A 26-year-old woman who is 32 weeks’ pregnant with her first child presents to her obstetrician for a routine visit. Her pregnancy has been uneventful and she has been feeling well, although somewhat anxious over the arrival of her first child. She has blood drawn for glucose levels following a 1-hour glucose tolerance test, but the laboratory mistakenly runs the sample for thyroid hormones; testing reveals the following values:

Total thyroxine: 20.5 µg/dL
Free thyroxine: 7.0 ng/dL
Total triiodothyronine: 280 ng/dL
Thyroid-stimulating hormone: 2.2 µU/mL

Given her thyroid hormone levels, what is the most appropriate next step in management?

A. Nothing; this woman does not have hyperthyroidism
B. Nothing; asymptomatic hyperthyroidism does not require treatment during pregnancy
C. Treatment with propylthiouracil because hyperthyroidism can have deleterious effects on the developing fetus
D. Treatment with surgery because hyperthyroidism can have deleterious effects on the developing fetus
E. Treatment with thyroxine because hyperthyroidism can have deleterious effects on the developing fetus

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A 31-year-old woman is brought to the emergency department after a motor vehicle crash. According to the paramedics, her left arm was pinned between the steering wheel and the door, so extrication was prolonged. The patient is fully oriented and complaining of severe pain in her upper arm. She is holding her arm in a protected position and is refusing a physical examination. X-ray of the left arm reveals a humeral shaft fracture. Which of the following signs of neurologic injury would this patient most likely have?

A. Claw hand
B. Deltoid paralysis
C. Intrinsic hand weakness
D. Waiter’s tip
E. Winged scapula
F. Wrist Drop

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A 63-year-old postmenopausal woman is referred to the gynecologic clinic by her primary care physician for evaluation of genital pruritus of 1 months’ duration. She has a remote history of human papillomavirus infection. She denies changes in vaginal discharge or vaginal bleeding. She also denies constitutional symptoms or weight loss. On examination she is in no apparent distress and heart rate is 70/min, blood pressure is 100/58 mm Hg, and respiratory rate is 10/min. Genital examination reveals an ulcerative white lesion approximately 1 cm in diameter on her labia majora. What is the most appropriate next step in management?

A. Obtain a biopsy of the lesion
B. Prescribe estrogen cream to be applied to area
C. Treat with acyclovir
D. Treat with cryotherapy
E. Treat with fluconazole
F. Treat with metronidazole

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An investigator wishes to assess whether vaccination increases the incidence of developmental diseases such as autism. He asks parents of recently diagnosed cases about their child’s vaccination history and compares their responses to those of parents of children who have not been diagnosed with autism. What is the most significant type of potential bias present in this study design?

A. Confounding bias
B. Lead-time bias
C. Length bias
D. Measurement bias
E. Recall bias

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A 38-year-old man is brought to the emergency department with crushing chest pain radiating to his left arm and mild shortness of breath that began approximately 30 minutes ago. ECG showed ST-segment elevation in leads II, III, AVF, and V4-V6 and a threefold increase in cardiac enzyme levels. His medical history is negative, but he has a positive family history of “heart problems” in his brother and in several members on his father’s side of the family. Physical examination reveals numerous painless yellow bumps on his elbows, knees, and ankle, which he has had since late childhood. His blood triglyceride level is 130 mg/dL, and his LDL cholesterol level is 320 mg/dL. The remaining laboratory values are unremarkable. Which of the following is the most likely explanation for these findings?

A. Excessive alcohol consumption
B. Inheritance of one mutant LDL cholesterol receptor gene
C. Lack of thyroid hormones
D. Lipoprotein lipase abnormality
E. Resistance to insulin hormone

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A 30-year-old woman presents to a primary care physician for a new patient visit. She reports recurrent episodes of pneumonia, bronchitis, and otitis over the past 4 years. Although her vaccinations were up to date, she developed tetanus following a foot laceration last year. Her lymph nodes and tonsils are enlarged. Laboratory testing reveals low IgG, IgA, and IgM levels. After referral to a hematologist, who rules out other acquired and genetic causes of her hypogammaglobulinemia, she is diagnosed with common variable immunodeficiency. This woman is at the highest risk of developing which of the following condition?

A. Cardiovascular disease
B. Lymphoma
C. Miscarriage
D. Renal disease
E. Splenic autoinfarction

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A 32-year-old man is stabbed in the left chest and presents to the emergency department in distress. His pulse is 130/min, blood pressure is 70/50 mm Hg, and respiratory rate is 39/min. The stab wound is in the left fifth intercostal space in the midaxillary line. On examination his trachea is deviated to the right, jugular veins are distended bilaterally, and he has absent breath sounds and hyperresonance to percussion on the left side. Subcutaneous emphysema is palpated on the left thoracic wall. What is the best next step in management?

A. Needle thoracostomy
B. Chest tube thoracotomy
C. Pericardiocentesis
D. Surgical exploration
E. Diagnostic peritoneal lavage

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Which of the following laboratory findings are characteristic of hemophilia B? PT refers to prothrombin time and aPTT refers to activated partial thromboplastin time.

A. A
B. B
C. C
D. D
E. E

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A 53-year-old woman with a history of polycystic kidney disease undergoes a renal transplant from a cadaveric donor. She experiences several bouts of acute rejection that are controlled by appropriate increases in immunosuppression during the first year posttransplant. During her fourth posttransplant year her creatinine is rising gradually. Transcutaneous biopsy reveals architectural distortion and sclerosis of the renal tubules. What is the most likely outcome of the patient’s condition?

A. Development of lymphoproliferative tumors requiring decreased immunosuppression
B. Gradual onset of renal failure and return to dialysis
C. Requirement of chronic antibiotic prophylaxis against urinary tract infection
D. Response to increased chronic immunosuppression
E. Response to a short course of high-dose steroids

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A 42-year-old stock broker with coronary artery disease presents to the emergency department with complaints of worsening chest pain that he began to experience during his walk earlier that morning. His wife insisted that he see a physician because he has been experiencing palpitations, dyspnea, and angina over the past 3 days. His blood pressure is 70/50 mm Hg, heart rate is 140/min, and oxygen saturation is 94% on room air; he has an irregular respiratory rate of 22/min. On physical examination he is fully oriented but slightly confused and distressed. An ECG is taken and shown in the image. What is the best next step in management?

A. Anticoagulation with warfarin
B. Close clinical observation
C. Echocardiogram
D. Electrocardioversion
E. Rate control with a ?-blocker

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