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1 | No. # | Questions | Answer from on OpenEvidence? | Answer from Dr.Oracle | Answer from MediSearch | Answer from ChatGPT4o | |||||||||||||||||||||
2 | 1 | A 30-year-old woman comes to the office because of a 3-day history of joint pain in her hands and a rash over her chest and arms that is slowly resolving. The joint pain in her hands has persisted and is exacerbated by writing or typing. She rates the pain as a 3 on a 10-point scale. The patient is a preschool teacher and reports that one of her students had a facial rash and fever 1 week prior to the development of her symptoms. The patient's medical history is unremarkable and her only medication is an oral contraceptive. She is in a monogamous relationship with her husband. She does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. BMI is 22 kg/m2. Vital signs are temperature 38.1°C (100.5°F), pulse 94/min, respirations 18/min, and blood pressure 107/58 mm Hg. Physical examination discloses a blanching, erythematous, papular rash on the anterior chest and proximal upper extremities. The first and second metacarpophalangeal joints of both hands are tender and swollen. The wrist joints also are tender to palpation but there is minimal swelling. Which of the following microorganisms is most likely to have caused this patient's symptoms? (A) Adenovirus (B) Borrelia burgdorferi (C) Coxsackievirus (D) Ehrlichia chaffeensis (E) Parvovirus B19 | See Supplemental Sheet | (E) Parvovirus B19 | (E) Parvovirus B19 | (E) Parvovirus B19 | |||||||||||||||||||||
3 | 2 | A 34-year-old elementary school teacher comes to the office because of a 1-month history of worsening right upper quadrant abdominal pain and discomfort. She describes the pain as a dull ache and says it is not affected by eating or defecating. She has not had nausea or changes in appetite or bowel habits. She feels the pain constantly while she is awake, but it rarely keeps her from sleeping. Acetaminophen provides occasional relief. She has been otherwise healthy. Medical history is unremarkable and her only other medication is an oral contraceptive. Vital signs are normal. Abdominal examination discloses hepatomegaly but no palpable masses or evidence of cirrhosis. Results of liver function tests and serum α- fetoprotein concentration are within the reference ranges. Serologic studies for hepatitis B and C are negative. Ultrasonography of the abdomen shows a 4×4-cm mass in the right lobe of the liver. Which of the following is the most likely diagnosis? (A) Hepatic adenoma (B) Hepatocellular cancer (C) Hydatid cyst (D) Metastatic ovarian cancer | See Supplemental Sheet | (A) Hepatic adenoma | (A) Hepatic adenoma | (A) Hepatic adenoma | |||||||||||||||||||||
4 | 3 | A 12-year-old girl is brought to the emergency department by her mother because of a 1-week history of worsening swelling in her legs. The patient also noticed blood in her urine yesterday. The bleeding has not recurred. She had an upper respiratory tract infection and sore throat 1 week ago that caused her to miss several days of school. Medical history is otherwise unremarkable and she takes no routine medications. Menarche has not yet occurred. BMI is 20 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 78/min, respirations 12/min, and blood pressure 136/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. Physical examination discloses erythema of the posterior pharynx, mild cervical lymphadenopathy, and 3+ pitting edema to both knees. Results of urinalysis are shown: Protein 150 mg/dL Blood Positive Leukocyte esterase Positive Nitrite Negative WBCs 5−10/hpf RBCs 10−25/hpf Casts 1−2/lpf Results of which of the following laboratory studies are most likely to be abnormal in this patient? (A) Bleeding time (B) Erythrocyte count (C) Serum concentration of C3 (D) Serum IgA concentration (E) Serum rheumatoid factor assay | See Supplemental Sheet | (C) Serum concentration of C3 | (C) Serum concentration of C3 | (C) Serum concentration of C3 | |||||||||||||||||||||
5 | 4 | A 45-year-old woman comes to the office because she has noticed during the past several months that her fingernails have become white, increasingly brittle, and seem to lift off her nail beds easily. During this time, she also has had episodes of feeling warm and perspiring. Medical history is remarkable for intravenous drug use 25 years ago. The patient takes only a multivitamin. Last menstrual period was 3 weeks ago. She appears thin and mildly anxious. She is 170 cm (5 ft 7 in) tall and weighs 48.5 kg (107 lb); BMI is 17 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 106/min, respirations 20/min, and blood pressure 136/92 mm Hg. Physical examination of the hands shows a white discoloration of the nail beds. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Chronic obstructive pulmonary disease (B) Diabetes mellitus (C) Endocarditis (D) Hyperthyroidism (E) Perimenopause | See Supplemental Sheet | (D) Hyperthyroidism | (D) Hyperthyroidism | (D) Hyperthyroidism | |||||||||||||||||||||
6 | 5 | A 30-year-old woman, who has been a patient in the practice for several years, comes to the office to ask for advice. Her husband has a family history of retinitis pigmentosa and she wants to know the probability of her 4-year-old son developing the disease. A family pedigree is shown. Which of the following is the most appropriate statement to the patient? (A) A geneticist should be consulted to answer her question (B) Her son must be tested to determine if he is affected (C) Her son will not be affected (D) She does not need to know, since there is nothing she can do if her son does have the condition (E) There is a 100% chance that her son will be affected | (A) A geneticist should be consulted to answer her question | (A) A geneticist should be consulted to answer her question | (A) A geneticist should be consulted to answer her question | ||||||||||||||||||||||
7 | 6 | A 48-year-old man comes to the clinic because of a 10-year history of recurrent, intrusive thoughts that his house will be broken into and damaged by criminals or accidentally destroyed by a fire when he is not home. These thoughts have worsened during the past 2 months. He reports now spending 4 hours daily checking that the doors and windows are closed and locked and that the stove and oven are turned off; he previously spent 2 hours daily doing these tasks. He says he cannot keep a job or leave the house very much because of the amount of time he spends checking these things. He has no other history of serious illness and takes no medications. Physical examination shows no abnormalities. On mental status examination, he has an anxious mood and a sad affect. He is fully oriented. He is not having hallucinations or delusions. The most effective pharmacotherapy for this patient is an agent that targets which of the following neurotransmitters? (A) γ-Aminobutyric acid (B) Dopamine (C) Glutamate (D) Norepinephrine (E) Serotonin | See Supplemental Sheet | (E) Serotonin | (A) γ-Aminobutyric acid | (A) γ-Aminobutyric acid | |||||||||||||||||||||
8 | 7 | A phase 2, multicenter trial was conducted to determine the efficacy of a new vaccine for prevention of HIV infection. The study enrolled 4000 subjects, aged 20 to 65 years. Of these subjects, 2100 were men and 1900 were women; 2500 were white, 1000 were African American, 300 were Hispanic, and 200 were Asian/Pacific Islanders. Results of the trial showed no overall benefit of the vaccine. However, post hoc analysis disclosed a small but statistically significant vaccine protection among African American subjects. Which of the following is the most accurate rationale for questioning the validity of efficacy analysis of the HIV vaccine among the African American study subjects? (A) Allocation bias favored African American subjects (B) HIV infection is more prevalent among African American populations (C) The study was not blinded (D) There was a Type II error (E) Vaccine response among African American subjects was not the primary outcome measure | See Supplemental Sheet | (E) Vaccine response among African American subjects was not the primary outcome measure | (E) Vaccine response among African American subjects was not the primary outcome measure | (A) Allocation bias favored African American subjects | |||||||||||||||||||||
9 | 8 | A 12-year-old boy with sickle cell disease and type 1 diabetes mellitus is brought to the office by his mother for an initial visit. The family recently moved to the area. Type 1 diabetes mellitus was diagnosed in the patient 6 years ago. Since that time, he has been treated with insulin and dietary management. His insulin regimen has not changed during the past year; however, his mother says he has been only marginally compliant with his insulin and dietary regimens. His diabetic diary shows home fingerstick blood glucose concentrations ranging from 140–200 mg/dL during the past 3 months. He admits to checking his glucose concentrations infrequently. Measurement of hemoglobin A1c obtained last week was 5.4%. The patient's vital signs are temperature 36.8°C (98.2°F), pulse 72/min, respirations 24/min, and blood pressure 110/64 mm Hg. Physical examination shows no abnormalities. Which of the following is the most likely explanation for the discrepancy between the patient's home fingerstick blood glucose concentrations and his hemoglobin A1c? (A) He has iron deficiency anemia (B) His daily glucose control is better than recorded (C) His glucometer is reading falsely high and should be replaced (D) His hemoglobin A1c is likely a result of laboratory error and should be repeated (E) His sickle cell disease is affecting his hemoglobin A1c | See Supplemental Sheet | (E) His sickle cell disease is affecting his hemoglobin A1c | (E) His sickle cell disease is affecting his hemoglobin A1c | (E) His sickle cell disease is affecting his hemoglobin A1c | |||||||||||||||||||||
10 | 9 | A 35-year-old man, who has been your patient for the past year, comes to the office to request that a copy of his medical records be sent to another physician in town. The patient has an overdue account balance of $750, which he has not paid for several months. He signs an office form authorizing release of health information and provides the name and address of the other physician to whom he would like the records sent. It is most appropriate to inform this patient of which of the following regarding his request for release of his medical records? (A) They will be released to his new physician promptly (B) They will be released when he makes a payment on his account (C) They will be released when he pays his balance in full (D) They will be released when his new physician contacts your office and requests them | See Supplemental Sheet | (A) They will be released to his new physician promptly | N/A | (C) They will be released when he pays his balance in full | |||||||||||||||||||||
11 | 10 | A 47-year-old man is admitted to the intensive care unit because of lower gastrointestinal bleeding. He has a history of alcohol-induced cirrhosis. Physical examination shows marked ascites and splenomegaly; the spleen tip is palpated 4 cm below the left costal margin. Results of laboratory studies are shown: Serum Blood Creatinine 1.5 mg/dL Hematocrit 29% Hemoglobin 9.7 g/dL Platelet count 105,000/mm3 PT 25 seconds INR 2.5 Which of the following mechanisms most increases this patient’s risk for bleeding? (A) Decreased production of factor VII (B) Defective platelet aggregation (C) Deficiency of thrombopoietin (D) Inhibition of vitamin K epoxide reductase (E) Splenic sequestration | See Supplemental Sheet | (A) Decreased production of factor VII | (B) Defective platelet aggregation | (B) Defective platelet aggregation | |||||||||||||||||||||
12 | 11 | A 57-year-old woman comes to the office for a preoperative evaluation 2 weeks before undergoing scheduled laparoscopic cholecystectomy. Medical history is otherwise unremarkable and the patient takes no medications. Family history is significant for stable angina in her father and rheumatoid arthritis in her mother. The patient has a 102-year-old grandmother who resides in a nursing care facility and has Parkinson disease. The patient does not smoke cigarettes or drink alcoholic beverages. During the interview, her face is expressionless. She has a flexed posture and is unable to open her mouth wide. She is 173 cm (5 ft 8 in) tall and weighs 81 kg (179 lb); BMI is 27 kg/m2. Vital signs are normal. Physical examination discloses thickening and hardening of the skin over the dorsum of the hands and forearms, as well as mild kyphosis. Strength testing shows no abnormalities; muscle tension is normal. Passive and active range of motion of the upper extremities is full. Gait is slow and deliberate. The remainder of the physical examination discloses no abnormalities. Prior to surgery, further evaluation is indicated for which of the following conditions in this patient? (A) Osteitis deformans (Paget disease) (B) Parkinson disease (C) Progressive supranuclear palsy (D) Sarcopenia (E) Systemic sclerosis (scleroderma) | (E) Systemic sclerosis (scleroderma) | (B) Parkinson disease | (C) Progressive supranuclear palsy | ||||||||||||||||||||||
13 | 12 | A 52-year-old man with hepatic cirrhosis comes to the emergency department because of a 3-hour history of vomiting blood. Esophagogastroduodenoscopy confirms actively bleeding esophageal varices. Based on the abstract shown, the physician is considering an emergency portacaval shunt (EPCS) procedure rather than endoscopic sclerotherapy (EST). According to the results in the abstract, approximately how many patients must be treated with EPCS rather than EST to prevent one case of recurrent portal-systemic encephalopathy? (A) 1 (B) 3 (C) 5 (D) 10 (E) 16 | (E) 16 | (C) 5 | Unable to Answer | ||||||||||||||||||||||
14 | 13 | A 52-year-old man with hepatic cirrhosis comes to the emergency department because of a 3-hour history of vomiting blood. Esophagogastroduodenoscopy confirms actively bleeding esophageal varices. Based on the abstract shown, the physician is considering an emergency portacaval shunt (EPCS) procedure rather than endoscopic sclerotherapy (EST). Which of the following most strongly limits the generalizability of this study's findings? (A) The allocation was concealed (B) EPCS is available only at specialty centers (C) The follow-up period was too short (D) The patients were not blinded (E) Unmeasured confounders were not controlled by the study design | (B) EPCS is available only at specialty centers | (B) EPCS is available only at specialty centers | (E) Unmeasured confounders were not controlled by the study design | ||||||||||||||||||||||
15 | 14 | A 52-year-old man with hepatic cirrhosis comes to the emergency department because of a 3-hour history of vomiting blood. Esophagogastroduodenoscopy confirms actively bleeding esophageal varices. Based on the abstract shown, the physician is considering an emergency portacaval shunt (EPCS) procedure rather than endoscopic sclerotherapy (EST). Which of the following conclusions is most appropriate based on the results presented in the table? (A) The 95% confidence interval for the difference in survival between EPCS and EST for Child-Pugh class A patients includes 0 years (B) EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring transfusion (C) The median survival after EPCS is statistically significantly less for Child-Pugh class C than for Child-Pugh class B (D) The randomization procedure was ineffective in decreasing bias in this study | (B) EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring transfusion | (C) The median survival after EPCS is statistically significantly less for Child-Pugh class C than for Child-Pugh class B | (A) The 95% confidence interval for the difference in survival between EPCS and EST for Child-Pugh class A patients includes 0 years | ||||||||||||||||||||||
16 | 15 | A 32-year-old man comes to the office because of a 10-day history of a red rash that has spread over his entire torso. He says the rash is not itchy or painful. He reports having a flu-like illness nearly 5 weeks ago, with associated headache, neck stiffness, muffled hearing, and a canker sore on his tongue. All of these symptoms have resolved without treatment. Additional medical history is unremarkable and he takes no medications. BMI is 18 kg/m2. Vital signs are normal. Specific additional history should be obtained to determine whether which of the following has occurred during the past 6 months? (A) Blood transfusions (B) Exposure to toxic chemicals (C) International travel (D) Tobacco use (E) Unprotected sexual intercourse | See Supplemental Sheet | (E) Unprotected sexual intercourse | (C) International travel | (C) International travel | |||||||||||||||||||||
17 | 16 | The nurse at a local elementary school contacts you about 12 children she has seen in the past 2 weeks. All of the children had similar symptoms of nasal congestion, sneezing, nonproductive coughing, and eye irritation. None of the children had fevers. Several teachers and support staff have reported having the same symptoms. No similar outbreaks have been reported in the community. There was a fire in the school several weeks ago with significant smoke and water damage to classrooms, the cafeteria, and the school ventilation system. Repairs were quickly made and classes resumed. The most likely cause for the students' and teachers' symptoms is exposure to which of the following? (A) Asbestos (B) Legionella pneumophila (C) Mold spores (D) Mycoplasma pneumoniae (E) Respiratory syncytial virus | See Supplemental Sheet | (C) Mold spores | (C) Mold spores | (C) Mold spores | |||||||||||||||||||||
18 | 17 | A 20-year-old man comes to the office at the request of his family for an examination 1 day after a motor vehicle accident for which he was at fault. The patient was arrested for the third time after police discovered he had been driving under the influence of alcohol. He has been your patient since early adolescence, and he has a history of truancy, shoplifting, and two attempts to run away from home. He dropped out of high school in his senior year. He was fired from his most recent job because he threatened a coworker with a hammer. He has been unemployed for the past 8 months, and as a result he has many unpaid debts. He seems unconcerned about his current difficulties and has no plans for seeking employment or paying his debts. Despite these facts, you find the patient charming and interactive, and he conveys a sincere intention to change his behavior. Which of the following is the most likely diagnosis? (A) Antisocial personality disorder (B) Borderline personality disorder (C) Conduct disorder (D) Narcissistic personality disorder (E) Schizotypal personality disorder | See Supplemental Sheet | (A) Antisocial personality disorder | (A) Antisocial personality disorder | (A) Antisocial personality disorder | |||||||||||||||||||||
19 | 18 | A 45-year-old limousine driver comes to the office for an initial appointment because he would like you to fill out and sign a legal document at the request of his attorney. The patient states that he is filing a lawsuit against the limousine company that employs him because he developed post-traumatic stress disorder following a motor vehicle collision. He appears irritable and tense as he provides his history. He relays his symptoms by reading them aloud from a written list. At this time, which of the following is the most appropriate approach toward confirming the underlying diagnosis of this patient? (A) Administer amobarbital and then interview the patient (B) Ask the patient to provide a narrative with detailed description of the incident and of his symptoms (C) Interview the patient under hypnosis (D) Interview the patient while paying close attention to his willingness to make eye contact (E) Tell the patient he is exhibiting behaviors that are suggestive of malingering and see how he responds | See Supplemental Sheet | (B) Ask the patient to provide a narrative with detailed description of the incident and of his symptoms | (B) Ask the patient to provide a narrative with detailed description of the incident and of his symptoms | (B) Ask the patient to provide a narrative with detailed description of the incident and of his symptoms | |||||||||||||||||||||
20 | 19 | A 39-year-old woman comes to the office because of gradually increasing shortness of breath while doing her usual household activities. She also reports fatigue, a feeling of heaviness in her chest with exertion, trouble sleeping, and the very recent onset of a rapid heart beat and fluttering in her chest. She says, "I was always sick as a child." She does not smoke cigarettes, and she is not currently taking any medications other than occasional aspirin. Her father died of a myocardial infarction at age 55 years. She is married and has two teenaged children. She did have some shortness of breath at the end of her second pregnancy. Physical examination today shows a thin woman with an irregular pulse of 130/min. Thyroid gland is normal to palpation. There is a prominent diastolic rumble heard best over the apical area of her heart. Lungs are clear; there is no hepatomegaly or pretibial edema. Which of the following is the most helpful diagnostic study at this time? (A) Chest x-ray (B) ECG (C) Serum anti-streptolysin O titer (D) Serum C-reactive protein concentration (E) Serum thyroid-stimulating hormone (TSH) concentration | See Supplemental Sheet | (B) ECG | (B) ECG | (B) ECG | |||||||||||||||||||||
21 | 20 | A 10-year-old boy with a traumatic brain injury sustained during infancy is examined in the nursing care facility where he resides because he has had no urine output during the past 24 hours. During the past 4 days, he has had decreasing urine output, intermittent fever, rhinorrhea, and cough. As a result of his brain injury, the patient has severe developmental delay and a seizure disorder. He is fed orally, but he is nonverbal and nonambulatory. Medications are levetiracetam, docusate, and multivitamins. The patient is 131 cm (4 ft 2 in; 10th percentile) tall and weighs 26 kg (57 lb; 10th percentile). BMI is 14 kg/m2 (10th percentile). Vital signs are temperature 38.8°C (101.8°F), pulse 80/min, respirations 25/min, and blood pressure 110/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. The patient appears thin. He is awake and is not in apparent distress. He is responsive to touch. Auscultation of the lungs discloses scattered coarse crackles and rhonchi but good air entry and normal work of breathing. Results of laboratory studies are shown: Serum Blood Urea nitrogen 78 mg/dL Hematocrit 37% Creatinine 3.2 mg/dL Hemoglobin 12.5 g/dL Na+ 131 mEq/L WBC 12,000/mm3 K+ 5.6 mEq/L Neutrophils, segmented 60% Cl− 88 mEq/L Lymphocytes 40% HCO3− 16 mEq/L Platelet count 250,000/mm3 Urine Specific gravity 1.030 (N=1.003–1.029) Creatinine 90 mg/dL Na+ 8 mEq/L Which of the following is the most likely cause of this patient's altered kidney function? (A) Acute tubular necrosis (B) Decreased intravascular volume (C) Medication-related interstitial nephritis (D) Neurogenic bladder (E) Pyelonephritis | See Supplemental Sheet | (B) Decreased intravascular volume | (A) Acute tubular necrosis | (A) Acute tubular necrosis | |||||||||||||||||||||
22 | 21 | A 47-year-old woman is brought to the emergency department by ambulance 30 minutes after a motor vehicle collision in which the car she was driving overturned. At the scene, the patient was immobilized and an intravenous line was started. On arrival, the patient indicates pain in the right lower extremity caused by an open wound in the right popliteal fossa. She appears distressed. Vital signs are temperature 36.5°C (97.7°F), pulse 120/min, respirations 18/min, and blood pressure 90/75 mm Hg. Pulse oximetry on 50% oxygen via nonrebreather mask shows an oxygen saturation of 95%. Lungs are clear to auscultation and cardiac examination discloses no abnormalities. The abdomen is soft without tenderness. The right lower extremity is bruised and ecchymotic above the knee. The femoral pulse is 2+ bilaterally and the popliteal and tibial pulses are absent on the right and 2+ on the left. Neurologic examination discloses decreased motor function below the right knee and decreased sensation over the distal right lower extremity. X-ray and intraoperative arteriogram of the right lower extremity are shown. Which of the following is the most likely cause of the findings on the arteriogram? (A) Anterior dislocation of the right knee (B) Arterial spasm (C) Fracture of the right femur (D) Fracture of the right tibia and fibula (E) Posterior dislocation of the right knee | (E) Posterior dislocation of the right knee | (D) Fracture of the right tibia and fibula | (C) Fracture of the right femur | ||||||||||||||||||||||
23 | 22 | A 27-year-old man comes to the office with his wife because of a recent episode of loss of muscle control. He says, "I was at a reception, someone told a joke, and when I laughed, my legs collapsed!" His wife says that he recovered in a few seconds and he did not lose consciousness. He has a long history of sleepiness and he is able to go to sleep quickly. He usually awakens feeling refreshed after a short nap. He has no history of similar episodes or hallucinations. There is no family history of similar problems. Vital signs are normal. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Narcolepsy (B) Primary hypersomnia (C) A seizure disorder (D) Sleep paralysis (E) Vasovagal syndrome | See Supplemental Sheet | (A) Narcolepsy | (A) Narcolepsy | (A) Narcolepsy | |||||||||||||||||||||
24 | 23 | A study is being conducted to assess mesothelioma in shipyard workers. A large shipyard firm has provided the asbestos exposure records of all employees during the past 50 years. The health insurer for the workers has provided claims data that documents all chest x-rays and diagnoses of mesothelioma among current workers and retirees. The study enrolled shipyard workers who were diagnosed with mesothelioma and shipyard workers who were not diagnosed with mesothelioma. All subjects in the study had to have chest x‑rays. Which of the following is the best rationale for selecting a comparison group that had chest x-rays? (A) Address confounding (B) Demonstrate causality (C) Minimize ascertainment bias (D) Reduce recall bias | See Supplemental Sheet | (C) Minimize ascertainment bias | (C) Minimize ascertainment bias | (C) Minimize ascertainment bias | |||||||||||||||||||||
25 | 24 | An 88-year-old man with osteoarthritis is brought to the office by his daughter because of a 2-day history of severe low back pain and inability to walk. He says he has not fallen and does not recall any trauma to his back. Five years ago, he underwent bilateral hip replacement. His pain and mobility improved following the operation but have worsened during the past year. He now is most comfortable using a wheelchair for ambulation but is able to ambulate for short distances with a walker and assistance. One year ago, carcinoma of the prostate was diagnosed, but he declined therapy and said, "I'm an old man. When my time comes, I want to die. Just keep me as comfortable as you can." Vital signs today are temperature 36.6°C (97.9°F), pulse 88/min, respirations 16/min, and blood pressure 188/66 mm Hg. The patient is grimacing with pain and holding his lower back. Palpation discloses point tenderness over L3 through L4, and S1. X-rays of the lumbosacral spine show lytic lesions and compression fracture. The patient refuses additional diagnostic studies. The daughter fears that her father will be "abandoned" if he is not evaluated for additional treatment. Which of the following is the most appropriate next step in response to the daughter's concern? (A) Explain the daughter's concerns to the patient and persuasively present the advantages of further evaluation (B) Explain to the daughter that no significant treatment will result from further testing and recommend having a home health nurse (C) Obtain consultation with an oncologist to assess the patient's need for further testing (D) Reassure the daughter and recommend hospice care consultation (E) Reassure the daughter and recommend transfer of the patient to an assisted living facilit | See Supplemental Sheet | (D) Reassure the daughter and recommend hospice care consultation | (D) Reassure the daughter and recommend hospice care consultation | (A) Explain the daughter's concerns to the patient and persuasively present the advantages of further evaluation | |||||||||||||||||||||
26 | 25 | A 23-year-old man comes to the office because of a 7-day history of fever, crampy abdominal pain, and diarrhea. He says the abdominal pain worsens with oral intake. He has been having 8 to 10 episodes of diarrhea daily. He has not traveled recently and has had no sick contacts. Medical history is unremarkable and he takes no medications. He does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. He is not sexually active. Vital signs are temperature 38.3°C (101.0°F), pulse 118/min, respirations 18/min, and blood pressure 108/58 mm Hg. Bowel sounds are hyperactive. The abdomen is diffusely tender to palpation; no masses are palpated. Neither the liver edge nor the spleen can be palpated. Digital rectal examination shows grossly bloody stool. A stool culture is obtained, and empiric pharmacotherapy is initiated. Which of the following microorganisms is the most likely cause of this patient's condition? (A) Campylobacter jejuni (B) Candida albicans (C) Enterovirus (D) Giardia lamblia | See Supplemental Sheet | (A) Campylobacter jejuni | (A) Campylobacter jejuni | (A) Campylobacter jejuni | |||||||||||||||||||||
27 | 26 | Results of the stool culture show growth of Campylobacter jejuni. The patient returns to the office 3 weeks later. He reports total resolution of his fever and gastrointestinal symptoms after completion of prescribed ciprofloxacin therapy, but he has had pain and swelling of his left knee during the past 3 days. The pain worsens with weight bearing. He rates the pain as a 6 on a 10-point scale. Vital signs are temperature 37.1°C (98.8°F), pulse 78/min, respirations 16/min, and blood pressure 112/58 mm Hg. Physical examination discloses erythema and warmth of the left knee with marked synovitis. Direct palpation and flexion of the knee elicit pain. Which of the following is the most appropriate diagnostic study to determine the cause of this patient's symptoms? (A) Blood cultures (B) CD4+ T-lymphocyte count (C) Human leukocyte antigen-B27 assay (D) Serum rheumatoid factor assay (E) Stool culture | See Supplemental Sheet | (C) Human leukocyte antigen-B27 assay | (A) Blood cultures | (A) Blood cultures | |||||||||||||||||||||
28 | 27 | A 46-year-old woman, gravida 1, para 1, comes to the office because of a 2-week history of black discharge from her right nipple. The patient had mammography and ultrasonography of the breasts 2 months ago for evaluation of increased glandularity, palpated in the upper outer quadrant of the right breast, noted at her most recent annual examination. The studies showed likely benign findings with recommended follow-up in 6 months. Medical history is otherwise unremarkable and she takes no medications. BMI is 30 kg/m2. Vital signs are normal. Palpation of the right breast discloses glandularity in the upper outer quadrant but no other masses. There is scant, black discharge from the right nipple. Which of the following is the most appropriate next step in diagnosis? (A) Ductography (B) Excisional biopsy of glandular tissue (C) Repeat mammography (D) Repeat ultrasonography of the right breast (E) No further workup is indicated | See Supplemental Sheet | (A) Ductography | (B) Excisional biopsy of glandular tissue | (A) Ductography | |||||||||||||||||||||
29 | 28 | A physician is conducting a retrospective review of a trial involving the use of Drug X in patients with a specific disease. It is known that Drug X is associated with an increased probability of cancer in patients who use the drug. A total of 600 individuals with a specific disease were included in the trial. Of the participants, 200 individuals received Drug X and 400 individuals did not receive it. One hundred individuals who received Drug X died of a particular type of cancer and 100 individuals who did not receive the drug died of the same type of cancer. Based on these data, which of the following is the relative risk of death from this type of cancer in individuals who take Drug X as compared with individuals who do not take Drug X? (A) Individuals who take Drug X have an equal risk of dying from this type of cancer (B) Individuals who take Drug X have four times the risk of dying from this type of cancer (C) Individuals who take Drug X have three times the risk of dying from this type of cancer (D) Individuals who take Drug X have two times the risk of dying from this type of cancer (E) The risk for dying cannot be determined from the data | See Supplemental Sheet | (D) Individuals who take Drug X have two times the risk of dying from this type of cancer | (D) Individuals who take Drug X have two times the risk of dying from this type of cancer | (D) Individuals who take Drug X have two times the risk of dying from this type of cancer | |||||||||||||||||||||
30 | 29 | A 23-year-old woman is brought to the emergency department by her friend because of headache, vomiting, and diarrhea that developed rapidly 6 hours ago. She also has had associated fever, chills, generalized muscle pain, and diffuse rash. The patient previously was healthy and has had no known exposure to anyone who has been ill. Medical history is unremarkable and her only medication is an oral contraceptive. She is currently menstruating. She does not smoke cigarettes or use illicit drugs. She drinks one to two alcoholic beverages weekly. She is disoriented to person, place, and time. Vital signs are temperature 39.2°C (102.6°F), pulse 114/min, respirations 26/min, and blood pressure 82/44 mm Hg. Pulse oximetry on oxygen at 2 L/min via nasal cannula shows an oxygen saturation of 90%. Examination of the skin shows diffuse macular erythema. Lungs are clear to auscultation. Cardiac examination discloses normal heart sounds and no murmur. Bowel sounds are hypoactive. Results of laboratory studies are shown: Serum Blood ALT 164 U/L Hemoglobin 16.4 g/dL AST 130 U/L WBC 14,300/mm3 with left shift Urea nitrogen 57 mg/dL Platelet count 52,000/mm3 Creatinine 2.2 mg/dL A response to which of the following is the most likely cause of this patient's condition? (A) Bacterial endotoxin (B) Bacterial exotoxin (C) Immunoglobulin E antibody (D) Immunoglobulin G antibody (E) Viral capsid (F) Viral coat | See Supplemental Sheet | (B) Bacterial exotoxin | (B) Bacterial exotoxin | (B) Bacterial exotoxin | |||||||||||||||||||||
31 | 30 | A 68-year-old man comes to the office because of a 4-week history of increasing stiffness in his shoulders and upper arms. He is an avid golfer and has been unable to play in the morning because of the stiffness. He says that the stiffness is somewhat improved in the afternoon. He also has felt fatigued and sometimes "headachy and feverish." Medical history is significant for arthritis in his knees treated with acetaminophen, which has not relieved his shoulder and arm pain, and hyperlipidemia treated with pravastatin. He is a retired radiologist. Vital signs are temperature 37.7°C (99.8°F), pulse 76/min, respirations 18/min, and blood pressure 145/80 mm Hg. There is no tenderness in the shoulder girdle, and range of motion is normal bilaterally. The remainder of the physical examination discloses no abnormalities. Results of additional laboratory studies are shown: Serum Blood Creatine kinase 88 U/L Hematocrit 36% Hemoglobin 12.0 g/dL WBC 8600/mm3 ESR 88 mm/h Which of the following is the most significant risk factor for the development of this patient's condition? (A) Age (B) Gender (C) History of osteoarthritis (D) Previous occupation (E) Use of pravastatin | See Supplemental Sheet | (A) Age | (A) Age | (A) Age | |||||||||||||||||||||
32 | 31 | A 16-month-old girl is brought to the emergency department by emergency medical technicians because of a generalized tonic-clonic seizure that began 25 minutes ago and has continued despite administration of 0.5 mg/kg rectal diazepam 10 minutes ago. The patient was at home at the time of the seizure. In the emergency department, she is given an additional 0.5 mg/kg dose of diazepam intravenously and the convulsion terminates. Within 2 minutes, her oxygen saturation drops to 75% and she appears cyanotic. Respirations are 10/min and shallow. She receives bag-valve-mask ventilation, followed by intubation and mechanical ventilation. Medical history is unremarkable. She takes no medications. Temperature is 39.1°C (102.5°F). Which of the following is the most likely underlying cause of the patient's respiratory insufficiency? (A) Airway occlusion (B) Encephalitis (C) Medication-induced suppression of central respiratory drive (D) Meningitis (E) Ongoing nonconvulsive seizure activity | See Supplemental Sheet | (C) Medication-induced suppression of central respiratory drive | (C) Medication-induced suppression of central respiratory drive | (C) Medication-induced suppression of central respiratory drive | |||||||||||||||||||||
33 | 32 | A 32-year-old woman comes to the emergency department because of a 3-day history of fatigue and postural light- headedness. She also reports nausea with one episode of vomiting this morning and adds that her stools and urine have been darker than usual lately. Medical history is significant for stage III-B Hodgkin lymphoma. She started the first cycle of chemotherapy 8 days ago. Additional medications include ferrous gluconate, hydrocodone, and prochlorperazine. She is currently receiving 0.9% saline at 75 mL/hr. Vital signs today are temperature 37.5°C (99.5°F), pulse 76/min supine and 80/min standing, respirations 16/min, and blood pressure 125/65 mm Hg supine and 120/60 mm Hg standing. Pulse oximetry on room air shows an oxygen saturation of 94%. Lungs are clear to auscultation. Cardiac examination discloses a soft systolic murmur at the left upper sternal border. There is no hepatosplenomegaly or tenderness on abdominal examination. Rectal examination discloses no masses. Stool is black and test for occult blood is negative. Results of laboratory studies are shown: Blood Urine Hematocrit 24% Specific gravity 1.032 (N=1.010–1.025) WBC 2400/mm3 Bilirubin Negative Platelet count 78,000/mm3 RBC Negative Which of the following is the most likely explanation for the patient's current condition? (A) Adverse effect of medications (B) Bone marrow metastases (C) Gastrointestinal blood loss (D) Hemodilution (E) Hemolytic anemia | See Supplemental Sheet | (A) Adverse effect of medications | (C) Gastrointestinal blood loss | (C) Gastrointestinal blood loss | |||||||||||||||||||||
34 | 33 | A male neonate, who was born at 36 weeks' gestation 2 hours ago in the labor and delivery unit of the hospital, now shows signs of respiratory difficulty. The mother, an 18-year-old primigravid woman, smoked one pack of cigarettes daily throughout her pregnancy. She received prenatal care during most of the pregnancy. One episode of chlamydial cervicitis was detected during the last trimester and treated with azithromycin. The neonate was born via cesarean delivery due to fetal heart rate decelerations. The amniotic fluid was stained with light particulate meconium. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. The patient is 50 cm (20 in; 50th percentile) long and weighs 3005 g (6 lb 10 oz; 50th percentile); head circumference is 35 cm (14 in; 50th percentile). The infant's vital signs now are temperature 36.6°C (97.8°F), pulse 150/min, and respirations 70/min. Pulse oximetry on room air shows an oxygen saturation of 95%. Physical examination discloses mild subcostal and intercostal retractions. Chest x-ray shows prominent pulmonary vascular markings and fluid in the intralobar fissures. Which of the following is the most likely diagnosis? (A) Chlamydial pneumonia (B) Group B streptococcal sepsis (C) Meconium aspiration syndrome (D) Respiratory distress syndrome (E) Transient tachypnea of newborn | See Supplemental Sheet | (E) Transient tachypnea of newborn | (C) Meconium aspiration syndrome | (C) Meconium aspiration syndrome | |||||||||||||||||||||
35 | 34 | A 35-year-old man is brought to the emergency department 30 minutes after a bicycle accident because of pain in his left arm. The patient is 183 cm (6 ft) tall and weighs 79 kg (175 lb); BMI is 24 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 75/min, respirations 16/min, and blood pressure 116/68 mm Hg. On arrival, the patient is awake and alert. Examination of the cervical spine shows no abnormalities. The left forearm is diffusely tender to palpation, and the patient is unable to extend his elbow. X-ray of the left forearm is shown. Which of the following is the most likely diagnosis? (A) Fractured radius, dislocated ulna (B) Fractured radius only (C) Fractured ulna, dislocated humerus (D) Fractured ulna, dislocated radius (E) Fractured ulna only | (D) Fractured ulna, dislocated radius | (D) Fractured ulna, dislocated radius | (A) Fractured radius, dislocated ulna | ||||||||||||||||||||||
36 | 35 | A 26-year-old doctoral candidate comes to the office 1 day after she passed bloody mucus with her stool. She noticed mild abdominal cramping and some constipation preceding the episode; she has not had diarrhea or melanotic stools. She has not had any exposure to unusual or poorly kept food or to any known infectious agents. She says she has been under considerable stress because of the anticipated defense of her thesis. Her only medication is acetaminophen for occasional headaches. Her father had colon cancer and died at age 48 years from metastatic disease. She recalls being told that an aunt died of an unknown abdominal tumor. The patient's vital signs are temperature 37.6°C (99.6°F), pulse 90/min, respirations 18/min, and blood pressure 110/74 mm Hg. Abdomen is mildly distended, nontympanitic, and tender to palpation only in the right lower quadrant. There is no rebound tenderness or guarding. Pelvic examination shows no masses or mucosal lesions. Rectal examination elicits pain and bloody mucus. Which of the following is the most appropriate diagnostic study? (A) Colonoscopy (B) Esophagogastroduodenoscopy (C) Lower gastrointestinal barium study (D) Ultrasonography of the appendix (E) Upper gastrointestinal barium study with small-bowel follow-through | See Supplemental Sheet | (A) Colonoscopy | (A) Colonoscopy | (A) Colonoscopy | |||||||||||||||||||||
37 | 36 | A 15-year-old girl is brought to the office by her parents because of a 2-month history of progressively worsening gait disturbance. She has fallen several times, once striking her head and causing a brief loss of consciousness. Her parents say, "She's been acting like a delinquent lately. We think she might be using drugs." Medical history is remarkable for asthma treated with a corticosteroid inhaler as needed. Family history is remarkable for multiple sclerosis in a maternal aunt, parkinsonism in her paternal grandfather, and cancer in several paternal relatives, including a grandmother who died from a hemangioblastoma. Vital signs are normal. The patient is awake and alert, but she avoids eye contact and will not answer questions. Auscultation of the lungs discloses expiratory wheezing. Cardiac and abdominal examinations disclose no abnormalities. She has mild bilateral papilledema. Her stance and gait are wide-based, and she is unable to perform a tandem walk. Toxicology screening of the urine is positive for marijuana and cocaine metabolites. Which of the following is the most likely initial working diagnosis? (A) Cerebellar tumor (B) Drug-related ataxia (C) Epidural hematoma (D) Juvenile-onset parkinsonism (E) Multiple sclerosis | See Supplemental Sheet | (A) Cerebellar tumor | (B) Drug-related ataxia | (B) Drug-related ataxia | |||||||||||||||||||||
38 | 37 | A 70-year-old man is brought to the emergency department by his son because of a 2-day history of right upper quadrant abdominal pain, chills, and confusion. He has vomited twice during this time despite decreased food intake. The patient has hypertension controlled with hydrochlorothiazide. Medical and surgical history is otherwise unremarkable. Vital signs are temperature 40.2°C (104.4°F), pulse 110/min, respirations 18/min, and blood pressure 100/60 mm Hg. The patient appears seriously ill without evidence of jaundice. Abdominal examination discloses tenderness to palpation over the liver without guarding. Results of laboratory studies are shown: Serum Blood Amylase 350 U/L WBC 16,500/mm3 with prominent immature forms Bilirubin, total 2.1 mg/dL Neutrophils, segmented 42% Neutrophils, bands 25% Serum urea nitrogen and creatinine concentrations are within the reference ranges, as are results of liver function tests. Ultrasonography of the abdomen shows multiple stones in the gallbladder and a common bile duct measuring 9 mm in diameter. Intravenous fluids and a broad-spectrum antibiotic are administered. Which of the following is the most likely diagnosis? (A) Acute cholecystitis (B) Acute pancreatitis (C) Cholangitis (D) Hepatitis (E) Liver abscess | See Supplemental Sheet | (C) Cholangitis | (C) Cholangitis | (C) Cholangitis | |||||||||||||||||||||
39 | 38 | A 70-year-old woman comes to the office because of worsening tremor of her hands. The tremor has been present for most of her life and initially was mild and would occur only when she was tired or stressed. During the past month the shaking has become more noticeable and frequent. She is now embarrassed to eat with other people because of how obvious the tremor has become. The patient has been taking fluoxetine for the past 3 weeks to help her to cope with the death of her husband 2 months ago. Medical history is also remarkable for essential hypertension controlled with lisinopril and hyperlipidemia controlled with atorvastatin. Her only other medication is occasional ibuprofen for joint pain. She used to drink one to two alcoholic beverages monthly but now drinks one glass of wine daily because, she says, it reduces her tremor. She is 168 cm (5 ft 6 in) tall and weighs 70 kg (155 lb); BMI is 25 kg/m2. Vital signs are temperature 36.4°C (97.6°F), pulse 80/min, respirations 18/min, and blood pressure 130/85 mm Hg. Physical examination shows a moderate tremor of both hands that is not present at rest. Complete blood count, serum chemistry profile, and serum thyroid function tests are ordered and results are pending. Which of the following is the most likely cause of the patient's worsening tremor? (A) Adverse effect of fluoxetine therapy (B) Bereavement reaction (C) Early Parkinson disease (D) Increase in alcohol consumption (E) Mini-strokes | See Supplemental Sheet | (A) Adverse effect of fluoxetine therapy | (A) Adverse effect of fluoxetine therapy | (A) Adverse effect of fluoxetine therapy | |||||||||||||||||||||
40 | 39 | A 70-year-old woman comes to the office because of a 1-month history of gradually worsening shortness of breath. Medical history is significant for hypertension and hyperlipidemia. Routine medications are atorvastatin and lisinopril. The patient appears to be in respiratory distress. Vital signs are temperature 36.7°C (98.0°F), pulse 122/min and irregularly irregular, respirations 28/min, and blood pressure 144/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Pulmonary examination discloses dullness to percussion three-quarters of the way up on the left. Results of laboratory studies are shown: Serum Blood Urea nitrogen 29 mg/dL Hematocrit 38% Creatinine 1.0 mg/dL Hemoglobin 12.9 g/dL Na+ 142 mEq/L WBC 7800/mm3 K+ 4.1 mEq/L Cl− 99 mEq/L HCO3− 24 mEq/L Glucose 102 mg/dL ECG shows atrial fibrillation with a rapid ventricular response. Chest x-ray shows a large left pleural effusion. Which of the following is the most appropriate next step in evaluation? (A) Bone marrow biopsy (B) Pericardiocentesis (C) Pleurodesis (D) Thoracentesis (E) Video-assisted thoracoscopy | See Supplemental Sheet | (D) Thoracentesis | (D) Thoracentesis | (D) Thoracentesis | |||||||||||||||||||||
41 | 40 | A 67-year-old man, who has been recovering in the hospital following surgical repair of a contained ruptured abdominal aortic aneurysm 10 days ago, suddenly develops severe abdominal pain. He does not have chest pain or shortness of breath. The patient's postoperative course had been uncomplicated until 4 days ago, when he developed a low-grade fever. He has been unable to tolerate a full liquid diet during the past 4 days. Medical history is remarkable for hypertension, hypercholesterolemia, and a myocardial infarction 6 years ago. Regular medications include metoprolol, lovastatin, and an 81-mg aspirin daily. He has smoked one pack of cigarettes daily for the past 40 years, and he typically drinks three to five beers daily. Vital signs now are temperature 38.1°C (100.6°F), pulse 68/min and regular, respirations 16/min, and blood pressure 150/90 mm Hg. Physical examination shows bilateral cataracts. Auscultation of the chest discloses diffuse mild wheezes and a grade 1/6 soft systolic ejection murmur at the cardiac apex. Palpation of the abdomen discloses mild to moderate mid and right upper quadrant abdominal tenderness. There is no guarding, rebound, or palpable mass. Rectal examination shows no abnormalities. Peripheral pulses are normal. Neurologic examination discloses no abnormalities. Serum electrolyte concentrations are within the reference ranges. Leukocyte count is 15,800/mm3 with mild left shift. Urinalysis shows no abnormalities. ECG shows an old inferior myocardial infarction. Chest x-ray shows scarring at the left and right cardiac bases; no masses or infiltrates are present. Which of the following is the most appropriate additional diagnostic study? (A) Arteriography of the abdomen (B) Blood cultures (C) MRI of the abdomen (D) Ultrasonography of the abdomen (E) No additional studies are needed | See Supplemental Sheet | (D) Ultrasonography of the abdomen | (D) Ultrasonography of the abdomen | (D) Ultrasonography of the abdomen | |||||||||||||||||||||
42 | 41 | A 5-year-old boy is brought to the emergency department by his parents because of a 2-day history of favoring his right leg when walking. Today, he has refused to bear weight on the right leg and had a temperature to 38.2°C (100.8°F). Treatment with ibuprofen has relieved the fever but has not improved the leg pain. The child has no known history of trauma. His parents report that he has been healthy except for a recent upper respiratory tract infection that has resolved. The child is lying supine on a gurney with his right lower extremity flexed and externally rotated at the hip. Vital signs are temperature 37.8°C (100.1°F), pulse 110/min, respirations 20/min, and blood pressure 88/50 mm Hg. Internal rotation of the right hip causes the child to cry. Examination of the right lower extremity discloses no deformity, ecchymosis, erythema, or swelling. The right foot is neurovascularly intact. Plain x-ray of the hips is shown. Which of the following is the most appropriate additional imaging study to obtain at this time? (A) Arthrography of the right hip (B) CT scan of the abdomen (C) MRI of the lumbar spine (D) Radionuclide bone scan (E) Ultrasonography of the hips | (E) Ultrasonography of the hips | (E) Ultrasonography of the hips | (E) Ultrasonography of the hips | ||||||||||||||||||||||
43 | 42 | A 31-year-old woman, gravida 3, para 2, who is at 32 weeks' gestation, is admitted to the hospital because of a 1-week history of progressive dyspnea and wheezing. She says her heart is "racing" and she is coughing up a small amount of blood-streaked sputum. Medical history is significant for hypothyroidism, for which she takes levothyroxine. An intravenous catheter is placed. Vital signs are temperature 36.9°C (98.4°F), pulse 132/min, respirations 32/min, and blood pressure 135/78 mm Hg. Pulse oximetry on 100% oxygen via nasal cannula shows an oxygen saturation of 92%. Auscultation of the lungs discloses decreased breath sounds at the bases with expiratory crackles bilaterally. Cardiac examination discloses an irregularly irregular rhythm, an indistinct point of maximal impulse, and a loud S1. A grade 3/6, low-pitched, diastolic, rumbling murmur is audible at the apex; a distinct snapping sound precedes the murmur. Fetal heart rate is 144/min. Which of the following is the most likely cause of the findings in this patient? (A) Atrial septal defect with development of pulmonary hypertension (B) Chronic mitral regurgitation secondary to rheumatic heart disease (C) Coarctation of the aorta (D) Congenital aortic stenosis (E) Mitral stenosis complicated by atrial fibrillatio | See Supplemental Sheet | (E) Mitral stenosis complicated by atrial fibrillatio | (E) Mitral stenosis complicated by atrial fibrillatio | ||||||||||||||||||||||
44 | 43 | A 70-year-old man is admitted to the hospital through the emergency department because of a 12-hour history of severe nausea and four episodes of vomiting of undigested food. During the past week, he has had worsening nausea, heartburn following meals, and early satiety. Medical history is significant for type 2 diabetes mellitus diagnosed 20 years ago, hyperlipidemia, and hypertension. Medications are intermediate-acting insulin twice daily and insulin lispro before meals. He also takes enalapril and atorvastatin. On admission, the patient appears uncomfortable. Vital signs are temperature 36.2°C (97.1°F), pulse 102/min, respirations 16/min, and blood pressure 105/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination discloses mild epigastric tenderness to palpation. The remainder of the examination discloses no abnormalities. Results of laboratory studies ordered in the emergency department are shown: Serum Blood ALT 23 U/L Hemoglobin A1c 8.2% AST 26 U/L Alkaline phosphatase 85 U/L Amylase 104 U/L Urea nitrogen 42 mg/dL Creatinine 1.32 mg/dL X-rays of the chest and abdomen disclose no abnormalities. Which of the following mechanisms is most likely responsible for this patient's current condition? (A) Accumulation of calcium carbonate and hemoglobin breakdown products in the bile ducts (B) Decreased gastric myoelectrical activity (C) Decreased gastric pH (D) Increased cholecystokinin activity | See Supplemental Sheet | (B) Decreased gastric myoelectrical activity | (B) Decreased gastric myoelectrical activity | (D) Increased cholecystokinin activity | |||||||||||||||||||||
45 | 44 | A 70-year-old woman comes to the office for an annual health maintenance examination. She describes a 1-year history of slowly progressive fatigue, diffuse muscle aches, and generalized pain. Medical history is significant for osteoporosis diagnosed 5 years ago. Medications include alendronate and calcium supplementation. Vital signs are normal. Physical examination is unremarkable for her age, with no point tenderness on palpation. Results of complete blood count, serum electrolyte and thyroid-stimulating hormone concentrations, liver function tests, and erythrocyte sedimentation rate are all within the reference ranges. Screening mammography and colonoscopy done 1 year ago disclosed no abnormalities. Which of the following is the most appropriate next step in evaluation? (A) DEXA scan (B) Electromyography and nerve conduction studies (C) MRI of the cervical spine (D) Serum antinuclear antibody assay (E) Serum 25-hydroxyvitamin D assay (F) No additional evaluation is indicated | See Supplemental Sheet | (E) Serum 25-hydroxyvitamin D assay | (E) Serum 25-hydroxyvitamin D assay | (E) Serum 25-hydroxyvitamin D assay | |||||||||||||||||||||
46 | 45 | A 22-year-old man comes to the emergency department because of a 4‑day history of cough productive of green sputum as well as fever, chills, and rigors. He also has had a 3‑day history of progressive shortness of breath; he now has shortness of breath at rest. He was evaluated in an urgent care center 1 day ago and was prescribed azithromycin, but his symptoms have worsened. He is using accessory muscles of respiration. He is diaphoretic and is able to give only one- to two-word answers to questions. Vital signs are temperature 39.1°C (102.3°F), pulse 138/min, respirations 40/min, and blood pressure 103/56 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 80%, and 100% oxygen is administered via nonrebreather face mask. Skin is mottled and there is cyanosis of the fingers and toes. Pupils measure 4 mm in diameter and are reactive to light. Mucous membranes are dry. Auscultation of the lungs discloses bilateral crackles. The remainder of the physical examination discloses no abnormalities. Laboratory studies are ordered; results of arterial blood gas analysis on 100% oxygen via nonrebreather face mask are shown: PO2 50 mm Hg PCO2 44 mm Hg pH 7.34 Oxygen saturation 85% Chest x-ray shows bilateral infiltrates with a normal cardiac silhouette and no effusions. Which of the following is the most likely underlying cause of this patient's condition? (A) Abnormalities of diffusion of oxygen (B) Hypoventilation (C) Obstructive lung disease (D) Ventilation-perfusion mismatch and shunt | See Supplemental Sheet | (D) Ventilation-perfusion mismatch and shunt | (D) Ventilation-perfusion mismatch and shunt | (D) Ventilation-perfusion mismatch and shunt | |||||||||||||||||||||
47 | 46 | A 33-year-old male physician reports for a shift in the emergency department. A nurse alerts you that he noticed a faint odor of alcohol near the physician. When approached, the physician appears tired and more disheveled than usual. There is an odor of alcohol on his breath. He is a skilled and talented physician with no known history of substance or alcohol use disorder. He is married with three children, and his wife is pregnant with twins. The physician was recently hired and has had no actions on his license by any state medical board. Which of the following is the most appropriate next step? (A) Ask the physician if he is sober, and if he says yes, allow him to complete his shift (B) Explain to the physician that you suspect he is intoxicated and ask him to submit to a blood sample to check his blood alcohol concentration (C) Relieve the physician of duty and alert the hospital's patient safety officer (D) Tell the physician that you can cover the remainder of the shift alone, so that he can sleep in his office (E) Tell the physician you detect alcohol on his breath, and he needs to go home and should not return until he is sober | See Supplemental Sheet | (C) Relieve the physician of duty and alert the hospital's patient safety officer | (C) Relieve the physician of duty and alert the hospital's patient safety officer | (C) Relieve the physician of duty and alert the hospital's patient safety officer | |||||||||||||||||||||
48 | 47 | A 60-year-old man comes to the office because of a 1-year history of progressive left groin pain. The pain is worse with exercise and is relieved with rest. He says the pain is beginning to affect his ability to carry out his daily activities. He says, "It even hurts when I'm turning over in bed." He does not recall any trauma to the area. He also has had generalized mild stiffness of his joints during the past 3 years. He takes atorvastatin for hyperlipidemia and lisinopril for hypertension. Medical history is otherwise unremarkable. He does not smoke cigarettes. He drinks one alcoholic cocktail daily. He is 178 cm (5 ft 10 in) tall and weighs 68 kg (150 lb); BMI is 22 kg/m2. Vital signs are temperature 37.4°C (99.3°F), pulse 82/min, respirations 18/min, and blood pressure 120/78 mm Hg. The patient walks with a slight limp and has difficulty changing position. Abduction of the left hip elicits pain. Physical examination of the patient's other joints discloses no abnormalities. Which of the following is the most appropriate imaging study at this time? (A) CT scan of the hips (B) MRI of the hips (C) Radionuclide bone scan (D) Plain x-ray of the left hip (E) Skeletal survey | See Supplemental Sheet | (D) Plain x-ray of the left hip | (D) Plain x-ray of the left hip | (D) Plain x-ray of the left hip | |||||||||||||||||||||
49 | 49 | A 35-year-old woman comes to the office for follow-up of chronic pelvic pain. The patient has had deep pelvic pain since undergoing total abdominal hysterectomy and radiation therapy for treatment of cervical cancer 5 years ago. She reports constant, severe aching pain; she rates the pain at its maximum as a 10 on a 10‑point scale. The pain worsens during intercourse. All subsequent cancer follow-up has been negative. Medical history otherwise is unremarkable. The patient has taken oxycodone for her pain for 3 years, but she now reports that the oxycodone only partially relieves her pain. She requests either an increased dose of oxycodone or a change in her prescription to controlled-release morphine, which was recently given to her by a friend. She has smoked one pack of cigarettes daily for the past 15 years. She does not drink alcoholic beverages. BMI is 18 kg/m2. She appears lethargic. She is oriented to person, place, and time but speaks slowly with slurred speech. Vital signs are normal. Examination of the skin shows no abnormalities. Pupils are pinpoint and react sluggishly. 49. Which of the following is the most appropriate next step in management? (A) Inform the patient that she must find a new physician (B) Maintain the dose of oxycodone and add naproxen (C) Order a urine toxicology screening (D) Report the patient's unauthorized drug use to the police (E) Switch oxycodone to sustained-release morphine | See Supplemental Sheet | (C) Order a urine toxicology screening | (C) Order a urine toxicology screening | (C) Order a urine toxicology screening | |||||||||||||||||||||
50 | 50 | A 35-year-old woman comes to the office for follow-up of chronic pelvic pain. The patient has had deep pelvic pain since undergoing total abdominal hysterectomy and radiation therapy for treatment of cervical cancer 5 years ago. She reports constant, severe aching pain; she rates the pain at its maximum as a 10 on a 10‑point scale. The pain worsens during intercourse. All subsequent cancer follow-up has been negative. Medical history otherwise is unremarkable. The patient has taken oxycodone for her pain for 3 years, but she now reports that the oxycodone only partially relieves her pain. She requests either an increased dose of oxycodone or a change in her prescription to controlled-release morphine, which was recently given to her by a friend. She has smoked one pack of cigarettes daily for the past 15 years. She does not drink alcoholic beverages. BMI is 18 kg/m2. She appears lethargic. She is oriented to person, place, and time but speaks slowly with slurred speech. Vital signs are normal. Examination of the skin shows no abnormalities. Pupils are pinpoint and react sluggishlWhich of the following is the most appropriate next step in management? Urine toxicology screening is positive for diazepam, methadone, and oxycodone. The patient returns to the office 1 week later to discuss these results. Which of the following is the most appropriate opening remark? (A) "I am concerned that you are abusing pain medicine. I would like for you to consider a substance abuse treatment program." (B) "I cannot be your physician any longer because of your drug abuse. I'm going to give you 30 days to find a new physician." (C) "I would like to know where you have been getting the methadone and diazepam that you are taking." (D) "The test showed that you take other drugs that I have not prescribed to you. I must report this to the police." | See Supplemental Sheet | (A) "I am concerned that you are abusing pain medicine. I would like for you to consider a substance abuse treatment program." | (C) "I would like to know where you have been getting the methadone and diazepam that you are taking." | (A) "I am concerned that you are abusing pain medicine. I would like for you to consider a substance abuse treatment program." | |||||||||||||||||||||
51 | 51 | A 24-year-old woman, gravida 1, para 1, comes to the office because she and her husband have been trying to conceive for the past year without success. She gave birth to her first child at age 18 years by cesarean delivery following fetal distress. She then developed postpartum endometritis that resolved with intravenous antibiotic therapy. She used an intrauterine device (IUD) for 1 year following her first pregnancy but had the device removed because of intermenstrual bleeding. Medical history is also remarkable for chlamydial cervicitis treated with antibiotic therapy as an outpatient at age 21 years, and recurrent bacterial vaginosis that had been treated with metronidazole therapy during her pregnancy and on two other occasions. Vital signs today are within normal limits. Breast and pelvic examinations disclose no abnormalities. Hysterosalpingography shows bilateral hydrosalpinx. Which of the following factors in this patient's history most increased her risk for development of her condition? (A) Bacterial vaginosis (B) Cesarean delivery (C) Chlamydial cervicitis (D) Postpartum endometritis (E) Use of an IUD | See Supplemental Sheet | (C) Chlamydial cervicitis | (D) Postpartum endometritis | (C) Chlamydial cervicitis | |||||||||||||||||||||
52 | 52 | Patient Information Age: 62 years Gender: M, self-identified Ethnicity: unspecified Site of Care: office History Reason for Visit/Chief Concern: "My legs hurt when I walk, and it's getting worse." History of Present Illness: • 3-month history of worsening leg pain • pain exacerbated by walking; peak intensity after 1 block • pain resolves completely with rest • pain rated 4/10 at worst Past Medical History: • hypertension • mild angina • type 2 diabetes mellitus Medications: • lisinopril • metoprolol • furosemide • glyburide • lovastatin Allergies: • no known drug allergies Psychosocial History: • has smoked one-half pack of cigarettes daily for 44 years Physical Examination Temp Pulse Resp BP O2 Sat Ht Wt BMI 36.0°C 72/min 14/min 140/90 mm Hg – 164 cm 90 kg 33 kg/m2 (96.8°F) (5 ft 5 in) (198 lb) • Appearance: no acute distress • HEENT: funduscopic shows grade 2/4 arteriovenous nicking • Neck: no jugular venous distention • Pulmonary: clear to auscultation; mildly diminished lung sounds • Cardiac: no bruits; distant heart sounds • Abdominal: obese; no tenderness, guarding, masses, bruits, or hepatosplenomegaly • Extremities: no joint erythema, edema, or warmth; no hair on toes; no femoral bruits; dorsalis pedis, radial, and femoral pulses intact • Neurologic: sensation to vibration intact Question: Which of the following is the most appropriate diagnostic study? (A) Ankle brachial index (B) Arteriography (C) ECG (D) Echocardiography (E) MUGA scan | See Supplemental Sheet | (A) Ankle brachial index | (A) Ankle brachial index | (A) Ankle brachial index | |||||||||||||||||||||
53 | 53 | In determining the usefulness of a D-dimer assay in ruling out pulmonary embolism as a diagnosis in a 27-year-old woman with pleuritic chest pain and nonproductive cough, a recent study in the medical literature is reviewed. The study evaluates the use of D-dimer assay in 1500 patients (705 female and 795 male) ranging in age from 19 years to 57 years (mean age is 36 years), whose examining physicians had a low clinical suspicion that the patients had pulmonary embolism. All patients in the study underwent a D-dimer assay, followed by CT angiography of the chest to confirm or exclude the diagnosis of pulmonary embolism. Study results are shown: D-Dimer CT Angiography Positive CT Angiography Negative Total Positive 88 312 400 Negative 0 1100 1100 Total 88 1412 1500 Which of the following is the most appropriate conclusion about this data in regard to patients with low clinical suspicion for pulmonary embolism? (A) D-Dimer assay results should be used to determine the need for ordering CT angiography for patients suspected of having a pulmonary embolism (B) False-negative D-dimer assay results are common in patients with confirmed pulmonary embolism (C) False-positive D-dimer assay results are rarely encountered (D) A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism (E) A positive D-Dimer assay has a high positive predictive value for diagnosing pulmonary embolism | See Supplemental Sheet | (D) A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism | (D) A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism | (D) A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism | |||||||||||||||||||||
54 | 54 | A 37-year-old man is admitted to the hospital for treatment for cocaine dependency. He says he has tried repeatedly to abstain from cocaine use but lives in a part of town where there are heavy drug sales. He did not like his hospital outpatient group but liked his single session at a 12-step program for cocaine dependency. Vital signs are temperature 37.0°C (98.6°F), pulse 70/min, respirations 16/min, and blood pressure 125/85 mm Hg. He appears thin. Physical examination discloses good muscle strength and no focal neurologic deficits. The patient is using insurance coverage through his wife but does not wish for his diagnosis to be disclosed to anyone. He is on probation after a conviction for aggravated robbery 3 years ago. There is also a warrant for his arrest for assault and battery. After listening to his requests and weighing your obligations, you should disclose this patient's diagnosis only to which of the following? (A) His 12-step program sponsor (B) His probation officer (C) His wife (D) Insurance company (E) Police | See Supplemental Sheet | (D) Insurance company | (A) His 12-step program sponsor | (B) His probation officer | |||||||||||||||||||||
55 | 55 | A 5-week-old infant is brought to the office by his mother for an initial well-child visit. He was born at 37 weeks' gestation via cesarean delivery because of chorioamnionitis. The infant had fetal distress that was documented by fetal monitoring during labor. The mother became jaundiced in the immediate postpartum period and was found to have hepatitis C (HCV) and HIV infection. She is unaware of her hepatitis B (HBV) status but knows that her son received the hepatitis B vaccination on the second day of life. The infant's weight today is 3912 g (8 lb 10 oz); physical examination shows no abnormalities. The mother wants to know what chance her child has of having contracted HIV or HCV infection from her. The risk for vertical transmission of HIV is approximately 20%. The mother is advised and appropriate management is planned for the infant regarding HIV. To determine the risk of HCV transmission, a recently published study of risk factors for perinatal transmission of HCV in 155 mothers coinfected with HIV and HCV is reviewed. Results of the study are shown: Association of Gestational and Infant Factors With Mother-to-Infant HCV Transmission 155 Mothers with HIV and HCV Infection Factor HCV Transmission, % RR 95% CI p Value Gestational Age <37 weeks 8.4 1.0 — ≥37 weeks 8.3 0.99 0.32 to 3.06 0.99 Cesarean Delivery No 6.0 1.0 — Yes 13.3 2.21 0.69 to 7.06 0.24 Chorioamnionitis No 7.0 1.0 — Yes 33.3 4.77 0.86 to 26.3 0.21 Use of Fetal Electrode No 7.0 1.0 — Yes 3.3 0.66 0.09 to 4.89 0.99 Infant HIV- infected No 5.4 1.0 — Yes 17.1 3.19 1.14 to 8.93 0.04 RR=relative risk; CI=confidence interval Based on these data, which of the following is the most appropriate conclusion regarding the five potential risk factors for transmission of HCV? (A) All factors appeared to have an effect on HCV transmission (B) Fetal electrode monitoring was protective against HCV (C) Infant HIV infection was the only significantly associated factor (D) Maternal chorioamnionitis was the most significantly associated factor (E) No factor was significantly associated | See Supplemental Sheet | (C) Infant HIV infection was the only significantly associated factor | (E) No factor was significantly associated | (E) No factor was significantly associated | |||||||||||||||||||||
56 | 56 | A 45-year-old man with AIDS comes to the community health center because of a 1-week history of fever, chills, sweating, mild shortness of breath, and nonproductive cough. Medical history is also remarkable for pneumonia 3 years ago that required hospitalization. Today, he says that he lost his job 6 months ago, is now homeless, and cannot afford to buy his antiretroviral medications. Vital signs are temperature 38.6°C (101.5°F), pulse 82/min, respirations 20/min, and blood pressure 116/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The health center is very busy with several patients waiting to be evaluated. Which of the following is the most appropriate next step? (A) Arrange a direct admission to the hospital for this patient (B) Continue with obtaining a thorough history and examining this patient (C) Place masks on the patient and yourself and then continue to evaluate him (D) Send this patient for chest x-rays, and while they are being obtained examine the next patient | See Supplemental Sheet | (C) Place masks on the patient and yourself and then continue to evaluate him | (A) Arrange a direct admission to the hospital for this patient | (A) Arrange a direct admission to the hospital for this patient | |||||||||||||||||||||
57 | 57 | A 45-year-old man comes to the office for a follow-up examination 2 days after he was seen in the emergency department for a generalized tonic-clonic seizure. He was prescribed chlordiazepoxide upon being discharged but did not fill the prescription. The patient says that this was his third seizure in the past 2 years; prior to that he had no history of seizures. Medical history is also remarkable for a 10-year history of daily ingestion of two six-packs of beer. He has not had any alcoholic beverages for the past 5 days. He takes no medications. The patient says that his seizures usually occur after he abstains from alcohol for a period of time. Vital signs are normal. Physical examination shows scattered spider angiomata on his chest and abdomen. Liver is enlarged, smooth, and nontender. CT scan of the head with contrast done in the emergency department 2 days ago showed no abnormalities. Which of the following is the most appropriate next step? (A) Lumbar puncture for examination of cerebrospinal fluid (B) MRI of the brain (C) Repeat CT scan of the head in 1 week (D) Sleep-deprived electroencephalography (E) No further evaluation is necessary | See Supplemental Sheet | (E) No further evaluation is necessary | (B) MRI of the brain | (E) No further evaluation is necessary | |||||||||||||||||||||
58 | 58 | A case-control study is conducted to assess risk factors predicting inpatient mortality among geriatric patients with community-acquired pneumonia. Results of the study include the odds ratios shown below, which were calculated from a multivariable logistic regression equation: Predictor Variables Odds Ratio 95% CI Hypotension (systolic blood pressure ≤100 mm Hg) 3.32 (1.65 to 5.11) Hypoxemia (PO2 ≤ 50 mm Hg) 2.43 (1.55 to 3.32) Lung infiltrate present on chest x-ray at time of admission 1.35 (0.76 to 2.24) When the other covariates are controlled, which of the following is the most appropriate conclusion regarding these data? (A) The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension (B) The risk for inpatient mortality is increased more by hypoxemia than by hypotension (C) The risk for inpatient mortality is increased when there is a pulmonary infiltrate present on chest x-ray at the time of admission (D) The risk for inpatient mortality is significantly affected by all of these predictor variables | See Supplemental Sheet | (A) The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension | (A) The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension | (A) The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension | |||||||||||||||||||||
59 | 59 | A 38-year-old man comes to the office because of a 2-month history of intermittent episodes of hot flushes, chest discomfort, and excessive sweating, with associated panic. The episodes have been increasing in frequency and now are occurring daily. The patient says there is no specific precipitating cause of the episodes, but he has noticed that the episodes occur most frequently in the afternoon. He does not have any new stressors in his life. Medical history is significant for hypertension and type 2 diabetes mellitus. Medications are lisinopril and metformin. Family history is significant for hyperparathyroidism in an aunt and the death of an uncle from medullary thyroid cancer. The patient's BMI is 33 kg/m2. Vital signs are temperature 36.9°C (98.4°F), pulse 74/min, respirations 18/min, and blood pressure 138/92 mm Hg. Physical examination discloses no abnormalities. Results of serum laboratory studies are shown: Calcium 9.8 mg/dL Urea nitrogen 15 mg/dL Creatinine 1.0 mg/dL Na+ 140 mEq/L K+ 3.8 mEq/L Cl− 102 mEq/L HCO3− 28 mEq/L ECG shows no abnormalities. Which of the following is the most appropriate diagnostic study at this time? (A) Plasma renin activity (B) Serum aldosterone concentration (C) Serum free metanephrine concentration (D) Serum parathyroid hormone concentration (E) No study is indicated | See Supplemental Sheet | (C) Serum free metanephrine concentration | (C) Serum free metanephrine concentration | (C) Serum free metanephrine concentration | |||||||||||||||||||||
60 | 60 | A 19-year-old woman is referred to the office by her counselor for evaluation of possible depression. The counselor describes the patient as polite, conscientious, cooperative, open to therapy, and always present and on time for her weekly sessions. The patient's relationship with her high school boyfriend ended 6 months ago. She had dated him through high school, and he had "looked out for her as a friend" since the 6th grade. She says, "I feel helpless and don't know what to do without him." She admits that she often cannot make decisions, such as whether to go to college. She says, "I always mess things up." She is still sad and often tearful about her ex-boyfriend, but she has not had alterations in her sleep habits, appetite, weight, or energy level. She has not had any thoughts about death. Medical history is unremarkable and she takes no medications. BMI is 24 kg/m2. Vital signs are normal and physical examination discloses no abnormalities. Which of the following is the most appropriate initial response to this patient's self-deprecating description? (A) "College is full of many great once-in-a-lifetime opportunities. You should go." (B) "Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up." (C) "If you find yourself needing some guidance, call me." (D) "You're overreacting. You just need to give it a little more time. | See Supplemental Sheet | (B) "Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up." | (B) "Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up." | (B) "Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up." | |||||||||||||||||||||
61 | 61 | A 35-year-old man comes to the office because of 1-week history of mid low back pain that radiates down his right leg. The pain began after the patient lifted a heavy box onto his truck. He rates his current pain as an 8 on a 10-point scale. He has been unable to find a comfortable position and has been sleeping in a recliner. Medical history is unremarkable and he takes no medications. He has smoked one pack of cigarettes daily for the past 25 years, and he drinks a six-pack of beer on Friday and Saturday nights. BMI is 27 kg/m2. He appears uncomfortable and stands during the physical examination. Vital signs are normal. Straight-leg raise test is positive on the right, with loss of right ankle reflex. The remainder of the physical examination discloses no abnormalities. Which of the following is the most likely explanation for this patient’s symptoms? (A) Displacement of the nucleus pulposus (B) Hypertrophy of the facet joints (C) Osteophyte formation (D) Spondylolisthesis (E) Thickening of ligamentum flavum | See Supplemental Sheet | (A) Displacement of the nucleus pulposus | (A) Displacement of the nucleus pulposus | (A) Displacement of the nucleus pulposus | |||||||||||||||||||||
62 | 62 | A 71-year-old woman is brought to the emergency department by her daughter for evaluation of her mental status. The daughter says, "I visited mom today for the first time in 6 months; her memory has worsened, her bills are unpaid, and her house is unusually messy." The patient says, "I'm perfectly healthy." Medical history is significant for hypertension diagnosed more than 25 years ago, and two small strokes occurring 3 years and 7 months ago. The daughter gives you three empty medicine bottles from her mother's home: metoprolol, hydrochlorothiazide, and aspirin. The patient is 165 cm (5 ft 5 in) tall and weighs 59 kg (130 lb); BMI is 22 kg/m2. Vital signs are temperature 36.4°C (97.6°F), pulse 76/min, respirations 16/min, and blood pressure 196/112 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Muscle strength in her left hand is 1/5. Strength in the right extremities is 4/5. The patient is oriented only to self; she does not know the day of the week or today's date. She recalls 0 of 3 words at 5 minutes, and she is unable to name 2 objects, correctly draw interlocking pentagons, or count backwards by serial sevens. Complete blood count, renal function studies, liver function studies, and urinalysis are all within the reference ranges. ECG shows no abnormalities. Which of the following is the most likely underlying cause of the patient's symptoms? (A) Alzheimer disease (B) Amyotrophic lateral sclerosis (C) Cortical basal ganglionic degeneration (D) Neurosyphilis (E) Vascular dementia | See Supplemental Sheet | (E) Vascular dementia | (E) Vascular dementia | (E) Vascular dementia | |||||||||||||||||||||
63 | 63 | A 7-year-old boy is brought to the emergency department by his mother because of a 2-day history of chest pressure and mild shortness of breath. He also has had intermittent fever for the past 2 weeks and a 2.3-kg (5-lb) weight loss during the past month. He has not had rhinorrhea, cough, or chest pain. Medical history is otherwise unremarkable and he takes no medications other than acetaminophen for fever. Vaccinations are up-to-date. He appears mildly ill but is not in respiratory distress. Vital signs are temperature 37.5°C (99.5°F), pulse 100/min, respirations 20/min, and blood pressure 100/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Lungs are clear to auscultation. Cardiac examination discloses no abnormalities. Liver span is normal, and spleen tip is palpated at the left costal margin. Several 2 × 3-cm, nontender, nonmobile lymph nodes are noted in the inguinal canal and axillae. Chest x-ray is obtained and shown. When the patient returns from the radiology department, he is in moderate respiratory distress and reports chest pain. Which of the following is the most likely explanation for this patient's worsening condition? (A) Airway compression (B) Cardiac arrhythmia (C) Cardiac tamponade (D) Hyperkalemia (E) Hypocalcemia | (C) Cardiac tamponade | (A) Airway compression | (C) Cardiac tamponade | ||||||||||||||||||||||
64 | 64 | A 45-year-old woman with a history of seizure disorder comes to the office because she has had seizures daily for the past 3 weeks, despite adhering to her medication regimen. Medical history is also significant for borderline hypertension for the past year and alcohol abuse. She admits that she has been drinking two beers daily since she lost her job 3 weeks ago. Medications include phenobarbital. Family history is significant for type 2 diabetes mellitus and hypertension in both parents and in all of her grandparents, heart disease in her sister, and death of her paternal grandfather of complications from alcohol abuse. The patient smoked one pack of cigarettes daily for 20 years but quit smoking 1 year ago. Since losing her job, the patient has been earning money by driving her neighbors' children to school and driving another neighbor to hospital appointments. BMI is 22 kg/m2. Vital signs are temperature 37.1°C (98.8°F), pulse 80/min, respirations 16/min, and blood pressure 138/86 mm Hg. Physical examination discloses no abnormalities. Serum phenobarbital concentration is obtained and results are pending. Which of the following is the priority in management at today's visit? (A) Discussing a new treatment regimen for the patient's seizure disorders (B) Evaluating the patient for depressive disorder (C) Evaluating the patient's ability/desire to stop drinking alcoholic beverages (D) Instructing the patient to stop driving | See Supplemental Sheet | (D) Instructing the patient to stop driving | (C) Evaluating the patient's ability/desire to stop drinking alcoholic beverages | (A) Discussing a new treatment regimen for the patient's seizure disorders | |||||||||||||||||||||
65 | 65 | A randomized controlled trial is conducted to assess the effectiveness of a new combination-drug antihypertensive therapy (Drug X) compared with a standard antihypertensive single-drug therapy. Study participants include 140 women (70%) and 60 men (30%) ages 30 to 60 years, with baseline blood pressure measurements of 150/95 mm Hg or higher. The investigators defined antihypertensive therapy as effective if the treatment resulted in a blood pressure measurement below 140/90 mm Hg. When designing the study, the investigators set the probability of wrongly finding that Drug X is more effective than the standard therapy as 1%; they set the probability of wrongly finding that the effectiveness of the two drugs is the same as 10%. Which of the following is the most accurate estimate of the statistical power in this study? (A) 1% (B) 10% (C) 40% (D) 90% (E) 99% | See Supplemental Sheet | (D) 90% | (D) 90% | (D) 90% | |||||||||||||||||||||
66 | 66 | A 65-year-old woman comes to the office for blood pressure medication management. Medical history is significant for poorly controlled hypertension, psoriasis, and psoriatic arthritis previously treated with methotrexate. Additional medical history is significant for alcohol use disorder and elevated liver function tests. Medications include enalapril, spironolactone, and topical corticosteroids. Vital signs are normal except for a blood pressure of 160/104 mm Hg. Physical examination discloses thick, scaly plaques on the scalp, buttocks, and upper and lower extremities. There are several spider angiomata on the chest and abdomen. The abdomen is distended and a fluid wave is noted. She has 2+ lower extremity edema. The patient says she would like to try a new drug called Essepro to treat her hypertension because she can get a 3-month supply of the medication for free. Which of the following is the most appropriate response to the patient's request for the medication? (A) Essepro should be prescribed because she can get it for free (B) Essepro should not be prescribed because it can worsen her psoriasis (C) Essepro should not be prescribed because it is similar to her other medications (D) Essepro should not be prescribed because the patient has severe liver disease (E) Essepro should only be used for hypertensive emergencies | See Supplemental Sheet | (D) Essepro should not be prescribed because the patient has severe liver disease | (D) Essepro should not be prescribed because the patient has severe liver disease | (D) Essepro should not be prescribed because the patient has severe liver disease | |||||||||||||||||||||
67 | 67 | A 65-year-old woman comes to the office for blood pressure medication management. Medical history is significant for poorly controlled hypertension, psoriasis, and psoriatic arthritis previously treated with methotrexate. Additional medical history is significant for alcohol use disorder and elevated liver function tests. Medications include enalapril, spironolactone, and topical corticosteroids. Vital signs are normal except for a blood pressure of 160/104 mm Hg. Physical examination discloses thick, scaly plaques on the scalp, buttocks, and upper and lower extremities. There are several spider angiomata on the chest and abdomen. The abdomen is distended and a fluid wave is noted. She has 2+ lower extremity edema. The patient says she would like to try a new drug called Essepro to treat her hypertension because she can get a 3-month supply of the medication for free. Which of the following interpretations can be made correctly from the graph on blood pressure reduction in the advertisement? (A) Blood pressure reduction from the three doses of Essepro cannot be compared to reduction with placebo because the number of patients on active drugs are higher than the number of patients on placebo (B) Doubling the highest dose of Essepro will decrease diastolic pressure from baseline by at least 15 mm Hg (C) The highest dose of Essepro should be used because it offers the greatest benefit (D) There is no clinically important difference in blood pressure reduction between the three dose groups (E) The significance of drug effect vs placebo cannot be determined because of the low P value | (D) There is no clinically important difference in blood pressure reduction between the three dose groups | (D) There is no clinically important difference in blood pressure reduction between the three dose groups | (D) There is no clinically important difference in blood pressure reduction between the three dose groups | ||||||||||||||||||||||
68 | 68 | A 19-year-old woman comes to her university's health center because of a 1-week history of nasal stuffiness, occasional clear rhinorrhea, and a mild sore throat. Two days ago, she began to feel hot, but she has not taken her temperature. Medical history is unremarkable and her only medication is an oral contraceptive. She has no history of allergies. She does not smoke cigarettes. BMI is 22 kg/m2. Vital signs are temperature 38.1°C (100.6°F), pulse 88/min, respirations 16/min, and blood pressure 116/74 mm Hg. Physical examination discloses tenderness over the left maxillary sinus without purulent drainage. There is clear fluid behind the left tympanic membrane, enlarged tonsils bilaterally, and pain with tapping of the left upper incisors. The left frontal sinus does not transilluminate. Cardiopulmonary examination discloses no abnormalities. Which of the following is the most likely underlying mechanism of this patient's sinusitis? (A) Eustachian tube dysfunction (B) Mucosal edema (C) Nasal polyps (D) Oral contraceptive use (E) Tonsillar hyperplasia | See Supplemental Sheet | (B) Mucosal edema | (B) Mucosal edema | (B) Mucosal edema | |||||||||||||||||||||
69 | 69 | A 40-year-old woman comes to the office because of a 2-month history of fatigue, and generalized aching and weakness of the proximal muscles of all four extremities. The patient initially noticed the weakness only while she was getting in and out of her car, but during the past 2 weeks, the weakness has progressed, so that she now has difficulty combing her hair. Since the symptoms began, she also has had aching of the joints in her hands that has responded partially to ibuprofen. She was adopted and family history is unknown. She has two teenaged children who are well. She appears uncomfortable. She is 170 cm (5 ft 7 in) tall and weighs 68 kg(150 lb); BMI is 24 kg/m2. Vital signs are temperature 37.7°C (99.8°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. The patient is alert and fully oriented. Physical examination discloses cracking of the skin of both hands that involves the tips and lateral sides of several fingers. The muscles of the upper arms and legs are somewhat tender to pressure. Results of serum laboratory studies show a creatine kinase concentration of 600 U/L and a lactate dehydrogenase concentration of 800 U/L. Results of complete blood count are within the reference ranges. Which of the following is the most likely diagnosis? (A) Fibromyalgia (B) Myasthenia gravis (C) Polymyositis (D) Scleroderma | See Supplemental Sheet | (C) Polymyositis | (C) Polymyositis | (C) Polymyositis | |||||||||||||||||||||
70 | 70 | A new diagnostic test for HIV infection is developed. The new serum biomarker concentration is measured in 711 men and women, ages 25 to 65 years. Of these individuals, 336 were previously determined to have HIV and 375 do not have HIV. Stratified results of the new serum biomarker test are shown: New Serum Biomarker Number of Individuals Number of Individuals Concentration Positive for HIV (Total=336) Negative for HIV (Total=375) >100 U/mL 120 10 76–100 U/mL 100 30 51–75 U/mL 75 75 26–50 U/mL 30 60 0–25 U/mL 11 200 Which of the following is the likelihood ratio that is associated with a serum biomarker concentration greater than 100 U/mL? (A) 2 (B) 8 (C) 13 (D) 25 (E) 33 | See Supplemental Sheet | (C) 13 | (C) 13 | (C) 13 | |||||||||||||||||||||
71 | 71 | A 40-year-old man comes to the office for a preemployment physical examination. The patient has been generally healthy. Medical history is unremarkable and he takes no routine medications. Vital signs are normal. Physical examination shows a palpable nodule in the right lobe of the thyroid gland. Serum thyroid-stimulating hormone concentration is within the reference range. Ultrasonography of the thyroid gland confirms a solid, 1-cm nodule. Which of the following is the most appropriate next step in evaluation? (A) CT scan of the neck (B) Fine-needle aspiration of the nodule (C) Radionuclide thyroid scan (D) Thyroidectomy (E) Observation only | See Supplemental Sheet | (B) Fine-needle aspiration of the nodule | (B) Fine-needle aspiration of the nodule | (B) Fine-needle aspiration of the nodule | |||||||||||||||||||||
72 | 72 | A 35-year-old man was admitted to the hospital 3 days ago because of pneumonia, but he has shown no clinical improvement despite ceftriaxone and azithromycin therapy. Upon admission, the patient exhibited blood-streaked sputum and chest x-ray showed hilar adenopathy. Medical history is otherwise unremarkable. The patient is a construction worker and he returned home 1 week ago from the southwest United States, where he had been temporarily employed. He does not smoke cigarettes. BMI is 20 kg/m2. Vital signs today are temperature 38.5°C (101.3°F), pulse 106/min, respirations 22/min, and blood pressure 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. PPD skin test is nonreactive. Acid-fast smears of three sputum samples were all negative. Complete blood count at the time of admission showed a normal leukocyte count with 15% eosinophils. Results of blood culture have been negative since admission. Which of the following is most likely to provide a diagnosis? (A) Bacterial culture of sputum (B) CT scan of the chest (C) Fungal culture of the blood (D) Serologic study for Coccidioides immitis (E) Sputum cytologic study (F) Urine assay for Legionella antigen | See Supplemental Sheet | (D) Serologic study for Coccidioides immitis | (D) Serologic study for Coccidioides immitis | (D) Serologic study for Coccidioides immitis | |||||||||||||||||||||
73 | 73 | A 25-year-old man with Down syndrome and mild intellectual developmental disorder is brought to the office by his parents. He is their only child, and they are concerned that his current lifestyle is increasing his risk for coronary artery disease and stroke. The patient has a systolic murmur and also underwent surgical repair of an atrial septal defect at 1 year of age. He has smoked one pack of cigarettes daily for 5 years. He lives in a group home and works about 25 hours each week in a fast-food restaurant. He has a few friends and is romantically involved with a woman from his church group. The patient is 157 cm (5 ft 2 in) tall and weighs 91 kg (200 lb); BMI is 36 kg/m2. Vital signs are normal. A grade 2/6 systolic murmur is heard best at the apex. The parents would like him to stop smoking and follow a healthier diet, and they feel the only way to monitor and control his behavior is for him to move back into their home. They request your assistance in obtaining legal guardianship of their son. Which of the following is the most appropriate initial recommendation? (A) Advise the parents not to influence their son's decision in this matter (B) Arrange for evaluation of their son's competency (C) Enroll their son in a smoking cessation program (D) Initiate a family meeting to discuss the parents' concerns with their son (E) Obtain legal advice regarding guardianship | See Supplemental Sheet | (D) Initiate a family meeting to discuss the parents' concerns with their son | (D) Initiate a family meeting to discuss the parents' concerns with their son | (C) Enroll their son in a smoking cessation program | |||||||||||||||||||||
74 | 74 | A 45-year-old woman comes to the office because of a 3-day history of nasal congestion, headache, sore throat, and general malaise. She has developed a cough during the past 24 hours that is mildly productive of clear sputum. Except for occasional seasonal allergies, she has no previous history of medical problems. She takes no medications on a regular basis but during the past 3 days she has been taking an over-the-counter oral cold medication. She follows a strict low-fat vegetarian diet and she drinks three to four glasses of wine per week. She jogs 3 miles a day when she is not sick. Vital signs today are temperature 37.5°C (99.5°F), pulse 90/min, and blood pressure 140/94 mm Hg. Height is 170 cm (5 ft 7 in); weight is 54 kg (120 lb); BMI is 19 kg/m2. On physical examination she appears slightly anxious. Nasal mucosa is erythematous and swollen, and sinuses are nontender. Posterior pharynx is also erythematous but there are no exudates. Lungs are clear on auscultation and cardiac examination is normal. Repeat blood pressure measurement at the end of the examination is 142/96 mm Hg in the left arm and 138/94 mm Hg in the right arm. Which of the following is the most likely cause of her elevated blood pressure? (A) Acute viral illness (B) Chronic sinusitis (C) Essential hypertension (D) Her alcohol intake (E) Over-the-counter cold medication | See Supplemental Sheet | (E) Over-the-counter cold medication | (A) Acute viral illness | (E) Over-the-counter cold medication | |||||||||||||||||||||
75 | 75 | A 41-year-old woman comes to the emergency department because of a 3-day history of fever and a 2-day history of worsening flank pain with frequent and painful urination. She describes the pain as constant and says it worsens when she coughs or lies on her right side. She rates the pain as a 5 on a 10-point scale; ibuprofen has provided moderate relief of her pain. She also reports intermittent nausea but has not had vomiting or change in bowel habits. Medical history is significant for several uncomplicated urinary tract infections, most recently 8 months ago. Each infection resolved with antibiotic therapy. She currently takes no medications aside from her recent use of ibuprofen. She is sexually active with one male partner and uses condoms regularly. Vital signs are temperature 39.4°C (103.0°F), pulse 76/min, respirations 20/min, and blood pressure 128/74 mm Hg. Auscultation of the chest discloses normal S1 and S2. Abdomen is soft with normal bowel sounds. There is guarding on the right lateral side and tenderness to compression over the right costophrenic angle. Results of laboratory studies are shown: Serum Blood Urea nitrogen 18 mg/dL Hemoglobin 12.8 g/dL Creatinine 0.9 mg/dL WBC 20,000/mm3 Urine Neutrophils, segmented 80% Specific gravity 1.015 (N=1.003–1.029) Lymphocytes 15% Protein Negative Eosinophils 2% Occult blood Negative Monocytes 3% Leukocyte esterase Positive WBC Too numerous to count Casts Occasional Urine and blood cultures are obtained and sent for analysis. Antibiotic therapy is initiated. Which of the following is the most appropriate next step? (A) Cystoscopy (B) Echocardiography (C) MRI of the abdomen (D) Renal ultrasonography (E) No additional study is indicated | See Supplemental Sheet | (D) Renal ultrasonography | (D) Renal ultrasonography | (D) Renal ultrasonography | |||||||||||||||||||||
76 | 76 | A 41-year-old woman is brought to the emergency department by her husband because of nausea and dizziness that began suddenly 4 hours ago. She says she feels like the room is spinning. She has not vomited. She recalls receiving a blow to the left side of her neck 1 week ago when her dog jumped on her, but she has had no ill effects from that incident. Medical history is unremarkable. She takes no medications. Vital signs are normal. Physical examination shows mild ptosis of the left eyelid. The right pupil measures 4 mm in diameter and the left pupil measures 2 mm in diameter. Both pupils are reactive to light. Ocular motility is full. Nystagmus is present in both eyes on left lateral gaze. Left corneal reflex is diminished. Sensation to pinprick and cold is reduced over the left side of the face, right side of the chest, abdomen, and right upper and lower extremities. Which of the following pathophysiologic processes most accurately explains this patient's left-sided ptosis and decreased pupil size? (A) Parasympathetic overactivity (B) Parasympathetic underactivity (C) Postsynaptic neuromuscular junction defect (D) Presynaptic neuromuscular junction defect (E) Sympathetic overactivity (F) Sympathetic underactivity | See Supplemental Sheet | (F) Sympathetic underactivity | (F) Sympathetic underactivity | (F) Sympathetic underactivity | |||||||||||||||||||||
77 | 77 | A 34-year-old woman comes to the office because of a 3- to 4-week history of swelling of her legs and a 9-kg (20-lb) weight gain. Medical history is significant for sickle cell trait and mild anemia. She has been taking 800 mg of ibuprofen three times daily for Achilles tendinitis diagnosed 1 month ago. She has smoked five cigarettes daily for the past 15 years, and she drinks one to five beers on weekends. She experimented with cocaine briefly 16 years ago, but she has never used intravenous drugs. She has been in a monogamous sexual relationship for the past 12 years. Today, vital signs are temperature 37.2°C (99.0°F), pulse 88/min, respirations 16/min, and blood pressure 145/95 mm Hg. Physical examination discloses periorbital edema but no jugular venous distention. Lungs are clear to auscultation. Cardiac examination discloses an S1 and S2 without murmurs or gallops. Abdominal examination discloses bulging flanks and shifting dullness to percussion. Examination of the lower extremities shows pitting edema from the mid thigh to the ankles bilaterally. Results of which of the following studies are most likely to be abnormal in this patient? (A) Echocardiography (B) HIV antibody study (C) Serum B-type natriuretic peptide concentration (D) Toxicology screening of the urine (E) Urine protein concentration | See Supplemental Sheet | (E) Urine protein concentration | (E) Urine protein concentration | (A) Echocardiography | |||||||||||||||||||||
78 | 78 | A 54-year-old woman comes to the office because she has had intermittent shooting pain over her right cheek and jaw during the past 3 weeks. Each episode of pain lasts for 1 second or less. The pain is often triggered by cold air, chewing, tactile stimulation, and brushing her teeth. She has had no trauma to the face or head. Medical history is remarkable for tension headaches, obesity, and gastric bypass surgery. She is 165 cm (5 ft 5 in) tall and weighs 62 kg (137 lb); BMI is 23 kg/m2. Vital signs are normal. The patient cannot tolerate touch over the right side of the face. There is no facial weakness or loss of sensation. The remainder of the physical examination shows no abnormalities. CT scan of the head with and without contrast shows no abnormalities. Which of the following is the most appropriate pharmacotherapy at this time? (A) Carbamazepine (B) Lamotrigine (C) Levetiracetam (D) Topiramate (E) Zonisamide | See Supplemental Sheet | (A) Carbamazepine | (A) Carbamazepine | (A) Carbamazepine | |||||||||||||||||||||
79 | 79 | A 25-year-old man, who was admitted to the hospital 5 hours ago because of nausea, light-headedness, and muscle aches that began after he completed a marathon, now reports worsening pain in his right leg. On admission, the patient reported only mild muscle aching, but he now rates the pain in his right lower extremity as a 9 on a 10-point scale. Laboratory studies on admission were notable for a serum creatine kinase concentration of 10,000 U/L and a serum creatinine concentration of 1.7 mg/dL. Since admission the patient has received 5 L of 0.9% saline and his nausea and light-headedness have resolved. He is alert and fully oriented. Vital signs are temperature 36.9°C (98.5°F), pulse 88/min, respirations 16/min, and blood pressure 126/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Cardiopulmonary and abdominal examinations disclose no abnormalities. Passive flexion of the toes elicits pain over the anterior portion of the right lower extremity below the knee. Distal pulses are present in the lower extremities bilaterally. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies obtained 1 hour ago are shown: Serum Blood Urea nitrogen 12 mg/dL Hemoglobin 14.0 g/dL Creatinine 1.2 mg/dL WBC 14,000/mm3 Na+ 140 mEq/L Neutrophils, segmented 60% K+ 4.0 mEq/L Cl− 100 mEq/L HCO3− 24 mEq/L Which of the following is the most appropriate next step in management? (A) Application of ice to the right lower extremity (B) Cyclobenzaprine therapy (C) Measurement of lower extremity compartment pressures (D) MRI of the right lower extremity (E) Nonsteroidal anti-inflammatory drug therapy | See Supplemental Sheet | (C) Measurement of lower extremity compartment pressures | (C) Measurement of lower extremity compartment pressures | (C) Measurement of lower extremity compartment pressures | |||||||||||||||||||||
80 | 80 | A 9-year-old boy is brought to the office by his parents for a well-child examination. The patient and his family immigrated to the United States 2 months ago and he has not been evaluated by a physician in 4 years. He has been generally healthy. Medical history is significant for pneumonia at age 3 years. He takes no medications. He is at the 25th percentile for height, weight, and BMI. Vital signs are temperature 37.0°C (98.6°F), pulse 82/min, respirations 20/min, and blood pressure 112/74 mm Hg. Cardiac examination discloses a grade 3/6 systolic murmur audible along the left sternal border at the third and fourth intercostal spaces. Femoral pulses are weak and brachial pulses are strong; there is a radiofemoral delay. Chest x- ray discloses mild cardiomegaly with left ventricular prominence. ECG shows left ventricular hypertrophy. This patient is at greatest risk for which of the following complications? (A) Atrial fibrillation (B) Cor pulmonale (C) Systemic hypertension (D) Tricuspid valve regurgitation | See Supplemental Sheet | (C) Systemic hypertension | (C) Systemic hypertension | (B) Cor pulmonale | |||||||||||||||||||||
81 | 81 | A 25-year-old woman comes to the office because of a 2-day history of right lower quadrant abdominal pain and vaginal spotting. She describes the abdominal pain as cramping and rates it as a 4 on a 10-point scale. Medical history is unremarkable and the patient takes no medications. Menses are typically irregular but she thinks her last menstrual period was approximately 5 weeks ago. She is sexually active with one male partner and they use condoms occasionally. Vital signs are temperature 37.2°C (99.0°F), pulse 90/min, respirations 16/min, and blood pressure 110/65 mm Hg. Abdominal examination discloses tenderness to palpation of the right lower quadrant. Pelvic examination discloses dark blood in the vaginal vault. Hematocrit is 36%. Urine pregnancy test is positive. Pelvic ultrasonography shows a thickened endometrial lining and no adnexal masses. Which of the following is the most appropriate next step in management? (A) Admission to the hospital for observation (B) Diagnostic laparoscopy (C) Dilatation and curettage (D) Follow-up pelvic ultrasonography in 1 week (E) Serial serum β-hCG concentrations | See Supplemental Sheet | (E) Serial serum β-hCG concentrations | (E) Serial serum β-hCG concentrations | (E) Serial serum β-hCG concentrations | |||||||||||||||||||||
82 | 82 | A 32-year-old woman, gravida 4, para 4, comes to the office 1 week after an uncomplicated vaginal delivery of a 3020-g (6-lb 11-oz) term female newborn. She has been breast-feeding her daughter since birth. The patient says that she cries frequently for no reason, is irritable, and is worried about her infant's long-term health. The patient reports having no appetite. She says that her husband and mother say that she is depressed and think she is anorexic. She has not had auditory hallucinations, confusion, or disorientation. She denies suicidal or homicidal ideation. She has a history of postpartum psychosis following the birth of her first child; she had no similar symptoms after the births of her second and third children. Which of the following factors in this patient's history most strongly indicates a poor prognosis? (A) Anorexia (B) Depressed mood (C) History of psychosis (D) Multiparity | See Supplemental Sheet | (C) History of psychosis | (C) History of psychosis | (C) History of psychosis | |||||||||||||||||||||
83 | 83 | A 47-year-old man comes to the office to establish care. He recently moved to the area and has not been evaluated by a physician for more than 3 years. He reports a 1-year history of bilateral knee pain that worsens after prolonged standing, but he otherwise has felt well. Medical history is unremarkable and his only medication is acetaminophen as needed for his knee pain. Family history is significant for hypothyroidism in his mother and myocardial infarction in a paternal uncle at age 55 years. The patient drinks five to six beers weekly and does not smoke cigarettes. BMI is 32 kg/m2. Vital signs are temperature 36.1°C (97.0°F), pulse 78/min, respirations 12/min, and blood pressure 138/89 mm Hg. The patient is not in distress. Physical examination discloses no abnormalities. Results of fasting serum lipid studies obtained in preparation for today's visit are shown: Cholesterol Total 264 mg/dL HDL 54 mg/dL LDL 170 mg/dL Triglycerides 200 mg/dL Which of the following is the most appropriate next step in management regarding the patient's laboratory study results? (A) Prescribe atorvastatin (B) Prescribe cholestyramine (C) Recommend diet and low-impact exercise (D) Refer the patient to a cardiologist (E) Repeat fasting laboratory studies in 1 month | See Supplemental Sheet | (C) Recommend diet and low-impact exercise | (C) Recommend diet and low-impact exercise | (C) Recommend diet and low-impact exercise | |||||||||||||||||||||
84 | 84 | A 37-year-old man comes to the emergency department because he has felt nauseated and light-headed for the past hour. Medical history is significant for esophageal varices secondary to alcohol-related cirrhosis and ascites treated with spironolactone. He drinks eight to ten alcoholic beverages daily. While you are obtaining additional history, the patient vomits a large volume of bright red blood and becomes difficult to arouse. Vital signs are temperature 36.0°C (96.8°F), pulse 110/min, respirations 12/min, and blood pressure 90/50 mm Hg. Following initiation of intravenous fluids, which of the following is the most appropriate immediate management? (A) Arrange for transjugular intrahepatic portal vein shunting (B) Begin intravenous vasopressin therapy (C) Do endotracheal intubation (D) Do upper endoscopy (E) Insert an esophageal tube for balloon tamponade | See Supplemental Sheet | (C) Do endotracheal intubation | (E) Insert an esophageal tube for balloon tamponade | (D) Do upper endoscopy | |||||||||||||||||||||
85 | 85 | A 25-year-old man was admitted to the hospital yesterday with a massive hemothorax sustained as a result of a stab wound. Left lateral thoracotomy was done because more than 2 L of blood returned following chest tube placement. The thoracotomy disclosed a bleeding intercostal vessel that was repaired by suture ligation. Vital signs now are temperature 36.0°C (96.8°F), pulse 100/min, respirations 18/min, and blood pressure 120/78 mm Hg. Pulse oximetry on 5 L/min of oxygen via nasal cannula shows an oxygen saturation of 95%. Physical examination discloses a well-approximated staple line at the incision site and mild erythema. Decreased respiratory excursion is noted on the left side. The chest tube is draining a small amount of serosanguineous fluid; no air leak is noted. Which of the following is the most appropriate next step in management? (A) Administration of broad-spectrum antibiotics (B) Initiation of tube feedings (C) Pain reduction (D) Physical therapy (E) Psychological evaluation for post-traumatic stress disorder | See Supplemental Sheet | (C) Pain reduction | (C) Pain reduction | (C) Pain reduction | |||||||||||||||||||||
86 | 86 | A 45-year-old man returns to the office for ongoing treatment of tuberculous pericarditis. Pericardiocentesis 9 weeks ago showed a serosanguineous effusion; culture of the effusion was positive for Mycobacterium tuberculosis, and therapy with isoniazid, rifampin, and ethambutol was initiated. During the past 2 weeks, he has had increasing shortness of breath on minimal exertion, cough, pain in the right upper quadrant, and swelling of the lower extremities. BMI is 26 kg/m2. Vital signs today are temperature 37.0°C (98.6°F), pulse 100/min, respirations 22/min, and blood pressure 105/65 mm Hg. Physical examination discloses 10 cm of jugular venous distention. Lungs are clear to auscultation and percussion. Cardiac examination discloses distant but normal heart sounds. The liver is tender and is palpated 3 cm below the right costal margin. There is 2+ to 3+ pitting edema from the knees distally. HIV antibody test is negative. ECG shows nonspecific ST-T changes. Chest x-ray today is unchanged from the x-ray obtained at the time of diagnosis, which showed resolution of apical and perihilar infiltrates and a normal-sized heart. Which of the following is the most appropriate next step in management? (A) Add furosemide therapy and reevaluate in 4 weeks (B) Add prednisone therapy (C) Add streptomycin and cycloserine therapy (D) Order bronchoscopy for brushings and cytology (E) Order echocardiography | See Supplemental Sheet | (E) Order echocardiography | (E) Order echocardiography | (E) Order echocardiography | |||||||||||||||||||||
87 | 87 | A 40-year-old woman, gravida 2 para 2, comes to the office because of bulging veins in her legs that have slowly become more visible since she first noticed them 2 years ago. She says they seem to worsen when she stands for long periods of time, but she reports no associated pain. She is concerned that this problem may be life-threatening. Medical history is otherwise unremarkable and she takes no medications. Both of her pregnancies resulted in uncomplicated vaginal deliveries at 40 weeks' gestation. BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses compressible veins in both lower extremities below the knees that are worse on the left. The remainder of the examination discloses no abnormalities. Which of the following is the most appropriate next step? (A) Compression stockings (B) Surgical ligation of the largest veins (C) Venography (D) Venous duplex ultrasonography (E) Warfarin therapy | See Supplemental Sheet | (A) Compression stockings | (D) Venous duplex ultrasonography | (D) Venous duplex ultrasonography | |||||||||||||||||||||
88 | 88 | A 42-year-old woman, who sustained a bite to her left forearm from her cat 2 days ago, comes to the emergency department because of increased pain and redness at the injury site. The patient says the cat stays indoors and is up-to-date on its rabies vaccination. The patient's medical history is significant for type 1 diabetes mellitus. Her only medication is 70/30 insulin. BMI is 24 kg/m2. Vital signs are temperature 38.1°C (100.6°F), pulse 96/min, respirations 16/min, and blood pressure 134/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Examination of the left forearm discloses the wound shown in the photograph; the forearm is tender to palpation. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate antibiotic therapy to administer at this time? (A) Ampicillin-sulbactam (B) Cefazolin and gentamicin (C) Dicloxacillin and clindamycin (D) Levofloxacin (E) Vancomycin and metronidazole | (A) Ampicillin-sulbactam | (C) Dicloxacillin and clindamycin | (A) Ampicillin-sulbactam | ||||||||||||||||||||||
89 | 89 | A 39-year-old woman, gravida 2, para 2, comes to the community-based health center because of a 6-month history of a copious, foul-smelling vaginal discharge. She also reports spotting that began 6 months ago and has progressed to heavy bleeding during the past 3 weeks. Medical history is significant for an abnormal Pap smear in her 20s; her most recent Pap smear was done 12 years ago during her second pregnancy, and she recalls the results as being normal. She takes no medications. The patient was married for 18 years; her husband died 4 years ago and had undergone vasectomy after the birth of their last child. The patient has not had any new sexual partners since her husband's death. BMI is 32 kg/m2. Vital signs are temperature 37.2°C (99.0°F), pulse 90/min, respirations 14/min, and blood pressure 155/96 mm Hg. Speculum examination discloses normal vaginal mucosa. The cervix is friable with a 1-cm exophytic mass lateral to the cervical os at the nine o'clock position. Which of the following is the most critical factor in formulating a management plan for this patient? (A) Future fertility plans (B) Hypertension (C) Obesity (D) Patient age (E) Stage of disease | See Supplemental Sheet | (E) Stage of disease | (E) Stage of disease | (E) Stage of disease | |||||||||||||||||||||
90 | 90 | A 28-year-old man comes to the office for an annual health maintenance examination. He says he has been generally healthy. Three months ago he began walking three times weekly for at least 30 minutes, and he has eliminated salt from his diet after a blood pressure measurement at a local pharmacy was 160/96 mm Hg. Medical history is unremarkable and he takes no medications. Family history is remarkable for hyperlipidemia, hypertension, type 2 diabetes mellitus, and coronary artery disease. The patient is 188 cm (6 ft 2 in) tall and weighs 135 kg (298 lb); BMI is 38 kg/m2. Vital signs are temperature 36.8°C (98.2°F), pulse 102/min, respirations 18/min, and blood pressure 156/98 mm Hg. The abdomen is protuberant with no masses. The remainder of the physical examination discloses no abnormalities. Results of fasting laboratory studies are shown: Serum Blood Cholesterol Hematocrit 46% Total 202 mg/dL Hemoglobin 15.6 g/dL HDL 33 mg/dL WBC 9800/mm3 LDL 137 mg/dL Triglycerides 158 mg/dL Glucose 104 mg/dL Pharmacotherapy should be directed toward which of the following? (A) Aiding with metabolism of glucose (B) Decreasing pulse rate (C) Decreasing serum LDL-cholesterol concentration (D) Lowering blood pressure (E) Suppressing appetite | See Supplemental Sheet | (D) Lowering blood pressure | (D) Lowering blood pressure | (D) Lowering blood pressure | |||||||||||||||||||||
91 | 91 | A 22-year-old man comes to the office for evaluation 3 days after his girlfriend was diagnosed with trichomoniasis vaginalis. The patient has not had urethral discharge, dysuria, testicular pain, or genital skin lesions. He has been monogamous with his girlfriend and has been dating her for the past 6 months. He previously had one sexual partner at age 20 years. The patient has not consistently used condoms. He has never had any sexually transmitted diseases. Medical history is unremarkable and he takes no medications. Vital signs are normal. Genitourinary examination discloses no lesions or urethral discharge. Testes are symmetrical without tenderness or masses. There are shotty inguinal lymph nodes. In addition to recommending condom use, which of the following is the most appropriate next step? (A) Obtain a urethral swab for potassium hydroxide preparation (B) Order urinalysis and urine culture (C) Prescribe ceftriaxone and doxycycline therapy (D) Prescribe metronidazole therapy (E) Reassure the patient that no treatment is necessary | See Supplemental Sheet | (D) Prescribe metronidazole therapy | (A) Obtain a urethral swab for potassium hydroxide preparation | (C) Prescribe ceftriaxone and doxycycline therapy | |||||||||||||||||||||
92 | 92 | A 25-year-old man comes to the office because he has had a "coating" on his tongue during the past 2 weeks and has had an unintentional 4.5-kg (10-lb) weight loss during the past 6 months. He has not had oral pain or difficulty swallowing. Medical history is unremarkable and he takes no medications. He has smoked one pack of cigarettes daily for the past 5 years and he drinks two to three beers weekly. He is sexually active with two male partners and does not consistently use condoms. BMI is 25 kg/m2. Vital signs are temperature 37.1°C (98.8°F), pulse 83/min, respirations 16/min, and blood pressure 114/74 mm Hg. Oral examination shows a white plaque on the lateral aspect of the tongue bilaterally; an attempt to scrape the lesion from the tongue is unsuccessful. Anterior and posterior cervical lymph nodes are enlarged bilaterally but are mobile and not tender to palpation. The remainder of the physical examination discloses no abnormalities. A rapid HIV test is positive. Results of other laboratory studies are shown: Blood CD4+ T-lymphocyte count 128/mm3 Hematocrit 36% Hemoglobin 12.0 g/dL WBC 1400/mm3 Neutrophils, segmented 79% Eosinophils 3% Lymphocytes 11% Monocytes 7% Platelet count 124,000/mm3 Which is of the following is the most appropriate clinical intervention at this time? (A) Antiretroviral therapy (B) Liquid nitrogen therapy applied to the tongue lesions (C) Micafungin therapy (D) Surgical excision of the tongue lesions (E) Systemic chemotherapy with liposomal doxorubicin | See Supplemental Sheet | (A) Antiretroviral therapy | (A) Antiretroviral therapy | (A) Antiretroviral therapy | |||||||||||||||||||||
93 | 93 | A 24-year-old recent college graduate comes to the office because of a 3-year history of increased frequency of urination and occasional incontinence whenever she travels. She says the urinary symptoms typically begin a few days before she is going to fly and they stop the day after she arrives at her destination. She says she is anxious about flying and even slightly "panicky." She reports having had similar but milder symptoms prior to examinations before graduating. Medical history is otherwise unremarkable. Her only medication is an oral contraceptive. Vital signs are normal. Physical examination discloses no abnormalities. Urinalysis and urine culture are normal. Which of the following is the most appropriate next step? (A) Recommend behavioral therapy (B) Recommend psychoanalytic psychotherapy (C) Recommend that the patient avoid any stressful activities that cause the problem (D) Review the patient's sexual history (E) Reassure the patient that her symptoms will resolve in time | See Supplemental Sheet | (A) Recommend behavioral therapy | (A) Recommend behavioral therapy | (A) Recommend behavioral therapy | |||||||||||||||||||||
94 | 94 | A 22-year-old woman comes to the emergency department because of a 5-day history of sore throat and fever. During the past 3 days, she also has noticed a change in her voice and has had increased pain with swallowing. She has been taking acetaminophen since her symptoms began. Medical history is unremarkable and she takes no routine medications. Vital signs are temperature 40.0°C (104.0°F), pulse 130/min, respirations 18/min, and blood pressure 102/66 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination of the oropharynx shows erythema, edema, and anterior displacement of the right side of the soft palate. The uvula is deviated to the left. There is a white exudate on the right tonsil. Trismus is noted. Palpation of the neck discloses enlarged, tender, mobile anterior cervical lymph nodes. In addition to antibiotic therapy, which of the following is the most appropriate management? (A) Incision and drainage (B) Intravenous methylprednisolone therapy (C) Oral nystatin therapy (D) Salt water gargle (E) Tonsillectomy | See Supplemental Sheet | (A) Incision and drainage | (A) Incision and drainage | (A) Incision and drainage | |||||||||||||||||||||
95 | 95 | A 26-year-old man, who is admitted to the hospital to undergo cholecystectomy, bleeds excessively during the procedure and then develops a large wound hematoma. Medical history discloses that he has always tended to bruise excessively with trauma. His wounds oozed blood for 3 days following a dental extraction, which was his only previous surgical procedure. He says that his maternal grandfather and uncle were "bleeders." Initial coagulation studies show a normal platelet count, bleeding time, and prothrombin time. The partial thromboplastin time is moderately prolonged. Which of the following is the most appropriate statement to this patient and his wife regarding their children? (A) There is no evidence of a familial coagulation defect (B) Half of their daughters will have a clinically evident coagulation disorder (C) The sons of their daughters will be at risk for a clinically evident coagulation disorder (D) Their sons will be at risk for a clinically evident coagulation disorder (E) Their sons and daughters will be at risk for a significant coagulation disorder | See Supplemental Sheet | (C) The sons of their daughters will be at risk for a clinically evident coagulation disorder | (D) Their sons will be at risk for a clinically evident coagulation disorder | (D) Their sons will be at risk for a clinically evident coagulation disorder | |||||||||||||||||||||
96 | 96 | An 18-month-old boy is brought to the emergency department by his parents 2 hours after swallowing a dime. The parents note that the child has not had any choking, respiratory problems, feeding problems, or vomiting since the incident. Medical history is unremarkable and the child is up-to-date on vaccinations. He does not appear to be in pain. He is 82 cm (32 in; 50th percentile) long and weighs 12 kg (26 lb; 50th percentile). Vital signs are temperature 37.2°C (98.9°F), pulse 110/min, respirations 30/min, and blood pressure 90/51 mm Hg. Lungs are clear to auscultation. Abdominal examination discloses no tenderness. The remainder of the examination shows no abnormalities. X-ray of the abdomen is shown. Which of the following is the most appropriate management? (A) Administration of an oral bowel-cleansing solution (B) Endoscopic retrieval of the coin (C) Interventional radiologic retrieval of the coin (D) Surgical exploration of the stomach with coin retrieval (E) Observation only | (E) Observation only | (E) Observation only | (E) Observation only | ||||||||||||||||||||||
97 | 97 | A 29-year-old woman, gravida 3, para 3, comes to the office because of a 1-year history of recurrent low back pain. Rest and analgesics typically resolve the pain within 2 weeks. However, the pain recurs every 2 to 3 months. Medical history is remarkable for gestational diabetes during her pregnancies. She takes no medications except for an oral contraceptive. She walks 3 miles daily for exercise and works as a sales representative for a computer software company. She is 165 cm (5 ft 5 in) tall and weighs 100 kg (220 lb); BMI is 37 kg/m2. Vital signs are normal, and physical examination discloses no abnormalities. Which of the following is the most appropriate next step? (A) Administer an epidural injection of methylprednisolone (B) Order MRI of the lumbosacral spine (C) Order x-rays of the lumbosacral spine (D) Recommend beginning a weight loss program (E) Recommend decreasing physical activity | See Supplemental Sheet | (D) Recommend beginning a weight loss program | (D) Recommend beginning a weight loss program | (D) Recommend beginning a weight loss program | |||||||||||||||||||||
98 | 98 | A 46-year-old woman comes to the office because of a 4-month history of irregular vaginal bleeding that occurs every 2 weeks and lasts 3 to 5 days. Until 5 months ago when she missed a period, her periods had occurred at regular 30-day intervals and lasted for 5 days. She has not had vaginal pain or discharge, headache, dizziness, chest pain, or shortness of breath. Medical history is unremarkable. She takes no medications. Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 16/min, and blood pressure 120/60 mm Hg. Pelvic examination discloses normal external female genitalia. There is a small amount of blood in the cervical os. Uterus is 10 cm, mobile, anteverted, nontender, and irregular in shape. Adnexa are without masses or tenderness. Hemoglobin concentration is 10.2 g/dL. Which of the following is the most appropriate next step in evaluation? (A) Determination of serum thyroid-stimulating hormone and prolactin concentrations (B) CT scan of the pelvis (C) Endometrial biopsy (D) Hysteroscopy with dilatation and curettage (E) Trial of hormone replacement therapy | See Supplemental Sheet | (C) Endometrial biopsy | (C) Endometrial biopsy | (C) Endometrial biopsy | |||||||||||||||||||||
99 | 99 | A 36-year-old female advertising executive is referred to the office for evaluation of a fasting serum total cholesterol concentration of 249 mg/dL. She has a family history of early coronary artery disease (CAD) and her father died suddenly at age 46 years of myocardial infarction. She tells you that she has never had chest pain. She is not currently sexually active and has no children. She claims that her high-stress lifestyle makes it impossible for her to eat regular meals or to follow a special diet, and she usually eats fast food. She exercises two or three times a week for about 20 minutes on a treadmill. She has smoked one pack of cigarettes daily for the past 20 years. Her only medication is acetaminophen for tension headaches. She is 165 cm (5 ft 5 in) tall and weighs 76 kg (167 lb); BMI is 28 kg/m2. Vital signs today are normal. Physical examination discloses no abnormalities except for mild obesity. Institution of which of the following is the most essential step in the prevention of CAD in this patient? (A) Biofeedback-based stress reduction program (B) More rigorous and consistent exercise program (C) Smoking cessation program (D) Strict low-calorie diet (E) Strict low-fat diet | See Supplemental Sheet | (C) Smoking cessation program | (C) Smoking cessation program | (C) Smoking cessation program | |||||||||||||||||||||
100 | 100 | A 57-year-old man was admitted to the intensive care unit from the emergency department 3 hours ago for treatment of an acute exacerbation of chronic obstructive pulmonary disease. He was brought to the emergency department by ambulance following a 2-hour history of severe shortness of breath and non-productive cough. Chest x-ray obtained on arrival showed significant air-trapping but no infiltrate. The patient was intubated in the emergency department, but now his ventilator pressure alarm is sounding and his blood pressure is dropping. Medical history is otherwise unremarkable. Medications include ipratropium and prednisone. He has smoked 1½ packs of cigarettes daily for about 40 years. Vital signs are temperature 37.7°C (99.9°F), pulse 106/min, respirations 12/min on intermittent mandatory ventilation, and blood pressure 72/46 mm Hg. Pulse oximetry on 40% FIO2 shows an oxygen saturation of 91%. He appears obtunded and is poorly responsive. Physical examination shows jugular venous distention in the supine position; trachea is midline. Auscultation of the lungs discloses decreased breath sounds bilaterally with inspiratory and expiratory wheezing and a prolonged expiratory phase. Examination of the upper extremities shows 2+ digital clubbing bilaterally. There is no cyanosis or edema. Which of the following is the most appropriate management? (A) Adjustment of the ventilator settings (B) Insertion of bilateral chest tubes (C) Intravenous dopamine (D) Intravenous low-molecular-weight heparin (E) 1-L bolus of intravenous 0.9% saline (F) Needle decompression | See Supplemental Sheet | (A) Adjustment of Ventilator Settings | (F) Needle decompression | (E) 1-L bolus of intravenous 0.9% saline |