 minutes. She has had several similar episodes over the past few weeks. She has no significant past medical history and has a 10 pack-year smoking history. She takes no illicit drugs. Her blood pressure on arrival is 181/80 mmHg and her pulse is 134/min. If this patient was given metoprolol, how would her blood pressure respond?", "answer": "Hypertension due to alpha-1-adrenergic receptor stimulation", "options": {"A": "Hypotension due to beta-adrenergic receptor blockade", "B": "Hypotension due to alpha-1-adrenergic receptor blockade", "C": "Hypertension due to alpha-1-adrenergic receptor blockade", "D": "Hypertension due to alpha-1-adrenergic receptor stimulation", "E": "Hypertension due to alpha- and beta-adrenergic receptor blockade"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "emergency department", "severe headache", "anxiety", "diaphoresis", "palpitations", "30 minutes", "several similar episodes", "past", "weeks", "significant past medical history", "a 10", "smoking history", "illicit drugs", "blood pressure", "arrival", "80 mmHg", "pulse", "min", "patient", "given metoprolol", "blood pressure"]}
{"question": "A 43-year-old woman comes to the physician with a 2-week history of new pruritic plaques on the scalp and extensor surfaces of the elbows and knees. Ten years ago, she was diagnosed with psoriasis. Her only medication is topical calcipotriene. Physical examination shows well-demarcated, symmetrical, erythematous plaques with silvery scale. There is pitting of the nails on all fingers. Therapy with a high-potency topical medication that inhibits NF-κB and phospholipase A2 is begun. Long-term use of this agent is most likely to result in which of the following?", "answer": "Dermal collagen loss", "options": {"A": "Dysplastic nevi", "B": "Nonblanchable pinpoint macules", "C": "Decreased sebum production", "D": "Dermal collagen loss", "E": "Hair growth on upper lip"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "2-week history", "new", "plaques", "scalp", "extensor surfaces of", "elbows", "knees", "Ten years", "diagnosed", "psoriasis", "only medication", "topical calcipotriene", "well", "symmetrical", "erythematous plaques", "silvery scale", "pitting of", "nails", "fingers", "Therapy", "high", "topical", "inhibits", "phospholipase A2", "begun", "Long-term use of", "agent", "to result"]}
{"question": "A 25-year-old woman is brought to a psychiatrist’s office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient’s husband states that his family drove across the country to visit them and that his wife ‘threatened his parents with a knife’ at dinner last night. Police had to be called to calm her down. He states that she has been acting ‘really crazy’ for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of ‘hearing ghosts’ talking to her throughout the house were persisting and ‘getting worse’. There was also a 4-week period where she experienced insomnia and an unintentional weight loss of 12 pounds. She seemed sad throughout these episodes, and, according to her husband, was complaining of feeling ‘worthless’. Her general hygiene has also suffered from her recent lack of motivation and she insists that the ‘ghosts’ are asking her to kill as many people as she can so they won’t be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?", "answer": "Schizoaffective disorder", "options": {"A": "Schizoaffective disorder", "B": "Brief psychotic disorder", "C": "Schizophreniform disorder", "D": "Schizophrenia", "E": "Delusional disorder"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "psychiatrists office", "states", "worried", "recent behavior", "more violent", "patients", "states", "country to", "knife", "dinner", "night", "Police", "to", "called to", "states", "acting", "months", "initial behavior", "caused", "alarm", "deceased", "talking", "piece", "ceramic art", "living room", "Initially", "complaints", "hearing ghosts talking", "house", "getting worse", "4 week period", "insomnia", "unintentional weight loss", "pounds", "episodes", "of feeling worthless", "general hygiene", "suffered", "recent lack of motivation", "ghosts", "to kill", "so", "alone", "house", "extremely", "else", "states", "currently", "not", "medications", "illicit drugs", "far", "not smoke", "patient", "not make", "speak", "psychiatrist", "speak", "following", "diagnosis", "patient"]}
{"question": "A 27-year-old previously healthy man presents to the clinic complaining of bloody diarrhea and abdominal pain. Sexual history reveals that he has sex with men and women and uses protection most of the time. He is febrile with all other vital signs within normal limits. Physical exam demonstrates tenderness to palpation of the right upper quadrant. Subsequent ultrasound shows a uniform cyst in the liver. In addition to draining the potential abscess and sending it for culture, appropriate medical therapy would involve which of the following?", "answer": "Metronidazole and iodoquinol", "options": {"A": "Amphotericin", "B": "Nifurtimox", "C": "Supportive therapy", "D": "Sulfadiazine and pyrimethamine", "E": "Metronidazole and iodoquinol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old", "healthy man presents", "clinic", "bloody diarrhea", "abdominal pain", "history reveals", "sex", "uses protection", "time", "febrile", "vital", "normal", "Physical exam", "tenderness", "palpation", "right upper quadrant", "Subsequent ultrasound", "uniform cyst", "liver", "draining", "potential abscess", "sending", "culture", "appropriate medical therapy", "following"]}
{"question": "An 81-year-old man is brought to the physician by his daughter after being found wandering on the street. His daughter says that over the past several months he has been more aggressive towards friends and family. She also reports several episodes in which he claimed to see two strangers in her apartment. He sometimes stares blankly for several minutes and does not react when addressed. He has hypertension, hyperlipidemia, and was diagnosed with Parkinson disease 10 months ago. His current medications include carbidopa-levodopa, hydrochlorothiazide, and atorvastatin. His temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 150/85 mm Hg. He is confused and oriented to person and place but not to time. There is a resting tremor in his right upper extremities. There is muscle rigidity in the upper and lower extremities. He is able to walk without assistance but has a slow gait with short steps. Mental status examination shows short-term memory deficits. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Lewy body deposition", "options": {"A": "Lewy body deposition", "B": "Vascular infarcts", "C": "Frontotemporal lobe atrophy", "D": "Thiamine deficiency", "E": "Impaired CSF absorption"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["81 year old man", "brought", "physician", "found", "street", "past", "months", "more aggressive", "reports several episodes", "to see two", "apartment", "sometimes stares", "minutes", "not", "hypertension", "hyperlipidemia", "diagnosed", "Parkinson disease 10 months", "current medications include carbidopa-levodopa", "hydrochlorothiazide", "atorvastatin", "temperature", "98", "pulse", "99 min", "blood pressure", "85 mm Hg", "confused", "oriented to person", "place", "not", "time", "resting tremor", "right upper extremities", "muscle rigidity", "upper", "lower extremities", "able to", "assistance", "slow gait", "short steps", "Mental status", "deficits", "following", "underlying cause", "patient's condition"]}
{"question": "A 55-year-old woman comes to the physician because of fever, chills, headache, and nausea over the past 3 days. Nine months ago, she returned from a vacation in Indonesia where she had experienced similar symptoms and episodic fever. She was treated with chloroquine and recovered uneventfully. Her temperature is 39.1°C (102.4°F), pulse is 97/min, and blood pressure is 123/85 mm Hg. Physical examination shows scleral icterus. The abdomen is soft; bowel sounds are active. Neurologic examination is unremarkable. Her hemoglobin concentration is 10 g/dL. A photomicrograph of a peripheral blood smear is shown. Which of the following is the most likely cause of the recurrence of symptoms in this patient?", "answer": "Reactivation of dormant liver stage", "options": {"A": "Decline in circulating antibodies", "B": "Reinfection by Anopheles mosquito", "C": "Natural drug resistance", "D": "Reactivation of dormant liver stage", "E": "Dissemination within macrophages"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "fever", "chills", "headache", "nausea", "past 3 days", "Nine months", "returned", "Indonesia", "similar symptoms", "episodic fever", "treated with chloroquine", "recovered", "temperature", "pulse", "97 min", "blood pressure", "85 mm Hg", "scleral icterus", "abdomen", "soft", "bowel sounds", "active", "Neurologic examination", "unremarkable", "hemoglobin concentration", "10 g/dL", "photomicrograph", "peripheral blood smear", "following", "most likely cause", "recurrence", "symptoms", "patient"]}
{"question": "A 6-month-old child is brought to the pediatrician by his parents for difficulty feeding and poor motor function. 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 until 2 months ago. He started having trouble latching onto his bottle. He has also become extremely lethargic. Examination reveals diminished muscle tone in all four limbs, areflexia, and hepatosplenomegaly. A ophthalmoscopic exam reveals macular cherry red spots. Which of the following is most likely deficient in this child?", "answer": "Sphingomyelinase", "options": {"A": "ß-Glucosidase", "B": "Hexosaminidase A", "C": "Arylsulfatase A", "D": "Ceramidase", "E": "Sphingomyelinase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month", "brought", "pediatrician", "difficulty feeding", "poor motor function", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "months", "started", "latching", "bottle", "extremely lethargic", "reveals diminished muscle tone", "four limbs", "areflexia", "hepatosplenomegaly", "ophthalmoscopic exam reveals macular cherry red spots", "following", "deficient", "child"]}
{"question": "A 29-year-old G1P0 woman, at 12 weeks estimated gestational age, presents for her first prenatal visit. Past medical history reveals the patient has type O+ blood and that her husband has type A+ blood. The patient is worried about the risk of her baby having hemolytic disease. Which of the following is correct regarding fetomaternal incompatibility in this patient?", "answer": "It is a rare cause of newborn hemolytic disease", "options": {"A": "It cannot affect first borns", "B": "It is more severe than RhO (D) alloimmunization", "C": "Prenatal detection is very important because fetomaternal incompatibility is associated with severe fetal anemia", "D": "A direct Coombs test is strongly positive", "E": "It is a rare cause of newborn hemolytic disease"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old", "woman", "weeks estimated gestational age", "presents", "Past medical history reveals", "patient", "type O", "blood", "type A", "blood", "patient", "worried", "baby", "hemolytic disease", "following", "correct", "patient"]}
{"question": "An 80-year-old male is found dead at home and brought in for an autopsy. The patient's heart shows a diminished ventricular chamber volume and the interventricular septum appears sigmoid shaped. The left atrium appears enlarged as well. A few calcifications are seen on the undamaged aortic valves. Microscopic examination reveals increased connective tissue in the myocardium and brown perinuclear cytoplasmic granules in numerous myocardial cells as shown in the exhibit. Which of the following most likely explains this patient's cardiac findings?", "answer": "Expected age related changes", "options": {"A": "Chronic hemolytic anemia", "B": "Dilated cardiomyopathy", "C": "Expected age related changes", "D": "Hypertrophic cardiomyopathy", "E": "Uncontrolled hypertension"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["80 year old male", "found dead", "home", "brought", "autopsy", "patient's heart", "diminished ventricular chamber volume", "interventricular septum appears sigmoid shaped", "left atrium appears enlarged", "well", "few calcifications", "seen", "aortic valves", "Microscopic examination reveals increased connective tissue", "myocardium", "brown perinuclear cytoplasmic granules", "numerous", "following most likely", "patient's cardiac findings"]}
{"question": "A 39-year-old man comes to the physician because of a 4-month history of fatigue. During this period, he has also had a 7.7-kg (17-lb) weight loss, despite having a normal appetite. He is sexually active with 3 female partners and uses condoms inconsistently. An HIV screening test and confirmatory test are both positive. CD4+ T-lymphocyte count is 570/mm3 (N ≥ 500) and the viral load is 104 copies/mL. Treatment with lamivudine, zidovudine, and indinavir is begun. The patient is most likely to experience which of the following adverse effects?", "answer": "Urolithiasis", "options": {"A": "Hyperpigmentation of palms and soles", "B": "Hepatotoxicity", "C": "Urolithiasis", "D": "Pancreatitis", "E": "Stevens-Johnson syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "4 month history", "fatigue", "period", "7.7 kg", "weight loss", "normal appetite", "sexually active", "female", "uses condoms", "HIV screening test", "confirmatory test", "positive", "CD4", "T-lymphocyte count", "mm3", "N", "500", "viral load", "copies/mL", "Treatment", "lamivudine", "zidovudine", "indinavir", "begun", "patient", "to", "following adverse effects"]}
{"question": "A 49-year-old obese woman presents with a chronic non-healing ulcer on the right medial malleolus. Past medical history is significant for type 2 diabetes mellitus, diagnosed 10 years ago, poorly managed with metformin. Review of systems is significant for a recurrent white vaginal discharge. The patient is afebrile, and her vital signs are within normal limits. Her BMI is 31 kg/m2. On physical examination, there is a 2 cm by 2 cm nontender, erythematous shallow ulcer present over the right medial malleolus. Sensation is decreased symmetrically in the lower extremities below the level of the midcalf. Which of the following histopathological findings would most likely be seen in the peripheral nerves in this patient?", "answer": "Reduced axonal fiber diameter and fiber density", "options": {"A": "Wallerian degeneration", "B": "Reduced axonal fiber diameter and fiber density", "C": "Acute perivascular inflammation", "D": "Lymphocytic infiltration of the endoneurium", "E": "Accumulation of beta-pleated sheets of amyloid protein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old obese woman presents", "chronic non-healing ulcer", "right medial malleolus", "Past medical history", "significant", "type 2 diabetes mellitus", "diagnosed", "poorly", "metformin", "Review of systems", "significant", "recurrent white vaginal discharge", "patient", "afebrile", "vital signs", "normal limits", "BMI", "31 kg/m2", "2", "2", "nontender", "erythematous shallow ulcer present", "right medial malleolus", "Sensation", "decreased", "lower extremities", "level", "following histopathological findings", "most likely", "seen", "peripheral nerves", "patient"]}
{"question": "A 72-year-old woman is brought to the emergency department by her daughter because of left-sided weakness for 1 hour. She does not have headache or blurring of vision. She has hypertension, hypercholesterolemia, type 2 diabetes, and coronary artery disease. She has smoked one half-pack of cigarettes daily for 45 years. Her medications include atorvastatin, amlodipine, metformin, and aspirin. Her temperature is 37°C (98.6°F), pulse is 92/min, and blood pressure is 168/90 mm Hg. Examination shows a left facial droop. Muscle strength is decreased on the left side. Deep tendon reflexes are 3+ on the left. Sensation to pinprick, light touch, and vibration as well as two-point discrimination are normal. Which of the following is the most likely cause of these findings?", "answer": "Lipohyalinosis of lenticulostriate arteries", "options": {"A": "Atherosclerosis of the internal carotid artery", "B": "Rupture of an intracranial aneurysm", "C": "Lipohyalinosis of lenticulostriate arteries", "D": "Dissection of the vertebral artery", "E": "Embolism from the left atrium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old woman", "brought", "emergency department", "left-sided weakness", "1 hour", "not", "headache", "blurring of vision", "hypertension", "hypercholesterolemia", "type 2 diabetes", "coronary artery disease", "smoked one half pack", "cigarettes daily", "years", "medications include atorvastatin", "amlodipine", "metformin", "aspirin", "temperature", "98", "pulse", "min", "blood pressure", "90 mm Hg", "left facial droop", "Muscle strength", "decreased", "left side", "Deep tendon reflexes", "3", "left", "Sensation", "light touch", "vibration", "two point", "normal", "following", "most likely cause", "findings"]}
{"question": "A 27-year-old male is brought to the emergency room following a violent assault in which he was stabbed in the chest. The knife penetrated both the left lung and the left ventricle. Where did the knife most likely enter his chest?", "answer": "Left fifth intercostal space in the midclavicular line", "options": {"A": "Left seventh intercostal space in the midaxillary line", "B": "Left seventh intercostal space in the midclavicular line", "C": "Left fifth intercostal space just lateral to the sternum", "D": "Left fifth intercostal space in the midaxillary line", "E": "Left fifth intercostal space in the midclavicular line"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old male", "brought", "emergency room following", "violent assault", "stabbed", "chest", "knife penetrated", "left lung", "left ventricle", "knife", "likely enter", "chest"]}
{"question": "A 69-year-old man is brought to the emergency department for severe tearing lower back pain for 12 hours. The pain radiates to the flank and he describes it as 8 out of 10 in intensity. He has nausea and has vomited several times. He has no fever, diarrhea, or urinary symptoms. When he stands up suddenly, he becomes light-headed and has to steady himself for approximately 1 to 2 minutes before he is able to walk. He has hypertension and hyperlipidemia. Two years ago, he had a myocardial infarction and underwent coronary artery bypass grafting of his right coronary artery. He has smoked one and a half packs of cigarettes daily for 40 years and drinks 1 to 2 beers daily. His current medications include chlorthalidone, atorvastatin, lisinopril, and aspirin. He appears acutely ill. His temperature is 37.2°C (98.9°F), pulse is 130/min and regular, respirations are 35/min, and blood pressure is 80/55 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 85%. Examination shows a pulsatile mass in the abdomen. Intravenous fluids and high-flow oxygen are started. Thirty minutes later, the patient dies. Which of the following was the strongest predisposing factor for the condition leading to this patient's death?", "answer": "Smoking", "options": {"A": "Advanced age", "B": "Hyperlipidemia", "C": "Male sex", "D": "Hypertension", "E": "Smoking"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["69 year old man", "brought", "emergency department", "severe tearing lower back pain", "12 hours", "pain radiates", "flank", "out", "10", "intensity", "nausea", "vomited", "times", "fever", "diarrhea", "urinary symptoms", "stands up", "light-headed", "to steady", "approximately", "2 minutes", "able to", "hypertension", "hyperlipidemia", "Two years", "myocardial infarction", "coronary artery", "right", "smoked one", "half packs", "cigarettes daily", "40 years", "1", "2", "daily", "current medications include chlorthalidone", "atorvastatin", "lisinopril", "aspirin", "appears", "ill", "temperature", "98 9F", "pulse", "min", "regular", "respirations", "35 min", "blood pressure", "80", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "85", "pulsatile mass in", "abdomen", "high", "oxygen", "started", "Thirty minutes later", "patient", "following", "strongest predisposing factor", "condition leading", "patient's death"]}
{"question": "A 48-year-old African American male presents to his primary care provider complaining of facial swelling. He reports a three-day history of worsening swelling primarily around his eyes. The patient’s medical history is notable for sickle cell disease and poorly controlled hypertension. The patient currently takes enalapril, hydrochlorothiazide, and amlodipine but has a history of medication non-adherence. He has a 15 pack-year smoking history. His temperature is 99.1°F (37.3°C), blood pressure is 155/100 mmHg, pulse is 90/min, and respirations are 20/min. Physical examination is notable for periorbital swelling and 1+ bilateral lower extremity edema. Multiple serum and urine labs are ordered. A kidney biopsy in this patient would most likely yield which of the following sets of findings on light and electron microscopy?", "answer": "Segmental sclerosis and negative immunofluorescence and foot process effacement", "options": {"A": "Wire looping capillaries and subendothelial immune complex deposition", "B": "Hypercellular glomeruli with neutrophils and subepithelial immune complex deposition", "C": "Increased mesangial cellularity and mesangial immune complex deposition", "D": "Diffusely thickened capillaries and subepithelial immune complex deposition", "E": "Segmental sclerosis and negative immunofluorescence and foot process effacement"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["48 year old", "male presents", "primary care provider", "facial swelling", "reports", "three day history", "worsening swelling", "eyes", "patients medical history", "notable", "sickle cell disease", "poorly controlled hypertension", "patient currently", "enalapril", "hydrochlorothiazide", "amlodipine", "history", "medication non-adherence", "smoking history", "temperature", "99", "blood pressure", "100 mmHg", "pulse", "90 min", "respirations", "20 min", "notable", "periorbital swelling", "1", "bilateral lower extremity edema", "Multiple serum", "urine labs", "ordered", "kidney biopsy", "patient", "following sets", "findings", "light", "electron microscopy"]}
{"question": "A 28-year-old man comes to the physician because of a 9-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He has difficulty falling asleep and wakes up at least 3 times per night. He worries about paying his bills, failing law school, and disappointing his parents. He can no longer concentrate in class and failed the last exam. He feels on edge most days and avoids socializing with his classmates. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. There is no personal or family history of serious illness. He is sexually active with his girlfriend. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 3 years. He appears anxious. Vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?", "answer": "Buspirone", "options": {"A": "Buspirone", "B": "Doxepin", "C": "Propranolol", "D": "Lorazepam", "E": "Valerian\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "month history", "sleep disturbances", "restlessness", "difficulty acquiring erections", "difficulty falling asleep", "wakes up", "times", "night", "worries", "paying", "bills", "failing law school", "longer concentrate", "failed", "last exam", "edge", "days", "worries", "underlying medical condition", "causing", "symptoms", "Previous diagnostic evaluations", "unremarkable", "personal", "family history", "serious illness", "sexually active", "history", "drinking alcohol excessively", "early 20s", "not", "alcohol", "past", "years", "appears anxious", "Vital signs", "normal limits", "mental status", "oriented to person", "place", "time", "abnormalities", "psychotherapy", "treatment", "following drugs", "most appropriate", "patient"]}
{"question": "A 27-year-old woman presents for a checkup. She is 20 weeks pregnant and has been admitted to the hospital multiple times during her pregnancy for seizures. She has a known seizure disorder but discontinued her valproic acid when she became pregnant. The patient's past medical history is otherwise unremarkable. She does not smoke, drink alcohol, or use any drugs. She generally prefers not to take medications and sees a shaman for her care typically. Given her recent hospitalization, the patient agrees to start carbamazepine. Which of the following is the most appropriate treatment for this patient at this time?", "answer": "Folate", "options": {"A": "Folate", "B": "Iron", "C": "Magnesium", "D": "Vitamin B12", "E": "Vitamin D"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old woman presents", "checkup", "20 weeks pregnant", "multiple times", "pregnancy", "seizures", "known seizure disorder", "discontinued", "valproic acid", "pregnant", "patient's past", "unremarkable", "not smoke", "use", "drugs", "not to", "medications", "sees", "Given", "recent", "patient agrees to start carbamazepine", "following", "most appropriate", "patient", "time"]}
{"question": "A previously healthy 4-year-old boy is brought to the physician because of blisters and redness on his neck and chest for 2 days. He has also had a fever. He is lethargic and has not eaten well since the rash appeared. He has not had coughing, wheezing, or dysuria. He is an only child and there is no family history of serious illness. His immunizations are up-to-date. His temperature is 38.9°C (102°F), pulse is 90/min, and blood pressure is 80/40 mm Hg. Examination shows flaccid blisters over his neck and trunk that rupture easily. Areas of erythematous moist skin are also noted. Twirling an eraser over the trunk results in a blister. Oropharyngeal examination is normal. Laboratory studies show:\nHemoglobin 12 g/dL\nLeukocyte count 22,000/mm3\nSegmented neutrophils 77%\nEosinophils 3%\nLymphocytes 18%\nMonocytes 2%\nErythrocyte sedimentation rate 60 mm/h\nUrinalysis is normal. Which of the following is the most likely diagnosis?\"", "answer": "Staphylococcal scalded skin syndrome", "options": {"A": "Staphylococcal scalded skin syndrome", "B": "Pemphigus vulgaris", "C": "Scarlet fever", "D": "Bullous pemphigoid", "E": "Toxic epidermal necrolysis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "blisters", "redness", "neck", "chest", "2 days", "fever", "lethargic", "not eaten well", "rash appeared", "not", "coughing", "wheezing", "dysuria", "family history", "serious illness", "immunizations", "date", "temperature", "pulse", "90 min", "blood pressure", "80 40 mm Hg", "flaccid", "neck", "trunk", "rupture easily", "Areas of moist", "noted", "Twirling", "trunk results", "blister", "Oropharyngeal", "normal", "Laboratory studies", "Hemoglobin", "g", "count", "mm3 Segmented", "Eosinophils", "Monocytes", "Erythrocyte sedimentation rate 60 mm/h Urinalysis", "normal", "following", "diagnosis"]}
{"question": "A 56-year-old woman comes to the emergency department because of a 3-day history of malaise, dysuria, blurred vision, and a painful, itchy rash. The rash began on her chest and face and spread to her limbs, palms, and soles. One week ago, she was diagnosed with trigeminal neuralgia and started on a new medicine. She appears ill. Her temperature is 38°C (100.4°F) and pulse is 110/min. Physical examination shows conjunctival injection and ulceration on the tongue and palate. There is no lymphadenopathy. Examination of the skin shows confluent annular, erythematous macules, bullae, and desquamation of the palms and soles. The epidermis separates when the skin is lightly stroked. Which of the following is the most likely diagnosis?", "answer": "Stevens-Johnson syndrome", "options": {"A": "Bullous pemphigoid", "B": "Stevens-Johnson syndrome", "C": "Pemphigus vulgaris", "D": "Drug-induced lupus erythematosus", "E": "DRESS syndrome"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "3-day history", "malaise", "dysuria", "blurred vision", "painful", "itchy rash", "rash began", "chest", "face", "spread", "limbs", "soles", "One week", "diagnosed", "trigeminal neuralgia", "started", "new medicine", "appears ill", "temperature", "100", "pulse", "min", "conjunctival injection", "ulceration", "tongue", "palate", "lymphadenopathy", "Examination of", "skin", "confluent annular", "erythematous macules", "bullae", "desquamation", "palms", "soles", "epidermis separates", "skin", "lightly stroked", "following", "diagnosis"]}
{"question": "A 23-year-old woman presents to her primary care physician for knee pain. The pain started yesterday and has not improved since then. The patient is generally in good health. She attends college and plays soccer for her school's team. Three days ago, she was slide tackled during a game and her leg was struck from the outside. She fell to the ground and sat out for the rest of the game. It was not until yesterday that she noticed swelling in her knee. She also feels as if her knee is unstable and does not feel confident bearing weight on her leg during athletic activities. Her past medical history is notable for asthma, which is currently treated with an albuterol inhaler. On physical exam, you note bruising over her leg, knee, and lateral thigh, and edema of her knee. Passive range of motion of the knee is notable only for minor clicking and catching of the joint. The patient's gait appears normal, though the patient states that her injured knee does not feel stable. Further physical exam is performed and imaging is ordered. Which of the following is the most likely diagnosis?", "answer": "Medial meniscal tear", "options": {"A": "Anterior cruciate ligament tear", "B": "Posterior cruciate ligament tear", "C": "Medial collateral ligament tear", "D": "Medial meniscal tear", "E": "Iliotibial band syndrome"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old woman presents", "primary care physician", "knee pain", "pain started", "not improved since then", "patient", "attends college", "plays", "school's", "Three days", "slide", "leg", "struck", "outside", "fell", "sat out", "not", "swelling", "knee", "knee", "unstable", "not", "confident bearing weight", "leg", "past medical history", "notable", "asthma", "currently treated with", "albuterol inhaler", "note bruising", "leg", "knee", "lateral thigh", "edema of", "knee", "Passive range", "motion", "notable only", "minor", "catching", "joint", "patient's gait appears normal", "patient states", "injured knee", "not", "stable", "Further", "performed", "imaging", "ordered", "following", "diagnosis"]}
{"question": "A 67-year-old man presents to the emergency department with abdominal pain that started 1 hour ago. The patient has a past medical history of diabetes and hypertension as well as a 40 pack-year smoking history. His blood pressure is 107/58 mmHg, pulse is 130/min, respirations are 23/min, and oxygen saturation is 98% on room air. An abdominal ultrasound demonstrates focal dilation of the aorta with peri-aortic fluid. Which of the following is the best next step in management?", "answer": "Emergent surgical intervention", "options": {"A": "Administer labetalol", "B": "Counsel the patient in smoking cessation", "C": "Emergent surgical intervention", "D": "Serial annual abdominal ultrasounds", "E": "Urgent surgery within the next day"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "emergency department", "abdominal pain", "started 1 hour", "patient", "past medical diabetes", "hypertension", "40", "smoking history", "blood pressure", "58 mmHg", "pulse", "min", "respirations", "23 min", "oxygen saturation", "98", "room air", "abdominal ultrasound", "focal dilation", "aorta", "peri-aortic fluid", "following", "best next step"]}
{"question": "A 15-year-old boy comes to the physician because of severe muscle cramps and pain for 3 months. He first noticed these symptoms while attending tryouts for the high school football team. Since then, he becomes easily fatigued and has severe muscle pain and swelling after 10 minutes of playing. However, after a brief period of rest, the symptoms improve, and he is able to return to the game. Two days ago, he had an episode of reddish-brown urine after playing football. There is no family history of serious illness. He appears healthy. Vital signs are within normal limits. Physical and neurological examinations show no abnormalities. Serum creatine kinase concentration is 333 U/L. Urinalysis shows:\nBlood 2+\nProtein negative\nGlucose negative\nRBC negative\nWBC 1–2/hpf\nWhich of the following is the most likely cause of this patient's symptoms?\"", "answer": "Myophosphorylase deficiency", "options": {"A": "Thyroid hormone deficiency", "B": "Dystrophin gene mutation", "C": "Myophosphorylase deficiency", "D": "Acid maltase deficiency", "E": "CTG repeat in the DMPK gene"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "physician", "severe muscle cramps", "pain", "months", "first", "symptoms", "attending", "high football", "Since then", "easily fatigued", "severe muscle", "swelling", "10 minutes", "playing", "brief period", "symptoms", "able to return", "Two days", "episode of", "brown urine", "playing football", "family history", "serious illness", "appears healthy", "Vital signs", "normal limits", "Physical", "neurological examinations", "abnormalities", "Serum creatine kinase concentration", "333 U/L", "Urinalysis", "Blood", "Protein negative Glucose", "RBC", "WBC", "hpf", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 82-year-old man who is currently being managed by the internal medicine service agrees to be examined by medical students as part of their training in physical examination. He is visited by a small group of medical students under the instruction of a preceptor and allows the students to make observations. They find that he has bibasilar crackles that are most prominent during inspiration as well as some wheezing. Furthermore, he coughs up some sputum during the exam, and this sputum is found to have a rust color. He does not report any pain and no skin findings are seen. Which of the following is most closely associated with the cause of this patient's physical exam findings?", "answer": "Left heart failure", "options": {"A": "Left heart failure", "B": "Long bone fractures", "C": "Protein C/S deficiency", "D": "Smoking", "E": "Tall, thin males"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "currently", "internal medicine service agrees to", "examined", "medical students", "part of", "training", "small", "medical students", "to make observations", "find", "crackles", "most prominent", "inspiration", "wheezing", "coughs", "sputum", "exam", "sputum", "found to", "rust color", "not report", "pain", "skin findings", "seen", "following", "most", "associated with", "cause", "patient's physical exam findings"]}
{"question": "A 2500-g (5.5-lb) male newborn is delivered at 35 weeks' gestation to a 25-year-old woman, gravida 2, para 1. The pregnancy was complicated by oligohydramnios. Pulse oximetry on room air shows an oxygen saturation of 78%. Examination in the delivery room shows that the newborn's skin appears blue with weak cry and irregular breathing and gasping. The nose is flat with bilateral epicanthal folds. The ears are low-set with broad auricles. The lower jaw is abnormally displaced backwards. The right lower limb appears shorter than the left lower limb with displaced right great toe. Breath sounds are decreased bilaterally. Renal ultrasound shows bilateral dilatation of the renal pelvis and ureters. Which of the following is most likely to confirm the underlying cause of this patient's condition?", "answer": "Voiding cystourethrogram", "options": {"A": "Voiding cystourethrogram", "B": "Echocardiography", "C": "Karyotyping", "D": "Blood cultures", "E": "X-ray of the chest\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2500", "male newborn", "delivered", "35 weeks", "gestation", "year old woman", "gravida 2", "para 1", "pregnancy", "complicated", "oligohydramnios", "Pulse oximetry", "room air", "oxygen saturation", "delivery", "newborn's skin appears blue", "weak cry", "irregular breathing", "gasping", "nose", "flat", "bilateral epicanthal folds", "ears", "low-set", "broad auricles", "lower jaw", "displaced backwards", "right lower limb appears shorter", "left lower limb", "displaced right great toe", "Breath sounds", "decreased", "Renal ultrasound", "bilateral dilatation of the renal pelvis", "ureters", "following", "to confirm", "underlying cause", "patient's condition"]}
{"question": "A 5-year-old girl presents to the physician with increased muscle cramping in her lower extremities after walking extended distances. The young girl is in the 10th percentile for height. Her past medical history is notable only for a cystic hygroma detected shortly after birth. Which of the following findings is most likely in this patient?", "answer": "Inferior erosion of the ribs", "options": {"A": "Decreased blood pressure in the upper and lower extremities", "B": "Barr bodies on buccal smear", "C": "Endocardial cushion defect", "D": "Inferior erosion of the ribs", "E": "Apparent hypertrophy of the calves"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old girl presents", "physician", "increased muscle cramping", "lower extremities", "walking extended distances", "young girl", "percentile", "height", "past medical history", "notable only", "cystic hygroma detected", "birth", "following findings", "patient"]}
{"question": "A 30-year-old African American man comes to the doctor's office for an annual checkup. He feels healthy and his only concern is an occasional headache after work. Past medical history is significant for an appendectomy 10 years ago and a fractured arm playing football in high school. His mother has type 2 diabetes mellitus, while his father and grandfather both have hypertension. He does not drink alcohol, smoke cigarettes, or use drugs. His vital signs include: pulse 78/min and regular, respiratory rate 16/min, and temperature 36.8°C (98.2°F). Physical examination reveals an overweight African American man 167 cm (5 ft 6 in) tall and weighing 80 kg (176 lb) with a protuberant belly. BMI is 28.7 kg/m2. The remainder of the examination is unremarkable. During his last 2 visits, his blood pressure readings have been 140/86 mm Hg and 136/82 mm Hg. Today his blood pressure is 136/86 mm Hg and his laboratory tests show:\nSerum Glucose (fasting) 90.0 mg/dL\nSerum Electrolytes: \nSodium 142.0 mEq/L\nPotassium 3.9 mEq/L\nChloride 101.0 mEq/L\nSerum Creatinine 0.8 mg/dL\nBlood urea nitrogen 9.0 mg/dL\nUrinalysis:\nGlucose Negative\nKetones Negative\nLeukocytes Negative\nNitrite Negative\nRBCs Negative\nCasts Negative\nWhich of the following is the next best step in the management of this patient?", "answer": "Recommend weight loss, more exercise, and a salt-restricted diet.", "options": {"A": "Start him on lisinopril.", "B": "Start him on hydrochlorothiazide.", "C": "Order a glycosylated hemoglobin test (HbA1c).", "D": "Start him on hydrochlorothiazide and lisinopril together.", "E": "Recommend weight loss, more exercise, and a salt-restricted diet."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["30 year old", "man", "doctor's office", "annual checkup", "healthy", "only", "occasional headache", "Past medical history", "significant", "appendectomy", "fractured arm playing football", "high school", "type 2 diabetes mellitus", "hypertension", "not", "alcohol", "smoke cigarettes", "use drugs", "vital signs include", "pulse", "min", "regular", "respiratory rate", "min", "temperature 36", "98", "reveals", "overweight", "man", "5 ft 6", "tall", "80 kg", "protuberant belly", "BMI", "kg/m2", "unremarkable", "last", "blood pressure", "mm Hg", "mm Hg", "Today", "blood pressure", "mm Hg", "laboratory tests", "Serum Glucose", "fasting", "90 0 mg/dL Serum Electrolytes", "Sodium", "mEq/L Potassium", "Chloride", "Blood", "Urinalysis", "Glucose Negative Ketones", "Nitrite", "Casts Negative", "following", "next best step", "patient"]}
{"question": "A 4-year-old girl is brought to the physician with a 3-month history of progressive intermittent pain and swelling involving both knees, right ankle, and right wrist. The patient has been undergoing treatment with acetaminophen and ice packs, both of which relieved her symptoms. The affected joints feel \"stuck” and are difficult to move immediately upon waking up in the morning. However, the patient can move her joints freely after a few minutes. She also complains of occasional mild eye pain that resolves spontaneously. Five months ago, she was diagnosed with an upper respiratory tract infection that resolved without treatment. Vital signs are within normal limits. Physical examination shows swollen and erythematous joints, which are tender to touch. Slit-lamp examination shows an anterior chamber flare with signs of iris inflammation bilaterally. Laboratory studies show:\nBlood parameters\nHemoglobin 12.6 g/dL\nLeukocyte count 8,000/mm3\nSegmented neutrophils 76%\nEosinophils 1%\nLymphocytes 20%\nMonocytes 3%\nPlatelet count 360,000/mm3\nErythrocyte sedimentation rate 36 mm/hr\nSerum parameters\nAntinuclear antibodies 1:320\nRheumatoid factor negative\nWhich of the following is the most likely diagnosis?", "answer": "Oligoarticular juvenile idiopathic arthritis", "options": {"A": "Acute lymphocytic leukemia", "B": "Enthesitis-related arthritis", "C": "Oligoarticular juvenile idiopathic arthritis", "D": "Postinfectious arthritis", "E": "Seronegative polyarticular juvenile idiopathic arthritis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old girl", "brought", "physician", "3 month history", "progressive intermittent pain", "swelling involving", "knees", "right ankle", "right wrist", "patient", "treatment", "acetaminophen", "ice packs", "relieved", "symptoms", "affected joints", "difficult to move immediately", "waking", "morning", "patient", "move", "joints freely", "minutes", "occasional mild eye", "Five months", "diagnosed", "upper respiratory tract infection", "resolved", "treatment", "Vital signs", "normal", "Physical examination", "swollen", "erythematous joints", "tender", "touch", "Slit-lamp examination", "anterior chamber flare", "signs of iris inflammation", "Laboratory studies", "Blood parameters", "12", "8", "mm3 Segmented", "76", "Eosinophils", "20", "360", "Erythrocyte sedimentation rate 36 mm", "Antinuclear antibodies", "320 Rheumatoid factor negative", "following", "diagnosis"]}
{"question": "A 28-year-old woman with a past history of type 1 diabetes presents to your office with a 2-week history of vaginal itching and soreness accompanied by a white, clumpy vaginal discharge which she says resembles cheese curds. Her last HbA1c from a month ago was 7.8%, and her last cervical cytology from 10 months ago was reported as normal. She has a blood pressure of 118/76 mmHg, respiratory rate of 14/min, and heart rate of 74/min. Pelvic examination reveals multiple small erythematous lesions in the inguinal and perineal area, vulvar erythema, and excoriations. Inspection demonstrates a normal cervix and a white, adherent, thick, non-malodorous vaginal discharge. Which of the following is most likely to be present in a saline wet mount from the vaginal discharge of this patient?", "answer": "Hyphae", "options": {"A": "Motile flagellates", "B": "Clue cells on saline smear", "C": "Hyphae", "D": "Multinucleated giant cells", "E": "Gram-negative diplococci"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "past history of type 1 diabetes presents", "office", "2-week history", "vaginal itching", "soreness", "white", "clumpy vaginal discharge", "curds", "last", "month", "last cervical cytology", "10 months", "reported", "normal", "blood pressure", "76 mmHg", "respiratory rate", "min", "74 min", "Pelvic", "reveals multiple small erythematous lesions", "inguinal", "perineal area", "vulvar erythema", "excoriations", "Inspection", "normal cervix", "white", "adherent", "thick", "non", "vaginal discharge", "following", "to", "present", "wet mount", "vaginal", "patient"]}
{"question": "A 33-year-old woman comes to the physician for the evaluation of bleeding from her gums for 2 weeks. These episodes occur spontaneously and are self-limiting. She has also had purplish skin lesions over her legs for 2 months. Last week, she had one episode of hematuria and watery diarrhea, both of which resolved without treatment. She has mild asthma. Her brother has hemophilia. Her only medication is a fenoterol inhaler. She appears healthy. Her temperature is 37.1°C (99.3°F), pulse is 88/min, respirations are 14/min, and blood pressure is 122/74 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender; there is no organomegaly. Oropharyngeal examination shows gingival bleeding. There are petechiae over the neck and the right upper extremity and purpuric spots over both lower extremities. Laboratory studies show:\nHemoglobin 13.3 mg/dL\nMean corpuscular volume 94 μm3\nLeukocyte count 8,800/mm3\nPlatelet count 18,000/mm3\nBleeding time 9 minutes\nProthrombin time 14 seconds (INR=0.9)\nPartial thromboplastin time 35 seconds\nSerum\nGlucose 88 mg/dL\nCreatinine 0.9 mg/dL\nWhich of the following is the most likely underlying mechanism of this patient's symptoms?\"", "answer": "IgG antibodies against platelets", "options": {"A": "Deficient Von Willebrand factor", "B": "Shiga-like toxin", "C": "Consumptive coagulopathy", "D": "IgG antibodies against platelets", "E": "Decrease in ADAMTS13 activity"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "bleeding", "gums", "2 weeks", "episodes occur", "limiting", "skin lesions", "legs", "2 months", "Last week", "one episode of hematuria", "watery diarrhea", "resolved", "treatment", "mild asthma", "hemophilia", "only medication", "fenoterol inhaler", "appears healthy", "temperature", "99", "pulse", "88 min", "respirations", "min", "blood pressure", "74 mm Hg", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "organomegaly", "Oropharyngeal", "gingival bleeding", "petechiae", "neck", "right upper extremity", "purpuric spots", "lower extremities", "Laboratory studies", "Hemoglobin", "mg/dL Mean corpuscular volume", "Leukocyte count", "Bleeding", "minutes Prothrombin time 14 seconds", "INR 0.9", "Partial thromboplastin time", "seconds Serum Glucose", "mg dL Creatinine 0.9", "dL", "following", "underlying mechanism", "patient", "ymptoms?"]}
{"question": "A 4-year-old boy is brought to the physician by his mother because of left-sided neck swelling that has slowly progressed over the past 4 weeks. He has no history of serious illness. Temperature is 38°C (100.4°F). Physical examination shows a non-tender, mobile mass in the left submandibular region with overlying erythema. A biopsy of the mass shows caseating granulomas. Pharmacotherapy with azithromycin and ethambutol is initiated. This patient is most likely to experience which of the following adverse effects related to ethambutol use?", "answer": "Color blindness", "options": {"A": "Orange urine", "B": "Acute kidney injury", "C": "Color blindness", "D": "Methemoglobinemia", "E": "Peripheral neuropathy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "physician", "of left-sided neck swelling", "slowly progressed", "past 4 weeks", "history", "serious illness", "Temperature", "100", "non-tender", "mobile mass", "left submandibular region", "erythema", "biopsy", "mass", "caseating granulomas", "Pharmacotherapy", "azithromycin", "ethambutol", "initiated", "patient", "to", "following adverse effects related", "ethambutol use"]}
{"question": "A 14-year-old boy is brought to the pediatrician by his parents with complaints of extra teeth in his lower and upper jaws. He was born by cesarean section at full term and his birth weight was 3.6 kg (7.9 lb). Until 6 months of age, he was breastfed and after that, solid foods were started. He did not cry immediately after birth, for which he was admitted to the intensive care unit where he also developed jaundice. There is a family history of intellectual disability. His motor milestones were delayed. His intelligence quotient (IQ) is 56. His temperature is 37.0ºC (98.6ºF), pulse is 88/min, and respiratory rate is 20/min. On physical examination, he has behavior disorders with autistic features, elongated face with large forehead, and prominent chin. His intraoral examination shows the presence of multiple teeth with crowding in both the upper and lower jaws, along with high arch palate and macroglossia. Genital examination reveals enlarged testicles. Panoramic radiographic examination shows teeth crowding in the maxillary and mandibular dental arches and congenital absence of some teeth. Which of the following is the most likely trinucleotide repeat that explains these findings?", "answer": "CGG", "options": {"A": "CGG", "B": "CAG", "C": "GAA", "D": "CTG", "E": "GCC"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "pediatrician", "complaints", "extra teeth", "lower", "upper jaws", "born by cesarean section", "full term", "birth weight", "3.6 kg", "months", "age", "breastfed", "started", "not", "immediately", "birth", "jaundice", "family history of intellectual disability", "motor", "delayed", "intelligence quotient", "temperature", "98", "pulse", "88 min", "respiratory rate", "20 min", "behavior disorders", "autistic features", "elongated face", "large forehead", "prominent chin", "intraoral", "presence", "multiple teeth", "crowding", "upper", "lower jaws", "high arch palate", "macroglossia", "Genital examination reveals enlarged testicles", "Panoramic radiographic examination", "teeth", "maxillary", "mandibular dental arches", "congenital absence of", "teeth", "following", "trinucleotide repeat", "findings"]}
{"question": "A 28-year-old woman visits her physician with complaints of inability to become pregnant despite frequent unprotected sexual intercourse with her husband for over a year. She breastfed her only child until about 13 months ago, when the couple decided to have a second child. Over the past year, the patient has had only 4 episodes of menstrual bleeding. She reports occasional milk discharge from both breasts. Her only medication currently is daily pantoprazole, which she takes for dyspepsia. Her BMI is 29 kg/m2. Physical examination and vitals are normal. Pelvic examination indicates no abnormalities. The patient’s breast examination reveals full breasts and a few drops of milk can be expressed from both nipples. Estradiol, serum follicle-stimulating hormone (FSH), testosterone, and thyroid-stimulating hormone (TSH) levels are within the normal range. Which of the following best explains these findings?", "answer": "Prolactinoma", "options": {"A": "Pantoprazole", "B": "Primary ovarian insufficiency", "C": "Prolactinoma", "D": "Sheehan’s syndrome", "E": "Normal findings"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "complaints", "to", "pregnant", "frequent unprotected sexual intercourse", "year", "breastfed", "about", "months", "couple", "to", "second child", "past year", "patient", "only", "episodes of menstrual bleeding", "reports occasional milk discharge", "breasts", "only medication currently", "daily pantoprazole", "dyspepsia", "BMI", "29 kg/m2", "normal", "Pelvic examination", "abnormalities", "patients breast examination reveals full breasts", "few drops", "milk", "nipples", "Estradiol", "serum follicle-stimulating hormone", "testosterone", "thyroid-stimulating hormone", "levels", "normal range", "following best", "findings"]}
{"question": "A 53-year-old man is admitted to the intensive care unit from the emergency department with severe pancreatitis. Overnight, he starts to develop severe hypoxemia, and he is evaluated by a rapid response team. On exam the patient is breathing very quickly and has rales and decreased breath sounds bilaterally. He is placed on 50% FiO2, and an arterial blood gas is collected with the following results:\n\npH: 7.43\npCO2: 32 mmHg\npO2: 78 mmHg\n\nThe oxygen status of the patient continues to deteriorate, and he is placed on ventilator support. Which of the following would most likely be seen in this patient?", "answer": "Intra-alveolar hyaline membrane formation", "options": {"A": "Decreased lecithin to sphingomyelin ratio", "B": "Diffuse lipid droplets and globules", "C": "Hemosiderin-laden alveolar macrophages", "D": "Intra-alveolar hyaline membrane formation", "E": "Large clot in pulmonary artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency department", "severe pancreatitis", "Overnight", "starts to", "severe hypoxemia", "exam", "patient", "breathing very", "rales", "decreased breath sounds", "50", "FiO2", "arterial blood gas", "collected", "following results", "pH", "pCO2", "mmHg pO2", "mmHg", "oxygen status", "patient", "to deteriorate", "ventilator support", "following", "most likely", "seen", "patient"]}
{"question": "Several weeks after starting a new medication for rheumatoid arthritis, a 44-year-old woman comes to the physician because of painful ulcers in her mouth. Oral examination shows inflammation and swelling of the tongue and oropharynx and ulcers on the buccal mucosa bilaterally. Skin examination shows soft tissue swelling over her proximal interphalangeal joints and subcutaneous nodules over her elbows. Serum studies show an alanine aminotransferase level of 220 U/L, aspartate aminotransferase level of 214 U/L, and creatinine level of 1.7 mg/dL. Which of the following is the most likely primary mechanism of action of the drug she is taking?", "answer": "Inhibition of dihydrofolate reductase", "options": {"A": "Inhibition of thymidylate synthase", "B": "Inhibition of dihydrofolate reductase", "C": "Inhibition of inosine monophosphate dehydrogenase", "D": "Inhibition of cyclooxygenase", "E": "Inhibition of NF-κB"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Several weeks", "starting", "new medication", "rheumatoid arthritis", "year old woman", "physician", "of painful", "mouth", "inflammation", "swelling of", "tongue", "oropharynx", "ulcers", "buccal mucosa", "Skin examination", "soft tissue swelling", "proximal interphalangeal joints", "subcutaneous nodules", "elbows", "Serum studies", "alanine aminotransferase level", "U/L", "aspartate aminotransferase level", "U/L", "creatinine level", "mg/dL", "following", "primary mechanism of action", "drug"]}
{"question": "A 68-year-old man comes to the physician for a routine health maintenance examination. His wife has noticed that his left eye looks smaller than his right eye. He has had left shoulder and arm pain for 3 months. He has hypertension and coronary artery disease. Current medications include enalapril, metoprolol, aspirin, and atorvastatin. His medical history is significant for gonorrhea, for which he was treated in his 30's. He has smoked two packs of cigarettes daily for 35 years. He does not drink alcohol. His temperature is 37°C (98.6°F), pulse is 71/min, and blood pressure is 126/84 mm Hg. The pupils are unequal; when measured in dim light, the left pupil is 3 mm and the right pupil is 5 mm. There is drooping of the left eyelid. The remainder of the examination shows no abnormalities. Application of apraclonidine drops in both eyes results in a left pupil size of 5 mm and a right pupil size of 4 mm. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the chest", "options": {"A": "Applanation tonometry", "B": "Erythrocyte sedimentation rate", "C": "Rapid plasma reagin", "D": "CT scan of the chest", "E": "Anti-acetylcholine receptor antibodies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "routine", "left eye looks smaller", "right eye", "left shoulder", "arm pain", "months", "hypertension", "coronary artery disease", "Current medications include enalapril", "metoprolol", "aspirin", "atorvastatin", "medical history", "significant", "gonorrhea", "treated", "30's", "smoked two packs", "cigarettes daily", "35 years", "not", "alcohol", "temperature", "98", "pulse", "min", "blood pressure", "84 mm Hg", "pupils", "unequal", "measured", "dim light", "left pupil", "3 mm", "right pupil", "5 mm", "left eyelid", "abnormalities", "Application", "apraclonidine drops", "eyes results", "left pupil size of", "mm", "right pupil size of", "mm", "following", "most appropriate next step"]}
{"question": "A 28-year-old man is brought to the emergency department after his girlfriend found him twitching and jerking in the yard while gardening. Shortly after he became obtunded, emergency medical services reported 1 episode of emesis during transport. His blood pressure is 85/50 mmHg, pulse is 55/min, and respirations are irregular. Physical examination demonstrates marks on his left forearm, pinpoint pupils, diaphoresis, and fasciculations of his left calf. Following initial stabilization and respiratory support, what is the best next step?", "answer": "Atropine and pralidoxime", "options": {"A": "Atropine", "B": "Atropine and pralidoxime", "C": "Lamotrigine", "D": "Naloxone", "E": "Naltrexone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "found", "twitching", "jerking", "yard", "obtunded", "reported 1 episode of emesis", "transport", "blood pressure", "85 50 mmHg", "pulse", "min", "respirations", "irregular", "marks", "left forearm", "pinpoint pupils", "diaphoresis", "fasciculations", "left calf", "Following initial stabilization", "respiratory support", "best next step"]}
{"question": "A 73-year-old female presents to you for an office visit with complaints of getting lost. The patient states that over the last several years, the patient has started getting lost in places that she is familiar with, like in her neighborhood while driving to her church. She has also has difficulty remembering to pay her bills. She denies any other complaints. Her vitals are normal, and her physical exam does not reveal any focal neurological deficits. Her mini-mental status exam is scored 19/30. Work up for secondary causes of cognitive decline is negative. Which of the following should be included in the patient's medication regimen to slow the progression of disease?", "answer": "Memantine", "options": {"A": "Ropinirole", "B": "Memantine", "C": "Bromocriptine", "D": "Pramipexole", "E": "Pergolide"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female presents", "complaints", "getting lost", "patient states", "last", "years", "patient", "started getting lost", "places", "familiar", "neighborhood", "church", "difficulty", "to pay", "bills", "complaints", "normal", "not reveal", "focal neurological deficits", "mini-mental status exam", "scored", "30", "Work up", "secondary causes", "cognitive decline", "negative", "following", "included", "patient's medication regimen", "slow", "progression", "disease"]}
{"question": "A 65-year-old man comes to the physician because of a 10-month history of progressive shortness of breath and a cough productive of a small amount of white phlegm. Bilateral end-expiratory wheezing is heard on auscultation of the chest. Pulmonary function tests show total lung capacity that is 108% of predicted, an FEV1 that is 56% of predicted, and an FEV1:FVC ratio of 62%. Which of the following interventions is most likely to slow the decline in FEV1 in this patient?", "answer": "Smoking cessation", "options": {"A": "Smoking cessation", "B": "Breathing exercises", "C": "Salmeterol therapy", "D": "Fluticasone therapy", "E": "Alpha-1 antitrypsin therapy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old man", "physician", "of a 10 month history", "progressive shortness", "breath", "cough productive", "small amount", "white phlegm", "Bilateral end", "heard", "auscultation", "chest", "Pulmonary function tests", "total lung capacity", "predicted", "FEV1", "predicted", "FEV1:FVC ratio", "62", "following interventions", "slow", "FEV1", "patient"]}
{"question": "A 28-year-old woman survives a plane crash in the Arctic region of Alaska. She is unable to recover any food from the crash site but is able to melt snow into drinking water using a kettle and a lighter. A rescue helicopter finally finds her after 12 days, and she is flown to a hospital. At this time, which of the following substances is mostly responsible for supplying her brain with energy?", "answer": "Acetoacetate", "options": {"A": "Acetoacetate", "B": "Amino acids", "C": "Cholesterol", "D": "Free fatty acids", "E": "Glucose"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman survives", "plane", "Arctic region", "Alaska", "unable to recover", "food", "site", "able", "melt", "using", "lighter", "rescue helicopter", "finds", "days", "hospital", "time", "following", "mostly responsible", "supplying", "brain", "energy"]}
{"question": "A 31-year-old woman presents to the emergency department with a 2-week history of dry cough and shortness of breath on exertion. She says that she has also been feeling joint pain that has been increasing over time and is worst in the mornings. Finally, she has noticed painful swellings that have been appearing on her body over the last month. Her past medical history is significant for childhood asthma that does not require any current medications. She drinks socially and has smoked 2 packs per day since she was 16 years old. Physical exam reveals erythematous nodular lesions on her trunk and upper extremities. Serum protein electrophoresis shows polyclonal gammopathy. Which of the following would most likely also be seen in this patient?", "answer": "Noncaseating granulomas", "options": {"A": "Acid-fast rods", "B": "Antibodies to small nuclear ribonucleoproteins", "C": "Golden-brown fusiform rods", "D": "Macrophages with black phagocytosed particles", "E": "Noncaseating granulomas"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["31 year old woman presents", "emergency department", "2-week history", "dry cough", "shortness of breath", "exertion", "joint pain", "increasing", "time", "worst", "mornings", "painful swellings", "appearing", "body", "last month", "past medical history", "significant", "childhood asthma", "not", "current medications", "smoked 2 packs per day", "years old", "reveals erythematous nodular lesions", "trunk", "upper extremities", "Serum protein electrophoresis", "polyclonal gammopathy", "following", "seen", "patient"]}
{"question": "A 59-year-old man comes to the emergency department because of progressive abdominal swelling and shortness of breath for 1 week. He drinks 12 to 13 alcoholic beverages daily. He appears emaciated. Examination shows pallor, jaundice, hepatomegaly, gynecomastia, and a protuberant abdomen with a fluid wave and shifting dullness. Periodic monitoring of which of the following markers is most appropriate for this patient?", "answer": "Alpha-fetoprotein", "options": {"A": "S-100 protein", "B": "Alpha-fetoprotein", "C": "Carcinoembryonic antigen", "D": "Cancer antigen 19-9", "E": "Beta-human chorionic gonadotropin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["59 year old man", "emergency department", "progressive abdominal swelling", "shortness of breath", "1 week", "daily", "appears emaciated", "pallor", "jaundice", "hepatomegaly", "gynecomastia", "protuberant abdomen", "fluid wave", "shifting dullness", "Periodic", "following markers", "most appropriate", "patient"]}
{"question": "An 7-month-old boy is brought to the pediatrician by his parents due to progressively worsening weakness for the last three months. The parents also describe the boy as having an exaggerated response when startled as well as diminishing response to visual stimuli. At birth, the boy was healthy and remained as such for the first few months of life. The mother says pregnancy was unremarkable, and the boy was born at 39 weeks with no complications during delivery. He is up to date on his vaccinations. The boy's grandparents immigrated from an eastern European country. Physical examination reveals hyperreflexia. Abdominal examination reveals no abnormalities. On fundoscopy, the following is seen. Which of the following is most likely deficient in this patient?", "answer": "Hexosaminidase A", "options": {"A": "α-Galactosidase", "B": "ß-Glucosidase", "C": "Hexosaminidase A", "D": "Hexosaminidase B", "E": "Arylsulfatase A"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "pediatrician", "due to", "worsening weakness", "three months", "boy", "exaggerated response", "diminishing response to visual stimuli", "birth", "boy", "healthy", "first", "months", "pregnancy", "unremarkable", "boy", "born", "weeks", "complications", "delivery", "date", "vaccinations", "boy's", "eastern European country", "reveals hyperreflexia", "Abdominal", "reveals", "abnormalities", "fundoscopy", "following", "seen", "following", "deficient", "patient"]}
{"question": "A 68-year-old man presents to the clinic for a regular health checkup. He is hypertensive and was diagnosed with congestive heart failure last year. He has hyperlipidemia but does not take any medication for it. Although he takes his antihypertensive medications regularly, his blood pressure recordings at home tend to range between 150/98 and 160/90 mm Hg. Today, his blood pressure is 147/96 mm Hg. The doctor decides to add indapamide to his medication list and asks the patient to follow up within 2 weeks. The patient is compliant with the medication. He comes back to the physician in just one week complaining of muscle cramping and weakness. Which of the following is the most likely cause of his symptoms?", "answer": "Hypokalemia", "options": {"A": "Hypocalcemia", "B": "Hypoglycemia", "C": "Hyperlipidemia", "D": "Hyperuricemia", "E": "Hypokalemia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "clinic", "regular health checkup", "hypertensive", "diagnosed", "congestive heart failure", "year", "hyperlipidemia", "not", "medication", "antihypertensive medications", "blood pressure", "at home", "range", "98", "90 mm Hg", "Today", "blood pressure", "96 mm Hg", "doctor", "to add indapamide", "patient to follow up", "2 weeks", "patient", "compliant", "medication", "back", "physician in", "one week", "muscle cramping", "weakness", "following", "most likely cause", "symptoms"]}
{"question": "A 35-year-old female presents to her PCP at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping on eBay. Despite a lack of sleep, she is \"full of energy\" during the day at her teaching job, which she believes is \"beneath [her], anyway.\" She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. Which of the following is the best initial treatment?", "answer": "Valproate and olanzapine", "options": {"A": "Valproate", "B": "Valproate and venlafaxine", "C": "Valproate and olanzapine", "D": "Haloperidol", "E": "Electroconvulsive therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old female presents", "PCP", "3 weeks", "behavior", "patient", "night", "shopping", "lack", "sleep", "full of energy", "day", "not", "psychiatric", "past", "reports", "episode of", "diagnosed depression", "years", "patient", "thoughts of suicide", "Pregnancy test", "negative", "following", "best initial treatment"]}
{"question": "A 10-day-old newborn is undergoing surgery for the removal of a branchial cleft cyst. Histopathology of the cyst shows squamous cells with lymphoid infiltrate and keratinaceous cellular debris embedded in adipose tissue with a high concentration of mitochondria. Which of the following substances is most likely to be found within these mitochondria?", "answer": "Thermogenin", "options": {"A": "Thermogenin", "B": "Leptin", "C": "Kinesin", "D": "Ubiquitin", "E": "Clathrin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 day old newborn", "surgery", "the removal of", "branchial cleft cyst", "Histopathology", "squamous cells", "lymphoid infiltrate", "cellular debris embedded", "adipose tissue", "high concentration", "mitochondria", "following", "to", "found", "mitochondria"]}
{"question": "A 32-year-old physician is cleaning his pool when he splashes the hydrochloric acid in his left eye. He feels immediate pain and burning. His eye starts to tear profusely, and he can barely open it. His medical history is significant for psoriasis. He is farsighted and has glasses for reading and computer work. He uses topical calcipotriene and topical triamcinolone as needed. His only surgery was a tonsillectomy as a child. He is married and has one son who is healthy. His mother has Graves disease. He drinks a glass of wine with dinner but denies tobacco or recreational drug use. Which of the following is the best initial step in management?", "answer": "Irrigate with tap water", "options": {"A": "Apply topical bacitracin", "B": "Call the patient’s ophthalmologist", "C": "Go to the emergency department immediately", "D": "Irrigate with alkali solution", "E": "Irrigate with tap water"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old physician", "pool", "splashes", "left eye", "immediate pain", "burning", "eye starts to tear", "open", "medical history", "significant", "psoriasis", "farsighted", "glasses", "computer", "uses topical calcipotriene", "topical triamcinolone as needed", "only surgery", "tonsillectomy", "child", "married", "one", "healthy", "Graves disease", "glass", "dinner", "tobacco", "recreational drug use", "following", "best initial step"]}
{"question": "A previously healthy 31-year-old woman comes to the emergency department because of sudden, severe epigastric pain and vomiting for the past 4 hours. She reports that the pain radiates to the back and began when she was having dinner and drinks at a local brewpub. Her temperature is 37.9°C (100.2°F), pulse is 98/min, respirations are 19/min, and blood pressure is 110/60 mm Hg. Abdominal examination shows epigastric tenderness and guarding but no rebound. Bowel sounds are decreased. Laboratory studies show:\nHematocrit 43%\nLeukocyte count 9000/mm3\nSerum\nNa+ 140 mEq/L\nK+ 4.5 mEq/L\nCa2+ 9.0 mg/dL\nLipase 170 U/L (N = < 50 U/L)\nAmylase 152 U/L\nAlanine aminotransferase (ALT, GPT) 140 U/L\nIntravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?\"", "answer": "Right upper quadrant abdominal ultrasound", "options": {"A": "Contrast-enhanced abdominal CT scan", "B": "Right upper quadrant abdominal ultrasound", "C": "Plain x-ray of the abdomen", "D": "Measure serum triglycerides", "E": "Blood alcohol level assay"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy 31 year old woman", "emergency department", "sudden", "severe epigastric", "vomiting", "past", "hours", "reports", "pain radiates", "back", "began", "dinner", "local", "temperature", "100", "pulse", "98 min", "respirations", "min", "blood pressure", "60 mm Hg", "Abdominal", "epigastric tenderness", "guarding", "Bowel sounds", "decreased", "Laboratory studies", "Hematocrit", "Serum", "mEq", "K", "4", "mg", "Lipase", "U", "N", "50 U/L", "Amylase", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L Intravenous fluid resuscitation", "begun", "following", "most appropriate next step"]}
{"question": "A 54-year-old man with a history of hyperlipidemia presents to the emergency department complaining of left sided chest pain. He says the pain began 3 hours ago while he was cooking dinner in his kitchen. The pain radiates to his left arm and stomach. He also complains of feeling anxious and heart palpitations. Temperature is 98.7°F (37.1°C), blood pressure is 130/80 mmHg, pulse is 101/min, and respirations are 22/min. Inspection demonstrates a diffuse diaphoresis, and cardiac auscultation reveals an S4 gallop. Cardiac catheterization reveals occlusion of the left anterior descending artery, and a vascular stent is placed. The patient is discharged on aspirin, atorvastatin, and an antiplatelet medication. Which of the following is the mechanism of action of the most likely prescribed antiplatelet medication?", "answer": "Irreversible ADP receptor antagonism", "options": {"A": "Antithrombin III activation", "B": "Direct factor Xa inhibition", "C": "GPIIb/IIIa inhibition", "D": "Irreversible ADP receptor antagonism", "E": "Reversible ADP receptor antagonism"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["54 year old man", "history of hyperlipidemia presents", "emergency department", "of left sided chest", "pain began 3 hours", "dinner", "kitchen", "pain radiates", "left arm", "stomach", "anxious", "heart palpitations", "Temperature", "98", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "Inspection", "diffuse diaphoresis", "cardiac auscultation reveals", "S4 gallop", "reveals occlusion", "left anterior descending artery", "vascular stent", "patient", "aspirin", "atorvastatin", "antiplatelet medication", "following", "mechanism of action", "likely", "antiplatelet medication"]}
{"question": "A 43-year-old Caucasian female with a long history of uncontrolled migraines presents to general medical clinic with painless hematuria. She is quite concerned because she has never had symptoms like this before. Vital signs are stable, and her physical examination is benign. She denies any groin pain, flank pain, or costovertebral angle tenderness. She denies any recent urinary tract infections or dysuria. Urinary analysis confirms hematuria and a serum creatinine returns at 3.0. A renal biopsy reveals papillary necrosis and a tubulointerstitial infiltrate. What is the most likely diagnosis?", "answer": "Analgesic nephropathy", "options": {"A": "Analgesic nephropathy", "B": "Kidney stone", "C": "Bladder cancer", "D": "Kidney cancer", "E": "Sickle cell disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "female", "long history of uncontrolled migraines presents", "general medical clinic", "painless hematuria", "never", "symptoms", "Vital", "stable", "benign", "groin pain", "flank pain", "costovertebral angle tenderness", "recent urinary tract infections", "dysuria", "Urinary analysis confirms hematuria", "serum creatinine returns", "3.0", "renal biopsy reveals papillary necrosis", "infiltrate", "diagnosis"]}
{"question": "A 38-year-old man comes to the physician because of a 2-week history of abdominal pain and an itchy rash on his buttocks. He also has fever, nausea, and diarrhea with mucoid stools. One week ago, the patient returned from Indonesia, where he went for vacation. Physical examination shows erythematous, serpiginous lesions located in the perianal region and the posterior thighs. His leukocyte count is 9,000/mm3 with 25% eosinophils. Further evaluation is most likely to show which of the following findings?", "answer": "Rhabditiform larvae on stool microscopy", "options": {"A": "Rhabditiform larvae on stool microscopy", "B": "Oocysts on acid-fast stool stain", "C": "Giardia lamblia antibodies on stool immunoassay", "D": "Branching septate hyphae on KOH preparation", "E": "Entamoaeba histolytica antibodies on stool immunoassay"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "2-week history", "abdominal pain", "itchy", "buttocks", "fever", "nausea", "diarrhea", "mucoid stools", "One week", "patient returned", "Indonesia", "erythematous", "lesions", "perianal region", "posterior thighs", "leukocyte count", "mm3", "eosinophils", "Further", "to", "following findings"]}
{"question": "A 35-year-old woman comes to the physician because of headaches, irregular menses, and nipple discharge for the past 4 months. Breast examination shows milky white discharge from both nipples. Her thyroid function tests and morning cortisol concentrations are within the reference ranges. A urine pregnancy test is negative. An MRI of the brain is shown. Which of the following sets of changes is most likely in this patient?\n $$$ Serum estrogen %%% Serum progesterone %%% Dopamine synthesis $$$", "answer": "↓ ↓ ↑", "options": {"A": "↔ ↔ ↔", "B": "↑ ↔ ↔", "C": "↓ ↓ ↓", "D": "↓ ↓ ↑", "E": "↑ ↑ ↔"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "physician", "headaches", "irregular menses", "nipple discharge", "past", "months", "Breast examination", "milky white discharge from both nipples", "thyroid function tests", "morning cortisol", "reference ranges", "urine pregnancy test", "negative", "MRI of", "brain", "following sets", "changes", "patient", "Serum", "progesterone", "Dopamine"]}
{"question": "A 30-year-old woman visits her local walk-in clinic and reports more than one week of progressive shortness of breath, dyspnea on effort, fatigue, lightheadedness, and lower limb edema. She claims she has been healthy all year round except for last week when she had a low-grade fever, malaise, and myalgias. Upon examination, her blood pressure is 94/58 mm Hg, heart rate is 125/min, respiratory rate is 26/min, and body temperature is 36.4°C (97.5°F). Her other symptoms include fine rattles in the base of both lungs, a laterally displaced pulse of maximum intensity, and regular, rhythmic heart sounds with an S3 gallop. She is referred to the nearest hospital for stabilization and further support. Which of the following best explains this patient’s condition?", "answer": "Disruption of the dystrophin-glycoprotein complex", "options": {"A": "Disruption of the dystrophin-glycoprotein complex", "B": "Cardiomyocyte hypertrophy", "C": "Fibrofatty replacement of the myocardium", "D": "IgA antiendomysial antibodies", "E": "Eosinophilic infiltration"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old woman", "local walk-in clinic", "reports more", "one week of progressive shortness", "breath", "dyspnea on effort", "fatigue", "lightheadedness", "lower limb edema", "healthy", "year round", "week", "low-grade fever", "malaise", "myalgias", "blood pressure", "58 mm Hg", "heart rate", "min", "respiratory rate", "min", "body temperature", "36", "97", "symptoms include fine", "the base of", "lungs", "displaced pulse", "maximum intensity", "regular", "rhythmic heart sounds", "S3 gallop", "nearest", "stabilization", "further support", "following best", "patients condition"]}
{"question": "A 46-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has a history of seizures controlled with levetiracetam. She has needed glasses for the past 13 years. Her father died of pancreatic cancer. She is 175 cm (5 ft 9 in) tall and weighs 79 kg (174 lbs); BMI is 25.8 kg/m2. Vital signs are within normal limits. A photograph of the face is shown. This patient is most likely to be at increased risk for which of the following conditions?", "answer": "Coronary artery disease", "options": {"A": "Optic glioma", "B": "Squamous cell carcinoma", "C": "Gastric cancer", "D": "Coronary artery disease", "E": "Renal angiomyolipoma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "routine", "well", "history", "seizures controlled", "levetiracetam", "needed glasses", "past", "years", "died of pancreatic cancer", "5 ft 9", "tall", "kg", "lbs", "BMI", "kg/m2", "Vital signs", "normal limits", "photograph", "face", "patient", "to", "increased risk", "following conditions"]}
{"question": "A 36-year-old man presents to his physician with the complaint of bilateral lower back pain. The pain is 5/10, constant, aching, aggravated by bending forward and lying supine, and is alleviated by resting in a neutral position. The pain appeared 3 days ago after the patient overstrained at the gym. He does not report changes in sensation or limb weakness. The patient works as a business analyst. The patient’s weight is 88 kg (194 lb), and the height is 186 cm (6 ft 1 in). The vital signs are within normal limits. The neurological examination shows equally normal lower limb reflexes, and preserved muscle tone and power. The paravertebral palpation of the lumbar region increases the pain. Which of the following non-pharmacological interventions is the most appropriate in the presented case?", "answer": "Maintaining usual activity as tolerated", "options": {"A": "Bed rest for 3 days", "B": "Manual traction", "C": "Maintaining usual activity as tolerated", "D": "Therapeutic ultrasonography", "E": "Electromyographic biofeedback"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old man presents", "physician", "complaint of bilateral lower back pain", "pain", "5/10", "constant", "aching", "aggravated", "bending forward", "lying supine", "neutral position", "pain appeared 3 days", "patient", "not report changes", "sensation", "limb weakness", "patient", "business analyst", "patients weight", "88 kg", "height", "ft", "vital signs", "normal limits", "neurological examination", "normal lower limb reflexes", "preserved muscle tone", "power", "paravertebral palpation", "lumbar increases", "pain", "following non pharmacological interventions", "most appropriate", "case"]}
{"question": "A 16-year-old boy comes to the physician with a 4-day history of sore throat and mild fever. He is on the varsity soccer team at his high school, but has been unable to go to practice for the last few days because he has been very tired and is easily exhausted. He has no history of serious illness and takes no medications. His mother has type 2 diabetes mellitus. He appears weak and lethargic. His temperature is 38.7°C (101.7°F), pulse is 84/min, and blood pressure is 116/78 mm Hg. Examination shows enlarged, erythematous, and exudative tonsils; posterior cervical lymphadenopathy is present. Abdominal examination shows no abnormalities. His hemoglobin concentration is 14.5 g/dL and leukocyte count is 11,200/mm3 with 48% lymphocytes. A heterophile antibody test is positive. In addition to supportive therapy, which of the following is the most appropriate next step in management?", "answer": "Write a medical note that excuses from soccer events", "options": {"A": "Write a medical note that excuses from soccer events", "B": "Oral amoxicillin therapy", "C": "Oral corticosteroid therapy", "D": "Intravenous acyclovir therapy", "E": "Intravenous foscarnet therapy\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "physician", "4-day history", "sore throat", "mild fever", "high school", "unable to go to", "days", "very tired", "easily exhausted", "history", "serious illness", "medications", "type 2 diabetes mellitus", "appears weak", "lethargic", "temperature", "pulse", "84 min", "blood pressure", "mm Hg", "enlarged", "erythematous", "exudative tonsils", "posterior cervical lymphadenopathy", "present", "Abdominal", "abnormalities", "hemoglobin concentration", "g/dL", "leukocyte count", "200 mm3", "48", "lymphocytes", "heterophile antibody", "positive", "supportive therapy", "following", "most appropriate next step"]}
{"question": "A 54-year-old woman presents to her primary care physician complaining of watery diarrhea for the last 3 weeks. She reports now having over 10 bowel movements per day. She denies abdominal pain or rash. A basic metabolic profile is notable for the following: Na: 127 mEq/L; K 2.1 mEq/L; Glucose 98 mg/dL. Following additional work-up, octreotide was started with significant improvement in symptoms and laboratory values. Which of the following is the most likely diagnosis?", "answer": "VIPoma", "options": {"A": "VIPoma", "B": "Glucagonoma", "C": "Somatostatinoma", "D": "Insulinoma", "E": "Gastrinoma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old woman presents", "primary care physician", "watery diarrhea", "last", "weeks", "reports now", "over 10 bowel movements", "day", "abdominal pain", "rash", "basic metabolic profile", "notable", "following", "Na", "mEq/L", "K", "mEq/L", "Glucose 98 mg/dL", "Following additional work-up", "octreotide", "started", "significant", "symptoms", "laboratory values", "following", "diagnosis"]}
{"question": "A 16-year-old girl is brought to the physician by her mother because she has not attained menarche. She has no history of serious illness. She is at 50th percentile for height and weight. Examination shows no breast glandular tissue and no pubic hair development. The remainder of the examination shows no abnormalities. A urine pregnancy test is negative. An ultrasound of the pelvis shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Serum FSH level", "options": {"A": "GnRH stimulation test", "B": "Reassurance", "C": "Progesterone challenge test", "D": "Serum FSH level", "E": "Serum testosterone level"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "not", "menarche", "history", "serious illness", "50th percentile", "height", "weight", "breast glandular tissue", "pubic hair development", "abnormalities", "urine pregnancy test", "negative", "ultrasound", "pelvis", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 52-year-old Caucasian male presents to your office with an 8 mm dark lesion on his back. The lesion, as seen below, has irregular borders and marked internal color variation. Upon excisional biopsy, the presence of which of the following would best estimate the risk of metastasis in this patient’s lesion:", "answer": "Vertical tumor growth", "options": {"A": "Palisading nuclei", "B": "Keratin pearls", "C": "Vertical tumor growth", "D": "Cellular atypia", "E": "Increased production of melanosomes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "male presents", "office", "mm dark lesion", "back", "lesion", "seen", "irregular borders", "marked internal color variation", "excisional biopsy", "presence", "following", "best estimate", "metastasis", "patients lesion"]}
{"question": "A 5-year-old child is brought to a pediatric clinic by his mother for a rash that started a few days ago. The mother adds that her son has also had a fever and sore throat since last week. His immunizations are up to date. On examination, a rash is present over the trunk and upper extremities and feels like sandpaper to touch. An oropharyngeal examination is suggestive of exudative pharyngitis with a white coat over the tongue. The physician swabs the throat and uses the swab in a rapid antigen detection test kit. He also sends the sample for microbiological culture. The physician then recommends empiric antibiotic therapy and tells the mother that if the boy is left untreated, the likelihood of developing a complication later in life is very high. Which of the following best explains the mechanism underlying the development of the complication the physician is talking about?", "answer": "Molecular mimicry", "options": {"A": "Antigenic shift", "B": "Bacterial tissue invasion", "C": "Molecular mimicry", "D": "Toxin-mediated cellular damage", "E": "Genetic drift"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year", "brought", "pediatric clinic", "rash", "started", "few days", "adds", "fever", "sore throat", "week", "immunizations", "date", "rash", "present", "trunk", "upper extremities", "touch", "oropharyngeal", "suggestive of exudative pharyngitis", "white coat", "tongue", "physician swabs", "throat", "uses", "swab", "rapid antigen detection test kit", "sends", "sample", "culture", "physician then", "empiric antibiotic therapy", "boy", "left untreated", "likelihood", "complication later", "very high", "following best", "mechanism", "development", "complication", "physician", "talking about"]}
{"question": "A 19-year-old man with unknown medical history is found down on a subway platform and is brought to the hospital by ambulance. He experiences two episodes of emesis en route. In the emergency department, he appears confused and is complaining of abdominal pain. His temperature is 37.0° C (98.6° F), pulse is 94/min, blood pressure is 110/80 mmHg, respirations are 24/min, oxygen saturation is 99% on room air. His mucus membranes are dry and he is taking rapid, deep breathes. Laboratory work is presented below:\n\nSerum:\nNa+: 130 mEq/L\nK+: 4.3 mEq/L\nCl-: 102 mEq/L\nHCO3-: 12 mEq/L\nBUN: 15 mg/dL\nGlucose: 362 mg/dL\nCreatinine: 1.2 mg/dL\nUrine ketones: Positive\n\n\nThe patient is given a bolus of isotonic saline and started on intravenous insulin drip. Which of the following is the most appropriate next step in management?", "answer": "Intravenous potassium chloride", "options": {"A": "Subcutaneous insulin glargine", "B": "Intravenous isotonic saline", "C": "Intravenous sodium bicarbonate", "D": "Intravenous potassium chloride", "E": "Intravenous 5% dextrose and 1/2 isotonic saline"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "unknown medical history", "found", "subway", "brought", "hospital", "ambulance", "two episodes of emesis en route", "emergency department", "appears confused", "abdominal pain", "temperature", "0", "98", "F", "pulse", "min", "blood pressure", "80 mmHg", "respirations", "min", "oxygen saturation", "99", "room air", "mucus membranes", "dry", "rapid", "deep", "Laboratory", "Serum", "Na", "mEq/L K", "4", "mEq/L", "mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1.2 mg/dL Urine ketones", "Positive", "patient", "given", "bolus", "isotonic saline", "started", "intravenous insulin", "following", "most appropriate next step"]}
{"question": "A physiologist is studying various mediators that modulate coronary circulation. He is particularly looking at mediators that are activated via the clotting cascade, primarily activated factor XII. He finds that when the clotting cascade starts, it leads to the activation of factor XII, which in turn activates the enzyme kallikrein. This enzyme activates high and low-molecular-weight precursors of certain mediators, which work by contracting the visceral smooth muscle while relaxing the vascular smooth muscle. They are primarily associated with hypersensitivity and can cause an increase in capillary permeability, pain, and mobilize leukocytes. Which of the following is the precursor protein for the mediators the physiologist is studying?", "answer": "Kininogen", "options": {"A": "L-Arginine", "B": "Arachidonic acid", "C": "Hydroxytryptophan", "D": "Kininogen", "E": "Prothrombin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["physiologist", "studying various mediators", "modulate coronary circulation", "looking", "mediators", "clotting cascade", "activated factor XII", "finds", "clotting cascade starts", "leads", "turn activates", "enzyme kallikrein", "enzyme activates high", "low molecular weight", "certain mediators", "visceral smooth muscle", "relaxing", "vascular smooth muscle", "associated with hypersensitivity", "cause", "increase", "capillary permeability", "pain", "mobilize", "following", "precursor protein", "mediators", "physiologist", "studying"]}
{"question": "A 61-year-old man presents with gradually increasing shortness of breath. For the last 2 years, he has had a productive cough on most days. Past medical history is significant for hypertension and a recent admission to the hospital for pneumonia. He uses a triamcinolone inhaler and uses an albuterol inhaler as a rescue inhaler. He also takes lisinopril and a multivitamin daily. He has smoked a pack a day for the last 32 years and has no intention to quit now. Today, his blood pressure is 142/97 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.4°C (99.3°F). On physical exam, he has tachypnea and has some difficulty finishing his sentences. His heart has a regular rate and rhythm. Auscultation of his lungs reveals wheezing and rhonchi that improves after a deep cough. Fremitus is absent. Pulmonary function tests show FEV1/FVC of 55% with no change in FEV1 after albuterol treatment. Which of the following is the most likely pathology associated with this patients disease?", "answer": "Inflamed bronchus with hypertrophy and hyperplasia of mucous glands", "options": {"A": "Permanent bronchial dilation", "B": "Chronic granulomatous inflammation with bilateral hilar lymphadenopathy", "C": "Airway hypersensitivity", "D": "Inflamed bronchus with hypertrophy and hyperplasia of mucous glands", "E": "Consolidation and red hepatization"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old man presents", "increasing shortness of breath", "last", "years", "productive cough", "days", "Past medical history", "significant", "hypertension", "recent", "pneumonia", "uses", "triamcinolone inhaler", "uses", "albuterol inhaler", "lisinopril", "multivitamin daily", "smoked", "pack", "day", "years", "intention to", "now", "Today", "blood pressure", "97 mm Hg", "heart rate", "97 min", "respiratory rate", "min", "temperature", "99", "tachypnea", "difficulty finishing", "heart", "regular rate", "rhythm", "Auscultation", "lungs reveals wheezing", "rhonchi", "improves", "deep cough", "Fremitus", "absent", "Pulmonary function tests", "FEV1/FVC", "change", "FEV1", "albuterol treatment", "following", "pathology associated with", "patients disease"]}
{"question": "A 3-year-old boy is brought to the physician for presurgical evaluation before undergoing splenectomy. One year ago, he was diagnosed with hereditary spherocytosis and has received 6 blood transfusions for severe anemia since then. His only medication is a folate supplement. Immunizations are up-to-date. His temperature is 36.7°C (98°F), pulse is 115/min, respirations are 24/min, and blood pressure is 110/60 mm Hg. Examination shows conjunctival pallor and jaundice. The spleen tip is palpated 5 cm below the left costal margin. Which of the following is the most appropriate recommendation to prevent future morbidity and mortality in this patient?", "answer": "Daily penicillin prophylaxis", "options": {"A": "Subcutaneous injection of deferoxamine", "B": "Vaccination against hepatitis B virus", "C": "Daily penicillin prophylaxis", "D": "Daily warfarin prophylaxis", "E": "Administration of hydroxyurea"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "physician", "splenectomy", "One year ago", "diagnosed", "hereditary spherocytosis", "received", "blood transfusions", "severe anemia", "then", "only medication", "Immunizations", "date", "temperature", "36", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "conjunctival pallor", "jaundice", "spleen tip", "5 cm", "left costal margin", "following", "most appropriate", "to prevent future morbidity", "mortality", "patient"]}
{"question": "A 4-year-old boy presents with a history of recurrent bacterial infections, including several episodes of pneumococcal sepsis. His 2 maternal uncles died after having had similar complaints. Lab investigations reveal an undetectable level of all serum immunoglobulins. Which of the following is the most likely diagnosis of this patient?", "answer": "Bruton agammaglobulinemia", "options": {"A": "Common variable immunodeficiency", "B": "Hereditary angioedema", "C": "Chediak-Higashi syndrome", "D": "Bruton agammaglobulinemia", "E": "DiGeorge syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy presents", "history of recurrent bacterial infections", "including several episodes of pneumococcal sepsis", "2", "died", "similar complaints", "Lab", "reveal", "undetectable level", "serum immunoglobulins", "following", "diagnosis", "patient"]}
{"question": "A 63-year-old man is brought to the emergency department for evaluation of abdominal pain. The pain started four days ago and is now a diffuse crampy pain with an intensity of 6/10. The patient has nausea and has vomited twice today. His last bowel movement was three days ago. He has a history of hypertension and recurrent constipation. Five years ago, he underwent emergency laparotomy for a perforated duodenal ulcer. His father died of colorectal cancer at the age of 65 years. The patient has been smoking one pack of cigarettes daily for the past 40 years. Current medications include lisinopril and lactulose. His temperature is 37.6°C (99.7°F), pulse is 89/min, and blood pressure is 120/80 mm Hg. Abdominal examination shows distention and mild tenderness to palpation. There is no guarding or rebound tenderness. The bowel sounds are high-pitched. Digital rectal examination shows no abnormalities. An x-ray of the abdomen is shown. In addition to fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?", "answer": "Nasogastric tube placement and bowel rest", "options": {"A": "Ciprofloxacin and metronidazole", "B": "PEG placement and enteral feeding", "C": "Colonoscopy", "D": "Nasogastric tube placement and bowel rest", "E": "Surgical bowel decompression"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old man", "brought", "emergency department", "evaluation", "abdominal", "pain started four days", "now", "diffuse crampy pain", "intensity", "6/10", "patient", "nausea", "vomited twice today", "last bowel movement", "three days", "history of hypertension", "recurrent constipation", "Five years", "emergency laparotomy", "perforated duodenal ulcer", "died", "colorectal cancer", "age", "65", "patient", "smoking one pack", "cigarettes daily", "past 40 years", "Current include lisinopril", "lactulose", "temperature", "99", "pulse", "min", "blood pressure", "80 mm Hg", "Abdominal", "distention", "mild tenderness", "palpation", "guarding", "rebound tenderness", "bowel sounds", "high-pitched", "Digital rectal examination", "abnormalities", "x-ray of", "abdomen", "fluid resuscitation", "following", "most appropriate next step", "patient"]}
{"question": "A 30-year-old man comes to the emergency department because of a painful rash for 2 days. The rash initially appeared on his left lower abdomen and has spread to the rest of the abdomen and left upper thigh over the last 24 hours. Pain is exacerbated with movement. He initially thought the skin rash was an allergic reaction to a new laundry detergent, but it did not respond to over-the-counter antihistamines. Six weeks ago, the patient was diagnosed with Hodgkin's lymphoma and was started on doxorubicin, bleomycin, vinblastine, and dacarbazine. He is sexually active with one female partner and uses condoms for contraception. His temperature is 37.9°C (100.2°F), pulse is 80/min, and blood pressure is 117/72 mm Hg. Examination shows two markedly enlarged cervical lymph nodes. A photograph of the rash is shown. Which of the following is the most appropriate next step in management?", "answer": "Inpatient treatment with intravenous acyclovir", "options": {"A": "Outpatient treatment with oral penicillin V", "B": "Inpatient treatment with oral ivermectin", "C": "Outpatient treatment with topical permethrin", "D": "Inpatient treatment with intravenous acyclovir", "E": "Inpatient treatment with intravenous ceftriaxone\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old man", "emergency department", "of", "painful rash", "2 days", "rash initially appeared", "left lower abdomen", "spread", "abdomen", "left upper thigh", "24 hours", "Pain", "exacerbated", "movement", "initially", "skin rash", "allergic reaction to", "new laundry detergent", "not", "to over-the-counter antihistamines", "Six weeks", "patient", "diagnosed", "Hodgkin's lymphoma", "started", "doxorubicin", "bleomycin", "vinblastine", "dacarbazine", "sexually active", "one female", "uses condoms", "contraception", "temperature", "100", "pulse", "80 min", "blood pressure", "72 mm Hg", "two markedly enlarged cervical lymph nodes", "photograph", "rash", "following", "most appropriate next step"]}
{"question": "A 27-year-old man with seizure disorder is brought to the emergency department by his girlfriend after falling while climbing a building. The girlfriend reports that he was started on a new medication for treatment of depressed mood, low energy, and difficulty sleeping 2 weeks ago by his physician. She says that he has had unstable emotions for several months. Over the past 3 days, he has not slept and has spent all his time “training to climb Everest.” He has never climbed before this period. He also spent all of his savings buying mountain climbing gear. Physical examination shows ecchymoses over his right upper extremity, pressured speech, and easy distractibility. He is alert but not oriented to place. Which of the following drugs is the most likely cause of this patient's current behavior?", "answer": "Venlafaxine", "options": {"A": "Lithium", "B": "Quetiapine", "C": "Bupropion", "D": "Venlafaxine", "E": "Selegiline"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man", "seizure disorder", "brought", "emergency department", "falling", "climbing", "building", "reports", "started", "new medication", "treatment", "depressed mood", "difficulty sleeping 2 weeks", "physician", "unstable emotions", "months", "past", "days", "not slept", "spent", "time training", "climb", "never climbed", "period", "spent", "savings", "gear", "ecchymoses", "right upper extremity", "pressured speech", "easy distractibility", "alert", "not oriented to place", "following drugs", "most likely cause", "patient's current behavior"]}
{"question": "A 16-year-old boy is brought to the emergency department 20 minutes after collapsing while playing basketball. There is no personal or family history of serious illness. On arrival, there is no palpable pulse and no respiratory effort is seen. He is declared dead. The family agrees to an autopsy. Which of the following is most likely to be found in this patient?", "answer": "Interventricular septal hypertrophy", "options": {"A": "Defect in the atrial septum", "B": "Postductal narrowing of the aorta", "C": "Atheromatous plaque rupture", "D": "Interventricular septal hypertrophy", "E": "Pericardial fluid collection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department 20 minutes", "collapsing", "playing basketball", "personal", "family history", "serious illness", "arrival", "palpable pulse", "respiratory effort", "seen", "dead", "agrees", "autopsy", "following", "to", "found", "patient"]}
{"question": "A 67-year-old man comes to the physician because of worsening lower back pain for 6 weeks. He reports that the pain is most intense with movement and that it sometimes occurs at night. Over the past 3 months, he has noticed a weakened urinary stream. He has not seen any blood in his urine. His only daily medication is ibuprofen. Examination shows no spinal deformities. Palpation of the lumbar spinal process elicits tenderness. Muscle strength is normal. Which of the following is the most likely cause of this patient’s back pain?", "answer": "Malignancy", "options": {"A": "Malignancy", "B": "Lumbar spinal stenosis", "C": "Osteoporosis", "D": "Disc herniation", "E": "Lumbar strain"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old man", "physician", "of worsening lower back", "weeks", "reports", "pain", "most intense", "movement", "sometimes occurs", "night", "past 3 months", "urinary stream", "not seen", "blood in", "urine", "only daily medication", "ibuprofen", "spinal deformities", "Palpation", "lumbar", "process elicits tenderness", "Muscle", "normal", "following", "most likely cause of", "patients back pain"]}
{"question": "A 47-year-old woman presents to her primary care physician for a wellness checkup. The patient states that she currently feels well and has no complaints. She has failed multiple times at attempting to quit smoking and has a 40 pack-year smoking history. She drinks 4 alcoholic beverages every night. The patient is currently taking a multivitamin and vitamin D supplements. She has also attempted to eat more salmon given that she has heard of its health benefits. Physical exam is notable for back stiffness on mobility testing. The patient states that she frequently has back pain when sitting. Laboratory values are obtained 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: 75 pg/mL (normal 10 - 65 pg/mL)\n\nUrine:\nColor: Yellow\npH: 7.0\nBlood: 1+\nProtein: Negative\nNitrite: Positive\nBacteria: Positive\nCa2+: Low\nBenzodiazepines: Positive\n\nWhich of the following is the best explanation for this patient’s electrolyte abnormalities?", "answer": "Familial hypocalciuric hypercalcemia", "options": {"A": "Familial hypocalciuric hypercalcemia", "B": "Hyperparathyroidism", "C": "Hypervitaminosis D", "D": "Multiple myeloma", "E": "Renal cell carcinoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "checkup", "patient states", "currently", "well", "complaints", "failed multiple times", "smoking", "40", "smoking history", "4", "night", "patient", "currently", "multivitamin", "vitamin D supplements", "to eat more", "given", "heard", "health benefits", "notable", "back stiffness", "mobility testing", "patient states", "frequently", "back pain", "sitting", "Laboratory values", "obtained", "seen", "Serum", "Na", "mEq/L", "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", "75 pg/mL", "normal 10", "65 pg/mL", "Urine", "Color", "Yellow pH", "0 Blood", "1", "Protein", "Negative Nitrite", "Positive Bacteria", "Positive Ca2", "Low Benzodiazepines", "Positive", "following", "best explanation", "patients electrolyte abnormalities"]}
{"question": "A previously healthy 73-year-old man comes to the physician at his wife's insistence because of a skin lesion on his back. He lives with his wife and works for a high-profile law firm where he represents several major clients. Physical examination shows a 7-mm, brownish-black papule with irregular borders. When the doctor starts to mention possible diagnoses, the patient interrupts her and says that he does not want to know the diagnosis and that she should just do whatever she thinks is right. A biopsy of the skin lesion is performed and histological examination shows clusters of infiltrative melanocytes. Upon repeat questioning, the patient reaffirms his wish to not know the diagnosis. Which of the following is the most appropriate response from the physician?", "answer": "\"\"\"I would like to know more about why you don't want to hear your test results.\"\"\"", "options": {"A": "\"\"\"I have a moral obligation as a physician to inform you about the diagnosis.\"\"\"", "B": "\"\"\"I would like to do further testing to investigate how far this cancer has spread.\"\"\"", "C": "\"\"\"I don't have to tell you, but I will have to tell your wife so we can plan your therapy.\"\"\"", "D": "\"\"\"I'll have to consult with the ethics committee to determine further steps.\"\"\"", "E": "\"\"\"I would like to know more about why you don't want to hear your test results.\"\"\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old man", "physician", "skin lesion", "back", "lives with", "wife", "high profile law firm", "several major", "7-mm", "black papule", "irregular borders", "doctor starts to", "possible diagnoses", "patient interrupts", "not", "to", "diagnosis", "right", "biopsy of", "skin lesion", "performed", "histological examination", "clusters", "infiltrative", "repeat", "patient", "wish", "not", "diagnosis", "following", "most appropriate response", "physician"]}
{"question": "A 55-year-old man comes to the physician for a follow-up examination. He feels well. He has hyperlipidemia and type 2 diabetes mellitus. He takes medium-dose simvastatin and metformin. Four months ago, fasting serum studies showed a LDL-cholesterol of 136 mg/dL and his medications were adjusted. Vital signs are within normal limits. On physical examination, there is generalized weakness of the proximal muscles. Deep tendon reflexes are 2+ bilaterally. Fasting serum studies show:\nTotal cholesterol 154 mg/dL\nHDL-cholesterol 35 mg/dL\nLDL-cholesterol 63 mg/dL\nTriglycerides 138 mg/dL\nGlucose 98 mg/dL\nCreatinine 1.1 mg/dL\nCreatine kinase 260 mg/dL\nWhich of the following is the most appropriate next step in management of this patient's hyperlipidemia?\"", "answer": "Discontinue simvastatin, start pravastatin in 3 weeks", "options": {"A": "Discontinue simvastatin, start pravastatin in 3 weeks", "B": "Continue simvastatin, add niacin", "C": "Discontinue simvastatin, start fenofibrate now", "D": "Increase the dose of simvastatin", "E": "Discontinue simvastatin, start niacin in 3 weeks"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "follow-up examination", "well", "hyperlipidemia", "type 2 diabetes mellitus", "medium dose simvastatin", "metformin", "Four months", "fasting serum studies", "LDL-cholesterol", "mg/dL", "medications", "adjusted", "Vital signs", "normal limits", "generalized weakness", "proximal muscles", "Deep tendon reflexes", "2", "Fasting serum studies", "Total cholesterol", "mg/dL HDL-cholesterol", "LDL", "Glucose", "Creatinine", "Creatine kinase", "following", "most appropriate next step", "patient", "yperlipidemia?"]}
{"question": "A 15-year-old girl presents with four days of malaise, painful joints, nodular swelling over her elbows, low-grade fever, and a rash on her chest and left shoulder. Two weeks ago, she complained of a sore throat that gradually improved but was not worked up. She was seen for a follow-up approximately one week later. At this visit her cardiac exam was notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. Which of the following is the best step in the management of this patient?", "answer": "Penicillin therapy", "options": {"A": "Penicillin therapy", "B": "NSAIDS for symptomatic relief", "C": "Aortic valve replacement", "D": "Mitral valve repair", "E": "Reassurance that this is a benign murmur and send home"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl presents", "four days", "malaise", "painful joints", "nodular swelling", "elbows", "low-grade fever", "rash", "chest", "left shoulder", "Two weeks", "sore throat", "improved", "not worked up", "seen", "follow-up approximately one week later", "notable", "late diastolic murmur heard best", "apex", "left lateral decubitus position", "radiation", "following", "best step", "patient"]}
{"question": "A 3-year-old girl is brought to the pediatrician by her parents who are concerned that she is not developing normally. They say she does not talk and avoids eye contact. She prefers to sit and play with blocks by herself rather than engaging with other children. They also note that she will occasionally have violent outbursts in inappropriate situations. She is otherwise healthy. In the office, the patient sits quietly in the corner of the room stacking and unstacking blocks. Examination of the patient shows a well-developed female with no physical abnormalities. Which of the following is the most likely diagnosis in this patient?", "answer": "Autism spectrum disorder", "options": {"A": "Autism spectrum disorder", "B": "Cri-du-chat syndrome", "C": "Fragile X syndrome", "D": "Oppositional defiant disorder", "E": "Rett syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "pediatrician", "not", "not talk", "to sit", "play", "blocks", "engaging", "children", "note", "occasionally", "violent outbursts", "inappropriate", "healthy", "office", "patient sits", "corner", "room stacking", "blocks", "well", "female", "physical abnormalities", "following", "diagnosis", "patient"]}
{"question": "An 82-year-old man—a retired physics professor—presents with progressive difficulty walking. He has bilateral knee osteoarthritis and has used a walker for the past several years. For the past 6 months, he has experienced problems walking and maintaining balance and has been wheelchair-bound. He has fallen several times, hitting his head a few times but never losing consciousness. He complains of occasional difficulty remembering names and phone numbers, but his memory is otherwise fine. He also complains of occasional incontinence. Physical examination reveals a slow wide-based gait with small steps and intermittent hesitation. He scores 22 out of 30 on the Mini-Mental State Examination (MMSE). A brain MRI demonstrates dilated ventricles with high periventricular fluid-attenuated inversion recovery (FLAIR) signal. A large-volume lumbar puncture improves his gait. Which of the following is the most likely risk factor for the development of this condition?", "answer": "Subarachnoid hemorrhage", "options": {"A": "Alzheimer’s disease", "B": "Diabetes mellitus", "C": "Epilepsy", "D": "Hypertension", "E": "Subarachnoid hemorrhage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old mana retired", "progressive difficulty walking", "bilateral knee osteoarthritis", "used", "walker", "past", "years", "past 6 months", "balance", "wheelchair-bound", "fallen", "times", "hitting", "head", "few times", "never", "consciousness", "occasional difficulty", "names", "memory", "fine", "occasional incontinence", "reveals", "slow wide-based gait", "small steps", "intermittent", "scores", "out", "30", "Mini-Mental State Examination", "brain MRI", "dilated ventricles", "high", "fluid-attenuated inversion recovery", "large volume lumbar puncture improves", "gait", "following", "risk factor", "development", "condition"]}
{"question": "A 44-year-old man presents to his primary care physician for muscle pain and weakness. He says that his muscle pain mainly affects his legs. He also experiences difficulty with chewing gum and has poor finger dexterity. Medical history is significant for infertility and cataracts. On physical exam, the patient's face is long and narrow with a high arched palate and mild frontal balding. There is bilateral ptosis and temporalis muscle and sternocleidomastoid muscle wasting. Creatine kinase level is mildly elevated. Which of the following is most likely to be found on genetic testing?", "answer": "DMPK gene CTG expansion", "options": {"A": "DMPK gene CTG expansion", "B": "DYSF gene missense mutation", "C": "Dystrophin gene nonsense mutation", "D": "Dystrophin gene non-frameshift mutation", "E": "No genetic abnormality"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "muscle pain", "weakness", "muscle pain", "legs", "difficulty", "chewing", "poor finger dexterity", "Medical history", "significant", "infertility", "cataracts", "patient's face", "long", "narrow", "high arched palate", "mild frontal balding", "bilateral ptosis", "temporalis muscle", "sternocleidomastoid", "Creatine kinase level", "mildly elevated", "following", "to", "found", "genetic testing"]}
{"question": "A 10-year-old boy is brought to the pediatric clinic because of a sore throat of 1-week duration. He also has a cough and fever. He has pain when swallowing and sometimes water regurgitates from his nose when drinking. He was diagnosed with acute tonsillitis by his primary care physician 1 month ago, for which he received a week-long course of amoxicillin. His immunization status is unknown as he recently moved to the US from Asia. On examination, he is alert and oriented to time, place, and person. On inspection of his oral cavity, an edematous tongue with a grey-white membrane on the soft palate and tonsils is noted. The neck is diffusely swollen with bilateral tender cervical lymphadenopathy. Which of the following is the cause of this patient’s condition and could have been prevented through vaccinations in childhood?", "answer": "Corynebacterium diphtheriae", "options": {"A": "Streptococcus pyogenes", "B": "Corynebacterium diphtheriae", "C": "Haemophilus influenzae b", "D": "Agranulocytosis", "E": "Epstein Barr virus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A 10 year old boy", "brought", "pediatric clinic", "sore throat", "1-week duration", "cough", "fever", "pain", "swallowing", "sometimes water regurgitates", "nose", "drinking", "diagnosed", "acute tonsillitis", "primary care physician", "month", "received", "week long course", "amoxicillin", "immunization status", "unknown", "recently moved to", "Asia", "alert", "oriented to time", "place", "inspection", "oral cavity", "edematous tongue", "grey white membrane", "soft palate", "tonsils", "noted", "neck", "swollen", "bilateral tender cervical lymphadenopathy", "following", "cause", "patients condition", "prevented", "vaccinations", "childhood"]}
{"question": "A 48-year-old woman comes to the emergency room with chest pain. She describes the pain as a squeezing sensation in her chest with radiation to the left shoulder. The episode began about 15 minutes ago when she was sitting reading a book. She has had this pain before, typically in the evenings, though prior episodes usually resolved after a couple of minutes. Her pulse is 112/min, blood pressure is 121/87 mmHg, and respiratory rate is 21/min. An ECG shows ST-segment elevations in the inferior leads. Serum troponins are negative on two successive blood draws and the ECG shows no abnormalities 30 minutes later. Which of the following is the best long-term treatment for this patient's symptoms?", "answer": "Diltiazem", "options": {"A": "Clopidogrel", "B": "Diltiazem", "C": "Aspirin", "D": "Enalapril", "E": "Metoprolol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old woman", "emergency room", "chest pain", "pain", "squeezing sensation", "chest", "radiation", "left shoulder", "episode began", "15 minutes", "sitting", "pain", "evenings", "prior episodes usually resolved", "couple", "minutes", "pulse", "min", "blood pressure", "87 mmHg", "respiratory rate", "min", "ECG", "ST-segment elevations", "inferior leads", "Serum troponins", "negative", "two", "blood draws", "ECG", "abnormalities 30 minutes later", "following", "best", "patient's symptoms"]}
{"question": "A 68-year-old man is brought to the emergency department because of progressive weakness of his lower extremities and urinary incontinence for the past 2 weeks. Over the past 2 months, he has had increasing back pain. His temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 106/60 mm Hg. Examination shows an ataxic gait. Muscle strength is decreased in bilateral lower extremities. Sensation to pain, temperature, and position sense is absent in the buttocks, perineum, and lower extremities. Ankle clonus is present. Digital rectal examination is unremarkable. An x-ray of the spine shows multiple sclerotic lesions in the thoracic and lumbar vertebrae. Further evaluation of this patient is most likely to show which of the following?", "answer": "Elevated prostate-specific antigen", "options": {"A": "Left testicular mass", "B": "Irregular, asymmetric mole", "C": "Enlarged left thyroid lobe", "D": "Bence Jones protein in the urine", "E": "Elevated prostate-specific antigen"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "progressive weakness", "lower extremities", "urinary incontinence", "past 2 weeks", "past", "months", "increasing back pain", "temperature", "98", "pulse", "88 min", "blood pressure", "60 mm Hg", "ataxic gait", "Muscle strength", "decreased in bilateral lower extremities", "Sensation", "pain", "temperature", "position sense", "absent", "buttocks", "perineum", "lower extremities", "Ankle clonus", "present", "Digital rectal examination", "unremarkable", "x-ray of", "spine", "multiple sclerotic lesions", "lumbar vertebrae", "Further", "to", "following"]}
{"question": "A 51-year-old African American man with a history of poorly controlled hypertension presents to the emergency room with blurry vision and dyspnea. He reports rapid-onset blurred vision and difficulty breathing 4 hours prior to presentation. He takes lisinopril, hydrochlorothiazide, and spironolactone but has a history of poor medication compliance. He has a 50 pack-year smoking history and drinks 4-6 shots of vodka per day. His temperature is 99.2°F (37.3°C), blood pressure is 195/115 mmHg, pulse is 85/min, and respirations are 20/min. On exam, he is ill-appearing and pale. He is intermittently responsive and oriented to person but not place or time. Fundoscopic examination reveals swelling of the optic disc with blurred margins. A biopsy of this patient’s kidney would most likely reveal which of the following?", "answer": "Concentrically thickened arteriolar tunica media with abundant nuclei", "options": {"A": "Anuclear arteriolar thickening", "B": "Calcific deposits in the arterial media without luminal narrowing", "C": "Concentrically thickened arteriolar tunica media with abundant nuclei", "D": "Endothelial proliferation and luminal narrowing with a chronic inflammatory infiltrate", "E": "Fibrous atheromatous plaques in the arteriolar intima"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "man", "history of poorly controlled hypertension presents", "emergency room", "blurry vision", "dyspnea", "reports rapid-onset blurred vision", "difficulty breathing 4 hours prior to", "lisinopril", "hydrochlorothiazide", "spironolactone", "history", "poor medication", "50", "smoking history", "4-6 shots", "day", "temperature", "99", "blood pressure", "mmHg", "pulse", "85 min", "respirations", "20 min", "exam", "ill appearing", "pale", "responsive", "oriented to person", "not place", "time", "Fundoscopic", "reveals swelling", "optic disc", "blurred margins", "biopsy of", "patients kidney", "most likely reveal", "following"]}
{"question": "A pharmaceutical company is studying the effect of a novel compound that they have discovered to treat osteoporosis. They perform a randomized controlled clinical trial to study if this compound has an effect on the incidence of hip fractures among osteoporotic patients. They find that there is no statistical difference between the experimental and control groups so they do not pursue the compound further. Two years later, a second team tests the same compound and finds that the compound is effective, and follow up studies confirm that the compound has a statistically significant effect on fracture risk. Which of the following most likely describes what occurred in the first study?", "answer": "Type II error", "options": {"A": "Design bias", "B": "Selection bias", "C": "Type I error", "D": "Type II error", "E": "Type III error"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["studying", "effect", "novel compound", "to treat osteoporosis", "perform", "to study", "compound", "effect", "incidence of hip fractures", "patients", "find", "difference", "experimental", "not", "compound further", "Two years later", "second", "tests", "same compound", "finds", "compound", "effective", "confirm", "compound", "statistically significant effect", "fracture", "following most likely", "first study"]}
{"question": "A 58-year-old woman comes to the physician because of constipation, loss of appetite, and increased urinary frequency for the past 8 weeks. She has a history of hypertension and underwent mastectomy for breast cancer 9 months ago. Her sister has hyperthyroidism and her mother died of complications from breast cancer at the age of 52 years. She does not smoke or drink alcohol. Current medications include chlorthalidone. Her temperature is 36.2°C (97.2°F), pulse is 102/min, and blood pressure is 142/88 mm Hg. Physical examination shows dry mucous membranes. Abdominal examination shows mild, diffuse abdominal tenderness to palpation with decreased bowel sounds. Her serum creatinine concentration is 1.2 mg/dL and serum calcium concentration is 12 mg/dL. Serum parathyroid hormone levels are decreased. Which of the following is the most appropriate long-term pharmacotherapy?", "answer": "Zoledronic acid", "options": {"A": "Magnesium oxide", "B": "Denosumab", "C": "Furosemide", "D": "Zoledronic acid", "E": "Prednisone\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["58 year old woman", "physician", "constipation", "loss of appetite", "increased urinary frequency", "past", "weeks", "history of hypertension", "mastectomy", "breast cancer", "months", "hyperthyroidism", "died", "complications", "breast cancer", "the age of", "years", "not smoke", "Current medications include chlorthalidone", "temperature", "36", "97", "pulse", "min", "blood pressure", "88 mm Hg", "dry mucous membranes", "Abdominal", "mild", "diffuse abdominal tenderness", "palpation", "decreased bowel sounds", "serum concentration", "1.2 mg/dL", "serum concentration", "mg/dL", "Serum parathyroid hormone levels", "decreased", "following", "most appropriate long-term pharmacotherapy"]}
{"question": "A 61-year-old man is brought to the emergency department because of a 2-day history of fever, chills, and headache. He frequently has headaches, for which he takes aspirin, but says that this headache is more intense. His wife claims that he has also not been responding right away to her. He has a 20-year history of hypertension and poorly controlled type 2 diabetes mellitus. His current medications include metformin and lisinopril. He has received all recommended childhood vaccines. His temperature is 39°C (102.2F°), pulse is 100/min, and blood pressure is 150/80 mm Hg. He is lethargic but oriented to person, place, and time. Examination shows severe neck rigidity with limited active and passive range of motion. Blood cultures are obtained and a lumbar puncture is performed. Which of the following is the most likely causal organism?", "answer": "Streptococcus pneumoniae", "options": {"A": "Streptococcus agalactiae", "B": "Staphylococcus aureus", "C": "Neisseria meningitidis", "D": "Streptococcus pneumoniae", "E": "Escherichia coli"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["61 year old man", "brought", "emergency department", "2-day history", "fever", "chills", "headache", "frequently", "headaches", "aspirin", "headache", "more intense", "not", "right", "20 year history of hypertension", "poorly controlled type 2 diabetes mellitus", "current medications include metformin", "lisinopril", "received", "childhood vaccines", "temperature", "pulse", "100 min", "blood pressure", "80 mm Hg", "lethargic", "oriented to person", "place", "time", "severe neck rigidity", "limited active", "passive range of motion", "Blood cultures", "obtained", "lumbar puncture", "performed", "following", "causal"]}
{"question": "A 34-year-old female comes to the ED complaining of epigastric pain and intractable nausea and vomiting for the last 24 hours. Her vitals are as follows: Temperature 38.1 C, HR 97 beats/minute, BP 90/63 mm Hg, RR 12 breaths/minute. Arterial blood gas and labs are drawn. Which of the following sets of lab values is consistent with her presentation?", "answer": "pH 7.51, PaCO2 50 , serum chloride 81 mEq/L, serum bicarbonate 38 mEq/L", "options": {"A": "pH 7.39, PaCO2 37 , serum chloride 102 mEq/L, serum bicarbonate 27 mEq/L", "B": "pH 7.36, PaCO2 75 , serum chloride 119 mEq/L, serum bicarbonate 42 mEq/L", "C": "pH 7.46, PaCO2 26 , serum chloride 102 mEq/L, serum bicarbonate 16 mEq/L", "D": "pH 7.51, PaCO2 50 , serum chloride 81 mEq/L, serum bicarbonate 38 mEq/L", "E": "pH 7.31, PaCO2 30 , serum chloride 92 mEq/L, serum bicarbonate 15 mEq/L"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "epigastric pain", "intractable nausea", "vomiting", "24 hours", "follows", "Temperature", "97 beats/minute", "BP 90 63 mm Hg", "RR", "breaths/minute", "Arterial blood gas", "labs", "following sets", "lab values"]}
{"question": "A 48-year-old man comes to the physician because of worsening shortness of breath and nocturnal cough for the past 2 weeks. On two occasions, his cough was bloody. He had a heart condition as a child that was treated with antibiotics. He emigrated to the US from Kazakhstan 15 years ago. Pulmonary examination shows crackles at both lung bases. Cardiac examination is shown. Which of the following is the most likely diagnosis?", "answer": "Mitral valve stenosis", "options": {"A": "Aortic valve regurgitation", "B": "Mitral valve prolapse", "C": "Mitral valve stenosis", "D": "Mitral valve regurgitation", "E": "Tricuspid valve stenosis\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old man", "physician", "of worsening shortness", "breath", "nocturnal cough", "past 2 weeks", "two occasions", "cough", "bloody", "heart condition", "child", "treated with", "Kazakhstan 15 years", "Pulmonary examination", "crackles", "lung bases", "following", "diagnosis"]}
{"question": "A 32-year-old woman comes to the emergency department because of a 12-hour history of a severe headache. She does not smoke or use illicit drugs. Her blood pressure at admission is 180/125 mm Hg. Physical examination shows a bruit in the epigastric region. Fundoscopy shows bilateral optic disc swelling. Which of the following investigations is most likely to confirm the diagnosis?", "answer": "CT angiography", "options": {"A": "Urinary catecholamine metabolites", "B": "Echocardiography", "C": "Serum 17-hydroxyprogesterone level", "D": "Oral sodium loading test", "E": "CT angiography"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "emergency department", "of", "12-hour history", "severe headache", "not smoke", "use illicit", "blood pressure", "mm Hg", "bruit", "epigastric region", "Fundoscopy", "bilateral optic disc swelling", "following", "to confirm", "diagnosis"]}
{"question": "A grant reviewer at the National Institutes of Health is determining which of two studies investigating the effects of gastric bypass surgery on fasting blood sugar to fund. Study A is spearheaded by a world renowned surgeon, is a multi-center study planning to enroll 50 patients at each of 5 different sites, and is single-blinded. Study B plans to enroll 300 patients from a single site and will be double-blinded by virtue of a sham surgery for the control group. The studies both plan to use a t-test, and they both report identical expected treatment effect sizes and variance. If the reviewer were interested only in which trial has the higher power, which proposal should he fund?", "answer": "Study B, because it has a larger sample size", "options": {"A": "Study A, because it has a superior surgeon", "B": "Study A, because it is a multi-center trial", "C": "Study B, because it has a larger sample size", "D": "Study B, because it is double blinded", "E": "Both studies have the same power"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["grant reviewer", "two studies investigating", "effects of gastric bypass surgery", "fasting blood sugar to fund", "Study", "surgeon", "planning", "50 patients", "of", "different sites", "single", "plans to", "300 patients", "single site", "double", "sham surgery", "studies", "plan to use a t test", "report identical", "treatment", "variance", "reviewer", "only", "higher power", "fund"]}
{"question": "A 48-year-old woman presents to the physician because of facial flushing and weakness for 3 months, abdominal discomfort and bloating for 6 months, and profuse watery diarrhea for 1 year. She reports that her diarrhea was episodic initially, but it has been continuous for the past 3 months. The frequency ranges from 10 to 12 bowel movements per day, and the diarrhea persists even if she is fasting. She describes the stools as odorless, watery in consistency, and tea-colored, without blood or mucus. She has not been diagnosed with any specific medical conditions, and there is no history of substance use. Her temperature is 36.9°C (98.4°F), heart rate is 88/min, respiratory rate is 18/min, and blood pressure is 110/74 mm Hg. Her physical exam shows decreased skin turgor, and the abdominal exam does not reveal any significant abnormality. Laboratory studies show:\nSerum glucose 216 mg/dL (12.0 mmol/L)\nSerum sodium 142 mEq/L (142 mmol/L)\nSerum potassium 3.1 mEq/L (3.1 mmol/L)\nSerum chloride 100 mEq/L (100 mmol/L)\nSerum calcium 11.1 mg/dL (2.77 mmol/L)\nHer 24-hour stool volume is 4 liters. Which of the following tests is most likely to yield an accurate diagnosis?", "answer": "Plasma vasoactive intestinal peptide", "options": {"A": "Urinary 5-hydroxyindoleacetic acid excretion", "B": "Plasma gastrin level", "C": "Plasma vasoactive intestinal peptide", "D": "Plasma glucagon level", "E": "Plasma somatostatin level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old woman presents", "physician", "facial flushing", "weakness", "months", "abdominal discomfort", "bloating", "months", "watery diarrhea", "year", "reports", "diarrhea", "episodic initially", "past 3 months", "frequency ranges", "10", "bowel movements", "day", "diarrhea", "fasting", "stools", "watery", "consistency", "colored", "blood", "mucus", "not", "diagnosed", "specific medical conditions", "history of", "use", "temperature", "36", "98", "heart rate", "88 min", "respiratory rate", "min", "blood pressure", "74 mm Hg", "decreased skin turgor", "abdominal exam", "not reveal", "significant abnormality", "Laboratory studies", "Serum glucose", "mg/dL", "0 mmol/L", "Serum sodium", "mEq/L", "mmol/L", "Serum potassium", "mEq/L", "3.1 mmol/L", "Serum chloride 100 mEq/L", "100 mmol/L", "Serum calcium", "mg/dL", "2", "mmol/L", "hour stool volume", "4 liters", "following tests", "to", "accurate diagnosis"]}
{"question": "A 5-year-old boy is brought to the physician by his parents because of a 4-day history of arthralgias, abdominal pain, and lesions on his arms and legs. Ten days ago, he had an upper respiratory tract infection. A photograph of one of his legs is shown. Further evaluation is most likely to show which of the following?", "answer": "Hematuria", "options": {"A": "Genital ulcers", "B": "Hematuria", "C": "Tick bite", "D": "Conjunctivitis", "E": "Thrombocytopenia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "physician", "4-day history", "arthralgias", "abdominal pain", "lesions", "arms", "legs", "upper respiratory tract infection", "photograph", "one", "legs", "Further", "to", "following"]}
{"question": "A previously healthy 61-year-old man comes to the physician because of a 3-month history of intermittent fever, easy fatiguability, and a 4.4-kg (9.7-lb) weight loss. Physical examination shows conjunctival pallor. The spleen is palpated 5 cm below the left costal margin. Laboratory studies show a leukocyte count of 75,300/mm3 with increased basophils, a platelet count of 455,000/mm3, and a decreased leukocyte alkaline phosphatase score. A peripheral blood smear shows increased numbers of promyelocytes, myelocytes, and metamyelocytes. Which of the following is the most likely diagnosis?", "answer": "Chronic myeloid leukemia", "options": {"A": "Leukemoid reaction", "B": "Chronic lymphocytic leukemia", "C": "Essential thrombocythemia", "D": "Chronic myeloid leukemia", "E": "Acute promyelocytic leukemia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 61 year old man", "physician", "3 month history", "intermittent fever", "easy fatiguability", "4.4 kg", "weight loss", "conjunctival pallor", "spleen", "5 cm", "left costal margin", "Laboratory studies", "leukocyte count", "75 300 mm3", "increased basophils", "platelet count", "mm3", "decreased leukocyte alkaline phosphatase score", "peripheral blood smear", "increased numbers", "promyelocytes", "myelocytes", "metamyelocytes", "following", "diagnosis"]}
{"question": "A 60-year-old woman presents to the emergency department with progressive nausea and vomiting. She reports that approximately one day prior to presentation she experienced abdominal discomfort that subsequently worsened to severe nausea, vomiting, and two episodes of watery diarrhea. She recently noticed that her vision has become blurry along with mild alterations in color perception. Medical history is significant for congestive heart failure with a low ejection fraction. She cannot recall which medications she is currently taking but believes she is taking them as prescribed. Which of the following is a characteristic of the likely offending drug that led to this patient’s clinical presentation?", "answer": "Ratio of toxic dose to effective dose close to 1", "options": {"A": "High potency", "B": "Low potency", "C": "Ratio of toxic dose to effective dose much greater than 1", "D": "Ratio of toxic dose to effective dose close to 1", "E": "Low bioavailability"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old woman presents", "emergency department", "progressive nausea", "vomiting", "reports", "approximately one day prior to", "abdominal discomfort", "worsened", "severe nausea", "vomiting", "two episodes of watery diarrhea", "recently", "vision", "blurry", "mild", "Medical history", "significant", "congestive heart failure", "low ejection fraction", "medications", "currently", "following", "characteristic", "likely", "drug", "led", "patients"]}
{"question": "A 23-year-old man who lives in a beach house in Florida visits his twin brother who lives in the Rocky Mountains. They are out hiking and the visitor struggles to keep up with his brother. Which of the following adaptations is most likely present in the mountain-dwelling brother relative to his twin?", "answer": "Decreased oxygen binding ability of hemoglobin", "options": {"A": "Decreased mean corpuscular hemoglobin concentration", "B": "Decreased red blood cell 2,3-diphosphoglycerate", "C": "Decreased oxygen binding ability of hemoglobin", "D": "Decreased pulmonary vascular resistance", "E": "Decreased renal erythropoietin production"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old man", "lives", "beach house", "Florida", "lives", "Rocky Mountains", "out", "to keep", "following adaptations", "most likely present", "mountain dwelling", "twin"]}
{"question": "A 25-year-old G1P0000 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. The patient has a past medical history of mild intermittent asthma and migraine headaches. She currently uses her albuterol inhaler once a week and takes a prenatal vitamin. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 117/68 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and abdominal exam reveals a gravid uterus with fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?", "answer": "Expectant management", "options": {"A": "Expectant management", "B": "Weekly ultrasound", "C": "External cephalic version", "D": "Internal cephalic version", "E": "Caesarean section at 38 weeks"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "presents", "obstetricians office", "routine", "weeks gestation", "well", "complaints", "pregnancy", "uncomplicated", "Rh negative status", "received Rhogam", "weeks gestation", "patient", "past medical mild intermittent asthma", "migraine headaches", "currently uses", "albuterol inhaler", "week", "prenatal vitamin", "temperature", "98", "pulse", "70 min", "blood pressure", "mmHg", "respirations", "min", "Cardiopulmonary exam", "unremarkable", "abdominal exam reveals", "gravid uterus", "fundal height", "30 centimeters", "ultrasound reveals", "fetus", "transverse lie", "patient states", "to", "vaginal delivery", "following", "best next step"]}
{"question": "A 54-year-old man with a past medical history significant for hypertension, type 2 diabetes, and chronic obstructive pulmonary disease presents with complaints of nausea and abdominal pain for the past month. The pain is located in the epigastric region and is described as “burning” in quality, often following food intake. The patient denies any changes in bowel movements, fever, or significant weight loss. Medications include metformin, lisinopril, hydrochlorothiazide, albuterol inhaler, and fluconazole for a recent fungal infection. Physical examination was unremarkable except for a mildly distended abdomen that is diffusely tender to palpation and decreased sensation at lower extremities bilaterally. A medication was started for the symptoms. Two days later, the patient reports heart palpitations. An EKG is shown below. Which of the following is the medication most likely prescribed?", "answer": "Erythromycin", "options": {"A": "Aspirin", "B": "Erythromycin", "C": "Metformin", "D": "Omeprazole", "E": "Ranitidine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["54 year old man", "past medical history significant", "hypertension", "type 2 diabetes", "chronic obstructive pulmonary disease presents", "complaints", "nausea", "abdominal pain", "past month", "pain", "epigastric region", "burning", "quality", "often following food intake", "patient", "changes in bowel movements", "fever", "significant weight loss", "Medications include metformin", "lisinopril", "hydrochlorothiazide", "albuterol inhaler", "fluconazole", "recent fungal", "unremarkable", "mildly distended abdomen", "tender", "palpation", "decreased sensation", "lower extremities", "medication", "started", "symptoms", "Two days later", "patient reports heart palpitations", "EKG", "following", "medication", "likely"]}
{"question": "An investigator is studying the affinity of hemoglobin for oxygen in different clinical settings. An illustration of an oxygen-hemoglobin dissociation curve is shown. Curve A shows the test results of one of the research participants and curve B shows a normal oxygen-hemoglobin dissociation curve. Which of the following is most likely present in this research participant?", "answer": "Polycythemia", "options": {"A": "Temperature of 39.1°C (102.4°F)", "B": "Sickled red blood cells", "C": "Neutrophilia", "D": "Serum pH of 7.1", "E": "Polycythemia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "hemoglobin", "oxygen", "different clinical", "oxygen hemoglobin dissociation curve", "Curve", "test results", "one", "research", "curve", "normal oxygen hemoglobin dissociation curve", "following", "most likely present"]}
{"question": "A 24-year-old obese woman presents with a severe right-sided frontotemporal headache that started 2 days ago. There is no improvement with over-the-counter pain medications. Yesterday, the pain was so intense that she stayed in bed all day in a dark, quiet room instead of going to work. This morning she decided to come in after an episode of vomiting. She says she has experienced 5–6 similar types of headaches each lasting 12–24 hours over the last 6 months but never this severe. She denies any seizures, visual disturbances, meningismus, sick contacts or focal neurologic deficits. Her past medical history is significant for moderate persistent asthma, which is managed with ipratropium bromide and an albuterol inhaler. She is currently sexually active with 2 men, uses condoms consistently, and regularly takes estrogen-containing oral contraceptive pills (OCPs). Her vital signs include: blood pressure 122/84 mm Hg, pulse 86/min, respiratory rate 19/min, and blood oxygen saturation (SpO2) 98% on room air. Physical examination, including a complete neurologic exam, is unremarkable. A magnetic resonance image (MRI) of the brain appears normal. Which of the following is the best prophylactic treatment for this patient’s most likely condition?", "answer": "Amitriptyline", "options": {"A": "Sumatriptan", "B": "Methysergide", "C": "Gabapentin", "D": "Amitriptyline", "E": "Ibuprofen"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old obese woman presents", "severe right-sided frontotemporal headache", "started 2 days", "over-the-counter pain medications", "pain", "so intense", "bed all day", "dark", "quiet room", "to", "morning", "to", "episode of vomiting", "similar types", "headaches", "lasting", "hours", "months", "never", "severe", "seizures", "visual disturbances", "meningismus", "sick", "focal neurologic deficits", "past medical history", "significant", "moderate persistent", "ipratropium bromide", "albuterol inhaler", "currently sexually active with", "men", "uses condoms", "estrogen containing oral contraceptive pills", "vital signs include", "blood pressure", "84 mm Hg", "pulse", "min", "respiratory rate", "min", "blood oxygen saturation", "98", "room air", "including", "complete neurologic exam", "unremarkable", "magnetic resonance", "brain appears normal", "following", "best prophylactic treatment", "patients", "likely condition"]}
{"question": "In a community of 5,000 people, 40 people from 40 different households develop an infection with a new strain of influenza virus with an incubation period of 7 days. The total number of people in these households is 150. Ten days later, 90 new cases of the same disease are reported from these same households. Twenty-five more cases are reported from these households after a month. The total number of cases reported after a month from this community is 1,024. What is the secondary attack rate for this infection?", "answer": "(90/110) × 100", "options": {"A": "(115/150) × 100", "B": "(115/1024) × 100", "C": "(90/110) × 100", "D": "(90/150) × 100", "E": "(90/5000) × 100"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5", "people", "40", "different", "infection", "a new strain", "influenza virus", "incubation period", "7 days", "total number", "later", "90 new cases", "same disease", "reported", "same", "Twenty-five", "cases", "reported", "month", "total number", "cases reported", "month", "1", "secondary attack rate", "infection"]}
{"question": "A 22-year-old woman is brought to the emergency department by campus police for bizarre behavior. She was arrested while trying to break into her university's supercomputer center and was found crying and claiming she needs access to the high-powered processors immediately. Her boyfriend arrived at the hospital and reports that, over the past week, she has been staying up all night working on ‘various projects’. A review of her electronic medical record reveals that she was seen at student health 1 week ago for low energy and depressed mood, for which treatment was started. In the emergency department, she continues to appear agitated, pacing around the room and scolding staff for stopping her from her important work. Her speech is pressured, but she exhibits no evidence of visual or auditory hallucinations. The physical exam is otherwise unremarkable. Which of the following medications most likely precipitated this patient’s event?", "answer": "Sertraline", "options": {"A": "Alprazolam", "B": "Haloperidol", "C": "Lithium", "D": "Sertraline", "E": "Valproate"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "police", "bizarre behavior", "arrested", "to break", "university's supercomputer center", "found", "needs access", "high", "processors immediately", "hospital", "reports", "past week", "night", "various", "reveals", "seen", "1 week", "depressed mood", "treatment", "started", "emergency department", "to appear agitated", "room", "staff", "stopping", "important", "speech", "pressured", "visual", "auditory hallucinations", "unremarkable", "following medications", "likely precipitated", "patients event"]}
{"question": "You would like to conduct a study investigating potential risk factors that predispose patients to develop cirrhosis. Using a registry of admitted patients over the last 10 years at your local hospital, you isolate all patients who have been diagnosed with cirrhosis. Subsequently, you contact this group of patients, asking them to complete a survey assessing their prior exposure to alcohol use, intravenous drug abuse, blood transfusions, personal history of cancer, and other medical comorbidities. An identical survey is given to an equal number of patients in the registry who do not carry a prior diagnosis of cirrhosis. Which of the following best describes the type of study you are attempting to conduct?", "answer": "Case-control study", "options": {"A": "Cohort study", "B": "Meta-analysis", "C": "Case-control study", "D": "Cross-sectional study", "E": "Randomized controlled trial"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["to", "study investigating potential risk factors", "patients to", "cirrhosis", "Using", "last", "local hospital", "isolate", "patients", "diagnosed", "cirrhosis", "contact", "group", "patients", "to complete", "survey", "prior", "use", "intravenous drug abuse", "blood transfusions", "personal history of cancer", "medical comorbidities", "identical survey", "given to", "equal number of patients", "not carry", "prior diagnosis", "cirrhosis", "following best", "to"]}
{"question": "An 18-year-old female presents to general medical clinic with the report of a rape on her college campus. The patient was visiting a local fraternity, and after having a few drinks, awakened to find another student having intercourse with her. Aside from the risk of unintended pregnancy and sexually transmitted infections, this patient is also at higher risk of developing which of the following?", "answer": "Suicidality", "options": {"A": "Attention Deficit Hyperactivity Disorder", "B": "Bipolar Disorder", "C": "Suicidality", "D": "Schizoaffective Disorder", "E": "Schizophrenia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female presents", "general medical clinic", "report", "college", "patient", "local", "few", "to find", "intercourse", "risk of unintended pregnancy", "sexually transmitted infections", "patient", "higher risk of", "following"]}
{"question": "A 58-year-old man complains of ascending weakness, palpitations, and abdominal pain. He has a history of hypertension, type II diabetes mellitus, diabetic retinopathy, and end-stage renal disease requiring dialysis. He denies any recent infection. Physical examination is notable for decreased motor strength in both his upper and lower extremities, intact cranial nerves, as well as decreased bowel sounds. On further questioning, the patient shares that he has been depressed, as he feels he may not be able to see his grandchildren grow due to his complicated medical course. This caused him to miss two of his dialysis appointments. Which of the following will mostly likely be found on electrocardiography?", "answer": "Peaked T-waves and shortened QT interval", "options": {"A": "Progressive PR prolongation, followed by a 'drop' in QRS", "B": "S wave in lead I, Q wave in lead III, and inverted T wave in lead III", "C": "ST-segment elevation in leads II, III, and aVF", "D": "Peaked T-waves and shortened QT interval", "E": "Diffuse PR segment depression and ST-segment deviations"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["58 year old man", "ascending weakness", "palpitations", "abdominal pain", "history of hypertension", "type II diabetes mellitus", "diabetic retinopathy", "end-stage renal disease requiring dialysis", "recent infection", "notable", "decreased motor strength", "upper", "lower extremities", "intact cranial nerves", "decreased bowel sounds", "further", "patient", "depressed", "not", "able to see", "due to", "complicated course", "caused", "to miss two", "dialysis appointments", "following", "mostly likely", "found", "electrocardiography"]}
{"question": "After learning in a lecture that cesarean section rates vary from < 0.5% to over 30% across countries, a medical student wants to investigate if national cesarean section rates correlate with national maternal mortality rates worldwide. For his investigation, the student obtains population data from an international registry that contains tabulated cesarean section rates and maternal mortality rates from the last 10 years for a total of 119 countries. Which of the following best describes this study design?", "answer": "Ecological study", "options": {"A": "Case series", "B": "Meta-analysis", "C": "Retrospective cohort study", "D": "Ecological study", "E": "Prospective cohort study\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["cesarean section rates", "0.5", "30", "countries", "medical student", "to investigate", "cesarean section rates", "maternal mortality rates", "obtains population data", "contains", "cesarean section rates", "maternal mortality rates", "total", "countries", "following best"]}
{"question": "A 34-year-old woman presents to the fertility clinic with her husband for infertility workup. The patient reports that they have been having unprotected intercourse for 14 months without any successful pregnancy. She is G1P1, with 1 child from a previous marriage. Her menstrual cycle is regular and without pain. Physical and pelvic examinations are unremarkable. The husband denies erectile dysfunction, decrease in libido, or other concerns. A physical examination of the husband demonstrates tall long extremities and bilateral hard nodules behind the areola. What abnormality would you most likely find in the husband?", "answer": "Elevated aromatase levels", "options": {"A": "Decreased luteinizing hormone (LH) levels", "B": "Defective fibrillin", "C": "Elevated aromatase levels", "D": "Elevated homocysteine levels", "E": "Elevated testosterone levels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "fertility clinic", "infertility workup", "patient reports", "unprotected intercourse", "months", "successful pregnancy", "G1P1", "previous marriage", "menstrual cycle", "regular", "pain", "Physical", "pelvic examinations", "unremarkable", "erectile dysfunction", "decrease", "libido", "tall long extremities", "bilateral hard nodules", "areola", "abnormality", "most likely find"]}
{"question": "A 65-year-old man comes to the physician because of a 10-day history of episodic retrosternal pain, shortness of breath, and palpitations. The episodes occur when he climbs stairs or tries to walk briskly on his treadmill. The symptoms resolve when he stops walking. The previous evening he felt dizzy and weak during such an episode. He also reports that he had a cold 2 weeks ago. He was diagnosed with type 2 diabetes mellitus four years ago but is otherwise healthy. His only medication is glyburide. He appears well. His pulse is 62/min and is weak, respirations are 20/min, and blood pressure is 134/90 mmHg. Cardiovascular examination shows a late systolic ejection murmur that is best heard in the second right intercostal space. The lungs are clear to auscultation. Which of the following mechanisms is the most likely cause of this patient's current condition?", "answer": "Increased left ventricular oxygen demand", "options": {"A": "Increased left ventricular oxygen demand", "B": "Lymphocytic infiltration of the myocardium", "C": "Critical transmural hypoperfusion of the myocardium", "D": "Catecholamine-induced transient regional systolic dysfunction", "E": "Increased release of endogenous insulin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old man", "physician", "of a 10 day history", "episodic retrosternal pain", "shortness of breath", "palpitations", "episodes occur", "climbs stairs", "to", "treadmill", "symptoms", "stops", "previous evening", "dizzy", "weak", "episode", "reports", "cold", "weeks", "diagnosed", "type 2 diabetes mellitus four years", "healthy", "only medication", "glyburide", "appears well", "pulse", "62 min", "weak", "respirations", "20 min", "blood pressure", "90 mmHg", "late murmur", "best heard", "second right intercostal space", "lungs", "clear", "auscultation", "following mechanisms", "most likely cause", "patient's current condition"]}
{"question": "A 62-year-old male is rushed to the emergency department (ED) for what he believes is his second myocardial infarction (MI). His medical history is significant for severe chronic obstructive pulmonary disease (COPD) and a prior MI at the age of 58. After receiving aspirin, morphine, and face mask oxygen in the field, the patient arrives to the ED tachycardic (105 bpm), diaphoretic, and normotensive (126/86). A 12 lead electrocardiogram shows ST-elevation in I, aVL, and V5-V6. The attending physician suspects a lateral wall infarction. Which of following beta-blockers should be given to this patient and why?", "answer": "Metoprolol, because it is a selective ß1 > ß2 blocker", "options": {"A": "Propranolol, because it is a non-selective ß-blocker", "B": "Metoprolol, because it is a selective ß1 > ß2 blocker", "C": "Atenolol, because it is a selective ß2 > ß1 blocker", "D": "Labetalol, because it is a selective ß1 > ß2 blocker", "E": "Nadolol, because it is a selective ß1 > ß2 blocker"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old male", "rushed", "emergency department", "second myocardial infarction", "medical history", "significant", "severe chronic obstructive pulmonary disease", "prior MI", "age", "58", "receiving aspirin", "morphine", "face mask oxygen in the field", "patient", "ED tachycardic", "diaphoretic", "normotensive", "12 lead electrocardiogram", "ST-elevation", "I", "aVL", "V6", "attending physician", "lateral wall infarction", "following beta-blockers", "given", "patient"]}
{"question": "A 55-year-old woman presents to a primary care clinic for a physical evaluation. She works as a software engineer, travels frequently, is married with 2 kids, and drinks alcohol occasionally. She does not exercise regularly. She currently does not take any medications except for occasional ibuprofen or acetaminophen. She is currently undergoing menopause. Her initial vital signs reveal that her blood pressure is 140/95 mmHg and heart rate is 75/min. She weighs 65 kg (143 lb) and is 160 cm (63 in) tall. Her physical exam is unremarkable. A repeat measurement of her blood pressure is the same as before. Among various laboratory tests for hypertension evaluation, the physician requests fasting glucose and hemoglobin A1c levels. Which of the following is the greatest risk factor for type 2 diabetes mellitus?", "answer": "Body mass index", "options": {"A": "Age", "B": "Body mass index", "C": "Hypertension", "D": "Menopause", "E": "Occupation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care clinic", "software engineer", "frequently", "married", "alcohol occasionally", "not exercise", "currently", "not", "medications", "occasional ibuprofen", "acetaminophen", "currently", "menopause", "initial vital reveal", "blood pressure", "95 mmHg", "heart rate", "75 min", "65 kg", "63", "tall", "unremarkable", "repeat", "same", "before", "various laboratory tests", "hypertension", "physician", "fasting glucose", "hemoglobin levels", "following", "greatest risk factor", "type 2 diabetes mellitus"]}
{"question": "A 8-month-old boy is brought to the emergency department by his mother and father due to decreasing activity and excessive sleepiness. The patient was born at full-term in the hospital with no complications. The patient's parents appear incredibly worried as their son has had no medical issues in the past. They show you videos of the child happily playing with his parents the day before. The patient’s mother states that the patient hit his head while crawling this morning and since then has been difficult to arouse. His mother is worried because she thinks he had a fever earlier in the day and he was clutching his head and neck in pain. Physical examination shows a barely arousable boy with a large, full anterior fontanelle. The boy grimaces on palpation of his chest, and a radiograph show posterior rib fractures. Retinal examination shows bilateral retinal hemorrhages. Which of the following is the most likely cause for this patient’s presentation?", "answer": "Child abuse", "options": {"A": "Child abuse", "B": "Unintentional head injury", "C": "Vitamin K deficiency", "D": "Osteogenesis imperfecta", "E": "Bacterial meningitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "emergency department", "due to decreasing activity", "excessive sleepiness", "patient", "born", "full-term", "hospital", "complications", "patient's", "appear", "worried", "medical issues", "past", "videos", "child", "playing", "day", "patients", "states", "patient hit", "head", "morning", "since then", "difficult", "worried", "fever earlier", "day", "head and neck in pain", "boy", "large", "full anterior fontanelle", "boy grimaces", "palpation", "chest", "radiograph", "posterior rib fractures", "Retinal examination", "bilateral retinal hemorrhages", "following", "most likely cause", "patients"]}
{"question": "A 42-year-old woman comes to the physician because of a 2-month history of generalized itching and worsening fatigue. There is no personal or family history of serious illness. She takes eye drops for dry eyes. She occasionally takes acetaminophen for recurrent headaches. She drinks one alcoholic beverage daily. Vital signs are within normal limits. Examination shows jaundice and a nontender abdomen. The liver is palpated 3 cm below the right costal margin and the spleen is palpated 2 cm below the left costal margin. Laboratory studies show:\nHemoglobin 15.3 g/dL\nLeukocyte count 8,400/mm3\nProthrombin time 13 seconds\nSerum\nBilirubin\nTotal 3.5 mg/dL\nDirect 2.4 mg/dL\nAlkaline phosphatase 396 U/L\nAspartate aminotransferase (AST, GOT) 79 U/L\nAlanine aminotransferase (ALT, GPT) 73 U/L\nA liver biopsy specimen shows inflammation and destruction of small- and medium-sized intrahepatic bile ducts. Magnetic resonance cholangiopancreatography (MRCP) shows multiple small stones within the gallbladder and a normal appearance of extrahepatic bile ducts. Which of the following is the most appropriate next step in management?\"", "answer": "Dual-energy x-ray absorptiometry", "options": {"A": "Extracorporeal shock wave lithotripsy", "B": "Dual-energy x-ray absorptiometry", "C": "Administer N-acetylcysteine", "D": "Serum electrophoresis", "E": "Chest x-ray"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "2 month history", "generalized itching", "worsening fatigue", "personal", "family history", "serious illness", "eye", "dry", "occasionally", "acetaminophen", "recurrent headaches", "one", "daily", "Vital signs", "normal limits", "jaundice", "nontender abdomen", "liver", "3 cm", "right costal margin", "spleen", "2 cm", "left costal margin", "Laboratory studies", "Hemoglobin", "g dL Leukocyte count 8", "mm3 Prothrombin time", "Serum Bilirubin Total", "5 mg dL Direct 2.4 mg/dL Alkaline phosphatase", "U/L Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L", "liver biopsy specimen", "inflammation", "destruction", "small", "medium sized intrahepatic bile ducts", "Magnetic resonance cholangiopancreatography", "multiple small stones", "gallbladder", "normal appearance", "extrahepatic bile ducts", "following", "most appropriate next step"]}
{"question": "A 75-year-old man presents to the physician with difficulty breathing for the last 2 months. He denies any cough, fever, or chest pain. His past medical history is significant for hypertension for which he takes chlorothiazide. He has worked in the construction industry, applying insulation to roofs for over 20 years. He denies smoking, drinking, and illicit drug use. His pulse rate is 74/min, respiratory rate is 14/min, blood pressure is 130/76 mm Hg, and temperature is 36.8°C (98.2°F). Physical examination reveals some end-inspiratory crackles at the lung bases. No other examination findings are significant. The lung inflation curve is obtained for the patient and is shown in the image. Which of the following most likely accounts for this patient’s symptoms?", "answer": "Pulmonary fibrosis", "options": {"A": "Normal aging", "B": "Alpha-1 antitrypsin deficiency", "C": "Asthma", "D": "Idiopathic pulmonary hypertension", "E": "Pulmonary fibrosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["75 year old man presents", "physician", "difficulty breathing", "months", "cough", "fever", "chest pain", "past medical history", "significant", "hypertension", "chlorothiazide", "applying insulation", "roofs", "over 20 years", "smoking", "drinking", "illicit drug use", "pulse rate", "74 min", "respiratory rate", "min", "blood pressure", "76 mm Hg", "temperature", "36", "98", "reveals", "end inspiratory crackles", "lung bases", "examination findings", "significant", "lung inflation curve", "obtained", "patient", "following", "likely accounts", "patients symptoms"]}
{"question": "A 14-year-old boy presents to an urgent care clinic complaining of a runny nose that has lasted for a few weeks. He also reports sneezing attacks that last up to an hour, nasal obstruction, and generalized itching. He has similar episodes each year during the springtime that prevent him from going out with his friends or trying out for sports. His younger brother has a history of asthma. Which of the following diseases has a similar pathophysiology?", "answer": "Atopic dermatitis", "options": {"A": "Allergic contact dermatitis", "B": "Atopic dermatitis", "C": "Irritant contact dermatitis", "D": "Systemic lupus erythematosus", "E": "Dermatitis herpetiformis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "urgent care clinic", "runny nose", "lasted", "weeks", "reports sneezing attacks", "last", "hour", "nasal obstruction", "generalized itching", "similar episodes", "year", "prevent", "out", "out", "history of asthma", "following diseases", "similar pathophysiology"]}
{"question": "A 26-year-old G2P1 undergoes labor induction at 40 weeks gestation. The estimated fetal weight was 3890 g. The pregnancy was complicated by gestational diabetes treated with insulin. The vital signs were as follows: blood pressure 125/80 mm Hg, heart rate 91/min, respiratory rate 21/min, and temperature 36.8℃ (98.2℉). The blood workup yields the following results:\nFasting glucose 92 mg/dL\nHbA1c  7.8%\nErythrocyte count 3.3 million/mm3\nHb 11.6 mg/dL\nHt 46%\nThrombocyte count 240,000/mm3\nSerum creatinine 0.71 mg/dL\nALT 12 IU/L\nAST 9 IU/L\nWhich of the following should be administered during labor?", "answer": "5% dextrose", "options": {"A": "5% dextrose", "B": "Intravenous regular insulin", "C": "25% magnesium sulphate", "D": "Erythrocyte mass", "E": "Subcutaneous insulin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "labor induction", "40 weeks gestation", "estimated fetal", "g", "pregnancy", "complicated", "gestational diabetes treated with insulin", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "98", "blood workup", "following results", "Fasting", "mg", "8", "Erythrocyte count", "mm3", "6 mg", "Ht", "Thrombocyte count", "creatinine 0", "ALT", "AST 9", "following", "administered", "labor"]}
{"question": "A 33-year-old man is brought to the emergency department by his partner for 24 hours of fever, severe headache, and neck stiffness. His companion also comments that he has been vomiting several times in the past 8 hours and looks confused. His personal medical history is unremarkable. Upon examination, his blood pressure is 125/82 mm Hg, heart rate 110/mine, and temperature is 38.9 C (102F). There is no rash or any other skin lesions, his lung sounds are clear and symmetrical. There is nuchal rigidity, jolt accentuation of a headache, and photophobia. A lumbar puncture is taken, and cerebrospinal fluid is sent for analysis and a Gram stain (shown in the picture). The patient is put on empirical antimicrobial therapy with ceftriaxone and vancomycin. According to the clinical manifestations and Gram stain, which of the following should be considered in the management of this case?", "answer": "Prophylaxis with rifampin for close contacts", "options": {"A": "Addition of ampicillin", "B": "Prophylaxis with rifampin for close contacts", "C": "Switch to meropenem", "D": "Initiation of amphotericin", "E": "Initiation rifampin, isoniazid, pyrazinamide, and ethambutol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "24 hours", "fever", "severe headache", "neck stiffness", "vomiting several times", "past 8 hours", "looks confused", "personal medical history", "unremarkable", "blood pressure", "mm Hg", "heart rate", "temperature", "rash", "skin lesions", "lung sounds", "clear", "symmetrical", "nuchal rigidity", "headache", "photophobia", "lumbar puncture", "cerebrospinal fluid", "sent", "analysis", "Gram stain", "picture", "patient", "empirical antimicrobial therapy", "ceftriaxone", "vancomycin", "clinical manifestations", "Gram stain", "following"]}
{"question": "A 43-year-old male presents to a clinic for routine follow-up. He was diagnosed with hepatitis B several months ago. He does not have any complaints about his health, except for poor appetite. The general physical examination is normal. The laboratory investigation reveals mildly elevated aminotransferases. Which of the following findings indicate that the patient has developed a chronic form of his viral infection?", "answer": "HbsAg +, Anti-HbsAg -, Anti-HbcAg IgM -, Anti-HbcAg IgG +, HbeAg +, Anti-HbeAg -", "options": {"A": "HbsAg -, Anti-HbsAg -, Anti-HbcAg IgM +, Anti-HbcAg IgG -, HbeAg -, Anti-HbeAg +", "B": "HbsAg +, Anti-HbsAg -, Anti-HbcAg IgM +, Anti-HbcAg IgG -, HbeAg +, Anti-HbeAg -", "C": "HbsAg +, Anti-HbsAg -, Anti-HbcAg IgM -, Anti-HbcAg IgG +, HbeAg +, Anti-HbeAg -", "D": "HbsAg -, Anti-HbsAg +, Anti-HbcAg IgM -, Anti-HbcAg IgG -, HbeAg -, Anti-HbeAg -", "E": "HbsAg -, Anti-HbsAg +, Anti-HbcAg IgM -, Anti-HbcAg IgG +, HbeAg -, Anti-HbeAg +"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male presents", "clinic", "routine follow-up", "diagnosed", "hepatitis B", "months", "not", "complaints", "poor appetite", "normal", "laboratory", "reveals mildly elevated aminotransferases", "following findings", "patient", "chronic form", "viral"]}
{"question": "A 32-year-old man comes to the physician with involuntary lip smacking and hand and leg movements for the past two weeks. The movements are causing him difficulty walking and functioning at work. He has bipolar disorder treated with fluphenazine. Three months ago, he was hospitalized because of a manic episode, and his dosage was adjusted. Since then, he has not experienced a depressed mood, increased energy, irritability, or a change in his eating or sleeping patterns. He does not have suicidal or homicidal ideation. His temperature is 37.2°C (99°F), pulse is 75/min, and blood pressure is 126/78 mmHg. Examination shows repetitive lip smacking and dance-like hand and leg movements. His speech is not pressured, and his affect is appropriate. He is switched from fluphenazine to risperidone and his symptoms improve. Which of the following mechanisms explains this patient's improvement?", "answer": "Weaker dopamine antagonism", "options": {"A": "Weaker acetylcholine antagonism", "B": "Weaker histamine antagonism", "C": "Weaker acetylcholine agonism", "D": "Weaker dopamine antagonism", "E": "Weaker histamine agonism"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "lip smacking", "hand", "leg movements", "past two weeks", "movements", "causing", "difficulty walking", "functioning", "bipolar disorder treated with fluphenazine", "Three months", "hospitalized", "manic episode", "dosage", "adjusted", "then", "not", "depressed mood", "increased energy", "irritability", "change", "eating", "sleeping patterns", "not", "suicidal", "homicidal ideation", "temperature", "pulse", "75 min", "blood pressure", "mmHg", "lip smacking", "hand", "leg movements", "speech", "not pressured", "appropriate", "switched", "fluphenazine", "risperidone", "symptoms", "following mechanisms", "patient's"]}
{"question": "A 37-year-old-woman presents to the emergency room with complaints of fever and abdominal pain. Her blood pressure is 130/74 mmHg, pulse is 98/min, temperature is 101.5°F (38.6°C), and respirations are 23/min. The patient reports that she had a laparoscopic cholecystectomy 4 days ago but has otherwise been healthy. She is visiting her family from Nebraska and just arrived this morning from a 12-hour drive. Physical examination revealed erythema and white discharge from abdominal incisions and tenderness upon palpations at the right upper quadrant. What is the most probable cause of the patient’s fever?", "answer": "Wound infection", "options": {"A": "Pulmonary atelectasis", "B": "Pulmonary embolism", "C": "Residual gallstones", "D": "Urinary tract infection", "E": "Wound infection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency room", "complaints", "fever", "abdominal pain", "blood pressure", "74 mmHg", "pulse", "98 min", "temperature", "respirations", "23 min", "patient reports", "laparoscopic cholecystectomy", "days", "healthy", "Nebraska", "morning", "12-hour", "revealed erythema", "white discharge", "abdominal incisions", "tenderness", "palpations", "right upper quadrant", "cause", "patients fever"]}
{"question": "A 16-year-old girl comes to the physician because she is worried about gaining weight. She reports that at least twice a week, she eats excessive amounts of food but feels ashamed about losing control soon after. She is very active in her high school's tennis team and goes running daily to lose weight. She has a history of cutting her forearms with the metal tab from a soda can. Her last menstrual period was 3 weeks ago. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Physical examination shows enlarged, firm parotid glands bilaterally. There are erosions of the enamel on the lingual surfaces of the teeth. Which of the following is the most likely diagnosis?", "answer": "Bulimia nervosa", "options": {"A": "Obsessive-compulsive disorder", "B": "Borderline personality disorder", "C": "Bulimia nervosa", "D": "Anorexia nervosa", "E": "Body dysmorphic disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "gaining", "reports", "twice", "week", "eats excessive amounts", "food", "ashamed", "control", "very active", "high", "daily to", "weight", "history", "cutting", "forearms", "tab", "last menstrual period", "3 weeks", "5 ft 5", "tall", "57 kg", "BMI", "kg/m2", "enlarged", "firm parotid glands", "erosions of", "enamel", "lingual surfaces of", "teeth", "following", "diagnosis"]}
{"question": "A 37-year-old woman presents to the emergency department with a chief complaint of severe pain in her face. She states that over the past week she has experienced episodic and intense pain in her face that comes on suddenly and resolves on its own. She states she feels the pain over her cheek and near her eye. The pain is so severe it causes her eyes to tear up, and she is very self conscious about the episodes. She fears going out in public as a result and sometimes feels her symptoms come on when she thinks about an episode occurring while in public. While she is waiting in the emergency room her symptoms resolve. The patient has a past medical history of diabetes, constipation, irritable bowel syndrome, and anxiety. She is well known to the emergency department for coming in with chief complaints that often do not have an organic etiology. Her temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary and abdominal exams are within normal limits. Neurological exam reveals cranial nerves II-XII are grossly intact. The patient's pupils are equal and reactive to light. Pain is not elicited with palpation of the patient's face. Which of the following is the best initial step in management?", "answer": "Carbamazepine", "options": {"A": "Alprazolam", "B": "Carbamazepine", "C": "High flow oxygen", "D": "Ibuprofen", "E": "Regular outpatient follow up"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "chief complaint", "severe pain", "face", "states", "past week", "episodic", "intense pain", "face", "states", "pain", "cheek", "eye", "pain", "so severe", "causes", "eyes to tear", "very", "episodes", "out", "result", "sometimes", "symptoms", "episode occurring", "waiting", "emergency room", "symptoms", "patient", "past medical diabetes", "constipation", "irritable bowel syndrome", "anxiety", "well known", "emergency department", "chief complaints", "often", "not", "organic etiology", "temperature", "99", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "Cardiopulmonary", "abdominal exams", "normal limits", "Neurological exam reveals cranial nerves II XII", "intact", "patient's pupils", "equal", "reactive to light", "Pain", "not elicited", "palpation", "patient's face", "following", "best initial step"]}
{"question": "A 45-year-old man with type 2 diabetes mellitus presents to his family physician for a follow-up appointment. He is currently using a 3-drug regimen consisting of metformin, sitagliptin, and glipizide. Despite this therapeutic regimen, his most recent hemoglobin A1c level is 8.1%. Which of the following is the next best step for this patient?", "answer": "Discontinue glipizide; initiate insulin glargine 10 units at bedtime", "options": {"A": "Discontinue glipizide; initiate insulin glargine 10 units at bedtime", "B": "Discontinue metformin; initiate basal-bolus insulin", "C": "Discontinue metformin; initiate insulin aspart at mealtimes", "D": "Discontinue sitagliptin; initiate basal-bolus insulin", "E": "Discontinue metformin; initiate insulin glargine 10 units at bedtime"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "type 2 diabetes mellitus presents", "family physician", "follow-up appointment", "currently using", "3 drug regimen consisting", "metformin", "sitagliptin", "glipizide", "therapeutic regimen", "most recent hemoglobin level", "8.1", "following", "next best step", "patient"]}
{"question": "A 35-year-old woman has been trying to conceive with her 37-year-old husband for the past 4 years. After repeated visits to a fertility clinic, she finally gets pregnant. Although she missed most of her antenatal visits, her pregnancy was uneventful. A baby girl is born at the 38th week of gestation with some abnormalities. She has a flat face with upward-slanting eyes and a short neck. The tongue seems to be protruding from a small mouth. She has poor muscle tone and excessive joint laxity. The pediatrician orders an analysis of the infant’s chromosomes, also known as a karyotype (see image). The infant is most likely to suffer from which of the following conditions in the future?", "answer": "Acute lymphoblastic leukemia", "options": {"A": "Acute lymphoblastic leukemia", "B": "Chronic myelogenous leukemia", "C": "Immotile cilia syndrome", "D": "Macroorchidism", "E": "Red blood cell sickling"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "to", "year old", "past", "years", "repeated", "fertility", "gets pregnant", "missed most", "antenatal visits", "pregnancy", "baby girl", "born", "week", "gestation", "abnormalities", "flat face", "upward", "eyes", "short neck", "tongue", "to", "protruding", "small mouth", "poor muscle tone", "excessive joint laxity", "pediatrician orders", "analysis", "infants chromosomes", "known", "karyotype", "see", "infant", "to suffer", "following conditions", "future"]}
{"question": "A 64-year-old gentleman with hypertension is started on a new diuretic medication by his primary care physician because of poor blood pressure control on his previous regimen. Before starting, he is warned by his physician that the new medication may have side effects including hypokalemia and metabolic alkalosis. Furthermore it may cause alterations in his metabolites such as hyperglycemia, hyperlipidemia, hyperuricemia, and hypercalcemia. What is the mechanism of the class of diuretic most likely being recommended by the physician?", "answer": "NCC inhibitor in distal tubule", "options": {"A": "Osmotic diuresis", "B": "NKCC inhibitor in loop of Henle", "C": "NCC inhibitor in distal tubule", "D": "ENaC inhibitor in collecting duct", "E": "Aldosterone receptor inhibitor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["64 year old", "hypertension", "started", "new diuretic medication", "primary care physician", "of poor blood pressure control", "previous regimen", "starting", "physician", "new medication", "side effects including hypokalemia", "metabolic alkalosis", "cause", "metabolites", "hyperglycemia", "hyperlipidemia", "hyperuricemia", "hypercalcemia", "mechanism", "diuretic", "likely", "physician"]}
{"question": "A 66-year-old man presents to the outpatient department complaining of a rash similar to the ones in the image. The skin lesions have been present for about 2 weeks. It is present in the buttocks and both inferior limbs. There is no association of skin lesions with exposure to sunlight or medication use. The patient also reports joint pain affecting the distal and proximal joints in both the upper and lower limbs. The joint pain has been present for about a week and seems to improve with Tylenol use. The patient is a retired armed force personnel with an extensive tour of overseas duty. He received blood transfusion following a career-ending injury about 30 years ago. He denies alcohol and tobacco use. He is currently in a monogamous relationship with his wife for 40 years. His past medical history is significant for hypertension controlled on Enalapril. Physical examination shows mild pallor, multiple palpable purpuric lesions with occasional ulcerations bilaterally in the upper and lower limbs. Pulse rate is 88/min and blood pressure is 128/82 mm Hg. Laboratory test findings are:\nHIV I and II antibodies negative\nRheumatoid factor positive\nHepatitis C antigen positive\nHepatitis B surface antigen positive\nHepatitis B antibody positive\nAnti-neutrophil antibody positive\nHematocrit 38%\nWhich of the following mechanisms is most likely responsible for his clinical presentation?", "answer": "Virus-induced clonal expansion of autoreactive B lymphocytes", "options": {"A": "Cyto-proliferative effect of HCV on hepatocytes", "B": "Excessive uroporphyrinogen caused by HCV induced decarboxylase deficiency", "C": "Defective hepatic removal of IgA caused by chronic HCV", "D": "Monoclonal expansion of IgM caused by benign neoplasia", "E": "Virus-induced clonal expansion of autoreactive B lymphocytes"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["66 year old man presents", "outpatient", "complaining of a rash similar", "ones", "skin lesions", "present", "2 weeks", "present", "buttocks", "inferior limbs", "association", "skin lesions", "exposure to sunlight", "medication use", "patient", "reports joint pain affecting", "distal", "proximal joints", "upper", "lower limbs", "joint pain", "present", "week", "to", "Tylenol use", "patient", "retired armed force personnel", "extensive tour", "received blood transfusion following", "ending injury", "30 years", "alcohol", "tobacco use", "currently", "relationship", "40 years", "past medical history", "significant", "hypertension controlled", "Enalapril", "mild pallor", "multiple palpable purpuric lesions", "occasional ulcerations", "upper", "lower limbs", "Pulse rate", "88 min", "blood pressure", "mm Hg", "Laboratory test findings", "HIV I", "antibodies negative Rheumatoid factor", "Hepatitis", "B surface antigen", "neutrophil antibody", "Hematocrit", "following mechanisms", "responsible"]}
{"question": "A 68-year-old man is brought to the emergency department because of fever, progressive weakness, and cough for the past five days. He experienced a similar episode 2 months ago, for which he was hospitalized for 10 days while visiting his son in Russia. He states that he has never fully recovered from that episode. He felt much better after being treated with antibiotics, but he still coughs often during meals. He sometimes also coughs up undigested food after eating. For the last 5 days, his coughing has become more frequent and productive of yellowish-green sputum. He takes hydrochlorothiazide for hypertension and pantoprazole for the retrosternal discomfort that he often experiences while eating. He has smoked half a pack of cigarettes daily for the last 30 years and drinks one shot of vodka every day. The patient appears thin. His temperature is 40.1°C (104.2°F), pulse is 118/min, respirations are 22/min, and blood pressure is 125/90 mm Hg. Auscultation of the lungs shows right basal crackles. There is dullness on percussion at the right lung base. The remainder of the physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 15.4 g/dL\nLeukocyte count 17,000/mm3\nPlatelet count 350,000/mm3\nNa+ 139 mEq/L\nK+\n4.6 mEq/L\nCl- 102 mEq/L\nHCO3- 25 mEq/L\nUrea Nitrogen 16 mg/dL\nCreatinine 1.3 mg/dL\nAn x-ray of the chest shows a right lower lobe infiltrate. Which of the following is the most likely explanation for this patient's symptoms?\"", "answer": "Outpouching of the hypopharynx\n\"", "options": {"A": "Weak tone of the lower esophageal sphincter", "B": "Formation of a tissue cavity containing necrotic debris", "C": "Uncoordinated contractions of the esophagus", "D": "Unrestricted growth of pneumocytes with invasion of the surrounding tissue", "E": "Outpouching of the hypopharynx\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "fever", "progressive weakness", "cough", "past", "similar episode", "months", "hospitalized", "10 days", "Russia", "states", "never", "recovered", "episode", "much better", "treated with", "coughs often", "meals", "sometimes", "coughs", "undigested food", "eating", "last", "days", "coughing", "more frequent", "productive", "green sputum", "hydrochlorothiazide", "hypertension", "pantoprazole", "retrosternal discomfort", "often", "eating", "smoked half", "pack", "cigarettes daily", "last 30 years", "one shot", "day", "patient appears thin", "temperature", "40", "pulse", "min", "respirations", "min", "blood pressure", "90 mm Hg", "Auscultation", "lungs", "right basal crackles", "dullness", "percussion", "right lung base", "abnormalities", "Laboratory studies", "Hemoglobin 15.4 g", "Leukocyte", "mm3 Platelet count 350", "K", "6", "HCO3", "mg", "mg", "x-ray of", "chest", "right lower lobe infiltrate", "following", "explanation", "patient", "ymptoms?"]}
{"question": "Benzodiazepines are clinically useful because of their inhibitory effects on the central nervous system. Which of the following correctly pairs the site of action of benzodiazepines with the molecular mechanism by which a they exerts their effects?", "answer": "GABA-A receptors; increasing the frequency of activation of a chloride ion channel", "options": {"A": "GABA-A receptors; blocking action of GABA", "B": "GABA-B receptors; activating potassium channels", "C": "GABA-B receptors; activating a G-protein coupled receptor", "D": "GABA-A receptors; increasing the duration of activation of a chloride ion channel", "E": "GABA-A receptors; increasing the frequency of activation of a chloride ion channel"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["Benzodiazepines", "useful", "of", "effects", "central nervous system", "following", "pairs", "site of action", "benzodiazepines", "molecular mechanism", "exerts", "effects"]}
{"question": "A 57-year-old male with diabetes mellitus type II presents for a routine check-up. His blood glucose levels have been inconsistently controlled with medications and diet since his diagnosis 3 years ago. At this current visit, urinalysis demonstrates albumin levels of 250 mg/day. All prior urinalyses have shown albumin levels below 20 mg/day. At this point in the progression of the patient’s disease, which of the following is the most likely finding seen on kidney biopsy?", "answer": "Glomerular basement membrane thickening and mesangial expansion", "options": {"A": "Normal kidney biopsy, no pathological finding is evident at this time", "B": "Glomerular hypertrophy with slight glomerular basement membrane thickening", "C": "Glomerular basement membrane thickening and mesangial expansion", "D": "Kimmelstiel-Wilson nodules and tubulointerstitial fibrosis", "E": "Significant global glomerulosclerosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["57 year old male", "diabetes mellitus type II presents", "routine check-up", "blood glucose levels", "controlled with medications", "diet", "diagnosis", "years", "current", "urinalysis", "albumin levels", "mg/day", "prior urinalyses", "albumin levels", "20 mg/day", "point", "progression", "patients disease", "following", "finding seen", "kidney biopsy"]}
{"question": "A 26-year-old man comes to the physician for evaluation of fatigue, facial rash, hair loss, and tingling of his hands and feet. He has followed a vegetarian diet for the past 3 years and has eaten 8 raw egg whites daily for the past year in preparation for a bodybuilding competition. Physical examination shows conjunctival injections and a scaly, erythematous rash around the eyes and mouth. Laboratory studies show decreased activity of propionyl-coenzyme A carboxylase in peripheral blood lymphocytes. Which of the following substances is most likely to be decreased in this patient?", "answer": "Oxaloacetate", "options": {"A": "Cystathionine", "B": "Ribulose-5-phosphate", "C": "Adenine", "D": "Lactate", "E": "Oxaloacetate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "fatigue", "facial rash", "hair loss", "tingling", "hands", "feet", "followed", "vegetarian diet", "past", "years", "eaten", "daily", "past year", "preparation", "bodybuilding", "conjunctival injections", "scaly", "erythematous rash", "eyes", "mouth", "Laboratory studies", "decreased", "following", "to", "decreased", "patient"]}
{"question": "A full-term and healthy infant girl presents to the office for a newborn visit. The baby was born at 40 weeks to a 35-year-old G2P1 mother via cesarean section for breech presentation. She had an unremarkable delivery and hospital course, but family history is significant for a sister with developmental dysplasia of the hip (DDH). A physical exam is normal. During a discussion with the mother about the possibility of screening imaging for DDH she becomes very anxious and would like something done as soon as possible. What would be the imaging of choice in this scenario?", "answer": "Hip ultrasound at 6 weeks of age", "options": {"A": "Hip MRI at 6 weeks of age", "B": "Hip ultrasound at 6 weeks of age", "C": "Hip ultrasound within the next week", "D": "Hip radiograph at 6 weeks of age", "E": "Hip radiograph at 5 months of age"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["full-term", "healthy infant girl presents", "office", "newborn", "baby", "born", "40 weeks", "35 year old", "cesarean section", "breech presentation", "unremarkable delivery", "hospital course", "family history", "significant", "developmental dysplasia of the hip", "normal", "discussion", "possibility", "screening imaging", "DDH", "very anxious", "done", "possible", "imaging", "scenario"]}
{"question": "A 26-year-old man comes to the emergency department for evaluation of burning with urination and purulent urethral discharge for the past 3 days. He is sexually active with multiple female partners. Several months ago he was diagnosed with urethritis caused by gram-negative diplococci and received antibiotic treatment with complete resolution of his symptoms. A Gram stain of the patient's urethral discharge shows gram-negative intracellular diplococci. Which of the following properties of the infecting organism most contributed to the pathogenesis of this patient's recurrent infection?", "answer": "Variation of expressed pilus proteins", "options": {"A": "Expression of beta-lactamase genes", "B": "Synthesis of capsular polysaccharides", "C": "Absence of immunogenic proteins", "D": "Production of enzymes that hydrolyze urea", "E": "Variation of expressed pilus proteins"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "emergency department", "burning", "urination", "purulent urethral discharge", "past 3 days", "sexually active", "female", "months", "diagnosed", "urethritis caused", "received antibiotic treatment", "complete resolution", "symptoms", "Gram stain", "patient's urethral", "intracellular", "following properties", "infecting", "most", "pathogenesis", "patient's recurrent infection"]}
{"question": "A 54-year-old woman comes to the emergency department because of a 5-hour history of diffuse, severe abdominal pain, nausea, and vomiting. She reports that there is no blood or bile in the vomitus. Two weeks ago, she started having mild aching epigastric pain, which improved with eating. Since then, she has gained 1.4 kg (3 lb). She has a 2-year history of osteoarthritis of both knees, for which she takes ibuprofen. She drinks 1–2 glasses of wine daily. She is lying supine with her knees drawn up and avoids any movement. Her temperature is 38.5°C (101.3°F), pulse is 112/min, respirations are 20/min, and blood pressure is 115/70 mm Hg. Physical examination shows abdominal tenderness and guarding; bowel sounds are decreased. An x-ray of the chest is shown. Which of the following is the most likely cause of this patient's current symptoms?", "answer": "Perforated peptic ulcer", "options": {"A": "Perforated peptic ulcer", "B": "Acute pancreatitis", "C": "Acute mesenteric ischemia", "D": "Gastroesophageal reflux disease", "E": "Cholecystolithiasis\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old woman", "emergency department", "5 hour history", "diffuse", "severe abdominal", "nausea", "vomiting", "reports", "blood", "bile", "vomitus", "Two weeks", "started", "mild aching epigastric", "improved", "eating", "then", "gained 1.4 kg", "3", "2 year history", "knees", "ibuprofen", "glasses", "daily", "lying supine", "knees", "movement", "temperature", "pulse", "min", "respirations", "20 min", "blood pressure", "70 mm Hg", "abdominal tenderness", "guarding", "bowel sounds", "decreased", "x-ray of", "chest", "following", "most likely cause", "patient's current symptoms"]}
{"question": "A 52-year-old-woman presents to an urgent care clinic with right upper quadrant pain for the past few hours. She admits to having similar episodes of pain in the past but milder than today. Past medical history is insignificant. She took an antacid, but it did not help. Her temperature is 37°C (98.6°F ), respirations are 16/min, pulse is 78/min, and blood pressure is 122/98 mm Hg. Physical examination is normal, and she says that her pain has subsided. The urgent care provider suspects she has cholecystitis, so she undergoes a limited abdominal ultrasound to confirm it. However, no evidence of cholecystitis is seen with ultrasound, but adenomyomatosis of the gallbladder is incidentally noted. The patient has no clinical features suspicious for malignancy. What is the next best step in the management of this patient?", "answer": "No further treatment required", "options": {"A": "Cholecystectomy", "B": "Barium swallow study", "C": "Endoscopic retrograde cholangiopancreatography", "D": "Magnetic resonance cholangiopancreatography", "E": "No further treatment required"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "urgent care clinic", "right upper quadrant pain", "past", "hours", "to", "similar episodes of pain", "past", "milder", "today", "Past medical history", "antacid", "not help", "temperature", "98", "respirations", "min", "pulse", "min", "blood pressure", "98 mm Hg", "normal", "pain", "urgent care provider", "cholecystitis", "limited abdominal ultrasound to confirm", "cholecystitis", "seen", "ultrasound", "adenomyomatosis of", "gallbladder", "noted", "patient", "clinical features suspicious for malignancy", "next best step", "patient"]}
{"question": "A 67-year-old man presents to your office with a chief complaint of constipation and many other perturbing minor medical concerns. He reports tiring easily, which he attributes to old age and years of persistent pain in his back and ribs. A complete blood count shows low hemoglobin and elevated serum creatinine. A peripheral blood smear shows stacks of red blood cells among other findings, and serum electropheresis reveals an abnormal concentration of protein resulting in a spike. Which of the following additional findings would you expect to see in this patient?", "answer": "Bence-Jones proteins in the urine", "options": {"A": "Early satiety and splenomegaly", "B": "Smudge cells on peripheral smear", "C": "An elevated PSA and a nodular prostate", "D": "Bence-Jones proteins in the urine", "E": "No additional findings - normal aging explains symptoms"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["67 year old man presents", "office", "chief complaint", "constipation", "minor medical", "reports tiring easily", "attributes", "old age", "years", "persistent pain", "back", "ribs", "complete blood count", "low hemoglobin", "elevated serum creatinine", "peripheral blood smear", "stacks", "red blood cells", "findings", "serum", "reveals", "abnormal concentration", "protein resulting in", "following additional findings", "to see", "patient"]}
{"question": "A 16-year-old girl presents with episodes of sharp pain in her left upper limb. She says her symptoms gradually onset a few months ago and have progressively worsened. She describes her pain as severe and feeling like “someone stabbing me in my arm and then the pain moves down to my hand”. She says the pain is worse after physical activity and improves with rest. She also says she has some vision problems in her left eye. The patient is afebrile, and her vital signs are within normal limits. On physical examination, there are no visible deformities in the shoulders or upper extremities. Palpation of her left upper limb reveals tenderness mainly near her neck. Mild left-sided ptosis is present. There is anisocoria of her left pupil which measures 1 mm smaller than the right. The right upper limb is normal. A plain radiograph and an MRI are ordered (shown in the image). Which of the following focal neurologic deficits would most likely be seen on the left hand of this patient?", "answer": "Numbness over her left little finger", "options": {"A": "Numbness over her left thumb", "B": "Crutch palsy", "C": "Numbness over her left index finger", "D": "Numbness over her left little finger", "E": "Numbness over the thenar area of her left hand"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "episodes of sharp pain", "left upper limb", "symptoms", "onset", "few months", "worsened", "pain", "severe", "stabbing", "arm", "then", "pain moves", "hand", "pain", "worse", "improves", "vision problems", "left eye", "patient", "afebrile", "vital signs", "normal limits", "visible deformities", "shoulders", "upper extremities", "Palpation of", "left", "limb reveals tenderness", "neck", "Mild left-sided ptosis", "present", "anisocoria", "left pupil", "measures 1 mm smaller", "right", "right upper limb", "normal", "plain radiograph", "MRI", "ordered", "following focal neurologic deficits", "most likely", "seen", "left hand", "patient"]}
{"question": "A 45-year-old man presents with worsening joint pain and stiffness. Past medical history is significant for rheumatoid arthritis, diagnosed 3 months ago and managed with celecoxib and methotrexate, and occasional gastric reflux, managed with omeprazole. His vitals are a pulse of 80/min, a respiratory rate of 16/min, and blood pressure of 122/80 mm Hg. On physical examination, the left wrist is swollen, stiff, and warm to touch, and the right wrist is red and warm. There is limited active and passive range of motion at the proximal interphalangeal and metacarpophalangeal joints of both hands. The remainder of the examination is unremarkable. A plain radiograph of the hands shows progressive degeneration of multiple joints. Another drug, etanercept, is added to help control progressive arthritis. Which of the following diagnostic tests should be ordered before starting this new medication in this patient?", "answer": "Tuberculosis screening", "options": {"A": "Tuberculosis screening", "B": "Antinuclear antibody (ANA) level", "C": "Endoscopy", "D": "Bleeding time", "E": "Malignancy screening"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "worsening joint", "stiffness", "Past medical history", "significant", "rheumatoid arthritis", "diagnosed 3 months", "celecoxib", "methotrexate", "occasional gastric reflux", "omeprazole", "pulse", "80 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "left wrist", "swollen", "stiff", "warm to touch", "right wrist", "red", "warm", "limited active", "passive range of motion", "proximal", "joints of", "hands", "unremarkable", "radiograph of", "hands", "progressive degeneration", "multiple joints", "drug", "etanercept", "added to help control progressive arthritis", "following diagnostic tests", "ordered", "starting", "new medication", "patient"]}
{"question": "A 78-year-old male comes to the physician’s office for a routine check-up. He complains of increased lower extremity swelling, inability to climb the one flight of stairs in his home, and waking up in the middle of the night 2-3 times gasping for breath. He has had to increase the number of pillows on which he sleeps at night. These symptoms started 9 months ago and have been progressing. The doctor starts him on a medication regimen, one of which changes his Starling curve from A to B as shown in the Figure. Which of the following medications is most consistent with this mechanism of action?", "answer": "Digoxin", "options": {"A": "Metoprolol", "B": "Furosemide", "C": "Hydrochlorothiazide", "D": "Aspirin", "E": "Digoxin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old male", "physicians office", "routine check-up", "increased lower extremity swelling", "to climb", "one", "home", "waking", "middle", "night", "times gasping", "breath", "to increase", "number", "pillows", "sleeps", "night", "symptoms started", "months", "progressing", "doctor starts", "medication regimen", "one", "changes", "curve", "following medications", "most", "mechanism of action"]}
{"question": "A 68-year-old woman comes to the physician because of lower back pain that began suddenly 2 weeks ago after getting up from her chair. She has hypertension, chronic bilateral knee pain, and a history of breast cancer 15 years ago that was treated with lumpectomy. Her mother has rheumatoid arthritis. Medications include hydrochlorothiazide and acetaminophen. She appears well. Her vital signs are within normal limits. Physical examination shows tenderness to palpation of the lower spine. Both knees are enlarged and swollen. Neurologic examination shows sensorineural hearing impairment of the left ear. Her gamma-glutamyl transferase (GGT) is 30 U/L (N: 0–30 U/L), alkaline phosphatase (ALP) is 310 U/L, and serum calcium is 10.2 mg/dL. A spinal x-ray shows a fracture in the L4 vertebra. Which of the following is the most likely diagnosis?", "answer": "Paget disease of bone", "options": {"A": "Type 1 osteopetrosis", "B": "Primary biliary cholangitis", "C": "Rheumatoid arthritis", "D": "Paget disease of bone", "E": "Bone metastases"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "lower back pain", "began", "2 weeks", "getting", "chair", "hypertension", "chronic bilateral", "history of breast cancer", "years", "treated with lumpectomy", "rheumatoid arthritis", "Medications include hydrochlorothiazide", "acetaminophen", "appears well", "vital signs", "normal limits", "tenderness", "palpation", "lower spine", "knees", "enlarged", "swollen", "Neurologic examination", "sensorineural hearing impairment", "left ear", "gamma-glutamyl transferase", "30 U/L", "N", "U/L", "alkaline phosphatase", "U/L", "serum calcium", "10", "mg/dL", "spinal x-ray", "fracture", "L4 vertebra", "following", "diagnosis"]}
{"question": "A 4-year-old boy is brought in to his pediatrician by his mother because of several days of fever, irritability, and ear pain. His mother says that she was particularly concerned about his complaints of difficulty hearing and dizziness. Physical exam reveals a bulging tympanic membrane. As the pediatrician does the examination, she explains to the medical student accompanying her that the lining of the infected area is derived from the endodermal component of a certain embryological structure. The mesodermal component at the same level is most likely responsible for the development of which of the following structures?", "answer": "Mylohyoid muscle", "options": {"A": "Cricothyroid muscle", "B": "Mylohyoid muscle", "C": "Stylohyoid muscle", "D": "Stylopharyngeus muscle", "E": "Thyroarytenoid muscle"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "pediatrician", "mother", "days", "fever", "irritability", "ear pain", "complaints", "difficulty", "dizziness", "reveals", "bulging tympanic membrane", "pediatrician", "medical student", "lining", "infected area", "derived", "endodermal component", "certain embryological structure", "mesodermal component", "same level", "responsible", "development", "following structures"]}
{"question": "A 23-year-old woman comes to the physician because of right-sided blurry vision and eye pain for 4 days. She has a 6-day history of low-grade fever, headache, and malaise. One year ago, she was diagnosed with Crohn disease. Her only medication is prednisone. Her temperature is 38°C (100.4°F), pulse is 84/min, and blood pressure is 112/75 mm Hg. The right eyelid is erythematous and tender; there are multiple vesicles over the right forehead and the tip of the nose. Visual acuity is 20/20 in the left eye and 20/80 in the right eye. Extraocular movements are normal. The right eye shows conjunctival injection and reduced corneal sensitivity. Fluorescein staining shows a corneal lesion with a tree-like pattern. Which of the following is the most likely diagnosis?", "answer": "Herpes zoster keratitis", "options": {"A": "Pseudomonas keratitis", "B": "Anterior uveitis", "C": "Herpes zoster keratitis", "D": "Angle-closure glaucoma", "E": "Herpes simplex keratitis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "physician", "right-sided blurry vision", "eye pain", "4 days", "6-day history", "low-grade fever", "headache", "malaise", "One year ago", "diagnosed", "Crohn disease", "only medication", "prednisone", "temperature", "100", "pulse", "84 min", "blood pressure", "75 mm Hg", "right eyelid", "erythematous", "tender", "multiple vesicles", "right forehead", "tip of", "nose", "Visual acuity", "20/20", "left eye", "20/80", "right eye", "Extraocular movements", "normal", "right eye", "conjunctival injection", "reduced corneal", "Fluorescein staining", "corneal lesion", "tree", "pattern", "following", "diagnosis"]}
{"question": "A pathologist examines a tissue specimen in which cells are grouped together in acini with visible ducts between them. He finds a patch of pale cells with a rich blood supply among the highly basophilic and granular cells. A representative micrograph is shown in the image. Which statement is correct about these cells?", "answer": "There are several different types of cells within the patch that cannot be differentiated by light microscopy.", "options": {"A": "These cells should be separated from the basophils by a dense capsule.", "B": "These cells are often found to be damaged in acute pancreatitis with a subsequent increase in serum amylase levels.", "C": "Some of these cells undergo transformation and begin to secrete insulin to compensate for the loss of pancreatic beta cells.", "D": "There are several different types of cells within the patch that cannot be differentiated by light microscopy.", "E": "Some of these cells are capable of producing leptin, a hormone which regulates satiety."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["pathologist", "tissue specimen", "cells", "grouped together", "acini", "visible ducts", "finds", "patch", "pale cells", "rich blood supply", "highly basophilic", "granular cells", "micrograph", "correct", "cells"]}
{"question": "A 34-year-old woman presents to the emergency department with prominent hypotension and tachycardia. On examination, she has a low central venous pressure and high cardiac output. Her temperature is 38.9°C (102.0°F). The physician suspects a bacterial infection with a gram-negative bacterium. Samples are sent to the lab. Meanwhile, high volumes of fluids were given, but the blood pressure did not improve. She was started on noradrenaline. At the biochemical level, a major reaction was induced as part of this patient’s presentation. Of the following vitamins, which one is related to the coenzyme that participates in this induced biochemical reaction?", "answer": "Vitamin B3 (niacin)", "options": {"A": "Vitamin B1 (thiamine)", "B": "Vitamin B2 (riboflavin)", "C": "Vitamin B3 (niacin)", "D": "Vitamin B5 (pantothenic acid)", "E": "Vitamin B6 (pyridoxal phosphate)"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "prominent hypotension", "tachycardia", "low central venous pressure", "high cardiac output", "temperature", "physician", "bacterial infection with", "gram-negative bacterium", "sent", "lab", "high volumes of fluids", "given", "blood pressure", "not", "started", "noradrenaline", "biochemical level", "major reaction", "induced", "part of", "patients", "following vitamins", "one", "related", "coenzyme", "induced"]}
{"question": "A public health researcher is invited to participate in a government meeting on immunization policies. Other participants in the meeting include physicians, pediatricians, representatives of vaccine manufacturers, persons from the health ministry, etc. For a specific viral disease, there are 2 vaccines - one is a live attenuated vaccine (LAV) and the other is a subunit vaccine. Manufacturers of both the vaccines promote their own vaccines in the meeting. Non-medical people in the meeting ask the public health researcher to compare the 2 types of vaccines objectively. The public health researcher clearly explains the pros and cons of the 2 types of vaccines. Which of the following statements is most likely to have been made by the public health researcher in his presentation?", "answer": "LAV requires stricter requirements for cold chain maintenance as compared to a subunit vaccine", "options": {"A": "LAV has a less potential for immunization errors as compared to a subunit vaccine", "B": "LAV cannot cause symptomatic infection in a immunocompetent person and, therefore, is as safe as a subunit vaccine", "C": "LAV is equally safe as a subunit vaccine for administration to a pregnant woman", "D": "LAV requires stricter requirements for cold chain maintenance as compared to a subunit vaccine", "E": "LAV produces poorer immunological memory than a subunit vaccine as the later contains only specific immunogenic antigens"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["public health researcher", "to", "immunization", "include physicians", "pediatricians", "vaccine", "persons", "health", "specific viral disease", "2 vaccines", "one", "live attenuated", "subunit vaccine", "vaccines", "vaccines", "Non medical", "public health researcher to", "2 types", "vaccines", "public health researcher", "pros", "types", "vaccines", "following", "to", "made", "public health researcher"]}
{"question": "A 67-year-old man presents to his primary care physician for a decline in his hearing that he noticed over the past week. The patient has a past medical history of hypertension and diabetes mellitus and was recently diagnosed with bladder cancer which is currently appropriately being treated. The patient is a hunter and often goes shooting in his spare time. His recent sick contacts include his grandson who is being treated with amoxicillin for ear pain. Physical exam is notable for decreased hearing bilaterally. The Weber test does not localize to either ear, and the Rinne test demonstrates air conduction is louder than bone conduction. Which of the following is the most likely etiology for this patient's hearing loss?", "answer": "Medication regimen", "options": {"A": "Medication regimen", "B": "Otitis externa", "C": "Otitis media", "D": "Otosclerosis", "E": "Presbycusis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man presents", "primary care physician", "hearing", "past week", "patient", "past medical", "diabetes mellitus", "recently diagnosed", "bladder cancer", "currently", "treated", "patient", "hunter", "often", "shooting", "time", "recent sick", "include", "treated with amoxicillin", "ear pain", "notable", "decreased hearing", "Weber test", "not localize", "ear", "Rinne test", "air conduction", "louder", "bone conduction", "following", "etiology", "patient's hearing loss"]}
{"question": "A 57-year-old man is rushed to the emergency department by ambulance after being found on the floor gasping for air with severe shortness of breath by his partner. Past medical history is significant for congestive heart failure, hypertension, and hyperlipidemia. He normally takes chlorthalidone, atorvastatin, metoprolol, and valsartan, but he recently lost his job and insurance and has not been able to afford his medication in 2 months. Upon arrival at the hospital, his blood pressure is 85/50 mm Hg, heart rate is 110/min, respiratory rate is 24/min, oxygen saturation 90% on 100% oxygen, and temperature is 37.7°C (99.9°F). On physical exam, he appears obese and can only answer questions in short gasps as he struggles to breathe. His heart rate is tachycardic with a mildly irregular rhythm and auscultation of his lungs reveal crackles in the lower lobes, bilaterally. Which of the following physiologic changes is currently seen in this patient?", "answer": "↑ Plasma renin and angiotensin II activity, ↓ blood pressure, ↓ renal perfusion pressure, ↑ serum pH", "options": {"A": "↓ Plasma renin and angiotensin II activity, ↑ blood pressure, normal renal perfusion pressure, ↑ serum pH", "B": "↑ Plasma renin and angiotensin II activity, ↑ blood pressure, normal renal perfusion pressure, ↓ serum pH", "C": "Normal plasma renin and angiotensin II activity, ↓ blood pressure, ↓ renal perfusion pressure, ↓ serum pH", "D": "↑ Plasma renin and angiotensin II activity, ↓ blood pressure, ↓ renal perfusion pressure, ↑ serum pH", "E": "↑ Plasma renin and angiotensin II activity, ↑ blood pressure,↓ renal perfusion pressure, ↑ serum pH"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["57 year old man", "rushed", "emergency department", "ambulance", "found on", "floor gasping", "air", "Past medical history", "significant", "congestive heart failure", "hypertension", "hyperlipidemia", "chlorthalidone", "atorvastatin", "metoprolol", "valsartan", "recently lost", "not", "able to", "medication", "2 months", "arrival", "hospital", "blood pressure", "85 50 mm Hg", "heart rate", "min", "respiratory rate", "min", "oxygen saturation 90", "100", "temperature", "99 9F", "appears obese", "only", "short gasps", "to", "heart rate", "tachycardic", "mildly irregular rhythm", "auscultation", "lungs reveal crackles", "lower lobes", "following physiologic changes", "currently seen", "patient"]}
{"question": "A 23-year-old man presents to the emergency room following a stab wound to the back. He was in a bar when he got into an argument with another man who proceeded to stab him slightly right of the midline of his back. He is otherwise healthy and does not take any medications. He has one previous admission to the hospital for a stab wound to the leg from another bar fight 2 years ago. His temperature is 99°F (37.2°C), blood pressure is 115/80 mmHg, pulse is 100/min, and pulse oximetry is 99% on room air. Cardiopulmonary and abdominal exams are unremarkable; however, he has an abnormal neurologic exam. If this wound entered his spinal cord but did not cross the midline, which of the following would most likely be seen in this patient?", "answer": "Ipsilateral flaccid paralysis at the level of the lesion", "options": {"A": "Ipsilateral loss of pain and temperature sensation below the lesion", "B": "Contralateral loss of tactile, vibration, and proprioception below the lesion", "C": "Contralateral spasticity below the level of the lesion", "D": "Ipsilateral flaccid paralysis at the level of the lesion", "E": "Contralateral loss of sensation at the level of the lesion"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["23 year old man presents", "emergency room following", "stab", "back", "bar", "got", "man", "to stab", "slightly right of", "midline", "back", "healthy", "not", "medications", "one previous", "stab", "leg", "bar", "years", "temperature", "blood pressure", "80 mmHg", "pulse", "100 min", "pulse oximetry", "99", "room air", "Cardiopulmonary", "abdominal exams", "unremarkable", "abnormal neurologic exam", "wound entered", "spinal cord", "not", "midline", "following", "most likely", "seen", "patient"]}
{"question": "A 52-year-old man presents to the emergency department with 1-month of progressive dyspnea, decreased exercise tolerance, and inability to sleep flat on his back. He says that he been getting increasingly short of breath over the past few years; however, he attributed these changes to getting older. He started becoming very concerned when he was unable to climb the stairs to his apartment about 3 weeks ago. Since then, he has been experiencing shortness of breath even during activities of daily living. His past medical history is significant for heroin and cocaine use as well as periods of homelessness. Physical exam reveals a gallop that occurs just after the end of systole. Which of the following could lead to the same pathology that is seen in this patient?", "answer": "Vitamin B1 deficiency", "options": {"A": "Amyloid production", "B": "Myosin mutation", "C": "Radiation therapy", "D": "Turner syndrome", "E": "Vitamin B1 deficiency"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "1-month", "progressive dyspnea", "decreased exercise tolerance", "to sleep flat", "back", "getting", "short of breath", "past", "years", "attributed", "changes", "getting older", "started", "very", "unable to climb", "apartment", "3 weeks", "then", "shortness of breath", "past medical history", "significant", "heroin", "cocaine use", "periods", "homelessness", "reveals", "occurs", "end", "systole", "following", "lead", "same pathology", "seen", "patient"]}
{"question": "A 29-year-old woman presents to her gynecologist as part of her follow-up for her abnormal pap test a year ago. She has a normal menstrual cycle and has never been pregnant. She does not take oral contraceptive pills, as she is sexually inactive. She denies the use of any illicit drugs. Conventional cytology from her cervix uteri is done, which reveals pathological findings suggestive of a low-grade squamous intraepithelial lesion as shown in the photograph below. The same test last year revealed normal histological findings. What is the most likely process leading to these pathological findings in this patient’s pap smear?", "answer": "Dysplasia", "options": {"A": "Hyperplasia", "B": "Hypertrophy", "C": "Atrophy", "D": "Dysplasia", "E": "Anaplasia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "gynecologist", "part of", "follow-up", "abnormal pap test", "year", "normal menstrual cycle", "never", "pregnant", "not", "oral contraceptive pills", "inactive", "use", "illicit drugs", "Conventional cytology", "cervix uteri", "reveals pathological findings suggestive", "low-grade squamous intraepithelial lesion", "photograph", "same test", "year revealed normal histological findings", "process leading", "pathological findings", "patients pap smear"]}
{"question": "A 42-year-old man presents with unremitting diarrhea that has lasted for 2 weeks. He describes his bowel movements as watery, non-bloody, foul-smelling, and greasy. He also has cramping abdominal pain associated with the diarrhea. He says that his symptoms started right after he returned from a father-son camping trip to the mountains. His son has similar symptoms. His vital signs include: pulse 78/min, respiratory rate 15/min, temperature 37.2°C (99.0°F), and blood pressure 120/70 mm Hg. A stool sample is obtained and microscopic analysis is significant for the findings shown in the image below. Which of the following pathogens is most likely responsible for this patient’s condition?", "answer": "Giardia lamblia", "options": {"A": "Bacillus cereus", "B": "Campylobacter jejuni", "C": "Clostridium difficile", "D": "Giardia lamblia", "E": "Yersinia enterocolitica"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "diarrhea", "lasted", "2 weeks", "non bloody", "smelling", "greasy", "cramping abdominal associated with", "diarrhea", "symptoms started right", "returned", "trip", "mountains", "similar symptoms", "vital signs include", "pulse", "min", "respiratory rate", "min", "temperature", "99", "blood pressure", "70 mm Hg", "stool sample", "obtained", "microscopic analysis", "significant", "findings", "following", "responsible", "patients condition"]}
{"question": "A 35-year-old woman presents to the emergency department with swelling of her face and abdominal pain. She states she was outside doing yard work when her symptoms began. The patient has a past medical history of recently diagnosed diabetes and hypertension. Her current medications include lisinopril, metformin, and glipizide. Her temperature is 99.5°F (37.5°C), blood pressure is 149/95 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, the patient's cardiac and pulmonary exam are within normal limits. Dermatologic exam reveals edema of her hands, lips, and eyelids. There is mild laryngeal edema; however, the patient is speaking clearly and maintaining her airway. Which of the following is appropriate long-term management of this patient?", "answer": "Danazol", "options": {"A": "Fresh frozen plasma", "B": "Ecallantide", "C": "Danazol", "D": "Discontinue metformin", "E": "Prednisone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old woman presents", "emergency department", "swelling of", "face", "abdominal pain", "states", "outside", "symptoms began", "patient", "past medical recently diagnosed diabetes", "hypertension", "current medications include lisinopril", "metformin", "glipizide", "temperature", "99", "blood pressure", "95 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient's cardiac", "pulmonary exam", "normal limits", "Dermatologic exam reveals edema of", "hands", "lips", "eyelids", "mild laryngeal edema", "patient", "airway", "following", "appropriate long-term", "patient"]}
{"question": "A 40-year-old man comes to the physician because of a 5-month history of watery diarrhea and episodic crampy abdominal pain. He has no fever, nausea, or vomiting. Over the past 6 months, he has had a 1.8-kg (4-lb) weight loss, despite experiencing no decrease in appetite. His wife has noticed that sometimes his face and neck become red after meals or when he is in distress. A year ago, he was diagnosed with asthma. He has hypertension. Current medications include an albuterol inhaler and enalapril. He drinks one beer daily. His temperature is 36.7°C (98°F), pulse is 85/min, and blood pressure is 130/85 mm Hg. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard best at the left sternal border and fourth intercostal space. The abdomen is soft, and there is mild tenderness to palpation with no guarding or rebound. The remainder of the physical examination shows no abnormalities. A complete blood count is within the reference range. Without treatment, this patient is at greatest risk for which of the following conditions?", "answer": "Dementia", "options": {"A": "Asphyxia", "B": "Achlorhydria", "C": "Megaloblastic anemia", "D": "Dementia", "E": "Intestinal fistula"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old man", "physician", "5 month history", "watery diarrhea", "episodic crampy", "fever", "nausea", "vomiting", "past 6 months", "kg", "4", "weight loss", "decrease in appetite", "sometimes", "face", "neck", "red", "meals", "distress", "year", "diagnosed", "asthma", "hypertension", "Current medications include", "albuterol inhaler", "enalapril", "one", "daily", "temperature", "36", "pulse", "85 min", "blood pressure", "85 mm Hg", "lungs", "clear", "auscultation", "systolic murmur", "heard best", "left sternal border", "fourth intercostal space", "abdomen", "soft", "mild tenderness", "palpation", "guarding", "abnormalities", "complete blood count", "reference range", "treatment", "patient", "greatest", "following conditions"]}
{"question": "A 17-year-old boy is brought to the emergency department by his parents because of crushing chest pain, nausea, and vomiting for the past 2 hours. The pain is constant and radiates to his left shoulder. Over the past year, he has been admitted to the hospital twice for deep vein thrombosis. He has a history of learning disability and has been held back three grades. The patient is at the 99th percentile for length and the 45th percentile for weight. His pulse is 110/min, respirations are 21/min, and blood pressure is 128/84 mm Hg. His fingers are long and slender, and his arm span exceeds his body height. Electrocardiography shows ST-segment elevation in leads V1 and V2. His serum troponin I concentration is 2.0 ng/mL (N ≤ 0.04). Coronary angiography shows 90% occlusion of the proximal left anterior descending artery. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Downward lens subluxation", "options": {"A": "Bilateral gynecomastia", "B": "Downward lens subluxation", "C": "Macroorchidism", "D": "Saccular cerebral aneurysms", "E": "Ascending aortic aneurysm"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency department", "crushing chest pain", "nausea", "vomiting", "past", "hours", "pain", "constant", "radiates", "left shoulder", "past year", "twice", "deep vein thrombosis", "history", "learning", "held back three", "patient", "99th percentile", "length", "percentile", "weight", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "fingers", "long", "arm span", "body height", "Electrocardiography", "ST-segment elevation", "leads V1", "V2", "serum troponin I concentration", "2 0 ng/mL", "N", "0.04", "Coronary angiography", "90", "occlusion", "proximal left anterior descending artery", "Further", "to", "following findings"]}
{"question": "A 7-year-old Caucasian male presents with a temperature of 38°C. During the physical exam, the patient complains of pain when his femur is palpated. The patient's parents state that the fever started a few days after they noticed a honey-colored crusting on the left upper lip of the child's face. Culture of the bacteria reveals a catalase-positive, gram-positive cocci. Which of the following bacteria is most likely to be found in a biopsy of the child's left femur?", "answer": "Staphylococcus aureus", "options": {"A": "Staphylococcus aureus", "B": "Staphylococcus saprophyticus", "C": "Streptococcus pyogenes", "D": "Clostridium perfingens", "E": "Escherichia coli"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male presents", "temperature", "patient", "pain", "femur", "patient's", "state", "fever started", "few days", "colored crusting", "left upper lip of", "child's face", "Culture", "bacteria reveals", "catalase positive", "following bacteria", "to", "found", "biopsy of", "child's left femur"]}
{"question": "A 46-year-old woman complains of chronic cough for the past 3 weeks. She was recently diagnosed with hypertension and placed on an angiotensin receptor blocker therapy (ARBs). Chest X-ray shows large nodular densities bilaterally. Bronchial biopsy showed granulomatous inflammation of the pulmonary artery. Lab investigations showed a positive cANCA with a serum creatinine of 3.6 mg/dL. Urine analysis shows RBC casts and hematuria. Which is the most likely cause of this presentation?", "answer": "Granulomatosis with polyangiitis", "options": {"A": "Microscopic polyangitis", "B": "Churg-Strauss syndrome", "C": "Polyarteritis nodosa", "D": "Hypertensive medication", "E": "Granulomatosis with polyangiitis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "chronic cough", "past", "weeks", "recently diagnosed", "hypertension", "angiotensin receptor", "therapy", "ARBs", "Chest X-ray", "large nodular densities", "Bronchial biopsy", "granulomatous inflammation of", "pulmonary artery", "Lab", "positive cANCA", "serum creatinine of", "mg/dL", "Urine analysis", "casts", "hematuria", "most likely cause"]}
{"question": "A 32-year-old man comes to the physician because of recurrent episodes of palpitations, chest pain, shortness of breath, sweating, and dizziness over the past 4 months. These episodes are accompanied by intense fear of “losing control” over himself. Most of the episodes have occurred at work in situations when it would have been unacceptable to leave, such as during team meetings. The last episode occurred at home right before this visit, after he noticed that he was running late. He has been otherwise healthy. He occasionally drinks a beer or a glass of wine. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Thyroid function studies and an ECG show no abnormalities. Given his symptoms, this patient is at greatest risk of developing which of the following?", "answer": "Depressed mood and feeling of guilt", "options": {"A": "Preoccupation with an observed flaw in physical appearance", "B": "Abnormally elevated mood and flight of ideas", "C": "Depressed mood and feeling of guilt", "D": "Fear of spiders and heights", "E": "Disorganized speech and delusions"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "of recurrent episodes", "palpitations", "chest pain", "shortness of breath", "sweating", "dizziness", "past", "months", "episodes", "intense", "control", "Most of", "episodes", "unacceptable to", "as", "last episode", "at right", "visit", "late", "healthy", "occasionally", "glass", "Vital signs", "normal limits", "Cardiopulmonary", "abnormalities", "Thyroid function studies", "ECG", "abnormalities", "Given", "symptoms", "patient", "greatest", "following"]}
{"question": "A 68-year-old woman presents with shortness of breath and left-sided chest pain for a week. She says that her breathlessness is getting worse, and the chest pain is especially severe when she takes a deep breath. The patient denies any similar symptoms in the past. Her past medical history is insignificant except for occasional heartburn. She currently does not take any medication. She is a nonsmoker and drinks alcohol occasionally. She denies the use of any illicit drugs including marijuana. Vital signs are: blood pressure 122/78 mm Hg, pulse 67/min, respiratory rate 20/min, temperature 37.2°C (99.0°F). Her physical examination is remarkable for diminished chest expansion on the left side, absence of breath sounds at the left lung base, and dullness to percussion and decreased tactile fremitus on the left. A plain radiograph of the chest reveals a large left-sided pleural effusion occupying almost two-thirds of the left lung field. Thoracentesis is performed, and 2 L of fluid is drained from the thorax under ultrasound guidance. Which of the following patient positions and points of entry is the safest for performing a thoracentesis in this patient?", "answer": "With the patient in the sitting position, below the tip of the scapula midway between the spine and the posterior axillary line on the superior margin of the eighth rib", "options": {"A": "With the patient in the sitting position, below the tip of the scapula midway between the spine and the posterior axillary line on the superior margin of the eighth rib", "B": "With the patient in the sitting position, just above the fifth rib in the anterior axillary line", "C": "With the patient in the sitting position, at the midclavicular line on the second intercostal space", "D": "With the patient in the supine position, just above the fifth rib in the midaxillary line", "E": "With the patient in the supine position, in the fifth intercostal space right below the nipple"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "shortness of breath", "left-sided chest pain", "week", "breathlessness", "getting worse", "chest pain", "severe", "deep breath", "patient", "similar symptoms", "past", "past medical history", "occasional heartburn", "currently", "not", "medication", "nonsmoker", "alcohol occasionally", "use", "illicit drugs including marijuana", "Vital signs", "blood pressure", "mm Hg", "pulse 67 min", "respiratory rate 20 min", "temperature", "99", "diminished chest expansion", "left side", "absence", "breath sounds", "left lung base", "dullness", "percussion", "decreased tactile fremitus", "left", "plain radiograph of", "chest reveals", "large left sided pleural effusion", "almost two thirds", "lung field", "performed", "2", "fluid", "drained", "thorax", "ultrasound guidance", "following patient positions", "points", "performing", "patient"]}
{"question": "A 28-year-old woman presents to the clinic with complaints of occasional low-grade fever and joint pain for 1 month. She also complains of morning stiffness in the proximal interphalangeal joints of both hands, which lasts for 5 to 10 minutes. She recently noticed a pink rash on her nose and cheekbones. Her family history is significant for similar complaints in her mother. She is not taking any medications. On examination, her temperature is 37.6°C (99.6°F), pulse is 74/min, blood pressure is 110/70 mm Hg, and respirations are 18/min. Aphthous ulcers are noted on her oral mucosa. Which of the following tests would be most specific for confirming the diagnosis in this patient?", "answer": "Anti-double stranded DNA (dsDNA) antibodies", "options": {"A": "Anti-double stranded DNA (dsDNA) antibodies", "B": "Anti-histone antibodies", "C": "Anti-topoisomerase (anti-Scl 70) antibodies", "D": "Anti-Ro antibodies", "E": "Antinuclear antibodies (ANA)"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "clinic", "complaints", "occasional low-grade fever", "joint pain", "month", "morning stiffness", "the proximal interphalangeal joints of", "hands", "lasts", "10 minutes", "recently", "pink rash", "nose", "cheekbones", "family history", "significant", "similar complaints", "not", "medications", "temperature", "99", "pulse", "74 min", "blood pressure", "70 mm Hg", "respirations", "min", "Aphthous ulcers", "noted", "oral mucosa", "following tests", "most specific", "confirming", "diagnosis", "patient"]}
{"question": "A 50-year-old man presents to a physician with recurrent episodes of coughing over the last 3 years. He mentions that his cough has been accompanied by expectoration during 5–6 consecutive months every year for the last 3 years and he experiences breathing difficulty on exertion. He has been a smoker for the last 10 years. There is no family history of allergy. He was prescribed inhaled corticosteroids and an inhaled bronchodilator 1 month previously, but there has been no improvement. There is no history of fever or breathing difficulty at present. On physical examination his temperature is 37.0°C (98.6°F), the pulse is 84/min, the blood pressure 126/84 mm Hg, and the respiratory rate is 20/min. Auscultation of his chest reveals coarse rhonchi and wheezing bilaterally. His sputum is mucoid and microscopic examination shows predominant macrophages. His chest radiogram (posteroanterior view) shows flattening of the diaphragm, increased bronchovascular markings, and mild cardiomegaly. If lung biopsy is carried out, which of the following microscopic findings is most likely to be present in this patient?", "answer": "Hyperplasia of the mucus glands in the airways", "options": {"A": "Destruction of the pulmonary capillary bed", "B": "Variable-sized cysts against a background of densely scarred lung tissue", "C": "Hyperplasia of the mucus glands in the airways", "D": "Eosinophilic infiltration of the airways", "E": "Ossification of bronchial cartilage"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["50 year old man presents", "physician", "recurrent episodes of coughing", "last", "years", "cough", "expectoration", "consecutive months", "year", "years", "breathing difficulty", "exertion", "smoker", "family history of allergy", "inhaled corticosteroids", "inhaled bronchodilator", "month", "history", "fever", "breathing difficulty", "present", "temperature", "98", "pulse", "84 min", "blood pressure", "84 mm Hg", "respiratory rate", "20 min", "Auscultation", "chest reveals coarse rhonchi", "wheezing", "sputum", "mucoid", "microscopic examination", "predominant macrophages", "chest radiogram", "view", "flattening", "diaphragm", "increased", "markings", "mild cardiomegaly", "lung biopsy", "carried out", "following", "to", "present", "patient"]}
{"question": "A 25-year-old woman comes to the physician for a routine health maintenance examination. Her last visit was 3 years ago. She feels well. One year ago, she underwent a tubectomy after the delivery of her third child. She does not take any medications. Physical examination shows no abnormalities. A Pap smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?", "answer": "Loop electrosurgical excision procedure", "options": {"A": "Repeat cytology in 3 months", "B": "Laser ablative therapy", "C": "Loop electrosurgical excision procedure", "D": "Repeat cytology at 12 months", "E": "Colposcopy with endometrial sampling"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "routine", "last", "3 years", "well", "One year ago", "tubectomy", "delivery", "third child", "not", "medications", "abnormalities", "Pap smear", "high-grade squamous intraepithelial lesion", "following", "most appropriate next step"]}
{"question": "A 36-year-old man presents to his physician with an acute burning retrosternal sensation with radiation to his jaw. This sensation began 20 minutes ago when the patient was exercising at the gym. It does not change with position or with a cough. The patient’s vital signs include: blood pressure is 140/90 mm Hg, heart rate is 84/min, respiratory rate is 14/min, and temperature is 36.6℃ (97.9℉). Physical examination is only remarkable for paleness and perspiration. The patient is given sublingual nitroglycerin, the blood is drawn for an express troponin test, and an ECG is going to be performed. At the moment of performing ECG, the patient’s symptoms are gone. ECG shows increased R amplitude in I, II V3-V6, and ST depression measuring for 0.5 mm in the same leads. The express test for troponin is negative. Which of the following tests would be reasonable to perform next to confirm a diagnosis in this patient?", "answer": "Exercise stress testing", "options": {"A": "Blood test for CPK-MB", "B": "Echocardiography", "C": "Chest radiography", "D": "CT angiography", "E": "Exercise stress testing"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old man presents", "physician", "acute burning retrosternal sensation", "radiation", "jaw", "sensation began 20 minutes", "patient", "exercising", "not", "cough", "patients vital signs include", "blood pressure", "90 mm Hg", "heart rate", "84 min", "respiratory rate", "min", "temperature", "36", "97", "only", "paleness", "perspiration", "patient", "given sublingual nitroglycerin", "blood", "troponin test", "ECG", "to", "performed", "ECG", "patients symptoms", "ECG", "increased R amplitude", "I", "II V3 V6", "ST depression measuring", "0.5 mm", "same leads", "test", "troponin", "negative", "following tests", "to perform next to confirm", "diagnosis", "patient"]}
{"question": "A 58-year-old woman with a past medical history significant for major depressive disorder and generalized anxiety syndrome presents after having undergone menopause 3 years earlier. Today, she complains of intolerable hot flashes and irritability at work and at home. The remainder of the review of systems is negative. Physical examination reveals a grade 2/6 holosystolic murmur best heard at the apex, clear breath sounds, and normal abdominal findings. Her vital signs are all within normal limits. She requests hormonal replacement therapy (HRT) for the relief of her symptoms. Which of the following additional pieces of past medical history would make HRT contraindicated in this patient?", "answer": "Known or suspected personal history of breast cancer", "options": {"A": "Family history of breast cancer", "B": "Known or suspected personal history of breast cancer", "C": "Family history of endometrial cancer", "D": "Osteoporosis", "E": "Failure of symptomatic control with SSRI/SNRI"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old woman", "past medical history significant", "major depressive disorder", "generalized anxiety syndrome presents", "menopause", "years earlier", "Today", "hot flashes", "irritability", "at home", "of", "review", "systems", "negative", "reveals", "holosystolic murmur best heard", "apex", "clear breath sounds", "normal abdominal findings", "vital signs", "normal limits", "hormonal replacement therapy", "of", "following additional pieces", "past medical", "make HRT contraindicated", "patient"]}
{"question": "A 34-year-old man comes to the physician for a 1-week history of fever and generalized fatigue. Yesterday, he developed a rash all over his body. Two months ago, he had a painless lesion on his penis that resolved a few weeks later without treatment. He has asthma. Current medications include an albuterol inhaler. He is currently sexually active with 3 different partners. He uses condoms inconsistently. Vital signs are within normal limits. He has a diffuse maculopapular rash involving the trunk, extremities, palms, and soles. An HIV test is negative. Rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption test (FTA-ABS) are positive. The patient receives a dose of intramuscular benzathine penicillin G. Two hours later, he complains of headache, myalgias, and chills. His temperature is 38.8°C (101.8°F) , pulse is 105/min, respirations are 24/min, and blood pressure is 98/67 mm Hg. Which of the following is the most appropriate pharmacotherapy?", "answer": "Ibuprofen", "options": {"A": "Ceftriaxone", "B": "Ibuprofen", "C": "Epinephrine", "D": "Methylprednisolone", "E": "Phenylephrine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "1-week history", "fever", "generalized fatigue", "rash", "body", "Two months", "painless lesion", "penis", "resolved", "few weeks later", "treatment", "asthma", "Current medications include", "albuterol inhaler", "currently sexually active", "different", "uses condoms", "Vital signs", "normal limits", "diffuse maculopapular rash involving", "trunk", "extremities", "soles", "HIV test", "negative", "Rapid plasma reagin", "RPR", "fluorescent treponemal antibody absorption test", "positive", "patient receives", "dose", "intramuscular benzathine penicillin G", "Two hours later", "headache", "myalgias", "chills", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "98 67 mm Hg", "following", "most appropriate pharmacotherapy"]}
{"question": "A pharmaceutical company is testing a new antidepressant. During phase I of the drug trial, healthy volunteers are recruited, and the effects of the drug on the cardiovascular system are studied. A graphical representation of the volume-pressure relationship of the left ventricle of the heart is given below with the dashed line representing post medication changes. Which of the following is the most likely mechanism of the drug being studied?", "answer": "Gq-coupled receptor activation", "options": {"A": "Selective AT1 receptor blockade", "B": "Gs-coupled receptor activation", "C": "Gq-coupled receptor activation", "D": "M2 receptor activation", "E": "Delaying phase 0 of the pacemaker action potential"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["testing", "new antidepressant", "drug", "effects of", "drug", "cardiovascular system", "studied", "of", "volume pressure relationship", "left ventricle", "heart", "given", "line", "post medication changes", "following", "mechanism", "drug", "studied"]}
{"question": "A baby is delivered at 39 weeks without complications. Upon delivery, there are obvious craniofacial abnormalities, including micrognathia, cleft lip, and cleft palate. On further inspection, downward slanting eyes and malformed ears are seen. The child has an APGAR score of 9 and 9 at 1 and 5 minutes respectively. There are no signs of cyanosis or evidence of a heart murmur. Which of the following is the most likely underlying cause of this patient’s presentation at birth?", "answer": "Mutation in the TCOF1 gene", "options": {"A": "Retinoic acid use during gestation", "B": "Trisomy 18", "C": "Mutation of the SOX9 gene", "D": "Microdeletion at chromosome 22q14", "E": "Mutation in the TCOF1 gene"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["baby", "delivered", "weeks", "complications", "delivery", "craniofacial abnormalities", "including micrognathia", "cleft lip", "cleft palate", "further inspection", "downward", "eyes", "malformed ears", "seen", "child", "APGAR score", "9", "5 minutes", "signs", "cyanosis", "heart murmur", "following", "underlying cause", "patients", "birth"]}
{"question": "A 46-year-old woman with a history of type II diabetes mellitus is started on lisinopril for newly diagnosed hypertension by her primary care physician. At a follow-up appointment several weeks later, she reports decreased urine output, and she is noted to have generalized edema. Her creatinine is elevated compared to baseline. Given her presentation, which of the following changes in renal arteriolar blood flow and glomerular filtration rate (GFR) have likely occurred?", "answer": "Renal efferent arteriole vasodilation; decreased GFR", "options": {"A": "Renal afferent arteriole vasoconstriction; decreased GFR", "B": "Renal afferent arteriole vasodilation; increased GFR", "C": "Renal efferent arteriole vasoconstriction; increased GFR", "D": "Renal efferent arteriole vasodilation; decreased GFR", "E": "Renal efferent arteriole vasodilation; no change in GFR"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "history of type II diabetes mellitus", "started", "lisinopril", "diagnosed hypertension", "primary care physician", "follow-up appointment", "weeks later", "reports decreased urine output", "noted to", "generalized edema", "creatinine", "elevated", "baseline", "Given", "following changes", "renal arteriolar blood flow", "glomerular filtration rate", "likely"]}
{"question": "A 20-year-old female with type I diabetes mellitus presents to the emergency department with altered mental status. Her friend said that she has been out late either studying for upcoming tests or attending prayer group meetings. As far as the friend can recollect, the patient appeared to be in her usual state of health until only two days ago, when she was prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. The patient complained that the medication was making her feel nauseous and bloated. The patient also relies on glargine and lispro for glycemic control. Her temperature is 100.5°F (38.1°C), blood pressure is 95/55 mmHg, pulse is 130/min, and respirations are 30/min. Her pupils are equal and reactive to light bilaterally. The remainder of the physical exam is unremarkable. Her basic metabolic panel is displayed below:\n\nSerum:\nNa+: 116 mEq/L\nCl-: 90 mEq/L\nK+: 5.0 mEq/L\nHCO3-: 2 mEq/L\nBUN: 50 mg/dL\nGlucose: 1,200 mg/dL\nCreatinine: 1.5 mg/dL\n\nWhich of the following is true regarding this patient's presentation?", "answer": "Hyperkalemia is independent of the patient's total body potassium stores", "options": {"A": "Hyponatremia is independently associated with a poor prognosis", "B": "Hyperkalemia is independent of the patient's total body potassium stores", "C": "Hyperglycemia to this magnitude supports hyperglycemic hyperosmolar nonketotic syndrome", "D": "Azotemia independently contributes to the patient's encephalopathy", "E": "Hypochloremia to this magnitude supports a pure anion-gap metabolic acidosis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["20 year old female", "type I diabetes mellitus presents", "emergency department", "altered mental status", "out late", "studying", "tests", "attending", "group", "patient appeared to", "usual state of health", "only two days", "trimethoprim-sulfamethoxazole", "urinary tract infection", "patient", "medication", "making", "nauseous", "bloated", "patient", "glargine", "lispro", "glycemic control", "temperature", "100", "blood pressure", "95", "mmHg", "pulse", "min", "respirations", "30/min", "pupils", "equal", "reactive to light", "unremarkable", "basic metabolic panel", "displayed", "Serum", "Na", "mEq/L", "90 mEq/L K", "5 0 mEq/L HCO3", "2 mEq/L", "50 mg/dL Glucose", "1 200 mg/dL Creatinine", "1.5 mg/dL", "following", "true", "patient's"]}
{"question": "A 34-year-old woman visits the physician with complaints of difficulty swallowing and recurrent vomiting for the past 6 months. She even noticed food particles in her vomit a few hours after eating her meals. She has lost about 3.0 kg (6.6 lb) over the past 4 months. Her history is significant for a trip to Argentina last year. Her past medical history is insignificant. She is a non-smoker. On examination, her blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 78/min, temperature is 36.7°C (98.1°F), and her BMI is 24 kg/m². There is no abdominal tenderness, distension, or evidence of jaundice. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Barium XR", "options": {"A": "Biopsy", "B": "Surgery", "C": "Barium XR", "D": "Antibiotic therapy", "E": "Routine blood tests"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "complaints", "difficulty swallowing", "recurrent vomiting", "past 6 months", "vomit", "few hours", "eating", "meals", "lost", "3.0 kg", "6.6", "past", "months", "history", "significant", "trip", "Argentina", "year", "past medical history", "non-smoker", "blood pressure", "75 mm Hg", "respirations", "min", "pulse", "min", "temperature", "36", "98", "BMI", "kg/m", "abdominal tenderness", "distension", "jaundice", "following", "most appropriate next step", "patient"]}
{"question": "A 35-year-old woman presents to the emergency room with severe right lower quadrant abdominal pain. She has a history of tubal ligation 3 years ago and a history of chlamydia treated 15 years ago. She usually has very regular periods, but her last menstrual period was 10 weeks ago. On exam, she is afebrile, HR 117, blood pressure of 88/56 mmHg, and she has peritoneal signs including rebound tenderness. Urine Beta-hCG is positive. Hgb is 9.9 g/dL. What is the appropriate treatment?", "answer": "Laparotomy", "options": {"A": "Serial beta-hCG levels", "B": "Azithromycin", "C": "Methotrexate", "D": "Laparotomy", "E": "Blood transfusion"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman presents", "emergency room", "severe right lower quadrant abdominal pain", "history of tubal ligation", "years", "history", "treated", "years", "usually", "very regular periods", "last menstrual period", "10 weeks", "exam", "afebrile", "blood pressure", "88", "mmHg", "peritoneal signs including rebound tenderness", "Urine Beta-hCG", "positive", "Hgb", "g/dL", "appropriate treatment"]}
{"question": "A 47-year-old female comes to the emergency department because of increasing back pain for the past 2 weeks. She is unable to perform her daily chores. One month ago, she fell and hurt her back while working outside in the garden. The pain subsided with over-the-counter acetaminophen. She underwent a left mastectomy 1 year ago for breast cancer. She has type 2 diabetes mellitus. Current medications include metformin, sitagliptin, and a multivitamin. She appears uncomfortable. Her temperature is 38.9°C (102.0°F), pulse is 101/min, and blood pressure is 110/80 mm Hg. Examination of the back shows thoracic vertebral tenderness. She has mild stiffness on neck flexion. Muscle strength is decreased in the lower extremities. Deep tendon reflexes are 2+ bilaterally. Sensation to pain, fine touch, temperature, and proprioception is intact. Her hemoglobin concentration is 13.1 g/dL and leukocyte count is 19,300/mm3. Which of the following is the most appropriate next step in management?", "answer": "MRI of the spine", "options": {"A": "Serum protein electrophoresis", "B": "X-rays of the spine", "C": "Methylprednisone therapy", "D": "Vancomycin and nafcillin therapy", "E": "MRI of the spine"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old female", "emergency department", "of increasing back pain", "past 2 weeks", "unable to perform", "daily", "One month", "fell", "back", "outside", "garden", "pain", "over-the-counter acetaminophen", "left mastectomy", "year", "breast cancer", "type 2 diabetes mellitus", "Current medications include metformin", "sitagliptin", "multivitamin", "appears", "temperature", "pulse", "min", "blood pressure", "80 mm Hg", "of", "back", "thoracic vertebral tenderness", "mild stiffness", "neck flexion", "Muscle strength", "decreased", "lower extremities", "Deep tendon reflexes", "2", "Sensation", "pain", "fine touch", "temperature", "intact", "hemoglobin concentration", "g/dL", "leukocyte count", "300 mm3", "following", "most appropriate next step"]}
{"question": "A 67-year-old woman comes to the clinic complaining of progressive fatigue over the past 4 months. She noticed that she is feeling increasingly short of breath after walking the same distance from the bus stop to her home. She denies chest pain, syncope, lower extremity edema, or a cough. She denies difficulty breathing while sitting comfortably, but she has increased dyspnea upon walking or other mildly strenuous activity. Her past medical history includes mild osteoporosis and occasional gastric reflux disease. She takes oral omeprazole as needed and a daily baby aspirin. The patient is a retired accountant and denies smoking history, but she does admit to 1 small glass of red wine daily for the past 5 years. Her diet consists of a Mediterranean diet that includes fruits, vegetables, and fish. She states that she has been very healthy previously, and managed her own health without a physician for the past 20 years. On physical examination, she has a blood pressure of 128/72 mm Hg, a pulse of 87/min, and an oxygen saturation of 94% on room air. HEENT examination demonstrates mild conjunctival pallor. Lung and abdominal examinations are within normal limits. Heart examination reveals a 2/6 systolic murmur at the right upper sternal border.\nThe following laboratory values are obtained:\nHematocrit 29%\nHemoglobin 9.8 mg/dL\nMean red blood cell volume 78 fL\nPlatelets 240,000/mm3\nWhite blood cells 6,000/mm3\nWhat is the most likely reticulocyte range for this patient?", "answer": "< 1%", "options": {"A": "< 1%", "B": "0%", "C": "> 1.5%", "D": ">5%", "E": ">7%"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old woman", "clinic", "progressive fatigue", "past", "months", "short of breath", "same distance", "bus stop", "home", "chest pain", "syncope", "lower extremity edema", "cough", "difficulty breathing", "sitting", "increased dyspnea", "mildly", "past medical history includes mild osteoporosis", "occasional gastric disease", "oral omeprazole as needed", "daily baby aspirin", "patient", "retired accountant", "smoking history", "small glass", "daily", "past", "years", "diet consists", "Mediterranean diet", "includes", "states", "very healthy", "physician", "past 20 years", "blood pressure", "72 mm Hg", "pulse", "87 min", "oxygen saturation", "room air", "HEENT", "mild conjunctival pallor", "Lung", "abdominal", "normal limits", "reveals", "2/6 systolic murmur", "right upper sternal border", "following laboratory values", "obtained", "Hematocrit", "Hemoglobin", "fL", "mm3", "range", "patient"]}
{"question": "A 54-year-old man comes to the emergency department because of worsening shortness of breath, bilateral leg swelling, and constant chest pain which is not related to exertion for the last 2 weeks. The patient underwent an aortic valve replacement surgery for chronic aortic regurgitation 1 year ago, and his postoperative course was uncomplicated. He denies smoking or alcohol use. His blood pressure is 80/50 mm Hg, temperature is 36.6°C (97.9°F), and pulse is regular at 110/min. On physical examination, jugular veins are distended, +1 pitting edema is present on both ankles, and heart sounds are distant. Chest X-ray is shown in the exhibit. Transthoracic echocardiography shows large pericardial effusion, chamber collapse, and respiratory variation of ventricular filling. ECG of this patient will most likely show which of the following?", "answer": "Low voltage and beat-to-beat variations in the height of QRS complexes", "options": {"A": "Diffuse concave ST elevation and PR depression", "B": "S wave in lead I, Q wave with T-wave inversion in lead III", "C": "Right atrial enlargement, right ventricular enlargement, and right axis deviation", "D": "Low voltage and beat-to-beat variations in the height of QRS complexes", "E": "Tachycardia with discrete P waves with at least three different morphologies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["54 year old man", "emergency department", "of worsening shortness", "breath", "bilateral leg swelling", "constant chest", "not related", "exertion", "last", "weeks", "patient", "aortic valve replacement surgery", "chronic", "regurgitation 1 year", "postoperative course", "uncomplicated", "smoking", "blood pressure", "80 50 mm Hg", "temperature", "36", "97 9F", "pulse", "regular", "min", "jugular veins", "distended", "1 pitting edema", "present", "ankles", "heart sounds", "distant", "Chest X-ray", "Transthoracic echocardiography", "large pericardial effusion", "chamber collapse", "respiratory variation", "ventricular", "ECG", "patient", "most likely", "following"]}
{"question": "A 62-year-old man presents to his primary care physician for a follow-up appointment. The patient was the front seat driver in a head-on collision which resulted in a femur and pelvic fracture which was treated appropriately. The patient spent 3 weeks in the hospital and was then discharged 2 weeks ago. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He smokes 3 packs of cigarettes per day and drinks 4 alcoholic beverages every night. The patient says that he has been attempting to engage in sexual activities with his wife but has been unable to do so. He states this has never been a problem for him before. He also reports new-onset minor headaches and trouble sleeping for which he is taking trazodone. Which of the following is the most likely diagnosis?", "answer": "Neurologic damage", "options": {"A": "Atherosclerotic change", "B": "Increased prolactin", "C": "Medication changes", "D": "Neurologic damage", "E": "Psychologic"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man presents", "primary care physician", "follow-up appointment", "patient", "front", "driver", "head", "collision", "resulted", "femur", "pelvic fracture", "treated", "patient spent 3 weeks", "hospital", "then", "2 weeks", "patient", "past medical diabetes", "hypertension", "dyslipidemia", "smokes 3 packs", "cigarettes", "day", "4", "night", "patient", "unable to do", "states", "never", "problem", "reports new-onset minor headaches", "trouble sleeping", "trazodone", "following", "diagnosis"]}
{"question": "A 32-year-old woman, gravida 2 para 1, at 31 weeks' gestation is brought to the emergency department because of confusion. Three days ago, she developed diffuse abdominal pain, malaise, nausea, and vomiting. She has a 2-year history of gastroesophageal reflux disease. Four months ago, she spent 2 weeks in Belize for her honeymoon. Her previous pregnancy was complicated by preeclampsia, which was terminated by induction of labor at 37 weeks' gestation. Her only medication is esomeprazole. She appears tired. Her temperature is 38°C (100°F), pulse is 82/min, respirations are 19/min, and blood pressure is 118/79 mm Hg. She responds to sound and communicates in short sentences. Examination shows yellowish discoloration of the sclera and abdominal distention. There is tenderness to palpation of the right upper quadrant. When she is asked to hold her hands in extension, there is a notable flapping tremor. Her uterus is consistent in size with a 31-week gestation. Laboratory studies show:\nHematocrit 26%\nPlatelet count 90,000/mm3\nLeukocyte count 10,500/mm3\nProthrombin time (PT) 34 seconds\nPartial thromboplastin time (PTT) 48 seconds\nSerum\nTotal protein 5.0 g/dL\nAlbumin 2.6 g/dL\nGlucose 62 mg/dL\nCreatinine 2.1 mg/dL\nBilirubin, total 9.2 mg/dL\nIndirect 4.2 mg/dL\nAspartate aminotransferase 445 U/L\nAlanine aminotransferase 485 U/L\nAlkaline phosphatase 36 U/L\nAnti-HAV IgM antibody negative\nAnti-HAV IgG antibody positive\nHBsAG negative\nAnti-HBs antibody positive\nAnti-HBc antibody negative\nAnti-HCV antibody negative\nUrine studies show no abnormalities. Which of the following is the most likely diagnosis?\"", "answer": "Acute fatty liver of pregnancy", "options": {"A": "Preeclampsia", "B": "Acute fatty liver of pregnancy", "C": "HELLP syndrome", "D": "Intrahepatic cholestasis of pregnancy", "E": "Acute viral hepatitis B"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 2 para 1", "31 weeks", "estation ", "rought ", "mergency department ", "onfusion.", "hree  ays ", "iffuse  bdominal ", "alaise,", "ausea,", "omiting.", "- ear  istory of gastroesophageal reflux disease.", "our  onths ", "pent   weeks ", "elize ", "revious pregnancy ", "omplicated ", "reeclampsia,", "erminated ", "nduction of labor ", "eeks'", "station. ", "ly m dication i", "omeprazole. ", "pears t red. ", "mperature i", "lse i", "n, ", "spirations a", "n, ", "ood pressure i", " Hg. ", "sponds to sound a", "mmunicates i", "ort s", "scoloration o", "lera a", "dominal distention. ", "nderness t", "lpation o", "ght upper quadrant. ", " h ld h", "nds i", "tension, ", "table f apping tremor. ", "erus i", "ze w", "-w ek gestation. ", "boratory studies s", "atelet c", "ukocyte count 1", "othrombin time (", "rtial thromboplastin time (", "rum T otein 5", "g d  A bumin 2", "d  G", "/d", "eatinine 2", "m /d", "lirubin, ", "/d  I direct 4", "/d  A partate aminotransferase 4", "A anine a", "kaline phosphatase 3  U", "tibody n gative A", "G antibody p", "sAG n", "ine s udies s", "normalities. ", "llowing i", "agnosis?\""]}
{"question": "A 38-year-old woman presents with worsening fatigue and difficulty talking for the last few hours. Past medical history is significant for type 2 diabetes mellitus, managed with metformin and insulin. Additional current medications are a pill to ''calm her nerves'' that she takes when she has to perform live on stage for work. On physical examination, the patient is lethargic, easily confused, and has difficulty responding to questions or commands. There is also significant diaphoresis of the face and trunk present. Which of the following is the most likely etiology of this patient’s current symptoms?", "answer": "Masking of sympathetic nervous system dependent symptoms", "options": {"A": "Masking of sympathetic nervous system dependent symptoms", "B": "Increased GABAergic activity", "C": "Anticholinergic side effect", "D": "Direct opiate mu receptor stimulation", "E": "Hyperosmolar nonketotic coma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "worsening fatigue", "difficulty talking", "hours", "Past medical history", "significant", "type 2 diabetes mellitus", "metformin", "insulin", "Additional current medications", "pill to", "nerves", "to perform live", "stage", "patient", "lethargic", "easily confused", "difficulty", "significant diaphoresis", "face", "trunk present", "following", "etiology", "patients current symptoms"]}
{"question": "A 15-year-old boy is brought to the emergency room for evaluation of malaise, dyspnea, and yellow skin and sclera. On examination, he is tachycardic, tachypneic, and the O2 saturation is less than 90%. The levels of unconjugated bilirubin and hemoglobinemia are increased, and there is an increased number of reticulocytes in the peripheral blood. What is the most likely diagnosis?", "answer": "Hemolytic anemia", "options": {"A": "Anemia of chronic disease", "B": "Acute leukemia", "C": "Sideropenic anemia", "D": "Hemolytic anemia", "E": "Aplastic anemia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency room", "malaise", "dyspnea", "yellow skin", "sclera", "tachycardic", "tachypneic", "O2 saturation", "less than 90", "levels", "unconjugated bilirubin", "hemoglobinemia", "increased", "increased number", "reticulocytes", "peripheral blood", "diagnosis"]}
{"question": "A 12-year-old boy presents to the emergency department with severe abdominal pain and nausea. He first began to have diffuse abdominal pain 15 hours prior to presentation. Since then, the pain has moved to the right lower quadrant. On physical exam he has tenderness to light palpation with rebound tenderness. Lifting his right leg causes severe right lower quadrant pain. Which of the following nerves roots was most likely responsible for the initial diffuse pain felt by this patient?", "answer": "T10", "options": {"A": "C6", "B": "T4", "C": "T7", "D": "T10", "E": "L1"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "emergency department", "severe abdominal", "nausea", "first began to", "diffuse abdominal", "hours prior to", "then", "pain", "moved to", "right lower quadrant", "tenderness", "light palpation", "rebound tenderness", "right leg causes severe right lower quadrant pain", "following nerves roots", "responsible", "initial diffuse pain", "patient"]}
{"question": "A 48-year-old woman is admitted to the hospital with sepsis and treated with gentamicin. One week after her admission, she develops oliguria and her urine shows muddy brown casts on light microscopy. Days later, her renal function begins to recover, but she complains of weakness and develops U waves on EKG as shown in Image A. Which laboratory abnormality would you most expect to see in this patient?", "answer": "Hypokalemia", "options": {"A": "Hypocalcemia", "B": "Hypokalemia", "C": "Hyponatremia", "D": "Hypoglycemia", "E": "Hypermagnesemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old woman", "sepsis", "treated with gentamicin", "One week", "oliguria", "urine", "muddy brown casts", "light microscopy", "Days later", "renal function begins to recover", "weakness", "U waves", "EKG", "laboratory abnormality", "most", "to see", "patient"]}
{"question": "A plain CT scan of the patient's head is performed immediately and the result is shown. His temperature is 37.1°C (98.8°F), pulse is 101/min and blood pressure is 174/102 mm Hg. Which of the following is the most appropriate next step in management?", "answer": "Intravenous alteplase therapy", "options": {"A": "Decompressive surgery", "B": "Intravenous labetalol therapy", "C": "Oral aspirin therapy", "D": "Intravenous alteplase therapy", "E": "Surgical clipping"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["CT scan of", "patient's head", "performed immediately", "result", "temperature", "98", "pulse", "min", "blood pressure", "mm Hg", "following", "most appropriate next step"]}
{"question": "A 58-year-old Caucasian male is being treated for atrial fibrillation and angina complains of dyspnea on exertion. On exam, his heart rate 104-115/min and irregularly irregular at rest. He has no chest pain. You believe his rate control for atrial fibrillation is suboptimal and the likely cause of his dyspnea. You are considering adding verapamil to his current metoprolol for additional rate control of his atrial fibrillation. Which of the following side effects should you be most concerned about with this additional medication?", "answer": "Hypotension", "options": {"A": "Diarrhea", "B": "Shortening of action potential length at the AV node", "C": "Tachycardia", "D": "Hypotension", "E": "Torsades de pointes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old", "male", "treated", "atrial fibrillation", "angina", "dyspnea", "exertion", "exam", "heart rate", "min", "irregular", "chest pain", "rate control", "atrial fibrillation", "suboptimal", "likely cause", "dyspnea", "adding verapamil", "current metoprolol", "additional rate control", "atrial fibrillation", "following side effects", "most", "about", "additional medication"]}
{"question": "A 3-month-old male presents to the pediatrician with his mother for a well child visit. The patient drinks 4 ounces of conventional cow’s milk formula every three hours. He usually stools once per day, and urinates up to six times per day. His mother reports that he regurgitates a moderate amount of formula through his nose and mouth after most feeds. He does not seem interested in additional feeding after these episodes of regurgitation, and he has become progressively more irritable around meal times. The patient is starting to refuse some feeds. His mother denies ever seeing blood or streaks of red in his stool, and she denies any family history of food allergies or dermatological problems. The patient’s weight was in the 75th percentile for weight throughout the first month of life. Four weeks ago, he was in the 62nd percentile, and he is now in the 48th percentile. His height and head circumference have followed similar trends. On physical exam, the patient smiles reciprocally and can lift his head and chest when in the prone position. His abdomen is soft, non-tender, and non-distended.\n\nWhich of the following is the best next step in management?", "answer": "Counsel on positioning and thickening feeds", "options": {"A": "Obtain abdominal ultrasound", "B": "Counsel on positioning and thickening feeds", "C": "Initiate proton pump inhibitor", "D": "Provide reassurance", "E": "Switch to hydrolyzed formula"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 month old male presents", "pediatrician", "patient", "4 ounces", "conventional", "formula", "three hours", "usually stools", "day", "six times", "day", "reports", "regurgitates", "moderate amount", "formula", "nose", "mouth", "feeds", "not", "additional", "episodes of regurgitation", "irritable", "meal times", "patient", "starting to", "feeds", "seeing blood", "red", "stool", "family history of allergies", "dermatological problems", "patients weight", "percentile", "weight", "the first month of", "Four weeks", "percentile", "now", "percentile", "height", "head circumference", "followed similar trends", "patient smiles", "lift", "head", "chest", "prone position", "abdomen", "soft", "non-tender", "non distended", "following", "best next step"]}
{"question": "An 18-month-old boy is brought to the emergency department after losing consciousness. His mother states that he was running with other kids in the park when he suddenly fell down and became unresponsive for less than 1 minute. He has not had any immunizations due to their religious beliefs. The parents report that he plays with other children, but tires easily. He has had difficulty feeding, but there was no follow-up with a pediatrician. The heart rate was 120/min and the oxygen saturation was 91%. The height is in the 40th percentile and the weight is in the 50th percentile. On examination, the boy is crying with perioral cyanosis. The lung sounds are clear. S-1 is normal and there is a single S-2. A grade 2/6 systolic ejection murmur is appreciated at the left upper sternal border. When the child squats, the murmur is intensified and the cyanosis improves. What is the most appropriate next step in the management of this patient?", "answer": "Morphine, oxygen, IV fluids, and beta blockers", "options": {"A": "Diazepam", "B": "Morphine, oxygen, nitroglycerin, and aspirin", "C": "Morphine, oxygen, IV fluids, and beta blockers", "D": "Observation and reassurance", "E": "Antibiotics and supportive care"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "emergency department", "consciousness", "states", "park", "fell", "unresponsive", "1 minute", "not", "immunizations due to", "report", "plays", "children", "tires easily", "difficulty feeding", "follow-up", "pediatrician", "heart rate", "min", "oxygen saturation", "height", "percentile", "weight", "50th percentile", "boy", "perioral cyanosis", "lung sounds", "clear", "normal", "single", "grade", "systolic ejection murmur", "left upper sternal border", "child squats", "murmur", "cyanosis improves", "most appropriate next step", "patient"]}
{"question": "A 28-year-old man is admitted to the emergency department with a gunshot wound to the abdomen. He complains of weakness and diffuse abdominal pain. Morphine is administered and IV fluids are started by paramedics at the scene. On admission, the patient’s blood pressure is 90/60 mm Hg, heart rate is 103/min, respiratory rate is 17/min, the temperature is 36.2℃ (97.1℉), and oxygen saturation is 94% on room air. The patient is responsive but lethargic. The patient is diaphoretic and extremities are pale and cool. Lungs are clear to auscultation. Cardiac sounds are diminished. Abdominal examination shows a visible bullet entry wound in the left upper quadrant (LUQ) with no corresponding exit wound on the flanks or back. The abdomen is distended and diffusely tender with a rebound. Aspiration of the nasogastric tube reveals bloody contents. Rectal examination shows no blood. Stool guaiac is negative. Which of the following is the next best step in management?", "answer": "Exploratory laparotomy", "options": {"A": "Exploratory laparotomy", "B": "Focused assessment with sonography for trauma (FAST)", "C": "Abdominal X-ray", "D": "Abdominal CT", "E": "Diagnostic peritoneal lavage"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "emergency department", "gunshot", "abdomen", "weakness", "diffuse abdominal", "Morphine", "administered", "started", "paramedics", "patients blood pressure", "90 60 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "oxygen saturation", "room air", "patient", "responsive", "lethargic", "patient", "diaphoretic", "extremities", "pale", "cool", "Lungs", "clear", "auscultation", "Cardiac", "diminished", "Abdominal", "visible bullet", "wound", "left upper quadrant", "exit wound", "flanks", "back", "abdomen", "distended", "tender", "Aspiration", "nasogastric tube reveals bloody", "Rectal examination", "blood", "Stool", "negative", "following", "next best step"]}
{"question": "A 34-year-old woman presents with fatigue, depressed mood, weight gain, and constipation. She gradually developed these symptoms over the past 6 months. She is G2P2 with the last pregnancy 9 months ago. She had a complicated delivery with significant blood loss requiring blood transfusions. She used to have a regular 28-day cycle but notes that recently it became irregular with duration lasting up to 40 days, more pain, and greater blood loss. She does not report any chronic conditions, and she is not on any medications. She is a current smoker with a 10-pack-year history. Her blood pressure is 130/80 mm Hg, heart rate is 54/min, respiratory rate is 11/min, and temperature is 35.8°C (96.4°F). Her skin is dry and pale with a fine scaling over the forearms and shins. There is a mild, non-pitting edema of the lower legs. Her lungs are clear to auscultation. Cardiac auscultation does not reveal any pathological sounds or murmurs although S1 and S2 are dulled at all points of auscultation. The abdomen is mildly distended and nontender on palpation. Neurological examination is significant for decreased deep tendon reflexes. Her blood tests show the following results:\nErythrocytes count 3.4 million/mm3\nHb 12.2 mg/dL\nMCV 90 μm3\nReticulocyte count 0.3%\nLeukocyte count 5,600/mm3\nSerum vitamin B12 210 ng/mL\nT4 total 1.01 μU/mL\nT4 free 0.6 μU/mL\nTSH 0.2 μU/mL\nWhich of the following lab values should be used to monitor treatment in this patient?", "answer": "Free T4", "options": {"A": "Free T4", "B": "Vitamin B12", "C": "Total T3", "D": "MCV", "E": "TSH"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "fatigue", "depressed mood", "weight gain", "constipation", "symptoms", "past 6 months", "pregnancy", "months", "complicated delivery", "significant blood loss requiring blood transfusions", "used to", "regular", "day cycle", "notes", "recently", "irregular", "duration", "40 days", "more pain", "greater blood loss", "not report", "chronic conditions", "not", "medications", "current smoker", "10 year history", "blood pressure", "80 mm Hg", "heart rate", "54 min", "respiratory rate", "min", "temperature", "35", "96", "skin", "dry", "pale", "fine scaling", "forearms", "shins", "mild", "non-pitting edema of", "lower legs", "lungs", "clear", "auscultation", "Cardiac auscultation", "not reveal", "pathological", "murmurs", "S1", "S2", "dulled", "points", "auscultation", "abdomen", "mildly distended", "nontender", "palpation", "Neurological examination", "significant", "decreased deep tendon reflexes", "blood tests", "following results", "Erythrocytes count 3", "2 mg", "m3 Reticulocyte count", "3", "Leukocyte", "Serum", "T4 total", "6", "following lab values", "used to monitor"]}
{"question": "A 74-year-old right-handed woman was referred to the hospital due to concerns of a stroke. In the emergency department, the initial vital signs included blood pressure of 159/98 mm Hg, heart rate of 88/min, and respiratory rate of 20/min. She exhibited paucity of speech and apathy to her condition, although she complied with her physical examination. The initial neurologic evaluation included the following results:\nAwake, alert, and oriented to person, place, and time\nNo visual field deficits\nRight-sided gaze deviation with full range of motion with doll’s head maneuver\nNo facial asymmetry\nGrossly intact hearing\nNo tongue deviation, equal palatal elevation, and good guttural sound production\nAbsent pronator or lower extremity drift\nDecreased sensation to light touch on the right leg\nNormal appreciation of light touch, pressure, and pain\nNormal proprioception and kinesthesia\nManual muscle testing:\n5+ right and left upper extremities\n5+ right hip, thigh, leg, and foot\n3+ left hip and thigh\n2+ left leg and foot\nA head computed tomography (CT) scan and a head magnetic resonance imaging (MRI) confirmed areas of ischemia. Which artery is the most likely site of occlusion?", "answer": "Right anterior cerebral artery", "options": {"A": "Right anterior cerebral artery", "B": "Right middle cerebral artery stem (M1)", "C": "Superior division of the right middle cerebral artery", "D": "Inferior division of the right middle cerebral artery", "E": "Inferior division of the left middle cerebral artery"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["74 year old right-handed woman", "due to", "stroke", "emergency department", "initial vital included blood pressure", "159 98 mm Hg", "heart rate", "88 min", "respiratory rate", "20 min", "speech", "apathy", "condition", "complied", "included", "following results", "Awake", "alert", "oriented to person", "place", "time", "visual deficits Right-sided gaze deviation", "full range of motion", "head", "facial asymmetry", "intact hearing", "tongue deviation", "equal palatal elevation", "good", "sound", "Absent", "lower extremity", "Decreased", "light", "right leg Normal", "light touch", "pressure", "pain Normal", "kinesthesia Manual muscle testing", "5", "right", "left upper extremities", "right hip", "thigh", "leg", "foot", "left", "thigh", "left", "foot", "head computed tomography", "scan", "head magnetic resonance imaging", "confirmed areas of ischemia", "artery", "site of occlusion"]}
{"question": "A 65-year-old woman, with end-stage renal disease (ESRD) on hemodialysis, presents with pain, swelling and discoloration of her right leg and foot. She says that she started twice-weekly hemodialysis 2 weeks ago and has had no issues until 1 week ago when she noticed a warm, painful swelling of the back of her right leg and right foot after finishing her dialysis session. Over the week, she says these symptoms have steadily worsened and, in the last few days, her right foot has become discolored. Past medical history is significant for ESRD secondary to long-standing hypertension. Current medications are verapamil 200 mg orally daily and unfractionated heparin that is given during hemodialysis. Her vital signs include: temperature 37.0°C (98.6°F), blood pressure 145/75 mm Hg, pulse 88/min, respirations 15/min, and oxygen saturation 99% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is normal. Lungs are clear to auscultation. The abdomen is soft and nontender with no hepatosplenomegaly. The right calf is swollen, warm, and erythematous. Physical findings of the patient’s right foot are shown in the exhibit. Laboratory findings are significant for the following:\nSodium 141 mEq/L\nPotassium 4.9 mEq/L\nChloride 104 mEq/L\nBicarbonate 25 mEq/L\nBUN 32 mg/dL\nCreatinine 3.1 mg/dL\nGlucose (fasting) 75 mg/dL\n  Bilirubin, conjugated 0.5 mg/dL       \nBilirubin, total 1.0 mg/dL\nAST (SGOT) 22 U/L       \nALT (SGPT) 23 U/L       \nAlkaline phosphatase 56 U/L\n  Bleeding time 19 min      \nProthrombin time (PT) 11 s   \nPartial thromboplastin time (PTT) 30 s\n        WBC 8,500/mm3       \nRBC 4.10 x 106/mm3\nHematocrit 41.5%\nHemoglobin 13.5 g/dL       \nPlatelet count 100,000/mm3 (previously 200,000/mm3)\nWhich of the following is the next best diagnostic step in this patient?", "answer": "Heparin/PF4 enzyme-linked immunosorbent assay (ELISA)", "options": {"A": "Heparin/PF4 enzyme-linked immunosorbent assay (ELISA)", "B": "Functional assay for factor VIII", "C": "Serotonin release assay", "D": "Peripheral blood smear", "E": "Flow cytometry for CD55"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old woman", "end-stage renal disease", "hemodialysis", "presents", "pain", "swelling", "discoloration", "right leg", "foot", "started twice-weekly hemodialysis", "weeks", "issues", "1 week", "warm", "painful swelling of", "back", "right leg", "right foot", "finishing", "dialysis", "week", "symptoms", "worsened", "last", "days", "right foot", "discolored", "Past medical history", "significant", "ESRD secondary to long standing hypertension", "Current medications", "verapamil 200 mg orally daily", "unfractionated heparin", "given", "hemodialysis", "vital signs include", "temperature", "98", "blood pressure", "75 mm Hg", "pulse 88 min", "respirations", "min", "oxygen saturation 99", "room air", "patient", "alert", "normal", "Lungs", "clear", "auscultation", "abdomen", "soft", "nontender", "hepatosplenomegaly", "right calf", "swollen", "warm", "erythematous", "Physical findings of", "foot", "Laboratory findings", "significant", "following", "Sodium", "mEq", "Potassium", "Chloride", "Bicarbonate 25", "32 mg", "Creatinine", "Glucose", "fasting", "75 mg/dL", "Bilirubin", "conjugated 0.5 mg/dL", "Bilirubin", "total", "0 mg/dL AST", "U/L", "ALT", "23 U", "Alkaline phosphatase", "U", "Bleeding time", "Prothrombin time", "Partial thromboplastin time", "WBC 8 500 mm3", "4 10", "Hematocrit", "5", "Hemoglobin", "dL", "Platelet count 100", "200", "mm3", "following", "next best diagnostic step", "patient"]}
{"question": "A 62-year-old man is brought to the emergency room because of pain in his right hip. He was found lying on the floor several hours after falling onto his right side. Ten years ago, he received a renal transplant from a living related donor. He has a 4-year history of type 2 diabetes. Current medications include prednisone, cyclosporine, and metformin. Examination shows a shortened and externally rotated right leg. There is extensive bruising over the right buttock and thigh. X-ray of the right hip shows a displaced femoral neck fracture. The patient is resuscitated in the emergency room and taken to surgery for a right total hip replacement. Post-operative laboratory studies show:\nHemoglobin 11.2 g/dL\nSerum\nNa+ 148 mmol/L\nK+ 7.1 mmol/L\nCl- 119 mmol/L\nHCO3- 18 mmol/L\nUrea nitrogen 22 mg/dL\nCreatinine 1.6 mg/dL\nGlucose 200 mg/dL\nCreatine kinase 1,562 U/L\nHis urine appears brown. Urine dipstick is strongly positive for blood. ECG shows peaked T waves. Intravenous calcium gluconate is administered. What is the most appropriate next step in management?\"", "answer": "Administer intravenous insulin and glucose", "options": {"A": "Administer nebulized albuterol", "B": "Administer intravenous insulin and glucose", "C": "Initiate hemodialysis", "D": "Administer intravenous furosemide and normal saline", "E": "Administer intravenous sodium bicarbonate"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["62 year old man", "brought", "emergency room", "of pain in", "right hip", "found lying", "floor", "hours", "falling", "right side", "Ten years", "received", "renal transplant from", "living related donor", "4 year history", "type 2 diabetes", "Current medications include prednisone", "cyclosporine", "metformin", "shortened", "externally rotated right leg", "extensive bruising", "right buttock", "thigh", "X-ray", "right hip", "displaced femoral neck fracture", "patient", "resuscitated", "emergency room", "surgery", "right total hip replacement", "Post-operative laboratory studies", "Hemoglobin", "L K", "HCO3", "18", "Urea nitrogen", "Creatinine", "200", "U", "urine appears brown", "Urine dipstick", "positive", "blood", "ECG", "peaked T waves", "Intravenous calcium gluconate", "administered", "most appropriate next step"]}
{"question": "After an initial assessment in the emergency department, the patient is sent for an urgent CT scan of the head. CT scan reveals a mild hypodensity in the left cerebellum. What is the most likely etiology/cause?", "answer": "Arterial dissection", "options": {"A": "Arterial blood leakage", "B": "Arterial dissection", "C": "Cardiac emboli", "D": "Carotid stenosis", "E": "Lacunar infarction"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["initial assessment", "emergency department", "patient", "sent", "urgent CT scan of", "head", "reveals", "mild", "left cerebellum", "etiology cause"]}
{"question": "A 56-year-old female presents for initial evaluation by a rheumatologist with a chief complaint of back and joint pain. She says that she has been having mild pain for years, but that the pain has become worse over the course of the last 6 months. She clarifies that the pain is most severe in the mornings just after waking up but seems to improve throughout the day. She also notices that her mouth feels dry and she has difficulty eating dry food such as crackers. Finally, she has the sensation of having bits of sand in her eyes. She denies any past medical history or medication use. Serology for which of the following would most likely be positive in this patient?", "answer": "Anti-Ro and anti-La antibodies", "options": {"A": "Anti-smooth muscle antibody", "B": "Anti-centromere antibody", "C": "Anti-cyclic citrullinated peptide (CCP) antibody", "D": "Anti-Jo1 and anti-Mi2 antibodies", "E": "Anti-Ro and anti-La antibodies"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female presents", "initial evaluation", "rheumatologist", "chief complaint of back", "joint pain", "mild pain", "years", "pain", "worse", "course of", "months", "pain", "most severe", "mornings", "waking", "to", "day", "mouth", "dry", "difficulty eating", "sensation", "bits", "sand", "eyes", "past medical history", "medication use", "Serology", "of", "following", "most likely", "positive", "patient"]}
{"question": "A 50-year-old man presents with a rapid onset of severe, right periorbital pain, an ipsilateral throbbing headache, and blurred vision for the past hour. The patient says he was out walking with his friend when he felt short of breath. His friend gave him a puff of his rescue inhaler because it often relives his breathlessness, but, soon after that, the patient's eye symptoms started. No significant past medical history. His pulse is 100/min and regular, respirations are 18/min, temperature is 36.7°C (98.0°F), and blood pressure 130/86 mm Hg. On physical examination, his right pupil is fixed and dilated. Fundoscopic examination of the right eye is difficult due to 'clouding' of the cornea, and tonometry reveals increased intraocular pressure (IOP). Ibuprofen, acetazolamide, timolol, pilocarpine, and topical prednisolone are administered, but the patient's symptoms are only slightly reduced. Which of the following is the next best step in the management of this patient?", "answer": "Get an urgent ophthalmology consultation.", "options": {"A": "Administer systemic steroids.", "B": "Get an urgent ophthalmology consultation.", "C": "Anesthetize the eye and perform corneal indentation.", "D": "Add latanoprost.", "E": "Perform emergency iridotomy."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old man presents", "rapid onset", "severe", "right periorbital", "ipsilateral throbbing headache", "blurred vision", "past hour", "patient", "out", "short of breath", "gave", "puff", "inhaler", "often", "breathlessness", "patient's eye started", "significant past medical history", "pulse", "100 min", "regular", "respirations", "min", "temperature", "36", "98", "blood pressure", "mm Hg", "right pupil", "fixed", "dilated", "Fundoscopic examination of", "right eye", "difficult due to", "clouding", "cornea", "tonometry reveals increased intraocular pressure", "Ibuprofen", "acetazolamide", "timolol", "pilocarpine", "administered", "patient's symptoms", "only slightly reduced", "following", "next best step", "patient"]}
{"question": "A 47-year-old woman comes to the physician for a follow-up examination. She has type 1 diabetes mellitus, end-stage renal disease, and was recently started on erythropoietin for anemia. Her last hemodialysis session was yesterday. Current medications also include insulin, calcitriol, and sevelamer. She appears well. Her pulse is 68/min and regular, respirations are 12/min, and blood pressure is 169/108 mm Hg. Her blood pressure was normal at previous visits. Examination shows normal heart sounds. There are no carotid, femoral, or abdominal bruits. The lungs are clear to auscultation. Laboratory studies show a hemoglobin concentration of 12 g/dL, a serum creatinine concentration of 3.4 mg/dL, and BUN of 20 mg/dL. Which of the following is the most likely cause of this patient's hypertension?", "answer": "Erythropoietin therapy", "options": {"A": "Calcitriol therapy", "B": "Erythropoietin therapy", "C": "Autonomic neuropathy", "D": "Hypervolemia", "E": "Hypoglycemia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "type 1 diabetes mellitus", "end-stage renal disease", "recently started", "erythropoietin", "anemia", "last hemodialysis", "Current medications", "include insulin", "calcitriol", "sevelamer", "appears well", "pulse", "min", "regular", "respirations", "min", "blood pressure", "mm Hg", "blood pressure", "normal", "previous", "normal heart sounds", "carotid", "femoral", "abdominal bruits", "lungs", "clear", "auscultation", "Laboratory studies", "a hemoglobin concentration", "g/dL", "serum creatinine concentration", "mg dL", "BUN", "20 mg dL", "following", "most likely cause", "patient's hypertension"]}
{"question": "A 68-year-old man with alcohol use disorder is brought to the physician by his sister for frequent falls and an unsteady gait over the past 2 months. He has not seen a physician in 10 years. He appears emaciated and inattentive. He is oriented to person only. Physical examination shows a wide-based gait with slow, short steps. Eye examination shows lateral gaze paralysis and horizontal nystagmus. One month later, he dies. Which of the following is the most likely finding on autopsy?", "answer": "Small vessel hemorrhage in mammillary bodies", "options": {"A": "Small vessel hemorrhage in mammillary bodies", "B": "Degeneration of the frontotemporal lobe", "C": "Depigmentation of the substantia nigra", "D": "Widespread atrophy of cerebral cortex", "E": "Atrophy of the caudate and putamen"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "alcohol use disorder", "brought", "physician", "frequent falls", "unsteady gait", "past", "months", "not seen", "physician", "appears emaciated", "inattentive", "oriented to person only", "wide-based gait", "slow", "short steps", "Eye examination", "lateral gaze paralysis", "horizontal nystagmus", "One month later", "following", "finding", "autopsy"]}
{"question": "A 57-year-old woman comes to the physician because of increasing wrinkles on her face and sagging skin. She says that her skin used to be smooth and firm. Examination shows diffuse xerosis and mild atrophy, laxity, and fine wrinkles on the periorbital skin. Which of the following processes is most likely involved in the development of this patient's skin findings?", "answer": "Decrease in elastin fiber assembly", "options": {"A": "Decrease in lysyl oxidase activity", "B": "Decrease in elastin fiber assembly", "C": "Increase in fibroblast activity", "D": "Increase in lipofuscin deposition", "E": "Decreased crosslinking of collagen fibrils"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["57 year old woman", "physician", "of increasing wrinkles", "face", "sagging skin", "skin used to", "smooth", "firm", "diffuse xerosis", "mild atrophy", "laxity", "fine wrinkles", "periorbital skin", "following processes", "most likely involved", "development", "patient's skin"]}
{"question": "A 35-year-old woman presents with an inability to move her right arm or leg. She states that symptoms onset acutely 2 hours ago. Past medical history is significant for long-standing type 1 diabetes mellitus, well-managed with insulin. The patient reports a 15-pack-year smoking history. Family history is significant for breast cancer in her mother at age 66 and her father dying of a myocardial infarction at age 57. Review of systems is significant for excessive fatigue for the past week, and her last menstrual period that was heavier than normal. Her vitals signs include: temperature 38.8°C (101.8°F), blood pressure 105/75 mm Hg, pulse 98/min, respirations 15/min, and oxygen saturation 99% on room air. On physical examination, the patient appears pale and tired. The cardiac exam is normal. Lungs are clear to auscultation. The abdominal exam is significant for splenomegaly. There is a non-palpable purpura present on the lower extremities bilaterally. Conjunctiva and skin are pale. Laboratory results are pending. A peripheral blood smear is shown in the exhibit. Which of the following laboratory findings would least likely be seen in this patient?", "answer": "Elevated creatinine", "options": {"A": "Decreased platelets", "B": "Normal PTT and PT", "C": "Elevated creatinine", "D": "Elevated reticulocyte count", "E": "Elevated bilirubin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old woman presents", "to move", "right arm", "leg", "states", "symptoms onset", "hours", "Past medical history", "significant", "long standing type 1 diabetes mellitus", "well", "insulin", "patient reports", "smoking history", "Family history", "significant", "breast cancer", "mother", "age 66", "dying", "myocardial infarction", "age 57", "Review of systems", "significant", "excessive fatigue", "past week", "last menstrual period", "heavier", "normal", "signs include", "temperature", "blood pressure", "75 mm Hg", "pulse 98 min", "respirations", "min", "oxygen saturation 99", "room air", "patient appears pale", "tired", "normal", "Lungs", "clear", "auscultation", "abdominal exam", "significant", "splenomegaly", "non present", "lower extremities", "Conjunctiva", "skin", "pale", "Laboratory results", "peripheral blood smear", "following laboratory findings", "least likely", "seen", "patient"]}
{"question": "A 77-year-old male presents to the emergency department because of shortness of breath and chest discomfort. The patient states his ability to withstand activity has steadily declined, and most recently he has been unable to climb more than one flight of stairs without having to stop to catch his breath. On physical exam, the patient has a harsh crescendo-decrescendo systolic murmur heard over the right sternal boarder, with radiation to his carotids. Which of the following additional findings are most likely in this patient?", "answer": "A paradoxically split S2", "options": {"A": "A wide and fixed split S2", "B": "A constant, machine-like murmur heard between the scapulae", "C": "A paradoxically split S2", "D": "A diastolic murmur heard at the cardiac apex", "E": "A high-bitched, blowing, holosystolic murmur"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old male presents", "emergency department", "of shortness", "breath", "chest discomfort", "patient states", "ability to", "activity", "most recently", "unable to climb", "one", "to stop to catch", "breath", "patient", "harsh crescendo-decrescendo systolic murmur heard", "right sternal", "radiation", "carotids", "following additional findings", "patient"]}
{"question": "A 3-year-old boy is brought to the family physician by his parents. They are concerned that he has had multiple nosebleeds in the last 6 months and is always sick compared to other children. During this time period they have also noticed the formation of multiple bruises on his extremities and dry-itching skin on his hands, feet and elbow. On physical exam the physician notes moderate splenomegaly. What is the most likely diagnosis in this child?", "answer": "Wiskott-Aldrich Syndrome", "options": {"A": "X-linked Agammaglobulinemia", "B": "Severe Combined Immunodefiency", "C": "Wiskott-Aldrich Syndrome", "D": "Primary Eczema", "E": "Hyperimmunoglobulin E syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "family physician", "multiple nosebleeds", "months", "always sick", "children", "time period", "formation", "multiple bruises", "extremities", "dry itching skin", "hands", "feet", "elbow", "physician notes moderate splenomegaly", "diagnosis", "child"]}
{"question": "A 24-year-old, gravida 1, para 1 woman develops lower abdominal pain and fevers 4 days after undergoing a cesarean delivery under general anesthesia for prolonged labor. Since delivery, she has had malodorous lochia and difficulty breastfeeding due to breast pain. She has not had any shortness of breath or chest pain. She received intravenous intrapartum penicillin for group B streptococcus prophylaxis, but does not take any other medications on a regular basis. She appears ill. Her temperature is 38.8°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Examination shows a urinary catheter in place. Breasts are engorged and tender. Nipples are cracked with mild erythema. There is erythema surrounding a mildly tender, dry, low transverse, 12-cm incision in the lower abdomen. Pelvic examination shows dark-red, foul-smelling lochia and uterine tenderness. Her hemoglobin concentration is 9 g/dL, leukocyte count is 16,000/mm3, and platelet count is 300,000/mm3. Which of the following is the most likely cause of this patient's fever?", "answer": "Endometritis", "options": {"A": "Endometritis", "B": "Pyelonephritis", "C": "Normal postpartum fever", "D": "Chorioamnionitis", "E": "Mastitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "gravida 1", "para 1 woman", "lower abdominal pain", "fevers 4 days", "cesarean delivery", "general anesthesia", "prolonged labor", "delivery", "lochia", "difficulty breastfeeding due to breast pain", "not", "shortness of breath", "chest pain", "received intravenous intrapartum penicillin", "prophylaxis", "not", "medications", "regular basis", "appears ill", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "70 mm Hg", "urinary catheter", "place", "Breasts", "engorged", "tender", "Nipples", "cracked", "mild erythema", "erythema surrounding", "mildly tender", "dry", "low transverse", "incision", "lower abdomen", "Pelvic examination", "dark red", "smelling lochia", "uterine tenderness", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "platelet count", "300", "mm3", "following", "most likely cause", "patient's fever"]}
{"question": "A 67-year-old woman is brought to the emergency department by her caretakers for a change in behavior. The patient lives in a nursing home and was noted to have abnormal behavior, urinary incontinence, and trouble walking. The patient has been admitted to the hospital before for what seems to be negligence from her caretakers. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 120 mEq/L\nCl-: 98 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\nUrinalysis is notable for bacteruria without pyuria or nitrates. Physical exam is notable for a confused woman who is unable to answer questions appropriately. She states she has no pain or symptoms and is not sure why she is here. She thinks the year is 1982. Which of the following complications could be seen with treatment of this patient?", "answer": "Osmotic demyelination", "options": {"A": "Autoimmune pontine demyelination", "B": "Central nervous system infection", "C": "Cerebral edema", "D": "Diarrhea and flora destruction", "E": "Osmotic demyelination"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["67 year old woman", "brought", "emergency department", "caretakers", "change", "behavior", "patient lives in a nursing home", "noted to", "abnormal behavior", "urinary incontinence", "patient", "to", "negligence", "caretakers", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L", "98 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", "Urinalysis", "notable", "pyuria", "notable", "confused woman", "unable to", "states", "pain", "symptoms", "not sure", "year", "following complications", "seen"]}
{"question": "A 3-year-old boy is brought to the emergency department because of increasing shortness of breath for 2 days. He is at 30th percentile for height and at 25th percentile for weight. His temperature is 37.1°C (98.8°F), pulse is 144/min, respirations are 40/min, and blood pressure is 80/44 mm Hg. Bilateral crackles are heard at the lung bases. A grade 3/6 holosystolic murmur is heard over the left lower sternal border. A grade 2/6 mid-diastolic murmur is heard best in the left fourth intercostal space. Without treatment, this patient is at risk of developing which of the following?", "answer": "Polycythemia", "options": {"A": "Cerebral aneurysm", "B": "Polycythemia", "C": "Secondary hypertension", "D": "Thrombocytosis", "E": "Myocardial ischemia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "of increasing shortness", "breath", "2 days", "percentile", "height", "percentile", "weight", "temperature", "98", "pulse", "min", "respirations", "40 min", "blood pressure", "80", "mm Hg", "Bilateral crackles", "heard", "lung bases", "holosystolic murmur", "heard", "left lower sternal border", "mid-diastolic murmur", "heard best", "left fourth intercostal space", "treatment", "patient", "at risk", "following"]}
{"question": "A 33-year-old man presents to the emergency room for diarrhea. He states it is profuse and watery and has not been improving over the past week. He is generally healthy; however, he was recently hospitalized during spring break and treated for alcohol intoxication and an aspiration pneumonia. While on spring break, the patient also went camping and admits eating undercooked chicken and drinking from mountain streams. His temperature is 100.5°F (38.1°C), blood pressure is 111/74 mmHg, pulse is 110/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for a fatigued appearing man. His abdomen is non-tender. Which of the following is the best management of this patient?", "answer": "Vancomycin", "options": {"A": "Ciprofloxacin", "B": "Ciprofloxacin and metronidazole", "C": "Metronidazole", "D": "No treatment indicated", "E": "Vancomycin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency room", "diarrhea", "states", "watery", "not", "improving", "past week", "healthy", "recently hospitalized", "spring break", "treated", "alcohol intoxication", "aspiration pneumonia", "spring break", "patient", "eating", "drinking", "mountain", "temperature", "100", "blood pressure", "74 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "fatigued appearing man", "abdomen", "non-tender", "following", "best", "patient"]}
{"question": "A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She states that she initially had dull stomach pain about 6 hours ago, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of serious illness. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most likely diagnosis?", "answer": "Appendicitis", "options": {"A": "HELLP syndrome", "B": "Nephrolithiasis", "C": "Acute cholangitis", "D": "Appendicitis", "E": "Pyelonephritis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old woman", "gravida 1", "para 0", "30 weeks", "gestation", "brought", "emergency department", "of progressive upper abdominal pain", "past hour", "patient vomited", "hospital", "states", "initially", "dull stomach pain", "hours", "now", "pain", "upper abdomen", "more severe", "personal", "family history", "serious illness", "sexually active", "not smoke", "Medications include folic acid", "multivitamin", "temperature", "pulse", "100 min", "blood pressure", "80 mm Hg", "right upper quadrant tenderness", "abnormalities", "Laboratory studies", "leukocyte count", "mm3", "Urinalysis", "mild pyuria", "following", "diagnosis"]}
{"question": "An 8-year-old female is given omalizumab for the treatment of bronchial asthma. Omalizumab treats asthma through which mechanism?", "answer": "Inhibition of IgE binding to mast cells", "options": {"A": "Inhibition of IgE binding to mast cells", "B": "Binding to nuclear receptors", "C": "Inhibition of leukotriene binding to receptor", "D": "Inhibition of phosphodiesterase breakdown of cAMP", "E": "Mediating type IV hypersensitivity reaction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "given omalizumab", "treatment", "bronchial asthma", "treats asthma", "mechanism"]}
{"question": "A 49-year-old man seeks evaluation at an urgent care clinic with a complaint of palpitations for the past few hours. He denies any chest pain, shortness of breath, or sweating. He is anxious and appears worried. His medical history is unremarkable with the exception of mild bronchial asthma. He only uses medications during an asthma attack and has not used medications since last week. He is a former smoker and drinks a couple of beers on weekends. His heart rate is 146/min, respiratory rate is 16/min, temperature is 37.6°C (99.68°F), and blood pressure is 120/80 mm Hg. The physical examination is unremarkable, and an electrocardiogram is ordered. Which of the following groups of drugs should be given to treat his symptoms?", "answer": "Selective β1-receptor antagonist", "options": {"A": "α1-receptor antagonist", "B": "Selective β1-receptor antagonist", "C": "Non-selective β-receptor antagonist", "D": "α-receptor agonist", "E": "β-receptor agonist"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "urgent care clinic", "complaint", "palpitations", "past", "hours", "chest pain", "shortness of breath", "sweating", "anxious", "appears worried", "medical history", "unremarkable", "mild bronchial asthma", "only uses medications", "asthma attack", "not used medications", "week", "former smoker", "couple", "weekends", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "blood pressure", "80 mm Hg", "unremarkable", "electrocardiogram", "ordered", "following groups", "drugs", "given to treat", "symptoms"]}
{"question": "A 26-year-old female college student is brought back into the university clinic for acting uncharacteristically. The patient presented to the same clinic 6 weeks ago with complaints of depressed mood, insomnia, and weightloss. She had been feeling guilty for wasting her parent’s money by doing so poorly at the university. She felt drained for at least 2 weeks before presenting to the clinic for the first time. She was placed on an antidepressant and was improving but now presents with elevated mood. She is more talkative with a flight of ideas and is easily distractible. Which of the following statements is most likely true regarding this patient’s condition?", "answer": "Her diagnosis of unipolar depression is incorrect.", "options": {"A": "Her diagnosis of unipolar depression is incorrect.", "B": "Her new symptoms need to last at least 7 days.", "C": "The patient may have a history of mania.", "D": "The patient may have psychotic features.", "E": "Antidepressants are inappropriate."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "brought back", "university clinic", "patient", "same clinic", "weeks", "complaints", "depressed mood", "insomnia", "weightloss", "wasting", "money", "so poorly", "university", "drained", "2 weeks", "clinic", "first time", "antidepressant", "improving", "now presents", "elevated mood", "more", "flight of ideas", "easily distractible", "following", "true", "patients condition"]}
{"question": "A 13-year-old boy has been suspended 5 times this year for arguing with teachers. He has presented a pattern of negativism and hostility that has lasted for about 8 months. When asked about the suspensions, he admits that he loses his temper easily and often blames the principal for not being fair to him. He usually finds an argument before finishing his homework. At home, he goes out of his way to annoy his siblings. He gets furious if his legal guardian finds out about it and confiscates his smartphone. Which of the following is an additional behavior characteristic of this patient’s most likely diagnosis?", "answer": "Hostile and disobedient behavior towards authority", "options": {"A": "Destruction of property and theft", "B": "Hostile and disobedient behavior towards authority", "C": "Killing and/or harming small animals", "D": "Physical aggression", "E": "Violating the rights of others"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "suspended 5 times", "year", "teachers", "pattern", "negativism", "lasted", "months", "suspensions", "easily", "often", "principal", "not", "fair", "usually finds", "finishing", "home", "goes out", "to", "gets", "finds out", "smartphone", "following", "additional behavior characteristic", "patients", "likely diagnosis"]}
{"question": "A 32-year-old woman patient presents to her family physician with recurrent retrosternal chest pain. She has had similar episodes for the past 7 months along with difficulty swallowing solid as well as liquid food. She recently completed an 8-week course of a proton pump inhibitor, but she is still bothered by the feeling that food gets stuck down her 'food pipe'. Her pain is not related to exertion. She denies any history of acid reflux disease. Her blood pressure is 125/81 mm Hg, respirations are 21/min, pulse is 78/min, and temperature is 36.7°C (98.1°F). She currently does not have pain. A barium swallow X-ray image is normal. Which of the following test would aid in the diagnosis of this patient's condition?", "answer": "Manometry", "options": {"A": "Electrocardiogram", "B": "Upper GI endoscopy", "C": "Manometry", "D": "Additional therapy with proton pump inhibitors", "E": "Injection of botulinum toxin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman patient presents", "family physician", "recurrent retrosternal", "similar episodes", "past", "months", "difficulty swallowing solid", "liquid food", "recently completed", "week course", "proton pump inhibitor", "food gets stuck", "food pipe", "pain", "not related", "exertion", "history of acid reflux disease", "blood pressure", "81 mm Hg", "respirations", "min", "pulse", "min", "temperature", "36", "98", "currently", "not", "pain", "barium swallow X-ray", "normal", "following test", "aid", "diagnosis", "patient's condition"]}
{"question": "A 49-year-old sexually active woman presents with dysuria and urinary frequency. She denies any previous urinary tract infections (UTIs), but she says that her mother has had frequent UTIs. Her medical history includes type 2 diabetes mellitus, hypertension, cervical cancer, and hypercholesterolemia. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and denies any illicit drug use. Her 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. On physical examination, her lung sounds are clear. She has a grade 2/6 holosystolic murmur heard best over the left upper sternal border. She also has tenderness in the suprapubic area. A urinalysis shows the presence of numerous leukocytes, leukocyte esterase, and nitrites. Which of the following factors would not classify a UTI as complicated?", "answer": "The causative organism is Pseudomonas aeruginosa", "options": {"A": "The patient has diabetes", "B": "The causative organism is Candida albicans", "C": "The causative organism is Pseudomonas aeruginosa", "D": "The patient has an indwelling catheter", "E": "The patient has nephrolithiasis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old sexually active woman presents", "dysuria", "urinary frequency", "previous urinary tract infections", "frequent UTIs", "medical history includes type 2 diabetes mellitus", "hypertension", "cervical cancer", "hypercholesterolemia", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "illicit drug use", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 87 min", "respiratory rate", "min", "lung sounds", "clear", "holosystolic murmur heard best", "left upper sternal border", "tenderness", "suprapubic area", "urinalysis", "presence", "numerous", "leukocyte esterase", "following factors", "not", "UTI", "complicated"]}
{"question": "A 58-year-old woman with a history of nephrolithiasis presents with fever and acute-onset right flank pain. The patient says that 2 days ago she developed sudden-onset right flank pain and nausea which has progressively worsened. She describes the pain as severe, colicky, localized to the right flank, and radiating to the groin. This morning she woke with a fever and foul-smelling urine. She has no significant past medical history. Vital signs are temperature 40.0°C (104.0°F), blood pressure 110/70 mm Hg, pulse 92/min, and respiratory rate 21/min. Physical examination shows severe right costovertebral angle tenderness. Her laboratory findings are significant for the following:\nWBC 12,500/mm3\nRBC 4.20 x 106/mm3\nHematocrit 41.5%\nHemoglobin 14.0 g/dL\nPlatelet count 225,000/mm3\nUrinalysis:\nColor Dark yellow\nClarity Clarity Turbid\npH 5.9\nSpecific gravity 1.026\nGlucose None\nKetones None\nNitrites Positive\nLeukocyte esterase Positive\nBilirubin Negative\nUrobilirubin 0.6 mg/dL\nProtein Trace\nRBC 325/hpf\nWBC 8,200/hpf\nBacteria Many\nA non-contrast CT of the abdomen and pelvis shows an obstructing 7-mm diameter stone lodged at the ureteropelvic junction. There is also evidence of hydronephrosis of the right kidney. Which of the following is the best course of treatment for this patient?", "answer": "Admit to hospital for percutaneous nephrostomy and IV antibiotics", "options": {"A": "Discharge home with oral antibiotics", "B": "Administer hydrochlorothiazide", "C": "Admit to hospital for IV antibiotics", "D": "Administer potassium citrate", "E": "Admit to hospital for percutaneous nephrostomy and IV antibiotics"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["58 year old woman", "history of nephrolithiasis presents", "fever", "acute-onset right flank", "patient", "2 days", "sudden-onset right flank", "nausea", "worsened", "pain", "severe", "colicky", "localized", "right flank", "radiating to", "groin", "morning", "woke", "fever", "foul-smelling urine", "significant past medical history", "Vital signs", "temperature 40", "blood pressure", "70 mm Hg", "pulse", "min", "respiratory rate", "min", "severe right costovertebral angle tenderness", "laboratory findings", "significant", "following", "WBC 12 500 mm3", "4 20", "Hematocrit", "Hemoglobin", "0 g/dL Platelet count 225", "Urinalysis", "Color Dark yellow Clarity", "Turbid pH", "Specific gravity 1", "Glucose", "Ketones", "Positive Leukocyte esterase", "Bilirubin Negative", "0", "Protein Trace RBC 325 hpf WBC 8 200", "Bacteria", "non contrast CT of", "abdomen", "pelvis", "obstructing", "mm diameter stone", "ureteropelvic junction", "hydronephrosis", "right kidney", "following", "best course", "treatment", "patient"]}
{"question": "An investigator is developing a new vaccine. After injecting the agent, the immune response is recorded by measuring vaccine-specific antibodies at subsequent timed intervals. To induce the maximum immunogenic response, this vaccine should have which of the following properties?", "answer": "Weakened live microorganisms", "options": {"A": "Foreign intact polysaccharide bound to protein", "B": "Chemically inactivated microorganism", "C": "Foreign intact polysaccharide", "D": "Foreign denaturated protein", "E": "Weakened live microorganisms"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "new vaccine", "injecting", "agent", "immune response", "recorded", "measuring vaccine specific antibodies", "subsequent timed intervals", "To induce", "maximum immunogenic response", "vaccine", "following properties"]}
{"question": "A 34-year-old woman with a seizure disorder comes to the physician because of fever, fatigue, and a productive cough with foul-smelling sputum for 2 weeks. Her temperature is 38.3°C (100.9°F). Physical examination shows dullness to percussion over the right lung fields. An x-ray of the chest shows a cavitary infiltrate with an air-fluid level in the right lower lobe of the lung. Cultures of an aspirate of the infiltrate grow Peptostreptococcus and Prevotella species. Which of the following is the most likely predisposing factor for this patient's condition?", "answer": "Periodontal infection", "options": {"A": "Recent hospitalization", "B": "Intravenous drug use", "C": "Crowded housing situation", "D": "Periodontal infection", "E": "Contaminated air conditioning system"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "seizure disorder", "physician", "fever", "fatigue", "productive cough", "foul-smelling sputum", "2 weeks", "temperature", "100 9F", "dullness", "percussion", "right lung fields", "x-ray of", "chest", "infiltrate", "air-fluid level", "the right lower lobe of", "lung", "aspirate", "infiltrate", "following", "predisposing factor", "patient's condition"]}
{"question": "A 27-year-old man presents to the clinic for his annual health check-up. He currently complains of fatigue for the past few months. He has no significant past medical history. He admits to being sexually active with men and also is an intravenous drug user. He has never received a hepatitis B vaccine. His blood pressure is 122/98 mm Hg, the respiratory rate is 16/min, the pulse is 68/min, and the temperature is 37.0°C (98.6°F). On physical examination, he appears fatigued and unkempt. His tongue and buccal mucosa appear moist and without ulcerations or lesions. There are no murmurs or gallops on cardiac auscultation. His lungs are clear bilaterally. No lesions are present on the surface of the skin nor skin discoloration. The physician proceeds to order a hepatitis B panel to assess the patient’s serologic status:\nHBV DNA positive\nHBsAg negative\nHBeAg  negative\nHBsAb negative\nHBcAb positive\nHBeAb negative\nWhich of the following disease states is the patient exhibiting?", "answer": "Convalescent (window) period", "options": {"A": "Acute infection", "B": "Chronic infection", "C": "Immune from vaccine", "D": "Immune from natural infection", "E": "Convalescent (window) period"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["27 year old man presents", "clinic", "annual health check-up", "currently", "fatigue", "past", "months", "significant past medical history", "to", "sexually active with men", "intravenous drug user", "never received", "hepatitis B vaccine", "blood pressure", "98 mm Hg", "respiratory rate", "min", "pulse", "min", "temperature", "98", "appears fatigued", "unkempt", "tongue", "buccal mucosa appear moist", "ulcerations", "lesions", "murmurs", "cardiac auscultation", "lungs", "clear", "lesions", "present", "surface of", "skin", "skin discoloration", "physician", "to order", "hepatitis", "panel to", "patients serologic status", "HBV DNA positive HBsAg negative", "HBsAb", "HBcAb", "HBeAb", "following disease states", "patient"]}
{"question": "A 45-year-old construction worker presents to his primary care physician with a painful and swollen wrist joint. A joint aspiration shows crystals, which are shown in the accompanying picture. Which of the following is the most likely diagnosis?", "answer": "Monosodium urate crystals", "options": {"A": "Monosodium urate crystals", "B": "Hydroxyapatite crystals", "C": "Calcium pyrophosphate crystals", "D": "Cholesterol crystals", "E": "Charcot Leyden crystals"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old construction worker presents", "primary care physician", "painful", "swollen", "joint aspiration", "crystals", "picture", "following", "diagnosis"]}
{"question": "A 62-year-old man presents with epigastric pain over the last 6 months. He says the pain gets worse with food, especially coffee. He also complains of excessive belching. He says he has tried omeprazole recently, but it has not helped. No significant past medical history or current medications. On physical examination, there is epigastric tenderness present on deep palpation. An upper endoscopy is performed which reveals gastric mucosa with signs of mild inflammation and a small hemorrhagic ulcer in the antrum. A gastric biopsy shows active inflammation, and the specimen stains positive with Warthin–Starry stain, revealing Helicobacter pylori. Which of the following is the next, best step in the management of this patient’s condition?", "answer": "Give amoxicillin, clarithromycin, and omeprazole", "options": {"A": "Start famotidine and erythromycin", "B": "Observation", "C": "Perform colonoscopy", "D": "Give amoxicillin, clarithromycin, and omeprazole", "E": "Give amoxicillin, erythromycin and omeprazole"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man presents", "epigastric pain", "last", "months", "pain gets worse", "food", "excessive belching", "omeprazole recently", "not helped", "significant past medical history", "current medications", "epigastric tenderness present", "deep palpation", "upper endoscopy", "performed", "reveals gastric mucosa", "signs", "mild inflammation", "small hemorrhagic", "antrum", "gastric biopsy", "active inflammation", "stains positive", "revealing", "following", "next", "best step", "management", "patients condition"]}
{"question": "A 68-year-old man comes to the emergency room with difficulty in breathing. He was diagnosed with severe obstructive lung disease a few years back. He uses his medication but often has to come to the emergency room for intravenous therapy to help him breathe. He was a smoker for 40 years smoking two packs of cigarettes every day. Which of the following best represents the expected changes in his ventilation, perfusion and V/Q ratio?", "answer": "Low ventilation, normal perfusion and low V/Q ratio", "options": {"A": "Higher ventilation and perfusion with lower V/Q ratio", "B": "Low ventilation, normal perfusion and low V/Q ratio", "C": "Lower ventilation and perfusion, but higher V/Q ratio", "D": "Medium ventilation and perfusion, V/Q that equals 0.8", "E": "Normal ventilation, low or nonexistent perfusion and infinite V/Q ratio"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency room", "difficulty", "breathing", "diagnosed", "severe obstructive lung disease", "few years back", "uses", "medication", "often", "to", "emergency room", "intravenous therapy to help", "smoker", "40 years smoking two packs", "cigarettes", "day", "following best", "changes", "ventilation", "perfusion", "V/Q ratio"]}
{"question": "A 67-year-old African American male presents to the emergency room complaining of nausea and right flank pain. He reports that these symptoms have worsened over the past two days. His past medical history is notable for congestive heart failure, hypertension, hyperlipidemia, and diabetes mellitus. He currently takes aspirin, losartan, metoprolol, atorvastatin, hydrochlorothiazide, furosemide, and metformin. He is allergic to fluoroquinolones. His temperature is 102.9°F (39.4°C), blood pressure is 100/50 mmHg, pulse is 120/min, and respirations are 28/min. On exam, he demonstrates right costovertebral angle tenderness. Urinalysis reveals 30 WBCs/hpf and positive leukocyte esterase. He is admitted and started on a broad-spectrum combination intravenous antibiotic. He recovers well and is discharged with plans to follow up in 2 weeks. At his follow-up, he reports that he has developed transient visual blurring whenever he turns his head to the right or left. He also reports that he has fallen at home multiple times. What is the mechanism of action of the drug that is most likely responsible for this patient’s current symptoms?", "answer": "Inhibition of ribosomal 30S subunit", "options": {"A": "Inhibition of ribosomal 30S subunit", "B": "Inhibition of ribosomal 50S subunit", "C": "Inhibition of dihydropteroate synthase", "D": "Inhibition of transpeptidase", "E": "Inhibition of DNA gyrase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old", "male presents", "emergency room", "nausea", "right flank pain", "reports", "symptoms", "worsened", "past two days", "past medical history", "notable", "congestive heart failure", "hypertension", "hyperlipidemia", "diabetes mellitus", "currently", "aspirin", "losartan", "metoprolol", "atorvastatin", "hydrochlorothiazide", "furosemide", "metformin", "allergic", "fluoroquinolones", "temperature", "9F", "blood pressure", "100 50 mmHg", "pulse", "min", "respirations", "min", "exam", "right costovertebral angle tenderness", "Urinalysis reveals 30 WBCs/hpf", "positive leukocyte esterase", "started", "broad spectrum", "intravenous", "recovers well", "to follow up", "2 weeks", "follow-up", "reports", "transient visual blurring", "turns", "head", "right", "left", "reports", "fallen at home multiple times", "mechanism of action", "drug", "responsible", "patients current symptoms"]}
{"question": "A 21-year-old woman comes to the physician because of a 1-week history of shortness of breath and dry cough. Eight weeks ago, she received a lung transplant from an unrelated donor. Current medications include prednisone, cyclosporine, and azathioprine. Her temperature is 37.8°C (100.1°F). Physical examination is unremarkable other than a well-healed surgical scar. Pulmonary function tests show a decline in FEV1 and FVC compared to values from several weeks ago. Histological examination of a lung biopsy specimen shows perivascular and interstitial lymphocytic infiltrates with bronchiolar inflammation. This patient's condition is most likely caused by T cell sensitization against which of the following?", "answer": "Donor MHC class II antigen", "options": {"A": "Donor ABO antigen", "B": "Donor MHC class II antigen", "C": "Recipient MHC class I antigen", "D": "Streptococcal C polysaccharide antigen", "E": "CMV glycoprotein B antigen"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old woman", "physician", "of", "1-week history", "shortness", "breath", "dry cough", "Eight weeks", "received", "unrelated", "Current medications include prednisone", "cyclosporine", "azathioprine", "temperature", "100", "unremarkable", "well healed surgical scar", "Pulmonary function tests", "FEV1", "FVC", "values from several weeks", "Histological", "of", "lung specimen", "perivascular", "interstitial lymphocytic infiltrates", "bronchiolar inflammation", "patient's condition", "most likely caused", "sensitization", "following"]}
{"question": "An investigator is developing a new intravenous medication that acts as a selective agonist at β-2 receptors. In addition to causing bronchodilation, this drug is most likely to have which of the following effects?", "answer": "Bladder detrusor relaxation", "options": {"A": "Decreased skeletal glycogenolysis", "B": "Increased gastrointestinal peristalsis", "C": "Peripheral vasoconstriction", "D": "Bladder detrusor relaxation", "E": "Increased uterine tone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "new intravenous medication", "acts", "agonist", "receptors", "causing bronchodilation", "drug", "to", "following effects"]}
{"question": "A 42-year-old female with a history of systemic lupus erythematous (SLE) has a 3-year history of daily prednisone (20 mg) use. Due to long-term prednisone use, she is at increased risk for which of the following?", "answer": "Pathologic fractures", "options": {"A": "Hair loss", "B": "Weight loss", "C": "Pancreatic insufficiency", "D": "Systolic hypertension", "E": "Pathologic fractures"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "history", "systemic lupus erythematous", "3 year history", "daily prednisone", "20 mg", "use", "long-term prednisone use", "increased risk", "following"]}
{"question": "A 17-year-old girl comes to the physician for an annual health maintenance examination. She feels well. She has no history of serious illness and her only medication is an oral contraceptive. Her mother was diagnosed with breast cancer at the age of 42 years. She is currently sexually active with 1 male partner and uses condoms inconsistently. Her immunizations are up-to-date. Her vital signs are within normal limits. Physical and pelvic examinations shows no abnormalities. An HIV test is negative. Which of the following is the most appropriate next step in management?", "answer": "Nucleic acid amplification testing", "options": {"A": "Complete blood count", "B": "Nucleic acid amplification testing", "C": "PAP smear", "D": "Rapid plasma reagin test", "E": "Herpes simplex virus 2 serology"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "physician", "annual health maintenance examination", "well", "history", "serious illness", "only medication", "oral contraceptive", "diagnosed", "breast cancer", "age", "years", "currently sexually active", "male", "uses condoms", "immunizations", "date", "vital signs", "normal limits", "Physical", "pelvic examinations", "abnormalities", "HIV test", "negative", "following", "most appropriate next step"]}
{"question": "A 74-year-old man presents to the emergency department with sudden-onset abdominal pain that is most painful around the umbilicus. The pain began 16 hours ago and has no association with meals. He has not been vomiting, but he has had several episodes of bloody loose bowel movements. He was hospitalized 1 week ago for an acute myocardial infarction. He has had diabetes mellitus for 35 years and hypertension for 20 years. He has smoked 15–20 cigarettes per day for the past 40 years. His temperature is 36.9°C (98.42°F), blood pressure is 95/65 mm Hg, and pulse is 95/min. On physical examination, the patient is in severe pain, there is mild periumbilical tenderness, and a bruit is heard over the epigastric area. Which of the following is the definitive test to assess the patient condition?", "answer": "Mesenteric angiography", "options": {"A": "Mesenteric angiography", "B": "CT scanning", "C": "Plain abdominal X-rays", "D": "Colonoscopy", "E": "Complete blood count"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["74 year old man presents", "emergency department", "sudden abdominal", "painful", "umbilicus", "pain began", "hours", "association", "meals", "not", "vomiting", "several episodes of bloody loose bowel movements", "hospitalized 1 week", "acute myocardial infarction", "diabetes mellitus", "35 years", "hypertension", "20 years", "smoked", "cigarettes", "day", "past 40 years", "temperature", "36", "98", "blood pressure", "95 65 mm Hg", "pulse", "95 min", "patient", "severe pain", "mild periumbilical tenderness", "bruit", "heard", "epigastric area", "following", "definitive test to", "patient condition"]}
{"question": "A previously healthy 24-year-old male is brought to the emergency department because of fevers, congestion, and chest pain for 3 days. The chest pain is exacerbated by deep inspiration. He takes no medications. His temperature is 37.5°C (99.5°F), blood pressure is 118/75 mm Hg, pulse is 130/min, and respirations are 12/min. He appears weak and lethargic. Cardiac examination shows a scratchy sound best heard along the left sternal border when the patient leans forward. There are crackles in both lung bases. Examination of the lower extremities shows pitting edema. Results of a rapid influenza test are negative. EKG shows diffuse ST-elevations with depressed PR interval. An echocardiogram shows left ventricular chamber enlargement with contractile dysfunction. Infection with which of the following pathogens is the most likely cause of this patient's symptoms?", "answer": "Picornavirus", "options": {"A": "Togavirus", "B": "Paramyxovirus", "C": "Flavivirus", "D": "Orthomyxovirus", "E": "Picornavirus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old male", "brought", "emergency department", "fevers", "congestion", "chest pain", "3 days", "chest pain", "exacerbated", "deep inspiration", "medications", "temperature", "99", "blood pressure", "75 mm Hg", "pulse", "min", "respirations", "min", "appears weak", "lethargic", "scratchy sound best heard", "left sternal border", "patient", "forward", "crackles", "lung bases", "Examination of the lower extremities", "pitting edema", "Results", "a rapid influenza test", "negative", "EKG", "diffuse ST elevations", "depressed PR interval", "echocardiogram", "left ventricular chamber enlargement", "contractile dysfunction", "Infection", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 56-year-old man comes to the physician because of chest pain and shortness of breath for 3 days. The pain is present at rest and worsens with deep inspiration. His temperature is 37.2°C (99°F), pulse is 102/min, respirations are 23/min, and blood pressure is 135/88 mm Hg. Examination shows decreased breath sounds at the left lower lobe. Laboratory studies show:\nHematocrit 42%\nLeukocyte count 6,500/μL\nSerum\nFasting glucose 90 mg/dL\nLactate dehydrogenase 75 U/L\nTotal protein 7.2 g/dL\nAn x-ray of the chest shows a small left-sided pleural effusion but no other abnormalities. A diagnostic thoracentesis is performed and 100 mL of bloody fluid are aspirated from the left pleural space. Pleural fluid analysis shows a lactate dehydrogenase of 65 U/L and a total protein of 5.1 g/dL. Pleural fluid cytology shows normal cell morphology. Further evaluation of this patient is most likely to show a history of which of the following?\"", "answer": "Prolonged immobilization", "options": {"A": "Oropharyngeal dysphagia", "B": "Infliximab use", "C": "Prolonged immobilization", "D": "Congestive heart failure", "E": "Asbestos exposure"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "chest pain", "shortness of breath", "3 days", "pain", "present", "worsens", "deep inspiration", "temperature", "pulse", "min", "respirations", "23 min", "blood pressure", "88 mm Hg", "decreased breath sounds", "left lower lobe", "Laboratory studies", "Hematocrit", "Leukocyte 6 500", "Serum Fasting glucose 90", "dL Lactate dehydrogenase", "2", "dL", "x-ray of", "chest", "small left-sided pleural effusion", "abnormalities", "diagnostic thoracentesis", "performed", "100 mL", "bloody fluid", "aspirated", "left pleural space", "Pleural fluid analysis", "a lactate dehydrogenase", "65 U/L", "total protein", "1 g dL", "Pleural", "normal cell morphology", "Further", "to", "history"]}
{"question": "A concerned father brings his 2 year-old son to the clinic for evaluation. In the past 24 hours, the child has had multiple episodes of painless bloody stools. On physical examination, the child's vital signs are within normal limits. There is mild generalized discomfort on palpation of the abdomen but no rebound or guarding. A technetium-99m (99mTc) pertechnetate scan indicates increased activity in two locations within the abdomen. Cells originating in which organ account for the increased radionucleotide activity?", "answer": "Stomach", "options": {"A": "Stomach", "B": "Pancreas", "C": "Small intestine", "D": "Gallbladder", "E": "Liver"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2 year old", "clinic", "past 24 hours", "child", "multiple episodes of painless bloody stools", "child's vital signs", "normal limits", "mild generalized discomfort", "palpation of", "abdomen", "guarding", "pertechnetate scan", "increased activity", "two locations", "abdomen", "Cells", "organ account", "increased", "activity"]}
{"question": "A previously healthy 5-year-old boy is brought to the emergency department because of abdominal pain and vomiting for 6 hours. His mother immediately brought him after noticing that he had gotten into the medicine cabinet. The mother is 5 months' pregnant. He appears uncomfortable. His temperature is 37.2°C (99°F), pulse is 133/min and blood pressure is 80/50 mm Hg. Examination shows diffuse abdominal tenderness; there is no guarding or rigidity. Digital rectal examination shows dark-colored stools. Laboratory studies show:\nHemoglobin 13.2 g/dL\nLeukocyte count 14,100/mm3\nSerum\nNa+ 136 mEq/L\nK+ 3.3 mEq/L\nCl- 105 mEq/L\nUrea nitrogen 26 mg/dL\nGlucose 98 mg/dL\nCreatinine 1.1 mg/dL\nArterial blood gas analysis on room air shows:\npH 7.31\npCO2 32 mm Hg\nHCO3- 16 mEq/L\nIntravenous fluids are administered. Which of the following is the most appropriate next step in management?\"", "answer": "Deferoxamine", "options": {"A": "Syrup of ipecac", "B": "Deferoxamine", "C": "Sodium bicarbonate", "D": "Activated charcoal", "E": "Calcium EDTA"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "abdominal pain", "vomiting", "hours", "immediately brought", "gotten", "medicine cabinet", "5 months", "regnant.", "ppears ", "emperature ", "ulse ", "in ", "lood pressure ", "0/ 0  m Hg.", "iffuse  bdominal tenderness;", "uarding ", "igidity.", "igital rectal examination ", "ark- olored ", "aboratory studies ", "emoglobin ", "eukocyte count ", "m3 ", "  +", "05 ", "g/", "8  g/", "reatinine ", "rterial blood gas analysis ", "oom air ", "H 7. 1  CO2 ", "m Hg  CO3-", "Eq/L ", "dministered.", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "A 57-year-old man is brought to the emergency department by a social worker from the homeless shelter. The man was acting strangely and then found unresponsive in his room. The social worker says she noticed many empty pill bottles near his bed. The patient has a past medical history of multiple hospital admissions for acute pancreatitis, dehydration, and suicide attempts. He is not currently taking any medications and is a known IV drug user. His temperature is 99.2°F (37.3°C), blood pressure is 107/48 mmHg, pulse is 140/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for a man with a Glasgow coma scale of 6. Laboratory values are ordered as seen below.\n\nHemoglobin: 10 g/dL\nHematocrit: 30%\nLeukocyte count: 5,500/mm^3 with normal differential\nPlatelet count: 147,000/mm^3\n\nSerum:\nAlbumin: 1.9 g/dL\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 29 mg/dL\nGlucose: 65 mg/dL\nCreatinine: 1.5 mg/dL\nCa2+: 10.2 mg/dL\nProthrombin time: 27 seconds\nPartial thromboplastin time: 67 seconds\nAST: 12 U/L\nALT: 10 U/L\n\nWhich of the following is the most effective therapy for this patient's underlying pathology?", "answer": "Liver transplant", "options": {"A": "Colloid-containing fluids", "B": "Factor 2, 7, 9, and 10 concentrate", "C": "Fresh frozen plasma", "D": "Liver transplant", "E": "Supportive therapy, thiamine, dextrose, naloxone, and NPO"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["57 year old man", "brought", "emergency department", "social worker", "homeless shelter", "man", "acting", "then found unresponsive", "room", "social worker", "empty pill bottles", "bed", "patient", "past medical multiple", "acute pancreatitis", "dehydration", "suicide attempts", "not currently", "medications", "known IV drug user", "temperature", "99", "blood pressure", "48 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "man", "Glasgow coma scale", "Laboratory values", "ordered", "seen", "Hemoglobin", "10 g/dL Hematocrit", "30", "Leukocyte count", "5 500 mm", "normal differential Platelet count", "mm", "Serum", "Albumin", "1.9 g/dL Na", "mEq/L", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "29 mg/dL Glucose", "65 mg/dL Creatinine", "1.5 mg/dL Ca2", "10", "mg/dL Prothrombin time", "27 seconds Partial thromboplastin time", "67 seconds AST", "U/L ALT", "10 U/L", "following", "most effective therapy", "patient's", "pathology"]}
{"question": "A 75-year-old man presents to the physician because of bloody urine, which has occurred several times over the past month. He has no dysuria, flank pain, nausea, or vomiting. He has no history of serious illness and takes no medications. He is a 40-pack-year smoker. The vital signs are within normal limits. Physical exam shows no abnormalities except generalized lung wheezing. The laboratory test results are as follows:\nUrine\nBlood 3+\nRBC > 100/hpf\nWBC 1–2/hpf\nRBC casts Negative\nBacteria Not seen\nWhich of the following is the most appropriate diagnostic study at this time?", "answer": "Cystoscopy", "options": {"A": "Chest X-ray", "B": "Computed tomography (CT) urogram", "C": "Cystoscopy", "D": "Intravenous (IV) pyelography", "E": "Ureteroscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "physician", "bloody urine", "several times", "past", "dysuria", "flank pain", "nausea", "vomiting", "history", "serious illness", "medications", "40", "smoker", "vital signs", "normal limits", "abnormalities", "generalized lung wheezing", "laboratory test results", "follows", "Urine", "RBC", "100 hpf WBC", "casts Negative Bacteria Not seen", "following", "most appropriate diagnostic", "time"]}
{"question": "A 23-year-old woman with a past medical history significant for cardiac palpitations and hypothyroidism presents with cyclical lower abdominal pain and pelvic pain. Upon further questioning, she endorses difficulty conceiving over the last 12 months. On a review of systems, she endorses occasional pain with intercourse, which has become more frequent over the last 6 months. On physical examination, her heart and lungs are clear to auscultation, her abdomen has mild tenderness in the lower quadrants, and she shows normal range of motion in her extremities. Given the patient’s desire to conceive, what is the most definitive treatment for her presumed condition?", "answer": "Laparoscopy and lesion ablation", "options": {"A": "Oral contraceptive pills (OCPs)", "B": "NSAIDS", "C": "Leuprolide", "D": "Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO)", "E": "Laparoscopy and lesion ablation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["23 year old woman", "past medical history significant", "cardiac palpitations", "hypothyroidism presents", "cyclical lower abdominal pain", "pelvic pain", "further", "difficulty conceiving", "12 months", "review of systems", "occasional", "more frequent", "months", "heart", "lungs", "clear", "auscultation", "abdomen", "mild tenderness", "lower quadrants", "normal range of motion", "extremities", "Given", "patients", "to", "most definitive treatment", "presumed condition"]}
{"question": "A 10-year-old girl is brought to the neurologist for management of recently diagnosed seizures. Based on her clinical presentation, the neurologist decides to start a medication that works by blocking thalamic T-type calcium channels. Her parents are cautioned that the medication has a number of side effects including itching, headache, and GI distress. Specifically, they are warned to stop the medication immediately and seek medical attention if they notice skin bullae or sloughing. Which of the following conditions is most likely being treated in this patient?", "answer": "Absence seizures", "options": {"A": "Absence seizures", "B": "Complex seizures", "C": "Simple seizures", "D": "Status epilepticus", "E": "Tonic-clonic seizures"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 year old girl", "brought", "neurologist", "management", "recently diagnosed seizures", "Based", "neurologist", "to start", "medication", "blocking thalamic", "type calcium channels", "medication", "number", "side effects including itching", "headache", "GI distress", "to stop", "medication immediately", "medical", "skin bullae", "sloughing", "following conditions", "most likely", "treated", "patient"]}
{"question": "A scientist performed an experiment to produce hybrid viruses by mixing two different serotypes of influenza virus, H1N1 and H2N2, in a respiratory epithelium cell line. Several days later, the scientist collected the media and analyzed the viral progeny. She found the following serotypes of virus: H1N1, H2N2, H1N2, and H2N1. Which of the following terms best explains the appearance of new serotypes?", "answer": "Reassortment", "options": {"A": "Recombination", "B": "Reassortment", "C": "Complementation", "D": "Phenotypic mixing", "E": "Transformation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["scientist performed", "to", "viruses", "mixing", "different", "respiratory epithelium", "Several days later", "scientist collected", "media", "viral", "found", "following", "following terms best", "appearance", "new"]}
{"question": "A 56-year-old woman comes to the physician because of a 3-month history of progressive weakness. She has no history of serious illness and takes no medications. Her vital signs are within normal limits. Physical examination shows a violaceous rash over her eyelids and flat-topped erythematous papules over the dorsal surface of interphalangeal joints. Muscle strength is 4/5 at the shoulders and hips but normal elsewhere. This patient is at greatest risk for which of the following conditions?", "answer": "Ovarian adenocarcinoma", "options": {"A": "Pheochromocytoma", "B": "Hodgkin lymphoma", "C": "Renal clear cell carcinoma", "D": "Oat cell lung cancer", "E": "Ovarian adenocarcinoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "3 month history", "progressive weakness", "history", "serious illness", "medications", "vital signs", "normal", "Physical examination", "violaceous rash", "eyelids", "flat topped erythematous papules", "dorsal surface", "interphalangeal joints", "Muscle", "4/5", "shoulders", "hips", "normal", "patient", "greatest", "following conditions"]}
{"question": "A 52-year-old man comes to the physician because of a 5-month history of progressive lethargy, shortness of breath, and difficulty concentrating. His friends have told him that he appears pale. He has smoked half a pack of cigarettes daily for the past 20 years. Neurological examination shows reduced sensation to light touch and pinprick in the toes bilaterally. Laboratory studies show:\nHemoglobin 8.2 g/dL\nMean corpuscular volume 108 μm3\nSerum\nVitamin B12 (cyanocobalamin) 51 ng/L (N = 170–900)\nFolic acid 13 ng/mL (N = 5.4–18)\nAn oral dose of radiolabeled vitamin B12 is administered, followed by an intramuscular injection of nonradioactive vitamin B12. A 24-hour urine sample is collected and urine vitamin B12 levels are unchanged. The procedure is repeated with the addition of oral intrinsic factor, and 24-hour urine vitamin B12 levels increase. This patient's findings indicate an increased risk for which of the following conditions?\"", "answer": "Gastric carcinoma", "options": {"A": "Colorectal carcinoma", "B": "Gastric carcinoma", "C": "De Quervain thyroiditis", "D": "Type 2 diabetes mellitus", "E": "Celiac disease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "5 month history", "progressive lethargy", "shortness of breath", "difficulty concentrating", "appears pale", "smoked half", "pack", "cigarettes daily", "past 20 years", "Neurological examination", "reduced", "light", "toes", "Laboratory studies", "Hemoglobin", "g Mean corpuscular volume", "m3 Serum Vitamin B12", "cyanocobalamin", "ng/L", "N", "Folic acid", "ng/mL", "N", "5", "oral dose", "radiolabeled vitamin B12", "administered", "followed", "intramuscular injection of", "vitamin B12", "24-hour urine sample", "collected", "urine vitamin B12 levels", "unchanged", "procedure", "repeated", "addition", "oral intrinsic factor", "hour urine vitamin B12 levels increase", "patient", "indings ", "ncreased risk ", "ollowing  onditions?"]}
{"question": "A 70-year-old man comes to the physician for the evaluation of an 8-week history of blood in his stool. Two months ago, he had an episode of bronchitis and was treated with amoxicillin. Since then, he has noticed blood in his stool and on the toilet paper occasionally. The patient has had intermittent constipation for the past 5 years. Six months ago, he had severe left lower quadrant pain and fever that resolved with antibiotic therapy. He underwent a colonoscopy 3 years ago, which did not show any evidence of malignancy. He takes levothyroxine for hypothyroidism. He had smoked one pack of cigarettes daily for 45 years, but quit smoking 10 years ago. He drinks one glass of red wine every night. He appears pale. He is 180 cm (5 ft 11 in) tall and weighs 98 kg (216 lb); BMI is 32 kg/m2. His temperature is 36°C (96.8°F), pulse is 85/min, and blood pressure is 135/80 mm Hg. Physical examination shows pale conjunctivae. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender with no organomegaly. Digital rectal examination shows no masses. Test of the stool for occult blood is positive. Laboratory studies show:\nHemoglobin 11 g/dL\nMean corpuscular volume 76 μm3\nRed cell distribution width 17% (N = 13–15)\nLeukocyte count 5,000/mm3\nWhich of the following is the most likely diagnosis?\"", "answer": "Diverticulosis", "options": {"A": "Colorectal carcinoma", "B": "Diverticulosis", "C": "Ischemic colitis", "D": "Hemorrhoids", "E": "Pseudomembranous colitis\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["70 year old man", "physician", "evaluation", "week history", "blood", "stool", "Two months", "episode of bronchitis", "treated with amoxicillin", "Since then", "blood in", "stool", "toilet paper occasionally", "patient", "intermittent constipation", "past", "years", "Six months", "severe left lower quadrant pain", "fever", "resolved", "antibiotic therapy", "colonoscopy", "years", "not", "malignancy", "levothyroxine", "hypothyroidism", "smoked one pack", "cigarettes daily", "years", "smoking", "one glass", "night", "appears pale", "5 ft", "tall", "98 kg", "BMI", "kg/m2", "temperature", "96", "pulse", "85 min", "blood pressure", "80 mm Hg", "pale conjunctivae", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "organomegaly", "Digital rectal examination", "masses", "Test", "stool", "occult blood", "positive", "Laboratory studies", "Hemoglobin", "g", "Mean corpuscular volume", "m3 Red cell distribution width 17", "N", "Leukocyte count", "mm3", "following", "diagnosis"]}
{"question": "An overweight 57-year-old woman comes to her primary care physician for a routine checkup. She has no current complaints and takes no medications. Her mother and brother have type 2 diabetes mellitus and hypertension. Vital signs show a blood pressure of 145/95 mmHg, temperature of 37°C (98.6°F), and a pulse of 85/minute. Her lab results are shown:\nFasting blood glucose 158 mg/dL\n HbA1c  8.6%\n Low-density lipoprotein  210 mg/dL\n High-density lipoprotein  27 mg/dL\n Triglycerides  300 mg/dL\nWhich of the following tests is recommended for this patient?", "answer": "Digital fundus photography now, then yearly follow-up", "options": {"A": "Albumin-to-creatinine ratio after 5 years, then yearly follow-up", "B": "Monofilament test after 5 years, then yearly follow-up", "C": "Fasting lipid profile every 5 years", "D": "Digital fundus photography after 5 years, then yearly follow-up", "E": "Digital fundus photography now, then yearly follow-up"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["overweight 57 year old woman", "primary care physician", "routine checkup", "current complaints", "medications", "type 2 diabetes mellitus", "hypertension", "Vital signs", "blood pressure", "95 mmHg", "temperature", "98", "pulse", "85 minute", "lab results", "Fasting blood glucose", "mg", "8.6", "Low-density lipoprotein", "High-density lipoprotein", "Triglycerides", "following tests", "patient"]}
{"question": "A 27-year-old man comes to the physician because of a 4-month history of unintentional weight gain, fatigue, and decreased sexual desire. There is no personal or family history of serious illness. His blood pressure is 149/88 mm Hg. Physical examination shows central obesity and abdominal striae. He has a prominent soft tissue bulge at the dorsum of his neck. Laboratory studies show a 24-hour urinary free cortisol of 200 μg (N < 50) and a morning serum ACTH of 1 pg/mL (N = 7–50). Which of the following tests is most likely to confirm the underlying etiology of this patient's symptoms?", "answer": "Abdominal CT", "options": {"A": "CRH stimulation test", "B": "ACTH stimulation test", "C": "Chest CT", "D": "Abdominal CT", "E": "Brain MRI"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man", "physician", "4 month history", "unintentional weight gain", "fatigue", "decreased sexual desire", "personal", "family history", "serious illness", "blood pressure", "88 mm Hg", "central obesity", "abdominal striae", "prominent soft tissue bulge", "the dorsum of", "neck", "Laboratory studies", "hour urinary free cortisol", "200 g", "50", "morning serum ACTH", "1 pg mL", "N", "750", "following tests", "to confirm", "underlying etiology", "patient's symptoms"]}
{"question": "A 59-year-old woman comes to the physician because of worsening shortness of breath for the past two weeks. Physical examination shows decreased breath sounds at both lung bases. The abdomen is distended and there is shifting dullness with a positive fluid wave. Ultrasound of the abdomen shows a large collection of peritoneal fluid and a hypoechoic mass involving the left ovary. Microscopic examination of a biopsy specimen from the ovarian mass shows clusters of spindle-shaped cells. Which of the following is the most likely diagnosis?", "answer": "Ovarian fibroma", "options": {"A": "Serous cystadenoma", "B": "Endometrioma", "C": "Ovarian thecoma", "D": "Dermoid cyst", "E": "Ovarian fibroma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["59 year old woman", "physician", "of worsening shortness", "breath", "past two weeks", "decreased breath sounds", "lung bases", "abdomen", "distended", "shifting dullness", "positive fluid wave", "Ultrasound of", "abdomen", "large collection", "peritoneal", "mass involving", "left ovary", "Microscopic examination of", "biopsy", "ovarian mass", "clusters", "shaped", "following", "diagnosis"]}
{"question": "A 39-year-old woman presents to her primary care physician because she has been experiencing intermittent abdominal pain for the last 2 weeks. She says that the pain is squeezing in nature, is located in the right upper quadrant, and is particularly severe after eating a meal. After a diagnosis is made, the patient asks why the pain gets worse after eating. The physician explains that food is detected by the gastrointestinal tract through numerous receptors and that this information is transmitted to other parts of the body to cause compensatory changes. The neurons responsible for transmitting this information are most likely located in a layer of the intestine that has which of the following characteristics?", "answer": "Contains large blood vessels and large lymphatic vessels", "options": {"A": "Connective tissue that envelops the other layers", "B": "Contains cells that primarily absorb nutrients", "C": "Contains large blood vessels and large lymphatic vessels", "D": "Contracts to generate peristaltic waves", "E": "Contracts to generate local movement in mucosa"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "intermittent abdominal pain", "weeks", "pain", "squeezing", "nature", "right upper quadrant", "severe", "eating", "diagnosis", "made", "patient", "pain gets worse after eating", "physician", "food", "detected", "gastrointestinal tract", "numerous receptors", "transmitted", "parts", "body to cause compensatory changes", "responsible", "transmitting", "most likely", "layer", "intestine", "following characteristics"]}
{"question": "A 41-year-old man comes to the physician because of a 7-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He started a new job as a project coordinator 8 months ago. He has difficulty falling asleep and lies awake worrying about his family, next day's meetings, and finances. He can no longer concentrate on his tasks at work. He feels tense most days and avoids socializing with his friends. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 10 years. He appears anxious. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?", "answer": "Buspirone", "options": {"A": "Escitalopram", "B": "Propranolol", "C": "Clonazepam", "D": "Amitriptyline", "E": "Buspirone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "month history", "sleep disturbances", "restlessness", "difficulty acquiring erections", "started", "new job", "project coordinator", "months", "difficulty falling asleep", "awake worrying", "next day's", "finances", "longer concentrate", "tense", "days", "worries", "underlying medical condition", "causing", "symptoms", "Previous diagnostic evaluations", "unremarkable", "history", "drinking alcohol excessively", "early 20s", "not", "alcohol", "past", "appears anxious", "abnormalities", "psychotherapy", "treatment", "following drugs", "most appropriate", "patient"]}
{"question": "A new study shows a significant association between patients with a BMI >40 and a diagnosis of diabetes (odds ratio: 7.37; 95% CI 6.39-8.50) compared to non-diabetic patients. Which of the following hypothetical studies most likely yielded these results.", "answer": "A study consisting of 500 patients with diabetes and 500 patients without diabetes comparing BMI of subjects in both groups", "options": {"A": "A study consisting of 1000 non-diabetic subjects; 500 patients with a BMI > 40 and 500 patients with normal BMI, followed for diagnosis of diabetes over their life time", "B": "A study consisting of 500 patients with diabetes and 500 patients without diabetes comparing BMI of subjects in both groups", "C": "A study consisting of 1000 genetically similar mice; 500 randomized to diet to maintain normal weight and 500 randomized to high caloric intake with the outcome of diabetes rates in both groups after 1 year", "D": "A study of 1000 patients with BMI > 40 with diabetes; 500 randomized to inpatient diet and exercise with goal BMI <25, and 500 randomized to no treatment with an outcome of glycemic control without medication after 1 year", "E": "A study of 1000 patients comparing rates of diabetes diagnoses and BMIs of diabetic and non-diabetic patients"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["new study", "significant association", "patients", "BMI", "40", "diagnosis", "diabetes", "odds ratio", "95", "CI", "50", "non diabetic patients", "following", "studies", "likely", "results"]}
{"question": "A 14-year-old girl is brought to the physician because of a 1-week history of fever, malaise, and chest pain. She describes the pain as 6 out of 10 in intensity and that it is more severe if she takes a deep breath. The pain is centrally located in the chest and does not radiate. Three weeks ago, she had a sore throat that resolved without treatment. She has no personal history of serious illness. She appears ill. Her temperature is 38.7°C (101.7°F). Examination shows several subcutaneous nodules on the elbows and wrist bilaterally. Breath sounds are normal. A soft early systolic murmur is heard best at the apex in the left lateral position. Abdominal examination is unremarkable. Laboratory studies show:\nHemoglobin 12.6 g/dL\nLeukocyte count 12,300/mm3\nPlatelet count 230,000/mm3\nErythrocyte sedimentation rate 40 mm/hr\nSerum\nAntistreptolysin O titer 327 U/mL (N < 200 U/mL)\nShe is treated with aspirin and penicillin and her symptoms resolve. An echocardiography of the heart done 14 days later shows no abnormalities. Which of the following is the most appropriate next step in management?\"", "answer": "Intramuscular benzathine penicillin every 4 weeks for 10 years", "options": {"A": "Intramuscular benzathine penicillin every 4 weeks for 10 years", "B": "Low-dose prednisone therapy for a month", "C": "Intramuscular benzathine penicillin every 4 weeks until the age of 40", "D": "Intramuscular benzathine penicillin every 4 weeks until the age of 21", "E": "Intramuscular benzathine penicillin every 4 weeks for 5 years"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "physician", "1-week history", "fever", "malaise", "chest pain", "pain", "out", "10", "intensity", "more severe", "deep breath", "pain", "chest", "not radiate", "Three weeks", "sore throat", "resolved", "treatment", "personal history", "serious illness", "appears ill", "temperature", "several subcutaneous", "elbows", "wrist", "Breath sounds", "normal", "soft early", "heard best", "apex", "left lateral position", "Abdominal", "unremarkable", "Laboratory studies", "Hemoglobin 12.6 g dL Leukocyte count", "300 mm3 Platelet count", "Erythrocyte sedimentation rate 40 mm hr Serum Antistreptolysin O titer", "mL", "N", "200 U/mL", "treated with aspirin", "penicillin", "symptoms", "echocardiography", "heart", "days later", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 58-year-old woman presents to her primary care physician for a wellness checkup. She recently had a DEXA scan that placed her at 2 standard deviations below the mean for bone density. She is following up today to discuss her results. The patient has a past medical history of asthma, breast cancer, COPD, anxiety, irritable bowel syndrome, endometrial cancer, and depression. She is currently taking clonazepam, albuterol, and fluoxetine. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 95% on room air. The patient is treated appropriately and sent home. She returns 1 month later for a follow up visit. She has been taking her medications as prescribed. She endorses episodes of feeling febrile/warm which resolve shortly thereafter. Otherwise she is doing well. Which of the following is true of the medication she was most likely started on?", "answer": "Estrogen receptor antagonist in the uterus", "options": {"A": "Estrogen receptor agonist in the uterus", "B": "Estrogen receptor antagonist in the uterus", "C": "Induces osteoclast apoptosis", "D": "Mineral replacement", "E": "Parathyroid hormone analogue"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old woman presents", "primary care physician", "checkup", "recently", "DEXA scan", "at", "standard", "mean", "bone density", "following up today to", "results", "patient", "past medical", "breast cancer", "COPD", "anxiety", "irritable bowel syndrome", "endometrial cancer", "depression", "currently", "clonazepam", "albuterol", "fluoxetine", "temperature", "99", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "95", "room air", "patient", "treated", "sent home", "returns 1 month later", "medications", "episodes of", "febrile warm", "well", "following", "true", "medication", "most likely started"]}
{"question": "A 62-year-old man with a history notable for alpha-thalassemia now presents to an urgent care clinic with complaints of increased thirst and urinary frequency. The physical exam is unremarkable, although there is a bronze discoloration of his skin. The laboratory analysis reveals a fasting blood glucose of 192 mg/dL, and a HbA1c of 8.7. Given the following options, what is the best treatment for the patient’s underlying disease?", "answer": "Recurrent phlebotomy", "options": {"A": "Metformin", "B": "Basal insulin", "C": "Basal and bolus insulin", "D": "Recurrent phlebotomy", "E": "Deferoxamine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man", "history notable", "alpha-thalassemia now presents", "urgent care clinic", "complaints", "increased thirst", "urinary frequency", "unremarkable", "bronze discoloration of", "skin", "laboratory analysis reveals", "fasting blood glucose", "mg/dL", "Given", "following options", "best", "disease"]}
{"question": "A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?", "answer": "Conversion disorder", "options": {"A": "Somatization disorder", "B": "Somatoform pain disorder", "C": "Conversion disorder", "D": "Hypochondriasis", "E": "Body dysmorphic disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old woman presents", "convulsions", "patients", "found", "hour", "immediately called", "ambulance", "extremely", "receiving supportive care", "social worker following", "sexual assault", "few days", "patient", "history", "seizures", "significant past medical history", "medications", "patients vital signs include", "temperature", "98", "pulse", "min", "blood pressure", "99 mm Hg", "respiratory rate", "min", "patient", "side to side", "eyes", "closed", "resistance to opening", "following", "diagnosis", "patient"]}
{"question": "A 67-year-old man comes to the physician because of difficulty walking for 2 months. He has been falling to his left side when he walks more than a few feet. His speech has also changed in the past few months, and he now pauses between each syllable. He has never had similar symptoms before. He has hypertension and cirrhosis as a result of alcoholic liver disease. He does not smoke and he no longer drinks alcohol. His current medications include lisinopril and hydrochlorothiazide daily. His vital signs are within normal limits. Physical examination shows discrete scleral icterus and jaundice. There is ascites and gynecomastia present. Neurological examination shows nystagmus with fast beats toward the left. He has dysmetria and tremor when performing left-sided finger-nose-finger testing, and dysdiadochokinesia with rapid alternating movements. He has a wide-based gait and a pronator drift of the left arm. He has full range of motion in his arms and legs without rigidity. He has full muscle strength, and sensation to light touch is intact. Further evaluation is most likely to show which of the following?", "answer": "Left-sided cerebellar tumor", "options": {"A": "Increased number of trinucleotide CAG repeats", "B": "Decreased serum thiamine levels", "C": "Periventricular plaques", "D": "Left-sided cerebellar tumor", "E": "Left-sided posterior capsular infarct"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man", "physician", "of difficulty walking", "months", "falling", "left side", "walks more", "feet", "speech", "changed", "past", "months", "now pauses", "never", "similar symptoms", "hypertension", "cirrhosis", "result of alcoholic liver disease", "not smoke", "longer", "alcohol", "current medications include lisinopril", "hydrochlorothiazide daily", "vital signs", "normal", "Physical examination", "discrete scleral icterus", "jaundice", "ascites", "gynecomastia present", "Neurological examination", "nystagmus", "fast", "left", "dysmetria", "tremor", "left-sided finger-nose", "testing", "dysdiadochokinesia", "rapid alternating movements", "wide-based gait", "pronator drift", "left arm", "full range of motion", "arms", "legs", "rigidity", "full muscle strength", "sensation", "light touch", "intact", "Further", "to", "following"]}
{"question": "A 23-year-old man comes to the physician with a 1-week history of sharp, substernal chest pain that is worse with inspiration and relieved with leaning forward. He has also had nausea and myalgias. His father has coronary artery disease. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Cardiac examination shows a high-pitched rubbing sound between S1 and S2 that is best heard at the left sternal border. An ECG shows depressed PR interval and diffuse ST elevations. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Acute viral infection", "options": {"A": "Dressler syndrome", "B": "Acute myocardial infarction", "C": "Mycobacterium tuberculosis infection", "D": "Systemic lupus erythematosus", "E": "Acute viral infection"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["23 year old man", "physician", "1-week history of sharp", "chest pain", "worse", "inspiration", "relieved", "forward", "nausea", "myalgias", "coronary artery disease", "temperature", "99", "pulse", "min", "blood pressure", "84 mm Hg", "high-pitched rubbing sound", "S1", "S2", "best heard", "left sternal border", "ECG", "depressed PR interval", "diffuse ST elevations", "following", "most likely cause", "patients symptoms"]}
{"question": "A 73-year-old man presents to a dermatology clinic after his family physician finds an ulcerated plaque on the dorsal surface of his nose. This lesion has changed in size and form and has bled on multiple occasions even after the patient adopted sun-protection measures. The patient’s medical history is relevant for cigarette smoking and hypertension. Physical examination reveals a poorly defined, erythematous, ulcerated plaque on the surface of the nose (see image). The lesion is diagnosed as squamous cell carcinoma, and the patient undergoes standard excision. However, the pathology report indicates an incomplete excision. Which of the following should be the next step in the management of this case?", "answer": "Mohs surgery", "options": {"A": "Mohs surgery", "B": "Photodynamic therapy", "C": "Cryotherapy", "D": "Radiation therapy", "E": "Imiquimod"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "dermatology clinic", "family physician finds", "ulcerated plaque", "dorsal surface", "nose", "lesion", "changed in size", "form", "bled", "multiple occasions", "patient adopted sun protection measures", "patients medical history", "relevant", "cigarette smoking", "hypertension", "reveals", "poorly", "erythematous", "ulcerated plaque", "surface", "nose", "see", "lesion", "diagnosed", "squamous cell carcinoma", "patient", "standard excision", "incomplete excision", "following", "next step"]}
{"question": "A 65-year-old woman presents to your office after three days of fever and productive cough. She is taking Tylenol for her fever and her last dose was yesterday morning. She reports reddish brown sputum. She has a history of hypertension and hypercholesterolemia for which she takes lisinopril and a statin. She has never smoked and drinks 1-2 glasses of wine a week. She recently returned from Italy and denies having any sick contacts. On physical exam, her temperature is 102.2°F (39°C), blood pressure is 130/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 95% on room air. She has decreased breath sounds in the left lower lobe. Chest x-ray is shown. The causative organism would most likely show which of the following?", "answer": "Optochin sensitivity", "options": {"A": "Beta hemolysis", "B": "Gamma hemolysis", "C": "Optochin resistance", "D": "Optochin sensitivity", "E": "Novobiocin sensitivity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old woman presents", "office", "three days", "fever", "productive cough", "Tylenol", "fever", "last dose", "morning", "reports", "brown sputum", "history of hypertension", "hypercholesterolemia", "lisinopril", "statin", "never smoked", "1-2 glasses", "week", "recently returned", "Italy", "sick", "temperature", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "pulse oximetry", "95", "room air", "decreased breath sounds", "left lower lobe", "Chest x-ray", "most likely", "following"]}
{"question": "A 53-year-old woman presents for a follow-up. She took some blood tests recently for her yearly physical, and her random blood sugar level was found to be 251 mg/dL. She was asked to repeat her blood sugar and come back with the new reports. At that time, her fasting blood sugar level was 130 mg/dL and the postprandial glucose level was 245 mg/dL. Her HbA1c is 8.9%. She has had occasions where she felt light-headed and felt better only after she had something to eat. Her physician starts her on a drug to help her control her sugar levels. He also advised that she should get her liver enzymes checked with a repeat HbA1c in 3 months. Which of the following is the mechanism of action of the drug that she was most likely prescribed?", "answer": "Acts as an agonist at the peroxisome proliferator-activated receptor-Ƴ.", "options": {"A": "Stimulates the release of insulin from the pancreas.", "B": "Increases the uptake of glucose and reduces peripheral insulin resistance.", "C": "Acts as an agonist at the peroxisome proliferator-activated receptor-Ƴ.", "D": "Inhibit alpha-glucosidase in the intestines.", "E": "Decreases the secretion of glucagon."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "follow-up", "blood recently", "yearly physical", "random blood sugar level", "found to", "mg/dL", "to repeat", "blood sugar", "back", "new", "time", "fasting blood sugar level", "mg/dL", "postprandial glucose level", "mg/dL", "occasions", "light-headed", "better only", "to eat", "physician starts", "drug to help", "control", "sugar levels", "liver enzymes", "repeat", "3 months", "following", "mechanism of action", "drug", "most likely"]}
{"question": "You are conducting a study on hypertension for which you have recruited 60 African-American adults. If the biostatistician for your study informs you that the sample population of your study is approximately normal, the mean systolic blood pressure is 140 mmHg, and the standard deviation is 7 mmHg, how many participants would you expect to have a systolic blood pressure between 126 and 154 mmHg?", "answer": "57 participants", "options": {"A": "10 participants", "B": "41 participants", "C": "57 participants", "D": "68 participants", "E": "Not enough information provided."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["study", "hypertension", "60", "adults", "study informs", "approximately normal", "mean systolic", "mmHg", "standard deviation", "mmHg", "to", "systolic blood pressure", "mmHg"]}
{"question": "A 35-year-old male is brought to the emergency room after he was found to have a blood pressure of 180/100 mm Hg during a routine health check-up with his family physician. Past medical history is insignificant and both of his parents are healthy. He currently does not take any medication. The patient’s blood pressure normalizes before the emergency department physician can evaluate him. During the physical examination, his blood pressure is 148/80 mm Hg, heart rate is 65/min, temperature is 36.8°C (98.2°F), and respirations are 14/min. He has a round face, centripetal obesity, and striae on the skin with atrophy over the abdomen and thighs. On visual field examination, he is found to have loss of vision in the lateral visual fields bilaterally  You order a low dose dexamethasone suppression test, which is positive, and you proceed to measure ACTH and obtain a high-dose dexamethasone suppression test. If this is a pituitary gland disorder, which of the following lab abnormalities is most likely present in this patient?", "answer": "Before test: ACTH high, after test: cortisol suppression", "options": {"A": "Before test: ACTH high, after test: aldosterone suppression", "B": "Before test: ACTH low, after test: cortisol elevation", "C": "Before test: ACTH high, after test: cortisol suppression", "D": "Before test: ACTH low, after test: aldosterone normalizes", "E": "Before test: ACTH high, after test: cortisol elevation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old male", "brought", "emergency room", "found to", "blood pressure", "100 mm Hg", "health check-up", "family physician", "Past medical history", "healthy", "currently", "not", "medication", "patients blood pressure", "emergency department physician", "blood pressure", "80 mm Hg", "heart rate", "65 min", "temperature", "36", "98", "respirations", "min", "round face", "centripetal obesity", "striae", "skin", "atrophy", "abdomen", "thighs", "visual examination", "found to", "loss of vision", "lateral visual fields", "order", "low dose dexamethasone suppression test", "positive", "to measure ACTH", "obtain", "high-dose dexamethasone suppression test", "pituitary gland disorder", "following lab abnormalities", "most likely present", "patient"]}
{"question": "A 45-year-old man presents to his primary care physician for a wellness checkup. He states that he feels fatigued at times but feels near his baseline. The patient smokes 1 pack of cigarettes per day, drinks alcohol occasionally, and has a past medical history of poorly controlled diabetes. His temperature is 98.6°F (37.0°C), blood pressure is 167/108 mmHg, pulse is 80/min, respirations are 10/min, and oxygen saturation is 98% on room air. Physical exam reveals an overweight man with a ruddy complexion. Bilateral gynecomastia is noted for which the patient inquires about cosmetic surgery as a treatment. Laboratory values are ordered as seen below.\n\nHemoglobin: 14 g/dL\nHematocrit: 42%\nLeukocyte count: 6,500/mm^3 with normal differential\nPlatelet count: 185,000/mm^3\n\nSerum:\nNa+: 142 mEq/L\nCl-: 102 mEq/L\nK+: 3.2 mEq/L\nHCO3-: 31 mEq/L\nBUN: 27 mg/dL\nGlucose: 173 mg/dL\nCreatinine: 1.5 mg/dL\nCa2+: 9.8 mg/dL\n\nA CT scan demonstrates bilateral abnormal abdominal masses. Which of the following is the best next step in management?", "answer": "Eplerenone", "options": {"A": "Eplerenone", "B": "Hydrochlorothiazide", "C": "Lisinopril", "D": "Spironolactone", "E": "Surgical excision"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "checkup", "states", "fatigued", "times", "baseline", "patient smokes", "pack", "cigarettes", "day", "alcohol occasionally", "past medical poorly controlled diabetes", "temperature", "98", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "10/min", "oxygen saturation", "98", "room air", "reveals", "overweight man", "complexion", "Bilateral gynecomastia", "noted", "patient", "cosmetic surgery", "treatment", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "6 500 mm 3", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "3.2 mEq/L HCO3", "31 mEq/L", "27 mg/dL Glucose", "mg/dL Creatinine", "1.5 mg/dL Ca2", "mg/dL", "CT scan", "bilateral abnormal abdominal masses", "following", "best next step"]}
{"question": "A 39-year-old woman comes to the physician because of an 8-month history of progressive fatigue, shortness of breath, and palpitations. She has a history of recurrent episodes of joint pain and fever during childhood. She emigrated from India with her parents when she was 10 years old. Cardiac examination shows an opening snap followed by a late diastolic rumble, which is best heard at the fifth intercostal space in the left midclavicular line. This patient is at greatest risk for compression of which of the following structures?", "answer": "Esophagus", "options": {"A": "Trachea", "B": "Thoracic duct", "C": "Vagus nerve", "D": "Hemiazygos vein", "E": "Esophagus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "month history", "progressive fatigue", "shortness of breath", "palpitations", "history of recurrent episodes", "joint pain", "fever", "childhood", "India", "old", "opening snap followed by", "late diastolic rumble", "best heard", "fifth intercostal space", "left midclavicular line", "patient", "greatest", "compression", "following structures"]}
{"question": "A 5-week-old male infant is rushed to the emergency department due to severe vomiting and lethargy for the past 3 days. His mother describes the vomiting as forceful and projectile and contains undigested breast milk, but she did not notice any green fluids. He has not gained much weight in the past 3 weeks and looks very thin. He has a pulse of 144/min, temperature of 37.5°C (99.5°F), and respiratory rate of 18/min. Mucous membranes are dry and the boy is lethargic. Abdominal examination reveals a palpable mass in the epigastrium that becomes more prominent after vomiting with visible peristaltic movements over the epigastrium. Barium-contrast studies show a double channel appearance of the pylorus. What is the best immediate step in the management of this patient’s condition?", "answer": "Correct electrolyte imbalances", "options": {"A": "Reassurance and observation", "B": "Pyloromyotomy", "C": "Whipple procedure", "D": "Correct electrolyte imbalances", "E": "Nasogastric tube feeding"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 week old male infant", "rushed", "emergency department", "severe vomiting", "lethargy", "past 3 days", "vomiting", "projectile", "contains", "breast milk", "not", "green fluids", "not gained", "weight", "past", "weeks", "looks very thin", "pulse", "min", "temperature", "99", "respiratory rate", "min", "Mucous membranes", "dry", "boy", "lethargic", "Abdominal", "reveals", "palpable mass", "epigastrium", "more prominent", "vomiting", "visible peristaltic movements", "epigastrium", "contrast studies", "double channel appearance", "pylorus", "best immediate step", "management", "patients condition"]}
{"question": "Thirty minutes after delivery, a 3400-g (7.5-lb) female newborn develops cyanosis of her lips and oral mucosa. She was born at 36 weeks of gestation to a 30-year-old woman, gravida 1, para 0. Apgar scores are 7 and 8 at 1 and 5 minutes, respectively. Pregnancy was complicated by polyhydramnios. The patient's temperature is 37°C (98.6°F), pulse is 144/min, respirations are 52/min, and blood pressure is 70/40 mm Hg. Examination shows foaming and drooling at the mouth. Bilateral crackles are heard at the lung bases. There is a harsh 3/6 systolic murmur along the left sternal border. The abdomen is soft and mildly distended. There is an anterior ectopic anus. Insertion of a nasogastric tube is attempted. An x-ray of the chest and abdomen is shown. Which of the following is the most likely diagnosis?", "answer": "Esophageal atresia with tracheoesophageal fistula to the distal esophageal segment", "options": {"A": "Esophageal atresia with tracheoesophageal fistula to the proximal esophageal segment", "B": "H‑type tracheoesophageal fistula without esophageal atresia", "C": "Esophageal atresia with tracheoesophageal fistula to the distal esophageal segment", "D": "Esophageal atresia with tracheoesophageal fistula to the proximal and distal esophageal segments", "E": "Esophageal atresia without tracheoesophageal fistula"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Thirty minutes", "delivery", "3400", "female newborn", "cyanosis", "lips", "oral mucosa", "born", "36 weeks of gestation", "30 year old woman", "gravida 1", "para 0", "Apgar scores", "8", "1", "5 minutes", "Pregnancy", "complicated", "polyhydramnios", "patient's temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "70 40 mm Hg", "foaming", "drooling", "mouth", "Bilateral crackles", "heard", "lung bases", "harsh", "systolic murmur", "left sternal border", "abdomen", "soft", "mildly distended", "anterior ectopic", "Insertion of", "nasogastric tube", "x-ray of", "chest", "abdomen", "following", "diagnosis"]}
{"question": "Following a gastric surgery, a 45-year-old woman complains of severe nausea and vomiting on the second post-operative day. On physical examination, her vitals are stable and examination of the abdomen reveals no significant abnormality. As she is already receiving an appropriate dosage of ondansetron, the surgeon adds metoclopramide to her treatment orders. Following addition of the drug, she experiences significant relief from nausea and vomiting. Which of the following mechanisms best explains the action of this drug?", "answer": "Inhibition of dopamine receptors in the area postrema", "options": {"A": "Enhancement of small intestinal and colonic motility by dopamine antagonism", "B": "Inhibition of dopamine receptors in the area postrema", "C": "Decreased esophageal peristaltic amplitude", "D": "Stimulation of motilin receptors in gastrointestinal smooth muscle", "E": "Inhibition of serotonin receptors on the nucleus tractus solitarius"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Following", "gastric surgery", "year old woman", "severe nausea", "vomiting", "second post-operative day", "stable", "examination of", "abdomen reveals", "significant abnormality", "receiving", "appropriate dosage", "ondansetron", "surgeon adds metoclopramide", "treatment", "Following addition", "drug", "significant relief", "nausea", "vomiting", "following mechanisms best", "action", "drug"]}
{"question": "A 19-year-old boy presents to the emergency department with difficulty breathing, which began 1 hour ago. He has had persistent bronchial asthma since 3 years of age and has been prescribed inhaled fluticasone (400 μg/day) by his pediatrician. He has not taken the preventer inhaler for the last 2 weeks and visited an old house today that had a lot of dust accumulated on the floor. On physical examination, his temperature is 36.8°C (98.4°F), the pulse is 110/min, and the respiratory rate is 24/min. There are no signs of respiratory distress, and chest auscultation reveals bilateral wheezing. Which of the following medications is most likely to provide quick relief?", "answer": "Inhaled albuterol", "options": {"A": "Inhaled albuterol", "B": "Inhaled salmeterol", "C": "Inhaled fluticasone", "D": "Inhaled cromolyn", "E": "Oral montelukast"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "emergency department", "difficulty breathing", "began 1 hour", "persistent bronchial asthma", "years", "age", "inhaled fluticasone", "400 g/day", "pediatrician", "not", "inhaler", "2 weeks", "old house today", "lot", "floor", "temperature", "36", "98", "pulse", "min", "respiratory rate", "min", "signs", "respiratory distress", "chest auscultation reveals bilateral wheezing", "following medications", "to", "quick relief"]}
{"question": "Six days after being admitted to the hospital for a cholecystectomy, a 56-year-old woman has high-grade fevers, chills, malaise, and generalized weakness. She has been hospitalized twice in the last year for acute cholecystitis. She had a molar extraction around 2 weeks ago. Her last colonoscopy was 8 months ago and showed a benign polyp that was removed. She has mitral valve prolapse, hypertension, rheumatoid arthritis, and hypothyroidism. Current medications include metformin, rituximab, levothyroxine, and enalapril. Her temperature is 38.3°C (101°F), pulse is 112/min, and blood pressure is 138/90 mm Hg. Examination shows painless macules over her palms and soles and linear hemorrhages under her nail beds. The lungs are clear to auscultation. There is a grade 3/6 systolic murmur heard best at the apex. Blood is drawn and she is started on intravenous antibiotic therapy. Two sets of blood cultures grow coagulase-negative staphylococci. An echocardiography shows a large oscillating vegetation on the mitral valve and moderate mitral regurgitation. Which of the following is the strongest predisposing factor for this patient's condition?", "answer": "Infected peripheral venous catheter", "options": {"A": "Predamaged heart valve", "B": "Colonic polyp", "C": "Recent dental procedure", "D": "Immunosuppression", "E": "Infected peripheral venous catheter"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Six days", "cholecystectomy", "year old woman", "high-grade fevers", "chills", "malaise", "generalized weakness", "hospitalized twice", "year", "acute cholecystitis", "molar extraction", "2 weeks", "last colonoscopy", "months", "benign polyp", "removed", "mitral valve prolapse", "hypertension", "rheumatoid arthritis", "hypothyroidism", "Current medications include metformin", "rituximab", "levothyroxine", "enalapril", "temperature", "pulse", "min", "blood pressure", "90 mm Hg", "painless macules", "soles", "linear hemorrhages", "nail beds", "lungs", "clear", "auscultation", "systolic murmur heard best", "apex", "Blood", "started", "intravenous antibiotic therapy", "Two sets of blood cultures", "echocardiography", "large", "vegetation", "mitral valve", "moderate mitral regurgitation", "following", "strongest predisposing factor", "patient's condition"]}
{"question": "A 6-year-old right-handed boy is brought to the emergency department because of difficulty speaking and inability to raise his right arm. The patient’s mother says his symptoms started suddenly 1 hour ago and have not improved. She says he has never had these symptoms before. No other significant past medical history. The patient was born full-term via spontaneous transvaginal delivery and has met all developmental goals. The family immigrated from Nigeria 3 months ago, and the patient is currently following a vaccination catch-up schedule. His vital signs include: temperature 36.8°C (98.2°F), blood pressure 111/65 mm Hg, pulse 105/min. Height is at the 30th percentile and weight is at the 25th percentile for age and sex. Physical examination is remarkable for generalized pallor, pale conjunctiva, jaundice, and complete loss of strength in the right arm (0/5). His peripheral blood smear is shown in the picture. Which of the following is the most effective preventive measure for this patient’s condition?", "answer": "Regular blood transfusion", "options": {"A": "Warfarin", "B": "Aspirin", "C": "Carotid endarterectomy", "D": "Regular blood transfusion", "E": "Oral penicillin VK"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old right-handed boy", "brought", "emergency department", "difficulty speaking", "to", "right arm", "patients", "symptoms started", "hour", "not improved", "never", "symptoms", "significant past medical history", "patient", "born full", "spontaneous transvaginal delivery", "met", "developmental", "Nigeria", "months", "patient", "currently following", "vaccination catch", "vital signs include", "temperature 36", "98", "blood pressure", "65 mm Hg", "pulse", "min", "Height", "percentile", "weight", "percentile", "age", "sex", "generalized pallor", "pale conjunctiva", "jaundice", "complete loss of strength", "right arm", "0/5", "peripheral blood smear", "picture", "following", "most effective preventive measure", "patients condition"]}
{"question": "A 53-year-old woman comes to the physician because of progressive headache and fatigue for the past 2 months. One year ago, she was diagnosed with Cushing disease, which was ultimately treated with bilateral adrenalectomy. Current medications are hydrocortisone and fludrocortisone. Examination shows generalized hyperpigmentation of the skin and bitemporal visual field defects. Serum studies show an ACTH concentration of 1250 pg/mL (N = 20–100). Which of the following is the most appropriate next step in management?", "answer": "Perform radiotherapy of the pituitary", "options": {"A": "Administer bromocriptine", "B": "Administer metyrapone", "C": "Perform radiotherapy of the pituitary", "D": "Reduce dosage of glucocorticoids", "E": "Resect small cell lung carcinoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "progressive headache", "fatigue", "past", "months", "One year ago", "diagnosed", "Cushing disease", "treated with bilateral adrenalectomy", "Current medications", "hydrocortisone", "fludrocortisone", "generalized hyperpigmentation of the skin", "bitemporal visual field defects", "Serum studies", "ACTH concentration", "pg/mL", "N", "following", "most appropriate next step"]}
{"question": "A 35-year-old woman presents to her family doctor worried that she might have a heart condition. For the past 7 months, she has been having short panic attacks where she feels short of breath, sweaty, and feels like her heart wants to jump out her chest. During these attacks, she feels like she ‘is going crazy’. She has now mapped out all of the places she has had an attack such as the subway, the crowded pharmacy near her house, and an elevator at her work that is especially slow and poorly lit. She actively avoids these areas to prevent an additional episode. She is afraid that during these attacks she may not be able to get the help she needs or escape if needed. No significant past medical history. The patient takes no current medications. Her grandfather died of a heart attack at the age of 70 and she is worried that it might run in the family. The patient is afebrile and vital signs are within normal limits. Laboratory results are unremarkable. Which of the following is the most likely diagnosis for this patient’s condition?", "answer": "Panic disorder and agoraphobia", "options": {"A": "Panic disorder and agoraphobia", "B": "Panic disorder", "C": "Social anxiety disorder", "D": "Agoraphobia", "E": "Generalized anxiety disorder"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old woman presents", "family doctor worried", "heart condition", "past", "months", "short panic attacks", "short of breath", "sweaty", "heart", "jump out", "chest", "attacks", "now", "out", "places", "attack", "subway", "pharmacy", "house", "elevator", "slow", "poorly lit", "areas to prevent", "additional episode", "attacks", "not", "able to", "help", "needs", "needed", "significant past medical history", "patient", "current medications", "died", "heart attack", "age", "70", "worried", "run in", "patient", "afebrile", "vital signs", "normal limits", "Laboratory results", "unremarkable", "following", "diagnosis", "patients condition"]}
{"question": "A 25-year-old woman comes to the emergency department because of a mild headache, dizziness, fatigue, and nausea over the past several hours. She has no history of serious illness and takes no medications. She lives in a basement apartment and uses a wood stove for heating. Her temperature is 36°C (96.8°F) and pulse is 120/min. Arterial blood gas analysis shows a carboxyhemoglobin level of 11% (N = < 1.5). Which of the following mechanisms is the underlying cause of this patient's symptoms?", "answer": "Inhibition of mitochondrial cytochrome c oxidase", "options": {"A": "Inhibition of mitochondrial succinate dehydrogenase", "B": "Inhibition of mitochondrial ATP synthase", "C": "Increased oxygen binding capacity", "D": "Inhibition of mitochondrial cytochrome c oxidase", "E": "Increased mitochondrial membrane permeability"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "emergency department", "mild headache", "dizziness", "fatigue", "nausea", "past", "hours", "history", "serious illness", "medications", "lives in", "basement apartment", "uses", "wood stove", "temperature", "96", "pulse", "min", "Arterial blood gas analysis", "carboxyhemoglobin level", "N", "1.5", "following mechanisms", "underlying cause", "patient's symptoms"]}
{"question": "A 31-year-old woman with a history of anorexia nervosa diagnosed 2 years ago presents for follow up. She says that, although she feels some improvement with cognitive-behavioral therapy (CBT), she is still struggling with her body image and fears gaining weight. She says that for the past 3 weeks she has noticed her ankles are uncomfortably swollen in the mornings. She also mentions that she still is having intermittent menstruation; her last menstrual cycle was 4 months ago. The patient denies any suicidal ideations. She has no other significant past medical history. She denies any history of smoking, alcohol consumption, or recreational drug use. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 55/min, blood pressure 100/69 mm Hg, and respiratory rate 18/min. Her body mass index (BMI) is 17.1 kg/m2, improved from 16.9 kg/m2, 6 months ago. Her physical examination is significant for an irregular heart rhythm on cardiopulmonary auscultation. There is also significant 3+ pitting edema in the lower extremities bilaterally. An ECG reveals multiple isolated premature ventricular contractions (PVCs) with 1 10-sec episode of bigeminy. Which of the following aspects of this patient’s history and physical examination would be the strongest indication for inpatient hospitalization?", "answer": "Lower extremity edema", "options": {"A": "BMI of 17.1 kg/m2", "B": "Amenorrhea", "C": "Bigeminy", "D": "Pulse 55/min", "E": "Lower extremity edema"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["31 year old woman", "history of anorexia nervosa diagnosed 2 years", "presents", "follow up", "cognitive-behavioral therapy", "gaining weight", "past", "weeks", "ankles", "swollen", "mornings", "intermittent menstruation", "last menstrual cycle", "4 months", "patient", "suicidal ideations", "significant past medical history", "history of smoking", "recreational drug use", "patients vital signs include", "temperature", "98", "pulse", "min", "blood pressure 100 69 mm Hg", "respiratory rate", "min", "body mass index", "kg/m2", "improved", "kg/m2", "months", "significant", "irregular heart rhythm", "cardiopulmonary auscultation", "significant", "pitting edema", "lower extremities", "ECG reveals multiple isolated premature ventricular contractions", "10 sec episode of bigeminy", "following aspects", "strongest", "inpatient"]}
{"question": "A 54-year-old man with a long-standing history of chronic obstructive pulmonary disease (COPD) presents to the clinic for progressive shortness of breath. The patient reports generalized fatigue, distress, and difficulty breathing that is exacerbated with exertion. Physical examination demonstrates clubbing of the fingers, and an echocardiogram shows right ventricular hypertrophy. The patient is placed on a medication for symptom control. One month later, the patient returns for follow up with some improvement in symptoms. Laboratory tests are drawn and shown below:\n\nSerum:\nNa+: 137 mEq/L\nCl-: 101 mEq/L\nK+: 4.8 mEq/L\nHCO3-: 25 mEq/L\nBUN: 8.5 mg/dL\nGlucose: 117 mg/dL\nCreatinine: 1.4 mg/dL\nThyroid-stimulating hormone: 1.8 µU/mL\nCa2+: 9.6 mg/dL\nAST: 159 U/L\nALT: 201 U/L\n\nWhat is the mechanism of action of the likely medication given?", "answer": "Competitive inhibition of endothelin-1 receptors", "options": {"A": "Beta-2 agonist", "B": "Competitive inhibition of endothelin-1 receptors", "C": "Competitive inhibition of muscarinic receptors", "D": "Inhibition of phosphodiesterase-5", "E": "Prostacylin with direct vasodilatory effects"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year", "man", "long standing history of chronic obstructive pulmonary disease", "presents", "clinic", "progressive shortness of breath", "patient reports generalized fatigue", "distress", "difficulty breathing", "exacerbated", "exertion", "clubbing of the fingers", "echocardiogram", "right ventricular hypertrophy", "patient", "medication", "symptom control", "One month later", "patient returns", "follow up", "symptoms", "Laboratory tests", "Serum", "Na", "137 mEq L", "mEq/L K", "4.8 mEq/L HCO3", "mEq/L", "8.5 mg/dL Glucose", "mg/dL Creatinine", "1.4 mg/dL Thyroid-stimulating hormone", "1.8 U/mL Ca2", "dL AST", "U/L ALT", "U/L", "mechanism of action", "likely medication given"]}
{"question": "A 34-year-old woman, gravida 4, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. The previous pregnancies ended in spontaneous abortion between the 8th and 10th week of gestation. She feels well but is worried about having another miscarriage. She has no history of serious illness. Previous gynecologic evaluations showed no abnormalities. The patient takes a daily prenatal multivitamin. Her temperature is 36.5°C (97.7°F), pulse is 85/min, and blood pressure is 125/85 mm Hg. Examination shows a violaceous, reticular rash on the lower extremities.\nHemoglobin 10.5 g/dL\nLeukocyte count 5,200/mm3\nPlatelet count 120,000/mm3\nProthrombin time 13 seconds\nPartial thromboplastin time 49 seconds\nSerum\nNa+ 140 mEq/L\nK+ 4.4 mEq/L\nCl- 101 mEq/L\nUrea nitrogen 12 mg/dL\nCreatinine 1.1 mg/dL\nAST 20 U/L\nALT 15 U/L\nAnti-beta 2 glycoprotein-1 antibody positive\nWhich of the following is the most appropriate next step in management?\"", "answer": "Aspirin and enoxaparin", "options": {"A": "Heparin bridged to warfarin", "B": "Glucocorticoids and plasmapharesis", "C": "Aspirin and enoxaparin", "D": "Enoxaparin", "E": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 4", "para 0", "weeks", "estation ", "hysician ", "revious pregnancies  nded ", "pontaneous abortion ", "eek ", "estation.", "ell ", "orried ", "iscarriage.", "istory ", "erious  llness.", "revious  ynecologic ", "bnormalities.", "atient ", "aily  renatal  ultivitamin.", "emperature ", "6.", "7.", "ulse ", "5/ in,", "lood pressure ", "5  m Hg.", "iolaceous,", "eticular  ash ", "ower extremities.", "latelet ", "l-", " ", "ntibody positive ", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "A 32-year-old Caucasian woman presents to her primary care physician’s office with a chief complaint of excessive facial and arm hair. On further questioning, she reveals that in the past year, she has often gone more than 3 months without menstruating. On exam she is well-appearing; her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 60/min, and BMI is 30 kg/m^2. Labwork confirms the suspected diagnosis. What is the best initial treatment (Rx) for this disease AND what other comorbid conditions (CC) should be tested for at this time?", "answer": "Rx: Weight loss, CC: Insulin resistance and lipid dysfunction", "options": {"A": "Rx: Combined oral contraceptives, CC: Infertility and insulin resistance", "B": "Rx: Weight loss, CC: Infertility and insulin resistance", "C": "Rx: Weight loss, CC: Infertility and lipid dysfunction", "D": "Rx: Combined oral contraceptives, CC: Insulin resistance and lipid dysfunction", "E": "Rx: Weight loss, CC: Insulin resistance and lipid dysfunction"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "woman presents", "primary care physicians office", "chief complaint", "excessive facial", "arm hair", "further", "reveals", "past year", "often", "more", "months", "exam", "well appearing", "temperature", "98", "blood pressure", "80 mmHg", "pulse", "60 min", "BMI", "30 kg/m", "confirms", "suspected diagnosis", "best initial treatment", "Rx", "disease", "comorbid conditions", "time"]}
{"question": "A 29-year-old man is brought to the emergency department 20 minutes after sustaining a gunshot wound to the abdomen. On arrival, he is awake and oriented to person, place, and time. He appears agitated. His pulse is 102/min, respirations are 20/min, and blood pressure is 115/70 mm Hg. The pupils are equal and reactive to light. Abdominal examination shows an entrance wound in the right upper quadrant above the umbilicus. There is an exit wound on the right lower back next to the lumbar spine. Breath sounds are normal bilaterally. There is diffuse mild tenderness to palpation with no guarding or rebound. Cardiac examination shows no abnormalities. Intravenous fluid therapy is begun. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the abdomen", "options": {"A": "CT scan of the abdomen", "B": "Close observation", "C": "Diagnostic laparoscopy", "D": "Immediate laparotomy", "E": "Diagnostic peritoneal lavage"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old man", "brought", "emergency department 20 minutes", "sustaining", "gunshot", "abdomen", "arrival", "awake", "oriented to person", "place", "time", "appears agitated", "pulse", "min", "respirations", "20 min", "blood pressure", "70 mm Hg", "pupils", "equal", "reactive to light", "Abdominal", "entrance wound", "right upper quadrant", "umbilicus", "exit wound", "right lower next to", "lumbar spine", "Breath sounds", "normal", "diffuse mild tenderness", "palpation", "guarding", "abnormalities", "Intravenous fluid", "begun", "following", "most appropriate next step"]}
{"question": "A 42-year-old woman presents with fatigue. She says that her symptoms have gradually onset after she recently had a total thyroidectomy due to Graves’ disease. Past medical history is otherwise unremarkable. The patient is afebrile, and her vital signs are within normal limits. Physical examination is unremarkable. Laboratory findings are significant for the following:\n  Potassium 4.2 mEq/L\n  Calcium 7.8 mg/dL\n  Chloride 102 mEg/L\n  Vitamin D3 8 ng/mL (ref range: 25–80 ng/mL)\nA deficiency of which of the following is the most likely cause of this patient’s symptoms?", "answer": "Parathyroid hormone (PTH)", "options": {"A": "1-alpha-hydroxylase", "B": "Thyroid-stimulating hormone (TSH)", "C": "25-hydroxycholecalciferol", "D": "Calcitonin", "E": "Parathyroid hormone (PTH)"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "fatigue", "symptoms", "onset", "recently", "total thyroidectomy due to Graves disease", "Past medical history", "unremarkable", "patient", "afebrile", "vital signs", "normal limits", "unremarkable", "Laboratory findings", "significant", "following", "Potassium", "mEq", "Calcium", "mg", "Chloride", "mEg", "Vitamin", "ng/mL", "ref range", "ng/mL", "deficiency", "following", "most likely cause", "patients symptoms"]}
{"question": "A 36-year-old female presents to her gynecologist for a check-up. She has had normal Pap smears as recommended every 3 years since she turned 30 years old. The physician conducts a pelvic examination that is without abnormality and obtains a cervical Pap smear. The results of the patient's Pap smear from the visit return as high grade squamous intraepithelial lesion (HGSIL). Which of the following is the best next step in the management of this patient?", "answer": "Perform colposcopy", "options": {"A": "Repeat Pap smear in 12 months", "B": "Repeat Pap smear in 3 years", "C": "Obtain HPV DNA test", "D": "Perform colposcopy", "E": "Radical hysterectomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["36 year old female presents", "gynecologist", "check-up", "normal Pap smears", "3 years", "turned 30 years old", "physician", "pelvic examination", "abnormality", "obtains", "cervical Pap smear", "results", "patient's Pap smear", "return", "high grade squamous intraepithelial lesion", "following", "best next step", "patient"]}
{"question": "An 88-year-old man is brought to his primary care physician by his son. The patient has been in excellent health his entire life, but in the last few years appears to have grown steadily confused. He frequently calls his son about things that they have already discussed, forgets where he has placed his keys, and recently the patient's son noticed several unpaid bills on the patient's desk at home. The patient is upset at being \"dragged\" into see the physician and claims that everything is fine--he is just \"getting older\". A complete neurologic exam is normal except for significant difficulty with recall tasks. In the course of the medical work-up, you obtain a CT scan and see the findings in figure A. What is the most likely cause of this patient's CT findings?", "answer": "Cortical atrophy", "options": {"A": "Blockage of the cerebral aqueduct", "B": "Cortical atrophy", "C": "Increased CSF production", "D": "Congenital malformation", "E": "Infection"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["88 year old man", "brought", "primary care physician", "patient", "excellent", "entire life", "last", "years appears to", "confused", "frequently calls", "forgets", "recently", "patient", "everal ", "ills ", "atient'", " home. ", "tient i", "agged\" ", "e t", "ysician a", "ne--", "tting o der\".", "mplete n urologic exam i", "rmal e", "gnificant d fficulty w", "urse o", "dical w rk-up, ", "tain a", " scan a", "e t", "ndings i", "st l kely c use o", "tient's", "fi dings?"]}
{"question": "A 39-year-old woman presents to the family medicine clinic to be evaluated by her physician for weight gain. She reports feeling fatigued most of the day despite eating a healthy diet and exercising regularly. The patient smokes a half-pack of cigarettes daily and has done so for the last 23 years. She is employed as a phlebotomist by the Red Cross. She has a history of hyperlipidemia for which she takes atorvastatin. She is unaware of her vaccination history, and there is no documented record of her receiving any vaccinations. Her heart rate is 76/min, respiratory rate is 14/min, temperature is 37.3°C (99.1°F), body mass index (BMI) is 33 kg/m2, and blood pressure is 128/78 mm Hg. The patient appears alert and oriented. Lung and heart auscultation are without audible abnormalities. The physician orders a thyroid panel to determine if that patient has hypothyroidism. Which of the following recommendations may be appropriate for the patient at this time?", "answer": "Hepatitis B vaccination", "options": {"A": "Hepatitis B vaccination", "B": "Low-dose chest CT", "C": "Hepatitis C vaccination", "D": "Mammogram", "E": "Shingles vaccination"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "family medicine clinic to", "physician", "weight gain", "reports", "fatigued most of the day", "eating", "healthy diet", "exercising", "patient smokes", "half pack", "cigarettes daily", "so", "23 years", "employed", "phlebotomist", "history of hyperlipidemia", "atorvastatin", "of", "vaccination history", "record", "receiving", "vaccinations", "heart rate", "76 min", "respiratory rate", "min", "temperature", "99", "body mass index", "kg/m2", "blood pressure", "mm Hg", "patient appears alert", "oriented", "Lung", "heart auscultation", "abnormalities", "physician orders", "thyroid panel to", "patient", "hypothyroidism", "following", "appropriate", "patient", "time"]}
{"question": "A 75-year-old man comes to the physician because of a 4-month history of progressive shortness of breath and chest pressure with exertion. Cardiac examination shows a crescendo-decrescendo systolic murmur that is heard best in the second right intercostal space. Radial pulses are decreased and delayed bilaterally. Transesophageal echocardiography shows hypertrophy of the left ventricle and a thick, calcified aortic valve. The area of the left ventricular outflow tract is 30.6 mm2. Using continuous-wave Doppler measurements, the left ventricular outflow tract velocity is 1.0 m/s, and the peak aortic valve velocity is 3.0 m/s. Which of the following values most closely represents the area of the stenotic aortic valve?", "answer": "10.2 mm2", "options": {"A": "16.0 mm2", "B": "10.2 mm2", "C": "23 mm2", "D": "6.2 mm2", "E": "2.0 mm2"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old man", "physician", "of", "4 month history", "progressive shortness", "breath", "chest pressure", "exertion", "crescendo-decrescendo systolic murmur", "heard best", "second right intercostal space", "Radial pulses", "decreased", "delayed", "Transesophageal echocardiography", "hypertrophy", "left ventricle", "thick", "calcified aortic valve", "area", "left ventricular outflow tract", "30", "mm2", "Using", "wave Doppler measurements", "left ventricular outflow tract velocity", "1 0 m", "peak aortic valve velocity", "3 0 m", "following values", "area of", "stenotic aortic valve"]}
{"question": "A newborn male born prematurely at 33 weeks is noted to have mild dyspnea and difficulty with feeding. Examination reveals bounding peripheral radial pulses and a continuous 'machine-like' murmur. The patient is subsequently started on indomethacin. Which of the following is the embryologic origin of the structure most likely responsible for this patient's presentation?", "answer": "6th aortic arch", "options": {"A": "1st branchial cleft", "B": "4th branchial arch", "C": "4th branchial pouch", "D": "6th aortic arch", "E": "6th branchial pouch"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["newborn male born", "weeks", "noted to", "mild dyspnea", "difficulty", "feeding", "reveals bounding peripheral radial pulses", "continuous", "machine", "murmur", "patient", "started", "indomethacin", "following", "embryologic origin", "structure", "likely responsible", "patient's"]}
{"question": "An 18-year-old female visits your obstetrics clinic for her first prenatal check up. It's her first month of pregnancy and other than morning sickness, she is feeling well. Upon inquiring about her past medical history, the patient admits that she used to be very fearful of weight gain and often used laxatives to lose weight. After getting therapy for this condition, she regained her normal body weight but continues to struggle with the disease occasionally. Given this history, how could her past condition affect the pregnancy?", "answer": "Postpartum depression for mother", "options": {"A": "Down syndrome in newborn", "B": "Postpartum depression for mother", "C": "Bradycardia in newborn", "D": "Anemia in newborn", "E": "Seizure for mother"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female", "obstetrics", "first prenatal check up", "first month", "pregnancy", "other", "morning sickness", "well", "past medical history", "patient", "used to", "very fearful", "weight gain", "often used laxatives to", "weight", "getting therapy", "condition", "normal body weight", "disease occasionally", "Given", "history", "past condition", "pregnancy"]}
{"question": "A 4-year-old boy presents to the pediatrician's office for a well child checkup. He does not speak during the visit and will not make eye contact. The father explains that the child has always been shy with strangers. However, the child speaks a lot at home and with friends. He can speak in 4 word sentences, tells stories, and parents understand 100% of what he says. He names colors and is starting to recognize letters. However, his pre-kindergarten teachers are concerned that even after 5 months in their class, he does not speak during school at all. The father notes that he is equally as shy in church, which he has been going to his entire life. Which of the following is most likely?", "answer": "Selective mutism", "options": {"A": "Autism spectrum disorder", "B": "Child abuse at school", "C": "Expressive speech delay", "D": "Normal development", "E": "Selective mutism"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old boy presents", "pediatrician's office", "well child checkup", "not speak", "not make", "child", "always", "shy", "child speaks", "lot at home", "speak", "stories", "100", "names colors", "starting to", "pre kindergarten teachers", "months", "not speak", "school", "notes", "shy", "church", "entire life", "following"]}
{"question": "A 61-year-old man with Alzheimer disease is brought to the emergency department 20 minutes after ingesting an unknown amount of his medications in a suicide attempt. He reports abdominal cramps, diarrhea, diaphoresis, and muscular weakness and spasms in his extremities. His temperature is 38.4°C (101.1°F), pulse is 51/min, respirations are 12/min and labored, and blood pressure is 88/56 mm Hg. Physical examination shows excessive salivation and tearing, and small pupils bilaterally. Treatment with atropine is initiated. Shortly after, most of his symptoms have resolved, but he continues to have muscular spasms. Administration of which of the following is the most appropriate next step in management of this patient?", "answer": "Pralidoxime", "options": {"A": "Carbachol", "B": "Physostigmine", "C": "Pancuronium", "D": "Benztropine", "E": "Pralidoxime"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["61 year old man", "Alzheimer disease", "brought", "emergency department 20 minutes", "unknown amount", "medications", "suicide attempt", "reports abdominal cramps", "diarrhea", "diaphoresis", "muscular weakness", "spasms", "extremities", "temperature", "pulse", "min", "respirations", "min", "labored", "blood pressure", "88", "mm Hg", "excessive salivation", "tearing", "small pupils", "Treatment", "atropine", "initiated", "most", "symptoms", "resolved", "to", "muscular spasms", "Administration of", "following", "most appropriate next step", "patient"]}
{"question": "A 46-year-old woman comes to the physician because of a 3-day history of diarrhea and abdominal pain. She returned from a trip to Egypt 4 weeks ago. Her vital signs are within normal limits. There is mild tenderness in the right lower quadrant. Stool studies show occult blood and unicellular organisms with engulfed erythrocytes. Which of the following is the most appropriate initial pharmacotherapy for this patient?", "answer": "Metronidazole", "options": {"A": "Doxycycline", "B": "Metronidazole", "C": "Albendazole", "D": "Paromomycin", "E": "Ciprofloxacin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "3-day history", "diarrhea", "abdominal pain", "returned", "trip", "Egypt", "weeks", "vital signs", "normal limits", "mild tenderness", "right lower quadrant", "Stool studies", "occult blood", "erythrocytes", "following", "most appropriate initial pharmacotherapy", "patient"]}
{"question": "A 36-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. She is alert, awake, and oriented. There is no family history of serious illness and her only medication is an oral contraceptive. Her temperature is 37.3°C (99°F), pulse is 100/min, respirations are 20/min, and blood pressure is 102/80 mm Hg. Physical examination shows ecchymoses over the trunk and abdomen. A FAST scan of the abdomen is negative. An x-ray of the chest shows no fractures. A contrast-enhanced CT scan of the chest and abdomen is performed that shows a 4-cm sharply defined liver mass with a hypoattenuated central scar. Which of the following is the most appropriate next step in management?", "answer": "Reassurance and observation", "options": {"A": "Reassurance and observation", "B": "Biopsy of the mass", "C": "Discontinue the oral contraceptive", "D": "Percutaneous aspiration of the mass", "E": "Surgical resection of the mass"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old woman", "brought", "emergency department", "involved", "motor vehicle collision", "alert", "awake", "oriented", "family history", "serious illness", "only medication", "oral contraceptive", "temperature", "pulse", "100 min", "respirations", "20 min", "blood pressure", "80 mm Hg", "ecchymoses", "trunk", "abdomen", "FAST scan", "abdomen", "negative", "x-ray of", "chest", "fractures", "contrast-enhanced CT scan", "chest", "abdomen", "performed", "4", "liver mass", "hypoattenuated central scar", "following", "most appropriate next step"]}
{"question": "Two hours after a 2280-g male newborn is born at 38 weeks' gestation to a 22-year-old primigravid woman, he has 2 episodes of vomiting and jitteriness. The mother has noticed that the baby is not feeding adequately. She received adequate prenatal care and admits to smoking one pack of cigarettes daily while pregnant. His temperature is 36.3°C (97.3°F), pulse is 171/min and respirations are 60/min. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows pale extremities. There is facial plethora. Capillary refill time is 3 seconds. Laboratory studies show:\nHematocrit 70%\nLeukocyte count 7800/mm3\nPlatelet count 220,000/mm3\nSerum\nGlucose 38 mg/dL\nCalcium 8.3 mg/dL\nWhich of the following is the most likely cause of these findings?\"", "answer": "Intrauterine hypoxia\n\"", "options": {"A": "Transient tachypnea of the newborn", "B": "Intraventricular hemorrhage", "C": "Hyperinsulinism", "D": "Congenital heart disease", "E": "Intrauterine hypoxia\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Two hours", "g male newborn", "born", "weeks", "estation ", "ear- ld  rimigravid  oman,", "as ", "pisodes of  omiting ", "itteriness.", "aby ", "ot ", "eceived  dequate ", "moking  ne  ack ", "igarettes  aily ", "regnant.", "emperature ", "6.", "7.", "ulse ", "in ", "espirations ", "0/ in.", "ulse oximetry ", "oom air ", "xygen saturation ", "ale  xtremities.", "acial  lethora.", "apillary refill time ", "  econds.", "aboratory studies ", "ematocrit ", "eukocyte count ", "m3  latelet count ", "erum Glucose ", "g/ L  alcium ", "L ", "ollowing ", "ost  ikely  ause ", "indings?"]}
{"question": "A 20-year-old man comes to the physician because of dark urine and decreased urine output for 2 days. He had a skin infection that required antibiotic treatment 3 weeks ago but stopped the antibiotics early because the infection had resolved. His blood pressure is 140/90 mm Hg. Physical examination shows periorbital edema bilaterally. A photomicrograph of a renal biopsy specimen is shown. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Elevated Anti-DNase B titer", "options": {"A": "Mutation in type IV collagen", "B": "Impaired glutathione regeneration", "C": "Mesangial IgA deposition", "D": "Decreased platelet count", "E": "Elevated Anti-DNase B titer"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["20 year old man", "physician", "dark urine", "decreased urine output", "2 days", "skin infection", "required antibiotic treatment", "weeks", "stopped", "early", "infection", "resolved", "blood pressure", "90 mm Hg", "periorbital edema", "photomicrograph", "renal biopsy specimen", "Further", "to", "following findings"]}
{"question": "A 7-year-old boy with a history of fetal alcohol syndrome is brought by his mother to the emergency room for malaise and lethargy. His mother reports that the family was on vacation in a cabin in the mountains for the past 10 days. Five days ago, the child developed a fever with a max temperature of 102.6°F (39.2°F). She also reports that he was given multiple medications to try to bring down his fever. Although his fever resolved two days ago, the child has become increasingly lethargic. He started having non-bilious, non-bloody emesis one day prior to presentation. His current temperature is 100°F (37.8°C), blood pressure is 95/55 mmHg, pulse is 110/min, and respirations are 22/min. On exam, the child is lethargic and minimally reactive. Mild hepatomegaly is noted. A biopsy of this patient’s liver would likely reveal which of the following?", "answer": "Microvesicular steatosis", "options": {"A": "Microvesicular steatosis", "B": "Macrovesicular steatosis", "C": "Hepatocyte necrosis with ballooning degeneration", "D": "Macronodular cirrhosis", "E": "Micronodular cirrhosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "history", "fetal alcohol syndrome", "brought", "emergency room", "malaise", "lethargy", "reports", "mountains", "past 10 days", "Five", "child", "fever", "temperature", "reports", "given multiple medications to", "to", "fever", "fever resolved two days", "child", "lethargic", "started", "non bilious", "bloody emesis one day prior to", "current temperature", "blood pressure", "95", "mmHg", "pulse", "min", "respirations", "min", "exam", "child", "lethargic", "reactive", "Mild hepatomegaly", "noted", "biopsy of", "patients liver", "likely reveal", "following"]}
{"question": "A 25-year-old woman presents to the ED with a diffuse, erythematous rash in the setting of nausea, vomiting, and fever for 2 days. Physical exam reveals a soaked tampon in her vagina. Blood cultures are negative. The likely cause of this patient's disease binds to which molecule on T cells?", "answer": "Variable beta portion of the T-cell receptor", "options": {"A": "CD3", "B": "Gamma chain of the IL-2 receptor", "C": "CD40 ligand", "D": "Variable beta portion of the T-cell receptor", "E": "Fas ligand"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "diffuse", "erythematous", "setting", "nausea", "vomiting", "fever", "2 days", "reveals", "soaked tampon in", "vagina", "Blood cultures", "negative", "likely cause", "patient's"]}
{"question": "A 22-year-old woman comes to the physician because of pain and swelling of her left foot. Three days ago, she cut her foot on an exposed rock at the beach. Her temperature is 37.7°C (100°F). Examination of the left foot shows edema around a fluctuant erythematous lesion on the lateral foot. Which of the following is most likely the primary mechanism for the development of edema in this patient?", "answer": "Separation of endothelial junctions", "options": {"A": "Fluid production by bacteria", "B": "Increased capillary hydrostatic pressure", "C": "Decreased plasma oncotic pressure", "D": "Systemic cytokine release", "E": "Separation of endothelial junctions"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "pain", "swelling of", "left foot", "Three days", "cut", "foot", "exposed rock", "beach", "temperature", "Examination of", "left foot", "edema", "fluctuant erythematous lesion", "lateral foot", "following", "primary mechanism", "development", "edema", "patient"]}
{"question": "A 60-year-old woman with a history of atrial arrhythmia arrives in the emergency department with complaints of tinnitus, headache, visual disturbances, and severe diarrhea. The patient is given oxygen by nasal cannula. ECG leads, pulse oximeter and an automated blood pressure cuff are applied. The patient suddenly faints. Her ECG indicates the presence of a multifocal ventricular tachycardia with continuous change in the QRS electrical axis. Which of the following drugs is most likely responsible for this patient's symptoms?", "answer": "Quinidine", "options": {"A": "Digoxin", "B": "Quinidine", "C": "Lidocaine", "D": "Amiodarone", "E": "Verapamil"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old woman", "history", "atrial arrhythmia", "emergency department", "complaints", "tinnitus", "headache", "visual disturbances", "severe diarrhea", "patient", "given oxygen", "nasal cannula", "ECG leads", "pulse oximeter", "automated blood pressure cuff", "applied", "patient", "faints", "ECG", "presence", "multifocal ventricular tachycardia", "change", "QRS electrical axis", "following drugs", "responsible", "patient's symptoms"]}
{"question": "A 35-year-old soldier is rescued from a helicopter crash in the Arctic Circle and brought back to a treatment facility at a nearby military base. On arrival, the patient's wet clothes are removed. He appears pale and is not shivering. He is unresponsive to verbal and painful stimuli. His temperature is 27.4°C (81.3°F), pulse is 30/min and irregular, respirations are 7/min, and blood pressure is 83/52 mm Hg. Examination shows fixed, dilated pupils and diffuse rigidity. The fingers and toes are white in color and hard to the touch. An ECG shows atrial fibrillation. In addition to emergent intubation, which of the following is the most appropriate next step in management?", "answer": "Intravenous administration of warmed normal saline", "options": {"A": "Intravenous administration of tissue plasminogen activator", "B": "Intravenous administration of diltiazem", "C": "Application of heating pads to the extremities", "D": "Intravenous administration of warmed normal saline", "E": "Emergent electrical cardioversion"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old soldier", "rescued", "helicopter", "Arctic Circle", "brought back", "treatment facility", "nearby military base", "arrival", "patient's wet clothes", "removed", "appears pale", "not shivering", "unresponsive", "verbal", "painful", "temperature", "27", "81", "pulse", "30/min", "irregular", "respirations", "min", "blood pressure", "83", "mm Hg", "fixed", "dilated", "diffuse rigidity", "fingers", "toes", "white", "color", "hard", "touch", "ECG", "atrial fibrillation", "intubation", "following", "most appropriate next step"]}
{"question": "A 44-year-old woman comes to the physician for the evaluation of right knee pain for 1 week. The pain began after the patient twisted her knee during basketball practice. At the time of the injury, she felt a popping sensation and her knee became swollen over the next few hours. The pain is exacerbated by walking up or down stairs and worsens throughout the day. She also reports occasional locking of the knee. She has been taking acetaminophen during the past week, but the pain is worse today. Her mother has rheumatoid arthritis. The patient is 155 cm (4 ft 11 in) tall and weighs 75 kg (165 lb); BMI is 33 kg/m2. Vital signs are within normal limits. Examination shows effusion of the right knee; range of motion is limited by pain. There is medial joint line tenderness. Knee extension with rotation results in an audible snap. Further evaluation is most likely to show which of the following?", "answer": "Hyperintense line in the meniscus on MRI", "options": {"A": "Hyperintense line in the meniscus on MRI", "B": "Anterior tibial translation on examination", "C": "Trabecular loss in the proximal femur on x-ray", "D": "Erosions and synovial hyperplasia on MRI", "E": "Posterior tibial translation on examination"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "evaluation", "right knee pain", "1 week", "pain began", "patient twisted", "knee", "basketball", "time", "injury", "popping sensation", "knee", "swollen", "next", "hours", "pain", "exacerbated", "worsens", "day", "reports occasional locking", "knee", "acetaminophen", "past week", "pain", "worse today", "rheumatoid arthritis", "patient", "4 ft", "tall", "75 kg", "BMI", "kg/m2", "Vital signs", "normal limits", "effusion", "right knee", "range of motion", "limited", "pain", "medial joint line tenderness", "Knee extension", "rotation", "snap", "Further", "to", "following"]}
{"question": "A 31-year-old man living in a remote tropical village presents with a swollen left leg and scrotum (see image). He says that his symptoms started more than 2 years ago with several small swollen areas near his groin and have gradually and progressively worsened. He has also noticed that over time, there has been a progressive coarsening and fissuring of the skin overlying the swollen areas. Blood samples drawn at night show worm-like organisms under microscopy. Which of the following arthropods is the vector for the organism most likely responsible for this patient’s condition?", "answer": "Mosquito", "options": {"A": "Mosquito", "B": "Tick", "C": "Tsetse fly", "D": "Sandfly", "E": "Human louse"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old man living", "remote", "village presents", "swollen left", "scrotum", "see", "symptoms started more", "years", "several small swollen areas", "groin", "worsened", "time", "progressive", "fissuring of", "skin", "swollen areas", "Blood samples", "night", "worm", "microscopy", "following", "vector", "likely responsible", "patients condition"]}
{"question": "A 17-year-old female is found to have an inherited deficiency of alpha-galactosidase A. Skin biopsy shows accumulation of ceramide trihexose in the tissue. Which of the following abnormalities would be expected in this patient?", "answer": "Angiokeratomas", "options": {"A": "Cherry red spots on macula", "B": "Histiocytes with a wrinkled tissue paper appearance", "C": "Gargoyle-like facies", "D": "Corneal clouding", "E": "Angiokeratomas"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "found to", "inherited deficiency", "Skin biopsy", "accumulation", "ceramide", "tissue", "following abnormalities", "patient"]}
{"question": "A 39-year-old woman presents to your office with 4 days of fever, sore throat, generalized aching, arthralgias, and tender nodules on both of her shins that arose in the last 48 hours. Her medical history is negative for disease and she does not take oral contraceptives or any other medication regularly. The physical examination reveals the vital signs that include body temperature 38.5°C (101.3°F), heart rate 85/min, blood pressure 120/65 mm Hg, tender and enlarged submandibular lymph nodes, and an erythematous, edematous, and swollen pharynx with enlarged tonsils and a patchy white exudate on the surface. She is not pregnant. Examination of the lower limbs reveals erythematous, tender, immobile nodules on both shins. You do not identify ulcers or similar lesions on other areas of her body. What is the most likely diagnosis in this patient?", "answer": "Erythema nodosum", "options": {"A": "Alpha-1 antitrypsin deficiency", "B": "Erythema induratum", "C": "Cutaneous polyarteritis nodosa", "D": "Henoch-Schönlein purpura", "E": "Erythema nodosum"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "office", "4 days", "fever", "sore throat", "generalized aching", "arthralgias", "tender nodules", "shins", "48 hours", "medical history", "negative", "disease", "not", "oral contraceptives", "medication", "reveals", "vital signs", "include body temperature", "heart rate 85 min", "blood pressure", "65 mm Hg", "tender", "enlarged submandibular lymph nodes", "erythematous", "edematous", "swollen pharynx", "enlarged tonsils", "patchy white exudate", "surface", "not pregnant", "Examination of", "lower limbs reveals erythematous", "tender", "immobile nodules", "shins", "not", "ulcers", "similar lesions", "areas", "body", "diagnosis", "patient"]}
{"question": "A 66-year-old man is brought to the emergency department because of weakness of his left leg for the past 30 minutes. His pants are soaked with urine. He has hypertension and atrial fibrillation. His temperature is 37°C (98.6°F), pulse is 98/min, and blood pressure is 160/90 mm Hg. Examination shows equal pupils that are reactive to light. Muscle strength is 2/5 in the left lower extremity. Plantar reflex shows an extensor response on the left. Within one minute of the onset of this patient's symptoms, the cells in his right anteromedial cortical surface enlarge significantly. Which of the following is the most likely explanation of the described cellular change?", "answer": "Intracellular depletion of ATP", "options": {"A": "Rupture of lysosomes", "B": "Influx of extracellular calcium", "C": "Intracellular depletion of ATP", "D": "Release of pro-apoptotic proteins", "E": "Breakdown of the cell membrane"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["66 year old man", "brought", "emergency department", "of weakness", "left leg", "past 30 minutes", "pants", "soaked", "urine", "hypertension", "atrial fibrillation", "temperature", "98", "pulse", "98 min", "blood pressure", "90 mm Hg", "equal pupils", "reactive to light", "Muscle strength", "2/5", "left lower extremity", "Plantar reflex", "extensor response", "left", "one minute", "onset", "patient's symptoms", "cells", "right anteromedial cortical surface", "following", "cellular change"]}
{"question": "A 23-year-old male presents to his primary care physician after an injury during a rugby game. The patient states that he was tackled and ever since then has had pain in his knee. The patient has tried NSAIDs and ice to no avail. The patient has no past medical history and is currently taking a multivitamin, fish oil, and a whey protein supplement. On physical exam you note a knee that is heavily bruised. It is painful for the patient to bear weight on the knee, and passive motion of the knee elicits some pain. There is laxity at the knee to varus stress. The patient is wondering when he can return to athletics. Which of the following is the most likely diagnosis?", "answer": "Lateral collateral ligament tear", "options": {"A": "Medial collateral ligament tear", "B": "Lateral collateral ligament tear", "C": "Anterior cruciate ligament tear", "D": "Posterior cruciate ligament tear", "E": "Meniscal tear"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old male presents", "primary care physician", "injury", "patient states", "ever", "then", "pain in", "knee", "patient", "NSAIDs", "ice", "patient", "past medical history", "currently", "multivitamin", "fish oil", "protein supplement", "note", "knee", "bruised", "painful", "patient to", "weight", "knee", "passive motion", "knee elicits", "pain", "laxity", "knee", "varus stress", "patient", "return", "following", "diagnosis"]}
{"question": "An 80-year-old woman is brought to the emergency department due to the gradual worsening of confusion and lethargy for the past 5 days. Her son reports that she had recovered from a severe stomach bug with vomiting and diarrhea 3 days ago without seeing a physician or going to the hospital. The patient’s past medical history is notable for type 2 diabetes mellitus and hypertension. She takes hydrochlorothiazide, metformin, a children’s aspirin, and a multivitamin. The patient is not compliant with her medication regimen. Physical examination reveals dry oral mucous membranes and the patient appears extremely lethargic but arousable. She refuses to answer questions and has extreme difficulty following the conversation. Laboratory results are as follows:\nSodium 126 mEq/L\nPotassium 3.9 mEq/L\nChloride 94 mEq/L\nBicarbonate 25 mEq/L\nCalcium 8.1 mg/dL\nGlucose 910 mg/dL\nUrine ketones Trace\nWhich of the following may also be found in this patient?", "answer": "Increased BUN/creatinine ratio", "options": {"A": "Characteristic breath odor", "B": "Flapping hand tremor", "C": "Increased BUN/creatinine ratio", "D": "Diffuse abdominal pain", "E": "Rapid and deep respiration"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["80 year old woman", "brought", "emergency department due to", "gradual worsening", "confusion", "lethargy", "past 5 days", "reports", "recovered", "severe stomach bug", "vomiting", "diarrhea 3 days", "seeing", "physician", "hospital", "patients past medical history", "notable", "type 2 diabetes mellitus", "hypertension", "hydrochlorothiazide", "metformin", "aspirin", "multivitamin", "patient", "not compliant", "medication regimen", "reveals dry oral mucous membranes", "patient appears extremely lethargic", "to", "extreme difficulty following", "Laboratory results", "follows", "Sodium", "mEq/L Potassium", "Chloride", "Bicarbonate", "Calcium 8.1 mg/dL Glucose", "Urine", "Trace", "following", "found", "patient"]}
{"question": "A 73-year-old man presents to the emergency department complaining of abdominal pain with nausea and vomiting, stating that he “can’t keep anything down”. He states that the pain has been gradually getting worse over the past 2 months, saying that, at first, it was present only an hour after he ate but now is constant. He also says that he has been constipated for the last 2 weeks, which has also been getting progressively worse. His last bowel movement was 4 days ago which was normal. He states that he cannot pass flatus. The patient’s past medical history is significant for hypertension and an episode of pneumonia last year. The patient is afebrile and his pulse is 105/min. On physical examination, the patient is uncomfortable. His lungs are clear to auscultation bilaterally. His abdomen is visibly distended and diffusely tender with tympany on percussion. A contrast CT scan of the abdomen shows dilated loops of small bowel with collapsed large bowel. Which of the following is the most likely cause of this patient’s condition?", "answer": "Mass effect from a tumor", "options": {"A": "Incarcerated hernia", "B": "Mass effect from a tumor", "C": "Crohn's disease", "D": "Adhesions", "E": "Diverticulitis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "abdominal pain", "nausea", "vomiting", "stating", "cant keep", "states", "pain", "getting worse", "past", "months", "first", "present only", "hour", "ate", "now", "constant", "constipated", "2 weeks", "getting", "worse", "last bowel movement", "4 days", "normal", "states", "pass flatus", "patients past medical history", "significant", "hypertension", "episode of pneumonia", "year", "patient", "afebrile", "pulse", "min", "patient", "lungs", "clear", "auscultation", "abdomen", "distended", "tender", "tympany", "percussion", "contrast", "abdomen", "dilated loops", "small bowel", "collapsed large bowel", "following", "most likely cause", "patients condition"]}
{"question": "A 20-year-old college student has elevated stress levels due to her rigorous academic schedule, social commitments, and family pressures. She complains of never having enough time for all her responsibilities. Which of the following hormones acts by intracellular receptors to exert the physiologic effects of her stress?", "answer": "Cortisol", "options": {"A": "Cortisol", "B": "Glucagon", "C": "Growth hormone", "D": "Norepinephrine", "E": "Prolactin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["20 year old", "elevated stress levels due to", "rigorous", "social", "pressures", "never", "time", "following hormones acts", "intracellular receptors to exert", "physiologic", "stress"]}
{"question": "A 61-year-old female is referred to an oncologist for evaluation of a breast lump that she noticed two weeks ago while doing a breast self-examination. Her past medical history is notable for essential hypertension and major depressive disorder for which she takes lisinopril and escitalopram, respectively. Her temperature is 98.6°F (37°C), blood pressure is 120/65 mmHg, pulse is 82/min, and respirations are 18/min. Biopsy of the lesion confirms a diagnosis of invasive ductal carcinoma with metastatic disease in the ipsilateral axillary lymph nodes. The physician starts the patient on a multi-drug chemotherapeutic regimen. The patient successfully undergoes mastectomy and axillary dissection and completes the chemotherapeutic regimen. However, several months after completion of the regimen, the patient presents to the emergency department with dyspnea, chest pain, and palpitations. A chest radiograph demonstrates an enlarged cardiac silhouette. This patient’s current symptoms could have been prevented by administration of which of the following medications?", "answer": "Dexrazoxane", "options": {"A": "Vincristine", "B": "Dexrazoxane", "C": "Aspirin", "D": "Rosuvastatin", "E": "Cyclophosphamide"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old female", "referred", "oncologist", "breast lump", "two weeks", "breast self-examination", "past medical history", "notable", "essential hypertension", "major depressive disorder", "lisinopril", "escitalopram", "temperature", "98", "blood pressure", "65 mmHg", "pulse", "min", "respirations", "min", "Biopsy", "lesion confirms", "diagnosis", "invasive ductal carcinoma", "metastatic disease", "ipsilateral axillary lymph nodes", "physician starts", "patient", "multi drug chemotherapeutic regimen", "patient", "mastectomy", "axillary dissection", "completes", "chemotherapeutic regimen", "several months", "completion", "regimen", "patient presents", "emergency department", "dyspnea", "chest pain", "palpitations", "chest radiograph", "enlarged cardiac silhouette", "patients current symptoms", "prevented", "administration of", "following medications"]}
{"question": "A 58-year-old woman presents with frequent headaches for the past few months. She says the pain starts randomly and is unrelated to any stimulus. She also says that has difficulty falling asleep and has had problems concentrating at work for several months. While she occasionally thinks about committing suicide, she denies any suicidal plans. Her appetite is diminished. No significant past medical history. No current medications. There is no family history of depression or psychiatric illness. The physical exam is unremarkable. The thyroid-stimulating hormone (TSH) level is 3.5 uU/mL. The patient is started on amitriptyline and asked to follow-up in 2 weeks. At her follow-up visit, the patient reports slight improvement in her mood and has no more headaches, but she complains of lightheadedness when she rises out of bed in the morning or stands up from her desk at work. Which of the following pharmacological effects of amitriptyline is most likely responsible for her lightheadedness?", "answer": "Blockage of α1 adrenergic receptors", "options": {"A": "Blockage of muscarinic receptors", "B": "Decreased reuptake of norepinephrine", "C": "Blockage of α1 adrenergic receptors", "D": "Decreased reuptake of serotonin", "E": "Blockage of H1 histamine receptors"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old woman presents", "frequent headaches", "past", "months", "pain starts", "unrelated", "difficulty falling asleep", "several months", "occasionally", "committing suicide", "suicidal plans", "appetite", "diminished", "significant past medical history", "current medications", "family history of depression", "psychiatric illness", "unremarkable", "thyroid-stimulating hormone", "level", "3.5 uU/mL", "patient", "started", "amitriptyline", "to follow-up", "2 weeks", "patient reports slight", "mood", "more headaches", "lightheadedness", "out", "morning", "stands up", "following pharmacological effects", "amitriptyline", "responsible", "lightheadedness"]}
{"question": "A new real time-PCR test for the hepatitis C virus is approved for medical use. The manufacturer sets the threshold number of DNA copies required to achieve a positive result such that the sensitivity is 98% and the specificity is 80%. The tested population has a hepatitis C prevalence of 0.7%. Which of the following changes in the prevalence, incidence, or threshold concentration will increase the positive predictive value of the test, if the other two values are held constant?", "answer": "An increase in prevalence", "options": {"A": "An increase in incidence", "B": "An increase in prevalence", "C": "A decrease in incidence", "D": "A decrease in prevalence", "E": "Lowering the threshold concentration required for a positive test."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A", "test", "hepatitis", "virus", "approved", "medical use", "sets", "threshold number", "DNA copies required to", "positive result", "sensitivity", "specificity", "80", "population", "a hepatitis C prevalence", "0.7", "following changes", "prevalence", "incidence", "threshold concentration", "increase", "positive predictive value of", "test", "two values", "held constant"]}
{"question": "A 4080-g (9-lb) male newborn is delivered at term to a 32-year-old woman, gravida 2, para 1. Apgar scores are 8 and 9 at 1- and 5-minutes, respectively. Examination in the delivery room shows both feet pointing downwards and inwards. Both the forefeet are twisted medially in adduction, with the hindfeet elevated and the midfeet appearing concave. Both Achilles tendons are taut on palpation. There are skin creases on the medial side of both feet. The deformity persists despite attempts to passively straighten the foot. X-rays of both feet confirm the suspected diagnosis. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Repositioning and serial casting", "options": {"A": "Foot abduction brace", "B": "Surgery", "C": "Reassurance", "D": "Repositioning and serial casting", "E": "Physiotherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["g", "male newborn", "delivered", "term", "year old woman", "gravida 2", "para 1", "Apgar scores", "5-minutes", "delivery", "feet pointing downwards", "inwards", "forefeet", "twisted", "adduction", "hindfeet elevated", "midfeet appearing concave", "Achilles tendons", "taut", "palpation", "skin creases", "medial side of", "feet", "deformity", "foot", "X-rays of both", "confirm", "suspected diagnosis", "following", "most appropriate next step", "patient"]}
{"question": "A 4390-g (9-lb 11-oz) male newborn is delivered at term to a 28-year-old primigravid woman. Pregnancy was complicated by gestational diabetes mellitus. Labor was prolonged by the impaction of the fetal shoulder and required hyperabduction of the left upper extremity. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Vital signs are within normal limits. Examination in the delivery room shows a constricted left pupil. There is drooping of the left eyelid. Active movement of the left upper extremity is reduced. Further evaluation of this newborn is most likely to show which of the following?", "answer": "Absent unilateral grasp reflex", "options": {"A": "Generalized hypotonia", "B": "Absent nasolabial fold", "C": "Absent unilateral grasp reflex", "D": "Lower back mass", "E": "Decreased movement of unilateral rib cage\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["g", "oz", "male newborn", "delivered", "term", "year old primigravid woman", "Pregnancy", "complicated", "gestational diabetes mellitus", "Labor", "prolonged", "impaction", "fetal shoulder", "required", "left upper extremity", "Apgar scores", "8", "1", "5 minutes", "Vital signs", "normal limits", "delivery room", "constricted left", "left", "Active", "upper", "reduced", "Further evaluation", "newborn", "to", "following"]}
{"question": "A 4-year-old girl presents to the emergency department after persistent vomiting and complaints that her abdomen hurts. Her parents came home to their daughter like this while she was at home being watched by the babysitter. The child is otherwise healthy. Family history is notable for depression, suicide, neuropathic pain, diabetes, hypertension, cancer, and angina. The child is now minimally responsive and confused. Her temperature is 100°F (37.8°C), blood pressure is 100/60 mmHg, pulse is 140/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for a confused girl who is vomiting bloody emesis into a basin. Laboratory studies are ordered as seen below.\n\nSerum:\nNa+: 140 mEq/L\nCl-: 101 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 11 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.0 mg/dL\n\nRadiography is notable for a few radiopaque objects in the stomach. Urine and serum toxicology are pending. Which of the following is the most likely intoxication?", "answer": "Iron", "options": {"A": "Acetaminophen", "B": "Aspirin", "C": "Iron", "D": "Lead", "E": "Nortriptyline"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old girl presents", "emergency department", "persistent vomiting", "complaints", "abdomen", "home", "at home", "child", "healthy", "Family history", "notable", "depression", "suicide", "neuropathic pain", "diabetes", "hypertension", "cancer", "angina", "child", "now", "responsive", "confused", "temperature", "blood pressure", "100 60 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "100", "room air", "notable", "confused girl", "vomiting bloody emesis", "basin", "Laboratory studies", "ordered", "seen", "Serum", "Na", "mEq/L", "mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1 0 mg/dL", "Radiography", "notable", "radiopaque", "stomach", "Urine", "serum toxicology", "following", "intoxication"]}
{"question": "A 70-year-old woman comes to the physician because of a 4-month history of fatigue, worsening swelling of her ankles, and a 5-kg (11-lb) weight gain. Neurologic examination shows diminished two-point discrimination in her fingers. Laboratory studies show a hemoglobin A1c concentration of 9.2% and a creatinine concentration of 1.3 mg/dL. Urine dipstick shows heavy proteinuria. A biopsy specimen of this patient's kidney is most likely to show which of the following?", "answer": "Nodular glomerulosclerosis", "options": {"A": "Split glomerular basement membrane", "B": "Immune complex deposition", "C": "Interstitial inflammation", "D": "Wire looping of capillaries", "E": "Nodular glomerulosclerosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["70 year old woman", "physician", "4 month history", "fatigue", "worsening swelling", "ankles", "5 kg", "weight gain", "Neurologic examination", "diminished two point", "fingers", "Laboratory studies", "hemoglobin concentration", "creatinine concentration", "mg/dL", "Urine dipstick", "heavy proteinuria", "biopsy specimen", "patient's kidney", "to", "following"]}
{"question": "An 11-year-old male with light purple eyes presents with gradual loss of bilateral visual acuity. Over the past several years, vision has worsened from 20/20 to 20/100 in both eyes. He also has mild nystagmus when focusing on objects such as when he is trying to do his homework. He is diagnosed with a disease affecting melanin production in the iris. If both of his parents are unaffected, which of the following represents the most likely probabilities that another male or female child from this family would be affected by this disorder?", "answer": "Male: 50% Female: 0%", "options": {"A": "Same as general population", "B": "Male: 25% Female: 25%", "C": "Male: 50% Female: 50%", "D": "Male: 50% Female: 0%", "E": "Male: 100% Female: 0%"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male", "light purple eyes presents", "gradual loss of bilateral visual acuity", "past", "years", "vision", "worsened", "20/20", "20/100", "eyes", "mild nystagmus", "focusing", "to", "diagnosed", "disease affecting melanin", "iris", "following", "probabilities", "male", "female child", "affected", "disorder"]}
{"question": "A 75-year-old man comes to his primary care physician because he has been having diarrhea and difficulty breathing. The diarrhea has been intermittent with frequent watery stools that occur along with abdominal cramps. Furthermore, the skin on his face and upper chest feels hot and changes color in episodes lasting from a few minutes to hours. Finally, the patient complains of loss of appetite and says that he has unexpectedly lost 20 pounds over the last two months. Based on clinical suspicion, magnetic resonance imaging is obtained showing a small mass in this patient's lungs. Which of the following is associated with the most likely cause of this patient's symptoms?", "answer": "It also arises in the GI tract", "options": {"A": "Contains psammoma bodies", "B": "It also arises in the GI tract", "C": "Has keratin pearls and intercellular bridges", "D": "Most common lung cancer in non-smokers and females", "E": "Stains positive for vimentin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["75 year old man", "primary care physician", "diarrhea", "difficulty breathing", "diarrhea", "intermittent", "frequent watery stools", "occur", "abdominal cramps", "skin", "face", "upper chest", "hot", "changes color", "episodes lasting", "minutes", "hours", "patient", "of loss", "appetite", "lost 20 pounds", "two months", "Based", "clinical", "magnetic resonance imaging", "obtained", "small mass", "patient's lungs", "following", "associated with", "likely cause", "patient's symptoms"]}
{"question": "An 8-year-old boy is brought to the physician by his foster mother because of complaints from his teachers regarding poor performance at school for the past 8 months. He does not listen to their instructions, often talks during class, and rarely completes his school assignments. He does not sit in his seat in the classroom and often cuts in line at the cafeteria. His foster mother reports that he runs around a lot inside the house and refuses to help his sister with chores and errands. He frequently interrupts his foster mother's conversations with others and talks excessively. She has found him trying to climb on the roof on multiple occasions. He was placed in foster care because of neglect by his biological parents 3 years ago. Physical examination shows no abnormalities. Neurologic examination shows no focal findings. Mental status examination shows a neutral affect. Which of the following is the most likely diagnosis?", "answer": "Attention-deficit/hyperactivity disorder", "options": {"A": "Age-appropriate behavior", "B": "Conduct disorder", "C": "Oppositional defiant disorder", "D": "Attention-deficit/hyperactivity disorder", "E": "Hearing impairment"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "complaints", "teachers", "poor performance", "school", "past", "months", "not", "instructions", "often talks", "rarely completes", "school assignments", "not sit", "classroom", "often cuts in line", "reports", "runs", "lot", "house", "to help", "frequently interrupts", "others", "talks excessively", "found", "climb", "roof", "multiple occasions", "of neglect", "years", "Physical", "abnormalities", "Neurologic examination", "focal findings", "Mental status", "neutral", "following", "diagnosis"]}
{"question": "A 30-year-old Caucasian male is brought to the emergency room for recurrent diarrhea. He has had multiple upper respiratory infections since birth and does not take any medications at home. It is determined that Giardia lamblia is responsible for the recurrent diarrhea. The physician performs a serum analysis and finds normal levels of mature B lymphocytes. What other finding on serum analysis predisposes the patient to recurrent diarrheal infections?", "answer": "Deficiency in IgA", "options": {"A": "Deficiency in CD8+ T cells", "B": "Deficiency in neutrophils", "C": "Deficiency in IgA", "D": "Deficiency in NK cells", "E": "Deficiency in IgG"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old", "male", "brought", "emergency room", "recurrent diarrhea", "multiple upper", "birth", "not", "medications at home", "responsible", "recurrent diarrhea", "physician performs", "serum analysis", "finds normal levels", "mature B lymphocytes", "finding", "serum analysis", "patient", "recurrent infections"]}
{"question": "Paramedics are called to a 35-year-old man who had accidentally amputated his left index finger tip with a knife. He has no significant past medical history. His temperature is 37.2°C (99°F), pulse is 96/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. His left index finger is amputated distal to the distal interphalangeal joint at the level of the nail bed, and exposed bone is visible. There is profuse bleeding from the wound site. His ability to flex, extend, abduct, and adduct the joints is preserved and sensation is intact. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step prior to transporting this patient to the emergency department?", "answer": "Wrap finger tip in gauze damp with saline in a sealed plastic bag placed on ice water", "options": {"A": "Wrap finger in gauze wet with iodine in a sealed plastic bag placed on ice", "B": "Preserve finger tip in cooled saline water", "C": "Preserve finger tip in warm saline water", "D": "Wrap finger tip in gauze damp with saline in a sealed plastic bag placed on ice water", "E": "Place finger tip on ice in a sealed plastic bag"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Paramedics", "called", "35 year old man", "amputated", "left index finger tip", "knife", "significant past medical history", "temperature", "pulse", "96 min", "blood pressure", "72 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "99", "left index finger", "amputated distal", "interphalangeal joint", "level", "nail bed", "exposed bone", "visible", "bleeding", "wound", "ability", "extend", "joints", "preserved", "sensation", "intact", "abnormalities", "following", "most appropriate next step prior transporting", "patient", "emergency department"]}
{"question": "A 22-year-old medical student presents to a community health center due to an episode of loss of consciousness 3 days ago. She also has a history of multiple episodes of dizziness in the last year. These episodes almost always occur when she is observing surgery in the operating room. She describes her dizziness as a feeling of lightheadedness, warmth, excessive sweating, and palpitations. She feels that she will fall down if she stood longer and usually sits on the floor or leaves the room until the feeling subsides. Three days ago, she collapsed while observing an open cholecystectomy but regained consciousness after a few seconds. Once she regained consciousness, she was pale and sweating excessively. Her medical history is significant for migraines, but she is not on prophylactic therapy. Her younger brother has cerebral palsy, and her uncle had a sudden death at the age of 25. Her blood pressure is 120/80 mm Hg when lying down and 118/80 mm Hg when in a standing position. The rest of the physical examination is within normal limits. What is the next best step in the management of this patient?", "answer": "Electrocardiogram (ECG)", "options": {"A": "Echocardiogram", "B": "Electrocardiogram (ECG)", "C": "Electroencephalogram (EEG)", "D": "MRI of the brain", "E": "Psychiatric evaluation for anxiety"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old medical student presents", "community health center due to", "episode of loss", "consciousness 3 days", "history of multiple episodes", "dizziness", "last year", "episodes almost always occur", "observing surgery", "operating room", "dizziness", "feeling", "lightheadedness", "warmth", "excessive sweating", "palpitations", "fall", "stood longer", "usually sits", "floor", "room", "Three days", "collapsed", "observing", "open cholecystectomy", "consciousness", "seconds", "consciousness", "pale", "sweating excessively", "medical history", "significant", "migraines", "not", "prophylactic therapy", "cerebral palsy", "sudden death at", "age", "blood pressure", "80 mm Hg", "lying", "80 mm Hg", "standing position", "normal limits", "next best step", "patient"]}
{"question": "A 51-year-old Caucasian female presents to her primary care provider complaining of intermittent chest pain. She reports that over the past 6 months, she has developed burning chest pain that occurs whenever she exerts herself. The pain decreases when she rests. Her past medical history is notable for type II diabetes mellitus. Her family history is notable for multiple myocardial infarctions in her father and paternal grandmother. She currently takes aspirin and metformin. Her primary care provider starts her on a medication which is indicated given her medical history and current symptoms. However, 10 days later, she presents to the emergency room complaining of weakness and muscle pain. Her plasma creatine kinase level is 250,000 IU/L. This patient was most likely started on a medication that inhibits an enzyme that produces which of the following?", "answer": "Mevalonic acid", "options": {"A": "Farnesyl pyrophosphate", "B": "HMG-CoA", "C": "Lanosterol", "D": "Mevalonic acid", "E": "Squalene"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "female presents", "primary care provider", "of intermittent chest pain", "reports", "past 6 months", "burning chest pain", "occurs", "exerts", "pain decreases", "past medical history", "notable", "type II diabetes mellitus", "family history", "notable", "multiple myocardial infarctions", "currently", "aspirin", "metformin", "primary care provider starts", "medication", "indicated given", "medical history", "current symptoms", "10 days later", "presents", "emergency room", "weakness", "muscle pain", "plasma creatine kinase level", "IU/L", "patient", "most likely started", "medication", "inhibits", "enzyme", "following"]}
{"question": "A 26-year-old man presents to his primary care physician complaining of impotence. He reports that he has a healthy, long-term relationship with a woman whom he hopes to marry, but he is embarrassed that he is unable to have an erection. Which of the following is the next best step?", "answer": "Evaluate nocturnal tumescence", "options": {"A": "Obtain a sperm sample", "B": "Evaluate nocturnal tumescence", "C": "Duplex penile ultrasound", "D": "Prescribe sildenafil", "E": "Prescribe vardenafil"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician complaining of impotence", "reports", "healthy", "long-term relationship", "woman", "marry", "embarrassed", "unable to", "erection", "following", "next best step"]}
{"question": "A cohort study was done to assess the differential incidence of diabetes in patients consuming a typical western diet, versus those consuming a Mediterranean diet. A total of 600 subjects were included with 300 in each arm. Results are as follows:\n  Diabetes development No-diabetes development\nWestern diet 36 264\nMediterranean diet 9 291\nWhat is the odds ratio of developing diabetes for a given subject consuming the western diet as compared to a subject who consumes the Mediterranean diet?", "answer": "4.4", "options": {"A": "1.0", "B": "3.2", "C": "4.4", "D": "5.6", "E": "6.7"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["cohort study", "to", "differential incidence", "diabetes", "patients", "typical western diet", "Mediterranean diet", "total", "600 subjects", "included", "300", "arm", "Results", "follows", "Diabetes development", "diabetes development Western diet 36", "Mediterranean diet", "odds ratio", "diabetes", "given subject", "western diet", "subject", "Mediterranean diet"]}
{"question": "Researchers are investigating the effects of an Amazonian plant extract as a novel therapy for certain types of tumors. When applied to tumor cells in culture, the extract causes widespread endoplasmic reticulum stress and subsequent cell death. Further experiments show that the extract acts on an important member of a protein complex that transduces proliferation signals. When this protein alone is exposed to the plant extract, its function is not recovered by the addition of chaperones. Which type of bond is the extract most likely targeting?", "answer": "Covalent bonds between carboxyl and amino groups", "options": {"A": "Hydrogen bonds", "B": "Ionic bonds", "C": "Hydrophobic interactions", "D": "Covalent bond between two sulfide groups", "E": "Covalent bonds between carboxyl and amino groups"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["Researchers", "investigating", "effects", "plant extract", "novel therapy", "certain", "tumors", "applied", "culture", "causes widespread endoplasmic reticulum stress", "subsequent cell death", "Further", "acts", "important member", "a protein complex", "proliferation", "protein alone", "exposed", "plant extract", "function", "not recovered", "addition", "chaperones", "type", "likely targeting"]}
{"question": "A 37-year-old woman accompanied by her husband presents to the emergency department after loss of consciousness 30 minutes ago. The husband reports that she was sitting in a chair at home and began having sustained rhythmic contractions of all 4 extremities for approximately 1 minute. During transport via ambulance she appeared confused but arousable. Her husband reports she has no medical conditions, but for the past 2 months she has occasionally complained of episodes of sweating, palpitations, and anxiety. Her brother has epilepsy and her mother has type 1 diabetes mellitus. Laboratory studies obtained in the emergency department demonstrate the following:\n\nSerum:\nNa+: 136 mEq/L\nK+: 3.8 mEq/L\nCl-: 100 mEq/L\nHCO3-: 19 mEq/L\nBUN: 16 mg/dL\nCreatinine: 0.9 mg/dL\nGlucose: 54 mg/dL\nC-peptide: Low\n\nWhich of the following is the most likely diagnosis?", "answer": "Surreptitious insulin use", "options": {"A": "Alpha cell tumor", "B": "Beta cell tumor", "C": "Diabetic ketoacidosis", "D": "Surreptitious insulin use", "E": "Surreptitious sulfonylurea use"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "presents", "emergency department", "loss of consciousness 30 minutes", "reports", "sitting", "chair at home", "began", "sustained rhythmic contractions", "extremities", "approximately", "minute", "transport", "ambulance", "appeared confused", "reports", "medical conditions", "past", "months", "occasionally", "episodes", "sweating", "palpitations", "anxiety", "epilepsy", "type 1 diabetes mellitus", "Laboratory studies obtained", "emergency department", "following", "Serum", "Na", "mEq/L K", "3", "mEq/L", "100 mEq/L HCO3", "mEq/L", "mg/dL Creatinine", "0.9 mg/dL Glucose", "54 mg/dL C-peptide", "Low", "following", "diagnosis"]}
{"question": "A healthy 36-year-old Caucasian man takes part in an experimental drug trial. The drug is designed to lower glomerular filtration rate (GFR) while simultaneously raising the filtration fraction. Which of the following effects on the glomerulus would you expect the drug to have?", "answer": "Afferent arteriole constriction and efferent arteriole constriction", "options": {"A": "Afferent arteriole constriction and efferent arteriole vasodilation", "B": "Afferent arteriole constriction and efferent arteriole constriction", "C": "Afferent arteriole dilation and efferent arteriole vasodilation", "D": "Afferent arteriole dilation and efferent arteriole constriction", "E": "Increased oncotic pressure in Bowman's space"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 36 year old", "man", "part", "experimental", "drug", "to lower glomerular filtration rate", "simultaneously", "fraction", "following effects", "glomerulus", "drug to"]}
{"question": "A pathologist is investigating the cytology of cells that have been infected with a particularly virulent strain of the influenza virus. The physician suspects that the virus results in cell death after viral replication in order to expedite the spread of the virus. She recalls that there are three known biochemical mechanisms of initiating programmed cellular death: 1) transmembrane receptor-mediated interaction, 2) stimuli producing intracellular signals leading to mitochondrial-initiated events, and 3) release of cytoplasmic granules into a cell via a perforin molecule. Which of the following biochemical components plays a common role in all of these 3 processes?", "answer": "Caspase-3", "options": {"A": "FAS ligand", "B": "Caspase-3", "C": "Bax", "D": "Bcl-2", "E": "CD-95 protein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["pathologist", "investigating", "cytology", "cells", "infected", "physician", "results in cell death", "viral replication", "order to expedite", "spread", "three known biochemical mechanisms of initiating", "cellular death", "1", "transmembrane receptor mediated interaction", "2", "intracellular", "leading", "mitochondrial initiated", "3", "release", "cytoplasmic granules", "cell", "perforin", "following biochemical components plays", "common role", "processes"]}
{"question": "A 15-year-old girl is hospitalized because of increased fatigue and weight loss over the past 2 months. The patient has no personal or family history of a serious illness. She takes no medications, currently. Her blood pressure is 175/74 mm Hg on the left arm and 90/45 on the right. The radial pulse is 84/min but weaker on the right side. The femoral blood pressure and pulses show no abnormalities. Temperature is 38.1℃ (100.6℉). The muscles over the right upper arm are slightly atrophic. The remainder of the examination reveals no abnormalities. Laboratory studies show the following results:\nHemoglobin 10.4 g/dL\nLeukocyte count 5,000/mm3\nErythrocyte sedimentation rate 58 mm/h\nMagnetic resonance arteriography reveals irregularity, stenosis, and poststenotic dilation involving the proximal right subclavian artery. Prednisone is initiated with improvement of her symptoms. Which of the following is the most appropriate next step in the patient management?", "answer": "Carvedilol + hydrochlorothiazide", "options": {"A": "Carvedilol + hydrochlorothiazide", "B": "Cyclophosphamide", "C": "Plasmapheresis", "D": "Rituximab", "E": "Surgery"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "hospitalized", "increased fatigue", "weight loss", "past", "months", "patient", "personal", "family history", "serious illness", "medications", "currently", "blood pressure", "74 mm Hg", "left arm", "90", "right", "radial pulse", "84 min", "weaker", "right side", "femoral blood pressure", "pulses", "abnormalities", "Temperature", "100", "muscles", "right upper arm", "slightly atrophic", "reveals", "abnormalities", "Laboratory studies", "following results", "Hemoglobin 10.4 g/dL Leukocyte count", "mm3 Erythrocyte sedimentation rate", "h Magnetic resonance arteriography reveals irregularity", "stenosis", "dilation involving", "proximal right subclavian artery", "Prednisone", "initiated", "symptoms", "following", "most appropriate next step", "patient"]}
{"question": "A neonate appears irritable and refuses to feed. The patient is febrile and physical examination reveals a bulge at the anterior fontanelle. A CSF culture yields Gram-negative bacilli that form a metallic green sheen on eosin methylene blue (EMB) agar. The virulence factor most important to the development of infection in this patient is:", "answer": "K capsule", "options": {"A": "Exotoxin A", "B": "LPS endotoxin", "C": "Fimbrial antigen", "D": "IgA protease", "E": "K capsule"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["neonate appears irritable", "to", "patient", "febrile", "reveals", "bulge", "anterior fontanelle", "CSF culture", "form", "metallic green", "eosin methylene blue", "agar", "virulence factor most important", "development", "infection", "patient"]}
{"question": "A 16-year-old female is brought to the primary care clinic by her mother. The mother is concerned about her daughter’s grades, which have been recently slipping. Per the mother, the patient usually earns a mix of As and Bs in her classes, but this past semester she has been getting Cs and a few Ds. Her mother is also frustrated because she feels like her daughter is acting out more and “hanging out with some no-good friends.” Upon questioning the patient with her mother in the room, the patient does not say much and makes no eye contact. The mother is asked to leave the room and the patient is questioned again about any stressors. After rapport is established, the patient breaks down and tearfully admits to trying various drugs in order to “fit in with her friends.” She says that she knows the drugs “are not good for me” but has been very stressed out about telling her friends she’s not interested. Detailed questioning reveals that the patient has been using alcohol, cocaine, and marijuana 2-3 times per week. The patient becomes agitated at the end of the interview and pleads for you to not tell her mother. She says that she knows they’re illegal but is very afraid of what her parents would say. What is the best action in response to the adolescent’s request?", "answer": "Reassure the patient that there is confidentiality in this situation but encourage her to tell her mother", "options": {"A": "Apologize and say that you must inform her mother because the use of these drugs is illegal", "B": "Apologize and say that you must inform legal authorities because the use of these drugs is illegal", "C": "Apologize and say that you must inform her mother because these drugs pose a danger to her health", "D": "Agree to the patient’s request and do not inform the patient’s mother", "E": "Reassure the patient that there is confidentiality in this situation but encourage her to tell her mother"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "brought", "primary care clinic", "recently", "patient usually earns", "mix", "past semester", "getting Cs", "few", "hanging out", "good", "patient", "room", "patient", "not", "much", "makes", "to", "room", "patient", "rapport", "established", "patient breaks down", "various drugs", "order to fit", "drugs", "not good", "very stressed out", "shes not", "Detailed", "reveals", "patient", "using alcohol", "cocaine", "marijuana", "times", "week", "patient", "agitated", "end", "not", "very", "best action", "response", "adolescents"]}
{"question": "A 60-year-old woman comes to the physician because of a 2-week history of severe, retrosternal chest pain. She also has pain when swallowing solid food and medications. She has hypertension, type 2 diabetes mellitus, poorly-controlled asthma, and osteoporosis. She was recently admitted to the hospital for an acute asthma exacerbation that was treated with bronchodilators and a 7-day course of oral corticosteroids. Her current medications include aspirin, amlodipine, metformin, insulin, beclomethasone and albuterol inhalers, and alendronate. Vital signs are within normal limits. Examination of the oral pharynx appears normal. The lungs are clear to auscultation. An upper endoscopy shows a single punched-out ulcer with normal surrounding mucosa at the gastroesophageal junction. Biopsies of the ulcer are taken. Which of the following is the most appropriate next step in management?", "answer": "Discontinue alendronate", "options": {"A": "Start ganciclovir", "B": "Discontinue alendronate", "C": "Start pantoprazole", "D": "Discontinue amlodipine", "E": "Start fluconazole"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old woman", "physician", "of", "2-week history", "severe", "retrosternal chest pain", "pain", "swallowing", "medications", "hypertension", "type 2 diabetes mellitus", "poorly controlled asthma", "osteoporosis", "recently", "acute asthma exacerbation", "treated with bronchodilators", "7-day course", "oral corticosteroids", "current medications include aspirin", "amlodipine", "metformin", "insulin", "beclomethasone", "albuterol inhalers", "alendronate", "Vital signs", "normal limits", "Examination of", "oral pharynx appears normal", "lungs", "clear", "auscultation", "upper endoscopy", "single punched out ulcer", "normal surrounding mucosa", "gastroesophageal junction", "Biopsies of", "ulcer", "following", "most appropriate next step"]}
{"question": "A 36-year-old woman is admitted to the hospital because of irritability, nausea, and diarrhea. She has a history of recreational oxycodone use and last took a dose 48 hours ago. Physical examination shows mydriasis, rhinorrhea, and piloerection. A drug is administered that provides an effect similar to oxycodone but does not cause euphoria. Which of the following best explains the difference in effect?", "answer": "Lower efficacy", "options": {"A": "Lower bioavailability", "B": "Lower potency", "C": "Lower efficacy", "D": "Lower affinity", "E": "Lower tolerance"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["36 year old woman", "irritability", "nausea", "diarrhea", "history of", "oxycodone use", "last", "dose 48 hours", "mydriasis", "rhinorrhea", "piloerection", "drug", "administered", "effect similar", "oxycodone", "not cause euphoria", "following best", "difference", "effect"]}
{"question": "A 6-year-old girl is brought to a clinic with complaints of fever and sore throat for 2 days. This morning, she developed a rash on her face and neck which is progressing towards the trunk. The teachers in her school report that none of her classmates has similar symptoms. She has a normal birth history. On physical examination, the child looks healthy. The heart rate is 90/min, respiratory rate is 20/min, temperature is 39.0°C (102.2°F), and blood pressure is 90/50 mm Hg. An oropharyngeal examination reveals circumoral pallor with a red tongue, as shown in the photograph below. The chest and cardiac examinations are within normal limits. No hepatosplenomegaly is noted. What is the most likely diagnosis?", "answer": "Scarlet fever", "options": {"A": "Scarlet fever", "B": "Erythema Infectiosum", "C": "Kawasaki disease", "D": "Roseola", "E": "Measles"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "clinic", "complaints", "fever", "sore throat", "2 days", "morning", "rash on", "face", "neck", "progressing", "trunk", "teachers", "school report", "similar symptoms", "normal", "child looks healthy", "heart rate", "90 min", "respiratory rate", "20 min", "temperature", "blood pressure", "90 50 mm Hg", "oropharyngeal", "reveals circumoral pallor", "red tongue", "photograph", "chest", "normal limits", "hepatosplenomegaly", "noted", "diagnosis"]}
{"question": "A 4-day-old healthy male infant is born with normal internal and external male reproductive organs. Karyotype analysis reveals a 46XY genotype. Production of what substance by which cell type is responsible for the development of the normal male seminal vesicles, epididymides, ejaculatory ducts, and ductus deferens?", "answer": "Testosterone; Leydig cells", "options": {"A": "Testis-determining factor; Sertoli cells", "B": "Testis-determining factor; Leydig cells", "C": "Testosterone; Sertoli cells", "D": "Testosterone; Leydig cells", "E": "Mullerian inhibitory factor; Sertoli cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 day old healthy male infant", "born", "normal internal", "external male reproductive organs", "Karyotype analysis reveals", "46XY genotype", "responsible", "development", "normal male seminal vesicles", "epididymides", "ejaculatory ducts", "ductus deferens"]}
{"question": "A 51-year-old man presents to his primary care physician with 3 months of increasing fatigue. He says that he has been feeling short of breath while walking to his office from the parking lot and is no longer able to participate in recreational activities that he enjoys such as hiking. His wife also comments that he has been looking very pale even though they spend a lot of time outdoors. His past medical history is significant for acute kidney injury after losing blood during a car accident as well as alcoholic hepatitis. Physical exam reveals conjunctival pallor, and a peripheral blood smear is obtained with the finding demonstrate in figure A. Which of the following is associated with the most likely cause of this patient's symptoms?", "answer": "Increased production of platelet derived growth factor", "options": {"A": "Abnormal triglyceride handling", "B": "Increased production of platelet derived growth factor", "C": "Inhibition of metalloproteinase activity", "D": "Mutation in cytoskeletal proteins", "E": "Mutation in glycolysis pathway protein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "3 months", "increasing fatigue", "short of breath", "office", "parking lot", "longer able to", "looking very pale", "spend", "lot", "time outdoors", "past medical history", "significant", "acute kidney injury", "blood", "car accident", "alcoholic hepatitis", "reveals conjunctival pallor", "peripheral blood smear", "obtained", "finding", "following", "associated with", "likely cause", "patient's symptoms"]}
{"question": "A 47-year-old man is referred to the outpatient psychiatry clinic for depressed mood. He was diagnosed with pancreatic cancer recently. Since then, he has not been able to go to work. Over the past several weeks, he has had significant unintentional weight loss and several bouts of epigastric pain. He lost his father to cancer when he was 10 years old. After a complete history and physical examination, the patient is diagnosed with major depressive disorder, provisional. Which of the following statements regarding this patient’s psychiatric condition is true?", "answer": "This patient must have anhedonia or depressed mood.", "options": {"A": "This patient must have anhedonia or depressed mood.", "B": "This patient may have a history of elated mood.", "C": "This patient has preserved social and occupational functioning.", "D": "This patient may have pressured speech.", "E": "This patient’s symptoms must have been present for at least 1 month."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "referred", "outpatient psychiatry clinic", "depressed mood", "diagnosed", "pancreatic cancer recently", "then", "not", "able to go to", "past", "weeks", "significant unintentional weight loss", "several bouts", "epigastric pain", "lost", "cancer", "old", "complete history", "patient", "diagnosed", "major depressive disorder", "following", "patients psychiatric condition", "true"]}
{"question": "A 68-year-old man is admitted to the intensive care unit after open abdominal aortic aneurysm repair. The patient has received 4 units of packed red blood cells during the surgery. During the first 24 hours following the procedure, he has only passed 200 mL of urine. He has congestive heart failure and hypertension. Current medications include atenolol, enalapril, and spironolactone. He appears ill. His temperature is 37.1°C (98.8°F), pulse is 110/min, respirations are 18/min, and blood pressure is 110/78 mm Hg. Examination shows dry mucous membranes and flat neck veins. The remainder of the examination shows no abnormalities. Laboratory studies show a serum creatinine level of 2.0 mg/dL and a BUN of 48 mg/dL. His serum creatinine and BUN on admission were 1.2 mg/dL and 18 mg/dL, respectively. Further evaluation of this patient is most likely to reveal which of the following findings?", "answer": "Low urine sodium", "options": {"A": "Decreased urine osmolarity", "B": "Leukocyte casts", "C": "Hematuria", "D": "Low urine sodium", "E": "Proteinuria"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "open abdominal aortic aneurysm repair", "patient", "received 4 units", "packed red blood cells", "surgery", "first 24 hours following", "procedure", "only passed 200 mL", "urine", "congestive heart failure", "hypertension", "Current medications include atenolol", "enalapril", "spironolactone", "appears ill", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "dry mucous membranes", "flat neck veins", "abnormalities", "Laboratory studies", "serum creatinine level", "2.0 mg/dL", "BUN", "48 mg dL", "serum creatinine", "on admission", "1.2 mg/dL", "mg/dL", "Further", "to reveal", "following findings"]}
{"question": "A 5-year-old boy is brought to the physician by his parents because of 2 episodes of screaming in the night over the past week. The parents report that their son woke up suddenly screaming, crying, and aggressively kicking his legs around both times. The episodes lasted several minutes and were accompanied by sweating and fast breathing. The parents state that they were unable to stop the episodes and that their son simply went back to sleep when the episodes were over. The patient cannot recall any details of these incidents. He has a history of obstructive sleep apnea. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Sleep terror disorder", "options": {"A": "Insomnia disorder", "B": "Restless legs syndrome", "C": "Sleep terror disorder", "D": "Nightmare disorder", "E": "Sleepwalking disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "physician", "of", "episodes", "night", "past week", "report", "woke up", "legs", "times", "episodes lasted several minutes", "sweating", "fast breathing", "state", "unable to stop", "episodes", "back to sleep", "episodes", "over", "patient", "details", "history", "obstructive sleep apnea", "medications", "vital signs", "normal", "Physical examination", "abnormalities", "following", "diagnosis"]}
{"question": "A 17-year-old boy is brought to the pediatrician by his mother for fatigue. The patient reports that he was supposed to try out for winter track this year, but he had to quit because his “legs just give up.” He also reports increased difficulty breathing with exercise but denies chest pain or palpitations. He has no chronic medical conditions and takes no medications. He has had no surgeries in the past. The mother reports that he met all his pediatric milestones and is an “average” student. He is up-to-date on all childhood vaccinations, including a recent flu vaccine. On physical examination, there is mild lumbar lordosis. The patient’s thighs appear thin in diameter compared to his lower leg muscles, and he walks on his toes. An electrocardiogram shows 1st degree atrioventricular nodal block. Which of the following is the most likely cause of the patient’s condition?", "answer": "Abnormal dystrophin", "options": {"A": "Abnormal dystrophin", "B": "Absent dystrophin", "C": "Peripheral nerve demyelination", "D": "Sarcomere protein dysfunction", "E": "Trinucleotide repeats"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "pediatrician", "fatigue", "patient reports", "to", "out", "winter track", "year", "to", "legs", "give", "reports increased difficulty", "exercise", "chest pain", "palpitations", "chronic medical conditions", "medications", "surgeries", "past", "reports", "met", "pediatric", "average", "date", "childhood vaccinations", "including", "recent flu vaccine", "mild lumbar lordosis", "patients thighs appear thin", "diameter", "lower", "walks", "toes", "electrocardiogram", "1st degree atrioventricular nodal block", "following", "most likely cause", "patients condition"]}
{"question": "An otherwise healthy 1-month-old girl is brought to the physician because of a 1-day history of multiple episodes of bilious vomiting. She is diagnosed with intestinal malrotation and volvulus and undergoes emergency laparotomy. During surgery, a 3 x 3 cm cystic mass is excised from behind the umbilicus. Microscopic examination of the mass shows mature nonciliated columnar epithelium with some goblet cells lining the inner cyst wall. Dilation of which of the following structures is the most likely cause of this patient's mass?", "answer": "Vitelline duct", "options": {"A": "Urachus", "B": "Umbilical ring", "C": "Vitelline duct", "D": "Ovarian follicle", "E": "Common bile duct"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "month old girl", "brought", "physician", "of", "1-day history", "multiple episodes", "bilious vomiting", "diagnosed", "intestinal malrotation", "volvulus", "emergency laparotomy", "surgery", "3", "cystic mass", "umbilicus", "Microscopic examination", "mass", "mature", "lining", "inner cyst", "Dilation", "following structures", "most likely cause", "patient's mass"]}
{"question": "A 34-year-old woman comes to the emergency department because of right flank pain and vomiting for 5 hours. She has had fever and chills for the past 2 days. She attended a barbecue 3 days ago, where she ate egg salad. She underwent surgery for left ovarian torsion a year ago. Menses occur at regular 28-day intervals and last 5 days. She is sexually active with 2 male partners and uses condoms inconsistently. Her only medication is an oral contraceptive pill. She is 163 cm (5 ft 4 in) tall and weighs 72.5 kg (160 lb); BMI is 27.5 kg/m2. She appears uncomfortable. Her temperature is 38.9°C (102°F), pulse is 101/min, and blood pressure is 118/76 mm Hg. The lungs are clear to auscultation. The right lower quadrant and right flank show severe tenderness to palpation. Pelvic examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.8 g/dL\nLeukocyte count 14,200/mm3\nPlatelet count 230,000/mm3\nSerum\nNa+ 136 mEq/L\nK+ 3.8 mEq/L\nCl- 103 mEq/L\nUrea nitrogen 23 mg/dL\nCreatinine 1.2 mg/dL\nUrine\nBlood 1+\nProtein 1+\nGlucose negative\nLeukocyte esterase positive\nNitrites negative\nRBC 6–8/hpf\nWBC 80–85/hpf\nWhich of the following is the most likely diagnosis?\"", "answer": "Pyelonephritis", "options": {"A": "Ovarian torsion", "B": "Gastroenteritis", "C": "Urethritis", "D": "Pelvic inflammatory disease", "E": "Pyelonephritis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "emergency department", "right flank pain", "vomiting", "hours", "fever", "chills", "past 2 days", "attended", "days", "ate egg", "surgery", "left ovarian", "year", "Menses occur", "regular", "day intervals", "last 5 days", "sexually active", "male", "uses condoms", "only medication", "oral contraceptive pill", "5 ft 4", "tall", "72", "kg", "BMI", "27", "kg/m2", "appears", "temperature", "pulse", "min", "blood pressure", "76 mm Hg", "lungs", "clear", "auscultation", "right lower quadrant", "right flank", "severe tenderness", "palpation", "Pelvic examination", "abnormalities", "Laboratory studies", "12.8", "count", "Platelet count", "Serum", "K", "RBC", "following", "diagnosis"]}
{"question": "A 5-year-old boy is brought to the pediatrician by his mother for a recurring cough and difficult breathing. He was tentatively diagnosed with asthma last year, and the mother was advised to administer albuterol nebulizers at home when symptoms occur. The boy has only required nebulizers once every 10 days. The mother says his cough is usually accompanied by a prominent wheeze and nebulizers have not been of much help. On examination, the child appears lethargic. His trachea is slightly deviated to the right, and auscultation of the chest reveals diminished breath sounds with a unilateral wheeze on the right. Which of the following pulmonary flow-volume loops best represents this patient’s most likely condition?", "answer": "Chart C", "options": {"A": "Chart A", "B": "Chart B", "C": "Chart C", "D": "Chart D", "E": "Chart E"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "pediatrician", "recurring cough", "difficult breathing", "diagnosed", "asthma", "year", "administer albuterol nebulizers at home", "symptoms occur", "boy", "only required nebulizers", "10 days", "cough", "usually", "prominent wheeze", "nebulizers", "not", "much help", "child appears lethargic", "trachea", "slightly deviated", "right", "auscultation", "chest reveals diminished breath sounds", "unilateral wheeze", "right", "following pulmonary flow-volume loops best", "patients", "likely condition"]}
{"question": "A 74-year-old African-American woman is brought to the emergency department by her home health aid. The patient was eating breakfast this morning when she suddenly was unable to lift her spoon with her right hand. She attempted to get up from the table, but her right leg felt weak. One hour later in the emergency department, her strength is 0/5 in the right upper and right lower extremities. Strength is normal in her left upper and lower extremities. Sensation is normal bilaterally. An emergency CT of the head does not show signs of hemorrhage. Subsequent brain MRI shows an infarct involving the internal capsule. Which of the following is true about her disease process?", "answer": "The most important risk factors are hypertension and diabetes", "options": {"A": "The most important risk factors are hypertension and diabetes", "B": "The most common cause is embolism originating from the left atrium", "C": "It is caused by ischemia to watershed areas", "D": "IV thrombolysis cannot be used", "E": "The most important risk factors are ethnicity and sex"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["74 year old", "woman", "brought", "emergency department", "patient", "eating breakfast", "morning", "unable to lift", "spoon", "right hand", "to get", "table", "right leg", "weak", "One hour later", "emergency department", "strength", "0/5", "right upper", "right lower extremities", "Strength", "normal", "left upper", "lower extremities", "Sensation", "normal", "emergency CT of", "head", "not", "signs of hemorrhage", "Subsequent brain MRI", "infarct involving", "internal capsule", "following", "true", "disease process"]}
{"question": "A 60-year-old male presents to your office for follow-up after an upper gastrointestinal (GI) endoscopy revealed the presence of esophageal varices. His medical history is significant for cirrhosis caused by heavy alcohol abuse for the past 20 years. He was instructed to follow-up with his primary care physician for management of his condition. Which of the following is the most appropriate next step for prevention of future variceal bleeding?", "answer": "Nadolol", "options": {"A": "Careful observation", "B": "Octreotide", "C": "Nadolol", "D": "Isosorbide mononitrate", "E": "Transjugular intrahepatic portosystemic shunt"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old male presents", "office", "follow-up", "upper gastrointestinal", "endoscopy revealed", "presence", "esophageal varices", "medical history", "significant", "cirrhosis caused", "heavy alcohol abuse", "past 20 years", "to follow-up", "primary", "management", "condition", "following", "most appropriate next step", "prevention", "future variceal bleeding"]}
{"question": "A 3-year-old boy is taken to the ER by his parents due to his elevated temperature. He has had a fever (>101.1 deg F) for a little over a week, and over that time, his parents noticed his eyes had gotten a little pink, and his palms and soles were red and swollen. His lips and tongue are also peeling. His parents note he has not taken any new medications, and they did not notice any runny nose, sore throat, cough, or changes in his bowel or bladder habits. In the ER, his vitals are as follows: temperature is 101.3 deg F (38.5 deg C), blood pressure is 90/60 mmHg, pulse is 125/min, and respirations are 20/min. His exam is notable for bilateral injected conjunctivae, right-sided cervical lymphadenopathy, erythematous and edematous palms and soles, and erythema multiforme-like rash over his trunk. Appropriate lab tests and imaging were performed. Which of the following is the most worrisome complication of this boy's disease process?", "answer": "Coronary artery aneurysms", "options": {"A": "Digital gangrene", "B": "Coronary artery aneurysms", "C": "Glomerulonephritis", "D": "Endocardial valve damage", "E": "Toxic endodermal necrolysis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 year old boy", "ER", "due to", "elevated temperature", "fever", "deg", "week", "over", "time", "eyes", "gotten", "little pink", "soles", "red", "swollen", "lips", "tongue", "peeling", "note", "not", "new medications", "not", "runny nose", "sore throat", "cough", "changes", "bowel", "bladder", "ER", "follows", "temperature", "deg F", "blood pressure", "90 60 mmHg", "pulse", "min", "respirations", "20 min", "exam", "notable", "bilateral injected conjunctivae", "right-sided cervical lymphadenopathy", "erythematous", "edematous", "soles", "erythema multiforme", "rash", "trunk", "Appropriate lab tests", "imaging", "performed", "following", "most", "complication of", "boy's disease process"]}
{"question": "A 22-year-old woman seeks evaluation at a local walk-in clinic for severe lower abdominal pain, vaginal discharge, and painful intercourse for the last couple of weeks. Her last day of menstruation was 1 week ago, and since then the pain has worsened. She is an out-of-town college student engaged in an open relationship with a fellow classmate and another partner from her hometown. Additional concerns include painful micturition and a low-grade fever for the same duration. The physical examination reveals a heart rate of 120/min, respiratory rate of 24/min, and temperature of 38.6°C (101.5°F). The pelvic examination shows an erythematous cervix with a mucopurulent exudate. The cervix bleeds when manipulated with a swab and is extremely tender with movement. Based on the clinical findings, which of the following agents is the most likely cause of her condition?", "answer": "Neisseria gonorrhoeae", "options": {"A": "Neisseria gonorrhoeae", "B": "Mycobacterium tuberculosis", "C": "Mycoplasma genitalium", "D": "Streptococcus agalactiae", "E": "Chlamydia trachomatis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "local walk-in clinic", "severe lower abdominal pain", "vaginal discharge", "painful intercourse", "couple", "weeks", "last day", "menstruation", "1 week", "since then", "pain", "worsened", "out", "town", "engaged", "open relationship", "Additional concerns include painful micturition", "low-grade fever", "same duration", "reveals", "heart rate", "min", "respiratory rate", "min", "temperature", "pelvic examination", "erythematous cervix", "mucopurulent exudate", "cervix bleeds", "manipulated", "swab", "extremely tender", "movement", "Based", "clinical findings", "following agents", "most likely cause", "condition"]}
{"question": "A 35-year-old man comes to the physician because of a rash on the thigh for 10 days. He reports that the rash has been enlarging and is intensely itchy. Two weeks ago, he adopted a stray dog from an animal shelter. Vital signs are within normal limits. A photograph of the examination findings is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Dermatophyte infection", "options": {"A": "Psoriasis", "B": "Erythrasma", "C": "Pityriasis rosea", "D": "Dermatophyte infection", "E": "Tinea versicolor"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old man", "physician", "of", "rash", "thigh", "10 days", "reports", "rash", "enlarging", "itchy", "Two weeks", "adopted", "shelter", "Vital signs", "normal limits", "photograph", "examination findings", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 50-year-old man with hypertension comes to the physician for a routine follow-up evaluation. His blood pressure is 146/98 mm Hg. The physician wishes to prescribe lisinopril. The patient says that his blood pressure is high when he is “anxious” and requests alprazolam instead of lisinopril. Which of the following is the most appropriate initial response by the physician?", "answer": "“What have you heard about the use of alprazolam to treat high blood pressure?”", "options": {"A": "“I would recommend fluoxetine because alprazolam can cause dependence.”", "B": "“I would recommend consultation with a psychiatrist.”", "C": "“Anxiety can cause temporary spikes in blood pressure, but it does not cause a long-term increase in blood pressure.”", "D": "“What have you heard about the use of alprazolam to treat high blood pressure?”", "E": "“Lisinopril is more effective to treat hypertension. If you do not control your high blood pressure, you may develop a stroke.”"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old man", "hypertension", "physician", "routine follow-up", "blood pressure", "98 mm Hg", "physician wishes to", "lisinopril", "patient", "blood pressure", "high", "anxious", "alprazolam", "lisinopril", "following", "most appropriate initial response", "physician"]}
{"question": "A 78-year-old right-handed male is brought in by ambulance after being found down in his home. After being aroused, the patient has difficulty answering questions and appears to be frustrated by his inability to communicate. He is able to speak his name and a few other words but his speech is not fluent. Subsequent neurologic exam finds that the patient is able to comprehend both one and two step instructions; however, he is unable to repeat phrases despite being able to understand them. He also has difficulty writing despite retaining fine motor control. CT reveals an acute stroke to his left hemisphere. Damage to which of the following sets of structures would be most likely to result in this pattern of deficits?", "answer": "Inferior frontal gyrus", "options": {"A": "Inferior frontal gyrus", "B": "Superior temporal gyrus", "C": "Arcuate fasciculus", "D": "Watershed zone", "E": "Precentral gyrus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old right-handed male", "brought", "ambulance", "found", "home", "patient", "difficulty answering questions", "appears to", "communicate", "able to speak", "name", "few", "speech", "not fluent", "Subsequent neurologic exam finds", "patient", "able to", "one", "two step instructions", "unable to repeat", "able to", "difficulty writing", "retaining fine motor control", "CT reveals", "acute stroke", "left hemisphere", "Damage", "following sets", "structures", "to result", "pattern", "deficits"]}
{"question": "A 66-year-old man presents to the emergency department for a 1-hour history of right arm weakness. He was having breakfast this morning when his right arm suddenly became weak, causing him to drop his coffee mug. He also noticed that he was slurring his speech and had some additional weakness in his right leg. He had no symptoms prior to the onset of the weakness and noted no other unusual phenomena. These symptoms lasted for about 30 minutes, but they resolved completely by the time he arrived at the emergency department. His medical history is notable for hypertension and hyperlipidemia, but he does not receive close follow-up from a primary care physician for these conditions. The patient currently is not taking any medications. His pulse is 75/min, the blood pressure is 160/95 mm Hg, and the respiratory rate is 14/min. Physical exam is remarkable for a high-pitched sound heard on auscultation of the neck, the remainder of the exam, including a complete neurological exam, is entirely unremarkable. CT angiography of the head and neck shows no active hemorrhage and 80% stenosis of the left internal carotid artery. Which of the following is the next best step in the long-term management of this patient?", "answer": "Carotid endarterectomy", "options": {"A": "Carotid endarterectomy", "B": "Administration of tissue plasminogen activator (tPA)", "C": "Brain MRI", "D": "Initiation of aspirin and atorvastatinInitiation of aspirin and atorvastatin", "E": "Initiation of lisinopril"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["66 year old man presents", "emergency department", "hour history of right arm weakness", "breakfast", "morning", "right arm", "weak", "causing", "to drop", "mug", "slurring", "speech", "additional weakness", "right", "symptoms prior to", "onset", "weakness", "noted", "unusual", "symptoms lasted", "30 minutes", "resolved completely", "time", "emergency department", "medical history", "notable", "hypertension", "hyperlipidemia", "not receive close follow-up", "primary care physician", "conditions", "patient currently", "not", "medications", "pulse", "75 min", "blood pressure", "95 mm Hg", "respiratory rate", "min", "high-pitched sound heard", "auscultation", "neck", "exam", "including", "complete neurological exam", "unremarkable", "CT angiography of", "head and neck", "active hemorrhage", "80", "stenosis", "left", "following", "next best step", "long-term", "patient"]}
{"question": "A 62-year-old woman is seen in the hospital for neutropenic fever. She was admitted 1 week ago for newly diagnosed acute myeloid leukemia. Due to her chemotherapy, she became pancytopenic. Last night, during a packed red blood cell transfusion, she became febrile to 102.6°F (39.3°C), her blood pressure was 92/55, pulse was 112/min, respirations were 16/min, and oxygen saturation was 94% on room air. The transfusion was stopped, intravenous fluids were started, and blood cultures were drawn. The patient also complained of chest pain and shortness of breath. A chest radiograph was obtained and was normal. This morning, she reports “dark urine” but denies dysuria or abnormal vaginal discharge. Her prophylactic antimicrobials started at the time of her chemotherapy include acyclovir, levofloxacin, and fluconazole. The patient’s temperature this morning is 98.7°F (37.1°C), blood pressure is 110/72 mmHg, pulse is 88/min, and respirations are 17/min with an oxygen saturation of 95% on room air. On physical examination, she has 1+ pitting peripheral edema of bilateral lower extremities to the mid-shin. Her jugular venous pressure is 6 cm. Her labs show neutropenia, normocytic anemia, thrombocytopenia, elevated lactose dehydrogenase, elevated total bilirubin, and decreased haptoglobin. Coagulation studies show an increase in bleeding time with normal D-dimer levels. Which of the following is the most likely cause of the patient’s symptoms?", "answer": "ABO incompatibility", "options": {"A": "ABO incompatibility", "B": "Disseminated intravascular coagulation", "C": "Severe urosepsis", "D": "Transfusion associated circulatory overload", "E": "Transfusion related acute lung injury"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old woman", "seen", "hospital", "neutropenic fever", "1 week", "diagnosed acute myeloid leukemia", "chemotherapy", "pancytopenic", "night", "packed red blood cell transfusion", "febrile", "blood pressure", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "transfusion", "stopped", "started", "blood cultures", "patient", "of chest pain", "shortness of breath", "chest radiograph", "obtained", "normal", "morning", "reports dark urine", "dysuria", "abnormal vaginal discharge", "prophylactic antimicrobials started", "time", "chemotherapy include acyclovir", "levofloxacin", "fluconazole", "patients temperature", "morning", "98", "blood pressure", "72 mmHg", "pulse", "88 min", "respirations", "min", "95", "room air", "has 1", "pitting peripheral edema of bilateral lower extremities", "shin", "jugular venous pressure", "labs", "neutropenia", "normocytic anemia", "thrombocytopenia", "elevated lactose dehydrogenase", "elevated total bilirubin", "decreased haptoglobin", "Coagulation studies", "increase", "bleeding time", "normal", "levels", "following", "most likely cause", "patients symptoms"]}
{"question": "A 3-year-old African-American boy presents with a rapid onset of severe abdominal pain. He has a palpably enlarged mass in the left upper quadrant of his abdomen. Complete blood count is notable for a hemoglobin of 7.2 g/dL. Serum haptoglobin level returns normal. Serum unconjugated bilirubin is elevated. The corrected reticulocyte count is elevated. Which of the following is the most likely explanation for the findings above?", "answer": "Extravascular hemolysis", "options": {"A": "Aplastic crisis", "B": "Acute chest syndrome", "C": "Renal infarction", "D": "Intravascular hemolysis", "E": "Extravascular hemolysis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["3 year old", "boy presents", "rapid onset", "severe abdominal", "enlarged mass", "left upper quadrant of", "abdomen", "Complete blood count", "notable", "a hemoglobin", "7.2 g/dL", "Serum haptoglobin level returns normal", "unconjugated", "elevated", "corrected reticulocyte count", "elevated", "following", "findings above"]}
{"question": "A 62-year-old man comes to the physician because of a persistent cough for the past 2 weeks. During this time, he has also had occasional discomfort in his chest. Three weeks ago, he had a sore throat, headache, and a low-grade fever, which were treated with acetaminophen and rest. He has a history of hypertension and hyperlipidemia. His father died of myocardial infarction at the age of 57 years. He has smoked a pack of cigarettes daily for the past 40 years. Current medications include enalapril and atorvastatin. His temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 145/90 mm Hg. Physical examination shows no abnormalities. An x-ray of the chest is shown. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the chest", "options": {"A": "Esophageal manometry", "B": "CT scan of the chest", "C": "Arteriography", "D": "Genetic testing", "E": "Endovascular repair"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["62 year old man", "physician", "of", "persistent cough", "past 2 weeks", "time", "occasional discomfort in", "chest", "Three weeks", "sore throat", "headache", "low-grade fever", "treated with acetaminophen", "history of hypertension", "hyperlipidemia", "died", "myocardial infarction", "age", "57 years", "smoked", "pack", "cigarettes daily", "past 40 years", "Current include enalapril", "atorvastatin", "temperature", "98", "pulse", "70 min", "blood pressure", "90 mm Hg", "abnormalities", "x-ray of", "chest", "following", "most appropriate next step"]}
{"question": "A 31-year-old male with cirrhosis, dementia, and Parkinson-like symptoms is diagnosed with a hereditary metabolic disease resulting from the accumulation of a certain metal in various tissues. Impairment of which of the following elimination pathways is most likely responsible?", "answer": "Secretion into bile", "options": {"A": "Secretion into bile", "B": "Loop of Henle secretion into lumen of kidney", "C": "Glomerular filtration", "D": "Bleeding", "E": "Duodenal secretion"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old male", "cirrhosis", "dementia", "symptoms", "diagnosed", "hereditary metabolic resulting", "accumulation", "certain", "various tissues", "Impairment", "following elimination", "responsible"]}
{"question": "An x-ray of the chest shows an extensive consolidation within the right lower lobe consistent with lobar pneumonia. Sputum and blood cultures are sent to the laboratory for analysis, and empiric antibiotic treatment with intravenous cefotaxime is begun. Which of the following is most likely to have prevented this patient's pneumonia?", "answer": "Incentive spirometry", "options": {"A": "Incentive spirometry", "B": "Rapid sequence induction", "C": "Prolonged bed rest", "D": "Perioperative antibiotic prophylaxis", "E": "Smoking cessation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["x-ray of", "chest", "extensive consolidation", "right lower lobe", "lobar pneumonia", "Sputum", "blood cultures", "sent", "laboratory", "analysis", "empiric antibiotic treatment", "intravenous cefotaxime", "begun", "following", "to", "prevented", "patient's pneumonia"]}
{"question": "A 58-year-old man with history of diabetes and hypertension suffers a cardiac arrest at home. The family calls 911, yet no one performs CPR. Five minutes after the arrest, EMS arrives to begin resuscitation. At this point, which region of the CNS is most likely to suffer ischemic damage?", "answer": "Hippocampus", "options": {"A": "Thalamus", "B": "Spinal cord", "C": "Pons", "D": "Medulla", "E": "Hippocampus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old man", "history", "diabetes", "hypertension suffers", "cardiac arrest at home", "calls", "performs CPR", "Five minutes", "arrest", "to begin resuscitation", "point", "region", "CNS", "to suffer ischemic damage"]}
{"question": "A 77-year-old man with type 2 diabetes mellitus is admitted to the hospital because of chest pain and dyspnea. Serum troponin levels are elevated and an ECG shows ST-segment depressions in the lateral leads. Percutaneous coronary angiography is performed and occlusion of the distal left anterior descending coronary artery is identified. Pharmacotherapy with eptifibatide is initiated and a drug-eluting stent is placed in the left anterior descending coronary artery. The mechanism by which eptifibatide acts is similar to the underlying pathophysiology of which of the following conditions?", "answer": "Glanzmann thrombasthenia", "options": {"A": "Von Willebrand disease", "B": "Vitamin K deficiency", "C": "Protein C deficiency", "D": "Thrombotic thrombocytopenic purpura", "E": "Glanzmann thrombasthenia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "type 2 diabetes mellitus", "chest pain", "dyspnea", "Serum troponin levels", "elevated", "ECG", "ST-segment depressions", "lateral leads", "Percutaneous coronary angiography", "performed", "occlusion", "distal left anterior descending coronary artery", "identified", "Pharmacotherapy", "eptifibatide", "initiated", "drug-eluting stent", "left anterior descending coronary artery", "mechanism", "eptifibatide acts", "similar", "underlying pathophysiology", "following conditions"]}
{"question": "A 66-year-old man comes to the physician for a follow-up examination after a below-knee amputation of the right lower leg. Three weeks ago, he had an acute arterial embolism that could not be revascularized in time to save the leg. He now reports episodic hot, shooting, and tingling pain in the right lower leg that began shortly after the amputation. He has type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 30 years. His current medications are metformin and prophylactic subcutaneous heparin. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 135/88 mm Hg. Physical examination shows a slightly erythematous stump with clean sutures. The skin overlying the stump is warm and well-perfused. Muscle strength and sensation are normal throughout the remaining extremity and the left lower extremity. Which of the following is the most likely diagnosis?", "answer": "Phantom limb pain", "options": {"A": "Phantom limb pain", "B": "Foreign body reaction", "C": "Reinfarction", "D": "Diabetic neuropathy", "E": "Osteomyelitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old man", "physician", "follow-up examination", "below-knee amputation", "right lower leg", "Three weeks", "acute arterial embolism", "not", "time", "leg", "now reports episodic hot", "shooting", "tingling pain in", "right lower leg", "began", "amputation", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "past 30 years", "current medications", "metformin", "prophylactic subcutaneous heparin", "temperature", "98", "pulse", "min", "blood pressure", "88 mm Hg", "slightly erythematous stump", "sutures", "skin", "stump", "warm", "well perfused", "Muscle strength", "sensation", "normal", "remaining extremity", "left lower extremity", "following", "diagnosis"]}
{"question": "Four days after undergoing liver transplantation, a 47-year-old man develops fever, chills, malaise, and confusion while in the intensive care unit. His temperature is 39.1°C (102.4°F). Blood cultures grow an organism. Microscopic examination of this organism after incubation at 25°C (77°F) for 3 hours is shown. Which of the following is the most likely causal organism of this patient's symptoms?", "answer": "Candida albicans", "options": {"A": "Aspergillus fumigatus", "B": "Candida albicans", "C": "Cryptococcus neoformans", "D": "Histoplasma capsulatum", "E": "Malassezia furfur"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Four days", "liver transplantation", "year old man", "fever", "chills", "malaise", "confusion", "intensive care unit", "temperature", "Blood cultures", "Microscopic examination", "3 hours", "following", "causal", "patient's symptoms"]}
{"question": "An 18-year-old man presents to his primary care provider for a routine checkup. He feels well and has no complaints. He is the captain of his high school football team and will be attending college on a football scholarship the following year. His past medical history is unremarkable. He underwent a laparoscopic appendectomy at age 13. He takes no medications and has no allergies. His temperature is 99.1°F (37.3°C), blood pressure is 155/85 mmHg, pulse is 96/min, and respirations are 16/min. On examination, he has severe nodulocystic acne. He has gained 15 pounds and 1/2 inch in height since his last visit one year ago. Mild gynecomastia and testicular shrinkage are noted. This patient is at the greatest risk of developing which of the following?", "answer": "Hepatic adenoma", "options": {"A": "Hepatic adenoma", "B": "Hepatocellular carcinoma", "C": "Renal cyst", "D": "Testicular enlargement", "E": "Type 1 diabetes mellitus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "routine checkup", "well", "complaints", "high school football", "attending college", "football", "following year", "past medical history", "unremarkable", "laparoscopic appendectomy", "age", "medications", "allergies", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "96 min", "respirations", "min", "severe nodulocystic acne", "gained", "pounds", "1/2 inch", "height", "last", "one year ago", "Mild gynecomastia", "testicular shrinkage", "noted", "patient", "greatest", "following"]}
{"question": "A 72-year-old man with a 4-year history of Parkinson disease comes to the physician for evaluation of his medication. Since his last visit one year ago, he has had increased tremor and bradykinesia up to an hour before his next scheduled dose and sometimes feels like he does not respond to some doses at all. One week ago, he was entirely unable to move for about a minute when he wanted to exit an elevator. The physician prescribes a drug that increases the bioavailability of levodopa by preferentially preventing its peripheral methylation. This patient was most likely prescribed which of the following drugs by the physician?", "answer": "Entacapone", "options": {"A": "Carbidopa", "B": "Entacapone", "C": "Ropinirole", "D": "Amantadine", "E": "Rasagiline"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old man", "history of", "disease", "physician", "last", "one year ago", "increased tremor", "bradykinesia", "hour", "next scheduled dose", "sometimes", "not", "doses", "One week", "unable to move", "minute", "wanted to exit", "elevator", "physician", "drug", "increases", "bioavailability", "levodopa", "preventing", "peripheral", "patient", "most likely", "following drugs", "physician"]}
{"question": "A 31-year-old woman has a follow-up visit with her psychiatrist. She was recently diagnosed with major depressive disorder and was started on citalopram 3 months ago. Her dosage was increased one time 6 weeks ago. She has come in to discuss her progress and notes that she feels “normal again” and “happier” and has not experienced her usual feelings of depression, crying spells, or insomnia. Her appetite has also improved and she is performing better at work, stating that she has more focus and motivation to complete her assignments. During the beginning of her treatment, she states that she had occasional headaches and diarrhea, but that she no longer has those side effects. Which of the following is the most appropriate next step in this patient’s management?", "answer": "Maintain the current dose of citalopram for several months", "options": {"A": "Lower the dose of citalopram", "B": "Maintain the current dose of citalopram for several months", "C": "Increase the dose of citalopram", "D": "Discontinue the citalopram", "E": "Discontinue the citalopram and switch to amitriptyline"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["31 year old woman", "psychiatrist", "recently diagnosed", "major depressive disorder", "started", "citalopram", "months", "dosage", "increased", "weeks", "progress", "notes", "normal", "not", "usual feelings", "depression", "spells", "insomnia", "appetite", "improved", "performing better", "stating", "more focus", "to complete", "assignments", "beginning", "treatment", "states", "occasional headaches", "diarrhea", "longer", "side effects", "following", "most appropriate next step", "patients"]}
{"question": "A 43-year-old construction worker presents to the emergency department two hours after sustaining a deep laceration to his left forearm by a piece of soiled and rusted sheet metal. His vital signs are stable, there is no active bleeding, his pain is well controlled, and a hand surgeon has been notified about damage to his forearm tendons. He does not recall receiving any vaccinations in the last 30 years and does not know if he was vaccinated as a child. What is the appropriate post-exposure prophylaxis?", "answer": "Tetanus vaccine + immunoglobulin", "options": {"A": "IV metronidazole only", "B": "Anthrax vaccine", "C": "Tetanus vaccine booster only", "D": "Tetanus immunglobulin only", "E": "Tetanus vaccine + immunoglobulin"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old construction worker presents", "emergency department two hours", "sustaining", "deep laceration", "left forearm", "piece", "rusted", "vital signs", "stable", "active bleeding", "pain", "well controlled", "hand surgeon", "damage", "forearm tendons", "not", "receiving", "vaccinations", "30 years", "not", "vaccinated", "child", "appropriate post-exposure prophylaxis"]}
{"question": "A 53-year-old woman presents with a feeling of pelvic pressure which worsens with prolonged standing, pain on sexual intercourse, and lower back pain. She reports no urinary or fecal incontinence. She is G3P3 with no history of any gynecological disease and is premenopausal. All pregnancies were without complication and resolved with full-term vaginal deliveries. The patient has sex with her husband who is her single sexual partner and uses oral contraceptives. Her vital signs are within normal limits and physical examination is unremarkable. A gynecological examination reveals bulging of the posterior vaginal wall in the lower portion of the vagina which increases in the upright position and Valsalva maneuver. The cervix is in its normal position. The uterus is not enlarged, ovaries are nonpalpable. Damage to which of the following structures might contribute to the patient’s condition?", "answer": "Rectovaginal fascia", "options": {"A": "Rectovaginal fascia", "B": "Cardinal ligaments", "C": "Round ligaments", "D": "Pubocervical fascia", "E": "Uterosacral ligaments"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "pelvic pressure", "worsens", "prolonged standing", "pain on sexual intercourse", "lower back pain", "reports", "urinary", "fecal incontinence", "history of", "gynecological disease", "premenopausal", "pregnancies", "complication", "resolved", "full-term vaginal deliveries", "patient", "sex", "single", "uses oral contraceptives", "vital signs", "normal limits", "unremarkable", "reveals bulging of", "posterior vaginal wall", "lower portion", "vagina", "increases", "upright position", "Valsalva maneuver", "cervix", "normal position", "uterus", "not enlarged", "ovaries", "nonpalpable", "Damage", "following structures", "patients condition"]}
{"question": "A 64-year-old woman presents to the emergency department with a 1-hour history of shortness of breath and chest pain. She said that the symptoms came on suddenly and that the chest pain is worse when she tries to take a deep breath. Her past medical history is significant for a previous deep venous thrombosis for which she was taking a blood thinner. She also has diabetes, hypertension, hyperlipidemia, and partial seizures which are treated with metformin, lisinopril, atorvastatin, and carbamazepine and valproic acid, respectively. Which of these drugs is most likely responsible for causing this patient's blood thinner medications to fail?", "answer": "Carbamazepine", "options": {"A": "Atorvastatin", "B": "Carbamazepine", "C": "Lisinopril", "D": "Metformin", "E": "Valproic acid"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["64 year old woman presents", "emergency department", "hour history of shortness", "breath", "chest pain", "symptoms", "chest pain", "worse", "to", "deep breath", "past medical history", "significant", "previous deep venous thrombosis", "blood thinner", "diabetes", "hypertension", "hyperlipidemia", "partial seizures", "treated with metformin", "lisinopril", "atorvastatin", "carbamazepine", "valproic acid", "drugs", "responsible", "causing", "patient's blood thinner medications to fail"]}
{"question": "5 days after receiving chemotherapy for ovarian cancer, a 74-year-old woman comes to the physician for a follow-up examination. She feels well and has no complaints. Her leukocyte count is 3,500/mm3 (11% neutrophils and 89% lymphocytes). This patient's profound granulocytopenia is most likely to predispose her to infection with which of the following organisms?", "answer": "Enterococcus faecalis", "options": {"A": "Enterococcus faecalis", "B": "Gardnerella vaginalis", "C": "Giardia lamblia", "D": "Cytomegalovirus infection", "E": "Pneumocystis jirovecii"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 days", "receiving chemotherapy", "ovarian cancer", "74 year old woman", "physician", "follow-up examination", "well", "complaints", "leukocyte count", "3 500 mm3", "lymphocytes", "patient's profound granulocytopenia", "to", "infection", "following"]}
{"question": "A 60-year-old man presents to your office because he noticed a \"weird patch\" on the floor of his mouth. He states that he noticed it a few months ago, but did not report it because it did not hurt. However, he is concerned because it has not regressed and seems to have changed in shape. On examination, you notice the patient has poor dentition and he admits to using chewing tobacco daily. The patch on the floor of his mouth is red with irregular borders. Which of the following would be an appropriate way to counsel this patient on his current condition?", "answer": "This lesion necessitates biopsy.", "options": {"A": "This lesion is due to an infection.", "B": "This lesion is closely associated with chronic Hepatitis C infection.", "C": "This lesion necessitates biopsy.", "D": "This lesion carries no increased risk of cancer.", "E": "Tobacco use is not a risk factor."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man presents", "office", "patch", "the floor of", "mouth", "states", "few months", "not report", "not", "not regressed", "to", "changed in shape", "patient", "poor dentition", "to using", "daily", "The patch", "floor of", "mouth", "red", "irregular borders", "following", "appropriate", "to counsel", "patient", "current condition"]}
{"question": "A 58-year-old woman comes to the physician for evaluation of worsening fatigue for 1 week. She also has a 1-year history of hand pain and stiffness. Four months ago, she started a new medication for these symptoms. Medications used prior to that included ibuprofen, prednisone, and hydroxychloroquine. Examination shows a subcutaneous nodule on her left elbow and old joint destruction with Boutonniere deformity. Her hemoglobin concentration is 10.1 g/dL, leukocyte count is 3400/mm3, and platelet count is 101,000/mm3. Methylmalonic acid levels are normal. Which of the following could have prevented this patient's laboratory abnormalities?", "answer": "Leucovorin", "options": {"A": "Vitamin B6", "B": "Vitamin B12", "C": "Amifostine", "D": "2-Mercaptoethanesulfonate", "E": "Leucovorin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old woman", "physician", "worsening fatigue", "1 week", "year history", "hand pain", "stiffness", "Four months", "started", "new medication", "symptoms", "Medications used prior to", "included ibuprofen", "prednisone", "hydroxychloroquine", "subcutaneous nodule", "left elbow", "old joint destruction", "Boutonniere deformity", "hemoglobin concentration", "10", "g/dL", "leukocyte count", "3400 mm3", "platelet count", "mm3", "Methylmalonic acid levels", "normal", "following", "prevented", "patient's laboratory abnormalities"]}
{"question": "A 32-year-old previously healthy female presents to her primary care physician with double vision. She first noted the double vision yesterday and saw no improvement this morning. She does not think it is worsening. She has not had any changes in her normal routine though she recalls one episode of right arm weakness 2 months ago. She did not seek treatment and the weakness subsided after several days. She does not have a history of head trauma. She denies headache, fever, chills, nausea, vomiting, paresthesias, extremity pain, or weakness. On exam she has right adduction palsy on leftward gaze. She has no focal weakness. Which of the following additional physical exam findings is associated with the lesion responsible for her ocular findings?", "answer": "Horizontal nystagmus in the left eye on leftward gaze", "options": {"A": "Horizontal nystagmus in the left eye on leftward gaze", "B": "Ptosis on the right", "C": "Proptosis of the right eye", "D": "Left abduction palsy on leftward gaze", "E": "Afferent pupillary defect in the left eye"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "healthy female presents", "primary care physician", "double vision", "first noted", "double vision", "saw", "morning", "not", "worsening", "not", "changes", "normal routine", "one episode of right arm weakness", "months", "not", "treatment", "weakness", "days", "not", "history", "head trauma", "headache", "fever", "chills", "nausea", "vomiting", "paresthesias", "extremity pain", "weakness", "exam", "right adduction palsy", "gaze", "focal weakness", "following additional physical exam findings", "associated with", "lesion responsible", "ocular findings"]}
{"question": "A team of researchers is investigating different mechanisms of transmitting sensory information in the body. They are particularly interested in the different types of sensory receptors. From a sample of tissue, they isolate a receptor that is encased in deep skin layers and joints. The receptor adapts quickly and they discover its role is to sense vibration and pressure. Which of the following types of nerve fibers is most likely used by this receptor to transmit sensory information?", "answer": "Large, myelinated fibers", "options": {"A": "Small, unmyelinated fibers", "B": "Small, myelinated fibers", "C": "Large, unmyelinated fibers", "D": "Large, myelinated fibers", "E": "Dendritic endings"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["researchers", "investigating different mechanisms", "transmitting sensory information", "body", "different", "receptors", "sample", "tissue", "isolate", "receptor", "encased", "deep skin layers", "joints", "receptor adapts", "role", "to sense vibration", "pressure", "following types", "nerve fibers", "most likely used by", "receptor to transmit sensory"]}
{"question": "A 28-year-old African American woman comes to the emergency department with intermittent and progressively worsening dizziness with near-fainting incidents for the last 3 weeks. She denies fever, weight loss, nausea, vomiting, or chest pain. Her medical history is significant for a chronic cough and intermittent skin rashes that spontaneously resolved after a few weeks. She does not smoke tobacco but drinks alcohol socially. The patient lives alone with no pets. Her temperature is 37°C (98.6°F), blood pressure is 122/80 mm Hg, pulse is 43/min, and respirations are 12/min. On physical examination, cervical lymphadenopathy is noted. No heart murmurs are heard. ECG shows sinus rhythm with 2:1 atrioventricular block and left bundle branch block. Chest X-ray shows prominent hilar lymphadenopathy. Which of the following is the most likely diagnosis?", "answer": "Sarcoidosis", "options": {"A": "Carotid artery stenosis", "B": "Cardiac myxoma", "C": "Non-Hodgkin’s lymphoma", "D": "Small cell lung cancer", "E": "Sarcoidosis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "woman", "emergency department", "intermittent", "worsening dizziness", "fainting", "last", "weeks", "fever", "weight loss", "nausea", "vomiting", "chest pain", "medical history", "significant", "chronic cough", "intermittent skin rashes", "resolved", "weeks", "not smoke tobacco", "alcohol", "patient lives alone", "temperature", "98", "blood pressure", "80 mm Hg", "pulse", "min", "respirations", "min", "cervical lymphadenopathy", "noted", "heart murmurs", "heard", "ECG", "sinus rhythm", "1 atrioventricular block", "left bundle branch block", "Chest X-ray", "prominent hilar lymphadenopathy", "following", "diagnosis"]}
{"question": "A 36-year-old woman comes to the physician for evaluation of unintentional weight gain of 5.5 kg (12.2 lb) and irregular menstrual cycles over the past 2 months. She does not take any medications. Her blood pressure is 155/85 mm Hg. Physical examination shows central obesity, hyperpigmentation of the palmar creases, and violaceous scarring of the abdomen. Early morning serum cortisol levels are elevated and serum adrenocorticotropic hormone (ACTH) is within the reference range after a low-dose dexamethasone suppression test. A high-dose dexamethasone suppression test shows suppression of ACTH. Further evaluation is most likely to show which of the following findings?", "answer": "Bilateral hyperplasia of the zona fasciculata", "options": {"A": "Atrophy of the pituitary gland", "B": "Benign adenoma of the adrenal medulla", "C": "Nodular hypertrophy of the zona reticularis", "D": "Bilateral hyperplasia of the zona fasciculata", "E": "Unilateral carcinoma of the adrenal cortex"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old woman", "physician", "unintentional weight gain", "kg", "irregular menstrual cycles", "past", "months", "not", "medications", "blood pressure", "85 mm Hg", "central obesity", "hyperpigmentation", "palmar creases", "violaceous scarring", "abdomen", "Early morning serum cortisol levels", "elevated", "serum adrenocorticotropic hormone", "reference range", "low-dose dexamethasone suppression test", "high-dose dexamethasone suppression test", "suppression", "ACTH", "Further", "to", "following findings"]}
{"question": "A 45-year-old gentleman with a history of poorly controlled diabetes mellitus is referred to a nephrologist for evaluation of the possibility of early stage kidney failure. Upon evaluation, the nephrologist decides to assess the patient's renal plasma flow by performing a laboratory test. Which of the following substances would be the best for estimating this value?", "answer": "Para-aminohippurate (PAH)", "options": {"A": "Creatinine", "B": "Inulin", "C": "Glucose", "D": "Para-aminohippurate (PAH)", "E": "Urea"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "history of poorly controlled diabetes mellitus", "referred", "nephrologist", "possibility", "early stage kidney failure", "nephrologist", "to", "patient's renal plasma flow", "performing", "laboratory test", "following", "best", "estimating", "value"]}
{"question": "A 43-year-old woman comes to the physician because of a 2-week history of malaise, nausea, and a 3-kg (6.6-lb) weight loss. She has been drinking 8–9 alcoholic beverages daily for the past 20 years. Her temperature is 37.8°C (100°F) and pulse is 105/min. Examination shows jaundice and hepatosplenomegaly. A photomicrograph of a section of a biopsy specimen of the liver is shown. Which of the following mechanisms best explains the findings shown?", "answer": "Increased glycerol 3-phosphate formation", "options": {"A": "Excessive interstitial TGF-β activity", "B": "Decreased clearance of N-acetyl-p-benzoquinone imine", "C": "Intracellular accumulation of lactate", "D": "Increased glycerol 3-phosphate formation", "E": "Estrogen-mediated glandular hyperplasia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "2-week history", "malaise", "nausea", "3 kg", "6.6", "weight loss", "drinking", "daily", "past 20 years", "temperature", "pulse", "min", "jaundice", "hepatosplenomegaly", "photomicrograph", "section", "biopsy specimen", "liver", "following mechanisms best", "findings"]}
{"question": "A 48-year-old female with a history of hypertension, type II diabetes mellitus, hypothyroidism, and asthma undergoes a scheduled total abdominal hysterectomy for symptomatic fibroids. She is given a dose of preoperative prophylactic antibiotics. Her urinary catheter is removed on post-operative day one. She is on low-molecular-weight heparin for deep vein thrombosis prophylaxis. On post-operative day four, the patient complains of abdominal pain. She denies cough, nausea, vomiting, or dysuria, but has had 3-4 loose stools over her hospitalization. Her temperature is 101.0°F (38.3°C), blood pressure is 97/59 mmHg, pulse is 106/min, and respirations are 16/min. The surgical wound has new erythema with dusky patches and abundant cloudy discharge. The patient reports new decreased sensation around her wound site. Her lungs are clear to auscultation and abdomen is soft with hypoactive bowel sounds. She has no costovertebral angle tenderness. Urinalysis is within normal limits and urine culture grows >100,000 CFU/mL of Escherichia coli.\n\nWhich of the following is the best next step in management?", "answer": "Vancomycin/piperacillin-tazobactam/clindamycin and debridement of the surgical wound", "options": {"A": "Discontinue low-molecular-weight heparin", "B": "Oral levofloxacin for 3 days", "C": "Oral vancomycin for 10-14 days", "D": "Vancomycin/piperacillin-tazobactam/clindamycin and observation", "E": "Vancomycin/piperacillin-tazobactam/clindamycin and debridement of the surgical wound"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["48 year old female", "history of hypertension", "type II diabetes mellitus", "hypothyroidism", "asthma", "scheduled total abdominal hysterectomy", "symptomatic fibroids", "given", "dose", "preoperative prophylactic antibiotics", "urinary catheter", "removed", "post-operative day one", "low-molecular-weight heparin", "deep vein thrombosis prophylaxis", "post-operative day four", "patient", "abdominal pain", "cough", "nausea", "vomiting", "dysuria", "3-4 loose stools", "temperature", "blood pressure", "97 59 mmHg", "pulse", "min", "respirations", "min", "surgical wound", "new erythema", "dusky patches", "abundant cloudy discharge", "patient reports new decreased sensation", "wound site", "lungs", "clear", "auscultation", "abdomen", "soft", "hypoactive bowel sounds", "costovertebral angle tenderness", "Urinalysis", "normal limits", "urine culture", "100", "CFU/mL", "following", "best next step"]}
{"question": "A 1-month-old boy is brought to the emergency department 25 minutes after having a seizure. His mother reports that he has become lethargic and does not cry as vigorously anymore. Examination shows muscular hypotonia and hepatomegaly. Arterial blood gas on room air shows metabolic acidosis. Serum studies show elevated levels of methylmalonic acid. A deficiency of which of the following types of enzymes is the most likely cause of this patient's condition?", "answer": "Mutase", "options": {"A": "Phosphorylase", "B": "Phosphatase", "C": "Carboxylase", "D": "Hydroxylase", "E": "Mutase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old boy", "brought", "emergency department", "minutes", "seizure", "reports", "lethargic", "not", "vigorously", "muscular hypotonia", "hepatomegaly", "Arterial blood gas", "room air", "metabolic", "Serum studies", "elevated levels", "methylmalonic acid", "deficiency", "following types", "enzymes", "most likely cause", "patient's condition"]}
{"question": "A 22-year-old patient presents to the rural medicine clinic for a physical examination. She has a past medical history of major depressive disorder. The patient has a history of smoking 1 pack of cigarettes daily for 5 years. She states that she is not currently sexually active, but had sexual intercourse in the past. Her paternal grandfather died of a heart attack at the age of 60. She takes citalopram by mouth once every morning. The blood pressure is 110/70 mm Hg, the heart rate is 76/min, and the respiratory rate is 12/min. Her physical examination reveals a well-nourished, alert, and oriented female. While auscultating the heart, a 2/6 holosystolic murmur at the left upper sternal border is present. Which of the following would be the most appropriate next step for this patient?", "answer": "Pap smear", "options": {"A": "Pap smear", "B": "Pap smear and HPV testing", "C": "Colposcopy and biopsy", "D": "Education on breast self-examinations", "E": "Screening for hyperlipidemia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old patient presents", "rural medicine clinic", "past medical major", "patient", "history of smoking", "pack", "cigarettes daily", "states", "not currently sexually active", "sexual intercourse", "past", "died", "heart attack", "age", "60", "citalopram", "mouth", "morning", "blood pressure", "70 mm Hg", "heart rate", "76 min", "respiratory rate", "min", "reveals", "well-nourished", "alert", "oriented female", "heart", "2/6 holosystolic murmur", "left upper sternal border", "present", "following", "most appropriate next step", "patient"]}
{"question": "A 66-year-old homeless HIV-positive male presents with numbness in his hands and feet. The patient says that his symptoms started gradually a couple weeks ago and have slowly worsened. He describes numbness initially in just his fingertips and toes but it has now spread to involve his entire hands and feet. Past medical history is significant for HIV diagnosed many years ago, for which the patient has never sought treatment. The patient also has a long history of various illnesses, especially chronic diarrhea, but he is unable to remember any details. He currently takes no medications. The patient has been homeless for years, and he denies any alcohol or drug use. Review of systems is significant for a sore tongue. His temperature is 37°C (98.6°F), blood pressure is 100/65 mm Hg, pulse is 102/min, respiratory rate is 25/min, and oxygen saturation is 97% on room air. On physical exam, the patient is alert and oriented, his body habitus is cachectic, and his BMI is 17 kg/m2. His tongue appears erythematous and smooth with loss of papillae, but no lesions or evidence of infection is noted. Cardiac exam is normal apart from tachycardia. Lungs are clear to auscultation. His abdomen is soft and nontender with no hepatosplenomegaly. There is decreased 2-point discrimination in the hands and feet bilaterally. Strength in the hands and feet is 4/5 bilaterally. Reflexes are absent in the ankles. Gait is slightly wide-based and ataxic, and there is a positive Romberg sign. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Elevated levels of methylmalonic acid (MMA)", "options": {"A": "Elevated levels of methylmalonic acid (MMA)", "B": "Poorly controlled, undiagnosed diabetes", "C": "Autoimmune reaction", "D": "Disseminated bacterial infection", "E": "Deposition of an insoluble protein"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["66 year old homeless HIV-positive male presents", "numbness", "hands", "feet", "patient", "symptoms started", "couple weeks", "slowly worsened", "numbness initially", "fingertips", "toes", "now spread to", "entire hands", "feet", "Past medical history", "significant", "HIV diagnosed", "years", "patient", "never", "treatment", "patient", "long history", "various illnesses", "chronic diarrhea", "unable to", "details", "currently", "medications", "patient", "homeless", "years", "alcohol", "drug use", "Review of systems", "significant", "sore tongue", "temperature", "98", "blood pressure", "100 65 mm Hg", "pulse", "min", "respiratory rate", "min", "oxygen saturation", "97", "room air", "patient", "alert", "oriented", "body", "cachectic", "BMI", "kg/m2", "tongue appears erythematous", "smooth", "loss", "papillae", "lesions", "infection", "noted", "normal", "tachycardia", "Lungs", "clear", "auscultation", "abdomen", "soft", "nontender", "hepatosplenomegaly", "decreased 2-point discrimination", "hands", "feet", "Strength", "hands", "feet", "4/5", "Reflexes", "absent", "ankles", "Gait", "slightly wide based", "ataxic", "positive Romberg sign", "following", "most likely cause", "patients symptoms"]}
{"question": "A 47-year-old woman presents to the emergency department in a frantic state and demands immediate treatment for an allergic reaction, which started soon after she had lunch (approximately 1 hour ago). She had her usual meal consisting of homemade salad and lemonade. She was recently started on niacin because she could not tolerate statins. The only other medication she takes is captopril for hypertension. She has no respiratory difficulty and denies rhinorrhea, epiphora, and diarrhea. She is complaining of a stinging sensation on her face. She has no history of allergies and no family history of allergies. The vital signs include: pulse 90/min, respirations 16/min, blood pressure 120/80 mm Hg, and oxygen saturation, 98% on room air. On physical examination, the face and trunk have a flushed appearance. The rest of the physical examination is unremarkable. The attending physician reassures her that she is not in any immediate danger, and in fact, her symptoms subsided over the next hour. She is advised to take aspirin 30 minutes before her other medications and sent home. Which of the following is the etiology of her symptoms?", "answer": "Prostaglandin release", "options": {"A": "Anxiety", "B": "Drug overdose", "C": "A mild allergic reaction", "D": "Prostaglandin release", "E": "Serotonin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "state", "demands immediate treatment", "allergic reaction", "started", "lunch", "approximately", "hour", "usual", "consisting", "recently started", "niacin", "not", "statins", "only", "medication", "captopril", "hypertension", "respiratory difficulty", "rhinorrhea", "epiphora", "diarrhea", "stinging sensation", "face", "history of allergies", "family history of allergies", "vital signs include", "pulse 90 min", "respirations", "min", "blood pressure", "80 mm Hg", "oxygen saturation", "98", "room air", "face", "trunk", "flushed appearance", "unremarkable", "attending physician", "not", "immediate", "fact", "symptoms", "next hour", "to", "aspirin 30 minutes", "medications", "sent home", "following", "etiology", "symptoms"]}
{"question": "A 51-year-old man comes to the physician for 2 months of intermittent low-grade fever, malaise, and joint pain. He has a history of recurrent dental abscesses requiring drainage but has otherwise been healthy. His temperature is 38.3°C (100.9°F) and pulse is 112/min. Physical examination shows a new holosystolic murmur in the left midclavicular line that radiates to the axilla. There are linear reddish-brown lesions underneath the nail beds and tender violaceous nodules on the bilateral thenar eminences. Two sets of blood cultures grow Streptococcus mutans. A transthoracic echocardiogram shows moderate regurgitation of the mitral valve. Which of the following mechanisms is most likely directly involved in the pathogenesis of this patient's valvular condition?", "answer": "Fibrin clot formation", "options": {"A": "Antibody cross-reaction", "B": "Sterile platelet thrombi deposition", "C": "Leaflet calcification and fibrosis", "D": "Coagulative necrosis", "E": "Fibrin clot formation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "2 months", "intermittent low-grade fever", "malaise", "joint pain", "history", "recurrent dental abscesses", "drainage", "healthy", "temperature", "100 9F", "pulse", "min", "new holosystolic murmur", "left midclavicular line", "radiates", "axilla", "linear", "brown lesions", "nail beds", "tender violaceous nodules", "bilateral thenar", "Two sets of blood cultures", "transthoracic echocardiogram", "moderate regurgitation", "mitral valve", "following mechanisms", "directly involved", "pathogenesis", "patient's valvular condition"]}
{"question": "A 4-year-old boy is brought to the physician by his mother because of painless lesions on his face that he has had since shortly after birth. They recently moved to the USA from Indonesia where they had limited access to healthcare. A photograph of the lesions is shown. Which of the following is the most likely diagnosis?", "answer": "Infantile hemangioma", "options": {"A": "Infantile hemangioma", "B": "Verruca vulgaris", "C": "Neurofibromas", "D": "Spider angioma", "E": "Molluscum contagiosum"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["4 year old boy", "brought", "physician", "painless lesions", "face", "since", "birth", "recently moved to", "USA", "Indonesia", "limited access to healthcare", "photograph", "lesions", "following", "diagnosis"]}
{"question": "A 30-year-old man is diagnosed with multi-drug resistant tuberculosis after a recent trip to Eastern Europe. After drug susceptibility testing is completed, he is given a regimen of antibiotics as treatment. He returns two weeks later complaining of decreased visual acuity and color-blindness. Which drug of the following is the mechanism of action of the drug that is most likely to cause this side effect?", "answer": "Inhibition of arabinogalactan synthesis", "options": {"A": "Inhibition of mycolic acid synthesis", "B": "Inhibition of arabinogalactan synthesis", "C": "Binding to ergosterol and formation of a transmembrane channel", "D": "Inhibition of RNA synthesis", "E": "Inhibition of RNA translation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old man", "diagnosed", "multi-drug resistant tuberculosis", "recent trip", "Eastern Europe", "drug susceptibility", "completed", "given", "regimen", "treatment", "returns two weeks later", "decreased visual acuity", "color-blindness", "drug", "following", "mechanism of action", "drug", "to cause", "side effect"]}
{"question": "A 5-year-old boy is brought to the physician because of intermittent abdominal cramps and recurrent episodes of foul-smelling greasy diarrhea for 3 months. He has a history of recurrent upper respiratory infection. The abdomen is diffusely tender to palpation and resonant to percussion. A photomicrograph of a stool sample is shown. This patient is at increased risk for which of the following?", "answer": "Hypersensitivity reaction to transfusion", "options": {"A": "Hypersensitivity reaction to transfusion", "B": "Gastric adenocarcinoma", "C": "Progressive peripheral neuropathy", "D": "Cutaneous granulomas", "E": "Disseminated tuberculosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 year old boy", "brought", "physician", "intermittent abdominal cramps", "recurrent episodes of", "smelling greasy diarrhea", "3 months", "history", "recurrent upper respiratory infection", "abdomen", "tender", "palpation", "resonant", "percussion", "photomicrograph", "stool sample", "patient", "increased risk", "following"]}
{"question": "A 23-year-old man comes to the emergency department for 2 days of severe headaches. The pain is most intense on his left forehead and eye. He had similar symptoms last summer. He has been taking indomethacin every 6 hours for the last 24 hours but has not had any relief. He has smoked 1 pack of cigarettes daily for the past 5 years. He works as an accountant and describes his work as very stressful. Physical examination shows drooping of the left eyelid, tearing of the left eye, and rhinorrhea. The left pupil is 2 mm and the right pupil is 4 mm. There is localized tenderness along the right supraspinatus muscle. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Cluster headache", "options": {"A": "Giant cell arteritis", "B": "Medication overuse headache", "C": "Cluster headache", "D": "Trigeminal neuralgia", "E": "Tension headache"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old man", "emergency department", "2 days", "severe headaches", "pain", "most intense", "left forehead", "eye", "similar symptoms last summer", "indomethacin", "6 hours", "not", "relief", "smoked 1 pack", "cigarettes daily", "past", "years", "accountant", "very stressful", "drooping", "left eyelid", "tearing", "left", "rhinorrhea", "left pupil", "2 mm", "right pupil", "4 mm", "localized tenderness", "right supraspinatus muscle", "abnormalities", "following", "diagnosis"]}
{"question": "A research group wants to assess the relationship between childhood diet and cardiovascular disease in adulthood. A prospective cohort study of 500 children between 10 to 15 years of age is conducted in which the participants' diets are recorded for 1 year and then the patients are assessed 20 years later for the presence of cardiovascular disease. A statistically significant association is found between childhood consumption of vegetables and decreased risk of hyperlipidemia and exercise tolerance. When these findings are submitted to a scientific journal, a peer reviewer comments that the researchers did not discuss the study's validity. Which of the following additional analyses would most likely address the concerns about this study's design?", "answer": "Stratification", "options": {"A": "Blinding", "B": "Crossover", "C": "Matching", "D": "Stratification", "E": "Randomization"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["group", "to", "relationship", "childhood diet", "cardiovascular disease", "adulthood", "500 children", "10", "years", "age", "recorded", "year", "then", "patients", "20 years later", "presence", "cardiovascular disease", "statistically significant association", "found", "childhood consumption", "hyperlipidemia", "exercise tolerance", "findings", "submitted", "journal", "reviewer", "researchers", "not", "study's validity", "following additional analyses", "most likely"]}
{"question": "A 40-year-old male with Down syndrome is brought to your clinic by his mother. She reports that over the past few months he has started having difficulty managing his daily routine at his assisted-living facility and no longer seems like himself. She says that last week he wandered away from the facility and was brought back by police. Additionally, he has stopped taking his regular antiepileptic medication, and she is concerned that he might have a seizure. TSH is checked and is normal. Which of the following is most likely to be responsible for this man's current presentation?", "answer": "Abnormal protein metabolism", "options": {"A": "Expansion of trinucleotide repeats", "B": "Abnormal protein metabolism", "C": "Hormone deficiency", "D": "Premature degradation of a protein", "E": "Nutritional deficiency"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["40 year old male", "Down syndrome", "brought", "clinic", "reports", "past", "months", "started", "difficulty", "daily routine", "assisted-living facility", "longer", "last week", "facility", "brought back", "police", "stopped", "regular antiepileptic medication", "seizure", "normal", "following", "to", "responsible", "man's current"]}
{"question": "A 14-year-old Caucasian male patient found to have low serum copper, high urine copper, and low serum ceruloplasmin is placed on penicillamine for management of his genetic disorder. Which of the following is LEAST consistent with this patient's clinical picture?", "answer": "Kinky, easily breakable hair", "options": {"A": "Kinky, easily breakable hair", "B": "Cirrhosis", "C": "Hemiballismus", "D": "Corneal deposits", "E": "Parkinson-like symptoms"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male patient found to", "low serum copper", "high urine copper", "low serum ceruloplasmin", "penicillamine", "management", "genetic", "following", "LEAST", "patient's clinical picture"]}
{"question": "A 59-year-old man is brought to the emergency department 30 minutes after having a seizure. His wife reports that the patient has been having recurrent headaches and has become increasingly irritable over the past 3 months. Physical examination shows a spastic paresis of the right lower extremity. The Babinski sign is present on the right side. An MRI of the brain is shown. Which of the following is the most likely diagnosis?", "answer": "Meningioma", "options": {"A": "Pituitary adenoma", "B": "Metastatic brain tumor", "C": "Ependymoma", "D": "Oligodendroglioma", "E": "Meningioma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["59 year old man", "brought", "emergency department 30 minutes", "seizure", "reports", "patient", "recurrent headaches", "irritable", "past 3 months", "spastic paresis of", "right lower extremity", "Babinski sign", "present", "right side", "MRI of", "brain", "following", "diagnosis"]}
{"question": "A high-throughput screen to identify new sympathomimetic compounds was developed such that a transgenic line of cells was created that contained the alpha-1 (red), alpha-2 (yellow), beta-1 (green) and beta-2 (blue) receptors. When each of the receptors was activated a different fluorescent protein was expressed and new compounds with different properties could be identified by the fluorescence that they induced. Compound 7583 selectively induced the expression of the blue fluorescent protein. Which of the following known sympathomimetic medications if administered would similarly result in expression of only the blue fluorescent protein?", "answer": "Albuterol", "options": {"A": "Albuterol", "B": "Midrodrine", "C": "Epinephrine", "D": "Isoproterenol", "E": "Fenoldopam"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["high", "screen to", "new sympathomimetic compounds", "created", "contained", "alpha-1", "red", "alpha-2", "yellow", "beta", "green", "beta", "blue", "receptors", "receptors", "different fluorescent protein", "new compounds", "different properties", "identified", "induced", "Compound", "induced", "blue fluorescent", "following known sympathomimetic medications", "administered", "result", "expression", "only", "blue fluorescent protein"]}
{"question": "A 53-year-old man is brought by his daughter to the clinic. She lives a town away but visits often. She reports that on recent visits, his mood has been volatile, ranging from aggressive at some moments to depressed at others. She has noticed some new jerky movements which she has never seen before and has been quite forgetful. She is concerned that he might be abusing alcohol and drugs. What changes would you expect in the brain of this patient?", "answer": "Decreased GABA at the caudate", "options": {"A": "Increased norepinephrine at the locus ceruleus", "B": "Increased acetylcholine at the caudate", "C": "Decreased seratonin at the raphe nucleus", "D": "Decreased GABA at the caudate", "E": "Decreased dopamine at the ventral tegmentum and substantia nigra pars compacta"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "clinic", "lives", "town", "often", "reports", "recent", "mood", "volatile", "ranging", "aggressive", "depressed", "others", "new jerky movements", "never seen", "forgetful", "abusing alcohol", "drugs", "changes", "brain", "patient"]}
{"question": "A male newborn is delivered at term to a 30-year-old woman. Pregnancy and delivery were uncomplicated. At birth, the umbilical cord is noted to be large. When the newborn cries, straw-colored fluid leaks from the umbilicus. The external genitalia appear normal. Which of the following is the most likely cause of this newborn's symptoms?", "answer": "Failed obliteration of an allantoic remnant", "options": {"A": "Abnormal fusion of the urethral folds", "B": "Failed closure of the vitelline duct", "C": "Failed obliteration of an allantoic remnant", "D": "Infection of the umbilical cord stump", "E": "Malformation of the medial umbilical ligament"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["male newborn", "delivered", "term", "30 year old woman", "Pregnancy", "delivery", "uncomplicated", "birth", "umbilical cord", "noted to", "large", "newborn", "straw colored fluid leaks", "umbilicus", "external genitalia appear normal", "following", "most likely cause", "newborn's symptoms"]}
{"question": "A medical student is performing research on the properties of viruses in order to determine the transmission patterns of various organisms. He accidentally drops a rack of tubes and spills various virus samples on the benchtop. Upon seeing this, the laboratory technician wipes down the workbench with alcohol in order to clean up the spill. Which of the following organisms would most likely still be alive after this cleaning?", "answer": "Adenovirus and rhinovirus", "options": {"A": "Adenovirus and coronavirus", "B": "Adenovirus and herpesvirus", "C": "Adenovirus and rhinovirus", "D": "Coronavirus and herpesvirus", "E": "Coronavirus and rhinovirus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["medical student", "performing", "properties", "viruses", "order to", "transmission patterns", "various", "drops", "rack", "tubes", "various", "seeing", "laboratory technician wipes", "alcohol", "order", "clean up", "following", "alive"]}
{"question": "An 3-year-old boy is brought in to his pediatrician by his mother after she noticed that the child was starting to turn yellow. She has not noticed any behavioral changes. On exam, the boy is icteric but is behaving normally. His temperature is 98.8°F (37.1°C), blood pressure is 108/78 mmHg, pulse is 78/min, and respirations are 14/min. His labs are drawn, and he is found to have an unconjugated hyperbilirubinemia with a serum bilirubin of 15 mg/dL. The mother is counseled that this boy’s condition may require phenobarbital as a treatment to reduce his bilirubin levels. Which of the following is the most likely defect in this child?", "answer": "Reduced UDP-glucuronosyltransferase activity", "options": {"A": "Absent UDP-glucuronosyltransferase activity", "B": "Defective liver excretion of bilirubin due to ABCC2 mutation", "C": "Defective liver excretion of bilirubin due to SLCO1B1 and SLCO1B3 mutations", "D": "Impaired bilirubin uptake", "E": "Reduced UDP-glucuronosyltransferase activity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "pediatrician", "child", "starting to turn yellow", "not", "behavioral changes", "exam", "boy", "icteric", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "labs", "found to", "unconjugated hyperbilirubinemia", "serum bilirubin", "mg/dL", "counseled", "boys condition", "phenobarbital", "treatment to", "bilirubin levels", "following", "defect", "child"]}
{"question": "A 20-year-old woman presents to the emergency department after developing a widespread rash when she was playing in the park. She states she feels somewhat light-headed. She is otherwise healthy and has no significant past medical history. Her temperature is 97.0°F (36.1°C), blood pressure is 84/54 mmHg, pulse is 130/min, respirations are 22/min, and oxygen saturation is 95% on room air. Physical exam is notable for bilateral wheezing and a diffuse urticarial rash. Which of the following is the next best step in management?", "answer": "Epinephrine", "options": {"A": "Albuterol", "B": "Continuous monitoring", "C": "Diphenhydramine", "D": "Epinephrine", "E": "Normal saline"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["20 year old woman presents", "emergency department", "widespread rash", "playing", "park", "states", "somewhat light-headed", "healthy", "significant past medical history", "temperature", "97", "36", "blood pressure", "84 54 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "95", "room air", "notable", "bilateral wheezing", "diffuse urticarial", "following", "next best step"]}
{"question": "A 55-year-old woman with rheumatoid arthritis comes to the physician because of a 3-month history of worsening fatigue and dyspnea. She has felt short-of-breath when walking up the stairs to her apartment. Menopause occurred 5 years ago. Her medications are methotrexate and folic acid supplementation. Physical examination shows conjunctival pallor, tenderness of bilateral wrists and knees, and ulnar deviation of the fingers. Her hematocrit is 27%, mean corpuscular volume is 84 μm3, and serum ferritin is 375 ng/mL. Which of the following has most likely contributed to the patient's current symptoms?", "answer": "Increased release of hepcidin by hepatocytes", "options": {"A": "Increased activity of ferroportin-1 in enterocytes", "B": "Increased release of iron from macrophages", "C": "Increased release of hepcidin by hepatocytes", "D": "Increased production of reticulocytes in bone marrow", "E": "Increased concentration of transferrin in serum"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "rheumatoid arthritis", "physician", "3 month history", "worsening fatigue", "dyspnea", "short-of-breath", "apartment", "Menopause", "medications", "methotrexate", "folic acid supplementation", "conjunctival pallor", "tenderness", "bilateral wrists", "knees", "ulnar deviation of the fingers", "hematocrit", "mean corpuscular volume", "84 m3", "serum ferritin", "375 ng/mL", "following", "most likely", "patient's current symptoms"]}
{"question": "A 65-year-old man presents with complaints of weakness and swollen gums for the past 3 weeks. He also says he cut his finger while cooking, and the bleeding took more than 10 minutes to stop. He has a family history of diabetes mellitus type 2 and prostate cancer. Current medications are multivitamin. His blood pressure is 122/67 mm Hg, the respiratory rate is 13/min, and the temperature is 36.7°C (98.0°F). On physical examination, the patient seems pale and lethargic. On cardiac exam, a pulmonary valve flow murmur is heard. There is significant hepatosplenomegaly present, and several oral mucosal petechiae in the oral cavity are noted. Gum hypertrophy is also present. A peripheral blood smear reveals myeloperoxidase-positive cells and Auer Rods. A bone marrow biopsy shows > 30% of blast cells. Which of the following chromosomal abnormalities is associated with this patient’s most likely diagnosis?", "answer": "t(15;17)", "options": {"A": "JAK2 mutation", "B": "t(9;22)", "C": "t(15;17)", "D": "t(11;14)", "E": "t(8;14)"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old man presents", "complaints", "weakness", "swollen gums", "past", "weeks", "cut", "finger", "bleeding", "more", "10 minutes to stop", "family history of diabetes mellitus type 2", "prostate cancer", "Current medications", "multivitamin", "blood pressure", "67 mm Hg", "respiratory rate", "min", "temperature", "36", "98", "patient", "pale", "lethargic", "pulmonary valve flow murmur", "heard", "significant hepatosplenomegaly present", "several oral mucosal petechiae", "cavity", "noted", "Gum hypertrophy", "present", "peripheral blood smear reveals myeloperoxidase positive cells", "Auer Rods", "bone marrow biopsy", "30", "following chromosomal abnormalities", "associated with", "patients", "likely diagnosis"]}
{"question": "An otherwise healthy 16-year-old girl comes to the physician because she has not had a menstrual period. Examination shows normal breast development. There is coarse pubic and axillary hair. Pelvic examination shows a blind vaginal pouch. Ultrasonography shows normal ovaries and an atretic uterus. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Agenesis of the paramesonephric duct", "options": {"A": "Deficiency of 5-alpha reductase", "B": "End-organ insensitivity to androgens", "C": "Monosomy of sex chromosomes", "D": "Agenesis of the paramesonephric duct", "E": "Deficiency of 17-alpha-hydroxylase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old girl", "physician", "not", "menstrual period", "normal breast development", "coarse pubic", "axillary hair", "Pelvic examination", "blind vaginal pouch", "Ultrasonography", "normal ovaries", "atretic uterus", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 75-year-old woman is being treated for atrial fibrillation. She presents to the clinic with complaints of nausea, vomiting, photophobia, and yellow-green vision with yellow halos around the lights. She has a heart rate of 64/min, blood pressure is 118/76 mm Hg, and respiratory rate is 15/min. Physical examination reveals regular heart sounds with clear lung sounds bilaterally. Liver function tests are normal. Toxicity of which of the following anti-arrhythmic drugs would best fit this clinical picture?", "answer": "Digoxin", "options": {"A": "Digoxin", "B": "Amiodarone", "C": "Propafenone", "D": "Sotalol", "E": "Atenolol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["75 year old woman", "treated", "atrial fibrillation", "presents", "clinic", "complaints", "nausea", "vomiting", "photophobia", "vision", "halos", "heart rate", "64 min", "blood pressure", "76 mm Hg", "respiratory rate", "min", "reveals regular heart", "clear lung sounds", "Liver function tests", "normal", "Toxicity", "following anti-arrhythmic drugs", "best fit", "clinical picture"]}
{"question": "A 40-year-old man is rushed to the emergency department after being involved in a motor vehicle accident. He has lacerations on his right arm and some minor abrasions on his face and lower limbs. The resident on call quickly manages the patient with proper care of his open wounds in the emergency department. The patient is admitted to the surgery unit for the daily care of his wounds. His lacerations begin to heal with proper dressing and occasional debridement. Which of the following best describes the healing process in this patient?", "answer": "Healing by secondary intention will occur along with the deposition of large amount of granulation tissue.", "options": {"A": "Abundant lymphocytes accumulate during the healing process, forming a granuloma.", "B": "The formation of granulation tissue is not affected by factors such as blood sugar and decreased circulation of blood.", "C": "Healing by secondary intention will occur along with the deposition of large amount of granulation tissue.", "D": "Healing involves abscess formation, which should be drained.", "E": "Healing by primary intention will occur without granulation tissue formation."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old man", "rushed", "emergency department", "involved", "motor vehicle accident", "lacerations", "right", "minor abrasions", "face", "lower limbs", "resident", "call", "open wounds", "emergency department", "patient", "surgery unit", "daily care", "wounds", "lacerations begin", "heal", "dressing", "occasional debridement", "following best", "healing process", "patient"]}
{"question": "Hormone balance is essential for maintaining a normal pregnancy. Early on, elevated progesterone levels are needed to maintain pregnancy and progesterone is produced in excess by the corpus luteum. In the normal menstrual cycle the corpus luteum involutes, but this process is impeded during pregnancy because of the presence of which hormone?", "answer": "Human chorionic gonadotropin", "options": {"A": "Cortisol", "B": "Human chorionic gonadotropin", "C": "Estrogen", "D": "Progesterone", "E": "Inhibin A"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Hormone balance", "essential", "normal", "Early", "elevated", "needed to", "pregnancy", "progesterone", "excess", "corpus luteum", "normal menstrual cycle", "corpus luteum involutes", "process", "pregnancy", "presence", "hormone"]}
{"question": "A 32-year-old man comes to the emergency department because of worsening shortness of breath and a productive cough for 3 days. He sustained trauma to the right hemithorax during a fight 3 weeks ago. He had significant pain and mild shortness of breath following the incident but did not seek medical care. He does not smoke or drink alcohol. He is a construction worker. His temperature is 38.4°C (101.1°F), pulse is 95/min, respirations are 18/min, and blood pressure is 120/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Pulmonary examination shows decreased breath sounds over the right lower lung fields. CT scan of the chest shows fractures of the right 7th and 8th ribs, right pleural splitting and thickening, and a dense fluid collection in the pleural space. Which of the following is the most likely diagnosis?", "answer": "Pleural empyema", "options": {"A": "Viral pleurisy", "B": "Lung abscess", "C": "Chylothorax", "D": "Pleural empyema", "E": "Mesothelioma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "emergency department", "of worsening shortness", "breath", "productive cough", "3 days", "sustained trauma", "right hemithorax", "weeks", "significant pain", "mild shortness of breath following", "not", "medical care", "not smoke", "construction worker", "temperature", "pulse", "95 min", "respirations", "min", "blood pressure", "75 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "96", "Pulmonary", "decreased breath sounds", "right", "CT scan of", "chest", "fractures", "right", "ribs", "right pleural splitting", "thickening", "dense fluid collection", "pleural", "following", "diagnosis"]}
{"question": "A cross-sectional oral health survey was designed to assess both functional and psychosocial effects of dental disease on the elderly population of Buda, Texas (US). Printed surveys that consisted of 50 open-ended questions on dental disease history and dental hygiene were mailed to the selected members of a target population. However, the response rate was not satisfactory, as a large percentage of the selected study participants either did not return the survey or failed to answer all of the questions posed. The researchers opted for 2 strategies: prompt those who did not respond with a second letter that guaranteed complete confidentiality and broaden the pool of selected participants. Depending on the final response rate and the researchers’ statistical skills, the bias in the final publication will be more pronounced if...?", "answer": "...the difference between the observed and nonrespondent answers is increased.", "options": {"A": "....the proportion of nonrespondents from the targeted sample is decreased.", "B": "...the specific weighting-class adjustments are used on the final data.", "C": "...the difference between the observed and nonrespondent answers is increased.", "D": "...the auxiliary population variables are introduced by means of a calibration method.", "E": "...the imputation techniques for data correction are employed."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["oral health", "to", "functional", "psychosocial effects", "dental disease", "population", "Texas", "surveys", "consisted", "50 open-ended", "dental", "dental hygiene", "mailed", "response rate", "not satisfactory", "large percentage", "either", "not return", "survey", "failed to", "researchers opted", "prompt", "not", "second letter", "complete", "pool", "Depending", "final response rate", "researchers", "bias", "final publication", "more"]}
{"question": "A 16-year-old boy is brought to the physician for a follow-up examination. He has a 6-year history of type 1 diabetes mellitus and his only medication is insulin. Seven months ago, he was treated for an episode of diabetic ketoacidosis. He has previously been compliant with his diet and insulin regimen. He wants to join the high school soccer team. Vital signs are within normal limits. His hemoglobin A1C is 6.3%. Which of the following is the most appropriate recommendation at this time?", "answer": "Lower insulin dosage on days of exercise", "options": {"A": "Advise against physical activity", "B": "Lower insulin dosage on days of exercise", "C": "Switch from insulin to metformin", "D": "Increase insulin dosage on days of exercise", "E": "Limit activity to 20 minutes per day"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "follow-up examination", "year history of type 1 diabetes mellitus", "only medication", "insulin", "Seven months", "treated", "episode of diabetic ketoacidosis", "insulin regimen", "to", "high school", "Vital signs", "normal limits", "hemoglobin A1C", "6.3", "following", "most appropriate", "time"]}
{"question": "A 58-year-old woman comes to the physician because of headaches for 1 month. She describes them as 7 out of 10 in intensity. She has no nausea. Two years ago, she was treated for invasive lobular carcinoma of the left breast. She underwent a left mastectomy and multiple cycles of chemotherapy. She has been in good health since this treatment. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 118/72 mm Hg. There is a well-healed scar on the left side of the chest. There is no lymphadenopathy. The abdomen is soft and nontender; there is no organomegaly. Neurologic examination shows no focal findings. An MRI of the brain shows a 4-cm temporal hyperintense mass near the surface of the brain. Which of the following is the most appropriate next step in management?", "answer": "Surgical resection", "options": {"A": "Whole brain radiation therapy", "B": "Surgical resection", "C": "Chemotherapy", "D": "Antibiotic therapy", "E": "Palliative care"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old woman", "physician", "of headaches", "month", "out", "10", "intensity", "nausea", "Two years", "treated", "invasive lobular carcinoma of the left breast", "left mastectomy", "multiple cycles", "chemotherapy", "treatment", "temperature", "98", "pulse", "90 min", "blood pressure", "72 mm Hg", "well healed scar", "left side of", "chest", "lymphadenopathy", "abdomen", "soft", "nontender", "organomegaly", "Neurologic examination", "focal findings", "MRI of", "brain", "4", "temporal", "mass", "surface of", "brain", "following", "most appropriate next step"]}
{"question": "A 44-year-old man presents to his primary care physician due to a shock-like pain in his left leg. He describes the pain as sharp and lasting a few minutes at a time. He has noticed being \"clumsy\" when walking in a dark room. Approximately 2 weeks ago, he was helping his daughter move and this required him to lift heavy boxes. He denies any trauma to the back or lower back pain. Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. He is currently sexually active and is in a monogamous relationship with his wife. Approximately 15 years ago, he noted a painless genital lesion. On physical exam, there is a miotic pupil that does not constrict with light but constricts with convergence and accommodation. Strength, reflex, and sensory exam of the lower extremity is unremarkable. The patient has a positive Romberg test. Which of the following is most likely the cause of this patient's symptoms?", "answer": "Sexually transmitted infection", "options": {"A": "Acute ischemic cerebellar stroke", "B": "Diabetic peripheral neuropathy", "C": "Lumbar disc herniation", "D": "Lumbar spinal stenosis", "E": "Sexually transmitted infection"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "primary care physician due to", "shock", "pain in", "left leg", "pain", "sharp", "few minutes", "time", "clumsy", "walking in", "dark room", "Approximately", "weeks", "helping", "move", "required", "to lift heavy boxes", "trauma", "back", "lower back pain", "Medical history", "significant", "hypertension", "hyperlipidemia", "type 2 diabetes mellitus", "currently sexually active", "relationship", "Approximately", "years", "noted", "painless genital lesion", "miotic pupil", "not", "light", "convergence", "accommodation", "Strength", "reflex", "lower extremity", "unremarkable", "patient", "positive Romberg test", "following", "cause", "patient", "ymptoms?"]}
{"question": "The VALIANT trial compared the effect of captopril and valsartan on mortality in patients with myocardial infarction complicated by heart failure. Subjects were randomly assigned to treatment with either captopril or valsartan and subsequently followed for 2 years. The primary endpoint was death from any cause. The study concluded that valsartan was as effective as captopril in patients who are at high risk for cardiac events after an MI. Which of the following describes this type of study?", "answer": "Randomized controlled trial", "options": {"A": "Randomized controlled trial", "B": "Cohort study", "C": "Cross-sectional study", "D": "Case-control study", "E": "Crossover study"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["effect", "captopril", "valsartan", "mortality", "patients", "myocardial infarction complicated", "heart failure", "Subjects", "assigned", "treatment", "either captopril", "valsartan", "followed", "years", "death", "cause", "study concluded", "valsartan", "effective", "captopril", "patients", "high risk", "cardiac", "MI", "following"]}
{"question": "A 45-year-old woman comes to the physician because of a 3-month history of mild right upper abdominal pain. She has not had any fevers, chills, or weight loss. There is no personal or family history of serious illness. Medications include transdermal estrogen, which she recently started taking for symptoms related to menopause. Abdominal examination shows no abnormalities. Ultrasonography of the liver shows a well-demarcated, homogeneous, hyperechoic mass surrounded by normal liver tissue. A biopsy of the lesion would put this patient at greatest risk for which of the following complications?", "answer": "Intraperitoneal hemorrhage", "options": {"A": "Intraperitoneal hemorrhage", "B": "Biliary peritonitis", "C": "Bacteremia", "D": "Metastatic spread", "E": "Anaphylactic shock"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "3 month history", "mild right upper", "not", "fevers", "chills", "weight loss", "personal", "family history", "serious illness", "Medications include transdermal estrogen", "recently started", "symptoms related", "menopause", "Abdominal", "abnormalities", "Ultrasonography of the liver", "well", "homogeneous", "hyperechoic mass surrounded", "normal liver tissue", "biopsy", "lesion", "patient", "greatest", "following complications"]}
{"question": "A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls \"normal\" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also:", "answer": "Increase with squatting or handgrip", "options": {"A": "Radiate to the neck", "B": "Increase with squatting or handgrip", "C": "Increase with inspiration", "D": "Also have a mid-systolic click loudest at S2", "E": "Have a characteristic machine-like sound"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "woman presents", "clinic", "shortness of breath", "reports", "symptoms", "progressed", "past", "months", "now impacting", "quality of life", "complete", "usual exercise routine", "normal", "childhood illnesses", "including sore throats", "fevers", "never required hospitalization", "Vital signs", "temperature", "degrees Celsius", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "oxygen saturation 98", "room air", "reveals", "high-pitched", "blowing murmur", "cardiac", "One", "murmur"]}
{"question": "A 73-year-old man dies 4 months after being diagnosed with advanced adenocarcinoma of the colon. Examination of the heart at autopsy shows vegetations lining the mitral valve margins. The vegetations are loosely attached and can be easily scraped off. Microscopic examination shows the vegetations to be composed of interwoven fibrin strands with mononuclear cells. The mitral valve endothelium is intact. Which of the following is the most likely underlying cause of these autopsy findings?", "answer": "Procoagulant release", "options": {"A": "Procoagulant release", "B": "Dystrophic calcifications", "C": "Antibody cross-reactivity", "D": "Bacterial colonization", "E": "Metastatic infiltration"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "months", "diagnosed", "advanced adenocarcinoma of the colon", "autopsy", "vegetations lining", "mitral valve margins", "vegetations", "easily scraped", "Microscopic examination", "vegetations to", "fibrin strands", "mitral valve endothelium", "intact", "following", "underlying cause", "autopsy findings"]}
{"question": "A 22-year-old primigravid woman comes to the physician for her first prenatal visit at 10 weeks' gestation. She has no history of serious illness. She has been using cocaine for the past two years. Without cessation of cocaine use, which of the following complications is most likely to occur?", "answer": "Premature delivery", "options": {"A": "Premature delivery", "B": "Obstructed labor", "C": "Congenital heart defect", "D": "Neural tube defects", "E": "Polyhydramnios"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old primigravid woman", "physician", "10 weeks", "gestation", "history", "serious illness", "using cocaine", "past two years", "of cocaine use", "following complications", "to occur"]}
{"question": "An 18-year-old man comes to the physician because of severe left shoulder pain after a basketball match. During the game, the patient sustained an injury to the posterior part of his outstretched arm after being blocked by a defender. Examination shows no gross deformity of the left shoulder. Palpation of the shoulder elicits mild tenderness. Internal rotation of the arm against resistance shows weakness. These findings are most specific for injury to which of the following muscles?", "answer": "Subscapularis", "options": {"A": "Supraspinatus", "B": "Deltoid", "C": "Subscapularis", "D": "Infraspinatus", "E": "Teres minor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "of severe left shoulder pain", "basketball match", "patient sustained", "injury", "posterior part of", "arm", "blocked", "gross deformity", "left", "Palpation", "elicits mild tenderness", "Internal rotation", "arm", "resistance", "weakness", "findings", "most specific", "injury", "following muscles"]}
{"question": "A six-month-old male presents to the pediatrician for a well-child visit. His mother reports that the patient has just started eating solids and sleeps well throughout the night. She notes that she often puts the patient to sleep on his stomach because he seems to breathe more easily in that position. The patient’s mother has noticed that the patient’s breathing becomes more “strained” when lying on his back. She cannot remember when this problem began, but she believes it has gotten worse in recent weeks. The patient was born at 40 weeks gestation and has no other past medical history. The patient’s temperature is 98.0°F (36.7°C), blood pressure is 75/55 mmHg, pulse is 115/min, and respirations are 24/min. His oxygen saturation is 98% on room air. On physical exam, the patient appears comfortable and has inspiratory stridor that improves while leaning forward. His lungs are otherwise clear to auscultation bilaterally. Which of the following is the most likely cause of this patient’s respiratory symptoms?", "answer": "Laryngomalacia", "options": {"A": "Epiglottitis", "B": "Foreign body aspiration", "C": "Laryngomalacia", "D": "Laryngotracheitis", "E": "Vascular ring"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["six-month old male presents", "pediatrician", "reports", "patient", "started eating solids", "sleeps well", "night", "notes", "often", "patient to sleep", "stomach", "to", "more easily", "position", "patients", "patients breathing", "more strained", "lying on", "back", "problem began", "gotten worse", "recent weeks", "patient", "born", "40 weeks gestation", "past medical history", "patients temperature", "98", "36", "blood pressure", "75", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "patient appears", "inspiratory stridor", "improves", "forward", "lungs", "clear", "auscultation", "following", "most likely cause", "patients respiratory"]}
{"question": "A 36-year-old woman comes to the physician because of blurred vision and difficulty keeping her eyes open. She also has occasional difficulty chewing, especially when eating meat or other foods that require prolonged chewing. The symptoms are worse at the end of the day. Physical examination shows bilateral drooping of the eyelids, which becomes more pronounced when she is asked to look upwards for 30 seconds. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Decreased generation of end plate potential", "options": {"A": "Inhibition of calcium release from the sarcoplasmic reticulum", "B": "Interrupted transmission of T-tubule depolarization", "C": "Sustained blockade of actin myosin-binding sites", "D": "Decreased generation of end plate potential", "E": "Impaired flow of calcium ions between gap junctions"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old woman", "physician", "blurred vision", "difficulty keeping", "eyes open", "occasional difficulty chewing", "eating", "prolonged chewing", "symptoms", "worse", "end", "day", "bilateral drooping", "eyelids", "more", "to look", "30 seconds", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 32-year-old man presents to the emergency room for a generalized tonic-clonic seizure. After stabilizing the patient, a full radiologic evaluation reveals multiple contrast-enhancing lesions in the brain, lungs, and liver. According to his wife, he lost several pounds in the last few months. The medical history is relevant for cryptorchidism, with abdominal testes that were surgically transferred to the scrotum just before he turned 1-year old. His lab investigation reveals:\nα-fetoprotein: \n9 ng/mL (normal values < 10 ng/mL)\nHuman chorionic gonadotropin: \n1,895 IU/L (normal values < 0.5 IU/L)\nWhich of the following microscopic features best describes the lesions seen in this patient's imaging study?", "answer": "Intimate association of syncytiotrophoblast and cytotrophoblast cells", "options": {"A": "Glomerulus-like structure with a mesoderm core, a central capillary, and lined with germ cells", "B": "Germ cells with well-defined borders, central nuclei, prominent nucleoli, and clear cytoplasm", "C": "Cells with hyaline-like globules", "D": "Mixture of primitive neuroectoderm, loose mesenchyme, and primitive glandular structures", "E": "Intimate association of syncytiotrophoblast and cytotrophoblast cells"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency room", "generalized tonic-clonic seizure", "stabilizing", "patient", "full radiologic", "reveals multiple contrast-enhancing lesions", "brain", "lungs", "liver", "lost several pounds", "months", "medical history", "relevant", "cryptorchidism", "abdominal testes", "surgically transferred", "scrotum", "turned 1-year old", "lab", "reveals", "fetoprotein", "ng/mL", "normal values", "10 ng/mL", "Human chorionic gonadotropin", "1", "IU/L", "normal values", "0.5 IU L", "following microscopic features best", "lesions seen", "patient's imaging study"]}
{"question": "A 62-year-old woman with type 2 diabetes mellitus comes to the physician because of a 1-year history of progressively worsening paresthesias in her upper limbs. She has accidentally burned her fingers on hot dishes several times. She was involved in a motor vehicle collision 3 years ago. Neurologic examination shows absent temperature sensation with normal fine touch sensation over the upper extremities and chest. Without treatment, this patient is at increased risk of developing which of the following?", "answer": "Drooping of the eyelid", "options": {"A": "Exaggerated biceps reflex", "B": "Decreased Mini-Mental State Examination score", "C": "Absent anal wink reflex", "D": "Drooping of the eyelid", "E": "Absent knee-jerk reflex"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "type 2 diabetes mellitus", "physician", "year history", "worsening paresthesias", "upper limbs", "burned", "fingers", "hot dishes", "times", "involved", "motor vehicle collision", "years", "Neurologic examination", "absent temperature sensation", "normal fine touch", "upper extremities", "chest", "treatment", "patient", "increased risk", "following"]}
{"question": "A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation is admitted to the hospital 30 minutes after spontaneous rupture of membranes. Her pregnancy has been complicated by gestational diabetes treated with insulin. Her first child was delivered vaginally. Her immunizations are up-to-date. She delivers the child via cesarean section without complications after failure to progress for 16 hours. Fourteen hours after birth, she reports having body aches and feeling warm. She has to change her perineal pad every 2–3 hours. She has abdominal cramping, especially when breastfeeding. She has voided her bladder four times since the birth. She appears uncomfortable. Her temperature is 37.9°C (100.2°F), pulse is 85/min, respirations are 18/min, and blood pressure is 115/60 mm Hg. The abdomen is soft, distended, and nontender. There is a healing transverse suprapubic incision without erythema or discharge. A firm, nontender uterine fundus is palpated at the level of the umbilicus. There is bright red blood on the perineal pad. The breasts are engorged and tender, without redness or palpable masses. Which of the following is the most appropriate next step in management?", "answer": "Observation\n\"", "options": {"A": "Dilation and curettage", "B": "Pelvic ultrasound", "C": "Hysterectomy", "D": "Administration of intravenous clindamycin and gentamycin", "E": "Observation\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "gestation", "30 minutes", "spontaneous rupture of membranes", "pregnancy", "complicated", "gestational diabetes treated with insulin", "first child", "delivered", "immunizations", "date", "delivers", "child", "cesarean section", "complications", "failure to progress", "hours", "Fourteen hours after birth", "reports", "body aches", "warm", "to change", "perineal pad", "23 hours", "abdominal cramping", "breastfeeding", "voided", "bladder four times", "birth", "appears", "temperature", "100", "pulse", "85 min", "respirations", "min", "blood pressure", "60 mm Hg", "abdomen", "soft", "distended", "nontender", "healing transverse suprapubic incision", "erythema", "discharge", "firm", "nontender uterine fundus", "level", "umbilicus", "bright red blood", "perineal pad", "breasts", "engorged", "tender", "redness", "following", "most appropriate next step"]}
{"question": "A 45-year-old chronic smoker presents to the physician with a complaint of worsening left shoulder pain for several months which has become acutely worse the past 2 weeks and now radiates down his left arm. Physical examination reveals a palpable 2 x 1.5 cm supraclavicular lymph node along with decreased grip strength in his left hand. Examination of the face reveals partial ptosis of the left eyelid and miosis of the left eye. Laboratory testing shows the following values:\nSodium (Na+) 135 mEq/L\nPotassium (K+) 3.6 mEq/L\nChloride (Cl-) 100 mEq/L\nBUN 12 mg/dL\nCreatinine (Cr) 0.6 mg/dL\nMagnesium (Mg2+) 1.5 mg/dL\nPhosphate 3 mg/dL\nCalcium (Ca2+) 8.5 mg/dL\nAn X-ray of the chest reveals a soft tissue mass at the apex of the left lung with possible involvement of the first rib. What is the most likely diagnosis?", "answer": "Pancoast tumor", "options": {"A": "Pulmonary hamartoma", "B": "Mesothelioma", "C": "Pancoast tumor", "D": "Subclavian aneurysm", "E": "Osteophyte"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old chronic smoker presents", "physician", "complaint", "worsening left shoulder pain", "several months", "worse", "past 2 weeks", "now radiates", "left arm", "reveals", "palpable", "supraclavicular", "decreased grip strength", "left hand", "face reveals partial ptosis of", "left eyelid", "miosis", "left eye", "Laboratory testing", "following values", "Sodium", "Na", "mEq/L Potassium", "K", "3.6 mEq/L", "100 mEq/L", "12 mg Creatinine", "0 mg", "Magnesium", "Mg2", "1.5 mg/dL Phosphate", "Calcium", "Ca2", "8.5 mg/dL", "X-ray of", "chest reveals", "soft tissue mass", "apex of", "left lung with possible involvement", "first rib", "diagnosis"]}
{"question": "A 24-year-old 70 kilogram African-American man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain under monitored anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn. Overnight, the nurse continues to increase the patient's midazolam infusion rate, but she also notices that his left toes are cold to touch with significant edema. His temperature is 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula. No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity. A delta pressure of 25 mmHg is obtained in the left leg. What is the best next step in management?", "answer": "Escharotomy", "options": {"A": "Amputation", "B": "Escharotomy", "C": "Fasciotomy", "D": "Intravenous fluid infusion based on Parkland formula", "E": "Transfer to burn center"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old 70 kilogram", "man", "epilepsy refractory", "valproic acid", "phenytoin", "levetiracetam", "magnetic resonance imaging", "brain", "monitored anesthetic", "wakes up", "pain due to", "electrocardiogram lead", "caused", "significant thermal burn", "left leg", "medical", "electroencephalogram", "midazolam infusion", "seizure suppression", "supportive care", "burn", "Overnight", "nurse", "to increase", "patient's midazolam infusion rate", "left toes", "cold to touch", "significant edema", "temperature", "blood pressure", "75 mmHg", "pulse", "80 min", "respirations", "10/min", "oxygen saturation", "95", "liters nasal cannula", "posterior tibial pulses", "detected", "left lower extremity", "mmHg", "obtained", "left leg", "best next step"]}
{"question": "A 60-year-old African American woman presents to her ophthalmologist with blurry vision. She reports a 2-month history of decreased vision primarily affecting her right eye. Her past medical history is notable for type 1 diabetes and hypertension. She takes insulin and enalapril. She has a 40-pack-year smoking history and drinks a glass of wine at dinner each night. Her family history is notable for glaucoma in her mother and severe diabetes complicated by nephropathy and retinopathy in her father. Her temperature is 99°F (37.2°C), blood pressure is 134/82 mmHg, pulse is 88/min, and respirations are 18/min. On exam, she is well-appearing and in no acute distress. The physician asks the patient to look forward and shines a penlight first in one eye, then the other, alternating quickly to observe the pupillary response to the light. When the light is shined in the right eye, both pupils partially constrict. When the light is shined in the left eye, both pupils constrict further. When the light is moved back to the right eye, both eyes dilate slightly to a partially constricted state. Where is the most likely site of this patient’s lesion?", "answer": "Optic nerve", "options": {"A": "Ciliary ganglion", "B": "Lateral geniculate nucleus", "C": "Lens", "D": "Oculomotor nerve", "E": "Optic nerve"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["60 year old", "woman presents", "ophthalmologist", "blurry vision", "reports", "2 month history", "decreased vision", "affecting", "right eye", "past medical history", "notable", "type 1 diabetes", "hypertension", "insulin", "enalapril", "40", "smoking history", "glass", "dinner", "night", "family history", "notable", "glaucoma", "severe diabetes complicated", "nephropathy", "retinopathy", "temperature", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "exam", "well appearing", "acute distress", "physician", "patient to look forward", "first", "one eye", "then", "alternating", "to observe", "pupillary response to", "light", "light", "right eye", "pupils", "light", "left eye", "pupils", "further", "light", "moved back", "right eye", "eyes dilate slightly", "constricted state", "site of", "patients lesion"]}
{"question": "A 47-year-old man with a history of diabetes mellitus presents for a primary care visit. His diabetes is well controlled on metformin, with fasting glucose concentrations between 110–150 mg/dl. His blood pressure on multiple office visits are between 115-130/75-85 mmHg. Today his temperature is 98°F (36.7 °C), blood pressure is 125/80 mmHg, pulse is 86/min, and respirations are 15/min. Labs are obtained with the following results:\n\nHemoglobin A1c: 6.7%\nGlucose: 120 mg/dl\nCholesterol (plasma): 190 mg/dL\nUrine albumin: 60mg/24hr\n\nWhich of the following treatments is effective in slowing the progression of the most likely cause of this patient's abnormal albumin result?", "answer": "Enalapril", "options": {"A": "No effective treatments", "B": "Enalapril", "C": "Metformin", "D": "Simvastatin", "E": "Aspirin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "history of diabetes mellitus presents", "diabetes", "well controlled", "metformin", "fasting glucose concentrations", "mg/dl", "blood pressure", "multiple", "75 85 mmHg", "Today", "temperature", "36", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "Labs", "obtained", "following results", "Hemoglobin A1c", "Glucose", "mg/dl Cholesterol", "plasma", "mg/dL Urine albumin", "following treatments", "effective", "slowing", "progression", "likely cause", "patient's abnormal albumin result"]}
{"question": "A 24-year-old woman with a missed menstrual cycle has a positive pregnancy test. The estimated gestational age is 4 weeks. The patient questions the pregnancy test results and mentions that a urinary pregnancy test she took 3 weeks ago was negative. What is the explanation for the patient’s first negative pregnancy test result?", "answer": "The syncytiotrophoblast had not yet developed to produce human chorionic gonadotropin at that term.", "options": {"A": "The embryonic liver has not yet developed to produce human chorionic gonadotropin at that term.", "B": "The syncytiotrophoblast had not yet developed to produce human chorionic gonadotropin at that term.", "C": "Pregnancy test becomes positive during organogenesis so should be expected positive no earlier than at week 4.", "D": "Human chorionic gonadotropin starts to be produced by the uterus only after the embryonic implantation which has not yet occurred.", "E": "Human chorionic gonadotropin can only be found in the urine after its placental production is started."}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "missed menstrual cycle", "positive pregnancy test", "estimated gestational age", "4 weeks", "patient", "pregnancy test results", "urinary pregnancy test", "3 weeks", "negative", "explanation", "patients first negative pregnancy test result"]}
{"question": "A 68-year-old man is brought to the emergency department by ambulance after he fainted in the supermarket. He recently had 2 days of gastroenteritis, but did not come to the hospital for treatment. He also recently arrived in Denver for a vacation, but normally lives in Florida. His past medical history is significant for morbid obesity and heavy alcohol use. Arterial blood gas and serum chemistry results are shown below:\n\nSodium: 138 mEq/L\nChloride: 121 mEq/L\nBicarbonate: 8 mEq/L\npH: 7.25\nPaCO2: 20 mmHg\n\nWhich of the following etiologies is most likely responsible for this patient's findings?", "answer": "Diarrhea", "options": {"A": "Altitude sickness", "B": "Diarrhea", "C": "Ethanol consumption", "D": "Hypoventilation", "E": "Vomiting"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "fainted", "supermarket", "recently", "2 days", "gastroenteritis", "not", "hospital", "treatment", "recently", "lives", "Florida", "past medical history", "significant", "morbid obesity", "heavy alcohol use", "Arterial blood gas", "serum chemistry results", "Sodium", "mEq/L", "mEq/L Bicarbonate", "mEq/L pH", "20 mmHg", "following etiologies", "responsible", "patient's findings"]}
{"question": "A 15-year-old boy is brought to the emergency department by his mother because of a 5-hour history of right lower quadrant pain, vomiting, and abdominal distention. Examination shows a palpable mass in the right lower quadrant of the abdomen. An x-ray of the abdomen shows a dilated ascending colon with an air-fluid level in the small intestine. A test is performed in which electrodes are placed on the nasal epithelium and the nose is perfused with several different solutions. When a chloride-free solution is administered, hyperpolarization across the nasal epithelium is absent. Which of the following is the most common cause of mortality in patients with the condition described here?", "answer": "Pulmonary infection", "options": {"A": "Liver cirrhosis", "B": "Pulmonary embolism", "C": "Diabetes mellitus", "D": "Pulmonary infection", "E": "Nephrolithiasis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "hour history", "right lower quadrant pain", "vomiting", "abdominal distention", "palpable mass", "right lower quadrant of", "abdomen", "x-ray of", "abdomen", "dilated ascending colon", "air-fluid level", "small intestine", "test", "performed", "electrodes", "nasal epithelium", "nose", "perfused", "different", "free solution", "administered", "nasal epithelium", "absent", "following", "most common cause", "mortality", "patients", "condition"]}
{"question": "An 8-year-old boy is brought by his mother to his pediatrician because his urine is tea-colored and his face has appeared puffy for the past 2 days. He suffered a fever and sore throat several weeks ago that was treated with ibuprofen. 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. Today, his heart rate is 100/min, the respiratory rate is 22/min, the blood pressure is 130/80 mm Hg, and the temperature is 36.8°C (98.2°F). On physical exam the boy has mild periorbital swelling. A urine dipstick reveals 1+ proteinuria and urinalysis reveals 10–15 red cells/high power field and dysmorphic red cells. The pediatrician is concerned with the child’s hypertension, facial edema, and abnormal urine analysis results. Which of the following best represents the mechanism of this patient’s condition?", "answer": "Immune complex deposition", "options": {"A": "Diffuse mesangial IgA deposition", "B": "Immune complex deposition", "C": "Complement-dependent antibody reaction", "D": "Complement-independent reaction", "E": "Podocyte injury"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "urine", "colored", "face", "appeared puffy", "past 2 days", "suffered", "fever", "sore throat", "weeks", "treated with ibuprofen", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "Today", "heart rate", "100 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "temperature", "36", "98", "boy", "mild periorbital swelling", "urine dipstick reveals 1", "proteinuria", "urinalysis reveals", "red cells/high power field", "dysmorphic", "pediatrician", "childs hypertension", "facial edema", "abnormal urine analysis results", "following best", "mechanism", "patients condition"]}
{"question": "A 39-year-old man presents to his primary care physician with new onset lower extremity edema, fatigue, and hematuria. His symptoms began approximately 2 weeks prior to presentation and have progressively worsened. Medical history is significant for opioid-use disorder with heroin treated with methadone. He is in a monogamous relationship with a female partner of 4 years and does not use condoms. He denies cigarette smoking, alcohol use, and last used heroin approximately 1 month ago. His temperature is 99°F (37.2°C), blood pressure is 152/98 mmHg, pulse is 83/min, and respirations are 17/min. On physical exam, there is conjunctival pallor, scleral icterus, a 14 cm liver span, acrocyanosis, and lower extremity 2+ pitting edema. Urinalysis demonstrates proteinuria and dysmorphic red blood cells. Laboratory testing reveals a mildly decreased C3 and decreased C4 serum concentration. Which of the following will most likely be present on renal biopsy in this patient?", "answer": "Diffuse mesangial cell proliferation with capillary wall thickening", "options": {"A": "Apple-green birefringence on Congo red stain", "B": "Diffuse mesangial cell proliferation with capillary wall thickening", "C": "Enlarged and hypercellular glomeruli", "D": "Glomerular basement membrane thinning and splitting", "E": "Normal appearing glomerulus"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "new onset lower extremity edema", "fatigue", "hematuria", "symptoms began approximately 2 weeks prior to", "worsened", "Medical history", "significant", "opioid-use disorder", "heroin treated with methadone", "relationship", "female", "years", "not use condoms", "cigarette smoking", "last used heroin approximately", "month", "temperature", "blood pressure", "98 mmHg", "pulse", "83 min", "respirations", "min", "conjunctival pallor", "scleral icterus", "liver span", "acrocyanosis", "lower extremity", "pitting edema", "Urinalysis", "proteinuria", "dysmorphic red blood cells", "Laboratory testing reveals", "mildly decreased C3", "decreased C4 serum", "following", "most likely", "present", "renal biopsy", "patient"]}
{"question": "A 16-year-old boy presents after suffering a tonic-clonic seizure. He says it had a duration of 2 minutes and a postictal period of 10 minutes. Patient denies any similar episodes in the past. Past medical history is unremarkable. Family history is significant for his mother and older brother who died of colorectal cancer at ages 40 and 20, respectively. On physical examination, the patient is drowsy but arousable and responsive to commands. Both pupils are symmetrical and responsive to light. An MRI of the brain reveals an infratentorial hypointense cerebellar mass with a small cystic area. Which of the following is the most likely diagnosis in this patient?", "answer": "Turcot syndrome", "options": {"A": "Peutz-Jeghers syndrome", "B": "Lynch syndrome", "C": "Gardner syndrome", "D": "Turcot syndrome", "E": "Cowden syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "suffering", "tonic-clonic seizure", "duration", "minutes", "period", "10 minutes", "Patient", "similar episodes", "past", "medical history", "unremarkable", "Family history", "significant", "died", "colorectal cancer", "ages 40", "20", "patient", "drowsy", "responsive", "pupils", "symmetrical", "responsive", "light", "MRI of", "brain reveals", "infratentorial", "cerebellar mass", "small cystic area", "following", "diagnosis", "patient"]}
{"question": "A 2-day-old boy fails to pass meconium for the first 48 hours of life. He was born at term to a healthy 19-year-old woman after an uncomplicated pregnancy. At birth, his weight was 3.9 kg (8.6 lb); at the time of presentation, he weighs 3.8 kg (8.4 lb). His vital signs are as follows: blood pressure 70/50 mm Hg, heart rate 130/min, respiratory rate 33/min, and temperature 37.0℃ (98.6℉). On physical examination, he is fussy and appears mildly dehydrated. Bowel sounds are active on auscultation. His abdomen is mildly distended and no masses can be identified on palpation. The patient’s anus is patent. An upper gastrointestinal study with oral contrast demonstrates normal anatomy. A lower gastrointestinal series with barium enema reveals a large amount of retained barium contrast within a dilated sigmoid colon and a normal appearing rectum. The barium solution retention persisted beyond 24 hours after administration. Which of the following best describes the cause of the patient’s symptoms?", "answer": "Failure of neural crest cells to migrate caudally to intestinal wall during embryogenesis", "options": {"A": "Failure of neural crest cells to migrate caudally to intestinal wall during embryogenesis", "B": "Disruption of apoptosis of intestinal cells", "C": "Hypertrophy of the muscular layer of the lower sigmoid colon", "D": "Propelling of a polyp distally by peristalsis", "E": "Decreased blood supply to developing intestine in the embryonic period"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2-day old boy fails to pass meconium", "first 48 hours", "born", "term", "healthy", "year old woman", "uncomplicated", "birth", "weight", "3.9 kg", "8.6", "time", "3", "kg", "8.4", "vital signs", "follows", "blood pressure 70 50 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "0", "98", "fussy", "appears mildly dehydrated", "Bowel sounds", "active", "auscultation", "abdomen", "mildly distended", "masses", "identified", "palpation", "patients anus", "patent", "upper gastrointestinal study", "oral contrast", "normal anatomy", "lower gastrointestinal series", "barium enema reveals", "large amount", "retained barium contrast", "dilated sigmoid colon", "normal appearing rectum", "retention", "24 hours", "administration", "following best", "cause", "patients symptoms"]}
{"question": "A 34-year-old woman with a past medical history of obesity and longstanding GERD presents to the emergency room with chest pain. She describes the pain as central with a sensation of something being stuck in her chest, and this is the third episode in the last month. The prior two incidents occurred at the gym while she was drinking a sport drink and resolved after resting for 3-4 minutes. This episode started after she received news that her father had just had a heart attack at age 69 and has lasted for 15 minutes. The patient also notes several months of intermittent difficulty swallowing but denies palpitations, diaphoresis, or shortness of breath. The patient has a family history of scleroderma in her mother. In the emergency room, her temperature is 98.4°F (36.8°C), blood pressure is 143/82 mmHg, pulse is 89/min, and respirations are 16/min. The patient appears mildly uncomfortable but exam is otherwise unremarkable. Which of the following is the most appropriate confirmatory test for this patient’s condition?", "answer": "Esophageal manometry", "options": {"A": "Endoscopy", "B": "Esophageal manometry", "C": "Barium swallow", "D": "EKG", "E": "Troponin I"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "past medical", "GERD presents", "emergency room", "chest pain", "pain", "central", "sensation", "stuck", "chest", "third episode", "month", "prior two", "drinking", "resolved", "minutes", "episode started", "received", "heart attack", "age 69", "lasted", "15 minutes", "patient", "notes several months", "intermittent difficulty swallowing", "palpitations", "diaphoresis", "shortness of breath", "patient", "family history of scleroderma", "emergency room", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "patient appears mildly", "exam", "unremarkable", "following", "most appropriate confirmatory test", "patients condition"]}
{"question": "A 35-year-old man comes to the physician because of several episodes of crushing substernal chest pain on exertion over the past 6 weeks. The pain occurs when he goes for his morning run and disappears if he slows down to a walk. The patient is concerned because two of his uncles died of myocardial infarction in their early 50s. Physical examination shows yellow plaques on both the palms. An ECG shows no abnormalities. Serum lipid studies show:\nTotal cholesterol 650 mg/dL\nHDL cholesterol 30 mg/dL\nVLDL cholesterol 185 mg/dL\nTriglycerides 800 mg/dL\nChylomicron remnants elevated\nWhich of the following is the most likely cause of this patient's symptoms?\"", "answer": "Defective apolipoprotein E\n\"", "options": {"A": "Hepatic overproduction of VLDL", "B": "Defective apolipoprotein B-100", "C": "Decreased apolipoprotein B-48", "D": "Decreased apolipoprotein C-II", "E": "Defective apolipoprotein E\n\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["35 year old man", "physician", "of several episodes", "crushing substernal chest pain", "exertion", "past", "weeks", "pain occurs", "morning run", "slows", "patient", "two", "died", "myocardial infarction", "early", "yellow plaques", "ECG", "abnormalities", "Serum lipid studies", "Total cholesterol", "mg/dL HDL cholesterol 30", "VLDL", "Triglycerides", "Chylomicron remnants elevated", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 35-year-old woman comes to the physician because of a 2-month history of vaginal bleeding after intercourse. Menarche occurred at the age of 13 years and menses occur at regular 28-day intervals. Gynecologic examination shows an irregular lesion at the cervical os. Histological evaluation of a cervical biopsy specimen obtained on colposcopy confirms a diagnosis of in-situ cervical cancer. This cancer is most likely derived from which of the following types of cells?", "answer": "Non-keratinized stratified squamous epithelium", "options": {"A": "Simple columnar epithelium with tubular glands", "B": "Ciliated simple columnar epithelium", "C": "Non-keratinized stratified squamous epithelium", "D": "Simple cuboidal epithelium", "E": "Keratinized stratified squamous epithelium"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old woman", "physician", "2 month history", "vaginal bleeding", "intercourse", "Menarche", "age", "years", "menses occur", "regular", "day intervals", "irregular lesion", "cervical", "Histological", "obtained", "colposcopy confirms", "diagnosis", "in-situ cervical cancer", "cancer", "most likely derived", "following"]}
{"question": "A 55-year-old college professor with a long-standing history of neuropathic pain presents to a medical clinic with weight loss and early morning awakening for the past several months. She feels as if she has no energy to go about her work. She complains that she is not as focused at work or home as she used to be and finds both her life and work unfulfilling. She has had these symptoms for the past 2 months. She was started on antidepressants in the past, but the antidepressants did not provide any significant improvement. She eventually improved and has been in remission for almost 1 year now. She would really like a simple treatment option to address both her neuropathic pain and her depression, and she is started on a tricyclic antidepressant. What safety advice is most important for this patient’s treatment plan?", "answer": "The medication can cause serotonin syndrome.", "options": {"A": "The medication can cause serotonin syndrome.", "B": "The medication can cause agranulocytosis.", "C": "The medication can lower the seizure threshold.", "D": "The medication has a very short half-life.", "E": "This medication is rarely lethal at high doses."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old college professor", "long standing history", "neuropathic pain presents", "medical clinic", "weight loss", "early morning awakening", "past", "months", "energy to go", "not", "focused", "home", "used to", "finds", "symptoms", "past", "months", "started", "antidepressants", "past", "antidepressants", "not", "significant", "improved", "remission", "almost", "year now", "simple treatment option to", "neuropathic pain", "depression", "started", "tricyclic antidepressant", "most important", "patients"]}
{"question": "A 8-month-old girl is brought to the emergency department because of fever, vomiting, and diarrhea for 3 days. Her parents report at least 10 watery stools daily. She has had three upper respiratory tract infections since she started daycare 2 months ago, but has otherwise been developing normally. Her mother has a history of celiac disease. The patient is at the 57th percentile for height and the 65th percentile for weight. Her immunizations are incomplete. Her temperature is 38.5°C (101.3°F), pulse is 145/min, and blood pressure is 92/54 mm Hg. Examination shows dry mucous membranes and decreased skin turgor. Bowel sounds are hyperactive. A complete blood count and serum concentrations of glucose, urea nitrogen, and creatinine are within the reference range; there is hypokalemia. In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in management?", "answer": "Enzyme immunoassay of stool", "options": {"A": "Sonography of the abdomen", "B": "Administration of antidiarrheal medication", "C": "Blood cultures", "D": "Examination of the stool for ova and parasites", "E": "Enzyme immunoassay of stool"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["month old girl", "brought", "emergency department", "fever", "vomiting", "diarrhea", "3 days", "report at least 10 watery stools daily", "three upper respiratory tract infections", "started daycare 2 months", "history of", "disease", "patient", "percentile", "height", "percentile", "weight", "immunizations", "incomplete", "temperature", "pulse", "min", "blood pressure", "54 mm Hg", "dry mucous membranes", "decreased", "Bowel sounds", "hyperactive", "complete blood count", "serum", "glucose", "urea nitrogen", "creatinine", "reference range", "hypokalemia", "intravenous fluid resuscitation", "following", "most appropriate next step"]}
{"question": "A 5-year-old girl is brought to her pediatrician for vaccinations and a physical. She is a generally healthy child with no thumb on her right hand and a shortened and deformed left thumb. She was born at 39 weeks gestation via spontaneous vaginal delivery and is up to date on all vaccines and meeting all developmental milestones. On physical examination her vital signs are stable. On auscultation of the heart, the pediatrician notes a wide fixed split in the second heart sound (S2) and a medium-pitched systolic ejection murmur at the left sternal border. The murmur is not harsh in quality and is not accompanied by a thrill. Her echocardiogram confirms the diagnosis of acyanotic congenital heart defect with left-to-right shunt. Which of the following genetic syndromes is most consistent d with this girl’s congenital defects?", "answer": "Holt-Oram syndrome", "options": {"A": "Alagille syndrome", "B": "DiGeorge syndrome", "C": "Holt-Oram syndrome", "D": "Marfan syndrome", "E": "Williams-Beuren syndrome"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["5 year old girl", "brought", "pediatrician", "vaccinations", "physical", "healthy child", "thumb", "right hand", "shortened", "deformed left thumb", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "vital signs", "stable", "auscultation of", "heart", "pediatrician notes", "wide fixed split", "second heart sound", "S2", "medium-pitched systolic ejection murmur", "left sternal border", "murmur", "not harsh", "quality", "not", "thrill", "echocardiogram confirms", "diagnosis", "congenital heart defect", "left-to-right shunt", "following genetic syndromes", "most", "girls congenital defects"]}
{"question": "A 23-year-old woman presents to the emergency department with pain and frequent urination. She states she has felt uncomfortable with frequent small-volume urinary voids for the past 3 days, which have progressively worsened. The patient has no past medical history. She currently smokes 1 pack of cigarettes per day and engages in unprotected sex with 2 male partners. Her temperature is 103°F (39.4°C), blood pressure is 127/68 mmHg, pulse is 97/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiac, pulmonary, and abdominal exams are within normal limits. There is tenderness upon palpation of the left costovertebral angle and the left flank. Urine is collected and a pregnancy test is negative. Which of the following is the best next step in management?", "answer": "Levofloxacin and outpatient followup", "options": {"A": "Abscess drainage and IV antibiotics", "B": "Analgesics, encourage oral fluid intake, and discharge", "C": "Ceftriaxone and hospital admission", "D": "Levofloxacin and outpatient followup", "E": "Nitrofurantoin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old woman presents", "emergency department", "pain", "frequent urination", "states", "frequent small volume urinary voids", "past", "days", "worsened", "patient", "past medical history", "currently smokes 1 pack", "cigarettes", "day", "2 male", "temperature", "blood pressure", "mmHg", "pulse", "97 min", "respirations", "min", "oxygen saturation", "98", "room air", "Cardiac", "pulmonary", "abdominal exams", "normal limits", "tenderness", "palpation", "left costovertebral angle", "left flank", "Urine", "collected", "pregnancy test", "negative", "following", "best next step"]}
{"question": "A 37-year-old woman presents to the occupational health clinic for a new employee health screening. She has limited medical records prior to her immigration to the United States several years ago. She denies any current illness or significant medical history. Purified protein derivative (PPD) is injected on the inside of her left forearm for tuberculosis (TB) screening. Approximately 36 hours later, the patient comes back to the occupational health clinic and has an indurated lesion with bordering erythema measuring 15 mm in diameter at the site of PPD injection. Of the following options, which is the mechanism of her reaction?", "answer": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "options": {"A": "Type I–anaphylactic hypersensitivity reaction", "B": "Type II–cytotoxic hypersensitivity reaction", "C": "Type III–immune complex-mediated hypersensitivity reaction", "D": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "E": "Type III and IV–mixed immune complex and cell-mediated hypersensitivity reactions"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "occupational health clinic", "new employee health screening", "limited medical records prior to", "United States", "years", "current illness", "significant medical history", "Purified protein derivative", "injected", "left forearm", "Approximately 36 hours later", "patient", "back", "occupational health clinic", "indurated lesion", "bordering erythema measuring", "mm", "diameter", "site of PPD injection", "following options", "mechanism", "reaction"]}
{"question": "A 32-year-old HIV positive female known to be non-adherent to her treatment regimen, presents to the hospital with the complaint of new-onset headaches. Her vital signs are only significant for a low-grade fever. Neurological examination reveals right-sided upper motor neuron signs, as well as a inattention and difficulty with concentration. The patient currently does not have a primary medical provider. A CT of the patients head is shown in the image below. What is the next best step in management for this patient?", "answer": "Begin treatment with pyrimethamine-sulfadiazine", "options": {"A": "Perform a biopsy of the lesion", "B": "Perform an analysis for 14-3-3 protein levels", "C": "Begin treatment with pyrimethamine-sulfadiazine", "D": "Begin treatment with albendazole and corticosteroids", "E": "Begin treatment with acyclovir"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old HIV positive female known to", "non", "treatment regimen", "presents", "hospital", "complaint", "new-onset headaches", "vital signs", "only significant", "low-grade fever", "Neurological examination reveals right-sided upper motor neuron signs", "inattention", "difficulty", "concentration", "patient currently", "not", "primary medical provider", "CT of", "patients head", "next best step", "patient"]}
{"question": "A 29-year-old woman, gravida 1, para 1, comes to the physician because of difficulty conceiving for one year. She is sexually active with her husband 4–5 times a week. Pregnancy and delivery of her first child 3 years ago were uncomplicated. She returned to work as an event coordinator 12 months ago and has found the transition stressful. Menses previously occurred at 30-day intervals and lasted for 3–4 days with moderate flow. Her last menstrual period was three months ago. She has occasional vaginal dryness. The patient runs 5 to 10 miles every day. Her BMI is 19.0 kg/m2. Her pulse is 73/min and blood pressure is 125/70 mm Hg. Abdominal examination shows no abnormalities. Pelvic examination shows dry vaginal mucosa. A serum pregnancy test is negative. Serum studies show:\nProlactin 18 μg/L\nThyroid-stimulating hormone 2.5 mU/L\nFollicle-stimulating hormone 3.6 U/L\nLuteinizing hormone 2.3 U/L\nUltrasound of the pelvis shows no abnormalities. In addition to dietary and exercise counseling, which of the following is the most appropriate next step in management?\"", "answer": "Offer pulsatile gonadotropin-releasing hormone therapy", "options": {"A": "Offer clomiphene citrate therapy", "B": "Offer in vitro fertilization", "C": "Offer pulsatile gonadotropin-releasing hormone therapy", "D": "Offer human chorionic gonadotropin therapy", "E": "Obtain MRI of the pituitary gland"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "gravida 1", "para 1", "physician", "difficulty conceiving", "one year", "sexually active", "times", "week", "Pregnancy", "delivery", "first", "years", "uncomplicated", "returned to", "event coordinator 12 months", "found", "transition stressful", "Menses", "30 day intervals", "lasted", "days", "moderate", "last menstrual period", "three months", "occasional vaginal dryness", "patient runs 5", "10 miles", "day", "BMI", "0 kg/m2", "pulse", "min", "blood pressure", "70 mm Hg", "Abdominal", "abnormalities", "Pelvic examination", "dry vaginal", "serum pregnancy test", "negative", "Serum studies", "Prolactin", "g", "Thyroid", "mU", "Follicle-stimulating hormone", "U", "Luteinizing hormone", "Ultrasound", "pelvis", "abnormalities", "dietary", "exercise counseling", "following", "most appropriate next step"]}
{"question": "A neonate is noted to have very light skin, light blue eyes, and sparse blonde-white hair. The family states that the baby is much lighter in appearance than anyone else in the family. Both parents are Fitzpatrick skin type III with dark brown hair. On further exam, the baby's temperature is 98.4°F (36.9°C), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 14/min. The patient is oxygenating well at SpO2 of 97% on room air with no respiratory distress. All reflexes are appropriate, and the APGAR score is 10. A referral is placed with Ophthalmology for a comprehensive eye exam. The condition is believed to be due to an enzyme deficiency, and a hair bulb assay is performed. Which of the following substrates should be incubated with the specimen in order to determine the activity of the enzyme in question for this disease?", "answer": "Dihydroxyphenylalanine", "options": {"A": "Dihydroxyphenylalanine", "B": "Dopamine", "C": "Homogentisic Acid", "D": "Pyridoxine", "E": "Tetrahydrobiopterin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["neonate", "noted to", "very light skin", "light", "white hair", "states", "baby", "much lighter", "appearance", "else", "Fitzpatrick skin type III", "dark brown hair", "further exam", "baby's temperature", "98", "36", "blood pressure", "70 mmHg", "pulse", "88 min", "respirations", "min", "patient", "well", "97", "room air", "respiratory distress", "reflexes", "appropriate", "APGAR score", "10", "Ophthalmology", "comprehensive eye exam", "condition", "to", "due to", "enzyme deficiency", "hair bulb assay", "performed", "following substrates", "incubated", "order to", "disease"]}
{"question": "A 2-year-old girl is brought to the emergency room by her parents for seizure-like activity earlier today. Her mother describes that she was napping when both of her arms began to twitch and she started foaming at the mouth. She was unresponsive during this time and the episode lasted a total of 30 seconds. The mother denies any fever, pain, recent trauma, changes in feeding, or gastrointestinal changes in her daughter. She states her daughter has recently been lethargic and is currently receiving antibiotics for an ear infection. The patient was born vaginally at home via a midwife without any complications. A physical examination is unremarkable. Results of her laboratory studies are shown below.\n\nHemoglobin: 13 g/dL\nHematocrit: 38%\nLeukocyte count: 7,600/mm^3 with normal differential\nPlatelet count: 170,000/mm^3\n\nSerum:\nNa+: 136 mEq/L\nCl-: 101 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 20 mEq/L\nBUN: 25 mg/dL\nGlucose: 34 mmol/L\nCreatinine: 0.8 mg/dL\nThyroid-stimulating hormone: 3.2 µU/mL\nCa2+: 9.3 mg/dL\nAST: 183 U/L\nALT: 220 U/L\n\nWhat is the most likely explanation for this patient’s symptoms?", "answer": "Medium-chain acyl-CoA dehydrogenase deficiency", "options": {"A": "Accumulation of sphingomyelin", "B": "Defieincy of myophosphorylase", "C": "Infection with Streptococcus pneumoniae", "D": "Medium-chain acyl-CoA dehydrogenase deficiency", "E": "Primary carnitine deficiency"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["2 year old girl", "brought", "emergency room", "seizure", "activity earlier today", "napping", "arms began to twitch", "started foaming at", "mouth", "unresponsive", "time", "episode lasted", "total", "30 seconds", "fever", "pain", "recent trauma", "changes", "gastrointestinal changes", "states", "recently", "lethargic", "currently receiving antibiotics", "ear", "patient", "born", "home", "midwife", "complications", "unremarkable", "Results", "laboratory studies", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "7 600 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "3.9 mEq/L HCO3", "20 mEq/L", "mg/dL Glucose", "mmol/L Creatinine", "0.8 mg/dL Thyroid-stimulating hormone", "3.2 U/mL Ca2", "dL AST", "U/L ALT", "U/L", "patients symptoms"]}
{"question": "A first-year medical student is analyzing data in a nationwide cancer registry. She identified a group of patients who had recently undergone surgery for epithelial ovarian cancer and achieved a complete clinical response to chemotherapy. Some of these patients had been scheduled to receive annual abdominal CTs while other patients had not been scheduled for such routine imaging surveillance. The medical student then identified a subgroup of patients who have developed recurrent metastatic disease despite their previous complete clinical response to chemotherapy and surgery. She compared patients who were diagnosed with metastatic cancer during routine follow-up imaging with patients who were diagnosed with metastatic cancer based on clinical symptoms at routine follow-up history and physical exams. She found that the average survival of patients who underwent routine imaging was four months longer than the survival of their peers who were diagnosed based on history and physical exam. Which of the following is a reason why these results should be interpreted with caution?", "answer": "Lead-time bias", "options": {"A": "Observer bias", "B": "Lead-time bias", "C": "Confounding bias", "D": "Length-time bias", "E": "Surveillance bias"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["first year medical student", "data", "identified", "patients", "recently", "surgery", "epithelial ovarian cancer", "complete clinical response", "chemotherapy", "patients", "scheduled to receive annual abdominal CTs", "patients", "not", "scheduled", "routine imaging surveillance", "medical student then identified", "patients", "recurrent metastatic disease", "previous complete clinical response", "chemotherapy", "surgery", "patients", "diagnosed", "metastatic cancer", "routine follow-up imaging", "patients", "diagnosed", "metastatic cancer based", "clinical symptoms", "routine follow-up history", "found", "average survival", "patients", "routine imaging", "four months longer", "survival", "diagnosed based", "history", "following", "results", "interpreted"]}
{"question": "A 43-year-old man is brought to the physician for a follow-up examination. He has a history of epilepsy that has been treated with a stable dose of phenytoin for 15 years. He was recently seen by another physician who added a drug to his medications, but he cannot recall the name. Shortly after, he started noticing occasional double vision. Physical examination shows slight vertical nystagmus and gait ataxia. Which of the following drugs was most likely added to this patient's medication regimen?", "answer": "Cimetidine", "options": {"A": "Modafinil", "B": "Nafcillin", "C": "Cimetidine", "D": "St. John's wort", "E": "Rifampin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "physician", "follow-up examination", "history of epilepsy", "treated with", "stable dose", "phenytoin", "years", "recently seen by", "physician", "added", "drug", "medications", "name", "started", "occasional double vision", "slight vertical nystagmus", "gait ataxia", "following drugs", "most likely added", "patient's medication regimen"]}
{"question": "A 28-year-old man presents to his psychiatrist for continuing cognitive behavioral therapy for bipolar disorder. At this session, he reveals that he has had fantasies of killing his boss because he feels he is not treated fairly at work. He says that he has been stalking his boss and has made detailed plans for how to kill him in about a week. He then asks his psychiatrist not to reveal this information and says that he shared it only because he knew these therapy sessions would remain confidential. Which of the following actions should the psychiatrist take in this scenario?", "answer": "Contact the police to warn them about this threat against the patient's wishes", "options": {"A": "Ask for the patient's permission to share this information and share only if granted", "B": "Contact the police to warn them about this threat against the patient's wishes", "C": "Refer the patient to the ethics board of the hospital that meets in 1 week", "D": "Respect patient confidentiality and do not write down this information", "E": "Write the information in the note but do not contact the police"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "psychiatrist", "cognitive behavioral therapy", "bipolar disorder", "reveals", "boss", "not treated", "stalking", "boss", "made detailed plans", "to kill", "about", "week", "then", "psychiatrist not to reveal", "shared", "only", "therapy", "confidential", "following actions", "psychiatrist", "scenario"]}
{"question": "A 32-year-old woman is admitted to the hospital with headache, photophobia, vomiting without nausea, and fever, which have evolved over the last 12 hours. She was diagnosed with systemic lupus erythematosus at 30 years of age and is on immunosuppressive therapy, which includes oral methylprednisolone. She has received vaccinations—meningococcal and pneumococcal vaccination, as well as BCG. Her vital signs are as follows: blood pressure 125/70 mm Hg, heart rate 82/min, respiratory rate 15/min, and temperature 38.7°C (101.7°F). On examination, her GCS score is 15. Pulmonary, cardiac, and abdominal examinations are within normal limits. A neurologic examination does not reveal focal symptoms. Moderate neck stiffness and a positive Brudzinski’s sign are noted. Which of the following would you expect to note in a CSF sample?", "answer": "Listeria monocytogenes growth in the CSF culture", "options": {"A": "Lymphocytic pleocytosis", "B": "Formation of a spiderweb clot in the collected CSF", "C": "Haemophilus influenzae growth is the CSF culture", "D": "Decrease in CSF protein level", "E": "Listeria monocytogenes growth in the CSF culture"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "headache", "photophobia", "vomiting without nausea", "fever", "evolved", "12 hours", "diagnosed", "systemic lupus erythematosus", "30 years", "age", "immunosuppressive therapy", "includes", "received", "pneumococcal vaccination", "vital signs", "follows", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "GCS score", "Pulmonary", "cardiac", "abdominal", "normal limits", "neurologic examination", "not reveal focal symptoms", "Moderate neck stiffness", "positive", "sign", "noted", "following", "to note", "CSF"]}
{"question": "A 45-year-old female presents to the emergency room as a trauma after a motor vehicle accident. The patient was a restrained passenger who collided with a drunk driver traveling approximately 45 mph. Upon impact, the passenger was able to extricate herself from the crushed car and was sitting on the ground at the scene of the accident. Her vitals are all stable. On physical exam, she is alert and oriented, speaking in complete sentences with a GCS of 15. She has a cervical spine collar in place and endorses exquisite cervical spine tenderness on palpation. Aside from her superficial abrasions on her right lower extremity, the rest of her examination including FAST exam is normal. Rapid hemoglobin testing is within normal limits. What is the next best step in management of this trauma patient?", "answer": "CT cervical spine", "options": {"A": "CT cervical spine", "B": "Remove the patient’s cervical collar immediately", "C": "Discharge home and start physical therapy", "D": "Consult neurosurgery immediately", "E": "Initiate rapid sequence intubation."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old female presents", "emergency room", "trauma", "motor vehicle", "patient", "restrained", "approximately", "mph", "impact", "able to", "crushed car", "sitting", "stable", "alert", "oriented", "complete", "GCS", "cervical collar", "place", "cervical spine tenderness", "palpation", "superficial abrasions", "right lower extremity", "including FAST exam", "normal", "Rapid hemoglobin", "normal limits", "next best step", "management", "trauma patient"]}
{"question": "A 41-year-old man presents to the emergency department with several days of hand tremor, vomiting, and persistent diarrhea. His wife, who accompanies him, notes that he seems very “out of it.” He was in his usual state of health last week and is now having difficulties at work. He has tried several over-the-counter medications without success. His past medical history is significant for bipolar disorder and both type 1 and type 2 diabetes. He takes lithium, metformin, and a multivitamin every day. At the hospital, his heart rate is 90/min, respiratory rate is 17/min, blood pressure is 130/85 mm Hg, and temperature is 37.0°C (98.6°F). The man appears uncomfortable. His cardiac and respiratory exams are normal and his bowel sounds are hyperactive. His lithium level is 1.8 mEq/L (therapeutic range, 0.6–1.2 mEq/L). Which of the following may have contributed to this patient’s elevated lithium level?", "answer": "Decreased salt intake", "options": {"A": "Decreased salt intake", "B": "Weight loss", "C": "Large amounts of caffeine intake", "D": "Addition of fluoxetine to lithium therapy", "E": "Addition of lurasidone to lithium therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "several days of hand tremor", "vomiting", "persistent diarrhea", "notes", "very out", "usual state of health", "week", "now", "difficulties", "over-the-counter medications", "past medical history", "significant", "bipolar disorder", "type 1", "type 2 diabetes", "lithium", "metformin", "multivitamin", "day", "hospital", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "85 mm Hg", "temperature", "98", "man appears", "cardiac", "respiratory exams", "normal", "bowel sounds", "hyperactive", "lithium level", "1.8 mEq/L", "therapeutic range", "0 61 mEq/L", "following", "patients elevated lithium level"]}
{"question": "A 45-year-old man presents for a routine checkup. He says he has arthralgia in his hands and wrists. No significant past medical history. The patient takes no current medications. Family history is significant for his grandfather who died of liver cirrhosis from an unknown disease. He denies any alcohol use or alcoholism in the family. The patient is afebrile and vital signs are within normal limits. On physical examination, there is bronze hyperpigmentation of the skin and significant hepatomegaly is noted. The remainder of the exam is unremarkable. Which of the following is true about this patient’s most likely diagnosis?", "answer": "A triad of cirrhosis, diabetes mellitus, and skin pigmentation is characteristic", "options": {"A": "The associated dilated cardiomyopathy is irreversible", "B": "The arthropathy is due to iron deposition in the joints.", "C": "A hypersensitivity reaction to blood transfusions causes the iron to accumulate", "D": "Increased ferritin activity results in excess iron accumulation", "E": "A triad of cirrhosis, diabetes mellitus, and skin pigmentation is characteristic"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "routine checkup", "arthralgia", "hands", "wrists", "significant past medical history", "patient", "current medications", "Family history", "significant", "died of liver cirrhosis", "unknown disease", "alcoholism in", "family", "patient", "afebrile", "vital signs", "normal limits", "bronze hyperpigmentation of the skin", "significant hepatomegaly", "noted", "exam", "unremarkable", "following", "true", "patients", "likely diagnosis"]}
{"question": "A 35-year-old man comes to the physician because of a 2-month history of upper abdominal pain that occurs immediately after eating. The pain is sharp, localized to the epigastrium, and does not radiate. He reports that he has been eating less frequently to avoid the pain and has had a 4-kg (8.8-lb) weight loss during this time. He has smoked a pack of cigarettes daily for 20 years and drinks 3 beers daily. His vital signs are within normal limits. He is 165 cm (5 ft 5 in) tall and weighs 76.6 kg (169 lb); BMI is 28 kg/m2. Physical examination shows mild upper abdominal tenderness with no guarding or rebound. Bowel sounds are normal. Laboratory studies are within the reference range. This patient is at greatest risk for which of the following conditions?", "answer": "Gastrointestinal hemorrhage", "options": {"A": "Malignant transformation", "B": "Biliary tract infection", "C": "Pyloric scarring", "D": "Gastrointestinal hemorrhage", "E": "Subhepatic abscess formation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old man", "physician", "2 month history", "upper abdominal pain", "occurs immediately", "eating", "pain", "sharp", "localized", "epigastrium", "not radiate", "reports", "eating less frequently to", "pain", "4 kg", "8.8", "weight loss", "time", "smoked", "pack", "cigarettes daily", "20 years", "3", "daily", "vital signs", "normal limits", "5 ft 5", "tall", "76", "kg", "BMI", "kg/m2", "mild upper abdominal tenderness", "guarding", "Bowel sounds", "normal", "Laboratory", "reference range", "patient", "greatest", "following conditions"]}
{"question": "A 47-year-old female with a history of poorly controlled type I diabetes mellitus and end-stage renal disease undergoes an allogeneic renal transplant. Her immediate post-operative period is unremarkable and she is discharged from the hospital on post-operative day 4. Her past medical history is also notable for major depressive disorder, obesity, and gout. She takes sertraline, allopurinol, and insulin. She does not smoke or drink alcohol. To decrease the risk of transplant rejection, her nephrologist adds a medication known to serve as a precursor to 6-mercaptopurine. Following initiation of this medication, which of the following toxicities should this patient be monitored for?", "answer": "Pancytopenia", "options": {"A": "Hyperlipidemia", "B": "Osteoporosis", "C": "Hirsutism", "D": "Cytokine storm", "E": "Pancytopenia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year", "female", "history of poorly", "type I diabetes mellitus", "end-stage renal disease", "allogeneic renal", "immediate post-operative period", "unremarkable", "discharged from", "hospital", "post-operative day 4", "past medical history", "notable", "major depressive disorder", "obesity", "gout", "sertraline", "allopurinol", "insulin", "not smoke", "To decrease", "transplant rejection", "nephrologist adds", "medication known to", "6-mercaptopurine", "Following initiation", "medication", "following toxicities", "patient", "monitored"]}
{"question": "A 2-year-old boy is brought to the physician because of coughing and difficulty breathing that started shortly after his mother found him in the living room playing with his older brother's toys. He appears anxious. Respirations are 33/min and pulse oximetry on room air shows an oxygen saturation of 88%. Physical examination shows nasal flaring and intercostal retractions. Auscultation of the lungs shows a high-pitched inspiratory wheeze and absent breath sounds on the right side. There is no improvement in his oxygen saturation after applying a non-rebreather mask with 100% FiO2. Which of the following terms best describes the most likely underlying mechanism of the right lung's impaired ventilation?", "answer": "Right-to-left shunt", "options": {"A": "Alveolar hyperventilation", "B": "Alveolar dead space", "C": "Diffusion limitation", "D": "Alveolar hypoventilation", "E": "Right-to-left shunt"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 year old boy", "brought", "physician", "coughing", "difficulty breathing", "started", "found", "living room playing", "toys", "appears anxious", "Respirations", "min", "pulse oximetry", "room air", "oxygen saturation", "88", "nasal flaring", "intercostal retractions", "Auscultation", "lungs", "high-pitched inspiratory wheeze", "absent breath sounds", "right side", "oxygen saturation", "applying", "non-rebreather mask", "100", "FiO2", "following terms best", "underlying mechanism", "right lung's impaired ventilation"]}
{"question": "A 26-year-old man undergoing surgical correction of his deviated septum experiences excessive bleeding on the operating room table. Preoperative prothrombin time and platelet count were normal. The patient’s past medical history is significant for frequent blue blemishes on his skin along with easy bruising since he was a child. He indicated that he has some sort of genetic blood disorder running in his family but could not recall any details. Which of the following is the most appropriate treatment for this patient’s most likely condition?", "answer": "Desmopressin and tranexamic acid", "options": {"A": "Desmopressin and tranexamic acid", "B": "Cryoprecipitate", "C": "Fresh frozen plasma", "D": "Recombinant factor IX", "E": "Red blood cell transfusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "surgical correction", "deviated septum", "excessive bleeding", "operating room table", "Preoperative prothrombin time", "platelet count", "normal", "patients past medical history", "significant", "frequent blue blemishes", "skin", "easy bruising", "child", "indicated", "sort of genetic blood disorder", "not", "details", "following", "appropriate treatment", "patients", "condition"]}
{"question": "A 32-year-old woman comes to the physician for a routine examination. She has no history of serious medical illness. She appears well. Physical examination shows several hundred pigmented lesions on the back and upper extremities. A photograph of the lesions is shown. The remainder of the examination shows no abnormalities. This patient is at increased risk of developing a tumor with which of the following findings?", "answer": "S100-positive epithelioid cells with fine granules", "options": {"A": "Atypical keratinocytes forming keratin pearls", "B": "S100-positive epithelioid cells with fine granules", "C": "Spindle endothelial cells forming slit-like spaces", "D": "Mucin-filled cells with peripheral nuclei", "E": "Pale, round cells with palisading nuclei"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "routine", "history of serious medical illness", "appears well", "several", "pigmented", "back", "upper extremities", "photograph", "lesions", "abnormalities", "patient", "increased risk", "following"]}
{"question": "A 51-year-old man comes to the physician because of progressive shortness of breath, exercise intolerance, and cough for the past 6 months. He is no longer able to climb a full flight of stairs without resting and uses 3 pillows to sleep at night. He has a history of using cocaine in his 30s but has not used any illicit drugs for the past 20 years. His pulse is 99/min, respiratory rate is 21/min, and blood pressure is 95/60 mm Hg. Crackles are heard in both lower lung fields. An x-ray of the chest shows an enlarged cardiac silhouette with bilateral fluffy infiltrates and thickening of the interlobar fissures. Which of the following findings is most likely in this patient?", "answer": "Decreased lung compliance", "options": {"A": "Decreased pulmonary vascular resistance", "B": "Decreased lung compliance", "C": "Decreased forced expiratory volume", "D": "Increased carbon dioxide production", "E": "Increased residual volume\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "of progressive shortness", "breath", "exercise intolerance", "cough", "past 6 months", "longer able to climb", "full", "uses 3 pillows to sleep", "night", "history", "using cocaine", "30s", "not used", "illicit drugs", "past 20 years", "pulse", "99 min", "respiratory rate", "min", "blood pressure", "95 60 mm Hg", "Crackles", "heard", "lower lung fields", "x-ray of", "chest", "enlarged cardiac silhouette", "bilateral", "infiltrates", "thickening", "interlobar fissures", "following findings", "patient"]}
{"question": "A 15-year-old teenager presents for a sports physical. His blood pressure is 110/70 mm Hg, temperature is 36.5°C (97.7°F), and heart rate is 100/min. On cardiac auscultation, an early diastolic heart sound is heard over the cardiac apex while the patient is in the left lateral decubitus position. A transthoracic echocardiogram is performed which shows an ejection fraction of 60% without any other abnormalities. Which of the following is the end-systolic volume in this patient if his cardiac output is 6 L/min?", "answer": "40 mL", "options": {"A": "50 mL", "B": "60 mL", "C": "100 mL", "D": "40 mL", "E": "120 mL"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old teenager presents", "physical", "blood pressure", "70 mm Hg", "temperature", "36", "97", "heart rate", "100 min", "cardiac auscultation", "early diastolic heart sound", "heard", "cardiac apex", "patient", "left lateral decubitus position", "transthoracic echocardiogram", "performed", "ejection fraction of 60", "abnormalities", "following", "end-systolic volume", "patient", "cardiac output", "min"]}
{"question": "A 41-year-old woman presents to her primary care provider reporting abdominal pain. She reports a three-hour history of right upper quadrant sharp pain that started an hour after her last meal. She denies nausea, vomiting, or changes in her bowel habits. She notes a history of multiple similar episodes of pain over the past two years. Her past medical history is notable for type II diabetes mellitus, major depressive disorder, and obesity. She takes glyburide and sertraline. Her temperature is 98.6°F (37°C), blood pressure is 140/85 mmHg, pulse is 98/min, and respirations are 18/min. On examination, she is tender to palpation in her right upper quadrant. She has no rebound or guarding. Murphy’s sign is negative. No jaundice is noted. The hormone responsible for this patient’s pain has which of the following functions?", "answer": "Promote relaxation of the sphincter of Oddi", "options": {"A": "Increase growth hormone secretion before meals", "B": "Increase pancreatic bicarbonate secretion", "C": "Promote gallbladder relaxation", "D": "Promote migrating motor complexes", "E": "Promote relaxation of the sphincter of Oddi"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "primary care provider", "abdominal pain", "reports", "three hour history", "right upper quadrant sharp pain", "started", "hour", "nausea", "vomiting", "changes in", "bowel habits", "notes", "history of multiple similar episodes", "pain", "past two years", "past medical history", "notable", "type II diabetes mellitus", "major depressive disorder", "obesity", "glyburide", "sertraline", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "98 min", "respirations", "min", "tender", "palpation", "right upper quadrant", "guarding", "Murphys sign", "negative", "jaundice", "noted", "hormone responsible", "patients pain", "following functions"]}
{"question": "A 1-year-old boy brought in by his mother presents to his physician for a routine checkup. On examination, the child is happy and playful and meets normal cognitive development markers. However, the child’s arms and legs are not meeting development goals, while his head and torso are. The mother states that the boy gets this from his father. Which of the following is the mutation associated with this presentation?", "answer": "Overactivation of FGFR3", "options": {"A": "FBN1 gene mutation", "B": "Underactivation of FGFR3", "C": "GAA repeat", "D": "Deletion of DMD", "E": "Overactivation of FGFR3"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy brought", "presents", "physician", "routine checkup", "child", "playful", "normal cognitive development markers", "childs arms", "legs", "not", "development", "head", "torso", "states", "boy gets", "following", "mutation associated with"]}
{"question": "A 33-year-old man is being evaluated for malaise and fatigability. He says that he hasn’t been able to perform at work, can’t exercise like before, and is constantly tired. He also says that his clothes have ‘become larger’ in the past few months. Past medical history is significant for gastroesophageal reflux disease, which is under control with lifestyle changes. His blood pressure is 110/70 mm Hg, the temperature is 37.0°C (98.6°F), the respiratory rate is 17/min, and the pulse is 82/min. On physical examination, an enlarged, painless, mobile, cervical lymph node is palpable. A complete blood count is performed.\nHemoglobin 9.0 g/dL\nHematocrit 37.7%\nLeukocyte count 5,500/mm3\n Neutrophils 65%\n Lymphocytes 30%\n Monocytes 5%\nMean corpuscular volume 82.2 μm3\nPlatelet count 190,000 mm3\nErythrocyte sedimentation rate 35 mm/h\nC-reactive protein 8 mg/dL\nA biopsy of the lymph node is performed which reveals both multinucleated and bilobed cells. The patient is started on a regimen of drugs for his condition. Echocardiography is performed before treatment is started and shows normal ejection fraction, ventricle function, and wall motion. After 2 rounds of chemotherapy, another echocardiography is performed by protocol, but this time all heart chambers are enlarged, and the patient is suffering from severe exertion dyspnea. Which of the drugs below is most likely responsible for these side effects?", "answer": "Adriamycin", "options": {"A": "Adriamycin", "B": "Bleomycin", "C": "Vinblastine", "D": "Dacarbazine", "E": "Rituximab"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "malaise", "fatigability", "hasnt", "able to perform", "cant exercise", "constantly tired", "clothes", "larger", "past", "months", "medical history", "significant", "gastroesophageal reflux disease", "control", "blood pressure", "70 mm Hg", "temperature", "98", "respiratory rate", "min", "pulse", "min", "enlarged", "painless", "mobile", "cervical lymph node", "palpable", "complete blood count", "dL", "count", "Neutrophils", "Lymphocytes", "Monocytes", "Mean corpuscular volume", "rate", "C-reactive protein", "dL", "biopsy of", "lymph node", "performed", "reveals", "multinucleated", "bilobed cells", "patient", "started", "regimen", "drugs", "condition", "Echocardiography", "performed", "treatment", "started", "normal ejection fraction", "ventricle function", "wall motion", "2", "chemotherapy", "echocardiography", "performed by protocol", "time", "heart chambers", "enlarged", "patient", "suffering", "severe exertion", "drugs", "responsible", "side effects"]}
{"question": "A 27-year-old man presents to the emergency department with severe substernal pain at rest, which radiates to his left arm and jaw. He reports that he has had similar but milder pain several times in the past during strenuous exercise. He had heart transplantation due to dilatory cardiomyopathy 5 years ago with an acute rejection reaction that was successfully treated with corticosteroids. He had been taking 1 mg tacrolimus twice a day for 3.5 years but then discontinued it and had no regular follow-ups. The man does not have a family history of premature coronary artery disease. His blood pressure is 110/60 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.3°C (99.1°F). On physical examination, the patient is alert, responsive, and agitated. Cardiac auscultation reveals a fourth heart sound (S4) and an irregularly irregular heart rhythm. His ECG shows ST elevation in leads I, II, V5, and V6, and ST depression in leads III and aVF. His complete blood count and lipidogram are within normal limits. The patient’s cardiac troponin I and T levels are elevated. A coronary angiogram reveals diffuse concentric narrowing of all branches of the left coronary artery. What is the most likely causative mechanism of this patient’s cardiac ischemia?", "answer": "Obliterative arteriopathy", "options": {"A": "Vasospasm of distal coronary arteries branches", "B": "Left ventricular hypertrophy", "C": "Obliterative arteriopathy", "D": "Increased oxygen demand due to tachycardia", "E": "Granulomatous vasculitis of coronary arteries"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old man presents", "emergency department", "severe", "pain at rest", "radiates", "left arm", "jaw", "reports", "similar", "milder pain", "times", "past", "heart transplantation due to", "cardiomyopathy", "years", "acute rejection reaction", "treated with corticosteroids", "1 mg tacrolimus twice a day", "years", "then discontinued", "regular follow-ups", "man", "not", "family history of premature coronary artery disease", "blood pressure", "60 mm Hg", "heart rate", "97 min", "respiratory rate", "min", "temperature", "99", "patient", "alert", "responsive", "agitated", "Cardiac auscultation reveals", "fourth heart sound", "S4", "irregular heart rhythm", "ECG", "ST elevation", "leads I", "V6", "ST depression", "leads III", "aVF", "complete blood count", "normal limits", "patients cardiac troponin I", "levels", "elevated", "coronary angiogram reveals diffuse concentric narrowing", "branches of", "left coronary artery", "mechanism", "patients"]}
{"question": "A 24-hour-old neonate girl is brought to the clinic by her mother because of a blue-spotted skin rash. Her mother says she is from a rural area. She did not receive any prenatal care including vaccinations and prenatal counseling. The neonate does not react to sounds or movements, and on physical examination, a continuous murmur is heard over the left upper sternal border on auscultation. Which of the following cardiac findings is most likely in this patient?", "answer": "Patent ductus arteriosus", "options": {"A": "Coarctation of the aorta", "B": "Mitral valve prolapse", "C": "Patent ductus arteriosus", "D": "Tetralogy of Fallot", "E": "Ventricular septal defect"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["hour old neonate girl", "brought", "clinic", "blue", "skin", "rural area", "not receive", "including vaccinations", "prenatal counseling", "neonate", "not react", "movements", "continuous murmur", "heard", "left upper sternal border", "auscultation", "following cardiac findings", "patient"]}
{"question": "A 60-year-old man comes to the physician because his wife has noticed that his left eye looks smaller than his right. He has had worsening left shoulder and arm pain for 3 months. He has smoked two packs of cigarettes daily for 35 years. Examination shows left-sided ptosis. The pupils are unequal but reactive to light; when measured in dim light, the left pupil is 3 mm and the right pupil is 5 mm. Which of the following is the most likely cause of this patient's ophthalmologic symptoms?", "answer": "Compression of the stellate ganglion", "options": {"A": "Thrombosis of the cavernous sinus", "B": "Aneurysm of the posterior cerebral artery", "C": "Dissection of the carotid artery", "D": "Compression of the stellate ganglion", "E": "Infiltration of the cervical plexus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old man", "physician", "left eye looks smaller", "right", "worsening left shoulder", "arm pain", "months", "smoked two packs", "cigarettes daily", "35 years", "left-sided ptosis", "pupils", "unequal", "reactive to light", "measured", "dim light", "left pupil", "3 mm", "right pupil", "5 mm", "following", "most likely cause", "patient's ophthalmologic symptoms"]}
{"question": "A 22-year-old male presents to the emergency department after a motor vehicle accident. The patient is conscious and communicating with hospital personnel. He is in pain and covered in bruises and scrapes. The patient was the driver in a head-on motor vehicle collision. The patient's temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 120/70 mmHg, respirations are 18/min, and oxygen saturation is 99% on room air. A full trauma assessment is being performed and is notable for 0/5 strength in the right upper extremity for extension of the wrist. The patient is started on IV fluids and morphine, and radiography is ordered. The patient has bilateral breath sounds, a normal S1 and S2, and no signs of JVD. His blood pressure 30 minutes later is 122/70 mmHg. Which of the following fractures is most likely in this patient?", "answer": "Midshaft humerus", "options": {"A": "Humeral neck", "B": "Midshaft humerus", "C": "Supracondylar", "D": "Ulnar", "E": "Radial"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male presents", "emergency department", "motor vehicle accident", "patient", "communicating", "hospital personnel", "pain", "covered", "bruises", "scrapes", "patient", "driver", "head", "motor vehicle", "patient's temperature", "99", "pulse", "min", "blood pressure", "70 mmHg", "respirations", "min", "oxygen saturation", "99", "room air", "full", "performed", "notable", "0/5 strength", "right upper extremity", "extension", "wrist", "patient", "started", "morphine", "radiography", "ordered", "patient", "bilateral breath sounds", "normal S1", "S2", "signs", "JVD", "blood pressure 30 minutes later", "70 mmHg", "following fractures", "patient"]}
{"question": "A 58-year-old man comes to the physician because of a 3-month history of diffuse muscle pain, malaise, pain in both knees, recurrent episodes of abdominal and chest pain. He has also had a 5-kg (11-lb) weight loss over the past 4 months. Four years ago, he was diagnosed with chronic hepatitis B infection and was started on tenofovir. There are several ulcerations around the ankle and calves bilaterally. Perinuclear anti-neutrophil cytoplasmic antibodies are negative. Urinalysis shows proteinuria and hematuria. Muscle biopsy shows a transmural inflammation of the arterial wall with leukocytic infiltration and fibrinoid necrosis. Which of the following is the most likely diagnosis?", "answer": "Polyarteritis nodosa", "options": {"A": "Giant cell arteritis", "B": "Polyarteritis nodosa", "C": "Granulomatosis with polyangiitis", "D": "Thromboangiitis obliterans", "E": "Microscopic polyangiitis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old man", "physician", "3 month history", "diffuse muscle", "malaise", "pain in both knees", "recurrent episodes of abdominal", "chest pain", "5 kg", "weight loss", "past", "months", "Four years", "diagnosed", "chronic", "started", "tenofovir", "several ulcerations", "ankle", "calves", "Perinuclear anti-neutrophil cytoplasmic antibodies", "negative", "Urinalysis", "proteinuria", "hematuria", "Muscle biopsy", "transmural inflammation", "arterial", "infiltration", "fibrinoid necrosis", "following", "diagnosis"]}
{"question": "A 28-year-old woman presents to a physician with complaints of fever, cough, and cold for the last 2 days. She does not have any other symptoms and she has no significant medical history. She has recently started using combined oral contraceptive pills (OCPs) for birth control. On physical examination, the temperature is 38.3°C (101.0°F), the pulse is 98/min, the blood pressure is 122/80 mm Hg, and the respiratory rate is 14/min. The nasal mucosa and pharynx are inflamed, but there is no purulent discharge. Auscultation of the chest does not reveal any abnormalities. She mentions that she has been a heavy smoker for the last 5 years, smoking about 15–20 cigarettes per day. The physician suggests she should discontinue using combined OCPs and choose an alternative contraception method. Which of the following best explains the rationale behind the physician's suggestion?", "answer": "Smoking is likely to increase the risk of developing deep vein thrombosis and pulmonary embolism in women taking OCPs", "options": {"A": "Smoking inhibits CYP1A2, therefore there is an increased risk of estrogen-related side effects of OCPs", "B": "Smoking induces CYP3A4, therefore OCPs would be ineffective", "C": "Smoking induces CYP1A2, therefore OCPs would be ineffective", "D": "Smoking inhibits CYP3A4, therefore there is an increased risk of progestin-related side effects of OCPs", "E": "Smoking is likely to increase the risk of developing deep vein thrombosis and pulmonary embolism in women taking OCPs"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "physician", "complaints", "fever", "cough", "cold", "2 days", "not", "symptoms", "significant medical history", "recently started using combined oral contraceptive pills", "for birth control", "temperature", "pulse", "98 min", "blood pressure", "80 mm Hg", "respiratory rate", "min", "nasal mucosa", "pharynx", "inflamed", "purulent discharge", "Auscultation", "chest", "not reveal", "abnormalities", "heavy smoker", "years", "smoking", "cigarettes", "day", "physician", "discontinue using combined OCPs", "contraception method", "following best", "physician's"]}
{"question": "A 27-year-old man is brought to the emergency department shortly after sustaining injuries in a building fire. On arrival, he appears agitated and has shortness of breath. Examination shows multiple second-degree burns over the chest and abdomen and third-degree burns over the upper extremities. Treatment with intravenous fluids and analgesics is begun. Two days later, the patient is confused. His temperature is 36°C (96.8°F), pulse is 125/min, and blood pressure is 100/58 mm Hg. Examination shows violaceous discoloration and edema of the burn wounds. His leukocyte count is 16,000/mm3. Blood cultures grow gram-negative, oxidase-positive, non-lactose fermenting rods. The causal organism actively secretes a virulence factor that acts primarily via which of the following mechanisms?", "answer": "Inhibition of protein synthesis", "options": {"A": "Inhibition of phagocytosis", "B": "Overwhelming release of cytokines", "C": "Increase in fluid secretion", "D": "Inhibition of protein synthesis", "E": "Inhibition of neurotransmitter release\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man", "brought", "emergency department", "sustaining injuries", "building fire", "arrival", "appears agitated", "shortness of breath", "multiple second-degree burns", "chest", "abdomen", "third-degree burns", "upper extremities", "Treatment", "analgesics", "begun", "Two days later", "patient", "confused", "temperature", "96", "pulse", "min", "blood pressure", "100 58 mm Hg", "violaceous discoloration", "edema", "burn wounds", "leukocyte count", "mm3", "Blood cultures", "gram negative", "oxidase positive", "non lactose", "causal", "secretes", "virulence factor", "acts", "following mechanisms"]}
{"question": "A 32-day-old boy is brought to the emergency department because he is found to be febrile and listless. He was born at home to a G1P1 mother without complications, and his mother has no past medical history. On presentation he is found to be febrile with a bulging tympanic membrane on otoscopic examination. Furthermore, he is found to have an abscess around his rectum that discharges a serosanguinous fluid. Finally, the remnants of the umbilical cord are found to be attached and necrotic. Which of the following processes is most likely abnormal in this patient?", "answer": "Neutrophil migration", "options": {"A": "Actin remodeling", "B": "Antibody class switching", "C": "Microtubule organization", "D": "Neutrophil migration", "E": "Reactive oxygen species production"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["day old boy", "brought", "emergency department", "found to", "febrile", "listless", "born at home", "G1P1", "complications", "past medical history", "found to", "febrile", "bulging tympanic membrane", "otoscopic", "found to", "abscess", "rectum", "discharges", "serosanguinous fluid", "remnants", "umbilical cord", "found to", "necrotic", "following processes", "abnormal", "patient"]}
{"question": "A 37-year-old woman, G1P0, visits her gynecologist’s office for a routine prenatal checkup. During her quadruple screening test, her alpha-fetoprotein levels were increased while the β-hCG and pregnancy-associated plasma protein were decreased. There is also evidence of increased nuchal translucency on the scanning of the male fetus. A confirmatory test indicates signs of a genetic syndrome. The woman is counseled that her child will most likely have a severe intellectual disability. Physical features of this condition include polydactyly, cleft palate, micrognathia and clenched fists. This genetic condition also affects the formation of the brain and can lead to stillbirth. Most babies do not survive beyond the first year of life. Which of the following is responsible for this type of genetic syndrome?", "answer": "Nondisjunction of chromosomes", "options": {"A": "In utero infections", "B": "Error in metabolism", "C": "Genomic imprinting", "D": "Nondisjunction of chromosomes", "E": "Autosomal dominant genes"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "gynecologists office", "routine prenatal checkup", "quadruple", "alpha-fetoprotein levels", "increased", "hCG", "pregnancy associated plasma", "decreased", "increased nuchal translucency", "scanning", "male fetus", "confirmatory test", "signs", "genetic syndrome", "woman", "counseled", "child", "most likely", "severe intellectual disability", "Physical features", "condition include polydactyly", "cleft palate", "micrognathia", "clenched fists", "genetic condition", "formation", "brain", "lead", "stillbirth", "babies", "not survive", "first year", "following", "responsible", "type", "genetic syndrome"]}
{"question": "A 16-year-old boy comes to the emergency department because of painful urination and urethral discharge for 3 days. He has multiple sexual partners and only occasionally uses condoms. His vital signs are within normal limits. The result of nucleic acid amplification testing for Neisseria gonorrhoeae is positive. The patient requests that his parents not be informed of the diagnosis. Which of the following initial actions by the physician is most appropriate?", "answer": "Administer intramuscular and oral antibiotics", "options": {"A": "Order urinary PCR testing in two weeks", "B": "Perform urethral swab culture for antibiotic sensitivities", "C": "Request parental consent prior to prescribing antibiotics", "D": "Discuss results with patient's primary care physician", "E": "Administer intramuscular and oral antibiotics"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "emergency department", "painful urination", "urethral discharge", "3 days", "multiple sexual partners", "only occasionally uses condoms", "vital signs", "normal limits", "result", "nucleic acid amplification testing", "positive", "patient", "not", "informed", "diagnosis", "following initial actions", "physician", "most appropriate"]}
{"question": "A 30-year-old man comes to the emergency department because of fever and productive cough for the past 4 days. During this period, he has had shortness of breath and chest pain that is worse on inspiration. He also reports fatigue and nausea. He has refractory schizophrenia and recurrent asthma attacks. He used to attend college but was expelled after threatening to harm one of his professors 2 months ago. His temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. Crackles and bronchial breath sounds are heard on auscultation of the left lung. Laboratory studies show:\nHemoglobin 13.5 g/dL\nLeukocyte count 1,100/mm3\nSegmented neutrophils 5%\nEosinophils 0%\nLymphocytes 93%\nMonocytes 2%\nPlatelet count 260,000/mm3\nWhich of the following medications is this patient most likely taking?\"", "answer": "Clozapine", "options": {"A": "Clozapine", "B": "Olanzapine", "C": "Haloperidol", "D": "Risperidone", "E": "Chlorpromazine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old man", "emergency department", "fever", "productive cough", "past 4 days", "period", "shortness of breath", "chest pain", "worse", "inspiration", "reports fatigue", "nausea", "refractory schizophrenia", "recurrent asthma attacks", "used to attend college", "to", "one", "professors", "months", "temperature", "pulse", "90 min", "respirations", "20 min", "blood pressure", "80 mm Hg", "Crackles", "bronchial breath sounds", "heard", "auscultation", "left lung", "Laboratory studies", "Hemoglobin", "g", "count", "mm3 Segmented", "Eosinophils 0", "Lymphocytes 93", "Monocytes", "Platelet count", "following medications", "patient", "likely"]}
{"question": "A 27-year-old woman comes to the clinic for blisters on both hands. The patient has a past medical history of asthma, eczema, and a car accident 2 years ago where she sustained a concussion. She also reports frequent transient episodes of blurred vision that clear with artificial tears. When asked about her blisters, the patient claims she was baking yesterday and forgot to take the pan out with oven gloves. Physical examination demonstrates weeping blisters bilaterally concentrated along the palmar surfaces of both hands and decreased pinprick sensation along the arms bilaterally. What is the most likely explanation of this patient’s symptoms?", "answer": "Syringomyelia at the cervico-thoracic region", "options": {"A": "Brain contusion", "B": "Multiple sclerosis", "C": "Sjogren syndrome", "D": "Syringomyelia at the cervico-thoracic region", "E": "Syringomyelia at the lumbar region"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old woman", "clinic", "blisters", "hands", "patient", "past medical", "eczema", "car accident", "years", "sustained", "concussion", "reports frequent transient episodes of blurred vision", "clear", "artificial tears", "blisters", "patient", "forgot to", "pan out", "oven gloves", "weeping blisters", "concentrated", "palmar surfaces of", "hands", "decreased pinprick sensation", "arms", "patients symptoms"]}
{"question": "A 30-year-old man presents with heartburn for the past couple of weeks. He says he feels a burning sensation in his chest, at times reaching his throat, usually worse after eating spicy foods. He is overweight and actively trying to lose weight. He also has tried other lifestyle modifications for the past couple of months, but symptoms have not improved. He denies any history of cough, difficulty swallowing, hematemesis, or melena. The patient says he often drinks a can of beer in the evening after work and does not smoke. His blood pressure is 124/82 mm Hg, pulse is 72/min and regular, and respiratory rate is 14/min. Abdominal tenderness is absent. Which of the following is the next best step in the management of this patient?", "answer": "Start omeprazole.", "options": {"A": "Start omeprazole.", "B": "Start sucralfate.", "C": "Start famotidine.", "D": "Start oral antacids.", "E": "H. pylori screening"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old man presents", "heartburn", "past couple", "weeks", "burning sensation", "chest", "times reaching", "throat", "usually worse after eating", "overweight", "to", "weight", "lifestyle modifications", "past couple", "months", "symptoms", "not improved", "history", "cough", "difficulty swallowing", "hematemesis", "melena", "patient", "often", "evening", "not smoke", "blood pressure", "mm Hg", "pulse", "72 min", "regular", "respiratory rate", "min", "Abdominal tenderness", "absent", "following", "next best step", "patient"]}
{"question": "A 62-year-old man is brought to his primary care physician by his wife because she is concerned that he has become more confused over the past month. Specifically, he has been having difficulty finding words and recently started forgetting the names of their friends. She became particularly worried when he got lost in their neighborhood during a morning walk. Finally, he has had several episodes of incontinence and has tripped over objects because he \"does not lift his feet off the ground\" while walking. He has a history of hypertension and diabetes but has otherwise been healthy. His family history is significant for many family members with early onset dementia. Which of the following treatments would most likely be effective for this patient?", "answer": "Placement of shunt", "options": {"A": "Better control of diabetes and hypertension", "B": "Galantamine", "C": "Placement of shunt", "D": "Selegiline", "E": "Tetrabenazine"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old man", "brought", "primary care physician", "more confused", "past month", "difficulty finding words", "recently started forgetting", "names", "worried", "got lost", "neighborhood", "morning", "several episodes of incontinence", "tripped", "not lift", "feet", "ground", "history of hypertension", "diabetes", "healthy", "family history", "significant", "early onset dementia", "following treatments", "most likely", "effective", "patient"]}
{"question": "A 65-year-old veteran with a history of hypertension, diabetes, and end-stage renal disease presents with nausea, vomiting, and abdominal pain. The patient was found to have a small bowel obstruction on CT imaging. He is managed conservatively with a nasogastric tube placed for decompression. After several days in the hospital, the patient’s symptoms are gradually improving. Today, he complains of left leg swelling. On physical exam, the patient has a swollen left lower extremity with calf tenderness on forced dorsiflexion of the ankle. An ultrasound confirms a deep vein thrombus. An unfractionated heparin drip is started. What should be monitored to adjust heparin dosing?", "answer": "Activated partial thromboplastin time", "options": {"A": "Prothrombin time", "B": "Activated partial thromboplastin time", "C": "Internationalized Normal Ratio (INR)", "D": "Creatinine level", "E": "Liver transaminase levels"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65-year-old", "history of hypertension", "diabetes", "end-stage renal disease presents", "nausea", "vomiting", "abdominal pain", "patient", "found to", "small bowel obstruction", "CT imaging", "nasogastric tube", "decompression", "several days in", "hospital", "patients symptoms", "improving", "Today", "of left leg swelling", "patient", "swollen left lower extremity", "calf", "forced dorsiflexion of", "ankle", "ultrasound confirms", "deep vein thrombus", "unfractionated heparin drip", "started", "monitored to", "heparin"]}
{"question": "A 30-year-old gravida 2 para 2 presents to a medical clinic to discuss contraception options. She had a normal vaginal delivery of a healthy baby boy with no complications 2 weeks ago. She is currently doing well and is breastfeeding exclusively. She would like to initiate a contraceptive method other than an intrauterine device, which she tried a few years ago, but the intrauterine device made her uncomfortable. The medical history includes migraine headaches without aura, abnormal liver function with mild fibrosis, and epilepsy as a teenager. She sees multiple specialists due to her complicated history, but is stable and takes no medications. There is a history of breast cancer on the maternal side. On physical examination, the temperature is 36.5°C (97.7°F), the blood pressure is 150/95 mm Hg, the pulse is 89/min, and the respiratory rate is 16/min. After discussing the various contraceptive methods available, the patient decides to try combination oral contraceptive pills. Which of the following is an absolute contraindication to start the patient on combination oral contraceptive pills?", "answer": "Breastfeeding", "options": {"A": "Breastfeeding", "B": "History of epilepsy", "C": "Elevated blood pressure", "D": "Mild liver fibrosis", "E": "Migraine headaches"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old gravida 2 para", "presents", "medical clinic to", "contraception options", "normal vaginal delivery", "healthy baby boy", "complications", "weeks", "currently", "well", "breastfeeding", "to initiate", "contraceptive method", "intrauterine device", "few years", "intrauterine device made", "medical history includes migraine headaches without aura", "abnormal function", "mild", "epilepsy", "teenager", "sees multiple specialists due to", "complicated history", "stable", "medications", "history of breast cancer", "side", "temperature", "36", "97", "blood pressure", "95 mm Hg", "pulse", "min", "respiratory rate", "min", "various contraceptive methods available", "patient", "to", "combination oral contraceptive pills", "following", "absolute contraindication to start", "patient", "combination oral contraceptive pills"]}
{"question": "A 31-year-old African American woman with a history of Addison's disease presents with widespread, symmetric hypopigmented patches and macules overlying her face and shoulders. After a thorough interview and using a Wood’s lamp to exclude fungal etiology, vitiligo is suspected. Complete blood count shows leukocytes 6,300, Hct 48.3%, Hgb 16.2 g/dL, mean corpuscular volume (MCV) 90 fL, and platelets 292. Which of the statements below about this patient’s suspected disease is correct?", "answer": "The course usually is slowly progressive with spontaneous repigmentation in 15% of patients.", "options": {"A": "The course usually is slowly progressive with spontaneous repigmentation in 15% of patients.", "B": "The disease is relapsing and remitting with complete interval repigmentation.", "C": "Keloid formation is associated with regions of depigmentation.", "D": "Vitiligo is self-limited and will resolve in 8-14 weeks.", "E": "Topical corticosteroids are inappropriate for patients with limited disease."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["31 year old", "woman", "history of", "disease presents", "widespread", "symmetric hypopigmented patches", "macules", "face", "shoulders", "using", "Woods lamp to exclude fungal etiology", "vitiligo", "suspected", "Complete blood count", "leukocytes 6 300", "Hct 48", "Hgb", "g/dL", "mean corpuscular volume", "90 fL", "platelets", "about", "patients suspected disease", "correct"]}
{"question": "A 46-year-old woman comes to the physician for a follow-up examination after a Pap smear showed atypical squamous cells. A colposcopy-directed biopsy of the cervix shows evidence of squamous cell carcinoma. The malignant cells from this lesion are most likely to drain into which of the following group of lymph nodes?", "answer": "Internal iliac", "options": {"A": "Internal iliac", "B": "Right supraclavicular", "C": "Inferior mesenteric", "D": "Superficial inguinal", "E": "Left supraclavicular"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "Pap smear", "colposcopy directed biopsy of", "cervix", "squamous cell carcinoma", "malignant cells", "lesion", "to drain", "following group", "lymph nodes"]}
{"question": "A 29-year-old G2P1001 presents to her obstetrician’s office complaining of dyspareunia. She endorses ongoing vaginal dryness resulting in uncomfortable intercourse over the last month. In addition, she has noticed a gritty sensation in her eyes as well as difficulty tasting food and halitosis. She denies pain with urination and defecation. Her medications include a daily multivitamin, folic acid, and over-the-counter eye drops. The patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 121/80 mmHg, and respirations are 13/min. Physical exam is notable for a well-appearing female with fullness in the bilateral cheeks and reduced salivary pool. For which of the following is the patient’s fetus at increased risk?", "answer": "Heart block", "options": {"A": "Macrosomia", "B": "Neonatal hypoglycemia", "C": "Heart block", "D": "Pulmonary hypertension", "E": "Meconium aspiration"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old", "presents", "obstetricians office", "dyspareunia", "vaginal dryness resulting in", "intercourse", "last month", "addition", "gritty sensation", "eyes", "difficulty tasting food", "halitosis", "pain", "urination", "defecation", "medications include", "daily multivitamin", "folic acid", "over-the-counter eye drops", "patients temperature", "98", "pulse", "70 min", "blood pressure", "80 mmHg", "respirations", "min", "notable", "well appearing female", "fullness", "bilateral cheeks", "reduced salivary pool", "following", "patients fetus at increased risk"]}
{"question": "A healthy mother gives birth to a child at 40 weeks of gestation. On examination, the child has ambiguous genitalia. A karyotype analysis reveals the presence of a Y chromosome. Additional workup reveals the presence of testes and a normal level of serum luteinizing hormone (LH) and testosterone. Which of the following is the most likely cause of this patient’s condition?", "answer": "5-alpha reductase deficiency", "options": {"A": "Androgen receptor deficiency", "B": "Failed migration of neurons producing gonadotropin releasing hormone (GnRH)", "C": "Presence of two X chromosomes", "D": "5-alpha reductase deficiency", "E": "Aromatase deficiency"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "gives birth", "child", "40 weeks of gestation", "child", "ambiguous genitalia", "karyotype analysis reveals", "presence", "Y chromosome", "Additional workup reveals", "presence", "testes", "normal level", "serum luteinizing hormone", "testosterone", "following", "most likely cause", "patients condition"]}
{"question": "A 30-year-old man who was recently placed on TMP-SMX for a urinary tract infection presents to urgent care with a new rash. The vital signs include: blood pressure 121/80 mm Hg, pulse 91/min, respiratory rate 18/min, and temperature 36.7°C (98.2°F). Physical examination reveals a desquamative skin covering both of his lower extremities. A basic chemistry panel reveal sodium 139 mmol/L, potassium 3.8 mmol/L, chloride 110 mmol/L, carbon dioxide 47, blood urea nitrogen 23 mg/dL, creatinine 0.9 mg/dL, and glucose 103 mg/dL. Which of the following is the most likely diagnosis?", "answer": "Toxic epidermal necrolysis (TEN)", "options": {"A": "Dermatitis herpetiformis", "B": "Steven-Johnson syndrome (SJS)", "C": "Seborrheic dermatitis", "D": "Atopic dermatitis", "E": "Toxic epidermal necrolysis (TEN)"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["30 year old man", "recently", "TMP-SMX", "urinary tract infection presents", "urgent care", "new rash", "vital signs include", "blood pressure", "80 mm Hg", "pulse", "min", "respiratory rate", "min", "temperature 36", "98", "reveals", "desquamative skin covering", "lower extremities", "basic chemistry panel reveal sodium", "mmol/L", "potassium", "mmol/L", "mmol/L", "carbon dioxide", "blood urea nitrogen 23 mg/dL", "creatinine 0.9 mg/dL", "glucose", "mg/dL", "following", "diagnosis"]}
{"question": "A 40-year-old man with a history of type I diabetes presents to the emergency room in respiratory distress. His respirations are labored and deep, and his breath odor is notably fruity. Which of the following laboratory results would you most expect to find in this patient?", "answer": "Increased urine H2PO4-", "options": {"A": "Increased serum HCO3-", "B": "Decreased serum H+", "C": "Decreased urine H+", "D": "Increased urine HCO3-", "E": "Increased urine H2PO4-"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["40 year old man", "history", "I diabetes presents", "emergency room", "respiratory distress", "respirations", "labored", "deep", "breath odor", "following laboratory results", "most", "to find", "patient"]}
{"question": "A 4-year-old boy presents to the ED with a one day history of severe right eye pain accompanied by nausea, vomiting, and headache. He is afebrile and he appears to be alert despite being irritable. Three days ago an ophthalmologist prescribed eye drops for his right eye but his parents do not know the name of the medication. On exam, his right eye is hard to palpation and moderately dilated. His left eye is unremarkable. What is the mechanism of action of the medication that most likely provoked this acute presentation?", "answer": "Muscarinic antagonist inhibiting pupillary sphincter muscle contraction", "options": {"A": "Muscarinic antagonist inhibiting pupillary sphincter muscle contraction", "B": "Iris neovascularization", "C": "M3 agonist causing ciliary muscle contraction", "D": "Agonist of prostaglandin F receptor increasing aqueous fluid production", "E": "Alpha-adrenergic agonist increasing aqueous fluid production"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["4 year old boy presents", "one day history of severe right eye pain", "nausea", "vomiting", "headache", "afebrile", "appears to", "alert", "irritable", "Three days", "ophthalmologist", "eye", "right", "not", "exam", "right eye", "hard", "palpation", "moderately dilated", "left eye", "unremarkable", "mechanism of action", "medication", "most likely provoked", "acute"]}
{"question": "A 33-year-old woman presents to the clinic complaining of a 9-month history of weight loss, fatigue, and a general sense of malaise. She additionally complains of an unusual sensation in her chest upon rapidly rising from a supine to a standing position. Current vitals include a temperature of 36.8°C (98.2°F), pulse of 72/min, blood pressure of 118/63 mm Hg, and a respiratory rate of 15/min. Her BMI is 21 kg/m2. Auscultation demonstrates an early-mid diastole low-pitched sound at the apex of the heart. A chest X-ray reveals a poorly demarcated abnormality in the heart and requires CT imaging for further analysis. What would most likely be seen on CT imaging?", "answer": "Tumor within the left atria", "options": {"A": "Tumor within the right atria", "B": "Fistula between the right and left atria", "C": "Normal cardiac imaging", "D": "Tumor within the left atria", "E": "Connection between the pulmonary artery and aorta"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic", "of", "month history", "weight loss", "fatigue", "general sense", "malaise", "unusual sensation", "chest", "rapidly", "supine", "standing position", "Current", "include", "temperature", "36", "98", "pulse", "72 min", "blood pressure", "63 mm Hg", "respiratory rate", "min", "BMI", "kg/m2", "Auscultation", "early", "diastole low-pitched sound", "the apex of", "heart", "chest X-ray reveals", "poorly", "abnormality", "heart", "CT imaging", "further analysis", "most likely", "seen", "CT imaging"]}
{"question": "A 38-year-old man presents to the physician with fever and malaise for 4 days. He has headaches and joint pain. A pruritic rash appeared on the trunk yesterday. He had blood in his ejaculate twice. His hearing has become partially impaired. There is no history of serious illnesses or the use of medications. Ten days ago, he traveled to Brazil where he spent most of the time outdoors in the evenings. He did not use any control measures for mosquito bites. His temperature is 38.2℃ (100.8℉); the pulse is 88/min; the respiratory rate is 13/min, and the blood pressure is 125/60 mm Hg. Conjunctival suffusion is noted. A maculopapular rash is present over the trunk and proximal extremities without the involvement of the palms or soles. Several joints of the hands are tender to palpation. The abdomen is soft with no organomegaly. A peripheral blood smear shows no pathogenic organisms. Which of the following is the most likely diagnosis?", "answer": "Zika virus disease", "options": {"A": "Chagas disease", "B": "Malaria", "C": "Rocky Mountain spotted fever", "D": "Whipple’s disease", "E": "Zika virus disease"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "physician", "fever", "malaise", "4 days", "headaches", "joint pain", "pruritic rash appeared", "trunk", "blood", "ejaculate twice", "hearing", "impaired", "history", "serious illnesses", "use of medications", "Brazil", "spent most of the time outdoors", "evenings", "not use", "control measures", "mosquito bites", "temperature", "100", "pulse", "88 min", "respiratory rate", "min", "blood pressure", "60 mm Hg", "Conjunctival", "noted", "maculopapular rash", "present", "trunk", "proximal extremities", "involvement", "soles", "joints of", "hands", "tender", "palpation", "abdomen", "soft", "organomegaly", "peripheral blood smear", "following", "diagnosis"]}
{"question": "A 30-year-old Japanese female presents with flu-like symptoms and weak pulses in her upper extremities. An angiogram reveals granulomatous inflammation of the aortic arch. Which of the following disease processes is most similar to this patient's disease?", "answer": "Temporal arteritis", "options": {"A": "Temporal arteritis", "B": "Polyarteritis nodosa", "C": "Kawasaki disease", "D": "Buerger's disease", "E": "Infectious vasculitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old", "female presents", "flu-like symptoms", "weak pulses", "upper extremities", "angiogram reveals granulomatous inflammation of the aortic arch", "following disease processes", "most similar", "patient's disease"]}
{"question": "A 3-month-old girl is brought to the emergency department in respiratory distress after her parents noticed that she was having difficulty breathing. They say that she developed a fever 2 days ago and subsequently developed increasing respiratory difficulty, lethargy, and productive cough. On presentation, her temperature is 103°F (39.5°C), blood pressure is 84/58 mmHg, pulse is 141/min, and respirations are 48/min. Physical exam reveals subcostal retractions and consolidation in the right lower lung field. She is also found to have coarse facial features and restricted joint movement. Serum laboratory tests reveal abnormally elevated levels of lysosomal enzymes circulating in the blood. The enzyme that is most likely defective in this patient has which of the following substrates?", "answer": "Mannose", "options": {"A": "Ceremide", "B": "Dermatan sulfate", "C": "Galactocerebroside", "D": "Mannose", "E": "Sphingomyelin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["3 month old girl", "brought", "emergency department", "respiratory distress", "difficulty breathing", "fever", "days", "increasing respiratory difficulty", "lethargy", "productive cough", "temperature", "blood pressure", "84 58 mmHg", "pulse", "min", "respirations", "48 min", "reveals subcostal retractions", "consolidation", "right lower lung field", "found to", "coarse facial features", "restricted joint movement", "Serum laboratory tests reveal", "elevated levels", "lysosomal enzymes circulating", "blood", "enzyme", "defective", "patient", "following substrates"]}
{"question": "A 33-year-old woman comes to the physician because of a 4-month history of intermittent lower abdominal cramps associated with diarrhea, bloating, and mild nausea. During this period, she has had a 5-kg (11-lb) weight loss. She feels like she cannot fully empty her bowels. She has no history of serious illness. She has a high-fiber diet. Her father is of Ashkenazi Jewish descent. She appears well. Her temperature is 36.9°C (98.5°F), pulse is 90/min, and blood pressure is 130/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Abdominal examination shows mild tenderness to palpation in the right lower quadrant without guarding or rebound. Bowel sounds are normal. Test of the stool for occult blood is negative. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 12,000 mm3, platelet count is 480,000 mm3, and erythrocyte sedimentation rate is 129 mm/h. A barium enema shows ulceration and narrowing of the right colon. Which of the following is the most likely diagnosis?", "answer": "Crohn disease", "options": {"A": "Ulcerative colitis", "B": "Celiac disease", "C": "Intestinal carcinoid tumor", "D": "Crohn disease", "E": "Diverticulitis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "4 month history", "intermittent lower abdominal cramps associated with diarrhea", "bloating", "mild nausea", "period", "5 kg", "weight loss", "empty", "bowels", "history", "serious illness", "high-fiber diet", "descent", "appears well", "temperature", "36", "98", "pulse", "90 min", "blood pressure", "90 mm Hg", "lungs", "clear", "auscultation", "Cardiac examination", "murmurs", "rubs", "Abdominal", "mild tenderness", "palpation", "right lower quadrant", "guarding", "Bowel sounds", "normal", "Test", "stool", "occult blood", "negative", "hemoglobin concentration", "10.5 g/dL", "leukocyte count", "mm3", "platelet count", "480", "mm3", "erythrocyte sedimentation rate", "mm/h", "barium enema", "ulceration", "narrowing of the right colon", "following", "diagnosis"]}
{"question": "A 67-year-old man with dilated cardiomyopathy is admitted to the cardiac care unit (CCU) because of congestive heart failure exacerbation. A medical student wants to determine the flow velocity across the aortic valve. She estimates the cross-sectional area of the valve is 5 cm2and the volumetric flow rate is 55 cm3/s. Which of the following best represents this patient's flow velocity across the aortic valve?", "answer": "0.11 m/s", "options": {"A": "0.009 m/s", "B": "0.0009 m/s", "C": "2.75 m/s", "D": "0.11 m/s", "E": "0.09 m/s"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["67 year old man", "dilated cardiomyopathy", "cardiac care unit", "congestive heart failure exacerbation", "medical student", "to", "flow velocity", "aortic valve", "estimates", "area", "valve", "5", "volumetric flow rate", "cm3", "following best", "patient's flow velocity", "aortic valve"]}
{"question": "A 24-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the emergency department for vaginal bleeding, cramping lower abdominal pain, and dizziness. She also has had fevers, chills, and foul-smelling vaginal discharge for the past 2 days. She is sexually active with one male partner, and they use condoms inconsistently. Pregnancy and delivery of her first child were uncomplicated. She appears acutely ill. Her temperature is 38.9°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 88/50 mm Hg. Abdominal examination shows moderate tenderness to palpation over the lower quadrants. Pelvic examination shows a tender cervix that is dilated with clots and a solid bloody mass within the cervical canal. Her serum β-human chorionic gonadotropin concentration is 15,000 mIU/mL. Pelvic ultrasound shows an intrauterine gestational sac with absent fetal heart tones. Which of the following is the most appropriate next step in management?", "answer": "Intravenous clindamycin and gentamicin followed by suction and curettage", "options": {"A": "Intravenous clindamycin and gentamicin followed by oral misoprostol", "B": "Oral clindamycin followed by outpatient follow-up in 2 weeks", "C": "Intravenous clindamycin and gentamicin followed by suction and curettage", "D": "Intravenous clindamycin and gentamycin followed by close observation", "E": "Oral clindamycin followed by suction curettage"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "10 weeks", "gestation", "emergency department", "vaginal bleeding", "cramping lower abdominal pain", "dizziness", "fevers", "chills", "foul-smelling vaginal discharge", "past 2 days", "sexually active", "one male", "use condoms", "Pregnancy", "delivery", "first child", "uncomplicated", "appears", "ill", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "88 50 mm Hg", "Abdominal", "moderate tenderness", "palpation", "lower quadrants", "Pelvic examination", "tender cervix", "dilated", "clots", "solid bloody mass", "cervical", "serum", "human chorionic gonadotropin concentration", "mIU/mL", "Pelvic ultrasound", "intrauterine gestational sac", "absent fetal heart tones", "following", "most appropriate next step"]}
{"question": "A 17-year-old girl presents to the family doctor with fever, headache, sore throat, dry cough, myalgias, and weakness. Her symptoms began acutely 2 days ago. On presentation, her blood pressure is 110/80 mm Hg, heart rate is 86/min, respiratory rate is 18/min, and temperature is 39.0°C (102.2°F). Physical examination reveals conjunctival injection and posterior pharyngeal wall erythema. Rapid diagnostic testing of a throat swab for influenza A+B shows positive results. Which of the following statements is true regarding the process of B cell clonal selection and the formation of specific IgG antibodies against influenza virus antigens in this patient?", "answer": "After somatic hypermutation, only a small amount of B cells antigen receptors have increased affinity for the antigen.", "options": {"A": "The first event that occurs after B lymphocyte activation is V(D)J recombination.", "B": "During antibody class switching, variable region of antibody heavy chain changes, and the constant one stays the same.", "C": "Deletions are the most common form of mutations that occur during somatic hypermutation in this patient’s B cells.", "D": "V(D)J recombination results in the formation of a B cell clone, which produces specific antibodies against influenza virus antigens.", "E": "After somatic hypermutation, only a small amount of B cells antigen receptors have increased affinity for the antigen."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl presents", "family doctor", "fever", "headache", "sore throat", "dry cough", "myalgias", "weakness", "symptoms began", "days", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "reveals conjunctival injection", "posterior pharyngeal wall erythema", "Rapid diagnostic testing", "throat swab", "influenza", "B", "positive results", "following", "true", "process", "clonal", "formation", "specific IgG antibodies", "patient"]}
{"question": "A 23-year-old man comes to the physician because of a whistling sound during respiration for the past 3 weeks. He reports that the whistling is becoming louder, and is especially loud when he exercises. He says the noise is frustrating for him. Six months ago, the patient underwent outpatient treatment for an uncomplicated nasal fracture after being hit in the nose by a high-velocity stray baseball. Since the accident, the patient has been taking aspirin for pain. He has a history of asymptomatic nasal polyps. His temperature is 37°C (98.6°F), pulse is 70/min, respirations are 12/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Which of the following would have prevented the whistling during respiration?", "answer": "Nasal septal hematoma drainage", "options": {"A": "Nasal septal hematoma drainage", "B": "Nasal polyp removal", "C": "Antibiotic therapy", "D": "Rhinoplasty", "E": "Septoplasty"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old man", "physician", "of", "sound", "respiration", "past", "weeks", "reports", "louder", "loud", "exercises", "Six months", "patient", "uncomplicated nasal fracture", "hit", "nose", "high velocity", "baseball", "patient", "aspirin", "pain", "history", "asymptomatic nasal polyps", "temperature", "98", "pulse", "70 min", "respirations", "min", "blood pressure", "70 mm Hg", "abnormalities", "following", "prevented", "whistling", "respiration"]}
{"question": "A 17-year-old boy with behavioral changes is brought in by his concerned parents. The patient’s parents say that he has been acting very odd and having difficulty academically for the past 4 months. The patient says that he has been worried and distracted because he is certain the government is secretly recording him although he cannot provide a reason why. He mentions that he does feel depressed sometimes and no longer gets joy out of playing the guitar and his other previous activities. He has no significant past medical history. The patient denies any history of smoking, alcohol consumption, or recreational drug use. He is afebrile, and his vital signs are within normal limits. Physical examination is unremarkable. On mental status examination, the patient is slightly disheveled and unkempt. He has a disorganized monotonous speech pattern. He expresses tangential thinking and has a flat affect. During the exam, it is clear that he suffers from auditory hallucinations. Which of the following is the most likely diagnosis in this patient?", "answer": "Schizophreniform disorder", "options": {"A": "Brief psychotic disorder", "B": "Schizophreniform disorder", "C": "Schizophrenia", "D": "Schizoaffective disorder", "E": "Schizotypal personality disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "behavioral changes", "brought", "patients", "acting very odd", "difficulty", "past", "months", "patient", "worried", "certain", "recording", "depressed sometimes", "longer gets", "out", "playing", "previous", "significant past medical history", "patient", "history of smoking", "recreational drug use", "afebrile", "vital signs", "normal", "Physical examination", "unremarkable", "mental status", "patient", "slightly", "unkempt", "disorganized monotonous speech pattern", "tangential thinking", "flat affect", "exam", "clear", "suffers", "auditory hallucinations", "following", "diagnosis", "patient"]}
{"question": "A 1-month-old boy is brought to the emergency department by his parents for recent episodes of non-bilious projectile vomiting and refusal to eat. The boy had no problem with passing meconium or eating at birth; he only started having these episodes at 3 weeks old. Further history reveals that the patient is a first born male and that the boy’s mother was treated with erythromycin for an infection late in the third trimester. Physical exam reveals a palpable mass in the epigastrum. Which of the following mechanisms is likely responsible for this patient’s disorder?", "answer": "Hypertrophy of smooth muscle", "options": {"A": "Defect of lumen recanalization", "B": "Hypertrophy of smooth muscle", "C": "Intestinal vascular accident", "D": "Neural crest cell migration failure", "E": "Pancreatic fusion abnormality"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "emergency department", "recent episodes of non bilious projectile vomiting", "to eat", "boy", "problem", "meconium", "eating", "birth", "only started", "episodes", "weeks old", "Further history reveals", "patient", "first born male", "boys", "treated with erythromycin", "infection late", "third trimester", "reveals", "palpable mass", "following mechanisms", "likely responsible", "patients disorder"]}
{"question": "A 24-year-old man presents with difficulty breathing and blurred vision in the left eye. No significant past medical history or current medications. He has had more than 6 sexual partners (both men and women) and did not use any form of protection during sexual intercourse. No significant family history. Upon physical examination, the patient has crackles in all lobes bilaterally. Ophthalmologic exam reveals a single white lesion in the left eye with an irregular, feathery border, as well as evidence of retinal edema and necrosis. A rapid HIV test is positive. What is the mechanism of action of the drug that can be given to treat the ocular symptoms in this patient?", "answer": "Guanosine analog that preferably inhibits viral DNA polymerase", "options": {"A": "Blocks CCR5 receptor preventing viral entry", "B": "Guanosine analog that preferably inhibits viral DNA polymerase", "C": "A neuraminidase inhibitor preventing release of viral progeny", "D": "Prevents viral uncoating", "E": "Inhibits A-site tRNA binding during translation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "difficulty breathing", "blurred vision", "left eye", "significant past medical history", "current medications", "more", "not use", "form", "protection", "sexual intercourse", "significant family history", "patient", "crackles", "lobes", "Ophthalmologic exam reveals", "single white lesion", "left", "irregular", "feathery border", "retinal edema", "necrosis", "rapid HIV", "positive", "mechanism of action", "drug", "given to treat", "ocular symptoms", "patient"]}
{"question": "A 9-year-old boy is brought to the emergency department by ambulance due to difficulty breathing. On presentation he is found to be straining to breathe. Physical exam reveals bilateral prolonged expiratory wheezing, difficulty speaking, and belly breathing. Radiographs also reveal hyperinflation of the lungs. He is given oxygen as well as albuterol, which begins to reverse the flow limitation in the airway segments of this patient. The airway segment that is most susceptible to this type of flow limitation has which of the following characteristics?", "answer": "Distal most extent of smooth muscle", "options": {"A": "Contains c-shaped hyaline cartilage rings", "B": "Contains mucous producing goblet cells", "C": "Distal most extent of smooth muscle", "D": "Lined by only simple cuboidal cells", "E": "Lined by type I and type II pneumocytes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "emergency department", "ambulance due to difficulty breathing", "found to", "straining", "reveals bilateral prolonged expiratory wheezing", "difficulty speaking", "belly breathing", "Radiographs", "reveal hyperinflation of", "lungs", "given oxygen", "albuterol", "begins to reverse", "limitation", "airway segments", "patient", "airway segment", "most susceptible", "type of flow limitation", "following characteristics"]}
{"question": "A 48-year-old man comes to the physician because of a 3-month history of fatigue, polyuria, and blurry vision. His BMI is 33 kg/m2 and his blood pressure is 147/95 mm Hg. Laboratory studies show a serum glucose concentration of 192 mg/dL and hemoglobin A1c concentration of 7.2%. Urinalysis shows 1+ glucose, 1+ protein, and no ketones. Which of the following is the most appropriate pharmacotherapy to prevent cardiovascular disease in this patient?", "answer": "Lisinopril therapy", "options": {"A": "Lisinopril therapy", "B": "Sleeve gastrectomy", "C": "Aspirin therapy", "D": "Insulin therapy", "E": "Gemfibrozil therapy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["48 year old man", "physician", "3 month history", "fatigue", "polyuria", "blurry vision", "BMI", "kg/m2", "blood pressure", "95 mm Hg", "Laboratory studies", "serum glucose concentration", "mg dL", "hemoglobin concentration", "Urinalysis", "1", "glucose", "1", "protein", "ketones", "following", "most appropriate pharmacotherapy to prevent cardiovascular", "patient"]}
{"question": "Background and Methods:\nAldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1,663 patients who had NYHA class III or IV heart failure, a left ventricular ejection fraction of no more than 35%, and who were being treated with an angiotensin-converting-enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily and 841 to receive placebo. The primary endpoint was death from all causes.\nResults:\nThe trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46%) and 284 in the spironolactone group (35%; relative risk of death, 0.70; 95% confidence interval, 0.60 to 0.82; P<0.001). This 30% reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from progressive heart failure and sudden death from cardiac causes. The frequency of hospitalization for worsening heart failure was 35% lower in the spironolactone group than in the placebo group (relative risk of hospitalization, 0.65; 95% confidence interval, 0.54 to 0.77; P<0.001). In addition, patients who received spironolactone had a significant improvement in the symptoms of heart failure, as assessed on the basis of the New York Heart Association functional class (P<0.001). Gynecomastia or breast pain was reported in 10% of men who were treated with spironolactone, as compared with 1 percent of men in the placebo group (P<0.001). The incidence of serious hyperkalemia was minimal in both groups of patients.\nTo which of the following patients are the results of this clinical trial applicable?", "answer": "A 56-year-old male with NYHA class III heart failure with an LVEF of 32%, current taking lisinopril, furosemide, and digoxin", "options": {"A": "An 82-year-old female with NYHA class II heart failure with an LVEF of 22%, taking lisinopril, furosemide, and digoxin", "B": "A 65-year-old male with newly diagnosed NYHA class IV heart failure and a LVEF of 21%, about to begin medical therapy", "C": "A 56-year-old male with NYHA class III heart failure with an LVEF of 32%, current taking lisinopril, furosemide, and digoxin", "D": "An 86-year-old female recently found to have an LVEF of 34%, currently taking furosemide and carvedilol", "E": "A 78-year-old male with NYHA class II heart failure and LVEF 36%"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Methods", "Aldosterone", "important", "pathophysiology", "heart", "enrolled 1", "patients", "NYHA class III", "IV heart failure", "left ventricular ejection fraction", "35", "treated with", "angiotensin-converting-enzyme inhibitor", "loop diuretic", "cases digoxin", "total", "patients", "assigned to receive", "daily", "to receive placebo", "death", "causes", "Results", "discontinued early", "mean follow-up period", "months", "interim analysis", "spironolactone", "efficacious", "deaths", "placebo group", "spironolactone group", "relative", "of death", "0 70", "95", "confidence interval", "0 60", "82", "P 0.001", "30", "death", "patients", "spironolactone group", "attributed", "lower risk", "death", "progressive heart failure", "sudden death", "cardiac causes", "frequency", "worsening heart failure", "35", "lower", "spironolactone group", "placebo group", "relative risk", "0.65", "95", "confidence interval", "0 54", "77", "P 0.001", "addition", "patients", "received spironolactone", "significant", "symptoms", "heart failure", "basis", "New York Heart Association functional class", "P 0.001", "Gynecomastia", "breast pain", "reported", "10", "treated with spironolactone", "1 percent", "men", "placebo group", "P 0.001", "incidence", "serious hyperkalemia", "minimal", "groups", "patients", "following patients", "results", "applicable"]}
{"question": "A 56-year-old man presents for an annual checkup. He has no complaints at the moment of presentation. He was diagnosed with diabetes mellitus a year ago and takes metformin 1000 mg per day. The patient also has a history of postinfectious myocarditis that occurred 15 years ago with no apparent residual heart failure. His family history is unremarkable. He has a 15-pack-year history of smoking, but he currently does not smoke. He is a retired weightlifting athlete who at the present works as a coach and continues to work out. His BMI is 29 kg/m2. The blood pressure is 120/85 mm Hg, heart rate is 85/min, respiratory rate is 14/min, and temperature is 36.6℃ (97.9℉). Physical examination is only remarkable for an increased adiposity. The ECG is significant for increased R amplitude in leads I, II, and V3-6 and an incomplete left bundle branch block. Which of the following is most likely included in the treatment regimen of this patient?", "answer": "Fosinopril", "options": {"A": "No management is required since the patient is asymptomatic", "B": "Diltiazem", "C": "Amlodipine", "D": "Furosemide", "E": "Fosinopril"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "annual checkup", "complaints", "diagnosed", "diabetes mellitus", "year", "metformin", "mg", "day", "patient", "history of", "myocarditis", "years", "residual heart failure", "family history", "unremarkable", "history of smoking", "currently", "not smoke", "retired", "athlete", "present", "coach", "to work out", "BMI", "29 kg/m2", "blood pressure", "85 mm Hg", "heart rate", "85 min", "respiratory rate", "min", "temperature", "36", "97", "only", "increased adiposity", "ECG", "significant", "increased R amplitude", "leads I", "V3", "incomplete left bundle branch block", "following", "most likely included", "treatment regimen", "patient"]}
{"question": "A 6-year-old male presents to the emergency department after falling from his scooter. The patient reports that he fell sideways off the scooter as he rounded a curve in the road, and he describes dull, aching pain along his left side where he hit the ground. The patient’s parents report that he has never had any serious injury but that he has always seemed to bruise easily, especially after he started playing youth soccer this fall. His parents deny that he has ever had nosebleeds or bleeding from the gums, and they have never seen blood in his stool or urine. His mother notes that her brother has had similar problems. On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation. Laboratory tests are performed and reveal the following:\n\nHemoglobin: 14 g/dL\nHematocrit: 41%\nMean corpuscular volume: 89 µm3\nReticulocyte count: 0.8%\nLeukocyte count: 4,700/mm3\nProthrombin time (PT): 13 seconds\nPartial thromboplastin time (PTT): 56 seconds\nBleeding time (BT): 4 minutes\n\nWhich of the following is the most likely underlying pathophysiology of this patient's presentation?", "answer": "Factor VIII deficiency", "options": {"A": "Factor VIII deficiency", "B": "Factor IX deficiency", "C": "Factor VIII antigen deficiency", "D": "GP1b deficiency", "E": "Anti-platelet antibodies"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male presents", "emergency department", "falling", "patient reports", "fell", "rounded", "curve", "road", "dull", "aching pain", "left", "hit", "patients", "report", "never", "serious injury", "always", "to bruise easily", "started playing youth", "fall", "nosebleeds", "bleeding", "gums", "never seen blood in", "stool", "urine", "notes", "similar", "patient", "extensive bruising", "lateral left thigh", "tenderness", "palpation", "Laboratory tests", "performed", "reveal", "following", "Hemoglobin", "g/dL Hematocrit", "Mean corpuscular volume", "m3 Reticulocyte count", "0.8", "Leukocyte count", "4 700 mm3 Prothrombin time", "seconds Partial thromboplastin time", "seconds Bleeding time", "4 minutes", "following", "underlying pathophysiology", "patient's"]}
{"question": "A 38-year-old man comes to the physician because of fever, malaise, cough, and shortness of breath for 2 months. He has had a 4-kg (9-lb) weight loss during the same period. He works at a flour mill and does not smoke cigarettes. His temperature is 38.1°C (100.6°F) and pulse oximetry shows 95% on room air. Diffuse fine crackles are heard over both lung fields. A chest x-ray shows patchy reticulonodular infiltrates in the mid and apical lung fields bilaterally. A photomicrograph of a lung biopsy specimen is shown. Which of the following cytokines have the greatest involvement in the pathogenesis of the lesion indicated by the arrow?", "answer": "Interferon gamma and interleukin-2", "options": {"A": "Tumor necrosis factor alpha and interleukin-4", "B": "Interferon gamma and interleukin-2", "C": "Interferon alpha and interleukin-1", "D": "Interleukin-4 and interleukin-10", "E": "Transforming growth factor beta and interleukin-12"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "fever", "malaise", "cough", "shortness of breath", "2 months", "4 kg", "weight loss", "same period", "mill", "not smoke cigarettes", "temperature", "100", "pulse oximetry", "95", "room air", "Diffuse fine crackles", "heard", "lung fields", "chest x-ray", "patchy", "infiltrates", "apical lung fields", "photomicrograph of", "lung biopsy", "following cytokines", "greatest involvement", "pathogenesis", "lesion indicated", "arrow"]}
{"question": "A group of investigators is examining the effect of the drug orlistat as an adjunct therapy to lifestyle modification on weight loss in obese volunteers. 800 obese participants were randomized to receive orlistat in addition to counseling on lifestyle modification and 800 obese participants were randomized to receive counseling on lifestyle modification alone. At the conclusion of the study, the investigators found that patients who underwent combined therapy lost a mean of 8.2 kg (18.1 lb), whereas patients counseled on lifestyle modification alone lost a mean of 4.3 kg (9.5 lb) (p < 0.001). The investigators also observed that of the 120 participants who did not complete the study, 97 participants were in the lifestyle modification group and 23 participants were in the combination group. Based on this information, the investigators should be most concerned about which of the following?", "answer": "Attrition bias", "options": {"A": "Error in randomization", "B": "Lead-time bias", "C": "Attrition bias", "D": "Nonresponse bias", "E": "Confounding bias"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigators", "examining", "effect of", "drug orlistat", "therapy", "lifestyle modification", "weight loss", "obese volunteers", "800", "randomized to receive orlistat in addition to counseling", "lifestyle modification", "800 obese", "randomized to receive counseling", "lifestyle modification alone", "study", "investigators found", "patients", "combined therapy lost", "mean", "kg", "patients counseled", "lifestyle modification alone lost", "mean", "kg", "9.5", "p", "0.001", "investigators", "observed", "not complete", "study", "97", "lifestyle modification group", "23", "combination group", "Based", "investigators", "most"]}
{"question": "A 14-year-old girl is brought to the physician because of a 1-week history of malaise and chest pain. Three weeks ago, she had a sore throat that resolved without treatment. Her temperature is 38.7°C (101.7°F). Examination shows several subcutaneous nodules on her elbows and wrist bilaterally and a new-onset early systolic murmur best heard at the apex in the left lateral position. An endomysial biopsy is most likely to show which of the following?", "answer": "Fibrinoid necrosis with histiocytic infiltrate", "options": {"A": "Coagulative necrosis with neutrophilic infiltrate", "B": "Fibrinoid necrosis with histiocytic infiltrate", "C": "Deposits of misfolded protein aggregates", "D": "Myocardial infiltration with eosinophilic proteins", "E": "Fibrosis with myofibrillar disarray"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "1-week history", "malaise", "chest pain", "Three weeks", "sore throat", "resolved", "treatment", "temperature", "several subcutaneous", "elbows", "wrist", "new-onset early systolic murmur best heard", "apex", "left lateral position", "endomysial biopsy", "to", "following"]}
{"question": "A study of a new antihypertensive drug that affects glomerular filtration rate is being conducted. Infusion of drug X causes constriction of the efferent arteriole. After infusion of the drug, the following glomerular values are obtained from an experimental subject: hydrostatic pressure of the glomerular capillary (PGC) of 48 mm Hg, oncotic pressure of the glomerular capillary (πGC) of 23 mm Hg, hydrostatic pressure of Bowman’s space (PBS) of 10 mm Hg, and oncotic pressure of Bowman’s space (πBS) of 0 mm Hg. Which of the following best measures net filtration pressure in this participant?", "answer": "15 mm Hg", "options": {"A": "15 mm Hg", "B": "35 mm Hg", "C": "61 mm Hg", "D": "0 mm Hg", "E": "81 mm Hg"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["study", "new antihypertensive drug", "glomerular filtration rate", "Infusion of drug", "causes constriction", "efferent arteriole", "infusion of", "drug", "following glomerular values", "obtained", "experimental subject", "pressure of", "glomerular capillary", "48 mm Hg", "of", "glomerular capillary", "23 mm Hg", "Bowmans space", "10 mm Hg", "Bowmans space", "0 mm Hg", "following best measures net", "pressure"]}
{"question": "A 62-year-old woman comes to the physician because of worsening mental status over the past month. Her husband reports that she was initially experiencing lapses in memory but has recently started having difficulties performing activities of daily living. She appears withdrawn and avoids eye contact. Examination shows diffuse involuntary muscle jerking that can be provoked by loud noises. A cerebrospinal fluid analysis shows elevated concentration of 14-3-3 protein. Four months later, the patient dies. Pathologic examination of the brain on autopsy is most likely to show which of the following findings?", "answer": "Spongiform vacuolation of the cortex", "options": {"A": "Degeneration of the substantia nigra pars compacta", "B": "Marked atrophy of caudate and putamen", "C": "Focal inflammatory demyelination and gliosis", "D": "Deposits of amyloid beta peptides", "E": "Spongiform vacuolation of the cortex"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["62 year old woman", "physician", "of worsening mental status", "past month", "reports", "initially", "lapses", "memory", "recently started", "difficulties performing", "appears withdrawn", "eye contact", "Examination", "diffuse involuntary muscle jerking", "provoked", "loud", "cerebrospinal fluid analysis", "elevated concentration", "14-3-3 protein", "Four months later", "Pathologic", "brain", "autopsy", "to", "following findings"]}
{"question": "A 65-year-old man comes to the physician because of fatigue and nausea for 1 week. Over the past six months, he has had to get up twice every night to urinate. Occasionally, he has had discomfort during urination. He has arterial hypertension. His father died of renal cell carcinoma. Current medications include ramipril. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 124/78 mm Hg. The abdomen is soft and nontender. Cardiac and pulmonary examinations show no abnormalities. Rectal examination shows a symmetrically enlarged and smooth prostate. Serum studies show:\nHemoglobin 14.9 g/dL\nLeukocyte count 7500/mm3\nPlatelet count 215,000/mm3\nSerum\nNa+ 136 mEq/L\nCl- 101 mEq/L\nK+ 4.9 mEq/L\nHCO3- 23 mEq/L\nGlucose 95 mg/dL\nUrea nitrogen 25 mg/dL\nCreatinine 1.9 mg/dL\nPSA 2.1 ng/mL (normal <4 ng/mL)\nUrine\nBlood negative\nProtein 1+\nGlucose negative\nRBC casts negative\nWhich of the following is the most appropriate next step in management?\"", "answer": "Renal ultrasonography", "options": {"A": "Four-glass test", "B": "CT scan of the abdomen and pelvis", "C": "Transrectal ultrasonography", "D": "Renal ultrasonography", "E": "Ureteral stenting"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man", "physician", "fatigue", "nausea", "1 week", "past six months", "to get", "twice", "night to", "Occasionally", "discomfort", "urination", "arterial hypertension", "died", "renal cell carcinoma", "Current medications include ramipril", "temperature", "99", "pulse", "88 min", "blood pressure", "mm Hg", "abdomen", "soft", "nontender", "Cardiac", "pulmonary", "abnormalities", "Rectal examination", "enlarged", "smooth prostate", "Serum studies", "Hemoglobin", "Leukocyte count", "Platelet count", "L", "HCO3", "mg", "Urea nitrogen", "Creatinine", "mL", "normal", "4 ng/mL", "Urine Blood negative Protein 1", "Glucose", "RBC casts negative", "following", "most appropriate next step"]}
{"question": "A 25-year-old man comes to the physician because of right-sided painless scrotal swelling that he noticed yesterday while taking a shower. He is currently sexually active with two female partners and uses condoms inconsistently. He immigrated to the US from Argentina 2 years ago. His immunization records are unavailable. He has smoked one pack of cigarettes daily for the last 5 years. He is 170 cm (5 ft 7 in) tall and weighs 70 kg (154 lb); BMI is 24.2 kg/m2. He appears healthy and well nourished. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 125/75 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft with dull lower abdominal discomfort. Testicular examination shows a solid mass in the right testis that is firm and nontender. A light held behind the scrotum does not shine through. The mass is not reduced when the patient is in a supine position. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?", "answer": "Testicular tumor", "options": {"A": "Orchitis", "B": "Hydrocele testis", "C": "Scrotal hernia", "D": "Testicular torsion", "E": "Testicular tumor"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "right sided painless scrotal swelling", "shower", "currently sexually active", "two female", "uses condoms", "Argentina", "years", "unavailable", "smoked one pack", "cigarettes daily", "last", "years", "5 ft", "tall", "70 kg", "BMI", "kg/m2", "appears healthy", "well nourished", "temperature", "98", "pulse", "72 min", "blood pressure", "75 mm Hg", "lungs", "clear", "auscultation", "Cardiac examination", "abnormalities", "abdomen", "soft", "dull lower abdominal discomfort", "Testicular", "solid mass", "right", "firm", "nontender", "light held", "scrotum", "not shine", "mass", "not reduced", "patient", "supine position", "abnormalities", "following", "diagnosis", "patient"]}
{"question": "Two days after undergoing an emergency laparotomy following a motor vehicle collision, a 37-year-old man has increased thirst. Examination shows dry mucous membranes and decreased skin turgor. A review of his chart shows his urine output to be in excess of his fluid intake. Laboratory studies show a serum sodium concentration of 151 mEq/L and urine osmolality of 110 mOsmol/kg H2O. One hour after the administration of desmopressin, the serum sodium concentration is 146 mEq/L and urine osmolality is 400 mOsmol/kg H2O. One week later, his laboratory values are within normal limits. This patient's condition was most likely caused by damage to which of the following structures?", "answer": "Posterior pituitary", "options": {"A": "Posterior pituitary", "B": "Adrenal cortex", "C": "Proximal renal tubule", "D": "Collecting duct", "E": "Supraoptic nucleus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Two days", "emergency laparotomy following", "motor vehicle collision", "year old man", "increased thirst", "dry mucous membranes", "decreased skin turgor", "urine output to", "excess", "fluid", "Laboratory studies", "serum concentration", "mEq/L", "urine osmolality of", "mOsmol/kg H2O", "One hour", "administration", "desmopressin", "serum concentration", "mEq/L", "urine osmolality", "400 mOsmol/kg H2O", "One week later", "laboratory values", "normal limits", "patient's condition", "most likely caused", "damage", "following structures"]}
{"question": "A 10-year-old girl is brought to the emergency department because of lower abdominal pain for the past 12 hours. The pain has progressively worsened and was accompanied by occasional episodes of diarrhea. She has vomited twice. Her mother has Crohn disease. Her temperature is 38.1°C (100.6°F), pulse is 95/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. The abdomen is soft, and there is mild tenderness to palpation in the right lower quadrant without rebound or guarding. Bowel sounds are normal. Her hemoglobin concentration is 13.0 g/dL, leukocyte count is 12,800/mm3, and platelet count is 345,000/mm3. Urine dipstick is negative for nitrites and leukocyte esterase. Urinalysis shows 3 WBC/hpf and no RBCs. Which of the following is the most appropriate next step in management?", "answer": "Ultrasound of the abdomen", "options": {"A": "Ultrasound of the abdomen", "B": "Colonoscopy", "C": "CT scan of the abdomen", "D": "X-ray of the abdomen", "E": "MRI of the abdomen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["A 10 year old girl", "brought", "emergency department", "of lower abdominal pain", "past 12 hours", "pain", "worsened", "occasional episodes of diarrhea", "vomited twice", "Crohn disease", "temperature", "100", "pulse", "95 min", "respirations", "20 min", "blood pressure", "70 mm Hg", "abdomen", "soft", "mild tenderness", "palpation", "right lower quadrant", "guarding", "Bowel sounds", "normal", "hemoglobin concentration", "0 g/dL", "leukocyte count", "800 mm3", "platelet count", "mm3", "Urine dipstick", "negative", "leukocyte esterase", "Urinalysis", "3 WBC/hpf", "following", "most appropriate next step"]}
{"question": "A 57-year-old man comes to the emergency department with fatigue and palpitations for several weeks. An ECG shows atrial fibrillation. Echocardiography shows thrombus formation in the left atrium. Which of the following organs is most likely to continue to function in the case of an embolic event?", "answer": "Liver", "options": {"A": "Spleen", "B": "Brain", "C": "Kidney", "D": "Liver", "E": "Colon"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["57 year old man", "emergency department", "fatigue", "palpitations", "weeks", "ECG", "atrial fibrillation", "Echocardiography", "thrombus formation", "left atrium", "following organs", "to", "to function", "case", "embolic event"]}
{"question": "A 28-year-old female patient with a history of schizophrenia, type 2 diabetes mellitus, and hypothyroidism comes to clinic stating she would like to be put back on a medication. She recently stopped taking her haloperidol as it made it hard for her to \"sit still.\" She requests to be put on olanzapine as a friend from a support group said it was helpful. Why should this medication be avoided in this patient?", "answer": "The patient has type 2 diabetes", "options": {"A": "The patient is at a high risk for torsades de pointes", "B": "There is a high risk for retinopathy", "C": "The patient has type 2 diabetes", "D": "The patient may develop galactorrhea", "E": "Tardive dyskinesia will likely result from the prolonged use of olanzapine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female patient", "history of schizophrenia", "type 2 diabetes mellitus", "hypothyroidism", "clinic stating", "to", "back", "medication", "recently stopped", "haloperidol", "made", "hard", "sit", "to", "olanzapine", "helpful", "medication", "patient"]}
{"question": "A 16-year-old girl presents to her physician with itching, soreness, and irritation in the vulvar region. She reports that these episodes have occurred 6–7 times a year since the age of 5. She used to treat these symptoms with topical ketoconazole cream, but this time it failed to help. She also has had several episodes of oral candidiasis in the past. She is not sexually active and does not take any medication. Her vital signs are as follows: the blood pressure is 115/80 mm Hg, the heart rate is 78/min, the respiratory rate is 15/min, and the temperature is 35.5°C (97.7°F). Examination shows vulvovaginal erythema with cottage cheese-like plaques and an intact hymen. Wet mount microscopy is positive for yeast. Along with a swab culture, the physician orders a dihydrorhodamine test and myelin peroxidase staining for a suspected primary immunodeficiency. The dihydrorhodamine test is positive, and the myeloperoxidase staining reveals diminished staining. Which of the following best describes this patient’s condition?", "answer": "The patient is likely to have another immune impairment besides the one for which she was tested.", "options": {"A": "The patient’s phagocytes are unable to generate an oxidative burst to kill intracellular bacteria.", "B": "The patient is likely to have another immune impairment besides the one for which she was tested.", "C": "The patient should receive prophylactic courses of wide spectrum antibiotics to prevent infections.", "D": "The patient’s phagocytes can only perform extracellular killing.", "E": "The patient is susceptible to all mycotic infections."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "physician", "itching", "soreness", "irritation", "vulvar region", "reports", "episodes", "67 times", "year", "age", "used to treat", "symptoms", "time", "failed to help", "several episodes of oral candidiasis", "past", "not sexually active", "not", "medication", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "35", "97", "vulvovaginal erythema", "plaques", "intact hymen", "Wet mount microscopy", "positive", "yeast", "swab culture", "physician orders", "test", "myelin peroxidase staining", "suspected primary immunodeficiency", "test", "positive", "myeloperoxidase staining reveals diminished staining", "following best", "patients condition"]}
{"question": "A 46-year-old man comes to the physician with chronic abdominal pain. He has a 3-year history of severe peptic ulcer disease and esophagitis. Two months ago, he took omeprazole, clarithromycin, and amoxicillin for 14 days. His medical history is otherwise unremarkable. Currently, he takes omeprazole 60 mg/day. He is a 10 pack-year smoker and consumes alcohol regularly. Vital signs are within normal limits. Mild epigastric tenderness is noted on deep palpation of the epigastrium. Laboratory studies show:\nSerum\nCalcium 9.5 mg/dL\nPhosphorus 4 mg/dL\nAn upper endoscopy shows several large ulcers in the antrum and 2nd and 3rd parts of the duodenum. The rapid urease test is negative. Fasting gastrin levels are elevated. PET-CT with Ga-Dotatate shows a single mass in the wall of the duodenum. No other mass is detected. Pituitary MRI shows no abnormality. Which of the following is the most appropriate next step in management?", "answer": "Surgical resection", "options": {"A": "Adjuvant therapy with octreotide", "B": "Biological therapy with interferon-alpha", "C": "Quadruple therapy for Helicobacter pylori", "D": "Smoking cessation", "E": "Surgical resection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "chronic abdominal pain", "3 year history of severe peptic ulcer disease", "esophagitis", "Two months", "omeprazole", "clarithromycin", "amoxicillin", "days", "medical history", "unremarkable", "Currently", "omeprazole 60 mg/day", "a 10", "smoker", "alcohol", "Vital signs", "normal limits", "Mild epigastric tenderness", "noted", "deep palpation", "epigastrium", "Laboratory studies", "Serum Calcium 9.5 mg dL Phosphorus", "dL", "upper endoscopy", "several large ulcers", "antrum", "2nd", "3rd parts of", "duodenum", "rapid urease", "negative", "Fasting gastrin levels", "elevated", "PET-CT", "Ga Dotatate", "single mass", "wall of", "duodenum", "mass", "detected", "Pituitary MRI", "abnormality", "following", "most appropriate next step"]}
{"question": "A 16-day-old male newborn is brought to the emergency department because of fever and poor feeding for 2 days. He became very fussy the previous evening and cried for most of the night. He was born at 36 weeks' gestation and weighed 2430 g (5 lb 3 oz). The pregnancy and delivery were uncomplicated. The mother does not recall any sick contacts at home. He currently weighs 2776 g (6 lb 2 oz). He appears irritable. His temperature is 38.6°C (101.5°F), pulse is 180/min, and blood pressure is 82/51 mm Hg. Examination shows scleral icterus. He becomes more agitated when picked up. There is full range of motion of his neck and extremities. The anterior fontanelle feels soft and flat. Neurologic examination shows no abnormalities. Blood cultures are drawn and fluid resuscitation is initiated. A urinalysis obtained by catheterization shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?", "answer": "Lumbar puncture", "options": {"A": "MRI of the head", "B": "Reassurance", "C": "Urine culture", "D": "CT scan of the head", "E": "Lumbar puncture"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["day old male newborn", "brought", "emergency department", "fever", "poor feeding", "2 days", "very fussy", "previous evening", "night", "born", "36 weeks", "gestation", "g", "oz", "pregnancy", "delivery", "uncomplicated", "not", "sick", "at home", "currently", "g", "oz", "appears irritable", "temperature", "pulse", "min", "blood pressure", "mm Hg", "scleral icterus", "more agitated", "full range of motion", "neck", "extremities", "anterior fontanelle", "soft", "flat", "Neurologic examination", "abnormalities", "Blood cultures", "fluid resuscitation", "initiated", "urinalysis obtained", "catheterization", "abnormalities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 24-year-old man comes to the emergency department because of left shoulder pain hours after suffering a fall from a height of approximately 10 feet while rock climbing about 5 hours ago. He initially thought the pain would resolve with rest but it became more severe over the last 2 hours. Last year while rock climbing he fell onto his right shoulder and “needed a sling to fix it”. He has psoriasis. His only medication is topical clobetasol. His pulse is 95/min, respiratory rate is 16/minute, and blood pressure is 114/70 mm Hg. Examination shows full passive and active range of motion at the left shoulder. There is no tenderness to palpation at the acromioclavicular joint. There are silvery plaques over both knees and elbows. Abdominal exam shows 7/10 left upper quadrant tenderness with voluntary guarding. A complete blood count and serum concentrations of electrolytes are within the reference range. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the abdomen", "options": {"A": "Serial vital signs for at least nine hours", "B": "CT scan of the abdomen", "C": "Abdominal ultrasound", "D": "Radiographs of the left shoulder", "E": "MRI of the left shoulder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "of left shoulder pain hours", "suffering", "fall", "height of approximately 10 feet", "rock climbing", "hours", "initially", "pain", "more severe", "hours", "year", "rock climbing", "fell", "right shoulder", "needed", "sling", "psoriasis", "only medication", "topical clobetasol", "pulse", "95 min", "respiratory rate", "minute", "blood pressure", "70 mm Hg", "full passive", "active range of motion", "left shoulder", "tenderness", "palpation", "acromioclavicular joint", "silvery plaques", "knees", "elbows", "Abdominal exam", "10 left upper quadrant tenderness", "guarding", "complete blood count", "serum", "electrolytes", "reference range", "following", "most appropriate next step"]}
{"question": "A 3-year-old boy is brought to the emergency department because of persistent fever and cough. Three days ago, he was diagnosed with pneumonia and acute otitis media. He was started on ampicillin-sulbactam and clarithromycin, but his symptoms did not improve. The mother reports that her son has been hospitalized 3 times due to pneumonia. He was first diagnosed with pneumonia at the age of 10 months. She also reports several episodes of bilateral otitis media and recurrent respiratory tract infections. His immunizations are up-to-date. He is at the 50th percentile for height and 20th percentile for weight. He appears fatigued. His temperature is 38°C (100.4°F). Pneumatic otoscopy shows purulent otorrhea bilaterally. Pulmonary examination shows decreased breath sounds over both lung fields. The palatine tonsils and adenoids are hypoplastic. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Tyrosine kinase gene mutation", "options": {"A": "Defective NADPH oxidase", "B": "Defective IL-2R gamma chain", "C": "Defect in the ATM gene", "D": "WAS gene mutation", "E": "Tyrosine kinase gene mutation"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "persistent fever", "cough", "Three days", "diagnosed", "pneumonia", "acute otitis media", "started", "ampicillin-sulbactam", "clarithromycin", "symptoms", "not", "reports", "hospitalized 3 times due to pneumonia", "first diagnosed", "pneumonia", "age", "10 months", "reports several episodes of bilateral otitis media", "recurrent respiratory tract infections", "immunizations", "date", "50th percentile", "height", "percentile", "weight", "appears fatigued", "temperature", "100", "Pneumatic otoscopy", "purulent otorrhea", "Pulmonary", "decreased breath sounds", "lung fields", "palatine tonsils", "adenoids", "hypoplastic", "following", "underlying cause", "patient's condition"]}
{"question": "A 70-year-old woman is brought to her physician by her daughter who reports that the patient has been increasingly confused and forgetful over the past year. The daughter reports that the patient has difficulty finding words, remembering names, and maintaining a conversation. She has gotten lost twice while driving. Her past medical history is known for obesity, diabetes, and atrial fibrillation. She takes metformin, glyburide, and warfarin. She drinks socially and has a 30 pack-year smoking history. Her family history is notable for Parkinson’s disease in her father and stroke in her mother. A head CT demonstrates sulcal widening and narrowing of the gyri. The physician decides to start the patient on a medication known to inhibit a cell surface glutamate receptor. Which of the following is a downstream effect of this medication?", "answer": "Decreased intracellular calcium", "options": {"A": "Decreased intracellular calcium", "B": "Increased intracellular calcium", "C": "Increased intracellular sodium", "D": "Increased intracellular acetylcholine", "E": "Decreased intracellular acetylcholine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["70 year old woman", "brought", "physician", "reports", "patient", "confused", "forgetful", "past year", "reports", "patient", "difficulty finding words", "names", "gotten lost twice", "past medical history", "known", "obesity", "diabetes", "atrial fibrillation", "metformin", "glyburide", "warfarin", "30", "smoking history", "family history", "notable", "Parkinsons disease", "stroke", "head CT", "sulcal widening", "narrowing", "physician", "to start", "patient", "medication known to inhibit", "cell surface glutamate receptor", "following", "downstream effect", "medication"]}
{"question": "A 67-year-old farmer presents to the emergency department with a chief complaint of unusual behavior. His wife states that since this morning he has experienced dryness and flushing of his skin while working outside. As the day went on, the patient found it exceedingly difficult to urinate and had to create significant abdominal pressure for a weak stream of urine to be produced. Currently, the patient seems confused and responds incoherently. The patient has a past medical history of Parkinson's disease, alcohol abuse, irritable bowel syndrome, anxiety, diabetes mellitus, hypertension, constipation and a suicide attempt when he was 23 years old. He is currently taking lisinopril, hydrochlorothiazie, metformin, insulin, benztropine, levodopa/carbidopa, and vitamin C. The only other notable symptoms this patient has experienced are recent severe seasonal allergies. On physical exam you note dry, flushed skin, and a confused gentleman. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air. Lab values are ordered. Which of the following is the most likely cause of this patient's presentation?", "answer": "Medication", "options": {"A": "Medication", "B": "Insecticide exposure", "C": "Alcohol", "D": "Infection", "E": "Heat stroke"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old farmer presents", "emergency department", "chief complaint", "unusual behavior", "states", "morning", "dryness", "flushing", "skin", "outside", "day", "patient found", "difficult to", "to create significant abdominal pressure", "weak stream of urine to", "Currently", "patient", "confused", "patient", "past medical Parkinson's disease", "alcohol abuse", "irritable bowel syndrome", "anxiety", "diabetes mellitus", "hypertension", "constipation", "suicide attempt", "23 years old", "currently", "lisinopril", "metformin", "insulin", "benztropine", "levodopa/carbidopa", "vitamin C", "only", "notable symptoms", "patient", "recent severe seasonal", "note dry", "flushed", "confused", "temperature", "99", "pulse", "min", "blood pressure", "90 mmHg", "respirations", "min", "oxygen saturation", "96", "room air", "Lab values", "ordered", "following", "most likely cause", "patient's"]}
{"question": "A 65-year-old man is brought to the emergency department by his wife because of progressive lethargy and confusion during the past 2 days. His wife reports that he has been complaining of nausea and increased urination for the past 5 days. He also developed a cough 1 week ago. He has a history of a cerebrovascular accident 3 years ago and was diagnosed with hypertension 10 years ago. Current medications include lisinopril and aspirin. His temperature is 38.5°C (101.3°F), pulse is 114/min, respirations are 15/min, and blood pressure is 108/75 mm Hg. He is somnolent and oriented only to person. Examination shows dry mucous membranes and decreased skin turgor. Crackles are heard at the left lung base. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Blood glucose measurement", "options": {"A": "Chest x-ray", "B": "Serum calcium measurement", "C": "Broad-spectrum antibiotics", "D": "Blood glucose measurement", "E": "Arterial blood gas analysis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man", "brought", "emergency department", "progressive lethargy", "confusion", "past 2 days", "reports", "nausea", "increased urination", "past 5 days", "cough", "week", "history of", "cerebrovascular accident", "years", "diagnosed", "hypertension", "Current medications include lisinopril", "aspirin", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "75 mm Hg", "somnolent", "oriented only", "dry mucous membranes", "decreased skin turgor", "Crackles", "heard", "left lung base", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 59-year-old man comes to the emergency department because of progressively worsening chest pain and nausea that started while visiting a local bar 30 minutes ago. The pain radiates to the epigastric area. He has a 10-year history of untreated hypertension. He has smoked 1 pack of cigarettes daily for 35 years. The patient is diaphoretic and in marked distress. His pulse is 94/min, respirations are 28/min, and blood pressure is 161/92 mm Hg. Pulse oximetry on 2 L/min of oxygen via nasal cannula shows an oxygen saturation of 97%. Cardiac examination shows a regular heartbeat and a systolic ejection murmur heard best over the upper right sternal border. The lungs are clear to auscultation bilaterally. Pedal pulses are intact. An ECG shows inverted T waves in leads I, avL, and V5-6. Urine toxicology screening is positive for cocaine. Which of the following drugs is contraindicated in the management of this patient's condition?", "answer": "Propranolol", "options": {"A": "Propranolol", "B": "Diazepam", "C": "Prasugrel", "D": "Diltiazem", "E": "Aspirin\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["59 year old man", "emergency department", "worsening chest pain", "nausea", "started", "local", "30 minutes", "pain radiates", "epigastric area", "a 10 year history of untreated hypertension", "smoked 1 pack", "cigarettes daily", "35 years", "patient", "diaphoretic", "marked distress", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "L/min", "oxygen", "nasal cannula", "oxygen saturation", "97", "regular heartbeat", "systolic ejection murmur heard best", "upper right sternal border", "lungs", "clear", "auscultation", "Pedal pulses", "intact", "ECG", "inverted T waves", "leads I", "avL", "Urine toxicology", "positive", "cocaine", "following drugs", "contraindicated", "management", "patient's"]}
{"question": "A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?", "answer": "Elevated serum CK", "options": {"A": "Elevated serum calcitonin", "B": "Elevated serum CK", "C": "Low serum TSH", "D": "Activating TSH-receptor immunoglobulins", "E": "Hypocalcemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female presents", "recent muscle", "fatigue", "constipation", "reveals", "bradycardic patient", "cool", "dry skin", "following lab values", "to", "present", "patient's"]}
{"question": "A 26-year-old gravida 2 para 1 presents to her physician at 12 weeks gestation. She has no complaints. Her previous pregnancy 5 years ago had an uncomplicated course with vaginal delivery of a healthy boy at 39 + 1 weeks gestation. Her weight is 75 kg (165 lb) and the height is 168 cm (5 ft 6 in). On presentation, the blood pressure is 110/70 mm Hg, the heart rate is 83/min, the respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉). The physical examination is within normal limits. The gynecologic examination demonstrates a fetal heart rate of 180/min. The uterus cannot be palpated and the ultrasound exam is benign. Blood testing showed the following:\nRBC count 3.9 million/mm3\nLeukocyte count 11,100/mm3\nHb 11.6 g/dL\nHct 32%\nMCV 87 fl\nReticulocyte count 0.4%\nThe patient’s blood type is A neg. Which testing is indicated in this patient?", "answer": "Indirect Coombs test", "options": {"A": "Measurement of serum iron", "B": "Direct Coombs test", "C": "White blood cell differential", "D": "Indirect Coombs test", "E": "Measurement of serum vitamin B12"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old gravida 2 para 1 presents", "physician", "weeks gestation", "complaints", "previous pregnancy 5 years", "uncomplicated course", "vaginal", "healthy boy", "weeks gestation", "weight", "75 kg", "height", "5 ft 6", "blood pressure", "70 mm Hg", "heart rate", "83 min", "respiratory rate", "min", "temperature", "36", "97", "normal limits", "fetal heart rate", "min", "uterus", "ultrasound exam", "benign", "Blood testing", "following", "RBC count", "million mm3 Leukocyte", "100", "Hb", "6 g/dL Hct 32", "MCV 87 fl", "4", "patients blood type", "neg", "testing", "indicated", "patient"]}
{"question": "A 34-year-old man presents to his primary care physician with frequent urination. He was recently hospitalized following a severe motorcycle accident in which he suffered multiple injuries to his head and extremities. He reports that he has been constantly thirsty and has been urinating four to five times per night since being discharged from the hospital one week prior to presentation. His past medical history is notable for type II diabetes mellitus, which is well controlled on metformin. He has a 10 pack-year smoking history and drinks 3-4 alcoholic beverages per day. His temperature is 98.8°F (37.1°C), blood pressure is 110/70 mmHg, pulse is 95/min, and respirations are 18/min. Physical examination reveals delayed capillary refill and decreased skin turgor. Notable laboratory results are shown below:\n\nSerum:\nNa+: 148 mEq/L\nCl-: 101 mEq/L\nK+: 3.7 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 110 mg/dL\nHemoglobin A1c: 5.7%\n\nThis patient’s condition is most likely caused by defective production in which of the following locations?", "answer": "Supraoptic nucleus of the hypothalamus", "options": {"A": "Supraoptic nucleus of the hypothalamus", "B": "Lateral nucleus of the hypothalamus", "C": "Posterior pituitary", "D": "Anterior pituitary", "E": "Posterior nucleus of the hypothalamus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "frequent urination", "recently hospitalized following", "severe motorcycle accident", "suffered multiple injuries", "head", "extremities", "reports", "constantly thirsty", "four", "five times", "night", "discharged from", "hospital one week", "past medical history", "notable", "type II diabetes mellitus", "well controlled", "metformin", "a 10", "smoking history", "3", "day", "temperature", "98", "blood pressure", "70 mmHg", "pulse", "95 min", "respirations", "min", "reveals delayed capillary refill", "decreased skin turgor", "Notable laboratory results", "Serum", "Na", "mEq/L", "mEq/L K", "3", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "mg/dL Hemoglobin A1c", "5", "patients condition", "most likely caused", "defective", "following locations"]}
{"question": "An 88-year-old man presents to his primary care physician due to insomnia. The patient’s wife states that she often sees him sitting awake at night, seemed visibly irritated. This has persisted for years but worsened recently when the patient attended a funeral for one of his friends in the military. The patient states that he has trouble sleeping and finds that any slight sound causes him to feel very alarmed. Recently, the patient has been having what he describes as strong memories of events that occurred with his fellow soldiers while at war. At times he awakes in a cold sweat and has not been able to get quality sleep in weeks. The patient has a past medical history of anxiety, obesity, and type II diabetes mellitus. His current medications include insulin, metformin, lisinopril, sodium docusate, and fish oil. Which of the following is the best initial medical therapy for this patient?", "answer": "Escitalopram", "options": {"A": "Bupropion", "B": "Buspirone", "C": "Clonazepam", "D": "Escitalopram", "E": "Trazodone"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["88 year old man presents", "primary care physician", "insomnia", "patients", "states", "often sees", "sitting awake", "night", "years", "worsened recently", "patient attended", "one", "military", "patient states", "trouble sleeping", "finds", "slight sound causes", "to", "very alarmed", "Recently", "patient", "strong memories", "soldiers", "times", "awakes", "cold sweat", "not", "able to", "quality sleep", "weeks", "patient", "past medical anxiety", "obesity", "type II diabetes mellitus", "current medications include insulin", "metformin", "lisinopril", "sodium docusate", "fish oil", "following", "best initial medical", "patient"]}
{"question": "A 66-year-old man presents to the office complaining of abdominal pain. He reports that the pain is mid-epigastric and “gnawing.” It worsens after meals but improves “somewhat” with antacids. The patient’s medical history is significant for hypertension, hyperlipidemia, and gout. He takes aspirin, lisinopril, atorvastatin, and allopurinol. He uses ibuprofen during acute gout attacks and takes over the counter multivitamins. He also started drinking ginkgo tea once a week after his wife saw a news story on its potential benefits. The patient has a glass of whiskey after work 2 nights a week but denies tobacco or illicit drug use. An upper endoscopy is performed that reveals a gastric ulcer. A urease breath test is positive for Heliobacter pylori. The patient is prescribed bismuth subsalicylate, omeprazole, metronidazole, and tetracycline for 2 weeks. At follow-up, the patient continues to complain of abdominal pain. He has taken all his medications as prescribed along with 10-12 tablets of antacids a day. He denies hematemesis, hematochezia, or melena. Biopsy from the previous upper endoscopy was negative for malignancy. A repeat urease breath test is positive. Which of the following is the most likely cause for the patient’s poor treatment response?", "answer": "Antacid use", "options": {"A": "Alcohol use", "B": "Allopurinol", "C": "Antacid use", "D": "Ginkgo tea", "E": "Ibuprofen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["66 year old man presents", "office", "abdominal pain", "reports", "pain", "mid epigastric", "gnawing", "worsens", "meals", "improves somewhat", "antacids", "patients medical history", "significant", "hypertension", "hyperlipidemia", "gout", "aspirin", "lisinopril", "atorvastatin", "allopurinol", "uses ibuprofen", "acute gout attacks", "over the counter multivitamins", "started drinking ginkgo", "week", "saw", "story", "potential benefits", "patient", "glass", "nights", "week", "tobacco", "illicit drug use", "upper endoscopy", "performed", "reveals", "gastric ulcer", "urease breath", "positive", "pylori", "patient", "bismuth subsalicylate", "omeprazole", "metronidazole", "tetracycline", "2 weeks", "follow-up", "patient", "to", "abdominal pain", "medications", "10", "tablets", "antacids", "day", "hematemesis", "hematochezia", "melena", "Biopsy", "previous upper", "negative", "malignancy", "repeat urease breath", "positive", "following", "most likely cause", "poor", "response"]}
{"question": "A 17-year-old boy is brought to the emergency department by his brother after losing consciousness 1 hour ago. The brother reports that the patient was skateboarding outside when he fell on the ground and started to have generalized contractions. There was also some blood coming from his mouth. The contractions stopped after about 1 minute, but he remained unconscious for a few minutes afterward. He has never had a similar episode before. There is no personal or family history of serious illness. He does not smoke or drink alcohol. He does not use illicit drugs. He takes no medications. On arrival, he is confused and oriented only to person and place. He cannot recall what happened and reports diffuse muscle ache, headache, and fatigue. He appears pale. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 130/80 mm Hg. There is a small wound on the left side of the tongue. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference ranges. Toxicology screening is negative. An ECG shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the head", "options": {"A": "Lorazepam therapy", "B": "Reassurance and follow-up", "C": "Lumbar puncture", "D": "CT scan of the head", "E": "Electroencephalography\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "consciousness", "hour", "reports", "patient", "outside", "fell", "started to", "generalized contractions", "blood", "mouth", "contractions stopped", "about", "minute", "unconscious", "minutes", "never", "similar episode", "personal", "family history", "serious illness", "not smoke", "not use illicit drugs", "medications", "arrival", "confused", "oriented only", "place", "reports diffuse muscle ache", "headache", "fatigue", "appears pale", "temperature", "98", "pulse", "80 min", "blood pressure", "80 mm Hg", "small wound", "left side", "tongue", "complete blood count", "serum", "electrolytes", "urea nitrogen", "creatinine", "reference ranges", "Toxicology screening", "negative", "ECG", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 59-year-old man comes to the physician because of urinary frequency and perineal pain for the past 3 days. During this time, he has also had pain with defecation. He is sexually active with his wife only. His temperature is 39.1°C (102.3°F). His penis and scrotum appear normal. Digital rectal examination shows a swollen, exquisitely tender prostate. His leukocyte count is 13,400/mm3. A urine culture obtained prior to initiating treatment is most likely to show which of the following?", "answer": "Gram-negative, lactose-fermenting rods in pink colonies", "options": {"A": "Gram-negative, lactose-fermenting rods in pink colonies", "B": "Gram-negative, oxidase-positive rods in green colonies", "C": "Gram-negative, encapsulated rods in mucoid colonies", "D": "Weakly staining, obligate intracellular bacilli", "E": "Gram-negative, aerobic, intracellular diplococci"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old man", "physician", "urinary frequency", "perineal pain", "past 3 days", "time", "pain", "defecation", "sexually active", "only", "temperature", "penis", "scrotum appear normal", "Digital rectal examination", "swollen", "tender prostate", "leukocyte count", "400 mm3", "urine culture obtained prior to initiating treatment", "to", "following"]}
{"question": "A 32-year-old woman is brought to the emergency department for the evaluation of burn injuries that she sustained after stumbling into a bonfire 1 hour ago. The patient has severe pain in her left leg and torso, and minimal pain in her right arm. She does not smoke cigarettes. She takes no medications. She is tearful and in moderate distress. Her temperature is 37.2°C (99.0°F), pulse is 88/min, respirations are 19/min, and blood pressure is 118/65 mm Hg. Her pulse oximetry is 98% on room air. Cardiopulmonary examination shows no abnormalities. There are two tender, blanchable erythemas without blisters over a 5 x 6 -cm area of the left abdomen and a 3 x 2-cm area of the left anterior thigh. There is also an area of white, leathery skin and tissue necrosis encircling the right upper extremity just proximal to the elbow, which is dry and nontender. An ECG shows normal sinus rhythm with no ST or T wave changes. She is started on intravenous fluids. Which of the following is the most appropriate next step in management?", "answer": "Monitoring of peripheral pulses and capillary filling", "options": {"A": "Serial arterial blood gas analysis", "B": "Soft-tissue ultrasound", "C": "Intravenous ampicillin therapy", "D": "Monitoring of peripheral pulses and capillary filling", "E": "X-ray of the chest"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "evaluation", "burn", "sustained", "stumbling", "hour", "patient", "severe pain in", "left leg", "torso", "minimal pain in", "right arm", "not smoke cigarettes", "medications", "tearful", "moderate distress", "temperature", "99", "pulse", "88 min", "respirations", "min", "blood pressure", "65 mm Hg", "pulse oximetry", "98", "room air", "Cardiopulmonary", "abnormalities", "two tender", "erythemas", "blisters", "5 x", "area", "left abdomen", "3", "2-cm area", "left thigh", "area", "white", "leathery skin", "tissue necrosis encircling", "right upper extremity", "proximal", "elbow", "dry", "nontender", "ECG", "normal sinus rhythm", "ST", "T wave changes", "started", "following", "most appropriate next step"]}
{"question": "An 8-year-old boy is brought to the emergency department after falling from a trampoline and landing on his left arm. On presentation, he is found to be holding his left arm against his chest and says that his arm is extremely painful just above the elbow. Radiographs are obtained showing the finding in figure A. The boy's arm is reduced and placed into a splint pending surgical fixation. If this patient's fracture is associated with a nerve injury, which of the following actions would he most likely be unable to perform in the emergency department?", "answer": "Thumb flexion", "options": {"A": "Elbow flexion", "B": "Finger crossing", "C": "Finger extension", "D": "Shoulder abduction", "E": "Thumb flexion"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "emergency department", "falling", "trampoline", "landing", "left arm", "found to", "holding", "left arm", "chest", "arm", "extremely painful", "elbow", "Radiographs", "obtained", "finding", "boy's arm", "reduced", "splint", "surgical fixation", "patient's fracture", "associated with", "nerve injury", "following actions", "most likely", "unable to perform", "emergency department"]}
{"question": "A 30-year-old woman came to her OBGYN for an infertility consultation. The patient reports having intercourse with her husband at least 3 times per week with increasing frequency during the periods. The lab reports of her husband revealed an adequate sperm count. After the work-ups was complete, her OBGYN prescribed a medication similar to GnRH to be administered in a pulsatile manner. Which drug is prescribed to the patient?", "answer": "Leuprolide", "options": {"A": "Danazol", "B": "Leuprolide", "C": "Anastrazole", "D": "Clomiphene", "E": "Mestranol"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old woman", "OBGYN", "infertility", "intercourse", "times per week", "increasing frequency", "periods", "lab", "revealed", "adequate", "count", "work-ups", "complete", "OBGYN", "medication similar", "GnRH to", "administered", "pulsatile", "drug", "patient"]}
{"question": "A 51-year-old man presents to his primary care provider for recurrent epigastric pain. He reports a 3-month history of gnawing epigastric and chest pain that is worse after meals and after lying down. His past medical history is notable for obesity, hypertension, and hyperlipidemia. He takes lisinopril and rosuvastatin. He has a 30 pack-year smoking history and drinks 4-5 beers per day. On exam, he is well-appearing and in no acute distress. He has no epigastric tenderness. He is prescribed an appropriate medication for his symptoms and is told to follow up in 2 weeks. He returns 2 weeks later with improvement in his symptoms, and a decision is made to continue the medication. However, he returns to clinic 3 months later complaining of decreased libido and enlarged breast tissue. Which of the following medications was this patient most likely taking?", "answer": "Cimetidine", "options": {"A": "Cimetidine", "B": "Famotidine", "C": "Lansoprazole", "D": "Nizatidine", "E": "Calcium carbonate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "recurrent epigastric pain", "reports", "3 month history", "gnawing epigastric", "chest pain", "worse", "meals", "lying", "past medical history", "notable", "obesity", "hypertension", "hyperlipidemia", "lisinopril", "rosuvastatin", "30", "smoking history", "4", "day", "exam", "well appearing", "acute distress", "epigastric tenderness", "appropriate medication", "symptoms", "to follow up", "2 weeks", "returns 2 weeks later", "symptoms", "made to", "medication", "returns", "clinic", "months later", "decreased libido", "enlarged breast tissue", "following medications", "patient", "likely"]}
{"question": "A 22-year-old Caucasian G1 presents to her physician at 29 weeks gestation for a checkup. The  medical history is unremarkable and the current pregnancy has been uncomplicated. Her weight is 81 kg (178.6 lb) and the height is 169 cm (5 ft 6 in). She has gained 13 kg (28.6 lb) during the pregnancy. She has no abnormalities on physical examination. Which of the following screening tests should be obtained ?", "answer": "Non-fasting oral glucose tolerance test with 50 g of glucose", "options": {"A": "Fasting glucose level", "B": "Non-fasting oral glucose tolerance test with 50 g of glucose", "C": "Fasting oral glucose test with 50 g of glucose", "D": "Non-fasting oral glucose load test with 75 g of glucose", "E": "Measurement of HbA1c"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "G1 presents", "physician", "29 weeks gestation", "checkup", "medical history", "unremarkable", "current pregnancy", "uncomplicated", "weight", "81 kg", "height", "5 ft 6", "gained", "kg", "28.6", "pregnancy", "abnormalities", "following", "obtained"]}
{"question": "A 45-year-old man is brought to the emergency department 30 minutes after falling off a staircase and hitting his head on the handrail. He was unconscious for 10 minutes and vomited twice. On arrival, he is drowsy. Examination shows a fixed, dilated left pupil and right-sided flaccid paralysis. A CT scan of the head shows a skull fracture in the region of the pterion and a biconvex hyperdensity overlying the left frontotemporal lobe. This patient's condition is most likely caused by damage to a vessel that enters the skull through which of the following foramina?", "answer": "Foramen spinosum", "options": {"A": "Foramen lacerum", "B": "Jugular foramen", "C": "Foramen rotundum", "D": "Foramen magnum", "E": "Foramen spinosum"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department 30 minutes", "falling", "staircase", "hitting", "head", "handrail", "unconscious", "10 minutes", "vomited twice", "arrival", "drowsy", "fixed", "dilated left pupil", "right-sided flaccid paralysis", "CT scan of", "head", "skull fracture", "region of", "pterion", "left frontotemporal lobe", "patient's condition", "most likely caused", "damage", "vessel", "enters", "skull", "following foramina"]}
{"question": "A 5-day-old male newborn is brought to the physician by his mother for the evaluation of progressive yellowing of his skin for 2 days. The mother reports that the yellowing started on the face and on the forehead before affecting the trunk and the limbs. She states that she breastfeeds every 2–3 hours and that the newborn feeds well. He has not vomited and there have been no changes in his bowel habits or urination. The patient was born at 38 weeks' gestation via vaginal delivery and has been healthy. His newborn screening was normal. His vital signs are within normal limits. Physical examination shows scleral icterus and widespread jaundice. The remainder of the examination shows no abnormalities. Serum studies show:\nBilirubin\nTotal 8 mg/dL\nDirect 0.5 mg/dL\nAST 16 U/L\nALT 16 U/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Reassurance", "options": {"A": "Phototherapy", "B": "Exchange transfusion", "C": "Abdominal sonography", "D": "Intravenous immunoglobulin", "E": "Reassurance"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["5 day old male newborn", "brought", "physician", "the", "of progressive yellowing", "skin", "2 days", "reports", "yellowing started", "face", "forehead", "affecting", "trunk", "limbs", "states", "breastfeeds", "23 hours", "newborn feeds well", "not vomited", "changes in", "bowel habits", "urination", "patient", "born", "weeks", "estation ", "aginal delivery ", "ealthy.", "ewborn screening ", "ormal.", "ital signs ", "ormal limits.", "cleral icterus ", "idespread  aundice.", "bnormalities.", "erum  tudies ", "ilirubin Total ", "g/dL  irect  .5  g/dL  ST  6  /L  LT  6 ", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "A previously healthy 32-year-old man is brought to the emergency department by his girlfriend after having a seizure. Earlier that day, he also experienced a nosebleed that took 30 minutes to stop when applying pressure. He has had no sick contacts or history of epilepsy or other seizure disorder. He does not take any medications. His temperature is 39.1 °C (102.4 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg. He is confused and disoriented. Examination shows pallor and scattered petechiae over the trunk and arms. The neck is supple, and neurological examination is otherwise within normal limits. Laboratory studies show:\nHemoglobin 9 g/dL\nLeukocyte count 8,200/mm3\nPlatelet count 34,000/mm3\nProthrombin time 13 seconds\nPartial thromboplastin time 30 seconds\nFibrin split products negative\nSerum\nCreatinine 2.9 mg/dL\nBilirubin\nTotal 3.2 mg/dL\nDirect 0.4 mg/dL\nLactate dehydrogenase 559 U/L\nA peripheral blood smear shows numerous schistocytes. Which of the following is the most appropriate next step in management?\"", "answer": "Plasma exchange therapy", "options": {"A": "Transfusion of packed red blood cells", "B": "Plasma exchange therapy", "C": "Fresh frozen plasma transfusion", "D": "Platelet transfusion", "E": "Intravenous tranexamic acid\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department", "seizure", "Earlier", "day", "nosebleed", "30 minutes to stop", "applying pressure", "sick", "history of epilepsy", "seizure disorder", "not", "medications", "temperature", "F", "pulse", "min", "respirations", "min", "blood pressure", "70 mm Hg", "confused", "disoriented", "pallor", "scattered petechiae", "trunk", "arms", "neck", "supple", "neurological examination", "normal limits", "Laboratory studies", "Leukocyte count", "mm3 Platelet count", "time", "seconds Partial thromboplastin time", "Fibrin split products negative Serum Creatinine 2", "mg", "mg", "Direct 0.4 mg/dL Lactate dehydrogenase", "U L", "peripheral blood smear", "numerous schistocytes", "following", "most appropriate next step"]}
{"question": "A 4-year-old girl is brought to the physician because of a nonpruritic, painless rash that has been on her face for 5 days. She was born at term and has been healthy throughout childhood. Her 62-year-old maternal grandmother has bullous pemphigoid. Her development is adequate for her age and immunizations are up-to-date. She appears healthy and well-nourished. Her temperature is 37.0°C (98.6°F) pulse is 90/min, and respiratory rate is 18/min. Examination shows a crusted rash on the right side of the patient's face. An image of the patient's lower face is shown. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Topical mupirocin therapy", "options": {"A": "Oral acyclovir therapy", "B": "Oral cephalexin therapy", "C": "Oral clindamycin therapy", "D": "Topical miconazole therapy", "E": "Topical mupirocin therapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old girl", "brought", "physician", "nonpruritic", "painless rash", "face", "5 days", "born", "term", "healthy", "childhood", "62 year old", "bullous pemphigoid", "development", "adequate", "age", "immunizations", "date", "appears healthy", "well-nourished", "temperature", "98", "pulse", "90 min", "respiratory rate", "min", "crusted rash", "right side of", "patient's face", "patient's lower face", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 24-year-old female medical student presents to the emergency department after she develops sudden difficulty breathing and vague chest pain while preparing for exams. The chest pain is non-pleuritic without radiation. She denies any recent travel. She denies any hemoptysis, nausea, vomiting, or leg pain. She only takes oral contraceptives; she denies smoking or alcohol use. Her vitals reveal a heart rate of 120 beats per minute, blood pressure of 100/80 mm Hg, and respiratory rate of 30 per minute. She is afebrile. Otherwise, her physical exam is unremarkable. A CT scan of her chest with IV contrast reveals filling defects along her left pulmonary artery. Which of the following is the most likely mechanism of this finding?", "answer": "Hypercoagulability", "options": {"A": "Venous stasis", "B": "Endothelial injury", "C": "Dehydration", "D": "Hypercoagulability", "E": "Anxiety"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female medical student presents", "emergency department", "sudden difficulty breathing", "vague chest pain", "exams", "chest pain", "non pleuritic", "radiation", "recent", "hemoptysis", "nausea", "vomiting", "leg pain", "only", "oral contraceptives", "smoking", "reveal", "heart rate", "minute", "blood pressure", "100 80 mm Hg", "respiratory rate", "30", "minute", "afebrile", "unremarkable", "CT scan of", "chest", "IV contrast reveals filling defects", "left pulmonary artery", "following", "mechanism", "finding"]}
{"question": "A 1-year-old immigrant girl has not received any recommended vaccines since birth. She attends daycare and remains healthy despite her daily association with several other children for the past 3 months at a home day-care facility. Which of the following phenomena explains why she has not contracted any vaccine-preventable diseases such as measles, diphtheria, or pertussis?", "answer": "Herd immunity", "options": {"A": "Genetic drift", "B": "Genetic shift", "C": "Tolerance", "D": "Immune evasion", "E": "Herd immunity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "girl", "not received", "vaccines", "birth", "attends daycare", "healthy", "daily association", "several", "children", "past 3 months", "day", "facility", "following", "not contracted", "vaccine preventable diseases", "measles", "diphtheria", "pertussis"]}
{"question": "A 37-year-old woman presents to her physician with a decreased interest in her daily activities. She says that she has noticed a decreased motivation to participate in her daily routine.  She says she feels sad and depressed on most days of the week. She reports her symptoms have been there for about two months but have been more severe for the past 3 weeks. She also says she is unable to sleep well at night and feels tired most of the day, which is affecting her job performance. The patient reports a 10-pack-year smoking history which has increased in frequency lately and she would like to quit. Lately, she has observed an inability to reach orgasm during intercourse and has also lost all interest in sex. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Bupropion", "options": {"A": "Venlafaxine", "B": "Mirtazapine", "C": "Bupropion", "D": "Fluoxetine", "E": "Trazodone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physician", "decreased interest", "decreased motivation to", "daily routine", "depressed", "days of the week", "reports", "symptoms", "two months", "more severe", "past", "weeks", "unable to sleep well", "night", "tired most of the day", "affecting", "job performance", "patient reports a 10", "smoking history", "increased", "frequency", "to", "observed", "to reach orgasm", "intercourse", "lost", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "Two 19-year-old men are referred by their professor and mentor to a psychiatrist for substance abuse management. The two friends have both used different stimulants for 3 years—Drug A and Drug B, respectively. Both use these substances cyclically. Use of Drug A usually lasts for about 12 hours. The cycle for Drug B lasts several days. A month ago, both men visited the emergency room (ER) due to acute intoxication. Clinical features in the emergency department included hypotension, bradycardia, sweating, chills, mydriasis, nausea, and psychomotor agitation. After a urine drug screen, the psychiatrist identifies both the drugs and informs the professor that although both Drug A and Drug B are stimulants, their mechanisms of action are different. Drug A is an alkaloid that is naturally present in the leaves of the coca plant, while it is possible to make Drug B from over-the-counter nasal decongestant products. Which of the following options best describes the mechanism of action of both drugs?", "answer": "Drug A predominantly acts by inhibiting the reuptake of monoamine neurotransmitters (dopamine, serotonin, and norepinephrine) at the synapse, while Drug B does not.", "options": {"A": "Drug A transiently increases the extracellular concentration of dopamine in the reward circuit, while Drug B does not.", "B": "Drug A predominantly acts by inhibiting the reuptake of monoamine neurotransmitters (dopamine, serotonin, and norepinephrine) at the synapse, while Drug B does not.", "C": "Drug A predominantly acts by increasing the release of monoamine neurotransmitters (dopamine, serotonin, and norepinephrine) into the synapse, while Drug B does not.", "D": "Drug A increases serotonin activity, while Drug B does not.", "E": "Drug A increases norepinephrine activity, while Drug B does not."}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two", "year old", "referred", "professor", "psychiatrist", "substance abuse", "two", "used different stimulants", "Drug", "use", "substances", "Use of Drug", "usually", "12 hours", "cycle", "Drug", "days", "month", "emergency room", "due to acute intoxication", "Clinical features", "emergency department included hypotension", "bradycardia", "sweating", "chills", "mydriasis", "nausea", "psychomotor agitation", "urine drug screen", "psychiatrist", "drugs", "informs", "professor", "Drug", "Drug", "stimulants", "mechanisms of action", "different", "Drug", "alkaloid", "present", "coca", "possible to make Drug", "over-the-counter nasal decongestant products", "following options best", "mechanism of action", "drugs"]}
{"question": "A 45-year-old woman presents to the clinic for a routine examination. She has a chronic history of systemic lupus erythematosus, diagnosed at age 27. Medications include hydroxychloroquine and low-dose prednisone. She has had no recent flare-ups and is compliant with her medication. Anticardiolipin and anti-beta-2 glycoprotein-1 antibodies are negative, and she has had no history of thrombi or emboli. Physical examination is normal except for mild bilateral tenderness and swelling of the knees. Creatinine and GFR are normal. Which of the following is the next best step in management to monitor disease activity?", "answer": "Anti-dsDNA antibody levels", "options": {"A": "Urinalysis and renal biopsy", "B": "Anti-dsDNA antibody levels", "C": "Anti-Smith antibody levels", "D": "Reduce dosage and taper off hydroxychloroquine", "E": "Arthrocentesis and synovial fluid analysis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "clinic", "routine", "chronic history of systemic lupus erythematosus", "diagnosed", "age 27", "Medications include hydroxychloroquine", "low-dose prednisone", "recent flare-ups", "compliant", "medication", "anti-beta-2 glycoprotein-1 antibodies", "negative", "history", "thrombi", "emboli", "normal", "mild bilateral tenderness", "swelling of", "knees", "Creatinine", "GFR", "normal", "following", "next best step", "to monitor disease activity"]}
{"question": "A 10-year-old boy is brought to a pediatrician by his mother for evaluation of fever, malaise, and rash with severe itching all over his body for the past 5 days. His immunization history is unavailable. His vital signs include: pulse 110/min, temperature 37.8°C (100.0°F), and respiratory rate 26/min. On examination of the skin, diffuse peeling vesicular lesions involving the arms and chest are observed. The pediatrician diagnosis the boy with chickenpox and reassures the mother. A few days later the boy returns to the clinic for a follow-up with his mother. The skin lesions have healed and there are scars. The formation of these scars is best described by which of the following statements?", "answer": "It is a part of the healing process of acute inflammation.", "options": {"A": "The scars represent complete resolution of acute inflammation.", "B": "It is a part of the healing process of acute inflammation.", "C": "The scars are permanent and remain for life in all cases.", "D": "Neutrophils, plasma cells, and macrophages are the predominant cells in these lesions.", "E": "The lesions now have progressed on to chronic inflammation."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A 10 year old boy", "brought", "pediatrician", "mother", "fever", "malaise", "rash", "severe itching all", "body", "past 5 days", "immunization history", "unavailable", "vital signs include", "pulse", "min", "temperature", "100", "respiratory rate", "min", "examination of", "skin", "diffuse peeling vesicular lesions involving", "arms", "chest", "observed", "pediatrician diagnosis", "boy", "chickenpox", "few days later", "boy returns", "clinic", "follow-up", "skin lesions", "healed", "scars", "formation", "scars", "best", "following"]}
{"question": "A 15-year-old girl is brought to her pediatrician's office complaining of frequent diarrhea, fatigue, and inability to gain weight. Her vital signs are within normal limits, and her BMI is 17. She describes her stools as pale, malodorous, and bulky. She often has abdominal bloating. Her symptoms are most prominent after breakfast when she typically consumes cereal. After several weeks of careful evaluation and symptomatic treatment, the pediatrician recommends an esophagogastroduodenoscopy. A diagnostic biopsy shows blunting of intestinal villi and flat mucosa with multiple intraepithelial lymphocytes. Which of the following is the patient likely deficient in?", "answer": "IgA", "options": {"A": "IgA", "B": "IgM", "C": "IgG", "D": "IgE", "E": "IgD"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "pediatrician's office", "fatigue", "to gain weight", "vital signs", "normal limits", "BMI", "stools", "pale", "bulky", "often", "abdominal bloating", "symptoms", "most prominent", "breakfast", "several weeks", "symptomatic treatment", "pediatrician", "esophagogastroduodenoscopy", "diagnostic biopsy", "blunting", "intestinal villi", "flat mucosa", "multiple", "following", "patient likely deficient"]}
{"question": "A 23-year-old man is brought to the emergency department by a coworker for an injury sustained at work. He works in construction and accidentally shot himself in the chest with a nail gun. Physical examination shows a bleeding wound in the left hemithorax at the level of the 4th intercostal space at the midclavicular line. Which of the following structures is most likely injured in this patient?", "answer": "Left upper lobe of the lung", "options": {"A": "Right atrium of the heart", "B": "Superior vena cava", "C": "Inferior vena cava", "D": "Left atrium of the heart", "E": "Left upper lobe of the lung"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["23 year old man", "brought", "emergency department", "injury sustained", "construction", "shot", "chest", "nail gun", "bleeding wound", "left hemithorax", "level", "4th intercostal space", "midclavicular line", "following structures", "most likely injured", "patient"]}
{"question": "A 23-year-old woman presents to her primary care physician due to amenorrhea. The patient states that historically she has her period once every three months but recently has not had it at all. Otherwise, she has no other complaints. The patient recently started college and is a varsity athlete for the track team. She works part time in a coffee shop and is doing well in school. The patient is not sexually active and does not drink alcohol, use illicit drugs, or smoke. She has no significant past medical history and occasionally takes ibuprofen for headaches. Her temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 50/min, respirations are 10/min, and oxygen saturation is 98% on room air. On physical exam, you note a young, lean, muscular woman in no acute distress. Which of the following is the most likely long-term outcome in this patient?", "answer": "Osteoporosis", "options": {"A": "Endometrial cancer", "B": "Infertility", "C": "Osteoarthritis", "D": "Osteoporosis", "E": "Anorexia nervosa"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old woman presents", "primary care physician", "amenorrhea", "patient states", "period", "three months", "recently", "not", "complaints", "patient recently started college", "athlete", "track", "part time", "shop", "well", "school", "patient", "not sexually active", "not", "alcohol", "use illicit", "smoke", "significant past medical history", "occasionally", "ibuprofen", "headaches", "temperature", "99", "blood pressure", "100", "mmHg", "pulse", "50 min", "respirations", "10/min", "oxygen saturation", "98", "room air", "note", "young", "muscular woman", "acute distress", "following", "long-term"]}
{"question": "A 40-year-old man who was previously antisocial, low energy at work, and not keen to attend office parties was arrested and brought to the emergency department after he showed up to the office Christmas party out of control. He was noted to be very energetic and irritable. He spent the entire evening hijacking conversations and sharing his plans for the company that will save it from inevitable ruin. What other finding are you most likely to find in this patient’s current condition?", "answer": "Irresponsibility", "options": {"A": "Irresponsibility", "B": "Hypersomnia after days of not sleeping", "C": "Patient completing numerous outstanding projects", "D": "Rapid but interruptible speech pattern", "E": "Patient is unlikely to have a major depressive episode"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old man", "antisocial", "not", "to attend office", "arrested", "brought", "emergency department", "office", "control", "noted to", "very energetic", "irritable", "spent", "entire evening", "plans", "company", "finding", "to find", "patients current condition"]}
{"question": "A 70-year-old man is at his dermatologist’s office for the treatment of a severely pruritic erythroderma with scaling on his buttocks that has been slowly progressing over the past two weeks. The patient works as a truck driver and has a history of hypertension treated with enalapril. The patient reports having tried an over-the-counter cream on the rash without improvement. The vital signs are within normal range. On physical exam, he has multiple confluent and well-demarcated pink patches on his buttocks and legs with some scaling and enlarged inguinal lymph nodes. The dermatologist orders a skin biopsy that reveals Pautrier microabscesses. What is the most likely diagnosis?", "answer": "Mycosis fungoides", "options": {"A": "Psoriasis", "B": "Linchen planus", "C": "Atopic dermatitis", "D": "Mycosis fungoides", "E": "Kaposi sarcoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man", "dermatologists office", "treatment", "severely", "erythroderma", "scaling", "buttocks", "slowly progressing", "past two weeks", "patient", "truck driver", "history of hypertension treated with enalapril", "over-the-counter cream", "rash", "vital signs", "normal range", "multiple confluent", "well", "pink patches", "buttocks", "legs", "scaling", "enlarged inguinal", "dermatologist orders", "skin biopsy", "reveals Pautrier microabscesses", "diagnosis"]}
{"question": "A 31-year-old G6P6 woman with a history of fibroids gives birth to twins via vaginal delivery. Her pregnancy was uneventful, and she reported having good prenatal care. Both placentas are delivered immediately after the birth. The patient continues to bleed significantly over the next 20 minutes. Her temperature is 97.0°F (36.1°C), blood pressure is 124/84 mmHg, pulse is 95/min, respirations are 16/min, and oxygen saturation is 98% on room air. Continued vaginal bleeding is noted. Which of the following is the most appropriate initial step in management?", "answer": "Bimanual massage", "options": {"A": "Bimanual massage", "B": "Blood product transfusion", "C": "Hysterectomy", "D": "Oxytocin", "E": "Uterine artery embolization"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["31 year old", "woman", "history", "fibroids gives birth", "twins", "vaginal delivery", "pregnancy", "reported", "good", "placentas", "delivered immediately", "birth", "patient", "to bleed", "next 20 minutes", "temperature", "97", "36", "blood pressure", "84 mmHg", "pulse", "95 min", "respirations", "min", "oxygen saturation", "98", "room air", "vaginal bleeding", "noted", "following", "most appropriate initial step"]}
{"question": "A 13-year-old boy is brought to the pediatrician by his parents who are concerned about his short stature. He also has had recurrent episodes of diarrhea. Past medical history is significant for iron deficiency anemia diagnosed 6 months ago. Physical examination is unremarkable except that he is in the 9th percentile for height. Serum anti-tissue transglutaminase (anti-tTG) antibodies are positive. An upper endoscopy along with small bowel luminal biopsy is performed. Which of the following histopathologic changes would most likely be present in the mucosa of the duodenal biopsy in this patient?", "answer": "Blunting of the intestinal villi", "options": {"A": "Neutrophilic infiltration", "B": "Blunting of the intestinal villi", "C": "Granulomas extending through the layers of the intestinal wall", "D": "Crypt aplasia", "E": "Cuboidal appearance of basal epithelial cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "short stature", "recurrent episodes of diarrhea", "Past medical history", "significant", "iron deficiency anemia diagnosed", "months", "unremarkable except", "percentile", "height", "Serum anti tissue transglutaminase", "antibodies", "positive", "upper endoscopy", "small bowel luminal biopsy", "performed", "following histopathologic changes", "most likely", "present", "mucosa of", "duodenal biopsy", "patient"]}
{"question": "An 11-year-old girl is brought into the clinic by her parents, who are distraught over her behavior. They state that over the past several months she has started to act oddly, combing the hair of her toy dolls for hours without stopping and repetitively counting her steps in the house. She is often brought to tears when confronted about these behaviors. The patient has no past medical history. When questioned about family history, the mother states she has needed close medical follow-up in the past, but declines to elaborate. The patient's vital signs are all within normal limits. On physical exam the patient is a well nourished 11-year-old girl in no acute distress. She has occasional motor tics, but the remainder of the exam is benign. What is the diagnosis in this patient?", "answer": "Obsessive compulsive disorder (OCD)", "options": {"A": "Autism spectrum disorder (ASD)", "B": "Generalized anxiety disorder (GAD)", "C": "Obsessive compulsive disorder (OCD)", "D": "Tourette's syndrome", "E": "Major depressive disorder (MDD)"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "clinic", "behavior", "state", "past", "months", "started to act", "combing", "hair", "toy", "hours", "stopping", "counting", "steps", "house", "often brought", "tears", "behaviors", "patient", "past medical history", "family history", "states", "needed close medical follow-up", "past", "to", "patient's vital signs", "normal limits", "patient", "well nourished", "year old girl", "acute distress", "occasional motor tics", "exam", "benign", "diagnosis", "patient"]}
{"question": "A 46-year-old man accountant is admitted to the emergency department with complaints of retrosternal crushing pain that radiates to his left arm and jaw. The medical history is significant for hyperlipidemia and arterial hypertension, for which he is prescribed a statin and ACE inhibitor, respectively. An ECG is obtained and shows an ST-segment elevation in leads avF and V2-V4. The blood pressure is 100/50 mm Hg, the pulse is 120/min, and the respiratory rate is 20/min. His BMI is 33 kg/m2 and he has a 20-year history of smoking cigarettes. Troponin I is elevated. The patient undergoes percutaneous coronary intervention immediately after admission. Angioplasty and stenting were successfully performed. On follow-up the next day, the ECG shows decreased left ventricular function and local hypokinesia. The patient is re-evaluated 14 days later. The echocardiography reveals a normal ejection fraction and no hypokinesis. Which of the phenomena below explains the patient’s clinical course?", "answer": "Myocardial stunning", "options": {"A": "Coronary steal syndrome", "B": "Reperfusion injury", "C": "Myocardial hibernation", "D": "Myocardial stunning", "E": "Coronary collateral circulation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man accountant", "emergency department", "complaints", "retrosternal crushing", "radiates", "left arm", "jaw", "medical history", "significant", "hyperlipidemia", "arterial hypertension", "statin", "ACE inhibitor", "ECG", "obtained", "ST-segment elevation", "leads avF", "V2", "blood pressure", "100 50 mm Hg", "pulse", "min", "respiratory rate", "20 min", "BMI", "kg/m2", "20 year history of smoking cigarettes", "Troponin I", "elevated", "patient", "percutaneous coronary intervention immediately", "Angioplasty", "stenting", "performed", "follow-up", "next day", "ECG", "decreased left ventricular function", "local hypokinesia", "patient", "re", "days later", "echocardiography reveals", "normal ejection fraction", "hypokinesis", "patients clinical course"]}
{"question": "A 27-year-old woman, primigravida, gave birth to a boy 3 months ago and now presents the newborn to your clinic for evaluation. She did not receive prenatal care. She reports that she was taking a medication for her mood swings, but cannot remember the medication’s name. The baby was born cyanotic, with a congenital malformation of the heart that is characterized by apical displacement of the septa and posterior tricuspid valve leaflets. A chest radiograph is shown in the image. Which of the following medications was the mother most likely taking?", "answer": "Lithium", "options": {"A": "Buspirone", "B": "Clozapine", "C": "Losartan", "D": "Lithium", "E": "Enalapril"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old woman", "primigravida", "gave birth", "boy", "months", "now presents", "newborn", "clinic", "not receive", "reports", "medication", "mood swings", "medications name", "baby", "born cyanotic", "congenital malformation", "heart", "apical displacement", "septa", "posterior tricuspid valve leaflets", "chest radiograph", "following medications", "likely"]}
{"question": "An investigator is studying gene expression in a mouse model. She inactivates the assembly of small nuclear ribonucleoproteins (snRNPs) in motor nerve cells. Which of the following processes is most likely to be affected as a result?", "answer": "Removal of introns", "options": {"A": "Folding of proteins", "B": "Aminoacylation of tRNA", "C": "Activity of 3′ to 5′ proofreading", "D": "Unwinding of DNA strands", "E": "Removal of introns"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying gene expression", "assembly", "small nuclear ribonucleoproteins", "following processes", "to", "affected", "result"]}
{"question": "A 29-year-old woman comes to the physician for evaluation of a mass in the left breast that she first noticed 2 weeks ago. During this period, the mass has not increased in size and the patient has had no pain. Three months ago, she hit her left chest against the closet door, which was painful for a day. Menses occurs at regular 28-day intervals and last for 5 days with moderate flow. Her last menstrual period was 3 weeks ago. Physical examination shows dense breasts and a 2.5-cm well-defined, rubbery, mobile mass that is nontender in the upper outer quadrant of the left breast. There is no axillary adenopathy. Which of the following is the most likely diagnosis?", "answer": "Fibroadenoma", "options": {"A": "Phyllodes tumor", "B": "Fibrocystic changes of the breast", "C": "Fibroadenoma", "D": "Lobular carcinoma", "E": "Fat necrosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "physician", "mass", "left breast", "first", "2 weeks", "period", "mass", "not increased in size", "patient", "pain", "Three months", "hit", "left chest", "door", "painful", "day", "Menses occurs", "regular", "day intervals", "last", "5 days", "moderate", "last menstrual period", "3 weeks", "dense breasts", "2.5", "well-defined", "rubbery", "mobile mass", "nontender", "upper outer quadrant of", "left breast", "axillary adenopathy", "following", "diagnosis"]}
{"question": "A 70 year-old man comes to the physician for difficulty swallowing for 6 months. During this time, he has occasionally coughed up undigested food. He did not have weight loss or fever. Four weeks ago, he had an episode of sore throat, that resolved spontaneously. He has smoked one pack of cigarettes daily for 5 years. He has gastroesophageal reflux disease and osteoporosis. Current medications include alendronate and omeprazole. His temperature is 37.0°C (98.6°F), pulse is 84/min, and blood pressure is 130/90 mmHg. On examination, he has foul-smelling breath and a fluctuant mass on the right neck. Which of the following is most likely involved in the pathogenesis of this patient's symptoms?", "answer": "Abnormal esophageal motor function", "options": {"A": "Deep neck space infection", "B": "Degeneration of neurons in the esophageal wall", "C": "Cellular dysplasia", "D": "Abnormal esophageal motor function", "E": "Adverse effect of medication\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["70 year old man", "physician", "difficulty swallowing", "months", "time", "occasionally coughed", "undigested food", "not", "weight loss", "fever", "Four weeks", "episode of sore throat", "resolved", "smoked one pack", "cigarettes daily", "gastroesophageal reflux disease", "osteoporosis", "Current medications include alendronate", "omeprazole", "temperature", "98", "pulse", "84 min", "blood pressure", "90 mmHg", "foul smelling breath", "fluctuant mass", "right neck", "following", "most likely involved", "pathogenesis", "patient's symptoms"]}
{"question": "A bacterial isolate obtained from a hospitalized patient is found to be resistant to amikacin. The isolated bacteria most likely has which of the following characteristics?", "answer": "Enhanced ability to transfer acetyl groups", "options": {"A": "D-Ala to D-Lac mutation", "B": "DNA topoisomerase II mutation", "C": "Low-affinity penicillin binding protein", "D": "Increased drug influx capacity", "E": "Enhanced ability to transfer acetyl groups"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["bacterial isolate obtained", "hospitalized patient", "found to", "resistant to amikacin", "isolated bacteria", "likely", "following characteristics"]}
{"question": "A 10-year-old boy is brought to the pediatrician by his parents with complaints of short stature with small hands and skin hypopigmentation. A detailed development history reveals that he was born by normal vaginal delivery at full term and his neonatal period was uneventful. Until he was 6 months of age, he was breast-fed and then solid foods were started. At the age of 3 years, his parents noted that he had difficulty in sucking and swallowing. They also noted a weak cry. His motor milestones were delayed. His intelligence quotient (IQ) is 65. His temperature is 37.0ºC (98.6°F), pulse is 88/min, and respirations are 20/min. He has a short stature and falls in the obese category according to his body mass index. His neurologic examination shows the presence of hypotonia. Panoramic radiographic examination shows anterior teeth crowding and the presence of residual roots in some teeth. Which of the following is the most likely cause of this condition?", "answer": "Paternal inheritance", "options": {"A": "Maternal inheritance", "B": "Paternal inheritance", "C": "Both paternal inheritance and maternal inheritance", "D": "Infectious in origin", "E": "Nutritional and metabolic in origin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["A 10 year old boy", "brought", "pediatrician", "complaints", "short stature", "small hands", "skin hypopigmentation", "detailed development history reveals", "born by normal vaginal delivery", "full term", "neonatal period", "months", "age", "breast-fed", "then", "started", "age", "years", "noted", "difficulty", "sucking", "swallowing", "noted", "weak cry", "motor", "delayed", "intelligence quotient", "65", "temperature", "98", "pulse", "88 min", "respirations", "20 min", "short stature", "falls", "obese", "body mass index", "neurologic examination", "presence", "hypotonia", "Panoramic radiographic examination", "anterior teeth crowding", "presence", "residual", "teeth", "following", "most likely cause", "condition"]}
{"question": "A 37-year-old woman is brought to the physician for worsening depressive mood and irritability. Her mood changes began several months ago. Her husband has also noticed shaky movements of her limbs and trunk for the past year. The patient has no suicidal ideation. She has no history of serious illness and takes no medications. Her father died by suicide at the age of 45 years. Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 128/72 mm Hg. She speaks slowly and quietly and only looks at the floor. She registers 3/3 words but can recall only one word 5 minutes later. Examination shows irregular movements of the arms and legs at rest. Extraocular eye movements are normal. Muscle strength is 5/5 throughout, and deep tendon reflexes are 2+ bilaterally. Further evaluation is most likely to show which of the following?", "answer": "Caudate nucleus atrophy on MRI", "options": {"A": "Mitral vegetations on echocardiogram", "B": "Positive Babinski sign on physical examination", "C": "Oligoclonal bands on lumbar puncture", "D": "Poor performance on an IQ test", "E": "Caudate nucleus atrophy on MRI"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "physician", "worsening", "mood", "irritability", "mood changes began several months", "shaky movements", "limbs", "trunk", "past year", "patient", "suicidal ideation", "history", "serious illness", "medications", "died", "suicide", "age", "years", "temperature", "98", "pulse", "76 min", "blood pressure", "72 mm Hg", "speaks slowly", "only looks", "floor", "3/3", "only one", "minutes later", "irregular movements", "arms", "legs", "rest", "Extraocular eye movements", "normal", "Muscle strength", "5/5", "deep tendon reflexes", "2", "Further", "to", "following"]}
{"question": "A 55-year-old man presents to his primary care physician for a regular check-up. The patient was born in Germany in 1960 in with shortened limbs, underdeveloped digits, absent external ears, and a cleft palate. He is currently in a wheelchair. His past medical history is also notable for hypertension and allergies. He takes lisinopril daily and loratadine as needed. His mother had a complicated past medical history and took multiple medications during her pregnancy. His temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 20/min. The drug that most likely caused this patient's condition is also indicated for which of the following?", "answer": "Multiple myeloma", "options": {"A": "Acne vulgaris", "B": "Deep venous thrombosis", "C": "Multiple myeloma", "D": "Bipolar disease", "E": "Recurrent miscarriage"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care physician", "regular check-up", "patient", "born in Germany", "shortened limbs", "digits", "absent external", "cleft palate", "currently", "wheelchair", "past medical history", "notable", "hypertension", "allergies", "lisinopril daily", "loratadine as needed", "complicated past medical history", "multiple medications", "pregnancy", "temperature", "98", "blood pressure", "80 mmHg", "pulse", "90 min", "respirations", "20 min", "drug", "most likely caused", "patient's condition", "indicated"]}
{"question": "A 29-year-old woman presents to her gynecologist because of chronic pelvic pain that she has been experiencing for the last 6 months. Specifically, she says that she has severe pain during menstruation that is localized primarily to her lower abdomen and pelvis. In addition, she has been having pain while defecating and during intercourse. She has no past surgical history and her past medical history is significant for asthma. She uses protection while having intercourse with her long time boyfriend and has never been pregnant. Physical exam reveals adnexal tenderness and the presence of an adnexal mass. Laparoscopic examination is conducted showing several cysts filled with dark brown fluid on her ovaries and powder burn marks along her peritoneal surfaces. Which of the following markers would most likely be elevated in this patient?", "answer": "CA-125", "options": {"A": "Alpha-fetoprotein", "B": "Beta-hCG", "C": "Bombesin", "D": "CA-125", "E": "CA-19-9"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "gynecologist", "chronic pelvic pain", "months", "severe", "menstruation", "localized", "lower abdomen", "pelvis", "addition", "pain", "intercourse", "past surgical history", "past medical history", "significant", "asthma", "uses protection", "intercourse", "long time", "never", "pregnant", "reveals adnexal tenderness", "presence", "adnexal mass", "Laparoscopic", "several cysts", "dark brown fluid", "ovaries", "powder burn marks", "peritoneal surfaces", "following markers", "most likely", "elevated", "patient"]}
{"question": "A 70-year-old man presented to the emergency department complaining of left-sided weakness for the past 5 hours. Past medical history is significant for a previous ischemic stroke involving the right posterior cerebral artery and left-sided homonymous hemianopia. He also has a history of type-II diabetes mellitus and hypertension. He takes an 81 mg aspirin, amlodipine, atorvastatin, and a vitamin supplement with calcium and vitamin D. A brain MRI reveals a small atrophic area of the left occipital lobe and a new acute infarct involving the territory of the right middle cerebral artery. Electrocardiogram (ECG) shows normal sinus rhythm. An echocardiogram reveals mild left ventricular hypertrophy with an ejection fraction of 55%. Doppler ultrasound of the carotid arteries reveals no significant narrowing. What is the next step in the management to prevent future risks of stroke?", "answer": "Add dipyridamole", "options": {"A": "Add dipyridamole", "B": "Add warfarin", "C": "Increase aspirin to 325 mg", "D": "Administer tPA", "E": "Stop aspirin and start warfarin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old man", "emergency department", "left-sided weakness", "past", "hours", "medical history", "significant", "previous ischemic stroke involving", "right posterior cerebral artery", "left sided homonymous hemianopia", "history of type-II diabetes mellitus", "hypertension", "amlodipine", "atorvastatin", "calcium", "vitamin D", "brain MRI reveals", "small atrophic area", "left occipital", "new acute infarct involving", "territory", "right middle cerebral artery", "Electrocardiogram", "normal sinus rhythm", "echocardiogram reveals", "left ventricular hypertrophy", "ejection fraction of", "Doppler ultrasound", "carotid arteries reveals", "significant narrowing", "next step", "to prevent future"]}
{"question": "A 34-year-old primigravid woman comes to the physician for a prenatal visit at 37-weeks' gestation because of worsening back pain for 3 weeks. The pain is worse with extended periods of walking, standing, and sitting. She has not had any changes in bowel movements or urination. Her mother has rheumatoid arthritis. Examination of the back shows bilateral pain along the sacroiliac joint area as a posterior force is applied through the femurs while the knees are flexed. She has difficulty actively raising either leg while the knee is extended. Motor and sensory function are normal bilaterally. Deep tendon reflexes are 2+. Babinski sign is absent. Pelvic examination shows a uterus consistent in size with a 37-weeks' gestation. There is no tenderness during abdominal palpation. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Relaxation of the pelvic girdle ligaments", "options": {"A": "Spinal cord compression", "B": "Vertebral bone compression fracture", "C": "Placental abruption", "D": "Relaxation of the pelvic girdle ligaments", "E": "Rheumatoid arthritis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old primigravid woman", "physician", "weeks", "gestation", "of worsening back pain", "weeks", "pain", "worse", "extended periods", "standing", "sitting", "not", "changes in bowel movements", "urination", "rheumatoid arthritis", "of", "back", "bilateral pain", "sacroiliac joint area", "posterior", "applied", "femurs", "knees", "flexed", "difficulty", "leg", "knee", "extended", "Motor", "sensory function", "normal", "Deep tendon reflexes", "2", "Babinski sign", "absent", "Pelvic examination", "uterus", "size", "weeks", "gestation", "tenderness", "abdominal palpation", "following", "explanation", "patient's"]}
{"question": "An investigator studying immune response administers a 0.5 mL intradermal injection of an autoclaved microorganism to a study volunteer. Four weeks later, there is a 12-mm, indurated, hypopigmented patch over the site of injection. Which of the following is the most likely explanation for the observed skin finding?", "answer": "Increased activity of CD4+ Th1 cells", "options": {"A": "Increased lipid uptake by macrophages", "B": "Increased antibody production by B cells", "C": "Increased activity of neutrophils", "D": "Increased activity of CD4+ Th1 cells", "E": "Increased release of transforming growth factor beta"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator studying immune response administers", "0.5 mL intradermal injection", "autoclaved", "study volunteer", "Four weeks later", "mm", "indurated", "hypopigmented patch", "site of injection", "following", "observed skin finding"]}
{"question": "A 37-year-old woman comes to the physician because of oligomenorrhea and intermittent vaginal spotting for 5 months. Menses previously occurred at regular 28-day intervals and lasted for 5 days with normal flow. She has also noted increased hair growth on her chin. She is not sexually active. She takes no medications. Physical examination shows temporal hair recession and nodulocystic acne on her cheeks and forehead. There is coarse hair on the chin and the upper lip. Pelvic examination shows clitoral enlargement and a right adnexal mass. Laboratory studies show increased serum testosterone concentration; serum concentrations of androstenedione and dehydroepiandrosterone are within the reference ranges. Ultrasonography of the pelvis shows a 10-cm right ovarian tumor. Which of the following is the most likely diagnosis?", "answer": "Sertoli-Leydig cell tumor", "options": {"A": "Ovarian thecoma", "B": "Dermoid cyst", "C": "Ovarian dysgerminoma", "D": "Serous cystadenoma", "E": "Sertoli-Leydig cell tumor"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "oligomenorrhea", "intermittent vaginal spotting", "months", "Menses", "regular", "day intervals", "lasted", "5 days", "normal", "noted increased hair growth", "chin", "not sexually active", "medications", "temporal hair recession", "nodulocystic acne", "cheeks", "forehead", "coarse", "chin", "upper lip", "Pelvic examination", "clitoral enlargement", "right adnexal mass", "Laboratory studies", "increased serum concentration", "serum", "androstenedione", "dehydroepiandrosterone", "reference ranges", "Ultrasonography of", "pelvis", "a 10", "right ovarian tumor", "following", "diagnosis"]}
{"question": "A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill and her condition has been worsening. Her daughter experienced a severe headache and had a stiff neck. This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine. The patient was born at 39 weeks and met all her developmental milestones. She is currently up to date on her vaccinations. Her temperature is 99.5°F (37.5°C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air. The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics. Which of the following is the best underlying explanation for this patient's presentation?", "answer": "Intentional contamination", "options": {"A": "Gastroenteritis", "B": "Intentional contamination", "C": "Meningitis", "D": "Sepsis", "E": "Urinary tract infection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "emergency department", "fever", "similar symptoms", "weeks", "treated", "infection", "treated", "urinary tract infection 10 weeks", "last night", "ill", "condition", "worsening", "severe headache", "stiff neck", "morning", "responsive", "vomited several times", "small amount", "dark cloudy", "patient", "born", "weeks", "met", "currently", "date", "vaccinations", "temperature", "99", "blood pressure", "60 35 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "started", "vasopressors", "broad spectrum", "following", "best underlying explanation", "patient's"]}
{"question": "A 35-year-old woman comes to your office with a variety of complaints. As part of her evaluation, she undergoes laboratory testing which reveals the presence of anti-centromere antibodies. All of the following symptoms and signs would be expected to be present EXCEPT:", "answer": "Hypercoagulable state", "options": {"A": "Pallor, cyanosis, and erythema of the hands", "B": "Calcium deposits on digits", "C": "Blanching vascular abnormalities", "D": "Hypercoagulable state", "E": "Heartburn and regurgitation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "office", "complaints", "part of", "laboratory testing", "reveals", "presence", "anti-centromere antibodies", "following symptoms", "signs", "to", "present"]}
{"question": "A 46-year-old woman comes to the physician for a 6-month history of worsening bronchial asthma control. Before this issue began, she only used her salbutamol inhaler once a day. Now, she has to use it multiple times daily and also reports frequent nighttime awakening. Seven months ago, she moved to an apartment that is damp and has mold on some of the walls. The physician injects 0.1 mL of Candida albicans extract on the mid-volar surface of the right arm intradermally. After 48 hours there is a palpable induration of 17 mm. This reaction is most likely a result of release of which of the following substances?", "answer": "Interferon-γ", "options": {"A": "Tryptase", "B": "Interleukin-10", "C": "Lysozyme", "D": "Interferon-γ", "E": "Superoxide anion\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history of worsening bronchial asthma control", "issue began", "only used", "salbutamol inhaler", "day", "Now", "to use", "multiple times daily", "reports frequent nighttime awakening", "Seven months", "moved to", "apartment", "damp", "walls", "physician injects 0", "Candida albicans extract", "mid volar surface of", "right arm", "48 hours", "palpable induration", "mm", "reaction", "result", "release", "following"]}
{"question": "A 31-year-old, G1P0 woman at 35 weeks of gestation comes to the emergency room for a severe headache. She reports that she was washing the dishes 2 hours ago when a dull headache came on and progressively worsened. She also reports 2 episodes of intermittent blurred vision over the past hour that has since cleared. Nothing similar has ever happened before. She denies any precipitating events, trauma, mental status changes, abdominal pain, lightheadedness, fever, ulcers, or urinary changes. Her temperature is 98.9°F (37.1°C), blood pressure is 160/110 mmHg, pulse is 98/min, respirations are 12/min, and oxygen saturation is 98%. A physical examination demonstrates a rash on her face that she attributes to a recent change in cosmetics. A urine test demonstrates the presence of protein. What is the most likely explanation for this patient’s symptoms?", "answer": "Abnormal placental spiral arteries", "options": {"A": "Abnormal placental spiral arteries", "B": "Neoplasm of meningeal tissue", "C": "Premature separation of the placenta from the uterine wall", "D": "Production of pathogenic autoantibodies and tissue injury", "E": "Rupture of an aneurysm"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old", "woman", "35 weeks of gestation", "emergency room", "severe headache", "reports", "dishes", "hours", "dull headache", "worsened", "reports 2 episodes of intermittent blurred vision", "past hour", "since cleared", "similar", "before", "precipitating", "trauma", "mental status changes", "abdominal pain", "lightheadedness", "fever", "ulcers", "urinary changes", "temperature", "98 9F", "blood pressure", "mmHg", "pulse", "98 min", "respirations", "min", "oxygen saturation", "98", "rash", "face", "attributes", "recent change", "cosmetics", "urine test", "presence", "protein", "patients symptoms"]}
{"question": "A 43-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 a restrained passenger. On arrival, he has shortness of breath and is in severe pain. His pulse is 130/min, respirations are 35/min, and blood pressure is 90/40 mm Hg. Examination shows superficial abrasions and diffuse crepitus at the left shoulder level. Cardiac examination shows tachycardia with no murmurs, rubs, or gallops. The upper part of the left chest wall moves inward during inspiration. Breath sounds are absent on the left. He is intubated and mechanically ventilated. Two large bore intravenous catheters are placed and infusion of 0.9% saline is begun. Which of the following is the most likely cause of his symptoms?", "answer": "Flail chest", "options": {"A": "Diaphragmatic rupture", "B": "Phrenic nerve paralysis", "C": "Cardiac tamponade", "D": "Sternal fracture", "E": "Flail chest"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "minutes", "involved", "high speed motor vehicle collision", "restrained", "arrival", "shortness of breath", "severe pain", "pulse", "min", "respirations", "35 min", "blood pressure", "90 40 mm Hg", "superficial abrasions", "diffuse crepitus", "left shoulder level", "tachycardia", "murmurs", "rubs", "upper part of", "left chest wall moves inward", "inspiration", "Breath", "absent", "left", "intubated", "ventilated", "Two large bore intravenous catheters", "infusion", "0.9", "saline", "begun", "following", "most likely cause", "symptoms"]}
{"question": "A 66-year-old man presents to the emergency room with blurred vision, lightheadedness, and chest pain that started 30 minutes ago. The patient is awake and alert. His history is significant for uncontrolled hypertension, coronary artery disease, and he previously underwent percutaneous coronary intervention. He is afebrile. The heart rate is 102/min, the blood pressure is 240/135 mm Hg, and the O2 saturation is 100% on room air. An ECG is performed and shows no acute changes. A rapid intravenous infusion of a drug that increases peripheral venous capacitance is started. This drug has an onset of action that is less than 1 minute with rapid serum clearance than necessitates a continuous infusion. What is the most severe side effect of this medication?", "answer": "Cyanide poisoning", "options": {"A": "Cyanide poisoning", "B": "Lupus-like syndrome", "C": "Status asthmaticus", "D": "Intractable headache", "E": "Increased intraocular pressure"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old man presents", "emergency room", "blurred vision", "lightheadedness", "chest pain", "started 30 minutes", "patient", "awake", "alert", "history", "significant", "uncontrolled hypertension", "coronary artery disease", "percutaneous coronary intervention", "afebrile", "heart rate", "min", "blood pressure", "mm Hg", "O2 saturation", "100", "room air", "ECG", "performed", "acute changes", "rapid intravenous infusion of", "drug", "increases peripheral venous capacitance", "started", "drug", "onset of action", "less than", "minute", "rapid serum clearance", "continuous infusion", "most severe side effect", "medication"]}
{"question": "A 75-year-old man is brought to the emergency department because of a 5-hour history of worsening chest pain and dyspnea. Six days ago, he fell in the shower and since then has had mild pain in his left chest. He appears pale and anxious. His temperature is 36.5°C (97.7°F), pulse is 108/min, respirations are 30/min, and blood pressure is 115/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows decreased breath sounds and dullness to percussion over the left lung base. There is a 3-cm (1.2-in) hematoma over the left lower chest. An x-ray of the chest shows fractures of the left 8th and 9th rib, increased opacity of the left lung, and mild tracheal deviation to the right. Which of the following is the most appropriate next step in management?", "answer": "Chest tube insertion in the fifth intercostal space at the midaxillary line\n\"", "options": {"A": "Admission to the ICU and observation", "B": "Needle thoracentesis in the eighth intercostal space at the posterior axillary line", "C": "Emergency thoracotomy", "D": "Pericardiocentesis", "E": "Chest tube insertion in the fifth intercostal space at the midaxillary line\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["75 year old man", "brought", "emergency department", "of", "5 hour history", "worsening chest pain", "dyspnea", "Six days", "since then", "mild pain in", "left chest", "appears pale", "anxious", "temperature", "36", "97", "pulse", "min", "respirations", "30/min", "blood pressure", "58 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "88", "decreased breath sounds", "dullness", "percussion", "left lung base", "3", "1.2", "hematoma", "left lower chest", "x-ray of", "chest", "fractures", "left", "rib", "increased opacity", "left lung", "mild tracheal deviation", "right", "following", "most appropriate next step"]}
{"question": "A 36-year-old woman comes to the physician because of growths around her anus that developed over the past 4 weeks. They are not painful and she does not have blood in her stool. She is sexually active with two male partners and uses condoms inconsistently. She appears healthy. Vital signs are within normal limits. Examination shows nontender, irregular, hyperkeratotic sessile lesions in the perianal area around 4–7 mm in diameter. There is no lymphadenopathy. The application of a dilute solution of acetic acid turns the lesions white. Which of the following is the most likely cause of the lesions?", "answer": "Human papilloma virus", "options": {"A": "Poxvirus", "B": "Treponema pallidum", "C": "Malignant transformation", "D": "Benign fibroepithelial growth", "E": "Human papilloma virus"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old woman", "physician", "of growths", "anus", "past 4 weeks", "not painful", "not", "blood in", "stool", "sexually active", "two male", "uses condoms", "appears healthy", "Vital signs", "normal limits", "nontender", "irregular", "hyperkeratotic sessile", "perianal area", "mm", "diameter", "lymphadenopathy", "application", "dilute", "turns", "lesions white", "following", "most likely cause", "lesions"]}
{"question": "A 26-year-old woman comes to the physician because of intermittent episodes of cramping lower abdominal pain and bloating over the past 3 months. These episodes are often associated with non-bloody, watery, frothy stools, and excessive flatulence. The cramping does not subside after defecation. She reports that her symptoms typically begin an hour or two after eating ice cream, cheese, or pudding. She is otherwise healthy. Her only medication is an iron supplement and an oral contraceptive pill. The patient's height is 158 cm (5 ft 2 in) and her weight is 59 kg (130 lb); her BMI is 23.6 kg/m2. Abdominal examination is normal. Which of the following is the most appropriate next step in management?", "answer": "Hydrogen breath test", "options": {"A": "Fecal fat test", "B": "D-xylose absorption test", "C": "Jejunal biopsy", "D": "Hydrogen breath test", "E": "Serum IgE levels"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "of intermittent episodes", "cramping lower abdominal pain", "bloating", "past 3 months", "episodes", "often associated with non bloody", "watery", "frothy", "excessive flatulence", "cramping", "not", "defecation", "reports", "symptoms", "begin", "hour", "two", "eating", "pudding", "healthy", "only medication", "iron supplement", "oral contraceptive pill", "patient's height", "5 ft 2", "weight", "59 kg", "BMI", "23", "kg/m2", "Abdominal", "normal", "following", "most appropriate next step"]}
{"question": "A 56-year-old woman presents with 5-day history of progressively worsening shortness of breath and bilateral pleuritic chest pain. She also has been having associated fatigue, low grade fever, and night sweats. Her temperature is 38.1°C (100.6°F), pulse is 106/min, respiratory rate is 26/min, and blood pressure is 136/88 mm Hg. On physical examination, she is diaphoretic and in mild respiratory distress. Cardiac auscultation reveals a faint 2/6 systolic murmur best heard over the lower left sternal border. Her neck veins are distended, and abdominal examination shows significant hepatomegaly. Echocardiography is performed and results are shown below. Which of the following is the most likely underlying cause of this patient’s clinical presentation?", "answer": "Infective endocarditis", "options": {"A": "Fat embolism", "B": "Infective endocarditis", "C": "Myocardial infarction", "D": "Rheumatic fever", "E": "Small cell lung cancer"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "5-day history", "worsening shortness of breath", "bilateral pleuritic chest pain", "associated fatigue", "low grade fever", "night sweats", "temperature", "100", "pulse", "min", "respiratory rate", "min", "blood pressure", "88 mm Hg", "diaphoretic", "mild respiratory distress", "Cardiac auscultation reveals", "faint", "systolic murmur best heard", "lower left sternal border", "neck veins", "distended", "abdominal", "significant hepatomegaly", "Echocardiography", "performed", "results", "following", "underlying cause", "patients"]}
{"question": "A 78-year-old female presents to her primary care provider complaining of shaking of her hands. She reports that her hands shake when she is pouring her coffee in the morning and when she is buttoning her shirt. She has noticed that her tremor improves with the several beers she has every night with dinner. She has a past medical history of hypertension, atrial fibrillation, moderate persistent asthma, acute intermittent porphyria, and urinary retention. Her home medications include hydrochlorothiazide, warfarin, bethanechol, low-dose inhaled fluticasone, and an albuterol inhaler as needed. On physical exam, she has an irregularly irregular heart rhythm without S3/S4. She has mild wheezing on pulmonary exam. She has no tremor when her hands are in her lap. A low-amplitude tremor is present during finger-to-nose testing. Her neurological exam is otherwise unremarkable.\n\nWhich of the following is a contraindication to the first-line treatment of this condition?", "answer": "Asthma", "options": {"A": "Acute intermittent porphyria", "B": "Asthma", "C": "Heavy alcohol use", "D": "Urinary retention", "E": "Warfarin use"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female presents", "primary care provider", "of shaking", "hands", "reports", "hands shake", "morning", "buttoning", "shirt", "tremor improves", "night", "dinner", "past medical", "atrial fibrillation", "moderate persistent", "acute intermittent porphyria", "urinary retention", "home medications include hydrochlorothiazide", "warfarin", "bethanechol", "low-dose inhaled fluticasone", "albuterol inhaler as needed", "irregular heart rhythm", "S3 S4", "mild wheezing", "pulmonary exam", "tremor", "hands", "lap", "low amplitude tremor", "present", "finger", "nose testing", "neurological exam", "unremarkable", "following", "contraindication", "first-line treatment", "condition"]}
{"question": "A 34-year-old woman, gravida 1, para 0, at 16 weeks' gestation comes to the physician for a routine prenatal visit. She feels well. She has no history of serious illness. She has smoked one pack of cigarettes daily for 10 years but quit when she learned she was pregnant. She does not drink alcohol or use illicit drugs. Her mother has type 1 diabetes mellitus, and her father has asthma. Current medications include a prenatal multivitamin. She appears well. Her vital signs are within normal limits. Physical examination shows no abnormalities. Serum studies show:\nAlpha-fetoprotein decreased\nUnconjugated estriol decreased\nHuman chorionic gonadotropin increased\nInhibin A increased\nDuring counseling regarding the potential for fetal abnormalities, the patient says that she would like a definitive diagnosis as quickly as possible. Which of the following is the most appropriate next step in management?\"", "answer": "Amniocentesis", "options": {"A": "Reassurance", "B": "Cell-free fetal DNA testing", "C": "Amniocentesis", "D": "Chorionic villus sampling", "E": "Pelvic ultrasound"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "weeks", "estation ", "hysician ", "outine ", "ell.", "istory ", "erious  llness.", "moked  ne  ack ", "igarettes  aily ", "regnant.", "ot ", "lcohol ", "se  llicit ", "ype 1 diabetes mellitus,", "sthma.", "urrent medications  nclude ", "renatal  ultivitamin.", "ppears  ell.", "ital signs ", "ormal limits.", "bnormalities.", "erum  tudies ", "lpha-fetoprotein  ecreased  nconjugated estriol  ecreased  uman chorionic gonadotropin  ncreased  nhibin A  ncreased ", "ounseling ", "otential ", "etal abnormalities,", "atient ", "efinitive  iagnosis ", "ossible.", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "A 55-year-old black male otherwise healthy presents for a yearly physical. No significant past medical history. Current medications are a multivitamin and rosuvastatin 20 mg orally daily. Vitals are temperature 37°C (98.6°F), blood pressure 155/75 mm Hg, pulse 95/min, respirations 16/min, and oxygen saturation 99% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is significant for a high-pitched diastolic murmur loudest at the left sternal border. Peripheral pulses are bounding and prominent followed by a quick collapse on palpation. Lungs are clear to auscultation. The abdomen is soft and nontender. Chest X-ray is normal. ECG is significant for left axis deviation and broad bifid P-waves in lead II. Transthoracic echocardiography shows a bicuspid aortic valve, severe aortic regurgitation, left atrial enlargement and left ventricular dilatation and hypertrophy. Left ventricular ejection fraction is 45%. Which of the following is the best course of treatment for this patient?", "answer": "Admit to hospital for aortic valve replacement", "options": {"A": "Reassurance and recommend long-term follow-up with outpatient cardiology for clinical surveillance with regular echocardiography", "B": "Outpatient management on nifedipine 45 mg orally daily", "C": "Outpatient management on enalapril 10 mg orally twice daily", "D": "Administer dobutamine and nitroprusside", "E": "Admit to hospital for aortic valve replacement"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old black male", "healthy presents", "yearly physical", "significant past medical history", "Current medications", "multivitamin", "rosuvastatin 20 mg orally daily", "temperature", "98", "blood pressure", "75 mm Hg", "pulse 95 min", "respirations", "min", "oxygen saturation 99", "room air", "patient", "alert", "significant", "high-pitched diastolic murmur loudest", "left sternal border", "Peripheral pulses", "bounding", "prominent followed by", "quick collapse", "palpation", "Lungs", "clear", "auscultation", "abdomen", "soft", "nontender", "Chest X-ray", "normal", "ECG", "significant", "left axis deviation", "broad bifid P-waves", "lead II", "Transthoracic echocardiography", "bicuspid aortic valve", "severe aortic regurgitation", "left atrial enlargement", "left ventricular dilatation", "hypertrophy", "Left ventricular ejection fraction", "following", "best course", "treatment", "patient"]}
{"question": "A 44-year-old woman presents to the outpatient infectious disease clinic. She has a known history of HIV, well-controlled on HAART for the past 8 years. She currently has no additional significant medical conditions. She feels well and a physical examination is within normal limits. She denies any current tobacco use, alcohol use, or illicit drug use, although she has a history of heroin use (injection). Her 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. She has no complaints and is up to date on all of her vaccinations and preventative care. Which of the following malignancies can be seen and is often associated with AIDS?", "answer": "Kaposi’s sarcoma", "options": {"A": "Colonic adenocarcinoma", "B": "Kaposi’s sarcoma", "C": "Secondary osteosarcoma", "D": "Thymomas", "E": "Malignant melanoma"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "outpatient infectious disease clinic", "known history", "HIV", "well-controlled", "HAART", "past", "years", "currently", "additional significant medical conditions", "well", "normal limits", "current tobacco use", "illicit drug use", "history of heroin use", "injection", "vital signs include", "temperature", "36", "98", "blood pressure", "74 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "complaints", "date", "of", "vaccinations", "preventative care", "following malignancies", "seen", "often associated with AIDS"]}
{"question": "A 13-year-old boy presents to the emergency department with severe right-lower-quadrant abdominal pain. Workup reveals acute appendicitis, and he subsequently undergoes laparoscopic appendectomy. The appendix is sent for histological examination. A pathologist reviews the slide shown in the image below. Which statement about the structures marked within the yellow circles is correct?", "answer": "In children, appendicitis can frequently arise from certain changes in these structures.", "options": {"A": "In children, appendicitis can frequently arise from certain changes in these structures.", "B": "The only part of the digestive system in which this structure can be found is the appendix.", "C": "Neutrophils are the major components of these structures.", "D": "These structures are not normally present within the appendix.", "E": "These structures belong to the primary lymphatic system."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "emergency department", "severe right-lower-quadrant abdominal pain", "Workup reveals acute appendicitis", "laparoscopic appendectomy", "appendix", "sent", "histological examination", "pathologist", "slide", "structures marked", "yellow circles", "correct"]}
{"question": "A 21-year-old female college student is brought to the university clinic by her roommates. They became worried because they noted long strands of hair all over the dormitory room floor. This has progressively worsened, with the midterms approaching. During discussions with the physician, the roommates also mention that she aggressively manipulates her scalp when she becomes upset or stressed. Physical examination reveals an otherwise well but anxious female with patches of missing and varying lengths of hair. A dermal biopsy is consistent with traumatic alopecia. What is the single most appropriate treatment for this patient?", "answer": "Cognitive-behavior therapy or behavior modification", "options": {"A": "Cognitive-behavior therapy or behavior modification", "B": "Clomipramine", "C": "Venlafaxine", "D": "Phenelzine", "E": "Electroconvulsive therapy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["21-year-old female", "brought", "university clinic", "worried", "noted long strands", "hair", "dormitory room floor", "worsened", "approaching", "discussions", "physician", "manipulates", "scalp", "stressed", "reveals", "well", "anxious female", "patches", "missing", "lengths of hair", "dermal biopsy", "traumatic alopecia", "single", "appropriate", "patient"]}
{"question": "A 47-year-old Hispanic man presents with complaints of recent heat intolerance and rapid heart rate. The patient has also experienced recent unintentional weight loss of 15 pounds. Physical exam reveals tachycardia and skin that is warm to the touch. A radioactive iodine uptake scan of the thyroid reveals several focal nodules of increased iodine uptake. Prior to this study, the physician had also ordered a serum analysis that will most likely show which of the following?", "answer": "Low TSH and high T4", "options": {"A": "High TSH and low T4", "B": "Low TSH and high T4", "C": "High TSH and normal T4", "D": "High TSH and high T4", "E": "Low TSH and low T4"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "man presents", "complaints of recent heat intolerance", "rapid heart rate", "patient", "recent unintentional weight loss of", "pounds", "reveals tachycardia", "skin", "warm", "touch", "radioactive iodine uptake scan", "thyroid reveals several focal nodules", "increased iodine uptake", "study", "physician", "ordered", "serum analysis", "most likely", "following"]}
{"question": "A 74-year-old man is brought to the emergency department because of increasing abdominal pain and distention for 3 days. The pain is diffuse and colicky, and he describes it as 4 out of 10 in intensity. His last bowel movement was 5 days ago. He has not undergone any previous abdominal surgeries. He has hypertension, chronic lower back pain, coronary artery disease, and hypercholesterolemia. Prior to admission, his medications were enalapril, gabapentin, oxycodone, metoprolol, aspirin, and simvastatin. He appears uncomfortable. His temperature is 37.3°C (99.1°F), pulse is 93/min, and blood pressure is 118/76 mm Hg. Examination shows a distended and tympanitic abdomen; bowel sounds are reduced. There is mild tenderness to palpation in the lower abdomen with no guarding or rebound. Rectal examination shows an empty rectum. Laboratory studies show:\nHemoglobin 13.1 g/dL\nSerum\nNa+ 134 mEq/L\nK+ 2.7 mEq/L\nCl- 98 mEq/L\nUrea nitrogen 32 mg/dL\nCreatinine 1 mg/dL\nAn x-ray of the abdomen shows a dilated cecum and right colon and preservation of the haustrae. A CT scan of the abdomen and pelvis with contrast shows a cecal diameter of 11 cm. The patient is kept NPO and intravenous fluids with electrolytes are administered. A nasogastric tube and rectal tube are inserted. Thirty-six hours later, he still has abdominal pain. Examination shows a distended and tympanitic abdomen. Serum concentrations of electrolytes are within the reference range. Which of the following is the most appropriate next step in management?\"", "answer": "Neostigmine therapy", "options": {"A": "Percutaneous cecostomy", "B": "Neostigmine therapy", "C": "Laparotomy", "D": "Metronidazole therapy", "E": "Colonoscopy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["74 year old man", "brought", "emergency department", "increasing abdominal pain", "distention", "3 days", "pain", "diffuse", "colicky", "4 out", "10", "intensity", "last bowel movement", "5 days", "not", "previous abdominal surgeries", "hypertension", "chronic lower back pain", "coronary artery disease", "hypercholesterolemia", "medications", "enalapril", "gabapentin", "oxycodone", "metoprolol", "aspirin", "simvastatin", "appears", "temperature", "99", "pulse", "min", "blood pressure", "76 mm Hg", "distended", "tympanitic abdomen", "bowel sounds", "reduced", "mild tenderness", "palpation", "lower abdomen", "guarding", "Rectal examination", "empty rectum", "Laboratory studies", "Hemoglobin", "g", "Serum", "mEq", "Urea nitrogen", "mg", "Creatinine", "x-ray of", "abdomen", "dilated cecum", "right colon", "preservation", "CT scan", "abdomen", "pelvis", "contrast", "cecal diameter", "patient", "kept NPO", "intravenous fluids", "electrolytes", "administered", "nasogastric tube", "rectal tube", "Thirty-six hours later", "abdominal pain", "distended", "tympanitic abdomen", "Serum", "electrolytes", "reference range", "following", "most appropriate next step"]}
{"question": "A 68-year-old man comes to the physician because of a 2-day history of a rash across his trunk and extremities. For the past 3 months, he has had persistent pruritus in these areas. He started hiking in the woods with his grandson last week to try to lose weight. His grandson, who often spends the weekends with him, recently had impetigo. He has hypertension, hyperlipidemia, and osteoarthritis of his thumbs. Five months ago, he was treated for a gout attack of his left hallux. Current medications include captopril, hydrochlorothiazide, simvastatin, allopurinol, and ibuprofen. Vital signs are within normal limits. There are diffuse vesicles and tense blisters involving the chest, flexures of the arms, and shoulders. Rubbing the skin on his chest does not produce blisters. Oral examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings?", "answer": "Linear deposits of IgG and C3 along the basement membrane on direct immunofluorescence studies", "options": {"A": "Growth of Gram-positive bacteria on blood culture", "B": "Antibodies to tissue transglutaminase on serologic testing", "C": "Linear deposits of IgG and C3 along the basement membrane on direct immunofluorescence studies", "D": "Spongiotic dermatitis on skin biopsy", "E": "Subepidermal separation with full thickness epidermal necrosis on skin biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "2-day history", "rash", "trunk", "extremities", "past 3 months", "persistent pruritus", "areas", "started", "woods", "week to", "to", "weight", "often spends", "weekends", "recently", "impetigo", "hypertension", "hyperlipidemia", "osteoarthritis of", "thumbs", "Five months", "treated", "gout attack", "left hallux", "Current medications include captopril", "hydrochlorothiazide", "simvastatin", "allopurinol", "ibuprofen", "Vital signs", "normal limits", "diffuse vesicles", "tense blisters involving", "chest", "flexures", "arms", "shoulders", "Rubbing", "skin", "chest", "not", "blisters", "abnormalities", "patient's condition", "most likely associated with", "following findings"]}
{"question": "A 51-year-old man is undergoing chemotherapy treatment for a rapidly progressive newly-diagnosed acute myelogenous leukemia. On day 4 of his hospitalization, the patient is noted to be obtunded. Other than the chemotherapy, he is receiving lansoprazole, acetaminophen, and an infusion of D5–0.9% normal saline at 50 mL/h. On examination, the patient’s blood pressure is 94/50 mm Hg, heart rate is 52/min, and respiratory rate is 14/min. The patient appears weak but is in no acute distress. Chest auscultation reveals bibasilar crackles and scattered wheezing. His abdomen is soft, non-distended, and with a palpable liver and spleen. His ECG shows peaked T waves and widened QRS complexes. What is the best next step in the management of this patient?", "answer": "Calcium chloride", "options": {"A": "Glucagon", "B": "Subcutaneous regular insulin", "C": "Polystyrene sulfonate", "D": "Calcium chloride", "E": "Atropine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "chemotherapy treatment", "rapidly progressive", "diagnosed acute myelogenous leukemia", "day 4", "patient", "noted to", "obtunded", "chemotherapy", "receiving lansoprazole", "acetaminophen", "infusion", "normal saline", "50 mL/h", "patients blood pressure", "50 mm Hg", "heart rate", "min", "respiratory rate", "min", "patient appears weak", "acute distress", "Chest auscultation reveals", "crackles", "scattered wheezing", "abdomen", "soft", "non distended", "palpable liver", "spleen", "ECG", "peaked T waves", "widened QRS complexes", "best next step", "patient"]}
{"question": "A 4-year-old boy is brought to the pediatrician’s office for a flu-like episode. His father tells the physician that his child has fallen ill several times over the past few months. He also has occasional bouts of night sweats and loss of appetite. He has lost 5 lbs (2.3 kg) in the last 6 months. At the pediatrician’s office, his temperature is 38.9°C (102°F), pulse is 105/min and respiration rate is 18/min. On physical examination, the pediatrician observes a flattened facial profile, prominent epicanthal folds, and a single palmar crease. There are petechiae on the arms and legs. Blood count shows pancytopenia. Bone marrow aspiration is diagnostic for ALL (acute lymphoblastic leukemia), but all cells also show a trisomy. Children with similar genetic anomalies are at an increased risk of developing which of the following neurological conditions as they grow older?", "answer": "Alzheimer’s disease", "options": {"A": "Lewy body dementia", "B": "Alzheimer’s disease", "C": "Amyotrophic lateral sclerosis", "D": "Pick’s disease", "E": "Parkinson’s dementia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "pediatricians office", "flu", "episode", "physician", "child", "fallen ill", "times", "past", "months", "occasional bouts", "night sweats", "loss of appetite", "lost 5 lbs", "kg", "last", "months", "pediatricians office", "temperature", "pulse", "min", "respiration rate", "min", "pediatrician observes", "flattened facial profile", "prominent epicanthal folds", "single palmar crease", "petechiae", "arms", "legs", "Blood count", "pancytopenia", "Bone marrow aspiration", "diagnostic", "acute lymphoblastic leukemia", "cells", "trisomy", "Children", "similar genetic anomalies", "increased risk", "following neurological conditions", "older"]}
{"question": "A 21-year-old man comes to the military base physician for evaluation of progressive discomfort in his right shoulder for the past 4 months. He joined the military 6 months ago and is part of a drill team. In anticipation of an upcoming competition, he has been practicing rifle drills and firing exercises 8 hours a day. Physical examination shows tenderness to palpation and a firm mass in the superior part of the right deltopectoral groove. Range of motion is limited by pain and stiffness. Which of the following is the most likely diagnosis?", "answer": "Myositis ossificans", "options": {"A": "Osteoid osteoma", "B": "Lipoma", "C": "Acromioclavicular joint separation", "D": "Myositis ossificans", "E": "Arteriovenous fistula"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old man", "military base physician", "progressive discomfort", "right shoulder", "past", "months", "military", "months", "part of", "drill", "rifle drills", "firing exercises 8 hours", "day", "tenderness", "palpation", "firm mass", "superior part of", "right deltopectoral groove", "Range", "motion", "limited", "pain", "stiffness", "following", "diagnosis"]}
{"question": "A 5-year-old girl is brought to the physician by her mother because of a 3-week history of a foul-smelling discharge from the left nostril. There was one episode of blood-tinged fluid draining from the nostril during this period. She has been mouth-breathing in her sleep for the past 4 days. She was born at term. Her 1-year-old brother was treated for viral gastroenteritis 3 weeks ago. She is at 60th percentile for height and at 70th percentile for weight. Her temperature is 37°C (98.6°F), pulse is 96/min, respirations are 23/min, and blood pressure is 96/54 mm Hg. Examination shows mucopurulent discharge in the left nasal cavity. Oral and otoscopic examination is unremarkable. Endoscopic examination of the nose confirms the diagnosis. Which of the following is the most appropriate next step in management?", "answer": "Foreign body extraction", "options": {"A": "Transnasal puncture and stenting", "B": "Foreign body extraction", "C": "Perform septoplasty", "D": "Adenoidectomy", "E": "Intranasal glucocorticoid therapy\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old girl", "brought", "physician", "mother", "week history", "smelling discharge", "left nostril", "one episode of blood-tinged fluid draining", "nostril", "period", "mouth-breathing", "sleep", "past", "days", "born", "term", "1-year-old", "treated", "viral gastroenteritis", "weeks", "percentile", "height", "percentile", "weight", "temperature", "98", "pulse", "96 min", "respirations", "23 min", "blood pressure", "96 54 mm Hg", "mucopurulent", "left", "Oral", "otoscopic", "unremarkable", "Endoscopic examination of", "nose confirms", "diagnosis", "following", "most appropriate next step"]}
{"question": "A previously healthy 57-year-old man is brought to the emergency department because of a 3-day history of fever and headache. He also has nausea and vomited twice in the past 24 hours. His temperature is 39.1°C (102.4°F). He is lethargic but oriented to person, place, and time. Examination shows severe neck rigidity with limited active and passive range of motion. A lumbar puncture is performed; cerebrospinal fluid analysis shows a neutrophilic pleocytosis and a decreased glucose concentration. A Gram stain of the patient's cerebrospinal fluid is most likely to show which of the following?", "answer": "Encapsulated, gram-positive cocci in pairs", "options": {"A": "Non-encapsulated, gram-negative cocci in pairs", "B": "Gram-positive cocci in clusters", "C": "Gram-negative bacilli", "D": "Encapsulated, gram-positive cocci in pairs", "E": "Gram-positive bacilli"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 57 year old man", "brought", "emergency department", "3-day history", "fever", "headache", "nausea", "vomited twice", "past 24 hours", "temperature", "lethargic", "oriented to person", "place", "time", "severe neck rigidity", "limited active", "passive range of motion", "lumbar puncture", "performed", "cerebrospinal fluid analysis", "neutrophilic pleocytosis", "decreased", "Gram stain", "patient's cerebrospinal fluid", "to", "following"]}
{"question": "A 35-year-old G2P0 presents to her physician to discuss the results of her 16-week obstetric screening tests. She has no complaints. Her previous pregnancy at 28 years of age was a spontaneous abortion in the first trimester. She has no history of gynecologic diseases. Her quadruple test shows the following findings:\nAlpha-fetoprotein\nLow\nBeta-hCG\nHigh\nUnconjugated estriol\nLow\nInhibin A\nHigh\nWhich of the following statements regarding the presented results is correct?\n ", "answer": "Maternal age is a significant risk factor for the condition of the patient, the increased risk of which is indicated by the results of the study.", "options": {"A": "Such results are associated with a 100% lethal fetal condition.", "B": "Maternal age is a significant risk factor for the condition of the patient, the increased risk of which is indicated by the results of the study.", "C": "Such results are a strong indicator of a monogenic disease.", "D": "The obtained results can be normal for women aged 35 and older.", "E": "The results show increased chances of aneuploidies associated with the sex chromosomes."}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old", "presents", "physician to", "results", "week obstetric screening tests", "complaints", "previous pregnancy at", "years", "age", "spontaneous abortion in", "first trimester", "history of gynecologic diseases", "quadruple test", "following findings", "Alpha-fetoprotein Low Beta-hCG High Unconjugated estriol", "Inhibin A High", "following", "results", "correct"]}
{"question": "A 35-year-old man comes to the clinic complaining of yellow discoloration of his skin and eyes for the past week. He also complains about loss of appetite, nausea, malaise, and severe tiredness. He has no known past medical history and takes over-the-counter acetaminophen for headache. He has smoked a half pack of cigarettes every day for the last 15 years and drinks alcohol occasionally. He has been sexually active with a new partner for a month and uses condoms inconsistently. His father and mother live in China, and he visited them last year. Temperature is 37°C (98.7°F), blood pressure is 130/90 mm Hg, pulse is 90/min, respirations are 12/min, and BMI is 25 kg/m2. On physical examination, his sclera and skin are icteric. Cardiopulmonary examination is negative, no lymphadenopathy is noted, and his abdomen is tender in the right upper quadrant (RUQ). His liver is palpated 3 cm below the costal margin. On laboratory investigations:\nLaboratory test\nComplete blood count \nHemoglobin 15 g/dL\nLeucocytes 13,000/mm3\nPlatelets 170,000/mm3\nBasic metabolic panel \nSerum Na+ 133 mEq/L\nSerum K+ 3.6 mEq/L\nSerum Cl- 107 mEq/L\nSerum HCO3- 26 mEq/L\nBUN 12 mg/dL\nLiver function test \nSerum bilirubin 3.4 mg/dL\nDirect bilirubin 2.5 mg/dL\nAST 2,100 U/L\nALT 2,435 U/L\nALP 130 U/L\nWhat is the next best step to do in this patient?", "answer": "HbsAg and Anti-IgM Hbc", "options": {"A": "USG of the abdomen", "B": "CT scan of the abdomen", "C": "Reassurance and counselling", "D": "HbsAg and Anti-IgM Hbc", "E": "ERCP"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old man", "clinic", "yellow discoloration", "skin", "eyes", "past week", "loss of appetite", "nausea", "malaise", "severe tiredness", "known past medical history", "over-the-counter acetaminophen", "headache", "smoked", "half pack", "cigarettes", "day", "years", "alcohol occasionally", "sexually active", "new", "month", "uses condoms", "live", "China", "last year", "Temperature", "98", "blood pressure", "90 mm Hg", "pulse", "90 min", "respirations", "min", "BMI", "kg/m2", "sclera", "skin", "icteric", "Cardiopulmonary", "negative", "lymphadenopathy", "noted", "abdomen", "tender", "right upper quadrant", "liver", "3", "costal margin", "laboratory", "blood", "Serum", "mEq", "mg", "bilirubin", "next best step to", "patient"]}
{"question": "A 42-year-old woman presents with loss of sensation in her left arm and hand. A rapid evaluation is performed to rule out stroke. No other focal neurologic deficits are found except for a loss of fine touch sensation in a C6 dermatome pattern. Further evaluation reveals that the patient was recently sick with an upper respiratory infection. A biopsy is performed and shows destruction of the cell bodies of sensory nerves. Which of the following structures is most likely been damaged?", "answer": "Dorsal root ganglion", "options": {"A": "Meissner's corpuscles", "B": "Dorsal root ganglion", "C": "Ventral root ganglion", "D": "Dorsal column", "E": "Lateral corticospinal tract"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "loss of sensation", "left arm", "hand", "rapid", "performed to rule out stroke", "focal neurologic deficits", "found", "loss of fine touch sensation", "C6 dermatome pattern", "Further", "reveals", "patient", "recently sick", "upper respiratory infection", "biopsy", "performed", "destruction", "cell bodies", "sensory nerves", "following structures", "most likely", "damaged"]}
{"question": "Lipidator is a nonionic surfactant that is used to disrupt the lipid membranes of cells. This disruption of the lipid membrane results in the release of all of its cytoplasmic contents. Which of the following viruses would not be disrupted if treated with this detergent?", "answer": "Picornavirus", "options": {"A": "Herpesvirus", "B": "Hepadnavirus", "C": "Flavivirus", "D": "Picornavirus", "E": "HIV"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["nonionic surfactant", "used to disrupt", "lipid membranes", "cells", "disruption", "lipid membrane results", "release", "cytoplasmic", "following viruses", "not", "disrupted", "treated with"]}
{"question": "A 52-year-old woman presents to her primary care physician with a 1-week history of facial drooping. Specifically, she has noticed that the left side of her face does not move when she tries to smile. Furthermore, she has been having difficulty closing her left eye. Her past medical history is significant for hypertension but she does not have any known prior neurological deficits. Imaging reveals a cranial mass that is compressing an adjacent nerve. Which tumor location would most likely be associated with this patient's symptoms?", "answer": "Internal auditory meatus", "options": {"A": "Foramen ovale", "B": "Internal auditory meatus", "C": "Jugular foramen", "D": "Optic canal", "E": "Superior orbital fissure"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "1-week history", "facial drooping", "left side of", "face", "not move", "smile", "difficulty closing", "left eye", "past medical history", "significant", "hypertension", "not", "known prior neurological deficits", "Imaging reveals", "cranial mass", "compressing", "adjacent nerve", "tumor location", "most likely", "associated with", "patient's symptoms"]}
{"question": "A 47-year-old woman comes to the physician because of a 5-month history of insomnia. She frequently experiences leg discomfort when trying to fall asleep that is relieved temporarily by movement. Her husband tells her that she frequently flexes her ankles upward when she sleeps. She appears fatigued and anxious. Physical examination shows no abnormalities. Laboratory studies including a complete blood count and iron studies are within the reference range. Which of the following is the most appropriate pharmacotherapy?", "answer": "Ropinirole", "options": {"A": "Ropinirole", "B": "Zolpidem", "C": "Nortriptyline", "D": "Atenolol", "E": "Sertraline"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "5 month history", "insomnia", "frequently", "leg discomfort", "to fall asleep", "relieved", "movement", "frequently", "ankles upward", "sleeps", "appears fatigued", "anxious", "abnormalities", "Laboratory studies including", "complete blood count", "iron studies", "reference range", "following", "most appropriate pharmacotherapy"]}
{"question": "A 72-year-old man comes to the emergency department for progressively worsening abdominal pain. The pain began 2 weeks ago and is localized to the right upper quadrant. He feels sick and fatigued. He also reports breathlessness when climbing the stairs to his first-floor apartment. He is a retired painter. He has hypertension and type 2 diabetes mellitus. He is sexually active with one female partner and does not use condoms consistently. He began having sexual relations with his most recent partner 2 months ago. He smoked 1 pack of cigarettes daily for 40 years but quit 10 years ago. He does not drink alcohol. Current medications include insulin and enalapril. He is 181 cm (5 ft 11 in) tall and weighs 110 kg (264 lb); BMI is 33.5 kg/m2. His vital signs are within normal limits. Physical examination shows jaundice, a distended abdomen, and tender hepatomegaly. There is no jugular venous distention. A grade 2/6 systolic ejection murmur is heard along the right upper sternal border. Laboratory studies show:\nHemoglobin 18.9 g/dL\nAspartate aminotransferase 450 U/L\nAlanine aminotransferase 335 U/L\nTotal bilirubin 2.1 mg/dL\nWhich of the following is the most likely cause of his symptoms?\"", "answer": "Hepatic vein obstruction", "options": {"A": "Hepatotropic viral infection", "B": "Increased iron absorption", "C": "Hepatic vein obstruction", "D": "Thickened pericaridium", "E": "Hepatic steatosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["72 year old man", "emergency department", "worsening abdominal pain", "pain began 2 weeks", "localized", "right upper quadrant", "sick", "fatigued", "reports breathlessness", "climbing", "first-floor apartment", "retired painter", "hypertension", "type 2 diabetes mellitus", "sexually active", "one female", "not use condoms", "began", "relations", "recent", "months", "smoked 1 pack", "cigarettes daily", "40 years", "not", "alcohol", "Current medications include insulin", "enalapril", "5 ft", "tall", "kg", "BMI", "kg/m2", "vital signs", "normal limits", "jaundice", "distended abdomen", "tender hepatomegaly", "jugular venous distention", "grade", "systolic ejection murmur", "heard", "right upper sternal border", "Laboratory studies", "Hemoglobin", "g dL Aspartate aminotransferase 450", "Alanine aminotransferase", "Total bilirubin", "dL", "following", "most likely cause", "symptoms"]}
{"question": "A 59-year-old man is brought to the emergency department because of a 2-hour history of abdominal pain and severe vomiting after ingesting an unknown medication in a suicide attempt. On the way to the hospital, he had a generalized tonic-clonic seizure. He has chronic obstructive pulmonary disease, coronary artery disease, and chronic back pain. His pulse is 130/min, respirations are 16/min, and blood pressure is 110/60 mm Hg. Serum studies show a glucose concentration of 180 mg/dL and a potassium concentration of 2.8 mEq/L. An ECG shows ventricular tachycardia. This patient's current findings are most likely caused by an overdose of which of the following drugs?", "answer": "Theophylline", "options": {"A": "Albuterol", "B": "Theophylline", "C": "Metoprolol", "D": "Amitriptyline", "E": "Acetaminophen\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["59 year old man", "brought", "emergency department", "2-hour history", "abdominal pain", "severe vomiting", "unknown medication", "suicide attempt", "hospital", "generalized tonic-clonic seizure", "chronic obstructive pulmonary disease", "coronary artery disease", "chronic back pain", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "Serum studies", "glucose concentration", "mg/dL", "potassium concentration", "mEq/L", "ECG", "ventricular tachycardia", "patient's current findings", "most likely caused", "overdose of", "following drugs"]}
{"question": "A 26-year-old woman presents to the clinic today complaining of weakness and fatigue. She is a vegetarian and often struggles to maintain an adequate intake of non-animal based protein. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and she currently denies any illicit drug use. Her past medical history is non-contributory. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 87/min, and respiratory rate 16/min. On physical examination, her pulses are bounding, the complexion is pale, the breath sounds are clear, and the heart sounds are normal. The spleen is mildly enlarged. Oxygen saturation was initially 81% on room air, with a new oxygen requirement of 8 L by face mask. She is at a healthy body mass index (BMI) of 22 kg/m2. The laboratory results indicate: mean corpuscular volume MCV: 71 fL, Hgb: 11.0, total iron-binding capacity (TIBC): 412 mcg/dL, transferrin saturation (TSAT): 11%. What is the most appropriate treatment for this patient?", "answer": "Iron replacement for 4–6 months", "options": {"A": "Iron replacement for 4–6 months", "B": "Lifelong Vitamin B6 supplementation", "C": "Lifelong Vitamin B1 supplementation", "D": "Folic acid supplementation", "E": "Obtain a bone-marrow biopsy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "clinic today", "weakness", "fatigue", "often", "to", "adequate intake", "non", "based protein", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "currently", "illicit drug use", "past medical history", "non contributory", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 87 min", "respiratory rate", "min", "pulses", "bounding", "complexion", "pale", "breath sounds", "clear", "heart sounds", "normal", "spleen", "mildly enlarged", "Oxygen saturation", "initially 81", "room air", "new oxygen requirement", "face mask", "healthy body mass index", "kg/m2", "laboratory results", "mean corpuscular volume MCV", "fL", "Hgb", "0", "total iron-binding capacity", "mcg/dL", "transferrin saturation", "most appropriate", "patient"]}
{"question": "An autopsy was performed on a 2-year-old male child. The clinical report stated that the child's parents were first cousins, and that he had deteriorated physically and mentally over the past year, becoming deaf, unable to eat, and paralyzed. A brain biopsy demonstrated the accumulation of GM2-gangliosides in the neurons. Which of the following enzymes was missing from this child?", "answer": "Hexosaminidase A", "options": {"A": "Sphingomyelinase", "B": "a-galactosidase A", "C": "ß-galactocerebrosidase", "D": "Hexosaminidase A", "E": "a-L-iduronidase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["autopsy", "performed", "year old male", "stated", "deteriorated", "past year", "deaf", "unable to eat", "brain biopsy", "accumulation", "GM2-gangliosides", "following enzymes", "missing", "child"]}
{"question": "A 70-year-old woman comes to the physician for a follow-up examination 2 months after undergoing a total hip replacement surgery. She reports that she has persistent difficulty in walking since the surgery despite regular physiotherapy. Examination of her gait shows sagging of the left pelvis when her right leg is weight-bearing. Which of the following nerves is most likely to have been injured in this patient?", "answer": "Right superior gluteal nerve", "options": {"A": "Left superior gluteal nerve", "B": "Right femoral nerve", "C": "Left inferior gluteal nerve", "D": "Left femoral nerve", "E": "Right superior gluteal nerve"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["70 year old woman", "physician", "follow-up examination", "months", "total hip replacement surgery", "reports", "persistent difficulty in walking", "surgery", "regular physiotherapy", "Examination of", "gait", "sagging", "left pelvis", "right leg", "weight-bearing", "following nerves", "to", "injured", "patient"]}
{"question": "A 35-year-old man seeks evaluation at a clinic with a 2-week history of pain during urination and a yellow-white discharge from the urethra. He has a history of multiple sexual partners and inconsistent use of condoms. He admits to having similar symptoms in the past and being treated with antibiotics. On genital examination, solitary erythematous nodules are present on the penile shaft with a yellow-white urethral discharge. The urinalysis was leukocyte esterase-positive, but the urine culture report is pending. Gram staining of the urethral discharge showed kidney bean-shaped diplococci within neutrophils. Urethral swabs were collected for cultures. Which of the following best explains why this patient lacks immunity against the organism causing his recurrent infections?", "answer": "Protein pili", "options": {"A": "Lipooligosaccharide", "B": "Protein pili", "C": "Exotoxin", "D": "Lack of vaccine", "E": "Complement deficiency"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man", "2-week history", "pain", "urination", "yellow white discharge", "urethra", "history", "multiple sexual partners", "inconsistent use of condoms", "to", "similar symptoms", "past", "treated with", "genital examination", "solitary erythematous nodules", "present", "penile shaft", "yellow white urethral discharge", "urinalysis", "leukocyte esterase positive", "urine culture report", "Gram staining", "urethral discharge", "shaped", "Urethral swabs", "collected", "following best", "patient lacks immunity", "causing", "recurrent infections"]}
{"question": "A 35-year-old woman is diagnosed with schizophrenia after nine months of experiencing auditory hallucinations and persecutory delusions. Over the next year, she fails to experience symptom relief from separate and appropriately dosed trials of olanzapine, quetiapine, and risperidone. At this point, which of the following treatment options is most likely to be effective?", "answer": "Clozapine", "options": {"A": "Aripiprazole", "B": "Haloperidol", "C": "Clozapine", "D": "Clonidine", "E": "Cognitive behavioral therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old woman", "diagnosed", "schizophrenia", "nine months", "auditory hallucinations", "persecutory delusions", "next year", "fails to", "separate", "dosed", "olanzapine", "quetiapine", "risperidone", "point", "following treatment options", "to", "effective"]}
{"question": "A 54-year-old woman comes to the physician because of an ulcer on her left ankle for 6 years. She has had multiple ulcers over her left lower extremity during this period that have subsided with wound care and dressing. She has type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include metformin, sitagliptin, and omeprazole. She appears anxious. She is 162 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 34 kg/m2. Vital signs are within normal limits. Examination shows a 7.5-cm (3-in) ulcer with elevated, indurated margins and a necrotic floor above the left medial malleolus. There are multiple dilated, tortuous veins along the left lower extremity. There is 2+ pretibial edema of the lower extremities bilaterally. The skin around the left ankle appears darker than the right and there are multiple excoriation marks. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient's current condition?", "answer": "Punch biopsy\n\"", "options": {"A": "Digital subtraction angiography", "B": "CT scan of the left leg", "C": "Perthes test", "D": "Trendelenburg test", "E": "Punch biopsy\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["54 year old woman", "physician", "of", "ulcer", "left ankle", "years", "multiple ulcers", "left lower extremity", "period", "wound care", "dressing", "type 2 diabetes mellitus", "gastroesophageal reflux disease", "Current medications include metformin", "sitagliptin", "omeprazole", "appears anxious", "5 ft 4", "tall", "kg", "BMI", "kg/m2", "Vital signs", "normal limits", "7.5", "3", "ulcer", "elevated", "indurated margins", "necrotic floor", "left medial malleolus", "multiple dilated", "tortuous veins", "left lower extremity", "2", "edema of", "lower extremities", "skin", "left ankle appears darker", "right", "multiple excoriation marks", "Cardiopulmonary", "abnormalities", "following", "most appropriate next step", "management", "patient's current condition"]}
{"question": "A 60-year-old woman presents to you with vision problems. Objects appear clear, but she just can't see as well as before. She says she first noticed this when she went to the movies with her grandkids, and she could not see the whole screen. She denies any complaints of redness, itchiness, or excessive tearing of her eyes. Current medications are captopril for her hypertension, acetaminophen for occasional headaches, and a daily multivitamin. Her vital signs are a blood pressure 130/80 mm Hg, pulse 80/min and regular, respiratory rate 14/min, and a temperature of 36.7°C (98.0°F). Eye examination reveals that her visual acuity is normal but the visual field is reduced with enlarged blind spots. Tonometry reveals mildly increased IOP. The patient is started on brimonidine. Which of the following statements best describes the therapeutic mechanism of action of this medication in this patient?", "answer": "Brimonidine causes release of prostaglandins that relax the ciliary muscle and increases uveoscleral outflow.", "options": {"A": "Brimonidine causes an increase in cAMP, leading to increased aqueous humor formation by the ciliary body.", "B": "Brimonidine causes immediate contraction of the ciliary body, leading to decreased uveoscleral outflow.", "C": "Brimonidine blocks the beta-receptors on the ciliary body to reduce aqueous humor production.", "D": "Peripheral vasoconstriction by brimonidine leads to better control of her hypertension.", "E": "Brimonidine causes release of prostaglandins that relax the ciliary muscle and increases uveoscleral outflow."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["60 year old woman presents", "vision problems", "appear clear", "see", "before", "first", "movies", "not see", "whole screen", "complaints", "redness", "itchiness", "excessive", "eyes", "Current medications", "captopril", "hypertension", "acetaminophen", "occasional headaches", "daily multivitamin", "vital signs", "blood pressure", "80 mm Hg", "pulse 80 min", "regular", "respiratory rate", "min", "temperature", "36", "98", "Eye examination reveals", "visual acuity", "normal", "visual field", "reduced", "enlarged blind spots", "Tonometry reveals mildly increased IOP", "patient", "started", "brimonidine", "following", "best", "mechanism", "patient"]}
{"question": "A 62-year-old woman presents to the office because she has noticed yellowish bumps and patches on her elbows and knees that seem to come and go. Recently she noticed the same yellow bumps on her eyelids. She is a new patient and reports that she is otherwise healthy but did not have insurance until recently so she has not been to the doctor in over 8 years. Past medical history is significant for occasional headaches that she treats with aspirin. She used to smoke a pack a day for the last 20 years but recently quit. Her father died of a heart attack at the age of 55 years and her mother had a stroke at 64 and lives in a nursing home. Her blood pressure is 135/87 mm Hg, the heart rate is 95/min, the respiratory rate is 12/min, and the temperature is 37.0°C (98.6°F). On physical exam, she has multiple tan-yellow, firm papules on her knees and elbows. The papules around her eyes are smaller and soft. You discuss the likely cause of the bumps and explain that you will need to order additional tests. What test should you perform?", "answer": "Lipid panel", "options": {"A": "Biopsy", "B": "PET scan", "C": "Celiac panel", "D": "Lipid panel", "E": "Erythrocyte sedimentation rate (ESR)"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old woman presents", "office", "patches", "elbows", "knees", "to", "go", "Recently", "same yellow bumps", "eyelids", "new patient", "reports", "healthy", "not", "recently", "not", "doctor", "over", "years", "Past medical history", "significant", "occasional headaches", "treats", "aspirin", "used to smoke", "pack", "day", "20 years", "recently", "died", "heart attack", "age", "years", "stroke", "64", "lives in a nursing home", "blood pressure", "87 mm Hg", "heart rate", "95 min", "respiratory rate", "min", "temperature", "98", "multiple tan yellow", "firm papules", "knees", "elbows", "papules", "eyes", "smaller", "soft", "likely cause", "need to order additional tests", "test", "perform"]}
{"question": "A previously healthy 47-year-old woman comes to the emergency department because of a 2-week history of fatigue, abdominal distention, and vomiting. She drinks 6 beers daily. Physical examination shows pallor and scleral icterus. A fluid wave and shifting dullness are present on abdominal examination. The intravascular pressure in which of the following vessels is most likely to be increased?", "answer": "Short gastric vein", "options": {"A": "Short gastric vein", "B": "Splenic artery", "C": "Inferior epigastric vein", "D": "Azygos vein", "E": "Gastroduodenal artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old woman", "emergency department", "2-week history", "fatigue", "abdominal distention", "vomiting", "daily", "pallor", "scleral icterus", "fluid wave", "shifting dullness", "present", "abdominal", "intravascular pressure", "following vessels", "to", "increased"]}
{"question": "One month after undergoing surgical spinal fusion because of a traumatic spinal cord injury, a 68-year-old man comes to the physician because of lower abdominal pain. He last voided yesterday. Physical examination shows a suprapubic mass and decreased sensation below the umbilicus. Urodynamic studies show simultaneous contractions of the detrusor muscle and the internal urethral sphincter. Urinary catheterization drains 900 mL of urine from the bladder. Which of the following is the most appropriate pharmacotherapy for this patient’s urinary symptoms?", "answer": "Prazosin", "options": {"A": "Neostigmine", "B": "Finasteride", "C": "Phenylephrine", "D": "Bethanechol", "E": "Prazosin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["One month", "surgical spinal fusion", "traumatic spinal cord injury", "year old man", "physician", "lower abdominal pain", "last voided", "suprapubic mass", "decreased sensation", "umbilicus", "Urodynamic studies", "simultaneous contractions", "detrusor muscle", "internal urethral sphincter", "Urinary catheterization drains 900 mL", "urine", "bladder", "following", "most appropriate pharmacotherapy", "patients urinary"]}
{"question": "A 24-year-old African American male with sickle cell disease has been followed by a hematologist since infancy. Two years ago, he was started on hydroxyurea for frequent pain crises but has not achieved good control. The addition of a Gardos channel blocking agent is being considered. What is the mechanism of action of this class of medications?", "answer": "Prevents RBC dehydration by inhibiting K+ efflux", "options": {"A": "Prevents RBC dehydration by inhibiting K+ efflux", "B": "Increases production of hemoglobin F", "C": "Prevents dehydration of RBCs by inhibiting Ca2+ efflux", "D": "Encourages alkalinization of the blood by facilitating H+/K+ antiporter activity", "E": "Increases water diffusion by increasing activity of aquaporin-1 receptors"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male", "sickle cell disease", "followed by", "hematologist", "infancy", "Two years", "started", "hydroxyurea", "frequent pain crises", "not", "good control", "addition", "channel blocking agent", "mechanism of action", "medications"]}
{"question": "A previously healthy 5-year-old boy is brought to the physician by his parents because of a 2-day history of poor balance and difficulty walking. He has fallen multiple times and is unable to walk up the stairs unassisted. He has also had difficulty tying his shoes and dressing himself. His family adheres to a vegetarian diet. He has not yet received any routine childhood vaccinations. His mother has a history of anxiety. He is at the 70th percentile for height and 30th percentile for weight. Vital signs are within normal limits. He is alert and oriented to person, place, and time. Physical examination shows a broad-based, staggering gait. He has difficulty touching his nose and cannot perform rapidly-alternating palm movements. Strength is 5/5 in the upper and lower extremities. Deep tendon reflexes are 1+ bilaterally. Skin examination shows several faint hyperpigmented macules on the chest. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Varicella zoster infection", "options": {"A": "Vitamin B1 deficiency", "B": "Varicella zoster infection", "C": "Accidental medication ingestion", "D": "Posterior fossa malignancy", "E": "Peripheral nerve demyelination"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "2-day history", "poor balance", "difficulty walking", "fallen multiple times", "unable to walk", "difficulty tying", "shoes", "dressing", "vegetarian diet", "not", "received", "routine childhood vaccinations", "history", "anxiety", "percentile", "height", "percentile", "weight", "Vital signs", "normal limits", "alert", "oriented to person", "place", "time", "broad-based", "staggering gait", "difficulty touching", "nose", "perform rapidly alternating palm movements", "Strength", "5/5", "upper", "lower extremities", "Deep tendon reflexes", "1", "Skin examination", "several faint hyperpigmented macules", "chest", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 58-year-old female presents to her primary care physician with a 1-month history of facial and chest flushing, as well as intermittent diarrhea and occasional difficulty breathing. On physical exam, a new-onset systolic ejection murmur is auscultated and is loudest at the left second intercostal space. Subsequent echocardiography reveals leaflet thickening secondary to fibrous plaque deposition on both the pulmonic and tricuspid valves. Which of the following laboratory abnormalities would most likely in this patient?", "answer": "Elevated urinary 5-hydroxyindoleacetic acid", "options": {"A": "Decreased serum chromogranin A", "B": "Elevated serum bicarbonate", "C": "Elevated urinary vanillylmandelic acid", "D": "Elevated serum potassium", "E": "Elevated urinary 5-hydroxyindoleacetic acid"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old female presents", "primary care physician", "month history", "facial", "chest flushing", "intermittent diarrhea", "occasional difficulty breathing", "new-onset systolic ejection murmur", "loudest", "left second intercostal space", "Subsequent echocardiography reveals leaflet thickening secondary to fibrous plaque deposition", "pulmonic", "tricuspid valves", "following laboratory abnormalities", "patient"]}
{"question": "A 53-year-old man is brought to the clinic by his son for the evaluation of unusual behavior. He is a shopkeeper by profession and sometimes behaves very rudely to the customers. Recently, he accused one of the customers of using black magic over his shop. He has been increasingly irritable, forgetting things, and having problems managing his finances over the past 8 months. He is also having difficulty finding words and recalling the names of objects during the conversation. There is no history of recent head trauma, fever, hallucinations, or abnormal limb movements. Past medical history is significant for a well-controlled type 2 diabetes mellitus. Family history is unremarkable. He does not smoke or use illicit drugs. Vital signs are stable with a blood pressure of 134/76 mm Hg, a heart rate of 88/min, and a temperature of 37.0°C (98.6°F). On physical examination, he has problems naming objects and planning tasks. Mini-mental state examination (MMSE) score is 26/30. Cranial nerve examination is normal. Muscle strength is normal in all 4 limbs with normal muscle tone and deep tendon reflexes. Sensory examination is also normal. What is the most likely diagnosis?", "answer": "Pick’s disease", "options": {"A": "Alzheimer’s disease", "B": "Creutzfeldt–Jakob disease", "C": "Huntington’s disease", "D": "Lewy body dementia", "E": "Pick’s disease"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "clinic", "unusual", "shopkeeper", "sometimes", "very", "Recently", "one", "using", "shop", "irritable", "forgetting", "finances", "past", "months", "difficulty finding words", "names", "history", "recent head", "fever", "hallucinations", "abnormal limb", "Past medical history", "significant", "well-controlled type 2 diabetes mellitus", "Family history", "unremarkable", "not smoke", "use illicit", "Vital signs", "stable", "blood pressure", "76 mm Hg", "heart rate", "88 min", "temperature", "98", "planning", "Mini-mental state examination", "score", "26/30", "normal", "Muscle strength", "normal", "limbs", "normal muscle tone", "deep tendon reflexes", "Sensory", "normal", "diagnosis"]}
{"question": "A 32-year-old G0P0 African American woman presents to the physician with complaints of heavy menstrual bleeding as well as menstrual bleeding in between her periods. She also reports feeling fatigued and having bizarre cravings for ice and chalk. Despite heavy bleeding, she does not report any pain with menstruation. Physical examination is notable for an enlarged, asymmetrical, firm uterus with multiple palpable, non-tender masses. Biopsy confirms the diagnosis of a benign condition. Which of the following histological characteristics would most likely be seen on biopsy in this patient?", "answer": "Whorled pattern of smooth muscle bundles with well-defined borders", "options": {"A": "Clustered pleomorphic, hyperchromatic smooth muscle cells with extensive mitosis", "B": "Granulosa cells scattered around collections of eosinophilic fluid", "C": "Laminated, concentric spherules with dystrophic calcification", "D": "Presence of endometrial glands and stroma in the myometrium", "E": "Whorled pattern of smooth muscle bundles with well-defined borders"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "woman presents", "physician", "complaints", "heavy menstrual bleeding", "menstrual bleeding", "periods", "reports", "fatigued", "ice", "chalk", "heavy bleeding", "not report", "pain", "menstruation", "notable", "enlarged", "asymmetrical", "firm", "multiple palpable", "non-tender masses", "Biopsy confirms", "diagnosis", "benign condition", "following histological characteristics", "most likely", "seen", "biopsy", "patient"]}
{"question": "A young immigrant girl presents with low-grade fever, sore throat, painful swallowing, and difficulty in breathing. Her voice is unusually nasal and her swollen neck gives the impression of “bull's neck”. On examination, a large gray membrane is noticed on the oropharynx as shown in the picture. Removal of the membrane reveals a bleeding edematous mucosa. Culture on potassium tellurite medium reveals several black colonies. What is the mechanism of action of the bacterial toxin responsible for this condition?", "answer": "ADP ribosylates EF-2 and prevents protein synthesis (ADP = adenosine diphosphate; EF-2 = elongation factor-2)", "options": {"A": "Travels retrogradely on axons of peripheral motor neurons and blocks the release of inhibitory neurotransmitters", "B": "Spreads to peripheral cholinergic nerve terminals and blocks the release of acetylcholine ", "C": "Cytotoxic to cells", "D": "ADP ribosylates EF-2 and prevents protein synthesis (ADP = adenosine diphosphate; EF-2 = elongation factor-2)", "E": "Causes muscle cell necrosis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["young", "girl presents", "low-grade fever", "sore throat", "painful swallowing", "difficulty", "breathing", "voice", "nasal", "swollen neck gives", "impression", "neck", "large gray membrane", "oropharynx", "picture", "Removal", "membrane reveals", "bleeding edematous mucosa", "potassium tellurite", "reveals several black colonies", "mechanism of action", "bacterial toxin responsible", "condition"]}
{"question": "A 68-year-old man is brought to the emergency department by ambulance after he was found to be altered at home. Specifically, his wife says that he fell and was unable to get back up while walking to bed. When she approached him, she found that he was unable to move his left leg. His past medical history is significant for hypertension, atrial fibrillation, and diabetes. In addition, he has a 20-pack-year smoking history. On presentation, he is found to still have difficulty moving his left leg though motor function in his left arm is completely intact. The cause of this patient's symptoms most likely occurred in an artery supplying which of the following brain regions?", "answer": "Cingulate gyrus", "options": {"A": "Cingulate gyrus", "B": "Globus pallidus", "C": "Lateral medulla", "D": "Lingual gyrus", "E": "Superior temporal gyrus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "found to", "altered at home", "fell", "unable to", "back", "bed", "approached", "found", "unable to move", "left leg", "past medical history", "significant", "hypertension", "atrial fibrillation", "diabetes", "addition", "20 year smoking history", "found to", "difficulty moving", "left leg", "left arm", "completely intact", "cause", "patient's symptoms", "likely", "artery supplying", "following brain regions"]}
{"question": "A 9-year-old boy is brought to the emergency room by his mother for weakness, diaphoresis, and syncope. His mother says that he has never been diagnosed with any medical conditions but has been having “fainting spells” over the past month. Routine lab work reveals a glucose level of 25 mg/dL. The patient is promptly given glucagon and intravenous dextrose and admitted to the hospital for observation. The patient’s mother stays with him during his hospitalization. The patient is successfully watched overnight and his blood glucose levels normalize on his morning levels. The care team discusses a possible discharge during morning rounds. One hour later the nurse is called in for a repeat fainting episode. A c-peptide level is drawn and shown to be low. The patient appears ill, diaphoretic, and is barely arousable. Which of the following is the most likely diagnosis in this child?", "answer": "Munchausen syndrome by proxy", "options": {"A": "Munchausen syndrome", "B": "Munchausen syndrome by proxy", "C": "Somatic symptom disorder", "D": "Conversion disorder", "E": "Insulinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency room", "weakness", "diaphoresis", "syncope", "never", "diagnosed", "medical conditions", "fainting spells", "past month", "Routine lab", "reveals", "glucose level", "mg/dL", "patient", "glucagon", "intravenous dextrose", "observation", "patient", "overnight", "blood glucose levels", "morning levels", "care team", "possible discharge", "One hour later", "nurse", "called", "repeat fainting episode", "c-peptide level", "to", "low", "patient appears ill", "diaphoretic", "following", "diagnosis", "child"]}
{"question": "A 35-year-old woman comes to the physician because of progressive left flank pain and increased urinary frequency for the past two weeks. Her appetite is normal and she has not had any nausea or vomiting. She has a history of type 1 diabetes mellitus that is poorly controlled with insulin. She is sexually active with her boyfriend, and they use condoms inconsistently. Her temperature is 38° C (100.4° F), pulse is 90/min, and blood pressure is 120/80 mm Hg. The abdomen is soft and there is tenderness to palpation in the left lower quadrant; there is no guarding or rebound. There is tenderness to percussion along the left flank. She complains of pain when her left hip is passively extended. Her leukocyte count is 16,000/mm3 and urine pregnancy test is negative. Urinalysis shows 3+ glucose. An ultrasound of the abdomen shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Psoas muscle abscess", "options": {"A": "Urinary tract infection", "B": "Ectopic pregnancy", "C": "Nephrolithiasis", "D": "Psoas muscle abscess", "E": "Uterine leiomyoma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "physician", "progressive left flank pain", "increased urinary frequency", "past two weeks", "appetite", "normal", "not", "nausea", "vomiting", "history of type 1 diabetes mellitus", "poorly controlled", "insulin", "sexually active", "use condoms", "temperature", "100", "F", "pulse", "90 min", "blood pressure", "80 mm Hg", "abdomen", "soft", "tenderness", "palpation", "left lower quadrant", "guarding", "tenderness", "percussion", "left flank", "pain", "left hip", "extended", "leukocyte count", "mm3", "urine pregnancy test", "negative", "Urinalysis", "3", "glucose", "ultrasound of", "abdomen", "abnormalities", "following", "diagnosis"]}
{"question": "A 27-year-old woman, gravida 3, para 2, delivers twins via an uncomplicated vaginal delivery. Both placentas are delivered shortly afterward. The patient received regular prenatal care and experienced no issues during her pregnancy. Over the next hour, she continues to experience vaginal bleeding, with an estimated blood loss of 1150 mL. Vital signs are within normal limits. Physical exam shows an enlarged, soft uterus. Which of the following is the most appropriate next step in management?", "answer": "Bimanual uterine massage", "options": {"A": "Methylergometrine", "B": "Hysterectomy", "C": "Curettage with suctioning", "D": "Tranexamic acid", "E": "Bimanual uterine massage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["27 year old woman", "gravida 3", "para 2", "delivers twins", "uncomplicated vaginal", "placentas", "delivered", "patient received regular", "issues", "pregnancy", "next hour", "to", "vaginal bleeding", "estimated blood loss of", "mL", "Vital signs", "normal limits", "enlarged", "soft", "following", "most appropriate next step"]}
{"question": "An otherwise healthy 78-year-old man is brought to the emergency department by his daughter because of a 1-day history of a diffuse headache and an inability to understand speech. There is no history of head trauma. He drinks one to two beers daily and occasionally more on weekends. His vital signs are within normal limits. Mental status examination shows fluent but meaningless speech and an inability to repeat sentences. A noncontrast CT scan of the head shows an acute hemorrhage in the left temporal lobe and several small old hemorrhages in bilateral occipital lobes. Which of the following is the most likely underlying cause of this patient's neurological symptoms?", "answer": "Amyloid angiopathy", "options": {"A": "Vascular lipohyalinosis", "B": "Ruptured vascular malformation", "C": "Hypertensive encephalopathy", "D": "Cardiac embolism", "E": "Amyloid angiopathy"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department", "of", "1-day history", "diffuse headache", "to", "speech", "history", "head trauma", "one", "two", "daily", "occasionally", "weekends", "vital signs", "normal", "Mental", "fluent", "speech", "to repeat", "CT scan of", "head", "acute hemorrhage", "left temporal lobe", "several small old hemorrhages", "bilateral occipital", "following", "underlying cause", "patient's neurological"]}
{"question": "A 40-year-old woman presents to her primary care physician complaining of a several-month history of episodic sweating and heart racing. Her husband noticed that she becomes pale during these episodes. She also has progressive episodic pounding headaches which are not relieved by paracetamol. Her family history is negative for hypertension, endocrinopathies, or tumors. Vital signs reveal a blood pressure of 220/120 mm Hg, temperature (normal) and pulse of 110/min. Fundus examination reveals hypertensive retinal changes. This patient condition is most likely due to neoplasm arising from which of the following?", "answer": "Adrenal chromaffin cells", "options": {"A": "Zona glomerulosa", "B": "Zona fasciculata", "C": "Zonta reticularis", "D": "Adrenal chromaffin cells", "E": "Extra-adrenal chromaffin cells"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old woman presents", "primary care physician", "month history", "episodic sweating", "heart racing", "pale", "episodes", "progressive episodic pounding headaches", "not relieved by paracetamol", "family history", "negative", "hypertension", "endocrinopathies", "tumors", "Vital signs reveal", "blood pressure", "mm Hg", "temperature", "normal", "pulse of", "min", "Fundus examination reveals hypertensive retinal changes", "patient condition", "due to neoplasm arising", "following"]}
{"question": "A 13-year-old boy is brought to the physician because of swelling around his eyes for the past 2 days. His mother also notes that his urine became gradually darker during this time. Three weeks ago, he was treated for bacterial tonsillitis. His temperature is 37.6°C (99.7°F), pulse is 79/min, and blood pressure is 158/87 mm Hg. Examination shows periorbital swelling. Laboratory studies show:\nSerum\nUrea nitrogen 9 mg/dL\nCreatinine 1.7 mg/dL\nUrine\nProtein 2+\nRBC 12/hpf\nRBC casts numerous\nA renal biopsy would most likely show which of the following findings?\"", "answer": "Granular deposits of IgG, IgM, and C3 on immunofluorescence", "options": {"A": "\"\"\"Spike-and-dome\"\" appearance of subepithelial deposits on electron microscopy\"", "B": "Splitting and alternating thickening and thinning of the glomerular basement membrane on light microscopy", "C": "Mesangial IgA deposits on immunofluorescence", "D": "Effacement of podocyte foot processes on electron microscopy", "E": "Granular deposits of IgG, IgM, and C3 on immunofluorescence"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy", "brought", "physician", "of swelling", "eyes", "past 2 days", "notes", "urine", "darker", "time", "Three weeks", "treated", "bacterial tonsillitis", "temperature", "99", "pulse", "min", "blood pressure", "87 mm Hg", "periorbital swelling", "Laboratory studies", "Serum Urea nitrogen", "Creatinine", "Protein", "RBC", "hpf", "casts numerous", "renal biopsy", "most likely", "following findings"]}
{"question": "A 71 year-old female is brought to the emergency room by her husband. The husband reports that they were taking a walk together one hour ago, when his wife experienced sudden, right arm and leg weakness. He noticed that she had slurred speech, and that she was not able to tell him where she was. The patient underwent an emergent CT scan, which was unremarkable, and was treated with tissue plasminogen activator (tPA). Which of the following EKG findings increases a patient's risk for this acute presentation?", "answer": "Atrial fibrillation", "options": {"A": "Supraventricular tachycardia", "B": "Atrial bigeminy", "C": "Normal sinus rhythm", "D": "Prolonged QT", "E": "Atrial fibrillation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "brought", "emergency room", "reports", "together one hour", "sudden", "right arm", "leg weakness", "slurred speech", "not able to", "patient", "CT scan", "unremarkable", "treated with tissue plasminogen activator", "following EKG findings increases", "patient's", "acute"]}
{"question": "A 23-year-old man presents with increasing neck pain for several months that does not improve with nonsteroidal anti-inflammatory drugs. The patient says he has had neck pain ever since he was involved in a motor vehicle accident 10 months ago. For the last 2 weeks, he says he has also noticed weakness and numbness in his hands and has difficulty gripping objects. Physical examination reveals a thermal injury that he says he got while holding a hot cup of coffee a week ago when he could not feel the warmth of the coffee mug. Strength is 4/5 bilaterally during elbow flexion and extension and wrist extension. He also has exaggerated deep tendon reflexes bilaterally and decreased sensation symmetrically on the dorsal and ventral surface of both forearms and hands. Which of the following additional findings would you expect to find in this patient?", "answer": "A cavitation in the cervical spinal cord", "options": {"A": "Fusion of cervical vertebrae", "B": "Hypoplasia of the cerebellar vermis", "C": "Bilateral carpal tunnel syndrome", "D": "A cavitation in the cervical spinal cord", "E": "Cervical spinal epidural abscess"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["23 year old man presents", "increasing neck pain", "several months", "not", "nonsteroidal anti-inflammatory drugs", "patient", "neck pain ever", "involved", "motor vehicle accident 10 months", "last", "weeks", "weakness", "numbness", "hands", "difficulty gripping", "reveals", "thermal injury", "got", "holding", "hot cup", "week", "not", "warmth", "mug", "Strength", "4/5", "elbow flexion", "extension", "wrist extension", "exaggerated deep tendon reflexes", "decreased sensation", "dorsal", "ventral surface of", "forearms", "hands", "following additional findings", "to find", "patient"]}
{"question": "A 45-year-old man presents to the emergency department because of fever and scrotal pain for 2 days. Medical history includes diabetes mellitus and morbid obesity. His temperature is 40.0°C (104.0°F), the pulse is 130/min, the respirations are 35/min, and the blood pressure is 90/68 mm Hg. Physical examination shows a large area of ecchymosis, edema, and crepitus in his perineal area. Fournier gangrene is suspected. A right internal jugular central venous catheter is placed without complication under ultrasound guidance for vascular access in preparation for the administration of vasopressors. Which of the following is the most appropriate next step?", "answer": "Obtain an immediate portable chest radiograph to evaluate line placement", "options": {"A": "Begin infusion of norepinephrine to maintain systolic blood pressure over 90 mm Hg", "B": "Begin infusion of normal saline through a central line", "C": "Begin to use the line after documenting the return of dark, non-pulsatile blood from all ports", "D": "Confirm line placement by ultrasound", "E": "Obtain an immediate portable chest radiograph to evaluate line placement"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "fever", "scrotal pain", "2 days", "Medical history includes diabetes mellitus", "morbid obesity", "temperature", "40", "pulse", "min", "respirations", "35 min", "blood pressure", "90", "mm Hg", "large area", "ecchymosis", "edema", "crepitus", "perineal area", "Fournier gangrene", "suspected", "right", "central venous catheter", "complication", "ultrasound guidance for vascular access", "preparation", "administration", "vasopressors", "following", "most appropriate next step"]}
{"question": "A 32-year-old man of Asian descent presents with a skin rash after being started on prophylactic doses of trimethoprim/sulfamethoxazole 3 weeks earlier. He was diagnosed with acquired immunodeficiency syndrome (AIDS) 2 months ago which prompted the initiation of prophylactic antibiotics. The vital signs include: blood pressure 112/72 mm Hg, temperature 40.0°C (104.0°F), respiratory rate 22/min, and heart rate 95/min. He has 20% total body surface area (TBSA) skin slough with scattered vesicles and erosions throughout his face and extremities, as shown in the image. He does have erosions on his lips, but he does not have any other mucosal involvement. Which of the following is most consistent with this patient’s findings?", "answer": "Stevens-Johnson syndrome", "options": {"A": "Erythema multiforme", "B": "Staphylococcal scalded skin syndrome", "C": "Stevens-Johnson syndrome", "D": "Drug rash with eosinophilia and systemic symptoms", "E": "Toxic shock syndrome"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "descent presents", "skin rash", "started", "prophylactic doses", "trimethoprim/sulfamethoxazole", "weeks earlier", "diagnosed", "acquired immunodeficiency syndrome", "months", "prompted", "initiation", "prophylactic antibiotics", "vital signs include", "blood pressure", "72 mm Hg", "temperature 40", "respiratory rate", "min", "heart rate 95 min", "20", "total", "skin slough", "scattered vesicles", "erosions", "face", "extremities", "erosions", "lips", "not", "mucosal involvement", "following", "most", "patients findings"]}
{"question": "A 43-year-old woman comes to the physician because of a 2-month history of chest pain. She describes the pain as intermittent and burning-like. She states that she has tried using proton pump inhibitors but has had no relief of her symptoms. She has had a 5-kg (11-lb) weight loss over the past 2 months. Her temperature is 36.7°C (98.1°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. Examination shows tightness of the skin of the fingers; there are small nonhealing, nonpurulent ulcers over thickened skin on the fingertips. Fine inspiratory crackles are heard at both lung bases. There is mild tenderness to palpation of the epigastrium. Which of the following is most likely associated with her diagnosis?", "answer": "Anti-topoisomerase antibodies", "options": {"A": "c-ANCA", "B": "Anti-topoisomerase antibodies", "C": "Anti-mitochondrial antibodies", "D": "Anti-histone antibodies", "E": "Anti-Ro/SSA and anti-La/SSB antibodies"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "2 month history", "chest pain", "pain", "intermittent", "burning", "states", "using proton pump inhibitors", "5 kg", "weight loss", "past", "months", "temperature", "36", "98", "pulse", "75 min", "blood pressure", "80 mm Hg", "tightness", "skin", "fingers", "small nonhealing", "ulcers", "thickened", "fingertips", "Fine inspiratory crackles", "heard", "lung bases", "mild tenderness", "palpation of", "epigastrium", "following", "most likely associated with", "diagnosis"]}
{"question": "A 27-year-old man presents to the emergency department with general weakness and fatigue. He states that he has not felt well for several days and can't take care of himself anymore due to fatigue. The patient has a past medical history of IV drug abuse, alcohol abuse, and multiple minor traumas associated with intoxication. His temperature is 104°F (40°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 19/min, and oxygen saturation is 98% on room air. A murmur is heard on cardiac exam. The patient is treated appropriately and transferred to the inpatient floor and recovers over the next several days. The patient has been unable to eat solids, though he has been drinking large amounts of juice. On day 5 of his stay, the patient states he feels much better. He is no longer febrile. His only concern is profuse and watery diarrhea and severe abdominal pain which he has been experiencing since yesterday. The patient is started on IV fluids and given oral fluid replacement as well. Which of the following is associated with the most likely underlying diagnosis?", "answer": "Pseudomembranes of fibrin", "options": {"A": "Anti-Saccharomyces cerevisiae antibody positivity (ASCA)", "B": "Ascitic fluid infection", "C": "Pseudomembranes of fibrin", "D": "Increased osmotic load", "E": "Schistocytes on peripheral smear"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old man presents", "emergency department", "general weakness", "fatigue", "states", "not", "well", "days", "fatigue", "patient", "past medical history of IV drug abuse", "alcohol abuse", "multiple minor traumas associated with intoxication", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "murmur", "heard", "patient", "treated", "transferred", "inpatient floor", "recovers", "next", "days", "patient", "unable to eat solids", "drinking large amounts", "day 5", "patient states", "much better", "longer febrile", "only", "watery diarrhea", "severe abdominal", "patient", "started", "given oral fluid replacement", "well", "following", "associated with", "likely underlying diagnosis"]}
{"question": "A 9-year-old boy is brought to the physician for evaluation of a 3-day history of fever, sore throat, and itchy, red eyes. His symptoms began while he was away at summer camp. His immunizations are not up-to-date. He appears ill. His temperature is 39.1°C (102.3°F). Physical examination shows erythema and edema of the conjunctivae and posterior pharyngeal wall. There is bilateral, tender, preauricular lymphadenopathy. Further evaluation shows infection with a DNA virus. Which of the following is the most likely causal pathogen?", "answer": "Adenovirus", "options": {"A": "Adenovirus", "B": "Parvovirus", "C": "Picornavirus", "D": "Paramyxovirus", "E": "Human herpes virus 4"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "3-day history", "fever", "sore throat", "itchy", "red", "symptoms began", "summer camp", "immunizations", "not", "date", "appears ill", "temperature", "erythema", "edema of", "conjunctivae", "posterior pharyngeal wall", "bilateral", "tender", "preauricular lymphadenopathy", "Further", "infection", "DNA virus", "following", "causal"]}
{"question": "A 70-year-old man presents to the emergency department with severe substernal chest pain of one hour’s duration. The patient was taking a morning walk when the onset of pain led him to seek care. His past medical history includes coronary artery disease, hyperlipidemia, and hypertension. Medications include aspirin, losartan, and atorvastatin. An electrocardiogram reveals ST elevations in the inferior leads II, III, and avF as well as in leads V5 and V6. The ST elevations found in leads V5-V6 are most indicative of pathology in which of the following areas of the heart?", "answer": "Lateral wall of left ventricle, left circumflex coronary artery", "options": {"A": "Inferior wall, right coronary artery", "B": "Interventricular septum, left anterior descending coronary artery", "C": "Lateral wall of left ventricle, left circumflex coronary artery", "D": "Left atrium, left main coronary artery", "E": "Right ventricle, left main coronary artery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man presents", "emergency department", "severe", "chest pain of one hours duration", "patient", "morning", "onset", "pain led", "to", "past medical history includes coronary artery disease", "hyperlipidemia", "hypertension", "Medications include aspirin", "losartan", "atorvastatin", "electrocardiogram reveals ST elevations", "inferior leads", "III", "avF as well", "leads", "V6", "ST elevations found", "leads", "V6", "most", "pathology", "following areas", "heart"]}
{"question": "A 68-year-old male visits his primary care physician after an episode of syncope during a tennis match. He reports exertional dyspnea with mild substernal chest pain. On physical exam a systolic crescendo-decrescendo murmur is heard best at the right 2nd intercostal space. This murmur was not heard at the patient's last appointment six months ago. Which of the following would most support a diagnosis of aortic stenosis?", "answer": "Murmur radiates to carotid arteries bilaterally", "options": {"A": "Presence of S3", "B": "Murmur radiates to carotid arteries bilaterally", "C": "Murmur radiates to axilla", "D": "Asymmetric ventricular hypertrophy", "E": "Double pulsation of the carotid pulse"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "primary care physician", "episode of syncope", "match", "reports exertional dyspnea", "mild substernal chest pain", "systolic crescendo-decrescendo murmur", "heard best", "right 2nd intercostal space", "murmur", "not heard", "six months", "following", "most support", "diagnosis of aortic stenosis"]}
{"question": "A 37-year-old man presents to the physician. He has been overweight since childhood. He has not succeeded in losing weight despite following different diet and exercise programs over the past several years. He has had diabetes mellitus for 2 years and severe gastroesophageal reflux disease for 9 years. His medications include metformin, aspirin, and pantoprazole. His blood pressure is 142/94 mm Hg, pulse is 76/min, and respiratory rate is 14/min. His BMI is 36.5 kg/m2. Laboratory studies show:\nHemoglobin A1C 6.6%\nSerum  \nFasting glucose 132 mg/dL\nWhich of the following is the most appropriate surgical management?", "answer": "Laparoscopic Roux-en-Y gastric bypass", "options": {"A": "Biliopancreatic diversion and duodenal switch (BPD-DS)", "B": "Laparoscopic adjustable gastric banding", "C": "Laparoscopic Roux-en-Y gastric bypass", "D": "Laparoscopic sleeve gastrectomy", "E": "No surgical management at this time"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "overweight", "childhood", "not", "weight", "following different diet", "exercise programs", "past", "years", "diabetes mellitus", "years", "severe gastroesophageal reflux disease", "years", "medications include metformin", "aspirin", "pantoprazole", "blood pressure", "mm Hg", "pulse", "76 min", "respiratory rate", "min", "BMI", "36", "kg/m2", "Laboratory studies", "Hemoglobin A1C", "Serum", "Fasting glucose", "mg/dL", "following", "most appropriate"]}
{"question": "An 8-year-old girl is brought to the emergency department because of a 2-day history of an intermittent, diffuse abdominal pain. She has also had a nonpruritic rash on her legs and swelling of her ankles for 1 week. Two weeks ago, she had a sore throat, which was treated with oral amoxicillin. Examination of the lower extremities shows non-blanching, raised erythematous papules. The ankle joints are swollen and warm, and their range of motion is limited by pain. Laboratory studies show a platelet count of 450,000/mm3. Test of the stool for occult blood is positive. Which of the following is the most likely diagnosis?", "answer": "Leukocytoclastic vasculitis", "options": {"A": "Immune thrombocytopenic purpura", "B": "Acute rheumatic fever", "C": "Juvenile idiopathic arthritis", "D": "Familial Mediterranean fever", "E": "Leukocytoclastic vasculitis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "emergency department", "2-day history", "intermittent", "diffuse abdominal pain", "nonpruritic rash", "legs", "swelling", "ankles", "1 week", "Two weeks", "sore throat", "treated with oral amoxicillin", "Examination of the lower extremities", "non blanching", "raised erythematous papules", "ankle joints", "swollen", "warm", "range of motion", "limited", "pain", "Laboratory studies", "platelet count", "450", "mm3", "Test", "stool", "occult blood", "positive", "following", "diagnosis"]}
{"question": "A 31-year-old physician notices that her senior colleague has been arriving late for work for the past 2 weeks. The colleague recently lost his wife to cancer and has been taking care of his four young children. Following the death of his wife, the department chair offered him extended time off but he declined. There have been some recent changes noted in this colleague that have been discussed among the resident physicians, such as missed clinic appointments, two intra-operative errors, and the smell of alcohol on his breath on three different occasions. Which of the following is the most appropriate action by the physician regarding her colleague?", "answer": "Inform the local Physician Health Program", "options": {"A": "Contact the colleague's friends and family", "B": "Confront the colleague in private", "C": "Inform the local Physician Health Program", "D": "Inform the colleague's patients about the potential hazard", "E": "Alert the State Licensing Board"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["31 year old physician", "late", "past 2 weeks", "recently lost", "cancer", "four young", "Following", "death", "chair offered", "extended time", "recent changes noted", "resident physicians", "missed clinic appointments", "two intra-operative errors", "smell", "alcohol", "breath", "three different occasions", "following", "most appropriate action", "physician"]}
{"question": "A 58-year-old man presents for a follow-up appointment. He recently was found to have a history of stage 2 chronic kidney disease secondary to benign prostatic hyperplasia leading to urinary tract obstruction. He has no other medical conditions. His father died at age 86 from a stroke, and his mother lives in an assisted living facility. He smokes a pack of cigarettes a day and occasionally drinks alcohol. His vital signs include: blood pressure 130/75 mm Hg, pulse 75/min, respiratory rate 17/min, and temperature 36.5°C (97.7°F). His physical examination is unremarkable. A 24-hour urine specimen reveals the following findings:\nSpecific gravity 1,050\npH 5.6\nNitrites (-)\nGlucose (-)\nProteins 250 mg/24hrs\nWhich of the following should be prescribed to this patient to decrease his cardiovascular risk?", "answer": "Enalapril", "options": {"A": "Ezetimibe", "B": "Enalapril", "C": "Carvedilol", "D": "Aspirin", "E": "Amlodipine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["58 year old man presents", "follow-up appointment", "recently", "found to", "history of", "chronic kidney disease secondary to benign prostatic hyperplasia leading", "urinary tract obstruction", "medical conditions", "died", "age", "stroke", "lives in", "assisted living facility", "smokes", "pack", "cigarettes", "day", "occasionally", "alcohol", "vital signs include", "blood pressure", "75 mm Hg", "pulse 75 min", "respiratory rate", "min", "temperature 36", "97", "unremarkable", "24-hour urine specimen reveals", "following findings", "Specific gravity", "pH", "Glucose", "Proteins", "mg", "following", "patient to decrease", "cardiovascular"]}
{"question": "A 25-year-old man comes to the physician because he and his wife have been unable to conceive despite regular unprotected sex for the past 15 months without using contraception. His wife has been tested and is fertile. The patient began puberty at the age of 14 years. He was treated for Chlamydia trachomatis 6 years ago. He is a professional cyclist and trains every day for 3–4 hours. He feels stressed because of an upcoming race. His blood pressure is 148/92 mm Hg. Physical examination of the husband shows a tall, athletic stature with uniform inflammatory papular eruptions of the face, back, and chest. Genital examination shows small testes. Which of the following is the most likely underlying cause of this patient's infertility?", "answer": "Anabolic steroid use", "options": {"A": "Psychogenic erectile dysfunction", "B": "Kallmann syndrome", "C": "Anabolic steroid use", "D": "Scrotal hyperthermia", "E": "Klinefelter syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "unable to", "regular", "past", "months", "using contraception", "fertile", "patient began puberty", "age", "years", "treated", "Chlamydia trachomatis", "years", "professional", "trains", "day", "hours", "stressed", "race", "blood pressure", "mm Hg", "tall", "stature", "uniform inflammatory papular eruptions", "face", "back", "chest", "Genital", "small testes", "following", "underlying cause", "patient's infertility"]}
{"question": "A 48-year-old male with a history of rhinitis presents to the emergency department with complaints of shortness of breath and wheezing over the past 2 days. He reports bilateral knee pain over the past month for which he recently began taking naproxen 1 week ago. Physical examination is significant for a nasal polyp and disappearance of bilateral radial pulses on deep inspiration. Which of the following is the most likely cause of this patient's physical examination findings?", "answer": "Asthma", "options": {"A": "Pulmonary hypertension", "B": "Interstitial lung fibrosis", "C": "Asthma", "D": "Pulmonary embolism", "E": "Cardiac tamponade"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old male", "history", "rhinitis presents", "emergency department", "complaints of shortness", "breath", "wheezing", "past 2 days", "reports bilateral knee pain", "past month", "recently began", "naproxen", "week", "significant", "nasal polyp", "bilateral radial pulses", "deep inspiration", "following", "most likely cause", "physical", "findings"]}
{"question": "A 58-year-old lifeguard develops squamous cell carcinoma of the skin on his forehead. Which of the following most likely preceded the development of this carcinoma?", "answer": "Dry, scaly, hyperkeratotic papule", "options": {"A": "Hamartomatous lesion of sebaceous glands", "B": "Dry, scaly, hyperkeratotic papule", "C": "A single, large pink patch", "D": "Dermatophyte infection", "E": "UVC exposure"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old lifeguard", "squamous cell carcinoma of the skin", "forehead", "following most likely preceded", "development", "carcinoma"]}
{"question": "A 29-year-old man is brought to the emergency department by his wife due to unusual behavior for the past week. She has noted several incidents when he spoke to her so fast that she could not understand what he was saying. She also says that one evening, he drove home naked after a night where he said he was ‘painting the town red’. She also says he has also been sleeping for about 2 hours a night and has barely had any sleep in the past 2 weeks. She says that he goes ‘to work’ in the morning every day, but she suspects that he has been doing other things. She denies any knowledge of similar symptoms in the past. On physical examination, the patient appears agitated and is pacing the exam room. He compliments the cleanliness of the floors, recommends the hospital change to the metric system, and asks if anyone else can hear ‘that ringing’. Laboratory results are unremarkable. The patient denies any suicidal or homicidal ideations. Which of the following is the most likely diagnosis in this patient?", "answer": "Bipolar disorder, type I", "options": {"A": "Major depressive disorder", "B": "Brief psychotic disorder", "C": "Schizoaffective disorder", "D": "Bipolar disorder, type I", "E": "Bipolar disorder, type II"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["29 year old man", "brought", "emergency department", "due to unusual behavior", "past week", "noted", "spoke", "fast", "not", "one evening", "home naked", "night", "painting", "town red", "sleeping", "hours", "night", "sleep", "past 2 weeks", "to", "morning", "day", "similar symptoms", "past", "patient appears agitated", "exam room", "cleanliness", "floors", "hospital change", "metric system", "else", "hear", "ringing", "Laboratory results", "unremarkable", "patient", "suicidal", "homicidal ideations", "following", "diagnosis", "patient"]}
{"question": "A 65-year-old man presents with a small painless ulcer with a raised border on his right forearm which has persisted for the last 3 weeks. His past history is significant for 3 occurrences of basal cell carcinoma on different areas of the body during the last 4 years, which have all been surgically excised. The morphology of the present lesion is also highly suggestive of basal cell carcinoma. The patient says that, if the lesion is a basal cell carcinoma, he does not want to undergo biopsy and surgery if it can be avoided. The patient is prescribed a cream, which is FDA-approved for the treatment of small superficial basal cell carcinomas in low-risk areas. The cream contains a chemotherapeutic agent, which is an antimetabolite and an S-phase-specific anticancer drug. Which of the following best explains the mechanism of action of this cream?", "answer": "Inhibition of thymidylate synthase", "options": {"A": "Inhibition of ribonucleotide reductase", "B": "Inhibition of DNA repair", "C": "Inhibition of thymidylate synthase", "D": "Inhibition of dihydrofolate reductase", "E": "Inhibition of de novo purine nucleotide synthesis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old man presents", "small painless ulcer", "raised border", "right forearm", "weeks", "past history", "significant", "occurrences", "basal cell carcinoma", "different areas", "body", "last", "years", "surgically", "morphology", "present lesion", "highly suggestive of basal cell carcinoma", "patient", "lesion", "basal cell carcinoma", "not", "to", "biopsy", "surgery", "patient", "cream", "approved", "treatment", "small superficial basal cell carcinomas", "low-risk areas", "cream contains", "chemotherapeutic agent", "antimetabolite", "an", "phase specific", "following best", "mechanism of action", "cream"]}
{"question": "A 29-year-old woman presents for a follow-up visit after an emergency appendectomy. The laparoscopic procedure went well with no complications. Physical examination reveals the surgical site is slightly tender but is healing appropriately. She is delighted that the operation went well and offers you a cake and VIP tickets to a musical concert. Which of the following is the most appropriate response?", "answer": "\"Thank you, but I cannot accept the tickets you offered. Accepting such a generous gift is against our policy. However, I will gladly accept your cake and distribute it among the staff.\"", "options": {"A": "\"Thank you, I will enjoy these gifts immensely.\"", "B": "\"No, I cannot accept these gifts, please take them with you as you leave.\"", "C": "\"May I pay you for them?\"", "D": "\"Thank you, but I cannot accept the tickets you offered. Accepting such a generous gift is against our policy. However, I will gladly accept your cake and distribute it among the staff.\"", "E": "\"Can you get another ticket for my friend?\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "emergency appendectomy", "laparoscopic procedure", "well", "complications", "reveals", "surgical site", "slightly tender", "healing", "operation", "well", "VIP", "musical", "following", "most appropriate response"]}
{"question": "A 62-year-old man presents to the emergency department with increased fatigue and changes in his vision. The patient states that for the past month he has felt abnormally tired, and today he noticed his vision was blurry. The patient also endorses increased sweating at night and new onset headaches. He states that he currently feels dizzy. The patient has a past medical history of diabetes and hypertension. His current medications include insulin, metformin, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy. Abdominal exam reveals splenomegaly and hepatomegaly. There are large, non-tender palpable lymph nodes in the patient's inguinal region. Neurological exam is notable for decreased sensation in the patients hands and feet. He also complains of a numb/tingling pain in his extremities that has been persistent during this time. Dermatologic exam is notable for multiple bruises on his upper and lower extremities. Which of the following is most likely to be abnormal in this patient?", "answer": "IgM", "options": {"A": "Calcium", "B": "IgA and IgG", "C": "IgM", "D": "Natural killer cells", "E": "T-cells"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["62 year old man presents", "emergency department", "increased fatigue", "changes", "vision", "patient states", "past month", "tired", "today", "vision", "blurry", "patient", "increased", "night", "new onset headaches", "states", "currently", "dizzy", "patient", "past medical diabetes", "hypertension", "current medications include insulin", "metformin", "lisinopril", "temperature", "99", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room", "Cardiopulmonary exam", "normal limits", "HEENT exam reveals non-tender posterior", "anterior chain lymphadenopathy", "Abdominal exam reveals splenomegaly", "hepatomegaly", "large", "non tender palpable lymph nodes", "patient's inguinal region", "Neurological exam", "notable", "decreased sensation", "patients hands", "feet", "numb tingling pain", "extremities", "persistent", "time", "Dermatologic exam", "notable", "multiple bruises", "upper", "lower extremities", "following", "to", "abnormal", "patient"]}
{"question": "A 42-year-old man presents to his primary care provider for a follow-up appointment after a new diagnosis of hypertension follow-up. The doctor mentions that a recent study where the effect of a healthy lifestyle education program on blood pressure was studied in 2 matched rural communities. One community received health education program and the other did not. What is the type of study most likely being described here?", "answer": "Community trial", "options": {"A": "Crossover study", "B": "Case-control trial", "C": "Explanatory study", "D": "Community trial", "E": "Cross-sectional study"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care provider", "follow-up appointment", "new diagnosis", "hypertension follow-up", "doctor", "recent study", "effect", "blood pressure", "studied", "matched", "One", "received", "education program", "not", "likely"]}
{"question": "A 50-year-old female radiologist who is interviewing for a night shift position states that she was fired from her past 3 previous positions because she had difficulty working with others. She states that she is perfect for this job however, as she likes to work on her own and be left alone. She emphasizes that she does not have any distractions or meaningful relationships, and therefore she is always punctual and never calls in sick. She is not an emotional individual. Which of the following personality disorders best fits this female?", "answer": "Schizoid", "options": {"A": "Schizotypal", "B": "Schizoid", "C": "Antisocial", "D": "Borderline", "E": "Obsessive-compulsive disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old female radiologist", "night shift position states", "fired", "past", "previous positions", "difficulty", "others", "states", "to", "left alone", "not", "distractions", "relationships", "always", "never calls", "sick", "not", "emotional", "following personality disorders best fits", "female"]}
{"question": "A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the temporal artery reveals arteritis. Five months later, the patient returns to her physician with a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and combing her hair. The patient states that this weakness has worsened gradually over the last 2 months. She reports that her headaches, jaw pain, and visual disturbances have resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and creatine kinase levels within normal limits. Which of the following is the most likely diagnosis in this patient's current presentation?", "answer": "Drug-induced myopathy", "options": {"A": "Mononeuritis multiplex", "B": "Polymyalgia rheumatica", "C": "Drug-induced myopathy", "D": "Polymyositis", "E": "Dermatomyositis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old female presents", "primary care physician", "headaches", "left temple", "scalp area", "neck stiffness", "occasional blurred vision", "pain in", "jaw", "chewing", "appropriate medical therapy", "initiated", "subsequent biopsy of the temporal artery reveals arteritis", "Five months later", "returns", "complaint", "weakness", "leading", "difficulty climbing stairs", "combing", "hair", "patient states", "weakness", "worsened", "months", "reports", "headaches", "jaw pain", "visual disturbances", "resolved", "significant", "strength", "hip flexion/extension", "shoulder flexion/extension abduction", "Initial laboratory work-up reveals ESR", "creatine kinase levels", "normal limits", "following", "diagnosis", "patient's current"]}
{"question": "A 67-year-old man presents to the office complaining of abdominal pain. He was started on a trial of proton pump inhibitors 5 weeks ago but the pain has not improved. He describes the pain as dull, cramping, and worse during meals. Medical history is unremarkable. Physical examination is normal except for tenderness in the epigastric region. Endoscopy reveals an eroding gastric ulcer in the proximal part of the greater curvature of the stomach overlying a large pulsing artery. Which of the following arteries is most likely visible?", "answer": "Left gastro-omental artery", "options": {"A": "Common hepatic artery", "B": "Left gastric artery", "C": "Right gastro-omental artery", "D": "Left gastro-omental artery", "E": "Cystic artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["67 year old man presents", "office", "abdominal pain", "started", "proton pump inhibitors", "weeks", "pain", "not improved", "pain", "dull", "cramping", "worse", "meals", "Medical history", "unremarkable", "Physical examination", "normal", "tenderness", "epigastric region", "Endoscopy reveals", "eroding gastric ulcer", "the proximal part of", "greater curvature", "stomach", "large pulsing artery", "following arteries", "visible"]}
{"question": "A mother brings her 2-year-old son to the pediatrician following an episode of abdominal pain and bloody stool. The child has otherwise been healthy and growing normally. On physical exam, the patient is irritable with guarding of the right lower quadrant of the abdomen. Based on clinical suspicion, pertechnetate scintigraphy demonstrates increased uptake in the right lower abdomen. Which of the following embryologic structures is associated with this patient’s condition?", "answer": "Vitelline duct", "options": {"A": "Metanephric mesenchyme", "B": "Ductus arteriosus", "C": "Vitelline duct", "D": "Paramesonephric duct", "E": "Allantois"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["her 2 year old", "pediatrician following", "episode of abdominal pain", "bloody stool", "child", "healthy", "patient", "irritable", "guarding of", "right lower quadrant", "abdomen", "Based", "clinical", "pertechnetate scintigraphy", "increased uptake", "right lower abdomen", "following embryologic structures", "associated with", "patients condition"]}
{"question": "A 59-year-old patient comes to the emergency department accompanied by his wife because of severe right leg pain and numbness. His condition suddenly started an hour ago. His wife says that he has a heart rhythm problem for which he takes a blood thinner, but he is not compliant with his medications. He has smoked 10–15 cigarettes daily for the past 15 years. His temperature is 36.9°C (98.42°F), blood pressure is 140/90 mm Hg, and pulse is 85/min and irregular. On physical examination, the patient is anxious and his right leg is cool and pale. Palpation of the popliteal fossa shows a weaker popliteal pulse on the right side compared to the left side. Which of the following is the best initial step in the management of this patient's condition?", "answer": "Urgent assessment for amputation or revascularization", "options": {"A": "Cilostazol", "B": "Decompressive laminectomy", "C": "Urgent assessment for amputation or revascularization", "D": "Oral acetaminophen and topical capsaicin", "E": "Arthroscopic synovectomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old patient", "emergency department", "severe right leg pain", "numbness", "condition", "started", "hour", "heart problem", "blood thinner", "not compliant", "medications", "smoked", "cigarettes daily", "past", "years", "temperature", "36", "98", "blood pressure", "90 mm Hg", "pulse", "85 min", "irregular", "patient", "anxious", "right leg", "cool", "pale", "Palpation", "popliteal fossa", "weaker popliteal pulse", "right side", "left side", "following", "best initial step", "management", "patient's"]}
{"question": "A 12-year-old girl is brought to the pediatrician by her father who is concerned about the child’s ability to sit in a moving vehicle. She frequently develops nausea and dizziness when riding in a car for more than 10 minutes. The child has vomited twice over the past month while riding in the car. Her symptoms are significantly impairing her ability to make it to school on time without having to stop and get out of the car. The child does well in school and has several close friends. On examination, the child is well-appearing and appropriately interactive. Dix-Hallpike maneuver is negative. Her gait is normal. Strength and range of motion are full and symmetric bilaterally in the upper and lower extremities. The father would like to know if there is anything his daughter can take to be able to sit in a moving vehicle without feeling ill. A medication with which of the following mechanisms of action is indicated to manage this patient’s symptoms?", "answer": "Muscarinic acetylcholine receptor antagonist", "options": {"A": "Alpha-2 adrenergic receptor agonist", "B": "Beta-1 adrenergic receptor agonist", "C": "Muscarinic acetylcholine receptor agonist", "D": "Muscarinic acetylcholine receptor antagonist", "E": "Nicotinic acetylcholine receptor agonist"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "pediatrician", "childs ability to sit", "moving vehicle", "frequently", "nausea", "dizziness", "more", "10 minutes", "child", "vomited twice", "past month", "symptoms", "impairing", "ability to make", "school on time", "to stop", "get out", "car", "child", "well", "school", "several", "child", "well appearing", "interactive", "Dix-Hallpike maneuver", "negative", "gait", "normal", "Strength", "range of motion", "full", "symmetric", "upper", "lower extremities", "to", "to", "able to sit", "moving vehicle", "ill", "medication", "of", "following mechanisms", "action", "indicated to", "patients symptoms"]}
{"question": "A 28-year-old female suffering from a urinary tract infection is given trimethoprim-sulfamethoxazole (TMP-SMX) by her physician. Several days later, she begins to experience itchiness and joint pain. Laboratory and histologic analysis reveals vasculitis and antibody complexes deposited near the basement membrane of the glomerulus. What other serological finding is expected with this presentation?", "answer": "Lowered serum levels of complement protein C3", "options": {"A": "Decreased levels of IgE", "B": "Increased levels of IgE", "C": "Decreased neutrophil count", "D": "Increased serum levels of complement protein C3", "E": "Lowered serum levels of complement protein C3"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female suffering", "urinary tract", "given trimethoprim-sulfamethoxazole", "physician", "days later", "begins to", "itchiness", "joint pain", "Laboratory", "histologic analysis reveals vasculitis", "antibody complexes deposited", "basement membrane", "glomerulus", "serological finding"]}
{"question": "A 27-year-old woman presents to your office complaining of difficulty swallowing, and she describes that \"there is something in the back of her throat\". Furthermore, she also feels an \"achy\" chest pain that has been getting progressively worse over the last few weeks. She denies having any fever, shortness of breath, cough, abdominal pain, heartburn, nausea, or vomiting. The patient has a history of wrist fracture as a child, migraines, and a recent diagnosis of myasthenia gravis. Which of the following is the most likely diagnosis?", "answer": "Benign tumor of the thymus", "options": {"A": "Benign tumor of the thymus", "B": "Superior vena cava syndrome", "C": "Anaplastic thyroid cancer", "D": "Mediastinitis", "E": "Thyroglossal duct cyst"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old woman presents", "office", "difficulty swallowing", "back of", "throat", "achy", "chest pain", "getting", "worse", "weeks", "fever", "shortness of breath", "cough", "abdominal pain", "heartburn", "nausea", "vomiting", "patient", "history fracture", "child", "migraines", "recent diagnosis", "myasthenia gravis", "following", "diagnosis"]}
{"question": "A 34-year-old woman comes to the physician for a follow-up appointment because of a blood pressure of 148/98 mm Hg at her last health maintenance examination four weeks ago. She feels well. She has a 20-year history of migraine with aura of moderate to severe intensity. For the past year, the headaches have been occurring 1–2 times per week. Her only medication is sumatriptan. She runs two to three times a week and does yoga once a week. She is sexually active with her husband and uses condoms inconsistently. Her father has type 2 diabetes mellitus and hypertension. Her temperature is 37.2°C (99.0°F), pulse is 76/min, respirations are 12/min, and blood pressure is 143/92 mm Hg. A repeat sitting blood pressure 20 minutes later is 145/94 mm Hg. Physical examination is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Propranolol", "options": {"A": "Hydrochlorothiazide", "B": "Lisinopril", "C": "Propranolol", "D": "Losartan", "E": "Prazosin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "follow-up appointment", "blood pressure", "98 mm Hg", "last", "four weeks", "well", "20 year history of migraine", "aura", "moderate", "severe intensity", "past year", "headaches", "occurring", "times", "week", "only medication", "sumatriptan", "runs two", "three times", "week", "yoga", "week", "sexually active", "uses condoms", "type 2 diabetes mellitus", "hypertension", "temperature", "99", "pulse", "76 min", "respirations", "min", "blood pressure", "mm Hg", "repeat sitting blood pressure 20 minutes later", "mm Hg", "unremarkable", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A mother brings her 25-month-old son to the pediatrician’s office for a well child visit. She reports he had an ear infection 3 months ago for which he took a short course of antibiotics but has otherwise been well. He is now in daycare where he likes to play with the other children. She says he can stack multiple cubes and enjoys playing with objects. He goes outside frequently to play with a ball and is able to kick it. While talking to the mother, the patient and his sister draw on paper quietly side by side. His mother says he knows about 200 words and he frequently likes to use “I” sentences, like “I read” and “I drink”. His mother does complain that he throws more tantrums than he used to and she has found it harder to get him to follow instructions, although he appears to understand them. Which of the following milestones is delayed in this child?", "answer": "None", "options": {"A": "Gross motor", "B": "Fine motor", "C": "Language", "D": "Social development", "E": "None"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["month old", "pediatricians office", "reports", "ear 3 months", "short course", "well", "now", "daycare", "to play", "children", "stack multiple cubes", "playing", "outside frequently to play", "ball", "able to", "talking", "patient", "paper", "side", "200", "frequently", "to use I", "I", "I", "throws more tantrums", "used", "found", "harder to", "to follow instructions", "appears to", "following", "delayed", "child"]}
{"question": "A 68-year-old man is brought to the emergency department 25 minutes after he was found shaking violently on the bathroom floor. His wife reports that he has become increasingly confused over the past 2 days and that he has been sleeping more than usual. He was started on chemotherapy 4 months ago for chronic lymphocytic leukemia. He is confused and oriented to person only. Neurological examination shows right-sided ptosis and diffuse hyperreflexia. An MRI of the brain shows disseminated, nonenhancing white matter lesions with no mass effect. A polymerase chain reaction assay of the cerebrospinal fluid confirms infection with a virus that has double-stranded, circular DNA. An antineoplastic drug with which of the following mechanisms of action is most likely responsible for this patient's current condition?", "answer": "Monoclonal antibody against CD20+", "options": {"A": "Free radical formation", "B": "Tyrosine kinase inhibitor", "C": "Topoisomerase II inhibitor", "D": "Monoclonal antibody against EGFR", "E": "Monoclonal antibody against CD20+"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "brought", "emergency department", "minutes", "found shaking", "bathroom floor", "reports", "confused", "past 2 days", "sleeping more", "usual", "started", "chemotherapy", "months", "chronic lymphocytic leukemia", "confused", "oriented to person only", "Neurological examination", "right-sided ptosis", "diffuse hyperreflexia", "MRI of", "brain", "disseminated", "nonenhancing white matter lesions", "mass effect", "polymerase chain reaction assay", "cerebrospinal fluid confirms infection", "virus", "double-stranded", "circular DNA", "antineoplastic drug", "of", "following mechanisms", "action", "responsible", "patient's current condition"]}
{"question": "A 29-year-old woman presents to her primary care provider complaining of lower back pain. She reports a 3 day history of extreme right lower back pain. She also reports mild dysuria. Her past medical history is notable for recurrent urinary tract infections leading to 3 emergency room visits over the past year. Her family history is notable for renal cell carcinoma in her paternal grandfather and diabetes in her father. Her temperature is 99.5°F (37.5°C), blood pressure is 125/75 mmHg, pulse is 82/min, and respirations are 18/min. On exam, she has mild right costovertebral angle tenderness. Radiography demonstrates a vague radiopaque structure in the right lower abdomen. Results of a urinalysis are shown below:\n\nAppearance: Hazy, yellow\nProtein: Negative\nSpecific gravity: 1.029\nWBC: 2+\nCasts: None\nBacteria: None\npH: 8.9\nBlood: Negative\nBilirubin: Negative\nUrobilinogen: < 2.0\n\nA urine culture is pending. Which of the following pathogens is most likely responsible for this patient’s condition?", "answer": "Proteus mirabilis", "options": {"A": "Escherichia coli", "B": "Enterococcus", "C": "Citrobacter freundii", "D": "Proteus mirabilis", "E": "Staphylococcus epidermidis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "primary care provider complaining of lower back pain", "reports", "3 day history of extreme right lower back pain", "reports mild dysuria", "past medical history", "notable", "recurrent urinary tract infections leading", "emergency room", "past year", "family history", "notable", "renal cell carcinoma", "diabetes", "temperature", "99", "blood pressure", "75 mmHg", "pulse", "min", "respirations", "min", "exam", "mild right costovertebral angle tenderness", "Radiography", "vague radiopaque structure", "right lower abdomen", "Results", "urinalysis", "Appearance", "yellow Protein", "Negative Specific gravity", "1", "WBC", "2", "Casts", "Bacteria", "pH", "Blood", "Negative Bilirubin", "Negative Urobilinogen", "2 0", "urine culture", "following", "responsible", "patients condition"]}
{"question": "An 8-month-old boy is brought to the emergency room by his mother who notes that the child has not been passing stool regularly. Palpation and radiographic imaging of the umbilical region reveal the presence of fecal material in an abnormal out-pocketing of bowel. Which of the following is a common complication seen in this condition?", "answer": "Ulceration", "options": {"A": "Enlarged rugal folds", "B": "Dysplasia", "C": "Ulceration", "D": "Megacolon", "E": "Paneth cell metaplasia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "emergency room", "notes", "child", "not", "passing stool", "Palpation", "imaging", "umbilical region reveal", "presence", "fecal", "abnormal out", "bowel", "following", "common complication seen", "condition"]}
{"question": "A 69-year-old woman is brought to the clinic for difficulty breathing over the past 2 months. She denies any clear precipitating factor but reports that her breathing has become progressively labored and she feels like she can’t breathe. Her past medical history is significant for heart failure, diabetes mellitus, and hypertension. Her medications include lisinopril, metoprolol, and metformin. She is allergic to sulfa drugs and peanuts. A physical examination demonstrates bilateral rales at the lung bases, pitting edema of the lower extremities, and a laterally displaced point of maximal impulse (PMI). She is subsequently given a medication that will reduce her volume status by competitively binding to aldosterone receptors. What is the most likely drug prescribed to this patient?", "answer": "Spironolactone", "options": {"A": "Amiloride", "B": "Atorvastatin", "C": "Furosemide", "D": "Hydrochlorothiazide", "E": "Spironolactone"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["69 year old woman", "brought", "clinic", "difficulty breathing", "past", "months", "clear precipitating factor", "reports", "breathing", "labored", "cant", "past medical history", "significant", "heart failure", "diabetes mellitus", "hypertension", "medications include lisinopril", "metoprolol", "metformin", "allergic", "sulfa drugs", "bilateral rales", "lung bases", "pitting edema", "lower extremities", "a", "displaced point", "maximal impulse", "given", "medication", "volume status", "drug", "patient"]}
{"question": "An 80-year-old woman presents with general malaise and low-grade fever. Physical examination reveals several retinal hemorrhages with pale centers, erythematous nodules on palms that are not painful, and splinter hemorrhages under her fingernails. Echocardiogram shows vegetations on the mitral valve. Blood culture indicates gram-positive bacteria which are catalase negative and able to grow in 40% bile; however, not in 6.5% NaCl. In addition to endocarditis, the doctor is concerned that the patient may also be suffering from which of the following medical conditions?", "answer": "Colon cancer", "options": {"A": "Subacute sclerosing panencephalitis", "B": "Sickle cell disease", "C": "Dental caries", "D": "HIV/AIDS", "E": "Colon cancer"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["80 year old woman presents", "general malaise", "low-grade fever", "reveals several retinal hemorrhages", "pale centers", "erythematous nodules", "not painful", "splinter hemorrhages", "fingernails", "Echocardiogram", "vegetations", "mitral valve", "Blood culture", "catalase negative", "able to", "40", "bile", "not", "NaCl", "endocarditis", "doctor", "patient", "suffering", "following medical conditions"]}
{"question": "A 63-year-old man presents to the physician with fever for 5 days. He has had increasing fatigue and dyspnea for the past 2 months. During this time, he has lost 3 kg (6.6 lb). He received outpatient treatment for pneumonia last month. He had urinary tract infection 2 weeks ago. He takes no other medications other than daily low dose aspirin and recent oral antibiotics. He does not smoke or drink alcohol. The vital signs include: temperature 38.5°C (101.3°F), pulse 93/min, respiration rate 18/min, and blood pressure 110/65 mm Hg. On physical examination, he has petechiae distally on the lower extremities and several purpura on the trunk and extremities. Several enlarged lymph nodes are detected in the axillary and cervical regions on both sides. The examination of the lungs, heart, and abdomen shows no abnormalities. The laboratory test results are as follows:\nHemoglobin 10 g/dL\nMean corpuscular volume 90 μm3\nLeukocyte count 18,000/mm3\nPlatelet count 40,000/mm3\nA Giemsa-stained peripheral blood smear is shown by the image. Which of the following is the most likely diagnosis?", "answer": "Acute myeloblastic leukemia", "options": {"A": "Acute myeloblastic leukemia", "B": "Burkitt lymphoma", "C": "Hairy cell leukemia", "D": "Hodgkin’s lymphoma", "E": "MALT lymphoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man presents", "physician", "fever", "5 days", "increasing fatigue", "dyspnea", "past", "months", "time", "lost 3 kg", "6.6", "received", "pneumonia", "month", "urinary tract infection", "weeks", "medications", "daily low dose aspirin", "recent oral", "not smoke", "vital signs include", "temperature", "pulse", "min", "respiration rate", "min", "blood pressure", "65 mm Hg", "petechiae", "lower extremities", "several purpura", "trunk", "extremities", "Several enlarged lymph nodes", "detected", "axillary", "cervical regions", "sides", "lungs", "heart", "abdomen", "abnormalities", "laboratory test results", "follows", "Hemoglobin", "g/dL Mean corpuscular volume 90 m3 Leukocyte count 18", "mm3 Platelet count 40", "Giemsa-stained peripheral blood smear", "following", "diagnosis"]}
{"question": "A 9-year-old girl is brought to her pediatrician by her mother for the evaluation of recent-onset seizures. She has had 2 episodes of generalized tonic-clonic seizures in the past 3 days. Each episode lasted for 1–2 minutes and aborted spontaneously. There is no history of fever, headache, altered behavior, diarrhea, vomiting, or previous seizure episodes. Past medical history is unremarkable. Physical examination reveals: blood pressure 102/64 mm Hg, heart rate 89/min, respiratory rate 16/min, and temperature 37.0°C (98.6°F). She looks anxious but oriented to time and space. Multiple flat hyperpigmented spots are present over her body, each more than 5 mm in diameter. Axillary freckling is present. Cranial nerves are intact. Muscle strength is normal in all 4 limbs with a normal sensory examination. Gait is normal. An eye examination is shown in the exhibit. What is the most likely diagnosis?", "answer": "Von Recklinghausen disease", "options": {"A": "Neurofibromatosis type 2", "B": "Sturge-Weber disease", "C": "Tuberous sclerosis", "D": "Von Recklinghausen disease", "E": "Wilson disease"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "pediatrician", "mother", "recent onset seizures", "2 episodes of generalized tonic-clonic seizures", "past", "days", "episode lasted", "minutes", "aborted", "history", "fever", "headache", "diarrhea", "vomiting", "previous seizure episodes", "Past medical history", "unremarkable", "reveals", "blood pressure", "64 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "looks anxious", "oriented to time", "space", "Multiple flat hyperpigmented", "present", "body", "more", "mm", "diameter", "Axillary freckling", "present", "Cranial nerves", "intact", "Muscle strength", "normal", "limbs", "normal sensory", "Gait", "normal", "eye examination", "diagnosis"]}
{"question": "A 7-year-old boy is brought to the emergency department by his parents. They state that he has had trouble walking the past day and this morning refuses to walk at all. The child has a past medical history of asthma, which is treated with albuterol. His temperature is 102°F (38.9°C), blood pressure is 77/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. Laboratory tests are drawn and shown below.\n\nHemoglobin: 10 g/dL\nHematocrit: 36%\nLeukocyte count: 13,500/mm^3 with normal differential\nPlatelet count: 197,000/mm^3\n\nAn MRI of the the thigh and knee is performed and demonstrates edema and cortical destruction of the distal femur. Which of the following is the most likely infectious agent in this patient?", "answer": "Staphylococcus aureus", "options": {"A": "Bacteroides species", "B": "Pseudomonas aeruginosa", "C": "Salmonella species", "D": "Staphylococcus aureus", "E": "Staphylococcus epidermidis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "state", "past day", "morning", "to", "child", "past medical", "treated with albuterol", "temperature", "blood pressure", "48 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory tests", "Hemoglobin", "10 g/dL Hematocrit", "36", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "MRI", "thigh", "knee", "performed", "edema", "cortical destruction", "distal femur", "following", "patient"]}
{"question": "A 24-year-old man presents to his family practitioner for routine follow-up of asthma. He is currently on albuterol, corticosteroids, and salmeterol, all via inhalation. The patient is compliant with his medications, but he still complains of episodic shortness of breath and wheezing. The peak expiratory flow (PEF) has improved since the last visit, but it is still less than the ideal predicted values based on age, gender, and height. Montelukast is added to his treatment regimen. What is the mechanism of action of this drug?", "answer": "Montelukast blocks receptors of some arachidonic acid metabolites.", "options": {"A": "Montelukast inhibits the release of inflammatory substances from mast cells.", "B": "Montelukast binds to IgE.", "C": "Montelukast activates adrenal receptors on the bronchial smooth muscles.", "D": "Montelukast blocks receptors of some arachidonic acid metabolites.", "E": "Montelukast inhibits lipoxygenase, thus decreasing the production of inflammatory leukotrienes."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "practitioner", "routine follow-up", "asthma", "currently", "albuterol", "corticosteroids", "salmeterol", "inhalation", "patient", "compliant", "medications", "of episodic shortness", "breath", "wheezing", "peak expiratory flow", "improved", "last", "ideal predicted values based", "age", "gender", "height", "Montelukast", "added", "treatment regimen", "mechanism of action", "drug"]}
{"question": "A 25-year-old medical student is doing an international health elective in the Amazon River basin studying tropical disease epidemiology. As part of his pre-trip preparation, he wants to be protected from malaria and is researching options for prophylaxis. Which of the following agents should be avoided for malarial prophylaxis in this patient?", "answer": "Chloroquine", "options": {"A": "Chloroquine", "B": "Mefloquine", "C": "Atovaquone-proguanil", "D": "Doxycycline", "E": "Quinine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old medical student", "elective", "basin studying tropical disease epidemiology", "part of", "pre trip preparation", "to", "malaria", "options", "prophylaxis", "following agents", "malarial prophylaxis", "patient"]}
{"question": "A 32-year-old woman presents complaining of nightmares. She reports that these “nightmares” happen when she is asleep and also sometimes when she is awake, but she cannot come up with another description for them. The episodes have been happening for at least 3 weeks now. She states that when it happens she feels “outside of her body,” like she’s “watching myself.” She also reports some chronic fatigue. The patient denies headaches, vision changes, dizziness, or loss in sensation or motor function. She has no notable medical or surgical history. She takes a multivitamin every day. She smokes 1 pack of cigarettes a day but denies alcohol or illicit drug use. The patient appears slightly anxious but is in no acute distress. A physical and neurological exam is normal. She denies suicidal or homicidal ideation. Which of the following is the most likely diagnosis for the patient’s symptoms?", "answer": "Depersonalization disorder", "options": {"A": "Brief psychotic disorder", "B": "Delusional disorder", "C": "Depersonalization disorder", "D": "Dissociative fugue disorder", "E": "Dissociative identity disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents complaining of nightmares", "reports", "nightmares", "asleep", "sometimes", "awake", "episodes", "weeks now", "states", "outside", "body", "shes", "reports", "chronic fatigue", "patient", "headaches", "vision changes", "dizziness", "loss", "sensation", "notable medical", "surgical history", "multivitamin", "day", "smokes 1 pack", "cigarettes", "day", "alcohol", "illicit drug use", "patient appears slightly anxious", "acute distress", "physical", "neurological exam", "normal", "suicidal", "homicidal ideation", "following", "diagnosis", "patients symptoms"]}
{"question": "A 38-year-old woman comes to the physician for a 6-week history of sleeping difficulties because she thinks that someone is watching her through security cameras. Her anxiety started 6 weeks ago when a security camera was installed outside her house by the police. Ever since, she has felt that she is being monitored by security cameras throughout the city. She avoids going outside whenever possible and refuses to take the subway. Whenever she needs to leave the house she wears large hats or hooded sweaters so that she cannot be recognized by the cameras. As soon as she arrives at her office or at home she feels safer. She was recently promoted to the team manager of a small advertising agency. She takes no medications. On mental status examination, she is alert, oriented, and shows normal range of affect. Urine toxicology screening is negative. The patient's symptoms are best described as which of the following?", "answer": "Delusions", "options": {"A": "Agoraphobia", "B": "Delusions", "C": "Derealization", "D": "Disorganized thoughts", "E": "Hallucinations"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "week history", "sleeping difficulties", "cameras", "anxiety started", "weeks", "camera", "outside", "house", "police", "Ever", "monitored", "cameras", "city", "outside", "possible", "to", "subway", "needs to", "house", "large hats", "hooded sweaters so", "cameras", "office", "at home", "recently", "manager", "small", "medications", "mental status", "alert", "oriented", "normal range", "Urine toxicology", "negative", "patient's symptoms", "best"]}
{"question": "A 49-year-old man with alcohol use disorder is brought to the emergency department immediately after two episodes of coffee-ground emesis. His pulse is 116/min and blood pressure is 92/54 mm Hg. Physical examination shows a distended abdomen with shifting dullness. Skin examination shows jaundice, erythematous palms, and dilated veins in the anterior abdominal wall. After fluid resuscitation, he is given a drug that decreases portal venous pressure. The drug works by inhibiting the secretion of splanchnic vasodilatory hormones as well as blocking glucagon and insulin release. This drug is a synthetic analog of a substance normally produced in which of the following cells?", "answer": "D cells", "options": {"A": "S cells", "B": "G cells", "C": "K cells", "D": "D cells", "E": "I cells\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "alcohol use disorder", "brought", "emergency department immediately", "two episodes of coffee-ground emesis", "pulse", "min", "blood pressure", "54 mm Hg", "distended abdomen", "shifting dullness", "Skin examination", "jaundice", "erythematous", "dilated veins", "anterior abdominal wall", "fluid resuscitation", "given", "drug", "decreases portal venous pressure", "drug", "secretion", "hormones", "blocking glucagon", "insulin release", "drug", "following cells"]}
{"question": "A 19-year-old college student is brought to the emergency department by his roommates after being found unconscious on their dorm room floor. His temperature is 102.0°F (38.9°C) and blood pressure is 85/64 mmHg. On physical examination, he has multiple rose-colored spots on the skin covering his abdomen and lower limbs. Lab tests reveal hyperkalemia and an arterial blood gas test that reads pH: 7.04, pCO2: 30.1 mmHg, pO2: 23.4 mmHg. What is the most likely diagnosis for this patient’s condition?", "answer": "Waterhouse-Friderichsen syndrome", "options": {"A": "Addison disease", "B": "Dengue hemorrhagic fever", "C": "Diabetic ketoacidosis", "D": "Typhoid fever", "E": "Waterhouse-Friderichsen syndrome"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "brought", "emergency department", "found unconscious on", "room floor", "temperature", "blood pressure", "85 64 mmHg", "multiple rose colored spots on", "skin covering", "abdomen", "lower limbs", "Lab tests reveal hyperkalemia", "arterial blood gas test", "pH", "pCO2", "30", "mmHg", "pO2", "23.4 mmHg", "diagnosis", "patients condition"]}
{"question": "A 39-year-old man with a history of major depression is brought into the emergency department by his concerned daughter. She reports that he was recently let go from work because of his sudden and erratic behavior at work. He was noted to be making inappropriate sexual advances to his female co-workers which is very out of his character. He seemed to be full of energy, running on little to no sleep, trying to fix all the companies problems and at times arguing with some of the senior managers. During admission, he was uninterpretable as he boasted about how he was right and that the managers were fools for not listening to his great ideas. What treatment options are available for this patient?", "answer": "Mood stabilizers, antipsychotics, benzodiazepines, ECT", "options": {"A": "Mood stabilizers, antipsychotics, benzodiazepines, ECT", "B": "Mood stabilizers, antipsychotics", "C": "Antipsychotics", "D": "Benzodiazepines", "E": "ECT"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "history of major depression", "brought", "emergency department", "reports", "recently let go", "sudden", "behavior", "noted to", "making inappropriate", "advances", "female co", "very out", "character", "to", "full of energy", "little", "sleep", "companies", "times", "managers", "uninterpretable", "about", "right", "managers", "not listening", "great", "treatment options", "available", "patient"]}
{"question": "A 24-year-old woman, gravida 2, para 1, at 33 weeks’ gestation, is admitted to the hospital for treatment of preterm labor. She has no history of serious illness and her only medication is a multivitamin. Her temperature is 37.2°C (99.0°F), pulse is 100/min, respirations are 20/min, and blood pressure is 100/75 mm Hg. Therapy with nifedipine and betamethasone is begun. The patient continues to have contractions; nifedipine is discontinued and treatment with high-dose terbutaline is initiated. Her contractions resolve. Three hours later, the patient reports fatigue and weakness. Neurologic examination shows proximal muscle weakness of the lower extremities. Deep tendon reflexes are 1+ bilaterally. Which of the following is most likely to confirm the diagnosis?", "answer": "Serum electrolytes", "options": {"A": "Serum electrolytes", "B": "Complete blood count", "C": "Serologic antibody testing", "D": "Amniotic fluid culture", "E": "Thyroid function tests"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks gestation", "treatment", "preterm labor", "history", "serious illness", "only medication", "multivitamin", "temperature", "99", "pulse", "100 min", "respirations", "20 min", "blood pressure", "100 75 mm Hg", "Therapy", "nifedipine", "betamethasone", "begun", "patient", "to", "contractions", "nifedipine", "discontinued", "treatment", "high-dose terbutaline", "initiated", "contractions", "Three hours later", "patient reports fatigue", "weakness", "Neurologic examination", "proximal muscle weakness of the lower extremities", "Deep tendon reflexes", "1", "following", "to confirm", "diagnosis"]}
{"question": "A 70-year-old male patient comes into your office because of leg pain. The patient states that his calves have been hurting more and more over the last two months. The pain isn't present at rest, but the pain develops as the patient starts walking and exerting himself. He states that stopping to rest is the only thing that relieves the pain. Of note, the patient's medical history is significant for 30-pack-years of smoking, hypertension, hyperlipidemia, and a previous myocardial infarction status-post angioplasty and stent. On exam, the patient's lower legs (below knee) have glossy skin with loss of hair. The dorsalis pedis pulses are barely palpable bilaterally. Which of the following is the best initial therapy for this patient?", "answer": "Lifestyle modifications", "options": {"A": "Lifestyle modifications", "B": "Cilostazol", "C": "Clopidogrel", "D": "Angioplasty and stenting", "E": "Arterial bypass surgery"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old male patient", "office", "leg pain", "patient states", "calves", "more", "more", "last two months", "pain", "present", "pain", "patient starts", "exerting", "states", "stopping to", "only", "relieves", "pain", "note", "patient's medical history", "significant", "30", "smoking", "hypertension", "hyperlipidemia", "previous myocardial infarction status post angioplasty", "stent", "exam", "patient's lower legs", "below knee", "skin", "loss of hair", "dorsalis pedis pulses", "palpable", "following", "best initial therapy", "patient"]}
{"question": "A 23-year-old man comes to the physician because of a 1-week history of muscle ache, fatigue, and fever that occurs every 2 days. He recently returned from a trip to Myanmar. A peripheral blood smear shows erythrocytes with brick-red granules. The physician recommends a combination of two antimicrobial drugs after confirming normal glucose-6-phosphate dehydrogenase activity. Which of the following is the most appropriate rationale for dual therapy?", "answer": "Prevention of infection relapse", "options": {"A": "Prevention of infection relapse", "B": "Therapy against polymicrobial infections", "C": "Prevention of drug resistance", "D": "Decrease in renal drug secretion", "E": "Decrease in enzymatic drug deactivation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old man", "physician", "1-week history", "muscle ache", "fatigue", "fever", "occurs", "2 days", "recently returned", "trip", "Myanmar", "peripheral blood smear", "erythrocytes", "red granules", "physician", "combination", "two antimicrobial drugs", "normal glucose-6-phosphate dehydrogenase activity", "following", "most appropriate", "dual therapy"]}
{"question": "A 20-year-old woman is brought to the emergency department by her parents after finding her seizing in her room at home. She has no known medical condition and this is her first witnessed seizure. She is stabilized in the emergency department. A detailed history reveals that the patient has been progressively calorie restricting for the past few years. Based on her last known height and weight, her body mass index (BMI) is 16.5 kg/m2. Which of the following electrolyte abnormalities would be of the most concern when this patient is reintroduced to food?", "answer": "Hypophosphatemia", "options": {"A": "Hypophosphatemia", "B": "Hypercalcemia", "C": "Hypermagnesemia", "D": "Hyponatremia", "E": "Hypokalemia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["20 year old woman", "brought", "emergency department", "finding", "room at home", "known medical condition", "first", "seizure", "stabilized", "emergency department", "detailed history reveals", "patient", "calorie restricting", "past", "years", "Based", "known height", "weight", "body mass index", "kg/m2", "following electrolyte abnormalities", "most", "patient", "food"]}
{"question": "A 27-year-old woman, gravida 3, para 1, at 22 weeks gestation visits her physician for a prenatal visit. She feels well. Her current pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. The patient’s previous pregnancies were complicated by preterm labor at 24 weeks gestation in one pregnancy and spontanious abortion at 22 weeks in the other. She takes a multivitamin with folate every day. At the physician’s office, her temperature is 37.2°C (99.0°F), and blood pressure is 109/61 mm Hg. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Fetal heart sounds are normal. An ultrasound shows a short cervix, measured at 20 mm. Which of the following is the most appropriate next step in management?", "answer": "Cerclage", "options": {"A": "Cerclage", "B": "Cervical pessary", "C": "Intramuscular progesterone", "D": "Intravenous betamethasone", "E": "Vaginal progesterone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old woman", "gravida 3", "para 1", "weeks gestation", "physician", "prenatal", "well", "current pregnancy", "uncomplicated", "attended", "prenatal appointments", "followed", "physician's", "screening", "diseases", "laboratory testing", "diet", "exercise", "patients previous pregnancies", "complicated", "preterm labor", "weeks", "one pregnancy", "abortion", "weeks", "multivitamin", "folate", "day", "physicians office", "temperature", "99", "blood pressure", "61 mm Hg", "Pelvic examination", "uterus", "size", "20 week gestation", "Fetal heart sounds", "normal", "ultrasound", "short cervix", "measured", "20 mm", "following", "most appropriate next step"]}
{"question": "A 23-year-old female presents to the emergency department complaining of a worsening headache. The patient reports that the headache started one month ago. It is constant and “all over” but gets worse when she is lying down or in the setting of bright lights. Review of systems is significant for low-grade fever, night sweats, cough, malaise, poor appetite, and unintentional weight loss of 12 pounds in the last two months. The patient is sexually active with multiple male partners and reports inconsistent condom use. She has a history of intravenous drug use, and has not been to a doctor in the last two years. The patient’s temperature is 100.4°F (38.0°C), blood pressure is 110/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air. On physical exam, pain is elicited upon passive flexion of the patient’s neck. A CT scan shows ventricular enlargement. A CD4+ count is 57 cells/µL blood. A lumbar puncture is performed with the following findings:\n\nCerebrospinal fluid:\nOpening pressure: 210 mmH2O\nGlucose: 32 mg/dL\nProtein: 204 mg/dL\nIndia ink stain: Positive\n\nLeukocyte count and differential:\nLeukocyte count: 200/mm^3\nLymphocytes: 100%\nRed blood cell count: 2\n\nWhat is the next best step in therapy?", "answer": "Administer amphotericin B and 5-flucytosine", "options": {"A": "Administer fluconazole", "B": "Administer amphotericin B and 5-flucytosine", "C": "Administer vancomycin and ceftriaxone", "D": "Administer acyclovir", "E": "Administer dexamethasone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old female presents", "emergency department complaining of a worsening headache", "patient reports", "headache started one month", "constant", "all", "gets worse", "lying", "setting", "bright", "Review of systems", "significant", "low-grade fever", "night sweats", "cough", "malaise", "poor appetite", "unintentional weight loss of", "pounds", "last two months", "patient", "sexually active", "male", "reports inconsistent", "not", "doctor", "last two years", "patients temperature", "100", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "98", "O2", "room air", "pain", "elicited", "passive flexion", "patients neck", "CT scan", "ventricular enlargement", "CD4", "count", "57 cells/L blood", "lumbar puncture", "performed", "following findings", "Cerebrospinal fluid", "Opening pressure", "mmH2O Glucose", "mg/dL Protein", "mg/dL", "Positive", "Leukocyte count", "differential", "Leukocyte count", "200 mm", "Lymphocytes", "100", "Red blood cell count", "2", "next best step", "therapy"]}
{"question": "A 67-year-old man is brought to the emergency department by his wife due to dizziness, trouble with walking, and progressively worsening headache. These symptoms began approximately two hours prior to arriving to the hospital and were associated with nausea and one episode of vomiting. Medical history is significant for hypertension, hypercholesterolemia, and type II diabetes mellitus, which is managed with lisinopril, atorvastatin, and metformin. His temperature is 99°F (37.2°C), blood pressure is 182/106 mmHg, pulse is 102/min, and respirations are 20/min. On physical examination, the patient has right-sided dysmetria on finger-to-nose testing and right-sided dysrhythmia on rapid finger tapping. This patient's abnormal physical exam findings is best explained by decreased neuronal input into which of the following nuclei?", "answer": "Dentate and interposed nuclei", "options": {"A": "Dentate and vestibular nuclei", "B": "Eboliform and fastigial nuclei", "C": "Dentate and interposed nuclei", "D": "Fastigial and globose nuclei", "E": "Vestibular and eboliform nuclei"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "brought", "emergency department", "due to dizziness", "worsening headache", "symptoms began approximately two hours prior to", "hospital", "associated with nausea", "one episode of vomiting", "Medical history", "significant", "hypertension", "hypercholesterolemia", "type II diabetes mellitus", "lisinopril", "atorvastatin", "metformin", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "20 min", "patient", "right-sided dysmetria", "finger", "nose testing", "right-sided dysrhythmia", "rapid finger tapping", "patient's abnormal physical exam findings", "best", "decreased", "following nuclei"]}
{"question": "A 52-year-old woman presents with fatigue and pain of the proximal interphalangeal and metacarpophalangeal joints for the past 6 months. She also has knee and wrist pain that has been present for the past 2 months, with morning stiffness that improves over the course of the day. Physical examination is significant for subcutaneous nodules. Laboratory tests are significant for the following:\nHemoglobin 12.5 g/dL\nRed blood cell count 4.9 x 106/µL\nWhite blood cell count 5,000/mm3\nPlatelet count 180,000/mm3\nCoombs' test Negative\nC-reactive peptide (CRP) Elevated\nErythrocyte sedimentation rate (ESR) Negative\nAnti-cyclic citrullinated peptide antibody (anti-CCP antibody) Moderately positive\nAnti-nuclear antibody (ANA) Negative\nRheumatoid factor (RF) Negative\nWhat is the most likely human leukocyte antigen (HLA) subtype associated with this disease?", "answer": "HLA-DR4", "options": {"A": "HLA-DR4", "B": "HLA-DR2", "C": "HLA-DR5", "D": "HLA-DQ2", "E": "HLA-B27"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "fatigue", "pain", "proximal", "metacarpophalangeal joints", "past 6 months", "knee", "wrist pain", "present", "past", "months", "morning stiffness", "improves", "course", "day", "significant", "subcutaneous nodules", "Laboratory tests", "significant", "following", "Hemoglobin 12.5 g/dL Red blood cell", "White blood cell", "mm3", "test Negative C reactive peptide", "Elevated Erythrocyte sedimentation rate", "Negative Anti-cyclic citrullinated peptide antibody", "anti antibody", "Moderately positive Anti-nuclear antibody", "Negative Rheumatoid factor", "human leukocyte antigen", "associated", "disease"]}
{"question": "A 27-year-old woman presents to the emergency department for sudden, bilateral, painful loss of vision. She states that her symptoms started last night and have persisted until this morning. The patient has a past medical history of peripheral neuropathy which is currently treated with duloxetine and severe anxiety. Her temperature is 99.5°F (37.5°C), blood pressure is 100/60 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient demonstrates 4/5 strength in her upper and lower extremities with decreased sensation in her fingers bilaterally. Towards the end of the exam, the patient embarrassingly admits to having an episode of urinary incontinence the previous night. An MRI is obtained and is within normal limits. Which of the following is the best next step in management and most likely finding for this patient?", "answer": "A lumbar puncture demonstrating oligoclonal bands", "options": {"A": "A repeat MRI 3 days later demonstrating periventricular lesions", "B": "A high resolution CT demonstrating hyperdense lesions", "C": "A lumbar puncture demonstrating oligoclonal bands", "D": "Urine toxicology panel demonstrating cocaine use", "E": "A psychiatric evaluation revealing multiple acute life stressors"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old woman presents", "emergency department", "sudden", "bilateral", "painful loss of vision", "states", "symptoms started last night", "morning", "patient", "past medical peripheral neuropathy", "currently treated with duloxetine", "severe anxiety", "temperature", "99", "blood pressure", "100 60 mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "4/5 strength", "upper", "lower extremities", "decreased sensation", "fingers", "end", "exam", "patient", "to", "episode of urinary incontinence", "previous night", "MRI", "obtained", "normal limits", "following", "best next step", "likely finding", "patient"]}
{"question": "A 36-year-old woman is fasting prior to a religious ceremony. Her only oral intake in the last 36 hours has been small amounts of water. The metabolic enzyme that is primarily responsible for maintaining normal blood glucose in this patient is located exclusively within the mitochondria. An increase in which of the following substances is most likely to increase the activity of this enzyme?", "answer": "Acetyl coenzyme A", "options": {"A": "Adenosine monophosphate", "B": "Glucagon", "C": "Oxidized nicotinamide adenine dinucleotide", "D": "Citrate", "E": "Acetyl coenzyme A"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["36 year old woman", "fasting prior to", "religious", "only oral intake", "36 hours", "small amounts", "water", "metabolic enzyme", "responsible", "normal blood glucose", "patient", "mitochondria", "increase", "following", "to increase"]}
{"question": "An 8-year-old boy is brought to the emergency department 3 hours after being bitten by his neighbor's dog. He was chasing the dog with a stick when it attacked him. He has fed the dog on multiple occasions and it has never bitten him before. His father saw the dog 2 hours after the incident and its behavior seemed normal. There is no personal or family history of serious illness in the family. The last vaccination the boy received was against varicella 2 years ago; he has never been immunized against rabies. He is not in acute distress. Vital signs are within normal limits. Examination shows a 2 cm (0.8 in) puncture wound on his left calf; there is minimal erythema around the wound. The remainder of the examination shows no abnormalities. A complete blood count is within the reference range. The wound is irrigated and washed with saline and chlorhexidine solution. Which of the following is the most appropriate next step in management?", "answer": "Observe the dog for 10 days", "options": {"A": "Observe the dog for 10 days", "B": "Euthanize the dog and test for rabies", "C": "Administer rabies vaccine and immune globulin", "D": "Administer rabies immune globulin", "E": "Administer rabies vaccine\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "hours", "bitten by", "dog", "stick", "attacked", "fed", "multiple occasions", "never bitten", "before", "saw", "hours", "behavior", "normal", "personal", "family history", "serious illness", "last vaccination", "boy received", "varicella", "years", "never", "rabies", "not", "acute distress", "Vital signs", "normal limits", "2", "0.8", "puncture wound", "left calf", "minimal erythema", "wound", "abnormalities", "complete blood count", "reference range", "wound", "irrigated", "washed", "chlorhexidine solution", "following", "most appropriate next step"]}
{"question": "A 15-year-old Caucasian male is brought to his pediatrician by his parents, who note the development of a tremor in their child. Urine and serum analysis reveal elevated levels of copper. Which of the following clinical manifestations would the physician most expect to see in this patient?", "answer": "Kaiser-Fleischer rings", "options": {"A": "Diabetes mellitus", "B": "Kaiser-Fleischer rings", "C": "Panacinar emphysema", "D": "Increased serum ceruloplasmin", "E": "Hepatocytes that stain with Prussian blue"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "male", "brought", "pediatrician", "note", "development", "tremor", "child", "Urine", "serum analysis reveal elevated levels", "copper", "of", "following clinical manifestations", "physician most", "to see", "patient"]}
{"question": "A 61-year-old man is brought to the emergency department by his son after collapsing to the ground while at home. His son immediately performed cardiopulmonary resuscitation and later the patient underwent successful defibrillation after being evaluated by the emergency medical technician. The patient has a medical history of hypertension, hyperlipidemia, and type II diabetes mellitus. He has smoked one-half pack of cigarettes for approximately 30 years. The patient was admitted to the cardiac intensive care unit, and after a few days developed acute onset right upper extremity weakness. His temperature is 99°F (37.2°C), blood pressure is 145/91 mmHg, pulse is 102/min and irregularly irregular, and respirations are 16/min. On physical examination, the patient is alert and orientated to person, place, and time. His language is fluent and he is able to name, repeat, and read. His strength is 5/5 throughout except in the right hand, wrist, and arm, which is 2/5. Based on this patient's clinical presentation, the affected neuronal fibers decussate at which level of the central nervous system?", "answer": "Caudal medulla", "options": {"A": "Primary motor cortex", "B": "Thalamus", "C": "Pons", "D": "Caudal medulla", "E": "Spinal cord"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old man", "brought", "emergency department", "collapsing", "at home", "immediately performed cardiopulmonary resuscitation", "later", "patient", "successful defibrillation", "emergency medical technician", "patient", "medical", "hyperlipidemia", "type II diabetes mellitus", "smoked one half pack", "cigarettes", "approximately 30 years", "patient", "cardiac", "few days", "acute onset right upper extremity weakness", "temperature", "blood pressure", "mmHg", "pulse", "min", "irregular", "respirations", "min", "patient", "alert", "orientated", "place", "time", "fluent", "able to name", "repeat", "strength", "5/5", "right hand", "wrist", "arm", "2/5", "Based", "patient's", "affected", "fibers", "level", "central nervous system"]}
{"question": "A 67-year-old woman comes to the emergency department 1 hour after her husband saw her faint shortly after getting out of bed from a nap. She regained consciousness within 30 seconds and was fully alert and oriented. She has had 2 similar episodes in the last 5 years, once while standing in line at the grocery store and once when getting out of bed in the morning. 24-hour Holter monitoring and echocardiography were unremarkable at her last hospitalization 1 year ago. She has hypertension, depression, and asthma. Current medications include verapamil, nortriptyline, and an albuterol inhaler as needed. Her temperature is 37°C (98.4°F), pulse is 74/min and regular, respirations are 14/min, blood pressure is 114/72 mm Hg when supine and 95/60 mm Hg while standing. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. A complete blood count and serum concentrations of electrolytes, urea nitrogen, creatinine, and glucose are within the reference range. Bedside cardiac monitoring shows rare premature ventricular contractions and T-wave inversions in lead III. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Autonomic dysfunction", "options": {"A": "Adrenal insufficiency", "B": "Autonomic dysfunction", "C": "Structural cardiac abnormality", "D": "Hemorrhagic blood loss", "E": "Cardiac arrhythmia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old woman", "emergency department", "hour", "saw", "faint", "getting out", "bed", "nap", "consciousness", "30 seconds", "alert", "oriented", "2 similar episodes", "5 years", "standing in line", "grocery store", "morning", "hour Holter monitoring", "echocardiography", "unremarkable", "hospitalization 1 year", "hypertension", "depression", "asthma", "Current medications include verapamil", "nortriptyline", "albuterol inhaler as needed", "temperature", "98", "pulse", "74 min", "regular", "respirations", "min", "blood pressure", "72 mm Hg", "supine", "95 60 mm Hg", "standing", "Cardiopulmonary", "abnormalities", "Neurologic examination", "focal findings", "complete blood count", "serum", "electrolytes", "urea nitrogen", "creatinine", "glucose", "reference range", "cardiac monitoring", "rare premature ventricular contractions", "T-wave inversions", "lead III", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 45-year-old executive travels frequently around the world. He often has difficulty falling asleep at night when he returns home. You suspect a circadian rhythm disorder is responsible for his pathology. Which of the following regulates the circadian rhythm?", "answer": "Suprachiasmatic nucleus of hypothalamus", "options": {"A": "Anterior hypothalamus", "B": "Posterior hypothalamus", "C": "Ventromedial area of hypothalamus", "D": "Supraoptic area of hypothalamus", "E": "Suprachiasmatic nucleus of hypothalamus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old executive", "frequently", "often", "difficulty falling asleep", "night", "returns home", "circadian rhythm disorder", "responsible", "pathology", "following", "circadian rhythm"]}
{"question": "A 16-year-old male presents to his pediatrician concerned that he is not maturing like his friends. He has a history of cleft palate status-post multiple surgeries and asthma treated with budesonide and albuterol. He is a good student and is very active on his school’s gymnastics team. His mother is also concerned that her son does not understand good personal hygiene. She reports that he always forgets to put on deodorant. When asked about this, he says he does not notice any body odor on himself or others. His temperature is 99.2°F (37.3°C), blood pressure is 105/70 mmHg, pulse is 70/min, and respirations are 18/min. His height and weight are in the 20th and 25th percentiles, respectively. On physical examination, his penis and testicles show no evidence of enlargement. He has no pubic or axillary hair. Which of the following sets of hormone levels is most likely to be found in this patient?", "answer": "Decreased testosterone, decreased FSH, decreased LH, decreased GnRH", "options": {"A": "Decreased testosterone, decreased FSH, decreased LH, decreased GnRH", "B": "Increased testosterone, decreased FSH, decreased LH, decreased GnRH", "C": "Decreased testosterone, increased FSH, increased LH, increased GnRH", "D": "Decreased testosterone, decreased FSH, decreased LH, increased GnRH", "E": "Normal testosterone, normal FSH, normal LH, normal GnRH"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "pediatrician", "not maturing", "history of cleft palate", "multiple surgeries", "asthma treated with budesonide", "albuterol", "good", "very active", "schools", "not", "good", "reports", "always forgets to", "deodorant", "not", "body odor", "others", "temperature", "99", "blood pressure", "70 mmHg", "pulse", "70 min", "respirations", "min", "height", "weight", "percentiles", "penis", "testicles", "enlargement", "pubic", "axillary hair", "following sets", "hormone levels", "to", "found", "patient"]}
{"question": "A 26-year-old primigravid woman at 10 weeks' gestation comes to the physician for a prenatal visit. Pregnancy was confirmed by an ultrasound 3 weeks earlier after the patient presented with severe nausea and vomiting. The nausea and vomiting have subsided without medication. She has no vaginal bleeding or discharge. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 10-week gestation. Transvaginal ultrasonography shows a gestational sac with a mean diameter of 23 mm and an embryo 6 mm in length with absent cardiac activity. Which of the following is the most appropriate next step in management?", "answer": "Misoprostol therapy", "options": {"A": "Serial β-HCG measurements", "B": "Misoprostol therapy", "C": "Cervical cerclage", "D": "Thrombophilia work-up", "E": "Methotrexate therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old primigravid woman", "10 weeks", "gestation", "physician", "Pregnancy", "confirmed by", "ultrasound", "weeks earlier", "patient presented", "severe nausea", "vomiting", "nausea", "vomiting", "medication", "vaginal bleeding", "discharge", "Vital signs", "normal limits", "Pelvic examination", "uterus", "size", "a 10 week gestation", "Transvaginal ultrasonography", "gestational sac", "mean diameter", "23 mm", "embryo", "mm", "length", "absent cardiac activity", "following", "most appropriate next step"]}
{"question": "A 67-year-old man is brought to the emergency department when he was found obtunded at the homeless shelter. The patient is currently not responsive and smells of alcohol. The patient has a past medical history of alcohol use, IV drug use, and hepatitis C. His temperature is 99°F (37.2°C), blood pressure is 95/65 mmHg, pulse is 95/min, respirations are 13/min, and oxygen saturation is 95% on room air. The patient is started on IV fluids, and his pulse decreases to 70/min. On physical exam, the patient has an abdominal exam notable for distension and a positive fluid wave. The patient displays mild yellow discoloration of his skin. The patient has notable poor dentition and poor hygiene overall. A systolic murmur is heard along the left sternal border on cardiac exam. Pulmonary exam is notable for mild bibasilar crackles. Laboratory values are ordered, and return as below:\n\nHemoglobin: 10 g/dL\nHematocrit: 32%\nLeukocyte count: 7,500 cells/mm^3 with normal differential\nPlatelet count: 227,000/mm^3\n\nSerum:\nNa+: 125 mEq/L\nCl-: 100 mEq/L\nK+: 5.0 mEq/L\nHCO3-: 24 mEq/L\nBUN: 51 mg/dL\nGlucose: 89 mg/dL\nCreatinine: 2.2 mg/dL\nCa2+: 10.0 mg/dL\nAST: 22 U/L\nALT: 19 U/L\n\nUrine:\nColor: Amber\nNitrites: Negative\nSodium: 12 mmol/24 hours\nRed blood cells: 0/hpf\n\nOver the next 24 hours, the patient produces very little urine. Which of the following best explains this patient’s renal findings?", "answer": "Liver failure", "options": {"A": "Congestive heart failure", "B": "Dehydration", "C": "Liver failure", "D": "Nephrotoxic agent", "E": "Postrenal azotemia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man", "brought", "emergency department", "found obtunded", "homeless shelter", "patient", "currently not responsive", "smells", "alcohol", "patient", "past medical history of alcohol use", "IV drug use", "hepatitis C", "temperature", "blood pressure", "95 65 mmHg", "pulse", "95 min", "respirations", "min", "oxygen saturation", "95", "room air", "patient", "started", "pulse decreases", "70 min", "patient", "abdominal exam notable", "distension", "positive fluid wave", "patient displays mild yellow discoloration of", "skin", "patient", "notable poor dentition", "poor hygiene overall", "systolic murmur", "heard", "left sternal border", "Pulmonary exam", "notable", "mild", "crackles", "Laboratory values", "ordered", "return", "Hemoglobin", "10 g/dL Hematocrit", "Leukocyte count", "7 500 cells mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "5 0 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "2.2 mg/dL Ca2", "10 0 mg/dL AST", "U/L ALT", "U/L", "Urine", "Color", "Amber", "Negative Sodium", "mmol 24 hours Red blood cells", "0 hpf", "next 24", "patient", "very little urine", "following best", "patients renal findings"]}
{"question": "Two days after spontaneous delivery, a 23-year-old woman has progressively worsening, throbbing pain in the back of her head. The pain radiates to the neck and shoulder area. The patient is nauseous and had one episode of clear emesis. She wants to be in a dark and quiet room. The patient's symptoms are exacerbated when she gets up to go to the bathroom and mildly improve with bed rest. The pregnancy was uncomplicated and she attended all prenatal health visits. She underwent epidural analgesia for delivery with adequate pain relief. Her postpartum course was free of obstetric complications. Her vital signs are within normal limits. She is alert and oriented. On examination, neck stiffness is present. Neurological examination shows no other abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Epidural blood injection", "options": {"A": "Head CT angiography", "B": "Send coagulation panel", "C": "Cerebrospinal fluid analysis", "D": "Continued bed rest", "E": "Epidural blood injection"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Two days", "spontaneous delivery", "23 year old woman", "worsening", "throbbing pain in", "back of", "head", "pain radiates", "neck", "shoulder area", "patient", "nauseous", "one episode of clear emesis", "to", "dark", "quiet room", "patient's symptoms", "exacerbated", "gets", "go", "bathroom", "mildly", "bed rest", "pregnancy", "uncomplicated", "attended", "epidural analgesia", "delivery", "adequate pain relief", "postpartum course", "free", "obstetric complications", "vital signs", "normal limits", "alert", "oriented", "neck stiffness", "present", "Neurological examination", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 42-year-old man presents to the emergency department with persistent cough. The patient states that for the past week he has been coughing. He also states that he has seen blood in his sputum and experienced shortness of breath. On review of systems, the patient endorses fever and chills as well as joint pain. His temperature is 102°F (38.9°C), blood pressure is 159/98 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 7,500/mm^3 with normal differential\nPlatelet count: 107,000/mm^3\n\nSerum:\nNa+: 138 mEq/L\nCl-: 101 mEq/L\nK+: 4.2 mEq/L\nHCO3-: 24 mEq/L\nBUN: 32 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.9 mg/dL\nCa2+: 10.0 mg/dL\nAST: 11 U/L\nALT: 10 U/L\n\nUrine:\nColor: Amber, cloudy\nRed blood cells: Positive\nProtein: Positive\n\nWhich of the following is the best next step in management?", "answer": "Type IV collagen antibody levels", "options": {"A": "Steroids", "B": "Azithromycin", "C": "Type IV collagen antibody levels", "D": "p-ANCA levels", "E": "Renal biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "persistent cough", "patient states", "past week", "coughing", "states", "seen blood", "sputum", "shortness of breath", "review of systems", "patient", "fever", "chills", "joint pain", "temperature", "blood pressure", "98 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "7 500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "mEq/L K", "4.2 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "99 mg/dL Creatinine", "1.9 mg/dL Ca2", "10 0 mg/dL AST", "U/L ALT", "10 U/L", "Urine", "Color", "Amber", "cloudy Red blood cells", "Positive Protein", "Positive", "following", "best next step"]}
{"question": "A previously healthy 5-year-old boy is brought to the emergency department because of fever, irritability, malaise, and left knee pain for 4 days. Four days ago, he fell off his bike and scraped his elbow. His temperature is 39.1°C (102.4°F). The patient walks with a limp. Examination shows swelling and point tenderness over the medial aspect of the left knee. An MRI of the left knee shows edema of the bone marrow and destruction of the medial metaphysis of the tibia. Which of the following is the most likely causal organism?", "answer": "Staphylococcus aureus", "options": {"A": "Staphylococcus epidermidis", "B": "Brucella melitensis", "C": "Staphylococcus aureus", "D": "Pseudomonas aeruginosa", "E": "Pasteurella multocida"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old boy", "brought", "emergency department", "fever", "irritability", "malaise", "left knee pain", "4 days", "Four", "fell", "bike", "scraped", "elbow", "temperature", "walks", "limp", "swelling", "point tenderness", "medial aspect of", "left knee", "MRI of", "left knee", "edema of", "bone marrow", "destruction of", "medial metaphysis", "tibia", "following", "causal"]}
{"question": "A 64-year-old woman presents to her primary care physician complaining of difficulty maintaining her balance while walking. Her husband comes along to the appointment with her, because he feels that she has not been acting herself at home lately. After further questioning him, it is noted that she has recently been voiding urine unintentionally at inappropriate times. If there is suspicion for an intracranial process, what would most likely be seen on MRI and what is the treatment?", "answer": "Dilated ventricles; ventricular shunt", "options": {"A": "Constricted ventricles; ventricular shunt", "B": "Constricted ventricles; surgical resection", "C": "Dilated ventricles; ventricular shunt", "D": "Dilated ventricles; surgical resection", "E": "Constricted ventricles; watch and wait"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["64 year old woman presents", "primary care physician", "difficulty", "balance", "appointment", "not", "acting", "at home", "further", "noted", "recently", "voiding urine", "inappropriate times", "intracranial process", "most likely", "seen", "MRI", "treatment"]}
{"question": "A 55-year-old man with type 2 diabetes mellitus comes to the physician for a routine health maintenance. He feels well. His blood pressure is 155/60 mm Hg. Physical exam shows no abnormalities. Laboratory studies show a glucose concentration of 150 mg/dL and a hemoglobin A1c concentration of 9%. Treatment with lisinopril is initiated. Which of the following findings would be expected two days after initiating lisinopril therapy?\n $$$ Glomerular filtration rate %%% Renal plasma flow %%% Filtration fraction $$$", "answer": "↓ ↑ ↓", "options": {"A": "↑ no change ↑", "B": "↓ no change ↓", "C": "↓ ↓ no change", "D": "↓ ↑ ↓", "E": "↓ ↓ ↑"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "type 2 diabetes mellitus", "physician", "routine", "well", "blood pressure", "60 mm Hg", "abnormalities", "Laboratory studies", "glucose concentration", "mg/dL", "a hemoglobin A1c concentration", "Treatment", "lisinopril", "initiated", "following findings", "two days", "initiating lisinopril therapy", "Glomerular filtration rate", "Renal plasma flow", "fraction"]}
{"question": "A 3629-g (8-lb) newborn is examined shortly after spontaneous vaginal delivery. She was delivered at 40 weeks' gestation and pregnancy was uncomplicated. Her mother is concerned because she is not moving her left arm as much as her right arm. Physical examination shows her left arm to be adducted and internally rotated, with the forearm extended and pronated, and the wrist flexed. The Moro reflex is present on the right side but absent on the left side. Which of the following brachial plexus structures is most likely injured in this infant?", "answer": "Upper trunk", "options": {"A": "Upper trunk", "B": "Long thoracic nerve", "C": "Lower trunk", "D": "Axillary nerve", "E": "Posterior cord"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["newborn", "examined", "spontaneous vaginal delivery", "delivered", "40 weeks", "gestation", "pregnancy", "uncomplicated", "not moving", "left arm", "much", "right arm", "left arm to", "internally rotated", "forearm extended", "wrist flexed", "Moro reflex", "present", "right side", "absent", "left side", "following brachial plexus structures", "most likely injured", "infant"]}
{"question": "A 45-year-old woman presents to the office complaining of bilateral joint pain and stiffness in her hand joints for the past 3 months. She reports increasing difficulty holding a coffee cup or pen due to stiffness, especially in the morning. Over-the-counter ibuprofen partially relieves her symptoms. Past medical history is significant for dysthymia and gastroesophageal reflux disease. Vital signs are normal except for a low-grade fever. On examination, there is mild swelling and tenderness in the proximal interphalangeal and metacarpophalangeal joints and wrists. Nontender and non-pruritic nodules near the elbows are noted. Chest and abdominal examination are normal. X-rays of the hands reveal soft tissue swelling, joint space narrowing, and bony erosions. Her hematocrit is 32%, and her erythrocyte sedimentation rate is 40 mm/hr. This patient is at greatest risk for which of the following?", "answer": "Osteoporosis", "options": {"A": "Disease progression to distal interphalangeal joints", "B": "Osteoporosis", "C": "Sacroiliac joint inflammation", "D": "Obstructive pulmonary disease", "E": "Osteitis deformans"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "office", "bilateral joint", "stiffness in", "hand joints", "past 3 months", "reports increasing difficulty holding", "cup", "pen due to stiffness", "the morning", "Over", "counter ibuprofen", "relieves", "symptoms", "Past medical history", "significant", "dysthymia", "gastroesophageal reflux disease", "Vital signs", "normal", "low-grade fever", "mild swelling", "tenderness", "proximal", "metacarpophalangeal joints", "wrists", "Nontender", "non-pruritic nodules", "elbows", "noted", "Chest", "abdominal", "normal", "X-rays", "hands reveal soft tissue swelling", "joint space narrowing", "bony erosions", "hematocrit", "erythrocyte sedimentation rate", "40 mm", "patient", "greatest", "following"]}
{"question": "A 40-year-old woman comes to the physician for a preoperative examination before undergoing a planned elective cholecystectomy. She has a history of myasthenia gravis, for which she takes oral pyridostigmine. She has had occasional episodes of muscle weakness, blurred vision, and slurred speech recently. Physical examination shows mild ptosis bilaterally. The pupils are normal in size and reactive bilaterally. Muscle strength is 3/5 at the hips and shoulders. Sensory examination shows no abnormalities. After the administration of 10 mg of edrophonium, her ptosis resolves, and her proximal muscle strength improves to 5/5. This patient is most likely to benefit from which of the following interventions?", "answer": "Increase the dose of pyridostigmine", "options": {"A": "Administer timed doses of edrophonium", "B": "Increase the dose of pyridostigmine", "C": "Discontinue treatment with pyridostigmine", "D": "Initiate treatment with intravenous atropine", "E": "Add glycopyrrolate as needed"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["40 year old woman", "physician", "preoperative", "planned elective cholecystectomy", "history", "myasthenia gravis", "oral pyridostigmine", "occasional episodes of muscle weakness", "blurred vision", "slurred speech recently", "mild ptosis", "pupils", "normal", "size", "reactive", "Muscle strength", "3/5", "hips", "shoulders", "Sensory", "abnormalities", "administration", "10 mg", "edrophonium", "ptosis", "proximal improves", "patient", "to benefit", "following interventions"]}
{"question": "A 42-year-old woman presents to the emergency department with abdominal pain. She states that she was eating dinner when she suddenly felt abdominal pain and nausea. The pain did not improve after 30 minutes, so her husband brought her in. The patient has a past medical history of diabetes that is well-treated with exercise and metformin. Her temperature is 101°F (38.3°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals right upper quadrant tenderness and guaiac negative stools. Which of the following is optimal management for this patient's condition?", "answer": "NPO, IV fluids, analgesics, antibiotics, cholescystecomy within 72 hours", "options": {"A": "NPO, IV fluids, analgesics, antibiotics", "B": "NPO, IV fluids, analgesics, antibiotics, emergent cholecystectomy", "C": "NPO, IV fluids, analgesics, antibiotics, cholescystecomy within 24 hours", "D": "NPO, IV fluids, analgesics, antibiotics, cholescystecomy within 48 hours", "E": "NPO, IV fluids, analgesics, antibiotics, cholescystecomy within 72 hours"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency department", "abdominal pain", "states", "eating dinner", "abdominal pain", "nausea", "pain", "not", "30 minutes", "brought", "patient", "past medical diabetes", "well treated with exercise", "metformin", "temperature", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "reveals right upper quadrant tenderness", "guaiac negative stools", "following", "optimal management", "patient's"]}
{"question": "An otherwise healthy 56-year-old man comes to the physician for a 2-year history of recurrent upper abdominal pain and fullness that worsens after meals. Urea breath test is positive. An endoscopy shows diffuse mucosal atrophy and patchy erythema, but no ulcer. A biopsy from which of the following areas is most likely to yield an accurate diagnosis?", "answer": "Gastric antrum", "options": {"A": "Gastric fundus", "B": "Distal esophagus", "C": "Gastric antrum", "D": "Duodenal bulb", "E": "Gastric pylorus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "2 year history", "recurrent upper", "fullness", "worsens", "meals", "Urea breath", "positive", "endoscopy", "diffuse mucosal atrophy", "patchy erythema", "ulcer", "biopsy", "following areas", "to", "accurate diagnosis"]}
{"question": "To study the flow of blood in the systemic circulation, partially occlusive stents are placed in the pulmonary trunk of a physiological system while the pressure in the right atrium is monitored. A graph where the right atrial pressure is a function of venous return is plotted. Assuming all circulatory nerve reflexes are absent in the system, at what point on the diagram shown below will the arterial pressure be closest to the venous pressure?", "answer": "Point III", "options": {"A": "Point I", "B": "Point II", "C": "Point III", "D": "Point IV", "E": "Point V"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["To study", "flow", "blood", "systemic circulation", "occlusive stents", "pulmonary", "physiological system", "pressure", "right atrium", "monitored", "right atrial pressure", "function", "venous return", "circulatory nerve reflexes", "absent", "system", "point", "diagram", "arterial pressure", "closest", "venous pressure"]}
{"question": "A 63-year-old man presents to the emergency room with severe upper abdominal pain. His symptoms started 2 days prior to presentation and have progressed rapidly. He has been seen in the emergency room 3 times in the past year for acute alcohol intoxication. His past medical history is notable for multiple deep venous thromboses, hypertension, diabetes mellitus, gout, and a transient ischemic attack one year prior. He takes warfarin, lisinopril, metformin, glyburide, and allopurinol. His temperature is 100.0°F (37.8°C), blood pressure is 100/55 mmHg, pulse is 130/min, and respirations are 26/min. On exam, he is in acute distress but is able to answer questions appropriately. Hepatomegaly, splenomegaly, and scleral icterus are noted. There is a positive fluid wave. Laboratory analysis reveals an INR of 1.3. An abdominal ultrasound is ordered, and the patient is started on the appropriate management. However, before the ultrasound can begin, he rapidly loses consciousness and becomes unresponsive. He expires despite appropriate management. An autopsy the following day determines the cause of death to be a massive cerebrovascular accident. A liver biopsy demonstrates darkly erythematous congested areas in the centrilobular regions. This patient’s presenting symptoms are most likely caused by obstructive blood flow in which of the following vessels?", "answer": "Hepatic vein", "options": {"A": "Common hepatic artery", "B": "Hepatic vein", "C": "Inferior vena cava", "D": "Portal vein", "E": "Splenic vein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old man presents", "emergency room", "severe upper abdominal pain", "symptoms started 2 days prior to", "progressed rapidly", "seen", "emergency room", "times", "past year", "acute alcohol intoxication", "past medical history", "notable", "multiple deep venous thromboses", "hypertension", "diabetes mellitus", "gout", "transient ischemic attack one year prior", "warfarin", "lisinopril", "metformin", "glyburide", "allopurinol", "temperature", "100", "blood pressure", "100", "mmHg", "pulse", "min", "respirations", "min", "exam", "acute distress", "able to", "Hepatomegaly", "splenomegaly", "scleral icterus", "noted", "positive fluid", "Laboratory analysis reveals", "INR", "abdominal ultrasound", "ordered", "patient", "started", "appropriate", "ultrasound", "begin", "rapidly", "consciousness", "unresponsive", "appropriate", "autopsy", "following day", "cause of death to", "massive cerebrovascular accident", "liver biopsy", "erythematous congested areas", "centrilobular regions", "patients", "symptoms", "most likely caused", "obstructive blood flow", "following vessels"]}
{"question": "A 27-year-old African American male presents to his family physician for “spots” on his foot. Yesterday, he noticed brown spots on his foot that have a whitish rim around them. The skin lesions are not painful, but he got particularly concerned when he found similar lesions on his penis that appear wet. He recalls having pain with urination for the last 4 weeks, but he did not seek medical attention until now. He also has joint pain in his right knee which started this week. He is sexually active with a new partner and uses condoms inconsistently. His physician prescribes a topical glucocorticoid to treat his lesions. Which of the following risk factors is most commonly implicated in the development of this condition?", "answer": "HLA B27 allele", "options": {"A": "Race", "B": "HLA B27 allele", "C": "Co-infection with HIV", "D": "Diagnosis with psoriasis", "E": "Increased CRP serum levels"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old", "male presents", "family physician", "spots", "foot", "brown spots", "foot", "rim", "skin lesions", "not painful", "got", "found similar lesions", "penis", "appear wet", "pain", "urination", "last", "weeks", "not", "medical", "now", "joint pain in", "right knee", "started", "week", "sexually active", "new", "uses condoms", "physician", "topical glucocorticoid to treat", "lesions", "following risk factors", "most", "development", "condition"]}
{"question": "A 28-year-old pregnant female presents for a prenatal check-up at 20 weeks gestation, which includes routine screening ultrasound. Fetal ultrasound demonstrates bilateral multicystic dysplastic kidneys. Her pregnancy has been complicated by persistent oligohydramnios. The child requires significant pulmonary support upon delivery. Which of the following clinical findings is most likely present in this child as a result of these abnormalities?", "answer": "Clubbed feet", "options": {"A": "Urachal fistula", "B": "Esophageal atresia", "C": "Spina bifida occulta", "D": "Clubbed feet", "E": "Macrosomia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "prenatal check-up", "20 weeks gestation", "includes routine screening ultrasound", "Fetal", "bilateral multicystic dysplastic kidneys", "pregnancy", "complicated", "persistent oligohydramnios", "child", "significant pulmonary support", "delivery", "following clinical findings", "most likely present", "child", "result", "abnormalities"]}
{"question": "A 7-year-old boy is brought to the hospital for evaluation, he is accompanied by agents from child protective services after he was rescued from a home where he was being neglected. He was found locked in a closet and says that he was fed only once every 2 days for the past month. On presentation, he is found to be extremely emaciated with protruding ribs and prominent joints. He is provided with an appropriate rehydration and nourishment therapy. Despite his prolonged nutritional deprivation, the patient demonstrates appropriate cognitive function for his age. The transporter responsible for preventing cognitive decline in this malnourished patient has which of the following characteristics?", "answer": "Has high affinity for glucose", "options": {"A": "Facilitates insulin release", "B": "Has high affinity for glucose", "C": "Responsive to insulin", "D": "Has high affinity for fructose", "E": "Transports glucose against its concentration gradient"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "hospital", "agents", "home", "neglected", "found locked", "fed only", "2 days", "past month", "found to", "extremely emaciated", "protruding ribs", "prominent joints", "appropriate rehydration", "therapy", "prolonged nutritional deprivation", "patient", "appropriate", "age", "transporter responsible", "preventing cognitive decline", "malnourished patient", "following characteristics"]}
{"question": "A 23-year-old woman comes to the physician because of vaginal discharge for 4 days. Her last menstrual period was 3 weeks ago. Twelve months ago, she was diagnosed with trichomoniasis, for which she and her partner were treated with a course of an antimicrobial. She is sexually active with one male partner, and they use condoms inconsistently. Her only medication is a combined oral contraceptive that she has been taking for the past 4 years. A Gram stain of her vaginal fluid is shown. Which of the following is the most likely causal organism?", "answer": "Neisseria gonorrhoeae", "options": {"A": "Neisseria gonorrhoeae", "B": "Gardnerella vaginalis", "C": "Haemophilus ducreyi", "D": "Klebsiella granulomatis", "E": "Treponema pallidum"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old woman", "physician", "of vaginal discharge", "4 days", "last menstrual period", "3", "Twelve months", "diagnosed", "trichomoniasis", "treated with", "course", "antimicrobial", "sexually active", "one male", "use condoms", "only medication", "combined oral contraceptive", "past", "years", "Gram stain", "vaginal fluid", "following", "causal"]}
{"question": "A 52-year-old woman presents to the physician for a routine physical examination. She has type 2 diabetes that she treats with metformin. Her pulse is 85/min, respiratory rate is 15/min, blood pressure is 162/96 mm Hg, and temperature is 37.0°C (98.6°F). Treatment with a first-line drug is initiated. Which of the following is the most likely effect of this medication?\n  24-hour urine sodium Aldosterone Angiotensin II Peripheral vascular resistance Renin\nA Increased Decreased Decreased Decreased Increased\nB Increased Decreased Decreased Decreased Decreased\nC Increased Increased Increased Increased Increased\nD Decreased Increased Increased Decreased Increased\nE Increased Decreased Increased Decreased Increased", "answer": "A", "options": {"A": "A", "B": "B", "C": "C", "D": "D", "E": "E"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "physician", "routine physical examination", "type 2 diabetes", "treats", "metformin", "pulse", "85 min", "respiratory rate", "min", "blood pressure", "96 mm Hg", "temperature", "98", "Treatment", "first-line drug", "initiated", "following", "effect", "medication", "24-hour urine sodium Aldosterone Angiotensin II Peripheral vascular resistance Renin", "Increased Decreased", "Increased Decreased", "Increased Increased", "Decreased Increased", "Decreased", "Increased Decreased Increased"]}
{"question": "A 59-year-old man comes to the physician because of a 6-month history of numbness and burning sensation in his feet that is worse at rest. He has not been seen by a physician in several years. He is 178 cm (5 ft 10 in) tall and weighs 118 kg (260 lb); BMI is 37.3 kg/m2. Physical examination shows decreased sensation to pinprick, light touch, and vibration over the soles of both feet. Ankle jerk is 1+ bilaterally. His hemoglobin A1C concentration is 10.2%. Which of the following pathophysiological processes is most likely to be involved in this patient's condition?", "answer": "Accumulation of islet amyloid polypeptide", "options": {"A": "Accumulation of islet amyloid polypeptide", "B": "Complement-mediated destruction of insulin receptors", "C": "Increased production of adiponectin by adipocytes", "D": "Expression of human leukocyte antigen subtype DR4", "E": "Lymphocytic infiltration of islet cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old man", "physician", "month history", "numbness", "burning sensation", "feet", "worse", "not", "seen by", "physician", "several years", "5 ft 10", "tall", "kg", "BMI", "kg/m2", "decreased sensation", "light touch", "vibration", "soles of", "feet", "Ankle jerk", "1", "hemoglobin concentration", "10", "following pathophysiological processes", "to", "involved", "patient's condition"]}
{"question": "A 55-year-old woman who works as a chef is brought to the hospital for evaluation of burns sustained in a kitchen accident. Physical examination reveals 3rd-degree burns over the anterior surface of the right thigh and the lower limbs, which involve approx. 11% of the total body surface area (TBSA). The skin in the burned areas is thick and painless to touch, and the dorsalis pedis pulses are palpable but weak. Which of the following is the most appropriate next step in management?", "answer": "Early excision and split-thickness skin grafting", "options": {"A": "Early excision and full-thickness skin grafting", "B": "Early excision and split-thickness skin grafting", "C": "Delayed excision and skin grafting", "D": "Topical antibiotic application of mafenide acetate", "E": "Fluid resuscitation with Ringer’s lactate solution per the Parkland formula"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "chef", "brought", "hospital", "burns sustained", "kitchen", "reveals 3rd degree burns", "anterior surface of", "right thigh", "lower limbs", "total", "skin", "burned areas", "thick", "painless", "touch", "dorsalis pedis pulses", "palpable", "weak", "following", "most appropriate next step"]}
{"question": "A 7-year-old boy with a past medical history significant only for prior head lice infection presents to the clinic after being sent by the school nurse for a repeat lice infection. The boy endorses an itchy scalp, but a review of systems is otherwise negative. After confirming the child’s diagnosis and sending him home with appropriate treatment, the school nurse contacts the clinic asking for recommendations on how to prevent future infection. Which of the following would be the best option to decrease the likelihood of lice reinfestation?", "answer": "Treatment of household members with topical ivermectin", "options": {"A": "Observation with close monitoring", "B": "Encourage family to move out of their home", "C": "Treatment of household members with topical ivermectin", "D": "Treatment with oral albendazole", "E": "Treatment with topical clindamycin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "past medical history significant only", "prior head lice infection presents", "clinic", "sent", "school nurse", "repeat", "infection", "boy", "itchy scalp", "review of systems", "negative", "confirming", "childs diagnosis", "sending", "home", "appropriate treatment", "school nurse contacts", "clinic", "to prevent future infection", "following", "best option to decrease", "likelihood"]}
{"question": "A 24-year-old woman at 6 weeks gestation seeks evaluation at a local walk-in clinic because she has noticed a clear, sticky discharge from her right nipple for the past 1 week. The discharge leaves a pink stain on her bra. She does not have pain in her breasts and denies changes in skin color or nipple shape. The past medical history is significant for a major depressive disorder, for which she takes fluoxetine. The family history is negative for breast, endometrial, and ovarian cancers. The physical examination is unremarkable. There are no palpable masses or tenderness on breast exam and no skin discoloration or ulcers. The breasts are symmetric. The nipple discharge on the right side is a pink secretion that is sticky. There are no secretions on the left. The axillary lymph nodes are normal. Which of the following is the most likely diagnosis?", "answer": "Papilloma", "options": {"A": "Mastitis", "B": "Drug-induced", "C": "Papilloma", "D": "Breast cancer", "E": "Lactation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "6 weeks gestation", "local walk-in clinic", "clear", "discharge from", "right nipple", "past", "week", "discharge", "pink", "bra", "not", "pain in", "breasts", "changes in skin color", "nipple shape", "past medical history", "significant", "major depressive disorder", "fluoxetine", "family history", "negative", "breast", "endometrial", "ovarian cancers", "unremarkable", "tenderness", "breast", "skin discoloration", "ulcers", "breasts", "symmetric", "nipple discharge", "right side", "pink secretion", "secretions", "left", "axillary lymph nodes", "normal", "following", "diagnosis"]}
{"question": "A 56-year-old woman, gravida 3, para 3, comes to the physician because her left breast has become larger, hot, and itchy over the past 2 months. The patient felt a small lump in her left breast 1 year ago but did not seek medical attention at that time. She has hypertension and hyperlipidemia. Menarche was at the age of 11 years and menopause at the age of 46 years. Her mother died of breast cancer at the age of 45 years. The patient does not smoke or drink alcohol. Current medications include labetalol, simvastatin, and daily low-dose aspirin. She is 170 cm (5 ft 7 in) tall and weighs 78 kg (172 lb); BMI is 27 kg/m2. Her temperature is 37.7°C (99.9°F), pulse is 78/min, and blood pressure is 138/88 mm Hg. Examination shows large dense breasts. There is widespread erythema and edematous skin plaques over a breast mass in the left breast. The left breast is tender to touch and left-sided axillary lymphadenopathy is noted. Which of the following is the most likely diagnosis?", "answer": "Inflammatory breast cancer", "options": {"A": "Paget's disease of the breast", "B": "Mastitis", "C": "Breast fibroadenoma", "D": "Breast abscess", "E": "Inflammatory breast cancer"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "gravida 3", "para 3", "physician", "left breast", "larger", "hot", "itchy", "past", "months", "patient", "small lump in", "left breast", "year", "not", "medical", "time", "hypertension", "hyperlipidemia", "Menarche", "age", "years", "menopause at", "age", "years", "died of breast cancer", "age", "years", "patient", "not smoke", "Current medications include labetalol", "simvastatin", "daily low-dose aspirin", "5 ft", "tall", "kg", "BMI", "27 kg/m2", "temperature", "99 9F", "pulse", "min", "blood pressure", "88 mm Hg", "large dense breasts", "widespread erythema", "edematous skin plaques", "breast mass", "left breast", "left breast", "tender", "touch", "left-sided axillary lymphadenopathy", "noted", "following", "diagnosis"]}
{"question": "A 22-year-old man is brought to the emergency department 25 minutes after an episode of violent jerky movements of his arms and legs. He has no recollection of the episode. The episode lasted for 3–4 minutes. His girlfriend reports that he has not been sleeping well over the past month. He is only oriented to place and person. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 18/min, and blood pressure is 110/80 mm Hg. Neurologic examination shows no focal findings. A complete blood count as well as serum concentrations of glucose, electrolytes, and calcium are within the reference range. Urine toxicology screening is negative. An MRI of the brain shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Electroencephalography", "options": {"A": "Lorazepam", "B": "Lumbar puncture", "C": "Tilt table test", "D": "Electroencephalography", "E": "Lamotrigine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "minutes", "episode of violent jerky movements", "arms", "legs", "of", "episode", "episode lasted", "minutes", "reports", "not", "sleeping well", "past month", "only oriented to place", "temperature", "98", "pulse", "99 min", "respirations", "min", "blood pressure", "80 mm Hg", "Neurologic examination", "focal findings", "complete blood count", "serum", "glucose", "electrolytes", "calcium", "reference range", "Urine toxicology", "negative", "MRI of", "brain", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 60-year-old man is admitted to the ER for a severe persistent abdominal pain of 6 hours duration with nausea, vomiting, and steatorrhea. His medical history is relevant for multiple similar episodes of abdominal pain, hypertension, a recent fasting plasma glucose test of 150 mg/dL, and an HbA1c of 7.8%. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Physical examination is positive for epigastric tenderness. A computed tomography of the abdomen of the patient is shown in the picture. Which of the following laboratory results is most specific for this patient's condition?", "answer": "Low serum trypsin, low stool elastase", "options": {"A": "Elevated amylase, elevated lipase", "B": "Low serum trypsin, low stool elastase", "C": "Elevated ALT, elevated gamma-glutamyl transpeptidase", "D": "High serum trypsin, high stool elastase", "E": "Elevated alkaline phosphatase, elevated total bilirubin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old man", "ER", "severe persistent abdominal", "hours duration", "nausea", "vomiting", "steatorrhea", "medical history", "relevant", "multiple similar episodes of abdominal pain", "hypertension", "recent fasting plasma glucose test", "mg/dL", "temperature", "98", "respirations", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "positive", "epigastric tenderness", "computed tomography of", "abdomen", "patient", "picture", "following laboratory results", "most specific", "patient's condition"]}
{"question": "An investigator is studying the effect of chromatin structure on gene regulation. The investigator isolates a class of proteins that compact DNA by serving as spools upon which DNA winds around. These proteins are most likely rich in which of the following compounds?", "answer": "Lysine and arginine", "options": {"A": "Phosphate", "B": "Proline and alanine", "C": "Heparan sulfate", "D": "Lysine and arginine", "E": "Disulfide-bonded cysteine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "effect", "chromatin structure", "investigator isolates a", "proteins", "compact DNA", "serving", "spools", "DNA winds", "proteins", "rich", "following compounds"]}
{"question": "A 73-year-old man comes to the physician because of a 2-month history of intermittent blood in his stool. He has had no pain with defecation. Physical examination shows a 2-cm mass located above the dentate line. Further evaluation of the mass confirms adenocarcinoma. Which of the following describes the most likely route of hematogenous spread of the malignancy?", "answer": "Superior rectal vein → inferior mesenteric vein → hepatic portal vein", "options": {"A": "Superior rectal vein → inferior mesenteric vein → hepatic portal vein", "B": "Inferior rectal vein → inferior mesenteric vein → splenic vein", "C": "Inferior rectal vein → internal pudendal vein → internal iliac vein", "D": "Superior rectal vein → superior mesenteric vein → hepatic portal vein", "E": "Inferior rectal vein → internal pudendal vein → external iliac vein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "2 month history", "intermittent blood", "stool", "pain", "defecation", "2", "mass", "above", "line", "Further", "mass confirms adenocarcinoma", "following", "route", "hematogenous spread", "malignancy"]}
{"question": "A 12-year-old boy and his mother are brought to the emergency department after a motor vehicle accident. The boy was an unrestrained passenger in a head-on collision and was ejected from the front seat. The patient's mother was the driver and she is currently being resuscitated. Neither the child nor the mother are conscious; however, it is documented that the family are all Jehovah's witnesses and would not want a transfusion in an acute situation. The husband/father arrives to the trauma bay and confirms this wish that everyone in the family would not want a transfusion in accordance with their beliefs. The father is confirmed as the official healthcare proxy. Which of the following is the best next step in management?", "answer": "Do not transfuse the mother and transfuse the boy", "options": {"A": "Consult the hospital ethics committee", "B": "Do not transfuse the boy and transfuse the mother", "C": "Do not transfuse the boy or the mother", "D": "Do not transfuse the mother and transfuse the boy", "E": "Transfuse the boy and mother"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "motor vehicle accident", "boy", "head", "collision", "front", "patient's", "driver", "currently", "resuscitated", "child", "not", "transfusion", "acute", "trauma bay", "confirms", "wish", "not", "transfusion", "confirmed", "official", "following", "best next step"]}
{"question": "A 68-year-old woman comes to the physician because of increasing heartburn for the last few months. During this period, she has taken ranitidine several times a day without relief and has lost 10 kg (22 lbs). She has retrosternal pressure and burning with every meal. She has had heartburn for several years and took ranitidine as needed. She has hypertension. She has smoked one pack of cigarettes daily for the last 40 years and drinks one glass of wine occasionally. Other current medications include amlodipine and hydrochlorothiazide. She appears pale. Her height is 163 cm (5 ft 4 in), her weight is 75 kg (165 lbs), BMI is 27.5 kg/m2. Her temperature is 37.2°C (98.96°F), pulse is 78/min, and blood pressure is 135/80 mm Hg. Cardiovascular examination shows no abnormalities. Abdominal examination shows mild tenderness to palpation in the epigastric region. Bowel sounds are normal. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 10.2 g/dL\nMean corpuscular volume 78 μm\nMean corpuscular hemoglobin 23 pg/cell\nLeukocyte count 9,500/mm3\nPlatelet count 330,000/mm3\nSerum\nNa+ 137 mEq/L\nK+ 3.8 mEq/L\nCl- 100 mEq/L\nHCO3- 25 mEq/L\nCreatinine 1.2 mg/dL\nLactate dehydrogenase 260 U/L\nAlanine aminotransferase 18 U/L\nAspartate aminotransferase 15 U/L\nLipase (N < 280 U/L) 40 U/L\nTroponin I (N < 0.1 ng/mL) 0.029 ng/mL\nAn ECG shows normal sinus rhythm without ST-T changes. Which of the following is the most appropriate next step in the management of this patient?\"", "answer": "Esophagogastroduodenoscopy", "options": {"A": "24-hour esophageal pH monitoring", "B": "Trial of proton-pump inhibitor", "C": "Esophageal manometry", "D": "Barium swallow", "E": "Esophagogastroduodenoscopy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "of increasing heartburn", "months", "period", "ranitidine", "times", "day", "relief", "lost 10 kg", "lbs", "retrosternal pressure", "burning", "heartburn", "years", "ranitidine as needed", "hypertension", "smoked one pack", "cigarettes daily", "last 40 years", "one glass", "occasionally", "current medications include amlodipine", "hydrochlorothiazide", "appears pale", "height", "5 ft 4", "weight", "75 kg", "lbs", "BMI", "27", "kg/m2", "temperature", "98", "pulse", "min", "blood pressure", "80 mm Hg", "abnormalities", "Abdominal", "mild tenderness", "palpation", "epigastric region", "Bowel sounds", "normal", "abnormalities", "Laboratory studies", "10.2", "Mean corpuscular volume", "cell", "count", "mm3 Platelet count", "Serum", "K", "mg", "Aspartate", "Lipase", "N", "U/L", "40 U/L Troponin I", "N", "0.1 ng/mL", "0", "ng/mL", "ECG", "normal sinus rhythm", "ST", "changes", "following", "most appropriate next step", "patient"]}
{"question": "A 66-year-old man is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained passenger. His wife confirms that he has hypertension, atrial fibrillation, and chronic lower back pain. Current medications include metoprolol, warfarin, hydrochlorothiazide, and oxycodone. On arrival, he is lethargic and confused. His pulse is 112/min, respirations are 10/min, and blood pressure is 172/78 mm Hg. The eyes open spontaneously. The pupils are equal and sluggish. He moves his extremities in response to commands. There is a 3-cm scalp laceration. There are multiple bruises over the right upper extremity. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two large-bore peripheral intravenous catheters are inserted. A 0.9% saline infusion is begun. A focused assessment with sonography in trauma is negative. Plain CT of the brain shows a 5-mm right subdural hematoma with no mass effect. Fresh frozen plasma is administered. Which of the following is most likely to reduce this patient's cerebral blood flow?", "answer": "Hyperventilation", "options": {"A": "Hyperventilation", "B": "Decompressive craniectomy", "C": "Lumbar puncture", "D": "Intravenous hypertonic saline", "E": "Intravenous mannitol"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["66 year old man", "brought", "emergency department 20 minutes", "involved", "high speed motor vehicle collision", "confirms", "hypertension", "atrial fibrillation", "chronic lower back pain", "Current medications include metoprolol", "warfarin", "hydrochlorothiazide", "oxycodone", "arrival", "lethargic", "confused", "pulse", "min", "respirations", "10/min", "blood pressure", "mm Hg", "eyes open", "pupils", "equal", "sluggish", "moves", "3", "scalp laceration", "multiple bruises", "right upper extremity", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "Neurologic examination", "focal findings", "Two large bore peripheral intravenous catheters", "0.9", "saline infusion", "begun", "focused assessment", "sonography", "trauma", "negative", "CT of", "brain", "5-mm right subdural hematoma", "mass effect", "Fresh frozen plasma", "administered", "following", "to", "patient's cerebral blood flow"]}
{"question": "A 29-year-old woman comes to her primary care physician hoping she is pregnant. She reports that she had been taking oral contraceptive pills, but she stopped when she began trying to get pregnant about 7 months ago. Since then she has not had her period. She took a few home pregnancy tests that were negative, but she feels they could be wrong. She says she has gained 4 lbs in the past month, and her breasts feel full. Today, she expressed milk from her nipples. She complains of fatigue, which she attributes to stress at work, and headaches, to which she says “my sister told me she had headaches when she was pregnant.” She denies spotting or vaginal discharge. Her last menstrual period was at age 22, prior to starting oral contraceptive pills. Her medical and surgical history are non-significant. She has no history of sexually transmitted infections. She reports she and her husband are having intercourse 3-4 times a week. Her family history is significant for breast cancer in her mother and an aunt who died of ovarian cancer at 55. On physical examination, no breast masses are appreciated, but compression of the nipples produces whitish discharge bilaterally. A bimanual pelvic examination is normal. A urine pregnancy test is negative. Which of the following is the best initial step in management for this patient?", "answer": "Serum thyroid-stimulating hormone level", "options": {"A": "Mammogram", "B": "Magnetic resonance imaging of the head", "C": "Pelvic ultrasound", "D": "Serum follicle-stimulating hormone/luteinizing hormone ratio", "E": "Serum thyroid-stimulating hormone level"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["29 year old woman", "primary care physician", "pregnant", "reports", "oral contraceptive pills", "stopped", "began", "to", "pregnant", "7 months", "then", "not", "period", "few home pregnancy tests", "negative", "wrong", "gained 4 lbs", "past month", "breasts", "full", "Today", "milk", "nipples", "fatigue", "attributes", "stress", "headaches", "headaches", "pregnant", "spotting", "vaginal discharge", "last menstrual period", "age", "starting oral contraceptive pills", "medical", "surgical history", "non significant", "history", "sexually transmitted infections", "reports", "intercourse", "times", "week", "family history", "significant", "breast cancer", "died of ovarian cancer", "breast masses", "compression", "nipples", "discharge", "bimanual pelvic", "normal", "urine pregnancy test", "negative", "following", "best initial step", "patient"]}
{"question": "A 72-year-old man comes to the physician for a routine physical examination. He does not take any medications. Physical examination shows no abnormalities. Laboratory studies show a calcium concentration of 8.5 mg/dL, a phosphorus concentration of 3.1 mg/dL, an elevated bone-specific alkaline phosphatase concentration, and a normal urine deoxypyridinoline concentration. Which of the following is the most likely explanation for this patient's laboratory abnormalities?", "answer": "Increased osteoblast activity", "options": {"A": "Increased parafollicular C-cell activity", "B": "Decreased osteoclast activity", "C": "Increased osteoblast activity", "D": "Decreased parathyroid chief cell activity", "E": "Increased chondroblast activity"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man", "physician", "routine physical examination", "not", "medications", "abnormalities", "Laboratory studies", "calcium concentration", "8.5 mg/dL", "phosphorus concentration", "mg/dL", "elevated bone-specific alkaline phosphatase concentration", "normal deoxypyridinoline concentration", "following", "explanation", "patient's laboratory abnormalities"]}
{"question": "A 28-year-old woman who has never been pregnant presents to the physician for a follow-up examination. She has had 5 months of deep pain during sexual intercourse and pelvic pain that intensified prior to her menses. The pain has not subsided despite taking oral contraceptives. She denies any vaginal discharge or foul smell. She is in a monogamous relationship with her husband of 2 years. She has no history of any serious illnesses. Her vital signs are within normal limits. Physical examination shows tenderness on deep palpation of the hypogastrium. A speculum examination of the vagina and cervix shows no abnormalities or discharge. Serum studies show a beta hCG of 6 mIU/mL. A transabdominal ultrasound shows no abnormalities. Which of the following is most likely to establish a diagnosis?", "answer": "Laparoscopy", "options": {"A": "Abdominopelvic computed tomography (CT) scan", "B": "Cancer antigen 125 (CA-125)", "C": "Laparoscopy", "D": "Dilation and curettage", "E": "Wet-mount test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "never", "pregnant presents", "physician", "follow-up examination", "5 months", "deep pain", "sexual intercourse", "pelvic pain", "prior to", "menses", "pain", "not", "oral contraceptives", "vaginal discharge", "smell", "relationship", "years", "history", "serious illnesses", "vital signs", "normal", "Physical examination", "tenderness", "deep palpation of", "hypogastrium", "speculum examination of", "vagina", "cervix", "abnormalities", "discharge", "Serum studies", "a beta hCG", "mIU/mL", "transabdominal ultrasound", "abnormalities", "following", "to establish", "diagnosis"]}
{"question": "A 62-year-old woman with metastatic breast cancer comes to the physician because of a 2-day history of fever, chills, and new gluteal lesions. The lesions began as painless red macules and evolved into painful ulcers overnight. She received her fourth course of palliative chemotherapy 2 weeks ago. Her temperature is 38.2°C (100.8°F). Laboratory studies show a leukocyte count of 2,000/mm3 (20% segmented neutrophils). A photograph of one of the skin lesions is shown. Which of the following virulence factors is most likely involved in the pathogenesis of this patient's skin finding?", "answer": "Exotoxin A", "options": {"A": "Edema toxin", "B": "Heat-stable toxin", "C": "Toxic shock syndrome toxin-1", "D": "Exotoxin A", "E": "Endotoxin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "metastatic", "physician", "2-day history", "fever", "chills", "new gluteal lesions", "lesions began", "painless red macules", "evolved", "painful ulcers overnight", "received", "fourth course", "palliative chemotherapy 2 weeks", "temperature", "100", "Laboratory studies", "leukocyte count", "mm3", "20", "segmented neutrophils", "photograph", "one", "skin lesions", "following virulence factors", "most likely involved", "pathogenesis", "patient's skin finding"]}
{"question": "A 61-year-old female presents to her primary care physician complaining of fatigue and feeling sad. She reports that ever since her husband passed away 3 months ago, she has noticed a decrease in her energy level and reports frequently awaking at 2 in the morning and cannot fall back asleep. She sometimes wakes up and hears her husband's voice, constantly thinks about how much she misses him, and has recently thought about ways to kill herself including driving through a red light. She used to be an active member of her neighborhood’s bridge club but has stopped playing. She has lost 15 pounds and rarely feels hungry. Which of the following is the most likely diagnosis in this patient?", "answer": "Major depressive disorder", "options": {"A": "Bipolar II disorder", "B": "Major depressive disorder", "C": "Acute grief", "D": "Persistent depressive disorder", "E": "Schizoaffective disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old female presents", "primary care physician", "fatigue", "feeling sad", "reports", "ever", "passed", "months", "decrease", "energy level", "reports frequently awaking at", "morning", "fall back asleep", "sometimes wakes up", "hears", "voice", "constantly", "about", "misses", "recently", "to kill", "including", "used to", "active member", "neighborhoods bridge club", "stopped playing", "lost", "pounds", "rarely", "hungry", "following", "diagnosis", "patient"]}
{"question": "A physician is describing a case to his residents where a kidney transplant was rapidly rejected by the recipient minutes after graft perfusion. The physician most likely describes all of the following manifestations EXCEPT?", "answer": "Histological evidence of arteriosclerosis", "options": {"A": "Graft mottling", "B": "Graft cyanosis", "C": "Low urine output with evidence of blood", "D": "Histological evidence of arteriosclerosis", "E": "Histological evidence of vascular damage"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["physician", "case", "residents", "kidney transplant", "rapidly rejected", "minutes", "graft perfusion", "physician", "likely", "of", "following manifestations"]}
{"question": "A 32-year-old man comes to the physician because of a 3-month history of intermittent flank pain and reddish discoloration of urine. His blood pressure is 150/92 mm Hg. His serum creatinine concentration is 1.4 mg/dL. An abdominal CT scan is shown. This patient's condition is most likely caused by a genetic defect in which of the following locations?", "answer": "Short arm of chromosome 16", "options": {"A": "Short arm of chromosome 16", "B": "Short arm of chromosome 3", "C": "Long arm of chromosome 4", "D": "Long arm of chromosome 10", "E": "Short arm of chromosome 6"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "3 month history", "intermittent flank", "discoloration", "urine", "blood pressure", "mm Hg", "serum concentration", "1.4 mg/dL", "abdominal CT", "patient's condition", "most likely caused", "genetic defect", "following locations"]}
{"question": "A 6-year-old boy is brought to the physician because of inability to concentrate and difficulties completing assignments at school. His mother says that he frequently interrupts others during conversations at home and that his teachers often reprimand him for talking excessively in school. He refuses to play with the other children and often has physical altercations with his classmates. He can jump up and down but he cannot hop on one foot. He eats without assistance but has difficulty using silverware. He cannot follow three-step directions. There is no family history of serious illness. Examination shows a small head, wide-spaced eyes, and short palpebral fissures. His upper lip is thin and flat. He has a sunken nasal bridge and a small jaw. There is a 3/6 pansystolic murmur heard along the left lower sternal border. Which of the following is the most likely cause of these findings?", "answer": "Prenatal alcohol exposure", "options": {"A": "Nondisjunction of chromosome 21", "B": "Deletion of long arm of chromosome 7", "C": "Prenatal alcohol exposure", "D": "FMR1 gene mutation", "E": "Maternal intake of phenytoin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "to concentrate", "difficulties completing assignments", "school", "frequently interrupts others", "at home", "teachers often", "talking excessively", "school", "to play", "children", "often", "jump", "down", "hop", "one foot", "eats", "assistance", "difficulty using", "follow three step directions", "family history", "serious illness", "small head", "wide spaced eyes", "short palpebral fissures", "upper lip", "thin", "flat", "sunken nasal bridge", "small jaw", "3/6 pansystolic murmur heard", "left lower sternal border", "following", "most likely cause", "findings"]}
{"question": "A 27-year-old female is brought in by ambulance with altered mental status. She is in a comatose state, but is breathing spontaneously with deep and rapid respirations. Her vital signs are as follows: T 100.2F, BP 92/54 mmHg, HR 103 bpm, RR 28, and SpO2 97% on room air. Complete blood count reveals: WBC 12.7, hemoglobin 11.3, platelets 254. Basic metabolic panel reveals: sodium 137, potassium 4.2, chloride 100, bicarbonate 16, creatinine 1.78 An ABG is performed which showed pH 7.38, PaO2 94, PaCO2 26. Which of the following is the most likely cause of this patient’s presentation?", "answer": "Medication overdose", "options": {"A": "Undiagnosed type 1 diabetes mellitus", "B": "Severe sepsis", "C": "Medication overdose", "D": "Acute renal failure", "E": "Alcohol binging"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old female", "brought", "ambulance", "altered mental status", "comatose state", "breathing", "deep", "rapid respirations", "vital signs", "follows", "T 100", "BP", "54 mmHg", "RR", "97", "room air", "Complete blood count reveals", "WBC", "hemoglobin", "platelets", "Basic metabolic panel reveals", "sodium", "potassium", "100", "bicarbonate", "creatinine", "ABG", "performed", "pH 7", "PaO2", "following", "most likely cause", "patients"]}
{"question": "Researchers are studying the relationship between heart disease and alcohol consumption. They review the electronic medical records of 500 patients at a local hospital during the study period and identify the presence or absence of acute coronary syndrome (ACS) and the number of alcoholic drinks consumed on the day of presentation. The researchers determine the prevalence of ACS and of alcoholic drink consumption. They correlate the relationship between these two variables and find that patients who reported no alcohol consumption or 1 drink only that day had a lower risk of acute coronary syndrome than patients who reported 2 or more drinks. Which of the following is the most accurate description of this study type?", "answer": "Cross-sectional study", "options": {"A": "Randomized controlled trial", "B": "Case-control study", "C": "Cross-sectional study", "D": "Retrospective study", "E": "Prospective study"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Researchers", "studying", "relationship", "heart", "500 patients", "local hospital", "study period", "presence", "absence", "acute coronary syndrome", "number", "day", "researchers", "prevalence", "ACS", "relationship", "two variables", "find", "patients", "reported", "1", "only", "day", "lower risk", "acute coronary syndrome", "patients", "reported 2", "more", "following", "most accurate description", "study type"]}
{"question": "A 69-year-old man is brought to the emergency department because of a 1-week history of recurring black stools. On questioning, he reports fatigue and loss of appetite over the last 3 months. Twenty years ago, he underwent a partial gastrectomy for peptic ulcer disease. The patient's father died of metastatic colon cancer at the age of 57 years. He is 163 cm (5 ft 4 in) tall and weighs 55 kg (121 lb); BMI is 20.8 kg/m2. He appears chronically ill. His temperature is 36.5°C (97.7°F), pulse is 105/min, and blood pressure is 115/70 mm Hg. The conjunctiva appear pale. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. There is a well-healed scar on the upper abdomen. His hemoglobin concentration is 10.5 g/dL and his mean corpuscular volume is 101 μm3. An upper endoscopy shows a large nodular mass on the anterior wall of the lesser curvature of the gastric stump. Biopsy samples are obtained, showing polypoid, glandular formation of irregular-shaped and fused gastric cells with intraluminal mucus, demonstrating an infiltrative growth. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Abdominopelvic CT scan", "options": {"A": "Stool antigen test for H. pylori", "B": "Laparoscopy", "C": "Treatment with PPI, clarithromycin, and amoxicillin", "D": "Abdominopelvic CT scan", "E": "Vitamin B12 assessment"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old man", "brought", "emergency department", "1-week history", "recurring black stools", "reports fatigue", "loss of appetite", "last", "months", "Twenty years", "partial gastrectomy", "peptic ulcer disease", "patient's", "died of metastatic colon cancer", "age", "57 years", "5 ft 4", "tall", "kg", "BMI", "20", "kg/m2", "appears chronically ill", "temperature", "36", "97", "pulse", "min", "blood pressure", "70 mm Hg", "conjunctiva appear pale", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "nontender", "well healed scar", "upper abdomen", "hemoglobin concentration", "10.5 g/dL", "mean corpuscular volume", "m3", "upper endoscopy", "large nodular mass", "anterior wall", "lesser", "gastric stump", "Biopsy samples", "obtained", "polypoid", "glandular formation", "irregular shaped", "fused", "intraluminal", "infiltrative growth", "following", "most appropriate next step", "patient"]}
{"question": "A 21-year-old woman comes to the physician because of a 4-month history of fatigue. She admits to binge eating several times per month, after which she usually induces vomiting for compensation. She exercises daily in an effort to lose weight. She is 168 cm (5 ft 6 in) tall and weighs 60 kg (132 lb); BMI is 21.3 kg/m2. Physical examination shows calluses on the knuckles and bilateral parotid gland enlargement. Oropharyngeal examination shows eroded dental enamel and decalcified teeth. Which of the following is the most appropriate pharmacotherapy for this patient's condition?", "answer": "Fluoxetine", "options": {"A": "Orlistat", "B": "Mirtazapine", "C": "Buspirone", "D": "Venlafaxine", "E": "Fluoxetine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["21-year-old woman", "physician", "4 month history", "fatigue", "to binge eating", "times", "month", "usually induces vomiting", "compensation", "exercises daily", "effort to", "weight", "5 ft 6", "tall", "60 kg", "BMI", "kg/m2", "calluses", "knuckles", "bilateral parotid gland enlargement", "Oropharyngeal", "eroded dental enamel", "teeth", "following", "most appropriate pharmacotherapy", "patient's condition"]}
{"question": "A 33-year-old man comes to the physician with his wife for evaluation of infertility. They have been unable to conceive for 2 years. The man reports normal libido and erectile function. He has smoked one pack of cigarettes daily for 13 years. He does not take any medications. He has a history of right-sided cryptorchidism that was surgically corrected when he was 7 years of age. Physical examination shows no abnormalities. Analysis of his semen shows a low sperm count. Laboratory studies are most likely to show which of the following?", "answer": "Decreased inhibin B concentration", "options": {"A": "Increased placental ALP concentration", "B": "Increased prolactin concentration", "C": "Decreased inhibin B concentration", "D": "Decreased FSH concentration", "E": "Decreased testosterone concentration"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "infertility", "unable to", "years", "man reports", "erectile function", "smoked one pack", "cigarettes daily", "years", "not", "medications", "history", "right-sided cryptorchidism", "surgically corrected", "years", "age", "abnormalities", "Analysis", "semen", "low", "count", "Laboratory studies", "to", "following"]}
{"question": "A 17-year-old boy was brought to the emergency department because of palpitations and lightheadedness that began 16 hours ago. He admitted to binge drinking the night before. He was sedated and electrically cardioverted. An ECG that was recorded following cardioversion is shown. After regaining consciousness, he was admitted for observation. Serum concentration of creatinine and electrolytes were measured to be within the reference range. Twelve hours after cardioversion, the patient complains again of palpitations. He does not have lightheadedness or chest pain. His temperature is 37.1°C (98.8°F), pulse is 220/min, respirations are 20/min, and blood pressure is 112/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination shows no abnormalities. A newly recorded ECG shows a shortened PR interval, and wide, monomorphic QRS complexes with a regular rhythm. Which of the following is the most appropriate next best step in management?", "answer": "Administer procainamide", "options": {"A": "Administer magnesium sulfate", "B": "Administer verapamil", "C": "Administer atenolol", "D": "Administer procainamide", "E": "Administer adenosine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "palpitations", "lightheadedness", "began", "hours", "to", "night", "sedated", "ECG", "recorded following cardioversion", "consciousness", "admitted for observation", "Serum", "creatinine", "electrolytes", "measured to", "reference range", "Twelve hours", "cardioversion", "patient", "palpitations", "not", "lightheadedness", "chest pain", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "84 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "98", "abnormalities", "recorded ECG", "shortened PR interval", "wide", "QRS complexes", "regular rhythm", "following", "most appropriate next best step"]}
{"question": "A 4-year-old girl is brought to the emergency department after falling about from a chair and injuring her right leg. During the past 2 years, she has had two long bone fractures. She is at the 5th percentile for height and 20th percentile for weight. Her right lower leg is diffusely erythematous. The patient withdraws and yells when her lower leg is touched. A photograph of her face is shown. An x-ray of the right lower leg shows a transverse mid-tibial fracture with diffusely decreased bone density. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Type 1 collagen defect", "options": {"A": "Type 3 collagen defect", "B": "Type 5 collagen defect", "C": "Type 1 collagen defect", "D": "Type 4 collagen defect", "E": "Type 2 collagen defect"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old girl", "brought", "emergency department", "falling", "from", "chair", "right leg", "past", "years", "two long bone fractures", "5th percentile", "height", "percentile", "weight", "right lower leg", "erythematous", "patient", "lower leg", "touched", "photograph", "face", "x-ray", "right lower leg", "transverse", "tibial", "decreased bone density", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 21-year-old woman with type 1 diabetes mellitus suddenly develops tremors, cold sweats, and confusion while on a backpacking trip with friends. She is only oriented to person and is unable to follow commands. Her fingerstick blood glucose concentration is 28 mg/dL. Her friend administers an intramuscular injection with a substance that reverses her symptoms. Which of the following is the most likely mechanism of action of this drug?", "answer": "Activation of adenylyl cyclase", "options": {"A": "Activation of glucokinase", "B": "Inhibition of glucose-6-phosphatase", "C": "Inhibition of α-glucosidase", "D": "Activation of adenylyl cyclase", "E": "Inhibition of glycogen phosphorylase\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old woman", "type 1 diabetes mellitus", "tremors", "cold sweats", "confusion", "trip", "only oriented to person", "unable to follow", "fingerstick blood glucose concentration", "mg/dL", "administers", "intramuscular injection", "reverses", "symptoms", "following", "mechanism of action", "drug"]}
{"question": "A 52-year-old diabetic man presents with fever, headache, and excruciating pain in his right eye for the past 2 days. He says that he has been taking sitagliptin and metformin regularly. He endorses recently having a sore throat. On examination, vesicles are present in groups with an erythematous base on the upper eyelid, forehead, and nose on the right half of his face. The patient is prescribed an antiviral agent and sent home. Which of the following nerves is most likely involved?", "answer": "Ophthalmic nerve", "options": {"A": "Nasociliary nerve", "B": "Ophthalmic nerve", "C": "Supraorbital nerve", "D": "Supratrochlear nerve", "E": "Lacrimal nerve"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old diabetic man presents", "fever", "headache", "excruciating pain in", "right eye", "past 2 days", "sitagliptin", "metformin", "recently", "sore throat", "vesicles", "present", "groups", "erythematous base", "upper eyelid", "forehead", "nose", "right half", "face", "patient", "antiviral agent", "sent home", "following nerves", "most likely involved"]}
{"question": "A 42-year-old man presents to his primary care provider with recent swelling in his legs that has now spread to the lower part of his thighs. He sometimes has difficulty putting on his shoes and pants. He also noticed puffiness under his eyes over the last 3 weeks. A 24-hour urine collection confirms proteinuria of 5 g/day. Electron microscopy of a renal biopsy specimen reveals subepithelial deposits with a spike and dome pattern. Which of the following is associated with this patient’s condition?", "answer": "Hepatitis B infection", "options": {"A": "HIV infection", "B": "High HbA1C", "C": "Hepatitis B infection", "D": "Hodgkin's lymphoma", "E": "Monoclonal protein spike"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider", "recent swelling", "legs", "now spread", "lower part of", "thighs", "sometimes", "difficulty", "pants", "puffiness", "eyes", "last", "weeks", "24-hour urine collection confirms proteinuria", "5 g day", "Electron microscopy", "renal biopsy specimen reveals", "deposits", "dome pattern", "following", "associated with", "patients condition"]}
{"question": "A 24-year-old woman comes to the physician for an annual routine examination. Menses occur at regular 28-day intervals and last for 4 days with normal flow. Her last menstrual period was 3 weeks ago. She is sexually active with one male partner and they use condoms consistently. The patient is 160 cm (5 ft 3 in) tall and weighs 72 kg (150 lb); BMI is 28.1 kg/m2. She feels well. Pelvic examination shows a smooth, mobile right adnexal mass. A subsequent ultrasound of the pelvis shows a single, 2-cm large, round, hypoechoic mass with a thin, smooth wall in the right ovary. The mass has posterior wall enhancement, and there are no signs of blood flow or septae within the mass. Which of the following is the most appropriate next step in management?", "answer": "Follow-up examination", "options": {"A": "Diagnostic laparoscopy", "B": "CA-125 level", "C": "CT scan of the pelvis", "D": "Oral contraceptive", "E": "Follow-up examination"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "annual routine", "Menses occur", "regular", "day intervals", "last", "4 days", "normal", "last menstrual period", "3 weeks", "sexually active", "one male", "use condoms", "patient", "5 ft", "tall", "72 kg", "BMI", "kg/m2", "well", "Pelvic examination", "smooth", "mobile right adnexal mass", "subsequent ultrasound", "pelvis", "single", "large", "round", "mass", "thin", "smooth wall", "right ovary", "mass", "posterior wall enhancement", "signs", "blood flow", "mass", "following", "most appropriate next step"]}
{"question": "A 21-year-old man presents with fever, headache, and clouded sensorium for the past 3 days. His fever is low-grade. He says his headache is mild-to-moderate in intensity and associated with nausea, vomiting, and photophobia. There is no history of a sore throat, pain on urination, abdominal pain, or loose motions. He smokes 1–2 cigarettes daily and drinks alcohol socially. Past medical history and family history are unremarkable. His vital signs include: blood pressure 120/80 mm Hg, pulse 106/min, temperature 37.3°C (99.2°F). On physical examination, he is confused, disoriented, and agitated. Extraocular movements are intact. The neck is supple on flexion. He is moving all his 4 limbs spontaneously. A noncontrast CT scan of the head is within normal limits. A lumbar puncture is performed, and cerebrospinal fluid results are still pending. The patient is started on empiric intravenous acyclovir. Which of the following clinical features favors encephalitis rather than meningitis?", "answer": "Clouded sensorium", "options": {"A": "Clouded sensorium", "B": "Fever", "C": "Headache", "D": "Nausea and vomiting", "E": "Photophobia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["21-year-old man presents", "fever", "headache", "clouded sensorium", "past 3 days", "fever", "low-grade", "headache", "mild-to-moderate", "intensity", "associated with nausea", "vomiting", "photophobia", "history", "sore throat", "pain", "urination", "abdominal pain", "loose motions", "smokes", "cigarettes daily", "alcohol", "Past medical history", "family history", "unremarkable", "vital signs include", "blood pressure", "80 mm Hg", "pulse", "min", "temperature", "99", "confused", "disoriented", "agitated", "Extraocular movements", "intact", "neck", "supple", "flexion", "moving", "4 limbs", "CT scan of", "head", "normal limits", "lumbar puncture", "performed", "cerebrospinal fluid results", "patient", "started", "empiric intravenous acyclovir", "following clinical features favors encephalitis", "meningitis"]}
{"question": "A 68-year-old man comes to the physician because of a 3-month history of anorexia, weight loss, and cough productive of blood-tinged sputum with yellow granules. Four months ago he was treated for gingivitis. He has smoked 1 pack of cigarettes daily for 40 years. Examination shows crackles over the right upper lung field. An x-ray of the chest shows a solitary nodule and one cavitary lesion in the right upper lung field. A photomicrograph of a biopsy specimen from the nodule obtained via CT-guided biopsy is shown. Which of the following is the most appropriate pharmacotherapy?", "answer": "Penicillin G", "options": {"A": "Penicillin G", "B": "Cisplatin and paclitaxel", "C": "Trimethoprim-sulfamethoxazole", "D": "Rifampin, isoniazid, pyrazinamide, and ethambutol", "E": "Itraconazole"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "3 month history", "anorexia", "weight loss", "cough productive of blood tinged sputum", "yellow granules", "Four months", "treated", "gingivitis", "smoked 1 pack", "cigarettes daily", "40 years", "crackles", "right upper lung field", "x-ray of", "chest", "solitary nodule", "one", "lesion", "right upper lung field", "photomicrograph", "biopsy specimen", "nodule obtained", "CT-guided biopsy", "following", "most appropriate pharmacotherapy"]}
{"question": "A 70-year-old man comes to the physician because of intermittent shortness of breath while going up stairs and walking his dog. It began about 1 month ago and seems to be getting worse. He has also developed a dry cough. He has not had any wheezing, fevers, chills, recent weight loss, or shortness of breath at rest. He has a history of Hodgkin lymphoma, for which he was treated with chemotherapy and radiation to the chest 7 years ago. He also has hypertension, for which he takes lisinopril. Ten years ago, he retired from work in the shipbuilding industry. He has smoked half a pack of cigarettes daily since the age of 21. Vital signs are within normal limits. On lung auscultation, there are mild bibasilar crackles. A plain x-ray of the chest shows bilateral ground-glass opacities at the lung bases and bilateral calcified pleural plaques. Which of the following is the greatest risk factor for this patient's current condition?", "answer": "Occupational exposure", "options": {"A": "Occupational exposure", "B": "Smoking", "C": "Advanced age", "D": "Family history", "E": "Radiation therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old man", "physician", "of intermittent shortness", "breath", "began", "month", "to", "getting worse", "dry cough", "not", "wheezing", "fevers", "chills", "recent weight loss", "shortness of breath", "history of Hodgkin lymphoma", "treated with chemotherapy", "radiation", "chest", "years", "hypertension", "lisinopril", "Ten years", "retired", "smoked half", "pack", "cigarettes daily", "age", "Vital signs", "normal limits", "lung auscultation", "mild", "crackles", "plain x-ray", "chest", "bilateral ground-glass opacities", "lung bases", "bilateral calcified pleural plaques", "following", "greatest risk factor", "patient's current condition"]}
{"question": "A 65-year-old obese woman presents with changes in her left breast. The patient states that, about a month ago, she noticed that she was able to feel a hard mass in the upper outer quadrant of her left breast, which has not gone away. In addition, her nipple and skin overlying the breast have started to look different. Past medical history is significant for the polycystic ovarian syndrome (PCOS) and hypertension, well-managed with lisinopril. The patient has never been pregnant. Menopause was at age 53. Family history is significant for breast cancer in her mother at age 55, and her father who died of lung cancer at age 52. A review of systems is significant for a 13.6 kg (30 lb) weight loss in the last 2 months despite no change in diet or activity. Vitals include: temperature 37.0°C (98.6°F), blood pressure 120/75 mm Hg, pulse 97/min, respiratory rate 16/min, and oxygen saturation 99% on room air. The physical exam is significant for a palpable, hard, fixed mass in the upper outer quadrant of the left breast, as well as nipple retraction and axillary lymphadenopathy. Mammography of the left breast reveals a spiculated mass in the upper outer quadrant. A biopsy confirms invasive ductal carcinoma. Molecular analysis reveals that the tumor cells are positive for a receptor that is associated with a poor prognosis. Which of the following are indicated as part of this patient’s treatment?", "answer": "Trastuzumab", "options": {"A": "Goserelin", "B": "Tamoxifen", "C": "Trastuzumab", "D": "Anastrozole", "E": "Raloxifene"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old obese woman presents", "changes", "left breast", "patient states", "month", "able to", "hard mass", "upper outer quadrant of", "left breast", "not", "addition", "nipple", "skin", "breast", "started to look different", "Past medical history", "significant", "polycystic ovarian syndrome", "hypertension", "well", "lisinopril", "patient", "never", "pregnant", "Menopause", "age", "Family history", "significant", "breast cancer", "mother", "age", "died of lung cancer", "age", "review of systems", "significant", "13.6 kg", "30", "weight loss", "months", "change in diet", "activity", "include", "temperature", "98", "blood pressure", "75 mm Hg", "pulse 97 min", "respiratory rate", "min", "oxygen saturation 99", "room air", "significant", "palpable", "hard", "fixed mass", "upper outer quadrant of", "left breast", "nipple retraction", "axillary lymphadenopathy", "Mammography of", "left breast reveals", "spiculated mass", "upper outer quadrant", "biopsy confirms invasive ductal carcinoma", "reveals", "positive", "receptor", "associated with", "poor prognosis", "following", "indicated", "part of"]}
{"question": "An 11-year-old boy is brought to the doctor by his father because his father is worried about the boy's performance in school and his lack of a social life. His father is also worried about the ongoing bullying his son is experiencing due to swearing outbursts the boy has exhibited for several years. During these outbursts, the boy contorts his face, blinks repeatedly, and grunts. His father is worried that the bullying will worsen and would like to see if there is a medication that can help his son. Which of the following medications is most likely to be beneficial?", "answer": "Risperidone", "options": {"A": "Valproic acid", "B": "Risperidone", "C": "Lamotrigine", "D": "Clonazepam", "E": "Lithium"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "doctor", "worried", "boy's", "in school", "lack", "worried", "bullying", "due to swearing outbursts", "boy", "years", "outbursts", "boy", "face", "blinks repeatedly", "grunts", "worried", "bullying", "worsen", "to see", "medication", "help", "following medications", "to"]}
{"question": "A 54-year-old woman presents to the emergency room after falling on her right side at a bar and breaking her clavicle and 2 ribs. Her husband reports that she has had a 6-month history of diarrhea and has lost 6.8 kg (15 lb) over the last year without dieting or exercising. She has a family history of type I diabetes. On physical exam, ecchymosis is noted over her entire right shoulder, extending to her sternum and over her broken ribs. She also has other bruises in various stages of healing. Her abdomen is diffusely tender, radiating to her back, and there is a palpable midepigastric mass. The woman has a positive Romberg test, but the rest of her examination is normal. She is admitted for further evaluation. Her labs and pancreas biopsy histology are as follows:\nLaboratory tests\nSerum chemistries \nAlbumin 5.1 g/dL\nAmylase 124 U/L\nLipase 146 U/L\nBlood glucose (fasting)  180 mg/dL\nTriglycerides 140 mg/dL\nCholesterol, total 210 mg/dL\nHDL 25 mg/dL\nLDL 165 mg/dL\nSerum electrolytes \nSodium 137 mEq/L\nPotassium 3.5 mEq/L\nChloride 90 mEq/L\nInternational normalized ratio 2.5\nActivated partial thromboplastin time  30 s\n    Complete blood count\nHemoglobin 12.5 g/dL\nMean corpuscular volume 102 µm3\nPlatelets 150,000/mm3\nLeukocytes 6000/mm3\nStool analysis\nElastase low\nOccult blood absent\nWhich of the following is the best way to manage her condition in the long term?", "answer": "Insulin aspart and glargine with pancreatic enzyme replacement therapy", "options": {"A": "Thiamine and 50% dextrose", "B": "Gemcitabine alone", "C": "Pancreatic resection followed by 5-fluorouracil with leucovorin", "D": "Insulin aspart and glargine", "E": "Insulin aspart and glargine with pancreatic enzyme replacement therapy"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["54 year old woman presents", "emergency room", "falling", "right side", "bar", "breaking", "clavicle", "2 ribs", "reports", "6 month history", "diarrhea", "lost", "kg", "last year", "dieting", "exercising", "family history", "type I diabetes", "ecchymosis", "noted", "entire right shoulder", "extending", "sternum", "broken ribs", "bruises", "various stages", "healing", "abdomen", "tender", "radiating to", "back", "palpable", "mass", "woman", "positive Romberg test", "normal", "further", "labs", "pancreas biopsy histology", "follows", "Laboratory tests Serum", "Albumin", "g", "Amylase", "L Lipase", "Blood glucose", "fasting", "mg/dL Triglycerides", "Cholesterol", "total", "mg", "mg", "L", "normalized", "Activated partial thromboplastin time", "blood", "volume", "Stool", "Occult blood absent", "following", "best", "to", "condition", "long term"]}
{"question": "A 34-year-old G2P1 female at 37 weeks of gestation presents to the clinic for complaints of right-hand numbness and pain for the past month. She reports that the pain is usually worse at night and that she would sometimes wake up in the middle of the night from the “pins and needles.” She denies fever, weakness, or weight changes but endorses paresthesia and pain. The patient also reports a fall on her right hand 2 weeks ago. A physical examination demonstrates mild sensory deficits at the first 3 digits of the right hand but no tenderness with palpation. Strength is intact throughout. Which of the following findings would further support the diagnosis of this patient’s condition?", "answer": "Tingling when the right wrist is percussed", "options": {"A": "Hairline fracture of the scaphoid bone on magnetic resonance imaging (MRI)", "B": "Loss of sensation at the thenar eminence", "C": "Small cross-sectional area of the median nerve on ultrasonography", "D": "Tingling when the right wrist is percussed", "E": "Tingling when the wrists are extended 90 degrees"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "female", "weeks of gestation presents", "clinic", "complaints of right hand numbness", "pain", "past month", "reports", "pain", "usually worse", "night", "sometimes wake up", "middle", "night", "pins", "needles", "fever", "weakness", "weight changes", "paresthesia", "pain", "patient", "reports", "fall", "right hand 2 weeks", "mild sensory deficits", "first", "digits of", "right hand", "tenderness", "palpation", "Strength", "intact", "following findings", "further support", "diagnosis", "patients condition"]}
{"question": "A 6-year-old boy presents to his pediatrician’s office for muscle weakness. The patient is accompanied by his mother who states that he has difficulty running and walking up the stairs. The mother has noticed mild weakness when the patient attempts to sit up from a supine position since he was 4-years-old. Medical history is significant for fractures involving the arms and legs secondary to falling. On physical exam, the child does not appear to be in distress and is conversational. He has a waddling gait along with lumbar lordosis and bilateral calf enlargement. The patient uses his hands to push himself into an upright position when arising from the floor. He has absent patellar and ankle-jerk reflexes. Which of the following is the best next step to confirm the diagnosis?", "answer": "Genetic testing", "options": {"A": "Electrocardiogram", "B": "Electromyogram", "C": "Genetic testing", "D": "Muscle biopsy", "E": "Serum creatine kinase level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "pediatricians office", "muscle weakness", "patient", "states", "difficulty running", "mild weakness", "patient", "to sit up", "supine position", "4 years old", "Medical history", "significant", "fractures involving", "arms", "legs secondary to falling", "child", "not appear to", "distress", "waddling gait", "lumbar lordosis", "bilateral calf enlargement", "patient uses", "hands", "push", "upright position", "arising", "floor", "absent patellar", "ankle reflexes", "following", "best next step to confirm", "diagnosis"]}
{"question": "A 26-year-old male currently undergoing standard therapy for a recently diagnosed active tuberculosis infection develops sudden onset of fever and oliguria. Laboratory evaluations demonstrate high levels of eosinophils in both the blood and urine. Which of the following is most likely responsible for the patient’s symptoms:", "answer": "Rifampin", "options": {"A": "Rifampin", "B": "Isoniazid", "C": "Pyrazinamide", "D": "Ethambutol", "E": "Return of active tuberculosis symptoms secondary to patient non-compliance with anti-TB regimen"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male currently", "recently diagnosed active tuberculosis infection", "sudden", "fever", "oliguria", "Laboratory", "high levels", "eosinophils", "blood", "urine", "following", "responsible", "patients symptoms"]}
{"question": "A 3-year-old boy is brought to the physician for evaluation of a generalized, pruritic rash. The rash began during infancy and did not resolve despite initiating treatment with topical corticosteroids. Three months ago, he was treated for several asymptomatic soft tissue abscesses on his legs. He has been admitted to the hospital three times during the past two years for pneumonia. Physical examination shows a prominent forehead and a wide nasal bridge. Examination of the skin shows a diffuse eczematous rash and white plaques on the face, scalp, and shoulders. Laboratory studies show a leukocyte count of 6,000/mm3 with 25% eosinophils and a serum IgE concentration of 2,300 IU/mL (N = 0–380). Flow cytometry shows a deficiency of T helper 17 cells. The patient’s increased susceptibility to infection is most likely due to which of the following?", "answer": "Impaired chemotaxis of neutrophils", "options": {"A": "Impaired chemotaxis of neutrophils", "B": "Impaired DNA repair in lymphocytes", "C": "Impaired actin assembly in lymphocytes", "D": "Impaired Ig class-switching in lymphocytes", "E": "Impaired interferon-γ secretion by Th1 cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old boy", "brought", "physician", "generalized", "pruritic rash", "rash began", "infancy", "not", "initiating treatment", "topical corticosteroids", "Three months", "treated", "asymptomatic soft tissue abscesses", "legs", "three times", "past two years", "pneumonia", "prominent forehead", "wide nasal bridge", "Examination of", "skin", "diffuse eczematous rash", "white plaques", "face", "scalp", "shoulders", "Laboratory studies", "leukocyte count", "mm3", "eosinophils", "serum", "concentration", "300 IU/mL", "N", "Flow cytometry", "deficiency", "patients increased susceptibility to infection", "due to"]}
{"question": "A 2-month-old boy is brought to the pediatrician for a routine check-up. His mother says he is feeding well and has no concerns. He is at the 85th percentile for height and 82nd percentile for weight. Immunizations are up-to-date. Results of serum hepatitis B surface IgG antibody testing are positive. Which of the following best explains this patient's hepatitis B virus status?", "answer": "Passive immunity", "options": {"A": "Window period", "B": "Chronic infection", "C": "Spontaneous recovery", "D": "Vaccination reaction", "E": "Passive immunity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 month old boy", "brought", "pediatrician", "routine check-up", "well", "percentile", "height", "percentile", "weight", "Immunizations", "date", "Results", "serum", "surface IgG", "testing", "positive", "following best", "patient's hepatitis B virus status"]}
{"question": "A 60-year-old man comes to the physician because of progressive pain in his right hip and lower back over the past 4 weeks. He describes the pain as dull and constant. It is worse with exertion and at night. Over the past 2 months, he has helped his son with renovating his home, which required heavy lifting and kneeling. His father died of prostate cancer. He drinks 2–3 beers daily. Vital signs are within normal limits. Examination shows localized tenderness over the right hip and groin area; range of motion is decreased. Hearing is mildly decreased on the right side. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 15 g/dL\nSerum\nTotal protein 6.5 g/dL\nBilirubin 0.8 mg/dL\nAlanine aminotransferase 20 U/L\nAlkaline phosphatase (ALP) 950 U/L\nγ-Glutamyltransferase (GGT) 40 U/L (N=5–50)\nCalcium 9 mg/dL\nPhosphate 4 mg/dL\nParathyroid hormone\n450 pg/mL\nAn x-ray of the hip shows cortical thickening and prominent trabecular markings. Which of the following is the most likely underlying mechanism of this patient's symptoms?\"", "answer": "Increased rate of bone remodeling", "options": {"A": "Proliferation of plasma cells in the bone marrow", "B": "Increased rate of bone remodeling", "C": "Decreased bone mass with microarchitectural disruption", "D": "Infarction of the bone and marrow", "E": "Osteoblastic destruction of the bone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old man", "physician", "of progressive pain in", "right hip", "lower back", "past 4 weeks", "pain", "dull", "constant", "worse", "exertion", "night", "past", "months", "helped", "home", "required heavy", "kneeling", "died of prostate cancer", "23", "daily", "Vital signs", "normal limits", "localized tenderness", "right", "groin area", "range of motion", "decreased", "Hearing", "mildly decreased", "right side", "abnormalities", "Laboratory studies", "Hemoglobin", "dL Serum", "Bilirubin 0.8", "Alanine", "L Alkaline phosphatase", "Glutamyltransferase", "GGT", "40 U/L", "N 550", "Calcium", "mg/dL Phosphate", "Parathyroid hormone", "pg/mL", "x-ray", "hip", "cortical thickening", "prominent trabecular markings", "following", "underlying mechanism", "patient", "ymptoms?"]}
{"question": "A 32-year-old man comes to the physician because of low-grade fever, dry cough, and shortness of breath. His symptoms began 6 days ago while he was on vacation in Thailand where he went to an urgent care clinic and was started on cefuroxime. His temperature is 38.2°C (100.8°F). Physical examination shows decreased breath sounds at bilateral lung bases. An x-ray of the chest shows diffuse patchy infiltrates. Sputum analysis shows numerous neutrophils but no organisms. Giemsa stain shows epithelial cells with cytoplasmic inclusion bodies. This patient's condition did not improve after the initial treatment because of which of the following properties of the most likely causal pathogen?", "answer": "Lack of peptidoglycan in cell wall", "options": {"A": "Lack of peptidoglycan in cell wall", "B": "Enclosure by polysaccharide capsule", "C": "Formation of biofilms", "D": "Production of β-lactamase enzymes", "E": "Rapid alteration of drug binding sites"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "low-grade fever", "dry cough", "shortness of breath", "symptoms began 6 days", "Thailand", "urgent care clinic", "started", "cefuroxime", "temperature", "100", "decreased breath sounds", "bilateral lung bases", "x-ray of", "chest", "diffuse patchy infiltrates", "Sputum analysis", "numerous", "Giemsa stain", "epithelial cells", "cytoplasmic inclusion bodies", "patient's condition", "not", "initial treatment", "following properties", "likely causal pathogen"]}
{"question": "Four days after undergoing a coronary artery bypass graft for coronary artery disease, a 60-year-old man complains of abdominal fullness and bloating. Since his surgery, he has not had a bowel movement and is unable to pass flatus. He has no nausea or vomiting. Prior to the operation, the patient had daily bowel movements without abnormalities. He has a history of bipolar disorder and hypertension. His current medications include aspirin, atorvastatin, chlorpromazine, amlodipine, and prophylactic subcutaneous heparin. His temperature is 39°C (102.2°F), pulse is 110/min, and blood pressure is 120/80 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows a distended, tympanic abdomen with guarding and rebound tenderness; bowel sounds are hypoactive. Abdominal x-ray shows diffuse distention of the colon loops. A CT scan with contrast confirms the x-ray findings and shows a cecal dilation of 14 cm. Which of the following is the most appropriate next step in the management?", "answer": "Laparotomy", "options": {"A": "Nasogastric and rectal tube insertion", "B": "Colonoscopy", "C": "Intravenous neostigmine therapy", "D": "Laparotomy", "E": "Intravenous fluids and bowel rest\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Four days", "coronary artery bypass graft", "disease", "60 year old man", "abdominal fullness", "bloating", "surgery", "not", "bowel movement", "unable to pass flatus", "nausea", "vomiting", "operation", "patient", "daily bowel movements", "abnormalities", "history of bipolar disorder", "hypertension", "current medications include aspirin", "atorvastatin", "chlorpromazine", "amlodipine", "prophylactic subcutaneous heparin", "temperature", "pulse", "min", "blood pressure", "80 mm Hg", "Cardiopulmonary", "abnormalities", "Abdominal", "distended", "tympanic abdomen", "guarding", "rebound tenderness", "bowel sounds", "hypoactive", "Abdominal x-ray", "diffuse distention", "colon loops", "CT scan with contrast confirms", "x-ray findings", "cecal dilation", "following", "most appropriate next step"]}
{"question": "A 42-year-old woman presents with trouble focusing. She says that she has trouble focusing on simple tasks and her thoughts are very scattered. These difficulties have been present since she was a young student in elementary school. She says she had difficulty focusing both at school and at home. The patient is diagnosed with a psychiatric condition and is prescribed the medication that is recommended as the first-line treatment. Which of the following statements is true regarding this new medication?", "answer": "“Appetite suppression is a common side effect of this medication.”", "options": {"A": "“Appetite suppression is a common side effect of this medication.”", "B": "“Bupropion is less effective in adults with this disorder than this medication.”", "C": "“Chronic use of this medication can lead to tardive dyskinesia.”", "D": "“Hypotension is a common side effect of this medication.”", "E": "“Sedation is a common side effect of this medication.”"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "simple", "very scattered", "difficulties", "present", "young", "elementary school", "difficulty focusing", "school", "at home", "patient", "diagnosed", "psychiatric condition", "medication", "first-line treatment", "following", "true", "new medication"]}
{"question": "A 29-year-old woman presents to the fertility clinic due to an inability to conceive. She and her husband have been attempting to have children for over a year. She underwent menarche at 16 years of age and typically has menses every 29 days regularly. Her menstrual periods would last 6 days and are mildly painful. However, she reports that her last menstrual period was 3 months ago. Her medical history is non-contributory and she does not take any medications. Her temperature is 99°F (37.2°C), blood pressure is 125/76 mmHg, pulse is 78/min, and respirations are 15/min. Her body mass index is 26.3 kg/m^2. Physical examination is unremarkable. Urine hCG is negative, serum prolactin level is 75 ng/mL (normal < 20 ng/mL) and thyroid-stimulating hormone is 0.8 microU/mL. Which of the following is the best treatment option for this patient’s infertility?", "answer": "Cabergoline", "options": {"A": "Cabergoline", "B": "Clomiphene", "C": "Levothyroxine", "D": "Letrozole", "E": "Metformin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old woman presents", "fertility clinic", "to", "to", "children", "year", "menarche at", "years", "age", "menses", "29 days", "menstrual periods", "last 6 days", "mildly painful", "reports", "last menstrual period", "3 months", "medical history", "non contributory", "not", "medications", "temperature", "blood pressure", "76 mmHg", "pulse", "min", "respirations", "min", "body mass index", "kg/m", "unremarkable", "Urine hCG", "negative", "serum prolactin level", "75 ng/mL", "normal", "20 ng/mL", "thyroid-stimulating hormone", "0.8 microU/mL", "following", "best treatment option for", "patients infertility"]}
{"question": "A 47-year-old man with alcoholic cirrhosis comes to the physician for a follow-up examination. Examination of the skin shows erythema over the thenar and hypothenar eminences of both hands. He also has numerous blanching lesions over the trunk and upper extremities that have a central red vessel with thin extensions radiating outwards. Which of the following is the most likely underlying cause of these findings?", "answer": "Increased circulating estrogen", "options": {"A": "Increased circulating ammonia", "B": "Decreased circulating albumin", "C": "Decreased circulating thrombopoietin", "D": "Decreased circulating testosterone", "E": "Increased circulating estrogen"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "alcoholic cirrhosis", "physician", "follow-up examination", "skin", "erythema", "thenar", "hypothenar eminences", "hands", "numerous blanching lesions", "trunk", "upper extremities", "central red vessel", "thin extensions radiating outwards", "following", "underlying cause", "findings"]}
{"question": "An otherwise healthy 15-year-old boy comes to the physician for a routine health maintenance examination. He feels well and is doing well in school. He has no history of serious illness. Vital signs are within normal limits. The lungs are clear to auscultation. Cardiac auscultation shows no murmur, but a wide-split S2 that does not change with respiration. If left untreated, this patient is at increased risk for which of the following complications?", "answer": "Paradoxical embolism", "options": {"A": "Sudden cardiac death", "B": "Cerebral aneurysm", "C": "Left ventricular hypertrophy", "D": "Paradoxical embolism", "E": "Infective endocarditis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old boy", "physician", "routine", "well", "well", "school", "history", "serious", "Vital", "normal limits", "lungs", "clear", "auscultation", "Cardiac", "murmur", "wide split S2", "not change", "respiration", "left untreated", "patient", "increased risk", "following complications"]}
{"question": "A 33-year-old woman comes to the physician because of a 4-day history of fever and neck pain that radiates to the jaw and ears. She has also noticed swelling in the front part of her throat since the onset of the pain. She reports feeling anxious and sweating profusely over the past 2 days. She has no history of major illness and takes no medication. Her temperature is 38.1°C (100.6°F), pulse is 95/min, and blood pressure is 140/70 mm Hg. Examination shows moist palms and a bilateral fine resting tremor of the outstretched hands. Examination of the neck shows a thyroid gland that is tender, firm, and enlarged. Serum studies show:\nHemoglobin 12.7 g/dL\nESR 65 mm/h\nSerum\nCreatinine 0.7 mg/dL\nThyroid-stimulating hormone 0.063 μU/mL\nTriiodothyronine (T3) 218 ng/dL\nThyroxine (T4) 88 μg/dL\n123I scan shows an enlarged thyroid gland with multiple areas of decreased uptake. Which of the following is the most likely diagnosis?\"", "answer": "Subacute thyroiditis", "options": {"A": "Subacute thyroiditis", "B": "Thyroid lymphoma", "C": "Struma ovarii", "D": "Factitious hyperthyroidism", "E": "Toxic adenoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "4-day history", "fever", "neck pain", "radiates", "jaw", "ears", "swelling", "front part of", "throat", "onset", "pain", "reports", "anxious", "sweating", "past 2 days", "history", "major illness", "medication", "temperature", "100", "pulse", "95 min", "blood pressure", "70 mm Hg", "moist", "bilateral fine", "tremor of", "hands", "Examination of", "neck", "thyroid gland", "tender", "firm", "enlarged", "Serum studies", "Hemoglobin", "g dL ESR 65 mm/h Serum Creatinine", "dL Thyroid-stimulating hormone", "U/mL Triiodothyronine", "ng", "88 g/dL", "scan", "enlarged thyroid gland", "multiple areas", "decreased uptake", "following", "diagnosis"]}
{"question": "A 20-year-old female arrives at the urgent care clinic at her university’s health plan asking for an HIV test. She is an undergraduate at the university and just started having sexual intercourse with her new boyfriend. They use protection only occasionally so she wants to get tested to make sure everything is okay. She has never been tested for STDs before. She reports no symptoms and has not seen a physician regularly for any medical conditions in the past. Her family history is uncertain because she was adopted. Her HIV immunoassay and HIV-1/HIV-2 differentiation immunoassay both come back positive. She asks on the phone, “Doctor, tell it to me straight. Do I have AIDS?” Which of the following is the most accurate response?", "answer": "We need additional bloodwork to see if you have AIDS.", "options": {"A": "We have to get a confirmatory PCR test to see if you have AIDS.", "B": "You do not have AIDS because you just started having sex recently.", "C": "You have AIDS but this disease is now a manageable condition.", "D": "We need your partner's information to be sure of your diagnosis.", "E": "We need additional bloodwork to see if you have AIDS."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["20 year old female", "urgent care clinic", "HIV test", "university", "started", "sexual intercourse", "new", "use protection only occasionally", "to", "to make sure", "never", "STDs", "reports", "symptoms", "not seen", "physician", "medical conditions", "past", "family history", "uncertain", "adopted", "HIV immunoassay", "HIV-1", "differentiation immunoassay", "back positive", "phone", "Doctor", "to", "straight", "I", "AIDS", "following", "most accurate response"]}
{"question": "A 32-year-old woman visits the office with a complaint of recurrent abdominal pain for the past 2 months. She says the pain has been increasing every day and is located in the right upper quadrant. She has been using oral contraceptive pills for the past 2 years. She is a nonsmoker and does not drink alcohol. Her vital signs show a heart rate of 85/min, respiratory rate of 16/min, temperature of 37.6 °C (99.68 °F), and blood pressure of 120/80 mm Hg. Physical examination reveals right upper quadrant tenderness and hepatomegaly 3 cm below the right costal border. Her serology tests for viral hepatitis are as follows:\nHBsAg Negative\nAnti-HBs Negative\nIgM anti-HBc Negative\nAnti-HCV Negative\nA hepatic ultrasound shows hepatomegaly with diffusely increased echogenicity and a well-defined, predominantly hypoechoic mass in segment VI of the right lobe of the liver. What is the most likely diagnosis?", "answer": "Hepatic adenoma", "options": {"A": "Cholangiocarcinoma", "B": "Focal nodular hyperplasia", "C": "Hepatocellular carcinoma", "D": "Metastatic disease", "E": "Hepatic adenoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "office", "complaint", "recurrent abdominal pain", "past", "months", "pain", "increasing", "day", "right upper quadrant", "using oral contraceptive pills", "past", "years", "nonsmoker", "not", "alcohol", "vital signs", "heart rate", "85 min", "respiratory rate", "min", "temperature", "99", "F", "blood pressure", "80 mm Hg", "reveals right upper quadrant tenderness", "hepatomegaly 3 cm", "right costal border", "serology tests", "viral", "follows", "HBsAg Negative Anti HBs", "IgM", "HBc", "HCV Negative", "hepatic ultrasound", "hepatomegaly", "increased echogenicity", "well-defined", "mass", "segment VI of", "right lobe of", "liver", "diagnosis"]}
{"question": "A previously healthy 67-year-old man comes to the physician because of a history of recurrent right lower abdominal pain for the past 2 years. A CT scan shows a 1.2-cm (0.47-in) mass located in the terminal ileum. He undergoes surgical removal of the mass. A photomicrograph of the resected specimen is shown. Cells from this tissue are most likely to stain positive for which of the following?", "answer": "Chromogranin A", "options": {"A": "Desmin", "B": "Chromogranin A", "C": "Vimentin", "D": "Cytokeratin", "E": "Glial fibrillary acid protein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 67 year old man", "physician", "history", "recurrent right lower abdominal pain", "past", "years", "CT scan", "a", "2", "0", "mass", "terminal ileum", "surgical", "mass", "photomicrograph", "resected", "Cells", "tissue", "to", "positive"]}
{"question": "A 66-year-old woman presents to the emergency department with abdominal pain. Her symptoms began when she was eating dinner. She has a past medical history of obesity, constipation, intravenous drug use, and diabetes. The patient is instructed to be nil per os and is transferred to the surgical floor. Three days later she had a cholecystectomy and is recovering on the surgical floor. Her laboratory values are ordered as seen below.\n\nHemoglobin: 11 g/dL\nHematocrit: 33%\nLeukocyte count: 8,500/mm^3 with normal differential\nPlatelet count: 197,000/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\nCa2+: 10.5 mg/dL\nAlkaline phosphatase: 533 U/L\nGGT: 50 U/L\nAST: 22 U/L\nALT: 20 U/L\n\nThe patient is currently asymptomatic and states that she feels well. Which of the following is associated with this patient's underlying condition?", "answer": "Blastic and lytic skeletal lesions", "options": {"A": "Blastic and lytic skeletal lesions", "B": "Monoclonal plasma cell replication", "C": "Reemergence of a hepatitis infection", "D": "Repeat gastrointestinal tract obstruction", "E": "Qualitative bone defect"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["66 year old woman presents", "emergency department", "abdominal pain", "symptoms began", "eating dinner", "past medical", "constipation", "diabetes", "patient", "to", "nil per os", "transferred", "surgical floor", "Three days later", "cholecystectomy", "recovering", "surgical floor", "laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL Ca2", "10.5 mg/dL Alkaline phosphatase", "U/L GGT", "50 U/L AST", "U/L ALT", "20 U/L", "patient", "currently asymptomatic", "states", "well", "following", "associated with", "patient's", "condition"]}
{"question": "A 55-year-old obese woman is referred to the cardiology clinic for progressive dyspnea. She has had no recent travel or sick contacts. Besides a multivitamin, she has only tried online weight-loss medications for the past five years, including fenfluramine-phentermine. An echocardiogram reveals a dilated right ventricle with systolic pressure of 60 mmHg as well as both tricuspid and pulmonary regurgitation. A right heart catheterization shows a mean pulmonary artery pressure of 40 mmHg. What disease process is most analogous to this patient's presentation?", "answer": "Carcinoid syndrome", "options": {"A": "Subacute endocarditis", "B": "Carcinoid syndrome", "C": "Chronic thromboembolic disease", "D": "Left heart failure", "E": "Chronic obstructive pulmonary disease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old obese woman", "referred", "cardiology clinic", "progressive dyspnea", "recent", "sick", "multivitamin", "only", "weight-loss medications", "past five years", "including fenfluramine phentermine", "echocardiogram reveals", "dilated right ventricle", "systolic pressure", "60 mmHg", "tricuspid", "pulmonary regurgitation", "right heart catheterization", "mean pulmonary artery pressure", "40 mmHg", "disease process", "most", "patient's"]}
{"question": "An 18-year-old man seeks an evaluation from a physician for painful right axillary swelling since 2 days ago. He has malaise. He has no history of serious illnesses and takes no medications. He has a pet kitten which was recently treated for fleas. The temperature is 38.5℃ (101.3℉), the pulse is 88/min, the respiration rate is 14/min, and the blood pressure is 120/80 mm Hg. There are 2 painless papules on the patient’s right forearm that appeared on the healing scratch marks left by his pet kitten a few days ago. Several lymph nodes in the right axilla are enlarged and tender. The overlying skin is erythematous. No other lymphadenopathy is detected in other areas. The rest of the examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy at this time?", "answer": "No pharmacotherapy", "options": {"A": "Azithromycin", "B": "Doxycycline", "C": "Pyrimethamine", "D": "Streptomycin", "E": "No pharmacotherapy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "painful right", "days", "malaise", "history", "serious illnesses", "medications", "recently treated", "fleas", "temperature", "pulse", "88 min", "respiration rate", "min", "blood pressure", "80 mm Hg", "2 painless papules", "patients right forearm", "appeared", "healing scratch marks left", "few days", "lymph nodes", "right axilla", "enlarged", "tender", "skin", "erythematous", "lymphadenopathy", "detected", "areas", "abnormalities", "following", "most appropriate pharmacotherapy", "time"]}
{"question": "A prospective cohort study was conducted to assess the relationship between LDL-C and the incidence of heart disease. The patients were selected at random. Results showed a 10-year relative risk (RR) of 2.30 for people with elevated LDL-C levels compared to individuals with normal LDL levels. The p value was 0.04. This study is most likely to have which of the following 95% confidence intervals?", "answer": "1.01-3.70", "options": {"A": "1.01-3.70", "B": "1.00-3.60", "C": "0.09-3.50", "D": "0.08-3.40", "E": "0.07-3.30"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["to", "relationship", "the incidence of heart disease", "patients", "random", "Results", "a 10 year relative risk", "2 30", "elevated", "levels", "normal", "levels", "p value", "0.04", "study", "to", "following 95", "confidence intervals"]}
{"question": "A 60-year-old man is brought to the emergency department by police officers because he was seen acting strangely in public. The patient was found talking nonsensically to the characters on cereal boxes in a grocery store. Past medical history is significant for multiple hospitalizations for alcohol-related injuries and alcohol withdrawal seizures. Vital signs are within normal limits. On physical examination, the patient is disheveled and oriented x1. Neurologic examination shows horizontal nystagmus and severe ataxia is also noted, that after interviewing the patient, he forgets the face of persons and the questions asked shortly after he walks out the door. He, however, remembers events from his distant past quite well. Which of the following is the most likely diagnosis in this patient?", "answer": "Korsakoff amnesia", "options": {"A": "Delirium", "B": "Delirium tremens", "C": "Korsakoff amnesia", "D": "Schizophrenia", "E": "Dementia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "brought", "emergency department", "police officers", "seen acting", "patient", "found talking", "boxes", "grocery store", "Past medical history", "significant", "multiple", "alcohol related injuries", "alcohol withdrawal seizures", "Vital signs", "normal limits", "patient", "oriented", "Neurologic examination", "horizontal nystagmus", "severe ataxia", "noted", "patient", "forgets", "face", "walks out", "door", "distant past", "well", "following", "diagnosis", "patient"]}
{"question": "A 76-year-old man presents for a follow-up appointment at his primary care provider’s office. The patient has severe osteoarthritis, which substantially limits his daily physical activity. Several imaging studies have confirmed severe articular degeneration and evidence of bone grinding on bone in his hip joints. The patient suffers from chronic pain and depression that have been resistant to medication. At the physician’s office, his blood pressure is 119/67 mm Hg, the respirations are 18/min, the pulse is 87/min, and the temperature is 36.7°C (98.0°F). On physical examination, the patient has a flat affect and appears anxious. He has significant pain and limited passive and active range of motion of his hip joints bilaterally. This patient would most likely benefit from which of the following procedures if there are no contraindications?", "answer": "Total hip arthroplasty", "options": {"A": "Hip osteotomy", "B": "Hip resurfacing", "C": "Total hip arthroplasty", "D": "Arthroscopic debridement", "E": "Autologous chondrocyte implantation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["76 year old man presents", "follow-up appointment", "primary care providers office", "patient", "severe osteoarthritis", "limits", "physical", "imaging studies", "confirmed severe articular degeneration", "bone grinding", "bone", "hip", "patient suffers", "chronic pain", "depression", "resistant to medication", "physicians office", "blood pressure", "67 mm Hg", "respirations", "min", "pulse", "87 min", "temperature", "36", "98", "patient", "flat affect", "appears anxious", "significant pain", "limited passive", "active range of motion", "hip joints", "patient", "most likely benefit", "following procedures", "contraindications"]}
{"question": "A 7-year-old boy and the rest of his family visit a physician for a physical after migrating to the United States. His mother reports that her son is always fatigued and has no energy to play like the other kids in their remote village in Nigeria. He was born at 39 weeks via spontaneous vaginal delivery and is meeting all developmental milestones. He is behind on most of his vaccines, and they develop a plan to get him caught up. On examination, the boy presents with jaundice, mild hepatomegaly, and tachycardia. A CBC with manual differential reveals atypical appearing red blood cells. The physician takes time to review the lab work results with the mother, and he discusses her son’s diagnosis. It is expected that one molecule at the biochemical level should be high. Which of the following best describes this molecule and its significance in this patient?", "answer": "Pathological; an intermediate of glycolysis", "options": {"A": "Pathological; an intermediate of glycolysis", "B": "Physiological; an intermediate of gluconeogenesis", "C": "Pathological; an intermediate of the Krebs cycle", "D": "Physiological; an intermediate of the Krebs cycle", "E": "Physiological; found in the mitochondrial intermembrane space"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "physician", "physical", "migrating", "United States", "reports", "always fatigued", "energy to play", "remote village", "Nigeria", "born", "weeks", "spontaneous vaginal delivery", "most", "vaccines", "plan to", "caught", "boy presents", "jaundice", "mild hepatomegaly", "tachycardia", "CBC with manual differential reveals atypical appearing red blood cells", "physician", "time to", "lab", "results", "diagnosis", "one", "biochemical level", "high", "following best", "significance", "patient"]}
{"question": "A 14-year-old male of eastern European descent presents to the free clinic at a university hospital for a respiratory infection, which his mother explains occurs quite frequently. The male is noted to be of short stature, have a gargoyle-like facies, clouded corneas, poor dentition, and is severely mentally retarded. A urinalysis revealed large amounts of heparan and dermatan sulfate. Which of the following is the most likely diagnosis?", "answer": "Hurler's syndrome", "options": {"A": "Hurler's syndrome", "B": "Hunter's syndrome", "C": "Tay Sachs disease", "D": "Gaucher's disease", "E": "Fabry's disease"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male", "descent presents", "university hospital", "respiratory infection", "occurs", "frequently", "male", "noted to", "short stature", "facies", "clouded corneas", "poor dentition", "severely mentally retarded", "urinalysis revealed large amounts", "heparan", "dermatan sulfate", "following", "diagnosis"]}
{"question": "A 4-year-old girl is brought to the physician by her mother for a follow-up examination. She has a history of recurrent asthma attacks. The mother reports that her daughter has also had mild abdominal pain for the past 2 weeks. The patient's current medications include daily inhaled fluticasone and inhaled albuterol as needed. She appears well. Her temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 130/85 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Abdominal examination shows a left-sided, nontender, smooth abdominal mass that does not cross the midline. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Which of the following is the most likely diagnosis?", "answer": "Wilms' tumor", "options": {"A": "Polycystic kidney disease", "B": "Lymphoma", "C": "Wilms' tumor", "D": "Neuroblastoma", "E": "Renal cell carcinoma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old girl", "brought", "physician", "follow-up examination", "history of recurrent asthma attacks", "reports", "mild abdominal", "past 2 weeks", "patient's current medications include daily inhaled fluticasone", "inhaled albuterol as needed", "appears well", "temperature", "98", "pulse", "100 min", "blood pressure", "85 mm Hg", "lungs", "clear", "auscultation", "Cardiac examination", "murmurs", "rubs", "Abdominal", "left-sided", "nontender", "smooth abdominal", "not", "midline", "abnormalities", "complete blood count", "serum", "electrolytes", "urea nitrogen", "creatinine", "reference range", "following", "diagnosis"]}
{"question": "A 58-year-old man with a history of hepatitis C infection presents to his physician because of unintentional weight loss and weakness. He has lost 6.8 kg (15 lb) within the last 6 months. Vital signs are within normal limits. Physical examination shows jaundice, splenomegaly, and caput medusae. A complete metabolic panel is ordered. Which of the following tests is the most likely to result in a diagnosis?", "answer": "Alanine aminotransferase", "options": {"A": "Alanine aminotransferase", "B": "Alkaline phosphatase", "C": "Aspartate aminotransferase", "D": "Blood urea nitrogen", "E": "Troponin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old man", "history of hepatitis C infection presents", "physician", "unintentional weight loss", "weakness", "lost", "kg", "last", "months", "Vital signs", "normal", "Physical examination", "jaundice", "splenomegaly", "caput medusae", "complete metabolic panel", "ordered", "following tests", "to result", "diagnosis"]}
{"question": "An investigator studying fungal growth isolates organisms from an infant with diaper rash. The isolate is cultured and exposed to increasing concentrations of nystatin. Selected colonies continue to grow and replicate even at high concentrations of the drug. Which of the following is the most likely explanation for this finding?", "answer": "Reduced ergosterol content in cell membrane", "options": {"A": "Reduced ergosterol content in cell membrane", "B": "Inactivation of cytosine permease", "C": "Mutation of the β-glucan gene", "D": "Altered binding site of squalene epoxidase", "E": "Expression of dysfunctional cytochrome P-450 enzymes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator studying fungal growth isolates", "infant", "diaper rash", "isolate", "cultured", "exposed", "increasing", "nystatin", "colonies", "to", "replicate", "high concentrations", "drug", "following", "finding"]}
{"question": "A rheumatologist is evaluating the long-term risk of venous thromboembolism in patients with newly diagnosed rheumatoid arthritis by comparing two retrospective cohort studies. In study A, the hazard ratio for venous thromboembolism was found to be 1.7 with a 95% confidence interval of 0.89–2.9. Study B identified a hazard ratio for venous thromboembolism of 1.6 with a 95% confidence interval of 1.1–2.5. Which of the following statements about the reported association in these studies is most accurate?", "answer": "The p-value of study A is likely larger than the p-value of study B.", "options": {"A": "The results of study B are less likely to be accurate than the results of study A.", "B": "The HR of study B is less likely to be statistically significant than the HR of study A.", "C": "Study A likely had a larger sample size than study B.", "D": "The p-value of study A is likely larger than the p-value of study B.", "E": "The power of study B is likely smaller than the power of study A."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["rheumatologist", "long-term", "of venous thromboembolism", "patients", "diagnosed rheumatoid arthritis", "two", "hazard ratio", "venous thromboembolism", "found to", "1", "95", "confidence interval", "0", "9", "Study", "identified", "hazard ratio", "venous thromboembolism of", "95", "confidence interval", "12.5", "following", "reported association", "studies", "most accurate"]}
{"question": "A 17-year-old girl is brought into the clinic by her mother who is concerned that she may be depressed. The mother states that her daughter feels unattractive and does not fit into any of the social groups at school. When talking to the patient, it is discovered that she mostly avoids the kids in school because of fear of rejection. She usually keeps to herself and says she hasn’t involved herself in any group activities since elementary school. The patient’s mother is worried that this kind of behavior might continue or worsen if it progresses into her college years. Which of the following is the most likely diagnosis in this patient?", "answer": "Avoidant personality disorder", "options": {"A": "Avoidant personality disorder", "B": "Schizoid personality disorder", "C": "Social phobia", "D": "Dependent personality disorder", "E": "Body dysmorphic disorder"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "clinic", "depressed", "states", "unattractive", "not fit", "school", "mostly", "in school", "of fear", "rejection", "usually keeps", "hasnt involved", "group", "elementary school", "patients", "worried", "kind", "behavior", "worsen", "progresses", "college years", "following", "diagnosis", "patient"]}
{"question": "A 16-year-old female presents to her pediatrician complaining of 2 weeks of fever and 1 week of swollen lumps in her left armpit. Upon examination of the left upper extremity, her physician notes the presence of a single papule which the patient claimed appeared one week ago. The patient started her first job at a pet store 2.5 weeks ago. Which of the following is the vector of transmission of the causative agent?", "answer": "Cats", "options": {"A": "Animal urine", "B": "Cats", "C": "Parrots", "D": "Armadillos", "E": "Rabbits"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female presents", "pediatrician", "2 weeks", "fever", "1 week", "swollen lumps", "left armpit", "examination of the left upper extremity", "physician notes", "presence", "single papule", "patient", "appeared one week", "patient started", "first job", "store 2", "weeks", "following", "vector", "transmission", "causative agent"]}
{"question": "A 63-year-old woman presents to her primary care provider with her spouse for routine follow-up. She has a history of schizophrenia and is currently living at a nursing facility. Her symptoms first started 2 years ago, when she developed auditory hallucinations and her family noticed that her thoughts and speech became more tangential and disorganized. After being referred to a psychiatrist, the patient was started on medication. Currently she reports occasional auditory hallucinations, but her spouse states that her symptoms have improved dramatically with medication. On exam, her temperature is 98.4°F (36.9°C), blood pressure is 110/74 mmHg, pulse is 64/min, and respirations are 12/min. The patient has normal affect with well-formulated, non-pressured speech. She denies any audiovisual hallucinations. Notably, however, the patient has repetitive lip-smacking behavior and occasionally sweeps her tongue across her lips. The spouse is curious about how this developed. Which of the following is the most likely medication this patient was started on?", "answer": "Haloperidol", "options": {"A": "Clozapine", "B": "Haloperidol", "C": "Olanzapine", "D": "Quetiapine", "E": "Risperidone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old woman presents", "primary care provider", "routine follow-up", "history of schizophrenia", "currently living", "nursing facility", "symptoms first started 2 years", "auditory hallucinations", "speech", "more tangential", "referred", "psychiatrist", "patient", "started on medication", "Currently", "reports occasional auditory hallucinations", "states", "symptoms", "improved", "medication", "exam", "temperature", "98", "36", "blood pressure", "74 mmHg", "pulse", "64 min", "respirations", "min", "patient", "normal", "well", "non pressured speech", "audiovisual hallucinations", "patient", "repetitive lip-smacking behavior", "occasionally", "tongue", "lips", "following", "medication", "patient", "started"]}
{"question": "A 65-year-old G4P4 woman presents to her primary care physician complaining of a breast lump. She reports that she felt the lump while conducting a breast self-examination. Her past medical history is notable for endometrial cancer status post radical hysterectomy. She takes aspirin and fish oil. The patient drinks 3-4 alcoholic beverages per day and has a distant smoking history. Her temperature is 98.6°F (37°C), blood pressure is 130/75 mmHg, pulse is 90/min, and respirations are 18/min. A firm palpable mass in the upper outer quadrant of the right breast is noted on physical exam. Further workup reveals invasive ductal adenocarcinoma. She eventually undergoes radical resection and is started on a medication that is known to inhibit thymidylate synthetase. This patient is at increased risk for which of the following medication adverse effects?", "answer": "Photosensitivity", "options": {"A": "Peripheral neuropathy", "B": "Pulmonary fibrosis", "C": "Dilated cardiomyopathy", "D": "Ototoxicity", "E": "Photosensitivity"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["65 year old", "woman presents", "primary care physician", "breast lump", "reports", "lump", "breast self-examination", "past medical history", "notable", "endometrial cancer", "radical hysterectomy", "aspirin", "fish oil", "patient", "3", "day", "distant smoking history", "temperature", "98", "blood pressure", "75 mmHg", "pulse", "90 min", "respirations", "min", "firm", "mass", "upper outer quadrant of", "right breast", "noted", "Further workup reveals invasive ductal adenocarcinoma", "radical resection", "started", "medication", "known to inhibit thymidylate synthetase", "patient", "increased risk", "following medication adverse effects"]}
{"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 shows beak-like osteophytes on his 2nd and 3rd metacarpophalangeal joints, subchondral cysts, and osteopenia. 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. This patient is at risk of which of the following complications?", "answer": "Hypogonadism", "options": {"A": "Hypogonadism", "B": "Hepatic adenoma", "C": "Hypertrophic cardiomyopathy", "D": "Hepatic steatosis", "E": "Cryoglobulinemia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["59 year old man", "progressive joint pain", "swelling", "tenderness", "first", "second", "third", "joints of", "hands", "hand radiograph", "beak", "osteophytes", "2nd", "3rd metacarpophalangeal joints", "subchondral cysts", "osteopenia", "diabetes mellitus", "years", "not well controlled with medications", "Lab studies", "transferrin saturation", "88", "serum ferritin", "1 200 ng mL", "patient", "at risk", "following complications"]}
{"question": "A 60-year-old woman is brought to the emergency department because of altered mental status for 2 hours. She and her husband were at the grocery store when she suddenly could not remember why she was there or how she got there. She has not had any head trauma. She has a history of depression and migraines. She does not smoke and drinks a glass of wine each night with dinner. She takes fluoxetine daily. She appears distressed and anxious. Her vital signs are within normal limits. She is fully alert and oriented to self and place but not to time. Every few minutes she asks how she got to the emergency department. She is able to follow commands and sustain attention. She recalls 3/3 objects immediately and recalls 0/3 objects at 5 minutes. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Transient global amnesia", "options": {"A": "Transient global amnesia", "B": "Depersonalization/derealization disorder", "C": "Seizure", "D": "Dissociative amnesia", "E": "Migraine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["60 year old woman", "brought", "emergency department", "of altered mental status", "hours", "grocery store", "not", "got", "not", "head trauma", "history of depression", "migraines", "not smoke", "glass", "night", "dinner", "fluoxetine daily", "appears", "anxious", "vital signs", "normal limits", "alert", "oriented", "place", "not", "time", "few minutes", "got", "emergency department", "able to follow", "sustain", "3/3", "immediately", "0/3", "5 minutes", "neurological exam", "abnormalities", "following", "diagnosis"]}
{"question": "A team of biology graduate students are performing research on epigenetics and chromosome inactivation. The goal is to silence all the genes on a chromosome at once. The team chooses to develop a model based on a known human gene that can accomplish this task in vivo. Which of the genes listed below would be a suitable model for their research?", "answer": "XIST", "options": {"A": "SRY", "B": "XIST", "C": "Hox", "D": "Hedgehog", "E": "NF1"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["biology graduate students", "epigenetics", "to silence", "genes", "chromosome", "to", "based", "known human gene", "in vivo", "genes", "suitable"]}
{"question": "A 36-year-old man presents to a physician with the complaint of a dry cough for the last 2 months. He denies any nasal discharge, sneezing, nose congestion, blood in sputum, breathlessness, fever, or weight loss. He started smoking 2 years back. His temperature is 37.3°C (99.2°F), the heart rate is 88/min, the blood pressure is 118/78 mm Hg, and the respiratory rate is 18/min. Auscultation of the lungs reveals localized rhonchi over the left infrascapular region. His chest radiogram reveals a single, round-shaped nodule with scalloped margins in the lower zone of the left lung. The nodule is surrounded by normally aerated lung tissue, and its size is approx. 9 mm (0.35 in) in diameter. The physician explains to him that he requires further diagnostic evaluation, as the nodule could be malignant. On the radiogram, which of the following features of the nodule is associated with the increased possibility of a malignant lesion?", "answer": "Lack of calcification", "options": {"A": "Lack of calcification", "B": "Dense central nidus of calcification", "C": "Multiple punctate foci of calcification throughout the nodule", "D": "Bull’s eye calcification", "E": "Popcorn ball calcification"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old man presents", "physician", "complaint", "dry cough", "last", "months", "nasal discharge", "sneezing", "nose congestion", "blood", "sputum", "breathlessness", "fever", "weight loss", "started smoking 2 years back", "temperature", "99", "heart rate", "88 min", "blood pressure", "mm Hg", "respiratory rate", "min", "Auscultation", "lungs reveals localized rhonchi", "left infrascapular region", "chest radiogram reveals", "single", "round-shaped nodule", "scalloped margins", "lower zone", "left lung", "nodule", "surrounded", "lung tissue", "size", "mm", "0.35", "diameter", "physician", "further diagnostic evaluation", "nodule", "malignant", "radiogram", "following features", "nodule", "associated with", "increased possibility", "malignant lesion"]}
{"question": "A 23-year-old man comes to the physician because of progressive pain, redness, and swelling of his left forearm. The symptoms began after he scratched his arm on a metal table 4 days ago. Examination of the left forearm shows a 2-cm, tender, erythematous, fluctuant lesion at the site of trauma. Incision and drainage of the lesion is performed and a small amount of thick, white liquid is expressed. Which of the following cytokines is involved in the recruitment of the primary cell type found in this liquid?", "answer": "IL-8", "options": {"A": "IL-11", "B": "IL-8", "C": "IL-2", "D": "IL-5", "E": "IL-14"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old man", "physician", "progressive pain", "redness", "swelling", "left forearm", "symptoms began", "scratched", "arm", "table 4 days", "Examination of", "left forearm", "2", "tender", "erythematous", "fluctuant lesion", "site of trauma", "Incision", "drainage", "lesion", "performed", "small amount", "white", "following cytokines", "involved", "primary", "found", "liquid"]}
{"question": "Your test subject is a stout 52-year-old gentleman participating in a study on digestion. After eating a platter of meat riblets and beef strips a test subjects digestive tract undergoes vast hormonal changes. Which of the following changes likely occurred in this patient as a result of the meal?", "answer": "Increased release of secretin from S cells of the duodenum", "options": {"A": "Increased gastrin release leading to a decrease in proton secretion", "B": "Decreased cholecystokinin release from the I cells of the duodenum", "C": "Increased release of secretin from S cells of the duodenum", "D": "Decreased Ach release from the vagus nerve", "E": "Increased release of ghrelin from P/D1 cells of the stomach"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["test subject", "stout", "year old", "participating", "study", "digestion", "eating", "beef strips", "test subjects digestive tract", "hormonal changes", "following changes likely", "patient", "result"]}
{"question": "A 27-year-old G1P0 woman at 25 weeks estimated gestational age presents with a blood pressure of 188/99 mm Hg during a routine prenatal visit. She has no symptoms, except for a mild headache. The patient's heart rate is 78/min. An injectable antihypertensive along with a beta-blocker is administered, and her blood pressure returns to normal within a couple of hours. She is sent home with advice to continue the beta-blocker. The patient returns after a couple of weeks with joint pain in both of her knees and fatigue. A blood test for anti-histone antibodies is positive. Which of the following is the mechanism of action of the intravenous antihypertensive medication most likely used in this patient?", "answer": "Interference with action of inositol trisphosphate (IP3) on intracellular calcium release", "options": {"A": "Calcium channel antagonism", "B": "Potassium channel activation", "C": "Release endogenous nitrous oxide", "D": "Inhibition of phosphodiesterase enzyme", "E": "Interference with action of inositol trisphosphate (IP3) on intracellular calcium release"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old", "woman", "weeks estimated gestational age presents", "blood pressure", "99 mm Hg", "routine", "symptoms", "mild headache", "patient's heart rate", "min", "injectable antihypertensive", "beta-blocker", "administered", "blood pressure returns", "normal", "couple", "hours", "sent home", "to", "beta-blocker", "patient returns", "couple", "weeks", "joint pain in both", "knees", "fatigue", "blood test", "anti-histone antibodies", "positive", "following", "mechanism of action", "intravenous antihypertensive medication", "likely used", "patient"]}
{"question": "A 65-year-old man presents with acute abdominal pain accompanied by chills, nausea, and vomiting. His past medical history is significant for benign prostatic hyperplasia and diabetes mellitus type 2. His medications are tamsulosin and metformin. His last HbA1c, 5 months ago, was 6.7. He had a screening colonoscopy 5 years ago which was normal. He denies blood in the stool or urine and has had no change in bowel habits. Throughout the encounter, the patient has difficulty getting comfortable on the exam table. His temperature is 38.2°C (100.7°F), the heart rate is 103/min, the respiratory rate is 15/min, and the blood pressure is 105/85 mm Hg. Physical exam is significant for left costovertebral angle tenderness. Peritoneal signs are absent. CBC, CMP, and urinalysis results are pending. Abdominal X-ray is shown. Which of the following is the next best step in management?", "answer": "Surgical removal and antibiotics", "options": {"A": "Observation with hydration, bed rest, and analgesics", "B": "Amlodipine", "C": "Antibiotics", "D": "Surgical removal and antibiotics", "E": "Urine alkalinization"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man presents", "acute abdominal pain", "chills", "nausea", "vomiting", "past medical history", "significant", "benign prostatic hyperplasia", "diabetes mellitus type 2", "medications", "tamsulosin", "metformin", "last", "5 months", "screening colonoscopy", "years", "normal", "blood in", "stool", "urine", "change in bowel habits", "patient", "difficulty getting", "exam table", "temperature", "100", "heart rate", "min", "respiratory rate", "min", "blood pressure", "85 mm Hg", "significant", "left costovertebral angle tenderness", "Peritoneal signs", "absent", "CBC", "CMP", "urinalysis results", "Abdominal X-ray", "following", "next best step"]}
{"question": "A 74-year-old man returns to his physician to follow-up on laboratory studies obtained for anemia 2 weeks ago. He has no complaints. He has a 20-year history of hypertension and several years of knee osteoarthritis. He walks 2 miles a day. He does not smoke. He drinks alcohol moderately. He takes hydrochlorothiazide, losartan, and pain killers, including ibuprofen. The vital signs include: temperature 37.1°C (98.8°F), pulse 68/min, respiratory rate 12/min, and blood pressure 110/70 mm Hg. The physical examination shows no abnormalities. The laboratory studies show the following:\nLaboratory test\nHemoglobin 10 g/dL\nMean corpuscular volume 75 μm3\nLeukocyte count 5,000/mm3\nPlatelet count 350,000/mm3\nESR 18 mm/hr\nSerum\nFerritin 5 μg/L\nIron 30 μg/L\nTotal iron-binding capacity 500 μg/dL\nCalcium (Ca+) 9 mg/dL\nAlbumin 4 g/dL\nUrea nitrogen 14 mg/dL\nCreatinine 0.9 mg/dL\nMonoclonal protein on serum electrophoresis is 12 g/L (non-IgM). Clonal bone marrow plasma cells comprise 4% of the total number of cells. Skeletal survey with magnetic resonance imaging reveals no pathologic findings. In addition to iron deficiency anemia, which of the following diagnosis is most appropriate to consider?", "answer": "Monoclonal gammopathy of undetermined significance", "options": {"A": "Monoclonal gammopathy of undetermined significance", "B": "Smoldering (asymptomatic) multiple myeloma", "C": "Solitary plasmacytoma", "D": "Symptomatic multiple myeloma", "E": "Waldenstrom’s macroglobulinemia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["74 year old man returns", "physician to", "laboratory", "obtained", "anemia 2 weeks", "complaints", "20 year history of hypertension", "several years of knee osteoarthritis", "walks 2 miles", "day", "not smoke", "alcohol moderately", "hydrochlorothiazide", "losartan", "pain killers", "including ibuprofen", "vital signs include", "temperature", "98", "pulse", "min", "respiratory rate", "min", "blood pressure", "70 mm Hg", "abnormalities", "laboratory studies", "following", "test", "g dL Mean corpuscular volume", "m3 Leukocyte", "Platelet count", "18", "hr Serum", "Total iron-binding capacity 500", "dL Calcium", "Ca", "mg", "Albumin", "g", "nitrogen", "Creatinine", "Monoclonal protein", "serum electrophoresis", "g/L", "non IgM", "Clonal bone", "plasma", "4", "total number", "cells", "Skeletal survey", "magnetic resonance imaging reveals", "pathologic findings", "iron deficiency anemia", "following diagnosis", "most appropriate to"]}
{"question": "A 2-year-old boy is brought to the physician because of fever, productive cough, and shortness of breath. Since birth, he has had multiple respiratory infections requiring treatment with antibiotics. His immunizations are up-to-date. He is in the 10th percentile for height and weight. His temperature is 38°C (100.3°F). Examination detects diffuse bilateral wheezing and cervical lymphadenopathy. Flow cytometric analysis of a serum sample from the patient fails to fluoresce after incubation with dihydrorhodamine. This patient is at greatest risk of infection with which of the following organisms?", "answer": "Serratia marcescens", "options": {"A": "Enterococcus faecium", "B": "Serratia marcescens", "C": "Streptococcus pneumoniae", "D": "Clostridioides difficile", "E": "Streptococcus pyogenes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "brought", "physician", "fever", "productive cough", "shortness of breath", "birth", "multiple respiratory infections", "treatment", "antibiotics", "immunizations", "date", "percentile", "height", "weight", "temperature", "100", "detects diffuse bilateral wheezing", "cervical lymphadenopathy", "Flow cytometric analysis", "serum", "patient fails to", "patient", "greatest risk", "infection", "following"]}
{"question": "A 23-year-old woman presented to the clinic for her first prenatal appointment with fatigue and pain in the perineum for the past 8 days. The past medical history is benign and she claimed to have only had unprotected intercourse with her husband. She had a documented allergic reaction to amoxicillin 2 years ago. The vaginal speculum exam revealed a clean, ulcerated genital lesion, which was tender and non-exudative. No lymphadenopathy was detected. A rapid plasma reagin (RPR) test revealed a titer of 1:64 and the fluorescent treponemal antibody absorption (FTA- abs) test was positive. What is the next best step in the management of this patient?", "answer": "Penicillin desensitization, then intramuscular benzathine penicillin, G 2.4 million units", "options": {"A": "Parenteral ceftriaxone, 1 g x 10 days", "B": "Penicillin desensitization, then intramuscular benzathine penicillin, G 2.4 million units", "C": "Oral tetracycline, 500 mg 4 times daily x 1 week", "D": "Doxycycline, 100 mg twice daily x 14 days", "E": "Delay treatment until delivery"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "clinic", "first prenatal appointment", "fatigue", "pain", "perineum", "past", "days", "past medical history", "benign", "to", "only", "unprotected intercourse", "allergic reaction", "amoxicillin", "years", "vaginal exam revealed", "ulcerated genital lesion", "tender", "non-exudative", "lymphadenopathy", "detected", "rapid plasma reagin", "RPR", "test revealed", "titer", "fluorescent treponemal antibody absorption", "test", "positive", "next best step", "patient"]}
{"question": "A 63-year-old woman is brought to the emergency department by one of her neighbors because of fever and confusion. She has a 10-year history of diabetes mellitus and hemorrhoids. Her medications include insulin and metformin. Her blood pressure is 90/70 mm Hg, the pulse is 115/min, the respirations are 21/min, and the temperature is 39.5℃ (103.1℉). The cardiopulmonary examination shows no other abnormalities. The serum creatinine level is 2.5 mg/dL. An MRI shows swelling of subcutaneous soft tissue and gas. She is resuscitated with IV fluids. Broad-spectrum empiric IV antibiotics are administered. Which of the following is the most appropriate next step in management?", "answer": "Surgical debridement", "options": {"A": "Culture-based antibiotic therapy", "B": "High-dose IV steroids", "C": "Image-guided needle aspiration", "D": "Surgical debridement", "E": "No further management is indicated at this time"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old woman", "brought", "emergency department", "one", "fever", "confusion", "a 10 year history of diabetes mellitus", "hemorrhoids", "medications include insulin", "metformin", "blood pressure", "90 70 mm Hg", "pulse", "min", "respirations", "min", "temperature", "cardiopulmonary", "abnormalities", "serum creatinine level", "2.5 mg/dL", "MRI", "swelling of subcutaneous soft tissue", "gas", "resuscitated", "Broad spectrum empiric", "administered", "following", "most appropriate next step"]}
{"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 3 weeks. He recently quit the school's football team after missing many practices. He has also been avoiding his family and friends because he is not in the mood to see them but 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, 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": "Involuntary hospitalization after informing the parents", "B": "Agree to his wish for no further treatment", "C": "Reassure the patient that he will feel better", "D": "Begin paroxetine therapy", "E": "Start outpatient psychotherapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "of loss", "appetite", "sleeplessness", "extreme irritability", "weeks", "recently", "school's football", "missing", "not", "mood to see", "lonely", "not left", "room", "2 days", "prompted", "to", "physician", "medical conditions", "not", "medications", "not", "alcohol", "use recreational drugs", "waiting room", "mental status", "constricted", "intact", "better", "dead", "to", "treated", "to use", "licensed firearm to end", "misery", "weekend", "church", "following", "most appropriate next step"]}
{"question": "A 58-year-old man comes to the clinic complaining of increased urinary frequency for the past 3 days. The patient reports that he has had to get up every few hours in the night to go to the bathroom, and says \"whenever I feel the urge I have to go right away.” Past medical history is significant for a chlamydial infection in his twenties that was adequately treated. He endorses lower back pain and subjective warmth for the past 2 days. A rectal examination reveals a slightly enlarged prostate that is tender to palpation. What is the most likely explanation for this patient’s symptoms?", "answer": "Infection with Escherichia coli", "options": {"A": "Benign prostatic hyperplasia", "B": "Chemical irritation of the prostate", "C": "Infection with Escherichia coli", "D": "Prostatic adenocarcinoma", "E": "Reinfection with Chlamydia trachomatis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old man", "clinic", "increased urinary frequency", "past", "days", "patient reports", "to get", "hours", "night to go", "bathroom", "I", "I", "to go right", "Past medical history", "significant", "chlamydial infection", "twenties", "treated", "lower back pain", "subjective warmth", "past 2 days", "rectal examination reveals", "slightly enlarged prostate", "tender", "palpation", "patients symptoms"]}
{"question": "A 21-year-old woman presents with right eye irritation, redness, and watery discharge. These symptoms started abruptly 4 days ago. She is on summer vacation and does not report any contacts with evidently ill patients. However, during the vacation, she frequently visited crowded places. The patient denies any other symptoms. At the presentation, the patient’s vital signs include: blood pressure 125/80 mm Hg, heart rate 75/min, respiratory rate 14/min, and temperature 36.7℃ (98℉). The physical examination shows conjunctival injection, watery discharge, and mild follicular transformation of the conjunctiva of the right eye. There are no corneal lesions. Ipsilateral preauricular lymph nodes are enlarged. Which of the following would be a proper medical therapy for this patient", "answer": "No medical treatment required", "options": {"A": "Oral erythromycin", "B": "Acyclovir ointment", "C": "No medical treatment required", "D": "Levofloxacin drops", "E": "Tetracycline ointment"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["21-year-old woman presents", "right", "redness", "watery discharge", "symptoms started", "days", "summer", "not report", "contacts with", "ill patients", "frequently", "places", "patient", "symptoms", "patients vital signs include", "blood pressure", "80 mm Hg", "heart rate 75 min", "respiratory rate", "min", "temperature 36", "98", "conjunctival injection", "watery discharge", "mild follicular transformation of", "conjunctiva", "right eye", "corneal lesions", "Ipsilateral preauricular lymph nodes", "enlarged", "following", "medical", "patient"]}
{"question": "A 30-year-old man presents with a 1-month history of frequent intermittent headaches. He says the headaches typically occur between 3–4 times/day, mostly at night, each lasting minutes to 1–2 hours. He describes the pain as severe, stabbing, unilateral, and localized to the left periorbital region. He says he frequently notes increased tear production and conjunctival injection in the left eye and rhinorrhea during these headaches. He mentions that he had a similar 3-week episode of these same, frequent intermittent headaches 3 months ago which stopped completely until 1 month ago. He denies any seizures, loss of consciousness, nausea, vomiting, photophobia, or phonophobia. His past medical history is significant for stable angina secondary to coronary artery disease diagnosed on a stress echocardiogram 1 year ago. He reports occasional alcohol use, which he says precipitates the headaches, but denies any smoking or recreational drug use. The patient is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. A noncontrast computed tomography (CT) scan of the head is normal. Which of the following is the best abortive treatment for this patient?", "answer": "High-flow 100% oxygen", "options": {"A": "Sumatriptan", "B": "Dihydroergotamine", "C": "High-flow 100% oxygen", "D": "Hydrocodone", "E": "Intranasal lidocaine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old man presents", "month history of frequent intermittent headaches", "headaches", "occur", "times/day", "mostly", "night", "minutes", "12 hours", "pain", "severe", "stabbing", "unilateral", "localized", "left periorbital region", "frequently notes increased tear production", "conjunctival injection", "left eye", "rhinorrhea", "headaches", "similar", "week episode of", "same", "frequent intermittent headaches", "months", "stopped completely", "month", "seizures", "loss of consciousness", "nausea", "vomiting", "photophobia", "phonophobia", "past medical history", "significant", "stable angina secondary to coronary artery disease diagnosed", "stress echocardiogram", "year", "reports occasional", "precipitates", "headaches", "smoking", "recreational drug use", "patient", "afebrile", "vital signs", "normal limits", "unremarkable", "computed tomography", "scan of", "head", "normal", "following", "best"]}
{"question": "A 28-year-old man comes to the physician because of skin lesions on and around his anus. He noticed them 3 days ago. The lesions are not painful and he does not have any urinary complaints. He has smoked one pack of cigarettes daily for 10 years and he drinks 6–7 beers on weekends. He is sexually active with two male partners and uses condoms inconsistently. He appears healthy. A photograph of the perianal region is shown. The lesions turn white after application of a dilute acetic acid solution. The remainder of the examination shows no abnormalities. An HIV test is negative. Which of the following is the most appropriate next step in management?", "answer": "Curettage", "options": {"A": "Oral acyclovir", "B": "Topical mometasone", "C": "Radiotherapy", "D": "Parenteral benzathine penicillin", "E": "Curettage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of skin lesions", "anus", "3 days", "lesions", "not painful", "not", "urinary complaints", "smoked one pack", "cigarettes daily", "67", "weekends", "sexually active", "two male", "uses condoms", "appears healthy", "photograph", "perianal region", "lesions turn white", "application", "dilute", "abnormalities", "HIV test", "negative", "following", "most appropriate next step"]}
{"question": "A 28-year-old woman presents with severe diarrhea and abdominal pain. She says she has had 10 watery stools since the previous morning and is experiencing severe cramping in her abdomen. She reports similar past episodes of diarrhea with excruciating abdominal pain and mentions that she has taken diphenoxylate and atropine before which had helped her diarrhea and pain but resulted in severe constipation for a week. Which of the following receptors does diphenoxylate activate to cause the effects mentioned by this patient?", "answer": "µ receptor", "options": {"A": "NK1 receptor", "B": "H2 receptor", "C": "5-HT3 receptor", "D": "D2 receptor", "E": "µ receptor"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "severe diarrhea", "abdominal pain", "10 watery stools", "previous morning", "severe cramping", "abdomen", "reports similar past episodes of diarrhea", "excruciating abdominal", "diphenoxylate", "atropine", "helped", "diarrhea", "pain", "resulted", "severe constipation", "week", "following receptors", "diphenoxylate activate to cause", "effects", "patient"]}
{"question": "A 29-year-old woman comes to the physician because of poor balance and recurrent falls for the past month. She has also had blurry vision in her right eye for the past 2 weeks. She reports worsening of her symptoms after taking warm baths. Physical examination shows generalized hyperreflexia and an intention tremor. Romberg sign is positive. Visual acuity is 20/50 in the left eye and 20/100 in the right eye, and she is unable to distinguish red from green colors. The cells primarily affected by this patient's condition are most likely derived from which of the following embryologic structures?", "answer": "Neuroectoderm", "options": {"A": "Mesoderm", "B": "Endoderm", "C": "Neuroectoderm", "D": "Neural crest", "E": "Notochord"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "physician", "poor balance", "recurrent falls", "past month", "blurry vision", "right eye", "past 2 weeks", "reports worsening", "symptoms", "warm baths", "generalized hyperreflexia", "intention tremor", "Romberg sign", "positive", "Visual acuity", "20/50", "left eye", "20/100", "right eye", "unable to", "red", "green", "cells", "affected", "patient's", "most likely derived", "following embryologic structures"]}
{"question": "A 4-year-old boy is brought to the emergency department for a right ankle injury sustained during a fall earlier that morning. His parents report that he is 'clumsy' when he runs and has fallen multiple times in the last year. He has reached most of his developmental milestones but did not walk until the age of 17 months. He is an only child and was adopted at age 1. He appears tearful and in mild distress. His temperature is 37.2°C (98.9°F), pulse is 72/min, respirations are 17/min, and blood pressure is 80/50 mm Hg. His right ankle is mildly swollen with no tenderness over the medial or lateral malleolus; range of motion is full with mild pain. He has marked enlargement of both calves. Patellar and Achilles reflexes are 1+ bilaterally. Strength is 4/5 in the deltoids, knee flexors/extensors, and 5/5 in the biceps and triceps. Babinski sign is absent. When standing up from a lying position, the patient crawls onto his knees and slowly walks himself up with his hands. Which of the following is the most likely underlying mechanism of this patient's condition?", "answer": "Absence of dystrophin protein", "options": {"A": "SMN1 gene defect", "B": "Loss of the ATM protein", "C": "Myotonin protein kinase defect", "D": "Absence of dystrophin protein", "E": "Arylsulfatase A deficiency"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "brought", "emergency department", "right ankle injury sustained", "fall earlier", "morning", "report", "is", "clumsy", "runs", "fallen multiple times", "year", "reached most", "not", "age", "months", "adopted", "age", "appears tearful", "mild distress", "temperature", "98 9F", "pulse", "72 min", "respirations", "min", "blood pressure", "80 50 mm Hg", "right ankle", "mildly swollen", "tenderness", "medial", "lateral malleolus", "range of motion", "full", "mild pain", "marked enlargement", "calves", "Patellar", "Achilles reflexes", "1", "Strength", "4/5", "deltoids", "knee flexors extensors", "5/5", "biceps", "triceps", "Babinski sign", "absent", "standing up", "lying position", "patient crawls", "knees", "slowly walks", "hands", "following", "underlying mechanism", "patient's condition"]}
{"question": "A group of 6 college students with multiple sclerosis (MS) was evaluated for flares in a neurology clinic. The results are shown in the figure. Each row represents a patient. The gray bars represent the duration of the flare. The arrowheads indicate that disease was already present before and/or persisted beyond the timeframe of the study. Based on the figure, which of the following is the most valid statement about MS flares in this group of students?", "answer": "Incidence during the month of May was 2", "options": {"A": "Incidence from April 1st to June 1st was 3", "B": "Incidence during the month of May was 2", "C": "Incidence during the month of February was 3", "D": "The year-long prevalence was 4/6", "E": "Prevalence of the disease on May 15 was 4/6"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["multiple sclerosis", "flares", "neurology clinic", "results", "row", "patient", "gray bars", "duration", "flare", "disease", "present before", "timeframe", "study", "Based", "following", "most valid", "MS flares", "group"]}
{"question": "A 33-year-old man presents to the emergency department with sudden onset right hand and right leg weakness. The patient was at home cleaning when his symptoms began. He also complains of diffuse and severe pain throughout his entire body which he states he has experienced before. The patient is an immigrant from South America, and his medical history is not known. His temperature is 98.9°F (37.2°C), blood pressure is 128/67 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 99% on room air. CT of the head demonstrates no bleeding. Physical exam is notable for 2/5 strength in the patient's right arm and right leg. Which of the following is the best management in this patient?", "answer": "Exchange transfusion", "options": {"A": "Aspirin", "B": "Exchange transfusion", "C": "Heparin", "D": "Morphine and IV fluids", "E": "Tissue plasminogen activator"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "sudden onset right hand", "right", "patient", "at home", "symptoms began", "diffuse", "severe pain", "entire body", "states", "before", "patient", "South America", "medical history", "not known", "temperature", "98 9F", "blood pressure", "67 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "99", "room air", "CT of", "head", "bleeding", "notable", "strength", "patient's right arm", "right leg", "following", "best", "patient"]}
{"question": "A 28-year-old man presents to his primary care physician because he has been experiencing constipation for the last 6 days. He says that the constipation started 1 day after he started taking an over the counter medication for sinus congestion and a chronic cough. He has no other findings associated with the constipation. His past medical history is significant for seasonal allergies but he is not currently taking any other medications besides the one he reported. Which of the following drugs was most likely responsible for this patient's symptoms?", "answer": "Dextromethorphan", "options": {"A": "Dextromethorphan", "B": "Diphenhydramine", "C": "Guaifenesin", "D": "Loratadine", "E": "N-acetylcysteine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "constipation", "6 days", "constipation started 1 day", "started", "over the counter medication", "sinus congestion", "chronic cough", "findings associated with", "constipation", "past medical history", "significant", "seasonal allergies", "not currently", "medications", "one", "reported", "following drugs", "responsible", "patient's symptoms"]}
{"question": "A 28-year-old woman follows up at an outpatient surgery clinic with an abnormal scarring of her incisional wound from an abdominal surgical procedure  6 months ago. She gives a history of a wound infection with a purulent discharge 1 week after surgery. On examination of the scar, a dense, raised, healed lesion is noted at the incision site. She also complains of an occasional itching sensation over the scar. There is no history of such scar changes in her family. An image of the lesion is given below. Which of the following statements best describe the scar abnormality?", "answer": "There is excessive scar tissue projecting beyond the level of the surrounding skin, but not extending into the underlying subcutaneous tissue.", "options": {"A": "The scar has hair follicles and other adnexal glands within.", "B": "There is excessive scar tissue projecting beyond the level of the surrounding skin, but not extending into the underlying subcutaneous tissue.", "C": "This type of scar does not have claw-like projections.", "D": "Increased prevalence of this type of scar has no genetic basis or linkage.", "E": "This scar tissue is limited within the borders of the traumatized area."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman follows up", "outpatient surgery clinic", "abnormal scarring", "incisional wound", "abdominal surgical procedure", "months", "gives", "history", "wound infection", "purulent discharge 1", "surgery", "scar", "dense", "raised", "healed lesion", "noted", "incision site", "occasional itching sensation", "scar", "history", "scar changes", "lesion", "given", "following", "best", "scar abnormality"]}
{"question": "You are attempting to quantify the degree of infectivity of a novel respiratory virus. You assess 1,000 patients who have been exposed to the virus and find that 500 ultimately are found positive for the virus within a 1-year follow up period. Conversely, from a 1,000 patient control group who has not been exposed to carriers of the virus, only 5 became positive over the same 1-year period. What is the relative risk of a contracting this virus if exposed?", "answer": "[500/ (500 + 500)] / [5 / (5 + 995)]", "options": {"A": "[5 / (500 + 500)] / [5 / (995 + 995)]", "B": "[995 / (995 + 5)] / [500 / (500 + 500)]", "C": "[500/ (500 + 500)] / [5 / (5 + 995)]", "D": "(500 * 995) / (500 * 5)", "E": "(500 * 5) / (500 * 995)"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["to quantify", "degree", "infectivity", "novel respiratory virus", "1", "patients", "exposed", "find", "500", "found positive", "year follow up period", "patient control", "not", "exposed", "carriers", "only", "positive", "same", "year period", "relative risk", "exposed"]}
{"question": "A 19-year-old man comes to the physician because of recurrent yellowing of his eyes over the past 2 years. He reports that each episode lasts 1–2 weeks and resolves spontaneously. He has no family history of serious illness. He recently spent a week in Mexico for a vacation. He is sexually active with two partners and uses condoms inconsistently. He does not drink alcohol or use illicit drugs. His vital signs are within normal limits. Physical examination shows jaundice of the conjunctivae and the skin. The abdomen is soft with no organomegaly. The remainder of the physical examination shows no abnormalities. Laboratory studies show:\nSerum\nTotal bilirubin 4.0 mg/dL\nDirect bilirubin 3.0 mg/dL\nAlkaline phosphatase 75 U/L\nAST 12 U/L\nALT 12 U/L\nAnti-HAV IgG positive\nHBsAg negative\nAnti-HBsAg positive\nHCV RNA negative\nUrine\nBilirubin present\nUrobilinogen normal\nWhich of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Impaired hepatic storage of bilirubin", "options": {"A": "Destruction of the intralobular bile ducts", "B": "Inflammation of intra- and extrahepatic bile ducts", "C": "Impaired hepatic storage of bilirubin", "D": "Excess cellular bilirubin release", "E": "Defective bilirubin conjugation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "recurrent yellowing", "eyes", "past", "years", "reports", "episode", "weeks", "family history", "serious illness", "recently spent", "week", "Mexico", "sexually active", "two", "uses condoms", "not", "alcohol", "use illicit", "vital signs", "normal limits", "jaundice", "conjunctivae", "skin", "abdomen", "soft", "organomegaly", "abnormalities", "Laboratory studies", "Serum", "mg", "mg", "L AST", "Anti IgG positive HBsAg negative", "present Urobilinogen normal", "following", "underlying cause", "patient", "ondition?"]}
{"question": "A 49-year-old man presents to his primary care provider complaining of weakness and fatigue. He reports that he has started moving slower than normal and has noticed difficulty buttoning up his pants or tying his tie. He is accompanied by his wife who reports that he has started to move more slowly over the past 2 years. He has also become increasingly irritable and has had trouble sleeping. His past medical history is notable for hypertension, diabetes mellitus, and obesity. He takes enalapril and metformin. His family history is notable for multiple strokes in his mother and father. His temperature is 99°F (37.2°C), blood pressure is 140/90 mmHg, pulse is 90/min, and respirations are 17/min. On exam, strength is 4+/5 bilaterally in his upper extremities and 4/5 in his lower extremities. Some muscle atrophy is noted in his legs and feet. Patellar reflexes are 3+ bilaterally. He has a tremor in his right hand that diminishes when he is instructed to hold a pen in his hand. He is oriented to person, place and time. He states that he feels depressed but denies suicidal ideation. His physician prescribes multiple medications including a drug that is also indicated in the treatment of prolactinomas. Which of the following is the mechanism of action of this medication?", "answer": "Activate dopamine receptors", "options": {"A": "Activate dopamine receptors", "B": "Increase dopamine release", "C": "Inhibit dopamine receptors", "D": "Prevent dopamine degradation into 3,4-dihydroxyphenylacetic acid", "E": "Prevent dopamine degradation into 3-O-methyldopa"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "weakness", "fatigue", "reports", "started moving slower", "normal", "difficulty buttoning", "pants", "tying", "tie", "reports", "started to move more slowly", "past", "years", "irritable", "trouble sleeping", "past medical history", "notable", "hypertension", "diabetes mellitus", "obesity", "enalapril", "metformin", "family history", "notable", "multiple strokes", "temperature", "blood pressure", "90 mmHg", "pulse", "90 min", "respirations", "min", "exam", "strength", "4", "5", "upper extremities", "4/5", "lower extremities", "muscle atrophy", "noted", "legs", "feet", "Patellar reflexes", "3", "tremor", "right", "diminishes", "to hold", "pen", "hand", "oriented to person", "place", "time", "states", "depressed", "suicidal ideation", "physician", "multiple medications including", "drug", "indicated", "treatment", "prolactinomas", "following", "mechanism of action", "medication"]}
{"question": "A 1-year-old boy is brought to his pediatrician for a follow-up appointment. He was recently diagnosed with failure to thrive and developmental delay. His weight is 7 kg (15.4 lb), height is 61 cm (24 in), and head circumference is 42 cm (16.5 in). The patient’s father had a younger sister who suffered from mental and physical delay and died at a very young age. The patient was able to raise his head at the age of 7 months and began to sit alone only recently. He babbles, coos, and smiles to other people. On presentation, his blood pressure is 75/40 mm Hg, heart rate is 147/min, respiratory rate is 28/min, and temperature is 36.4°C (97.5°F). He has a coarse face with small deep orbits, proptotic eyes, big lips, and gingival hyperplasia. His skin is pale with decreased elasticity. His lung and heart sounds are normal. Abdominal examination reveals diminished anterior abdominal wall muscle tone and hepatomegaly. Muscle tone is increased in all groups of muscles on both upper and lower extremities. The physician becomes concerned and performs testing for the suspected hereditary disease. A blood test shows increased lysosomal enzyme concentration in the serum and decreased N-acetylglucosamine-1-phosphotransferase (GlcNAc phosphotransferase) activity within the leukocytes. Which of the statements listed below describes the mechanism of the patient’s condition?", "answer": "The lysosomal enzymes are secreted from the cells instead of being targeted to lysosomes because of lack of mannose phosphorylation on N-linked glycoproteins.", "options": {"A": "The patient’s symptoms are due to dysfunctional metabolism of sphingomyelin, which accumulates within the lysosomes.", "B": "There is impaired hydrolysis of GM2-ganglioside, which accumulates in the cytoplasm.", "C": "The lysosomal enzymes are secreted from the cells instead of being targeted to lysosomes because of lack of mannose phosphorylation on N-linked glycoproteins.", "D": "Due to enzyme deficiency, glycogen is extensively accumulated within the hepatocytes.", "E": "The symptoms result from defective glycolysis, which results in a total energy deficiency."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "pediatrician", "follow-up appointment", "recently diagnosed", "failure to thrive", "developmental delay", "weight", "kg", "15.4", "height", "61", "head circumference", "patients", "suffered", "physical delay", "died", "very young age", "patient", "able to", "head", "age", "months", "began to sit alone only recently", "smiles", "blood pressure", "75 40 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "coarse face", "small deep orbits", "proptotic eyes", "big lips", "gingival hyperplasia", "skin", "pale", "decreased elasticity", "lung", "heart sounds", "normal", "Abdominal", "reveals diminished anterior abdominal wall muscle tone", "hepatomegaly", "Muscle tone", "increased", "groups", "muscles", "upper", "lower extremities", "physician", "performs testing", "suspected hereditary disease", "blood test", "increased lysosomal enzyme concentration", "serum", "decreased", "acetylglucosamine", "phosphotransferase", "GlcNAc phosphotransferase", "activity", "mechanism", "patients condition"]}
{"question": "A 13-year-old girl presents with a right infected ingrown toenail. On examination, the skin on the lateral side of the toe is red, warm, swollen, and severely tender to touch. When gentle pressure is applied, pus oozes out. Culture and sensitivity analysis of the pus shows methicillin-resistant Staphylococcus aureus (MRSA). Which of the following antibiotics is most effective against this organism?", "answer": "Clindamycin", "options": {"A": "Cefotetan", "B": "Oral vancomycin", "C": "Clindamycin", "D": "Cefuroxime", "E": "Aztreonam"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl presents", "right infected ingrown toenail", "skin", "lateral side of", "toe", "red", "warm", "swollen", "severely tender", "touch", "gentle pressure", "applied", "pus", "out", "Culture", "sensitivity analysis", "pus", "methicillin-resistant Staphylococcus aureus", "following", "most effective"]}
{"question": "A 39-year-old man comes to the physician for a follow-up examination. He was diagnosed with latent tuberculosis infection 3 months ago. He has had generalized fatigue and dyspnea on exertion for the past 6 weeks. He does not smoke and drinks 2–3 beers on weekends. Vital signs are within normal limits. Examination shows conjunctival pallor. Laboratory studies show:\nHemoglobin 7.8 g/dL\nMean corpuscular volume 72 μm3\nRed cell distribution width 17% (N = 13–15)\nReticulocyte count 0.7%\nLeukocyte count 6,800/mm3\nPlatelet count 175,000/mm3\nSerum\nCreatinine 0.8 mg/dL\nIron 246 μg/dL\nFerritin 446 ng/mL\nTotal iron-binding capacity 212 μg/dL (N = 250–450)\nWhich of the following is the most likely cause of this patient's symptoms?\"", "answer": "Adverse effect of medication", "options": {"A": "Iron deficiency", "B": "Chronic inflammation", "C": "Beta thalessemia minor", "D": "Adverse effect of medication", "E": "Vitamin B12 deficiency\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "follow-up examination", "diagnosed", "latent tuberculosis infection", "months", "generalized fatigue", "dyspnea on exertion", "past", "weeks", "not smoke", "23", "weekends", "Vital signs", "normal limits", "conjunctival pallor", "Laboratory studies", "Hemoglobin", "g", "Mean corpuscular volume", "m3 Red cell distribution width 17", "N", "Reticulocyte count 0", "Leukocyte count 6 800 mm3 Platelet count", "Serum", "g", "mL Total iron-binding capacity", "N", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 33-year-old woman comes to the physician for a follow-up examination. She was treated for a urinary stone 1 year ago with medical expulsive therapy. There is no personal or family history of serious illness. Her only medication is an oral contraceptive pill that she has been taking for 12 years. She appears healthy. Physical examination shows no abnormalities. A complete blood count, serum creatinine, and electrolytes are within the reference range. Urinalysis is within normal limits. An ultrasound of the abdomen shows a well-demarcated hyperechoic 3-cm (1.2-in) hepatic lesion. A contrast-enhanced CT of the abdomen shows a well-demarcated 3-cm hepatic lesion with peripheral enhancement and subsequent centripetal flow followed by rapid clearance of contrast. There is no hypoattenuating central scar. In addition to stopping the oral contraceptive pill, which of the following is the most appropriate next step in management?", "answer": "Reimage in 6 months", "options": {"A": "Embolization of the mass", "B": "Percutaneous liver biopsy", "C": "Reimage in 6 months", "D": "Radiofrequency ablation of the mass", "E": "Surgical resection of the mass"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "treated", "urinary stone", "year", "medical expulsive therapy", "personal", "family history", "serious illness", "only medication", "oral contraceptive pill", "years", "appears healthy", "Physical examination", "abnormalities", "complete blood count", "serum creatinine", "electrolytes", "reference range", "Urinalysis", "normal limits", "ultrasound of", "abdomen", "well", "hyperechoic", "1.2", "hepatic lesion", "contrast", "CT of", "abdomen", "well", "hepatic lesion", "peripheral enhancement", "subsequent centripetal", "followed by rapid clearance", "contrast", "central scar", "stopping", "oral contraceptive pill", "following", "most appropriate next step"]}
{"question": "A 73-year-old man is brought to the emergency department because of fever, malaise, dyspnea, and a productive cough with purulent sputum for the past day. His temperature is 39.2°C (102.6°F). Pulmonary examination shows crackles over the right upper lung field. Sputum Gram stain shows gram-positive cocci. Despite the appropriate treatment, the patient dies 5 days later. At autopsy, gross examination shows that the right lung has a pale, grayish-brown appearance and a firm consistency. Microscopic examination of the tissue is most likely to show which of the following?", "answer": "Fibrinopurulent leukocytic exudate with lysed erythrocytes", "options": {"A": "Fibrinopurulent leukocytic exudate with lysed erythrocytes", "B": "Fibrinous exudate with erythrocytes, leukocytes, and bacteria", "C": "Resorbed exudate with aerated alveoli", "D": "Neutrophilic infiltrate in the bronchiolar walls and adjacent alveoli", "E": "Dilation of alveolar capillaries and serous exudate with abundant bacteria"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "fever", "malaise", "dyspnea", "productive cough", "purulent sputum", "past day", "temperature", "Pulmonary", "crackles", "right upper lung field", "Sputum Gram stain", "appropriate treatment", "patient", "days later", "autopsy", "gross examination", "right lung", "pale", "grayish brown appearance", "firm consistency", "Microscopic examination", "tissue", "to", "following"]}
{"question": "A 27-year-old woman presents to the clinic with a runny nose and productive cough for the past two weeks. She also complains of headaches and lethargy. She was started on sertraline after she was diagnosed with major depressive disorder 2 months ago and had the dosage periodically increased to achieve symptom control. She is afraid of starting any other medication because of possible side-effects or life-threatening drug interactions. What advice is the most accurate regarding possible complication to her current pharmacotherapy?", "answer": "Migraine medication can trigger a life-threatening complication.", "options": {"A": "Migraine medication can trigger a life-threatening complication.", "B": "Sertraline cannot be used concurrently with neuroleptics", "C": "Monoamine-oxidase-inhibitors are safe for concurrent use.", "D": "Over-the-counter (OTC) medications are safe for her to use.", "E": "Treat life-threatening complication with gradual drug withdrawal."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old woman presents", "clinic", "runny nose", "productive cough", "past two weeks", "headaches", "lethargy", "started", "sertraline", "diagnosed", "major depressive disorder 2 months", "dosage periodically increased to", "symptom control", "starting", "medication", "possible side-effects", "life-threatening drug interactions", "most accurate", "possible complication", "current pharmacotherapy"]}
{"question": "A 24-year-old man presents to the office, complaining of a rash and “not feeling well.” The patient reports fatigue, a headache, and a possible fever. He says he has felt this way since a camping trip with his family in North Carolina, but he denies any contact with sick individuals. On examination, his vital signs include: temperature 38.5°C (101.3°F), blood pressure 100/60 mm Hg, heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and O2 saturation 99% on room air. The patient appears unwell. He has a maculopapular rash on his upper and lower extremities, including the palms of his hands and soles of his feet. He says he started feeling sick a few days before he got the rash, which prompted him to come into the office. The patient denies itching but admits to some nausea and vomiting. He also admits to unprotected sex with a single female partner for the past three years. What is the most likely causative agent of this patient’s presentation?\n ", "answer": "A gram-negative bacteria transmitted via the Dermacentor tick", "options": {"A": "A sexually transmitted spirochete", "B": "A protozoan transmitted via the Ixodes tick", "C": "A gram-negative bacteria transmitted via the Dermacentor tick", "D": "A gram-negative bacterium transmitted via the Ixodes tick", "E": "A positive-sense, single-stranded RNA virus that is non-enveloped"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "office", "complaining of a rash", "not", "well", "patient reports fatigue", "headache", "possible fever", "trip", "North Carolina", "contact with sick individuals", "vital signs include", "temperature", "blood pressure 100 60 mm Hg", "heart rate", "beats per minute", "respiratory rate", "breaths per minute", "O2 saturation 99", "room air", "patient appears unwell", "maculopapular rash", "upper", "lower extremities", "including", "palms of", "hands", "soles of", "feet", "started feeling sick", "few days", "got", "rash", "prompted", "to", "office", "patient", "itching", "nausea", "vomiting", "female", "past three years", "causative agent", "patients"]}
{"question": "A 67-year-old man presents to the emergency department with anxiety and trouble swallowing. He states that his symptoms have slowly been getting worse over the past year, and he now struggles to swallow liquids. He recently recovered from the flu. Review of systems is notable only for recent weight loss. The patient has a 33 pack-year smoking history and is a former alcoholic. Physical exam is notable for poor dental hygiene and foul breath. Which of the following is the most likely diagnosis?", "answer": "Squamous cell carcinoma", "options": {"A": "Achalasia", "B": "Globus hystericus", "C": "Squamous cell carcinoma", "D": "Viral-induced gastroparesis", "E": "Zenker diverticulum"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "emergency department", "anxiety", "swallowing", "states", "symptoms", "slowly", "getting worse", "past year", "now", "to swallow", "recently recovered", "flu", "Review of systems", "notable only", "recent weight loss", "patient", "smoking history", "former alcoholic", "notable", "poor dental hygiene", "foul breath", "following", "diagnosis"]}
{"question": "A group of scientists studied the effects of cytokines on effector cells, including leukocytes. They observed that interleukin-12 (IL-12) is secreted by antigen-presenting cells (APCs) in response to bacterial lipopolysaccharide. When a CD4+ T cell is exposed to this interleukin, which of the following responses will it have?", "answer": "Cell-mediated immune responses", "options": {"A": "Cell-mediated immune responses", "B": "Activate B cells", "C": "Secrete IL–4", "D": "Releases granzymes", "E": "Responds to extracellular pathogens"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["scientists studied", "effects", "cytokines", "including", "observed", "interleukin-12", "secreted", "response to bacterial lipopolysaccharide", "exposed", "interleukin", "following responses"]}
{"question": "A 36-year-old woman presents with a whitish vaginal discharge over the last week. She also complains of itching and discomfort around her genitals. She says her symptoms are getting progressively worse. She has been changing her undergarments frequently and changed the brand of detergent she uses to wash her clothes, but it did not resolve her problem. Additionally, she admits to having painful urination and increased urinary frequency for the past one month, which she was told are expected side effects of her medication. The patient denies any recent history of fever or malaise. She has 2 children, both delivered via cesarean section in her late twenties. Past medical history is significant for hypertension and diabetes mellitus type 2. Current medications are atorvastatin, captopril, metformin, and empagliflozin. Her medications were changed one month ago to improve her glycemic control, as her HbA1c at that time was 7.5%. Her vital signs are a blood pressure of 126/84 mm Hg and a pulse of 78/min. Her fingerstick glucose is 108 mg/dL. Pelvic examination reveals erythema and mild edema of the vulva. A thick, white, clumpy vaginal discharge is seen. The vaginal pH is 4.0. Microscopic examination of a KOH-treated sample of the discharge demonstrates lysis of normal cellular elements with branching pseudohyphae. Which of the following is the next best step in the management of this patient?", "answer": "Start fluconazole.", "options": {"A": "Start metronidazole.", "B": "Stop empagliflozin.", "C": "Advise her to drink lots of cranberry juice.", "D": "Switch her from oral antidiabetic medication to insulin.", "E": "Start fluconazole."}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["36 year old woman presents", "vaginal discharge", "last week", "itching", "discomfort", "genitals", "symptoms", "getting", "worse", "changing", "undergarments frequently", "changed", "uses to", "clothes", "not", "problem", "to", "painful urination", "increased urinary frequency", "past one", "side effects", "medication", "patient", "recent history", "fever", "malaise", "has", "children", "delivered", "cesarean section", "late twenties", "Past medical history", "significant", "hypertension", "diabetes mellitus type 2", "Current medications", "atorvastatin", "captopril", "metformin", "empagliflozin", "medications", "changed one month", "to", "glycemic control", "time", "7.5", "vital signs", "blood pressure", "84 mm Hg", "pulse", "min", "fingerstick glucose", "mg/dL", "Pelvic examination reveals erythema", "mild edema of", "vulva", "thick", "white", "clumpy vaginal discharge", "seen", "vaginal pH", "4.0", "Microscopic examination", "KOH treated sample", "discharge", "lysis", "normal cellular elements", "branching", "following", "next best step", "patient"]}
{"question": "A 44-year-old female patient comes to the physician’s office with her husband with complaints of abdominal pain. For the past 4 months, she has experienced cramping right upper quadrant pain that starts after meals. The physician performs a right upper quadrant ultrasound that shows round echogenic masses in the gallbladder. The physician offers an elective cholecystectomy to the patient to improve her symptoms and explains the procedure in detail to the patient including potential risks and complications. The patient acknowledges and communicates her understanding of her diagnosis as well as the surgery and decides to proceed with the surgery in one month. The patient signs a form indicating her consent to this procedure. Which of the following must also be communicated to the patient at this time?", "answer": "The patient has the right to revoke her consent at any time before the procedure", "options": {"A": "A family member must also provide consent for this procedure", "B": "The patient must give consent again before the procedure", "C": "The patient has the right to revoke her consent at any time before the procedure", "D": "The patient’s consent was not necessary for this procedure", "E": "The results of the procedure must be disclosed to her husband"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female patient", "physicians office", "complaints", "abdominal pain", "past", "months", "cramping right upper quadrant pain", "starts", "meals", "physician performs", "right upper quadrant ultrasound", "round echogenic masses", "gallbladder", "physician", "elective cholecystectomy", "patient to", "symptoms", "procedure", "detail", "patient including potential", "complications", "patient", "communicates", "diagnosis", "surgery", "to", "surgery", "one month", "patient signs", "form", "consent", "procedure", "following", "communicated", "patient", "time"]}
{"question": "A patient presents to the clinic with symptoms of dizziness on standing up. He says it started soon after he was diagnosed with hypertension and started taking treatment for it. He has no other medical history. The physician decides to switch to another antihypertensive that does not cause orthostatic hypotension. Which of the following should be the drug of choice for this patient?", "answer": "Propanolol", "options": {"A": "Enalapril", "B": "Methyldopa", "C": "Clonidine", "D": "Amlodipine", "E": "Propanolol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["patient presents", "clinic", "symptoms", "dizziness", "standing up", "started", "diagnosed", "hypertension", "started", "treatment", "medical history", "physician", "to switch", "antihypertensive", "not cause orthostatic hypotension", "following", "drug", "patient"]}
{"question": "A 42-year-old woman comes to the physician with a 6-month history of breast tenderness and menstrual irregularities. Physical examination shows no abnormalities. An ultrasound of the pelvis shows a right adnexal mass. A laparoscopic right salpingo-oophorectomy is performed. Histologic examination of the adnexal mass shows small cuboidal cells arranged in clusters surrounding a central cavity with eosinophilic secretions. These cells resemble primordial follicles. Which of the following laboratory values was most likely increased in this patient at the time of presentation?", "answer": "Estradiol", "options": {"A": "Estradiol", "B": "Lactate dehydrogenase", "C": "α-fetoprotein", "D": "β-human chorionic gonadotropin", "E": "Follicle stimulating hormone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "month history of breast tenderness", "menstrual irregularities", "abnormalities", "ultrasound", "pelvis", "right adnexal mass", "laparoscopic right salpingo-oophorectomy", "performed", "Histologic examination", "adnexal mass", "small", "clusters surrounding", "central cavity", "eosinophilic secretions", "cells", "primordial follicles", "following laboratory values", "most likely increased", "patient", "time"]}
{"question": "A 50-year-old man presents to the emergency department complaining of chest pain and drooling that started immediately after eating a steak. His past medical history is significant for lye ingestion 5 years ago during a suicidal attempt. He also suffers from hypertension and diabetes mellitus, type 2. He takes fluoxetine, lisinopril, and metformin every day. He also regularly sees a counselor to cope with his previous suicide attempt. Both of his parents are still alive and in good health. His heart rate is 96/min, temperature is 36.7°C (98.1°F).On physical examination, the patient can talk normally and breaths without effort. He is drooling. The chest pain is vague and constant. A chest X-ray shows no subcutaneous emphysema. An endoscopy confirms the presence of a retained bolus of meat 24 cm beyond the incisors where a stricture is identified. The bolus is removed and the stricture is dilated. Which of the following anatomic spaces contains the stricture?", "answer": "The superior mediastinum", "options": {"A": "The superior mediastinum", "B": "The diaphragm", "C": "The anterior mediastinum", "D": "The posterior mediastinum", "E": "The epigastrium"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["50 year old man presents", "emergency department", "of chest pain", "drooling", "started immediately", "eating", "past medical history", "significant", "lye ingestion", "years", "suicidal attempt", "suffers", "hypertension", "diabetes mellitus", "type 2", "fluoxetine", "lisinopril", "metformin", "day", "sees", "counselor to", "previous suicide attempt", "alive", "heart rate", "96 min", "temperature", "36", "98", "patient", "talk", "breaths", "effort", "drooling", "chest pain", "vague", "constant", "chest X-ray", "subcutaneous emphysema", "endoscopy confirms", "presence", "retained bolus", "24 cm", "incisors", "stricture", "identified", "bolus", "removed", "stricture", "dilated", "following anatomic spaces contains", "stricture"]}
{"question": "A 45-year-old man presents with a chief complaint of pain in the great toe. He has a history of gout, which is under control. He was diagnosed with diabetes 5 years ago and is currently taking metformin. He was recently diagnosed with hypertension and was placed on a hypertensive drug. He is a non-smoker and does not abuse alcohol. The family history is significant for ischemic heart disease in his father. His current blood pressure is 136/84 mm Hg and the pulse is 78/min. The physical examination did not reveal any abnormalities. He uses over-the-counter multivitamin supplements. Which of the following drugs could have resulted in these symptoms?", "answer": "Thiazide diuretics", "options": {"A": "Angiotensin II receptor blockers (ARBs)", "B": "Thiazide diuretics", "C": "Calcium channel blockers (CCBs)", "D": "Angiotensin-converting enzyme (ACE) inhibitors", "E": "Beta-blockers"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "chief complaint", "pain", "great toe", "history of gout", "control", "diagnosed", "diabetes", "years", "currently", "metformin", "recently diagnosed", "hypertension", "hypertensive drug", "non-smoker", "not abuse alcohol", "family history", "significant", "ischemic heart disease", "current blood pressure", "84 mm Hg", "pulse", "min", "not reveal", "abnormalities", "uses over-the-counter multivitamin supplements", "following drugs", "resulted", "symptoms"]}
{"question": "A 15-year-old girl is brought to the physician for a school physical examination. She feels well. She is performing well in school and getting good grades. She is 147 cm (4 ft 10 in) tall and weighs 60 kg (132 lbs); BMI is 27.6 kg/m2. Her temperature is 37°C (98.6°F), pulse is 82/min, respirations are 16/min, and blood pressure is 138/82 mm Hg in the left arm and 110/74 mm Hg in the left leg. Physical examination shows an unusually short and broad neck with bilateral excess skin folds that extend to the shoulders and low-set ears. There is an increased carrying angle when she fully extends her arms at her sides. An x-ray of the chest shows inferior rib notching. Which of the following additional findings is most likely in this patient?", "answer": "Streak ovaries on pelvic ultrasound\n\"", "options": {"A": "Horseshoe adrenal gland on abdominal CT", "B": "Prolonged activated partial thromboplastin time", "C": "Uterine agenesis on pelvic exam", "D": "Mutation of FBN1 on genetic testing", "E": "Streak ovaries on pelvic ultrasound\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "physician", "school physical examination", "well", "performing well", "school", "getting good", "4 ft 10", "tall", "60 kg", "lbs", "BMI", "27", "kg/m2", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "left arm", "74 mm Hg", "left leg", "short", "broad neck", "bilateral excess skin folds", "extend", "shoulders", "low-set ears", "increased", "angle", "extends", "arms", "sides", "x-ray of", "chest", "inferior rib notching", "following additional findings", "patient"]}
{"question": "A 27-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician for a prenatal visit. She feels that her baby's movements have decreased recently. She says that she used to feel 10–12 movements/hour earlier, but that it has recently decreased to about 7–8/hour. Pregnancy and delivery of her first child were uncomplicated. Medications include folic acid and a multivitamin. 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 32-week gestation. The fetus is in a transverse lie presentation. The fetal heart rate is 134/min. A 14-minute recording of the nonstress test is shown. Which of the following is the most appropriate next step in managing this patient?", "answer": "Provide reassurance to the mother", "options": {"A": "Repeat the nonstress test weekly", "B": "Provide reassurance to the mother", "C": "Administer intravenous oxytocin", "D": "Perform vibroacoustic stimulation", "E": "Extend the nonstress test by 20 minutes"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old woman", "gravida 2", "para 1", "weeks", "gestation", "physician", "baby's movements", "decreased recently", "used to", "movements hour earlier", "recently decreased to", "hour", "Pregnancy", "delivery", "first child", "uncomplicated", "Medications include folic acid", "multivitamin", "temperature", "blood pressure", "60 mm Hg", "Pelvic examination", "uterus", "size", "week gestation", "fetus", "transverse", "presentation", "fetal heart rate", "min", "minute", "nonstress test", "following", "most appropriate next step", "patient"]}
{"question": "А 41-уеаr-old woman рrеѕеnts to thе offісе wіth a сomрlаіnt of а hеаdасhе for 1 month and a еріѕodе of аbnormаl bodу movеmеnt. The headaches are more severe іn thе mornіng, moѕtlу after waking up. Ѕhе doеѕn’t give a history of any mајor іllnеѕѕ or trauma in the past. Неr vіtаlѕ ѕіgnѕ include: blood рrеѕѕurе 160/80 mm Нg, рulѕе 58/mіn, tеmреrаturе 36.5°C (97.8°F), аnd rеѕріrаtorу rаtе 11/mіn. Оn fundoscopic ехаmіnаtіon, mіld раріllеdеmа is present. Her рuріlѕ аrе еquаl аnd rеасtіvе to lіght. No foсаl nеurologісаl dеfісіt сan bе еlісіtеd. A contrast computed tomography scan of the head is shown in the picture. Which of the following is the most likely biopsy finding in this case?", "answer": "Spindle cells concentrically arranged in whorled pattern with laminated calcification", "options": {"A": "Oligodendrocytes with round nuclei and clear surrounding cytoplasm giving a fried-egg appearance", "B": "Closely arranged thin walled capillaries with minimal intervening parenchyma", "C": "Pseudopalisading pleomorphic tumor cells", "D": "Spindle cells concentrically arranged in whorled pattern with laminated calcification", "E": "Large quantities of lymphocytes without a particular growth pattern"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["r old woman", "th", "1 month", "od", "bod", "headaches", "more severe", "th", "waking", "h", "give", "history", "mor lln", "trauma", "past", "r", "gn include", "blood", "80 mm g", "ul 58 mn", "36", "97", "rt", "mn", "fundoscopic", "mld", "present", "ul r", "rtv", "ltd", "contrast computed tomography scan of", "head", "picture", "following", "most likely biopsy", "case"]}
{"question": "A 40-year-old woman has complaints of dyspnea, cough, and arthritis in her ankle joints. A CT scan reveals multiples granulomas in both lungs, as well as bilateral hilar lymphadenopathy. On examination, cutaneous nodules over the trunk are found. Erythrocyte sedimentation rate, angiotensin-converting enzyme, and serum calcium levels are elevated. She is treated with steroids. What is the most likely diagnosis?", "answer": "Sarcoidosis", "options": {"A": "Hodgkin's lymphoma", "B": "Tuberculosis", "C": "Silicosis", "D": "Adenocarcinoma of the lung", "E": "Sarcoidosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["40 year old woman", "complaints", "dyspnea", "cough", "arthritis", "ankle joints", "CT scan reveals multiples granulomas", "lungs", "bilateral hilar lymphadenopathy", "cutaneous nodules", "trunk", "found", "Erythrocyte sedimentation rate", "angiotensin-converting enzyme", "serum calcium levels", "elevated", "treated with steroids", "diagnosis"]}
{"question": "A cell biologist is studying the activity of a novel chemotherapeutic agent against a cancer cell line. After incubation with the agent and cell detachment from the tissue culture plate, the DNA is harvested from the cells and run on a gel. Of note, there are large bands at every multiple of 180 base pairs on the gel. Which of the following explains the pathophysiology of this finding?", "answer": "Caspase activation", "options": {"A": "ATP depletion", "B": "Caspase activation", "C": "Cellular swelling", "D": "Protein denaturation", "E": "Release of lysosomal enzymes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["cell biologist", "studying", "activity", "novel chemotherapeutic agent", "cancer", "line", "agent", "cell detachment", "tissue culture plate", "DNA", "cells", "run", "gel", "note", "large bands", "multiple", "base pairs", "gel", "following", "pathophysiology", "finding"]}
{"question": "A 2-week-old newborn is brought to the physician because of worsening feeding difficulty since birth. Examination shows a grade 2/6 harsh holosystolic murmur, heard most clearly at the left lower sternal border, and a soft mid-diastolic rumble over the cardiac apex. Echocardiography shows shunting of blood through the ventricular septum during systole. The patient undergoes surgery for closure of the defect. Which of the following sets of changes are expected after successful repair of this cardiac defect?\n $$$ Left atrial pressure %%% Left ventricular pressure %%% Right ventricular pressure $$$", "answer": "↓ ↑ ↓", "options": {"A": "↓ ↑ no change", "B": "↓ ↑ ↓", "C": "↑ ↑ ↑", "D": "↓ ↓ ↓", "E": "↑ ↑ ↓"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 week old newborn", "brought", "physician", "worsening feeding difficulty", "birth", "Examination", "harsh holosystolic murmur", "heard", "left lower sternal border", "soft", "diastolic rumble", "cardiac apex", "Echocardiography", "shunting", "blood", "ventricular", "systole", "patient", "surgery", "closure", "defect", "following sets", "changes", "successful repair", "cardiac defect", "Left", "ventricular pressure", "Right ventricular pressure"]}
{"question": "A 77-year-old man with a history of advanced dementia, hypertension, Parkinson’s disease, and diabetes mellitus type 2 is brought to the hospital from a nursing home after several days of non-bloody diarrhea and vomiting. The patient is evaluated and admitted to the hospital. Physical examination shows a grade 2/6 holosystolic murmur over the left upper sternal border, clear lung sounds, a distended abdomen with normal bowel sounds, a resting tremor, and 2+ edema of the lower extremities up to the ankle. Over the next few hours, the nurse records a total of 21 cc of urine output over the past 5 hours. Which of the following criteria suggest pre-renal failure?", "answer": "Fractional excretion of sodium of 0.5%", "options": {"A": "Urine osmolarity of 280 mOsm/kg", "B": "Urine Na of 80 mEq/L", "C": "Urine/plasma creatinine ratio of 10", "D": "Fractional excretion of sodium of 0.5%", "E": "Urine/plasma osmolarity ratio of 0.8"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "history of advanced dementia", "hypertension", "Parkinsons disease", "diabetes mellitus type 2", "brought", "hospital", "nursing home", "days", "non bloody diarrhea", "vomiting", "patient", "holosystolic murmur", "left upper sternal border", "clear lung sounds", "distended abdomen", "normal bowel sounds", "resting tremor", "2", "edema of", "lower extremities", "ankle", "next", "hours", "nurse records", "total", "cc", "urine output", "past", "hours", "following", "pre renal failure"]}
{"question": "A 7-year-old boy is brought to the physician by his mother because of a 2-week history of intermittent shortness of breath and a dry cough that is worse at night. He had an upper respiratory tract infection 3 weeks ago. Lungs are clear to auscultation. Spirometry shows normal forced vital capacity and peak expiratory flow rate. The physician administers a drug, after which repeat spirometry shows a reduced peak expiratory flow rate. Which of the following drugs was most likely administered?", "answer": "Methacholine", "options": {"A": "Atenolol", "B": "Methacholine", "C": "Ipratropium bromide", "D": "Methoxyflurane", "E": "Epinephrine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "of", "2-week history", "intermittent shortness", "breath", "dry cough", "worse", "night", "upper respiratory tract infection", "weeks", "Lungs", "clear", "auscultation", "Spirometry", "normal forced vital capacity", "peak expiratory flow rate", "physician administers", "drug", "repeat spirometry", "reduced peak expiratory flow rate", "following drugs", "most likely administered"]}
{"question": "А 42-уеаr-old woman рrеѕеntѕ wіth fасіаl аѕуmmеtrу. The patient says yesterday she noticed that her face appeared to be dеvіаted to the rіght. Ѕhе dеnіеѕ аnу trаumа or rесеnt trаvеl. Неr раѕt mеdісаl hіѕtorу іѕ nonсontrіbutorу. Her vitals are blood pressure 110/78 mm Hg, temperature 36.5°C (97.8°F), pulse 78/min, and respiratory rate 11/min. Оn рhуѕісаl ехаmіnаtіon, thеrе іѕ drooріng of thе left ѕіdе of thе fасе. Тhе left nаѕolаbіаl fold іѕ аbѕеnt, аnd ѕhе іѕ unаblе to сloѕе hеr left еуе or wrinkle thе left ѕіdе of hеr forеhеаd. Whеn the patient аѕkеd to ѕmіlе, thе resulting аѕуmmеtrу is shown in the given photograph. The remainder of the nеurologіс ехаm іѕ normаl. A noncontrast CT scan of the head is unremarkable. Which of the following is the most likely cause of her presentation?", "answer": "Idiopathic", "options": {"A": "Varicella-Zoster infection", "B": "Lyme disease", "C": "Idiopathic", "D": "Cerebrovascular accident", "E": "Malignancy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["r old woman", "fl", "patient", "face appeared to", "h dn", "r t", "htor", "blood pressure", "mm Hg", "temperature 36", "97", "pulse", "min", "respiratory rate", "min", "hl", "thr", "th left d", "th f", "h left", "fold", "h", "lo", "left", "wrinkle th left d", "Whn", "patient kd", "ml", "th resulting", "photograph", "m", "CT scan of", "head", "unremarkable", "following", "most likely cause"]}
{"question": "You are the intern on the labor and delivery floor. Your resident asks you to check on the patient in Bed 1. She is a 27-year-old prima gravida with no significant past medical history. She has had an uncomplicated pregnancy and has received regular prenatal care. You go to her bedside and glance at the fetal heart rate tracing (Image A). What is the most likely cause of this finding?", "answer": "Fetal head compression", "options": {"A": "Fetal head compression", "B": "Utero-placental insufficiency", "C": "Cord compression", "D": "Fetal distress", "E": "Congenital heart block"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["intern", "labor", "delivery floor", "resident", "to check", "patient", "Bed", "27 year old prima gravida", "significant past medical history", "uncomplicated pregnancy", "received regular", "go", "fetal heart rate", "most likely cause", "finding"]}
{"question": "A 22-year-old woman presents to her primary care provider with an unrelenting headache accompanied by fever, chills, and malaise for the past 4 days. She also complains of an earache and dry hacking cough. Past medical history is noncontributory. She takes oral contraceptives and a multivitamin with calcium daily. She drinks alcohol socially and smokes occasionally. Today, her temperature is 37.9°C (100.2°F), pulse is 104/min, respiratory rate is 20/min and blood pressure is 102/82 mm Hg. On physical exam, she appears uncomfortable, but not ill. Her heart rate is elevated with a regular rhythm and her lungs have mild rhonchi in the lower lobes bilaterally. A chest X-ray shows patchy, diffuse infiltrates of the interstitium bilaterally that is worse in the lower lobes. A sputum culture is taken for stereomicroscopy. The pathogen organism appears small, pleomorphic, and lacks a cell wall. Which of the following is the most likely pathogen?", "answer": "Mycoplasma pneumonia", "options": {"A": "Streptococcus pneumonia", "B": "Legionella pneumophila", "C": "Staphylococcus pneumonia", "D": "Mycoplasma pneumonia", "E": "Haemophilus influenza"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "primary care provider", "headache", "fever", "chills", "malaise", "past 4 days", "earache", "dry hacking cough", "Past medical history", "oral contraceptives", "multivitamin", "calcium daily", "alcohol", "occasionally", "Today", "temperature", "100", "pulse", "min", "respiratory rate", "20 min", "blood pressure", "mm Hg", "appears", "not ill", "heart rate", "elevated", "regular rhythm", "lungs", "mild rhonchi", "lower lobes", "chest X-ray", "patchy", "diffuse infiltrates", "interstitium", "worse", "lower lobes", "sputum culture", "stereomicroscopy", "appears small", "pleomorphic", "lacks", "cell wall", "following"]}
{"question": "One day after doctors helped a 28-year-old primigravid woman deliver a 4,700 g (10 lb 6 oz) boy, the newborn has bluish discoloration of the lips and fingernails. His temperature is 37.3°C (99.1°F), the pulse is 166/min, the respirations are 63/min, and the blood pressure is 68/44 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 81%. Examination shows central cyanosis. A grade 2/6 holosystolic murmur is heard over the left lower sternal border. A single second heart sound is present. Supplemental oxygen does not improve cyanosis. An X-ray of the chest shows an enlarged cardiac silhouette with a narrowed mediastinum. Which of the following cardiac defects would be associated with this newborn’s diagnosis?", "answer": "Ventricular septal defect", "options": {"A": "Alignment of infundibular septum", "B": "Division of aorta and pulmonary artery", "C": "Fusion of endocardial cushion", "D": "Separation of tricuspid valve tissue from myocardium", "E": "Ventricular septal defect"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["One day", "doctors helped", "year old primigravid woman deliver", "4 700 g", "10", "6 oz", "boy", "newborn", "discoloration", "lips", "fingernails", "temperature", "99", "pulse", "min", "respirations", "63 min", "blood pressure", "mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "81", "central cyanosis", "holosystolic murmur", "heard", "left lower sternal border", "single second heart sound", "present", "Supplemental oxygen", "not", "cyanosis", "X-ray of", "chest", "enlarged cardiac silhouette", "narrowed mediastinum", "following cardiac defects", "associated with", "newborns diagnosis"]}
{"question": "A 44-year-old woman is admitted after an episode of dizziness and palpitations with a subsequent loss of consciousness. At the time of admission, the patient is alert, but then quickly becomes lethargic and reports reoccurrence of palpitations. Past medical history is significant for an episode of ventricular tachycardia 4 months ago, now managed with pharmacologic antiarrhythmic prophylaxis. An ECG is obtained and is shown on the image. Which of the following antiarrhythmic drugs below is most likely responsible for this patient's condition?", "answer": "Sotalol", "options": {"A": "Lidocaine", "B": "Sotalol", "C": "Propranolol", "D": "Verapamil", "E": "Diltiazem"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "episode of dizziness", "palpitations", "subsequent loss of consciousness", "time", "admission", "patient", "alert", "then", "lethargic", "reports", "of", "Past medical", "significant", "episode of ventricular tachycardia", "months", "now", "pharmacologic antiarrhythmic prophylaxis", "ECG", "obtained", "following antiarrhythmic drugs", "responsible", "patient's condition"]}
{"question": "A 62-year-old woman presents to the clinic with a lacerated wound on her left forearm. She got the wound accidentally when she slipped in her garden and scraped her hand against some nails sticking out of the fence. The patient has rheumatoid arthritis and takes methylprednisolone 16 mg/day. She cannot recall her vaccination history. On physical examination her blood pressure is 140/95 mm Hg, heart rate is 81/min, respiratory rate is 16/min, and temperature is 36.9°C (98.4°F). The wound is irregularly shaped and lacerated and measures 4 × 5 cm with a depth of 0.5 cm. It is contaminated with dirt. The physician decides to administer both the tetanus toxoid and immunoglobulin after wound treatment. What is true regarding the tetanus prophylaxis in this patient?", "answer": "The immunoglobulin administration will provide sufficient levels of anti-tetanus toxin antibodies until the production of the patient’s own antibodies starts.", "options": {"A": "It does not make sense to administer tetanus toxoid as it will fail to induce sufficient immunity in a patient who takes oral glucocorticoids.", "B": "The immunoglobulin is given to this patient to promote the action of the toxoid and antibody production.", "C": "The immunoglobulin administration will provide sufficient levels of anti-tetanus toxin antibodies until the production of the patient’s own antibodies starts.", "D": "It does not make sense to administer tetanus toxoid as it will fail to induce sufficient immunity in patients aged more than 60 years.", "E": "Immunoglobulin administration can provide constant levels of antibodies in the patient’s blood for more than 4 months."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman presents", "clinic", "lacerated wound", "left forearm", "got", "wound", "garden", "scraped", "hand", "nails sticking out", "patient", "rheumatoid arthritis", "day", "vaccination history", "blood pressure", "95 mm Hg", "heart rate", "81 min", "respiratory rate", "min", "temperature", "36", "98", "wound", "shaped", "lacerated", "measures 4", "5", "depth of 0", "contaminated", "dirt", "physician", "administer", "tetanus toxoid", "immunoglobulin", "wound treatment", "true", "tetanus prophylaxis", "patient"]}
{"question": "A 50-year-old man is brought to the emergency department because of a 3-day history of left flank pain. The patient has had two episodes of urolithiasis during the last year. He initially had pain with urination that improved with oxycodone. Over the past day, the pain has worsened and he has additionally developed fever and chills. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. His current medications include metformin and lisinopril. The patient appears ill and uncomfortable. His temperature is 39.1°C (102.3°F), pulse is 108/min, respirations are 22/min, and blood pressure is 90/62 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Examination of the back shows left costovertebral angle tenderness. Physical and neurologic examinations show no other abnormalities. Laboratory studies show:\nHemoglobin 14.2 g/dL\nLeukocyte count 13,900/mm3\nHemoglobin A1c 8.2%\nSerum\nNa+ 138 mEq/L\nK+ 3.8 mEq/L\nCl-\n98 mEq/L\nCalcium 9.3 mg/dL\nGlucose 190 mg/dL\nCreatinine 2.1 mg/dL\nUrine pH 8.3\nUrine microscopy\nBacteria moderate\nRBC 6–10/hpf\nWBC 10–15/hpf\nWBC casts numerous\nUltrasound shows enlargement of the left kidney with a dilated pelvis and echogenic debris. CT scan shows a 16-mm stone at the left ureteropelvic junction, dilation of the collecting system, thickening of the wall of the renal pelvis, and signs of perirenal inflammation. Intravenous fluid resuscitation and intravenous ampicillin, gentamicin, and morphine are begun. Which of the following is the most appropriate next step in the management of this patient?\"", "answer": "Percutaneous nephrostomy", "options": {"A": "Percutaneous nephrostomy", "B": "Tamsulosin therapy", "C": "Ureteroscopy and stent placement", "D": "Shock wave lithotripsy", "E": "Intravenous pyelography"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["50 year old man", "brought", "emergency department", "3-day history", "left flank pain", "patient", "two episodes of urolithiasis", "last year", "initially", "pain", "urination", "improved", "oxycodone", "past day", "pain", "worsened", "fever", "chills", "hypertension", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "20 years", "not", "alcohol", "current medications include metformin", "lisinopril", "patient appears ill", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "90 62 mm Hg", "lungs", "clear", "auscultation", "murmurs", "rubs", "of", "back", "left costovertebral angle tenderness", "Physical", "neurologic examinations", "abnormalities", "Laboratory studies", "Hemoglobin", "L", "mg", "mg", "Creatinine", "Urine", "WBC", "casts numerous Ultrasound", "enlargement", "left", "dilated pelvis", "echogenic", "CT scan", "mm stone", "left ureteropelvic junction", "dilation", "collecting system", "thickening of", "wall", "renal pelvis", "signs", "perirenal inflammation", "Intravenous fluid resuscitation", "intravenous ampicillin", "gentamicin", "morphine", "begun", "following", "most appropriate next step", "patient"]}
{"question": "A 48-year-old homeless man is brought to the emergency department 2 hours after his right arm was burned by a fire. He is diagnosed with extensive third-degree burns of the right forearm and upper arm and is admitted to the hospital for debridement and grafting. During his stay in the hospital, he suddenly develops confusion and agitation. Neurologic examination shows horizontal nystagmus and a broad-based gait. Laboratory studies show decreased erythrocyte transketolase activity. Administration of which of the following most likely caused this patient's current condition?", "answer": "Glucose", "options": {"A": "Cobalamin", "B": "Glucose", "C": "Aspirin", "D": "Hypertonic saline", "E": "Haloperidol"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old homeless man", "brought", "emergency department", "hours", "right arm", "burned by", "fire", "diagnosed", "extensive third-degree burns of", "right forearm", "upper arm", "debridement", "grafting", "stay", "hospital", "confusion", "agitation", "Neurologic examination", "horizontal nystagmus", "broad-based gait", "Laboratory studies", "decreased erythrocyte transketolase activity", "Administration", "following most likely caused", "patient's current condition"]}
{"question": "An 11-year-old girl comes to the physician with her mother because of a 2-day history of passing “cola-colored“ urine. During the past week, her mother noticed episodes of facial swelling. The patient had a rash on her face about 4 weeks ago. A renal biopsy after immunofluorescence is shown. Which of the following is the most likely diagnosis?", "answer": "Poststreptococcal glomerulonephritis", "options": {"A": "Poststreptococcal glomerulonephritis", "B": "IgA nephropathy", "C": "Membranoproliferative glomerulonephritis", "D": "Diffuse proliferative glomerulonephritis", "E": "Rapidly progressive glomerulonephritis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "physician", "mother", "2-day history", "passing cola colored urine", "past week", "episodes of facial swelling", "patient", "rash on", "face", "4 weeks", "renal biopsy", "immunofluorescence", "following", "diagnosis"]}
{"question": "A 69-year-old woman with type 2 diabetes mellitus has an HbA1c of 3.9% and has been using basal-bolus insulin to manage her diabetes for the past 5 years. She has been maintaining a healthy diet, taking her insulin as scheduled but her records show morning hyperglycemia before eating breakfast. To determine the cause of this hyperglycemia, you ask her to set an alarm and take her blood glucose at 3 am. At 4 am her blood glucose is 49 mg/dL. Which of the following statements best describes the management of this patient’s current condition?", "answer": "She is experiencing Somogyi effect so her nighttime insulin should be decreased", "options": {"A": "She is experiencing dawn phenomenon so her nighttime insulin should be increased", "B": "She is experiencing dawn phenomenon so her nighttime insulin should be decreased", "C": "She is experiencing Somogyi effect so her nighttime insulin should be increased", "D": "She is experiencing Somogyi effect so her nighttime insulin should be decreased", "E": "Hyperosmolar hyperglycemic state; increase nighttime insulin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old woman", "type 2 diabetes mellitus", "using basal bolus insulin to", "diabetes", "past", "years", "healthy diet", "insulin", "scheduled", "records", "morning hyperglycemia", "To", "cause", "hyperglycemia", "to set", "alarm", "blood glucose", "4", "blood glucose", "mg/dL", "following", "best", "management", "patients current condition"]}
{"question": "A 37-year-old man is brought to the emergency department after being attacked with a knife. Physical examination shows a 4-cm laceration in the midline of the right forearm. An MRI of the right arm shows damage to a nerve that runs between the superficial and deep flexor digitorum muscles. Loss of sensation over which of the following areas is most likely in this patient?", "answer": "Fingertip of the index finger", "options": {"A": "Palmar surface of the little finger", "B": "Lateral aspect of the forearm", "C": "Fingertip of the index finger", "D": "Medial aspect of the forearm", "E": "Dorsum of the thumb"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "attacked", "knife", "4", "laceration", "midline of", "right forearm", "MRI", "right arm", "damage", "nerve", "runs", "superficial", "deep flexor digitorum muscles", "Loss of sensation", "following areas", "patient"]}
{"question": "A 25-year-old nulliparous woman at 8 weeks' gestation comes to her physician accompanied by her husband for her first prenatal visit. She has no personal or family history of serious illness. Her vaccinations are up-to-date and she takes no medications. She has no history of recreational drug use and does not drink alcohol. Her vital signs are within normal limits. She is 167 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24.3 kg/m2. She tested negative for HIV, Chlamydia trachomatis, and Neisseria gonorrhoeae 4 years ago. Which of the following tests should be done at this visit?", "answer": "ELISA for HIV, rapid plasma reagin test, and serum HBsAg", "options": {"A": "Culture for group B streptococci, hepatitis C serology, and PPD skin test", "B": "Serum TSH, CMV serology, and PCR for HSV-2", "C": "PCR for HSV-2, culture for group B streptococci, and Western blot for HIV", "D": "VDRL, Western blot for HIV, and serum HBsAg", "E": "ELISA for HIV, rapid plasma reagin test, and serum HBsAg"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old nulliparous woman", "weeks", "gestation", "physician", "personal", "family history", "serious illness", "vaccinations", "date", "medications", "history of recreational drug use", "not", "alcohol", "vital signs", "normal limits", "5 ft 6", "tall", "kg", "BMI", "kg/m2", "negative", "HIV", "years", "following tests", "done"]}
{"question": "A 24-year-old woman presents with generalized edema, hematuria, and severe right-sided flank pain. Her vital signs are normal. A 24-hour urine collection shows >10 grams of protein in her urine. Serum LDH is markedly elevated. Contrast-enhanced spiral CT scan shows thrombosis of the right renal vein. Which of the following is the most likely mechanism behind this thrombosis?", "answer": "Urinary loss of antithrombin III", "options": {"A": "Severe dehydration", "B": "Urinary loss of antithrombin III", "C": "Hepatic synthetic failure", "D": "Oral contraceptive pills", "E": "Hereditary factor VIII deficiency"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "generalized", "hematuria", "severe right-sided flank pain", "vital signs", "normal", "24-hour urine collection", "10 grams", "protein", "urine", "Serum LDH", "markedly elevated", "Contrast CT scan", "thrombosis of", "right renal vein", "following", "mechanism", "thrombosis"]}
{"question": "Ten days after undergoing left hip replacement, a 73-year-old hospitalized man develops a fever, dyspnea, cough productive of yellow sputum, confusion, nausea, and diarrhea. Several patients in the hospital report similar symptoms. Physical examination shows decreased breath sounds on the left side and inspiratory crackles over the left lung. An x-ray of the chest shows opacities in the lower lobe of the left lung. Treatment with ampicillin does not improve his symptoms. Subsequent evaluation of the patient's urine detects a pathogen-specific antigen, confirming the diagnosis. Which of the following sources of infection is most likely responsible for this local disease outbreak?", "answer": "Colonization of the air conditioning system", "options": {"A": "Transmission via infectious respiratory droplets", "B": "Contamination of reheated hospital food", "C": "Colonization of the air conditioning system", "D": "Entry through colonized intravenous catheters", "E": "Insufficient adherence to hand hygiene measures"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["left hip replacement", "year old hospitalized man", "fever", "dyspnea", "cough productive", "yellow", "confusion", "nausea", "diarrhea", "patients in", "hospital report similar symptoms", "decreased breath sounds", "left side", "inspiratory crackles", "left lung", "x-ray of", "chest", "opacities", "the lower lobe of", "left lung", "Treatment", "ampicillin", "not", "symptoms", "Subsequent", "urine detects", "confirming", "diagnosis", "of", "following sources", "infection", "responsible", "local"]}
{"question": "A group of scientists is studying various methods of bacterial reproduction. They find out that bacteria also exchange genetic material via these reproductive processes. They are about to study one such method known as bacterial conjugation. Which of the following occurs through bacterial conjugation?", "answer": "Two Pseudomonas aeruginosa bacteria with identical copies of a plasmid after sharing DNA through sex pili.", "options": {"A": "Two Pseudomonas aeruginosa bacteria with identical copies of a plasmid after sharing DNA through sex pili.", "B": "Helicobacter pylori producing a prophage-encoded toxin.", "C": "A strain of MRSA acquiring the gene of capsulation from another encapsulated strain via DNA extraction.", "D": "A multidrug-resistant Shigella species passing resistance factor R to a Streptococcus species.", "E": "A single E. coli bacteria with resistance to gentamicin splits into two E. coli bacteria, both of which have resistance to gentamicin."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["scientists", "studying various methods", "bacterial reproduction", "find out", "bacteria", "exchange", "to study one", "method known", "following occurs"]}
{"question": "An 81-year-old man is brought in by his neighbor with altered mental status. The patient’s neighbor is unsure exactly how long he was alone, but estimates that it was at least 3 days. The neighbor says that the patient usually has his daughter at home to look after him but she had to go into the hospital recently. The patient is unable to provide any useful history. Past medical history is significant for long-standing hypercholesterolemia and hypertension, managed medically with rosuvastatin and hydrochlorothiazide, respectively. His vital signs include: blood pressure, 140/95 mm Hg; pulse, 106/min; temperature, 37.2°C (98.9°F); and respiratory rate, 19/min. On physical examination, the patient is confused and unable to respond to commands. His mucus membranes are dry and he has tenting of the skin. The remainder of the exam is unremarkable. Laboratory findings are significant for the following:\nSodium 141 mEq/L\nPotassium 4.1 mEq/L\nChloride 111 mEq/L\nBicarbonate 21 mEq/L\nBUN 40 mg/dL\nCreatinine 1.4 mg/dL\nGlucose (fasting) 80 mg/dL\n  Magnesium 1.9 mg/dL\nCalcium 9.3 mg/dL\nPhosphorous 3.6 mg/dL\n24-hour urine collection\nUrine Sodium 169 mEq/24 hr (ref: 100–260 mEq/24 hr)\nUrine Creatinine 79.5 g/24 hr (ref: 1.0–1.6 g/24 hr)\nWhich of the following is the most likely cause of this patient’s acute renal failure?", "answer": "Dehydration", "options": {"A": "Acute tubular necrosis", "B": "Dehydration", "C": "Sepsis", "D": "NSAID use", "E": "UTI due to obstructive nephrolithiasis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["81 year old man", "brought", "altered mental status", "patients", "unsure", "long", "alone", "estimates", "days", "patient usually", "at home to look", "to go", "hospital recently", "patient", "unable to", "useful history", "Past medical history", "significant", "long standing hypercholesterolemia", "hypertension", "rosuvastatin", "hydrochlorothiazide", "vital signs include", "blood pressure", "95 mm Hg", "pulse", "min", "temperature", "98 9F", "respiratory rate", "min", "patient", "confused", "unable to", "mucus membranes", "dry", "tenting of", "skin", "exam", "unremarkable", "Laboratory findings", "significant", "following", "Sodium", "mEq", "Bicarbonate", "dL Creatinine", "Glucose", "fasting", "mg", "Magnesium", "Calcium", "24-hour urine", "Sodium", "hr", "ref", "mEq/24 hr", "Urine Creatinine", "g", "hr", "ref", "1", "g", "hr", "following", "most likely cause", "patients acute renal failure"]}
{"question": "A 52-year-old man is brought to the emergency department by a friend because of a 5-day history of fever and cough productive of purulent sputum. One week ago, he was woken up by an episode of heavy coughing while lying on his back. He drinks large amounts of alcohol daily and has spent most of his time in bed since his wife passed away 2 months ago. His temperature is 38°C (100.4°F), pulse is 96/min, respirations are 24/min, and blood pressure is 110/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 87%. Physical examination shows poor dentition and swollen gums. A CT scan of the chest is most likely to show a pulmonary infiltrate in which of the following locations?", "answer": "Superior segment of the right lower lobe", "options": {"A": "Posterior basal segment of the right lower lobe", "B": "Apicoposterior segment of the left upper lobe", "C": "Superior segment of the right lower lobe", "D": "Posterior basal segment of the left lower lobe", "E": "Posterior segment of the right upper lobe"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "5-day history", "fever", "cough productive", "purulent", "One week", "woken up", "episode of heavy coughing", "lying on", "back", "large amounts", "alcohol daily", "spent most of", "time", "bed", "passed", "months", "temperature", "100", "pulse", "96 min", "respirations", "min", "blood pressure", "84 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "87", "poor dentition", "swollen gums", "CT scan of", "chest", "to", "pulmonary infiltrate", "following locations"]}
{"question": "A 42-year-old man is brought to the emergency department because his neck was fixed in lateral flexion. For the past week, the patient has been complaining of low-grade fever, head pain, and neck pain. His partner has also noticed him behaving erratically. His family and personal medical history are not relevant. Upon admission, he is found with a body temperature of 38.6°C (101.5°F), and physical examination is unremarkable except for neck pain and fixed lateral flexion of the neck. He is confused, but there are no motor or sensory deficits. Deep tendon reflexes are accentuated. Magnetic resonance imaging of the brain shows leptomeningeal and gyral enhancement. Which of the following explains this patient’s condition?", "answer": "Viral infection", "options": {"A": "Genetic mutation", "B": "Exposure to D2-antagonists", "C": "Trochlear nerve palsy", "D": "Viral infection", "E": "Acid-fast resistant bacilli infection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "neck", "fixed", "lateral flexion", "past week", "patient", "low-grade fever", "head pain", "neck pain", "personal medical history", "not relevant", "found", "body temperature", "unremarkable", "neck pain", "fixed lateral", "neck", "confused", "motor", "sensory deficits", "Deep tendon reflexes", "accentuated", "Magnetic resonance imaging", "brain", "leptomeningeal", "enhancement", "following", "patients condition"]}
{"question": "A 36-year-old software professional consults a physician to discuss his concerns about small-vessel vasculitis as his mother and sister both have autoimmune small-vessel vasculitides. He has read about vasculitides and recently he came across an article which stated that an analgesic that he often uses for relief from a headache can cause small-vessel vasculitis. Due to his positive family history, he is especially concerned about his risk of developing small-vessel vasculitis. Which of the following clinical presentations is most likely to occur in this man?", "answer": "Palpable purpura", "options": {"A": "Absence of pulses in the upper extremity", "B": "Infarction of an internal organ", "C": "Stroke", "D": "Aneurysm of an artery", "E": "Palpable purpura"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["36 year old software professional", "physician to", "small-vessel vasculitis", "autoimmune small-vessel vasculitides", "vasculitides", "recently", "stated", "analgesic", "often uses", "relief", "headache", "cause small-vessel vasculitis", "positive family history", "small-vessel vasculitis", "following", "to occur", "man"]}
{"question": "A 22-year-old man with no significant medical history presents with a two day history of bilateral eye redness, irritation, and watery mucous discharge as seen in the photograph provided. He has crusting of his eyes in the mornings without adhesion of his eyelids. He does not wear contact lenses and has had a sore throat the last three days. On physical exam, a left preauricular lymph node is enlarged and tender. An ophthalmologic exam reveals no additional abnormalities. Which of the following is the most appropriate treatment for this patient?", "answer": "Warm compresses", "options": {"A": "Topical erythromycin ointment", "B": "Oral azithromycin", "C": "Topical moxifloxacin", "D": "Warm compresses", "E": "Topical glucocorticoids"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "significant medical history presents", "two day history of bilateral eye redness", "irritation", "watery mucous discharge", "seen", "photograph", "crusting", "eyes", "mornings", "adhesion of", "eyelids", "not", "contact lenses", "sore throat", "last three days", "left preauricular lymph node", "enlarged", "tender", "ophthalmologic exam reveals", "additional abnormalities", "following", "most appropriate", "patient"]}
{"question": "A 58-year-old man with an unknown previous medical history is found on the floor at home by his daughter. During the initial assessment, the patient has right-sided arm weakness and incomprehensible speech. The patient is admitted to the hospital where he is diagnosed with an ischemic stroke where his magnetic resonance image (MRI) scan showed diffusion restriction in the right middle cerebral artery (MCA) territory. Further evaluation reveals the patient had been on the floor for about 2 days before he was found by his daughter. At presentation to the hospital, the blood pressure is 161/88 mm Hg and the heart rate is 104/min and regular. His laboratory values at the time of admission are shown:\nBUN 40 mg/dL\nCreatinine 1.9 mg/dL\nPotassium 5.3 mEq/dL\nSodium 155 mEq/dL\nChloride 100 mEq/dL\nHCO3 24 mmol/L\nHemoglobin 13.8 g/dL\nHematocrit 40%\nLeukocytes 11,000/mL\nPlatelets 300,000/µL\nSerum creatine kinase 40,000 U/L\nWhich of the following is most indicated in this patient?", "answer": "Forced diuresis with intravenous (IV) fluids", "options": {"A": "Forced diuresis with intravenous (IV) fluids", "B": "Stress echocardiography", "C": "Intravenous n-acetyl-cysteine", "D": "Transfusion of fresh frozen plasma (FFP)", "E": "Rhythm control with metoprolol"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old man", "unknown previous medical history", "found on", "floor at home", "initial assessment", "patient", "right-sided weakness", "incomprehensible speech", "patient", "diagnosed", "ischemic stroke", "magnetic resonance", "scan", "diffusion restriction", "right middle cerebral artery", "territory", "Further", "reveals", "patient", "floor", "about", "days", "found", "hospital", "blood pressure", "88 mm Hg", "heart rate", "min", "regular", "laboratory values", "time", "admission", "mg", "mg", "HCO3", "L", "g", "Leukocytes 11", "300", "kinase", "U", "following", "most indicated", "patient"]}
{"question": "A 16-year-old girl is brought to the emergency department by her parents because of fever, vomiting, rash, and worsening confusion since this morning. On questioning, her mother reports that her last menstrual period was 1 week ago and that she recently started using tampons. She appears lethargic and is only oriented to person. Her temperature is 40.4°C (104.7°F), pulse 174/minute, and blood pressure is 62/44 mm Hg. Examination shows oropharyngeal hyperemia and diffuse macular erythroderma. Which of the following is the most likely cause of this patient's condition?", "answer": "Polyclonal T cell activation", "options": {"A": "Erythrogenic toxin production", "B": "Lipooligosaccharide expression", "C": "Unregulated B cell proliferation", "D": "Generalized mast cell degranulation", "E": "Polyclonal T cell activation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl", "brought", "emergency department", "fever", "vomiting", "rash", "worsening confusion", "morning", "reports", "last menstrual period", "1 week", "recently started using tampons", "appears lethargic", "only oriented to person", "temperature", "40", "pulse", "minute", "blood pressure", "62", "mm Hg", "oropharyngeal hyperemia", "diffuse macular erythroderma", "following", "most likely cause", "patient's condition"]}
{"question": "A 27-year-old man is brought to the emergency department after a motor vehicle accident. He complains of tingling of his legs, and he is unable to move them. His temperature is 36.5°C (97.7°F), the blood pressure is 110/75 mm Hg, and the pulse is 88/min. On physical examination, pinprick sensation is absent below the umbilicus and there is no rectal tone. Muscle strength in the lower extremities is 1/5 bilaterally. He has 5/5 strength in his bilateral upper extremities. Plain films and computerized tomography (CT) show the displacement of the lumbar vertebrae. Which of the following is the best next step in the management of this patient?", "answer": "Intravenous methylprednisolone", "options": {"A": "Positron emission tomography (PET) scan of the spine", "B": "Intravenous methylprednisolone", "C": "CT myelography", "D": "Radiation therapy", "E": "Intravenous antibiotics"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old man", "brought", "emergency department", "motor vehicle accident", "tingling", "legs", "unable to move", "temperature", "36", "97", "blood pressure", "75 mm Hg", "pulse", "88 min", "pinprick sensation", "absent", "umbilicus", "rectal tone", "Muscle strength", "lower extremities", "1/5", "5/5 strength", "bilateral upper extremities", "Plain films", "computerized tomography", "displacement", "lumbar vertebrae", "following", "best next step", "patient"]}
{"question": "A 40-year-old Indian female is hospitalized with exertional dyspnea and lower extremity edema. The patient immigrated to the United States at age 15 and does not use tobacco, alcohol, or drugs. A mid-diastolic murmur is present and heard best at the apex. Which of the following symptoms would be most consistent with the rest of the patient’s presentation?", "answer": "Hoarseness", "options": {"A": "Hoarseness", "B": "Pulsus parodoxus", "C": "Asymmetric ventricular hypertrophy", "D": "Increased intracranial pressure", "E": "Hirsutism"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old", "female", "hospitalized", "exertional dyspnea", "lower extremity edema", "patient", "United States", "age", "not use tobacco", "alcohol", "drugs", "mid-diastolic murmur", "present", "heard best", "apex", "following symptoms", "most", "patients"]}
{"question": "A 14-year-old Caucasian girl presents to the pediatrician for poor balance. She reports a 7-month history of frequent falls that has progressively worsened. She has fallen 3 times in the past week and feels like she cannot walk normally. She was born full-term and spent 2 days in the neonatal intensive care unit for respiratory distress. She has had an otherwise normal childhood. Her family history is notable for multiple cardiac deaths before the age of 60. Her mother had a posterior spinal fusion for kyphoscoliosis as an adolescent. On exam, the patient has 4/5 strength in her bilateral upper and lower extremities. She walks with a staggering gait. Pes cavus is appreciated bilaterally. Skin examination is normal. This patient has a condition that is caused by a trinucleotide repeat of which of the following nucleotides?", "answer": "GAA", "options": {"A": "CAG", "B": "CGG", "C": "CTG", "D": "GAA", "E": "GAC"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "girl presents", "pediatrician", "poor balance", "reports", "month history of frequent falls", "worsened", "fallen", "times", "past", "born full-term", "spent 2 days", "neonatal intensive care unit", "respiratory distress", "normal childhood", "family history", "notable", "multiple cardiac deaths", "age", "60", "posterior spinal fusion", "kyphoscoliosis", "adolescent", "exam", "patient", "4/5 strength", "bilateral upper", "lower extremities", "walks", "staggering gait", "Pes cavus", "Skin examination", "normal", "patient", "condition", "caused", "trinucleotide repeat", "following"]}
{"question": "A 47-year-old farmer presents to his primary care physician for the first time appointment. The patient has never seen a doctor and states that he is in good health. He has worked as a farmer for the past 30 years and has no complaints. His temperature is 98.9°F (37.2°C), blood pressure is 197/118 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man in no current distress. Laboratory values are seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 101 mEq/L\nK+: 5.2 mEq/L\nHCO3-: 25 mEq/L\nBUN: 34 mg/dL\nGlucose: 179 mg/dL\nCreatinine: 2.1 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the best management of this patient's blood pressure?", "answer": "Lisinopril", "options": {"A": "Carvedilol", "B": "Hydrochlorothiazide", "C": "Lisinopril", "D": "Metoprolol", "E": "Nicardipine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old farmer presents", "primary care physician", "first time appointment", "patient", "never seen", "doctor", "states", "farmer", "past 30 years", "complaints", "temperature", "98 9F", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "obese man", "current distress", "Laboratory values", "seen", "Serum", "Na", "mEq/L", "mEq/L K", "5.2 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "2.1 mg/dL Ca2", "10", "mg/dL", "following", "best management", "patient's blood"]}
{"question": "A 26-year-old woman presents to the office complaining of bloating and consistent fatigue. Past medical notes on her record show that she has seen several doctors at the clinic in the past year for the same concerns. During the discussion, she admits that coming to the doctor intensifies her anxiety and she does not enjoy it. However, she came because she fears that she has colon cancer and says, “There’s gotta be something wrong with me, I can feel it.” Past medical history is significant for obsessive-compulsive disorder (OCD). She sees a therapist a few times a month. Her grandfather died of colon cancer at 75. Today, her blood pressure is 120/80 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and temperature is 37.0°C (98.6°F). Physical examination reveals a well-nourished, well-developed woman who appears anxious and tired. Her heart has a regular rhythm and her lungs are clear to auscultation bilaterally. Her abdomen is soft, non-tender, and non-distended. No masses are palpated, and a digital rectal examination is unremarkable. Laboratory results are as follows:\nSerum chemistry \nHemoglobin 13 g/dL \nHematocrit\n38%\nMCV 90 fl\nTSH\n4.1 μU/mL\nFecal occult blood test  negative\nWhich of the following is the most likely diagnosis?", "answer": "Illness anxiety disorder", "options": {"A": "Malingering", "B": "Somatic symptoms disorder", "C": "Body dysmorphic disorder", "D": "Illness anxiety disorder", "E": "Generalized anxiety disorder"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "office", "bloating", "fatigue", "Past", "seen several", "past year", "same", "discussion", "doctor", "anxiety", "not", "colon cancer", "wrong", "I", "Past medical history", "significant", "obsessive-compulsive disorder", "sees", "therapist", "few times", "month", "died of colon cancer", "75", "Today", "blood pressure", "80 mm Hg", "heart rate", "90 min", "respiratory rate", "min", "temperature", "98", "reveals", "well-nourished", "woman", "appears anxious", "tired", "heart", "regular rhythm", "lungs", "clear", "auscultation", "abdomen", "soft", "non-tender", "non distended", "masses", "digital rectal examination", "unremarkable", "Laboratory results", "follows", "Serum", "g", "MCV 90 fl", "mL", "blood test", "negative", "following", "diagnosis"]}
{"question": "A 45-year-old man presents to his primary care physician for lower extremity pain and unsteadiness. He describes the pain as severe and stabbing and affecting his lower extremities. These episodes of pain last for minutes at a time. He also reports knocking into furniture regularly. Medical history is significant for streptococcal pharyngitis, where he had a severe allergic reaction to appropriate treatment. He is currently sexually active with men and does not use condoms. On physical exam, his pupils are miotic in normal and low light. The pupils do not constrict further when exposed to the penlight and there is no direct or consensual pupillary dilation when the penlight is removed. The pupils constrict further when exposed to a near object. He has decreased vibration and proprioception sense in his lower extremities, absent lower extremity deep tendon reflexes, and a positive Romberg test. Which of the following is the best next step in management?", "answer": "Intravenous penicillin", "options": {"A": "Intramuscular penicillin", "B": "Intramuscular ceftriaxone", "C": "Intravenous doxycycline", "D": "Intravenous penicillin", "E": "Oral doxycycline"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician", "lower extremity pain", "unsteadiness", "pain", "severe", "stabbing", "affecting", "lower extremities", "episodes of pain last", "minutes", "time", "reports", "furniture", "Medical history", "significant", "streptococcal pharyngitis", "severe allergic", "appropriate treatment", "currently sexually active with men", "not use condoms", "pupils", "miotic", "normal", "low light", "pupils", "not", "further", "exposed", "direct", "pupillary dilation", "removed", "pupils", "further", "exposed", "decreased vibration", "sense", "lower extremities", "absent lower extremity deep tendon reflexes", "positive Romberg test", "following", "best next step"]}
{"question": "A 25-year-old male wrestler presents to his primary care physician for knee pain. He was in a wrestling match yesterday when he was abruptly taken down. Since then, he has had pain in his left knee. The patient states that at times it feels as if his knee locks as he moves it. The patient has a past medical history of anabolic steroid abuse; however, he claims to no longer be using them. His current medications include NSAIDs as needed for minor injuries from participating in sports. On physical exam, you note medial joint tenderness of the patient’s left knee, as well as some erythema and bruising. The patient has an antalgic gait as you observe him walking. Passive range of motion reveals a subtle clicking of the joint. There is absent anterior displacement of the tibia relative to the femur on an anterior drawer test. The rest of the physical exam, including examination of the contralateral knee is within normal limits. Which of the following structures is most likely damaged in this patient?", "answer": "Medial meniscus", "options": {"A": "Medial meniscus", "B": "Lateral meniscus", "C": "Medial collateral ligament", "D": "Lateral collateral ligament", "E": "Anterior cruciate ligament"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male", "presents", "primary care physician", "knee pain", "match", "then", "pain in", "left knee", "patient states", "times", "knee locks", "moves", "patient", "past medical anabolic", "longer", "using", "current medications include NSAIDs as needed", "minor injuries", "participating", "note medial joint tenderness of", "patients left knee", "erythema", "bruising", "patient", "antalgic gait", "observe", "Passive range of motion reveals", "subtle clicking", "joint", "absent anterior displacement of", "tibia", "femur", "anterior drawer test", "including", "contralateral knee", "normal limits", "following structures", "most likely damaged", "patient"]}
{"question": "A 71-year-old woman comes to the physician because of progressive shortness of breath and swollen legs for 4 weeks. She has tried sleeping in a raised position using 2 pillows but still wakes up occasionally from a choking sensation. She returned from a safari tour in Tanzania 3 months ago. She has type 2 diabetes mellitus, arterial hypertension, and gastroesophageal reflux disease. Her sister has polymyalgia rheumatica. Her current medications include insulin, enalapril, and omeprazole. She has smoked one half-pack of cigarettes daily for 45 years. Her temperature is 37°C (98.6°F), pulse is 112/min, respirations are 22/min, and blood pressure is 119/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Examination shows pitting edema below the knees and jugular venous distention. Crackles are heard at both lung bases. A photograph of her tongue is shown. Her hemoglobin concentration is 10.0 g/dL, leukocyte count is 6,100/mm3, and erythrocyte sedimentation rate is 62 mm/h. ECG shows sinus rhythm and low-voltage QRS complexes. Echocardiography shows symmetrical left ventricular hypertrophy, reduced diastolic filling, and an ejection fraction of 55%. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Multiple myeloma", "options": {"A": "Endocardial fibroelastosis", "B": "Systemic sclerosis", "C": "Multiple myeloma", "D": "Tuberculosis", "E": "Rheumatoid arthritis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "of progressive shortness", "breath", "swollen legs", "weeks", "sleeping", "raised position using 2 pillows", "wakes up occasionally", "choking sensation", "returned", "tour", "Tanzania", "months", "type 2 diabetes mellitus", "arterial hypertension", "gastroesophageal reflux disease", "polymyalgia rheumatica", "current medications include insulin", "enalapril", "omeprazole", "smoked one half pack", "cigarettes daily", "years", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "76 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "90", "pitting", "knees", "jugular venous distention", "Crackles", "heard", "lung bases", "photograph", "tongue", "hemoglobin concentration", "10 0 g/dL", "leukocyte count", "100 mm3", "erythrocyte sedimentation rate", "62 mm/h", "ECG", "sinus rhythm", "low voltage QRS complexes", "Echocardiography", "symmetrical left ventricular hypertrophy", "reduced diastolic", "ejection fraction of", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 6-year-old boy is brought to the pediatrician by his mother for diarrhea and a skin rash. His mother reports that he had a cough, sore throat, and runny nose 1 week ago. Although his upper respiratory symptoms improved after two days, he started having multiple watery bowel movements 3 days ago. He also developed a red pruritic rash on his arms, legs, and neck at that time. His mother also reports that he has had similar symptoms in the past that have occurred after the boy gets sick. His temperature is 98.8°F (37.1°C), blood pressure is 109/68 mmHg, pulse is 92/min, and respirations are 19/min. The child is alert and oriented to person but not place or time. He is unable to count to 10 even though his mother says he can normally count to 100 easily. He walks with a wide-based gait. An erythematous patchy rash is noted on his upper and lower extremities bilaterally. A complete blood count and basic metabolic panel are within normal limits. A urinalysis reveals elevated levels of neutral amino acids. Which of the following is the most appropriate acute treatment for this patient?", "answer": "Nicotinic acid", "options": {"A": "Nicotinic acid", "B": "Phenylbutyrate", "C": "Pyridoxine", "D": "Tryptophan", "E": "Tyrosine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "pediatrician", "diarrhea", "skin rash", "reports", "cough", "sore throat", "runny nose", "week", "upper respiratory symptoms improved", "two days", "started", "multiple", "days", "red pruritic rash", "arms", "legs", "neck", "time", "reports", "similar symptoms", "past", "boy gets sick", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "child", "alert", "oriented to person", "not place", "time", "unable to count", "10", "count", "100 easily", "walks", "wide-based", "erythematous patchy", "noted", "upper", "lower extremities", "complete blood count", "basic metabolic panel", "normal limits", "urinalysis reveals elevated levels", "neutral amino acids", "following", "most appropriate acute treatment", "patient"]}
{"question": "A 49-year-old man comes to the physician because of a 5-month history of progressive fatigue and exertional dyspnea. Cardiac examination shows a loud S2 in the 2nd left intercostal space. Right heart catheterization shows a pulmonary artery pressure of 32 mm Hg. Treatment with bosentan is initiated. The beneficial effect of this drug is due to binding to which of the following?", "answer": "Endothelin receptors", "options": {"A": "L-type voltage-gated calcium channels", "B": "Phosphodiesterase-5", "C": "Prostacyclin receptor", "D": "Adenosine receptors", "E": "Endothelin receptors"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "5 month history", "progressive fatigue", "exertional dyspnea", "loud S2", "2nd left intercostal space", "Right heart catheterization", "pulmonary artery pressure", "mm Hg", "Treatment", "bosentan", "initiated", "due to", "following"]}
{"question": "A 2-week-old newborn girl is brought to the physician for a follow-up examination after the initial newborn examination showed asymmetry of the legs. She was born at term to a 26-year-old woman, gravida 3, para 2. Pregnancy was complicated by a breech presentation and treated with an emergency lower-segment transverse cesarean section. The newborn's head circumference is 35 cm (13.7 in). She is at the 60th percentile for length and 75th percentile for weight. Cardiac examination shows no abnormalities. The spine and overlying skin do not indicate significant abnormalities. Abduction of the right hip after cupping the pelvis and flexing the right hip and knee causes a palpable clunk. The feet exhibit no deformities. Ultrasonography of the hip revealed a 50° angle between the lines along the bone acetabulum and the ilium. Which of the following is the most appropriate next step in management?", "answer": "Treat using a harness", "options": {"A": "Immobilize the hips with a spica cast", "B": "Obtain an MRI of the right hip", "C": "Obtain an X-ray of the right hip", "D": "Reassure the mother and schedule follow-up appointment in 4 weeks", "E": "Treat using a harness"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["2 week old newborn girl", "brought", "physician", "follow-up examination", "initial newborn", "asymmetry", "legs", "born", "term", "year old woman", "gravida 3", "para 2", "Pregnancy", "complicated", "breech presentation", "treated with", "emergency lower segment transverse cesarean", "newborn's head circumference", "35", "percentile", "length", "percentile", "weight", "abnormalities", "spine", "skin", "not", "significant abnormalities", "Abduction", "right", "cupping", "pelvis", "right hip", "knee causes", "palpable", "feet", "deformities", "Ultrasonography of", "hip revealed", "50 angle", "lines", "bone acetabulum", "ilium", "following", "most appropriate next step"]}
{"question": "A 26-year-old woman comes to the physician because of a progressive swelling in her mouth that she first noticed 5 years ago. Initially, the swelling was asymptomatic but has now caused some difficulty while chewing food for the past month. She has no pain. She has not undergone any dental procedures in the past 5 years. She has bronchial asthma. Her only medication is an albuterol inhaler. She appears healthy. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 110/70 mm Hg. Examination shows a 1.5-cm smooth, unilobular, bony hard, nontender mass in the midline of the hard palate. There is no cervical or submandibular lymphadenopathy. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Torus palatinus\n\"", "options": {"A": "Palatal pleomorphic adenoma", "B": "Necrotizing sialometaplasia", "C": "Nasopalatine duct cyst", "D": "Palatal abscess", "E": "Torus palatinus\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "of", "progressive swelling", "mouth", "first", "Initially", "swelling", "asymptomatic", "now caused", "difficulty", "chewing food", "past month", "pain", "not", "dental procedures", "past", "years", "bronchial asthma", "only medication", "albuterol inhaler", "appears healthy", "temperature", "98", "pulse", "70 min", "blood pressure", "70 mm Hg", "1", "smooth", "unilobular", "bony hard", "nontender mass", "midline", "hard palate", "cervical", "submandibular lymphadenopathy", "abnormalities", "following", "diagnosis"]}
{"question": "A 54-year-old man presents to the emergency department after vomiting blood an hour ago. He says this happens to him occasionally but denies feeling pain in these episodes. The man is disheveled and has slurred speech as he describes his symptoms. He is reluctant to give further history and wants immediate treatment of his condition. Upon examination, the patient has evidence of tortuous veins visible on his abdomen plus a yellow tinge to his sclerae. He suddenly begins vomiting copious amounts of blood and soon becomes unresponsive. His blood pressure drops to 70/40 mm Hg. He is given 3 units of whole blood but passes away shortly after the incident. Which of the following was the most likely cause of his vomiting of blood?", "answer": "Increased pressure in the distal esophageal vein due to increased pressure in the left gastric vein", "options": {"A": "Increased pressure in the distal esophageal vein due to increased pressure in the left gastric vein", "B": "Lacerations of the mucosa at the gastroesophageal junction", "C": "Perforation of the gastric mucosa", "D": "Decreased GABA activity due to downregulation of receptors", "E": "Inflammation of the portal tract due to a chronic viral illness"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old man presents", "emergency department", "vomiting blood", "hour", "occasionally", "pain", "episodes", "man", "slurred speech", "symptoms", "to give further history", "immediate treatment", "condition", "patient", "tortuous veins visible", "abdomen", "yellow", "sclerae", "begins vomiting copious amounts of blood", "unresponsive", "blood pressure drops", "70 40 mm Hg", "given 3 units of whole blood", "passes", "following", "most likely cause of", "vomiting", "blood"]}
{"question": "A 60-year-old man is brought to the emergency room because of fever and increasing confusion for the past 2 days. He has paranoid schizophrenia treated with chlorpromazine. He appears diaphoretic. His temperature is 40°C (104°F), pulse is 130/min, respirations are 29/min, and blood pressure is 155/100 mm Hg. Neurologic examination shows psychomotor agitation and incoherent speech. There is generalized muscle rigidity. His deep tendon reflexes are decreased bilaterally. Serum laboratory analysis shows a leukocyte count of 11,300/mm3 and serum creatine kinase concentration of 833 U/L. The most appropriate drug for this patient acts by inhibiting which of the following?", "answer": "Ryanodine receptor on the sarcoplasmic reticulum", "options": {"A": "Cholinesterase", "B": "Postsynaptic dopamine D2 receptors and serotonin 2A receptors", "C": "Ryanodine receptor on the sarcoplasmic reticulum", "D": "Histamine H1 receptor and serotonin 2 receptors", "E": "Beta adrenergic receptors"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "brought", "emergency room", "fever", "increasing confusion", "past 2 days", "paranoid schizophrenia treated with chlorpromazine", "appears diaphoretic", "temperature", "pulse", "min", "respirations", "29 min", "blood pressure", "100 mm Hg", "Neurologic examination", "psychomotor agitation", "incoherent speech", "generalized muscle rigidity", "deep tendon reflexes", "decreased", "Serum laboratory analysis", "leukocyte count", "11 300 mm3", "serum creatine kinase concentration", "U/L", "most appropriate drug", "patient acts", "following"]}
{"question": "A 10-month-old infant is brought to the emergency by his parents after a seizure. The parents report no history of trauma, fever, or a family history of seizures. However, they both say that the patient fell while he was running. Neurologic examination was normal. A head CT scan was ordered and is shown in figure A. Which of the following is most likely found in this patient?", "answer": "Retinal hemorrhages", "options": {"A": "Slipped capital femoral epiphysis", "B": "Retinal hemorrhages", "C": "Microcephaly", "D": "Rupture of middle meningeal artery", "E": "Intact bridging veins"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["A 10 month old infant", "brought", "emergency", "seizure", "report", "history", "trauma", "fever", "family history", "seizures", "patient fell", "Neurologic examination", "normal", "head CT scan", "ordered", "following", "most likely found", "patient"]}
{"question": "An 80-year-old woman presents to her cardiologist for a scheduled appointment. She was shown to have moderate atrial dilation on echocardiography 3 years ago and was started on oral medications. The patient insists that she does not want aggressive treatment because she wants her remaining years to be peaceful. She has not been compliant with her medications and declines further investigations. Her heart rate today is 124/min and irregular. Which of the following organs is least likely to be affected by complications of her condition if she declines further management?", "answer": "Liver", "options": {"A": "Brain", "B": "Eyes", "C": "Kidneys", "D": "Liver", "E": "Spleen"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["80 year old woman presents", "cardiologist", "scheduled appointment", "to", "moderate atrial dilation", "echocardiography", "years", "started", "oral medications", "patient", "not", "aggressive treatment", "remaining years to", "not", "compliant", "medications", "further", "heart rate today", "min", "irregular", "following organs", "least likely to", "affected", "complications", "condition", "further"]}
{"question": "A 3-year-old girl is brought in by her parents to her pediatrician for concerns about their child’s behavior. Since the parents started taking their child to daycare, they have become concerned that their daughter has not been behaving like other children her age. Most notably, she seldom responds when her name is called at home or at daycare. Additionally, she has been getting in trouble with the day care staff for not following directions but instead demanding to play with the train set at all times. She has been asked numerous times to share the toys, but the patient does not play with the other children. The parents state that the patient was born vaginally following a normal pregnancy, and the patient had been meeting developmental milestones all along. While she does not speak much, she is able to construct sentences up to 4-5 words. On exam, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 106/60 mmHg, pulse is 76/min, and respirations are 14/min. The patient does not cooperate with gross or fine motor testing, but she appears to have no trouble running around the room and draws very detailed trains with crayons. While drawing and standing, she frequently makes flapping motions with her hands. The patient has ample vocabulary, but speaks in a singsong voice mostly to herself and does not engage during the exam. Which of the following is the most likely diagnosis?", "answer": "Autism spectrum disorder", "options": {"A": "Attention-deficit hyperactivity disorder", "B": "Autism spectrum disorder", "C": "Normal development", "D": "Rett syndrome", "E": "Tourette syndrome"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 year old girl", "brought", "pediatrician", "started", "not", "children", "age", "seldom", "name", "called at home", "daycare", "getting", "day care staff", "not following directions", "demanding to play", "train set", "times", "numerous times to", "toys", "patient", "not play", "children", "state", "patient", "born", "following", "normal pregnancy", "patient", "not speak much", "able to", "exam", "patients temperature", "98", "36", "blood pressure", "60 mmHg", "pulse", "76 min", "respirations", "min", "patient", "not", "gross", "fine motor testing", "appears to", "room", "very detailed trains", "crayons", "standing", "frequently makes flapping motions", "hands", "patient", "speaks", "voice mostly", "not", "exam", "following", "diagnosis"]}
{"question": "A 27-year-old man comes to the physician because of multiple, dry, scaly lesions on his elbows. The lesions appeared 4 months ago and have progressively increased in size. They are itchy and bleed when he scratches them. There is no associated pain or discharge. He was diagnosed with HIV infection 6 years ago. He has smoked a pack of cigarettes daily for the past 10 years. Current medications include raltegravir, lamivudine, abacavir, and cotrimoxazole. An image of the lesions is shown. His CD4+ T-lymphocyte count is 470/mm3 (normal ≥ 500). Which of the following is the most likely cause of this patient's skin findings?", "answer": "Increased keratinocyte proliferation", "options": {"A": "HPV-2 infection", "B": "Malassezia furfur infection", "C": "Neoplastic T-cell Infiltration", "D": "Increased keratinocyte proliferation", "E": "Autoimmune melanocyte destruction\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old man", "physician", "multiple", "dry", "scaly lesions", "elbows", "lesions appeared 4 months", "increased in size", "itchy", "bleed", "scratches", "associated pain", "discharge", "diagnosed", "HIV infection", "years", "smoked", "pack", "cigarettes daily", "past", "Current include raltegravir", "lamivudine", "abacavir", "cotrimoxazole", "lesions", "CD4", "lymphocyte count", "mm3", "normal", "500", "following", "most likely cause", "patient's skin findings"]}
{"question": "A 45-year-old African-American woman presents with dyspnea, cough, and non-radiating chest pain. Her chest pain is relieved by leaning forward and worsens upon leaning backwards. A scratchy rub is heard best with the patient leaning forward. Physical examination did not elucidate evidence of a positive Kussmaul's sign, pulsus paradoxus, or pericardial knock. The patient most likely is suffering from which of the following?", "answer": "Acute pericarditis", "options": {"A": "Cardiac tamponade", "B": "Constrictive pericarditis", "C": "Acute pericarditis", "D": "Libman-Sacks endocarditis", "E": "Acute myocardial infarction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "woman presents", "dyspnea", "cough", "non radiating chest pain", "chest pain", "relieved by", "forward", "worsens", "backwards", "scratchy rub", "heard best", "patient", "forward", "not", "positive Kussmaul's sign", "pulsus paradoxus", "pericardial knock", "patient", "likely", "suffering"]}
{"question": "Shortly after the removal of a subclavian venous catheter by a surgical resident in an academic medical center, a 50-year-old man develops tachycardia, respiratory distress, and hypotension. Despite appropriate lifesaving treatment, the patient dies. Examination of the lungs during autopsy shows air in the main pulmonary artery. A root cause analysis is performed to prevent similar events occurring in the future. Which of the following actions is a primary approach for this type of error analysis?", "answer": "Conduct interviews with all staff members involved in the patient's care", "options": {"A": "Schedule a required lecture on central venous catheter removal for all residents", "B": "Examine the central line placement curriculum used for all surgical residents", "C": "Research other cases of catheter-associated venous air embolisms that have occurred nationally", "D": "Conduct interviews with all staff members involved in the patient's care", "E": "Review all possible causes of venous air embolism"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["removal of", "subclavian venous catheter", "surgical resident", "academic medical center", "50 year old man", "tachycardia", "respiratory distress", "hypotension", "appropriate lifesaving treatment", "lungs", "autopsy", "air", "main pulmonary artery", "root cause analysis", "performed to prevent similar", "occurring", "future", "following actions", "primary approach", "error analysis"]}
{"question": "A 63-year-old woman comes to the physician because of a skin lesion on her neck for 7 months. It is neither pruritic nor painful. She has tried using over-the-counter topical medications, but none have helped. She has hypertension, hypothyroidism, and gastroesophageal reflux disease. Current medications include amlodipine, hydrochlorothiazide, levothyroxine, and pantoprazole. She is a farmer and lives with her two children. Her temperature is 37.7°C (98.8°F), pulse is 80/min, respirations are 15/min, and blood pressure is 128/84 mm Hg. Examination shows a 5-mm (0.2-in) nontender, indurated, nodular lesion with rolled-out edges on the anterolateral aspect of the neck. There is a central area of ulceration. There is no cervical lymphadenopathy. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. In addition to dermoscopy, which of the following is the most appropriate next step in management?", "answer": "Perform an excisional biopsy of the entire lesion", "options": {"A": "Perform a punch biopsy of the center of the lesion", "B": "Perform an excisional biopsy of the entire lesion", "C": "Schedule external beam radiotherapy sessions", "D": "Perform cryotherapy on the lesion", "E": "Perform a wedge biopsy of the lesion and surrounding tissue"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old woman", "physician", "of", "skin lesion on", "neck", "months", "painful", "using over-the-counter topical medications", "helped", "hypertension", "hypothyroidism", "gastroesophageal reflux disease", "Current medications include amlodipine", "hydrochlorothiazide", "levothyroxine", "pantoprazole", "farmer", "lives with", "two children", "temperature", "98", "pulse", "80 min", "respirations", "min", "blood pressure", "84 mm Hg", "5-mm", "0.2", "nontender", "indurated", "nodular lesion", "rolled out edges", "anterolateral aspect", "neck", "central area", "ulceration", "cervical lymphadenopathy", "lungs", "clear", "auscultation", "Cardiac examination", "abnormalities", "dermoscopy", "following", "most appropriate next step"]}
{"question": "A 45-year-old man comes to the physician for a follow-up examination after being diagnosed with hypertension 6 months ago. He has cut salt out of his diet and started exercising regularly, but home blood pressure measurements continue to be elevated. His blood pressure is 160/85 mm Hg. An antihypertensive medication is prescribed that decreases blood pressure by decreasing the transmembrane calcium current across vascular smooth muscle cells. Side effects include peripheral edema and flushing. Which of the following best describes why this drug does not affect skeletal muscle contraction?", "answer": "Skeletal muscle contraction occurs independently of extracellular calcium influx", "options": {"A": "Skeletal muscle lacks voltage-gated L-type calcium channels", "B": "Skeletal muscle contraction occurs independently of extracellular calcium influx", "C": "Skeletal muscle ryanodine receptor activation occurs independently of membrane depolarization", "D": "Skeletal muscle preferentially expresses N-type and P-type calcium channels", "E": "Skeletal muscle calcium channels do not undergo conformational change when bound to this drug"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "follow-up examination", "diagnosed", "hypertension", "months", "cut", "out", "started exercising", "home", "to", "elevated", "blood pressure", "85 mm Hg", "antihypertensive medication", "decreases blood pressure", "decreasing", "transmembrane calcium current", "Side effects include peripheral edema", "flushing", "following best", "drug", "not", "skeletal muscle contraction"]}
{"question": "A 10-year-old boy presents with sudden shortness of breath. The patient’s mother says he was playing in the school garden 2 hours ago and suddenly started to complain of abdominal pain and vomited a few times. An hour later, he slowly developed a rash that involved his chest, arms, and legs, and his breathing became faster, with audible wheezing. He has no significant past medical history. His temperature is 37.0°C (98.6°F), blood pressure is 100/60 mm Hg, pulse is 130/min, and respirations are 25/min. On physical examination, there is a rash on his right arm (shown in the image, below). Which of the following cells will mainly be found in this patient if a histological sample is taken from the site of the skin lesion 4 hours from now?", "answer": "Neutrophils", "options": {"A": "Mast cells", "B": "Basophils", "C": "Fibroblasts", "D": "Plasma cells", "E": "Neutrophils"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["A 10 year old boy presents", "sudden shortness of breath", "patients", "playing", "school garden", "hours", "started to", "abdominal pain", "vomited", "few times", "hour later", "slowly", "rash", "involved", "chest", "arms", "legs", "breathing", "faster", "wheezing", "significant past medical history", "temperature", "98", "blood pressure", "100 60 mm Hg", "pulse", "min", "respirations", "min", "rash", "right arm", "following cells", "found", "patient", "histological", "site of", "skin lesion", "hours", "now"]}
{"question": "A 60-year-old man comes to the emergency department because of a 2-day history of sharp chest pain and a nonproductive cough. The pain worsens with deep inspiration and improves when he leans forward. Three weeks ago, the patient was diagnosed with an ST-elevation myocardial infarction and underwent stent implantation of the right coronary artery. His temperature is 38.4°C (101.1°F) and blood pressure is 132/85 mm Hg. Cardiac auscultation shows a high-pitched scratching sound during expiration. An x-ray of the chest shows enlargement of the cardiac silhouette and a left-sided pleural effusion. Which of the following is the most likely underlying cause of this patient's current condition?", "answer": "Immune response to cardiac antigens", "options": {"A": "Outpouching of ventricular wall", "B": "Occlusion of coronary artery stent", "C": "Embolism to left pulmonary artery", "D": "Immune response to cardiac antigens", "E": "Rupture of interventricular septum"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old man", "emergency department", "of", "2-day history", "sharp chest pain", "nonproductive cough", "pain worsens", "deep inspiration", "improves", "forward", "Three weeks", "patient", "diagnosed", "ST-elevation myocardial infarction", "stent implantation", "right coronary artery", "temperature", "blood pressure", "85 mm Hg", "Cardiac auscultation", "high-pitched", "sound", "expiration", "x-ray of", "chest", "enlargement", "cardiac", "left-sided pleural effusion", "following", "underlying cause", "patient's current condition"]}
{"question": "Which of the following correctly pairs a neurotransmitter with its location of synthesis?", "answer": "Serotonin -- Raphe nucleus", "options": {"A": "Norepinephrine -- Caudate nucleus", "B": "GABA -- Ventral tegmentum", "C": "Dopamine -- Locus ceruleus", "D": "Serotonin -- Raphe nucleus", "E": "Acetylcholine -- Nucleus accumbens"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["following", "pairs", "location"]}
{"question": "A 22-year-old man presents to the emergency department with abdominal pain. The patient states that he has had right lower quadrant abdominal pain for \"a while now\". The pain comes and goes, and today it is particularly painful. The patient is a college student studying philosophy. He drinks alcohol occasionally and is currently sexually active. He states that sometimes he feels anxious about school. The patient's father died of colon cancer at the age of 55, and his mother died of breast cancer when she was 57. The patient has a past medical history of anxiety and depression which is not currently treated. Review of systems is positive for bloody diarrhea. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. Abdominal exam reveals diffuse tenderness. A fecal occult blood test is positive. Which of the following is the most likely diagnosis?", "answer": "Inflammatory bowel syndrome", "options": {"A": "Appendicitis", "B": "Colon cancer", "C": "Infectious colitis", "D": "Inflammatory bowel syndrome", "E": "Irritable bowel syndrome"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "abdominal pain", "patient states", "right lower quadrant abdominal pain", "now", "pain", "today", "painful", "patient", "studying", "alcohol occasionally", "currently sexually active", "states", "sometimes", "anxious", "school", "patient", "ied  f colon cancer ", "ge ", "ied  f breast cancer ", "7.", "atient ", "ast  edical  nxiety ", "epression ", "ot  urrently  reated.", "eview of systems ", "ositive ", "loody diarrhea.", "emperature ", "9.", "lood pressure ", "00/ 8  mHg,", "ulse ", "in,", "espirations ", "in,", "xygen saturation ", "8%", "oom air.", "ardiopulmonary  xam ", "ormal limits.", "bdominal  xam  eveals  iffuse  enderness.", "ecal occult blood test ", "ositive.", "ollowing ", "iagnosis?"]}
{"question": "A 12-year-old girl is brought to the physician because of fatigue, dyspnea, and mild chest pain on exertion for 1 week. She does not have a fever or a rash. She had an upper respiratory infection 3 weeks ago. She returned from summer camp in Colorado 3 days ago. She says they went hiking and camping as part of their activities. Her temperature is 36.9°C (98.4°F), heart rate is 96/min, and blood pressure is 106/74 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Physical examination reveals jugular venous distention and 1+ pitting edema on both ankles. A few scattered inspiratory crackles are heard in the thorax and an S3 is heard at the apex. Abdominal examination is unremarkable. Her hemoglobin concentration is 11.6 g/dL, leukocyte count is 8900/mm3, and ESR is 10 mm/hr. An x-ray of the chest shows mild cardiac enlargement. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Coxsackie virus infection", "options": {"A": "Acute rheumatic fever", "B": "Giant cell myocarditis", "C": "Borrelia burgdorferi infection", "D": "Coxsackie virus infection", "E": "Rhinovirus infection"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "fatigue", "dyspnea", "mild chest pain on exertion", "1 week", "not", "fever", "rash", "upper respiratory infection", "weeks", "returned", "summer camp", "Colorado", "days", "part of", "temperature", "36", "98", "heart rate", "96 min", "blood pressure", "74 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "96", "reveals jugular venous distention", "1", "pitting edema", "ankles", "few scattered inspiratory crackles", "heard", "thorax", "S3", "heard", "apex", "Abdominal", "unremarkable", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "ESR", "10 mm", "x-ray of", "chest", "mild cardiac enlargement", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 2-year-old boy is brought to a pediatrician for recurrent respiratory infections. The parents explain that their child has gotten sick every month since 2 months of age. The boy had multiple upper respiratory infections and has been treated for pneumonia twice. He coughs frequently, and a trial of salbutamol has not helped much. The parents also mention that the child has bulky, irregular stools. The boy was started late on his vaccinations as his parents were in Asia on missionary work when he was born, but his vaccinations are now up to date. The patient's brother and sister are both healthy and have no medical concerns. The boy's delivery was unremarkable. A sweat chloride test is positive. Genetic testing shows the absence of the typical deletion in the implicated gene, but the gene length appears to be shortened by one base pair. Which mutation could account for this finding?", "answer": "Frameshift", "options": {"A": "Frameshift", "B": "Insertion", "C": "Missense", "D": "Nonsense", "E": "Silent"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2 year old boy", "brought", "pediatrician", "recurrent respiratory infections", "child", "gotten sick", "month", "months", "age", "boy", "multiple upper", "treated", "pneumonia twice", "coughs frequently", "salbutamol", "not helped much", "child", "bulky", "irregular stools", "boy", "started late", "vaccinations", "Asia", "missionary", "born", "vaccinations", "now", "date", "patient's", "healthy", "medical", "boy's delivery", "unremarkable", "sweat chloride test", "positive", "Genetic testing", "absence", "typical deletion", "gene", "gene length appears to", "shortened", "one", "mutation", "account", "finding"]}
{"question": "A 43-year-old man comes to the physician for evaluation of a headache he has had for the last 6 months. The patient reports that nothing helps to relieve the headache and that it is more severe in the morning. Throughout the last 2 months, he has been unable to maintain an erection and states that his sexual desire is low. There is no personal or family history of serious illness. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg. Examination shows an enlarged nose, forehead, and jaw and widened hands, fingers, and feet. His hands are sweaty. His serum glucose concentration is 260 mg/dL. Which of the following is the most appropriate next step in diagnosis?", "answer": "Serum IGF-1 measurement", "options": {"A": "Serum IGF-1 measurement", "B": "MRI of the brain", "C": "Oral glucose tolerance test", "D": "Basal prolactin measurement", "E": "24-hour urine cortisol measurement\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "headache", "last", "months", "patient reports", "helps to relieve", "headache", "more severe", "morning", "last", "months", "unable to", "erection", "states", "sexual desire", "low", "personal", "family history", "serious illness", "temperature", "98", "pulse", "80 min", "blood pressure", "90 mm Hg", "enlarged nose", "forehead", "jaw", "widened hands", "fingers", "feet", "hands", "sweaty", "serum", "mg/dL", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 68-year-old male presents with several years of progressively worsening pain in his buttocks. Pain is characterized as dull, worse with exertion especially when ascending the stairs. He has a history of diabetes mellitus type II, obesity, coronary artery disease with prior myocardial infarction, and a 44 pack-year smoking history. Current medications include aspirin, atorvastatin, metoprolol, lisinopril, insulin, metformin, and varenicline. Upon further questioning, the patient's wife states that her husband has also recently developed impotence. His temperature is 99.5°F (37.5°C), pulse is 90/min, blood pressure is 150/90 mmHg, respirations are 12/min, and oxygen saturation is 96% on room air. Which of the following is the best initial step in management?", "answer": "Ankle-brachial index", "options": {"A": "Cilostazol", "B": "Pentoxifylline", "C": "Guided exercise therapy", "D": "Ankle-brachial index", "E": "Angiography"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male presents", "years", "worsening pain in", "buttocks", "dull", "worse", "exertion", "ascending", "history of diabetes mellitus type II", "obesity", "coronary artery disease with prior myocardial infarction", "smoking history", "Current medications include aspirin", "atorvastatin", "metoprolol", "lisinopril", "insulin", "metformin", "varenicline", "further", "patient's", "states", "recently", "impotence", "temperature", "99", "pulse", "90 min", "blood pressure", "90 mmHg", "respirations", "min", "oxygen saturation", "96", "room air", "following", "best initial step"]}
{"question": "A 27-year-old man presents to the emergency department following a motor vehicle accident. Having been found as a restrained driver, he did not suffer from any chest injuries; nevertheless, his legs were pinned in position by the front of the highly damaged vehicle. After a prolonged extrication, the man sustained multiple fractures on his left femur and tibia. That same night, he underwent surgery to address his left leg fractures. In the next morning, the man suddenly developed severe dyspnea. Upon examination, he is noted to have a diffuse petechial rash. His vital signs are the following: blood pressure is 111/67 mm Hg, pulse rate is 107/min, respiratory rate is 27/min, oxygen saturation level is 82%, and his body temperature is normal. What is the most likely mechanism of his respiratory distress?", "answer": "Fat embolism", "options": {"A": "Pulmonary edema", "B": "Cardiac tamponade", "C": "Bacterial pneumonia", "D": "Spontaneous pneumothorax", "E": "Fat embolism"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["27 year old man presents", "emergency department following", "motor vehicle accident", "found", "restrained driver", "not suffer", "chest injuries", "legs", "pinned", "position", "front", "highly damaged vehicle", "prolonged extrication", "man sustained multiple fractures", "left femur", "tibia", "same night", "surgery to", "left leg fractures", "next morning", "man", "severe dyspnea", "noted to", "diffuse petechial", "vital signs", "following", "blood pressure", "67 mm Hg", "pulse rate", "min", "respiratory rate", "27 min", "oxygen saturation level", "body temperature", "normal", "mechanism", "respiratory distress"]}
{"question": "A 3-year-old is brought to the pediatrician by by his mother. She is concerned that he appears fatigued all the time. She also mentions that he struggles to get out of his seat after eating his meals and when he waddles when he walks now. The child was born at 39 weeks via spontaneous vaginal delivery. He is up to date on all his vaccines and meeting all developmental goals. A maternal uncle with similar symptoms that started in early childhood. He has a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F). The child appears lethargic. He was much more active during his previous well-child visit. Upon examination, the child has thick calves and uses his hands to support himself as he stands up from a sitting position. His reflexes are decreased bilaterally. Lab studies show elevated creatinine phosphokinase (CPK) and lactate dehydrogenase (LDH). Which of the following is the most likely cause of this patient’s condition?", "answer": "Nonsense mutation in DMD gene", "options": {"A": "Missense mutation in β-thalassemia gene", "B": "Missense mutation in DMD gene", "C": "Nonsense mutation in DMD gene", "D": "Nonsense mutation in DMPK gene", "E": "Mutation in WT gene"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old", "brought", "pediatrician", "appears fatigued", "time", "to get out", "eating", "meals", "walks now", "child", "born", "weeks", "spontaneous vaginal delivery", "date", "vaccines", "developmental", "similar symptoms", "started", "early childhood", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "98", "child appears lethargic", "much", "active", "previous", "child", "thick calves", "uses", "hands to support", "stands up", "sitting position", "reflexes", "decreased", "Lab studies", "elevated creatinine phosphokinase", "lactate dehydrogenase", "following", "most likely cause", "patients condition"]}
{"question": "A 5-month-old boy is brought to the physician by his parents because of difficulty breathing for the past hour. The parents report noisy breathing and bluish discoloration of their son's lips. During the past two months, the patient has had several upper respiratory tract infections and poor weight gain. Pregnancy and delivery were uncomplicated. His immunizations are up-to-date. He is at the 20th percentile for length and 5th percentile for weight. His temperature is 38°C (100.4°F), pulse is 160/min, respirations are 40/min, and blood pressure is 80/55 mm Hg. Crackles are heard over both lung fields. An x-ray of the chest shows bilateral interstitial infiltrates. Intubation is performed and methylprednisolone is administered. Methenamine silver staining of bronchial lavage fluid shows aggregates of 2 to 8 cysts with central spores. Serum IgA titers are decreased. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Defective CD40 ligand", "options": {"A": "Defective WAS gene", "B": "Defective CD40 ligand", "C": "Impaired lysosomal trafficking regulator gene", "D": "Tyrosine kinase gene mutation", "E": "Impaired NADPH oxidase"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 month old boy", "brought", "physician", "difficulty breathing", "past hour", "report noisy breathing", "discoloration", "lips", "past two months", "patient", "several upper respiratory tract infections", "poor weight gain", "Pregnancy", "delivery", "uncomplicated", "immunizations", "date", "percentile", "length", "5th percentile", "weight", "temperature", "100", "pulse", "min", "respirations", "40 min", "blood pressure", "80", "mm Hg", "Crackles", "heard", "lung fields", "x-ray of", "chest", "bilateral interstitial infiltrates", "Intubation", "performed", "methylprednisolone", "administered", "Methenamine silver staining of bronchial lavage fluid", "aggregates", "cysts", "central", "titers", "decreased", "following", "underlying cause", "patient's condition"]}
{"question": "A 68-year-old man presents to his primary care physician for fatigue. He is accompanied by his granddaughter who is worried that the patient is depressed. She states that over the past 2 months he has lost 15 lbs. He has not come to some family events because he complains of being “too tired.” The patient states that he tries to keep up with things he likes to do like biking and bowling with his friends but just tires too easily. He does not feel like he has trouble sleeping. He does agree that he has lost weight due to a decreased appetite. The patient has coronary artery disease and osteoarthritis. He has not been to a doctor in “years” and takes no medications, except acetaminophen as needed. Physical examination is notable for hepatomegaly. Routine labs are obtained, as shown below:\n\nLeukocyte count: 11,000/mm^3\nHemoglobin: 9 g/dL\nPlatelet count: 300,000/mm^3\nMean corpuscular volume (MCV): 75 µm^3\nSerum iron: 35 mcg/dL\n\nAn abdominal ultrasound reveals multiple, hypoechoic liver lesions. Computed tomography of the abdomen confirms multiple, centrally-located, hypoattenuated lesions. Which of the following is the next best step in management?", "answer": "Colonoscopy", "options": {"A": "Citalopram", "B": "Colonoscopy", "C": "Fine-needle aspiration", "D": "Fluorouracil, leucovorin, and oxaliplatin", "E": "Surgical resection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care physician", "fatigue", "worried", "patient", "depressed", "states", "past", "months", "lost", "lbs", "not", "tired", "patient states", "to keep", "to", "biking", "tires", "easily", "not", "trouble sleeping", "agree", "lost due to", "decreased", "patient", "coronary artery disease", "osteoarthritis", "not", "doctor", "years", "medications", "acetaminophen as needed", "notable", "hepatomegaly", "Routine labs", "obtained", "Leukocyte count", "mm", "Hemoglobin", "g/dL Platelet count", "300", "mm", "Mean corpuscular volume", "75 m", "Serum iron", "35 mcg/dL", "abdominal ultrasound reveals multiple", "liver lesions", "Computed tomography of", "abdomen confirms multiple", "hypoattenuated lesions", "following", "next best step"]}
{"question": "Eighteen hours after undergoing surgery for a splenic rupture and liver laceration following a high-speed motor vehicle collision, a 23-year-old man's pulse is 140/min, blood pressure is 80/50 mm Hg, and central venous pressure is 19 cm H2O. He was transfused with 6 units of packed red blood cells during surgery. Examination shows jugular venous distention. There is a midline surgical incision with no erythema or discharge. The abdomen is tense and distended. The total urine output over the past 6 hours is 90 mL. Serum studies show:\nUrea nitrogen 80 mg/dL\nCreatinine 3.0 mg/dL\nHCO3- 29 mEq/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Reopen abdomen and cover with plastic", "options": {"A": "Administration of fresh frozen plasma", "B": "Reopen abdomen and cover with plastic", "C": "Administration of intravenous antibiotics", "D": "Angiographic embolization", "E": "Hemicolonic resection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Eighteen hours", "surgery", "splenic rupture", "liver laceration following", "high speed motor vehicle collision", "23 year old man", "ulse ", "in,", "lood pressure ", "0/ 0  m Hg,", "entral venous pressure ", "m H2O.", "nits ", "acked red blood cells ", "urgery.", "ugular venous distention.", "idline surgical incision ", "rythema ", "ischarge.", "bdomen ", "ense ", "istended.", "otal  rine output ", "ast ", "ours ", "0  L.", "erum  tudies ", "rea ", "g/dL  reatinine ", " ", "CO3-", "9  Eq/L ", "ollowing ", "ost  ppropriate  ext  tep "]}
{"question": "A 30-year-old man presents to his family physician admitting to using heroin. He says he started using about 6-months ago when his back pain medication ran out. At first, he says he would borrow his wife’s Percocet but, eventually, that ran out and he had to find a different source. Since then, he has been having more and more issues related to his heroin use, and it has started to affect his work and home life. He is concerned that, if he continues like this, he might end up in real trouble. He denies sharing needles and is sincerely interested in quitting. He recalls trying to quit last month but recounts how horrible the withdrawal symptoms were. Because of this and the strong cravings, he relapsed shortly after his initial attempt. Methadone maintenance therapy is prescribed. Which of the following would most likely be the most important benefit of this new treatment plan in this patient?", "answer": "Improved interpersonal relationships", "options": {"A": "Improved interpersonal relationships", "B": "Euphoria without the side effects", "C": "Decreased incidence of hepatitis A", "D": "Depot dosing allowing for better compliance", "E": "Decreases methadone dependence"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old man presents", "family physician", "using heroin", "started using", "months", "back pain medication ran out", "first", "Percocet", "ran out", "to find", "different source", "then", "more", "more issues related", "heroin use", "started to", "home", "end", "real", "needles", "to", "last month", "withdrawal symptoms", "strong", "relapsed", "initial", "Methadone", "following", "most likely", "most important benefit", "new", "patient"]}
{"question": "A 53-year-old man presents to an urgent care center with severe fever that began during the day along with muscle and joint pains. He states that he felt fine the day before but then developed a fever to 103°F (39.4°C) and had to leave work after which he developed a headache and body pains. The patient states that he was recently in South Asia for a business trip and was otherwise feeling well since returning 2 weeks ago. On exam, the patient’s temperature is 103.3°F (39.6°C), blood pressure is 110/84 mmHg, pulse is 94/min, and respirations are 14/min. On physical exam, the patient appears flushed and has a rash that blanches when touched. On laboratory workup, the pathogen was identified as an enveloped virus with an icosahedral capsid and had positive-sense, single-stranded linear RNA. Which of the following is the most likely cause of this patient's presentation?", "answer": "Dengue virus", "options": {"A": "Coronavirus", "B": "Dengue virus", "C": "Marburg virus", "D": "Norovirus", "E": "Saint Louis encephalitis virus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "urgent care center", "severe fever", "began", "day", "muscle", "joint pains", "states", "fine", "day", "then", "fever", "to", "headache", "body pains", "patient states", "recently", "South Asia", "business trip", "well since returning 2 weeks", "exam", "patients temperature", "blood pressure", "84 mmHg", "pulse", "min", "respirations", "min", "patient appears flushed", "rash", "blanches", "touched", "laboratory workup", "identified", "capsid", "positive sense", "linear", "following", "most likely cause", "patient's"]}
{"question": "A 64-hour-old baby girl is being evaluated for discharge. She was born by forceps-assisted vaginal delivery at 39 weeks gestation. The mother has no chronic medical conditions and attended all her prenatal visits. The mother’s blood type is A+. On day 1, the patient was noted to have a scalp laceration. Breastfeeding was difficult at first but quickly improved upon nurse assistance. The patient has had adequate wet diapers since birth. Upon physical examination, the resident notes the infant has scleral icterus and jaundiced skin. The scalp laceration noted on day 1 is intact without fluctuance or surrounding erythema. When the infant is slightly lifted from the bed and released, she spread out her arms, pulls them in, and exhibits a strong cry. Labs are drawn as shown below:\n\nBlood type: AB-\nTotal bilirubin 8.7 mg/dL\nDirect bilirubin 0.5 mg/dL\n\nSix hours later, repeat total bilirubin is 8.3 mg/dL. Which of the following is the next best step in the management of the baby’s condition?", "answer": "Observation", "options": {"A": "Coombs test", "B": "Exchange transfusion", "C": "Switch to baby formula", "D": "Observation", "E": "Phototherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["64 hour old baby girl", "discharge", "born by forceps assisted vaginal delivery", "weeks gestation", "chronic medical conditions", "attended", "blood type", "day 1", "patient", "noted to", "scalp laceration", "Breastfeeding", "difficult", "first", "improved", "nurse assistance", "patient", "adequate wet diapers", "birth", "resident notes", "infant", "scleral icterus", "jaundiced skin", "scalp laceration noted", "day 1", "intact", "fluctuance", "surrounding erythema", "infant", "slightly lifted", "bed", "released", "spread out", "arms", "pulls", "strong", "Labs", "Blood type", "Total bilirubin 8", "mg dL Direct bilirubin 0.5 mg", "Six hours later", "repeat total bilirubin", "mg/dL", "following", "next best step", "management", "condition"]}
{"question": "An autopsy of a 75-year-old man reveals obliterating endarteritis of the vasa vasorum of the aorta. Which of the following investigations will most likely be positive in this patient?", "answer": "Rapid plasma reagin (RPR)", "options": {"A": "Perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA)", "B": "Increased double-stranded (ds) DNA titer", "C": "Increased ketonuria", "D": "Increased serum creatinine", "E": "Rapid plasma reagin (RPR)"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["autopsy", "75 year old man reveals obliterating endarteritis", "vasa vasorum", "aorta", "following", "most likely", "positive", "patient"]}
{"question": "A 43-year-old woman comes to the physician for a routine examination prior to starting a new job as a nurse. Over the past year, the patient has had mild shortness of breath and a cough productive of white sputum, particularly in the morning. She immigrated to the United States from South Africa with her parents 40 years ago. She received all appropriate immunizations during childhood, including the oral polio and BCG vaccine. She has smoked two packs of cigarettes daily for 30 years and drinks one glass of wine occasionally. Her only medication is a multivitamin. Her temperature is 36.5°C (97.7°F), pulse is 74/min, and blood pressure is 124/60 mm Hg. Bilateral wheezing is heard throughout both lung fields. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Which of the following is the most appropriate next step to evaluate for tuberculosis in this patient?", "answer": "Interferon-gamma release assay", "options": {"A": "Tuberculin skin test", "B": "Sputum culture", "C": "X-ray of the chest", "D": "PCR of the sputum", "E": "Interferon-gamma release assay"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "routine", "prior to starting", "new job", "nurse", "past year", "patient", "mild shortness of breath", "cough productive", "white", "morning", "United States", "South Africa", "40 years", "received", "appropriate immunizations", "childhood", "including", "oral polio", "BCG vaccine", "smoked two packs", "cigarettes daily", "30 years", "one glass", "occasionally", "only medication", "multivitamin", "temperature", "36", "97", "pulse", "74 min", "blood pressure", "60 mm Hg", "Bilateral wheezing", "heard", "lung fields", "complete blood count", "serum", "electrolytes", "urea nitrogen", "creatinine", "reference range", "following", "most appropriate next step to", "tuberculosis", "patient"]}
{"question": "A 24-year-old G1P0000 presents for her first obstetric visit and is found to be at approximately 8 weeks gestation. She has no complaints aside from increased fatigue and occasional nausea. The patient is a recent immigrant from Africa and is currently working as a babysitter for several neighborhood children. One of them recently had the flu, and another is home sick with chickenpox. The patient has no immunization records and does not recall if she has had any vaccinations. She is sexually active with only her husband, has never had a sexually transmitted disease, and denies intravenous drug use. Her husband has no past medical history. Exam at this visit is unremarkable. Her temperature is 98.7°F (37.1°C), blood pressure is 122/76 mmHg, pulse is 66/min, and respirations are 12/min. Which of the following immunizations should this patient receive at this time?", "answer": "Intramuscular flu vaccine", "options": {"A": "Intranasal flu vaccine", "B": "Tetanus/Diphtheria/Pertussis vaccine", "C": "Hepatitis B vaccine", "D": "Varicella vaccine", "E": "Intramuscular flu vaccine"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "presents", "first obstetric", "found to", "approximately", "weeks gestation", "complaints", "increased fatigue", "occasional nausea", "patient", "recent immigrant", "Africa", "currently", "several neighborhood children", "One", "recently", "flu", "home sick", "chickenpox", "patient", "not", "vaccinations", "sexually active", "only", "never", "sexually transmitted disease", "past medical history", "Exam", "unremarkable", "temperature", "98", "blood pressure", "76 mmHg", "pulse", "66 min", "respirations", "min", "following immunizations", "patient receive", "time"]}
{"question": "A 54-year-old man is brought to the emergency department by his wife because of progressive nausea, vomiting, and right-sided flank pain for 2 days. The pain is colicky and radiates to the groin. He has a history of gout and type 2 diabetes mellitus. Current medications are metformin and allopurinol. He recently began taking large amounts of a multivitamin supplement after he read on the internet that it may help to prevent gout attacks. Physical examination shows right-sided costovertebral angle tenderness. Oral examination shows dental erosions. A CT scan of the abdomen shows an 8-mm stone in the right proximal ureter. Microscopic examination of a urine sample shows bipyramidal, envelope-shaped crystals. An increased serum concentration of which of the following is the most likely cause of this patient’s symptoms?", "answer": "Vitamin C", "options": {"A": "Vitamin A", "B": "Vitamin B3", "C": "Vitamin E", "D": "Vitamin C", "E": "Uric acid"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["54 year old man", "brought", "emergency department", "progressive nausea", "vomiting", "right-sided flank pain", "days", "pain", "colicky", "radiates", "groin", "history of gout", "type 2 diabetes mellitus", "Current medications", "metformin", "allopurinol", "recently began", "large amounts", "multivitamin supplement", "internet", "help to prevent gout attacks", "right-sided costovertebral angle tenderness", "dental erosions", "CT scan", "abdomen", "mm stone", "right proximal ureter", "Microscopic examination", "urine sample", "envelope shaped crystals", "increased serum concentration", "following", "most likely cause", "patients symptoms"]}
{"question": "A 33-year-old man comes to the physician because of decreased hearing in his right ear for the past 4 months. During this period, he has also had multiple episodes of dizziness and a constant ringing noise in his right ear. Over the past 5 weeks, he has also noticed scant amounts of right-sided ear discharge. He has a history of multiple ear infections since childhood that were treated with antibiotics. Vital signs are within normal limits. Otoscopic examination shows a white pearly mass behind the right tympanic membrane. Placing a 512 Hz tuning fork in the center of the forehead shows lateralization to the right ear. Which of the following is the most appropriate therapy for this patient's symptoms?", "answer": "Surgical excision", "options": {"A": "Topical ciprofloxacin", "B": "Radiation therapy", "C": "Systemic corticosteroids", "D": "Fitting for hearing aids", "E": "Surgical excision"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of decreased hearing", "right ear", "past", "months", "period", "multiple episodes of dizziness", "constant ringing", "in", "right ear", "past", "weeks", "scant amounts of right-sided ear discharge", "history of multiple ear infections", "childhood", "treated with", "Vital signs", "normal limits", "Otoscopic", "mass", "right tympanic membrane", "Placing", "Hz tuning fork", "center", "forehead", "right ear", "following", "most appropriate therapy", "patient's symptoms"]}
{"question": "A 73-year-old woman presents to the emergency department with diffuse abdominal pain, nausea, and vomiting. Her daughter who accompanies her says she was in her usual state of health until two days ago when she started to complain of abdominal pain and was unable to tolerate oral intake. She has hypertension, congestive heart failure, atrial fibrillation, and osteoarthritis. She underwent an exploratory laparotomy for an ovarian mass a year ago where a mucinous cystadenoma was excised. Her medications include aspirin, nifedipine, lisinopril, metoprolol, warfarin, and Tylenol as needed for pain. She does not drink alcohol or smoke cigarettes. She appears ill and disoriented. Her temperature is 37.9°C (100.3°F), blood pressure is 102/60 mm Hg, pulse is 110/min and irregular, and respirations are 16/min. Examination shows diffuse tenderness to palpation of the abdomen. The abdomen is tympanitic on percussion. Bowel sounds are hyperactive. The lungs are clear to auscultation bilaterally. There is a soft crescendo-decrescendo murmur best auscultated in the right second intercostal space. Laboratory studies show:\nHemoglobin 10.2 g/dL\nLeukocyte count 14,000/mm3\nPlatelet count 130,000/mm3\nProthrombin time 38 seconds\nINR 3.2\nSerum\nNa+ 132 mEq/dL\nK+ 3.6 mEq/dL\nCl- 102 mEq/dL\nHCO3- 19 mEq/dL\nUrea nitrogen 36 mg/dl\nCreatinine 2.3 mg/dL\nLactate 2.8 mEq/dL (N= 0.5-2.2 mEq/dL)\nAn x-ray of the abdomen shows multiple centrally located dilated loops of gas filled bowel. There is no free air under the diaphragm. A nasogastric tube is inserted and IV fluids and empiric antibiotic therapy are started. Emergent exploratory laparotomy is planned. Which of the following is the next best step in management?\"", "answer": "Administer fresh frozen plasma and Vitamin K", "options": {"A": "Administer unfractionated heparin", "B": "Administer protamine sulfate", "C": "Administer fresh frozen plasma and Vitamin K", "D": "Administer platelet concentrate", "E": "Administer recombinant activated factor VII"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "diffuse abdominal", "nausea", "vomiting", "usual state of health", "two days", "started to", "abdominal pain", "unable to", "oral intake", "hypertension", "congestive heart failure", "atrial fibrillation", "osteoarthritis", "exploratory laparotomy", "ovarian mass", "year", "mucinous cystadenoma", "medications include aspirin", "nifedipine", "lisinopril", "metoprolol", "warfarin", "Tylenol as needed", "pain", "not", "alcohol", "smoke cigarettes", "appears ill", "disoriented", "temperature", "100", "blood pressure", "60 mm Hg", "pulse", "min", "irregular", "respirations", "min", "diffuse tenderness", "palpation of", "abdomen", "abdomen", "tympanitic", "percussion", "Bowel sounds", "hyperactive", "lungs", "clear", "auscultation", "soft crescendo", "murmur best", "right second intercostal space", "Laboratory studies", "10", "dL Leukocyte count", "Platelet count", "Prothrombin time", "Serum", "HCO3", "Urea", "mg", "8", "N", "mEq/dL", "x-ray of", "abdomen", "multiple", "dilated", "gas bowel", "free air", "diaphragm", "nasogastric tube", "empiric antibiotic therapy", "started", "exploratory laparotomy", "planned", "following", "next best step"]}
{"question": "You are asked to examine a 1-year-old child brought to the emergency department by his sister. The sister reports that the child has been acting strangely since that morning after \"getting in trouble\" for crying. The child appears lethargic and confused and is noted to have a cigarette burn on his forearm. Emergency head CT reveals a subdural hematoma. Which of the following additional findings is most likely?", "answer": "Bilateral retinal hemorrhages", "options": {"A": "Posterior rib fracture", "B": "Bilateral retinal hemorrhages", "C": "Skull fracture", "D": "Burns to buttocks", "E": "Epidural hematoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["to", "year", "brought", "emergency department", "reports", "child", "acting", "morning", "getting", "child appears lethargic", "confused", "noted to", "cigarette burn", "forearm", "Emergency head CT reveals", "subdural hematoma", "following additional findings"]}
{"question": "Paramedics respond to a call regarding an 18-year-old male with severe sudden-onset heart palpitations. The patient reports symptoms of chest pain, fatigue, and dizziness. Upon examination, his heart rate is 175/min and regular. His blood pressure is 110/75 mm Hg. Gentle massage below the level of the left mandible elicits an immediate improvement in the patient, as his heart rate returns to 70/min. What was the mechanism of action of this maneuver?", "answer": "Slowing conduction in the AV node", "options": {"A": "Increasing the refractory period in ventricular myocytes", "B": "Increasing sympathetic tone in systemic arteries", "C": "Decreasing the length of phase 4 of the SA node myocytes", "D": "Slowing conduction in the AV node", "E": "Decreasing the firing rate of carotid baroreceptors"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Paramedics", "call", "year old male", "severe sudden-onset heart palpitations", "patient reports symptoms of chest pain", "fatigue", "dizziness", "heart rate", "min", "regular", "blood pressure", "75 mm Hg", "Gentle massage", "level", "left mandible elicits", "immediate", "patient", "heart rate returns", "70 min", "mechanism of action"]}
{"question": "A 57-year-old female visits her primary care physician with 2+ pitting edema in her legs. She takes no medications and does not use alcohol, tobacco, or illicit drugs. 4.5 grams of protein are collected during 24-hour urine excretion. A kidney biopsy is obtained. Examination with light microscopy shows diffuse thickening of the glomerular basement membrane. Electron microscopy shows subepithelial spike and dome deposits. Which of the following is the most likely diagnosis:", "answer": "Membranous nephropathy", "options": {"A": "Minimal change disease", "B": "Postinfectious glomerulonephritis", "C": "Focal segmental glomerulosclerosis", "D": "Rapidly progressive glomerulonephritis", "E": "Membranous nephropathy"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["57 year old female", "primary care physician", "2", "pitting edema", "legs", "medications", "not use alcohol", "tobacco", "illicit drugs", "4.5 grams of protein", "collected", "hour urine excretion", "kidney biopsy", "obtained", "Examination", "light microscopy", "diffuse thickening of the glomerular basement membrane", "Electron microscopy", "dome deposits", "following", "diagnosis"]}
{"question": "A 28-year-old woman, gravida 1, para 0, at 10 weeks' gestation comes to the physician for her initial prenatal visit. She has no history of serious illness, but reports that she is allergic to penicillin. Vital signs are within normal limits. The lungs are clear to auscultation, and cardiac examination shows no abnormalities. Transvaginal ultrasonography shows an intrauterine pregnancy with no abnormalities. The fetal heart rate is 174/min. Routine prenatal laboratory tests are drawn. Rapid plasma reagin (RPR) test is 1:128 and fluorescent treponemal antibody absorption test (FTA-ABS) is positive. Which of the following is the most appropriate next step in management?", "answer": "Administer penicillin desensitization dose", "options": {"A": "Administer therapeutic dose of intramuscular penicillin G", "B": "Administer intravenous ceftriaxone", "C": "Administer penicillin desensitization dose", "D": "Administer oral azithromycin", "E": "Perform oral penicillin challenge test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "10 weeks", "gestation", "physician", "history", "serious illness", "reports", "allergic", "penicillin", "Vital signs", "normal limits", "lungs", "clear", "auscultation", "abnormalities", "Transvaginal ultrasonography", "intrauterine pregnancy", "abnormalities", "fetal heart rate", "min", "Routine prenatal laboratory", "Rapid plasma reagin", "RPR", "test", "1", "fluorescent treponemal antibody absorption test", "positive", "following", "most appropriate next step"]}
{"question": "A 46-year-old man is brought to the emergency room by police after being found passed out on the sidewalk. He is intermittently alert and smells strongly of alcohol. He is unable to provide a history, but an electronic medical record search reveals that the patient has a history of alcohol abuse and was seen in the emergency room twice in the past year for alcohol intoxication. Further review of the medical record reveals that he works as a day laborer on a farm. His temperature is 98.8°F (37.1°C), blood pressure is 122/78 mmHg, pulse is 102/min, and respirations are 14/min. On examination, he is somnolent but arousable. He has vomitus on his shirt. He is given intravenous fluids and provided with supportive care. He vomits twice more and is discharged 6 hours later. However, 6 days after discharge, he presents to the emergency room again complaining of shortness of breath and fever. His temperature is 102°F (38.9°C), blood pressure is 100/58 mmHg, pulse is 116/min, and respirations are 24/min. The patient is actively coughing up foul-smelling purulent sputum. Which of the following is the most likely cause of this patient’s current symptoms?", "answer": "Bacteroides melaninogenicus", "options": {"A": "Bacteroides melaninogenicus", "B": "Coxiella burnetii", "C": "Francisella tularensis", "D": "Legionella pneumonphila", "E": "Mycoplasma pneumoniae"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency room", "police", "found passed out", "sidewalk", "alert", "smells", "alcohol", "unable to", "history", "reveals", "patient", "history of alcohol abuse", "seen", "emergency room twice", "past year", "alcohol intoxication", "Further", "reveals", "day laborer", "farm", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "somnolent", "vomitus", "shirt", "given", "supportive care", "vomits twice", "6 hours later", "6 days", "discharge", "presents", "emergency room", "of shortness", "breath", "fever", "temperature", "blood pressure", "100 58 mmHg", "pulse", "min", "respirations", "min", "patient", "coughing", "foul-smelling purulent sputum", "following", "most likely cause", "patients current symptoms"]}
{"question": "A 27-year-old woman who resides in an area endemic for chloroquine-resistant P. falciparum malaria presents to the physician with fatigue, malaise, and episodes of fever with chills over the last 5 days. She mentions that she has episodes of shivering and chills on alternate days that last for approximately 2 hours, followed by high-grade fevers; then she has profuse sweating and her body temperature returns to normal. She also mentions that she is currently in her 7th week of pregnancy. The physical examination reveals the presence of mild splenomegaly. A peripheral blood smear confirms the diagnosis of P. falciparum infection. Which of the following is the most appropriate anti-malarial treatment for the woman?", "answer": "Quinine sulfate plus clindamycin", "options": {"A": "Mefloquine only", "B": "Chloroquine phosphate plus primaquine", "C": "Quinine sulfate plus clindamycin", "D": "Quinine sulfate plus doxycycline", "E": "Quinine sulfate plus sulfadoxine-pyrimethamine"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old woman", "area", "chloroquine resistant", "falciparum malaria presents", "physician", "fatigue", "malaise", "episodes of fever", "chills", "5 days", "episodes of shivering", "chills", "alternate days", "last", "approximately", "hours", "followed by high-grade fevers", "then", "profuse sweating", "body temperature returns", "normal", "currently", "week", "pregnancy", "reveals", "presence", "mild splenomegaly", "peripheral blood smear confirms", "diagnosis", "infection", "following", "most appropriate anti-malarial treatment", "woman"]}
{"question": "An 8-year-old boy presents to your office for a routine well-child visit. Upon physical examination, he is found to have a harsh-sounding, holosystolic murmur that is best appreciated at the left sternal border. The murmur becomes louder when you ask him to make fists with his hands. Which of the following is the most likely explanation for these findings?", "answer": "Ventricular septal defect", "options": {"A": "Aortic stenosis", "B": "Tricuspid atresia", "C": "Pulmonary hypertension", "D": "Ventricular septal defect", "E": "Left ventricular hypertrophy"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "office", "routine", "found to", "harsh sounding", "holosystolic murmur", "best", "left sternal border", "murmur", "louder", "to make", "hands", "following", "findings"]}
{"question": "A 50-year-old woman, gravida 5, para 5, comes to the physician for the evaluation of decreased sexual desire for approximately 6 months. She has been sexually active with her husband but reports that she has no desire in having sexual intercourse anymore. She states that she feels guilty and is worried about losing her husband if this problem goes on for a longer period of time. She also reports that they have had several fights recently due to financial problems. She has problems going to sleep and wakes up often, and is tired throughout the day. One year ago, the patient underwent hysterectomy with bilateral salpingo-oophorectomy due to uterine prolapse. Her last menstrual period was 2 years ago. She does not smoke. She drinks 3–4 glasses of wine daily. Vital signs are within normal limits. Physical examination shows no abnormalities except for an enlarged liver. Which of the following most likely explains this patient's loss of libido?", "answer": "Decreased testosterone", "options": {"A": "Chronic alcohol intake", "B": "Major depressive disorder", "C": "Decreased testosterone", "D": "Elevated prolactin", "E": "Stress"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["50 year old woman", "gravida 5", "physician", "decreased sexual desire", "approximately", "months", "sexually active", "reports", "sexual intercourse", "states", "worried", "problem", "longer period", "time", "reports", "several", "recently due to financial problems", "to sleep", "wakes up often", "tired", "day", "One year ago", "patient", "hysterectomy", "bilateral salpingo-oophorectomy", "uterine prolapse", "last menstrual period", "2 years", "not smoke", "glasses", "daily", "Vital signs", "normal", "Physical examination", "abnormalities", "enlarged", "following most likely", "patient's loss of libido"]}
{"question": "A 37-year-old previously healthy woman presents to the emergency room with right leg pain and difficulty breathing. She recently returned from a trip to Alaska and noticed her leg started to swell when she got home. Her medications include a multivitamin and oral contraceptives. She is diagnosed with a deep venous thrombosis complicated by a pulmonary embolism and started on anticoagulation. She remains stable and is discharged on the third hospital day with long-term anticoagulation. During the 2 month follow-up visit, the patient’s lab results are as follows:\n\nHemoglobin: 14 g/dL\nHematocrit: 44%\nLeukocyte count: 5,000/mm^3 with normal differential\nPlatelet count: 300,000/mm^3\nProthrombin time: 23 seconds\nPartial thromboplastin time (activated): 20 seconds\nBleeding time: 4 minutes\n\nWhich of the following factors is initially activated in the target pathway for her long-term treatment?", "answer": "VII", "options": {"A": "II", "B": "V", "C": "VII", "D": "IX", "E": "X"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "healthy woman presents", "emergency room", "right leg pain", "difficulty breathing", "recently returned", "trip", "Alaska", "leg started to swell", "got home", "medications include", "multivitamin", "oral contraceptives", "diagnosed", "deep venous thrombosis complicated", "pulmonary embolism", "started", "anticoagulation", "stable", "third hospital day", "long-term anticoagulation", "2 month", "lab", "follows", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "5", "mm", "normal differential Platelet count", "300", "mm", "Prothrombin time", "23 seconds Partial thromboplastin time", "20 seconds Bleeding time", "4 minutes", "following factors", "initially", "target"]}
{"question": "A 25-year-old man presents to the emergency department after fainting at his investment banking office. He states that he has experienced intermittent headaches since high school, but has never fainted. He reports eating multiple small meals regularly throughout the day. He further notes that multiple family members have frequently complained about headaches. Physical exam reveals a well-nourished, well-built, afebrile man with BP 170/80, HR 55, RR 10. Chemistries reveal Na 147, K 3, Cl 110, HCO3 30, BUN 25, Cr 1.1, glucose 120. A biopsy of the tissue most likely at issue in this patient will reveal the most abnormal cellular amounts of which of the following?", "answer": "smooth endoplasmic reticulum", "options": {"A": "rough endoplasmic reticulum", "B": "lysosome", "C": "peroxisome", "D": "smooth endoplasmic reticulum", "E": "beta-adrenergic receptor"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "fainting", "investment banking office", "states", "intermittent headaches", "high school", "never fainted", "reports eating multiple small meals", "day", "further notes", "frequently", "headaches", "reveals", "well-nourished", "afebrile man", "BP", "80", "RR 10", "Chemistries reveal Na", "K", "HCO3 30", "Cr", "glucose", "biopsy", "tissue", "likely", "issue", "patient", "reveal", "most abnormal cellular amounts"]}
{"question": "A 43-year-old man presents to the emergency department with nausea and vomiting. He says symptoms onset 4 hours ago and is progressively worsening. He denies any hematemesis. Past medical history is significant for a recent negative screening colonoscopy that was performed due to a family history of colon cancer. His vital signs are significant for a temperature of 39.5°C (103.1°F). Physical examination is unremarkable. A contrast CT of the abdomen reveals a colonic perforation. Laboratory findings are significant for an elevated WBC count with a predominant left shift, a decreased platelet count, increased PT and PTT, slightly decreased hemoglobin/hematocrit, and prolonged bleeding time. Which of the following is most closely related to this patient’s prolonged bleeding time?", "answer": "Fibrinogen", "options": {"A": "GpIIb/IIIa", "B": "Vitamin K", "C": "Fibrinogen", "D": "COX-1 and COX-2", "E": "Giant platelets"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "nausea", "vomiting", "symptoms onset", "hours", "worsening", "hematemesis", "Past medical history", "significant", "recent negative screening colonoscopy", "performed due to", "family history of colon cancer", "vital signs", "significant", "temperature", "unremarkable", "contrast CT of", "abdomen reveals", "colonic perforation", "Laboratory findings", "significant", "elevated WBC count", "predominant left shift", "decreased platelet count", "increased PT", "PTT", "slightly decreased", "prolonged bleeding time", "following", "most", "related", "patients prolonged bleeding time"]}
{"question": "A group of investigators is evaluating the diagnostic properties of a new blood test that uses two serum biomarkers, dityrosine and Nε-carboxymethyl-lysine, for the clinical diagnosis of autism spectrum disorder (ASD) in children. The test is considered positive only if both markers are found in the serum. 50 children who have been diagnosed with ASD based on established clinical criteria and 50 children without the disorder undergo testing. The results show:\nDiagnosis of ASD No diagnosis of ASD\nTest positive 45 15\nTest negative 5 35\nWhich of the following is the specificity of this new test?\"", "answer": "70%", "options": {"A": "30%", "B": "10%", "C": "88%", "D": "70%", "E": "90%"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigators", "diagnostic properties", "new blood test", "uses two serum biomarkers", "dityrosine", "N carboxymethyl-lysine", "clinical diagnosis", "autism spectrum disorder", "children", "test", "positive only", "markers", "found", "serum", "50 children", "diagnosed", "ASD based", "established clinical", "50 children", "disorder", "testing", "results", "Diagnosis", "ASD", "diagnosis", "ASD Test positive", "Test negative", "following", "specificity", "new test"]}
{"question": "A 51-year-old man is brought to the local emergency room in severe respiratory distress. The patient is an industrial chemist and was working in his lab with a new partner when a massive chemical spill occurred releasing fumes into their workspace. The patient and his lab partner attempted to clean up the spill before they realized it was too large for them to handle. They were not wearing protective equipment at the time, except for a pair of goggles. The fumes caused them both to begin coughing; however, this patient has a history significant for asthma. His condition worsened, which prompted lab management to call for an ambulance. On arrival at the emergency room, the patient’s respiratory rate is 42/min and oxygen saturation is 96% on room air. He is unable to speak on account of his coughing. He is clearly using accessory muscles with inspiration. A pulmonary exam reveals bilateral wheezes. He is given multiple nebulizer treatments of albuterol and is started on intravenous (IV) methylprednisolone. After 2 successive nebulizer treatments, the arterial blood gas test result shows pH 7.36, partial pressure of carbon dioxide (PCO2) 41 mm Hg, and partial pressure of oxygen (PO2) 79 mm Hg. He is now able to speak and the respiratory rate is 32/min. Which of the following is the best next step in this patient’s management?", "answer": "Continue to administer albuterol", "options": {"A": "Administer IV epinephrine", "B": "Administer IV prednisone in addition to IV methylprednisolone", "C": "Continue to administer albuterol", "D": "Switch from nebulized albuterol to nebulized ipratropium", "E": "Intubate the patient and begin mechanical ventilation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "local emergency room", "severe respiratory distress", "patient", "chemist", "lab", "new", "massive", "releasing", "patient", "lab", "to clean up", "large", "to", "not", "protective equipment", "time", "except for", "pair", "goggles", "caused", "to begin coughing", "patient", "history significant", "asthma", "condition worsened", "prompted lab", "to call", "ambulance", "arrival", "emergency room", "patients respiratory rate", "min", "oxygen saturation", "96", "room air", "unable", "speak", "account", "coughing", "using accessory muscles", "inspiration", "pulmonary exam reveals bilateral wheezes", "given multiple nebulizer treatments", "albuterol", "started", "intravenous", "methylprednisolone", "2", "nebulizer treatments", "arterial blood gas test result", "pH 7 36", "partial pressure", "carbon dioxide", "PCO2", "mm Hg", "partial pressure of oxygen", "PO2", "mm Hg", "now able", "speak", "respiratory rate", "min", "following", "best next step", "patients"]}
{"question": "Blood cultures are sent to the laboratory. Antibiotic treatment is started. Blood cultures confirm an infection with methicillin-susceptible Staphylococcus epidermidis. Which of the following is the most appropriate next step in management?", "answer": "Intravenous nafcillin + rifampin for 6 weeks + gentamicin for 2 weeks", "options": {"A": "Oral penicillin V + gentamicin for 4 weeks", "B": "Intravenous ampicillin + rifampin + ceftriaxone for 2 weeks", "C": "Oral gentamicin + ceftriaxone for 4 weeks", "D": "Oral amoxicillin for 6 weeks", "E": "Intravenous nafcillin + rifampin for 6 weeks + gentamicin for 2 weeks"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Blood cultures", "sent", "laboratory", "Antibiotic treatment", "started", "Blood cultures confirm", "infection", "methicillin susceptible", "following", "most appropriate next step"]}
{"question": "A 6-week-old child is brought to his pediatrician for a physical exam and hepatitis B booster. The boy was born at 39 weeks gestation via spontaneous vaginal delivery to a 19-year-old G-1-P-1. He was previously up to date on all vaccines and is mildly delayed in some developmental milestones. His mother is especially concerned with colic, as the boy cries endlessly at night. During the conversation, the infant's mother breaks down and starts crying and complaining about how tired she is and how she has no support from her family. She admits to repeatedly striking the infant in an effort to stop his crying. On physical exam, the infant’s vitals are normal. The child appears cranky and begins to cry during the exam. The infant's backside is swollen, red, and tender to touch. Which of the following is the best response to this situation?", "answer": "Contact child protective services", "options": {"A": "Confront the mother directly", "B": "Contact child protective services", "C": "Recommend treating the colic with a few drops of whiskey", "D": "Encourage the mother to take a class on parenting", "E": "Contact the hospital ethics committee"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["week", "brought", "pediatrician", "hepatitis B booster", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "year old G-1", "date", "vaccines", "mildly delayed", "developmental milestones", "colic", "boy", "night", "infant's", "breaks down", "starts", "tired", "support", "family", "to repeatedly", "infant", "effort to stop", "infants", "normal", "child appears", "begins", "exam", "infant's", "swollen", "red", "tender", "touch", "following", "best response"]}
{"question": "A 16-year-old girl presents to the emergency room with her 8-month-old daughter for evaluation of “turning blue when she cries.” The baby is found to have an atrial septal defect that is causing a left to right shunt, resulting in cyanosis and pulmonary hypertension. Surgical intervention is indicated; however, the mother wants to go to another hospital for a second opinion. Which of the following is the most appropriate next course of action?", "answer": "Allow the mother to take the patient for a second opinion.", "options": {"A": "Consult the mother's parents because she is a minor.", "B": "Contact child protective services.", "C": "Perform the surgery.", "D": "Allow the mother to take the patient for a second opinion.", "E": "Obtain a court order to perform the surgery."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "emergency room", "month old", "turning blue", "baby", "found to", "atrial septal defect", "causing", "left to right shunt", "resulting in cyanosis", "pulmonary hypertension", "Surgical intervention", "indicated", "to go", "hospital", "following", "most appropriate next course", "action"]}
{"question": "A 27-year-old man presents to the outpatient clinic with a swollen and painful toe. The pain intensity increased further after he went to a party last night. Which of the following is the drug of choice for the treatment of this patient's condition?", "answer": "Indomethacin", "options": {"A": "Aspirin", "B": "Probenecid", "C": "Rasburicase", "D": "Indomethacin", "E": "Allopurinol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "outpatient clinic", "swollen", "painful toe", "pain intensity increased further", "night", "following", "drug", "treatment", "patient's condition"]}
{"question": "A 30-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by iron deficiency anemia, which was treated with iron supplements. Her first pregnancy and vaginal delivery were uncomplicated. There is no personal or family history of serious illness. Her pulse is 90/min, respirations are 15/min, and blood pressure is 130/80 mm Hg. The abdomen is nontender and contractions are felt. Ultrasonography shows that the fetal long axis is at a right angle compared to the long axis of the maternal uterus. The fetal heart rate is 140/min and is reactive with no decelerations. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Cesarean section", "options": {"A": "Administration of oxytocin and normal vaginal birth", "B": "Vacuum-assisted delivery", "C": "Lateral positioning of the mother", "D": "Cesarean section", "E": "External cephalic version"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old woman", "gravida 2", "para 1", "40 weeks", "gestation", "active labor", "Pregnancy", "complicated", "iron deficiency anemia", "treated with iron supplements", "first pregnancy", "vaginal delivery", "uncomplicated", "personal", "family history", "serious illness", "pulse", "90 min", "respirations", "min", "blood pressure", "80 mm Hg", "abdomen", "nontender", "contractions", "Ultrasonography", "fetal long axis", "right angle", "long axis", "uterus", "fetal heart rate", "min", "reactive", "following", "most appropriate next step", "patient"]}
{"question": "A scientist is studying the process by which innate immune cells are able to respond to damage and pathogen infiltration. Specifically, she examines patients with an immunodeficiency where they are unable to respond to local infections. She notices that these patients do not produce pustulant fluid and do not have recruitment of immune cells in the first several hours of inflammation. Examining neutrophils within these patients reveals that they are able to slow their movement in a flow chamber by loosely attaching to purified vessel tissues. Subsequently, she shows that the neutrophils attach tightly to these vessel walls and move across the walls to the other side. Finally, when different levels of pathogenic proteins are placed on two sides of a purified vessel wall, the neutrophils from this patient do not exhibit a preference between the two sides. The step of neutrophil recruitment that is most likely defective in this patient involves which of the following mediators?", "answer": "C5a", "options": {"A": "C5a", "B": "Integrins", "C": "ICAM proteins", "D": "Nitric oxide", "E": "Selectins"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["scientist", "studying", "process", "immune cells", "able to", "to damage", "infiltration", "patients", "immunodeficiency", "unable to", "local infections", "patients", "not", "fluid", "not", "first", "hours", "inflammation", "Examining", "patients reveals", "able", "slow", "movement", "chamber", "purified vessel tissues", "vessel walls", "move", "walls", "side", "different levels", "pathogenic proteins", "two sides", "purified vessel wall", "patient", "not", "two sides", "step", "neutrophil recruitment", "defective", "patient", "following mediators"]}
{"question": "A 1-month-old boy is brought to the physician because of a 5-day history of generalized fatigue and multiple episodes of vomiting which is most pronounced after formula feeding. His vomiting progressed from 2–3 episodes on the first day to 6–8 episodes at present. The vomitus is whitish in color. The mother reports that he has been very hungry after each episode of vomiting. The patient was born at 38 weeks' gestation and weighed 3100 g (6 lb 13 oz); he currently weighs 3500 g (7 lb 11 oz). He appears irritable. His temperature is 37.1°C (98.8°F), pulse is 130/min, respirations are 43/min, and blood pressure is 74/36 mm Hg. Examination shows dry mucous membranes. The abdomen is soft and not distended. There is a round mass palpable in the epigastric region. The liver is palpated 1 cm below the right costal margin. Laboratory studies show:\nHemoglobin 15.3 g/dL\nLeukocyte count 6300/mm3\nPlatelet count 230,000/mm3\nSerum\nNa+ 133 mEq/L\nK+ 3.4 mEq/L\nCl- 92 mEq/L\nGlucose 77 mg/dL\nCreatinine 1.0 mg/dL\nA urinalysis shows a decreased pH. Which of the following is the most appropriate next step in the management of this patient?\"", "answer": "Administer IV 0.9% NaCl and replace electrolytes", "options": {"A": "Administer IV 0.9% NaCl and replace electrolytes", "B": "Perform emergency pyloromyotomy", "C": "Perform upper GI endoscopy", "D": "Obtain CT scan of the abdomen with contrast", "E": "Measure serum cortisol levels"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "physician", "5-day history", "generalized fatigue", "multiple episodes of vomiting", "most", "formula", "vomiting progressed", "23 episodes", "first day", "episodes", "present", "vomitus", "color", "reports", "very hungry", "episode of vomiting", "patient", "born", "weeks", "estation ", "100   ", "z)", "urrently ", "500   ", "z)", "ppears  rritable.", "emperature ", "8.", "ulse ", "in,", "espirations ", "in,", "lood pressure ", "4/ 6  m Hg.", "ry  ucous membranes.", "bdomen ", "oft ", "ot  istended.", "ound  ass  alpable ", "pigastric region.", "iver ", "  m ", "ight  ostal margin.", "aboratory studies ", "emoglobin  5.", "/ eukocyte count ", "m3  latelet count ", "  +", " ", "g/", "  g/", "rinalysis ", "ecreased pH.", "ollowing ", "ost  ppropriate  ext  tep ", "atient?"]}
{"question": "In order to study the association between coffee drinking and the subsequent development of lung cancer, a group of researchers decides to carry out a multicentric case-control study with a large number of participants–800 with a diagnosis of lung cancer, and 800 as age-adjusted controls. According to the results outlined in table 1 (below), 80% of those with lung cancer were regular coffee drinkers, resulting in an odds ratio of 23.\n  Lung cancer present Lung cancer absent\nCoffee drinking 640 120\nNo coffee drinking  160 680\nTable: Contingency table of coffee drinking in relation to the presence of lung cancer\nThe researchers concluded from this that regular consumption of coffee is strongly linked to the development of lung cancer. Which of the following systematic errors did they not take into account?", "answer": "Confounding bias", "options": {"A": "Observer bias", "B": "Selection bias", "C": "Confounding bias", "D": "Attrition bias", "E": "Information bias"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["order to study", "association", "drinking", "the subsequent development of lung cancer", "researchers", "to carry out", "multicentric", "large number", "diagnosis of lung cancer", "800", "age-adjusted controls", "results", "table", "80", "of", "lung cancer", "regular", "drinkers", "resulting in", "odds ratio", "23", "Lung cancer", "drinking 640", "drinking", "Table", "Contingency table", "drinking in", "the presence of lung cancer", "researchers concluded", "regular consumption", "the development of lung cancer", "following systematic errors", "not", "account"]}
{"question": "A 48-hour-old newborn presents in respiratory distress. He is gasping for breath in the neonatal intensive care unit (NICU) and has had a fever for the past 2 days with a temperature ranging between 37.2°C (99.0°F) and 38.6°C (101.5°F). He also has not been feeding well and seems to be lethargic. The patient was delivered normally at 36 weeks of gestation. His mother had a premature rupture of membranes, which occurred with her last pregnancy, as well. No history of infection during pregnancy. On physical examination, a bulging anterior fontanelle is noticed, along with tensing of the extensor muscles. A lumbar puncture is performed, and CSF analysis is pending. Which of the following would be the best course of treatment in this patient?", "answer": "Ampicillin and gentamicin", "options": {"A": "Ampicillin and gentamicin", "B": "Ampicillin and cefotaxime", "C": "Ampicillin and acyclovir", "D": "Ampicillin and ticarcillin", "E": "Ampicillin and sulbactam"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["48-hour old newborn presents", "respiratory distress", "gasping for breath", "neonatal intensive care unit", "fever", "past 2 days", "temperature ranging", "99", "not", "well", "to", "lethargic", "patient", "delivered", "36 weeks of gestation", "premature rupture of membranes", "pregnancy", "well", "history", "infection", "pregnancy", "bulging anterior", "tensing", "extensor muscles", "lumbar puncture", "performed", "CSF analysis", "following", "best course", "treatment", "patient"]}
{"question": "A 8-year-old boy is brought to the clinic by his father for an annual well-check. His dad reports that he has been “difficult to handle” as he would not listen and follow instructions at home. “Telling him to sit still and do something is just so hard,” the father says. His teacher also reports difficulties in the classroom where the child would talk out of turn and interrupt the class intermittently by doing something else. His grades have been suffering as a result. Otherwise, the patient has been healthy and up to date on his immunizations. What is the best course of management for this patient?", "answer": "Methylphenidate", "options": {"A": "Family therapy", "B": "Haloperidol", "C": "Methylphenidate", "D": "Psychodynamic therapy", "E": "Reassurance"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "clinic", "annual well check", "reports", "difficult", "not", "follow instructions", "home", "to sit", "hard", "teacher", "reports difficulties", "classroom", "child", "talk out", "turn", "interrupt", "else", "suffering", "result", "patient", "healthy", "date", "immunizations", "best course", "patient"]}
{"question": "A previously healthy 30-year-old woman comes to the physician because of a 3-month history of progressive shortness of breath and nonproductive cough. She also complains of constipation and fatigue during the same time period. She has not traveled recently or been exposed to any sick contacts. Physical examination shows injected conjunctivae and tender, erythematous nodules on both shins. The lungs are clear to auscultation. An x-ray of the chest is shown. Which of the following additional findings is most likely in this patient?", "answer": "Low serum CD4+ T-cell count", "options": {"A": "Positive interferon-gamma release assay", "B": "Low serum angiotensin-converting enzyme levels", "C": "Elevated serum parathyroid hormone levels", "D": "Low serum CD4+ T-cell count", "E": "Positive anti-dsDNA antibody testing"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 30 year old woman", "physician", "of", "3 month history", "progressive shortness", "breath", "nonproductive cough", "constipation", "fatigue", "same time period", "not", "recently", "exposed", "sick", "injected conjunctivae", "tender", "erythematous nodules", "shins", "lungs", "clear", "auscultation", "x-ray of", "chest", "following additional findings", "patient"]}
{"question": "A 29-year-old female reports having a positive home pregnancy test result 9 weeks ago. She presents today with vaginal bleeding and complains of recent onset abdominal pain. Ultrasound of the patient’s uterus is included as Image A. Subsequent histologic analysis (Image B) reveals regions of both normal as well as enlarged trophoblastic villi. Which of the following is the most likely karyotype associated with this pregnancy?", "answer": "69 XXY", "options": {"A": "46 XX, both of maternal origin", "B": "46 XY, both of paternal origin", "C": "69 XXY", "D": "47 XXY", "E": "45 XO"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old female", "positive home", "weeks", "presents today", "vaginal bleeding", "of recent onset abdominal pain", "Ultrasound", "patients uterus", "included", "Image", "Subsequent histologic analysis", "reveals regions", "normal", "enlarged trophoblastic villi", "following", "karyotype associated with", "pregnancy"]}
{"question": "A mother brings her infant for a regular well-child check-up with the pediatrician. During the routine developmental examination, the physician notes that the child is looking at him with his head lifted upwards when he is about to pick up the child from the table. At what age is it common to begin to observe this finding in a child, assuming that the child is developmentally normal?", "answer": "2 months", "options": {"A": "4 months", "B": "2 months", "C": "6 months", "D": "9 months", "E": "12 months"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["infant", "regular well check-up", "pediatrician", "routine developmental", "physician notes", "child", "looking", "head", "about", "pick", "child", "table", "age", "common to begin to observe", "finding", "child", "child", "normal"]}
{"question": "A 55-year-old man comes to the physician because of a 2-month history of headaches, facial numbness, recurrent epistaxis, and a 5-kg (11-lb) weight loss. He recently immigrated from Hong Kong. Examination shows right-sided cervical lymphadenopathy. Endoscopy shows an exophytic nasopharyngeal mass. Histologic examination of a biopsy specimen of the mass shows sheets of undifferentiated cells with nuclear pleomorphism and abundant mitotic figures. The patient most likely acquired the causal pathogen of his nasopharyngeal mass via which of the following routes of transmission?", "answer": "Transfer of saliva", "options": {"A": "Sexual contact", "B": "Tick bite", "C": "Transfer of saliva", "D": "Fecal-oral", "E": "Mother to baby"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "of", "2 month history", "headaches", "facial numbness", "recurrent epistaxis", "5 kg", "weight loss", "recently", "Hong Kong", "right-sided cervical lymphadenopathy", "Endoscopy", "exophytic nasopharyngeal mass", "Histologic examination", "biopsy", "sheets", "nuclear pleomorphism", "abundant mitotic figures", "patient", "likely acquired", "causal", "nasopharyngeal mass", "following routes", "transmission"]}
{"question": "An 8-year-old boy is brought to the physician by his parents for blurry vision for the past 2 months. He is at the 97th percentile for height and 25th percentile for weight. Physical examination shows joint hypermobility, a high-arched palate, and abnormally long, slender fingers and toes. Slit lamp examination shows superotemporal lens subluxation bilaterally. This patient's findings are most likely caused by a defect in which of the following structural proteins?", "answer": "Fibrillin", "options": {"A": "Laminin", "B": "Type III collagen", "C": "Fibrillin", "D": "Type I collagen", "E": "Keratin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "blurry vision", "past", "months", "percentile", "height", "percentile", "weight", "joint hypermobility", "high-arched palate", "long", "slender fingers", "toes", "Slit lamp examination", "lens subluxation", "patient's findings", "most likely caused", "defect", "following structural proteins"]}
{"question": "A 70-year-old man presents to a medical office with painful micturition for 2 weeks. He denies any other symptoms. The past medical history is unremarkable. He has been a smoker most of his life, smoking approx. 1 pack of cigarettes every day. The physical examination is benign. A urinalysis shows an abundance of red blood cells. A cystoscopy is performed, which reveals a slightly erythematous area measuring 1.5 x 1 cm on the bladder mucosa. A biopsy is obtained and microscopic evaluation shows cells with an increased nuclear: cytoplasmic ratio and marked hyperchromatism involving the full thickness of the epithelium, but above the basement membrane. Which of the following best describes the biopsy findings?", "answer": "Urothelial carcinoma-in-situ", "options": {"A": "Reactive atypia", "B": "Microinvasion", "C": "Urothelial metaplasia", "D": "Urothelial carcinoma-in-situ", "E": "Urothelial hyperplasia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man presents", "medical office", "painful micturition", "2 weeks", "symptoms", "past medical history", "unremarkable", "smoker", "smoking", "1 pack", "cigarettes", "day", "benign", "urinalysis", "abundance", "red blood cells", "cystoscopy", "performed", "reveals", "slightly erythematous area measuring 1.5", "bladder mucosa", "biopsy", "obtained", "microscopic", "cells", "increased nuclear", "cytoplasmic ratio", "marked hyperchromatism involving", "full thickness", "epithelium", "basement membrane", "following best", "biopsy findings"]}
{"question": "A 13-year-old girl is brought to the physician by her father because of a 1-month history of pain in her right knee. She is a competitive volleyball player and has missed several games recently due to pain. Examination shows swelling distal to the right knee joint on the anterior surface of the proximal tibia; there is no overlying warmth or deformity. Extension of the right knee against resistance is painful. Which of the following structures is attached to the affected anterior tibial area?", "answer": "Patellar ligament", "options": {"A": "Anterior cruciate ligament", "B": "Patellar ligament", "C": "Quadriceps tendon", "D": "Iliotibial band", "E": "Pes anserinus tendon"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "month history", "pain", "right knee", "missed", "recently due to pain", "swelling distal", "right knee joint", "anterior surface of", "proximal tibia", "warmth", "deformity", "Extension of", "right knee", "resistance", "painful", "following structures", "affected anterior tibial area"]}
{"question": "A 51-year-old woman presents the following significant and unintentional weight loss. She denies any personal 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. She also mentions that she had been struggling with her weight, so she was initially content with losing the weight, but her daughter convinced her to come to the office to be checked out. Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and she currently denies any illicit drug use, although she has a remote past of injection drug use with heroin. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 111/min and irregular, and respiratory rate 17/min. On physical examination, her pulses are bounding and complexion is pale, but breath sounds remain clear. Oxygen saturation was initially 91% on room air and electrocardiogram (ECG) showed atrial fibrillation. Upon further discussion with the patient, her physician discovers that she is having some cognitive difficulty. Her leukocyte count is elevated to 128,000/mm3, and she has elevated lactate dehydrogenase (LDH), uric acid, and B-12 levels. A BCR-ABL translocation is present, as evidenced by the Philadelphia chromosome. What is the most likely diagnosis for this patient?", "answer": "Chronic myelogenous leukemia", "options": {"A": "Acute lymphocytic leukemia", "B": "Acute myelogenous leukemia", "C": "Chronic lymphocytic leukemia", "D": "Chronic myelogenous leukemia", "E": "Hairy cell leukemia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "following significant", "unintentional weight loss", "personal history", "blood clots", "past", "to", "treated", "pulmonary embolism", "recent past", "weight", "initially", "weight", "to", "office to", "out", "past medical history", "significant", "preeclampsia", "hypertension", "polycystic ovarian syndrome", "hypercholesterolemia", "currently smokes 1 pack", "cigarettes", "day", "glass", "day", "currently", "illicit drug use", "remote past of injection drug use", "heroin", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate", "min", "irregular", "respiratory rate", "min", "pulses", "bounding", "complexion", "pale", "breath sounds", "clear", "Oxygen saturation", "initially", "room air", "electrocardiogram", "atrial fibrillation", "further discussion", "patient", "physician", "cognitive difficulty", "leukocyte count", "elevated", "mm3", "elevated lactate dehydrogenase", "uric acid", "levels", "BCR-ABL translocation", "present", "Philadelphia chromosome", "diagnosis", "patient"]}
{"question": "A 75-year-old man presents to the physician with a complaint of persistent back pain. The patient states that the pain has been constant and occurs throughout the day. He says that he has also been experiencing greater fatigue when carrying out his daily activities. On review of systems, the patient notes that he lost more than 10 pounds in the past month despite maintaining his usual diet and exercising less often due to his fatigue. Physical exam is notable for a systolic murmur at the right sternal border, mild crackles at the bases of both lungs, and tenderness to palpation of his lumbar spine. Laboratory values are below:\n\nSerum:\nNa+: 141 mEq/L\nCl-: 101 mEq/L\nK+: 4.2 mEq/L\nHCO3-: 23 mEq/L\nBUN: 20 mg/dL\nGlucose: 101 mg/dL\nCreatinine: 1.6 mg/dL\nCa2+: 12.8 mg/dL\n\nA peripheral blood smear is ordered for the patient’s work-up. Which of the following would be the most likely finding on peripheral blood smear?", "answer": "Rouleaux formation", "options": {"A": "Atypical lymphocytes", "B": "Echinocytes", "C": "Rouleaux formation", "D": "Schistocytes", "E": "Target cells"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "physician", "complaint of persistent back pain", "patient states", "pain", "constant", "occurs", "day", "greater fatigue", "out", "review of systems", "patient notes", "lost more", "10 pounds", "past month", "usual diet", "exercising less often due to", "fatigue", "notable", "systolic murmur", "right sternal border", "mild crackles", "the bases of", "lungs", "tenderness", "palpation", "lumbar spine", "Laboratory values", "Serum", "Na", "mEq/L", "mEq/L K", "4.2 mEq/L HCO3", "23 mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "1.6 mg/dL Ca2", "12.8 mg/dL", "peripheral blood smear", "ordered", "following", "finding", "peripheral"]}
{"question": "An 8-year-old girl is brought into your clinic with a 5 day history of decreased oral intake, body aches and lymphadenopathy. She has no significant medical history. Upon further questioning you find that the patient frequently plays outside, where she enjoys chasing the neighborhood cats and dogs. She has had no recent sick contacts or travel to foreign countries. The patients vital signs are: temperature 100.4F, HR 80, BP 105/75 and RR 15. Physical exam is significant for a 1-cm erythematous and tender lymph node in the right posterior cervical area (Figure 1). There is a nearly healed scratch in the right occipital region. What is the most likely diagnosis for this patient?", "answer": "Bartonella henselae infection", "options": {"A": "Acute lymphoblastic leukemia (ALL)", "B": "Extrapulmonary tuberculosis", "C": "Toxoplasmosis gandii infection", "D": "Bartonella henselae infection", "E": "Staphlococcal aureus adenitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "clinic", "5 day history", "decreased oral intake", "body aches", "lymphadenopathy", "significant medical history", "further", "find", "patient frequently plays outside", "neighborhood cats", "recent sick", "foreign countries", "patients vital signs", "temperature 100", "80", "BP", "75", "RR", "significant", "erythematous", "tender", "right posterior cervical", "nearly healed scratch", "right occipital region", "diagnosis", "patient"]}
{"question": "A 28-year-old G2P1 female with a history of hypertension presents to the emergency room at 33 weeks with headache and blurry vision. On exam, her vitals include BP 186/102 mmHg, HR 102 beats per minute, RR 15 breaths per minute, and T 98.9 degrees Fahrenheit. She undergoes an immediate Caesarian section, and although she is noted to have large-volume blood loss during the procedure, the remainder of her hospital course is without complications. Four weeks later, the patient returns to her physician and notes that she has had blurry vision and has not been able to lactate. A prolactin level is found to be 10 ng/mL (normal: 100 ng/mL). Which of the following is the most appropriate next step?", "answer": "Brain MRI", "options": {"A": "Galactogram", "B": "Observation of maternal-child interactions", "C": "Brain MRI", "D": "Head CT", "E": "Breast ultrasound"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "female", "history of hypertension presents", "emergency room", "weeks", "headache", "blurry vision", "exam", "include BP", "mmHg", "beats per minute", "RR", "breaths per minute", "T 98", "degrees Fahrenheit", "immediate Caesarian section", "noted to", "large volume blood loss", "procedure", "hospital course", "complications", "Four weeks later", "returns", "notes", "blurry vision", "not", "able", "lactate", "prolactin level", "found to", "10 ng/mL", "normal", "100 ng/mL", "following", "most appropriate next step"]}
{"question": "A female child presents to her pediatrician for a well child visit. Her mother reports that she is eating well at home and sleeping well throughout the night. She can jump and walk up and down stairs with both feet on each step. In the doctor’s office, the patient builds a six-cube tower and imitates a circle. She seems to have a vocabulary of over 50 words that she uses in two-word sentences. Her mother reports that the patient enjoys playing near other children and sometimes argues over toys with her older brother. On physical exam, she appears well developed and well nourished, and she is following along her growth curves. The child is assessed as developmentally normal.\n\nWhich of the following is an additional milestone associated with this child’s age?", "answer": "Follows two-step commands", "options": {"A": "Balances on one foot", "B": "Cuts with scissors", "C": "Follows two-step commands", "D": "Points to one body part", "E": "Turns pages in book"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["female child presents", "pediatrician", "reports", "eating well", "home", "sleeping well", "night", "jump", "feet", "step", "doctors office", "patient", "six cube tower", "circle", "to", "50", "uses", "two", "reports", "patient", "playing", "children", "sometimes", "toys", "appears well", "well nourished", "following", "growth curves", "child", "normal", "following", "additional", "associated with", "childs age"]}
{"question": "A 51-year-old woman comes to the emergency department because of a 1-day history of severe pain in her left knee. To lose weight, she recently started jogging for 30 minutes a few times per week. She has type 2 diabetes mellitus and hypertension treated with metformin and chlorothiazide. Her sister has rheumatoid arthritis. She is sexually active with two partners and uses condoms inconsistently. On examination, her temperature is 38.5°C (101.3°F), pulse is 88/min, and blood pressure is 138/87 mm Hg. The left knee is swollen and tender to palpation with a significantly impaired range of motion. A 1.5-cm, painless ulcer is seen on the plantar surface of the left foot. Which of the following is most likely to help establish the diagnosis?", "answer": "Perform arthrocentesis", "options": {"A": "Perform MRI of the knee", "B": "Perform arthrocentesis", "C": "Measure HLA-B27", "D": "Measure rheumatoid factor", "E": "Perform ultrasonography of the knee"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "1-day history", "severe pain", "left knee", "To", "weight", "recently started", "30 minutes", "few times", "week", "type 2 diabetes mellitus", "hypertension treated with metformin", "chlorothiazide", "rheumatoid arthritis", "sexually active", "two", "uses condoms", "temperature", "pulse", "88 min", "blood pressure", "87 mm Hg", "left knee", "swollen", "tender", "palpation", "impaired range of motion", "painless ulcer", "seen", "plantar surface of", "left foot", "following", "to help establish", "diagnosis"]}
{"question": "A 25-year-old man comes to the physician with intermittent bloody diarrhea over the past 2 months. He has occasional abdominal pain. His symptoms have not improved over this time. He has no history of a serious illness and takes no medications. His blood pressure is 110/70 mm Hg, pulse is 75/min, respirations are 14/min, and temperature is 37.8°C (100.0°F). Deep palpation of the abdomen shows mild tenderness in the right lower quadrant. Colonoscopy shows diffuse erythema with a sandpaper pattern involving the rectosigmoid and descending colon, with normal mucosa of the rest of the colon. Biopsy shows involvement of the mucosal and submucosal layers with distortion of crypt architecture and crypt abscess formation. This patient is most likely to develop which of the following hepatobiliary diseases?", "answer": "Primary sclerosing cholangitis", "options": {"A": "Cholangiocarcinoma", "B": "Cholelithiasis", "C": "Hepatocellular carcinoma", "D": "Primary biliary cirrhosis", "E": "Primary sclerosing cholangitis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "intermittent bloody", "past", "months", "occasional abdominal pain", "symptoms", "not improved", "time", "history", "serious illness", "medications", "blood pressure", "70 mm Hg", "pulse", "75 min", "respirations", "min", "temperature", "100", "Deep palpation of", "abdomen", "mild tenderness", "right lower quadrant", "Colonoscopy", "diffuse erythema", "pattern involving", "rectosigmoid", "descending colon", "normal mucosa", "colon", "Biopsy", "involvement", "mucosal", "submucosal layers", "distortion", "crypt architecture", "crypt", "patient", "to", "following hepatobiliary diseases"]}
{"question": "A 48-year-old woman presents to her primary care physician with the complaints of persistent fatigue, dizziness, and weight loss for the past 3 months. She has hypothyroidism for 15 years and takes thyroxine replacement. Her blood pressure is 90/60 mm Hg in a supine position and 65/40 mm Hg while sitting, temperature is 36.8°C (98.2°F) and pulse is 75/min. On physical examination, there is a mild increase in thyroid size, with a rubbery consistency. Her skin shows diffuse hyperpigmentation, more pronounced in the oral mucosa and palmar creases. The morning serum cortisol test is found to be 3 µg/dL. Which of the following is the best next step in this case?", "answer": "Adrenocorticotropic hormone (ACTH) stimulation test", "options": {"A": "Serum adrenocorticotropic hormone (ACTH)", "B": "Plasma aldosterone", "C": "Adrenocorticotropic hormone (ACTH) stimulation test", "D": "Adrenal imaging", "E": "21-hydroxylase antibodies"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old woman presents", "primary care physician", "complaints", "persistent fatigue", "dizziness", "weight loss", "past 3 months", "hypothyroidism", "years", "thyroxine replacement", "blood pressure", "90 60 mm Hg", "supine position", "65 40 mm Hg", "sitting", "temperature", "36", "98", "pulse", "75 min", "mild increase in thyroid size", "rubbery consistency", "skin", "diffuse hyperpigmentation", "more", "oral mucosa", "palmar creases", "morning serum", "found to", "3 g/dL", "following", "best next step", "case"]}
{"question": "A 17-year-old girl comes to your outpatient clinic. She is sexually active with multiple partners and requests a prescription for oral contraceptive pills. A urine pregnancy test in your office is negative. Which of the following is the most appropriate next step?", "answer": "Recommend sexually-transmitted infection screening and provide the requested prescription", "options": {"A": "Contact the patient's parents to obtain consent", "B": "Recommend sexually-transmitted infection screening and provide the requested prescription", "C": "Refer the patient for counseling and recommend sexually-transmitted infection screening", "D": "Perform urine drug screen", "E": "Advise against oral contraceptive medications and recommend condom use instead"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "outpatient clinic", "sexually active", "prescription for oral contraceptive pills", "urine pregnancy test", "office", "negative", "following", "most appropriate next step"]}
{"question": "A newborn infant presents with severe weakness. He was born to a G1P1 mother at 40 weeks gestation with the pregnancy attended by a midwife. The mother's past medical history is unremarkable. She took a prenatal vitamin and folic acid throughout the pregnancy. Since birth, the child has had trouble breastfeeding despite proper counseling. He also has had poor muscle tone and a weak cry. His temperature is 99.5°F (37.5°C), blood pressure is 57/38 mmHg, pulse is 150/min, respirations are 37/min, and oxygen saturation is 96% on room air. Physical exam reveals poor muscle tone. The patient's sucking reflex is weak, and an enlarged tongue is noted. An ultrasound is performed, and is notable for hypertrophy of the myocardium. Which of the following is the most likely diagnosis?", "answer": "Acid maltase deficiency", "options": {"A": "Acid maltase deficiency", "B": "Clostridium botulinum infection", "C": "Clostridium tetani infection", "D": "Familial hypertrophic cardiomyopathy", "E": "Spinal muscular atrophy type I disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["newborn infant presents", "severe weakness", "born", "G1P1", "40 weeks", "pregnancy attended", "midwife", "past medical history", "unremarkable", "prenatal vitamin", "folic acid", "pregnancy", "birth", "child", "breastfeeding", "counseling", "poor muscle tone", "weak cry", "temperature", "99", "blood pressure", "57", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "96", "room air", "reveals poor muscle tone", "patient's sucking reflex", "weak", "enlarged tongue", "noted", "ultrasound", "performed", "notable", "hypertrophy", "myocardium", "following", "diagnosis"]}
{"question": "A 2-week-old infant is brought to the emergency room because of 4 episodes of bilious vomiting and inconsolable crying for the past 3 hours. Abdominal examination shows no abnormalities. An upper GI contrast series shows the duodenojejunal junction to the right of the vertebral midline; an air-filled cecum is noted in the right upper quadrant. Which of the following is the most likely cause of this patient's condition?", "answer": "Incomplete intestinal rotation", "options": {"A": "Failure of duodenal recanalization", "B": "Incomplete intestinal rotation", "C": "Arrested rotation of ventral pancreatic bud", "D": "Hypertrophy and hyperplasia of the pyloric sphincter", "E": "Resorption of a small bowel segment"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 week old infant", "brought", "emergency room", "of 4 episodes", "bilious vomiting", "past", "hours", "Abdominal", "abnormalities", "upper GI contrast series", "duodenojejunal junction", "right", "vertebral midline", "air", "cecum", "noted", "right upper quadrant", "following", "most likely cause", "patient's condition"]}
{"question": "A 43-year-old male is admitted to the hospital for a left leg cellulitis. He is being treated with clindamycin and is recovering nicely. On the second day of his admission, a nurse incorrectly administers 100 mg of metoprolol which was intended for another patient with the same last name. The error is not discovered until the next day, at which time it is clear that the patient has suffered no ill effects of the medication and is not aware that an error has occurred. What is the proper course of action of the attending physician?", "answer": "Immediately disclose the error to the patient", "options": {"A": "Immediately disclose the error to the patient", "B": "Notify hospital administration but do not notify the patient as no ill effects occurred", "C": "Do not disclose the error to the patient as no ill effects occurred", "D": "Tell the nurse who administered the drug to notify the patient an error has occurred", "E": "Make a note in the patient's chart an error has occurred but do not disclose the error to the patient"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male", "left", "treated with clindamycin", "recovering", "second day", "nurse", "administers 100 mg", "metoprolol", "intended", "patient", "same", "name", "error", "not", "next day", "time", "clear", "patient", "suffered", "ill effects", "medication", "not", "error", "course", "action", "attending"]}
{"question": "A 42-year-old woman presents to her primary care physician with 2 weeks of abdominal pain. She says that the pain is squeezing in character and gets worse after she eats food. The pain is particularly bad after she eats dairy products so she has begun to avoid ice cream and cheese. Furthermore, she has noticed that she has been experiencing episodes of nausea associated with abdominal pain in the last 4 days. Physical exam reveals tenderness to palpation and rebound tenderness in the right upper quadrant of the abdomen. The molecule that is most likely responsible for the increased pain this patient experiences after eating fatty foods is most likely secreted by which of the following cells?", "answer": "I cells", "options": {"A": "D cells", "B": "G cells", "C": "I cells", "D": "P/D1 cells", "E": "S cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "2 weeks", "abdominal pain", "pain", "squeezing", "character", "gets worse", "eats food", "pain", "bad", "eats", "begun to", "episodes of nausea associated with abdominal pain", "last", "days", "reveals tenderness", "palpation", "tenderness", "right upper quadrant", "abdomen", "responsible", "increased pain", "patient", "eating", "most likely secreted", "following cells"]}
{"question": "A 65-year-old woman comes to clinic complaining of pain with chewing solid foods. She reports that she has been feeling unwell lately, with pains in her shoulders and hips, and she has lost five pounds in the past few months. Her vital signs are T 39C, RR 18 breaths/min, HR 95 bpm, BP 120/65 mmHg. When you ask her to stand from her chair to get on the exam table she moves stiffly but displays preserved proximal muscle strength. Another potential symptom or sign of this disease could be:", "answer": "Blindness", "options": {"A": "Violaceous rash across the eyelids", "B": "Blindness", "C": "Easily sunburned on face and hands", "D": "Hemoptysis", "E": "Thickened, tight skin on the fingers"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old woman", "clinic", "pain", "chewing solid foods", "reports", "unwell", "pains in", "shoulders", "hips", "lost five pounds", "past", "months", "vital signs", "T", "RR", "breaths/min", "95", "BP", "65 mmHg", "to stand", "chair to get", "exam table", "moves", "displays preserved proximal", "potential symptom", "sign", "disease"]}
{"question": "An 1800-g (4.0-lb) male newborn is delivered to a 26-year-old woman, gravida 2, para 1, at 33 weeks' gestation. The Apgar scores are 7 at 1 minute and 8 at 5 minutes. The pregnancy was complicated by iron deficiency anemia. The mother has no other history of serious illness. She has smoked one-half pack of cigarettes daily for the past 10 years. She does not drink alcohol. She has never used illicit drugs. Pregnancy and delivery of her first child were complicated by placenta previa. The mother has received all appropriate immunizations. It is most appropriate for the physician to recommend which of the following to the mother regarding her son's immunizations?", "answer": "Give first dose of diphtheria and tetanus toxoids, acellular pertussis (DTaP) vaccine at 2 months of chronological age", "options": {"A": "Give first dose of hepatitis B vaccine at 3 months of chronological age", "B": "Give first dose of influenza vaccine at 2 months of chronological age", "C": "Give first dose of varicella vaccine at 2 months of chronological age", "D": "Give first dose of Haemophilus influenza type b vaccine at 3 months of chronological age", "E": "Give first dose of diphtheria and tetanus toxoids, acellular pertussis (DTaP) vaccine at 2 months of chronological age"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["g", "0", "male newborn", "delivered", "year old woman", "gravida 2", "para 1", "weeks", "gestation", "Apgar scores", "minute", "5 minutes", "pregnancy", "complicated", "iron deficiency anemia", "history", "serious illness", "smoked one half pack", "cigarettes daily", "past", "not", "alcohol", "never used illicit drugs", "Pregnancy", "delivery", "first child", "complicated", "placenta previa", "received", "appropriate immunizations", "most appropriate", "physician to", "following", "immunizations"]}
{"question": "One day after undergoing a right hemicolectomy for colon cancer, a 55-year-old woman has back pain and numbness and difficulty moving her legs. Her initial postoperative course was uncomplicated. Current medications include prophylactic subcutaneous heparin. Her temperature is 37.2°C (98.9°F), pulse is 100/min, respirations are 18/min, and blood pressure is 130/90 mm Hg. Examination shows a well-positioned epidural catheter site without redness or swelling. There is weakness of the lower extremities. Deep tendon reflexes are absent in both lower extremities. Perineal sensation to pinprick is decreased. Her hemoglobin concentration is 11.2 g/dL, leukocyte count is 6,000/m3, and platelet count is 215,000/mm3. Her erythrocyte sedimentation rate is 19 mm/h. A T2-weighted MRI of the spine shows a 15-cm, hyperintense, epidural space-occupying lesion compressing the spinal cord at the level of L2–L5 vertebrae. Which of the following is the most appropriate next step in treatment?", "answer": "Perform surgical decompression", "options": {"A": "Observation", "B": "Perform surgical decompression", "C": "Perform CT-guided aspiration", "D": "Obtain lumbar puncture", "E": "Obtain blood cultures\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["One day", "right hemicolectomy", "colon cancer", "year old woman", "back pain", "numbness", "difficulty moving", "legs", "initial postoperative course", "uncomplicated", "Current medications include prophylactic subcutaneous heparin", "temperature", "98 9F", "pulse", "100 min", "respirations", "min", "blood pressure", "90 mm Hg", "well positioned epidural", "redness", "swelling", "weakness", "lower extremities", "Deep tendon reflexes", "absent", "lower extremities", "Perineal sensation", "pinprick", "decreased", "hemoglobin concentration", "g/dL", "leukocyte count", "m3", "platelet count", "mm3", "erythrocyte sedimentation rate", "mm/h", "weighted MRI of", "spine", "epidural space-occupying lesion compressing", "spinal cord", "level", "vertebrae", "following", "most appropriate next step", "treatment"]}
{"question": "A 10-month-old boy is brought to the physician by his mother because of a 2-day history of rhinorrhea, nasal congestion, and cough. He has been feeding normally and has not had vomiting or diarrhea. The infant was born at term via uncomplicated spontaneous vaginal delivery. Immunizations are up-to-date. Eight months ago, he was treated for a urinary tract infection. Four months ago, he had an uncomplicated upper respiratory infection. He is alert and well-appearing. His temperature is 38.4°C (101.1°F), pulse is 110/min, respirations are 32/min, and blood pressure is 90/56 mm Hg. Examination shows erythematous nasal mucosa. Scattered expiratory wheezing is heard throughout both lung fields. The remainder of the examination shows no abnormalities. An x-ray of the chest is shown. After administration of an antipyretic, which of the following is the most appropriate next step in management?", "answer": "Provide reassurance", "options": {"A": "Provide reassurance", "B": "Begin oral antibiotic therapy", "C": "Perform PPD skin testing", "D": "Obtain a thoracic CT scan", "E": "Measure T cell count"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["A 10 month old boy", "brought", "physician", "mother", "2-day history", "rhinorrhea", "nasal congestion", "cough", "not", "vomiting", "diarrhea", "infant", "born", "term", "uncomplicated spontaneous vaginal delivery", "Immunizations", "date", "Eight months", "treated", "urinary tract infection", "Four months", "uncomplicated upper respiratory infection", "alert", "well appearing", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "90", "mm Hg", "erythematous nasal mucosa", "Scattered expiratory wheezing", "heard", "lung fields", "abnormalities", "x-ray of", "chest", "following", "most appropriate next step"]}
{"question": "A 73-year-old man presents to his primary care physician with chest pain. He noticed the pain after walking several blocks, and the pain is relieved by sitting. On exam, he has a BP 155/89 mmHg, HR 79 bpm, and T 98.9 F. The physician refers the patient to a cardiologist and offers prescriptions for carvedilol and nitroglycerin. Which of the following describes the mechanism or effects of each of these medications, respectively?", "answer": "Decreased cAMP; Increased cGMP", "options": {"A": "Increased cAMP; Increased cAMP", "B": "Increased contractility; Decreased endothelial nitrous oxide", "C": "Decreased cAMP; Increased cGMP", "D": "Decreased cGMP; Increased venous resistance", "E": "Increased heart rate; Decreased arterial resistance"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care physician", "chest pain", "pain", "walking", "blocks", "pain", "relieved by sitting", "exam", "BP", "mmHg", "T 98", "F", "physician refers", "patient", "cardiologist", "prescriptions", "carvedilol", "nitroglycerin", "following", "mechanism", "effects", "medications"]}
{"question": "An 84-year-old man comes to the emergency department because of lower back pain and lower extremity weakness for 3 weeks. Over the past week, he has also found it increasingly difficult to urinate. He has a history of prostate cancer, for which he underwent radical prostatectomy 8 years ago. His prostate-specific antigen (PSA) level was undetectable until a routine follow-up visit last year, when it began to increase from 0.8 ng/mL to its present value of 64.3 ng/mL (N < 4). An MRI of the spine shows infiltrative vertebral lesions with a collapse of the L5 vertebral body, resulting in cord compression at L4–L5. The patient receives one dose of intravenous dexamethasone and subsequently undergoes external beam radiation. Which of the following cellular changes is most likely to occur as a result of this treatment?", "answer": "Generation of hydroxyl radicals", "options": {"A": "Formation of pyrimidine dimers", "B": "Disruption of microtubule assembly", "C": "Intercalation of neighbouring DNA base pairs", "D": "Generation of hydroxyl radicals", "E": "Formation of DNA crosslinks"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["84 year old man", "emergency department", "lower back pain", "lower extremity weakness", "weeks", "past week", "found", "difficult to", "history cancer", "radical prostatectomy", "years", "prostate-specific antigen", "level", "undetectable", "routine", "year", "began to increase", "0.8 ng/mL", "present value", "64", "ng/mL", "N", "4", "MRI of", "spine", "infiltrative vertebral lesions", "collapse", "L5", "body", "resulting in cord compression", "patient receives one dose", "intravenous dexamethasone", "external beam radiation", "following cellular changes", "to occur", "result", "treatment"]}
{"question": "A 33-year-old man presents to the emergency department with severe anxiety. He has had multiple episodes in the past treated with low dose lorazepam. The patient states that he feels as if he is going to die and that he cannot breathe. His past medical history is notable for depression and anxiety. His temperature is 98.1°F (36.7°C), blood pressure is 122/83 mmHg, pulse is 153/min, respirations are 13/min, and oxygen saturation is 98% on room air. The patient is given a low dose of lorazepam and reports a complete resolution of his symptoms. An ECG is performed and demonstrates prolongation of the P-R interval with a widened QRS complex. There is a P wave preceding every QRS complex, no dropped QRS complexes, and the P-R interval does not change. His initial lab values are unremarkable. Which of the following is the best management of this patient?", "answer": "Electrophysiological studies", "options": {"A": "Cardiac catheterization", "B": "Electrophysiological studies", "C": "No further management needed", "D": "Sodium bicarbonate", "E": "Transcutaneous pacing"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "severe anxiety", "multiple episodes", "past treated with low", "patient states", "to die", "past medical history", "notable", "depression", "anxiety", "temperature", "98", "36", "blood pressure", "83 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "given", "low", "lorazepam", "reports", "complete resolution", "symptoms", "ECG", "performed", "prolongation", "P-R interval", "widened QRS complex", "a", "wave preceding", "QRS complex", "QRS complexes", "P-R interval", "not change", "lab", "unremarkable", "following", "best", "patient"]}
{"question": "A 74-year-old male presents to his primary care physician complaining of left lower back pain. He reports a four-month history of worsening left flank pain. More recently, he has started to notice that his urine appears brown. His past medical history is notable for gout, hypertension, hyperlipidemia, and myocardial infarction status-post stent placement. He has a 45 pack-year smoking history and drinks 2-3 alcoholic beverages per day. His temperature is 100.9°F (38.3°C), blood pressure is 145/80 mmHg, pulse is 105/min, and respirations are 20/min. Physical examination is notable for left costovertebral angle tenderness. A CT of this patient’s abdomen is shown in figure A. This lesion most likely arose from which of the following cells?", "answer": "Proximal tubule cells", "options": {"A": "Proximal tubule cells", "B": "Distal convoluted tubule cells", "C": "Mesangial cells", "D": "Perirenal adipocytes", "E": "Collecting duct epithelial cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["74 year old male presents", "primary care physician complaining of left lower back pain", "reports", "four month history", "worsening left flank pain", "recently", "started to", "urine appears brown", "past medical history", "notable", "gout", "hypertension", "hyperlipidemia", "myocardial infarction status post stent placement", "smoking history", "2 3", "day", "temperature", "100 9F", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "20 min", "notable", "left costovertebral angle tenderness", "CT of", "patients abdomen", "lesion", "likely", "following cells"]}
{"question": "A 62-year-old man is brought to the emergency department by his wife for high blood pressure readings at home. He is asymptomatic. He has a history of hypertension and hyperlipidemia for which he takes atenolol and atorvastatin, however, his wife reports that he recently ran out of atenolol and has not been able to refill it due to lack of health insurance. His temperature is 36.8°C (98.2°F), the pulse 65/min, the respiratory rate 22/min, and the blood pressure 201/139 mm Hg. He has no papilledema on fundoscopic examination. A CT scan shows no evidence of intracranial hemorrhage or ischemia. Of the following, what is the next best step?", "answer": "Start or restart low-dose medication to reduce blood pressure gradually over the next 24–48 hours", "options": {"A": "Start or restart low-dose medication to reduce blood pressure gradually over the next 24–48 hours", "B": "Start or restart low-dose medication to reduce blood pressure aggressively over the next 24–48 hours", "C": "Start high-dose medication to bring his blood pressure to under 140/90 within 24 hours", "D": "Admit him to the ICU and start intravenous medication to reduce blood pressure by 10% in the first hour", "E": "Admit him to the ICU and start intravenous medication to reduce blood pressure by 25% in the first 4 hours"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man", "brought", "emergency department", "high blood pressure", "at home", "asymptomatic", "history of hypertension", "hyperlipidemia", "atenolol", "atorvastatin", "reports", "recently ran out", "atenolol", "not", "able", "due to lack of", "insurance", "temperature", "36", "98", "pulse 65 min", "respiratory rate", "min", "blood pressure", "mm Hg", "papilledema", "fundoscopic", "CT scan", "intracranial hemorrhage", "ischemia", "following", "next best step"]}
{"question": "A 45-year-old woman is in a high-speed motor vehicle accident and suffers multiple injuries to her extremities and abdomen. In the field, she was bleeding profusely bleeding and, upon arrival to the emergency department, she is lethargic and unable to speak. Her blood pressure on presentation is 70/40 mmHg. The trauma surgery team recommends emergency exploratory laparotomy. While the patient is in the trauma bay, her husband calls and says that the patient is a Jehovah's witness and that her religion does not permit her to receive a blood transfusion. No advanced directives are available. Which of the following is an appropriate next step?", "answer": "Provide transfusions as needed", "options": {"A": "Provide transfusions as needed", "B": "Ask husband to bring identification to the trauma bay", "C": "Withhold transfusion based on husband's request", "D": "Obtain an ethics consult", "E": "Obtain a court order for transfusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "high speed motor vehicle accident", "suffers multiple injuries", "extremities", "abdomen", "field", "bleeding", "bleeding", "arrival", "emergency department", "lethargic", "unable", "speak", "blood pressure", "70 40 mmHg", "trauma surgery team", "emergency exploratory laparotomy", "patient", "trauma bay", "calls", "patient", "religion", "not", "to receive", "blood transfusion", "advanced directives", "available", "following", "appropriate next step"]}
{"question": "A 21-year-old woman presents to her primary care physician for evaluation of malaise, joint pains, and rash. She has developed joint pain in her hands over the last month, and has noted a rash over her face that gets worse with sun exposure. She is taking no medication at the present time. On further physical examination, an erythematous rash with a small amount of underlying edema is seen on her face. Her complete blood count is remarkable due to a lymphocytopenia. What are other disorders known to cause lymphocytopenia?\nI 22q.11.2 deletion syndrome\nII Bruton tyrosine kinase (BTK) defect\nIII Diphyllobothrium latum infection\nIV Whole body radiation\nV Glanzmann-Riniker syndrome", "answer": "I, II, IV, V", "options": {"A": "I, II, III", "B": "I, III, V", "C": "III, IV", "D": "I, II, IV, V", "E": "III, V"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old woman presents", "primary care physician", "malaise", "joint pains", "rash", "joint pain", "hands", "last month", "noted", "rash", "face", "gets worse", "sun exposure", "medication", "present time", "further", "erythematous rash", "small amount", "underlying edema", "seen", "face", "complete blood count", "due to", "lymphocytopenia", "disorders known to cause lymphocytopenia", "I 22q", "deletion syndrome", "Bruton tyrosine kinase", "Diphyllobothrium latum infection IV Whole body radiation"]}
{"question": "A 33-year-old woman comes to the physician for a follow-up examination. She has a history of Crohn disease, for which she takes methotrexate. She and her husband would like to start trying to have a child. Because of the teratogenicity of methotrexate, the physician switches the patient from methotrexate to a purine analog drug that inhibits lymphocyte proliferation by blocking nucleotide synthesis. Toxicity of the newly prescribed purine analog would most likely increase if the patient was also being treated with which of the following medications?", "answer": "Febuxostat", "options": {"A": "Febuxostat", "B": "Pemetrexed", "C": "Rasburicase", "D": "Hydroxyurea", "E": "Cyclosporine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "history of Crohn disease", "methotrexate", "to start", "to", "child", "teratogenicity", "methotrexate", "physician switches", "patient", "methotrexate", "purine", "inhibits lymphocyte proliferation", "blocking", "Toxicity", "most likely increase", "patient", "treated with", "following medications"]}
{"question": "Antituberculosis treatment is started. Two months later, the patient comes to the physician for a follow-up examination. The patient feels well. She reports that she has had tingling and bilateral numbness of her feet for the past 6 days. Her vital signs are within normal limits. Her lips are dry, scaly, and slightly swollen. Neurologic examination shows decreased sensation to pinprick and light touch over her feet, ankles, and the distal portion of her calves. Laboratory studies show:\nLeukocyte count 7400 /mm3\nRBC count 2.9 million/mm3\nHemoglobin 10.8 g/dL\nHematocrit 30.1%\nMean corpuscular volume 78 fL\nMean corpuscular hemoglobin 24.2 pg/cell\nPlatelet count 320,000/mm3\nSerum\nGlucose 98 mg/dL\nAlanine aminotransferase (ALT) 44 U/L\nAspartate aminotransferase (AST) 52 U/L\nAdministration of which of the following is most likely to have prevented this patient's neurological symptoms?\"", "answer": "Pyridoxine", "options": {"A": "Vitamin B12", "B": "Vitamin E", "C": "Pyridoxine", "D": "Iron", "E": "Interferon beta\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Antituberculosis treatment", "started", "Two months later", "patient", "physician", "follow-up examination", "patient", "well", "reports", "tingling", "bilateral numbness of", "feet", "past", "days", "vital signs", "normal limits", "lips", "dry", "scaly", "slightly swollen", "Neurologic examination", "decreased sensation", "light touch", "feet", "ankles", "distal portion", "calves", "Laboratory studies", "Leukocyte count", "mm3", "million", "10.8 g", "30", "fL", "Platelet count 320", "Serum", "98", "Alanine aminotransferase", "ALT", "U/L Aspartate aminotransferase", "AST", "U/L Administration", "following", "to", "prevented", "patient", "eurological "]}
{"question": "Before starting a new job at a law firm, a 33-year-old woman speaks to a representative about the health insurance plan offered by the firm. The representative explains that treatment is provided by primary health care physicians who focus on preventive care. Patients require a referral by the primary care physician for specialist care inside the network; treatment by health care providers outside the network is only covered in the case of an emergency. When the prospective employee asks how prices are negotiated between the health insurance company and the health care providers, the physician explains that the health care providers get a fixed payment for each patient enrolled over a specific period of time, regardless of whether or not services are provided. This arrangement best describes which of the following health care payment models?", "answer": "Capitation", "options": {"A": "Per diem payment", "B": "Bundled payment", "C": "Fee-for-service", "D": "Discounted fee-for-service", "E": "Capitation"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["starting", "new job", "law firm", "year old woman speaks", "offered", "firm", "treatment", "primary health care physicians", "focus", "preventive care", "Patients", "specialist care", "network", "providers outside", "network", "only covered", "case", "emergency", "employee", "prices", "company", "health care providers", "physician", "health care providers", "fixed payment", "patient enrolled", "specific period", "time", "not", "arrangement best", "following", "payment"]}
{"question": "A 73-year-old man with a 50-year history of type 2 diabetes and stage 3 chronic kidney disease presents to his primary care doctor for a scheduled follow-up and routine labs. He states that he has had no real change in his health except that he feels like he has had bouts of lightheadedness and almost passing out, which resolve with sitting down. The patient does not have a history of syncope or arrhythmia. On his labs, he is found to have a hemoglobin of 11.0 g/dL. His estimated glomerular filtration rate is determined to be 45 ml/min/1.73m^2. Testing of his stool is negative for blood. Additionally, a peripheral blood smear demonstrates normochromic cells. As a result, the patient is started on erythropoietin. Which of the following likely describes the anemia?", "answer": "Normocytic anemia with decreased reticulocyte count", "options": {"A": "Macrocytic anemia with megaloblasts", "B": "Macrocytic anemia without megaloblasts", "C": "Microcytic anemia", "D": "Normocytic anemia with decreased reticulocyte count", "E": "Normocytic anemia with increased reticulocyte count"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "50", "history", "type 2 diabetes", "stage 3 chronic kidney disease presents", "primary care doctor", "scheduled follow-up", "routine labs", "states", "real change", "except", "bouts", "lightheadedness", "almost passing out", "sitting", "patient", "not", "history of syncope", "arrhythmia", "labs", "found to", "a hemoglobin", "0 g/dL", "estimated glomerular filtration rate", "to", "ml/min", "Testing", "stool", "negative", "blood", "peripheral blood smear", "normochromic cells", "result", "patient", "started", "erythropoietin", "following likely", "anemia"]}
{"question": "A 72-year-old man presents to the physician with severe lower back pain and fatigue for 3 months. The pain increases with activity. He has no history of a serious illness. He takes ibuprofen for pain relief. He does not smoke. The blood pressure is 105/65 mm Hg, the pulse is 86/min, the respirations are 16/min, and the temperature is 36.7℃ (98.1℉). The conjunctivae are pale. Palpation over the 1st lumbar vertebra shows tenderness. The heart, lung, and abdominal examination shows no abnormalities. No lymphadenopathy is palpated. The results of the laboratory studies show:\nLaboratory test\nHemoglobin 9 g/dL\nMean corpuscular volume 90 μm3\nLeukocyte count 5,500/mm3 with a normal differential\nPlatelet count 350,000/mm3\nSerum\nCalcium 11.5 mg/dL\nAlbumin 3.8 g/dL\nUrea nitrogen 54 mg/dL\nCreatinine 2.5 mg/dL\nLumbosacral computed tomography (CT) scan shows a low-density lesion in the 1st lumbar vertebra and several similar lesions in the pelvic bones. Which of the following is the most likely diagnosis?", "answer": "Multiple myeloma", "options": {"A": "Metastatic prostatic cancer", "B": "Multiple myeloma", "C": "Secondary hyperparathyroidism", "D": "Small-cell lung carcinoma", "E": "Waldenstrom’s macroglobulinemia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["72 year old man presents", "physician", "severe lower back pain", "fatigue", "months", "pain increases", "activity", "history", "serious illness", "ibuprofen", "pain relief", "not smoke", "blood pressure", "65 mm Hg", "pulse", "min", "respirations", "min", "temperature", "36", "98", "conjunctivae", "pale", "Palpation", "1st lumbar vertebra", "tenderness", "heart", "lung", "abdominal", "abnormalities", "lymphadenopathy", "results", "laboratory studies", "Laboratory 9 g/dL Mean corpuscular volume 90 m3 Leukocyte count 5", "mm3", "normal differential Platelet 350", "mm3", "Calcium", "mg", "g", "Urea nitrogen", "Creatinine 2", "Lumbosacral computed tomography", "scan", "low density lesion", "1st lumbar vertebra", "several similar lesions", "pelvic bones", "following", "diagnosis"]}
{"question": "A 28-year-old man visits his physician complaining of hematochezia over the last several days. He also has tenesmus and bowel urgency without any abdominal pain. He has had several milder episodes over the past several years that resolved on their own. He has no history of a serious illness and takes no medications. His blood pressure is 129/85 mm Hg; temperature, 37.4°C (99.3°F); and pulse, 75/min. On physical exam, his abdominal examination shows mild tenderness on deep palpation of the left lower quadrant. Digital rectal examination reveals anal tenderness and fresh blood. Stool examination is negative for pathogenic bacteria and an ova and parasite test is negative. Erythrocyte sedimentation rate is 28 mm/h. Colonoscopy shows diffuse erythema involving the rectum and extending to the distal sigmoid. The mucosa also shows a decreased vascular pattern with fine granularity. The remaining colon and distal ileum are normal. Biopsy of the inflamed mucosa of the sigmoid colon shows distorted crypt architecture. The most appropriate next step is to administer which of the following?", "answer": "Mesalamine", "options": {"A": "Azathioprine", "B": "Ciprofloxacin", "C": "Mesalamine", "D": "Metronidazole", "E": "Total parenteral nutrition"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "hematochezia", "last", "days", "tenesmus", "bowel urgency", "abdominal pain", "several milder episodes", "past", "years", "resolved", "history", "serious illness", "medications", "blood pressure", "85 mm Hg", "temperature", "99", "pulse", "75 min", "abdominal", "mild tenderness", "deep palpation of", "left lower quadrant", "Digital rectal examination reveals anal tenderness", "fresh blood", "Stool", "negative", "pathogenic bacteria", "parasite test", "negative", "Erythrocyte sedimentation rate", "mm/h", "Colonoscopy", "diffuse erythema involving", "rectum", "extending", "distal sigmoid", "mucosa", "decreased vascular pattern", "fine granularity", "remaining colon", "distal ileum", "normal", "Biopsy of", "inflamed mucosa", "sigmoid colon", "distorted crypt", "most appropriate next step", "administer", "following"]}
{"question": "A 4-year-old girl is brought to the physician for a well-child examination. She has been healthy apart from an episode of bronchiolitis as an infant. Her 6-year-old sister recently underwent surgery for ventricular septal defect closure. She is at the 60th percentile for height and weight. Her mother is concerned about the possibility of the patient having a cardiovascular anomaly. Which of the following is most likely to indicate a benign heart murmur in this child?", "answer": "A grade 2/6 continuous murmur heard at the right supraclavicular region", "options": {"A": "A grade 3/6 systolic ejection murmur heard along the left lower sternal border that increases on valsalva", "B": "A grade 4/6 midsystolic murmur at the right upper sternal border that increases on rapid squatting", "C": "A grade 2/6 continuous murmur heard at the right supraclavicular region", "D": "A grade 4/6 holosytolic murmur heard along the left lower sternal border that increases on hand grip", "E": "A grade 3/6 holosytolic murmur at the apex that increases on hand grip"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old girl", "brought", "physician", "well", "healthy", "episode of bronchiolitis", "infant", "year old", "recently", "surgery", "ventricular septal closure", "percentile", "height", "weight", "possibility", "patient", "cardiovascular anomaly", "following", "to", "benign heart murmur", "child"]}
{"question": "A mother with HIV has given birth to a healthy boy 2 days ago. She takes her antiretroviral medication regularly and is compliant with the therapy. Before being discharged, her doctor explains that she cannot breastfeed the child since there is a risk of infection through breastfeeding and stresses that the child can benefit from formula feeding. The physician stresses the importance of not overheating the formula since Vitamin C may be inactivated by overheating. Which process could be impaired if the mother boiled the formula longer than needed?", "answer": "Collagen synthesis", "options": {"A": "Heme synthesis", "B": "Purine synthesis", "C": "Collagen synthesis", "D": "Protein catabolism", "E": "Fatty acid metabolism"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["HIV", "given birth", "healthy boy 2 days", "antiretroviral medication", "doctor", "breastfeed", "child", "risk", "infection", "breastfeeding", "stresses", "child", "benefit", "formula", "physician stresses", "importance", "not overheating", "formula", "Vitamin C", "overheating", "process", "impaired", "boiled", "formula longer", "needed"]}
{"question": "A healthy 33-year-old gravida 1, para 0, at 15 weeks' gestation comes to the genetic counselor for a follow-up visit. Her uncle had recurrent pulmonary infections, chronic diarrhea, and infertility, and died at the age of 28 years. She does not smoke or drink alcohol. The results of an amniotic karyotype analysis show a deletion of Phe508 on chromosome 7. This patient's fetus is at greatest risk for developing which of the following complications?", "answer": "Meconium ileus", "options": {"A": "Duodenal atresia", "B": "Congenital megacolon", "C": "Cardiac defects", "D": "Meconium ileus", "E": "Neural tube defects"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old gravida 1", "para 0", "weeks", "gestation", "genetic counselor", "recurrent pulmonary infections", "chronic diarrhea", "infertility", "died", "age", "years", "not smoke", "results", "amniotic karyotype analysis", "deletion", "chromosome 7", "patient's fetus", "greatest", "following complications"]}
{"question": "Four days after being admitted to the intensive care unit for acute substernal chest pain and dyspnea, an 80-year-old man is evaluated for hypotension. Coronary angiography on admission showed an occlusion in the left anterior descending artery, and a drug-eluting stent was placed successfully. The patient has a history of hypertension and type 2 diabetes mellitus. Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. His temperature is 37.2 °C (99 °F), pulse is 112/min, respirations are 21/min, and blood pressure is 72/50 mm Hg. Cardiac examination shows a normal S1 and S2 and a new harsh, holosystolic murmur heard best at the left sternal border. There is jugular venous distention and a right parasternal heave. The lungs are clear to auscultation. Pitting edema extends up to the knees bilaterally. An ECG shows Q waves in the inferior leads. Which of the following is the most likely cause of this patient’s hypotension?", "answer": "Interventricular septum rupture", "options": {"A": "Ascending aortic dissection rupture", "B": "Post-infarction fibrinous pericarditis", "C": "Left ventricular free wall rupture", "D": "Left ventricular aneurysm rupture", "E": "Interventricular septum rupture"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Four days", "acute", "chest pain", "dyspnea", "80 year old man", "hypotension", "Coronary angiography on admission", "occlusion", "left anterior descending artery", "drug-eluting stent", "patient", "history of hypertension", "type 2 diabetes mellitus", "Current medications include aspirin", "clopidogrel", "metoprolol", "lisinopril", "atorvastatin", "temperature", "99 F", "pulse", "min", "respirations", "min", "blood pressure", "72 50 mm Hg", "normal S1", "S2", "new harsh", "holosystolic murmur heard best", "left sternal border", "jugular venous distention", "right parasternal heave", "lungs", "clear", "auscultation", "Pitting edema extends", "knees", "ECG", "Q waves", "inferior leads", "following", "most likely cause", "patients hypotension"]}
{"question": "A 68-year-old right hand-dominant man presents to the emergency room complaining of severe right arm pain after falling down a flight of stairs. He landed on his shoulder and developed immediate severe upper arm pain. Physical examination reveals a 2-cm laceration in the patient’s anterior right upper arm. Bone is visible through the laceration. An arm radiograph demonstrates a displaced comminuted fracture of the surgical neck of the humerus. Irrigation and debridement is performed immediately and the patient is scheduled to undergo definitive operative management of his fracture. In the operating room on the following day, the operation is more complicated than expected and the surgeon accidentally nicks a neurovascular structure piercing the coracobrachialis muscle. This patient would most likely develop a defect in which of the following?", "answer": "Lateral forearm skin sensation", "options": {"A": "Elbow extension", "B": "Forearm pronation", "C": "Lateral forearm skin sensation", "D": "Medial arm skin sensation", "E": "Wrist extension"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old right man presents", "emergency room", "severe right arm pain", "landed", "shoulder", "immediate severe upper arm pain", "reveals", "2 cm laceration", "patients anterior right upper", "Bone", "visible", "laceration", "arm radiograph", "displaced comminuted fracture of", "surgical neck of", "humerus", "Irrigation", "debridement", "performed immediately", "patient", "scheduled to", "definitive operative", "fracture", "operating room", "following day", "operation", "more complicated", "surgeon", "structure piercing", "coracobrachialis muscle", "patient", "most likely", "defect"]}
{"question": "A first-year medical student is conducting a summer project with his medical school's pediatrics department using adolescent IQ data from a database of 1,252 patients. He observes that the mean IQ of the dataset is 100. The standard deviation was calculated to be 10. Assuming that the values are normally distributed, approximately 87% of the measurements will fall in between which of the following limits?", "answer": "85–115", "options": {"A": "70–130", "B": "65–135", "C": "85–115", "D": "80–120", "E": "95–105\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["first year medical student", "summer", "medical school's pediatrics department using adolescent", "observes", "mean", "100", "standard deviation", "calculated to", "10", "values", "distributed", "approximately 87", "measurements", "fall in between", "following limits"]}
{"question": "The the mean, median, and mode weight of 37 newborns in a hospital nursery is 7 lbs 2 oz. In fact, there are 7 infants in the nursery that weigh exactly 7 lbs 2 oz. The standard deviation of the weights is 2 oz. The weights follow a normal distribution. A newborn delivered at 10 lbs 2 oz is added to the data set. What is most likely to happen to the mean, median, and mode with the addition of this new data point?", "answer": "The mean will increase; the median will stay the same; the mode will stay the same", "options": {"A": "The mean will increase; the median will increase; the mode will increase", "B": "The mean will stay the same; the median will increase; the mode will increase", "C": "The mean will stay the same; the median will increase; the mode will stay the same", "D": "The mean will increase; the median will stay the same; the mode will stay the same", "E": "The mean will increase; the median will increase; the mode will stay the same"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["mean", "median", "mode weight", "newborns", "hospital nursery", "7 lbs 2 oz", "infants", "nursery", "lbs", "oz", "standard deviation", "weights", "2 oz", "weights follow", "normal distribution", "newborn delivered", "10 lbs", "oz", "added", "mean", "median", "mode", "addition", "new data point"]}
{"question": "A 10-month-old boy is brought to the emergency department by his parents because he has a high fever and severe cough. His fever started 2 days ago and his parents are concerned as he is now listless and fatigued. He had a similar presentation 5 months ago and was diagnosed with pneumonia caused by Staphyloccocus aureus. He has been experiencing intermittent diarrhea and skin abscesses since birth. The child had an uneventful birth and the child is otherwise developmentally normal. Analysis of this patient's sputum reveals acute angle branching fungi and a throat swab reveals a white plaque with germ tube forming yeast. Which of the following is most likely to be abnormal in this patient?", "answer": "NADPH oxidase activity", "options": {"A": "Autoimmune regulator function", "B": "LFA-1 integrin binding", "C": "Lysosomal trafficking", "D": "NADPH oxidase activity", "E": "Thymus development"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["A 10 month old boy", "brought", "emergency department", "high fever", "severe cough", "fever started 2 days", "now listless", "fatigued", "similar", "months", "diagnosed", "pneumonia caused", "intermittent diarrhea", "skin abscesses", "birth", "child", "birth", "child", "normal", "Analysis", "patient's sputum reveals acute angle branching fungi", "throat swab reveals", "white plaque", "germ tube forming yeast", "following", "to", "abnormal", "patient"]}
{"question": "A 46-year-old woman comes to the physician for a routine health examination. She was last seen by a physician 3 years ago. She has been healthy aside from occasional mild flank pain. Her only medication is a multivitamin. Her blood pressure is 154/90 mm Hg. Physical examination shows no abnormalities. Serum studies show:\nSodium 141 mEq/L\nPotassium 3.7 mEq/L\nCalcium 11.3 mg/dL\nPhosphorus 2.3 mg/dL\nUrea nitrogen 15 mg/dL\nCreatinine 0.9 mg/dL\nAlbumin 3.6 g/dL\nSubsequent serum studies show a repeat calcium of 11.2 mg/dL, parathyroid hormone concentration of 890 pg/mL, and 25-hydroxyvitamin D of 48 ng/mL (N = 25–80). Her 24-hour urine calcium excretion is elevated. An abdominal ultrasound shows several small calculi in bilateral kidneys. Further testing shows normal bone mineral density. Which of the following is the most appropriate next step in management?\"", "answer": "Refer to surgery for parathyroidectomy", "options": {"A": "Refer to surgery for parathyroidectomy", "B": "Begin cinacalcet therapy", "C": "Order serum protein electrophoresis", "D": "Begin hydrochlorothiazide therapy", "E": "Perform percutaneous nephrolithotomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "routine", "last seen by", "physician", "years", "healthy", "occasional mild flank", "only medication", "multivitamin", "blood pressure", "90 mm Hg", "abnormalities", "Serum studies", "Sodium", "mEq", "Calcium", "mg dL Phosphorus 2", "mg dL Urea nitrogen", "Creatinine 0", "6 g", "Subsequent serum studies", "repeat calcium", "2 mg/dL", "parathyroid hormone concentration", "pg/mL", "25-hydroxyvitamin D", "48 ng/mL", "N", "hour urine calcium excretion", "elevated", "abdominal ultrasound", "several small calculi", "bilateral kidneys", "Further testing", "normal bone mineral density", "following", "most appropriate next step"]}
{"question": "A 12-year-old boy is brought in by his mother to the emergency department. He has had abdominal pain, fever, nausea, vomiting, and loss of appetite since yesterday. At first, the mother believed it was just a \"stomach flu,\" but she is growing concerned about his progressive decline. Vitals include: T 102.3 F, HR 110 bpm, BP 120/89 mmHg, RR 16, O2 Sat 100%. Abdominal exam is notable for pain over the right lower quadrant. What is the next best step in management in addition to IV hydration and analgesia?", "answer": "Right lower quadrant ultrasound", "options": {"A": "Abdominal CT scan with IV and PO contrast", "B": "Abdominal CT scan with IV contrast", "C": "Upright and supine abdominal radiographs", "D": "Right lower quadrant ultrasound", "E": "Abdominal MRI with gadolinium contrast"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "abdominal pain", "fever", "nausea", "vomiting", "loss of appetite", "first", "stomach flu", "progressive", "include", "T", "3 F", "BP", "mmHg", "RR", "O2 Sat 100", "Abdominal exam", "notable", "pain", "right lower quadrant", "next best step in", "addition to IV hydration", "analgesia"]}
{"question": "A 48-year-old man with a long history of mild persistent asthma on daily fluticasone therapy has been using his albuterol inhaler every day for the past month and presents requesting a refill. He denies any recent upper respiratory infections, but he says he has felt much more short of breath throughout this time frame. He works as a landscaper, and he informs you that he has been taking longer to complete some of his daily activities on the job. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. His physical exam reveals mild bilateral wheezes and normal heart sounds. What changes should be made to his current regimen?", "answer": "Add salmeterol to current regimen", "options": {"A": "Add ciclesonide to current regimen", "B": "Add salmeterol to current regimen", "C": "Discontinue fluticasone and instead use salmeterol", "D": "Add cromolyn to current regimen", "E": "Discontinue fluticasone and add ipratropium to current regimen"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old man", "long history of mild persistent asthma", "daily fluticasone therapy", "using", "albuterol inhaler", "day", "past month", "presents", "recent upper respiratory infections", "much", "short of breath", "time frame", "informs", "longer to complete", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 74 min", "respiratory rate", "min", "reveals mild bilateral wheezes", "normal heart sounds", "changes", "made", "current regimen"]}
{"question": "A 3500-g (7 lb 11 oz) healthy female newborn is delivered at 38 weeks' gestation. Chorionic villus sampling (CVS) in the first trimester showed a trisomy of chromosome 21 but the pregnancy was otherwise uncomplicated. Physical examination of the newborn is normal. Chromosomal analysis at birth shows a 46, XX karyotype. Which of the following is the most likely explanation for the prenatal chromosomal abnormality?", "answer": "Placental mosaicism", "options": {"A": "Maternal disomy", "B": "Phenotypic pleiotropy", "C": "Incomplete penetrance", "D": "Variable expressivity", "E": "Placental mosaicism"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3500 g", "oz", "healthy female newborn", "delivered", "weeks", "gestation", "Chorionic villus sampling", "first trimester", "trisomy", "chromosome 21", "pregnancy", "uncomplicated", "Physical examination", "newborn", "normal", "Chromosomal analysis", "birth", "XX karyotype", "following", "prenatal chromosomal abnormality"]}
{"question": "An 11-year-old girl presents with a 1-day history of frothy brown urine. She has no significant medical history and takes no medications. She reports that several of her classmates have been sick, and she notes that she had a very sore throat with a fever approx. 2 weeks ago. Her blood pressure is 146/94 mm Hg, heart rate is 74/min, and respiratory rate is 14/min. Laboratory analysis reveals elevated serum creatinine, hematuria with RBC casts, and elevated urine protein without frank proteinuria. Physical examination reveals a healthy-looking girl with no abdominal or costovertebral angle tenderness. Which of the following is the most likely diagnosis?", "answer": "Poststreptococcal glomerulonephritis", "options": {"A": "Alport syndrome", "B": "Minimal change disease", "C": "Membranoproliferative glomerulonephritis", "D": "Poststreptococcal glomerulonephritis", "E": "Henoch-Schönlein purpura"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl presents", "1-day history", "frothy brown", "significant medical history", "medications", "reports", "several", "sick", "notes", "very sore throat", "fever", "2 weeks", "blood pressure", "mm Hg", "heart rate", "74 min", "respiratory rate", "min", "Laboratory analysis reveals elevated serum creatinine", "hematuria", "casts", "elevated urine", "proteinuria", "reveals", "healthy looking girl", "abdominal", "costovertebral angle tenderness", "following", "diagnosis"]}
{"question": "A 16-year-old male adolescent presents to his pediatrician with increasing fatigue and breathlessness with exercise. His parents inform the doctor that they have recently migrated from a developing country, where he was diagnosed as having a large ventricular septal defect (VSD). However, due to their poor economic condition and scarce medical facilities, surgical repair was not performed in that country. The pediatrician explains to the parents that patients with large VSDs are at increased risk for several complications, including Eisenmenger syndrome. If the patient has developed this complication, he is not a good candidate for surgical closure of the defect. Which of the following clinical signs, if present on physical examination, would suggest the presence of this complication?", "answer": "Right ventricular heave", "options": {"A": "A loud first heart sound", "B": "A mid-diastolic low-pitched rumble at the apex", "C": "Right ventricular heave", "D": "Prominence of the left precordium", "E": "Lateral displacement of the apical impulse"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old male adolescent presents", "pediatrician", "increasing fatigue", "breathlessness", "exercise", "inform", "doctor", "recently migrated", "developing country", "diagnosed", "large ventricular septal defect", "poor economic condition", "medical facilities", "surgical repair", "not performed", "country", "pediatrician", "patients", "large VSDs", "increased risk", "several complications", "including Eisenmenger syndrome", "patient", "complication", "not", "good", "surgical closure", "defect", "following clinical signs", "present", "presence", "complication"]}
{"question": "A 59-year-old man presents to the emergency department with right-sided weakness and an inability to speak for the past 2 hours. His wife says he was gardening in his backyard when he suddenly lost balance and fell down. The patient has a past medical history of hypertension, diabetes mellitus, and coronary artery disease. Two years ago, he was admitted to the coronary intensive care unit with an anterolateral myocardial infarction. He has not been compliant with his medications since he was discharged. On physical examination, his blood pressure is 110/70 mm Hg, pulse is 110/min and irregular, temperature is 36.6°C (97.8°F), and respiratory rate is 18/min. Strength is 2/5 in both his right upper and right lower extremities. His right calf is edematous with visible varicose veins. Which of the following is the best method to detect the source of this patient’s stroke?", "answer": "ECG", "options": {"A": "Duplex ultrasound of his right leg", "B": "Carotid duplex", "C": "Head CT without contrast", "D": "ECG", "E": "V/Q scan of his lungs"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["59 year old man presents", "emergency department", "right-sided weakness", "speak", "past", "hours", "backyard", "lost balance", "fell", "patient", "past medical", "diabetes mellitus", "coronary artery disease", "Two years", "coronary", "anterolateral myocardial infarction", "not", "compliant", "medications", "blood pressure", "70 mm Hg", "pulse", "min", "irregular", "temperature", "36", "97", "respiratory rate", "min", "Strength", "2/5", "right upper", "right lower extremities", "right calf", "edematous", "visible varicose veins", "following", "best method to detect", "source", "patients stroke"]}
{"question": "A 3-year-old boy is brought to the emergency department because of worsening pain and swelling in both of his hands for 1 week. He appears distressed. His temperature is 38.5°C (101.4°F). Examination shows erythema, swelling, warmth, and tenderness on the dorsum of his hands. His hemoglobin concentration is 9.1 g/dL. A peripheral blood smear is shown. The drug indicated to prevent recurrence of this patient's symptoms is also used to treat which of the following conditions?", "answer": "Polycythemia vera", "options": {"A": "Primary syphilis", "B": "Chronic kidney disease", "C": "Megaloblastic anemia", "D": "Iron intoxication", "E": "Polycythemia vera"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "worsening pain", "swelling", "of", "hands", "1 week", "appears", "temperature", "erythema", "swelling", "warmth", "tenderness", "dorsum of", "hands", "hemoglobin concentration", "g/dL", "peripheral blood smear", "drug indicated to prevent recurrence", "patient's symptoms", "used to treat", "following conditions"]}
{"question": "A 30-year-old primigravid woman at 14 weeks' gestation comes to the physician for her first prenatal visit. She reports some nausea and fatigue. She takes lithium for bipolar disorder and completed a course of clindamycin for bacterial vaginosis 12 weeks ago. She works as a teacher at a local school. She smoked a pack of cigarettes daily for 12 years but stopped after finding out that she was pregnant. She does not drink alcohol. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 125/80 mm Hg. Pelvic examination shows a uterus consistent in size with a 14-week gestation. There is mild lower extremity edema bilaterally. Urinalysis is within normal limits. The patient's child is at increased risk for developing which of the following complications?", "answer": "Atrialized right ventricle", "options": {"A": "Ototoxicity and hearing loss", "B": "Atrialized right ventricle", "C": "Fetal hydantoin syndrome", "D": "Bone damage", "E": "Chorioretinitis\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old primigravid woman", "weeks", "gestation", "physician", "reports", "nausea", "fatigue", "lithium", "bipolar disorder", "completed", "course", "clindamycin", "bacterial vaginosis", "weeks", "teacher", "local school", "smoked", "pack", "cigarettes daily", "years", "stopped", "finding out", "pregnant", "not", "alcohol", "temperature", "98", "pulse", "80 min", "blood pressure", "80 mm Hg", "Pelvic examination", "uterus", "size", "week gestation", "mild lower extremity edema", "Urinalysis", "normal limits", "patient's child", "increased risk", "following complications"]}
{"question": "A 65-year-old woman with COPD comes to the emergency department with 2-day history of worsening shortness of breath and cough. She often has a mild productive cough, but she noticed that her sputum is more yellow than usual. She has not had any recent fevers, chills, sore throat, or a runny nose. Her only medication is a salmeterol inhaler that she uses twice daily. Her temperature is 36.7°C (98°F), pulse is 104/min, blood pressure is 134/73 mm Hg, respiratory rate is 22/min, and oxygen saturation is 85%. She appears uncomfortable and shows labored breathing. Lung auscultation reveals coarse bibasilar inspiratory crackles. A plain film of the chest shows mild hyperinflation and flattening of the diaphragm but no consolidation. She is started on supplemental oxygen via nasal cannula. Which of the following is the most appropriate initial pharmacotherapy?", "answer": "Prednisone and albuterol", "options": {"A": "Roflumilast and prednisone", "B": "Albuterol and montelukast", "C": "Prednisone and salmeterol", "D": "Albuterol and theophylline", "E": "Prednisone and albuterol"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["65-year-old woman", "COPD", "emergency department", "2-day history of worsening shortness", "breath", "cough", "often", "mild productive cough", "sputum", "more yellow", "usual", "not", "recent fevers", "chills", "sore throat", "runny nose", "only medication", "salmeterol inhaler", "uses twice daily", "temperature", "36", "pulse", "min", "blood pressure", "mm Hg", "respiratory rate", "min", "oxygen saturation", "85", "appears", "labored", "Lung auscultation reveals coarse", "inspiratory crackles", "plain film", "chest", "mild hyperinflation", "flattening", "diaphragm", "consolidation", "started", "supplemental oxygen", "nasal cannula", "following", "most appropriate initial pharmacotherapy"]}
{"question": "A 30-year-old woman comes to the emergency department because of weakness and fatigue for 2 days. She has also noticed that her urine is darker than usual. For the past week, she has had a persistent non-productive cough and low-grade fever. She has seasonal allergies. She drinks one to two glasses of wine on social occasions and does not smoke. Her temperature is 37.9°C (100.2°F), pulse is 88/min, respirations are 18/min, and blood pressure is 110/76 mm Hg. She has conjunctival pallor and scleral icterus. Cardiopulmonary examination shows bibasilar crackles. The remainder of the physical examination shows no abnormalities. Laboratory studies show:\nLeukocyte count 8,000/mm3\nHemoglobin 7.1 g/dL\nHematocrit 21%\nPlatelet count 110,000/mm3\nMCV 94 μm3\nSerum\nTotal bilirubin 4.3 mg/dL\nDirect 1.1 mg/dL\nIndirect 3.2 mg/dL\nAST 15 U/L\nALT 17 U/L\nLDH 1,251 U/L\nHaptoglobin 5.8 mg/dL (N = 41–165)\nAn x-ray of the chest shows bilateral patchy infiltrates. A peripheral blood smear shows spherocytes. Which of the following is most likely to confirm the diagnosis?\"", "answer": "Direct Coombs test", "options": {"A": "Osmotic fragility test", "B": "Direct Coombs test", "C": "ADAMTS13 activity and inhibitor profile", "D": "Hemoglobin electrophoresis", "E": "Flow cytometry"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["30 year old woman", "emergency department", "weakness", "fatigue", "2 days", "urine", "darker", "usual", "past week", "persistent non-productive cough", "low-grade fever", "seasonal allergies", "one", "two glasses", "social occasions", "not smoke", "temperature", "100", "pulse", "88 min", "respirations", "min", "blood pressure", "76 mm Hg", "conjunctival pallor", "scleral icterus", "Cardiopulmonary", "crackles", "abnormalities", "Laboratory studies", "Leukocyte", "mm3", "7 1", "dL Hematocrit", "MCV", "Serum Total bilirubin", "dL Direct 1", "mg/dL", "U", "LDH", "Haptoglobin", "8", "N", "x-ray of", "chest", "bilateral patchy infiltrates", "peripheral blood smear", "spherocytes", "following", "to confirm", "diagnosis"]}
{"question": "A 46-year-old woman comes to the physician for a follow-up examination. She had a blood pressure recording of 148/94 mm Hg on her previous visit one week ago. Her home blood pressure log shows readings of 151/97 and 146/92 mm Hg in the past week. She has no history of serious illness and takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Her pulse is 88/min and blood pressure is 150/96 mm Hg. Cardiopulmonary examination is unremarkable. Abdominal examination shows no abnormalities. The extremities are well perfused with strong peripheral pulses. Serum concentrations of electrolytes, creatinine, lipids, TSH, and fasting glucose are within the reference range. A urinalysis is within normal limits. Which of the following is the most appropriate next step in management?", "answer": "Electrocardiogram", "options": {"A": "Electrocardiogram", "B": "Plasma renin activity", "C": "Polysomnography", "D": "Echocardiography", "E": "Renal ultrasonography"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "blood pressure recording", "mm Hg", "previous", "one week", "home blood pressure log", "97", "mm Hg", "past week", "history", "serious illness", "medications", "5 ft", "tall", "kg", "BMI", "20 kg/m2", "pulse", "88 min", "blood pressure", "96 mm Hg", "Cardiopulmonary", "unremarkable", "Abdominal examination", "abnormalities", "extremities", "well perfused", "strong peripheral pulses", "Serum", "electrolytes", "creatinine", "lipids", "fasting glucose", "reference range", "urinalysis", "normal limits", "following", "most appropriate next step"]}
{"question": "A sample is taken of an ulcer in the inguinal region of a 29-year-old Malaysian male who has had unprotected sex in the past few months. Intracytoplasmic inclusions are seen in the Giemsa staining in Image A. On which of the following can the organism in the staining be grown?", "answer": "Yolk sac of a chick embryo", "options": {"A": "Bordet-Gengou agar", "B": "Löwenstein-Jensen agar", "C": "Charcoal yeast extract agar with cysteine and iron", "D": "Eaton's agar", "E": "Yolk sac of a chick embryo"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["ulcer", "inguinal region", "29 year old", "male", "past", "months", "inclusions", "seen", "Giemsa staining", "following", "staining"]}
{"question": "A 32-year-old man who recently emigrated from Colombia comes to the physician because of a 3-month history of shortness of breath and fatigue. Physical examination shows jugular venous distention and an additional late diastolic heart sound. Crackles are heard at the lung bases bilaterally. Cardiac catheterization is performed and left ventricular pressures are obtained. The left ventricular pressure-volume relationship compared to that of a healthy patient is shown. Which of the following is the most likely cause of this patient's heart failure?", "answer": "Cardiac sarcoidosis", "options": {"A": "Chagas heart disease", "B": "Viral myocarditis", "C": "Cardiac sarcoidosis", "D": "Alcohol use disorder", "E": "Thiamine deficiency"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "recently", "Colombia", "physician", "of", "3 month history", "shortness", "breath", "fatigue", "jugular venous distention", "additional late diastolic heart sound", "Crackles", "heard", "lung bases", "performed", "left ventricular pressures", "obtained", "left ventricular pressure volume relationship", "healthy patient", "following", "most likely cause", "patient's"]}
{"question": "A 23-year-old female college basketball player presents in Sports Clinic after she felt a \"pop\" in her knee after coming down with a rebound. To examine the patient, you have her lie down on the table with her knees flexed 90 degrees. With your hand around her knee you are able to draw the tibia toward you from underneath the femur. The torn structure implicated by this physical exam maneuver has which of the following attachments?", "answer": "The anterior intercondylar area of tibia and the posteromedial aspect of the lateral femur", "options": {"A": "The posterior intercondylar area of tibia and the posteromedial aspect of the lateral femur", "B": "The anterior intercondylar area of tibia and the posteromedial aspect of the lateral femur", "C": "The patella and tibial tuberosity", "D": "The lateral epicondyle of the femur and the head of fibula", "E": "The medial condyle of the femur and the medial condyle of the tibia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old female college basketball", "presents", "Clinic", "knee after", "To", "patient", "table", "knees flexed 90 degrees", "hand", "knee", "able to", "tibia", "femur", "torn structure", "following attachments"]}
{"question": "A 42-year-old man is brought to the emergency department after having a seizure. His wife states that the patient has been struggling with alcohol abuse and has recently decided to \"quit once and for all\". Physical exam is notable for a malnourished patient responsive to verbal stimuli. He has moderate extremity weakness, occasional palpitations, and brisk deep tendon reflexes (DTRs). EKG demonstrates normal sinus rhythm and a prolonged QT interval. What nutritional deficiency most likely contributed to these findings?", "answer": "Magnesium", "options": {"A": "Potassium", "B": "Calcium", "C": "Folate", "D": "Magnesium", "E": "Vitamin D"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "seizure", "states", "patient", "alcohol abuse", "recently", "notable", "malnourished patient responsive", "verbal", "moderate extremity weakness", "occasional palpitations", "brisk deep tendon reflexes", "EKG", "normal sinus rhythm", "prolonged QT interval", "nutritional deficiency", "likely", "findings"]}
{"question": "A 22-year-old man presents to his physician with a chronic cough which he has had for the last five years. He mentions that his cough is usually productive; however, sometimes it is dry. His past medical records show seven episodes of sinusitis over the last two years and two episodes of community acquired pneumonia. He is a non-smoker and there is no history of long-term exposure to passive smoking or other airway irritants. There is no family history of an allergic disorder. On physical examination, his vital signs are stable. General examination shows mild clubbing of his fingers and examination of his nasal turbinates reveals nasal polyps. Auscultation of his chest reveals crackles and scattered wheezing bilaterally. A high-resolution computed tomography (HRCT) of the chest shows dilated, “tram track” bronchi, predominantly involving upper lung fields. Which of the following is the next best step in the diagnostic evaluation of the patient?", "answer": "Measurement of sweat chloride levels", "options": {"A": "Sputum culture for acid-fast bacilli", "B": "Serum quantitative immunoglobulin levels", "C": "Measurement of sweat chloride levels", "D": "Skin testing for Aspergillus reactivity", "E": "Testing for swallowing function"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "chronic cough", "last five years", "cough", "usually productive", "sometimes", "dry", "past medical records", "seven episodes of sinusitis", "last two years", "two episodes of community acquired pneumonia", "non-smoker", "history", "long-term exposure", "airway irritants", "family history of", "allergic disorder", "vital signs", "stable", "General", "mild clubbing of", "fingers", "examination of", "nasal turbinates reveals nasal polyps", "Auscultation", "chest reveals crackles", "scattered wheezing", "high-resolution computed tomography", "of", "chest", "dilated", "tram track bronchi", "involving upper lung fields", "following", "next best step", "diagnostic", "patient"]}
{"question": "A 64-year-old male with a past medical history of obesity, diabetes, hypertension, and hyperlipidemia presents with an acute onset of nausea, vomiting, diaphoresis, and crushing substernal chest pain. Vital signs are temperature 37° C, HR 110, BP 149/87, and RR of 22 with an oxygen saturation of 99% on room air. Physical exam reveals a fourth heart sound (S4), and labs are remarkable for an elevated troponin. EKG is shown below. The pathogenesis of the condition resulting in this patient’s presentation involves:", "answer": "A fully obstructive thrombus at the site of a ruptured, ulcerated atherosclerotic plaque", "options": {"A": "Genetic inheritance of a mutation in ß-myosin or troponin expressed in cardiac myocytes", "B": "A fully obstructive thrombus at the site of a ruptured, ulcerated atherosclerotic plaque", "C": "A partially occlusive thrombus at the site of a ruptured, ulcerated atherosclerotic plaque", "D": "Destruction of the vasa vasorum caused by vasculitic phenomena", "E": "A stable atheromatous lesion without overlying thrombus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["64 year old male", "past medical", "diabetes", "hypertension", "hyperlipidemia presents", "acute onset", "nausea", "vomiting", "diaphoresis", "crushing", "chest pain", "Vital signs", "temperature", "BP", "87", "RR", "oxygen saturation", "99", "room air", "reveals", "fourth heart sound", "S4", "labs", "elevated troponin", "EKG", "pathogenesis", "condition resulting in", "patients"]}
{"question": "A 60-year-old man is brought to the emergency room because of fever and increasing confusion for the past 2 days. He has paranoid schizophrenia and hypertension. His current medications are chlorpromazine and amlodipine. He appears ill. He is not oriented to time, place, or person. His temperature is 40°C (104°F), pulse is 130/min, respirations are 29/min and blood pressure is 155/100 mm Hg. Examination shows diaphoresis. Muscle tone is increased bilaterally. Deep tendon reflexes are 1+ bilaterally. Neurologic examination shows psychomotor agitation. His speech is incoherent. Lungs are clear to auscultation. His neck is supple. The abdomen is soft and nontender. Serum laboratory analysis shows a leukocyte count of 11,300/mm3 and serum creatine kinase concentration of 833 U/L. Which of the following is the most appropriate initial pharmacotherapy?", "answer": "Dantrolene", "options": {"A": "Dantrolene", "B": "Clozapine", "C": "Cyproheptadine", "D": "Physostigmine", "E": "Propranolol"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["60 year old man", "brought", "emergency room", "fever", "increasing confusion", "past 2 days", "paranoid schizophrenia", "hypertension", "current medications", "chlorpromazine", "amlodipine", "appears ill", "not oriented to time", "place", "temperature", "pulse", "min", "respirations", "29 min", "blood pressure", "100 mm Hg", "diaphoresis", "Muscle tone", "increased", "Deep tendon reflexes", "1", "Neurologic examination", "psychomotor agitation", "speech", "incoherent", "Lungs", "clear", "auscultation", "neck", "supple", "abdomen", "soft", "nontender", "Serum laboratory analysis", "leukocyte count", "11 300 mm3", "serum creatine kinase concentration", "U/L", "following", "most appropriate initial pharmacotherapy"]}
{"question": "A 67-year-old man comes to the emergency department because of decreased vision and black spots in front of his left eye for the past 24 hours. He states that it feels as if 'a curtain is hanging over his eye.' He sees flashes of light intermittently. He has no pain or diplopia. He underwent cataract surgery on the left eye 2 weeks ago. He has hypertension and type 2 diabetes mellitus. His sister has open-angle glaucoma. Current medications include metformin, linagliptin, ramipril, and hydrochlorothiazide. Vital signs are within normal limits. Examination shows a visual acuity in the right eye of 20/25 and the ability to count fingers at 3 feet in the left eye. The pupils are equal and reactive. The corneal reflex is present. The anterior chamber shows no abnormalities. The confrontation test is normal on the right side and shows nasal and inferior defects on the left side. Cardiopulmonary examination shows no abnormalities. The patient is awaiting dilation for fundus examination. Which of the following is the most likely diagnosis?", "answer": "Retinal detachment", "options": {"A": "Degenerative retinoschisis", "B": "Retinal detachment", "C": "Acute angle-closure glaucoma", "D": "Endophthalmitis", "E": "Hemorrhagic choroidal detachment"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old man", "emergency department", "decreased vision", "black spots in front of", "left eye", "past 24 hours", "states", "curtain", "hanging", "eye", "sees flashes", "light", "pain", "diplopia", "cataract surgery", "left eye 2 weeks", "hypertension", "type 2 diabetes mellitus", "open-angle glaucoma", "Current medications include metformin", "linagliptin", "ramipril", "hydrochlorothiazide", "Vital signs", "normal limits", "visual acuity", "right eye", "20", "ability to count fingers", "3 feet", "left eye", "pupils", "equal", "reactive", "corneal reflex", "present", "anterior chamber", "abnormalities", "confrontation test", "normal", "right side", "nasal", "inferior defects", "left", "Cardiopulmonary", "abnormalities", "patient", "dilation", "fundus", "following", "diagnosis"]}
{"question": "A 65-year-old woman presents to her physician with the complaint of ringing in her right ear. She says it started about 3 months ago with associated progressive difficulty in hearing on the same side. Past medical history is significant for a hysterectomy 5 years ago due to dysfunctional uterine bleeding. She is currently not taking any medications. She is a non-smoker and drinks socially. On otoscopic examination, a red-blue pulsatile mass is observed behind the right tympanic membrane. A noncontrast CT scan of the head shows significant bone destruction resulting in a larger jugular foramen highly suggestive of a tumor derived from neural crest cells. Which of the cranial nerves are most likely to be involved in this type of lesion?", "answer": "Cranial nerves IX, X", "options": {"A": "Cranial nerves VII & VIII", "B": "Cranial nerves IX, X", "C": "Cranial nerves III, IV, VI", "D": "Cranial nerves I, II, V", "E": "Cranial nerves X, XI, XII"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old woman presents", "physician", "complaint", "ringing", "right ear", "started", "months", "with associated progressive difficulty", "hearing", "same side", "Past medical history", "significant", "hysterectomy", "years", "dysfunctional uterine bleeding", "currently not", "medications", "non-smoker", "otoscopic", "red blue pulsatile mass", "observed", "right tympanic membrane", "CT scan of", "head", "significant bone destruction resulting in", "larger jugular foramen highly suggestive of", "tumor derived", "cranial nerves", "to", "involved", "type", "lesion"]}
{"question": "A 3-year-old boy presents to a geneticist for generalized developmental delay. Upon presentation he is found to have a distinctive facial structure with prominent epicanthal folds and macroglossia. Further physical examination reveals a simian crease on his palms bilaterally. Based on these findings, the physician strongly suspects Down syndrome and obtains a karyotype. Surprisingly the karyotype shows 46 chromosomes with two normal appearing alleles of chromosome 21. Further examination with fluorescent probes reveals a third copy of chromosome 21 genes that have been incorporated into another chromosome. What is the name of this mechanism of Down syndrome inheritance?", "answer": "Robertsonian translocation", "options": {"A": "Nondisjunction", "B": "Mosaicism", "C": "Robertsonian translocation", "D": "Imprinting", "E": "Anticipation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy presents", "geneticist", "generalized developmental delay", "found to", "facial structure", "prominent epicanthal folds", "macroglossia", "Further", "reveals", "crease", "palms", "Based", "findings", "physician", "Down syndrome", "obtains", "karyotype", "karyotype", "chromosomes", "two normal appearing alleles", "21", "Further", "reveals", "third copy", "chromosome 21 genes", "chromosome", "name", "mechanism", "Down syndrome inheritance"]}
{"question": "A 6-month-old infant male is brought to the emergency department with a 1-hour history of vomiting and convulsions. He was born at home and had sporadic prenatal care though his parents say that he appeared healthy at birth. He initially fed well; however, his parents have noticed that he has been feeding poorly and is very irritable since they moved on to baby foods. They have also noticed mild yellowing of his skin but assumed it would go away over time. On presentation, he is found to be very sleepy, and physical exam reveals an enlarged liver and spleen. The rest of the physical exam is normal. Which of the following enzymes is most likely functioning abnormally in this patient?", "answer": "Aldolase B", "options": {"A": "Aldolase B", "B": "Fructokinase", "C": "Gal-1-phosphate uridyl transferase", "D": "Galactokinase deficiency", "E": "Lactase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old infant male", "brought", "emergency department", "hour history", "vomiting", "convulsions", "born at home", "sporadic", "appeared healthy", "birth", "initially fed well", "poorly", "very irritable", "moved", "to", "mild yellowing", "skin", "go", "time", "found to", "very sleepy", "reveals", "enlarged liver", "spleen", "normal", "following enzymes", "most likely functioning", "patient"]}
{"question": "A 24-year-old woman is brought to the physician for the evaluation of fatigue for the past 6 months. During this period, she has had recurrent episodes of constipation and diarrhea. She also reports frequent nausea and palpitations. She works as a nurse at a local hospital. She has tried cognitive behavioral therapy, but her symptoms have not improved. Her mother has hypothyroidism. The patient is 170 cm (5 ft 7 in) tall and weighs 62 kg (137 lb); BMI is 21.5 kg/m2. She appears pale. Vital signs are within normal limits. Examination shows calluses on the knuckles and bilateral parotid gland enlargement. Oropharyngeal examination shows eroded dental enamel and decalcified teeth. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Administration of fluoxetine", "options": {"A": "Administration of fluoxetine", "B": "Administration of mirtazapine", "C": "Administration of olanzapine", "D": "Administration of venlafaxine", "E": "Administration of topiramate\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "physician", "fatigue", "past 6 months", "period", "recurrent episodes of constipation", "diarrhea", "reports frequent nausea", "palpitations", "nurse", "local hospital", "cognitive behavioral therapy", "symptoms", "not improved", "hypothyroidism", "patient", "5 ft", "tall", "62 kg", "BMI", "kg/m2", "appears pale", "Vital signs", "normal limits", "calluses", "knuckles", "bilateral parotid gland enlargement", "Oropharyngeal", "eroded dental enamel", "teeth", "abnormalities", "following", "most appropriate next step"]}
{"question": "A 50-year-old woman comes to the physician because of intermittent pain and numbness in her right hand for 6 weeks. She has a pins-and-needles sensation that worsens at night and is relieved when she shakes her hand. She also has episodic left knee pain throughout the day. She has a history of hypertension controlled with lisinopril. She takes over-the-counter medications for constipation. Her BMI is 35 kg/m2. Her mother has a history of rheumatoid arthritis. She looks fatigued. Her pulse is 57/min and blood pressure is 120/75 mm Hg. On physical examination, there is normal range of motion in the wrists and digits. Sensation is decreased to light touch in the thumb and index finger. There is no thenar muscle atrophy. Deep tendon reflexes are 1+ and there is mild edema in the legs. Which of the following treatments is most likely to benefit the patient?", "answer": "L-thyroxine", "options": {"A": "L-thyroxine", "B": "Methotrexate", "C": "Ibuprofen", "D": "Surgical decompression", "E": "Oral prednisone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["50 year old woman", "physician", "intermittent pain", "numbness", "right", "weeks", "pins", "needles sensation", "worsens", "night", "relieved", "shakes", "hand", "episodic left knee pain", "day", "history of hypertension controlled", "lisinopril", "over-the-counter medications", "constipation", "BMI", "35 kg/m2", "history of rheumatoid arthritis", "looks fatigued", "pulse", "57 min", "blood pressure", "75 mm Hg", "normal range of motion", "wrists", "digits", "Sensation", "decreased", "light", "thumb", "index finger", "thenar muscle atrophy", "Deep tendon reflexes", "1", "mild edema", "legs", "following treatments", "to benefit", "patient"]}
{"question": "A 13-year-old female presents to the emergency room complaining of severe abdominal pain. She reports acute onset of diffuse abdominal pain twelve hours prior to presentation. She has vomited twice and has not had a bowel movement in that time. She is in the fetal position because it relieves the pain. Her past medical history is notable for asthma; however, she was adopted as a baby and her family history is unknown. Her temperature is 99.7°F (37.6°C), blood pressure is 130/85 mmHg, pulse is 110/min, and respirations are 22/min. Physical examination reveals abdominal distension and tenderness to palpation. A sausage-shaped abdominal mass is palpated in the right upper quadrant. Mucocutaneous blue-gray macules are evident on the child’s buccal mucosa. A mutation in which of the following genes is associated with this patient’s condition?", "answer": "STK11", "options": {"A": "C-KIT", "B": "NF1", "C": "TP53", "D": "APC", "E": "STK11"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female presents", "emergency room", "severe abdominal", "reports acute onset", "diffuse abdominal pain twelve hours", "vomited twice", "not", "bowel movement", "time", "fetal position", "relieves", "pain", "past medical history", "notable", "asthma", "adopted", "baby", "family history", "unknown", "temperature", "99", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "reveals abdominal distension", "tenderness", "palpation", "shaped abdominal mass", "right upper quadrant", "blue gray macules", "childs buccal mucosa", "following", "associated with", "patients condition"]}
{"question": "A 34-year-old woman presents to her OB/GYN with complaints of missing her last 3 periods as well as intermittent spontaneous milky-white nipple discharge bilaterally for the past 3 months. Vital signs are stable and within normal limits. Neurologic examination is without abnormality, including normal visual fields. Serology and MRI of the brain are ordered, with results pending. Which of the following sets of laboratory results would be expected in this patient?", "answer": "Increased prolactin, decreased FSH, decreased LH", "options": {"A": "Decreased prolactin, decreased FSH, decreased LH", "B": "Decreased prolactin, increased FSH, increased LH", "C": "Increased prolactin, decreased FSH, increased LH", "D": "Increased prolactin, decreased FSH, decreased LH", "E": "Increased prolactin, increased FSH, increased LH"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "OB/GYN", "complaints", "missing", "last", "periods", "intermittent spontaneous milky white nipple discharge", "past 3 months", "Vital signs", "stable", "normal limits", "Neurologic examination", "abnormality", "including normal visual fields", "Serology", "MRI of", "brain", "ordered", "results", "following sets", "laboratory results", "patient"]}
{"question": "A 29-year-old primigravid woman at 24 weeks' gestation comes to the physician for a prenatal visit. She feels well. She has no personal history of serious illness. Medications include iron supplements and a multivitamin. 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 24-week gestation. A 1-hour 50-g glucose challenge shows a glucose concentration of 155 mg/dL (N < 135 mg/dL). A 100-g oral glucose tolerance test shows glucose concentrations of 205 mg/dL (N < 180 mg/dL) and 154 mg/dL (N <140 mg/dL) at 1 and 3 hours, respectively. She refuses treatment with insulin. Which of the following complications is her infant at greatest risk of developing at birth?", "answer": "Hypocalcemia", "options": {"A": "Hypocalcemia", "B": "Omphalocele", "C": "Intrauterine growth restriction", "D": "Hypermagnesemia", "E": "Hyperglycemia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old primigravid woman", "weeks", "gestation", "physician", "well", "personal history", "serious illness", "Medications include iron supplements", "multivitamin", "temperature", "blood pressure", "60 mm Hg", "Pelvic examination", "uterus", "size", "week gestation", "hour 50 g glucose challenge", "glucose concentration", "mg/dL", "N", "mg/dL", "100 g oral glucose tolerance test", "glucose concentrations", "mg/dL", "N", "mg/dL", "mg/dL", "N", "mg/dL", "at 1", "3 hours", "treatment", "insulin", "following complications", "infant", "greatest", "birth"]}
{"question": "A 45-year-old man walks into an urgent care clinic complaining of a headache and dizziness. Earlier today he was in his normal state of health when symptoms started and lasted about 20 minutes. He did not lose consciousness or actually vomit. He also mentions that he was sweating a lot at that time. He has had similar dizzy spells on three separate occasions. His past medical history is significant for a total thyroidectomy 10 years ago for carcinoma. He takes levothyroxine and a multivitamin every day. Several family members seem to suffer from similar spells. At the clinic, his blood pressure is 140/90 mm Hg, his heart rate is 120/min, his respiratory rate is 18/min, and his temperature is 36.6 °C (98.0 °F). On physical exam, he appears quite anxious and uncomfortable. His heart rate is tachycardic with normal rhythm and his lungs are clear to auscultation bilaterally. Small nodules are observed on his buccal mucosa and tongue. The patient is referred to an endocrinologist for further assessment and CT. On CT exam, a mass is observed involving the medulla of his right adrenal gland. Which of the following additional symptoms is associated with this patients condition?", "answer": "Pale skin", "options": {"A": "Bronchospasm", "B": "Decreased cardiac contractility", "C": "Pale skin", "D": "Bradycardia", "E": "Pupillary constriction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A", "year old man walks", "urgent care clinic complaining of", "headache", "dizziness", "Earlier today", "normal state of health", "symptoms started", "lasted", "20 minutes", "not", "consciousness", "vomit", "sweating", "lot", "time", "similar dizzy spells", "three separate occasions", "past medical history", "significant", "total thyroidectomy", "carcinoma", "levothyroxine", "multivitamin", "day", "to suffer", "similar spells", "clinic", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98 0 F", "appears", "anxious", "heart rate", "tachycardic", "normal rhythm", "lungs", "clear", "auscultation", "Small nodules", "observed", "buccal mucosa", "tongue", "patient", "referred", "endocrinologist", "further", "CT", "CT exam", "mass", "observed involving", "medulla of", "right adrenal gland", "following additional symptoms", "associated with", "patients condition"]}
{"question": "A 68-year-old male with past history of hypertension, hyperlipidemia, and a 30 pack/year smoking history presents to his primary care physician for his annual physical. Because of his age and past smoking history, he is sent for screening abdominal ultrasound. He is found to have a 4 cm infrarenal abdominal aortic aneurysm. Surgical repair of his aneurysm is indicated if which of the following are present?", "answer": "Abdominal, back, or groin pain", "options": {"A": "Abdominal, back, or groin pain", "B": "Smoking history", "C": "Diameter >3 cm", "D": "Growth of < 0.5 cm in one year", "E": "Marfan's syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male", "past history of hypertension", "hyperlipidemia", "30", "smoking history presents", "primary care physician", "annual physical", "age", "past smoking", "sent", "screening abdominal ultrasound", "found to", "4", "abdominal aortic aneurysm", "Surgical repair", "indicated", "following", "present"]}
{"question": "Twelve hours after undergoing a femoral artery embolectomy, an 84-year-old man is found unconscious on the floor by his hospital bed. He had received a patient-controlled analgesia pump after surgery. He underwent 2 coronary bypass surgeries, 2 and 6 years ago. He has coronary artery disease, hypertension, hypercholesterolemia, gastroesophageal reflux, and type 2 diabetes mellitus. His current medications include metoprolol, atorvastatin, lisinopril, sublingual nitrate, and insulin. He appears pale. His temperature is 36.1°C (97°F), pulse is 120/min, respirations are 24/min, and blood pressure 88/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 85%. The patient does not respond to commands and withdraws his extremities to pain. The pupils are constricted bilaterally. Examination shows cold, clammy skin and jugular venous distention. There is ecchymosis on the right temple and maxilla. There is a surgical incision over the right thigh that shows no erythema or discharge. Crackles are heard at both lung bases. A new grade 2/6 systolic murmur is heard at the apex. He is intubated and mechanically ventilated. Further evaluation of this patient is most likely to show which of the following?", "answer": "A new left bundle branch block on an ECG", "options": {"A": "Transudate within the pericardial layers", "B": "A new left bundle branch block on an ECG", "C": "Pulsatile abdominal mass at the level of the umbilicus", "D": "Positive procalcitonin and interleukin-6 levels", "E": "Improved mental status after naloxone administration\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Twelve hours", "femoral artery embolectomy", "84 year old man", "found unconscious", "floor", "hospital bed", "received", "patient-controlled analgesia pump", "surgery", "2 coronary bypass surgeries", "2", "years", "coronary artery disease", "hypertension", "hypercholesterolemia", "gastroesophageal reflux", "type 2 diabetes mellitus", "current medications include metoprolol", "atorvastatin", "lisinopril", "sublingual nitrate", "insulin", "appears pale", "temperature", "36", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "85", "patient", "not", "extremities", "pain", "pupils", "constricted", "cold", "clammy skin", "jugular venous distention", "ecchymosis", "right temple", "maxilla", "surgical incision", "right thigh", "erythema", "discharge", "Crackles", "heard", "lung bases", "new", "systolic murmur", "heard", "apex", "intubated", "ventilated", "Further", "patient", "to", "following"]}
{"question": "An 8-year-old boy is brought to the physician because of a 2-month history of headaches. He is at the 25th percentile for weight and 80th percentile for height. His vital signs are within normal limits. Physical examination shows no abnormalities. CT scan of the head shows a small suprasellar cystic mass compressing the infundibular stalk. Serum concentration of which of the following hormones is most likely to be increased in this patient?", "answer": "Prolactin", "options": {"A": "Luteinizing hormone", "B": "Somatotropin", "C": "Prolactin", "D": "Adrenocorticotropic hormone", "E": "Vasopressin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "of", "2 month history", "headaches", "percentile", "weight", "80th percentile", "height", "vital signs", "normal", "Physical examination", "abnormalities", "CT scan of the head", "small suprasellar cystic mass compressing", "infundibular stalk", "Serum concentration", "following hormones", "to", "increased", "patient"]}
{"question": "A 39-year-old woman comes to the physician because of recurrent episodes of severe pain over her neck, back, and shoulders for the past year. The pain worsens with exercise and lack of sleep. Use of over-the-counter analgesics have not resolved her symptoms. She also has stiffness of the shoulders and knees and tingling in her upper extremities that is worse in the morning. She takes escitalopram for generalized anxiety disorder. She also has tension headaches several times a month. Her maternal uncle has ankylosing spondylitis. Examination shows marked tenderness over the posterior neck, bilateral mid trapezius, and medial aspect of the left knee. Muscle strength is normal. Laboratory studies, including a complete blood count, erythrocyte sedimentation rate, and thyroid-stimulating hormone are within the reference ranges. X-rays of her cervical and lumbar spine show no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Fibromyalgia", "options": {"A": "Polymyalgia rheumatica", "B": "Fibromyalgia", "C": "Axial spondyloarthritis", "D": "Polymyositis", "E": "Major depressive disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of recurrent episodes", "severe pain", "neck", "back", "shoulders", "past year", "pain worsens", "exercise", "lack of sleep", "Use", "over-the-counter analgesics", "not resolved", "symptoms", "stiffness", "shoulders", "knees", "tingling", "upper extremities", "worse", "morning", "escitalopram", "generalized anxiety disorder", "tension headaches", "times", "month", "ankylosing spondylitis", "marked tenderness", "posterior", "bilateral", "trapezius", "medial aspect of", "left knee", "Muscle strength", "normal", "Laboratory", "including", "complete blood count", "erythrocyte sedimentation rate", "thyroid-stimulating hormone", "reference ranges", "X-rays", "cervical", "lumbar spine", "abnormalities", "following", "diagnosis"]}
{"question": "A cross-sectional study of 650 patients with confirmed bronchogenic carcinoma was conducted in patients of all age groups in order to establish a baseline picture for further mortality comparisons. All patients were investigated using thoracic ultrasound and computed tomography of the chest. Also, data about the size of the mass, invasion of lymph nodes and chest wall, pleural effusion, and eventual paralysis of the diaphragm were noted. The bias that can arise in this case, and that may hamper further conclusions on the aggressiveness and mortality of bronchogenic carcinoma, may be explained as a tendency to which of the following aspects?", "answer": "Uncover more indolent cases of the disease preferentially", "options": {"A": "Find more cases of the disease in older cohorts", "B": "Observe only the late stages of a disease with more severe manifestations", "C": "Detect only asymptomatic cases of the disease", "D": "Uncover more indolent cases of the disease preferentially", "E": "Identify more instances of fatal disease"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["650 patients", "confirmed bronchogenic carcinoma", "patients", "age groups", "order to establish", "baseline picture", "further mortality", "patients", "investigated using", "ultrasound", "computed tomography of", "chest", "data", "size of", "mass", "invasion", "lymph nodes", "chest wall", "pleural effusion", "paralysis of", "diaphragm", "noted", "case", "hamper further", "aggressiveness", "mortality", "bronchogenic carcinoma", "following aspects"]}
{"question": "A randomized, controlled trial was undertaken by a team of clinical researchers to evaluate a new drug for the treatment of cluster headaches. This type of headache (that mostly affects men) is characterized by excruciating pain on 1 side of the head. After careful randomization and controlling for all of the known confounders, a total of 200 patients with cluster headaches were divided into 2 groups. The first group of study participants received 40 mg of the new drug, X, in the form of a powder mixed with water. The second group received 80 mg of verapamil (a calcium channel blocker that is commonly prescribed for cluster headaches) in the form of a labeled pill. Participants from both groups were mixed together in rooms designated for drug research purposes and could communicate freely. After the study period has finished without any loss to follow-up or skipped treatments, the outcome (pain alleviation) was assessed by trained researchers that were blinded to treatment assignment. Study results have shown that the new drug is more efficacious than current gold standard by both clinically and statistically significant margin. Therefore, the investigators concluded that this drug should be introduced for the treatment of cluster headaches. However, their conclusions are likely to be criticized on the grounds of which of the following?", "answer": "Response bias", "options": {"A": "Observer bias", "B": "Response bias", "C": "Convenience sampling bias", "D": "Attrition bias", "E": "Intention to treat bias"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["clinical researchers to", "new drug", "treatment", "cluster headaches", "type", "headache", "mostly", "excruciating pain", "1 side of", "head", "controlling", "known", "total", "200 patients", "cluster headaches", "divided", "first", "received 40 mg", "new drug", "form", "powder mixed", "water", "received 80 mg", "verapamil", "calcium channel blocker", "cluster headaches", "form", "labeled pill", "groups", "mixed together", "rooms designated", "purposes", "communicate freely", "study period", "finished", "loss to follow-up", "skipped treatments", "outcome", "pain", "trained researchers", "assignment", "Study results", "new drug", "more efficacious", "current gold standard", "statistically significant margin", "investigators concluded", "drug", "introduced", "treatment", "cluster headaches", "likely to"]}
{"question": "A previously healthy 15-year-old girl is brought to the physician by her parents for lethargy, increased thirst, and urinary frequency for 10 days. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2. Physical examination shows no abnormalities. Her serum glucose concentration is 224 mg/dL. A urine dipstick is positive for ketone bodies. Which of the following is most likely involved in the pathogenesis of this patient's condition?", "answer": "T-cell infiltration of pancreatic islets", "options": {"A": "Expression of human leukocyte antigen subtype A3", "B": "B-cell production of antimitochondrial antibodies", "C": "Complement-mediated destruction of insulin receptors", "D": "T-cell infiltration of pancreatic islets", "E": "Pancreatic islet amyloid polypeptide deposition"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old girl", "brought", "physician", "lethargy", "increased thirst", "urinary frequency", "10 days", "5 ft 8", "tall", "54 kg", "BMI", "kg/m2", "abnormalities", "serum", "mg/dL", "urine dipstick", "positive", "ketone bodies", "following", "most likely involved", "pathogenesis", "patient's condition"]}
{"question": "Last night you admitted a 72-year-old woman with severe COPD in respiratory distress. She is currently intubated and sedated and her family is at bedside. At the completion of morning rounds, the patient's adult son asks that you and the team take a minute to pray with him for his mother. What is the most appropriate response?", "answer": "\"I understand what you are experiencing and am happy to take a minute.\"", "options": {"A": "\"I'm sorry, but this is a public hospital, so we cannot allow any group prayers.\"", "B": "\"I understand what you are experiencing and am happy to take a minute.\"", "C": "\"I also believe in the power of prayer, so I will pray with you and insist that the rest of team joins us.\"", "D": "\"While I cannot offer you my prayers, I will work very hard to take care of your mother.\"", "E": "\"I don't feel comfortable praying for patients, but I will happily refer you to pastoral care.\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Last night", "72 year old woman", "severe COPD", "respiratory distress", "currently intubated", "sedated", "completion", "patient's", "minute", "pray", "most appropriate response"]}
{"question": "A previously healthy 32-year-old man comes to the physician because of a 2-month history of fatigue and daytime sleepiness. He works as an accountant and cannot concentrate at work anymore. He also has depressed mood and no longer takes pleasure in activities he used to enjoy, such as playing tennis with his friends. He has decreased appetite and has had a 4-kg (8.8-lb) weight loss of over the past 2 months. He does not have suicidal ideation. He is diagnosed with major depressive disorder and treatment with paroxetine is begun. The patient is at greatest risk for which of the following adverse effects?", "answer": "Decreased libido", "options": {"A": "Urinary retention", "B": "Increased suicidality", "C": "Decreased libido", "D": "Postural hypotension", "E": "Priapism"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "2 month history", "fatigue", "daytime sleepiness", "accountant", "concentrate", "depressed mood", "longer", "used", "as playing", "decreased appetite", "4 kg", "8.8", "weight loss of", "past", "months", "not", "suicidal ideation", "diagnosed", "major depressive disorder", "treatment", "paroxetine", "begun", "patient", "greatest", "following adverse effects"]}
{"question": "A 20-year-old woman is brought to the emergency department with a puncture wound on the right side of her chest. She was walking to her apartment when she was assaulted. As she resisted to give up her purse, the assailant stabbed her in the chest with a knife and ran away. She is in severe respiratory distress. Her heart rate is 140/min, respiratory rate is 28/min, and blood pressure is 145/65 mm Hg. The pulse oximetry shows an oxygen saturation of 84%. An oval puncture wound is seen on the right lateral aspect of her chest and she is stuporous. The heart sounds are normal and no jugular venous distension is seen. Distant breath sounds are present on the right. Which of the following changes during inspiration explains her breathing difficulty?", "answer": "Equal intrapleural and atmospheric pressures", "options": {"A": "Diminished inspiratory force due to pain", "B": "Decreased intrapleural pressure", "C": "Equal intrapleural and atmospheric pressures", "D": "Paralysis of the diaphragm", "E": "Increased elastic force of the chest wall pulling it inwards"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old woman", "brought", "emergency department", "puncture wound", "right side", "chest", "apartment", "assaulted", "to give", "stabbed", "chest", "knife", "ran away", "severe respiratory distress", "heart rate", "min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "pulse oximetry", "oxygen saturation", "84", "oval puncture wound", "seen", "right lateral aspect", "chest", "stuporous", "heart sounds", "normal", "jugular venous distension", "seen", "Distant breath sounds", "present", "right", "following changes", "inspiration", "breathing difficulty"]}
{"question": "A 54-year-old man electively underwent an open cholecystectomy for his cholelithiasis. The procedure was performed under general anesthesia with inhaled anesthetic agents after induction with an intravenous agent. The surgeon operated quickly, and the procedure was uncomplicated. As the surgery ended, the anesthesia resident stopped the anesthesia and noticed the oxygen saturation gradually decreasing to 84%. He quickly administers 100% oxygen and the hypoxia improves. Which of the following most likely accounts for the decreased oxygen saturation seen after the anesthesia was stopped in this patient?", "answer": "Diffusion hypoxia", "options": {"A": "Pneumothorax", "B": "Cardiotoxicity", "C": "Second gas effect", "D": "Laryngospasm", "E": "Diffusion hypoxia"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["54 year old man", "open cholecystectomy", "cholelithiasis", "procedure", "performed", "general anesthesia", "inhaled anesthetic agents", "induction", "intravenous agent", "surgeon operated", "procedure", "uncomplicated", "surgery ended", "anesthesia resident stopped", "anesthesia", "oxygen saturation", "decreasing", "84", "administers 100", "oxygen", "hypoxia improves", "following", "likely accounts", "decreased oxygen saturation seen", "anesthesia", "stopped", "patient"]}
{"question": "A 37-year-old woman presents to clinic for routine checkup. She has no complaints with the exception of occasional \"shortness of breath.\" Her physical examination is unremarkable with the exception of a \"snap\"-like sound after S2, followed by a rumbling murmur. You notice that this murmur is heard best at the cardiac apex. A history of which of the following are you most likely to elicit upon further questioning of this patient?", "answer": "Repeated episodes of streptococcal pharyngitis as a child", "options": {"A": "Family history of aortic valve replacement at a young age", "B": "Hyperflexibility, vision problems, and pneumothorax", "C": "Systolic click auscultated on physical exam 10 years prior", "D": "Repeated episodes of streptococcal pharyngitis as a child", "E": "Cutaneous flushing, diarrhea, and bronchospasm"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic", "routine checkup", "complaints", "of occasional", "shortness", "breath", "unremarkable", "snap", "sound", "S2", "followed by", "rumbling murmur", "murmur", "heard best", "cardiac apex", "history", "following", "to elicit", "further", "patient"]}
{"question": "A 57-year-old man comes to the emergency department because of shortness of breath and palpitations for 3 hours. He has had similar episodes intermittently for 4 months. His pulse is 140/min and blood pressure is 90/60 mm Hg. An ECG shows irregular narrow-complex tachycardia with no discernable P waves. Emergent electrical cardioversion is performed and the patient reverts to normal sinus rhythm. Pharmacotherapy with sotalol is begun. Which of the following is the most likely physiologic effect of this drug?", "answer": "Decreased AV nodal conduction", "options": {"A": "Decreased AV nodal conduction", "B": "Increased ventricular repolarization rate", "C": "Decreased Purkinje fiber conduction", "D": "Increased myocyte inotropy", "E": "Increased K+ efflux from myocytes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["57 year old man", "emergency department", "of shortness", "breath", "palpitations", "hours", "similar episodes", "months", "pulse", "min", "blood pressure", "90 60 mm Hg", "ECG", "irregular narrow complex tachycardia", "discernable P waves", "electrical cardioversion", "performed", "patient", "normal sinus rhythm", "Pharmacotherapy", "sotalol", "begun", "following", "physiologic effect of", "drug"]}
{"question": "A 53-year-old man presents to your Louisiana gulf coast community hospital with 48 hours of profuse watery diarrhea and 24 hours of vomiting and chills. The patient has a past medical history significant for hypertension and hypercholesterolemia. The patient denies sick contacts or any interaction with animals for the last month. Two days ago the patient attended a family crawfish boil where oysters, boiled crabs, and crawfish were consumed. Stool occult blood was negative. What is the most likely etiology of the patient's symptoms?", "answer": "Vibrio vulnificus", "options": {"A": "Campylobacter jejuni", "B": "Listeria monocytogenes", "C": "Vibrio vulnificus", "D": "Brucella melitensis", "E": "Shigella dysenteriae"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "Louisiana", "community hospital", "48 hours", "watery diarrhea", "24 hours", "vomiting", "chills", "patient", "past medical history significant", "hypertension", "hypercholesterolemia", "patient", "sick", "interaction", "animals", "last month", "Two days", "patient attended", "boil", "boiled crabs", "Stool occult blood", "negative", "etiology", "patient's symptoms"]}
{"question": "A 59-year-old presents with right-sided hemiparesis, right-sided sensory loss, leftward eye deviation, and slurred speech. A head CT is performed which is significant for a hyperdense lesion affecting the putamen. The patient has a history of hypertension treated with hydrochlorothiazide, but is non-adherent. Which of the following is most likely associated with the cause of this patient’s neurological deficits?", "answer": "Vessel lipohyalinosis and microaneurysm formation", "options": {"A": "Thrombotic development over ruptured atherosclerotic plaque", "B": "Vessel lipohyalinosis and microaneurysm formation", "C": "Amyloid deposition in small cortical vessels", "D": "Predisposed vessel rupture secondary to cortical atrophy", "E": "Saccular aneurysm rupture into the subarachnoid space"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["59 year old presents", "right-sided hemiparesis", "right-sided sensory loss", "eye deviation", "slurred speech", "head CT", "performed", "significant", "lesion affecting", "putamen", "patient", "history of hypertension treated with hydrochlorothiazide", "non-adherent", "following", "most likely associated with", "cause", "patients neurological deficits"]}
{"question": "A 58-year-old man is brought to the Emergency Department after 2 days of shortness breath, orthopnea, and lower limb edema. His past medical history is significant for hypertension and a myocardial infarction 3 years ago that required a coronary arterial bypass graft. He has not been able to take prescribed medicine in several months due to recent unemployment and issues with insurance. On admission, his blood pressure is 155/92 mmHg, heart rate is 102/min, respiratory rate is 24/min, and temperature is 36.4°C (97.5°F). On physical examination there are fine rales in both lungs, regular and rhythmic cardiac sounds with an S3 gallop and a grade II/VI holosystolic murmur. Initial laboratory tests are shown below:\nNa+ 140 mEq/L\nK+ 4.2 mEq/L\nCl- 105 mEq/L\nBUN 20 mg/dL\nCreatinine 0.8 mg/dL\nThe patient is stabilized and admitted to the hospital. The next day his blood pressure is 110/60 mmHg, heart rate is 110/min, respiratory rate is 18/min, and temperature is 36.4°C (97.5°F). This morning's laboratory tests are shown below:\nNa+  135 mEq/L\nK+ 3.2 mEq/L\nCl- 102 mEq/L\nBUN 45 mg/dL\nCreatinine 1.7 mg/dL\nWhich of the following best explains the changes seen in this patient?", "answer": "Diuretic therapy", "options": {"A": "Diuretic therapy", "B": "Cholesterol emboli", "C": "Chronic renal failure", "D": "Glomerular basement membrane damage", "E": "Urinary tract obstruction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old man", "brought", "Emergency Department", "2 days of shortness breath", "orthopnea", "lower limb edema", "past medical history", "significant", "hypertension", "myocardial infarction", "years", "required", "coronary arterial", "not", "able to", "medicine", "months", "recent unemployment", "issues", "blood pressure", "mmHg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "fine rales", "lungs", "regular", "rhythmic cardiac sounds", "S3 gallop", "VI holosystolic murmur", "Initial laboratory tests", "Na", "mEq", "K", "4", "105", "20 mg dL Creatinine 0.8", "dL", "patient", "stabilized", "next day", "blood pressure", "60 mmHg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "morning's laboratory tests", "Na", "mEq", "K", "45 mg dL Creatinine", "dL", "following best", "changes seen", "patient"]}
{"question": "A 28-year-old woman presents to discuss the results of her Pap smear. Her previous Pap smear 1 year ago showed atypical squamous cells of undetermined significance. This year the Pap smear was negative. She had a single pregnancy with a cesarean delivery. Currently, she and her partner do not use contraception because they are planning another pregnancy. She does not have any concurrent diseases and her family history is unremarkable. The patient is concerned about her previous Pap smear finding. She heard from her friend about a vaccine which can protect her against cervical cancer. She has never had such a vaccine and would like to be vaccinated. Which of the following answers regarding the vaccination in this patient is correct?", "answer": "HPV vaccination is not recommended for women older than 26 years of age.", "options": {"A": "The patient can receive the vaccine after the pregnancy test is negative.", "B": "The patient should receive this vaccination as soon as possible.", "C": "This vaccination does not produce proper immunity in people who had at least 1 abnormal cytology report, so is unreasonable in this patient.", "D": "The patient should undergo HPV DNA testing; vaccination is indicated if the DNA testing is negative.", "E": "HPV vaccination is not recommended for women older than 26 years of age."}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents to", "results", "Pap smear", "previous Pap smear 1 year", "year", "Pap smear", "negative", "single pregnancy", "cesarean delivery", "Currently", "not use contraception", "planning", "pregnancy", "not", "concurrent diseases", "family history", "unremarkable", "patient", "previous Pap smear finding", "heard", "vaccine", "cervical cancer", "never", "vaccine", "to", "vaccinated", "following", "vaccination", "patient", "correct"]}
{"question": "A 9-year-old girl is brought to the emergency room by her parents with severe shortness of breath, cough, and wheezing after playing with her friends in the garden. She has a history of bronchial asthma. Her vital signs are as follows: respiratory rate 39/min, pulse 121/min, blood pressure 129/67 mm Hg, and temperature 37.2°C (99°F). On physical exam, she looks confused and has bilateral diffuse wheezes on chest auscultation. Which of the following is the most appropriate drug to rapidly reverse her respiratory distress?", "answer": "Inhaled albuterol", "options": {"A": "Inhaled cromolyn", "B": "Intravenous propranolol", "C": "Inhaled beclomethasone", "D": "Inhaled albuterol", "E": "Oral montelukast"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "emergency room", "cough", "wheezing", "playing", "garden", "history of bronchial asthma", "vital signs", "follows", "respiratory rate", "min", "pulse", "min", "blood pressure", "67 mm Hg", "temperature", "looks confused", "bilateral diffuse wheezes", "chest auscultation", "following", "most appropriate drug", "rapidly reverse", "respiratory distress"]}
{"question": "A 45-year-old woman presents to the emergency department due to new-onset symptoms of asthma. She reports that the asthmatic attacks started a week ago. The past medical history includes gastroesophageal reflux disease and hepatitis B. On physical examination, the patient has bilateral foot drop as well as numbness and tingling sensation in all extremities. A complete blood count is relevant for eosinophilia of 9.1 × 108/L. Which of the markers below could explain all of the patient’s current symptoms?", "answer": "p-ANCA", "options": {"A": "ESR", "B": "p-ANCA", "C": "HLA B-27", "D": "Anti-Ro/SSA", "E": "Anti-histone antibodies"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department due to new-onset symptoms", "asthma", "reports", "asthmatic attacks started", "week", "past medical history includes gastroesophageal reflux disease", "hepatitis B", "patient", "bilateral foot drop", "numbness", "tingling sensation", "extremities", "complete blood count", "relevant", "eosinophilia", "markers", "patients current symptoms"]}
{"question": "A 45-year-old man is brought to the physician for a follow-up examination. Three weeks ago, he was hospitalized and treated for spontaneous bacterial peritonitis. He has alcoholic liver cirrhosis and hypothyroidism. His current medications include spironolactone, lactulose, levothyroxine, trimethoprim-sulfamethoxazole, and furosemide. He appears ill. His temperature is 36.8°C (98.2°F), pulse is 77/min, and blood pressure is 106/68 mm Hg. He is oriented to place and person only. Examination shows scleral icterus and jaundice. There is 3+ pedal edema and reddening of the palms bilaterally. Breast tissue appears enlarged, and several telangiectasias are visible over the chest and back. Abdominal examination shows dilated tortuous veins. On percussion of the abdomen, the fluid-air level shifts when the patient moves from lying supine to right lateral decubitus. Breath sounds are decreased over both lung bases. Cardiac examination shows no abnormalities. Bilateral tremor is seen when the wrists are extended. Genital examination shows reduced testicular volume of both testes. Digital rectal examination and proctoscopy show hemorrhoids. Which of the following potential complications of this patient's condition is the best indication for the placement of a transjugular intrahepatic portosystemic shunt (TIPS)?", "answer": "Recurrent variceal hemorrhage", "options": {"A": "Hepatic veno-occlusive disease", "B": "Recurrent variceal hemorrhage", "C": "Portal hypertensive gastropathy", "D": "Hepatic encephalopathy", "E": "Hepatic hydrothorax"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "physician", "follow-up examination", "Three weeks", "hospitalized", "treated", "spontaneous bacterial peritonitis", "alcoholic liver cirrhosis", "hypothyroidism", "current medications include spironolactone", "lactulose", "levothyroxine", "trimethoprim-sulfamethoxazole", "furosemide", "appears ill", "temperature", "36", "98", "pulse", "min", "blood pressure", "mm Hg", "oriented to place", "only", "scleral icterus", "jaundice", "3", "pedal edema", "Breast tissue appears enlarged", "several telangiectasias", "visible", "chest", "back", "Abdominal", "dilated tortuous veins", "percussion", "abdomen", "fluid air level shifts", "patient moves", "lying supine", "right lateral decubitus", "Breath sounds", "decreased", "lung bases", "abnormalities", "Bilateral tremor", "seen", "wrists", "extended", "Genital examination", "reduced testicular volume of", "testes", "Digital rectal examination", "proctoscopy", "hemorrhoids", "following potential complications", "patient's condition", "best", "placement", "transjugular intrahepatic portosystemic shunt", "TIPS"]}
{"question": "Three days after delivery of a male newborn, a 36-year-old gravida 1, para 1 woman has fever and pain in her left leg. Pregnancy was complicated by premature rupture of membranes; the child was delivered at 35 weeks' gestation by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. The patient has smoked half a pack of cigarettes daily for 5 years and continued to smoke during her pregnancy. Her temperature is 38.9°C (102°F), pulse is 110/min, and blood pressure is 110/80 mm Hg. Examination shows an edematous, erythematous, and warm left leg. Passive dorsiflexion of the left foot elicits pain in the calf. The peripheral pulses are palpated bilaterally. The uterus is nontender and palpated at the umbilicus. Ultrasonography of the left leg shows an incompressible left popliteal vein. Which of the following is the most appropriate initial step in management?", "answer": "Low molecular weight heparin", "options": {"A": "Low molecular weight heparin", "B": "Embolectomy", "C": "Urokinase", "D": "Warfarin", "E": "Graduated compression stockings"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Three days", "delivery", "male newborn", "36 year old gravida 1", "para 1 woman", "fever", "pain in", "left leg", "Pregnancy", "complicated", "premature rupture of membranes", "child", "delivered", "35 weeks", "gestation", "lower segment transverse cesarean", "fetal heart rate", "patient", "smoked half", "pack", "cigarettes daily", "to smoke", "pregnancy", "temperature", "pulse", "min", "blood pressure", "80 mm Hg", "edematous", "erythematous", "warm left leg", "Passive dorsiflexion of", "left foot elicits pain in", "calf", "peripheral pulses", "uterus", "nontender", "umbilicus", "Ultrasonography", "left leg", "left popliteal vein", "following", "most appropriate initial step"]}
{"question": "Three hours later, the patient is reassessed. Her right arm is put in an elevated position and physical examination of the extremity is performed. The examination reveals reduced capillary return and peripheral pallor. Pulse oximetry of her right index finger on room air shows an oxygen saturation of 84%. Which of the following is the most appropriate next step in management?", "answer": "Perform escharotomy", "options": {"A": "Perform fasciotomy", "B": "Perform right upper extremity amputation", "C": "Obtain split-thickness skin graft", "D": "Decrease rate of IV fluids", "E": "Perform escharotomy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["Three hours later", "patient", "right arm", "elevated position", "physical examination of the extremity", "performed", "reveals reduced capillary return", "peripheral pallor", "Pulse", "right index finger", "room air", "oxygen saturation", "84", "following", "most appropriate next step"]}
{"question": "A 65-year-old man comes to the emergency department because of sudden, worsening pain in his right calf and foot that started 30 minutes ago. He also has a tingling sensation and weakness in his right leg. He has had no similar episodes, recent trauma, or claudication. He has type 2 diabetes mellitus and was diagnosed with hypertension 20 years ago. His sister has systemic sclerosis. He works as an office administrator and sits at his desk most of the day. He has smoked one and a half packs of cigarettes daily for 30 years. Current medications include metformin and lisinopril. His pulse is 110/min, respirations are 16/min, and blood pressure is 140/90 mm Hg. His right leg is pale and cool to touch. Muscle strength in his right leg is mildly reduced. Pedal pulses are absent on the right. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Arterial embolism", "options": {"A": "Arterial vasospasm", "B": "Popliteal artery aneurysm", "C": "Atherosclerotic narrowing of the artery", "D": "Arterial embolism", "E": "Atheroembolism"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man", "emergency department", "sudden", "worsening pain in", "right calf", "foot", "started 30 minutes", "tingling sensation", "weakness", "right", "similar episodes", "recent trauma", "claudication", "type 2 diabetes mellitus", "diagnosed", "hypertension 20 years", "systemic sclerosis", "office administrator", "sits", "day", "smoked one", "half packs", "cigarettes daily", "30 years", "Current medications include metformin", "lisinopril", "pulse", "min", "respirations", "min", "blood pressure", "90 mm Hg", "right leg", "pale", "cool", "touch", "Muscle strength", "right leg", "mildly reduced", "Pedal", "absent", "right", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 24-year-old woman comes to the physician because of a 3-day history of lower abdominal pain and dysuria. She has a history of recurring urinary tract infections that have resolved with antibiotic treatment. She is sexually active with one male partner and they do not use condoms. She had mild pain during her last sexual intercourse one week ago. Her temperature is 38.2°C (100.8°F), pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows lower abdominal tenderness and bilateral inguinal lymphadenopathy. There is a small amount of purulent vaginal discharge. Bimanual examination shows uterine and cervical motion tenderness. Laboratory studies show:\nHemoglobin 12 g/dL\nLeukocyte count 13,500/mm3\nSegmented neutrophils 75%\nEosinophils 1%\nLymphocytes 22%\nMonocytes 2%\nPlatelet count 328,000/mm3\nErythrocyte sedimentation rate 82 mm/h\nUrine\nRBC 1–2/hpf\nWBC 0–1/hpf\nNitrite negative\nBacteria occasional\nUrine pregnancy test negative\nWhich of the following is the most appropriate pharmacotherapy?\"", "answer": "Intramuscular ceftriaxone and oral doxycycline", "options": {"A": "Oral metronidazole", "B": "Intramuscular leuprolide", "C": "Oral levofloxacin and azithromycin", "D": "Oral trimethoprim-sulfamethoxazole", "E": "Intramuscular ceftriaxone and oral doxycycline"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "3-day history", "lower abdominal pain", "dysuria", "history of recurring urinary tract infections", "resolved", "antibiotic treatment", "sexually active", "one male", "not use condoms", "mild pain", "sexual intercourse one week", "temperature", "100", "pulse", "min", "blood pressure", "70 mm Hg", "lower abdominal tenderness", "bilateral inguinal lymphadenopathy", "small amount", "purulent vaginal discharge", "Bimanual examination", "uterine", "cervical motion tenderness", "Laboratory studies", "Hemoglobin", "g", "count", "mm3 Segmented neutrophils", "Eosinophils 1", "Platelet count", "rate", "mm/h Urine RBC", "hpf", "Nitrite", "occasional", "test", "following", "most appropriate pharmacotherapy"]}
{"question": "A 33-year-old woman presents to a walk-in clinic for evaluation of some bumps around her eyes. The bumps are not itchy or painful. They have been getting larger since appearing last year. She has no other complaints. She has not sought out medical attention for the last 20 years due to lack of insurance coverage. Her medical history reveals no problems and she takes no medications. Her periods are regular. A review of systems reveals no other concerns. She does not drink, smoke, or use illicit drugs. Her vital signs show a heart rate of 86/min, respirations of 14/min, and blood pressure of 124/76 mm Hg. On examination, the rash is a series of small papules and plaques around her eyes. The rest of the examination is unremarkable. Which of the following initial blood tests are most appropriate at this time?", "answer": "Fasting lipid profile alone", "options": {"A": "Fasting blood glucose alone", "B": "Fasting blood glucose and lipid profile", "C": "Fasting lipid profile alone", "D": "Thyroid stimulating hormone alone", "E": "Fasting blood glucose, lipid profile, and thyroid stimulating hormone"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "walk-in clinic", "eyes", "not itchy", "painful", "getting larger", "appearing last year", "complaints", "not", "out medical", "20 years due to lack of insurance coverage", "medical history reveals", "medications", "periods", "regular", "review of systems reveals", "not", "smoke", "use illicit", "vital signs", "heart rate", "min", "respirations", "min", "blood pressure", "76 mm Hg", "rash", "series", "small papules", "plaques", "eyes", "unremarkable", "following initial blood tests", "most appropriate", "time"]}
{"question": "A 55-year-old man comes to the physician because of a 2-day history of severe perianal pain and bright red blood in his stool. Examination shows a bulging, red nodule at the rim of the anal opening. Which of the following arteries is the most likely source of blood to the mass found during examination?", "answer": "Internal pudendal", "options": {"A": "Deep circumflex iliac", "B": "Internal pudendal", "C": "Median sacral", "D": "Inferior gluteal", "E": "Superior rectal"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "2-day history", "severe perianal", "bright red blood in", "stool", "bulging", "red nodule", "rim", "anal opening", "following arteries", "source", "blood", "mass found"]}
{"question": "A 35-year-old man attends an appointment with a fertility specialist together with his wife. The couple has been attempting to conceive for over 2 years but without success. She has recently undergone a comprehensive gynecological exam and all the results were normal. He states that he has no prior medical history to report. He says that he does have a low libido compared to other men of his age. On physical examination, he is observed to be of a lean build with a height of 6ft 3 inches with slight evidence of gynecomastia. His testes are small and underdeveloped. His lab tests show an elevation of LH and FSH, along with azoospermia. Which of the following is the most likely cause of this man’s infertility?", "answer": "Presence of Barr body", "options": {"A": "Absence of chloride channel", "B": "Primary ciliary dyskinesia", "C": "Androgen insensitivity", "D": "Absent GnRH production", "E": "Presence of Barr body"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["35 year old man attends", "appointment", "fertility specialist", "couple", "to", "years", "recently", "comprehensive", "results", "normal", "states", "prior medical history to report", "low libido", "age", "observed to", "height", "inches", "slight", "gynecomastia", "testes", "small", "lab tests", "elevation", "LH", "azoospermia", "following", "most likely cause", "mans infertility"]}
{"question": "A 62-year-old woman is hospitalized after a recent viral illness complicated by congestive heart failure. She has a past medical history of obesity and hypertension controlled on lisinopril but was otherwise healthy until she developed fatigue and edema after a recent viral illness. In the hospital, she is started on furosemide to manage her fluid status. On day 5 of her admission, the patient’s temperature is 100.0°F (37.8°C), blood pressure is 136/88 mmHg, pulse is 90/min, and respirations are 14/min. The patient continues to have normal heart sounds, but with crackles bilaterally on lung auscultation. Edema is 3+ up to the bilateral knees. On labs, her leukocyte count is now 13,000/mm^3, up from 9,000/mm^3 the day before. Differential shows that this includes 1,000 eosinophils/mm^3. Creatinine is 1.7 mg/dL from 1.0 mg/dL the day before. Which of the following is most likely expected on urinary analysis?", "answer": "Leukocyte esterase positive", "options": {"A": "Bacteria > 100 CFU/mL", "B": "Crystals", "C": "Leukocyte esterase positive", "D": "Nitrites positive", "E": "Red blood cell casts"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman", "hospitalized", "recent viral illness complicated", "congestive heart failure", "past medical", "hypertension controlled", "lisinopril", "healthy", "fatigue", "edema", "recent viral illness", "hospital", "started", "furosemide to", "fluid status", "day 5", "patients temperature", "100", "blood pressure", "88 mmHg", "pulse", "90 min", "respirations", "min", "patient", "to", "normal heart sounds", "crackles", "lung auscultation", "Edema", "3", "bilateral knees", "labs", "leukocyte count", "now", "mm", "mm", "day", "Differential", "includes 1", "eosinophils mm", "Creatinine", "1.7 mg dL", "0", "dL", "day", "following", "most likely", "urinary analysis"]}
{"question": "A 36-year-old right-handed man presents with complaints of difficulty writing for the past 6 months. He denies right-hand weakness, numbness, pain, and trauma. He can do most normal activities with his right hand, but whenever he holds a pen and starts to write, he experiences painful muscle spasms in his hand and arm. He is an account clerk by profession, and this problem causes him so much distress that he has started writing with his left hand. He is physically active. Sleep and appetite are normal. Past medical history is unremarkable. Physical examination is completely within normal limits with normal muscle tone, strength, and deep tendon reflexes. When he is asked to hold a pen and write, his hand becomes twisted with abnormal posturing while attempting to write. What is the next step in the management of this patient?", "answer": "Botulinum injection", "options": {"A": "Botulinum injection", "B": "Electroencephalogram", "C": "Refer to the psychiatry clinic", "D": "Selective serotonin reuptake inhibitor", "E": "Wrist splint"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old right-handed man presents", "complaints", "difficulty writing", "past 6 months", "right-hand weakness", "numbness", "pain", "trauma", "most normal activities", "right hand", "holds", "pen", "starts", "write", "painful muscle spasms", "hand", "arm", "account clerk", "problem causes", "so much distress", "started", "left hand", "physically active", "Sleep", "appetite", "normal", "Past medical history", "unremarkable", "Physical examination", "completely", "normal limits", "normal muscle tone", "strength", "deep tendon reflexes", "to hold", "pen", "write", "hand", "twisted", "abnormal posturing", "write", "next step", "patient"]}
{"question": "A 37-year-old G1P0 at 15 weeks gestation presents for an amniocentesis after a routine triple screen demonstrated a mildly elevated serum AFP. A chromosomal analysis revealed the absence of a second sex chromosome. Which of the following features will the infant most likely have?", "answer": "Streak ovaries", "options": {"A": "Mental retardation", "B": "Macroglossia", "C": "Micrognathia", "D": "Cystic kidneys", "E": "Streak ovaries"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "weeks presents", "amniocentesis", "routine triple screen", "mildly elevated serum AFP", "chromosomal analysis revealed", "absence of", "second sex chromosome", "following features", "infant", "likely"]}
{"question": "A 16-year-old boy is brought to his primary care physician for evaluation of visual loss and is found to have lens subluxation. In addition, he is found to have mild scoliosis that is currently being monitored. Physical exam reveals a tall and thin boy with long extremities. Notably, his fingers and toes are extended and his thumb and little finger can easily encircle his wrist. On this visit, the boy asks his physician about a friend who has a very similar physical appearance because his friend was recently diagnosed with a pheochromocytoma. He is worried that he will also get a tumor but is reassured that he is not at increased risk for any endocrine tumors. Which of the following genetic principles most likely explains why this patient and his friend have a similar physical appearance and yet only one is at increased risk of tumors?", "answer": "Locus heterogeneity", "options": {"A": "Anticipation", "B": "Incomplete penetrance", "C": "Locus heterogeneity", "D": "Pleiotropy", "E": "Variable expression"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "primary care physician", "visual loss", "found to", "lens subluxation", "addition", "found to", "mild scoliosis", "currently", "monitored", "reveals", "tall", "thin boy", "long", "fingers", "toes", "extended", "thumb", "little finger", "easily", "wrist", "boy", "physician", "very similar physical appearance", "recently diagnosed", "pheochromocytoma", "worried", "tumor", "not", "increased risk", "endocrine tumors", "following genetic", "likely", "patient", "similar physical appearance", "only one", "increased risk", "tumors"]}
{"question": "A 19-year-old woman comes to the physician because of increased sweating for the past 6 months. She experiences severe sweating that is triggered by stressful situations and speaking in public. She is failing one of her university classes because of her avoidance of public speaking. She has not had any fevers, chills, weight loss, or night sweats. Her temperature is 36.6°C (98°F). Physical examination shows moist skin in the axillae and on the palms, soles, and face. Which of the following drugs is most likely to be effective for this patient's condition?", "answer": "Glycopyrrolate", "options": {"A": "Pilocarpine", "B": "Oxytocin", "C": "Physostigmine", "D": "Phenylephrine", "E": "Glycopyrrolate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "of increased sweating", "past 6 months", "severe sweating", "triggered by stressful", "failing one", "university", "not", "fevers", "chills", "weight loss", "night sweats", "temperature", "36", "moist", "axillae", "soles", "face", "following drugs", "to", "effective", "patient's condition"]}
{"question": "A 73-year-old man is admitted to the hospital for jaundice and weight loss. He is an immigrant from the Dominican Republic and speaks little English. A CT scan is performed showing a large mass at the head of the pancreas. When you enter the room to discuss these results with the patient, his daughter and son ask to speak with you outside of the patient's room. They express their desire to keep these results from their father, who is \"happy\" and would prefer not to know his poor prognosis. What is the appropriate response in this situation?", "answer": "Explore the reasoning behind the children's reluctance to have their father know his prognosis", "options": {"A": "Explore the reasoning behind the children's reluctance to have their father know his prognosis", "B": "Tell the children that you are obligated to tell the father his prognosis", "C": "Respect the children's wishes to hold prognosis information from their father", "D": "Deliver the information in English so that you have not withheld information but the patient will not understand", "E": "Bring the situation to the hospital ethics panel"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "jaundice", "weight loss", "Dominican Republic", "speaks little", "CT scan", "performed", "large mass", "the head of", "pancreas", "enter", "room to", "speak", "patient", "oom.", "o  eep ", "esults ", "ot  o ", "oor prognosis.", "ppropriate  esponse "]}
{"question": "A 55-year-old man is seen in the hospital for new onset shortness of breath. The patient was hospitalized 5 days ago after initially presenting with chest pain. He was found to have an ST-elevation myocardial infarction. He underwent percutaneous coronary intervention with stent placement with resolution of his chest pain. He states that he was doing well until yesterday when he developed dyspnea while walking around the hall and occasionally when getting out of bed to use the bathroom. His shortness of breath has since progressed, and he is now having trouble breathing even at rest. His medical history is also significant for type II diabetes mellitus and hypercholesterolemia. He takes aspirin, clopidogrel, metformin, and atorvastatin. His temperature is 97°F (36.1°C), blood pressure is 133/62, pulse is 90/min, respirations are 20/min, and oxygen saturation is 88% on room air. On physical examination, there is a holosystolic murmur that radiates to the axilla and an S3 heart sound. Coarse crackles are heard bilaterally. An electrocardiogram, a chest radiograph, and cardiac enzyme levels are pending. Which of the following is the most likely diagnosis?", "answer": "Papillary muscle rupture", "options": {"A": "Dressler syndrome", "B": "Free wall rupture", "C": "Interventricular septum rupture", "D": "Papillary muscle rupture", "E": "Thickened mitral valve leaflets"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "seen", "hospital", "new onset shortness of breath", "patient", "hospitalized 5 days", "initially", "chest pain", "found to", "ST-elevation myocardial infarction", "percutaneous coronary intervention", "stent placement", "resolution of", "chest pain", "states", "well", "dyspnea", "occasionally", "to use", "bathroom", "shortness of breath", "since progressed", "now", "trouble breathing", "medical history", "significant", "type II diabetes mellitus", "hypercholesterolemia", "aspirin", "clopidogrel", "metformin", "atorvastatin", "temperature", "36", "blood pressure", "62", "pulse", "90 min", "respirations", "20 min", "oxygen saturation", "88", "room air", "holosystolic murmur", "radiates", "axilla", "S3 heart sound", "Coarse crackles", "heard", "electrocardiogram", "chest radiograph", "cardiac enzyme levels", "following", "diagnosis"]}
{"question": "A mother brings her 2-year-old son to your office after she noticed a “sore on the back of his throat.” She states that her son had a fever and was complaining of throat pain 2 days ago. The child has also been fussy and eating poorly. On examination, the child has met all appropriate developmental milestones and appears well-nourished. He has submandibular and anterior cervical lymphadenopathy. On oral examination, less than 10 lesions are visible on bilateral tonsillar pillars and soft palate with surrounding erythema. After 4 days, the lesions disappear without treatment. Which of the following is the most likely causative agent?", "answer": "Coxsackievirus A", "options": {"A": "Type 2 sensitivity reaction", "B": "Herpes simplex virus type 1", "C": "Coxsackievirus A", "D": "Varicella-zoster", "E": "Staphylococcus aureus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["her 2 year old", "office", "sore", "back of", "throat", "states", "fever", "throat pain 2 days", "child", "fussy", "eating poorly", "child", "met", "appropriate", "appears well-nourished", "submandibular", "anterior cervical lymphadenopathy", "less than 10 lesions", "visible", "bilateral tonsillar pillars", "soft palate", "surrounding erythema", "4 days", "lesions", "treatment", "following", "causative agent"]}
{"question": "You are called to the bedside of a 75-year-old woman, who is post-op day 4 from a right total hip replacement. The patient appears agitated; she is trying to pull out her IV, and for the past 4 hours she has been accusing the nursing staff of trying to poison her. Her family notes that this behavior is completely different from her baseline; she has not shown any signs of memory loss or behavioral changes at home prior to the surgery. You note that she still has an indwelling catheter. She continues on an opioid-based pain regimen. All of the following are potential contributors to the patient’s presentation EXCEPT:", "answer": "Amyloid accumulation", "options": {"A": "Infection", "B": "Polypharmacy", "C": "Amyloid accumulation", "D": "Volume depletion", "E": "Electrolyte abnormalities"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["called", "75 year old woman", "post", "day 4", "right total hip replacement", "patient appears agitated", "to pull out", "IV", "past", "hours", "nursing staff", "poison", "notes", "behavior", "completely different", "baseline", "not", "signs of memory loss", "behavioral changes at home prior to", "surgery", "note", "indwelling catheter", "opioid based pain regimen", "following", "potential", "patients"]}
{"question": "A 53-year-old man presents to the emergency department with a complaint of chest pain for 5 hours. The chest pain is continuous and squeezing in nature, not relieved by aspirin, and not related to the position of respiration. The blood pressure was 102/64 mm Hg, and the heart rate was 73/min. On physical examination, heart sounds are normal on auscultation. His ECG shows sinus rhythm with ST-segment elevation in leads II and III, aVF, and reciprocal segment depression in precordial leads V1–V6. Tissue plasminogen activator therapy is administered to the patient intravenously within 1 hour of arrival at the hospital. After 6 hours of therapy, the patient’s clinical condition starts to deteriorate. An ECG now shows ventricular fibrillation. The patient dies, despite all the efforts made in the intensive care unit. What is the most likely pathological finding to be expected in his heart muscles on autopsy?", "answer": "Coagulative necrosis", "options": {"A": "Caseous necrosis", "B": "Coagulative necrosis", "C": "Fat necrosis", "D": "Liquefactive necrosis", "E": "Fibrinoid necrosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "complaint of chest pain", "5 hours", "chest pain", "squeezing", "nature", "not relieved by aspirin", "not related", "position", "respiration", "blood pressure", "64 mm Hg", "heart rate", "min", "heart sounds", "normal", "auscultation", "ECG", "sinus rhythm", "ST-segment elevation", "leads", "III", "aVF", "reciprocal segment depression", "precordial leads", "Tissue plasminogen activator therapy", "administered", "patient", "1 hour", "arrival", "hospital", "6 hours", "therapy", "patients clinical condition starts to deteriorate", "ECG now", "ventricular fibrillation", "patient", "efforts made", "intensive care unit", "pathological finding to", "heart muscles", "autopsy"]}
{"question": "A 44-year-old man presents to the clinic with recurrent epigastric pain following meals for a month. He adds that the pain radiates up his neck and throat. Over the counter antacids have not helped. On further questioning, he endorses foul breath upon waking in the morning and worsening of pain when lying down. He denies any recent weight loss. His temperature is 37°C  (98.6°F), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg. A physical examination is performed which is within normal limits except for mild tenderness on deep palpation of the epigastrium. An ECG performed in the clinic shows no abnormalities. What is the next best step in the management of this patient?", "answer": "Lansoprazole", "options": {"A": "Endoscopy", "B": "Barium swallow", "C": "Lansoprazole", "D": "Liquid antacid", "E": "Ranitidine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "clinic", "recurrent epigastric pain following meals", "month", "adds", "pain radiates", "neck", "throat", "Over the counter antacids", "not helped", "further", "foul breath", "waking", "morning", "worsening", "pain", "lying", "recent weight loss", "temperature", "98", "respirations", "min", "pulse", "70 min", "blood pressure", "100 84 mm Hg", "performed", "normal limits except for mild tenderness", "deep palpation of", "epigastrium", "ECG performed", "clinic", "abnormalities", "next best step", "patient"]}
{"question": "A 37-year-old woman, gravida 3, para 2, at 35 weeks' gestation is brought to the emergency department for the evaluation of lower abdominal and back pain and vaginal bleeding that started one hour ago. She has had no prenatal care. Her first two pregnancies were uncomplicated and her children were delivered vaginally. The patient smoked one pack of cigarettes daily for 20 years; she reduced to half a pack every 2 days during her pregnancies. Her pulse is 80/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. The uterus is tender, and regular hypertonic contractions are felt every 2 minutes. There is dark blood on the vulva, the introitus, and on the medial aspect of both thighs bilaterally. The fetus is in a cephalic presentation. The fetal heart rate is 158/min and reactive with no decelerations. Which of the following is the most appropriate next step in management?", "answer": "Vaginal delivery", "options": {"A": "Transvaginal ultrasonography", "B": "Vaginal delivery", "C": "Elective cesarean delivery", "D": "Administration of betamethasone", "E": "Administration of terbutaline"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 3", "para 2", "35 weeks", "gestation", "brought", "emergency department", "lower abdominal", "back pain", "vaginal bleeding", "started one hour", "first two pregnancies", "uncomplicated", "children", "delivered", "patient smoked one pack", "cigarettes daily", "20 years", "reduced", "half", "pack", "2 days", "pregnancies", "pulse", "80 min", "respirations", "min", "blood pressure", "80 mm Hg", "uterus", "tender", "regular hypertonic contractions", "2 minutes", "dark blood", "vulva", "introitus", "medial aspect of", "thighs", "fetus", "cephalic presentation", "fetal heart rate", "min", "reactive", "following", "most appropriate next step"]}
{"question": "A 28-year-old woman presents with right lower quadrant abdominal pain, fatigue, and low-volume diarrhea of intermittent frequency for the past 4 months. She also reports weight loss and believes it to be due to a decreased appetite. She has noticed herself being more \"forgetful\" and she denies seeing any blood in her stool, changes in diet, infection, or recent travel history. Her temperature is 99.5°F (37.5°C), blood pressure is 112/72 mmHg, pulse is 89/min, and respirations are 17/min. Physical examination is unremarkable. Laboratory testing is shown below:\n\nHemoglobin: 10.8 g/dL\nHematocrit: 32%\nPlatelet count: 380,000/mm^3\nMean corpuscular volume: 118 µm^3\nReticulocyte count: 0.27%\nLeukocyte count: 9,900 cells/mm^3 with normal differential\nErythrocyte sedimentation rate: 65 mm/h\n\nA colonoscopy is performed and demonstrates focal ulcerations with polypoid mucosal changes adjacent to normal appearing mucosa. A biopsy is obtained and shows ulcerations and acute and chronic inflammatory changes. Involvement of which of the following sites most likely explains this patient's clinical presentation?", "answer": "Ileum", "options": {"A": "Colon", "B": "Gastric antrum", "C": "Gastric fundus", "D": "Ileum", "E": "Jejunum"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "right lower quadrant abdominal pain", "fatigue", "low volume", "intermittent", "past", "months", "reports weight loss", "to", "due to", "decreased appetite", "more", "forgetful", "seeing", "blood in", "stool", "changes in diet", "infection", "recent", "history", "temperature", "99", "blood pressure", "72 mmHg", "pulse", "min", "respirations", "min", "unremarkable", "Laboratory testing", "Hemoglobin", "10.8 g/dL Hematocrit", "Platelet count", "mm", "Mean corpuscular volume", "m", "Reticulocyte count", "0 27", "Leukocyte count", "900 cells mm", "normal differential Erythrocyte sedimentation rate", "65 mm/h", "colonoscopy", "performed", "focal ulcerations", "polypoid mucosal changes adjacent to normal appearing mucosa", "biopsy", "obtained", "ulcerations", "acute", "chronic inflammatory changes", "Involvement of", "following sites", "likely", "patient"]}
{"question": "A 43-year-old man with a history of untreated HIV presents with fever, shortness of breath, and a nonproductive cough for the past week. Past medical history is significant for HIV diagnosed 10 years ago and never treated. His most recent CD4+ T cell count was 105/µL. Physical examination reveals bilateral crepitus over all lobes. No lymphadenopathy is present. A chest radiograph reveals bilateral infiltrates. Which of the following is the best treatment for this patient?", "answer": "Trimethoprim-sulfamethoxazole", "options": {"A": "Highly active antiretroviral therapy (HAART)", "B": "Trimethoprim-sulfamethoxazole", "C": "Ganciclovir", "D": "Azithromycin", "E": "Amphotericin B"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "history", "untreated HIV presents", "fever", "shortness of breath", "nonproductive cough", "past week", "medical history", "significant", "HIV diagnosed", "never treated", "most recent CD4", "T cell count", "reveals bilateral crepitus", "lobes", "lymphadenopathy", "present", "chest radiograph reveals bilateral infiltrates", "following", "best"]}
{"question": "A 1-week-old male newborn is brought to the physician for a follow-up examination after the results of newborn screening showed an increased serum concentration of phenylalanine. Genetic analysis confirms a diagnosis of phenylketonuria. The physician counsels the patient's family on the recommended dietary restrictions, including avoidance of artificial sweeteners that contain aspartame. Aspartame is a molecule composed of aspartate and phenylalanine and its digestion can lead to hyperphenylalaninemia in patients with phenylketonuria. Which of the following enzymes is primarily responsible for the breakdown of aspartame?", "answer": "Dipeptidase", "options": {"A": "Pepsin", "B": "Dipeptidase", "C": "Chymotrypsin", "D": "Trypsin", "E": "Carboxypeptidase A"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["week old male newborn", "brought", "physician", "follow-up examination", "newborn", "increased serum concentration", "phenylalanine", "Genetic analysis confirms", "diagnosis", "phenylketonuria", "physician counsels", "patient's", "dietary restrictions", "including", "contain aspartame", "aspartate", "phenylalanine", "digestion", "lead", "hyperphenylalaninemia", "patients", "phenylketonuria", "following enzymes", "responsible", "breakdown", "aspartame"]}
{"question": "An American doctor is on an outreach trip to visit local communities in Ethiopia. In one clinic, he found many cases of children ages 2–5 years who have significantly low weight and height for their age. These children also had pale sclerae, distended abdomens, dermatoses, and marked edema in the lower extremities. Malnutrition in these patients is investigated and classified as (kwashiorkor) protein malnutrition. Appropriate nutrition supplementation was ordered and shipped in for the affected families. Which of the following amino acids must be included for these patients?", "answer": "Methionine", "options": {"A": "Alanine", "B": "Tyrosine", "C": "Arginine", "D": "Glutamine", "E": "Methionine"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["doctor", "trip to", "local", "Ethiopia", "one clinic", "found", "cases", "children ages", "years", "significantly low", "height", "age", "children", "pale sclerae", "distended abdomens", "dermatoses", "marked edema", "lower extremities", "Malnutrition", "patients", "investigated", "kwashiorkor", "protein", "Appropriate nutrition supplementation", "ordered", "shipped", "affected", "following amino acids", "included", "patients"]}
{"question": "Under what physiologic state is the endogenous human analog of nesiritide produced?", "answer": "Increased ventricular stretch", "options": {"A": "Increased external stress", "B": "Increased ventricular stretch", "C": "Increased intracranial pressure", "D": "Increased circulatory volume presenting to the kidneys", "E": "Decreased circulatory volume presenting to the kidneys"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["physiologic state", "endogenous human", "nesiritide"]}
{"question": "A 9-year-old boy is brought to the physician for a well-child examination. His mother says his teachers report him being easily distracted, lagging behind his classmates in most of the subjects, and frequently falling asleep during class. She says that her son has complained of leg pain on multiple occasions. He is at the 45th percentile for height and 35th percentile for weight. Vital signs are within normal limits. Examination shows ptosis and a high-arched palate. Muscle strength is decreased in the face and hands. Muscle strength of the quadriceps and hamstrings is normal. Sensation is intact. Percussion of the thenar eminence causes the thumb to abduct and then relax slowly. Which of the following is the most likely diagnosis?", "answer": "Myotonic dystrophy", "options": {"A": "Spinal muscular atrophy", "B": "McArdle disease", "C": "Myotonic dystrophy", "D": "Juvenile dermatomyositis", "E": "Duchenne muscular dystrophy\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "well", "teachers report", "easily", "lagging", "most", "subjects", "frequently falling asleep", "leg pain", "multiple occasions", "percentile", "height", "percentile", "weight", "Vital signs", "normal limits", "ptosis", "high-arched palate", "Muscle strength", "decreased", "face", "hands", "Muscle strength of", "quadriceps", "hamstrings", "normal", "Sensation", "intact", "Percussion", "thenar eminence causes", "thumb", "then relax slowly", "following", "diagnosis"]}
{"question": "A 56-year old man is brought in by ambulance to the emergency department and presents with altered consciousness, confabulation, and widespread rash. He is recognized as a homeless man that lives in the area with a past medical history is significant for traumatic brain injury 4 years ago and chronic gastritis. He also has a long history of alcohol abuse. His vital signs are as follows: blood pressure 140/85 mm Hg, heart rate 101/min, respiratory rate 15/min, and temperature 36.1°C (97.0°F). His weight is 56 kg (123.5 lb) and height is 178 cm (5.8 ft). The patient is lethargic and his speech is incoherent. Examination reveals gingival bleeding, scattered corkscrew body hair, bruises over the forearms and abdomen, multiple petechiae, and perifollicular, hyperkeratotic papules over his extremities. His lung and heart sounds are normal. Abdominal palpation reveals tenderness over the epigastric area and hepatomegaly. Neurologic examination demonstrates symmetrically diminished reflexes in the lower extremities. Impairment of which of the following processes is the most likely cause of this patient’s hyperkeratotic rash?", "answer": "Hydroxylation of proline residues", "options": {"A": "Hydroxylation of proline residues", "B": "Carboxylation of clotting factors", "C": "Decarboxylation of histidine", "D": "Deamination of guanine", "E": "Ethanol oxidation to acetaldehyde"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "ambulance", "emergency department", "presents", "altered consciousness", "confabulation", "widespread rash", "homeless man", "lives", "area", "past medical history", "significant", "traumatic brain injury", "years", "chronic gastritis", "long history of alcohol abuse", "vital signs", "follows", "blood pressure", "85 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "weight", "kg", "height", "5.8 ft", "patient", "lethargic", "speech", "incoherent", "reveals gingival bleeding", "scattered corkscrew body hair", "bruises", "forearms", "abdomen", "multiple petechiae", "hyperkeratotic papules", "extremities", "lung", "heart sounds", "normal", "Abdominal palpation reveals tenderness", "epigastric area", "hepatomegaly", "Neurologic examination", "diminished reflexes", "lower extremities", "Impairment", "following processes", "most likely cause", "patients hyperkeratotic rash"]}
{"question": "An 8-year-old girl is brought to the emergency department by her parents because she complained of very fast heartbeats. The patient has previously been healthy without any childhood illnesses and has not needed to visit a physician in the past 2 years. On examination, the heart rate is 198/min. Further examination by the physician reveals a grade III holosystolic murmur over the anterior chest wall. ECG is immediately performed after her heart rate is reduced, and shows a short P-R interval with a slow upstroke of the QRS complex. Which of the following is the most likely diagnosis in this patient?", "answer": "Ebstein anomaly", "options": {"A": "Pulmonic stenosis", "B": "Tricuspid atresia", "C": "Ebstein anomaly", "D": "Tetralogy of Fallot", "E": "Atrial septal defect"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "emergency department", "very fast heartbeats", "patient", "healthy", "childhood illnesses", "not needed to", "physician", "past", "years", "heart rate", "min", "Further", "physician reveals", "grade III holosystolic murmur", "anterior chest wall", "ECG", "immediately performed", "heart rate", "reduced", "short P-R interval", "slow", "complex", "following", "diagnosis", "patient"]}
{"question": "A 78-year-old man with advanced lung cancer with metastases to the brain is brought to the physician by his daughter, with whom he lives. The daughter reports that her father's condition has been slowly deteriorating over the past 2 months. His seizures have been poorly controlled despite maximal medical therapy. He has had progressive loss of mobility, a decrease in executive function, and worsening pain. The patient has Medicaid insurance. Current medications include high-dose corticosteroids and immediate-release opioid analgesics. The need for increased assistance has been distressing to the family, and they are concerned about the patient's overall comfort. The daughter asks the physician about her father's eligibility for hospice care. Which of the following responses from the physician about this model of care is most appropriate?", "answer": "\"\"\"Your father is only eligible if his life expectancy is less than 6 months.\"\"\"", "options": {"A": "\"\"\"Hospice care is likely to hasten your father's death.\"\"\"", "B": "\"\"\"Your father would have to be moved from home to a center that specializes in hospice care.\"\"\"", "C": "\"\"\"Your father cannot enter hospice care if there is a definitive cure for his disease.\"\"\"", "D": "\"\"\"Your father is only eligible if his life expectancy is less than 6 months.\"\"\"", "E": "\"\"\"Your father's current medication regimen is incompatible with hospice care because of the risk of respiratory depression.\"\"\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "advanced lung", "metastases to", "brain", "brought", "physician", "lives", "reports", "condition", "slowly deteriorating", "past", "months", "seizures", "poorly controlled", "maximal medical therapy", "progressive loss", "mobility", "decrease", "worsening pain", "patient", "Medicaid", "Current medications include high-dose corticosteroids", "immediate-release opioid analgesics", "need", "increased assistance", "distressing", "family", "overall", "physician", "eligibility", "following responses", "physician", "most appropriate"]}
{"question": "A 26-year-old G1P0 mother is in the delivery room in labor. Her unborn fetus is known to have a patent urachus. Which of the following abnormalities would you expect to observe in the infant?", "answer": "Urine discharge from umbilicus", "options": {"A": "Myelomeningocele", "B": "Gastroschisis", "C": "Omphalocele", "D": "Meconium discharge from umbilicus", "E": "Urine discharge from umbilicus"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old", "delivery room", "labor", "unborn fetus", "known to", "patent urachus", "following abnormalities", "to observe", "infant"]}
{"question": "A 44-year-old woman is being treated by her oncologist for metastatic breast cancer. The patient had noticed severe weight loss and a fixed breast mass over the past 8 months but refused to see a physician until her husband brought her in. Surgery is scheduled, and the patient is given an initial dose of radiation therapy to destroy malignant cells. Which of the following therapies was administered to this patient?", "answer": "Induction therapy", "options": {"A": "Adjuvant therapy", "B": "Consolidation therapy", "C": "Induction therapy", "D": "Maintenance therapy", "E": "Salvage therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "treated", "oncologist", "metastatic breast cancer", "patient", "severe weight loss", "fixed breast mass", "past", "months", "to see", "physician", "brought", "Surgery", "scheduled", "patient", "given", "initial dose", "radiation therapy", "malignant cells", "following therapies", "administered", "patient"]}
{"question": "A 50-year-old man presents to the emergency department with chief complaints of abdominal pain, distension, and bloody diarrhea for a day. Abdominal pain was episodic in nature and limited to the left lower quadrant. It was also associated with nausea and vomiting. He also has a history of postprandial abdominal pain for several months. He had an acute myocardial infarction which was treated with thrombolytics 3 months ago. He is a chronic smoker and has been diagnosed with diabetes mellitus for 10 years. On physical examination, the patient is ill-looking with a blood pressure of 90/60 mm Hg, pulse 100/min, respiratory rate of 22/min, temperature of 38.0°C (100.5°F) with oxygen saturation of 98% in room air. The abdomen is tender on palpation and distended. Rectal examination demonstrates bright red color stool. Leukocyte count is 14,000/mm3. Other biochemical tests were within normal ranges. Abdominal X-ray did not detect pneumoperitoneum or air-fluid level. The recent use of antibiotics was denied by the patient and stool culture was negative for C. difficile. Contrast-enhanced CT scan revealed segmental colitis involving the distal transverse colon. What is the most likely cause of the patient’s symptoms?", "answer": "Atherosclerosis", "options": {"A": "Hypokalemia", "B": "Aneurysm", "C": "Clostridium difficile infection", "D": "Embolism", "E": "Atherosclerosis"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["50 year old man presents", "emergency department", "chief complaints", "abdominal pain", "distension", "bloody diarrhea", "day", "Abdominal pain", "episodic", "nature", "limited", "left lower quadrant", "associated with nausea", "vomiting", "history", "postprandial abdominal pain", "several months", "acute myocardial infarction", "treated with thrombolytics", "months", "chronic smoker", "diagnosed", "diabetes mellitus", "patient", "ill looking", "blood pressure", "90 60 mm Hg", "pulse 100 min", "respiratory rate", "min", "temperature", "100", "oxygen saturation", "98", "room air", "abdomen", "tender", "palpation", "distended", "Rectal examination", "bright red stool", "Leukocyte count", "mm3", "biochemical tests", "normal ranges", "Abdominal X-ray", "not detect pneumoperitoneum", "air-fluid level", "recent use of", "denied", "patient", "stool culture", "negative", "Contrast-enhanced CT scan revealed segmental colitis involving", "distal transverse colon", "most likely cause", "patients symptoms"]}
{"question": "A 46-year-old man comes to the physician for routine physical examination. His blood pressure is 158/96 mm Hg. Physical examination shows no abnormalities. Serum studies show a potassium concentration of 3.1 mEq/L. His plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio is 47 (N < 10). A saline infusion test fails to suppress aldosterone secretion. A CT scan of the abdomen shows bilateral adrenal gland abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Eplerenone therapy", "options": {"A": "Bilateral adrenalectomy", "B": "Eplerenone therapy", "C": "Amiloride therapy", "D": "Unilateral adrenalectomy", "E": "Propranolol therapy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "routine physical examination", "blood pressure", "96 mm Hg", "abnormalities", "Serum studies", "potassium concentration", "mEq/L", "plasma aldosterone concentration", "renin activity", "ratio", "N", "10", "infusion test fails to suppress aldosterone secretion", "CT scan", "abdomen", "bilateral adrenal gland abnormalities", "following", "most appropriate next step"]}
{"question": "In a routine medical examination, an otherwise healthy 12-year-old by is noted to have tall stature with a wide arm span and slight scoliosis. Chest auscultation reveals a heart murmur. Transthoracic echocardiography shows an enlarged aortic root and aortic valve insufficiency. Mutations in mutations in fibrillin-1 gene are positive. Plasma homocysteine levels are not elevated. This patient is at high risk for which of the following complications?", "answer": "Aortic aneurysm", "options": {"A": "Arterial and visceral rupture", "B": "Aortic aneurysm", "C": "Thrombotic events", "D": "Infertility", "E": "Pheochromocytoma"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["routine", "healthy", "year old", "noted to", "tall stature", "wide arm span", "slight scoliosis", "Chest auscultation reveals", "heart murmur", "Transthoracic echocardiography", "enlarged aortic root", "aortic valve insufficiency", "fibrillin-1 gene", "positive", "Plasma homocysteine levels", "not elevated", "patient", "high risk", "following complications"]}
{"question": "A 5-day-old boy is brought to the emergency department by his mother because of a 2-day history of difficulty feeding and multiple episodes of his lips turning blue. He was born at home via spontaneous vaginal delivery and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Physical examination shows grunting and moderate intercostal and subcostal retractions. Echocardiography shows a single vessel exiting from the heart. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Failure of neural crest cell migration", "options": {"A": "Failure of neural crest cell migration", "B": "Insufficient growth of endocardial cushions", "C": "Abnormal placement of the infundibular septum", "D": "Absent fusion of septum primum and septum secundum", "E": "Abnormal cardiac looping"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 day old boy", "brought", "emergency department", "mother", "2-day history", "difficulty feeding", "multiple episodes of", "lips turning blue", "born at home", "spontaneous vaginal delivery", "Apgar scores", "8", "1", "5 minutes", "moderate", "subcostal retractions", "Echocardiography", "single vessel exiting", "heart", "following", "underlying cause", "patient's condition"]}
{"question": "A 58-year-old woman presents to her primary care doctor with her husband. The patient's husband reports that his wife has been acting \"funny\" ever since she was in a motor vehicle accident 2 months ago. She's been very rude to him, their children, and her friends, often saying inappropriate things. She is not interested in her previous hobbies and will not watch her favorite television shows or play cards. Which of the following regions is suspicious for injury?", "answer": "Frontal lobe", "options": {"A": "Broca's area", "B": "Occipital lobe", "C": "Temporal lobe", "D": "Motor cortex", "E": "Frontal lobe"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old woman presents", "primary care doctor", "patient", "eports ", "cting ", "ver ", "otor vehicle accident ", "onths ", "he'", "ry r", "ildren, ", "ten s", "appropriate t", "t i", "evious h", "t w", "levision s", "ay c rds. ", "llowing r gions i", "spicious f", "jury?"]}
{"question": "A 32-year-old woman presents to a psychiatrist to discuss a recent event in her life. At a social function 2 days back, she met a man who introduced himself as having worked with her at another private company 3 years ago. However, she did not recognize him. She also says that she does not remember working at any such company at any time during her life. However, the patient’s husband says that she had indeed worked at that company for three months and had quit due to her boss’s abusive behavior towards her. The man who met her at the function had actually been her colleague at that job. The woman asks the doctor, “How is it possible? I am really not able to recall any memories of having worked at any such company. What’s going on here?”. Her husband adds that after she quit the job, her mood frequently has been low. The patient denies any crying episodes, suicidal ideas, not enjoying recreational activities or feelings of worthlessness. Her appetite and sleep patterns are normal. She is otherwise a healthy woman with no significant medical history and lives a normal social and occupational life. The patient reports no history of smoking, alcohol, or substance use. On physical examination, she is alert and well-oriented to time, place and person. During memory testing, she correctly remembers the date of her marriage that took place 5 years back and the food she ate over the last 2 days. Which of the following is the most likely diagnosis in this patient?", "answer": "Dissociative amnesia", "options": {"A": "Pseudodementia", "B": "Dissociative amnesia", "C": "Dissociative identity disorder", "D": "Dissociative fugue", "E": "Transient global amnesia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "psychiatrist to", "recent event", "life", "days back", "met", "man", "introduced", "private company", "years", "not", "not", "company", "time", "patients", "company", "three months", "due to", "abusive behavior", "man", "met", "function", "woman", "doctor", "possible", "I", "not able to", "memories", "company", "adds", "mood frequently", "low", "patient", "episodes", "suicidal", "not", "feelings of worthlessness", "appetite", "sleep patterns", "normal", "healthy", "significant medical history", "lives", "normal social", "occupational", "patient reports", "history of smoking", "alcohol", "substance use", "alert", "well oriented to time", "place", "memory testing", "date", "marriage", "place", "years back", "food", "ate", "2", "following", "diagnosis", "patient"]}
{"question": "A 12-year-old boy is brought by his parents to the physician for a fever for the past 2 days. His temperature is 101.3°F (38.5°C). His medical history is significant for sickle cell disease and recurrent infections. A year ago, he underwent spleen scintigraphy with technetium-99m that revealed functional hyposplenism. Which of the following findings would be found in a peripheral blood smear from this patient?", "answer": "Howell-Jolly bodies", "options": {"A": "Acanthocytes", "B": "Basophilic stippling", "C": "Heinz bodies", "D": "Howell-Jolly bodies", "E": "Schistocytes"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "fever", "past 2 days", "temperature", "medical history", "significant", "sickle cell disease", "recurrent infections", "year", "spleen scintigraphy", "revealed functional hyposplenism", "following findings", "found", "peripheral blood smear", "patient"]}
{"question": "A 35-year-old woman presents to the emergency department multiple times over the past 3 months feeling like her chest is about to explode. She has been screened on several occasions for acute coronary syndrome, but each time, her cardiac enzymes have all been within normal limits. She comes into the emergency room diaphoretic, short of breath, and complaining of chest pain. Her symptoms usually resolve within 30 minutes, but she is left with a lingering fear for the next attack. She does not know of any triggers for these episodes. After medical causes are ruled out, the patient is referred to outpatient psychiatry to confirm her most likely diagnosis. Which one of the following is correct regarding this patient’s most likely condition?", "answer": "The patient must have symptoms of elevated autonomic activity.", "options": {"A": "The patient must have symptoms of elevated autonomic activity.", "B": "Attacks occur at regular intervals.", "C": "There is a fixed number of attacks needed for diagnosis.", "D": "The patients must have symptoms for at least 3 months.", "E": "The patient must have a fear of not being able to escape."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old woman presents", "emergency department multiple times", "past 3 months", "chest", "to", "screened", "occasions", "acute coronary syndrome", "time", "cardiac enzymes", "normal limits", "emergency room diaphoretic", "breath", "of chest pain", "symptoms usually", "30 minutes", "left", "next attack", "not", "triggers", "episodes", "medical causes", "ruled out", "patient", "referred", "outpatient psychiatry to confirm", "diagnosis", "one", "following", "correct", "patients", "likely condition"]}
{"question": "An 18-month-old toddler is brought to a pediatric hematologist by his father. The boy was referred to this office for prolonged neutropenia. He has had several blood tests with an isolated low neutrophil count while hemoglobin, hematocrit, and platelet count is normal. 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. Today his complete blood count (CBC) with differential shows:\nHemoglobin: 15.5 g/dL\nPlatelets: 300,000 mm3\nNeutrophils: 20%\nBands: 2%\nLymphocytes: 40%\nMonocytes: 15%\nToday, he has a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F). On physical exam, the child appears healthy and is within expected growth parameters for his age and sex. A bone marrow biopsy shows normal bone marrow with 95% cellularity and trilineage maturation. Flow cytometry is normal with no abnormal markers noted. Which of the following is the most probable diagnosis in the present case?", "answer": "Chronic benign neutropenia", "options": {"A": "Chronic benign neutropenia", "B": "Chronic lymphoblastic leukemia", "C": "Sepsis", "D": "Aplastic anemia", "E": "Acute lymphoblastic leukemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old toddler", "brought", "pediatric hematologist", "boy", "referred", "office", "prolonged neutropenia", "several blood tests", "isolated low neutrophil count", "hemoglobin", "hematocrit", "platelet count", "normal", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "Today", "complete blood count", "CBC", "differential", "Hemoglobin", "g/dL Platelets", "300", "mm3", "20", "Bands", "2", "Lymphocytes", "40", "Today", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "98", "child appears healthy", "growth parameters", "age", "sex", "bone marrow biopsy", "normal bone marrow", "95", "cellularity", "maturation", "Flow cytometry", "normal", "abnormal markers noted", "following", "present case"]}
{"question": "A 4-year-old girl is brought to the physician for a routine checkup. She was recently adopted and has never seen a doctor before. The patient's parents state she was very emaciated when they adopted her and noticed she has trouble seeing in the evening. They also noted that she was experiencing profuse foul-smelling diarrhea as well, which is currently being worked up by a gastroenterologist. Her temperature is 97.8°F (36.6°C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. The girl appears very thin. She has dry skin noted on physical exam. Laboratory studies are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 4,500/mm^3 with normal differential\nPlatelet count: 191,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 3.8 mEq/L\nHCO3-: 28 mEq/L\nBUN: 20 mg/dL\nGlucose: 88 mg/dL\nCreatinine: 0.7 mg/dL\nCa2+: 9.0 mg/dL\n\nWhich of the following findings is also likely to be seen in this patient?", "answer": "Xerophthalmia", "options": {"A": "Ataxia", "B": "Cheilosis", "C": "Diarrhea", "D": "Perifollicular hemorrhages", "E": "Xerophthalmia"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["4 year old girl", "brought", "physician", "routine checkup", "recently adopted", "never seen", "doctor", "patient's", "state", "very emaciated", "adopted", "seeing", "evening", "noted", "smelling diarrhea", "well", "currently", "worked up", "gastroenterologist", "temperature", "97", "36", "blood pressure", "54 mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "girl appears very thin", "dry skin noted", "Laboratory studies", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "4 500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "3", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "88 mg/dL Creatinine", "0.7 mg/dL Ca2", "0", "dL", "following findings", "likely to", "seen", "patient"]}
{"question": "A 32-year-old man presents to the emergency department with vomiting, diarrhea, and abdominal pain 2 hours after eating seafood in a restaurant. He also mentions that immediately after ingestion of the food, he experienced tingling and numbness over the lips and face. On physical examination, his vital signs are stable. On neurological examination, he has reduced strength in the lower extremities, but deep tendon reflexes are present and normal. Laboratory evaluation of the seafood from the restaurant confirms the presence of a toxin which is known to block voltage-gated fast sodium channels. Which of the following toxins is the most likely cause of the patient’s symptoms?", "answer": "Tetrodotoxin", "options": {"A": "Latrotoxin", "B": "Domoic acid", "C": "Okadaic acid", "D": "Scombrotoxin", "E": "Tetrodotoxin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "emergency department", "vomiting", "diarrhea", "abdominal pain 2 hours", "eating", "restaurant", "immediately", "food", "tingling", "numbness", "lips", "face", "vital signs", "stable", "neurological examination", "reduced strength", "lower extremities", "deep tendon reflexes", "present", "normal", "Laboratory", "restaurant confirms", "presence of", "toxin", "known to block voltage-gated fast sodium channels", "following toxins", "most likely cause", "patients symptoms"]}
{"question": "A 24-year-old woman presents with a 3-month history of bloody diarrhea and intermittent abdominal pain. She says that after she has a bowel movement, she still feels as though she needs to go more. She also reports a 10-pound weight loss, significant fatigue, and frequent cravings to chew ice. Her past medical history is significant only for chronic iron deficiency anemia since high school. She currently takes a women’s multivitamin and ferrous sulfate 65 mg orally once daily. She is on the college track team but now is too tired to participate in practice. Her family history is significant for colon cancer and her grandmother died from breast cancer in her 70’s. Her vital signs include: temperature 37.0°C (98.6°F), pulse 102/min, respiratory rate 16/min, blood pressure 100/75 mm Hg. Physical examination is significant for conjunctival pallor, koilonychia, and the cutaneous findings shown in the exhibit. Laboratory tests show elevated ESR and C-reactive protein and findings consistent with iron deficiency anemia. A barium enema demonstrates a lead pipe appearance and a loss of haustra. Which of the following are the recommended screening guidelines for colorectal cancer for this patient?", "answer": "Colonoscopy by age 32 and repeated every 1–2 years thereafter", "options": {"A": "Colonoscopy by age 32 and repeated every 1–2 years thereafter", "B": "Colonoscopy by age 50 and repeated every 10 years thereafter", "C": "Colonoscopy by age 32 and repeated every 3 years thereafter", "D": "Colonoscopy by age 45 and repeated every 10 years thereafter", "E": "Flexible sigmoidoscopy by age 32 and repeated every 1–2 years thereafter"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "month history", "bloody diarrhea", "intermittent abdominal pain", "bowel movement", "needs to go more", "reports a 10 pound weight loss", "significant fatigue", "frequent", "to chew ice", "past medical history", "significant only", "chronic", "high school", "currently", "multivitamin", "orally", "daily", "college track", "now", "tired to", "in", "family history", "significant", "colon cancer", "died", "breast cancer", "vital signs include", "temperature", "98", "pulse", "min", "respiratory rate", "min", "blood pressure 100 75 mm Hg", "significant", "conjunctival pallor", "koilonychia", "cutaneous findings", "Laboratory tests", "elevated ESR", "C-reactive protein", "findings", "iron deficiency anemia", "barium enema", "lead pipe appearance", "loss", "haustra", "following", "screening", "for colorectal cancer", "patient"]}
{"question": "A 24-year-old woman presents to the emergency department with severe abdominal and lower back pain. She describes it as intense cramping and states that she experienced severe pain roughly 1 month ago that was similar. The patient's past medical history is non-contributory, and she states that her menses cause her to soak through 1 pad in a day. She is currently sexually active and does not use any contraception. Her vitals are within normal limits. The patient's abdominal exam is non-focal, and her pelvic exam reveals no adnexal masses or tenderness and no cervical motion tenderness. Which of the following is the most likely diagnosis?", "answer": "Primary dysmenorrhea", "options": {"A": "Adenomyosis", "B": "Appendicitis", "C": "Ectopic pregnancy", "D": "Leiomyoma", "E": "Primary dysmenorrhea"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman presents", "emergency department", "severe abdominal", "lower back pain", "intense cramping", "states", "severe pain", "month", "similar", "patient's past", "non contributory", "states", "menses cause", "to soak", "pad", "day", "currently sexually active", "not use", "contraception", "normal limits", "patient's abdominal exam", "non-focal", "pelvic exam reveals", "adnexal masses", "tenderness", "cervical motion tenderness", "following", "diagnosis"]}
{"question": "Which of the following factors gives the elastin molecule the ability to stretch and recoil?", "answer": "Cross-links between lysine residues", "options": {"A": "Hydroxylation of proline and lysine rich regions", "B": "Cross-links between lysine residues", "C": "Elastase activity", "D": "Triple helix formation", "E": "Cleavage of disulfide rich terminal regions"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["following factors gives", "elastin", "ability to stretch"]}
{"question": "A 68-year-old woman, otherwise healthy, is admitted to the coronary care unit due to acute ischemic cardiomyopathy. No other significant past medical history. Her vital signs include: pulse 116/min, respiratory rate 21/min, temperature 37.4°C (99.3°F), and blood pressure 160/100 mm Hg. On physical examination, the patient is in distress. Cardiopulmonary exam is positive for bilateral pulmonary crackles at the lung bases, tachycardia, and jugular venous distension. Her laboratory findings are significant for a hemoglobin of 7.8 g/dL. She is initially treated with oxygen, antiplatelet therapy, nitroglycerin, and beta-blockers. In spite of these treatments, her angina does not subside. The patient is not a candidate for percutaneous coronary intervention, so she is being prepared for a coronary artery bypass graft. Which of the following would be the next, best step in management of this patient?", "answer": "Transfuse packed red blood cells", "options": {"A": "Administer intravenous iron", "B": "Transfuse packed red blood cells", "C": "Transfuse whole blood", "D": "Treat with erythropoietin", "E": "Observation and supportive care"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "healthy", "coronary care unit", "acute ischemic cardiomyopathy", "significant past medical history", "vital signs include", "pulse", "min", "respiratory rate", "min", "temperature", "99", "blood pressure", "100 mm Hg", "patient", "distress", "Cardiopulmonary exam", "positive", "bilateral pulmonary crackles", "lung bases", "tachycardia", "jugular venous distension", "laboratory findings", "significant", "a hemoglobin", "dL", "initially treated with oxygen", "antiplatelet therapy", "nitroglycerin", "beta-blockers", "treatments", "angina", "not", "patient", "not", "percutaneous coronary intervention", "prepared", "coronary artery bypass graft", "following", "next", "best step", "patient"]}
{"question": "A goalkeeper of a famous soccer team gives an interview with a health agency regarding his childhood. He describes how when he was a child, he would constantly clear his throat in class and the teachers would write a note to his mother with advice to go see an ENT doctor. He complained of being restless, fidgety, and sometimes hyperactive in class, disrupting the environment and causing him many social problems. He would blurt out the answer at times and keep repeating it without any control, leading to some embarrassing timeouts. But he was always nice to his teachers, so he calls it a “benign frustration” rather than aggressively causing distress. He also talked about how his symptoms were dramatically improved with medication. Which of the following is an FDA approved drug for this patient’s most likely condition?", "answer": "Haloperidol", "options": {"A": "Clonazepam", "B": "Clonidine", "C": "Guanfacine", "D": "Haloperidol", "E": "Lithium"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["gives", "childhood", "child", "constantly clear", "throat", "teachers", "write", "note", "to go see", "ENT doctor", "restless", "fidgety", "sometimes hyperactive", "disrupting", "environment", "causing", "social problems", "out", "answer", "times", "keep repeating", "control", "leading", "always nice", "teachers", "calls", "benign", "causing distress", "talked about", "symptoms", "improved", "medication", "following", "approved drug", "patients", "likely condition"]}
{"question": "A 36-year-old healthy man presents to his physician to discuss his concerns about developing heart disease. His father, grandfather, and older brother had heart problems, and he has become increasingly worried he might be at risk. He takes no medications and his past medical history is only significant for an appendectomy at 20 years ago. He is married happily with 2 young children and works as a hotel manager and exercises occasionally in the hotel gym. He drinks 3–5 alcoholic beverages per week but denies smoking and illicit drug use. Today his blood pressure is 146/96 mm Hg, pulse rate is 80/min, and respiratory rate is 16/min. He has a body mass index of 26.8 kg/m2. His physical examination is otherwise unremarkable. Laboratory tests show:\nLaboratory test\nSerum glucose (fasting) 88 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 350 mg/dL\nHDL-cholesterol 40 mg/dL\nLDL-cholesterol 280 mg/dL\nTriglycerides 130 mg/dL\nBesides appropriate medications for his cholesterol and a follow-up for his hypertension, which of the following supplements is thought to provide a protective cardiovascular effect?", "answer": "Vitamin E", "options": {"A": "Folic acid", "B": "Thiamine", "C": "Vitamin B12", "D": "Vitamin E", "E": "Vitamin K"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old healthy man presents", "physician to", "heart disease", "heart problems", "worried", "at risk", "medications", "past medical history", "only significant", "appendectomy", "20 years", "married", "young children", "works", "hotel", "exercises occasionally", "hotel", "35", "week", "smoking", "illicit drug use", "Today", "blood pressure", "96 mm Hg", "pulse rate", "80 min", "respiratory rate", "min", "body mass index", "kg/m2", "unremarkable", "Laboratory tests", "Laboratory test Serum glucose", "fasting", "mg", "L Potassium", "creatinine 0.8 mg", "Blood", "Cholesterol", "total 350 mg/dL HDL-cholesterol 40", "LDL-cholesterol", "Triglycerides", "appropriate medications", "cholesterol", "follow-up", "hypertension", "following supplements", "to", "cardiovascular effect"]}
{"question": "A 22-year-old man comes to the emergency department for pain and swelling of his left knee one day after injuring it while playing soccer. While sprinting on the field, he slipped as he attempted to kick the ball and landed on the anterior aspect of his knee. He underwent an appendectomy at the age of 16 years. His vitals signs are within normal limits. Examination shows a swollen and tender left knee; range of motion is limited by pain. The tibial tuberosity shows tenderness to palpation. The left tibia is displaced posteriorly when force is applied to the proximal tibia after flexing the knee. The remainder of the examination shows no abnormalities. An x-ray of the left knee joint shows an avulsion fracture of the tibial condyle. Which of the following is the most likely diagnosis?", "answer": "Posterior cruciate ligament injury", "options": {"A": "Anterior cruciate ligament injury", "B": "Lateral meniscus injury", "C": "Posterior cruciate ligament injury", "D": "Medial meniscus injury", "E": "Medial collateral ligament injury"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "emergency department", "pain", "swelling of", "left knee one day", "playing", "field", "to", "ball", "landed", "anterior aspect of", "knee", "appendectomy", "age", "years", "signs", "normal limits", "swollen", "tender left knee", "range of motion", "limited", "pain", "tibial tuberosity", "tenderness", "palpation", "left tibia", "displaced", "applied", "proximal tibia", "knee", "abnormalities", "x-ray of", "left knee joint", "avulsion", "tibial condyle", "following", "diagnosis"]}
{"question": "A 49-year-old woman comes to the physician with a 2-month history of mild abdominal pain, nausea, and several episodes of vomiting. She often feels full after eating only a small amount of food. Abdominal examination shows mild right upper quadrant tenderness and a liver span of 16 cm. Ultrasonography shows a 5 x 4 cm hyperechoic mass in the left lobe of the liver. The mass is surgically excised. A photomicrograph of the resected specimen is shown. Which of the following is the most likely diagnosis?", "answer": "Cavernous hemangioma", "options": {"A": "Hepatocellular adenoma", "B": "Alveolar echinococcosis", "C": "Cavernous hemangioma", "D": "Focal nodular hyperplasia", "E": "Angiosarcoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "2 month history", "mild abdominal", "nausea", "several episodes of vomiting", "often", "full", "eating only", "small amount", "food", "Abdominal", "mild right upper quadrant tenderness", "liver span of", "Ultrasonography", "5", "4", "hyperechoic mass", "the left lobe of", "liver", "mass", "surgically", "photomicrograph", "resected", "following", "diagnosis"]}
{"question": "A pharmaceutical company has created an experimental medication, Drug Z, for patients with relapsing-remitting multiple sclerosis. Drug Z has been deemed to be safe in rats and is nearly ready for human trials. Before initiating a Phase I clinical trial, the company would like to study the medication’s pharmacokinetic properties in humans. The drug was found to have a half-life of 2.5 hours and is eliminated by first-order kinetics. The volume of distribution of the drug is determined to be 0.5 L/kg. The drug is administered intravenously and sublingually and plasma drug concentration vs. time plots are obtained. Intravenous administration of 10 mg of Drug Z yields an area under the curve (AUC) of 15 mg hr/L. Sublingual administration of 25 mg of Drug Z yields an area under the curve of 20 mg hr/L. What is the absolute bioavailability of this medication?", "answer": "53%", "options": {"A": "48%", "B": "53%", "C": "59%", "D": "67%", "E": "71%"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["created", "experimental medication", "Drug", "patients", "relapsing-remitting multiple sclerosis", "Drug", "to", "nearly ready", "human", "Before initiating", "company", "to study", "medications", "properties", "humans", "drug", "found to", "half", "hours", "eliminated", "first-order", "volume", "distribution", "drug", "to", "0.5 L kg", "drug", "administered", "plasma drug concentration", "time", "obtained", "Intravenous", "10 mg", "Drug", "area under the curve", "mg", "L", "Sublingual administration", "Drug", "area under the curve", "20 mg hr", "absolute bioavailability", "medication"]}
{"question": "A 42-year-old homeless male presents with fever and cough. He was found unconscious on the side of the road and was brought to the emergency room. He is noticeably drunk and is unable to answer any questions. On physical exam his temperature is 103°F (40°C), blood pressure is 130/85 mmHg, pulse is 110/min, respirations are 23/min, and pulse oximetry is 96% on room air. You note decreased breath sounds in the right lower lobe. The pathogen most likely responsible for this patient's symptoms has which of the following features?", "answer": "Gram-negative organism that produces mucoid colonies on MacConkey agar", "options": {"A": "Organism that forms black colonies on cysteine-tellurite agar", "B": "Disc-shaped yeast seen on methenamine silver stain", "C": "Gram-positive, catalase-positive organism that forms cocci in clusters", "D": "Negative-sense, single-stranded RNA virus", "E": "Gram-negative organism that produces mucoid colonies on MacConkey agar"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old homeless male presents", "fever", "cough", "found unconscious", "side", "road", "brought", "emergency room", "drunk", "unable to", "temperature", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "23 min", "pulse oximetry", "96", "room air", "note decreased breath sounds", "right lower lobe", "pathogen", "likely responsible", "patient's symptoms", "following features"]}
{"question": "A 45-year-old Caucasian male presents complaining of inability to open his mouth. Patient history reveals that he recently injured his foot from an exposed floor nail in his house. This patient's symptoms are likely the result of:", "answer": "Impaired motor neuron release of GABA", "options": {"A": "Impaired motor neuron release of ACh", "B": "Impaired motor neuron release of GABA", "C": "Increased production of gas in his soft tissues", "D": "Cross-reactivity of bacterial antigens", "E": "Bacterial infiltration of the central nervous system"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "male presents", "to open", "mouth", "Patient history reveals", "recently injured", "foot", "exposed floor nail", "house", "patient's symptoms", "likely", "result"]}
{"question": "An 18-year-old college student presents to the ED straight from chemistry lab where he ingested an unknown compound. He complains of a headache, and is flushed, tachypneic and tachycardic. Suspecting cyanide poisoning, you administer amyl nitrite which causes which of the following?", "answer": "Oxidation of ferrous iron in hemoglobin to ferric iron", "options": {"A": "Oxidation of ferrous iron in hemoglobin to ferric iron", "B": "A decrease in serum methemoglobin levels", "C": "Formation of thiocyanate", "D": "Chelation of the residue", "E": "Increase in intracellular NADH/NAD+ ratio"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "presents", "straight", "chemistry lab", "unknown compound", "headache", "flushed", "tachypneic", "tachycardic", "cyanide poisoning", "administer amyl nitrite", "causes", "following"]}
{"question": "A 76-year-old man presents to his physician with his daughter for evaluation of memory loss and disorientation that has become progressively worse over the last few years. The patient’s daughter states that the memory loss started with her father forgetting things ''here and there'' and the memory loss has progressed to the patient forgetting the names of loved ones and getting lost in familiar places. The medical history is non-contributory. On examination, the patient is awake and alert but only oriented to self (not time or place). The cardiopulmonary and neurologic exams are within normal limits. Routine lab work is performed to rule out infection and is found to be within normal limits. Four years later the patient passes away and an autopsy is performed to confirm the presumptive diagnosis. Brain biopsy slides are shown. What histologic features confirm this patient’s diagnosis?", "answer": "Aβ amyloid neuritic plaques", "options": {"A": "Lewy bodies", "B": "Aβ amyloid neuritic plaques", "C": "Ubiquitinated TDP-43", "D": "Beta-pleated sheet proteins resistant to proteases", "E": "Viral inclusions within oligodendrocytes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["76 year old man presents", "physician", "of memory loss", "disorientation", "worse", "years", "patients", "states", "memory loss started", "memory loss", "progressed", "patient forgetting", "names", "ones", "getting lost", "familiar places", "medical history", "non contributory", "patient", "awake", "alert", "only oriented", "not time", "place", "cardiopulmonary", "neurologic exams", "normal limits", "Routine lab", "performed to rule out infection", "found to", "normal limits", "Four years later", "patient passes", "autopsy", "performed to confirm", "presumptive diagnosis", "Brain biopsy", "histologic features confirm", "patients diagnosis"]}
{"question": "A 19-year-old female student presents to her physician for overall fatigue. She is having a hard time concentrating while studying and feeling tired most of the time. She also has had constipation for more than 3 weeks and rectal bleeding on occasions. She notices she is getting colder and often needs to wear warmer clothes than usual for the same weather. On examination, a small nodule around the size of 1cm is palpated in the left thyroid lobule; the gland is nontender. There is no lymphadenopathy. Her vital signs are: blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 87/min, and temperature is 36.1°C (97.0°F). Which of the following is the best next step in the management of this patient?", "answer": "Thyroid ultrasound", "options": {"A": "Serum T3 levels", "B": "Thyroid ultrasound", "C": "Serum calcitonin levels", "D": "Radionuclide thyroid scan", "E": "Combination T4 and T3 therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female", "presents", "physician", "overall fatigue", "hard time", "studying", "tired most of the time", "constipation", "3 weeks", "rectal bleeding", "occasions", "getting colder", "often needs to", "warmer clothes", "usual", "same", "small nodule", "size of", "left thyroid lobule", "gland", "nontender", "lymphadenopathy", "vital signs", "blood pressure", "75 mm Hg", "respirations", "min", "pulse", "87 min", "temperature", "36", "97", "following", "best next step", "patient"]}
{"question": "A 43-year-old man is brought to the emergency department because of severe back pain for 2 hours. He describes it as a stabbing pain between his scapulae that is 9 out of 10 in intensity. He has vomited once during this period. He has hypertension and type 2 diabetes mellitus. He has not seen a physician in 18 months. Current medications include metformin and enalapril. He is diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 100/min, respirations are 20/min, and blood pressure is 210/130 mm Hg. He is not oriented to person, place, or time. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Abdominal examination shows mild epigastric tenderness with no rebound or guarding. The radial pulse is decreased on the left side. Laboratory studies show:\nHemoglobin 13.1 g/dL\nLeukocyte count 10,000/mm3\nPlatelet count 230,000/mm3\nSerum\nNa+ 139 mEq/L\nK+ 4.1 mEq/L\nCl- 103 mEq/L\nGlucose 230 mg/dL\nCreatinine 3.9 mg/dL\nAlkaline phosphatase 55 U/L\nUrine toxicology screening is positive for opiates and cocaine. An ECG shows sinus tachycardia with no evidence of ischemia. An x-ray of the chest shows a widened mediastinum. Which of the following is the most appropriate next step in management?\"", "answer": "Transesophageal echocardiography", "options": {"A": "Transthoracic echocardiography", "B": "Gadolinium-enhanced MRA", "C": "Contrast-enhanced CT angiography", "D": "Transesophageal echocardiography", "E": "Aortography\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "of severe back pain", "hours", "stabbing pain", "scapulae", "out", "10", "intensity", "vomited", "period", "hypertension", "type 2 diabetes mellitus", "not seen", "physician", "months", "Current medications include metformin", "enalapril", "diaphoretic", "temperature", "99", "pulse", "100 min", "respirations", "20 min", "blood pressure", "mm Hg", "not oriented to person", "place", "time", "lungs", "clear", "auscultation", "murmurs", "rubs", "Abdominal", "mild epigastric tenderness", "guarding", "radial pulse", "decreased", "left side", "Laboratory studies", "Hemoglobin", "Leukocyte", "mm3 Platelet count", "Serum", "K", "Cl", "9", "Urine toxicology screening", "positive", "opiates", "cocaine", "ECG", "sinus tachycardia", "ischemia", "x-ray of", "chest", "widened mediastinum", "following", "most appropriate next step"]}
{"question": "A 67-year-old man presents to his primary care provider for routine follow-up. He complains of mild fatigue and occasional tingling in both feet. He reports that this numbness and tingling has led to him having 3 falls over the last month. He has had type 2 diabetes mellitus for 23 years and hypertension for 15 years, for which he takes metformin and enalapril. He denies tobacco or alcohol use. His blood pressure is 126/82 mm Hg, the heart rate is 78/min, and the respiratory rate is 15/min. Significant laboratory results are shown:\nHemoglobin 10 g/dL\nHematocrit 30%\nMean corpuscular volume (MCV) 110 fL\nSerum B12 level 210 picograms/mL\nWhich of the following is the best next step in the management of this patient’s condition?", "answer": "Methylmalonic acid level", "options": {"A": "Intrinsic factor antibody", "B": "Schilling test", "C": "Folic acid supplementation", "D": "Pregabalin or gabapentin", "E": "Methylmalonic acid level"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["67 year old man presents", "primary care provider", "routine follow-up", "mild fatigue", "occasional tingling", "feet", "reports", "numbness", "tingling", "led", "3 falls", "month", "type 2 diabetes mellitus", "23 years", "hypertension", "years", "metformin", "enalapril", "tobacco", "blood pressure", "mm Hg", "heart rate", "min", "respiratory rate", "min", "Significant laboratory results", "Hemoglobin", "g", "Hematocrit", "Mean corpuscular volume", "fL Serum B12 level", "picograms mL", "following", "best next step", "management", "patients condition"]}
{"question": "A previously healthy 31-year-old man comes to the emergency department because of acute onset of left flank pain radiating to his inner groin and scrotum for 3 hours. He also had nausea and one episode of hematuria. His only medication is a multivitamin. He appears uncomfortable. His temperature is 37°C (98.6°F), pulse is 104/min, respirations are 19/min, and blood pressure is 132/85 mm Hg. Physical examination shows marked tenderness in the left costovertebral area. He has normal skin turgor, a capillary refill time of < 1 second, and has been urinating normally. Laboratory studies show:\nSerum\nCalcium 9.5 mg/dL\nPhosphorus 4.3 mg/dL\nCreatinine 0.8 mg/dL\nUrea nitrogen 15 mg/dL\nUrine\npH 6.5\nRBCs 50–60/hpf\nA CT scan of the abdomen shows a 4-mm stone in the left distal ureter. Intravenous fluid resuscitation is begun and treatment with tamsulosin and ketorolac is initiated. Five hours later, he passes the stone. Metabolic analysis of the stone is most likely going to show which of the following?\"", "answer": "Calcium oxalate", "options": {"A": "Uric acid", "B": "Magnesium ammonium phosphate", "C": "Cystine", "D": "Xanthine", "E": "Calcium oxalate"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy 31 year old man", "emergency department", "acute onset", "left flank radiating", "inner groin", "scrotum", "hours", "nausea", "one episode of hematuria", "only medication", "multivitamin", "appears", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "marked tenderness", "left", "area", "normal", "capillary refill time", "1 second", "Laboratory studies", "Serum Calcium 9", "mg", "mg", "Creatinine 0", "Urea nitrogen", "Urine", "6", "hpf", "CT scan", "abdomen", "4-mm stone", "left distal ureter", "Intravenous fluid resuscitation", "begun", "treatment", "tamsulosin", "ketorolac", "initiated", "Five hours later", "passes", "stone", "Metabolic analysis", "stone", "most likely", "to", "following"]}
{"question": "A 50-year-old female teacher presents to the clinic with complaints of discoloration of the skin around the right ankle accompanied by itching. She began noticing it a month ago and the pruritus worsened over time. She also has some pain and swelling of the region every night, especially on days when she teaches late into the evening. Her past medical history is significant for diabetes mellitus type 2, for which she takes metformin. She lives with her husband and takes oral contraceptive pills. On examination, the physician observes hyperpigmentation of the medial aspect of her right ankle. The skin is dry, scaly, and edematous along with some superficial varicosities. Dorsiflexion of the foot is extremely painful. Peripheral pulses are equally palpable on both lower limbs. There is a small 2 cm ulcer noted near the medial malleolus with thickened neighboring skin and indurated edges. Laboratory studies show D-dimer of 1,000 µg/L and HbA1c of 9%. Doppler ultrasound of the lower extremity reveals an intramural thrombus in the popliteal vein. Which of the following is the most likely diagnosis in this patient?", "answer": "Stasis dermatitis", "options": {"A": "Basal cell carcinoma", "B": "Stasis dermatitis", "C": "Diabetic foot", "D": "Atopic dermatitis", "E": "Cellulitis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old female teacher presents", "clinic", "complaints of discoloration", "skin", "right ankle", "itching", "began", "month", "pruritus worsened", "time", "pain", "swelling", "region", "night", "days", "late", "evening", "past medical history", "significant", "diabetes mellitus type 2", "metformin", "lives with", "husband", "oral contraceptive pills", "physician observes hyperpigmentation of", "medial aspect", "right ankle", "skin", "dry", "scaly", "edematous", "superficial varicosities", "Dorsiflexion of", "foot", "extremely painful", "Peripheral pulses", "palpable", "lower limbs", "small", "ulcer noted", "medial malleolus", "thickened neighboring skin", "indurated edges", "Laboratory studies", "D-dimer", "g/L", "Doppler ultrasound", "lower extremity reveals", "intramural thrombus", "popliteal vein", "following", "diagnosis", "patient"]}
{"question": "A 22-year-old man comes to the physician because of a 2-month history of episodes of shortness of breath, lightheadedness, and palpitations. During the examination, he reports the onset of one such episode. His pulse is 170/min and regular, respirations are 22/min, and blood pressure is 100/65 mm Hg. An ECG shows a regular narrow complex tachycardia; no P waves are visible. A common clinical maneuver to diagnose and/or relieve the patient's symptoms involves stimulation of which of the following nerves?", "answer": "Glossopharyngeal", "options": {"A": "Trigeminal", "B": "Recurrent laryngeal", "C": "Facial", "D": "Phrenic", "E": "Glossopharyngeal"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "of", "2 month history", "episodes", "shortness", "breath", "lightheadedness", "palpitations", "reports", "onset", "one", "episode", "pulse", "min", "regular", "respirations", "min", "blood pressure", "100 65 mm Hg", "ECG", "regular narrow complex tachycardia", "P waves", "visible", "common clinical", "to diagnose", "relieve", "patient's symptoms", "stimulation", "following nerves"]}
{"question": "A 20-year-old man comes to the physician because he believes he has low testosterone. He states that he is embarrassed at his lack of musculature, despite lifting weights twice daily. Every day, he drinks a gallon of milk and several protein shakes in addition to 3 large meals. He is convinced that his female classmates at the community college he attends are secretly laughing at his scrawny appearance. Over the course of the semester, he has attended fewer and fewer classes out of embarrassment and shame. He is also concerned that his hair is thinning and applies topical minoxidil to his scalp 3 times daily. He spends 2 hours daily anxiously examining himself in the mirror. Today, he is wearing a long-sleeved shirt and a hat. His BMI is 26 kg/m2. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and a full range of affect. Serum studies show a normal testosterone concentration. Which of the following is the most likely diagnosis?", "answer": "Body dysmorphic disorder", "options": {"A": "Avoidant personality disorder", "B": "Body dysmorphic disorder", "C": "Obsessive compulsive disorder", "D": "Binge eating disorder", "E": "Generalized anxiety disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["20 year old man", "physician", "low testosterone", "states", "embarrassed", "lack", "musculature", "twice daily", "day", "gallon", "milk", "several protein shakes in addition to", "large meals", "female", "community college", "attends", "appearance", "course", "semester", "attended fewer", "fewer", "out", "hair", "thinning", "applies", "scalp", "times daily", "spends 2", "examining", "mirror", "Today", "long sleeved shirt", "hat", "BMI", "kg/m2", "abnormalities", "mental status", "anxious mood", "full range", "Serum studies", "normal testosterone concentration", "following", "diagnosis"]}
{"question": "Clinical study looks at the effect of childhood exposure of 2nd-hand smoking on the incidence of bronchogenic adenocarcinoma (BA). Study of 100 subjects (50 exposed to childhood 2nd-hand smoking and 50 healthy controls with no childhood exposure) involves monitoring the lifetime incidence of BA data from the study are shown in the table below:\nGroup\\BA Dx Yes No\nExposed 18 32\nControls 7 43\nWhich of the following statements is correct regarding the number needed to harm (NNH) based on this study?", "answer": "The NNH is inversely correlated with the relative risk increase.", "options": {"A": "If the incidence of BA increases in the control group, the NNH will decrease.", "B": "If the incidence of BA increases in the experimental group, the NNH will increase.", "C": "The NNH is 11.", "D": "The NNH is inversely correlated with the relative risk increase.", "E": "If the absolute risk in the exposed group increases, the NNH increases."}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["looks", "effect", "childhood exposure", "2nd hand smoking", "incidence", "adenocarcinoma", "100", "50 exposed", "childhood 2nd hand smoking", "50 healthy controls", "childhood exposure", "lifetime incidence", "BA data", "study", "table", "Group BA", "Exposed", "Controls", "following", "correct", "number needed", "based", "study"]}
{"question": "Two patients are vaccinated for poliomyelitis. Patient A receives the Sabin oral vaccine, and Patient B receives the Salk intramuscular vaccine. Six weeks after their initial vaccinations, which of the following would be the greatest difference regarding these two patients?", "answer": "Patient A has a higher level of duodenal IgA antibodies", "options": {"A": "Patient A has a higher level of duodenal IgA antibodies", "B": "Patient B has a higher level of duodenal IgA antibodies", "C": "Patient A has a lower level of serum IgA antibodies", "D": "Patient B has a lower level of serum IgM antibodies", "E": "Patient A has a higher level of serum IgG antibodies"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Two patients", "vaccinated", "poliomyelitis", "Patient", "receives", "Sabin oral vaccine", "Patient", "receives", "Salk intramuscular vaccine", "Six weeks", "initial vaccinations", "following", "greatest difference", "two patients"]}
{"question": "A 71-year-old woman comes to the physician because of dizziness and intermittent episodes of heart palpitations for 5 days. During this time, she has also had one episode of syncope. An ECG shows absence of P waves and irregular RR intervals. Treatment with an antiarrhythmic drug is initiated. The effect of the drug on the cardiac action potential is shown. Which of the following cardiac ion channels is most likely targeted by this drug?", "answer": "Voltage-gated potassium channels", "options": {"A": "Voltage-gated nonselective cation channels", "B": "Voltage-gated sodium channels", "C": "Voltage-gated potassium channels", "D": "Voltage-gated calcium channels", "E": "Voltage-gated chloride channels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "dizziness", "intermittent episodes of heart", "5 days", "time", "one episode of syncope", "ECG", "absence", "P waves", "irregular RR intervals", "Treatment", "antiarrhythmic drug", "initiated", "effect of", "drug", "cardiac action potential", "following cardiac ion channels", "most likely targeted", "drug"]}
{"question": "A 53-year-old woman presents to her primary care physician in order to discuss the results of a biopsy. Two weeks ago, her mammogram revealed the presence of suspicious calcifications in her right breast, and she subsequently underwent biopsy of these lesions. Histology of the lesions revealed poorly cohesive cells growing in sheets with a nuclear to cytoplasmic ratio of 1:1. Furthermore, these cells were found to undergo invasion into the surrounding tissues. Given these findings, the patient is referred to an oncologist for further evaluation. Upon further imaging, the patient is found to have no lymph node adenopathy and no distant site metastases. Which of the following would most properly describe the lesions found in this patient?", "answer": "High grade and low stage", "options": {"A": "High grade and high stage", "B": "High grade and no stage", "C": "High grade and low stage", "D": "Low grade and high stage", "E": "Low grade and low stage"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "order to", "results", "biopsy", "Two weeks", "mammogram revealed", "presence", "suspicious calcifications", "right breast", "biopsy", "lesions", "Histology", "lesions revealed poorly", "cells", "sheets", "nuclear", "cytoplasmic ratio", "1", "cells", "found to", "invasion", "surrounding tissues", "Given", "findings", "patient", "referred", "oncologist", "further", "further imaging", "patient", "found to", "lymph node adenopathy", "site", "following", "most", "lesions found", "patient"]}
{"question": "A graduate student is developing the research design for a current project on the detection of ovarian tumor markers in mice. The main method requires the use of chromogenic substrates, in which a reaction may be interpreted according to an enzyme-mediated color change. The detection of which of the substances below is routinely used in clinical practice and applies the above-described method?", "answer": "P24 antigen", "options": {"A": "ABO blood types", "B": "Anti-D antibodies", "C": "P24 antigen", "D": "Epstein-Barr virus infection", "E": "Antibodies in autoimmune hemolytic anemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["graduate student", "current", "the detection of ovarian tumor markers", "main method", "use of", "reaction", "interpreted", "enzyme mediated color change", "detection", "used", "clinical", "applies", "above", "method"]}
{"question": "A 12-year-old boy is brought to the physician because of a 6-day history of gradually worsening left knee pain. The pain is exacerbated by movement and kneeling. There is no pain at rest and no history of trauma to the knee. He is concerned because his soccer tryouts are in a few days. Vital signs are within normal limits. Examination shows mild swelling and tenderness to palpation of the left anterior, superior tibia. Extension of the left knee against resistance reproduces the knee pain; flexion is limited by pain. There is no local erythema or effusion of the left knee. A lateral view of an x-ray of his left knee is shown. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Traction apophysitis of the tibial tubercle", "options": {"A": "Impingement of the infrapatellar fat pad", "B": "Inflammation of the infrapatellar bursa", "C": "Chondromalacia patella", "D": "Traction apophysitis of the tibial tubercle", "E": "Osteochondritis dissecans of the knee"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "6-day history", "worsening left", "pain", "exacerbated", "movement", "kneeling", "pain at rest", "history", "trauma", "knee", "few days", "Vital signs", "normal limits", "mild swelling", "tenderness", "palpation", "left anterior", "superior tibia", "Extension", "knee", "resistance", "knee pain", "flexion", "limited", "pain", "local erythema", "effusion", "left knee", "lateral view of", "x-ray", "left knee", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 17-year-old teenager presents to the clinic with her parents complaining of headaches and loss of vision which began insidiously 3 months ago. She describes her headaches as throbbing, mostly on her forehead, and severe enough to affect her daily activities. She has not experienced menarche. Past medical history is noncontributory. She takes no medication. Both of her parents are alive and well. Today, her blood pressure is 110/70 mm Hg, the heart rate is 90/min, the respiratory rate is 17/min, and the temperature is 37.0°C (98.6°F). Breasts and pubic hair development are in Tanner stage I. Blood work is collected and an MRI is performed (the result is shown). Inhibition of which of the following hormones is the most likely explanation for the patient's signs and symptoms?", "answer": "Gonadotropins", "options": {"A": "Antidiuretic hormone", "B": "Thyroid-stimulating hormone", "C": "Gonadotropins", "D": "Adrenocorticotropic hormone", "E": "Prolactin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old teenager presents", "clinic", "headaches", "loss of vision", "began", "months", "headaches", "throbbing", "mostly", "forehead", "severe", "to", "not", "menarche", "Past medical history", "medication", "alive", "well", "Today", "blood pressure", "70 mm Hg", "heart rate", "90 min", "respiratory rate", "min", "temperature", "98", "Breasts", "pubic hair development", "Tanner I", "Blood", "collected", "MRI", "performed", "result", "Inhibition", "following hormones", "explanation", "patient's signs", "symptoms"]}
{"question": "A healthy 31-year-old woman comes to the physician because she is trying to conceive. She is currently timing the frequency of intercourse with at-home ovulation test kits. An increase in the levels of which of the following is the best indicator that ovulation has occurred?", "answer": "Progesterone", "options": {"A": "Estrogen", "B": "Gonadotropin-releasing hormone", "C": "Follicle stimulating hormone", "D": "Progesterone", "E": "Luteinizing hormone\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 31 year old woman", "physician", "to", "currently timing", "frequency", "intercourse", "at-home ovulation test kits", "increase", "levels", "following", "best indicator", "ovulation"]}
{"question": "A 32-year-old man presents with a 2-month history of increasing lethargy, frequent upper respiratory tract infections, and easy bruising. Past medical history is unremarkable. The patient reports a 14-pack-year smoking history and says he drinks alcohol socially. No significant family history. His vital signs include: temperature 36.8°C (98.2°F), blood pressure 132/91 mm Hg and pulse 95/min. Physical examination reveals conjunctival pallor and scattered ecchymoses on the lower extremities. Laboratory results are significant for the following:\nHemoglobin 8.2 g/dL\nLeukocyte count 2,200/mm3\nPlatelet count 88,000/mm3\nReticulocyte count 0.5%\nA bone marrow biopsy is performed, which demonstrates hypocellularity with no abnormal cell population. Which of the following is the most likely diagnosis in this patient? ", "answer": "Aplastic anemia", "options": {"A": "Aplastic anemia", "B": "Myelodysplastic syndrome", "C": "Infectious mononucleosis", "D": "Acute lymphocytic leukemia", "E": "Drug-induced immune pancytopenia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "month history", "increasing lethargy", "frequent upper respiratory tract infections", "easy bruising", "Past medical history", "unremarkable", "patient reports", "smoking history", "alcohol", "significant family history", "vital signs include", "temperature 36", "98", "blood pressure", "mm Hg", "pulse 95 min", "reveals conjunctival pallor", "scattered ecchymoses", "lower extremities", "Laboratory results", "significant", "following", "Hemoglobin", "g Leukocyte count", "200 mm3 Platelet count 88", "Reticulocyte", "0.5", "bone marrow biopsy", "performed", "hypocellularity", "population", "following", "diagnosis", "patient"]}
{"question": "A 2-year-old boy is brought to the physician for evaluation of delayed onset of speech. Over the past year, he has also had recurrent dizziness and three episodes of syncope. Examination of the ears shows clear auditory canals and intact tympanic membranes with normal light reflexes. Visual reinforcement audiometry shows bilateral sensorineural deafness. Genetic analysis reveals a mutation in the KCNQ1 gene causing a defect in slow voltage-gated potassium channels. An electrocardiogram of this patient is most likely to show which of the following?", "answer": "Prolongation of the QT interval", "options": {"A": "Pseudo-right bundle branch block", "B": "Slurred upstroke of the QRS complex", "C": "Epsilon wave following the QRS complex", "D": "Absence of P waves", "E": "Prolongation of the QT interval"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["2 year old boy", "brought", "physician", "evaluation", "delayed onset", "speech", "past year", "recurrent dizziness", "three episodes of syncope", "Examination", "ears", "clear auditory canals", "intact tympanic membranes", "normal light reflexes", "Visual reinforcement audiometry", "bilateral sensorineural deafness", "Genetic analysis reveals", "mutation", "KCNQ1 causing", "defect", "slow voltage-gated potassium channels", "electrocardiogram", "patient", "to", "following"]}
{"question": "A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?", "answer": "Observation and follow-up", "options": {"A": "Suprapubic catheterization", "B": "Intravenous pyelography", "C": "Laparotomy", "D": "Observation and follow-up", "E": "CT scan of the abdomen and pelvis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department 20 minutes", "control", "bicycle", "parked car", "bicycle hit", "lower abdomen", "arrival", "alert", "oriented", "pulse", "90 min", "respirations", "min", "blood pressure", "70 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "97", "pupils", "equal", "reactive to light", "multiple bruises", "chest", "lower extremities", "lungs", "clear", "auscultation", "Cardiac examination", "abnormalities", "abdomen", "soft", "nontender", "pelvic instability", "Rectal examination", "unremarkable", "complete blood count", "prothrombin time", "serum", "glucose", "creatinine", "electrolytes", "reference range", "Urine dipstick", "mildly positive", "blood", "Microscopic examination of", "urine", "20 RBCs/hpf", "following", "most appropriate next step"]}
{"question": "Four days after admission to the hospital for acute pancreatitis, a 41-year-old man develops hypotension and fever. His temperature is 39.1°C (102.3°F), pulse is 115/min, and blood pressure is 80/60 mm Hg. Physical examination shows warm extremities, asymmetric calf size, and blood oozing around his IV sites. There are numerous small, red, non-blanching macules and patches covering the extremities, as well as several large ecchymoses. His hemoglobin concentration is 9.0 g/dL. A peripheral blood smear shows schistocytes and decreased platelets. Which of the following sets of serum findings are most likely in this patient?\n $$$ Prothrombin time %%% Partial thromboplastin time %%% Fibrinogen %%% D-dimer $$$", "answer": "↑ ↑ ↓ ↑", "options": {"A": "↑ ↑ ↓ normal", "B": "Normal normal normal normal", "C": "↑ ↑ ↓ ↑", "D": "Normal ↑ normal normal", "E": "Normal normal normal ↑"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Four days", "hospital", "acute", "year old man", "hypotension", "fever", "temperature", "pulse", "min", "blood pressure", "80 60 mm Hg", "warm extremities", "asymmetric calf size", "blood", "IV sites", "numerous small", "red", "non blanching macules", "patches covering", "extremities", "several large ecchymoses", "hemoglobin concentration", "0 g/dL", "peripheral blood smear", "schistocytes", "decreased platelets", "following sets", "serum findings", "patient", "Prothrombin time", "Partial thromboplastin time", "Fibrinogen", "D-dimer"]}
{"question": "A 38-year-old man with a history of hypertension presents to his primary care physician for a headache and abdominal pain. His symptoms began approximately 1 week ago and have progressively worsened. He describes his headache as pressure-like and is mildly responsive to ibuprofen. His abdominal pain is located in the bilateral flank area. His hypertension is poorly managed with lifestyle modification and chlorthalidone. He had 1 urinary tract infection that was treated with ciprofloxacin approximately 6 months ago. He has a home blood pressure monitor, where his average readings are 155/95 mmHg. Family history is significant for his father expiring secondary to a myocardial infarction and his history was complicated by refractory hypertension and end-stage renal disease. His vital signs are significant for a blood pressure of 158/100 mmHg. Physical examination is notable for bilateral flank masses. Laboratory testing is significant for a creatinine of 3.1 mg/dL. Urinalysis is remarkable for hematuria and proteinuria. Which of the following will this patient most likely be at risk for developing?", "answer": "Mitral valve prolapse", "options": {"A": "Epilepsy", "B": "Lymphangioleiomyomatosis", "C": "Migraine headache", "D": "Mitral valve prolapse", "E": "Neuroendocrine pancreatic tumor"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "history of hypertension presents", "primary care physician", "headache", "abdominal pain", "symptoms began approximately", "week", "worsened", "headache", "pressure", "mildly responsive", "ibuprofen", "abdominal pain", "bilateral flank area", "hypertension", "poorly", "lifestyle modification", "chlorthalidone", "1 urinary tract infection", "treated with ciprofloxacin approximately", "months", "home blood pressure monitor", "average", "95 mmHg", "Family history", "significant", "expiring secondary to", "myocardial infarction", "history", "complicated", "refractory hypertension", "end-stage renal disease", "vital signs", "significant", "blood pressure of", "100 mmHg", "Physical examination", "notable", "bilateral flank", "Laboratory testing", "significant", "creatinine", "mg/dL", "Urinalysis", "hematuria", "proteinuria", "following", "patient", "likely", "at risk"]}
{"question": "A 22-year-old woman comes to the physician because of a 1-week history of nausea and vomiting. She has not had fever, abdominal pain, diarrhea, or vaginal bleeding. She does not remember the date of her last menstrual period. She uses oral contraceptive pills but occasionally forgot to take them. She had pelvic inflammatory disease 2 years ago and was treated with antibiotics. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 16/min, and blood pressure is 118/75 mm Hg. Physical examination shows no abnormalities. Pelvic examination shows a normal appearing vagina, cervix, uterus, and adnexa. A urine pregnancy test is positive. Her serum β-human chorionic gonadotropin concentration is 805 mIU/mL. Which of the following is the most appropriate next step in diagnosis?", "answer": "Transvaginal ultrasound in 4 days", "options": {"A": "Diagnostic laparoscopy now", "B": "Administer misoprostol now", "C": "Transvaginal ultrasound in 4 days", "D": "Schedule dilation and evacuation", "E": "Administer methotrexate now"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "1-week history", "nausea", "vomiting", "not", "fever", "abdominal pain", "diarrhea", "vaginal bleeding", "not", "date of", "last menstrual period", "uses oral contraceptive pills", "occasionally forgot to", "pelvic inflammatory disease", "years", "treated with", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "75 mm Hg", "abnormalities", "Pelvic examination", "normal appearing vagina", "cervix", "uterus", "adnexa", "urine pregnancy test", "positive", "serum", "human chorionic gonadotropin concentration", "mIU/mL", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 52-year-old man with chronic kidney disease presents for significant back pain that has gotten worse in the past 2 days. On exam, the patient has a moderate kyphosis with decreased range of motion of the spine secondary to pain. The patient has no neurologic deficits but is in severe pain. Lab work reveals a low normal serum calcium, slightly increased serum phosphate, and decreased serum vitamin D. What is the cause of this patient’s presentation?", "answer": "Increased bone turnover", "options": {"A": "Increased calcium absorption in the intestines", "B": "Markedly increased PTH", "C": "Drastic decrease in estrogen", "D": "Increased bone turnover", "E": "Decreased production of calcifediol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "chronic kidney disease presents", "significant back pain", "gotten worse", "past 2 days", "exam", "patient", "moderate kyphosis", "decreased range of motion", "spine secondary to pain", "patient", "neurologic deficits", "severe pain", "Lab", "reveals", "low normal", "slightly increased serum phosphate", "decreased serum vitamin", "cause", "patients"]}
{"question": "A 32-year-old woman brought to the emergency department because of a 1-week history of palpitations and shortness of breath. She has congestive heart failure. Current medications include furosemide, lisinopril, and atenolol. Her pulse is 124/min and irregularly irregular, and blood pressure is 110/70 mm Hg. Examination shows coarse crackles over the lower lung fields bilaterally. Treatment with digoxin is started. Five days later, an ECG shows prolongation of the PR interval. Which of the following is the most likely explanation for the observed effect of this drug?", "answer": "Increase in vagal tone", "options": {"A": "Inhibition of myocardial Na+/K+ ATPase", "B": "Inhibition of AV node L-type Ca2+ channels", "C": "Increase in vagal tone", "D": "Activation of Na+/Ca2+ exchanger", "E": "Decrease in intracellular cAMP"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman brought", "emergency department", "of", "1-week history", "palpitations", "shortness of breath", "congestive heart failure", "Current medications include furosemide", "lisinopril", "atenolol", "pulse", "min", "irregular", "blood pressure", "70 mm Hg", "coarse crackles", "lower lung fields", "Treatment", "digoxin", "started", "later", "ECG", "prolongation", "PR interval", "following", "observed effect of", "drug"]}
{"question": "A 65-year-old man presents to the physician with pain in his right calf over the last 3 months. He mentions that the pain typically occurs after he walks approximately 100 meters and subsides after resting for 5 minutes. His medical history is significant for hypercholesterolemia, ischemic heart disease, and bilateral knee osteoarthritis. His current daily medications include aspirin and simvastatin, which he has taken for the last 2 years. The physical examination reveals diminished popliteal artery pulses on the right side. Which of the following drugs is most likely to improve this patient's symptoms?", "answer": "Cilostazol", "options": {"A": "Acetaminophen", "B": "Amlodipine", "C": "Cilostazol", "D": "Isosorbide dinitrate", "E": "Ranolazine"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old man presents", "physician", "pain in", "right calf", "last", "months", "pain", "occurs", "walks approximately 100 meters", "5 minutes", "medical history", "significant", "hypercholesterolemia", "ischemic heart disease", "bilateral knee osteoarthritis", "current daily medications include aspirin", "simvastatin", "years", "reveals diminished popliteal artery pulses", "right side", "following drugs", "to", "patient's symptoms"]}
{"question": "An investigator is studying mechanisms of urea excretion in humans. During the experiment, a healthy male volunteer receives a continuous infusion of para-aminohippurate (PAH) to achieve a PAH plasma concentration of 0.01 mg/mL. A volume of 1.0 L of urine is collected over a period of 10 hours; the urine flow rate is 1.66 mL/min. The urinary concentration of PAH is measured to be 3.74 mg/mL and his serum concentration of urea is 0.2 mg/mL. Assuming a normal filtration fraction of 20%, which of the following best estimates the filtered load of urea in this patient?", "answer": "25 mg/min", "options": {"A": "25 mg/min", "B": "620 mg/min", "C": "124 mg/min", "D": "7 mg/min", "E": "166 mg/min"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying mechanisms", "urea excretion", "humans", "male", "receives", "continuous infusion", "para-aminohippurate", "to", "PAH plasma concentration", "0.01 mg/mL", "volume of 1.0", "urine", "collected", "period", "10 hours", "urine flow rate", "1.66 mL/min", "urinary concentration", "PAH", "measured to", "3 74 mg/mL", "serum", "urea", "0.2 mg/mL", "normal", "fraction of 20", "following best estimates", "filtered load", "urea", "patient"]}
{"question": "A 22-year-old student presents to the college health clinic with a 1-week history of fever, sore throat, nausea, and fatigue. He could hardly get out of bed this morning. There are no pets at home. He admits to having recent unprotected sex. The vital signs include: temperature 38.3°C (101.0°F), pulse 72/min, blood pressure 118/63 mm Hg, and respiratory rate 15/min. On physical examination, he has bilateral posterior cervical lymphadenopathy, exudates over the palatine tonsil walls with soft palate petechiae, an erythematous macular rash on the trunk and arms, and mild hepatosplenomegaly. What is the most likely diagnosis?", "answer": "Infectious mononucleosis", "options": {"A": "Rubella", "B": "Acute HIV infection", "C": "Toxoplasma infection", "D": "Infectious mononucleosis", "E": "Streptococcal pharyngitis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "clinic", "1-week history", "fever", "sore throat", "nausea", "fatigue", "get out", "bed", "morning", "at home", "to", "recent", "vital signs include", "temperature", "pulse 72 min", "blood pressure", "63 mm Hg", "respiratory rate", "min", "bilateral posterior cervical lymphadenopathy", "exudates", "palatine tonsil walls", "soft palate petechiae", "erythematous", "trunk", "arms", "mild hepatosplenomegaly", "diagnosis"]}
{"question": "An 18-year-old man presents to the emergency department after an automobile accident. His vitals have significantly dropped since admission. Upon examination, his abdomen is slightly distended, the ribs on the right side are tender and appear broken, and breath sounds are diminished at the base of the right lung. An abdominal ultrasound and chest X-ray are ordered. Ultrasound shows fluid in the abdominal cavity and trauma to the liver. X-ray confirmed broken ribs and pleural effusion on the right. Based on these findings, the surgeons recommend immediate surgery. Upon entering the abdomen, an exsanguinating hemorrhage is observed. The Pringle maneuver is used to reduce bleeding. What was clamped during this maneuver?", "answer": "Hepatoduodenal ligament", "options": {"A": "Aorta above coeliac axis", "B": "Hepatic artery only", "C": "Hepatic vein only", "D": "Hepatoduodenal ligament", "E": "Splenic artery only"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "automobile accident", "abdomen", "slightly distended", "ribs on", "right side", "tender", "appear", "breath sounds", "diminished", "base of", "right lung", "abdominal ultrasound", "chest X-ray", "ordered", "Ultrasound", "fluid", "abdominal", "trauma", "liver", "X-ray confirmed broken ribs", "pleural effusion", "right", "Based", "findings", "surgeons", "immediate surgery", "entering", "abdomen", "exsanguinating hemorrhage", "observed", "used to", "bleeding", "clamped"]}
{"question": "A 52-year-old woman comes to the physician because of a 3-month history of worsening chest pain and breathlessness during exercise. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Auscultation of the chest shows a murmur in the 2nd right intercostal space. A phonocardiogram of the murmur is shown. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Congenital leaflet fusion", "options": {"A": "Metastatic valvular calcification", "B": "Congenital leaflet fusion", "C": "Cystic medial necrosis", "D": "Sterile platelet thrombi formation", "E": "Viridans group streptococci infection"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "3 month history", "worsening chest pain", "breathlessness", "exercise", "history", "serious illness", "medications", "Vital signs", "normal limits", "Auscultation", "chest", "murmur", "2nd right intercostal space", "phonocardiogram", "murmur", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 45-year-old woman with type 2 diabetes mellitus is brought to the physician because of a 3-week history of nausea, abdominal pain, and confusion. She has a history of gastroesophageal reflux disease treated with over-the-counter antacids. She does not smoke or drink alcohol. Her only medication is metformin. Her pulse is 86/min and blood pressure is 142/85 mm Hg. Examination shows a soft abdomen. Arterial blood gas analysis on room air shows:\npH 7.46\nPCO2 44 mm Hg\nPO2 94 mm Hg\nHCO3- 30 mEq/L\nAn ECG shows a QT interval corrected for heart rate (QTc) of 0.36 seconds (N = 0.40–0.44). The serum concentration of which of the following substances is most likely to be increased in this patient?\"", "answer": "24,25-dihydroxycholecalciferol", "options": {"A": "Parathyroid hormone", "B": "Thyroid stimulating hormone", "C": "β-hydroxybutyrate", "D": "Phosphate", "E": "24,25-dihydroxycholecalciferol"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "type 2 diabetes mellitus", "brought", "physician", "3 week history", "nausea", "abdominal pain", "confusion", "history of gastroesophageal reflux disease treated with over-the-counter antacids", "not smoke", "only medication", "metformin", "pulse", "min", "blood pressure", "85 mm Hg", "soft abdomen", "Arterial blood gas analysis", "room air", "pH 7", "PCO2", "mm Hg PO2", "HCO3", "30 mEq/L", "ECG", "QT interval corrected for heart rate", "0.36 seconds", "N", "0 400 44", "serum concentration", "following", "to", "increased", "patient"]}
{"question": "A 3-week-old male newborn is brought to the physician by his 33-year-old mother for a well-child examination. He was born at term and delivered at home because his parents wanted a natural childbirth. The mother did not receive prenatal care. She has no history of serious illness and takes no medications. According to the mother, delivery was fast and without complications. He is being exclusively breastfed. He appears healthy. He is at 35th percentile for length and at 40th percentile for weight. Physical examination shows no abnormalities. This patient is at increased risk for which of the following complications at this time?", "answer": "Hemorrhage", "options": {"A": "Hemorrhage", "B": "Gastroenteritis", "C": "Iron deficiency anemia", "D": "Diabetes mellitus", "E": "Intussusception"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 week old male newborn", "brought", "physician", "year old", "well", "born", "term", "delivered at home", "wanted", "not receive", "history", "serious illness", "medications", "delivery", "fast", "complications", "breastfed", "appears healthy", "percentile", "length", "percentile", "weight", "abnormalities", "patient", "increased risk", "following complications", "time"]}
{"question": "A 38-year-old woman comes to the physician because of a 4-month history of crampy abdominal pain, recurrent watery diarrhea, and a 2.5-kg (5.5-lb) weight loss. Her husband has noticed that after meals, her face and neck sometimes become red, and she develops shortness of breath and starts wheezing. Examination shows a grade 3/6 systolic murmur heard best at the left lower sternal border. The abdomen is soft, and there is mild tenderness to palpation with no guarding or rebound. Without treatment, this patient is at greatest risk of developing which of the following conditions?", "answer": "Pigmented dermatitis", "options": {"A": "Achlorhydria", "B": "Laryngeal edema", "C": "Pigmented dermatitis", "D": "Megaloblastic anemia", "E": "T-cell lymphoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "4 month history", "crampy abdominal pain", "recurrent watery", "2.5 kg", "5.5", "weight loss", "meals", "face", "neck sometimes", "red", "shortness of breath", "starts wheezing", "systolic murmur heard best", "left lower sternal border", "abdomen", "soft", "mild tenderness", "palpation", "guarding", "treatment", "patient", "greatest", "following conditions"]}
{"question": "A 23-year-old man presents to his primary care physician with 2 weeks of headache, palpitations, and excessive sweating. He has no past medical history and his family history is significant for clear cell renal cell carcinoma in his father as well as retinal hemangioblastomas in his older sister. On presentation his temperature is 99°F (37.2°C), blood pressure is 181/124 mmHg, pulse is 105/min, and respirations are 18/min. After administration of appropriate medications, he is taken emergently for surgical removal of a mass that was detected by abdominal computed tomography scan. A mutation on which of the following chromosomes would most likely be seen in this patient?", "answer": "3", "options": {"A": "2", "B": "3", "C": "10", "D": "11", "E": "17"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old man presents", "primary care physician", "2 weeks", "headache", "palpitations", "excessive sweating", "past medical history", "family history", "significant", "clear cell renal cell carcinoma", "retinal hemangioblastomas", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "administration of appropriate medications", "surgical", "mass", "detected", "abdominal computed tomography scan", "mutation", "following chromosomes", "most likely", "seen", "patient"]}
{"question": "A 17-year-old male presents to the emergency department after a knife fight. He initially refused to come to the hospital, but one of his wounds overlying the right antecubital fossa would not stop bleeding. Vitals include: BP 90/65, HR 115, and RR 24. He reports that he is light-headed and having visual changes. You hold direct pressure over the wound on his right arm while the rest of the team resuscitates him with crystalloid and pRBCs. After his vitals signs normalize, you note that his right arm is cool and you are unable to palpate a radial pulse. The vascular surgery team explores his right arm, finding and repairing a lacerated brachial artery. Two hours post-operatively he is complaining of 10/10 pain in his right forearm and screams out loud when you passively move his fingers. What is the most appropriate next step in management?", "answer": "Measure forearm compartment pressures", "options": {"A": "Watchful waiting", "B": "Increase his dose of hydromorphone", "C": "Compressive bandage", "D": "Measure forearm compartment pressures", "E": "Nerve block"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "emergency department", "knife", "initially", "to", "hospital", "one", "wounds", "right antecubital fossa", "not stop bleeding", "include", "BP 90 65", "RR", "reports", "light-headed", "visual changes", "hold direct pressure", "wound", "right arm", "resuscitates", "crystalloid", "pRBCs", "signs", "note", "right arm", "cool", "unable to", "radial pulse", "vascular surgery", "right arm", "finding", "repairing", "lacerated brachial artery", "Two hours post", "10", "pain", "right forearm", "out loud", "move", "fingers", "most appropriate next step"]}
{"question": "A 59-year-old woman is admitted to the intensive care unit after surgery following a motor vehicle collision. She has received a total of four units of packed red blood cells. Physical examination shows dry mucous membranes and flat neck veins. Serum studies show a creatinine of 2.1 mg/dL and urine microscopy shows granular, muddy-brown casts. A renal biopsy specimen is obtained and examined under light microscopy. Which of the following reversible cellular changes is most likely to be present?", "answer": "Swelling of the mitochondria", "options": {"A": "Vacuolization of the endoplasmatic reticulum", "B": "Rupture of lysosomes", "C": "Swelling of the mitochondria", "D": "Release of cytochrome C", "E": "Protease-induced cytoskeletal damage"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["59 year old woman", "surgery following", "motor vehicle collision", "received", "total", "units", "packed red blood cells", "dry mucous membranes", "flat neck veins", "Serum studies", "creatinine", "mg/dL", "urine microscopy", "granular", "muddy brown casts", "renal biopsy specimen", "obtained", "examined", "light microscopy", "following reversible cellular changes", "to", "present"]}
{"question": "A 35-year-old man is brought to the emergency department 30 minutes after being involved in a motor vehicle collision. The patient was on his way to work before he lost control of his car and crashed into a tree. On arrival, the patient appears weak and lethargic. He has pain in his abdomen. His temperature is 37°C (98.6°F), pulse is 121/min, respirations are 22/min, and blood pressure is 85/60 mm Hg. He is oriented to person but not to place or time. The lungs are clear to auscultation. Cardiac examination shows tachycardia but no murmurs, rubs, or gallops. Abdominal examination shows several bruises above the umbilicus; there is diffuse abdominal tenderness. Focused assessment with sonography in trauma (FAST) is performed but the results are inconclusive. In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in management of this patient?", "answer": "Diagnostic peritoneal lavage", "options": {"A": "CT scan of the abdomen", "B": "Exploratory laparotomy", "C": "Nasogastric tube insertion", "D": "X-ray of the abdomen", "E": "Diagnostic peritoneal lavage"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["35 year old man", "brought", "emergency department 30 minutes", "involved", "motor vehicle collision", "patient", "to", "lost control", "car", "tree", "arrival", "patient appears weak", "lethargic", "pain", "abdomen", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "85 60 mm Hg", "oriented to person", "not to place", "time", "lungs", "clear", "auscultation", "Cardiac examination", "tachycardia", "murmurs", "rubs", "Abdominal", "several bruises", "umbilicus", "diffuse abdominal", "Focused assessment", "sonography", "trauma", "performed", "results", "inconclusive", "intravenous fluid resuscitation", "following", "most appropriate next step", "patient"]}
{"question": "A 41-year-old woman presents with occasional dyspareunia and vaginal bleeding after a sexual encounter. She is in a monogamous relationship and uses oral contraception. She does not have a family history of gynecologic malignancies. She has smoked 1 pack of cigarettes per day for 15 years and drinks several glasses of wine daily. She has not received HPV vaccination. Her blood pressure is 120/70 mm Hg, heart rate is 71/min, respiratory rate is 14/min, and temperature is 36.7°C (98.1°F). A speculum examination shows a nulliparous cervix in the mid-plane of the vaginal vault with a red discoloration—approx. 1 × 2 cm in diameter. Bimanual examination revealed no apparent pathologic changes. A Papanicolaou smear is shown in the exhibit. Gene coding for which of the following proteins is most likely to be mutated in the affected cells in this case?", "answer": "p53", "options": {"A": "EGFR", "B": "p53", "C": "Myc", "D": "Btk", "E": "c-Src"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "occasional dyspareunia", "vaginal bleeding", "relationship", "uses oral contraception", "not", "family history", "gynecologic malignancies", "smoked 1 pack", "cigarettes", "day", "years", "several glasses", "daily", "not received HPV vaccination", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "speculum", "nulliparous cervix", "mid-plane", "vaginal", "red", "2", "diameter", "Bimanual examination revealed", "pathologic changes", "Papanicolaou smear", "Gene", "following proteins", "to", "mutated", "affected cells", "case"]}
{"question": "A 23-year-old man is brought to the emergency department because of severe right shoulder pain and inability to move the shoulder for the past 30 minutes. The pain began after being tackled while playing football. He has nausea but has not vomited. He is in no apparent distress. Examination shows the right upper extremity externally rotated and slightly abducted. Palpation of the right shoulder joint shows tenderness and an empty glenoid fossa. The right humeral head is palpated below the coracoid process. The left upper extremity is unremarkable. The radial pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?", "answer": "Test sensation of the lateral shoulder", "options": {"A": "Neer impingement test", "B": "Closed reduction", "C": "Test sensation of the lateral shoulder", "D": "Drop arm test", "E": "Arthroscopic shoulder repair"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old man", "brought", "emergency department", "severe right shoulder pain", "to move", "shoulder", "past 30 minutes", "pain began", "playing football", "nausea", "not vomited", "distress", "right upper extremity externally rotated", "slightly", "Palpation", "right shoulder joint", "tenderness", "empty glenoid fossa", "right humeral head", "coracoid process", "left upper extremity", "unremarkable", "radial pulses", "palpable", "following", "most appropriate next step"]}
{"question": "A 20-year-old man is found lying unconscious on the floor of his room by his roommate. The paramedics arrive at the site and find him unresponsive with cold, clammy extremities and constricted, non-reactive pupils. He smells of alcohol and his vital signs show the following: blood pressure 110/80 mm Hg, pulse 100/min, and respiratory rate 8/min. Intravenous access is established and dextrose is administered. The roommate suggests the possibility of drug abuse by the patient. He says he has seen the patient sniff a powdery substance, and he sees the patient inject himself often but has never confronted him about it. After the initial assessment, the patient is given medication and, within 5–10 minutes of administration, the patient regains consciousness and his breathing improves. He is alert and cooperative within the next few minutes. Which of the following drugs was given to this patient to help alleviate his symptoms?\n ", "answer": "Naloxone", "options": {"A": "Ethanol", "B": "Methadone", "C": "Naloxone", "D": "Atropine", "E": "Dextrose"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old man", "found lying unconscious", "floor", "room", "paramedics", "site", "find", "unresponsive", "cold", "clammy extremities", "constricted", "non-reactive pupils", "smells", "alcohol", "vital signs", "following", "blood pressure", "80 mm Hg", "pulse 100 min", "respiratory rate", "min", "Intravenous access", "established", "dextrose", "administered", "possibility of drug abuse", "patient", "seen", "patient sniff", "powdery", "sees", "patient inject", "often", "never", "about", "initial assessment", "patient", "given medication", "510 minutes", "administration", "patient", "consciousness", "breathing improves", "alert", "next", "minutes", "following drugs", "given", "patient to help", "symptoms"]}
{"question": "A 22-year-old woman presents with a complaint of low energy levels for the past 6 months. She feels as if she has no energy to do anything and has lost interest in photography, which she was previously passionate about. Feelings of hopelessness occupy her mind and she can no longer focus at work. She says she forces herself to hang out with her friends at weekends but would rather stay home. She denies any suicidal ideation. Her past medical history is significant for bulimia nervosa, which was diagnosed when she was a teen and was controlled with cognitive behavioral therapy. In addition, she has gastroesophageal reflux, which is being treated with esomeprazole. The patient has a 10-pack-year smoking history but denies any alcohol or recreational drug use. On examination, she is afebrile and vital signs are within normal limits. Her BMI is 24 kg/m2. Further physical examination is unremarkable. Which of the following aspects of this patient’s history is a contraindication to using bupropion as an antidepressant?", "answer": "History of bulimia nervosa", "options": {"A": "History of bulimia nervosa", "B": "Age of 22 years", "C": "Smoking cessation", "D": "BMI of 24 kg/m2", "E": "Esomeprazole usage"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "complaint", "past 6 months", "energy", "lost", "passionate", "longer focus", "to hang out", "weekends", "home", "suicidal ideation", "past medical history", "significant", "bulimia nervosa", "diagnosed", "teen", "controlled", "cognitive behavioral therapy", "addition", "gastroesophageal reflux", "treated with esomeprazole", "patient", "a 10", "smoking history", "alcohol", "recreational drug use", "afebrile", "vital signs", "normal limits", "BMI", "kg/m2", "Further", "unremarkable", "following aspects", "contraindication", "using bupropion", "antidepressant"]}
{"question": "An 11-year-old girl presents to her pediatrician for evaluation of asymmetry that was detected during routine school screening. Specifically, she was asked to bend forwards while the school nurse examined her back. While leaning forward, her right scapula was found to be higher than her left scapula. She was also found to have a prominent line of spinal processes that diverged from the midline. She has been experiencing some back pain that she previously attributed to growth pains but otherwise has no symptoms. Her past medical history is significant only for mild allergies. She is sent to radiography for confirmation of the diagnosis and placed in a nighttime brace. Which of the following represents a complication of the most likely disease affecting this patient if it is left untreated?", "answer": "Restrictive lung disease", "options": {"A": "Arrhythmia", "B": "Congestive heart failure", "C": "Dislocation of the shoulders", "D": "Obstructive lung disease", "E": "Restrictive lung disease"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old girl presents", "pediatrician", "asymmetry", "detected", "routine school screening", "to bend forwards", "school nurse examined", "back", "forward", "right scapula", "found to", "higher", "left scapula", "found to", "prominent line", "spinal processes", "midline", "back pain", "attributed", "growth pains", "symptoms", "past medical history", "significant only", "mild allergies", "sent", "radiography", "confirmation of", "diagnosis", "nighttime brace", "following", "complication of", "likely disease affecting", "patient", "left untreated"]}
{"question": "A group of investigators is studying the effects of aberrant protein isoforms on the pathogenesis of lung cancer. They observe that three protein isoforms are transcribed from the same 30,160 base-pair-long DNA segment on chromosome 13q. The canonical protein has a primary peptide sequence of 1186 amino acids. The second isoform has 419 amino acids and 100% amino acid sequence homology with the canonical protein. The third isoform has 232 amino acids and 92% amino acid sequence homology with the canonical protein. Which of the following is most likely responsible for the observed phenomenon?", "answer": "Alternative pre-mRNA splicing", "options": {"A": "Cytosine hypermethylation", "B": "Site-specific recombination", "C": "Alternative pre-mRNA splicing", "D": "RNA interference", "E": "Post-translational protein trimming"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigators", "studying", "effects", "aberrant protein isoforms", "the pathogenesis of lung cancer", "observe", "three protein isoforms", "same 30", "long DNA segment", "chromosome", "protein", "primary", "amino acids", "second isoform", "amino acids", "100", "amino acid sequence homology", "protein", "third isoform", "amino acids", "amino acid sequence homology", "protein", "following", "responsible", "observed"]}
{"question": "A 54-year-old woman comes to the physician because of paresthesias and weakness in her left leg for one year. Her symptoms have become progressively worse during this period and have led to some difficulty walking for the past month. She has had frequent headaches for the past 4 months. She has a history of hypertension and hypothyroidism. Current medications include amlodipine and levothyroxine. Her temperature is 37.3°C (99.1°F), pulse is 97/min, and blood pressure is 110/80 mm Hg. Neurologic examination shows decreased muscle strength in the left lower extremity. Deep tendon reflexes of the lower extremity are 4+ on the left and 2+ on the right side. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, glucose, creatinine, and calcium are within the reference ranges. An MRI of the brain is shown. Which of the following is the most appropriate next step in management?", "answer": "Surgical resection", "options": {"A": "Surgical resection", "B": "Whole brain radiotherapy", "C": "Stereotactic brain biopsy", "D": "Stereotactic radiosurgery", "E": "Intrathecal methotrexate therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["54 year old woman", "physician", "paresthesias", "weakness", "left", "one year", "symptoms", "worse", "period", "led", "difficulty walking", "past month", "frequent headaches", "past", "months", "history of hypertension", "hypothyroidism", "Current medications include amlodipine", "levothyroxine", "temperature", "99", "pulse", "97 min", "blood pressure", "80 mm Hg", "Neurologic examination", "decreased muscle", "left", "Deep tendon reflexes of", "4", "left", "2", "right side", "abnormalities", "complete blood count", "serum", "electrolytes", "glucose", "creatinine", "calcium", "reference ranges", "MRI of", "brain", "following", "most appropriate next step"]}
{"question": "The rapid response team is called for a 74-year-old woman on an inpatient surgical floor for supraventricular tachycardia. The patient had surgery earlier in the day for operative management of a femur fracture. The patient has a history of hypertension, atherosclerosis, type 2 diabetes, and uterine cancer status post total abdominal hysterectomy 20 years prior. With carotid massage, valsalva maneuvers, and metoprolol, the patient breaks out of her supraventricular tachycardia. Thirty minutes later, the nurse notices a decline in the patient’s status. On exam, the patient has a temperature of 98.4°F (36.9°C), blood pressure of 102/74 mmHg, pulse of 86/min, and respirations are 14/min. The patient is now dysarthric with noticeable right upper extremity weakness of 2/5 in elbow flexion and extension. All other extremities demonstrate normal strength and sensation. Which of the following most likely contributed to this decline?", "answer": "Atherosclerosis", "options": {"A": "Atherosclerosis", "B": "Diabetes", "C": "Hypertension", "D": "Long bone fracture", "E": "Malignancy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["called", "74 year old woman", "inpatient surgical floor", "supraventricular tachycardia", "patient", "surgery earlier", "day", "operative", "of", "femur fracture", "patient", "history of hypertension", "atherosclerosis", "type 2 diabetes", "uterine cancer status post total abdominal hysterectomy 20 years prior", "carotid massage", "valsalva maneuvers", "metoprolol", "patient breaks out", "supraventricular tachycardia", "Thirty minutes later", "nurse", "patients status", "exam", "patient", "temperature", "98", "36", "blood pressure", "74 mmHg", "pulse", "min", "respirations", "min", "patient", "now", "right upper extremity weakness", "elbow flexion", "extension", "extremities", "normal strength", "sensation", "following most likely"]}
{"question": "A 42-year-old woman presents with exertional dyspnea and fatigue for the past 3 months. Her past medical history is significant for multiple episodes of mild diarrhea for many years, which was earlier diagnosed as irritable bowel syndrome (IBS). She denies any current significant gastrointestinal symptoms. The patient is afebrile and vital signs are within normal limits. Physical examination reveals oral aphthous ulcers and mild conjunctival pallor. Abdominal examination is unremarkable. There is a rash present on the peripheral extremities bilaterally (see image). Laboratory findings are significant for evidence of microcytic hypochromic anemia. FOBT is negative. Which of the following is the most likely diagnosis in this patient?", "answer": "Non-tropical sprue", "options": {"A": "Small intestinal bacterial overgrowth", "B": "Non-tropical sprue", "C": "Whipple's disease", "D": "Irritable bowel disease", "E": "Tropical sprue"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "exertional dyspnea", "fatigue", "past 3 months", "past medical history", "significant", "multiple episodes of mild diarrhea", "years", "earlier diagnosed", "irritable bowel syndrome", "current significant gastrointestinal symptoms", "patient", "afebrile", "vital signs", "normal", "Physical examination reveals oral aphthous ulcers", "mild conjunctival pallor", "Abdominal", "unremarkable", "rash present", "peripheral extremities", "see", "Laboratory findings", "significant", "microcytic hypochromic anemia", "FOBT", "negative", "following", "diagnosis", "patient"]}
{"question": "A 24-year-old woman in graduate school comes to the physician for recurrent headaches. The headaches are unilateral, throbbing, and usually preceded by blurring of vision. The symptoms last between 12 and 48 hours and are only relieved by lying down in a dark room. She has approximately two headaches per month and has missed several days of class because of the symptoms. Physical examination is unremarkable. The patient is prescribed an abortive therapy that acts by inducing cerebral vasoconstriction. Which of the following is the most likely mechanism of action of this drug?", "answer": "Activation of 5-HT1 receptors", "options": {"A": "Inhibition of β1- and β2-adrenergic receptors", "B": "Activation of 5-HT1 receptors", "C": "Inhibition of 5-HT and NE reuptake", "D": "Inhibition of voltage-dependent Na+ channels", "E": "Inactivation of GABA degradation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "graduate school", "physician", "recurrent headaches", "headaches", "unilateral", "throbbing", "usually preceded", "blurring of vision", "symptoms last", "48 hours", "only relieved by lying", "dark room", "approximately two headaches", "month", "missed", "days", "symptoms", "unremarkable", "patient", "therapy", "acts", "inducing", "vasoconstriction", "following", "mechanism of action", "drug"]}
{"question": "A 24-year-old woman comes to the physician because of pain and swelling of her left leg over the past 24 hours. The pain is worse while walking and improves when resting. Seven months ago, she was diagnosed with a pulmonary embolism and was started on warfarin. Anticoagulant therapy was discontinued 1 month ago. Her sister has systemic lupus erythematosus. The patient does not smoke. She currently takes no medications. Her temperature is 37.8°C (100°F), pulse is 78/min, and blood pressure is 123/72 mm Hg. On physical examination, the left calf is diffusely erythematous, swollen, and tender. Dorsal flexion of the left foot elicits pain. Cardiopulmonary examination shows no abnormalities. On duplex ultrasonography, the left popliteal vein is not compressible. Laboratory studies show an elevated serum concentration of D-dimer and insensitivity to activated protein C. Further examination is most likely to show which of the following?", "answer": "Mutation of coagulation factor V", "options": {"A": "Antiphospholipid antibodies", "B": "Mutation of coagulation factor V", "C": "Mutation of prothrombin", "D": "Elevated levels of homocysteine", "E": "Deficiency of protein C"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "pain", "swelling of", "left leg", "past 24 hours", "pain", "worse", "improves", "Seven months", "diagnosed", "pulmonary embolism", "started", "warfarin", "Anticoagulant", "discontinued 1 month", "systemic lupus erythematosus", "patient", "not smoke", "currently", "medications", "temperature", "pulse", "min", "blood pressure", "72 mm Hg", "left calf", "erythematous", "swollen", "tender", "Dorsal flexion of", "left foot elicits pain", "Cardiopulmonary", "abnormalities", "duplex ultrasonography", "left popliteal vein", "not compressible", "Laboratory studies", "elevated serum concentration", "D-dimer", "insensitivity", "activated protein C", "Further", "to", "following"]}
{"question": "A 23-year-old woman visits her general practitioner with left ear pain and fever. She complains of multiple episodes of respiratory infection including bronchitis, laryngitis, and sinusitis. She was diagnosed with systemic lupus erythematosus with nephritis 8 months ago and was placed on oral prednisone. Currently, she takes prednisone daily. Her vital signs are as follows: blood pressure 130/85 mm Hg, heart rate 79/min, respiratory rate 16/min, and temperature 37.5°C (99.5°F). Her weight is 78 kg (172 lb) and height is 169 cm (5 ft 6 in). Physical examination reveals a swollen erythematous left eardrum, erythematous macular rash over sun-exposed skin, and slight calf edema. Inhibition of which of the following pathways causes diminished immune cell activation in this patient?", "answer": "NF-kß pathways", "options": {"A": "Wnt pathway", "B": "NF-kß pathways", "C": "Hippo pathway", "D": "PI3K/AKT/mTOR pathway", "E": "Notch pathway"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "general", "left", "fever", "of multiple episodes", "respiratory infection including bronchitis", "laryngitis", "sinusitis", "diagnosed", "systemic lupus erythematosus", "nephritis", "months", "oral prednisone", "Currently", "prednisone daily", "vital signs", "follows", "blood pressure", "85 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "weight", "kg", "height", "5 ft 6", "reveals", "swollen erythematous left eardrum", "erythematous", "sun-exposed skin", "slight calf edema", "Inhibition", "following", "causes diminished immune cell activation", "patient"]}
{"question": "A 16-year-old girl with celiac disease is brought to the physician because of a 1-week history of generalized weakness and tingling around her mouth and in her fingertips. She also complains of abdominal cramps and nausea. In addition to following a gluten-free diet, she has been following a vegan diet for the past 2 years. Physical examination shows involuntary contractions of the muscle at the corner of her mouth and nose that are elicited by tapping on her right cheek. Her parathyroid hormone concentration is 834 pg/mL. Which of the following is the most likely underlying cause for this patient's current condition?", "answer": "Decreased intestinal absorption of ergocalciferol", "options": {"A": "Decreased conversion of 7-dehydrocholesterol to cholecalciferol", "B": "Decreased levels of renal 1α-hydroxylase", "C": "Decreased dietary intake of ergocalciferol", "D": "Decreased intestinal absorption of ergocalciferol", "E": "Autoimmune-mediated destruction of parathyroid tissue"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old girl", "celiac disease", "brought", "physician", "1-week history", "generalized weakness", "tingling", "mouth", "fingertips", "abdominal cramps", "nausea", "following", "following", "vegan diet", "past", "years", "involuntary contractions", "muscle", "corner of", "mouth", "nose", "elicited by", "right cheek", "parathyroid hormone concentration", "pg/mL", "following", "underlying cause", "patient's current condition"]}
{"question": "A 7-year-old girl is brought to the physician because of vaginal bleeding for 2 days. There is no personal or family history of serious illness. She is at the 95th percentile for height and at the 90th percentile for weight. Examination shows enlarged breasts, and the areola and papilla have formed a secondary mound. There is coarse pubic hair that does not extend to the inner thigh. The remainder of the examination show no abnormalities. An x-ray of the left hand and wrist shows a bone age of 11 years. Her serum luteinizing hormone concentration is 0.1 mIU/mL (N < 0.2 mIU/mL). Which of the following is the most appropriate next step in management?", "answer": "GnRH stimulation test", "options": {"A": "MRI of the brain", "B": "Ultrasound of the pelvis", "C": "Reassurance and follow-up", "D": "GnRH stimulation test", "E": "Serum dehydroepiandrosterone level"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "of vaginal bleeding", "2 days", "personal", "family history", "serious illness", "95th percentile", "height", "90th percentile", "weight", "enlarged breasts", "areola", "papilla", "formed", "secondary", "coarse pubic", "not extend", "inner thigh", "abnormalities", "x-ray", "left hand", "wrist", "bone", "years", "serum luteinizing hormone concentration", "0.1 mIU/mL", "N", "0.2 mIU/mL", "following", "most appropriate next step"]}
{"question": "An investigator studying disorders of hemostasis performs gene expression profiling in a family with a specific type of bleeding disorder. These patients were found to have abnormally large von Willebrand factor (vWF) multimers in their blood. Genetic analysis shows that the underlying cause is a mutation in the ADAMTS13 gene. This mutation results in a deficiency of the encoded metalloprotease, which is responsible for cleavage of vWF. Which of the following additional laboratory findings is most likely in these patients?", "answer": "Fragmented erythrocytes", "options": {"A": "Elevated haptoglobin", "B": "Urinary red blood cell casts", "C": "Elevated platelet count", "D": "Prolonged partial thromboplastin time", "E": "Fragmented erythrocytes"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator studying disorders of hemostasis performs gene expression profiling", "specific", "bleeding disorder", "patients", "found to", "large von Willebrand factor", "multimers", "blood", "Genetic", "underlying cause", "mutation", "ADAMTS13 gene", "mutation results", "deficiency", "metalloprotease", "responsible", "cleavage", "vWF", "following additional laboratory findings", "patients"]}
{"question": "A 71-year-old Caucasian male presents to your office with bloody diarrhea and epigastric pain that occurs 30 minutes after eating. He has lost 15 pounds in 1 month, which he attributes to fear that the pain will return following a meal. He has a history of hyperlipidemia and myocardial infarction. Physical exam and esophagogastroduodenoscopy are unremarkable. What is the most likely cause of this patient's pain?", "answer": "Atherosclerosis", "options": {"A": "Atherosclerosis", "B": "Peptic ulcer disease", "C": "Crohn's disease", "D": "Amyloid deposition", "E": "Diverticulosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "male presents", "office", "bloody diarrhea", "epigastric pain", "occurs 30 minutes", "eating", "lost", "pounds", "month", "attributes to", "pain", "return following", "history of hyperlipidemia", "myocardial infarction", "esophagogastroduodenoscopy", "unremarkable", "most likely cause", "patient's pain"]}
{"question": "A 10-year-old boy is brought to the physician with painful and enlarged lymph nodes in his right axilla that was noticed 5 days ago and has slowly grown bigger. He has had weakness, sweating, and poor appetite during this time. 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 does not take any medication. There are no similar cases in the family. On physical exam, his temperature is 38.2°C (100.8°F), the pulse is 89/min, the respiratory rate is 13/min, and the blood pressure is 110/60 mm Hg. In his right axilla, there are multiple tender, flocculent, and enlarged lymph nodes with overlying erythematous skin. There is a separate lesion on the child's forearm (see image). The lesion is painless to palpation and appears inflamed. Additional history should be obtained regarding which of the following?", "answer": "Contact with pets", "options": {"A": "Allergic rhinitis", "B": "Contact with pets", "C": "Frequent infections", "D": "Swimming", "E": "Tick bites"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["A 10 year old boy", "brought", "physician", "painful", "enlarged lymph nodes", "right axilla", "5 days", "slowly", "bigger", "weakness", "sweating", "poor appetite", "time", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "not", "medication", "similar cases", "temperature", "100", "pulse", "min", "respiratory rate", "min", "blood pressure", "60 mm Hg", "right axilla", "multiple tender", "enlarged lymph nodes", "erythematous", "separate lesion", "child's forearm", "see", "lesion", "painless", "palpation", "appears inflamed", "Additional history", "obtained", "following"]}
{"question": "A 4-year-old boy presents with bloody diarrhea. The patient’s mother states that he was fine this morning, but around midday, she received a call from his daycare center stating that the patient had a single bloody bowel movement. His mother states that there have been no recent changes in his diet, although they did attend a barbecue over the weekend. The patient has no recent history of fever, chills, or similar symptoms in the past. No significant past medical history. Initial laboratory studies show an elevated white blood cell (WBC) count, anemia, and a blood urea nitrogen (BUN)/creatinine ratio of 40. Stool examination shows 3+ blood but no fecal leukocytes. Which of the following tests would be diagnostic for this patient’s most likely condition?", "answer": "Stool culture in sorbitol-MacConkey medium", "options": {"A": "Gram stain for gull-winged, curved rods", "B": "Polymerase chain reaction (PCR) for DNA sequences in stool", "C": "Sigmoidoscopy", "D": "Stool culture in sorbitol-MacConkey medium", "E": "Test stool for C. difficile toxins"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy presents", "bloody diarrhea", "patients", "states", "fine", "morning", "midday", "received", "call", "daycare center stating", "patient", "single bloody bowel movement", "states", "recent changes", "diet", "attend", "weekend", "patient", "recent history", "fever", "chills", "similar symptoms", "past", "significant past medical history", "Initial laboratory studies", "elevated white blood cell", "count", "anemia", "blood urea nitrogen", "creatinine ratio", "40", "Stool examination", "3", "blood", "fecal leukocytes", "following tests", "diagnostic", "patients", "likely condition"]}
{"question": "A 52-year-old male presents with several months of fatigue, malaise, dry cough, and occasional episodes of painless hematuria. He recalls having had a sore throat several days prior to the onset of these symptoms that resolved without antibiotics. Physical exam is remarkable for diffusely coarse breath sounds bilaterally. Urinalysis reveals 2+ protein, 2+ blood, and numerous red blood cell casts are visible under light microscopy. Which is the most likely diagnosis?", "answer": "Microscopic polyangiitis", "options": {"A": "Diffuse membranous glomerulopathy", "B": "Microscopic polyangiitis", "C": "Focal segmental glomerulosclerosis", "D": "Acute poststreptococcal glomerulonephritis", "E": "Transitional cell bladder carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "months", "fatigue", "malaise", "dry cough", "occasional episodes of painless hematuria", "sore throat", "days prior to", "onset", "symptoms", "resolved", "coarse breath sounds", "Urinalysis reveals 2", "protein", "2", "blood", "numerous", "casts", "visible", "light microscopy", "diagnosis"]}
{"question": "A 68-year-old man comes to the physician for a wellness visit. Physical examination shows an enlarged and nodular prostate. Laboratory studies show elevated levels of prostate-specific antigen. A prostate biopsy confirms the diagnosis of prostate cancer and a radical prostatectomy is planned. This patient should be counseled on the increased risk of injury to which of the following structures?", "answer": "Cavernous nerve", "options": {"A": "Cavernous nerve", "B": "Superior vesical artery", "C": "External anal sphincter", "D": "Hypogastric nerve", "E": "Distal ureter\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "enlarged", "nodular prostate", "Laboratory studies", "elevated levels", "prostate-specific antigen", "prostate biopsy confirms the diagnosis of prostate cancer", "radical prostatectomy", "planned", "patient", "counseled", "increased risk", "injury", "following structures"]}
{"question": "An otherwise healthy 15-month-old boy is brought to the emergency department by his mother 1 hour after having a single episode of generalized tonic-clonic seizure, which stopped spontaneously after 1 minute. He was sleepy initially but is now awake and alert. His mother reports that he has had a fever and runny nose for the past 3 days. His temperature is 40.1°C (104.2°F). Physical examination shows no abnormalities. Analysis of his cerebrospinal fluid shows 3 cells/mm3, a glucose concentration of 68 mg/dL, and a protein concentration of 35 mg/dL. Administration of a drug that acts through which of the following mechanisms of action is most appropriate in this patient?", "answer": "Decreasing production of prostaglandin E2", "options": {"A": "Blocking voltage-gated Na+ channels", "B": "Increasing duration of Cl− channel opening", "C": "Decreasing production of prostaglandin E2", "D": "Inhibiting transpeptidase cross-linking", "E": "Blocking T-type Ca2+ channels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "month old boy", "brought", "emergency department", "hour", "single episode of generalized tonic-clonic seizure", "stopped", "minute", "sleepy initially", "now awake", "alert", "reports", "fever", "runny nose", "past 3 days", "temperature", "40", "abnormalities", "Analysis", "cerebrospinal fluid", "3 cells/mm3", "glucose concentration", "mg/dL", "a protein concentration", "35 mg/dL", "Administration", "drug", "acts", "of", "following mechanisms", "action", "most appropriate", "patient"]}
{"question": "A previously healthy 53-year-old man is brought to the emergency department 45 minutes after the onset of a severe headache. He returned from a vacation in the mountains 4 days ago, during which he went swimming in a freshwater lake. On arrival, he is confused. His temperature is 39°C (102.2°F) and blood pressure is 105/68 mm Hg. Neurologic examination shows diffuse hyperreflexia. An MRI of the brain shows asymmetrical, bitemporal hyperintensities. A lumbar puncture is performed. Cerebrospinal fluid analysis shows:\nLeukocyte count 120/mm3\nSegmented neutrophils 10%\nLymphocytes 90%\nErythrocyte count 15/mm3\nGlucose 45 mg/dL\nOpening pressure 130 mm Hg\nProtein 75 mg/dL\nWhich of the following is the most likely causal pathogen?\"", "answer": "Herpes simplex virus", "options": {"A": "Naegleria fowleri", "B": "Herpes simplex virus", "C": "La Crosse virus", "D": "Enterovirus", "E": "Rabies virus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy", "year old man", "brought", "emergency department 45 minutes", "onset", "severe headache", "returned", "mountains", "days", "lake", "arrival", "confused", "temperature", "blood pressure", "mm Hg", "Neurologic examination", "diffuse hyperreflexia", "MRI of", "brain", "asymmetrical", "bitemporal", "lumbar puncture", "performed", "Cerebrospinal fluid analysis", "Leukocyte count", "Segmented neutrophils", "Lymphocytes 90", "Glucose", "mg dL Opening pressure", "mm Hg", "dL", "following", "causal"]}
{"question": "A 10-year-old girl is brought to the physician because of itching of the vulva and anal region for the past 2 weeks. She has difficulty sleeping because of the itching. Physical examination shows excoriation marks around the vulva and perianal region. There is minor perianal erythema, but no edema or fissures. Microscopy of an adhesive tape applied to the perianal region shows multiple ova. Which of the following is the most appropriate treatment for this patient?", "answer": "Mebendazole", "options": {"A": "Mebendazole", "B": "Melarsoprol", "C": "Diethylcarbamazine", "D": "Nifurtimox", "E": "Praziquantel"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 year old girl", "brought", "physician", "of itching", "vulva", "anal region", "past 2 weeks", "difficulty sleeping", "itching", "excoriation marks", "vulva", "perianal region", "minor perianal erythema", "edema", "fissures", "Microscopy", "adhesive tape applied", "perianal region", "multiple", "following", "most appropriate", "patient"]}
{"question": "A 45-year-old female who recently immigrated to the United States presents to the community health clinic for episodes of disrupted vision. She is concerned because she knows several people from her hometown who went blind after having these episodes. Over the past several months, she also has developed itchy bumps on her back and lower extremities. Physical exam reveals black hyperpigmented nodules with edema and palpable lymphadenopathy, but is otherwise unremarkable without any visible discharge from the eyes. Her physician explains her underlying disease was likely transmitted by black flies. Which of the following is the most appropriate pharmacotherapy for this patient?", "answer": "Ivermectin", "options": {"A": "Diethylcarbamazine", "B": "Ivermectin", "C": "Mebendazole", "D": "Nifurtimox", "E": "Praziquantel"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female", "recently", "United States presents", "community clinic", "episodes of disrupted vision", "several", "blind", "episodes", "past", "months", "itchy", "back", "lower extremities", "reveals black hyperpigmented nodules", "edema", "palpable lymphadenopathy", "unremarkable", "visible discharge", "eyes", "physician", "underlying disease", "likely transmitted by", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 10-day-old male newborn is brought to the physician by his mother because of difficulty feeding and frequent nonbilious vomiting. His stool is soft and yellow-colored. The pregnancy was complicated by polyhydramnios and results from chorionic villus sampling showed a 47, XY, +21 karyotype. Physical examination shows mild abdominal distention and normal bowel sounds. An x-ray of the abdomen with oral contrast is shown. The most likely cause of his condition is due to a defect in which of the following embryologic processes?", "answer": "Rotation of the ventral pancreatic bud", "options": {"A": "Rotation of the ventral pancreatic bud", "B": "Foregut septation", "C": "Ganglion cell migration", "D": "Duodenal recanalization", "E": "Umbilical ring closure"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A 10 day old male newborn", "brought", "physician", "difficulty feeding", "frequent", "vomiting", "stool", "soft", "yellow-colored", "pregnancy", "complicated", "polyhydramnios", "results", "chorionic villus sampling", "XY", "karyotype", "mild abdominal distention", "normal bowel sounds", "x-ray of", "abdomen", "oral contrast", "most likely cause", "condition", "due to", "defect", "following embryologic processes"]}
{"question": "A 24-year-old sexually active man complains of painless growths on his penis. He is worried that he might have transmitted them to his girlfriend. Biopsy shows squamous cells with perinuclear cytoplasmic vacuolization, nuclear enlargement, and koilocytes. The doctor treats the patient by chemically ablating the warts with cryoablation. The patient encourages his girlfriend to get tested too, as he is worried she is at increased risk of developing a malignancy. Which cancer is the patient worried about?", "answer": "Cervical carcinoma", "options": {"A": "Kaposi sarcoma", "B": "Burkitt lymphoma", "C": "Hairy cell leukemia", "D": "Hepatocellular carcinoma", "E": "Cervical carcinoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old sexually active man", "painless growths", "penis", "worried", "transmitted", "Biopsy", "perinuclear cytoplasmic vacuolization", "nuclear enlargement", "doctor treats", "patient", "ablating", "warts", "cryoablation", "patient", "to", "worried", "increased risk", "malignancy", "cancer", "patient worried about"]}
{"question": "A 56-year-old woman is brought to the emergency department by her husband because of slurred speech and left facial droop for the past 30 minutes. During this period, she has also had numbness on the left side of her face. She has never had such an episode before. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Her father died of lung cancer 1 week ago. The patient has smoked one pack of cigarettes daily for 30 years. She drinks one glass of wine daily. Her current medications include metformin, sitagliptin, enalapril, and atorvastatin. She is 168 cm (5 ft 6 in) tall and weighs 86 kg (190 lb); BMI is 30.5 kg/m2. She is oriented to time, place, and person. Her temperature is 37°C (98.7°F), pulse is 97/min, and blood pressure is 140/90 mm Hg. Examination shows drooping of the left side of the face. Her speech is clear. Examination shows full muscle strength. Deep tendon reflexes are 2+ bilaterally. A finger-nose test and her gait are normal. Cardiopulmonary examination shows a right-sided carotid bruit. A complete blood count and serum concentrations of creatinine, glucose, and electrolytes are within the reference ranges. An ECG shows left ventricular hypertrophy. A noncontrast CT scan of the brain shows no abnormalities. On the way back from the CT scan, her presenting symptoms resolve. Which of the following is the most likely diagnosis?", "answer": "Transient ischemic attack", "options": {"A": "Conversion disorder", "B": "Partial seizure", "C": "Bell palsy", "D": "Transient ischemic attack", "E": "Multiple sclerosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "slurred speech", "left facial droop", "past 30 minutes", "period", "numbness", "left side of", "face", "never", "episode", "hypertension", "hypercholesterolemia", "type 2 diabetes mellitus", "died of lung cancer 1 week", "patient", "smoked one pack", "cigarettes daily", "30 years", "one glass", "daily", "current medications include metformin", "sitagliptin", "enalapril", "atorvastatin", "5 ft 6", "tall", "kg", "BMI", "30", "kg/m2", "oriented to time", "place", "temperature", "98", "pulse", "97 min", "blood pressure", "90 mm Hg", "drooping", "left side", "face", "speech", "clear", "full muscle strength", "Deep tendon reflexes", "2", "finger-nose test", "gait", "normal", "Cardiopulmonary", "right-sided carotid bruit", "complete blood count", "serum", "creatinine", "glucose", "electrolytes", "reference ranges", "ECG", "left ventricular hypertrophy", "CT scan", "brain", "abnormalities", "back", "CT scan", "symptoms", "following", "diagnosis"]}
{"question": "A 22-year-old white woman comes to the physician because of a 6-month history of lower abdominal pain. She has also had multiple episodes of loose stools with blood during this period. She has had painful bowel movements for 1 month. Over the past year, she has had a 10-kg (22-lb) weight loss. She was treated for streptococcal pharyngitis last week. Her maternal grandfather died of colon cancer at the age of 52 years. She does not smoke. She drinks three to five beers on social occasions. She is 162 cm (5 ft 4 in) tall and weighs 52 kg (115-lb); BMI is 19.7 kg/m2. Her temperature is 37°C (98.6°F), pulse is 60/min, respirations are 13/min, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and there is tenderness to palpation of the left lower quadrant. There is no guarding or rigidity. Rectal examination shows no masses. Laboratory studies show:\nHemoglobin 10.4 g/dL\nLeukocyte count 10,800/mm3\nPlatelet count 450,000/mm3\nSerum\nNa+ 138 mEq/L\nCl- 103 mEq/L\nK+ 4.9 mEq/L\nHCO3- 22 mEq/L\nUrea nitrogen 18 mg/dL\nCreatinine 0.6 mg/dL\nAntinuclear antibodies negative\nPerinuclear antineutrophil cytoplasmic antibodies positive\nAnti-Saccharomyces cerevisiae antibodies negative\nA colonoscopy is scheduled for the next day. Which of the following findings is most likely to be present on colonoscopy of this patient?\"", "answer": "Confluent inflammation of the colonic mucosa with edema, fibrin-covered ulcers, and loss of vascular pattern", "options": {"A": "Pseudomembranes overlying regions of colonic inflammation", "B": "Patchy inflammation of mucosa with cobblestone appearance and intervening areas of normal mucosa", "C": "Confluent inflammation of the colonic mucosa with edema, fibrin-covered ulcers, and loss of vascular pattern", "D": "Normal colonic mucosa", "E": "Numerous polyps extending throughout the colon"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old white woman", "physician", "month history", "lower abdominal pain", "multiple episodes of loose stools", "blood", "period", "painful bowel movements", "month", "past year", "a 10 kg", "weight loss", "treated", "streptococcal pharyngitis", "week", "died of colon cancer", "age", "years", "not smoke", "three", "five", "social occasions", "5 ft 4", "tall", "kg", "BMI", "kg/m2", "temperature", "98", "pulse", "60 min", "respirations", "min", "blood pressure", "70 mm Hg", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "tenderness", "palpation", "left lower quadrant", "guarding", "rigidity", "Rectal examination", "masses", "Laboratory studies", "Hemoglobin", "Leukocyte", "Serum", "9", "Urea", "mg", "Creatinine", "6 mg", "antibodies", "Perinuclear antineutrophil cytoplasmic antibodies", "negative", "colonoscopy", "scheduled", "next day", "following findings", "to", "present", "colonoscopy", "patient"]}
{"question": "A 44-year-old woman comes to the physician with increasingly yellow sclera and pruritus over the past 3 months. She has intermittent right-upper-quadrant pain and discomfort. She has no history of any serious illnesses and takes no medications. Her vital signs are within normal limits. Her sclera are icteric. Skin examination shows linear scratch marks on the trunk and limbs. The remainder of the physical examination is unremarkable. Laboratory studies show:\nComplete blood count\nHemoglobin 15 g/dL\nMean corpuscular volume 95 μm3\nLeukocyte count 6,000/mm3 with a normal differential\nSerum\nAlkaline phosphatase 470 U/L\nAspartate aminotransferase (AST, GOT) 38 U/L\nAlanine aminotransferase (ALT, GPT) 45 U/L\nγ-Glutamyltransferase (GGT) 83 U/L (N=5–50 U/L)\nBilirubin, total 2.7 mg/dL\nBilirubin, direct 1.4 mg/dL\nMagnetic resonance cholangiopancreatography (MRCP) shows a multifocal and diffuse beaded appearance of the intrahepatic and extrahepatic biliary ducts. Which of the following is the most appropriate diagnostic study at this time?", "answer": "Rectosigmoidoscopy", "options": {"A": "Endoscopic retrograde cholangiopancreatography (ERCP)", "B": "Liver biopsy", "C": "Rectosigmoidoscopy", "D": "Upper endoscopy", "E": "No further testing is indicated"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "yellow sclera", "pruritus", "past 3 months", "intermittent right-upper-quadrant pain", "discomfort", "history", "serious illnesses", "medications", "vital signs", "normal limits", "sclera", "icteric", "Skin examination", "linear scratch marks", "trunk", "limbs", "unremarkable", "Laboratory studies", "Complete blood count Hemoglobin", "g", "Mean corpuscular volume", "mm3", "normal differential Serum Alkaline phosphatase", "U/L Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L", "Glutamyltransferase", "GGT", "83 U/L", "N 550 U/L", "Bilirubin", "total", "mg/dL Bilirubin", "direct 1.4 mg/dL Magnetic resonance cholangiopancreatography", "multifocal", "diffuse beaded appearance", "intrahepatic", "extrahepatic biliary ducts", "following", "most appropriate diagnostic", "time"]}
{"question": "A 62-year-old woman presents with sudden onset of vertigo, difficulty walking, sensory changes on the left side of her face and the right side of the body, and left facial drooping. Her past medical history is significant for hypertension and hypercholesterolemia. On physical examination, there is left-sided Horner’s syndrome, hypoesthesia on the left side of the face, hypoesthesia on the right side of the body, left facial paralysis,  and left-sided limb ataxia, as well as dysmetria. There is also a loss of taste sensation in the anterior 2/3 of the tongue. Based on the above findings, where is the most likely location of the vascular occlusion in this patient?", "answer": "Anterior inferior cerebellar artery (AICA)", "options": {"A": "Anterior spinal artery (ASA)", "B": "Posterior inferior cerebellar artery (PICA)", "C": "Anterior inferior cerebellar artery (AICA)", "D": "Posterior cerebral artery (PCA)", "E": "Basilar artery"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman presents", "sudden onset", "vertigo", "difficulty walking", "sensory changes", "left side of", "face", "right side of", "body", "left facial drooping", "past medical history", "significant", "hypertension", "hypercholesterolemia", "left-sided Horners syndrome", "hypoesthesia", "left side of", "face", "hypoesthesia", "right side of", "body", "left facial paralysis", "left-sided limb ataxia", "dysmetria", "loss of sensation", "anterior 2/3 of", "tongue", "Based", "findings", "location of", "vascular occlusion", "patient"]}
{"question": "A previously healthy 15-year-old girl is brought to the emergency department 24 hours after the onset of a severe headache. She returned from a 1-week camping trip 3 days ago; she went spelunking and swimming in a freshwater lake during the trip. She is agitated, uncooperative, and oriented only to person. Her temperature is 38.9°C (102°F), pulse is 112/min, respirations are 20/min, and blood pressure is 100/68 mm Hg. There are several crusted insect bites on her extremities. Neurologic examination shows diffuse hyperreflexia and an extensor plantar response bilaterally. Her neck is supple without lymphadenopathy. An MRI of the brain shows asymmetrical, bitemporal hyperintensities. A lumbar puncture is performed. Cerebrospinal fluid analysis shows:\nOpening pressure 150 mm H2O\nGlucose 58 mg/dL\nProtein 108 mg/dL\nLeukocyte count 150/mm3\nSegmented neutrophils 15%\nLymphocytes 85%\nErythrocyte count 25/mm3\nWhich of the following is the most likely causal pathogen?\"", "answer": "Herpes simplex virus", "options": {"A": "West Nile virus", "B": "La Crosse virus", "C": "Tick-borne encephalitis virus", "D": "Enterovirus", "E": "Herpes simplex virus"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["healthy", "year old girl", "brought", "emergency department 24 hours", "onset", "severe headache", "returned", "1-week", "trip 3 days", "lake", "trip", "agitated", "oriented only", "temperature", "pulse", "min", "respirations", "20 min", "blood pressure", "100", "mm Hg", "several crusted insect bites", "extremities", "Neurologic examination", "diffuse hyperreflexia", "extensor plantar response", "neck", "supple", "lymphadenopathy", "MRI of", "brain", "asymmetrical", "bitemporal", "lumbar puncture", "performed", "Cerebrospinal fluid analysis", "Opening pressure", "mm H2O Glucose", "mg Protein", "Leukocyte count", "mm3 Segmented neutrophils", "Lymphocytes", "following", "causal"]}
{"question": "A 60-year-old man is brought to the emergency department 25 minutes after falling and hitting his left flank on a concrete block. He has severe left-sided chest pain and mild shortness of breath. He underwent a right knee replacement surgery 2 years ago. He has type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 42 years. Current medications include metformin, sitagliptin, and a multivitamin. He appears uncomfortable. His temperature is 37.5°C (99.5°F), pulse is 102/min, respirations are 17/min, and blood pressure is 132/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple abrasions on his left flank and trunk. The upper left chest wall is tender to palpation and bony crepitus is present. There are decreased breath sounds over both lung bases. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is soft and nontender. Focused assessment with sonography for trauma is negative. An x-ray of the chest shows nondisplaced fractures of the left 4th and 5th ribs, with clear lung fields bilaterally. Which of the following is the most appropriate next step in management?", "answer": "Adequate analgesia and conservative management", "options": {"A": "Continuous positive airway pressure", "B": "Prophylactic antibiotic therapy", "C": "Admission and surveillance in the intensive care unit", "D": "Adequate analgesia and conservative management", "E": "Internal fixation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["60 year old man", "brought", "emergency department", "minutes", "falling", "hitting", "left flank", "block", "severe left-sided chest pain", "mild shortness of breath", "right surgery 2 years", "type 2 diabetes mellitus", "smoked one pack", "cigarettes daily", "years", "Current medications include metformin", "sitagliptin", "multivitamin", "appears", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "90 mm Hg", "Pulse oximetry", "room air", "oxygen saturation", "96", "multiple abrasions", "left flank", "trunk", "upper left chest wall", "tender", "palpation", "bony crepitus", "present", "decreased breath sounds", "lung bases", "murmurs", "rubs", "abdomen", "soft", "nontender", "Focused assessment", "sonography", "trauma", "negative", "x-ray of", "chest", "nondisplaced fractures", "left 4th", "5th ribs", "clear lung fields", "following", "most appropriate next step"]}
{"question": "A 26-year-old woman presents to her primary care physician because she has been experiencing occasional fevers and chills for the last 3 weeks. She says that the fevers have been accompanied by abdominal pain and increased vaginal discharge. On presentation her temperature is 101.0°F (38.3°C), blood pressure is 113/75 mmHg, pulse is 105/min, and respirations are 12/min. On physical exam she is found to have tenderness over the lower abdominal quadrants, and speculum exam shows uterine inflammation as well as a retained intrauterine device. The most likely cause of this patient's symptoms should be treated with an antibiotic with which mechanism of action?", "answer": "Cell wall synthesis inhibitor", "options": {"A": "Cell wall synthesis inhibitor", "B": "DNA synthesis inhibitor", "C": "Folic acid synthesis inhibitor", "D": "Protein synthesis inhibitor", "E": "RNA synthesis inhibitor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "occasional fevers", "chills", "weeks", "fevers", "abdominal pain", "increased vaginal discharge", "temperature", "blood pressure", "75 mmHg", "pulse", "min", "respirations", "min", "found to", "tenderness", "lower abdominal quadrants", "speculum exam", "uterine inflammation", "retained intrauterine device", "most likely cause", "patient's symptoms", "treated with", "mechanism of action"]}
{"question": "A 38-year-old man comes to the physician because of a 3-week history of right-sided knee pain. He works as a bricklayer and reports that the pain worsens when he kneels. He has no history of trauma. Examination of the right knee shows erythema, fluctuant swelling, and tenderness on palpation of the kneecap. Passive flexion of the right knee elicits pain. Which of the following structures is most likely affected in this patient?", "answer": "Prepatellar bursa", "options": {"A": "Anserine bursa", "B": "Medial meniscus", "C": "Suprapatellar bursa", "D": "Synovial membrane", "E": "Prepatellar bursa"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "physician", "3 week history", "right-sided knee pain", "bricklayer", "reports", "pain worsens", "kneels", "history", "trauma", "right", "erythema", "fluctuant swelling", "tenderness", "palpation of", "kneecap", "Passive flexion", "right knee elicits pain", "following structures", "most likely affected", "patient"]}
{"question": "A 38-year-old woman presents with anxiety. She says that, for as long as she can remember, she has been anxious, especially when at work or in social situations, which she has difficulty controlling. She also reports difficulty sleeping, irritability, and muscle tension. She says her symptoms have significantly limited her work and personal relationships. She has no other significant past medical history. The patient denies any history of smoking, alcohol consumption or recreational drug use. She is afebrile, and her vitals signs are within normal limits. A physical examination is unremarkable. Which of the following medications would be the most appropriate first-line treatment for this patient’s most likely diagnosis?", "answer": "Paroxetine", "options": {"A": "Propranolol", "B": "Buspirone", "C": "Paroxetine", "D": "Alprazolam", "E": "Lurasidone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "anxiety", "long", "anxious", "difficulty controlling", "reports difficulty sleeping", "irritability", "muscle tension", "symptoms", "limited", "significant past medical history", "patient", "history of smoking", "recreational drug use", "afebrile", "signs", "normal limits", "unremarkable", "following medications", "appropriate first-line treatment", "patients", "diagnosis"]}
{"question": "A 28-year-old man presents to his physician with a complaint of a 4-week history of headaches that is affecting his academic performance. Over-the-counter medications do not seem to help. He also mentions that he has to raise his head each time to look at the board when taking notes. His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8°C (98.2°F). Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. CT scan of the head reveals a 1.5 x 1.2 cm heterogeneous mass in the epithalamus with dilated lateral and 3rd ventricles. What other finding is most likely to be associated with this patient’s condition?", "answer": "Pseudo-Argyll Robertson pupils", "options": {"A": "Medial strabismus", "B": "Sensorineural hearing loss", "C": "Pseudo-Argyll Robertson pupils", "D": "Eyes down and out", "E": "Conducting hearing loss"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "complaint of", "week history", "headaches", "affecting", "academic performance", "Over-the-counter medications", "not", "to help", "to", "head", "time to look", "board", "blood pressure", "75 mm Hg", "pulse", "min", "respiratory rate", "min", "temperature 36", "98", "Ophthalmic examination", "upward gaze palsy", "convergence-retraction nystagmus", "papilledema", "CT scan of", "head reveals a", "heterogeneous mass", "epithalamus", "dilated lateral", "3rd ventricles", "finding", "to", "associated with", "patients condition"]}
{"question": "A 41-year-old woman presents with acute onset severe epigastric pain radiating to the back that began a few hours ago. She also complains of nausea and has vomited twice in the past hour. She denies any history of similar symptoms or trauma in the past. Past medical history is significant for diabetes type 2 and HIV infection diagnosed 6 months ago long-standing mild intermittent asthma, and generalized anxiety disorder. She takes metformin for her diabetes but does not remember the names of her HIV medications. She reports moderate social alcohol use. Her vital signs include temperature 37.6°C (99.6 °F), pulse 95/min, blood pressure 110/74 mm Hg, respiratory rate 12/min Her body mass index (BMI) is 21 kg/m2. Laboratory findings are significant for the following:\nSerum amylase: 415 U/L\nSerum lipase: 520 U/L\nA contrast CT of the abdomen reveals an edematous pancreas with peripancreatic fluid collection with a normal gallbladder. Which of the following is the most likely etiology of this patient’s condition?", "answer": "HIV medication-related", "options": {"A": "HIV medication-related", "B": "Alcohol use", "C": "Abdominal trauma", "D": "Metformin", "E": "Congenital anomaly of the pancreas"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "acute onset severe epigastric pain radiating", "back", "began", "few hours", "nausea", "vomited twice", "past hour", "history", "similar symptoms", "trauma", "past", "Past medical history", "significant", "diabetes type 2", "HIV infection diagnosed", "months", "long standing mild intermittent asthma", "generalized anxiety disorder", "metformin", "diabetes", "not", "HIV", "reports moderate social", "vital signs include temperature", "99", "F", "pulse 95 min", "blood pressure", "74 mm Hg", "respiratory rate", "min", "body mass index", "kg/m2", "Laboratory findings", "significant", "following", "Serum amylase", "415 U/L Serum lipase", "520 U/L", "contrast CT of", "abdomen reveals", "edematous pancreas", "peripancreatic fluid collection", "normal gallbladder", "following", "etiology", "patients condition"]}
{"question": "A 34-year-old woman presents to the emergency department with sudden onset of painful vision loss in her left eye. The patient is otherwise healthy with a history only notable for a few emergency department presentations for numbness and tingling in her extremities with no clear etiology of her symptoms. Her temperature is 100°F (37.8°C), blood pressure is 122/83 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 98% on room air. Examination of the patient's cranial nerves reveals an inability to adduct the left eye when the patient is asked to look right. Which of the following is the most appropriate treatment?", "answer": "Methylprednisolone", "options": {"A": "Estriol", "B": "Glatiramer acetate", "C": "Interferon-beta", "D": "Methylprednisolone", "E": "Rituximab"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "sudden onset of painful vision loss", "left eye", "patient", "healthy", "history only notable", "emergency department", "numbness", "tingling", "extremities", "clear etiology", "symptoms", "temperature", "blood pressure", "83 mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient's", "reveals", "left eye", "patient", "to look right", "following", "most appropriate treatment"]}
{"question": "A 24-year-old man is taken to the emergency department by local law enforcement after they witnessed him physically assaulting a complete stranger. The officers report that they saw his eyes “moving back and forth quickly” and noted that he was very red-faced. The patient has no significant past medical or psychiatric history. His vital signs include: temperature 38.0°C (100.4°F), blood pressure 110/70 mm Hg, pulse 102/min, and respiratory rate 25/min. On physical examination, the patient is belligerent and refuses to cooperate during the examination. Rotary nystagmus is noted. Which of the following drugs would most likely be present in a urine toxicology screen from this patient?", "answer": "Phencyclidine hydrochloride (PCP)", "options": {"A": "Lysergic acid diethylamide (LSD)", "B": "Marijuana", "C": "Methamphetamine", "D": "Cocaine", "E": "Phencyclidine hydrochloride (PCP)"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man", "emergency department", "local", "assaulting", "complete", "report", "saw", "eyes moving back", "noted", "very red faced", "patient", "significant past medical", "psychiatric history", "vital signs include", "temperature", "100", "blood pressure", "70 mm Hg", "pulse", "min", "respiratory rate", "min", "patient", "to", "Rotary nystagmus", "noted", "following drugs", "most likely", "present", "urine toxicology", "patient"]}
{"question": "A 73-year-old man presents to his primary care physician endorsing 4-5 days of decreased urinary output and mild shortness of breath. He has a complex medical history, including uncontrolled diabetes mellitus type 2, hypertension, chronic kidney disease, and end-stage emphysema. It is determined that his kidney disease has progressed to the point of needing dialysis, which his primary care physician feels should be initiated promptly. However, the patient remarks, \"I would never want dialysis. I have friends who went through it, and it sounds awful. I would rather die comfortably, even if that is soon.\" After the physician explains what dialysis is, and the risks and alternatives to the procedure the patient is able to demonstrate his understanding of dialysis including the risks, benefits and alternatives. He appears to be in no distress and demonstrates a clear understanding. After discussing the patient's wishes further, which of the following is the most appropriate response on the part of the physician?", "answer": "\"I respect that this is ultimately your decision, and will focus on making sure you are comfortable\"", "options": {"A": "\"I will obtain an ethics consultation to help with this matter\"", "B": "\"I will involve a psychiatrist to help determine your capacity to refuse this treatment\"", "C": "\"I cannot be your physician going forward if you refuse to undergo dialysis\"", "D": "\"I strongly encourage you to reconsider your decision\"", "E": "\"I respect that this is ultimately your decision, and will focus on making sure you are comfortable\""}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "primary care physician", "4-5 days of decreased urinary output", "mild shortness of breath", "complex medical history", "including uncontrolled diabetes mellitus type 2", "hypertension", "chronic kidney disease", "end-stage emphysema", "kidney disease", "progressed", "point", "needing dialysis", "primary care physician", "initiated", "patient", "I", "never", "dialysis", "I", "sounds", "I", "die", "physician", "dialysis", "procedure", "patient", "able to", "dialysis including", "benefits", "appears to", "distress", "clear", "patient", "ishes  urther,", "ollowing ", "ost  ppropriate  esponse ", "art of ", "hysician?"]}
{"question": "A 26-year-old man with HIV and a recent CD4+ count of 800 presents to his PCP with fever, cough, and dyspnea. He notes that he recently lost his job as a construction worker and has not been able to afford his HAART medication. His temperature is 102.6°F (39.2°C), pulse is 75/min, respirations are 24/min, and blood pressure is 135/92 mmHg. Physical exam reveals a tachypneic patient with scattered crackles in both lungs, and labs show a CD4+ count of 145 and an elevated LDH. The chest radiography is notable for bilateral diffuse interstitial infiltrates. For definitive diagnosis, the physician obtains a sputum sample. Which stain should he use to visualize the most likely responsible organism?", "answer": "Silver stain", "options": {"A": "Ziehl-Neelsen stain", "B": "Silver stain", "C": "India ink stain", "D": "Periodic acid schiff stain", "E": "Carbol fuchsin stain"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "HIV", "recent CD4", "count", "800 presents", "PCP", "fever", "cough", "dyspnea", "notes", "recently lost", "construction worker", "not", "able to", "HAART medication", "temperature", "pulse", "75 min", "respirations", "min", "blood pressure", "mmHg", "reveals", "tachypneic patient", "scattered crackles", "lungs", "labs", "CD4", "count", "elevated LDH", "chest radiography", "notable", "bilateral diffuse interstitial infiltrates", "definitive diagnosis", "physician obtains", "sputum sample", "use to", "responsible"]}
{"question": "A 49-year-old woman is brought to the emergency department by her daughter because of increasing arthralgia, headache, and somnolence for the past week. She has a history of systemic lupus erythematosus without vital organ involvement. She last received low-dose glucocorticoids 2 months ago. Her temperature is 38.6 °C (101.5 °F), pulse is 80/min, respirations are 21/min, and blood pressure is 129/80 mm Hg. She is confused and disoriented. Examination shows scleral icterus and ecchymoses over the trunk and legs. Neurological examination is otherwise within normal limits. Laboratory studies show:\nHemoglobin 8.7 g/dL\nLeukocyte count 6,200/mm3\nPlatelet count 25,000/mm3\nProthrombin time 15 seconds\nPartial thromboplastin time 39 seconds\nFibrin split products negative\nSerum\nBilirubin\nTotal 4.9 mg/dL\nDirect 0.5 mg/dL\nA blood smear shows numerous fragmented red blood cells. Urinalysis shows hematuria and proteinuria. Which of the following is the most likely diagnosis?\"", "answer": "Thrombotic thrombocytopenic purpura", "options": {"A": "Immune thrombocytopenic purpura", "B": "Disseminated intravascular coagulation", "C": "Hemolytic uremic syndrome", "D": "Thrombotic thrombocytopenic purpura", "E": "Glanzmann thrombasthenia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "increasing arthralgia", "headache", "somnolence", "past week", "history of systemic lupus erythematosus", "vital organ involvement", "last received low-dose glucocorticoids", "months", "temperature", "F", "pulse", "80 min", "respirations", "min", "blood pressure", "80 mm Hg", "confused", "disoriented", "scleral icterus", "ecchymoses", "trunk", "legs", "Neurological examination", "normal limits", "Laboratory studies", "Hemoglobin", "g dL Leukocyte", "200 mm3 Platelet count", "Prothrombin time 15 seconds Partial thromboplastin time", "Fibrin split products negative Serum Bilirubin Total 4 9", "dL Direct 0.5 mg/dL", "blood smear", "numerous fragmented red blood cells", "Urinalysis", "hematuria", "proteinuria", "following", "diagnosis"]}
{"question": "A 28-year-old woman comes to the physician because of a 1-year history of intermittent buzzing in both her ears. She says she sometimes has episodes of mild dizziness which resolve spontaneously. She has a 15-year history of type 1 diabetes mellitus and episodes of low back pain. She does not smoke or drink alcohol. Current medications include insulin and aspirin. She works as a trombonist for a symphony orchestra. Her vital signs are within normal limits. On otoscopic examination, the tympanic membrane appears normal. Bone conduction is greater than air conduction in both ears. Weber test shows no lateralization. Which of the following is the most likely diagnosis?", "answer": "Otosclerosis", "options": {"A": "Drug-induced ototoxicity", "B": "Presbycusis", "C": "Endolymphatic hydrops", "D": "Otosclerosis", "E": "Diabetic otopathy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "year history", "intermittent", "ears", "sometimes", "episodes of mild dizziness", "year history of type 1 diabetes mellitus", "episodes of low back pain", "not smoke", "Current medications include insulin", "aspirin", "vital signs", "normal limits", "otoscopic", "tympanic membrane appears normal", "Bone", "greater than air conduction", "ears", "Weber test", "following", "diagnosis"]}
{"question": "A 25-year-old man comes to the physician for a 2-month history of abdominal discomfort, fatigue, and increased urinary frequency, especially at night. He has also noticed that despite eating more often he has lost 14-lbs (6-kg). He has a congenital solitary kidney and a history of Hashimoto thyroiditis, for which he takes levothyroxine. He has smoked two packs of cigarettes daily for 10 years. BMI is 18 kg/m2. His temperature is 36.7°C (98.1°F), pulse is 80/min, and blood pressure is 110/60 mm Hg. Physical examination is unremarkable. Serum studies show an osmolality of 305 mOsm/L and bicarbonate of 17 mEq/L. Urinalysis shows clear-colored urine with no organisms. Which of the following is most likely to be helpful in establishing the diagnosis?", "answer": "Serum glucose", "options": {"A": "Ultrasonography of the thyroid gland", "B": "Serum glucose", "C": "Water deprivation test", "D": "Serum creatinine", "E": "Digital rectal examination"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "2 month history", "abdominal discomfort", "fatigue", "increased urinary frequency", "night", "eating more often", "lost", "lbs", "kg", "congenital solitary kidney", "history", "Hashimoto thyroiditis", "levothyroxine", "smoked two packs", "cigarettes daily", "BMI", "kg/m2", "temperature", "36", "98", "pulse", "80 min", "blood pressure", "60 mm Hg", "unremarkable", "Serum studies", "osmolality", "305 mOsm/L", "bicarbonate", "mEq/L", "Urinalysis", "clear colored urine", "following", "to", "helpful", "establishing", "diagnosis"]}
{"question": "A 77-year-old man is brought to his primary care physician by his daughter. She states that lately, his speech has been incoherent. It seemed to have started a few weeks ago and has been steadily worsening. He is otherwise well; however, she notes that she has had to start him on adult diapers. The patient has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has been smoking 1 pack of cigarettes per day for over 40 years. His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 97% on room air. Physical exam reveals a confused elderly man who does not respond coherently to questions. Cardiac and pulmonary exam is within normal limits. Inspection of the patient's scalp reveals a healing laceration which the daughter claims occurred yesterday when he fell while walking. Gait testing is significant for the patient taking short steps with reduced cadence. Which of the following findings is most likely in this patient?", "answer": "Dilated ventricles on MRI", "options": {"A": "Decreased dopamine synthesis in the substantia nigra on dopamine uptake scan", "B": "Dilated ventricles on MRI", "C": "White matter T2 hyperintensities of the cerebral cortex on MRI", "D": "Minor atrophy of the cerebral cortex on CT", "E": "Severe atrophy of the cerebral cortex on MRI"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "primary care physician", "states", "speech", "incoherent", "to", "started", "few weeks", "worsening", "well", "notes", "to start", "adult diapers", "patient", "past medical", "hyperlipidemia", "type 2 diabetes mellitus", "smoking 1 pack", "cigarettes", "day", "40 years", "temperature", "98 9F", "blood pressure", "mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "97", "room air", "reveals", "confused elderly man", "not", "Cardiac", "pulmonary exam", "normal", "Inspection", "patient's scalp reveals", "healing laceration", "fell", "Gait testing", "significant", "patient", "short steps", "reduced", "following findings", "patient"]}
{"question": "A 23-year-old man comes to the physician because of a painless swelling on the left side of his jaw for 2 months. It has been progressively increasing in size and is draining thick, foul-smelling fluid. He had a molar extracted 3 months ago. Examination shows a 4-cm, tender, erythematous mass in the left submandibular region with purulent drainage. There is submandibular lymphadenopathy. A culture of the purulent material shows catalase-negative, gram-positive filamentous rods that do not stain with carbol fuchsin. Which of the following is the most likely causal pathogen?", "answer": "Actinomyces israelii", "options": {"A": "Mucor irregularis", "B": "Acinetobacter baumannii", "C": "Actinomyces israelii", "D": "Streptococcus pneumoniae", "E": "Nocardia asteroides\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old man", "physician", "of", "painless swelling", "left side", "jaw", "2 months", "increasing in size", "draining", "smelling", "molar extracted 3 months", "4", "tender", "erythematous mass", "left submandibular region", "purulent drainage", "submandibular lymphadenopathy", "purulent", "catalase negative", "filamentous", "not stain", "carbol fuchsin", "following", "causal"]}
{"question": "A 20-month-old boy is brought to the emergency department by his parents with fever and diarrhea that have persisted for the past 2 days. He has a history of repeated bouts of diarrhea, upper respiratory tract infections, and failure to thrive. His vital signs are as follows: blood pressure 80/40 mm Hg, pulse 130/min, temperature 39.0°C (102.2°F), and respiratory rate 30/min. Blood tests are suggestive of lymphopenia. The child is diagnosed with severe combined immune deficiency after additional testing. Which of the following is the most common association with this type of immunodeficiency?", "answer": "X-linked severe combined immunodeficiency", "options": {"A": "X-linked severe combined immunodeficiency", "B": "Adenosine deaminase deficiency", "C": "Janus-associated kinase 3 (JAK3) deficiency", "D": "Reticular dysgenesis", "E": "Bare lymphocyte syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["20 month old boy", "brought", "emergency department", "fever", "diarrhea", "past 2 days", "history", "repeated bouts", "diarrhea", "upper respiratory tract infections", "failure to thrive", "vital signs", "follows", "blood pressure 80 40 mm Hg", "pulse", "min", "temperature", "respiratory rate 30/min", "Blood tests", "suggestive of lymphopenia", "child", "diagnosed", "severe combined immune deficiency", "additional testing", "following", "most common", "immunodeficiency"]}
{"question": "A 68-year-old man seeks evaluation by a physician with complaints of worsening forgetfulness and confusion for 1 year. According to his wife, he has always been in good health and is generally very happy; however, he has started to forget important things. He recently had his driving license revoked because of multiple tickets, but he cannot recall having done anything wrong. This morning, he neglected to put on his socks and was quite agitated when she pointed this out to him. He denies having a depressed mood, sleep problems, or loss of interest. He occasionally has a glass of wine with dinner and has never smoked or used recreational drugs. His medical history and family medical history are unremarkable. His pulse is 68/min, respirations are 14/min, and blood pressure is 130/84 mm Hg. Except for a mini-mental state examination (MMSE) score of 20/30, the remainder of the physical examination is unremarkable. Imaging studies, including a chest X-ray and CT of the brain, reveal no pathologic findings. An electrocardiogram (ECG) is also normal. Laboratory testing showed the following:\nSerum glucose (fasting) 76 mg/dL\nSerum electrolytes:  \nSodium 140 mEq/L\nPotassium 4.1 mEq/L\nChloride 100 mEq/L\nSerum creatinine 0.9 mg/dL\nBlood urea nitrogen 11 mg/dL\nCholesterol, total: 180 mg/dL\nHDL-cholesterol 45 mg/dL\nLDL-cholesterol 75 mg/dL\nTriglycerides 135 mg/dL\nHemoglobin (Hb%) 16 g/dL\nMean corpuscular volume (MCV)  85 fL\nReticulocyte count 0.9%\nErythrocyte count 5 million/mm³\nThyroid-stimulating hormone 3.5 µU/mL\nUrinalysis \nGlucose Negative\nKetones Negative\nLeucocytes Negative\nNitrite Negative\nRBCs Negative\nCasts Negative\nWhich of the following is the most likely diagnosis?", "answer": "Alzheimer’s dementia", "options": {"A": "Alzheimer’s dementia", "B": "Creutzfeldt-Jakob disease", "C": "Lewy body dementia", "D": "Parkinson’s disease", "E": "Vascular dementia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "complaints", "worsening forgetfulness", "confusion", "year", "always", "started to forget important", "recently", "revoked", "multiple", "wrong", "morning", "neglected to", "socks", "agitated", "pointed", "out", "depressed mood", "sleep problems", "loss of interest", "occasionally", "glass", "dinner", "never smoked", "used recreational drugs", "medical history", "family medical history", "unremarkable", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "Except for", "mini-mental state examination", "score", "20/30", "unremarkable", "Imaging studies", "including", "chest X-ray", "CT of", "brain", "reveal", "pathologic findings", "electrocardiogram", "normal", "Laboratory testing", "following", "Serum glucose", "fasting", "76 mg/dL Serum electrolytes", "Blood", "Cholesterol", "total", "mg/dL HDL-cholesterol", "LDL-cholesterol 75", "Triglycerides", "Hemoglobin", "Hb", "g/dL Mean corpuscular volume", "fL Reticulocyte count 0 9", "5", "Thyroid-stimulating hormone 3", "mL Urinalysis", "Glucose Negative Ketones", "Nitrite", "Casts Negative", "following", "diagnosis"]}
{"question": "A 26-year-old woman is brought to the emergency department after a suicide attempt. Her mother found her next to an empty bottle of acetaminophen in the bathroom. The patient reports that she ingested about twenty-five 500 mg pills. She took the pills 1 hour prior to arrival to the emergency department. She has a history of major depressive disorder. She does not smoke or use illicit drugs. Current medications include fluoxetine. She is oriented to person, place, and time. Vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.5 g/dL\nLeukocyte count 8,000/mm3\nPlatelet count 150,000/mm3\nSerum\nProthrombin time 10.5 sec (INR=1.0)\nNa+ 141 mEq/L\nK+ 4.2 mEq/L\nCl- 101 mEq/L\nHCO3- 25 mEq/L\nUrea nitrogen 10 g/dL\nCreatinine 0.5 g/dL\nCa2+ 8.8 mg/dL\nTotal bilirubin 0.4 mg/dL\nAST 22 U/L\nALT 25 U/L\nAlkaline phosphatase 62 U/L\nWhich of the following is the most appropriate next step in management?\"", "answer": "Administer activated charcoal", "options": {"A": "Administer N-acetylcysteine", "B": "Administer activated charcoal", "C": "Admit for observation", "D": "List for liver transplant", "E": "Perform liver biopsy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "suicide attempt", "found", "next to", "empty bottle", "acetaminophen", "bathroom", "patient reports", "twenty-five 500 mg pills", "pills", "hour prior to arrival", "emergency department", "history of major depressive disorder", "not smoke", "use illicit", "Current medications include fluoxetine", "oriented to person", "place", "time", "Vital signs", "normal limits", "abnormalities", "Laboratory studies", "Hemoglobin 12.5 g/dL Leukocyte count", "mm3 Platelet count", "Serum Prothrombin time 10", "sec", "INR 1 0", "mEq/L K", "4", "HCO3", "Ca2", "8.8", "Total bilirubin", "AST", "U", "ALT", "Alkaline phosphatase 62", "following", "most appropriate next step"]}
{"question": "A 42-year-old woman is brought to the physician by her husband because she cries frequently and refuses to get out of bed. Over the past 3 weeks, she has been feeling sad and tired most of the time. She has difficulty staying asleep at night and often wakes up early in the morning. After losing her job as a waitress 1 month ago, she has been feeling guilty for not contributing to the household income anymore. She would like to find a new position but is unable to decide “what to do with her life”. She was diagnosed with anorexia nervosa at age 18 and has gone to psychotherapy several times since then. Her weight had been stable for the past 5 years; however, within the past 3 weeks, she has had a 2.8-kg (6.2-lb) weight loss. She would like to regain some weight. She is 160 cm (5 ft 3 in) tall and currently weighs 47 kg (104 lb); BMI is 18.4 kg/m2. Her temperature is 36.3°C (97.3°F), pulse is 58/min, and blood pressure is 110/60 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect. There is no evidence of suicidal ideation. Which of the following drugs is most likely to address both this patient's mood disorder and her desire to gain weight?", "answer": "Mirtazapine", "options": {"A": "Lithium", "B": "Mirtazapine", "C": "Olanzapine", "D": "Topiramate", "E": "Phenelzine\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "physician", "frequently", "to get out", "bed", "past", "weeks", "feeling sad", "tired most of the time", "difficulty staying asleep", "night", "often wakes up early", "morning", "job", "waitress 1 month", "not", "household income", "to find", "new position", "unable to", "to", "diagnosed", "anorexia nervosa", "age", "psychotherapy", "times", "then", "weight", "stable", "past", "years", "past", "weeks", "2", "kg", "6.2", "weight loss", "to", "weight", "5 ft", "tall", "currently", "kg", "BMI", "kg/m2", "temperature", "36", "97", "pulse", "58 min", "blood pressure", "60 mm Hg", "abnormalities", "Mental status", "depressed mood", "flat affect", "suicidal ideation", "following drugs", "to", "patient's", "to gain weight"]}
{"question": "A 2-month-old girl with a previous diagnosis of DiGeorge syndrome is brought to the emergency department with her parents following a seizure. Her mother states that the baby had been inconsolable all day and refused to feed. She was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines. Upon arrival to the hospital her heart rate is 120/min, respiratory rate is 40/min, and temperature of 37.0°C (98.6°F). On examination, she is afebrile and somnolent and her fontanelles are open and soft. While attempting to take her blood pressure, the patient’s arm and hand flex sharply and do not relax until the cuff is released. A light tap on the cheek results in an atypical facial muscle twitch. A CMP and CBC are drawn and sent for analysis. Which of the following is the most likely cause?", "answer": "Hypocalcemia", "options": {"A": "Hypernatremia", "B": "Hypocalcemia", "C": "Meningitis", "D": "High fever", "E": "Tetanus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 month old girl", "previous diagnosis", "DiGeorge syndrome", "brought", "emergency department", "following", "seizure", "states", "baby", "day", "to", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "arrival", "hospital", "heart rate", "min", "respiratory rate", "40 min", "temperature", "98", "afebrile", "somnolent", "fontanelles", "open", "soft", "to", "blood pressure", "patients arm", "hand", "not relax", "cuff", "released", "light", "cheek results", "atypical facial", "CMP", "CBC", "sent", "analysis", "following", "cause"]}
{"question": "A 2900-g (6.4-lb) male newborn is delivered at term to a 29-year-old primigravid woman. His mother had no routine prenatal care. She reports that the pregnancy was uncomplicated apart from a 2-week episode of a low-grade fever and swollen lymph nodes during her early pregnancy. She has avoided all routine vaccinations because she believes that “natural immunity is better.” The newborn is at the 35th percentile for height, 15th percentile for weight, and 3rd percentile for head circumference. Fundoscopic examination shows inflammation of the choroid and the retina in both eyes. A CT scan of the head shows diffuse intracranial calcifications and mild ventriculomegaly. Prenatal avoidance of which of the following would have most likely prevented this newborn's condition?", "answer": "Undercooked pork", "options": {"A": "Exposure to unvaccinated children", "B": "Undercooked pork", "C": "Unprotected sexual intercourse", "D": "Mosquito bites", "E": "Raw cow milk products"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["male newborn", "delivered", "term", "29 year old primigravid woman", "routine prenatal care", "reports", "pregnancy", "uncomplicated", "2-week episode of", "low-grade fever", "swollen lymph nodes", "early pregnancy", "routine vaccinations", "natural immunity", "better", "newborn", "percentile", "height", "percentile", "weight", "3rd percentile", "head circumference", "Fundoscopic examination", "inflammation of", "choroid", "retina", "eyes", "CT scan of", "head", "diffuse intracranial", "mild ventriculomegaly", "Prenatal", "following", "most likely prevented", "newborn's condition"]}
{"question": "A 6-year-old girl is brought to the physician for a well-child examination. There is no personal or family history of serious illness. She is at the 90th percentile for height and weight. Vital signs are within normal limits. Examination shows enlarged breast buds that extend beyond the areola. There is coarse pubic hair that does not extend onto the inner thigh. The remainder of the examination show no abnormalities. An x-ray of the left hand shows a bone age of 10 years. Following GnRH agonist stimulation, serum luteinizing hormone levels increase to twice the median. Which of the following is the most appropriate next best step in management?", "answer": "MRI of the brain", "options": {"A": "Leuprolide therapy", "B": "Reassurance and follow-up", "C": "MRI of the brain", "D": "Ultrasound of the pelvis", "E": "Anastrozole therapy\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "well", "personal", "family history", "serious illness", "90th percentile", "height", "weight", "Vital signs", "normal limits", "enlarged breast buds", "extend", "areola", "coarse pubic", "not extend", "inner thigh", "abnormalities", "x-ray", "left hand", "bone age", "Following GnRH agonist stimulation", "serum luteinizing hormone levels increase", "twice", "median", "following", "most appropriate next best step"]}
{"question": "A 67-year-old female presents to the emergency room with dry cough and malaise. She has no other complaints. She has a past medical history of a meningioma status post resection complicated by hemiplegia and has been managed with dexamethasone for several months. Her vital signs are T 100.4 F (38 C), O2 93% on room air, RR 20, BP 115/75 mmHg. Physical examination is notable for crackles bilaterally. A chest radiograph is obtained (Image A). The patient is admitted and initially treated guideline-compliant antibiotics for community-acquired pneumonia. Unfortunately, her respiratory function deteriorates. An arterial blood gas is drawn. On room air at sea level, PaO2 is 71 mmHg and PaCO2 is 34 mmHg. Induced sputum samples reveal organisms on methenamine silver stain. What is the best treatment strategy for this patient?", "answer": "Trimethoprim-sulfamethoxazole + steroids", "options": {"A": "Trimethoprim-sulfamethoxazole", "B": "Metronidazole", "C": "Trimethoprim-sulfamethoxazole + steroids", "D": "Piperacillin-tazobactam", "E": "Piperacillin-tazobactam + steroids"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old female presents", "emergency room", "dry cough", "malaise", "complaints", "past medical history", "meningioma", "resection complicated", "hemiplegia", "dexamethasone", "several months", "vital signs", "T 100 4 F", "O2", "room air", "RR 20", "BP", "75 mmHg", "notable", "crackles", "chest radiograph", "obtained", "patient", "initially treated", "compliant", "community-acquired pneumonia", "respiratory function deteriorates", "arterial blood gas", "room air", "sea level", "PaO2", "mmHg", "mmHg", "Induced sputum samples reveal", "methenamine silver stain", "best"]}
{"question": "You are called to see a chemotherapy patient who is complaining of severe nausea. This patient is a 52-year-old male with acute lymphoblastic leukemia (ALL) who began his first cycle of chemotherapy 2 days ago. Which of the following structures is involved in the pathway responsible for this patient's nausea?", "answer": "Medulla oblongata", "options": {"A": "Medulla oblongata", "B": "Medial geniculate nucleus", "C": "Lateral geniculate nucleus", "D": "Posterior hypothalamus", "E": "Ventral posterolateral nucleus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["called to see", "chemotherapy patient", "severe nausea", "patient", "year old male", "acute lymphoblastic leukemia", "began", "first cycle", "chemotherapy 2 days", "following structures", "involved", "responsible", "patient's nausea"]}
{"question": "A 52-year-old tow truck driver presents to the emergency room in the middle of the night complaining of sudden onset right ankle pain. He states that the pain came on suddenly and woke him up from sleep. It was so severe that he had to call an ambulance to bring him to the hospital since he was unable to drive. He has a history of hypertension and types 2 diabetes mellitus, for which he takes lisinopril and methotrexate. He has no other medical problems. The family history is notable for hypertension on his father’s side. The vital signs include: blood pressure 126/86 mm Hg, heart rate 84/min, respiratory rate 14/min, and temperature 37.2°C (99.0°F). On physical exam, the patient’s right ankle is swollen, erythematous, exquisitely painful, and warm to the touch. An arthrocentesis is performed and shows negatively birefringent crystals on polarized light. Which of the following is the best choice for treating this patient’s pain?", "answer": "Administer indomethacin", "options": {"A": "Administer allopurinol", "B": "Administer probenecid", "C": "Administer colchicine", "D": "Administer indomethacin", "E": "Administer febuxostat"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "truck driver presents", "emergency room in", "middle", "night", "sudden onset right ankle pain", "states", "pain", "woke", "sleep", "so severe", "to call", "ambulance to", "hospital", "unable to", "history of hypertension", "types 2 diabetes mellitus", "lisinopril", "methotrexate", "medical problems", "family history", "notable", "hypertension", "side", "vital signs include", "blood pressure", "mm Hg", "heart rate 84 min", "respiratory rate", "min", "temperature", "99", "patients right ankle", "swollen", "erythematous", "painful", "warm", "touch", "arthrocentesis", "performed", "birefringent crystals", "following", "best", "treating", "patients pain"]}
{"question": "A 63-year-old man with a history of diabetes mellitus presents with complaints of fatigue. He lives alone and has not seen a doctor in 10 years. He does not exercise, eats a poor diet, and drinks 1-2 beers per day. He does not smoke. He has never had a colonoscopy. Labs show a hemoglobin of 8.9 g/dL (normal 13.5 - 17.5), mean corpuscular volume of 70 fL (normal 80-100), serum ferritin of 400 ng/mL (normal 15-200), TIBC 200 micrograms/dL (normal 250-420), and serum iron 50 micrograms/dL (normal 65-150). Which of the following is the cause of his abnormal lab values?", "answer": "Chronic inflammation", "options": {"A": "Vitamin deficiency", "B": "Mineral deficiency", "C": "Mineral excess", "D": "Chronic inflammation", "E": "Occult bleeding"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old man", "history of diabetes mellitus presents", "complaints", "fatigue", "lives alone", "not seen", "doctor", "not exercise", "eats", "poor diet", "1", "day", "not smoke", "never", "colonoscopy", "Labs", "a hemoglobin", "g/dL", "normal", "mean corpuscular volume", "70 fL", "normal 80 100", "serum ferritin", "400 ng/mL", "normal", "200", "TIBC 200 micrograms dL", "normal", "420", "serum 50 micrograms dL", "normal 65", "following", "cause", "abnormal lab values"]}
{"question": "A 37-year-old woman, gravida 3, para 3, comes to the physician for a follow-up examination. She gave birth to her third child 8 months ago and now wishes to start a contraception method. Prior to her most recent pregnancy, she used a combined estrogen-progestin pill. Which of the following aspects of her history would be a contraindication for restarting an oral contraceptive pill?", "answer": "She smokes 1 pack of cigarettes daily", "options": {"A": "Her hemoglobin A1c is 8.6%", "B": "She smokes 1 pack of cigarettes daily", "C": "She has recurrent migraine headaches without aura", "D": "She has a history of cervical dysplasia", "E": "Her infant is still breastfeeding"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 3", "para 3", "physician", "follow-up examination", "gave birth", "third child", "months", "now wishes to start", "contraception method", "most recent pregnancy", "used", "combined estrogen progestin pill", "following aspects", "history", "contraindication", "restarting", "oral contraceptive pill"]}
{"question": "A 15-year-old boy is brought to the physician by his mother because of 4 months of strange behavior. She says that during this period, he has had episodic mood swings. She has sometimes found him in his room “seemingly drunk” and with slurred speech. These episodes usually last for approximately 15 minutes, after which he becomes irritable. He has had decreased appetite, and his eyes occasionally appear red. He has trouble keeping up with his schoolwork, and his grades have worsened. Physical examination shows an eczematous rash between the upper lip and nostrils. Neurologic examination shows a delay in performing alternating palm movements. Use of which of the following is the most likely cause of this patient's condition?", "answer": "Inhalants", "options": {"A": "Inhalants", "B": "Alcohol", "C": "Phencyclidine", "D": "Cocaine", "E": "Marijuana"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "months", "period", "episodic mood swings", "sometimes found", "room", "drunk", "slurred speech", "episodes usually last", "approximately 15 minutes", "irritable", "decreased appetite", "eyes occasionally appear red", "keeping", "worsened", "eczematous rash", "upper lip", "nostrils", "Neurologic examination", "delay", "performing alternating palm movements", "Use of", "following", "most likely cause", "patient's condition"]}
{"question": "A 40-year-old woman comes to the physician because of a small lump on the right side of her neck that she noticed while putting lotion on 1 week ago. She does not have any weight change, palpitations, or altered bowel habits. There is no family history of serious illness. Menses occur at regular 30-day intervals and lasts for 4 days. She appears well. Her temperature is 37°C (98.6° F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Examination shows a small swelling on the right side of the neck that moves with swallowing. There is no lymphadenopathy. Ultrasound of the neck shows a 0.9-cm (0.35-in) right lobe thyroid mass with microcalcifications and irregular margins. Which of the following is the most appropriate next step in diagnosis?", "answer": "Thyroid-stimulating hormone level", "options": {"A": "Fine-needle aspiration biopsy of the swelling", "B": "Open biopsy", "C": "Thyroid scintigraphy", "D": "Thyroid-stimulating hormone level", "E": "CT of the neck"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old woman", "physician", "of", "small lump", "right side", "neck", "lotion", "1 week", "not", "weight change", "palpitations", "altered bowel habits", "family history", "serious illness", "Menses occur", "regular 30 day intervals", "lasts", "4 days", "appears well", "temperature", "98", "F", "pulse", "88 min", "blood pressure", "74 mm Hg", "small swelling", "the right side of", "neck", "moves", "swallowing", "lymphadenopathy", "Ultrasound of the neck", "0.9", "0.35", "right lobe thyroid mass", "microcalcifications", "irregular margins", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 36-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of a gush of clear fluid from her vagina that occurred 1 hour prior. She reports painful pelvic cramping at regular 5-minute intervals. She has missed most of her prenatal care visit because of financial problems from her recent divorce. Her first child was delivered vaginally at 27 weeks' gestation due to spontaneous preterm labor. She has smoked one pack of cigarettes daily for 15 years but has reduced her intake to 2–3 cigarettes per day since finding out she was pregnant. She continues to use cocaine once a week. Vital signs are within normal limits. Sterile speculum examination shows fluid pooling in the vagina, and nitrazine paper testing confirms the presence of amniotic fluid. Which of the following puts her at highest risk of preterm delivery?", "answer": "History of spontaneous preterm birth\n\"", "options": {"A": "Low socioeconomic status", "B": "Smoking during pregnancy", "C": "Substance abuse during pregnancy", "D": "Advanced maternal age", "E": "History of spontaneous preterm birth\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["36 year old woman", "gravida 2", "para 1", "weeks", "gestation", "emergency department", "vagina", "1 hour prior", "reports painful pelvic cramping", "regular 5-minute intervals", "missed most", "of financial", "recent divorce", "first child", "delivered", "27 weeks", "gestation", "spontaneous preterm labor", "smoked one pack", "cigarettes daily", "years", "reduced", "intake", "23 cigarettes", "day", "finding out", "pregnant", "to use cocaine", "week", "Vital signs", "normal limits", "Sterile speculum", "fluid pooling", "vagina", "nitrazine paper testing confirms", "presence", "amniotic fluid", "following", "highest risk of preterm delivery"]}
{"question": "A 52-year-old woman comes to the physician because of a 3-week history of pain in her right knee. The pain is worse at the end of the day and when she walks. She says that it has become difficult for her to walk up the flight of stairs to reach her apartment. She has hypertension and psoriasis. Her sister has rheumatoid arthritis. She drinks 2–3 beers daily. Current medications include hydrochlorothiazide, topical betamethasone, and a multivitamin. She is 160 cm (5 ft 3 in) tall and weighs 92 kg (202 lb); BMI is 36 kg/m2. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 87/min, and blood pressure is 135/83 mm Hg. Cardiopulmonary examinations shows no abnormalities. There are several scaly plaques over the patient's upper and lower extremities. The right knee is not tender nor erythematous; range of motion is limited. Crepitus is heard on flexion and extension of the knee. Her hemoglobin concentration is 12.6 g/dL, leukocyte count is 9,000/mm3, and erythrocyte sedimentation rate is 16 mm/h. An x-ray of the right knee is shown. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Weight loss program", "options": {"A": "Intraarticular glucocorticoid injections", "B": "Weight loss program", "C": "Total joint replacement", "D": "Methotrexate therapy", "E": "Colchicine therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "3 week history", "pain", "right knee", "pain", "end", "walks", "difficult", "to reach", "apartment", "hypertension", "psoriasis", "rheumatoid arthritis", "23", "daily", "Current medications include hydrochlorothiazide", "multivitamin", "5 ft", "tall", "kg", "BMI", "36 kg/m2", "appears anxious", "temperature", "98", "pulse", "87 min", "blood pressure", "83 mm Hg", "Cardiopulmonary", "abnormalities", "several scaly plaques", "patient's upper", "lower extremities", "right knee", "not tender", "erythematous", "range of motion", "limited", "Crepitus", "heard", "flexion", "extension", "knee", "hemoglobin concentration", "12.6 g/dL", "leukocyte count", "mm3", "erythrocyte sedimentation rate", "mm/h", "x-ray of", "right knee", "following", "most appropriate next step", "patient"]}
{"question": "A 12-year-old female with no past medical history is found to have an abnormal cardiovascular exam during routine physical examination at her pediatrician’s office. All other components of her physical exam are normal. During evaluation for potential causes for her abnormal exam, an echocardiogram with doppler is done that shows flow between the atria. Which of the following would would have most likely been auscultated as a result of the pathology on her echocardiogram?", "answer": "Splitting of S2 in inspiration and expiration", "options": {"A": "Increased splitting of S1 with inspiration", "B": "Decreased splitting of S1 with inspiration", "C": "Normal splitting of S2", "D": "Increased splitting of S2 with inspiration", "E": "Splitting of S2 in inspiration and expiration"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old female", "past medical history", "found to", "abnormal", "exam", "routine physical", "pediatricians office", "components", "normal", "potential causes", "abnormal exam", "echocardiogram", "doppler", "atria", "following", "most likely", "result", "pathology", "echocardiogram"]}
{"question": "As part of a clinical research study, microscopic analysis of tissues obtained from surgical specimens is performed. Some of these tissues have microscopic findings of an increase in the size of numerous cells within the tissue with an increase in the amount of cytoplasm, but the nuclei are uniform in size. Which of the following processes shows such microscopic findings?", "answer": "Uterine myometrium in pregnancy", "options": {"A": "Uterine myometrium in pregnancy", "B": "Liver following partial resection", "C": "Ovaries following menopause", "D": "Cervix with chronic inflammation", "E": "Female breasts at puberty"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["part of", "clinical", "study", "microscopic analysis", "tissues obtained", "performed", "tissues", "increase", "size", "numerous cells", "tissue", "increase", "amount", "cytoplasm", "nuclei", "uniform", "size", "following processes"]}
{"question": "A 42-year-old man comes to the physician because of a 3-year history of urinating up to 20 times each day. He has not had any dysuria and nocturia. He has been evaluated by several urologists but has not received a specific diagnosis despite extensive diagnostic testing. Various pharmacologic treatments have not improved his symptoms. He quit his job 1 year ago and stopped attending social events because his frequent urination has been disruptive. He spends most of his time at the library trying to learn what could be causing his symptoms. He would like to undergo a CT scan of his entire body to evaluate for cancer. Physical examination and laboratory studies show no abnormalities. Mental status examination shows a depressed mood and constricted affect. There is no evidence of suicidal ideation. Which of the following is the most likely explanation for this patient's symptoms?", "answer": "Somatic symptom disorder", "options": {"A": "Malingering", "B": "Atypical depression", "C": "Somatic symptom disorder", "D": "Adjustment disorder", "E": "Recurrent urinary tract infections"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "3 year history", "20 times", "day", "not", "dysuria", "nocturia", "urologists", "not received", "specific diagnosis", "extensive", "testing", "Various pharmacologic treatments", "not improved", "symptoms", "job 1 year", "stopped attending", "frequent urination", "disruptive", "spends most of", "time", "library", "to", "causing", "symptoms", "to", "CT scan", "entire body to", "cancer", "laboratory studies", "abnormalities", "Mental status", "depressed mood", "constricted", "suicidal ideation", "following", "explanation", "patient's"]}
{"question": "A 62-year-old woman is brought to the emergency department of a busy suburban hospital because of a 1-week history of nausea and vomiting. She also has had intermittent fevers and headaches during the past 5 weeks. She does not have a stiff neck or sensitivity to light. She appears tired. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 15/min, and blood pressure is 135/85 mm Hg. She is alert and oriented to person, place, and time. Examination shows no abnormalities. A lumbar puncture is performed, and cerebrospinal fluid (CSF) is collected for analysis. On the way to the laboratory, the physician loses the CSF specimens. The physician decides that a repeat lumbar puncture should be performed. Before giving consent for the second procedure, the patient asks what the results are from the specimens obtained earlier. Which of the following responses by the physician is the most appropriate?", "answer": "\"\"\"I was unable to obtain results from the earlier tests because I misplaced the specimens. I sincerely apologize for the mistake.\"\"\"", "options": {"A": "\"\"\"I sincerely apologize; I misplaced the specimens. Thankfully, this is not a big issue because I can easily obtain more fluid.\"\"\"", "B": "\"\"\"I was unable to obtain results from the earlier tests because I misplaced the specimens. I sincerely apologize for the mistake.\"\"\"", "C": "\"\"\"I was not able to get the answers we needed from the first set of tests, so we need to repeat them.\"\"\"", "D": "\"\"\"Unfortunately, I was not able to get enough fluid in the specimens to perform the tests.\"\"\"", "E": "\"\"\"I sincerely apologize; the lab seems to have lost the specimens I obtained earlier.\"\"\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["62 year old woman", "brought", "emergency department", "suburban hospital", "1-week history", "nausea", "vomiting", "intermittent fevers", "headaches", "past", "weeks", "not", "stiff neck", "sensitivity to light", "appears tired", "temperature", "98", "pulse", "70 min", "respirations", "min", "blood pressure", "85 mm Hg", "alert", "oriented to person", "place", "time", "abnormalities", "lumbar puncture", "performed", "cerebrospinal fluid", "collected", "analysis", "laboratory", "physician", "CSF specimens", "physician", "repeat lumbar puncture", "performed", "Before giving consent", "second procedure", "patient", "results", "obtained earlier", "following responses", "physician", "most appropriate"]}
{"question": "A 74-year-old woman with a past medical history of hypertension, peripheral artery disease, and migraine headaches presents to the emergency department with a two hour history of severe abdominal pain. The patient cannot recall any similar episodes, although she notes occasional abdominal discomfort after eating. She describes the pain as sharp periumbilcal pain. She denies recent illness, fever, chills, nausea, vomiting, or diarrhea. Her last normal bowel movement was yesterday evening. Her temperature is 37.1°C (98.8°F), pulse is 110/min, blood pressure is 140/80 mmHg, and respirations are 20/min. On exam, the patient is grimacing and appears to be in significant discomfort. Heart and lung exams are within normal limits. The patient’s abdomen is soft and non-distended with diffuse periumbilical pain on palpation. There is no rebound tenderness or guarding, and bowel sounds are present. The rest of the exam is unremarkable. Labs in the emergency room show:\n\nSerum:\nNa+: 144 mEq/L\nCl-: 105 mEq/L\nK+: 3.7 mEq/L\nHCO3-: 20 mEq/L\nBUN: 15 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.2 mg/dL\nCa2+: 10.7 mg/dL\nPhosphorus: 5.2 mg/dL\nLactate: 7.0 mmol/L\nAmylase: 240 U/L\n\nHemoglobin: 13.4 g/dL\nHematocrit: 35%\nLeukocyte count: 12,100 cells/mm^3 with normal differential\nPlatelet count: 405,000/mm^3\n\nWhat is the next best step in diagnosis?", "answer": "CT angiography", "options": {"A": "D-dimer level", "B": "Plain abdominal radiograph", "C": "Exploratory laparotomy", "D": "CT angiography", "E": "Abdominal duplex ultrasound"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["74 year old woman", "past medical", "peripheral artery disease", "migraine headaches presents", "emergency department", "two hour history", "severe abdominal", "patient", "similar episodes", "notes occasional abdominal discomfort", "eating", "pain", "sharp", "recent illness", "fever", "chills", "nausea", "vomiting", "diarrhea", "last normal bowel movement", "evening", "temperature", "98", "pulse", "min", "blood pressure", "80 mmHg", "respirations", "20 min", "exam", "patient", "grimacing", "appears to", "significant discomfort", "Heart", "lung exams", "normal limits", "patients abdomen", "soft", "non distended", "diffuse periumbilical", "palpation", "rebound tenderness", "guarding", "bowel sounds", "present", "exam", "unremarkable", "Labs", "emergency room", "Serum", "Na", "mEq/L", "mEq/L K", "3", "mEq/L HCO3", "20 mEq/L", "mg/dL Glucose", "99 mg/dL Creatinine", "1.2 mg/dL Ca2", "10", "mg/dL Phosphorus", "5.2 mg/dL Lactate", "0 mmol/L Amylase", "U/L", "Hemoglobin", "13.4 g/dL Hematocrit", "35", "Leukocyte count", "mm", "normal differential Platelet count", "405", "mm", "next best step", "diagnosis"]}
{"question": "A 39-year-old man presents to his primary care physician with a 10-hour history of severe diarrhea. He says that he was recently at a company picnic and after returning home he began to experience severe watery diarrhea. He says that the diarrhea was accompanied by nausea and abdominal pain. His physician informs him that he was likely infected by a lactose-fermenting, gram-negative organism. Which of the following changes would be seen in a cell that was affected by the heat stable toxin produced by this organism?", "answer": "Increased cyclic guanosine monophosphate", "options": {"A": "Decreased cyclic adenosine monophosphate", "B": "Decreased cyclic guanosine monophosphate", "C": "Increased calcium", "D": "Increased cyclic adenosine monophosphate", "E": "Increased cyclic guanosine monophosphate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man presents", "primary care physician", "a 10 hour history", "severe diarrhea", "recently", "company", "returning home", "began to", "severe watery", "diarrhea", "nausea", "abdominal pain", "physician informs", "likely infected", "lactose", "gram negative", "following changes", "seen", "cell", "affected", "stable toxin"]}
{"question": "An investigator is studying the structure of the amino-terminal of the Huntingtin protein using x-ray crystallography. The terminal region is determined to have an α-helix conformation. Which of the following forces is most likely responsible for maintaining this conformation?", "answer": "Hydrogen bonds", "options": {"A": "Hydrophobic interactions", "B": "Disulfide bonds", "C": "Peptide bonds", "D": "Electrostatic side chain attraction", "E": "Hydrogen bonds"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["investigator", "studying", "structure", "terminal", "Huntingtin using x-ray crystallography", "terminal region", "to", "helix conformation", "following", "responsible", "conformation"]}
{"question": "A 65-year-old man with a past medical history of anterior myocardial infarction, peripheral arterial disease, and known patent foramen ovale presents to the emergency department after being found down from a fall on the sidewalk in the middle of winter. He states that his right leg feels numb and painful at the same time. He insists that he did not slip on ice or snow, yet fell suddenly. He is taking aspirin, simvastatin, and cilastazol. Vital signs show T 98.0 F, BP 100/60, HR 100, RR 18. His pulse is irregularly irregular. His right leg appears pale with no dorsalis pedis and posterior tibial pulses compared to 2+ pulses on the left. He cannot discern soft or sharp touch in his right leg. Which intervention will most likely improve the viability of this patient's right leg?", "answer": "Catheter-based thrombectomy / thrombolysis", "options": {"A": "Percutaneous transluminal stent implantation", "B": "Rivaroxaban", "C": "Warfarin", "D": "Catheter-based thrombectomy / thrombolysis", "E": "Heparin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65-year-old man", "past", "history of", "myocardial infarction", "peripheral arterial disease", "known patent foramen ovale presents", "emergency department", "found", "fall", "sidewalk", "middle", "winter", "states", "right leg", "numb", "painful", "same time", "not", "ice", "fell", "aspirin", "simvastatin", "Vital signs", "T 98 0 F", "BP 100 60", "100", "RR", "pulse", "irregular", "right leg appears pale", "posterior tibial pulses", "pulses", "left", "soft", "sharp touch", "right leg", "intervention", "most likely", "viability", "patient's right leg"]}
{"question": "A 3-year-old boy is brought to the physician by his parents for the evaluation of easy bruising for several months. Minor trauma also causes scratches that bleed. Two months ago, a fall from his bed caused a large forehead hematoma and a left elbow laceration. He sometimes does not eat because of pain while chewing. Vital signs are within normal limits. Examination shows that the skin can be stretched further than normal and is fragile. Range of motion of the joints is slightly increased. There is tenderness to palpation of the temporomandibular joints bilaterally. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Defective type V collagen", "options": {"A": "Impaired copper absorption", "B": "Factor VIII deficiency", "C": "Defective type III collagen", "D": "Defective type V collagen", "E": "Defective type I collagen\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 year old boy", "brought", "physician", "easy bruising", "several months", "Minor trauma", "causes scratches", "bleed", "Two months", "fall from", "bed caused", "large forehead hematoma", "left elbow laceration", "sometimes", "not eat", "pain", "chewing", "Vital signs", "normal limits", "skin", "stretched further", "normal", "fragile", "Range of motion", "joints", "slightly increased", "tenderness", "palpation of", "temporomandibular joints", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 64-year-old male presents to the emergency room with difficulty breathing. He recently returned to the USA following a trip to Singapore. He reports that he developed pleuritic chest pain, shortness of breath, and a cough. His temperature is 99°F (37.2°C), blood pressure is 140/85 mmHg, pulse is 110/min, and respirations are 24/min. A spiral CT reveals a pulmonary embolus in the right segmental pulmonary artery. Results from a complete blood count are all within normal limits. He is admitted and started on unfractionated heparin. Four days later, the patient develops unprovoked epistaxis. A complete blood count reveals the following:\n\nLeukocyte count: 7,000/mm^3\nHemoglobin: 14 g/dl\nHematocrit: 44%\nPlatelet count 40,000/mm^3\n\nWhat is the underlying pathogenesis of this patient’s condition?", "answer": "Autoantibodies directed against platelet factor 4", "options": {"A": "Loss of vitamin K-dependent clotting factors", "B": "Autoantibodies directed against platelet factor 4", "C": "Medication-mediated platelet aggregation", "D": "Autoantibodies directed against GPIIb/IIIa", "E": "ADAMTS13 deficiency"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["64 year old male presents", "emergency room", "difficulty breathing", "recently returned", "USA following", "trip", "Singapore", "reports", "pleuritic chest pain", "shortness of breath", "cough", "temperature", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "spiral CT reveals", "pulmonary", "right segmental", "artery", "Results", "complete blood count", "normal limits", "started", "unfractionated heparin", "Four days later", "patient", "epistaxis", "complete blood count reveals", "following", "Leukocyte count", "7", "mm", "Hemoglobin", "g/dl Hematocrit", "Platelet count 40", "mm", "underlying pathogenesis", "patients condition"]}
{"question": "An autopsy is performed on a 39-year-old man 5 days after he was found pulseless at his apartment by his neighbor. Examination of the brain shows liquefactive necrosis in the distribution of the right middle cerebral artery with surrounding edema. Immunophenotyping of a sample of the affected brain tissue shows numerous cells that express CD40 on their surface. On further histopathological evaluation, the morphology of these cells is not readily discernible with Nissl stain. These histological findings are most consistent with which of the following cell types?", "answer": "Microglia", "options": {"A": "Radial glial cells", "B": "Microglia", "C": "Astrocytes", "D": "Oligodendrocytes", "E": "Neurons"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["autopsy", "performed", "year old man 5 days", "found pulseless", "apartment", "Examination", "brain", "liquefactive necrosis", "distribution", "right middle cerebral artery", "surrounding edema", "Immunophenotyping", "sample", "affected brain", "numerous cells", "surface", "further histopathological", "morphology", "cells", "not", "discernible", "histological findings", "most", "following"]}
{"question": "A recent study shows that almost 40% of the antibiotics prescribed by primary care physicians in the ambulatory setting are for patients with a clinical presentation consistent with a viral acute respiratory tract infection. Recent evidence suggests that the implementation of a set of interventions may reduce such inappropriate prescribing. Which of the following strategies, amongst others, is most likely to achieve this goal?", "answer": "Local peer comparison", "options": {"A": "C-reactive protein (CRP) testing", "B": "Delayed antibiotic use", "C": "Local peer comparison", "D": "Procalcitonin testing", "E": "Testing for non-antibiotic-appropriate diagnoses"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["recent study", "almost 40", "primary care physicians", "ambulatory setting", "patients", "viral acute", "Recent", "set", "interventions", "following", "others", "to"]}
{"question": "A 14-year-old boy is brought to the physician for generalized fatigue and mild shortness of breath on exertion for 3 months. He has a history of recurrent patellar dislocations. He is at the 99th percentile for height and at the 30th percentile for weight. His temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 140/50 mm Hg. Examination shows scoliosis, a protruding breast bone, thin extremities, and flat feet. Ocular examination shows upwards displacement of bilateral lenses. A grade 3/6 early diastolic murmur is heard along the left sternal border. Further evaluation of this patient is most likely to show which of the following?", "answer": "Water hammer pulse", "options": {"A": "Paradoxical splitting of S2", "B": "Pulsus paradoxus", "C": "Fixed splitting of S2", "D": "Water hammer pulse", "E": "Radio-femoral pulse delay"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "generalized fatigue", "mild shortness of breath", "exertion", "months", "history of recurrent patellar dislocations", "99th percentile", "height", "percentile", "weight", "temperature", "98", "pulse", "99 min", "blood pressure", "50 mm Hg", "scoliosis", "protruding breast bone", "thin extremities", "flat", "Ocular examination", "displacement of bilateral lenses", "grade", "early diastolic murmur", "heard", "left sternal border", "Further", "to", "following"]}
{"question": "A 17-year old girl is brought to the physician by her mother because menarche has not yet occurred. She is at the 3rd percentile for height. Examination of a buccal mucosal scraping shows several cells with a single dark body attached to the nuclear membrane. Karyotyping of a neutrophil shows 45 chromosomes. Which of the following is the most likely underlying cause of this patient's cytogenetic abnormality?", "answer": "Postzygotic mitotic error", "options": {"A": "Uniparental isodisomy", "B": "Postzygotic mitotic error", "C": "Robertsonian translocation", "D": "Nondisjunction during meiosis I", "E": "Reciprocal translocation\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "menarche", "not", "3rd percentile", "height", "scraping", "several cells", "single dark body", "nuclear", "Karyotyping", "neutrophil", "chromosomes", "following", "underlying cause", "patient's cytogenetic abnormality"]}
{"question": "A 3-month-old boy is brought to the emergency department by his mother after a seizure at home. The mother is not sure how long the seizure lasted, but says that the boy was unresponsive and had episodes of stiffness and jerking of his extremities throughout the episode. The mother states that the boy has not seemed himself for the past several weeks and has been fussy with feeds. He does not sleep through the night. He has not had any recent infections or sick contacts.\n\nOn exam, the boy is lethargic. His temperature is 99.5°F (37.5°C), blood pressure is 70/40 mmHg, and pulse is 120/min. He has no murmurs and his lungs are clear to auscultation bilaterally. His abdomen appears protuberant, and his liver span is measured at 4.5 cm below the costal margin. Additionally, the boy has abnormally enlarged cheeks. A finger stick in the ED reveals a blood glucose level of 35 mg/dL. What would this patient’s response to a fasting-state glucagon stimulation test most likely be, and what enzyme defect does he have?", "answer": "No change in plasma glucose; glucose-6-phosphatase", "options": {"A": "Rise in plasma glucose; glycogen debranching enzyme", "B": "Rise in plasma glucose; glucose-6-phosphatase", "C": "Rise in plasma glucose; alpha-1,4-glucosidase", "D": "No change in plasma glucose; glycogen debranching enzyme", "E": "No change in plasma glucose; glucose-6-phosphatase"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["3 month old boy", "brought", "emergency department", "seizure at home", "not sure", "long", "seizure lasted", "boy", "unresponsive", "episodes of stiffness", "jerking", "extremities", "episode", "states", "boy", "not", "past", "weeks", "fussy", "feeds", "not sleep", "night", "not", "recent infections", "sick", "exam", "boy", "lethargic", "temperature", "99", "blood pressure", "70 40 mmHg", "pulse", "min", "murmurs", "lungs", "clear", "auscultation", "abdomen appears protuberant", "liver span", "measured", "costal margin", "boy", "enlarged cheeks", "finger stick", "reveals", "blood glucose level", "35 mg/dL", "patients response to", "fasting-state glucagon stimulation test", "likely", "enzyme defect"]}
{"question": "A 4-year-old boy is brought to the emergency department for evaluation of a fever for 1 day. The mother reports that he has had severe pain in his lower extremities and difficulty eating since yesterday. He has not had a cough, nausea, or vomiting. He was born at term and has been healthy. His immunizations are up-to-date. He appears irritable. His temperature is 38.5°C (101.3°F). Examination shows several flesh-colored, tender papules over the trunk, knees, palms, and soles. There are multiple 2-mm, reddish macules on the hard palate. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal organism of this patient's symptoms?", "answer": "Coxsackie A virus", "options": {"A": "Human herpesvirus 6", "B": "Rubella virus", "C": "Herpes simplex virus 1", "D": "Coxsackie A virus", "E": "Measles virus"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "brought", "emergency department", "fever", "1 day", "reports", "severe pain in", "lower extremities", "difficulty eating", "not", "cough", "nausea", "vomiting", "born", "term", "healthy", "immunizations", "date", "appears irritable", "temperature", "several flesh-colored", "tender papules", "trunk", "knees", "soles", "multiple", "mm", "macules", "hard palate", "abnormalities", "following", "causal", "patient's symptoms"]}
{"question": "After the administration of an erroneous dose of intravenous phenytoin for recurrent seizures, a 9-year-old girl is resuscitated because of bradycardia and asystole. Later, the patient is taken to the critical care unit and placed on mechanical ventilation. Neurologic consultation shows hypoxic brain injury. To reduce the incidence of similar events, which of the following is the most appropriate next step in management?", "answer": "Root cause analysis", "options": {"A": "Closed-loop communication", "B": "Computerized physician order entry", "C": "Root cause analysis", "D": "Structured handovers", "E": "Two patient identifiers"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["administration", "dose", "intravenous phenytoin", "recurrent seizures", "year old girl", "resuscitated", "bradycardia", "asystole", "Later", "patient", "critical care unit", "mechanical ventilation", "Neurologic", "hypoxic brain injury", "To", "incidence", "similar", "following", "most appropriate next step"]}
{"question": "A 70-year-old chronic smoker presents to the emergency department with a sudden onset of left-sided weakness. The past medical history is insignificant except for hypertension, for which he has been taking medications regularly. The vital signs include: blood pressure 165/110 mm Hg, pulse rate 78/min, respiratory rate 18/min, and temperature 36.1°C (97°F). The neurologic examination shows ⅗ muscle strength in the left upper and lower limbs. An occlusion of a branch of the right middle cerebral artery is suspected because the CT fails to show signs of hemorrhage. The HbA1C is 11%. Which of the following blood lipid components is the most important contributing factor leading to his condition?", "answer": "Oxidized low-density lipoprotein (ox-LDL)", "options": {"A": "Very low-density lipoprotein (VLDL)", "B": "Chylomicron", "C": "Oxidized low-density lipoprotein (ox-LDL)", "D": "Lipoprotein lipase (LPL)", "E": "High-density lipoprotein (HDL)-cholesterol"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old chronic smoker presents", "emergency department", "sudden onset", "left-sided weakness", "past medical history", "hypertension", "vital signs include", "blood pressure", "mm Hg", "pulse rate", "min", "respiratory rate", "min", "temperature 36", "neurologic examination", "muscle strength", "left upper", "lower limbs", "occlusion of", "branch", "right middle cerebral artery", "suspected", "CT fails to", "signs", "hemorrhage", "following blood components", "most important", "factor leading", "condition"]}
{"question": "An 80-year-old man comes to the office for evaluation of anemia. His medical history is relevant for end-stage renal disease and aortic stenosis. When questioned about his bowel movements, the patient mentions that he has occasional episodes of loose, black, tarry stools. His heart rate is 78/min, respiratory rate is 17/min, temperature is 36.6°C (97.8°F), and blood pressure is 80/60 mm Hg. Physical examination shows pale skin and conjunctiva and orthostasis upon standing. A complete blood count shows his hemoglobin is 8.7 g/dL, hematocrit is 27%, and mean corpuscular volume is 76 μm3. A colonoscopy is obtained. Which of the following is the most likely cause of this patient’s current condition?", "answer": "Angiodysplasia", "options": {"A": "Angiodysplasia", "B": "Colorectal cancer", "C": "Ischemic colitis", "D": "Portal hypertension", "E": "Colonic polyps"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["80 year old man", "office", "anemia", "medical history", "relevant", "end-stage renal disease", "aortic stenosis", "bowel movements", "patient", "occasional episodes of loose", "black", "tarry stools", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "blood pressure", "80 60 mm Hg", "pale skin", "conjunctiva", "orthostasis", "standing", "complete blood count", "hemoglobin", "g/dL", "hematocrit", "mean corpuscular volume", "76 m3", "colonoscopy", "obtained", "following", "most likely cause", "patients current condition"]}
{"question": "A 69-year-old man with history of coronary artery disease necessitating angioplasty and stent placement presents to the ED due to fever, chills, and productive cough for one day. He is started on levofloxacin and admitted because of his comorbidity and observed tachypnea of 35 breaths per minute. He is continued on his home medications including aspirin, clopidogrel, metoprolol, and lisinopril. He cannot ambulate as frequently as he would like due to his immediate dependence on oxygen. What intervention should be provided for deep venous thrombosis prophylaxis in this patient while hospitalized?", "answer": "Low molecular weight heparin", "options": {"A": "Aspirin is sufficient; hold clopidogrel", "B": "Clopidogrel is sufficient; hold aspirin", "C": "Aspirin and clopidogrel are sufficient", "D": "Warfarin", "E": "Low molecular weight heparin"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["69 year", "man", "history of coronary artery disease", "stent placement presents", "fever", "chills", "productive cough", "one day", "started", "levofloxacin", "comorbidity", "observed tachypnea", "35 breaths", "minute", "home medications including aspirin", "clopidogrel", "metoprolol", "lisinopril", "ambulate", "frequently", "due to", "immediate dependence", "oxygen", "intervention", "deep", "patient", "hospitalized"]}
{"question": "A 68-year-old woman presents to the physician with complaints of unexplained weight loss of approximately 5 kg (11.02 lb) over the last 6 months. Her other complaints include repeated stomatitis and diarrhea for 1 year. She was diagnosed with diabetes mellitus 1 year ago. Her temperature is 36.9°C (98.4°F), heart rate is 84/min, respiratory rate is 16/min, and blood pressure is 126/82 mm Hg. Physical examination reveals multiple, confluent, erythematous papules, plaques and bullous lesions over the extremities, the perioral region, and the perigenital region. An oral examination shows angular cheilitis, glossitis, and stomatitis. Which test is most likely to yield an accurate diagnosis for this patient?", "answer": "Serum glucagon", "options": {"A": "Serum gastrin", "B": "Serum glucagon", "C": "Serum insulin", "D": "Serum prolactin", "E": "Serum vasoactive intestinal polypeptide"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "complaints of unexplained weight loss", "approximately", "kg", "last", "months", "complaints include repeated stomatitis", "diarrhea", "year", "diagnosed", "diabetes mellitus", "year", "temperature", "36", "98", "heart rate", "84 min", "respiratory rate", "min", "blood pressure", "mm Hg", "reveals multiple", "confluent", "erythematous papules", "plaques", "bullous lesions", "extremities", "perioral region", "region", "angular cheilitis", "glossitis", "stomatitis", "test", "to", "accurate diagnosis", "patient"]}
{"question": "A 55-year-old man comes to the physician because of increasing swelling of the legs and face over the past 2 months. During this time, he has experienced fatigue and weight loss. He has no history of any serious illness and takes no medications. Vital signs are within normal range. On physical examination, both lower limbs show significant pitting edema extending above the knees. A photograph of the patient’s facial features is shown. His urinary protein is 3 g/24 h. Serum and urine electrophoresis shows monoclonal light chains. Skeletal survey shows no osteolytic lesions. Without treatment, which of the following is the most likely clinical course for this patient?", "answer": "Death within 1–2 years", "options": {"A": "Death within 1–2 years", "B": "Hyperviscosity syndrome", "C": "Long-term survival without serious complications", "D": "Richter’s transformation", "E": "Transformation into multiple myeloma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "of increasing swelling", "legs", "face", "past 2 months", "time", "fatigue", "weight loss", "history", "serious illness", "medications", "Vital signs", "normal range", "lower limbs", "significant pitting extending", "knees", "photograph of", "patients facial features", "urinary protein", "3 g/24 h", "Serum", "urine electrophoresis", "monoclonal light chains", "Skeletal survey", "osteolytic lesions", "treatment", "following", "clinical course", "patient"]}
{"question": "A six-month-old infant presents with chronic, persistent diarrhea, oral thrush, and a severe diaper rash. The infant was treated four weeks ago for an upper respiratory and ear infection. A family history is significant for a consanguineous relationship between the mother and father. Physical examination demonstrates the absence of palpable lymph nodes. Accumulation of which of the following would lead to this disease phenotype?", "answer": "Deoxyadenosine", "options": {"A": "Deoxyadenosine", "B": "Phenylalanine", "C": "Galactitol", "D": "Ceramide trihexoside", "E": "Sphingomyelin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["six-month old infant presents", "chronic", "persistent", "oral thrush", "severe diaper rash", "infant", "treated four weeks", "upper respiratory", "ear infection", "family history", "significant", "consanguineous relationship", "absence", "palpable lymph nodes", "Accumulation", "following", "lead", "disease phenotype"]}
{"question": "A 19-year-old Caucasian college student is home for the summer. Her parents note that she has lost quite a bit of weight. The daughter explains that the weight loss was unintentional. She also notes an increase in thirst, hunger, and urine output. Her parents decide to take her to their family physician, who suspects finding which of the following?", "answer": "Elevated ketone levels", "options": {"A": "Evidence of amyloid deposition in pancreatic islets", "B": "High T4 and T3 levels", "C": "Elevated ketone levels", "D": "Hypoglycemia", "E": "Hyperinsulinemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old", "home", "summer", "note", "lost", "bit", "weight", "weight loss", "unintentional", "notes", "increase", "thirst", "hunger", "urine output", "to", "family physician", "finding", "following"]}
{"question": "An 84-year-old woman with Alzheimer's disease is brought to the physician by her son for a follow-up examination. The patient lives with her son, who is her primary caregiver. He reports that it is becoming gradually more difficult to care for her. She occasionally has tantrums and there are times when she does not recognize him. She sleeps 6–8 hours throughout the day and is increasingly agitated and confused at night. When the phone, television, or oven beeps she thinks she is at the dentist's office and becomes very anxious. She eats 2–3 meals a day and has a good appetite. She has not fallen. She has not left the home in weeks except for short walks. She has a history of hypertension, hyperlipidemia, atrial fibrillation, and hypothyroidism. She takes levothyroxine, aspirin, warfarin, donepezil, verapamil, lisinopril, atorvastatin, and a multivitamin daily. Her temperature is 37°C (98.4°F), pulse is 66/min, respirations are 13/min, and blood pressure is 126/82 mm Hg. Physical examination shows no abnormalities. It is important to the family that the patient continues her care in the home. Which of the following recommendations is most appropriate at this time?", "answer": "Adhere to a regular sleep schedule", "options": {"A": "Start quetiapine daily", "B": "Start lorazepam as needed", "C": "Adhere to a regular sleep schedule", "D": "Frequently play classical music", "E": "Schedule frequent travel\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["84 year old woman", "Alzheimer's disease", "brought", "physician", "follow-up examination", "patient lives with", "son", "reports", "difficult to", "occasionally", "tantrums", "times", "not", "sleeps", "hours", "day", "agitated", "confused", "night", "phone", "television", "oven", "dentist's office", "very anxious", "eats 23 meals", "day", "good appetite", "not fallen", "not left", "home", "weeks", "short walks", "history of hypertension", "hyperlipidemia", "atrial fibrillation", "hypothyroidism", "levothyroxine", "aspirin", "warfarin", "donepezil", "verapamil", "lisinopril", "atorvastatin", "multivitamin daily", "temperature", "98", "pulse", "66 min", "respirations", "min", "blood pressure", "mm Hg", "abnormalities", "important", "patient", "following", "most appropriate", "time"]}
{"question": "A 24-year-old man is hospitalized for an elective gastrointestinal surgery 24 hours before the scheduled day of surgery. The surgeon has ordered food and fluids to be withheld from the patient from 12 hours before the surgery and the administration of intravenous isotonic saline. Based on his body weight, his fluid requirement for 12 hours is 900 mL. However, the following day, the surgeon finds that 3 pints of isotonic fluid (1 pint = 500 mL) were administered over the preceding last 12 hours. Which of the following options best describes the resulting changes in the volume of intracellular fluid (ICF) and the body osmolality of the patient?", "answer": "No change in ICF volume, no change in body osmolality", "options": {"A": "Increased ICF volume, no change in body osmolality", "B": "Increased ICF volume, decreased body osmolality", "C": "Decreased ICF volume, no change in body osmolality", "D": "Decreased ICF volume, increased body osmolality", "E": "No change in ICF volume, no change in body osmolality"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old man", "hospitalized", "elective gastrointestinal 24 hours", "scheduled day", "surgery", "surgeon", "ordered food", "fluids to", "patient", "12 hours", "surgery", "administration", "intravenous isotonic saline", "Based", "body weight", "fluid requirement", "12 hours", "900 mL", "following day", "surgeon finds", "3 pints", "fluid", "1 pint", "500 mL", "administered", "preceding last 12 hours", "following options best", "resulting changes in", "volume of intracellular fluid", "body osmolality", "patient"]}
{"question": "A 50-year-old man presents to the emergency department with a complaint of crushing chest pain. The pain started suddenly 30 minutes ago while he was walking his dog. The patient also complains of difficulty breathing and palpitations. The pain is described as starting behind the sternum and moving towards the left jaw. Medical history includes recently diagnosed hypercholesterolemia and peptic ulcer disease. He currently takes atorvastatin and omeprazole. The patient has smoked a pack of cigarettes per day for 10 years and consumes 2–3 beers on the weekends. His blood pressure is 148/90 mm Hg, the pulse is 106/min, and the respiratory rate is 22/min. Examination shows him to be visibly distressed, diaphoretic, and slightly hunched over. Aspirin is administered and blood work is sent to the laboratory. His ECG is shown in the picture. What is the best next step for this patient?", "answer": "Urgent percutaneous coronary intervention", "options": {"A": "Start heparin infusion and ICU admission", "B": "Perform an urgent bedside echocardiography", "C": "Urgent percutaneous coronary intervention", "D": "Monitor closely and wait for cardiac troponin levels", "E": "Order an urgent chest CT scan and provide analgesia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["50 year old man presents", "emergency department", "complaint of crushing chest pain", "pain started", "30 minutes", "patient", "difficulty breathing", "palpitations", "pain", "starting", "sternum", "moving", "left jaw", "Medical history includes recently diagnosed hypercholesterolemia", "peptic ulcer disease", "currently", "atorvastatin", "omeprazole", "patient", "smoked", "pack", "cigarettes", "day", "23", "weekends", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "min", "to", "diaphoretic", "slightly", "over", "Aspirin", "administered", "blood", "sent", "laboratory", "ECG", "picture", "best next step", "patient"]}
{"question": "A 25-year-old man is brought to the emergency department by his wife for evaluation of abnormal behavior that began 2 weeks ago. The patient has not slept in over a week and has been partying each night. He has never done this before. The patient has also been skipping work and purchased a car last week with money they had saved for their vacation to Italy. He has a past medical history of major depressive disorder and systemic lupus erythematosus. He normally drinks 2 beers per week but has been drinking 6–10 beers per day for the past two weeks. Current medications include hydroxychloroquine. He appears agitated and is wearing bright-colored mismatched clothing. His temperature is 36°C (96.8°F), pulse is 94/min, respirations are 18/min, and blood pressure is 130/85 mm Hg. Physical examination shows no abnormalities. On mental status examination, his speech is pressured and his thought process is tangential. A complete blood count, serum electrolytes, and liver enzyme activities are within the reference range; his serum creatinine is 1.8 mg/dL. Urinalysis shows 2+ proteinuria, and WBC casts. Toxicology screening is negative. This patient would most likely benefit from which of the following long-term treatments?", "answer": "Valproate", "options": {"A": "Dialectical behavioral therapy", "B": "Valproate", "C": "Clonazepam", "D": "Lithium", "E": "Escitalopram\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "abnormal", "began 2 weeks", "patient", "not slept", "week", "night", "never", "before", "patient", "skipping", "car", "week", "money", "Italy", "past medical major", "systemic lupus erythematosus", "2", "week", "drinking", "day", "past two weeks", "Current medications include hydroxychloroquine", "appears agitated", "bright colored mismatched clothing", "temperature", "96", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "abnormalities", "mental status", "speech", "pressured", "tangential", "complete blood count", "serum electrolytes", "liver enzyme", "reference range", "serum creatinine", "1.8 mg/dL", "Urinalysis", "2", "proteinuria", "WBC casts", "Toxicology screening", "negative", "patient", "most likely benefit", "following"]}
{"question": "A 30-year-old caucasian female comes to the physician because of chronic diarrhea and abdominal bloating that started 6 months ago. She also reports increasing fatigue and intermittent tingling in her hands and feet. She lost 5 kg (11 lb) of weight over the past 6 months without changing her diet or trying to lose weight. She and her husband have been trying to conceive for over a year without any success. Menses have been irregular at 28–45 day intervals and last for 1–2 days. She has generalized anxiety disorder for which she takes sertraline. Her height is 151 cm and weight is 50 kg; BMI is 22 kg/m2. Examination shows generalized pallor. Cardiopulmonary examination is normal. Test of the stool for occult blood is negative. Laboratory studies show:\nHemoglobin 9.5 g/dL\nLeukocyte count 3900/mm3\nPlatelet count 130,000/mm3\nSerum\nGlucose 100 mg/dL\nCreatinine 0.6 mg/dL\nThyroid-stimulating hormone 3.3 μU/mL\nVitamin B12 80 pg/mL (N > 200)\nIgA anti-tissue transglutaminase antibody negative\nSerum IgA decreased\nWhich of the following is the most appropriate next step in diagnosis?\"", "answer": "IgG deamidated gliadin peptide test", "options": {"A": "Plasma zinc concentration", "B": "Fecal fat test", "C": "IgG deamidated gliadin peptide test", "D": "IgA endomysial antibody", "E": "Skin prick test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old", "female", "physician", "chronic diarrhea", "abdominal bloating", "started", "months", "reports increasing fatigue", "intermittent tingling", "hands", "feet", "lost 5 kg", "weight", "past 6 months", "changing", "diet", "to", "weight", "to", "year", "Menses", "irregular", "day intervals", "last", "days", "generalized anxiety disorder", "sertraline", "height", "weight", "50 kg", "BMI", "kg/m2", "generalized pallor", "Cardiopulmonary", "normal", "Test", "stool", "occult blood", "negative", "Laboratory studies", "Hemoglobin 9.5 g dL Leukocyte count", "mm3 Platelet count", "dL", "0", "Thyroid-stimulating hormone 3", "mL", "80 pg mL", "N", "200", "anti tissue transglutaminase antibody negative", "decreased", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 7-year-old boy presents with difficulty swallowing, diarrhea, itching, and weakness. He also complains of episodes of headaches, sweating, and palpitations, which are accompanied by fear and tend to end with micturition. His mother is concerned about the strange nodules on his lips and eyelids. The boy's younger brother had similar nodules and died at 10 years of age of unknown causes. The patient’s vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 107/min, respiratory rate 14/min, and temperature 36.9℃ (98.4℉). The child is tall, thin, has disproportionately long arms and legs, and increased thoracic spine kyphosis. There are multiple yellow-white, sessile, painless nodules on the patient’s lips, and buccal and eyelid mucosa. There is a painless lump in the area of the left thyroid lobe and enlargement of the posterior cervical lymph nodes on the left side. What is the most probable embryonic origin of the cells in the lump?", "answer": "Neural crest cells", "options": {"A": "First pharyngeal groove", "B": "First pharyngeal pouch", "C": "Lateral plate mesoderm", "D": "Neurogenic placodes", "E": "Neural crest cells"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old boy presents", "difficulty swallowing", "diarrhea", "itching", "weakness", "episodes", "headaches", "sweating", "palpitations", "to end", "micturition", "nodules", "lips", "eyelids", "boy's", "similar nodules", "died", "10 years", "age", "unknown", "patients vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "98", "child", "tall", "thin", "long arms", "legs", "increased thoracic spine kyphosis", "multiple yellow white", "sessile", "painless nodules", "patients lips", "buccal", "eyelid mucosa", "painless lump", "area", "left thyroid lobe", "enlargement of", "posterior cervical lymph nodes", "left side", "embryonic origin", "cells", "lump"]}
{"question": "A 42-year-old woman with well-controlled HIV on antiretroviral therapy comes to the physician because of a 2-week history of a painless lesion on her right calf. Many years ago, she had a maculopapular rash over her trunk, palms, and soles that resolved spontaneously. Physical examination shows a 4-cm firm, non-tender, indurated ulcer with a moist, dark base and rolled edges. There is a similar lesion at the anus. Results of rapid plasma reagin testing are positive. Which of the following findings is most likely on microscopic examination of these lesions?", "answer": "Coagulative necrosis surrounded by fibroblast and macrophage infiltrate", "options": {"A": "Epithelioid cell infiltrate surrounding acellular, granular core", "B": "Epidermal hyperplasia with dermal lymphocytic infiltrate", "C": "Lichenoid hyperplasia with superficial neutrophilic infiltrate", "D": "Ulcerated epidermis with plasma cell infiltrate", "E": "Coagulative necrosis surrounded by fibroblast and macrophage infiltrate"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "well-controlled HIV", "antiretroviral therapy", "physician", "2-week history", "painless lesion", "right calf", "years", "maculopapular rash", "trunk", "soles", "resolved", "4", "firm", "non-tender", "indurated ulcer", "moist", "dark base", "rolled edges", "similar lesion", "anus", "Results", "rapid plasma reagin testing", "positive", "following findings", "microscopic examination", "lesions"]}
{"question": "A 58-year-old man presents to his primary care physician with a 3-week history of increasing pain in his legs and feet. Specifically, he says that he has been getting electric shock sensations that started in his feet, but have progressed up his leg. In addition, the pain is accompanied by numbness and tingling in his hands and feet bilaterally. His past medical history is significant for poorly controlled type 2 diabetes mellitus. Given these symptoms, his physician prescribes a new drug to help him cope with these symptoms. Which of the following is the mechanism of action for the medication that was most likely prescribed in this case?", "answer": "Serotonin norepinephrine reuptake inhibitor", "options": {"A": "Binding to mu opioid receptors", "B": "Increased duration of GABA channel opening", "C": "Increased frequency of GABA channel opening", "D": "Selective serotonin reuptake inhibitor", "E": "Serotonin norepinephrine reuptake inhibitor"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["58 year old man presents", "primary care physician", "3 week history", "increasing pain", "legs", "feet", "getting electric shock sensations", "started", "feet", "progressed up", "leg", "addition", "pain", "numbness", "tingling", "hands", "feet", "past medical history", "significant", "poorly controlled type 2 diabetes mellitus", "Given", "symptoms", "physician", "new drug to help", "symptoms", "following", "mechanism of action", "medication", "most likely", "case"]}
{"question": "A 22-year-old soldier sustains a stab wound to his chest during a military attack in Mali. He is brought to the combat medic by his unit for a primary survey. The soldier reports shortness of breath. He is alert and oriented to time, place, and person. His pulse is 99/min, respirations are 32/min, and blood pressure is 112/72 mm Hg. Examination shows a 2-cm wound at the left fourth intercostal space at the midclavicular line. Bubbling of blood is seen with each respiration at the wound site. There is no jugular venous distention. There is hyperresonance to percussion and decreased breath sounds on the left side. The trachea is at the midline. Which of the following is the most appropriate next step in management?", "answer": "Partially occlusive dressing", "options": {"A": "Partially occlusive dressing", "B": "Emergency pericardiocentesis", "C": "Emergency echocardiography", "D": "Needle thoracostomy", "E": "Supplemental oxygen\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old soldier sustains", "stab wound", "chest", "military attack", "Mali", "brought", "unit", "primary survey", "soldier", "shortness of breath", "alert", "oriented to time", "place", "pulse", "99 min", "respirations", "min", "blood pressure", "72 mm Hg", "2 cm wound", "left fourth intercostal space", "midclavicular line", "blood", "seen", "respiration", "wound site", "jugular venous distention", "hyperresonance", "percussion", "decreased breath sounds", "left side", "trachea", "midline", "following", "most appropriate next step"]}
{"question": "A 22-year-old G1P1 woman comes to the clinic asking about “the morning after pill.” She reports that she had sexual intercourse with her boyfriend last night and she thinks the condom broke. She is not using any other form of contraception. She reports her last menstrual period was 10 days ago, and they are normally regular. The patient’s medical history is significant for obesity, asthma and allergic rhinitis. Her medications include albuterol and occasional intranasal corticosteroids. She has no history of sexually transmitted diseases and is sexually active with only her current boyfriend of 5 years. The patient denies genitourinary symptoms. Her temperature is 98°F (36.7°C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 12/min with an oxygen saturation of 99% O2 on room air. Physical examination, including a pelvic exam, shows no abnormalities. The patient is worried because she is back in graduate school and cannot afford another child. Which of the following is the most effective emergency contraception?", "answer": "Copper intrauterine device", "options": {"A": "Copper intrauterine device", "B": "High-dose oral contraceptive therapy", "C": "Levonorgesterel pill", "D": "Levonorgesterel-releasing intrauterine device", "E": "Ulipristal pill"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old G1P1 woman", "clinic", "morning after pill", "reports", "sexual intercourse", "night", "condom", "not using", "form", "contraception", "reports", "last menstrual period", "10 days", "regular", "patients medical history", "significant", "obesity", "asthma", "allergic rhinitis", "medications include albuterol", "occasional intranasal corticosteroids", "history of sexually transmitted diseases", "sexually active", "only", "current", "years", "patient", "genitourinary symptoms", "temperature", "36", "blood pressure", "74 mmHg", "pulse", "63 min", "respirations", "min", "oxygen saturation", "99", "O2", "room air", "including", "pelvic exam", "abnormalities", "patient", "worried", "back", "graduate school", "child", "following", "most effective emergency contraception"]}
{"question": "A 15-year-old adolescent boy presents to his pediatrician for his scheduled follow-up after he was prescribed low-dose methylphenidate for treatment of attention-deficit/hyperactivity disorder 4 weeks ago. On follow-up, his mother reports mild improvement in his symptoms, but she also notes that his appetite has decreased significantly after starting the medication. This has led to a 1.6 kg (3.5 lb) weight loss over the last 4 weeks. His mother also reports that she no longer wants to continue the drug. Which of the following is the next drug of choice for pharmacological management of the condition?", "answer": "Atomoxetine", "options": {"A": "Atomoxetine", "B": "Clonidine", "C": "Dexmethylphenidate", "D": "Dextroamphetamine", "E": "Imipramine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old adolescent boy presents", "pediatrician", "scheduled follow-up", "methylphenidate", "attention-deficit/hyperactivity disorder", "follow-up", "reports mild", "symptoms", "notes", "appetite", "decreased", "starting", "medication", "led", "kg", "3.5", "weight loss", "weeks", "reports", "longer", "to", "drug", "following", "next drug", "pharmacological management", "condition"]}
{"question": "An investigator is studying the metabolism of an experimental drug that is known to have first order kinetics. Immediately after administering an intravenous dose of the drug to a patient, the serum concentration is 60 U/L. 3 hours later, the serum concentration of the drug is 30 U/L. 9 hours after administration, the serum concentration of the drug is most likely to be which of the following?", "answer": "7.5 U/L", "options": {"A": "5 U/L", "B": "3.75 U/L", "C": "7.5 U/L", "D": "15 U/L", "E": "0 U/L"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying", "metabolism", "experimental", "known to", "first order", "Immediately", "administering", "intravenous dose", "drug", "patient", "serum concentration", "60 U/L", "hours later", "serum concentration", "drug", "30 U/L", "hours", "administration", "serum concentration", "drug", "to", "following"]}
{"question": "A 26-year-old gravida-1-para-0 (G-1-P-0) presents for a routine prenatal check-up at 16 weeks gestation. The patient has no concerns but is excited to learn the gender of the baby. Genetic testing was performed that showed an XY genotype; however, an ultrasound does not reveal the development of external male genitalia. Which of the following is responsible for the initial step of the development of male characteristics?", "answer": "SRY gene product", "options": {"A": "Formation of the genital ridge", "B": "Formation of the paramesonephric duct", "C": "Conversion of testosterone to DHT", "D": "SRY gene product", "E": "Production of anti-Mullerian hormone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old gravida-1 para 0", "presents", "routine prenatal check-up", "weeks gestation", "patient", "excited to", "gender", "baby", "Genetic testing", "performed", "XY genotype", "ultrasound", "not reveal", "development", "external genitalia", "following", "responsible", "initial step", "development", "male characteristics"]}
{"question": "An 82-year-old woman presents to the emergency department after a fall. Imaging reveals diffuse trauma to the left humerus from the midshaft to the olecranon process with shearing of the periosteum. The orthopedic surgeon suggests a follow-up in 2 weeks. In that time, the patient develops worsening pain. At follow-up, she is found to have diffuse bone necrosis from the midshaft of the left humerus to the olecranon process. with no involvement of the distal arm structures. Which of the following structures must have been damaged to cause this diffuse bone necrosis?", "answer": "Volkmann’s canal", "options": {"A": "Haversian canal", "B": "Brachial artery", "C": "Volkmann’s canal", "D": "Ulnar nerve", "E": "Epiphyseal plate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "fall", "Imaging reveals diffuse trauma", "left humerus", "olecranon process", "shearing", "periosteum", "orthopedic surgeon", "follow-up", "2 weeks", "time", "patient", "worsening pain", "follow-up", "found to", "diffuse bone necrosis", "of", "left humerus", "olecranon process", "with", "involvement", "distal arm structures", "following structures", "damaged to cause", "diffuse bone"]}
{"question": "A 7-year-old boy with a sore throat, fever, and generalized malaise is admitted to the pediatric floor. On physical examination, he has diffuse white exudate on both tonsils, and also a palpable spleen with mild hepatomegaly. His blood smear shows large and abundant lymphocytes with blue-gray cytoplasm, irregular nuclei, and dark chromatin with inconspicuous nucleoli. Which of the following is the most likely diagnosis?", "answer": "Infectious mononucleosis", "options": {"A": "Infectious mononucleosis", "B": "Cytomegalovirus infection", "C": "Toxoplasmosis", "D": "Graves' disease", "E": "Viral hepatitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "sore throat", "fever", "generalized malaise", "pediatric floor", "diffuse white exudate on", "tonsils", "palpable spleen", "mild hepatomegaly", "blood smear", "large", "abundant lymphocytes", "blue gray cytoplasm", "irregular nuclei", "dark chromatin", "nucleoli", "following", "diagnosis"]}
{"question": "A 71-year-old man is brought to the emergency department because of severe, progressive left leg pain and tingling for 8 hours. The symptoms began while he was watching television. For several months, the patient has noticed calf cramping when going for long walks, as well as occasional foot tingling and numbness, but did not seek medical attention. He has no history of recent injuries. He has poorly-controlled hypertension, hyperlipidemia, type 2 diabetes mellitus, and osteoarthritis. He smoked one pack of cigarettes daily for 35 years but quit 15 years ago. He drinks three beers every night. Current medications include lisinopril, metoprolol succinate, atorvastatin, metformin, and ibuprofen. He appears to be in severe pain and is clutching his left leg. His temperature is 37.4°C (99.3°F), pulse is 110/min, respirations are 18/min, and blood pressure is 163/94 mm Hg. The lungs are clear to auscultation. There is a harsh II/VI systolic ejection murmur best heard at the right upper sternal border. The abdomen is soft and nontender. The left leg is cool to the touch with decreased popliteal, posterior tibial, and dorsalis pedis pulses. There is 5/5 strength on left hip, knee, and ankle testing. The left hip, knee, and ankle show no gross effusion, erythema, or tenderness to palpation. The remainder of the examination shows no abnormalities. Which of the following is most likely to confirm the diagnosis?", "answer": "Digital subtraction angiography", "options": {"A": "Creatine kinase concentration", "B": "Digital subtraction angiography", "C": "Fibrin degradation products", "D": "Ankle-brachial index", "E": "Compartment pressures\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "severe", "progressive left leg pain", "tingling", "8 hours", "symptoms began", "several months", "patient", "calf cramping", "long walks", "occasional foot tingling", "numbness", "not", "medical", "history of recent injuries", "poorly controlled hypertension", "hyperlipidemia", "type 2 diabetes mellitus", "osteoarthritis", "smoked one pack", "cigarettes daily", "35 years", "years", "three", "night", "Current medications include lisinopril", "metoprolol succinate", "atorvastatin", "metformin", "ibuprofen", "appears to", "severe pain", "left leg", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "lungs", "clear", "auscultation", "harsh II VI systolic ejection murmur best heard", "right upper sternal border", "abdomen", "soft", "nontender", "left leg", "cool", "touch", "decreased popliteal", "posterior tibial", "dorsalis pedis pulses", "5/5 strength", "left hip", "knee", "ankle testing", "left hip", "knee", "ankle", "gross effusion", "erythema", "tenderness", "palpation", "abnormalities", "following", "to confirm", "diagnosis"]}
{"question": "A 28-year-old gravida 2 para 1 is receiving care from her obstetrician at 28 weeks. She states that she has been having suprapubic pain and urinary frequency for the past week. Her past medical history is significant for dermatomyositis for which she takes prednisone every day. She does not smoke cigarettes or drinks alcohol. Her vital signs are within normal limits. Physical examination of the patient is within normal limits. A urine sample from the patient shows > 100,000 CFU of Escherichia coli. Urinalysis results are provided as follows:\nLeukocyte esterase  positive\nWBC 50-100 cells/HPF\nNitrite positive\nRBC 2 cells/HPF\nEpithelial cells 2 cells/HPF\nUrine pH 5.2\nWhich of the following is the best pharmacotherapy for this patient’s condition?", "answer": "Nitrofurantoin", "options": {"A": "Trimethoprim-sulfamethoxazole", "B": "Nitrofurantoin", "C": "Tetracycline", "D": "Cephalexin", "E": "Amoxicillin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old gravida 2 para 1", "receiving", "obstetrician", "weeks", "states", "suprapubic pain", "urinary frequency", "past week", "past medical history", "significant", "dermatomyositis", "prednisone", "day", "not smoke cigarettes", "alcohol", "vital signs", "normal limits", "Physical examination", "patient", "normal limits", "urine sample", "patient", "100", "Urinalysis results", "follows", "Leukocyte esterase", "positive WBC", "cells Nitrite", "Epithelial cells", "Urine", "following", "best pharmacotherapy", "patients condition"]}
{"question": "A 43-year-old woman visits her primary care physician complaining of abdominal pain for the past 6 months. She reports that the pain is localized to her lower abdomen and often resolves with bowel movements. She states that some days she has diarrhea while other times she will go 4-5 days without having a bowel movement. She started a gluten-free diet in hopes that it would help her symptoms, but she has not noticed much improvement. She denies nausea, vomiting, hematochezia, or melena. Her medical history is significant for generalized anxiety disorder and hypothyroidism. Her father has a history of colon cancer. The patient takes citalopram and levothyroxine. Physical examination reveals mild abdominal tenderness with palpation of lower quadrant but no guarding or rebound. A guaiac test is negative. A complete blood count is pending. Which of the following is the next best step in management?", "answer": "Colonoscopy", "options": {"A": "Anti-endomysial antibody titer", "B": "Colonoscopy", "C": "High fiber diet", "D": "Loperamide", "E": "Thyroid ultrasound"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "primary care physician", "abdominal pain", "past 6 months", "reports", "pain", "localized", "lower abdomen", "often", "bowel movements", "states", "days", "diarrhea", "times", "go 4-5 days", "bowel movement", "started", "help", "symptoms", "not", "nausea", "vomiting", "hematochezia", "melena", "medical history", "significant", "generalized anxiety disorder", "hypothyroidism", "history cancer", "patient", "citalopram", "levothyroxine", "reveals mild abdominal", "palpation", "lower quadrant", "guarding", "guaiac test", "negative", "complete blood count", "following", "next best step"]}
{"question": "A 26-year-old woman comes to the physician because of severe pain in her right wrist one day after falling onto her hands and knees while rollerskating. Physical examination shows abrasions over the knees and bruising over the volar aspect of the right wrist. There is swelling and tenderness on palpation of the volar wrist joint, as well as restricted range of motion due to pain. An x-ray of the hand shows volar dislocation of the lunate bone. Further evaluation is most likely to show which of the following?", "answer": "Paresthesia over the volar aspect of the first 3 fingers on wrist flexion", "options": {"A": "Paresthesia over the volar aspect of the first 3 fingers on wrist flexion", "B": "Anesthesia over the dorsal aspect of the first 3 fingers", "C": "Tenderness to palpation of the anatomic snuffbox", "D": "Involuntary flexion of the 4th and 5th interphalangeal joints when extending all fingers", "E": "Pale skin color on the volar surface when pressure is applied to the radial artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "of severe pain in", "right wrist one day", "falling", "hands", "knees", "abrasions", "knees", "bruising", "volar aspect", "right wrist", "swelling", "tenderness", "palpation of", "volar wrist joint", "restricted range of motion due to pain", "x-ray", "hand", "volar dislocation of", "lunate bone", "Further", "to", "following"]}
{"question": "A 56-year-old man with hypertension comes to the physician for a follow-up examination. His blood pressure is 165/92 mm Hg on the left arm and 162/90 mm Hg on the right arm. He reports that he is compliant with his medication and exercise regimen. The physician adds a drug to his antihypertensive medication regimen. This drug increases serum renin, angiotensin I, and angiotensin II levels, and decreases serum aldosterone levels, without affecting bradykinin levels. Which of the following drugs was most likely added to this patient's medication regimen?", "answer": "Candesartan", "options": {"A": "Candesartan", "B": "Aliskiren", "C": "Lisinopril", "D": "Triamterene", "E": "Metoprolol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "hypertension", "physician", "follow-up examination", "blood pressure", "mm Hg", "left arm", "90 mm Hg", "right arm", "reports", "compliant", "medication", "exercise regimen", "physician adds", "drug", "antihypertensive medication regimen", "drug increases serum renin", "angiotensin I", "angiotensin II levels", "decreases serum aldosterone levels", "affecting bradykinin levels", "following drugs", "most likely added", "patient's medication regimen"]}
{"question": "A 65-year-old man comes to the physician because of a 6-month history of muscle weakness. During this period, the patient has had low energy, intermittent nosebleeds, and a 5-kg (11-lb) weight loss. He also reports progressive hearing and vision problems. He has a history of pins-and-needles sensation, numbness, and pain in his feet. Vital signs are within normal limits. Physical examination shows a palpable liver tip 2–3 cm below the right costal margin. There is nontender lympadenopathy in the groins, axillae, and neck. Laboratory studies show:\nHemoglobin 8.8 g/dL\nWhite blood cells 6,300/mm3\nPlatelet count 98,000/mm3\nErythrocyte sedimentation rate 70 mm/h\nSerum\nNa+ 136 mmol/L\nK+ 3.6 mmol/L\nCr 1.3 mg/dL\nCa2+ 8.6 mg/dL\nAspartate aminotransferase 32 U/L\nAlanine aminotransferase 36 U/L\nAlkaline phosphatase 100 U/L\nLactate dehydrogenase 120 U/L\nA serum protein electrophoresis exhibits a sharp, narrow spike of monoclonal IgM immunoglobulin. Which of the following is the most likely diagnosis?\"", "answer": "Waldenstrom macroglobulinemia", "options": {"A": "Hairy cell leukemia", "B": "Multiple myeloma", "C": "Waldenstrom macroglobulinemia", "D": "Monoclonal gammopathy of undetermined significance", "E": "Mantle cell lymphoma\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old man", "physician", "month history", "muscle weakness", "period", "patient", "intermittent nosebleeds", "5 kg", "weight loss", "reports progressive hearing", "vision problems", "history", "pins", "needles sensation", "numbness", "pain in", "feet", "Vital signs", "normal limits", "palpable liver tip 23 cm", "right costal margin", "nontender", "groins", "axillae", "neck", "Laboratory studies", "8", "dL", "Cr 1", "mg dL", "mg", "Aspartate", "dehydrogenase", "serum protein electrophoresis", "a sharp", "narrow spike", "monoclonal IgM immunoglobulin", "following", "diagnosis"]}
{"question": "A previously healthy 6-week-old infant is brought to the emergency department because of fever, fatigue, and dry cough for one day. She has been feeding poorly and had difficulty latching on to breastfeed since yesterday. She has had nasal congestion. The mother reports that her daughter has not been going through as many diapers as usual. She was born by uncomplicated vaginal delivery at 42 weeks' gestation. Her mother is a cystic fibrosis carrier. The patient has been treated with acetaminophen for the last 24 hours, and vitamin D drops since birth. She appears irritable, pale, and lethargic. She is at the 25th percentile for both length and weight; she had the same percentiles at birth. Her temperature is 38.2°C (100.7°F) and respirations are 64/min. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows an ill-appearing infant with a cough and nasal flaring. Mucous membranes are dry. Chest examination shows intercostal and supraclavicular retractions. Expiratory wheezes are heard on auscultation. Which of the following is the most likely causal organism?", "answer": "Respiratory syncytial virus", "options": {"A": "Listeria monocytogenes", "B": "Respiratory syncytial virus", "C": "Rhinovirus", "D": "Coronavirus", "E": "Streptococcus pneumoniae"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "week old infant", "brought", "emergency department", "fever", "fatigue", "dry cough", "one day", "poorly", "difficulty latching", "breastfeed", "nasal congestion", "reports", "not", "diapers", "usual", "born", "uncomplicated vaginal", "weeks", "gestation", "cystic fibrosis carrier", "patient", "treated with acetaminophen", "last 24 hours", "vitamin D drops", "birth", "appears irritable", "pale", "lethargic", "percentile", "length", "weight", "same percentiles", "birth", "temperature", "100", "respirations", "64 min", "Pulse oximetry", "room air", "oxygen saturation", "ill appearing infant", "cough", "nasal flaring", "Mucous membranes", "dry", "Chest examination", "supraclavicular retractions", "Expiratory wheezes", "heard", "auscultation", "following", "causal"]}
{"question": "A 38-year-old woman presents to the physician’s clinic with a 6-month history of generalized weakness that usually worsens as the day progresses. She also complains of the drooping of her eyelids and double vision that is worse in the evening. Physical examination reveals bilateral ptosis after a sustained upward gaze and loss of eye convergence which improves upon placing ice packs over the eyes and after the administration of edrophonium. Which of the following is an intrinsic property of the muscle group affected in this patient?", "answer": "High ATPase activity", "options": {"A": "High myoglobin content", "B": "Increased amount of ATP generated per molecule of glucose", "C": "A small mass per motor unit", "D": "High ATPase activity", "E": "High density of mitochondria"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "month history", "generalized weakness", "usually worsens", "day progresses", "drooping", "eyelids", "double vision", "worse", "evening", "reveals bilateral ptosis", "sustained upward gaze", "loss", "eye", "improves", "placing ice packs", "eyes", "administration", "edrophonium", "following", "intrinsic property", "muscle affected", "patient"]}
{"question": "A 24-year-old professional wrestler recently participated in a charitable tournament event in Bora Bora, a tropical island that is part of the French Polynesia Leeward Islands. During his stay, he wore tight-fitting clothes and tight bathing trunks for extended periods. After 6 days, he observed symmetric, erythematous itchy rash in his groin, with a significant amount of moisture and scales. Central areas of the rash were hyperpigmented, and the border was slightly elevated and sharply demarcated. His penis and scrotum were not affected. He immediately visited a local dermatology clinic where a specialist conducted a Wood lamp examination to exclude the presence of a bacterial infection (primary infection due to Corynebacterium minutissimum). The working diagnosis was a fungal infection. Which topical agent should be recommended to treat this patient?", "answer": "Terbinafine", "options": {"A": "Nystatin", "B": "Ketoconazole", "C": "Terbinafine", "D": "Betamethasone/clotrimazole combination", "E": "Miconazole"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old professional", "recently", "event", "Bora Bora", "island", "part of", "French Polynesia Leeward Islands", "tight fitting clothes", "tight bathing trunks", "extended periods", "6 days", "observed symmetric", "erythematous itchy rash", "groin", "significant amount", "scales", "Central areas", "rash", "hyperpigmented", "border", "slightly elevated", "penis", "scrotum", "not affected", "immediately", "local dermatology clinic", "specialist", "lamp", "to exclude", "presence of", "bacterial infection", "primary infection due to Corynebacterium minutissimum", "working diagnosis", "fungal infection", "topical agent", "to treat", "patient"]}
{"question": "A 59-year-old woman comes to the clinic complaining of an intermittent, gnawing epigastric pain for the past 2 months. The pain is exacerbated with food and has been getting progressively worse. The patient denies any weight changes, nausea, vomiting, cough, or dyspepsia. Medical history is significant for chronic back pain for which she takes ibuprofen. Her father passed at the age of 55 due to pancreatic cancer. Labs were unremarkable except for a mild decrease in hemoglobin. To what medication is most appropriate to be switched from the current medication at this time?", "answer": "Acetaminophen", "options": {"A": "Acetaminophen", "B": "Aspirin", "C": "Naproxen", "D": "Omeprazole", "E": "Ranitidine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old woman", "clinic", "intermittent", "gnawing epigastric pain", "past", "months", "pain", "exacerbated", "food", "getting", "worse", "patient", "weight changes", "nausea", "vomiting", "cough", "dyspepsia", "Medical history", "significant", "chronic back pain", "ibuprofen", "passed", "age", "pancreatic cancer", "Labs", "unremarkable", "mild decrease", "hemoglobin", "medication", "most appropriate to", "switched", "current medication", "time"]}
{"question": "A 57-year-old woman presents to the emergency department for laboratory abnormalities detected by her primary care physician. The patient went to her appointment complaining of difficulty using her hands and swelling of her arms and lower extremities. The patient has notably smooth skin that seems to have not aged considerably. Upon seeing her lab values, her physician sent her to the ED. The patient has a past medical history of multiple suicide attempts, bipolar disorder, obesity, diabetes, and anxiety. Her current medications include lithium, insulin, captopril, and clonazepam. The patient's laboratory values are below.\n\nSerum:\nNa+: 140 mEq/L\nK+: 5.2 mEq/L\nCl-: 100 mEq/L\nHCO3-: 20 mEq/L\nBUN: 39 mg/dL\nGlucose: 127 mg/dL\nCreatinine: 2.2 mg/dL\nCa2+: 8.4 mg/dL\n\nThe patient is restarted on her home medications. Her temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 155/90 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air. Which of the following is the best next step in management?", "answer": "Start valproic acid and discontinue lithium", "options": {"A": "Continue medications and start metformin", "B": "Continue medications and start furosemide", "C": "Continue medications and add nifedipine", "D": "Start lisinopril and discontinue captopril", "E": "Start valproic acid and discontinue lithium"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["57 year old woman presents", "emergency department", "laboratory abnormalities detected", "primary care physician", "patient", "appointment", "difficulty using", "hands", "swelling of", "arms", "lower extremities", "patient", "smooth skin", "to", "not aged", "seeing", "lab values", "physician sent", "patient", "past medical multiple suicide attempts", "bipolar disorder", "obesity", "diabetes", "anxiety", "current medications include lithium", "insulin", "captopril", "clonazepam", "patient's laboratory values", "Serum", "Na", "mEq/L K", "5.2 mEq/L", "100 mEq/L HCO3", "20 mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "2.2 mg/dL Ca2", "8.4 mg/dL", "patient", "restarted", "home medications", "temperature", "99", "pulse", "80 min", "blood pressure", "90 mmHg", "respirations", "min", "oxygen saturation", "97", "room air", "following", "best next step"]}
{"question": "A 7-year-old patient is brought in by his mother for a routine check-up for school. The child is cooperative throughout the visit and excitedly talks about school. The mother congratulates her son on his behavior, and mentions that when he was being treated for leukemia three years ago, he would start crying in the parking lot even before they arrived at the clinic for his blood checks. The mother notes that since his remission, he has been better tolerating physician visits. She has occasionally been giving him candy before clinic visits to reward his good behavior after she noticed he stopped crying. Since getting these rewards, the patient has sometimes remarked that he enjoys visiting the clinic now. Which of the following best explains why this patient no longer cries at physician visits?", "answer": "Extinction", "options": {"A": "Classical conditioning", "B": "Positive reinforcement", "C": "Extinction", "D": "Acting out", "E": "Reaction formation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old patient", "brought", "routine check-up", "school", "child", "talks", "school", "behavior", "treated", "leukemia three years", "start", "parking lot", "clinic", "blood checks", "notes", "remission", "better", "occasionally", "giving", "clinic", "to", "stopped", "Since getting", "patient", "sometimes", "clinic now", "following best", "patient", "longer"]}
{"question": "A previously healthy 3-week-old infant is brought to the emergency department 6 hours after the onset of fever and persistent irritability. He had been well until 2 days ago, when he started feeding poorly and sleeping more than usual. He appears lethargic and irritable when roused for examination. His temperature is 39°C (102°F). He cries when he is picked up and when his neck is flexed. The remainder of the physical and neurological examinations show no other abnormalities. His serum glucose is 115 mg/mL. His total serum bilirubin is 6.3 mg/dL. Cerebrospinal fluid analysis shows:\nPressure 255 mm H2O\nErythrocytes 2/mm3\nLeukocyte count 710/mm3\nSegmented neutrophils 95%\nLymphocytes 5%\nProtein 86 mg/dL\nGlucose 22 mg/dL\nGram stain results of the cerebrospinal fluid are pending. Which of the following is the most appropriate initial antibiotic regimen for this patient?\"", "answer": "Ampicillin, gentamicin, and cefotaxime", "options": {"A": "Ampicillin and ceftriaxone", "B": "Gentamicin and cefotaxime", "C": "Ampicillin, gentamicin, and cefotaxime", "D": "Vancomycin, ampicillin, and cefotaxime", "E": "Vancomycin, ampicillin, and doxycycline"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy", "week old infant", "brought", "emergency department", "hours", "onset", "fever", "persistent irritability", "well", "2 days", "started", "poorly", "sleeping", "usual", "appears lethargic", "irritable", "temperature", "neck", "flexed", "physical", "neurological examinations", "abnormalities", "serum glucose", "mg/mL", "total serum bilirubin", "6.3 mg/dL", "Cerebrospinal fluid analysis", "Pressure", "mm H2O Erythrocytes", "Leukocyte count", "Segmented neutrophils", "Lymphocytes", "Protein", "mg Glucose", "dL Gram stain results", "cerebrospinal fluid", "following", "most appropriate initial", "regimen", "patient"]}
{"question": "A 27-year-old primigravida presents at 16 weeks gestation for a check-up. She has no co-existing diseases. Currently, she has no subjective complaints, but she worries about the results of her triple screen. She takes 400 mg of folic acid and 30 mg of iron daily. The results of the triple screen are shown below.\n  Measured values Reference values\nMaternal serum alpha-fetoprotein 2.9 MoM 0.85-2.5 MoM\nBeta-hCG 1.1 MoM 0.5-1 MoM\nUnconjugated estriol 1 MoM 0.5-3 MoM\nWhat would be the most proper next step in the management of this patient?", "answer": "Perform ultrasound examination", "options": {"A": "Perform amniocentesis", "B": "Recommend additional inhibit A test", "C": "Perform ultrasound examination", "D": "Test for CMV infection, rubella, and toxoplasmosis", "E": "Arrange a chorionic villus sampling procedure"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old primigravida presents", "weeks gestation", "check-up", "co", "diseases", "Currently", "subjective complaints", "worries", "results", "triple screen", "400 mg", "folic acid", "30 mg", "iron daily", "results", "triple screen", "Measured values Reference values", "serum alpha fetoprotein 2 9 MoM 0.85", "5", "Beta hCG 1", "Unconjugated estriol", "3", "most", "next step", "patient"]}
{"question": "A 71-year-old woman comes to the physician because of a 4-month history of worsening cough and a 4.5-kg (10-lb) weight loss. She has smoked one pack of cigarettes daily for 35 years. Physical examination shows wheezing over the right lung fields. Laboratory studies show a serum calcium concentration of 12.5 mg/dL. X-rays of the chest are shown. Which of the following is the most likely diagnosis?", "answer": "Squamous cell lung carcinoma", "options": {"A": "Lobar pneumonia", "B": "Small cell lung carcinoma", "C": "Tuberculosis", "D": "Sarcoidosis", "E": "Squamous cell lung carcinoma"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "4 month history", "worsening cough", "4.5 kg", "10", "weight loss", "smoked one pack", "cigarettes daily", "35 years", "wheezing", "right lung fields", "Laboratory studies", "serum calcium concentration of 12.5 mg/dL", "X-rays", "chest", "following", "diagnosis"]}
{"question": "A 12-year-old boy presents with recurrent joint pain that migrates from joint to joint and intermittent fever for the last several weeks. He also says that he has no appetite and has been losing weight. The patient is afebrile, and vital signs are within normal limits. On physical examination, he is pale with diffuse petechial bleeding and bruises on his legs. An abdominal examination is significant for hepatosplenomegaly. Ultrasound of the abdomen confirms hepatosplenomegaly and also shows multiple enlarged mesenteric lymph nodes. A complete blood count (CBC) shows severe anemia and thrombocytopenia with leukocytosis. Which of the following is the most likely diagnosis in this patient?", "answer": "Acute leukemia", "options": {"A": "Acute leukemia", "B": "Tuberculosis of the bone marrow", "C": "Aplastic anemia", "D": "Immunologic thrombocytopenic purpura", "E": "Chronic leukemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "recurrent joint", "migrates", "joint", "joint", "intermittent fever", "weeks", "appetite", "weight", "patient", "afebrile", "vital signs", "normal limits", "pale", "diffuse petechial", "bruises", "legs", "abdominal", "significant", "hepatosplenomegaly", "Ultrasound of", "abdomen confirms hepatosplenomegaly", "multiple enlarged mesenteric lymph nodes", "complete blood count", "CBC", "severe anemia", "thrombocytopenia", "leukocytosis", "following", "diagnosis", "patient"]}
{"question": "A 56 year old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?", "answer": "Timolol ophthalmic solution", "options": {"A": "Timolol ophthalmic solution", "B": "Epinephrine ophthalmic solution", "C": "Laser peripheral iridotomy", "D": "Anti-cholinergic ophthalmic solution", "E": "NSAID ophthalmic solution"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old female", "of moderate right eye pain", "headache", "acute onset", "blurry vision", "colored halos", "movie at home", "hour", "pain began", "physical exam", "right eye", "pupil", "dilated", "unresponsive", "light", "right eyeball", "firm to pressure", "Intraocular pressure", "measured", "tonometer", "elevated", "following", "most appropriate emergency"]}
{"question": "A 6-year-old boy is brought to the emergency department because of worsening confusion for the last hour. He has had high-grade fever, productive cough, fatigue, and malaise for the past 2 days. He has not seen a physician in several years. His temperature is 38.9°C (102°F), pulse is 133/min, respirations are 33/min, and blood pressure is 86/48 mm Hg. He is lethargic and minimally responsive. Mucous membranes are dry. Pulmonary examination shows subcostal retractions and coarse crackles bilaterally. Laboratory studies show a hemoglobin concentration of 8.4 g/dL and a leukocyte count of 16,000/mm3. A peripheral blood smear shows sickled red blood cells. Which of the following pathogens is the most likely cause of this patient's current condition?", "answer": "Streptococcus pneumoniae", "options": {"A": "Salmonella paratyphi", "B": "Streptococcus pneumoniae", "C": "Neisseria meningitidis", "D": "Staphylococcus aureus", "E": "Nontypeable Haemophilus influenzae"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency department", "of worsening confusion", "hour", "high-grade fever", "productive cough", "fatigue", "malaise", "past 2 days", "not seen", "physician", "years", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "48 mm Hg", "lethargic", "responsive", "Mucous membranes", "dry", "Pulmonary", "subcostal retractions", "coarse crackles", "Laboratory studies", "a hemoglobin concentration", "8.4 g/dL", "leukocyte count", "mm3", "peripheral blood smear", "sickled red blood cells", "following", "most likely cause", "patient's current condition"]}
{"question": "A 2-year-old female with abdominal pain undergoes laparoscopic surgery. An outpouching of tissue is excised from the ileum and sent to the laboratory for evaluation. The pathologist notes inflammation and the presence of mucosa, submucosa, and muscle in the walls of the specimen. Which of the following is the most likely diagnosis?", "answer": "Meckel's diverticulum", "options": {"A": "Hirschprung's disease", "B": "Crohn's disease", "C": "Meckel's diverticulum", "D": "Appendicitis", "E": "Henoch-Schonlein purpura"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["2 year old female", "abdominal pain", "laparoscopic surgery", "tissue", "ileum", "sent", "laboratory", "pathologist notes inflammation", "presence", "mucosa", "submucosa", "walls", "following", "diagnosis"]}
{"question": "A 33-year-old woman schedules an appointment at an outpatient clinic for the first time after moving to the US from Peru a few months ago. She complains of easy fatigability and shortness of breath with minimal exertion for the past 6 months. She further adds that her breathlessness is worse when she goes to bed at night. She is also concerned about swelling in her legs. As a child, she says she always had sore throats. She does not smoke or drink alcohol. Medical records are unavailable, but the patient says that she has always been healthy apart from her sore throats. The blood pressure is 114/90 mm Hg, the pulse is 109/min, the respiratory rate is 26/min, and the temperature is 36.7°C (98°F). On examination, she is icteric with distended jugular veins. Bilateral basal crepitations are audible on auscultation of the lungs. Also, a high-pitched apical holosystolic murmur is audible that radiates to the left axilla. A transthoracic echocardiogram reveals mitral regurgitation with an ejection fraction of 25%. Treatment should focus on which of the following?", "answer": "Decrease total peripheral resistance", "options": {"A": "Decrease total peripheral resistance", "B": "Increase inotropy of cardiac muscle", "C": "Increase left ventricular end diastolic pressure", "D": "Increase the rate of SA node discharge", "E": "Increase coronary blood flow"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "appointment", "outpatient clinic", "first time", "moving", "Peru", "few months", "easy fatigability", "shortness of breath", "minimal exertion", "past 6 months", "further adds", "breathlessness", "worse", "bed", "night", "swelling", "legs", "child", "always", "sore throats", "not smoke", "Medical records", "unavailable", "patient", "always", "healthy", "sore throats", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "min", "temperature", "36", "icteric", "distended jugular veins", "Bilateral basal crepitations", "auscultation", "lungs", "high-pitched apical holosystolic murmur", "radiates", "left axilla", "transthoracic echocardiogram reveals mitral regurgitation", "ejection fraction of", "Treatment", "focus"]}
{"question": "A 56-year-old man with chronic kidney failure is brought to to the emergency department by ambulance after he passed out during dinner. On presentation, he is alert and complains of shortness of breath as well as chest palpitations. An EKG is obtained demonstrating an irregular rhythm consisting of QT amplitudes that vary in height over time. Other findings include uncontrolled contractions of his muscles. Tapping of his cheek does not elicit any response. Over-repletion of the serum abnormality in this case may lead to which of the following?", "answer": "Bradycardia", "options": {"A": "Bradycardia", "B": "Diffuse calcifications", "C": "Kidney stones", "D": "Peaked T-waves", "E": "Seizures"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "chronic kidney failure", "brought to", "emergency department", "ambulance", "passed out", "dinner", "alert", "of shortness", "breath", "chest palpitations", "EKG", "obtained", "irregular rhythm consisting", "QT amplitudes", "height", "time", "findings include uncontrolled contractions", "muscles", "cheek", "not elicit", "response", "serum abnormality", "case", "lead"]}
{"question": "A 55-year-old man with recurrent pneumonia comes to the physician for a follow-up examination one week after hospitalization for pneumonia. He feels well but still has a productive cough. He has smoked 1 pack of cigarettes daily for 5 years. His temperature is 36.9°C (98.4°F) and respirations are 20/min. Cardiopulmonary examination shows coarse crackles at the right lung base. Microscopic examination of a biopsy specimen of the right lower lung parenchyma shows proliferation of clustered, cuboidal, foamy-appearing cells. These cells are responsible for which of the following functions?", "answer": "Lecithin production", "options": {"A": "Lecithin production", "B": "Cytokine release", "C": "Toxin degradation", "D": "Gas diffusion", "E": "Mucus secretion"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "recurrent pneumonia", "physician", "follow-up examination one week", "pneumonia", "well", "productive cough", "smoked 1 pack", "cigarettes daily", "temperature", "36", "98", "respirations", "20 min", "Cardiopulmonary", "coarse crackles", "the right lung base", "Microscopic examination of", "biopsy specimen", "lower", "proliferation", "clustered", "cuboidal", "foamy appearing cells", "cells", "responsible", "following functions"]}
{"question": "A pediatrician is called to examine a recently born dysmorphic boy. The birth weight was 1.6 kg (3.5 lb). On physical examination of the face and skull, the head was shown to be microcephalic with a prominent occiput and a narrow bifrontal diameter. The jaw was comparatively small with short palpebral fissures. The nose was narrow and the nasal ala was hypoplastic. Examination of the upper limbs revealed closed fists with the index fingers overlapping the 3rd fingers, and the 5th fingers overlapping the 4th fingers. The fingernails and toenails were hypoplastic and he had rocker-bottom feet. Based on these details, you suspect a particular chromosomal anomaly. Which of the following statements best describes this patient’s condition?", "answer": "95% of these patients die in the 1st year of life.", "options": {"A": "This condition is associated with teenage mothers.", "B": "95% of these patients die in the 1st year of life.", "C": "The condition is more common in males.", "D": "Thrombocytopenia is the least common hematologic abnormality in these patients.", "E": "The most common congenital heart disease is patent ductus arteriosus."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["pediatrician", "called to", "recently born dysmorphic boy", "birth weight", "1.6 kg", "3.5", "face", "skull", "head", "to", "microcephalic", "prominent occiput", "narrow bifrontal diameter", "jaw", "small", "short", "nose", "narrow", "nasal ala", "hypoplastic", "Examination of", "upper limbs revealed closed", "index fingers overlapping", "3rd fingers", "5th fingers overlapping", "4th fingers", "fingernails", "toenails", "hypoplastic", "rocker-bottom feet", "Based", "details", "chromosomal anomaly", "following", "best", "patients condition"]}
{"question": "A 60-year-old man comes to the emergency department because of nausea, headache, and generalized fatigue for 2 days. He has not vomited. He was diagnosed with small cell lung cancer and liver metastases around 3 months ago and is currently receiving chemotherapy with cisplatin and etoposide. His last chemotherapy cycle ended one week ago. He has chronic obstructive lung disease and type 2 diabetes mellitus. Current medications include insulin and a salmeterol-fluticasone inhaler. He appears malnourished. He is oriented to time, place, and person. His temperature is 37.1°C (98.8°F), pulse is 87/min, respirations are 13/min, and blood pressure is 132/82 mm Hg. There is no edema. Examination shows decreased breath sounds over the left lung. Cardiac examination shows an S4. The abdomen is soft and nontender. Neurological examination shows no focal findings. Laboratory studies show:\nHemoglobin 11.6 g/dL\nLeukocyte count 4,300/mm3\nPlatelet count 146,000/mm3\nSerum\nNa+ 125 mEq/L\nCl− 105 mEq/L\nK+ 4.5 mEq/L\nHCO3− 24 mEq/L\nGlucose 225 mg/dL\nTotal bilirubin 1.1 mg/dL\nAlkaline phosphatase 80 U/L\nAspartate aminotransferase (AST, GOT) 78 U/L\nAlanine aminotransferase (ALT, GPT) 90 U/L\nFurther evaluation of this patient is likely to show which of the following laboratory findings?\nSerum osmolality Urine osmolality Urinary sodium excretion\n(A) 220 mOsm/kg H2O 130 mOsm/kg H2O 10 mEq/L\n(B) 269 mOsm/kg H2O 269 mOsm/kg H2O 82 mEq/L\n(C) 255 mOsm/kg H2O 45 mOsm/kg H2O 12 mEq/L\n(D) 222 mOsm/kg H2O 490 mOsm/kg H2O 10 mEq/L\n(E) 310 mOsm/kg H2O 420 mOsm/kg H2O 16 mEq/L\"", "answer": "(B)", "options": {"A": "(A)", "B": "(B)", "C": "(C)", "D": "(D)", "E": "(E)\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old man", "emergency department", "nausea", "headache", "generalized fatigue", "2 days", "not vomited", "diagnosed", "small cell lung cancer", "liver metastases", "months", "currently receiving chemotherapy", "cisplatin", "etoposide", "last chemotherapy cycle ended one week", "chronic obstructive lung disease", "type 2 diabetes mellitus", "Current medications include insulin", "salmeterol-fluticasone inhaler", "appears malnourished", "oriented to time", "place", "temperature", "98", "pulse", "87 min", "respirations", "min", "blood pressure", "mm Hg", "edema", "decreased breath sounds", "left lung", "S4", "abdomen", "soft", "nontender", "Neurological examination", "focal findings", "Laboratory studies", "Hemoglobin", "Leukocyte 4 300 mm3 Platelet count", "L", "K", "HCO3", "mg", "80 U", "Aspartate", "AST", "U/L Alanine aminotransferase", "ALT", "GPT", "90 U/L Further", "likely to", "following laboratory findings", "Serum", "sodium excretion", "mOsm/kg H2O", "10 mEq/L", "mOsm/kg H2O", "mEq/L", "mOsm/kg H2O", "mEq L", "D", "mOsm/kg H2O", "10 mEq/L", "mOsm/kg H2O 420", "mEq/L"]}
{"question": "A 45-year-old woman repetitively visits the general surgery clinic worried that her inguinal hernia is incarcerated. 2 months ago, she was seen in the emergency department where she presented with a left lower abdominal swelling. The mass was easily reduced and the patient was referred to the general surgery clinic for elective surgical repair. Because her condition was deemed not urgent, she was informed that she was down on the surgical waiting list. Despite this, she continues to visit the clinic and the ED worried that her bowels are ‘trapped and dying.’ Each time she is reassured and any protrusion present is quickly reduced. She has previously frequently visited her primary care physician for complaints of abdominal pain and inconsistent bowel habits, but no etiology could be identified. She continues to intermittently have these symptoms and spends hours every day worrying about what may be going on. She has no other significant past medical history. Which of the following is the most appropriate diagnosis?", "answer": "Somatic symptom disorder", "options": {"A": "Conversion disorder", "B": "Malingering disorder", "C": "Factitious disorder", "D": "Illness anxiety disorder", "E": "Somatic symptom disorder"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "general surgery clinic worried", "inguinal hernia", "incarcerated", "months", "seen in", "emergency department", "left lower abdominal swelling", "mass", "easily reduced", "patient", "referred", "general surgery clinic", "elective", "condition", "not urgent", "informed", "surgical waiting list", "to", "clinic", "worried", "bowels", "dying", "time", "protrusion present", "reduced", "frequently", "primary care physician", "complaints", "abdominal pain", "inconsistent bowel habits", "etiology", "identified", "to", "symptoms", "spends hours", "day worrying", "significant past medical history", "following", "most appropriate diagnosis"]}
{"question": "A 3-year-old boy is brought to the physician by his parents for a well-child examination. The boy was born at term via vaginal delivery and has been healthy except for impaired vision due to severe short-sightedness. He is at the 97th percentile for height and 25th percentile for weight. Oral examination shows a high-arched palate. He has abnormally long, slender fingers and toes, and his finger joints are hyperflexible. The patient is asked to place his thumbs in the palms of the same hand and then clench to form a fist. The thumbs are noted to protrude beyond the ulnar border of the hand. Slit lamp examination shows lens subluxation in the superotemporal direction bilaterally. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Mutation in fibrillin-1 gene", "options": {"A": "Mutation in fibrillin-1 gene", "B": "Defective collagen cross-linking", "C": "Nondisjunction of sex chromosomes", "D": "Mutation of the FMR1 gene", "E": "Mutation in RET gene"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old boy", "brought", "physician", "well", "boy", "born", "term", "vaginal delivery", "healthy", "impaired vision", "severe short-sightedness", "percentile", "height", "percentile", "weight", "high-arched palate", "long", "slender fingers", "toes", "finger joints", "patient", "to place", "thumbs", "palms of", "same hand", "then", "to form", "fist", "thumbs", "noted to", "ulnar border of", "hand", "Slit lamp examination", "lens subluxation", "direction", "following", "underlying cause", "patient's condition"]}
{"question": "A patient presents to the emergency department with abdominal pain. While having dinner, the patient experienced pain that prompted the patient to come to the emergency department. The patient states that the pain is episodic and radiates to the shoulder. The patient's temperature is 98°F (36.7°C), blood pressure is 120/80 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Laboratory values are ordered and return as below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 4,500 cells/mm^3 with normal differential\nPlatelet count: 247,000/mm^3\n\nSerum:\nNa+: 140 mEq/L\nCl-: 100 mEq/L\nK+: 4.6 mEq/L\nHCO3-: 24 mEq/L\nBUN: 15 mg/dL\nGlucose: 90 mg/dL\nCreatinine: 0.8 mg/dL\nCa2+: 10.0 mg/dL\nAST: 11 U/L\nALT: 11 U/L\n\nOn physical exam, the patient demonstrates abdominal tenderness that is most prominent in the right upper quadrant. Which of the following represents the most likely demographics of this patient?", "answer": "A middle-aged overweight mother", "options": {"A": "A middle-aged male with a positive urea breath test", "B": "A middle-aged overweight mother", "C": "A middle-aged patient with a history of bowel surgery", "D": "An elderly diabetic with vascular claudication", "E": "An elderly smoker with painless jaundice"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["patient presents", "emergency department", "abdominal pain", "dinner", "patient", "pain", "prompted", "patient to", "emergency department", "patient states", "pain", "episodic", "radiates", "shoulder", "patient's temperature", "36", "blood pressure", "80 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory values", "ordered", "return", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "4 500 cells mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L", "100 mEq/L K", "4.6 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "90 mg/dL Creatinine", "0.8 mg/dL Ca2", "10 0 mg/dL AST", "U/L ALT", "U/L", "patient", "abdominal tenderness", "most prominent", "right upper quadrant", "following", "patient"]}
{"question": "A 62-year-old man comes to the physician for evaluation of multiple red spots on his trunk. He first noticed these several months ago, and some appear to have increased in size. One day ago, he scratched one of these spots, and it bled for several minutes. Physical examination shows the findings in the photograph. Which of the following is the most likely diagnosis?", "answer": "Cherry angioma", "options": {"A": "Cherry angioma", "B": "Amelanotic melanoma", "C": "Spider angioma", "D": "Seborrheic keratosis", "E": "Pyogenic granuloma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old man", "physician", "multiple red", "trunk", "first", "several months", "appear to", "increased in size", "One day", "scratched one", "spots", "bled", "minutes", "findings", "photograph", "following", "diagnosis"]}
{"question": "A 25-year-old man is brought by his wife to the emergency department due to sudden onset confusion that started 40 minutes ago. The patient’s wife says that he came home from work complaining of pain in his arms and legs. While resting on the couch, he mentioned feeling nauseous and then became quite confused. He has no previous medical history and takes no medications. He does not smoke and only drinks alcohol occasionally. His vital signs include pulse 80/min, respiratory rate 12/min, blood pressure 120/84 mm Hg, and SaO2 99% on room air. On physical examination, the patient is oriented x 0 and unable to answer questions or follow commands. Generalized pallor is present. There are also multiple scratches on the face and neck due to constant itching. Assuming this patient’s symptoms are due to his employment, he most likely works as which of the following?", "answer": "Diving instructor", "options": {"A": "Bird keeper", "B": "Diving instructor", "C": "Farmer", "D": "Fireman", "E": "Shipyard worker"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "to", "emergency department due", "sudden", "started 40 minutes", "patients", "home", "work", "pain", "arms", "legs", "nauseous", "then", "confused", "previous medical history", "medications", "not smoke", "only", "alcohol occasionally", "vital signs include pulse 80 min", "respiratory rate", "min", "blood pressure", "84 mm Hg", "99", "room air", "patient", "oriented", "0", "unable to", "follow", "Generalized pallor", "present", "multiple scratches", "face", "neck due to constant itching", "patients symptoms", "due to", "employment"]}
{"question": "A 3-year-old boy goes camping with his parents in the Appalachian mountains of Western North Carolina. While on the hiking trip, he is exposed to an antigen. After the exposure, this antigen is phagocytosed by a CD4+ T helper cell and is presented on an MHC class II molecule. This CD4+ T helper cell encounters a B cell in the lymph node shown in the image below. The mature B cell proliferates and differentiates to produce antibodies to target this antigen. In which of the following numbered sections of the lymph node does this B cell differentiation and proliferation most likely occur?", "answer": "3", "options": {"A": "1", "B": "2", "C": "3", "D": "4", "E": "5"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year", "boy", "Appalachian mountains", "Western North Carolina", "trip", "exposed", "exposure", "phagocytosed", "CD4", "MHC class II molecule", "CD4", "a B cell", "lymph node", "differentiates to", "antibodies to target", "following numbered sections", "lymph node", "B cell differentiation", "proliferation", "likely occur"]}
{"question": "A 73-year-old woman is brought to the physician by her son because of increasing forgetfulness over the past 2 years. Initially, she used to misplace keys and forget her dog's name or her phone number. Now, she often forgets about what she has seen on television or read about the day before. She used to go for a walk every morning but stopped one month ago after she became lost on her way back home. Her son has prevented her from cooking because she has had episodes of leaving the gas stove oven on after making a meal. She becomes agitated when asked questions directly but is unconcerned when her son reports her history and says he is overprotective of her. She has hypertension, coronary artery disease, and hypercholesterolemia. Current medications include aspirin, enalapril, carvedilol, and atorvastatin. She is alert and oriented to place and person but not to time. Vital signs are within normal limits. Short- and long-term memory deficits are present. Her speech rhythm is normal but is frequently interrupted as she thinks of words to frame her sentences. She makes multiple errors while performing serial sevens. Her clock drawing is impaired and she draws 14 numbers. Which of the following is the most likely diagnosis?", "answer": "Alzheimer disease", "options": {"A": "Normal pressure hydrocephalus", "B": "Lewy-body dementia", "C": "Frontotemporal dementia", "D": "Creutzfeld-Jakob disease", "E": "Alzheimer disease"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "physician", "increasing forgetfulness", "past", "years", "Initially", "used", "forget", "name", "Now", "often forgets", "seen", "television", "day", "used to go", "morning", "stopped one month", "lost", "back home", "prevented", "episodes of", "gas stove oven", "making", "agitated", "asked questions directly", "reports", "history", "hypertension", "coronary artery disease", "hypercholesterolemia", "Current medications include aspirin", "enalapril", "carvedilol", "atorvastatin", "alert", "oriented to place", "not", "time", "Vital signs", "normal limits", "Short", "deficits", "present", "speech rhythm", "normal", "frequently interrupted", "to frame", "makes multiple errors", "performing serial", "clock", "impaired", "numbers", "following", "diagnosis"]}
{"question": "A 32-year-old woman is brought to the emergency department by her husband because of an episode of hematemesis 2 hours ago. She has had dyspepsia for 2 years. Her medications include occasional ibuprofen for headaches. After initial stabilization, the risks and benefits of upper endoscopy and alternative treatments, including no therapy, are explained thoroughly. She shows a good understanding of her condition and an appreciation of endoscopic treatment and its complications. She decides that she wants to have an endoscopy to find the source of bleeding and appropriately manage the ulcer. Her medical records show advance directives that she signed 3 years ago; her sister, who is a nurse, has a durable power of attorney. Regarding obtaining informed consent, which of the following is the most accurate conclusion for providing endoscopic treatment for this patient?", "answer": "Documentation of her decision prior to treatment is required", "options": {"A": "Documentation of her decision prior to treatment is required", "B": "Endoscopic treatment may be performed without further action", "C": "Her decision to have an endoscopy is not voluntary", "D": "Her sister must sign the consent form", "E": "There are reasons to believe that she may not have decision-making capacity"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "of", "episode", "hematemesis", "hours", "dyspepsia", "years", "medications include occasional ibuprofen", "headaches", "initial stabilization", "benefits", "upper endoscopy", "treatments", "including", "therapy", "good", "condition", "endoscopic treatment", "complications", "to", "endoscopy to find", "source", "bleeding", "ulcer", "medical records", "advance directives", "3 years", "nurse", "informed", "following", "most accurate", "endoscopic treatment", "patient"]}
{"question": "A 25-year-old man is admitted to the hospital after a severe motor vehicle accident as an unrestrained front-seat passenger. Appropriate life-saving measures are given, and the patient is now hemodynamically stable. Physical examination shows a complete loss of consciousness. There are no motor or ocular movements with painful stimuli. The patient has bilaterally intact pupillary light reflexes. The patient is placed in a 30° semi-recumbent position for further examination. What is the most likely finding on the examination of this patient's right ear?", "answer": "Warm water causing ipsilateral saccadic movement.", "options": {"A": "Cold water causing ipsilateral saccadic movement.", "B": "Warm water causing ipsilateral slow pursuit.", "C": "Warm water causing ipsilateral saccadic movement.", "D": "Warm water mimicking the head turning left.", "E": "Cold water causing contralateral slow pursuit."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "severe motor vehicle accident", "Appropriate", "measures", "given", "patient", "now hemodynamically stable", "complete loss of consciousness", "motor", "ocular movements", "painful", "patient", "intact pupillary light reflexes", "patient", "30 semi-recumbent position", "further", "finding", "examination of", "right"]}
{"question": "A 68-year-old man presents to the emergency department with palpitations. He also feels that his exercise tolerance has reduced over the previous week. His past history is positive for ischemic heart disease and he has been on multiple medications for a long time. On physical examination, his temperature is 36.9°C (98.4°F), pulse rate is 152/min and is regular, blood pressure is 114/80 mm Hg, and respiratory rate is 18/min. Auscultation of the precordial region confirms tachycardia, but there is no murmur or extra heart sounds. His ECG is obtained, which suggests a diagnosis of atrial flutter. Which of the following findings is most likely to be present on his electrocardiogram?", "answer": "Atrioventricular block", "options": {"A": "Atrial rate above 400 beats per minute", "B": "Slurred upstroke of R wave", "C": "Atrioventricular block", "D": "No discernible P waves", "E": "Wenckebach phenomenon"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "palpitations", "exercise tolerance", "reduced", "previous week", "past history", "positive", "ischemic heart disease", "multiple medications", "long time", "temperature", "36", "98", "pulse rate", "min", "regular", "blood pressure", "80 mm Hg", "respiratory rate", "min", "Auscultation", "precordial region confirms tachycardia", "murmur", "extra heart sounds", "ECG", "obtained", "diagnosis", "atrial flutter", "following findings", "to", "present", "electrocardiogram"]}
{"question": "A 55-year-old man presents to the physician with a cough which he has had for the last 5 years. He also mentions that he has been feeling breathless when playing any active sport for the last 1 year. He is a manager in a corporate company and has been a regular smoker for 10 years. He has visited multiple physicians and undergone multiple diagnostic evaluations, without permanent benefit. On physical examination his temperature is 37.0°C (98.6°F), the heart rate is 88/min, the blood pressure is 122/80 mm Hg, and the respiratory rate is 20/min. Inspection suggests a barrel chest and auscultation reveals the presence of bilateral end-expiratory wheezing and scattered rhonchi. He undergoes a detailed diagnostic evaluation which includes a complete blood count, chest radiogram, arterial blood gas analysis, and pulmonary function tests, all of which confirm a diagnosis of chronic obstructive lung disease. After analyzing all the clinical information and diagnostic workup, the physician differentiates between emphysema and chronic bronchitis based on a single clue. Which of the following is the most likely clue that helped the physician in making the differential diagnosis?", "answer": "Decreased diffusion capacity of the lung for carbon monoxide (DLCO)", "options": {"A": "History of long-term exposure to cigarette smoke", "B": "Increased hematocrit in hematologic evaluation", "C": "Flattened diaphragm on chest X-ray", "D": "Presence of chronic respiratory acidosis in arterial blood gas analysis", "E": "Decreased diffusion capacity of the lung for carbon monoxide (DLCO)"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "physician", "cough", "last", "years", "breathless", "playing", "active", "year", "manager", "company", "regular smoker", "multiple physicians", "multiple diagnostic evaluations", "permanent benefit", "temperature", "98", "heart rate", "88 min", "blood pressure", "80 mm Hg", "respiratory rate", "20 min", "Inspection", "barrel chest", "auscultation reveals", "presence", "bilateral end", "scattered rhonchi", "detailed diagnostic evaluation", "includes", "complete blood count", "chest radiogram", "arterial blood gas analysis", "pulmonary function tests", "confirm", "diagnosis", "chronic obstructive lung disease", "clinical information", "diagnostic workup", "physician differentiates", "emphysema", "chronic bronchitis based", "single", "following", "most likely", "helped", "physician", "making", "differential diagnosis"]}
{"question": "A 24-year-old male is rushed to the emergency department after sustaining several gunshot wounds to the chest. He was found nonresponsive in the field and was intubated en route to the hospital. His vital signs are as follows: temperature is 98.8 deg F (37.1 deg C), blood pressure is 87/52 mmHg, pulse is 120/min, and respirations are 16/min. Physical examination is significant for decreased breath sounds and dullness to percussion over the right lung. A chest radiograph in the emergency department shows a large fluid collection in the right thoracic cavity. After aggressive fluid resuscitation is initiated, an emergent chest-tube was placed in the emergency department. The chest tube puts out 700 cc of frank blood and 300 cc/hr over the next 5 hours. A follow up post-chest tube insertion chest radiograph demonstrates significant residual right hemothorax. Which of the following is the next best step in management of this patient?", "answer": "Open thoracotomy", "options": {"A": "Clamp the chest tube", "B": "Place the chest tube to water seal", "C": "Remove the chest tube", "D": "Open thoracotomy", "E": "Tracheostomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old male", "rushed", "emergency department", "sustaining", "gunshot wounds to", "chest", "found", "field", "intubated en route", "hospital", "vital signs", "follows", "temperature", "98 8 deg F", "1", "blood pressure", "87", "mmHg", "pulse", "min", "respirations", "min", "significant", "decreased breath sounds", "dullness", "percussion", "right lung", "chest radiograph", "emergency department", "large fluid collection", "right thoracic cavity", "aggressive fluid resuscitation", "initiated", "chest-tube", "emergency department", "chest tube", "out 700 cc", "frank blood", "300 cc", "next", "hours", "follow up post chest tube insertion chest radiograph", "significant residual right hemothorax", "following", "next best step", "patient"]}
{"question": "A 5-year-old is brought into your office by his mother. His mother states that he is having 10-20 episodes per day where he stops responding to his mother and is found staring out of the window. During these periods, he blinks more frequently than normal, but returns to his normal self afterwards. These episodes last 30 to 60 seconds. His mother states that all of his milestones have been normal and he had an uncomplicated birth. His mother also denies any other recent illness. On exam, his vitals are normal. During one of these episodes in the office, his EEG shows three-per-second spike and wave discharge. What is the most likely diagnosis?", "answer": "Absence seizure", "options": {"A": "Febrile seizure", "B": "Benign focal epilepsy", "C": "Juvenile myoclonic epilepsy", "D": "Absence seizure", "E": "Hearing deficits"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["5 year old", "brought", "office", "states", "10-20 episodes", "day", "stops", "found staring out", "window", "periods", "blinks more frequently", "normal", "returns", "normal", "episodes last 30 to 60 seconds", "states", "normal", "uncomplicated birth", "recent illness", "exam", "normal", "one of", "episodes", "office", "EEG", "three", "second", "wave discharge", "diagnosis"]}
{"question": "A 19-year-old woman presents to the ED after multiple episodes of vomiting in the last 6 hours. The vomitus is non-bloody and non-bilious. The vomiting started shortly after she began having a throbbing, unilateral headache and associated photophobia. She has had several similar headaches in the past. Her vital signs are unremarkable. Which of the following is an appropriate therapy for this patient's vomiting?", "answer": "Chlorpromazine", "options": {"A": "Propranolol", "B": "Amitriptyline", "C": "Ergonovine", "D": "Chlorpromazine", "E": "Calcium channel blockers"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "multiple episodes of vomiting", "last", "hours", "vomitus", "non bloody", "non", "vomiting started", "began", "throbbing", "unilateral headache", "associated photophobia", "several similar headaches", "past", "vital signs", "unremarkable", "following", "appropriate therapy", "patient's vomiting"]}
{"question": "A 22-year-old woman is brought to the emergency department by her roommate for unusual behavior. They were at a party where alcohol and recreational drugs were consumed, but her roommate is unsure of what she may have taken or had to drink. She is otherwise healthy and does not take any medications. The patient appears anxious. Her temperature is 37.5°C (99.5°F), pulse is 110/min, respiratory rate is 16/min, and blood pressure is 145/82 mmHg. Examination shows dry mucous membranes and bilateral conjunctival injection. Breath sounds are normal. The abdomen is soft and nontender. Further evaluation will most likely reveal which of the following?", "answer": "Impaired reaction time", "options": {"A": "Respiratory depression", "B": "Decreased appetite", "C": "Increased libido", "D": "Pupillary constriction", "E": "Impaired reaction time"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "brought", "emergency department", "unusual behavior", "alcohol", "recreational drugs", "unsure", "to", "healthy", "not", "medications", "patient appears anxious", "temperature", "99", "pulse", "min", "respiratory rate", "min", "blood pressure", "mmHg", "dry mucous membranes", "bilateral conjunctival injection", "Breath sounds", "normal", "abdomen", "soft", "nontender", "Further", "most likely reveal", "following"]}
{"question": "A 62-year-old woman presents to her primary care physician for her annual check-up. She has no current complaints and says that she has been healthy over the last year. Her past medical history is significant for obesity and diabetes that is well controlled on metformin. She does not smoke and drinks socially. Selected lab results are shown below:\n\nHigh-density lipoprotein: 48 mg/dL\nLow-density lipoprotein: 192 mg/dL\nTriglycerides: 138 mg/dL\n\nGiven these results, the patient is placed on the drug that will be the best therapy for these findings. Which of the following is a potential side effect of this treatment?", "answer": "Hepatotoxicity", "options": {"A": "Gallstones", "B": "Gastrointestinal upset", "C": "Hepatotoxicity", "D": "Malabsorption", "E": "Pruritus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman presents", "primary care physician", "annual check-up", "current complaints", "healthy", "year", "past medical history", "significant", "obesity", "diabetes", "well controlled", "metformin", "not smoke", "lab results", "High-density lipoprotein", "48 mg/dL Low-density lipoprotein", "mg/dL Triglycerides", "mg/dL", "Given", "results", "patient", "drug", "best therapy", "findings", "following", "potential side", "treatment"]}
{"question": "A 67-year-old man presents to his primary care physician for fatigue. This has persisted for the past several months and has been steadily worsening. The patient has a past medical history of hypertension and diabetes; however, he is not currently taking any medications and does not frequently visit his physician. The patient has lost 20 pounds since his last visit. His laboratory values are shown below:\n\nHemoglobin: 9 g/dL\nHematocrit: 29%\nMean corpuscular volume: 90 µm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nCa2+: 11.8 mg/dL\n\nWhich of the following is the most likely diagnosis?", "answer": "Malignancy", "options": {"A": "Bone marrow aplasia", "B": "Intravascular hemolysis", "C": "Iron deficiency", "D": "Malignancy", "E": "Vitamin B12 and folate deficiency"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man presents", "primary care physician", "fatigue", "past", "months", "worsening", "patient", "past medical", "diabetes", "not currently", "medications", "not frequently", "physician", "patient", "lost 20 pounds", "last", "laboratory values", "Hemoglobin", "g/dL Hematocrit", "29", "Mean corpuscular volume", "90 m", "Serum", "Na", "mEq/L", "100 mEq/L K", "4", "mEq/L Ca2", "mg/dL", "following", "diagnosis"]}
{"question": "A 19-year-old male soccer player undergoes an exercise tolerance test to measure his maximal oxygen uptake during exercise. Which of the following changes are most likely to occur during exercise?", "answer": "Decreased physiologic dead space", "options": {"A": "Increased pulmonary vascular resistance", "B": "Decreased physiologic dead space", "C": "Decreased alveolar-arterial oxygen gradient", "D": "Increased arterial partial pressure of oxygen", "E": "Increased apical ventilation-perfusion ratio"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "exercise tolerance test to measure", "maximal oxygen uptake", "exercise", "following changes", "to occur", "exercise"]}
{"question": "A 15-year-old Caucasian female presents with Parkinson-like symptoms. Serum analysis shows increased levels of free copper and elevated liver enzymes. What test would prove most helpful in diagnosing the patient's underlying disease?", "answer": "Slit lamp examination", "options": {"A": "Serum detection of anti-myelin antibodies", "B": "Slit lamp examination", "C": "Vitamin B12 test", "D": "CT scan", "E": "Reflex test"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "female presents", "symptoms", "Serum analysis", "increased levels", "free copper", "elevated liver enzymes", "test", "helpful", "diagnosing", "patient's", "disease"]}
{"question": "A 60-year-old male comes to the emergency department because of a 3-day history of intermittent shortness of breath and palpitations. The episodes are unprovoked and occur randomly. The day before, he felt lightheaded while walking and had to sit down abruptly to keep from passing out. He has hypertension and coronary artery disease. Cardiac catheterization 5 years ago showed occlusion of the left anterior descending artery, and he underwent placement of a stent. Current medications include aspirin, metoprolol, lisinopril, and clopidogrel. He does not drink alcohol or use any illicit drugs. He has smoked one-half pack of cigarettes daily for 20 years. He appears well. His temperature is 37°C (98.6°F), pulse is 136/min, respirations are 18/min, and blood pressure is 110/85 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a rapid, irregular rhythm. Shortly after, an ECG is performed. Which of the following is the most likely cause of this patient's findings?", "answer": "Degeneration of sinoatrial node automaticity", "options": {"A": "Premature ventricular contractions", "B": "Abnormal automaticity within the ventricle", "C": "Degeneration of sinoatrial node automaticity", "D": "Dissociation of the atria and ventricles", "E": "Wandering atrial pacemaker"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["60 year old male", "emergency department", "of", "3-day history", "intermittent shortness", "breath", "palpitations", "episodes", "occur", "day", "lightheaded", "to sit down", "to keep", "out", "hypertension", "coronary artery disease", "5 years", "occlusion", "left anterior descending artery", "placement of", "stent", "Current medications include aspirin", "metoprolol", "lisinopril", "clopidogrel", "not", "alcohol", "use", "illicit drugs", "smoked one half pack", "cigarettes daily", "20 years", "appears well", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "lungs", "clear", "auscultation", "Cardiac examination", "rapid", "irregular rhythm", "ECG", "performed", "following", "most likely cause", "patient's findings"]}
{"question": "A 32-year-old woman presents to her primary care doctor complaining of increased fatigue and cold intolerance after her recent delivery. The patient delivered a healthy 39-week-old boy 3 weeks ago via spontaneous vaginal delivery. Delivery was complicated by postpartum hemorrhage requiring admission to the intensive care unit with blood transfusions. Pregnancy was otherwise uneventful, and the baby is healthy. The mother has had some difficulty with lactation, but is able to supplement her breast milk with formula feeds. On exam, her temperature is 97.7°F (36.5°C), blood pressure is 112/78 mmHg, pulse is 62/min, and respirations are 12/min. The patient does not have any neck masses or lymphadenopathy; however, her skin appears dry and rough. Which of the following serum lab abnormalities may be expected?", "answer": "Decreased prolactin", "options": {"A": "Decreased prolactin", "B": "Decreased thyroid releasing hormone", "C": "Increased follicle stimulating hormone", "D": "Increased glucocorticoids", "E": "Increased luteinizing hormone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care doctor", "increased fatigue", "cold intolerance", "recent delivery", "patient delivered", "healthy", "week old boy", "weeks", "spontaneous vaginal delivery", "complicated", "postpartum hemorrhage", "intensive care unit", "blood transfusions", "Pregnancy", "baby", "healthy", "difficulty", "lactation", "able to supplement", "breast", "feeds", "exam", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "62 min", "respirations", "min", "patient", "not", "neck masses", "lymphadenopathy", "skin appears dry", "following serum lab abnormalities"]}
{"question": "A 24-year-old woman comes to the physician because of progressively worsening joint pain. She has had diffuse, aching pain in her knees, shoulders, and hands bilaterally for the past few months, but the pain has become much more severe in the past few weeks. She also reports night sweats and generalized malaise. On physical examination, radial and pedal pulses are weak. There are erythematous nodules over the legs that measure 3–5 cm. Laboratory studies show:\nHematocrit 33.2%\nHemoglobin 10.7 g/dL\nLeukocyte count 11,300/mm3\nPlatelet count 615,000/mm3\nErythrocyte sedimentation rate 94 mm/h\nSerum\nC-reactive protein 40 mg/dL (N=0.08–3.1)\nWhich of the following is the most likely diagnosis?\"", "answer": "Takayasu arteritis", "options": {"A": "Temporal arteritis", "B": "Polyarteritis nodosa", "C": "Microscopic polyangiitis", "D": "Thromboangiitis obliterans", "E": "Takayasu arteritis"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old woman", "physician", "worsening joint pain", "diffuse", "aching pain in", "knees", "shoulders", "hands", "past", "months", "pain", "much", "severe", "past", "weeks", "reports night sweats", "generalized malaise", "pedal pulses", "weak", "erythematous nodules", "legs", "measure 35", "Laboratory studies", "Hematocrit", "Hemoglobin 10", "dL Leukocyte count", "300 mm3 Platelet count", "Erythrocyte sedimentation rate", "mm/h", "40", "dL", "N 0", "1", "following", "diagnosis"]}
{"question": "A 19-year-old college student is brought to the emergency department with persistent vomiting overnight. He spent all day drinking beer yesterday at a college party according to his friends. He appears to be in shock and when asked about vomiting, he says that he vomited up blood about an hour ago. At the hospital, his vomit contains streaks of blood. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 107/min, and blood pressure is 90/68 mm Hg. A physical examination is performed and is within normal limits. Intravenous fluids are started and a blood sample is drawn for typing and cross-matching. An immediate upper gastrointestinal endoscopy reveals a longitudinal mucosal tear in the distal esophagus. What is the most likely diagnosis?", "answer": "Mallory-Weiss tear", "options": {"A": "Boerhaave syndrome", "B": "Mallory-Weiss tear", "C": "Pill esophagitis", "D": "Esophageal candidiasis", "E": "Dieulafoy's lesion"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old", "brought", "emergency department", "persistent vomiting overnight", "spent all day", "college", "appears to", "shock", "vomiting", "vomited", "blood", "hour", "hospital", "vomit contains", "blood", "temperature", "98", "respirations", "min", "pulse", "min", "blood pressure", "90", "mm Hg", "performed", "normal limits", "started", "blood sample", "cross-matching", "immediate upper gastrointestinal endoscopy reveals", "longitudinal mucosal tear", "distal esophagus", "diagnosis"]}
{"question": "A 40-year-old woman presents to her primary care physician with a 2-month history of joint pain and morning stiffness that improves through the course of the day. Her left knee also sometimes bothers her. She has taken ibuprofen and tylenol without relief, and the pain is starting to upset her daily routine. On physical examination, the joints of her fingers and wrists are swollen and tender to touch. Her left knee also feels warm. The strength in both hands is reduced but the sensation is intact. On auscultation, the heart sounds are regular and the lungs are clear. Laboratory findings are presented below:\nHemoglobin 12.7 g/dL\nHematocrit 37.5%   \nLeukocyte count 5,500/mm3\nMean corpuscular volume 82.2 μm3\nPlatelet count 190,000/mm3\nErythrocyte sedimentation rate 45 mm/h\nC-reactive protein        14 mg/dL\nAnti-citrullinated protein antibody 43 (normal reference values: < 20)\nWhich of the following is the most appropriate treatment for this patient?", "answer": "Methotrexate", "options": {"A": "Ibuprofen", "B": "Hydroxychloroquine", "C": "Infliximab", "D": "Methotrexate", "E": "Etanercept"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old woman presents", "primary care physician", "2 month history", "joint pain", "morning stiffness", "improves", "course", "day", "left knee", "sometimes", "ibuprofen", "tylenol", "relief", "pain", "starting to", "daily routine", "joints of", "fingers", "wrists", "swollen", "tender", "touch", "left knee", "warm", "strength", "hands", "reduced", "sensation", "intact", "auscultation", "heart sounds", "regular", "lungs", "clear", "Laboratory findings", "Hemoglobin", "g", "volume", "rate", "protein", "antibody", "20", "following", "most appropriate", "patient"]}
{"question": "A 6-year-old boy is brought to the pediatrician by his foster father because he is concerned about the boy's health. He states that at seemingly random times he will have episodes of severe difficulty breathing and wheezing. Upon questioning, the pediatrician learns that these episodes do not appear to be associated with exercise, irritants, or infection. The pediatrician suspects the child has a type of asthma that is associated with eosinophils. In this type of asthma, what is released by the eosinophils to cause bronchial epithelial damage?", "answer": "Major basic protein", "options": {"A": "IL-5", "B": "Major basic protein", "C": "IgM", "D": "IL-8", "E": "Interferon-gamma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "boy's", "states", "random times", "episodes of severe difficulty breathing", "wheezing", "pediatrician", "episodes", "not appear to", "associated with exercise", "irritants", "infection", "pediatrician", "child", "asthma", "associated with eosinophils", "type", "asthma", "released", "eosinophils to cause bronchial epithelial damage"]}
{"question": "A 55-year-old man presents with fever, chills, fatigue, cough, sore throat, and breathlessness for the past 7 days. He describes the cough as productive and says he is fatigued all the time. He says he is a farmer with daily contact with rabbits, horses, sheep, pigeons, and chickens and reports cleaning the barn 3 days before his symptoms started. The patient denies any history of tick bites. Past medical history is irrelevant. His temperature is 39.4°C (103.0°F), pulse is 110/min, and respirations are 26/min. On physical examination, there are decreased breath sounds on the right side. A large tender node is palpable in the right axilla. A chest radiograph reveals multiple homogenous opacities in the lower lobe of the right lung and a right-sided pleural effusions. Gram staining of a sputum sample is negative for any organism. Serology tests are negative. Which of the following is the most likely causative organism for this patient’s condition?", "answer": "Francisella tularensis", "options": {"A": "Francisella tularensis", "B": "Bacillus anthracis", "C": "Staphylococcus aureus ", "D": "Yersinia pestis", "E": "Mycoplasma pneumoniae"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "fever", "chills", "fatigue", "cough", "sore throat", "breathlessness", "past 7 days", "cough", "productive", "fatigued", "time", "farmer with daily contact", "barn 3 days", "symptoms started", "patient", "history", "Past medical", "temperature", "pulse", "min", "respirations", "min", "decreased breath sounds", "right side", "large tender node", "palpable", "right axilla", "chest radiograph reveals multiple homogenous opacities", "the lower lobe of", "right lung", "right-sided pleural effusions", "Gram staining", "sputum sample", "negative", "Serology tests", "negative", "following", "patients condition"]}
{"question": "Two days after undergoing an uncomplicated total thyroidectomy, a 63-year-old woman has acute, progressive chest pain. The pain is sharp and burning. She feels nauseated and short of breath. The patient has a history of hypertension, type 1 diabetes mellitus, medullary thyroid cancer, multiple endocrine neoplasia type 2A, anxiety, coronary artery disease, and gastroesophageal reflux disease. She smoked half a pack of cigarettes daily for 24 years but quit 18 years ago. Current medications include lisinopril, insulin glargine, insulin aspart, sertraline, aspirin, ranitidine, and levothyroxine. She appears anxious and diaphoretic. Her temperature is 37.4°C (99.3°F), pulse is 64/min, respirations are 17/min, and blood pressure is 148/77 mm Hg. The lungs are clear to auscultation. Examination shows a 3-cm linear incision over the anterior neck with 1 mm of surrounding erythema and mild serous discharge. The chest wall and abdomen are nontender. There is 5/5 strength in all extremities and decreased sensation to soft touch on the feet bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Obtain an ECG and troponin T levels", "options": {"A": "Obtain an ECG and troponin T levels", "B": "Administer IV pantoprazole and schedule endoscopy", "C": "Discontinue levothyroxine and obtain fT4 levels", "D": "Administer IV levofloxacin and obtain chest radiograph", "E": "Obtain urine and plasma metanephrine levels"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Two days", "uncomplicated total thyroidectomy", "63 year old woman", "acute", "progressive chest pain", "pain", "sharp", "burning", "nauseated", "short of breath", "patient", "history of hypertension", "type 1 diabetes mellitus", "medullary thyroid cancer", "multiple endocrine neoplasia type 2A", "anxiety", "coronary artery disease", "gastroesophageal reflux disease", "smoked half", "pack", "cigarettes daily", "years", "years", "Current medications include lisinopril", "insulin glargine", "insulin aspart", "sertraline", "aspirin", "ranitidine", "levothyroxine", "appears anxious", "diaphoretic", "temperature", "99", "pulse", "64 min", "respirations", "min", "blood pressure", "mm Hg", "lungs", "clear", "auscultation", "Examination", "3", "linear incision", "anterior neck", "1 mm", "surrounding erythema", "mild serous discharge", "chest wall", "abdomen", "nontender", "5/5 strength", "extremities", "decreased sensation", "soft touch", "feet", "abnormalities", "following", "most appropriate next step"]}
{"question": "A young researcher is studying the structure of class I and class II major histocompatibility complex (MHC) molecules. He understands that these molecules are proteins, but the structures of class I MHC molecules are different from those of class II. Although all these molecules consist of α and β chains, some of their domains are polymorphic, meaning they are different in different individuals. He calls them ‘P’ domains. The other domains are nonpolymorphic, which remain invariant in all individuals. He calls these domains ‘N’ domains. Which of the following are examples of ‘N’ domains?", "answer": "α3 domain in class I molecules and β2 domain in class II molecules", "options": {"A": "β2-microglobulin in class I molecules and β1 domain in class II molecules", "B": "α1 domain in class I molecules and α1 domain in class II molecules", "C": "α2 domain in class I molecules and β2 domain in class II molecules", "D": "α1-α2 domains in class I molecules and α1-β1 domains in class II molecules", "E": "α3 domain in class I molecules and β2 domain in class II molecules"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["young researcher", "studying", "structure", "class I", "class II major histocompatibility complex", "molecules", "proteins", "structures", "class I MHC", "different", "consist", "chains", "domains", "polymorphic", "calls", "domains", "calls", "domains", "following", "domains"]}
{"question": "A 17-year-old boy is brought to the physician by his mother because of increasingly withdrawn behavior for the last two years. His mother reports that in the last 2–3 years of high school, her son has spent most of his time in his room playing video games. He does not have any friends and has never had a girlfriend. He usually refuses to attend family dinner and avoids contact with his siblings. The patient states that he prefers being on his own. When asked how much playing video games means to him, he replies that “it's okay.” When his mother starts crying during the visit, he appears indifferent. Physical and neurologic examinations show no other abnormalities. On mental status examination, his thought process is organized and logical. His affect is flattened. Which of the following is the most likely diagnosis?", "answer": "Schizoid personality disorder", "options": {"A": "Schizophreniform disorder", "B": "Schizoid personality disorder", "C": "Antisocial personality disorder", "D": "Avoidant personality disorder", "E": "Paranoid personality disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "withdrawn behavior", "last two years", "reports", "last 23 years", "high school", "spent most of", "time", "room playing video games", "not", "never", "usually", "to attend", "dinner", "contact with", "patient states", "playing video games", "starts", "appears indifferent", "Physical", "neurologic examinations", "abnormalities", "mental status", "organized", "flattened", "following", "diagnosis"]}
{"question": "A 42-year-old man presents with an oral cavity lesion, toothache, and weight loss. He is known to have been HIV-positive for 6 years, but he does not follow a prescribed antiretroviral regimen because of personal beliefs. The vital signs are as follows: blood pressure 110/80 mm Hg, heart rate 89/min, respiratory rate 17/min, and temperature 37.1°C (100.8°F). The physical examination revealed an ulcerative lesion located on the lower lip. The lesion was friable, as evidenced by contact bleeding, and tender on palpation. A CT scan showed the lesion to be a solid mass (7 x 6 x 7 cm3) invading the mandible and spreading to the soft tissues of the oral cavity floor. A biopsy was obtained to determine the tumor type, which showed a monotonous diffuse lymphoid proliferation of large cells with plasmablastic differentiation, and oval-to-round vesicular nuclei with fine chromatin. The cells are immunopositive for VS38c. DNA of which of the following viruses is most likely to be identified in the tumor cells?", "answer": "EBV", "options": {"A": "CMV", "B": "EBV", "C": "HHV-8", "D": "HHV-1", "E": "HPV-16"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "oral cavity lesion", "toothache", "weight loss", "known to", "HIV-positive", "years", "not follow", "antiretroviral regimen", "personal beliefs", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "100", "revealed", "ulcerative lesion", "lower lip", "lesion", "friable", "contact bleeding", "tender", "palpation", "CT scan", "lesion to", "solid mass", "7", "7 cm3", "mandible", "spreading", "soft tissues", "oral cavity floor", "biopsy", "obtained to", "tumor type", "diffuse lymphoid proliferation", "large cells", "plasmablastic differentiation", "oval", "round vesicular nuclei", "fine chromatin", "cells", "following", "to", "identified"]}
{"question": "A 58-year old man comes to his physician because of a 1-month history of increased thirst and nocturia. He is drinking a lot of water to compensate for any dehydration. His brother has type 2 diabetes mellitus. Physical examination shows dry mucous membranes. Laboratory studies show a serum sodium of 151 mEq/L and glucose of 121 mg/dL. A water deprivation test shows:\nSerum osmolality\n(mOsmol/kg H2O) Urine osmolality\n(mOsmol/kg H2O)\nInitial presentation 295 285\nAfter 3 hours without fluids 305 310\nAfter administration of antidiuretic hormone (ADH) analog 280 355\nWhich of the following is the most likely diagnosis?\"", "answer": "Partial central diabetes inspidus", "options": {"A": "Nephrogenic diabetes insipidus", "B": "Partial central diabetes inspidus", "C": "Complete central diabetes insipidus", "D": "Primary polydipsia", "E": "Osmotic diuresis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old man", "physician", "month history", "increased thirst", "nocturia", "drinking", "lot", "water to compensate", "dehydration", "type 2 diabetes mellitus", "dry mucous membranes", "Laboratory studies", "serum sodium", "mEq/L", "glucose", "mg/dL", "water deprivation test", "Serum osmolality", "mOsmol/kg H2O", "Urine osmolality", "mOsmol/kg H2O", "Initial presentation", "hours", "fluids 305", "administration", "antidiuretic hormone", "analog", "following", "diagnosis"]}
{"question": "A previously healthy 13-year-old girl is brought to the physician by her parents because of a 2-day history of low-grade fever, headache, nausea, and a sore throat. Examination of the oral cavity shows enlarged, erythematous tonsils with exudates and palatal petechiae. There is cervical lymphadenopathy. Her parents agree to her participating in a study of microbial virulence factors. A culture of the girl's throat is obtained and an organism is cultivated. The physician finds that the isolated organism is able to withstand phagocytosis when placed in fresh blood. The most likely explanation for this finding is the expression of which of the following?", "answer": "M Protein", "options": {"A": "IgA protease", "B": "Protein A", "C": "Streptolysin O", "D": "Hyaluronidase", "E": "M Protein"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["healthy", "year old girl", "brought", "physician", "2-day history", "low-grade fever", "headache", "nausea", "sore throat", "Examination of", "oral", "enlarged", "erythematous tonsils", "exudates", "palatal petechiae", "cervical lymphadenopathy", "agree", "participating", "a study", "virulence factors", "culture", "girl's throat", "obtained", "physician finds", "isolated", "able to", "phagocytosis", "fresh blood", "finding", "expression"]}
{"question": "A 40-year-old man comes to the physician for the evaluation of episodic headaches for 5 months. The headaches involve both temples and are 4/10 in intensity. The patient has been taking acetaminophen, but the headaches did not subside. He has also had visual disturbances, including double vision. He has no nausea, temperature intolerance, or weight changes. The patient does not smoke. He drinks 2–3 beers on weekends. He appears pale. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure 125/80 mm Hg. Ophthalmologic examination shows impaired peripheral vision bilaterally. An MRI scan of the head with contrast shows a 16 × 11 × 9 mm intrasellar mass. Further evaluation is most likely to show which of the following findings?", "answer": "Erectile dysfunction", "options": {"A": "Galactorrhea", "B": "Coarse facial features", "C": "Diffuse goiter", "D": "Erectile dysfunction", "E": "Abdominal striae"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old man", "physician", "of episodic headaches", "5 months", "headaches", "temples", "4/10", "intensity", "patient", "acetaminophen", "headaches", "not", "visual disturbances", "including double vision", "nausea", "temperature intolerance", "weight changes", "patient", "not smoke", "23", "weekends", "appears pale", "temperature", "98", "pulse", "75 min", "blood pressure", "80 mm Hg", "Ophthalmologic examination", "impaired peripheral", "MRI scan of", "head", "contrast", "mm", "mass", "Further", "to", "following findings"]}
{"question": "A 4-year-old boy is brought to the physician because of frequent falls, worsening muscle pain, and poor vision in low light conditions. His mother reports that he has been on a low-fat diet since infancy because of persistent diarrhea. He is at the 5th percentile for height and weight. Physical examination shows bilateral proximal muscle weakness and a wide ataxic gait. His serum cholesterol level is 21 mg/dL. Peripheral blood smear shows red blood cells with irregular spiny projections of varying size. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Post-prandial lipid-laden enterocytes", "options": {"A": "GAA trinucleotide repeats on chromosome 9", "B": "Post-prandial lipid-laden enterocytes", "C": "Sweat chloride levels > 60 mmol/L", "D": "IgA anti-tissue transglutaminase antibodies", "E": "Fibrofatty replacement of muscle tissue"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy", "brought", "physician", "frequent falls", "worsening muscle pain", "poor", "low light conditions", "reports", "low-fat diet", "infancy", "persistent diarrhea", "5th percentile", "height", "weight", "bilateral proximal", "wide ataxic gait", "serum cholesterol level", "mg/dL", "Peripheral blood smear", "red blood cells", "irregular", "projections", "size", "Further", "to", "following findings"]}
{"question": "A 52-year-old man presents to his primary care physician complaining of a blistering rash in his inguinal region. Upon further questioning, he also endorses an unintended weight loss, diarrhea, polydipsia, and polyuria. A fingerstick glucose test shows elevated glucose even though this patient has no previous history of diabetes. After referral to an endocrinologist, the patient is found to have elevated serum glucagon and is diagnosed with glucagonoma. Which of the following is a function of glucagon?", "answer": "Increased lipolysis", "options": {"A": "Inhibition of insulin release", "B": "Increased glycolysis", "C": "Decreased glycogenolysis", "D": "Increased lipolysis", "E": "Decreased ketone body producttion"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician complaining of a blistering rash", "inguinal region", "further", "unintended weight loss", "diarrhea", "polydipsia", "polyuria", "fingerstick glucose test", "elevated glucose", "patient", "previous history", "diabetes", "patient", "found to", "elevated serum glucagon", "diagnosed", "glucagonoma", "following", "function", "glucagon"]}
{"question": "A 38-year-old woman is brought to the emergency department because of 3 1-hour episodes of severe, sharp, penetrating abdominal pain in the right upper quadrant. During these episodes, she 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). Her 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 a test for occult blood is negative. Laboratory studies show:\nLaboratory test\nBlood  \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 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": "Cholangitis", "C": "Cholecystitis", "D": "Choledocholithiasis", "E": "Pancreatitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "of 3 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's", "5 ft 2", "tall", "kg", "BMI", "kg/m2", "temperature", "36", "98", "pulse", "80 min", "blood pressure", "95 mm Hg", "mild scleral icterus", "Cardiopulmonary", "abnormalities", "abdomen", "soft", "tenderness", "palpation", "right upper quadrant", "guarding", "Bowel sounds", "normal", "stool", "brown", "test", "occult blood", "negative", "Laboratory studies", "Laboratory test Blood", "12.5", "mm3", "Serum", "Alkaline phosphatase 348 U/L", "Abdominal", "normal liver", "common bile duct caliber", "10 mm", "normal", "6 mm", "gallbladder", "multiple gallstones", "wall thickening", "fluid", "following", "most likely cause", "findings"]}
{"question": "In a recently conducted case-control study that aimed to elucidate the causes of myelomeningocele (a neural tube defect in which there is an incomplete formation of the spinal bones), 200 mothers of infants born with the disease and 200 mothers of infants born without the disease were included in the study. Among the mothers of infants with myelomeningocele, 50% reported having experienced pharyngitis (sore throat) during pregnancy, compared with 5% of the mothers whose infants did not develop the condition. The researchers concluded that there is an association between pharyngitis during pregnancy and myelomeningocele; this conclusion was backed up by statistical analysis of the obtained results. Which type of bias may hamper the validity of the researchers’ conclusions?", "answer": "Recall bias", "options": {"A": "Surveillance bias", "B": "Attrition bias", "C": "Recall bias", "D": "Assessment bias", "E": "Neyman bias"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["recently", "aimed to", "causes", "myelomeningocele", "neural tube defect", "incomplete formation", "spinal bones", "200", "infants born", "disease", "200", "infants born", "disease", "included", "study", "infants", "myelomeningocele", "50", "reported", "pharyngitis", "sore throat", "pregnancy", "infants", "not", "condition", "researchers concluded", "association", "pharyngitis", "pregnancy", "myelomeningocele", "backed", "obtained results", "type", "hamper", "validity", "researchers"]}
{"question": "A 66-year-old woman presents to the primary care physician with complaints of involuntary loss of urine. This has been occurring over the past month for no apparent reason while suddenly feeling the need to urinate. History reveals triggers that stimulate the desire to pass urine, such as running water, handwashing, and cold weather. There is no family history of similar symptoms in her mother or any of her 8 children. Her blood pressure is 130/80 mm Hg, heart rate is 72/min, respiratory rate is 22/min, and temperature is 36.6°C (98.0°F). Physical examination is unremarkable. Urinalysis reveals the following:\nColor Yellow\nClarity/turbidity Clear\npH 5.5\nSpecific gravity 1.015\nNitrites Negative\nLeukocyte esterase Negative\nWhich of the following is the best next step in the management of this patient?", "answer": "Bladder training", "options": {"A": "Administer antimuscarinics", "B": "Bladder training", "C": "Administer antibiotics", "D": "Posterior tibial nerve stimulation", "E": "Surgery"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old woman presents", "primary care physician", "complaints", "loss", "urine", "occurring", "past month", "need to", "History reveals triggers", "to pass urine", "family history", "similar symptoms", "children", "blood pressure", "80 mm Hg", "heart rate", "72 min", "respiratory rate", "min", "temperature", "36", "98", "unremarkable", "Urinalysis reveals", "following", "Color Yellow Clarity turbidity", "pH", "Specific gravity", "Negative Leukocyte esterase", "following", "best next step", "patient"]}
{"question": "A 40-year-old woman with a recent history of carcinoma of the breast status post mastectomy and adjuvant chemotherapy one week ago presents for follow-up. She reports adequate pain control managed with the analgesic drug she was prescribed. Past medical history is significant for hepatitis C and major depressive disorder. The patient denies any history of smoking or alcohol use but says she is currently using intravenous heroin and has been for the past 10 years. However, she reports that she has been using much less heroin since she started taking the pain medication, which is confirmed by the toxicology screen. Which of the following is the primary mechanism of action of the analgesic drug she was most likely prescribed?", "answer": "Mixed agonist-antagonist at opioid receptors", "options": {"A": "Mixed agonist-antagonist at opioid receptors", "B": "Pure antagonist at opioid receptors", "C": "Inhibits prostaglandin synthesis", "D": "Pure agonist at the µ-opioid receptor", "E": "Central action via blockade of serotonin reuptake"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old woman", "recent history of carcinoma", "the breast", "mastectomy", "adjuvant chemotherapy one week", "presents", "follow-up", "reports adequate pain control", "analgesic drug", "Past medical history", "significant", "hepatitis C", "major depressive disorder", "patient", "history of smoking", "currently using intravenous heroin", "past", "reports", "using much", "heroin", "started", "pain medication", "confirmed by", "toxicology screen", "following", "primary mechanism of action", "analgesic drug", "most likely"]}
{"question": "A 68-year-old man is brought to the emergency department by ambulance from a homeless shelter. The report from the shelter describes the man as a loner expressing symptoms of depression. He has been living at the shelter for approximately 10 months and has no family or friends and few visitors. He spends most of his evenings drinking alcohol and being by himself. Which of the following statements is most accurate regarding this patient?", "answer": "Males are more likely to die from suicide than females.", "options": {"A": "Males are more likely to die from suicide than females.", "B": "Males attempt suicide more than females.", "C": "Males are more likely to use drug overdose as a means of suicide.", "D": "Females are more likely to self-inflict fatal injuries.", "E": "Suicide risk is highest among middle-age white women."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "homeless shelter", "report", "shelter", "man", "symptoms of depression", "living", "shelter", "approximately 10 months", "few", "spends most", "evenings drinking alcohol", "following", "most accurate", "patient"]}
{"question": "A 65-year-old man with a history of hypertension visits your office. His blood pressure on physical examination is found to be 150/90. You prescribe him metoprolol. Which of the following do you expect to occur as a result of the drug?", "answer": "Decreased serum renin levels as a consequence of ß1 receptor antagonism", "options": {"A": "Decreased PR interval on EKG", "B": "Decreased serum renin levels as consequence of ß2 antagonism", "C": "Increased serum renin levels as a consequence of ß2 receptor antagonism", "D": "Decreased serum renin levels as a consequence of ß1 receptor antagonism", "E": "Increased serum renin levels as a consequence of ß1 receptor antagonism"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65-year-old man", "history of hypertension", "office", "blood", "examination", "found to", "90", "metoprolol", "following", "to occur", "result", "drug"]}
{"question": "A 5-year-old boy is brought to the physician because of a nonpruritic rash on his face that began 5 days ago. It started as a bug bite on his chin that then developed into small pustules with surrounding redness. He has not yet received any routine childhood vaccinations. Physical examination shows small, clustered lesions with gold crusts along the lower lip and chin and submandibular lymphadenopathy. At a follow-up examination 2 weeks later, his serum anti-deoxyribonuclease B antibody titer is elevated. This patient is at greatest risk for which of the following complications?", "answer": "Glomerulonephritis", "options": {"A": "Reactive arthritis", "B": "Shingles", "C": "Glomerulonephritis", "D": "Orchitis", "E": "Myocarditis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "brought", "physician", "of", "nonpruritic rash", "face", "began 5 days", "started", "bug bite", "chin", "then", "small pustules", "surrounding redness", "not", "received", "routine", "Physical examination", "small", "clustered lesions", "gold crusts", "lower lip", "chin", "submandibular lymphadenopathy", "follow-up", "2 weeks later", "serum anti-deoxyribonuclease B antibody titer", "elevated", "patient", "greatest", "following complications"]}
{"question": "A 29-year-old G2P1 woman presents at 24 weeks gestation with complaints of blurred vision and headaches. Her symptoms have increased in frequency over the past several weeks. Her medical history is significant only for occasional tension headaches. She takes no medications besides an oral folic acid supplement. The vital signs are: blood pressure, 159/90 mm Hg; pulse, 89/min; and respiratory rate, 18/min. She is afebrile. She states that her husband, a nurse, took her blood pressure 2 days earlier and found it to be 154/96 mm Hg at the time. Previously, her blood pressures have always been < 120/80 mm Hg. What is the next best step to solidify the diagnosis?", "answer": "24-hour urine collection", "options": {"A": "Electrocardiogram", "B": "Non-contrast enhanced head CT", "C": "Serum CBC and electrolytes", "D": "24-hour urine collection", "E": "Fetal ultrasound"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["29 year old", "woman presents", "weeks gestation", "complaints", "blurred vision", "headaches", "symptoms", "increased", "frequency", "past", "weeks", "medical history", "significant only", "occasional tension headaches", "medications", "oral folic acid supplement", "vital signs", "blood pressure", "90 mm Hg", "pulse", "min", "respiratory rate", "min", "afebrile", "states", "nurse", "blood pressure", "days earlier", "found", "to", "96 mm Hg", "time", "blood pressures", "always", "80 mm Hg", "next best step to", "diagnosis"]}
{"question": "A 45-year-old male presents to the emergency room for toe pain. He reports that his right great toe became acutely painful, red, and swollen approximately five hours prior. He has had one similar prior episode six months ago that resolved with indomethacin. His medical history is notable for obesity, hypertension, and alcohol abuse. He currently takes hydrochlorothiazide (HCTZ). On physical examination, his right great toe is swollen, erythematous, and exquisitely tender to light touch. The patient is started on a new medication that decreases leukocyte migration and mitosis, and his pain eventually resolves; however, he develops nausea and vomiting as a result of therapy. Which of the following underlying mechanisms of action is characteristic of this patient’s new medication?", "answer": "Inhibits microtubule polymerization", "options": {"A": "Inhibits microtubule polymerization", "B": "Prevents conversion of xanthine to uric acid", "C": "Decreases phospholipase A2-induced production of arachidonic acid", "D": "Decreases cyclooxygenase-induced production of prostaglandins", "E": "Metabolizes uric acid to water-soluble allantoin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "emergency room", "toe pain", "reports", "right great toe", "painful", "red", "swollen approximately five hours prior", "one similar prior episode six months", "resolved", "indomethacin", "medical history", "notable", "obesity", "hypertension", "alcohol abuse", "currently", "hydrochlorothiazide", "right great toe", "swollen", "erythematous", "tender", "light touch", "patient", "started", "new medication", "decreases leukocyte migration", "mitosis", "pain", "nausea", "vomiting", "result", "therapy", "of", "following underlying mechanisms", "action", "characteristic", "patients new medication"]}
{"question": "A 24-year-old man is referred to an endocrinologist for paroxysms of headaches associated with elevated blood pressure and palpitations. He is otherwise healthy, although he notes a family history of thyroid cancer. His physical examination is significant for the findings shown in Figures A, B, and C. His thyroid is normal in size, but there is a 2.5 cm nodule palpable in the right lobe. On further workup, it is found that he has elevated plasma-free metanephrines and a normal TSH. Fine-needle aspiration of the thyroid nodule stains positive for calcitonin. The endocrinologist suspects a genetic syndrome. What is the most likely inheritance pattern?", "answer": "Autosomal dominant", "options": {"A": "Autosomal dominant", "B": "Autosomal recessive", "C": "Mitochondrial", "D": "X-linked dominant", "E": "X-linked recessive"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "referred", "endocrinologist", "paroxysms", "headaches associated with elevated blood pressure", "palpitations", "healthy", "notes", "family history of thyroid cancer", "significant", "findings", "thyroid", "normal", "size", "2.5", "nodule palpable", "right lobe", "further workup", "found", "elevated plasma free metanephrines", "normal", "Fine-needle aspiration of the thyroid nodule stains positive", "calcitonin", "endocrinologist", "genetic syndrome"]}
{"question": "A previously healthy 29-year-old man comes to the emergency department because of a 4-day history of abdominal pain and confusion. Prior to the onset of the abdominal pain, he visited a festival where he consumed large amounts of alcohol. Examination shows a distended abdomen, decreased bowel sounds, and diffuse tenderness to palpation. There is motor weakness in the upper extremities. Sensation is decreased over the upper and lower extremities. Laboratory studies show no abnormalities. Which of the following is the most appropriate therapy for this patient's condition?", "answer": "Hemin", "options": {"A": "Intravenous immunoglobulin", "B": "Hemin", "C": "Ethylenediaminetetraacetic acid", "D": "Chlordiazepoxide", "E": "Chloroquine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 29 year old man", "emergency department", "4-day history", "abdominal pain", "confusion", "Prior to", "onset", "abdominal", "large amounts", "alcohol", "distended abdomen", "decreased bowel sounds", "diffuse tenderness", "palpation", "motor weakness", "upper extremities", "Sensation", "decreased", "upper", "lower extremities", "Laboratory studies", "abnormalities", "following", "most appropriate therapy", "patient's condition"]}
{"question": "A 4-year-old Caucasian male patient presents with recurrent infections. During examination of his CD4 T-cells, it is noticed that his T-cells lack CD40 ligand. Which type of immunoglobulin is likely to be present in excess?", "answer": "IgM", "options": {"A": "IgA", "B": "IgE", "C": "IgG", "D": "IgM", "E": "IgD"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old", "male patient presents", "recurrent infections", "examination of", "CD4", "cells", "lack CD40 ligand", "type", "immunoglobulin", "likely to", "present", "excess"]}
{"question": "A 22-year-old woman is in her last few months at community college. She has a very important essay due in 2 weeks that will play a big part in determining her final grades. She decides to focus on writing this essay instead and not to worry about her grades until her essay is completed. Which of the following defense mechanisms best explains her behavior?", "answer": "Suppression", "options": {"A": "Repression", "B": "Suppression", "C": "Blocking", "D": "Dissociation", "E": "Denial"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "last", "months", "community college", "very important", "due", "2 weeks", "play", "big part", "determining", "final", "focus", "not", "worry", "completed", "following", "best", "behavior"]}
{"question": "A 93-year-old woman is brought to the physician because of a purple area on her right arm that has been growing for one month. She has not had any pain or itching of the area. She has hyperlipidemia, a history of basal cell carcinoma treated with Mohs surgery 2 years ago, and a history of invasive ductal carcinoma of the right breast treated with radical mastectomy 57 years ago. She has had chronic lymphedema of the right upper extremity since the mastectomy. Her only medication is simvastatin. She lives in an assisted living facility. She is content with her living arrangement but feels guilty that she is dependent on others. Vital signs are within normal limits. Physical examination shows extensive edema of the right arm. Skin exam of the proximal upper right extremity shows three coalescing, 0.5–1.0 cm heterogeneous, purple-colored plaques with associated ulceration. Which of the following is the most likely diagnosis?", "answer": "Lymphangiosarcoma", "options": {"A": "Lymphangiosarcoma", "B": "Cellulitis", "C": "Thrombophlebitis", "D": "Lichen planus", "E": "Kaposi sarcoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "physician", "of", "purple area", "right arm", "one month", "not", "pain", "itching", "area", "hyperlipidemia", "history of", "carcinoma treated with Mohs surgery", "years", "history of invasive ductal carcinoma", "the right breast treated with radical mastectomy 57 years", "chronic lymphedema of the right upper extremity", "mastectomy", "only medication", "simvastatin", "lives in", "assisted living facility", "dependent on others", "Vital signs", "normal", "Physical examination", "extensive edema of the right arm", "Skin exam", "proximal upper", "extremity", "three", "0", "heterogeneous", "purple-colored plaques with associated ulceration", "following", "diagnosis"]}
{"question": "A boy born vaginally in the 36th week of gestation to a 19-year-old woman (gravida 3, para 1) is assessed on his 2nd day of life. His vitals include: blood pressure is 85/40 mm Hg, pulse is 161/min, axillary temperature is 36.6°C (98.0°F), and respiratory rate is 44/min. He appears to be lethargic; his skin is jaundiced and slight acrocyanosis with several petechiae is noted. Physical examination reveals nystagmus, muffled heart sounds with a continuous murmur, and hepatosplenomegaly. The boy’s birth weight is 1.93 kg (4.25 lb) and Apgar scores at the 1st and 5th minutes were 5 and 8, respectively. His mother is unaware of her immunization status and did not receive any antenatal care. She denies any history of infection, medication use, or alcohol or illicit substance use during pregnancy. Serology for suspected congenital TORCH infection shows the following results:\nAnti-toxoplasma gondii IgM Negative\nAnti-toxoplasma gondii IgG Positive\nAnti-CMV IgM Negative\nAnti-CMV IgG Positive\nAnti-Rubella IgM Positive\nAnti-Rubella IgG Positive\nAnti-HSV IgM Negative\nAnti-HSV IgG Negative\nWhich cardiac abnormality would be expected in this infant on echocardiography?", "answer": "Patent ductus arteriosus", "options": {"A": "Pulmonary valve stenosis", "B": "Patent ductus arteriosus", "C": "Ventricular septal defect", "D": "Atrial septal defect", "E": "Atrialization of the right ventricle"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["boy born", "week", "gestation", "year old woman", "gravida 3", "para 1", "2nd day", "include", "blood pressure", "85 40 mm Hg", "pulse", "min", "axillary temperature", "36", "98", "respiratory rate", "min", "appears to", "lethargic", "skin", "jaundiced", "slight acrocyanosis", "petechiae", "noted", "reveals nystagmus", "heart", "continuous murmur", "hepatosplenomegaly", "boys birth weight", "1", "kg", "4", "Apgar scores", "1st", "5th minutes", "5", "immunization status", "not receive", "history", "infection", "medication use", "alcohol", "illicit substance use", "pregnancy", "Serology", "suspected congenital TORCH", "following results", "Anti-toxoplasma gondii IgM Negative", "Positive", "Rubella", "HSV", "cardiac abnormality", "infant", "echocardiography"]}
{"question": "A 23-year-old woman presents to the emergency department with severe abdominal pain. She states that the pain has been dull and progressive, but became suddenly worse while she was exercising. The patient's past medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. The patient states that she is sexually active and does not use condoms. She admits to drinking at least 5 standard alcoholic drinks a day. The patient also recently lost a large amount of weight for a fitness show she planned on entering. The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate. On physical exam you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back. On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant. Blood pressure is 80/40 mmHg, pulse is 110/minute, temperature is 99.5°F (37.5°C) and respirations are 15/minute with an oxygen saturation of 96% on room air. Intravenous fluids are started and labs are sent. A urinary ß-hCG has been ordered. Which of the following is most likely the diagnosis?", "answer": "Vascular ectasia within the liver", "options": {"A": "Obstruction of the common bile duct by radio-opaque stones", "B": "Obstruction of blood flow through the hepatic vein", "C": "Vascular ectasia within the liver", "D": "Ectopic implantation of a blastocyst", "E": "Inflammation of the pancreas"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old woman presents", "emergency department", "severe abdominal", "states", "pain", "dull", "progressive", "worse", "exercising", "patient's past", "notable", "depression", "anxiety", "gonococcal urethritis", "treated", "patient states", "sexually active", "not use condoms", "standard", "day", "patient", "recently lost", "large amount", "weight", "planned", "entering", "patient's current medications include oral contraceptive pills", "fluoxetine", "alprazolam", "ibuprofen", "acetaminophen", "folate", "note", "young woman", "shoulders", "thick neck", "acne", "forehead", "back", "abdominal exam", "note diffuse tenderness", "10", "pain", "palpation", "right upper quadrant", "Blood pressure", "80 40 mmHg", "pulse", "minute", "temperature", "99", "respirations", "minute", "96", "room air", "started", "labs", "sent", "urinary", "hCG", "ordered", "following", "diagnosis"]}
{"question": "A 22-year-old immigrant presents to his primary care physician for a general checkup. This is his first time visiting a physician, and he has no known past medical history. The patient’s caretaker states that the patient has experienced episodes of syncope and what seems to be seizures before but has not received treatment. His temperature is 98.1°F (36.7°C), blood pressure is 121/83 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for sensorineural deafness. Which of the following ECG changes is most likely to be seen in this patient?", "answer": "Prolonged QT interval", "options": {"A": "Increased voltages", "B": "Peaked T waves", "C": "Prolonged QRS interval", "D": "Prolonged QT interval", "E": "QT shortening"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "primary care physician", "general checkup", "first time", "physician", "known past medical history", "patients caretaker states", "patient", "episodes of syncope", "to", "seizures", "not received treatment", "temperature", "98", "36", "blood pressure", "83 mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "98", "room air", "notable", "sensorineural deafness", "following ECG changes", "to", "seen", "patient"]}
{"question": "A 29-year-old nulliparous woman is found upon transthoracic echocardiography to have a dilated aorta and mitral valve prolapse. The patient has a history of joint pain, and physical examination reveals pectus excavatum and stretch marks on the skin. She does not take any medications and has no history of past drug use. The patient’s findings are most likely associated with which of the following underlying diagnoses?", "answer": "Marfan syndrome", "options": {"A": "Ehlers-Danlos syndrome", "B": "Turner syndrome", "C": "DiGeorge syndrome", "D": "Friedrich’s ataxia", "E": "Marfan syndrome"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old nulliparous woman", "found", "transthoracic echocardiography to", "dilated aorta", "mitral valve prolapse", "patient", "history", "joint pain", "reveals pectus excavatum", "stretch", "skin", "not", "medications", "history of past drug use", "patients findings", "most likely associated with", "following underlying diagnoses"]}
{"question": "A 34-year-old woman comes to the physician with fever and malaise. For the past 2 days, she has felt fatigued and weak and has had chills. Last night, she had a temperature of 40.8°C (104.2°F). She has also had difficulty swallowing since this morning. The patient was recently diagnosed with Graves disease and started on methimazole. She appears uncomfortable. Her temperature is 38.3°C (100.9°F), pulse is 95/min, and blood pressure is 134/74 mm Hg. The oropharynx is erythematous without exudate. The lungs are clear to auscultation. Laboratory studies show:\nHematocrit 42%\nHemoglobin 13.4 g/dL\nLeukocyte count 3,200/mm3\nSegmented neutrophils 9%\nBasophils < 1%\nEosinophils < 1%\nLymphocytes 79%\nMonocytes 11%\nPlatelet count 230,000/mm3\nWhich of the following is the most appropriate next step in management?\"", "answer": "Discontinue methimazole", "options": {"A": "Bone marrow biopsy", "B": "Discontinue methimazole", "C": "Switch to propylthiouracil", "D": "Test for EBV, HIV, and CMV", "E": "Decrease methimazole dose"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "fever", "malaise", "past 2 days", "weak", "chills", "Last night", "temperature", "40", "difficulty swallowing", "morning", "patient", "recently diagnosed", "Graves disease", "started", "methimazole", "appears", "temperature", "100 9F", "pulse", "95 min", "blood pressure", "74 mm Hg", "oropharynx", "erythematous", "exudate", "lungs", "clear", "auscultation", "Laboratory studies", "Hematocrit 42", "Hemoglobin 13.4 g Leukocyte count", "200 mm3 Segmented neutrophils 9", "Basophils", "1", "Eosinophils", "1", "Platelet count", "mm3", "following", "most appropriate next step"]}
{"question": "A 6-year-old refugee with delayed growth and weakness is brought to the physician. Her family has been displaced several times over the last few years, and nutrition and housing were frequently inadequate. Examination of the lower limbs shows bowing of the legs with reduced proximal muscle strength. The abdomen is protruded. Inspection of the chest shows subcostal grooving during inspiration. An image of the patient’s wrist is shown. Which of the following is the most likely cause of this patient’s condition?", "answer": "Vitamin D deficiency", "options": {"A": "Defective collagen synthesis", "B": "Insufficient protein consumption", "C": "Low-calorie intake", "D": "Osteoclast hyperactivity", "E": "Vitamin D deficiency"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old", "delayed growth", "weakness", "brought", "physician", "displaced", "times", "years", "nutrition", "housing", "frequently inadequate", "Examination of", "lower limbs", "bowing of the legs", "reduced proximal muscle strength", "abdomen", "protruded", "Inspection", "chest", "subcostal grooving", "inspiration", "patients wrist", "following", "most likely cause", "patients condition"]}
{"question": "A 16-year-old boy presents with a long-standing history of anemia. Past medical history is significant for prolonged neonatal jaundice and multiple episodes of jaundice without fever. On physical examination, the patient shows generalized pallor, scleral icterus, and splenomegaly. His hemoglobin is 10 g/dL, and examination of a peripheral blood smear shows red cell basophilic stippling. Which of the following is the most likely diagnosis in this patient?", "answer": "Pyrimidine 5’-nucleotidase deficiency", "options": {"A": "Pyruvate kinase deficiency", "B": "Cytochrome b5 reductase deficiency", "C": "Lead poisoning", "D": "Pyrimidine 5’-nucleotidase deficiency", "E": "Glucose-6-phosphate dehydrogenase deficiency"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "long standing history", "Past medical", "significant", "prolonged neonatal jaundice", "multiple episodes of jaundice", "fever", "patient", "generalized pallor", "scleral icterus", "splenomegaly", "hemoglobin", "10 g/dL", "peripheral blood smear", "red cell basophilic stippling", "following", "diagnosis", "patient"]}
{"question": "A 19-year-old woman with a history of poorly controlled asthma presents to her pulmonologist for a follow-up visit. She was recently hospitalized for an asthma exacerbation. It is her third hospitalization in the past five years. She currently takes inhaled salmeterol and medium-dose inhaled budesonide. Her past medical history is also notable for psoriasis. She does not smoke and does not drink alcohol. Her temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 75/min, and respirations are 20/min. Physical examination reveals bilateral wheezes that are loudest at the bases. The patient’s physician decides to start the patient on zileuton. Which of the following is the most immediate downstream effect of initiating zileuton?", "answer": "Decreased production of leukotrienes", "options": {"A": "Decreased production of leukotrienes", "B": "Decreased signaling via the leukotriene receptor", "C": "Decreased IgE-mediated pro-inflammatory activity", "D": "Decreased mast cell degranulation", "E": "Decreased signaling via the muscarinic receptor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "history of poorly controlled asthma presents", "pulmonologist", "recently hospitalized", "asthma exacerbation", "third", "past five years", "currently", "inhaled salmeterol", "medium dose inhaled budesonide", "past medical history", "notable", "psoriasis", "not smoke", "not", "alcohol", "temperature", "98", "blood pressure", "65 mmHg", "pulse", "75 min", "respirations", "20 min", "reveals bilateral wheezes", "loudest", "bases", "to start", "patient", "zileuton", "following", "most immediate downstream effect", "initiating zileuton"]}
{"question": "A 6-year-old boy is brought to the emergency department with acute intermittent umbilical abdominal pain that began that morning. The pain radiates to his right lower abdomen and occurs every 15–30 minutes. During these episodes of pain, the boy draws up his knees to the chest. The patient has had several episodes of nonbilious vomiting. He had a similar episode 3 months ago. His temperature is 37.7°C (99.86°F), pulse is 99/min, respirations are 18/min, and blood pressure is 100/60 mm Hg. Abdominal examination shows periumbilical tenderness with no masses palpated. Abdominal ultrasound shows concentric rings of bowel in transverse section. Laboratory studies show:\nLeukocyte Count 8,000/mm3\nHemoglobin 10.6 g/dL\nHematocrit 32%\nPlatelet Count 180,000/mm3\nSerum\nSodium 143 mEq/L\nPotassium 3.7 mEq/L\nChloride 88 mEq/L\nBicarbonate 28 mEq/L\nUrea Nitrogen 19 mg/dL\nCreatinine 1.3 mg/dL\nWhich of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Meckel diverticulum", "options": {"A": "Intestinal adhesions", "B": "Meckel diverticulum", "C": "Acute appendicitis", "D": "Malrotation with volvulus", "E": "Intestinal polyps\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency department", "acute intermittent umbilical abdominal pain", "began", "morning", "pain radiates", "right lower abdomen", "occurs", "minutes", "episodes", "pain", "boy", "knees", "chest", "patient", "several episodes of", "vomiting", "similar episode", "months", "temperature", "99", "pulse", "99 min", "respirations", "min", "blood pressure", "100 60 mm Hg", "Abdominal", "periumbilical tenderness", "masses", "Abdominal ultrasound", "concentric rings", "bowel", "transverse section", "Laboratory studies", "Leukocyte", "Hemoglobin 10", "g", "Hematocrit", "Platelet Count", "L", "3 7", "88", "19 mg", "mg", "following", "underlying cause", "patient", "ondition?"]}
{"question": "A lung mass of a 50 pack-year smoker is biopsied. If ADH levels were grossly increased, what would most likely be the histologic appearance of this mass?", "answer": "Sheets of small round cells with hyperchromatic nuclei", "options": {"A": "Tall columnar cells bordering the alveolar septum", "B": "Sheets of small round cells with hyperchromatic nuclei", "C": "Layered squamous cells with keratin pearls", "D": "Hyperplasia of mucin producing glandular tissue", "E": "Pleomorphic giant cells with leukocyte fragments in cytoplasm"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["lung", "50", "smoker", "biopsied", "ADH levels", "increased", "most likely", "histologic appearance", "mass"]}
{"question": "A 26-year-old man presents to his primary care physician for a routine physical exam. He is concerned about a burning sensation that he feels in his throat whenever he eats large meals and is concerned he may have esophageal cancer like his uncle. The patient has a past medical history of irritable bowel syndrome and constipation. His current medications include whey protein supplements, fish oil, a multivitamin, and sodium docusate. The patient is concerned about his performance in school and fears he may fail out. He recently did poorly on an exam and it has caused him significant stress. He also is worried that his girlfriend is going to leave him. The patient claims that he thought he was going to be an incredible doctor some day, but now he feels like a terrible person. The patient also states that he feels guilty about his grandfather's death which occurred 1 year ago and he often reexperiences the funeral in his mind. He regularly has trouble sleeping for which he takes melatonin. The patient has been praying every 4 hours with the hopes that this will make things go better for him. Which of the following is the most likely diagnosis?", "answer": "Generalized anxiety disorder", "options": {"A": "Acute stress disorder", "B": "Depression", "C": "Generalized anxiety disorder", "D": "Obsessive compulsive disorder", "E": "Post traumatic stress disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care physician", "routine physical exam", "burning sensation", "throat", "eats large meals", "esophageal cancer", "patient", "past medical history of irritable bowel syndrome", "constipation", "current medications include", "protein supplements", "fish oil", "multivitamin", "sodium docusate", "patient", "in school", "fail out", "recently", "poorly", "exam", "caused", "significant stress", "worried", "to", "patient", "to", "doctor", "day", "now", "terrible", "patient", "states", "death", "1 year", "often", "trouble sleeping", "melatonin", "patient", "praying", "4 hours", "make", "go better", "following", "diagnosis"]}
{"question": "A 32-year-old man presents to the physician for a check-up as part of his immigration application. On auscultation, there is a mild rumble heard at the cardiac apex preceded by an opening snap. His blood pressure is 132/76 and heart rate is 78/min. The patient suffers from occasional asthma attacks but has noticed that he cannot hold his breath on exertion over the past 2 years. He is otherwise healthy. He does not recall if he had any serious infections during childhood, and there is no family history of congenital diseases. Which of the following could have been used to prevent the development of this condition?", "answer": "Penicillin", "options": {"A": "Penicillin", "B": "Alprostadil", "C": "Sulfasalazine", "D": "Indomethacin", "E": "PGE1 infusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "physician", "check-up", "part of", "application", "auscultation", "mild", "heard", "cardiac apex preceded", "opening snap", "blood pressure", "76", "heart rate", "min", "patient suffers", "occasional asthma attacks", "hold", "breath", "exertion", "past", "years", "healthy", "not", "serious infections", "childhood", "family history of congenital diseases", "following", "used to prevent", "development", "condition"]}
{"question": "A 82-year-old woman is brought to the physician by her son because he is concerned about her forgetfulness for the past 2 years. She occasionally walks into a room and forgets why she went there and often forgets where she left her keys. She is sometimes unable to recall a familiar individual's name. She reports that she has become slower at completing sudoku puzzles. She has been living independently since the death of her husband 3 years ago. She goes shopping, cooks her own meals, and plays bridge with her friends every weekend. She is not anxious about her memory lapses. She has no trouble sleeping but has been getting up earlier than she used to. She has hypertension that is managed with hydrochlorothiazide. She appears healthy. Vital signs are within normal limits. She is oriented to person, place, and time. Examination shows a normal gait. She describes her mood as “good” and her speech is normal. Her thought process is organized and her judgement is intact. She makes one error when performing serial sevens. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Aging", "options": {"A": "Aging", "B": "Alzheimer's disease", "C": "Lewy-body dementia", "D": "Vascular Dementia", "E": "Normal pressure hydrocephalus\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "physician", "forgetfulness", "past", "years", "occasionally walks", "room", "forgets", "often forgets", "left", "sometimes unable to", "familiar", "name", "reports", "slower", "completing", "living", "death", "years", "shopping", "cooks", "meals", "plays bridge", "weekend", "not anxious", "memory lapses", "trouble sleeping", "getting", "earlier", "used to", "hypertension", "hydrochlorothiazide", "appears healthy", "Vital signs", "normal limits", "oriented to person", "place", "time", "normal gait", "speech", "normal", "organized", "intact", "makes one error", "performing serial", "abnormalities", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 40-year-old man comes to the physician because of fatigue, increased sweating, and itching in his legs for the past 2 years. He has chronic bronchitis. He has smoked two packs of cigarettes daily for 24 years and drinks one to two beers every night. His only medication is a tiotropium bromide inhaler. His vital signs are within normal limits. He is 175 cm (5 ft 9 in) tall and weighs 116 kg (256 lb); BMI is 38 kg/m2. Physical examination shows facial flushing and bluish discoloration of the lips. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Abdominal examination shows no abnormalities. Laboratory studies show:\nErythrocyte count 6.9 million/mm3\nHemoglobin 20 g/dL\nMean corpuscular volume 91 μm3\nLeukocyte count 13,000/mm3\nPlatelet count 540,000/mm3\nSerum\nFerritin 8 ng/mL\nIron 48 μg/dL\nIron binding capacity 402 μg/dL (N: 251 - 406 μg/dL)\nWhich of the following is the most appropriate next step in treatment?\"", "answer": "Phlebotomy", "options": {"A": "Weight loss", "B": "Allogeneic stem cell transplantation", "C": "Hydroxyurea", "D": "Inhaled budesonide", "E": "Phlebotomy"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["40 year old man", "physician", "fatigue", "increased sweating", "itching", "legs", "past", "years", "chronic bronchitis", "smoked two packs", "cigarettes daily", "years", "one", "two", "night", "only medication", "tiotropium bromide inhaler", "vital signs", "normal limits", "5 ft 9", "tall", "kg", "BMI", "kg/m2", "facial flushing", "discoloration", "lips", "Scattered expiratory wheezing", "rhonchi", "heard", "lung fields", "Abdominal", "abnormalities", "Laboratory studies", "Erythrocyte", "mm3", "20 g/dL Mean corpuscular volume", "m3 Leukocyte count", "Platelet count", "Serum Ferritin 8 ng/mL Iron 48", "binding capacity", "N", "g/dL", "following", "most appropriate next step", "treatment"]}
{"question": "A 24-year-old woman comes to the clinic complaining of headache and sinus drainage for the past 13 days. She reports cold-like symptoms 2 weeks ago that progressively got worse. The patient endorses subjective fever, congestion, sinus headache, cough, and chills. She claims that this is her 5th episode within the past year and is concerned if “there’s something else going on.” Her medical history is significant for asthma that is adequately controlled with her albuterol inhaler. Her laboratory findings are shown below:\n\nSerum:\nHemoglobin: 16.2 g/dL\nHematocrit: 39 %\nLeukocyte count: 7,890/mm^3 with normal differential\nPlatelet count: 200,000/mm^3\nIgA: 54 mg/dL (Normal: 76-390 mg/dL)\nIgE: 0 IU/mL (Normal: 0-380 IU/mL)\nIgG: 470 mg/dL (Normal: 650-1500 mg/dL)\nIgM: 29 mg/dL (Normal: 40-345 mg/dL)\n\nWhat is the most likely diagnosis?", "answer": "Common variable immunodeficiency", "options": {"A": "Ataxia-telangiectasia", "B": "Common variable immunodeficiency", "C": "Selective IgA deficiency", "D": "Wiskott-Aldrich syndrome", "E": "X-linked agammaglobinemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "clinic", "headache", "sinus drainage", "past", "days", "reports cold", "symptoms", "weeks", "got worse", "patient", "subjective fever", "congestion", "sinus headache", "cough", "chills", "5th episode", "past year", "else", "medical history", "significant", "asthma", "controlled", "albuterol inhaler", "laboratory findings", "Serum", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "7", "mm", "normal differential Platelet count", "200", "mm", "IgA", "54 mg/dL", "Normal", "76", "mg/dL", "0 IU/mL", "Normal", "0", "IU/mL", "mg/dL", "Normal", "650 1500 mg/dL", "29 mg/dL", "Normal", "40", "mg/dL", "diagnosis"]}
{"question": "A 30-year-old man presents to his primary care physician for a routine check-up. During the appointment, he remarks that he has started noticing some thinning and hair loss without other symptoms. The physician reassures him that he is likely experiencing male-pattern baldness and explains that the condition is largely inherited. Specifically he notes that there are multiple genes that are responsible for the condition so it is difficult to predict the timing and development of hair loss. What genetic principle is being illustrated by this scenario?", "answer": "Polygenic inheritance", "options": {"A": "Pleiotropy", "B": "Anticipation", "C": "Polygenic inheritance", "D": "Uniparental disomy", "E": "Heteroplasmy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old man presents", "primary care physician", "routine check-up", "appointment", "started", "thinning", "hair loss", "symptoms", "physician", "likely", "male-pattern baldness", "condition", "inherited", "notes", "multiple genes", "responsible", "condition", "difficult to", "timing", "development of hair loss", "genetic", "scenario"]}
{"question": "A 67-year-old man comes to the physician because of a 3-month history of difficulty initiating urination. He wakes up at least 3–4 times at night to urinate. Digital rectal examination shows a symmetrically enlarged, nontender prostate with a rubbery consistency. Laboratory studies show a prostate-specific antigen level of 2.1 ng/mL (N < 4). Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Hyperplasia of lateral prostatic lobe tissue", "options": {"A": "Hyperplasia of lateral prostatic lobe tissue", "B": "Infiltrating neoplasia of bladder urothelium", "C": "Hypertrophy of middle prostatic lobe tissue", "D": "Lymphocytic infiltration of anterior prostatic lobe stroma", "E": "Infiltrating dysplasia of posterior prostatic lobe epithelium"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old man", "physician", "3 month history", "difficulty initiating urination", "wakes up", "times", "night to", "Digital rectal examination", "enlarged", "nontender prostate", "rubbery", "Laboratory studies", "prostate-specific antigen", "1 mL", "N", "4", "following", "underlying cause", "patient's symptoms"]}
{"question": "A 2860-g (6-lb 3-oz) male newborn is born at term to a primigravid woman via spontaneous vaginal delivery. The mother has had no routine prenatal care. She reports that there is no family history of serious illness. The initial examination of the newborn shows bowing of the legs and respiratory distress upon palpation of the chest. The skin and joints are hyperextensible. X-rays of the chest and skull show multiple rib fractures and small, irregular bones along the cranial sutures. The patient is at increased risk of which of the following complications?", "answer": "Hearing loss", "options": {"A": "Costochondral junction enlargement", "B": "Intestinal rupture", "C": "Intellectual disability", "D": "Spinal canal stenosis", "E": "Hearing loss"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["g", "oz", "male newborn", "born", "term", "primigravid woman", "spontaneous vaginal delivery", "routine prenatal care", "reports", "family history", "serious illness", "initial examination", "newborn", "bowing of the legs", "respiratory distress", "palpation", "chest", "skin", "joints", "X-rays of", "chest", "skull", "multiple rib fractures", "small", "irregular bones", "cranial sutures", "patient", "increased risk", "following complications"]}
{"question": "A 56-year-old man presents to his primary care provider because of a lack of flexibility in his right hand. He has noticed that his hand has become less flexible and more fixed over the past year and he now has trouble shaking other people’s hands comfortably. He has a history of chronic alcohol abuse, hepatitis C, and cirrhosis. His family history is insignificant. He has a 40 pack-year smoking history. At the physician’s office, his blood pressure is 118/67 mm Hg, the respirations are 18/min, the pulse is 77/min, and the temperature is 36.7°C (98.0°F). On physical examination, the 4th and 5th digits are mildly flexed with dense, rope-like cords extending down his palm. Additionally, small ulcerations are identified on his palm. Which of the following is considered the first-line therapy for this condition?", "answer": "Collagenase injections", "options": {"A": "Surgery", "B": "Colchicine", "C": "Anti-TNF drugs", "D": "Steroid injections", "E": "Collagenase injections"}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["year old man presents", "primary care provider", "lack", "flexibility", "right hand", "hand", "less flexible", "more fixed", "past year", "now", "shaking", "hands", "history of chronic alcohol abuse", "hepatitis C", "cirrhosis", "family history", "40", "smoking history", "physicians office", "blood pressure", "67 mm Hg", "respirations", "min", "pulse", "min", "temperature", "36", "98", "4th", "5th digits", "mildly flexed", "dense", "rope", "cords extending", "palm", "small ulcerations", "identified", "palm", "following", "first-line therapy", "condition"]}
{"question": "A 35-year-old man presents to the physician with concerns that a “bad flu” he has had for the past 10 days is getting worse and causing sleeplessness. On presentation today, his sore throat has improved; however, fever and chest and body aches persist despite the use of ibuprofen. He reports sharp, intermittent chest pain that worsens with exertion. He has not traveled outside the United States recently and does not have a history of substance abuse or alcohol use. Physical examination shows the temperature is 38.3°C (100.9°F), the heart rate is 110/min, the blood pressure is 120/60 mm Hg, and the oxygen saturation is 98% on room air. There is bilateral pedal edema at the level of the ankle. Auscultation reveals normal S1 and S2 and a third early diastolic heart sound. Jugular vein distention is observed. An ECG shows sinus tachycardia and diffuse ST-segment elevation throughout the precordial leads with 1.0-mm PR-segment depression in leads I and II.\nLaboratory results\nWBC 14,000/mm3\nLymphocyte count 70%\nHematocrit 45%\nCRP 56 mg/dL\nTroponin T 1.15 ng/mL\nTroponin I 0.2 ng/mL\nCk-MB 22 ng/mL\nCoxsackie type b viral antibody  positive\nA chest x-ray shows clear lung fields bilaterally and a mildly enlarged cardiac silhouette. Transthoracic ultrasound reveals a left ventricular ejection fraction of 30%. Which of the following is the cause of difficulty sleeping for this patient?", "answer": "Decreased cardiac contractility due to cardiac myocyte injury", "options": {"A": "Progressive cardiac ischemia caused by a plaque event", "B": "Impaired gaseous exchange caused by pulmonary edema", "C": "Lobar consolidation due to Staphylococcus aureus", "D": "Decreased cardiac contractility due to cardiac myocyte injury", "E": "Diffuse alveolar damage and hyaline membrane formation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old man presents", "physician", "bad flu", "past 10 days", "getting worse", "causing sleeplessness", "today", "sore throat", "improved", "fever", "chest", "body aches", "use of ibuprofen", "reports sharp", "intermittent chest pain", "worsens", "exertion", "not", "outside", "United States recently", "not", "history of substance abuse", "temperature", "100 9F", "heart rate", "min", "blood pressure", "60 mm Hg", "oxygen saturation", "98", "room air", "bilateral edema", "level", "ankle", "Auscultation reveals normal S1", "S2", "third early diastolic heart sound", "Jugular vein distention", "observed", "ECG", "sinus tachycardia", "diffuse ST-segment elevation", "precordial leads", "1 0 mm PR-segment depression", "leads I", "II", "Laboratory results WBC", "mm3", "count 70", "Hematocrit", "CRP", "mg", "Troponin", "15 ng/mL", "I 0.2", "mL Ck-MB", "type", "antibody", "positive", "chest x-ray", "clear lung fields", "mildly enlarged cardiac silhouette", "Transthoracic ultrasound reveals", "left ventricular ejection fraction of 30", "following", "cause", "difficulty sleeping", "patient"]}
{"question": "A 60-year-old man presents to the emergency department with shortness of breath, cough, and fever. He states that his symptoms started a few days ago and have been progressively worsening. The patient recently returned from international travel. He works from home and manages a chicken coop as a hobby. He has a past medical history of an ST-elevation myocardial infarction and recently has had multiple sick contacts. His temperature is 102°F (38.9°C), blood pressure is 187/108 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 93% on room air. A radiograph of the chest reveals bilateral pleural effusions. Pleurocentesis demonstrates the findings below:\n\nProtein ratio (pleural/serum): 0.8\nLactate dehydrogenase ratio (pleural/serum): 0.75\nGlucose: 25 mg/dL\n\nFurther analysis reveals a lymphocytic leukocytosis of the pleural fluid. Which of the following is the next best step in management?", "answer": "Rifampin, isoniazid, pyrazinamide, and ethambutol", "options": {"A": "Azithromycin and ceftriaxone", "B": "Azithromycin and vancomycin", "C": "Furosemide", "D": "Rifampin, isoniazid, pyrazinamide, and ethambutol", "E": "Supportive therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["60 year old man presents", "emergency department", "shortness of breath", "cough", "fever", "states", "symptoms started", "few days", "worsening", "patient recently returned", "international travel", "works", "home", "past medical history of", "ST-elevation myocardial infarction", "recently", "multiple sick", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "radiograph of", "chest reveals bilateral pleural effusions", "findings", "Protein ratio", "pleural serum", "0.8 Lactate dehydrogenase ratio", "pleural serum", "0.75 Glucose", "mg/dL", "Further analysis reveals", "lymphocytic leukocytosis", "pleural fluid", "following", "next best step"]}
{"question": "A 25-year-old sexually active male presents to an internal medicine physician for a routine health check up after having several unprotected sexual encounters. After appropriate testing the physician discusses with the patient that he is HIV+ and must be started on anti-retroviral treatment. Which of the following medications prescribed acts on the gp41 subunit of the HIV envelope glycoprotein?", "answer": "Enfuvirtide", "options": {"A": "Amantadine", "B": "Rimantadine", "C": "Zidovudine", "D": "Saquinavir", "E": "Enfuvirtide"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["year old sexually active male presents", "internal medicine physician", "routine health check up", "several", "appropriate testing", "physician", "patient", "HIV", "started", "treatment", "following medications", "acts", "gp41 subunit", "HIV envelope glycoprotein"]}
{"question": "A 36-year-old primigravid woman who recently immigrated to the United States presents to her gynecologist for the first time during the 28th week of her pregnancy. She hasn’t received any prenatal care or folic acid supplementation. The patient’s history reveals that she has received blood transfusions in the past due to “severe anemia.” Which of the following blood type situations would put the fetus at risk for hemolytic disease of the newborn?", "answer": "Mother is A negative, father is B positive", "options": {"A": "Mother is B positive, father is O negative", "B": "Mother is O positive, father is B negative", "C": "Mother is A negative, father is B positive", "D": "Mother is AB negative, father is O negative", "E": "Mother is O positive, father is AB negative"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["36 year old primigravid woman", "recently", "United States presents", "gynecologist", "first time", "week", "pregnancy", "hasnt received", "folic acid supplementation", "patients history reveals", "received blood transfusions", "past", "severe anemia", "following blood type", "fetus at risk", "hemolytic disease of the newborn"]}
{"question": "A 60-year-old male engineer who complains of shortness of breath when walking a few blocks undergoes a cardiac stress test because of concern for coronary artery disease. During the test he asks his cardiologist about what variables are usually used to quantify the functioning of the heart. He learns that one of these variables is stroke volume. Which of the following scenarios would be most likely to lead to a decrease in stroke volume?", "answer": "Heart failure", "options": {"A": "Anxiety", "B": "Exercise", "C": "Pregnancy", "D": "Heart failure", "E": "Digitalis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old male engineer", "of shortness", "breath", "few blocks", "cardiac stress test", "coronary artery disease", "test", "cardiologist", "variables", "usually used to quantify", "functioning", "heart", "one", "variables", "stroke volume", "following scenarios", "to lead", "decrease", "stroke volume"]}
{"question": "A 58-year-old woman presents to the clinic with an abnormal sensation on the left side of her body that has been present for the past several months. At first, the area seemed numb and she recalls touching a hot stove and accidentally burning herself but not feeling the heat. Now she is suffering from a constant, uncomfortable burning pain on her left side for the past week. The pain gets worse when someone even lightly touches that side. She has recently immigrated and her past medical records are unavailable. Last month she had a stroke but she cannot recall any details from the event. She confirms a history of hypertension, type II diabetes mellitus, and bilateral knee pain. She also had cardiac surgery 20 years ago. She denies fever, mood changes, weight changes, and trauma to the head, neck, or limbs. Her blood pressure is 162/90 mm Hg, the heart rate is 82/min, and the respiratory rate is 15/min. Multiple old burn marks are visible on the left hand and forearm. Muscle strength is mildly reduced in the left upper and lower limbs. Hyperesthesia is noted in the left upper and lower limbs. Laboratory results are significant for:\nHemoglobin 13.9 g/dL\nMCV 92 fL\nWhite blood cells 7,500/mm3\nPlatelets 278,000/mm3\nCreatinine 1.3 U/L\nBUN 38 mg/dL\nTSH 2.5 uU/L\nHemoglobin A1c 7.9%\nVitamin B12 526 ng/L\nWhat is the most likely diagnosis?", "answer": "Dejerine-Roussy syndrome", "options": {"A": "Complex regional pain syndrome", "B": "Conversion disorder", "C": "Dejerine-Roussy syndrome", "D": "Medial medullary syndrome", "E": "Subacute combined degeneration of spinal cord"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["58 year old woman presents", "clinic", "abnormal sensation", "left side of", "body", "present", "past", "months", "first", "area", "numb", "touching", "hot stove", "burning", "not", "Now", "suffering", "constant", "burning pain", "left side", "past week", "pain gets worse", "lightly touches", "side", "recently", "past medical records", "unavailable", "Last month", "stroke", "details", "event", "confirms", "history of hypertension", "type II diabetes mellitus", "bilateral knee pain", "cardiac surgery 20 years", "fever", "mood changes", "weight changes", "trauma", "head", "neck", "limbs", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "Multiple old burn marks", "visible", "left hand", "forearm", "Muscle strength", "mildly reduced", "left upper", "lower limbs", "Hyperesthesia", "noted", "left upper", "lower limbs", "Laboratory results", "significant", "Hemoglobin", "g", "MCV", "fL White blood cells", "500", "278", "1", "L", "uU", "Vitamin B12", "ng", "diagnosis"]}
{"question": "A young researcher is responsible for graphing laboratory data involving pulmonary blood flow and ventilation pattern obtained from a healthy volunteer who was standing in an upright position. After plotting the following graph, the researcher realizes he forgot to label the curves and the x-axis (which represents the position in the lung). Which of the following is the appropriate label for each point on the graph?", "answer": "A: Ventilation B: Blood flow C: Base of the lung D: Apex of the lung", "options": {"A": "A: Blood flow B: Ventilation C: Base of the lung D: Apex of the lung", "B": "A: Ventilation B: Blood flow C: Base of the lung D: Apex of the lung", "C": "A: Blood flow B: Ventilation C: Apex of the lung D: Base of the lung", "D": "A: Ventilation B: Blood flow C: Apex of the lung D: Base of the lung", "E": "A: Ventilation B: Blood flow C: Mid-portion of the lung D: Apex of the lung"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["young researcher", "responsible", "laboratory data involving pulmonary blood flow", "ventilation pattern obtained", "standing", "upright position", "following", "researcher", "forgot", "label", "curves", "axis", "position", "lung", "following", "appropriate label", "point"]}
{"question": "A 70-year-old man is brought to the emergency department by his wife because of lethargy, confusion, and nausea for the past 2 days. He has previously been healthy and has no past medical history. His only medications are a daily multivitamin and acetaminophen, which he takes daily for hip pain. Vital signs are within normal limits. He is disoriented to place and time but recognizes his wife. The remainder of his physical examination shows no abnormalities. Laboratory studies show a hemoglobin concentration of 9.1 g/dL, a serum calcium concentration of 14.7 mg/dL, and a serum creatinine of 2.2 mg/dL (previously 0.9 mg/dL). Which of the following is the most likely underlying mechanism of this patient's condition?", "answer": "Overproliferation of plasma cells\n\"", "options": {"A": "Excessive consumption of calcium", "B": "Ectopic PTHrP release", "C": "Increased serum levels of 1,25-hydroxyvitamin D", "D": "Excess PTH secretion from parathyroid glands", "E": "Overproliferation of plasma cells\n\""}, "meta_info": "step2&3", "answer_idx": "E", "metamap_phrases": ["70 year old man", "brought", "emergency department", "lethargy", "confusion", "nausea", "past 2 days", "healthy", "past medical history", "only medications", "daily multivitamin", "acetaminophen", "daily", "hip", "Vital signs", "normal limits", "disoriented to place", "time", "abnormalities", "Laboratory studies", "a hemoglobin concentration", "1 g/dL", "serum calcium concentration", "14.7 mg dL", "serum creatinine", "mg dL", "0.9 mg/dL", "following", "underlying mechanism", "patient's condition"]}
{"question": "A 3-day-old female infant presents with poor feeding, lethargy, vomiting after feeding, and seizures. Labs revealed ketoacidosis and elevated hydroxypropionic acid levels. Upon administration of parenteral glucose and protein devoid of valine, leucine, methionine, and threonine, and carnitine, the infant began to recover. Which of the following enzymes is most likely deficient in this infant?", "answer": "Propionyl-CoA carboxylase", "options": {"A": "Branched-chain ketoacid dehydrogenase", "B": "Phenylalanine hydroxylase", "C": "Propionyl-CoA carboxylase", "D": "Cystathionine synthase", "E": "Homogentisate oxidase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 day old female infant presents", "poor feeding", "lethargy", "vomiting", "seizures", "Labs revealed ketoacidosis", "elevated", "acid levels", "administration", "parenteral glucose", "protein", "valine", "leucine", "methionine", "threonine", "carnitine", "infant began to recover", "following enzymes", "deficient", "infant"]}
{"question": "A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient has prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?", "answer": "Ziprasidone", "options": {"A": "Ziprasidone", "B": "Olanzapine", "C": "Clozapine", "D": "Clonazepam", "E": "Chlorpromazine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "recurrent panic attacks", "worsening", "past", "weeks", "seeing things", "not present", "short attention span", "badly affected", "past 6 months", "significant past medical history", "current medications", "patient", "afebrile", "vital signs", "normal limits", "BMI", "kg/m2", "unremarkable", "patient", "antipsychotic medication", "effects", "new medication", "weight", "following medications", "best course", "treatment", "patient"]}
{"question": "An investigator is studying the relationship between fetal blood oxygen saturation and intrauterine growth restriction using MRI studies. The magnetic resonance transverse relaxation time (T2) is inversely related to the concentration of deoxyhemoglobin so that high concentrations of deoxyhemoglobin produce a low signal intensity on T2-weighted MRI. In a normal fetus, the T2 signal is most likely to be the highest in which of the following vessels?", "answer": "Ductus venosus", "options": {"A": "Pulmonary veins", "B": "Ductus venosus", "C": "Superior vena cava", "D": "Descending aorta", "E": "Right atrium\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "relationship", "fetal blood oxygen saturation", "intrauterine growth restriction using MRI studies", "magnetic resonance transverse relaxation time", "related", "concentration", "deoxyhemoglobin so", "high", "deoxyhemoglobin", "low signal intensity", "weighted MRI", "normal fetus", "to", "highest", "following vessels"]}
{"question": "A 29-year-old woman presents to her primary care physician because she has been experiencing episodes of intense fear. Specifically, she says that roughly once per week she will feel an intense fear of dying accompanied by chest pain, lightheadedness, sweating, and palpitations. In addition, she will feel as if she is choking which leads her to hyperventilate. She cannot recall any trigger for these episodes and is afraid that they will occur while she is driving or working. In order to avoid this possibility, she has been getting rides from a friend and has been avoiding interactions with her coworkers. These changes have not stopped the episodes so she came in for evaluation. This patient's disorder is most likely genetically associated with a personality disorder with which of the following features?", "answer": "Submissive, clingy, and low self-confidence", "options": {"A": "Criminality and disregard for rights of others", "B": "Eccentric appearance and magical thinking", "C": "Grandiosity, entitlement, and need for admiration", "D": "Social withdrawal and limited emotional expression", "E": "Submissive, clingy, and low self-confidence"}, "meta_info": "step1", "answer_idx": "E", "metamap_phrases": ["29 year old woman presents", "primary care physician", "episodes of intense", "week", "intense fear of dying", "chest pain", "lightheadedness", "sweating", "palpitations", "addition", "choking", "leads", "to hyperventilate", "trigger", "episodes", "occur", "order to", "possibility", "getting", "interactions", "changes", "not stopped", "episodes", "patient's disorder", "associated with", "personality disorder", "following features"]}
{"question": "A 72-year-old man who was involved in a traffic collision is brought to the emergency room by the ambulance service. He was in shock and comatose at the time of presentation. On examination, the heart rate is 60/min, and the blood pressure is 70/40 mm Hg. The patient dies, despite resuscitative efforts. Autopsy reveals multiple internal hemorrhages and other evidence of ischemic damage affecting the lungs, kidneys, and brain. The patient’s heart shows evidence of gross anomaly similar to the picture. While acute hypovolemia is the likely cause of the ischemic changes seen in the lungs, kidneys, and brain, which of the following best explains the gross anomaly of his heart?", "answer": "Senile calcific aortic stenosis", "options": {"A": "Aortic valve regurgitation", "B": "Mitral valve stenosis", "C": "Senile calcific aortic stenosis", "D": "Accumulation of amyloid in the myocardium", "E": "Genetic mutation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man", "involved", "traffic collision", "brought", "emergency room", "ambulance service", "shock", "comatose", "time", "heart rate", "60 min", "blood pressure", "70 40 mm Hg", "patient", "resuscitative efforts", "Autopsy reveals multiple internal hemorrhages", "ischemic damage affecting", "lungs", "kidneys", "brain", "patients heart", "gross anomaly similar", "picture", "acute hypovolemia", "likely cause", "ischemic changes seen", "lungs", "kidneys", "brain", "following best", "gross anomaly", "heart"]}
{"question": "A 75-year-old woman with metastatic colon cancer comes to the physician requesting assistance in ending her life. She states: “I just can't take it anymore; the pain is unbearable. Please help me die.” Current medications include 10 mg oral hydrocodone every 12 hours. Her cancer has progressed despite chemotherapy and she is very frail. She lives alone and has no close family. Which of the following is the most appropriate initial action by the physician?", "answer": "Increase her pain medication dose", "options": {"A": "Submit a referral to psychiatry", "B": "Submit a referral to hospice care", "C": "Consult with the local ethics committee", "D": "Increase her pain medication dose", "E": "Initiate authorization of physician-assisted suicide"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["75 year old woman", "metastatic colon cancer", "assistance", "ending", "states", "I", "pain", "help", "die", "Current medications include 10 mg oral hydrocodone", "12 hours", "cancer", "progressed", "chemotherapy", "very frail", "lives alone", "close", "following", "most appropriate initial action", "physician"]}
{"question": "A 40-year-old man presents with a swollen left big toe that started this morning. The patient states that he attended a party last night and drank 4 glasses of whiskey. He denies any trauma to the foot. The patient has a history of similar episodes in the past that were related to alcohol use. His symptoms were previously relieved with ibuprofen. However, the pain persisted despite treatment with the medication. Physical examination reveals a tender and erythematous, swollen left 1st metatarsophalangeal joint. Which of the following events most likely contributed to his condition?", "answer": "Upregulation of cellular adhesion molecules to promote neutrophil migration", "options": {"A": "Vasoconstriction", "B": "Downregulation of integrins in the neutrophils", "C": "Upregulation of cellular adhesion molecules to promote neutrophil migration", "D": "Decreased expression of selectin in the endothelium", "E": "Activation of cytosolic caspases"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old man presents", "swollen left big toe", "started", "morning", "patient states", "attended", "night", "4 glasses", "trauma", "foot", "patient", "history of similar episodes", "past", "related", "symptoms", "relieved", "ibuprofen", "pain", "treatment", "medication", "reveals", "tender", "erythematous", "swollen left 1st metatarsophalangeal joint", "following", "likely", "condition"]}
{"question": "A 35-year-old woman presents to a pre-operative evaluation clinic prior to an elective cholecystectomy. She has a 5 pack-year smoking history. The anesthesiologist highly recommends to discontinue smoking for at least 8 weeks prior to the procedure for which she is compliant. What is the most likely histology of her upper respiratory tract's epithelial lining at the time of her surgery?", "answer": "Pseudostratified columnar", "options": {"A": "Simple squamous", "B": "Stratified squamous", "C": "Stratified columnar", "D": "Pseudostratified columnar", "E": "Simple columnar"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman presents", "pre-operati