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Reaction to food additive

A 23-year-old woman is brought to the emergency department by her friends 30 minutes after the sudden onset ofnausea, facial flushing, and chest pressure while eating at a Thai restaurant. She does not have any known allergiesto foods or medications. She had asthma during childhood but has not required treatment for 5 years. On arrival, sheis diaphoretic and appears anxious. Temperature is 37.1°C (98.8°F), pulse is 92/min, respirations are 20/min, andblood pressure is 126/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination ofthe neck shows erythema; no masses or nodules are palpated. Cardiopulmonary examination shows noabnormalities. Which of the following is the most likely diagnosis?

D

Ask the patient if she would be willing to return to the office in 2 weeks to discuss treatment options again

A 45-year-old woman returns to the office to discuss results of a fine-needle aspiration biopsy of a 0.5-cm rightbreast mass obtained 1 week ago. She is unaccompanied. Medical history is unremarkable and she takes nomedications. Her mother and maternal aunt were diagnosed with breast cancer at the ages of 45 and 52 years,respectively. Physical examination discloses no palpable axillary nodes. The biopsy specimen showed malignantcells. The patient is counseled that she has an excellent chance of cure with lumpectomy and radiation therapy. Sheadamantly refuses this treatment plan and states that she will try natural therapies, including megavitamins andherbal remedies instead. After exploring the reasons behind the patient's decision, which of the following is the mostappropriate response?

C

S1 radiculopathy

A 47-year-old woman comes to the office because of a 2-month history of progressive weakness and numbness ofher right leg. She has a 3-year history of type 2 diabetes mellitus treated with metformin. She has worked as a stockperson in a storeroom for 12 years; she often moves and lifts heavy objects and sometimes crawls into tight spaces.On neurologic examination, muscle strength is 5−/5 in the hip extensor, thigh abductor, hamstring, andgastrocnemius muscles on the right and intact on the left. Muscle strength is intact in the iliopsoas, thigh adductor,quadriceps, and tibial anterior muscles bilaterally. Deep tendon reflexes are 1+ in the right ankle and 2+ in the leftankle. Sensation to light touch is mildly decreased over the lateral and inferior aspects of the right foot. Sensationotherwise is intact. Which of the following is the most likely diagnosis?

F

Parvovirus B19

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 andarms that is slowly resolving. The joint pain in her hands has persisted and is exacerbated by writing or typing. She rates thepain 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 andfever 1 week prior to the development of her symptoms. The patient's medical history is unremarkable and her onlymedication 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, papularrash on the anterior chest and proximal upper extremities. The first and second metacarpophalangeal joints of both hands aretender and swollen. The wrist joints also are tender to palpation but there is minimal swelling. Which of the followingmicroorganisms is most likely to have caused this patient's symptoms?

E

Hepatic adenoma

A 34-year-old woman comes to the office because of a 1-month history of worsening right upper quadrant abdominal pain and discomfort. She describes the pain as a dull ache and says it is not affected by eating or defecating. She has not had nausea or changes in appetite or bowel habits. She feels the pain constantly while she is awake, but it rarely keeps her fromsleeping. 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 arewithin 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

Serum concentration of C3

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/dLBlood: PositiveLeukocyte esterase: PositiveNitrite: NegativeWBCs: 5−10/hpfRBCs: 10−25/hpfCasts:1−2/lpf Results of which of the following laboratory studies are most likely to be abnormal in this patient?

C

Hyperthyroidism

A 45-year-old woman comes to the office because she has noticed during the past several months that her fingernails havebecome white, increasingly brittle, and seem to lift off her nail beds easily. During this time, she also has had episodes offeeling warm and perspiring. Medical history is remarkable for intravenous drug use 25 years ago. The patient takes only amultivitamin. Last menstrual period was 3 weeks ago. She appears thin and mildly anxious. She is 170 cm (5 ft 7 in) tall andweighs 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. Theremainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

D

Serotonin

A 48-year-old man comes to the clinic because of a 10-year history of recurrent, intrusive thoughts that his house will bebroken into and damaged by criminals or accidentally destroyed by a fire when he is not home. These thoughts haveworsened during the past 2 months. He reports now spending 4 hours daily checking that the doors and windows are closedand locked and that the stove and oven are turned off; he previously spent 2 hours daily doing these tasks. He says he cannotkeep a job or leave the house very much because of the amount of time he spends checking these things. He has no otherhistory of serious illness and takes no medications. Physical examination shows no abnormalities. On mental statusexamination, he has an anxious mood and a sad affect. He is fully oriented. He is not having hallucinations or delusions. Themost effective pharmacotherapy for this patient is an agent that targets which of the following neurotransmitters?

E

Stratification

Researchers from a large neurology center are conducting a study to examine the relationship between stress levels andfibromyalgia-related pain. Two hundred patients with fibromyalgia are randomly selected from the center for participation inthe study. During recruitment, a baseline interview is conducted with each participant to obtain sociodemographic andpersonality data. Participants are given a study-provided portable digital device and asked to maintain a daily schedule oftheir fibromyalgia pain and stress levels for 30 days using two well-validated and reliable self-reporting scales. Results showa positive and statistically significant relationship between stress levels and fibromyalgia-related pain (P<.05). Similarly,statistically significant relationships were found between Type A personality participants and increased stress levels (P<.01),as well as increased levels of fibromyalgia-related pain (P<.005). Which of the following is the most appropriate method tocontrol for the potential confounding effect of patients with a Type A personality?

E

His sickle cell disease is affecting his hemoglobin A1c

A 12-year-old boy with sickle cell disease and type 1 diabetes mellitus is brought to the office by his mother for an initialvisit. The family recently moved to the area. Type 1 diabetes mellitus was diagnosed in the patient 6 years ago. Since thattime, 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 diaryshows home fingerstick blood glucose concentrations ranging from 140–200 mg/dL during the past 3 months. He admits tochecking his glucose concentrations infrequently. Measurement of hemoglobin A1c obtained last week was 5.4%. Thepatient'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 discrepancybetween the patient's home fingerstick blood glucose concentrations and his hemoglobin A1c?

E

They will be released to his new physician promptly

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 medicalrecords be sent to another physician in town. The patient has an overdue account balance of $750, which he has not paid forseveral months. He signs an office form authorizing release of health information and provides the name and address of theother physician to whom he would like the records sent. It is most appropriate to inform this patient of which of the followingregarding his request for release of his medical records?

A

Decreased production of factor VII

A 47-year-old man is admitted to the intensive care unit because of lower gastrointestinal bleeding. He has a history ofalcohol-induced cirrhosis. Physical examination shows marked ascites and splenomegaly; the spleen tip is palpated 4 cmbelow the left costal margin. Results of laboratory studies are shown:Serum BloodCreatinine 1.5 mg/dL Hematocrit 29%Hemoglobin 9.7 g/dLPlatelet count 105,000/mm³PT 25 secondsINR 2.5Which of the following mechanisms most increases this patient’s risk for bleeding?

A

Systemic sclerosis (scleroderma)

A 57-year-old woman comes to the office for a preoperative evaluation 2 weeks before undergoing scheduled laparoscopiccholecystectomy. Medical history is otherwise unremarkable and the patient takes no medications. Family history issignificant for stable angina in her father and rheumatoid arthritis in her mother. The patient has a 102-year-old grandmotherwho resides in a nursing care facility and has Parkinson disease. The patient does not smoke cigarettes or drink alcoholicbeverages. 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 examinationdiscloses thickening and hardening of the skin over the dorsum of the hands and forearms, as well as mild kyphosis. Strengthtesting 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, furtherevaluation is indicated for which of the following conditions in this patient?

E

Unprotected sexual intercourse

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 saysthe rash is not itchy or painful. He reports having a flu-like illness nearly 5 weeks ago, with associated headache, neckstiffness, 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. Specificadditional history should be obtained to determine whether which of the following has occurred during the past 6 months?

E

Mold spores

The nurse at a local elementary school contacts you about 12 children he has seen in the past 2 weeks. All of the children hadsimilar 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 thecommunity. There was a fire in the school several weeks ago with significant smoke and water damage to classrooms, thecafeteria, and the school ventilation system. Repairs were quickly made and classes resumed. The most likely cause for thestudents' and teachers' symptoms is exposure to which of the following?

C

Antisocial personality disorder

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 forwhich he was at fault. The patient was arrested for the third time after police discovered he had been driving under theinfluence of alcohol. He has been your patient since early adolescence, and he has a history of truancy, shoplifting, and twoattempts to run away from home. He dropped out of high school in his senior year. He was fired from his most recent jobbecause he threatened a coworker with a hammer. He has been unemployed for the past 8 months, and as a result he hasmany unpaid debts. He seems unconcerned about his current difficulties and has no plans for seeking employment or payinghis debts. Despite these facts, you find the patient charming and interactive, and he conveys a sincere intention to change hisbehavior. Which of the following is the most likely diagnosis?

A

Ask the patient to provide a narrative with detailed description of the incident and of his symptoms

A 45-year-old man comes to the office for an initial appointment because he would like you to fill out and sign a legaldocument at the request of his attorney. The patient works as a limousine driver. He states that he is filing a lawsuit againstthe limousine company that employs him because he developed post-traumatic stress disorder following a motor vehiclecollision. He appears irritable and tense as he provides his history. He relays his symptoms by reading them aloud from awritten list. At this time, which of the following is the most appropriate approach toward confirming the underlying diagnosisof this patient?

B

ECG

A 39-year-old woman comes to the office because of gradually increasing shortness of breath while doing her usualhousehold activities. She also reports fatigue, a feeling of heaviness in her chest with exertion, trouble sleeping, and the veryrecent onset of a rapid heart beat and fluttering in her chest. She says, "I was always sick as a child." She does not smokecigarettes, and she is not currently taking any medications other than occasional aspirin. Her father died of a myocardialinfarction at age 55 years. She is married and has two teenaged children. She did have some shortness of breath at the end ofher second pregnancy. Physical examination today shows a thin woman with an irregular pulse of 130/min. Thyroid gland isnormal to palpation. There is a prominent diastolic rumble heard best over the apical area of her heart. Lungs are clear; thereis no hepatomegaly or pretibial edema. Which of the following is the most helpful diagnostic study at this time?

B

Decreased intravascular volume

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 delayand a seizure disorder. He is fed orally, but he is nonverbal and nonambulatory. Medications are levetiracetam, docusate, andmultivitamins. The patient is 131 cm (4 ft 2 in; 10th percentile) tall and weighs 26 kg (57 lb; 10th percentile). BMI is14 kg/m² (10th percentile). Vital signs are temperature 38.8°C (101.8°F), pulse 80/min, respirations 25/min, and bloodpressure 110/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. The patient appears thin. He isawake and is not in apparent distress. He is responsive to touch. Auscultation of the lungs discloses scattered coarse cracklesand rhonchi but good air entry and normal work of breathing. Results of laboratory studies are shown:Serum Blood Urea nitrogen 78 mg/dL Creatinine 3.2 mg/dL Na+ 131 mEq/L K+ 5.6 mEq/L Cl− 88 mEq/L HCO³ −16 mEq/L Urine Specific gravity 1.030 (N=1.003–1.029)Creatinine 90 mg/dLNa+ 8 mEq/LHematocrit 37%Hemoglobin 12.5 g/dLWBC 12,000/mm3Neutrophils, segmented 60%Lymphocytes 40%Platelet count 250,000/mm3Which of the following is the most likely cause of this patient's altered kidney function?

B

Narcolepsy

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 ata reception, someone told a joke, and when I laughed, my legs collapsed!" His wife says that he recovered in a few secondsand he did not lose consciousness. He has a long history of sleepiness and he is able to go to sleep quickly. He usuallyawakens feeling refreshed after a short nap. He has no history of similar episodes or hallucinations. There is no family historyof similar problems. Vital signs are normal. Physical examination shows no abnormalities. Which of the following is themost likely diagnosis?

A

Minimize ascertainment bias

A study is being conducted to assess mesothelioma in shipyard workers. A large shipyard firm has provided the asbestosexposure records of all employees during the past 50 years. The health insurer for the workers has provided claims data thatdocuments all chest x-rays and diagnoses of mesothelioma among current workers and retirees. The study enrolled shipyardworkers who were diagnosed with mesothelioma and shipyard workers who were not diagnosed with mesothelioma. Allsubjects in the study had to have chest x‐rays. Which of the following is the best rationale for selecting a comparison groupthat had chest x-rays?

C

Reassure the daughter and recommend hospice care consultation

An 88-year-old man with osteoarthritis is brought to the office by his daughter because of a 2-day history of severe low backpain and inability to walk. He says he has not fallen and does not recall any trauma to his back. Five years ago, he underwentbilateral 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 andassistance. One year ago, carcinoma of the prostate was diagnosed, but he declined therapy and said, "I'm an old man. Whenmy 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 hislower back. Palpation discloses point tenderness over L3 through L4, and S1. X-rays of the lumbosacral spine show lyticlesions 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 inresponse to the daughter's concern?

D

Campylobacter jejuni

A 23-year-old man comes to the office because of a 7-day history of fever, crampy abdominal pain, and diarrhea. He says theabdominal pain worsens with oral intake. He has been having 8 to 10 episodes of diarrhea daily. He has not traveled recently andhas had no sick contacts. Medical history is unremarkable and he takes no medications. He does not smoke cigarettes, drinkalcoholic 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 topalpation; no masses are palpated. Neither the liver edge nor the spleen can be palpated. Digital rectal examination shows grosslybloody 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

Human leukocyte antigen-B27 assay

A 23-year-old man comes to the office because of a 7-day history of fever, crampy abdominal pain, and diarrhea. He says theabdominal pain worsens with oral intake. He has been having 8 to 10 episodes of diarrhea daily. He has not traveled recently andhas had no sick contacts. Medical history is unremarkable and he takes no medications. He does not smoke cigarettes, drinkalcoholic 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 topalpation; no masses are palpated. Neither the liver edge nor the spleen can be palpated. Digital rectal examination shows grosslybloody stool. A stool culture is obtained, and empiric pharmacotherapy is initiated. Results of the stool culture show growth of Campylobacter jejuni. The patient returns to the office 3 weeks later. He reportstotal resolution of his fever and gastrointestinal symptoms after completion of prescribed ciprofloxacin therapy, but he hashad pain and swelling of his left knee during the past 3 days. The pain worsens with weight bearing. He rates the pain as a6 on a 10-point scale. Vital signs are temperature 37.1°C (98.8°F), pulse 78/min, respirations 16/min, and blood pressure112/58 mm Hg. Physical examination discloses erythema and warmth of the left knee with marked synovitis. Directpalpation and flexion of the knee elicit pain. Which of the following is the most appropriate diagnostic study to determine thecause of this patient's symptoms?

C

Ductography

A 46-year-old woman, gravida 1, para 1, comes to the office because of a 2-week history of black discharge from her rightnipple. The patient had mammography and ultrasonography of the breasts 2 months ago for evaluation of increasedglandularity, palpated in the upper outer quadrant of the right breast, noted at her most recent annual examination. Thestudies showed likely benign findings with recommended follow-up in 6 months. Medical history is otherwise unremarkableand she takes no medications. BMI is 30 kg/m2. Vital signs are normal. Palpation of the right breast discloses glandularity inthe upper outer quadrant but no other masses. There is scant, black discharge from the right nipple. Which of the following isthe most appropriate next step in diagnosis?

A

Individuals who take Drug X have two times the risk of dying from this type of cancer

A physician is conducting a retrospective review of a trial involving the use of Drug X in patients with a specific disease. It isknown that Drug X is associated with an increased probability of cancer in patients who use the drug. A total of600 individuals with a specific disease were included in the trial. Of the participants, 200 individuals received Drug X and400 individuals did not receive it. One hundred individuals who received Drug X died of a particular type of cancer and100 individuals who did not receive the drug died of the same type of cancer. Based on these data, which of the following isthe relative risk of death from this type of cancer in individuals who take Drug X as compared with individuals who do nottake Drug X?

D

Bacterial exotoxin

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 BloodALT: 164 U/L Hemoglobin: 16.4 g/dLAST: 130 U/L WBC 14,300/mm³ with left shiftUrea nitrogen: 57 mg/dL Platelet count 52,000/mm3Creatinine 2.2 mg/dLCan you provide me a diagnosis for this case? Given your diagnosis, a response to which of the following choices below is the most likely cause of this patient's condition?

B

Age

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 laboratorystudies are shown:Serum BloodCreatine kinase 88 U/L Hematocrit 36%Hemoglobin 12.0 g/dLWBC 8600/mm3ESR 88 mm/hWhich of the following is the most significant risk factor for the development of this patient's condition?

A

Medication-induced suppression of central respiratory drive

A 16-month-old girl is brought to the emergency department by emergency medical technicians because of a generalizedtonic-clonic seizure that began 25 minutes ago and has continued despite administration of 0.5 mg/kg rectal diazepam10 minutes ago. The patient was at home at the time of the seizure. In the emergency department, she is given an additional0.5 mg/kg dose of diazepam intravenously and the convulsion terminates. Within 2 minutes, her oxygen saturation drops to75% and she appears cyanotic. Respirations are 10/min and shallow. She receives bag-valve-mask ventilation, followed byintubation 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?

C

Adverse effect of medications

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 beendarker than usual lately. Medical history is significant for stage III-B Hodgkin lymphoma. She started the first cycle ofchemotherapy 8 days ago. Additional medications include ferrous gluconate, hydrocodone, and prochlorperazine. She iscurrently receiving 0.9% saline at 75 mL/hr. Vital signs today are temperature 37.5°C (99.5°F), pulse 76/min supine and80/min standing, respirations 16/min, and blood pressure 125/65 mm Hg supine and 120/60 mm Hg standing. Pulse oximetryon room air shows an oxygen saturation of 94%. Lungs are clear to auscultation. Cardiac examination discloses a softsystolic 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 areshown:Blood UrineHematocrit 24% Specific gravity 1.032 (N=1.010–1.025)WBC 2400/mm3 Bilirubin NegativePlatelet count 78,000/mm3 RBC NegativeWhich of the following is the most likely explanation for the patient's current condition?

A

Transient tachypnea of newborn

A male neonate, who was born at 36 weeks' gestation 2 hours ago in the labor and delivery unit of the hospital, now showssigns of respiratory difficulty. The mother, an 18-year-old primigravid woman, smoked one pack of cigarettes dailythroughout her pregnancy. She received prenatal care during most of the pregnancy. One episode of chlamydial cervicitiswas detected during the last trimester and treated with azithromycin. The neonate was born via cesarean delivery due to fetalheart rate decelerations. The amniotic fluid was stained with light particulate meconium. Apgar scores were 9 and 9 at 1 and5 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), pulse150/min, and respirations 70/min. Pulse oximetry on room air shows an oxygen saturation of 95%. Physical examinationdiscloses mild subcostal and intercostal retractions. Chest x-ray shows prominent pulmonary vascular markings and fluid inthe intralobar fissures. Which of the following diagnoses is most likely and explain your rationale on each choice?

E

Colonoscopy

A 26-year-old woman comes to the office 1 day after she passed bloody mucus with her stool. She noticed mild abdominalcramping and some constipation preceding the episode; she has not had diarrhea or melanotic stools. She has not had anyexposure to unusual or poorly kept food or to any known infectious agents. She says she has been under considerable stressbecause she is anticipating the defense phase of her PhD thesis soon. Her only medication is acetaminophen for occasionalheadaches. Her father had colon cancer and died at age 48 years from metastatic disease. She recalls being told that an auntdied of an unknown abdominal tumor. The patient's temperature is 37.6°C (99.6°F), pulse is 90/min, respirations are 18/min,and blood pressure is 110/74 mm Hg. Abdomen is mildly distended, nontympanitic, and tender to palpation only in the rightlower quadrant. There is no rebound tenderness or guarding. Pelvic examination shows no masses or mucosal lesions. Rectalexamination elicits pain and bloody mucus. Which of the following is the most appropriate diagnostic study?

A

Cerebellar tumor

A 15-year-old girl is brought to the office by her parents because of a 2-month history of progressively worsening gaitdisturbance. She has fallen several times, once striking her head and causing a brief loss of consciousness. Her parents statethat she has had behavioral changes during this time. Medical history is remarkable for asthma treated with a corticosteroidinhaler as needed. Family history is remarkable for multiple sclerosis in a maternal aunt, parkinsonism in her paternalgrandfather, and cancer in several paternal relatives, including a grandmother who died from a hemangioblastoma. Vitalsigns are normal. The patient is awake and alert, but she avoids eye contact and will not answer questions. Auscultation ofthe lungs discloses expiratory wheezing. Cardiac and abdominal examinations disclose no abnormalities. She has mildbilateral papilledema. Her stance and gait are wide-based, and she is unable to perform a tandem walk. Toxicology screeningof the urine is positive for marijuana and cocaine metabolites. Which of the following is the most likely initial workingdiagnosis?

A

Cholangitis

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 withoutguarding. Results of laboratory studies are shown:Serum: Amylase 350 U/L Bilirubin total 2.1 mg/dLBlood: WBC 16,500/mm3 with prominent immature formsNeutrophils, segmented 42% totalNeutrophils, 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?

C

Adverse effect of fluoxetine therapy

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

Thoracentesis

A 70-year-old woman comes to the office because of a 1-month history of gradually worsening shortness of breath. Medicalhistory is significant for hypertension and hyperlipidemia. Routine medications are atorvastatin and lisinopril. The patientappears 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 studiesare shown:Serum BloodUrea nitrogen 29 mg/dL Hematocrit 38%Creatinine 1.0 mg/dL Hemoglobin 12.9 g/dLNa+ 142 mEq/L WBC 7800/mm3K+ 4.1 mEq/LCl− 99 mEq/LHCO3− 24 mEq/LGlucose 102 mg/dLECG shows atrial fibrillation with a rapid ventricular response. Chest x-ray shows a large left pleural effusion. Which of thefollowing is the most appropriate next step in evaluation?

D

Ultrasonography of the abdomen

A 67-year-old man, who has been recovering in the hospital following surgical repair of a contained ruptured abdominalaortic 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 hasbeen 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 an81-mg aspirin daily. He has smoked one pack of cigarettes daily for the past 40 years, and he typically drinks three to fivebeers daily. Vital signs now are temperature 38.1°C (100.6°F), pulse 68/min and regular, respirations 16/min, and bloodpressure 150/90 mm Hg. Physical examination shows bilateral cataracts. Auscultation of the chest discloses diffuse mildwheezes and a grade 1/6 soft systolic ejection murmur at the cardiac apex. Palpation of the abdomen discloses mild tomoderate mid and right upper quadrant abdominal tenderness. There is no guarding, rebound, or palpable mass. Rectalexamination 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 leftand right cardiac bases; no masses or infiltrates are present. Which of the following is the most appropriate additionaldiagnostic study?

D

Mitral stenosis complicated by atrial fibrillation

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 historyof progressive dyspnea and wheezing. She says her heart is "racing" and she is coughing up a small amount of blood-streakedsputum. Medical history is significant for hypothyroidism, for which she takes levothyroxine. An intravenous catheter isplaced. 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 disclosesdecreased breath sounds at the bases with expiratory crackles bilaterally. Cardiac examination discloses an irregularlyirregular rhythm, an indistinct point of maximal impulse, and a loud S1. A grade 3/6, low-pitched, diastolic, rumblingmurmur is audible at the apex; a distinct snapping sound precedes the murmur. Fetal heart rate is 144/min. Which of thefollowing is the most likely cause of the findings in this patient?

E

Decreased gastric myoelectrical activity

A 70-year-old man is admitted to the hospital through the emergency department because of a 12-hour history of severenausea and four episodes of vomiting of undigested food. During the past week, he has had worsening nausea, heartburnfollowing 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. Healso 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 anoxygen saturation of 98%. Physical examination discloses mild epigastric tenderness to palpation. The remainder of theexamination discloses no abnormalities. Results of laboratory studies ordered in the emergency department are shown:Serum Blood ALT 23 U/L AST 26 U/LAlkaline phosphatase 85 U/LAmylase 104 U/LUrea nitrogen 42 mg/dLCreatinine 1.32 mg/dLHemoglobin A1c 8.2%X-rays of the chest and abdomen disclose no abnormalities. Which of the following will best explain the patient's condition?

B

Serum 25-hydroxyvitamin D assay

A 70-year-old woman comes to the office for an annual health maintenance examination. She describes a 1-year history ofslowly progressive fatigue, diffuse muscle aches, and generalized pain. Medical history is significant for osteoporosisdiagnosed 5 years ago. Medications include alendronate and calcium supplementation. Vital signs are normal. Physicalexamination is unremarkable for her age, with no point tenderness on palpation. Results of complete blood count, serumelectrolyte and thyroid-stimulating hormone concentrations, liver function tests, and erythrocyte sedimentation rate are allwithin the reference ranges. Screening mammography and colonoscopy done 1 year ago disclosed no abnormalities. Whichof the following is the most appropriate next step in evaluation?

E

Ventilation-perfusion mismatch and shunt

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 HgPCO2: 44 mm HgpH: 7.34Oxygen 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?

D

Relieve the physician of duty and alert the hospital's patient safety officer

A 33-year-old male physician reports for a shift in the emergency department. A nurse alerts you that he noticed a faint odorof alcohol near the physician. When approached, the physician appears tired and more disheveled than usual. There is anodor of alcohol on his breath. He is a skilled and talented physician with no known history of substance or alcohol usedisorder. He is married with three children, and his wife is pregnant with twins. The physician was recently hired and has hadno actions on his license by any state medical board. Which of the following is the most appropriate next step?

C

Plain x-ray of the left hip

A 60-year-old man comes to the office because of a 1-year history of progressive left groin pain. The pain is worse withexercise 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 mildstiffness 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 178cm (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 changingposition. 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?

D

Stage 1: High Sensitivity, Low Specificity; Stage 2: Low Sensitivity, High Specificity

A 2-stage screening program for ovarian cancer is being designed. Which of the following sets of sensitivity and specificity ismost likely preferred for Stage 1 and Stage 2 of the program?

B

Order a urine toxicology screening

A 35-year-old woman comes to the office for follow-up of chronic pelvic pain. The patient has had deep pelvic pain sinceundergoing 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. Allsubsequent cancer follow-up has been negative. Medical history otherwise is unremarkable. The patient has taken oxycodone forher pain for 3 years, but she now reports that the oxycodone only partially relieves her pain. She requests either an increased dose ofoxycodone or a change in her prescription to controlled-release morphine, which was recently given to her by a friend. She hassmoked one pack of cigarettes daily for the past 15 years. She does not drink alcoholic beverages. BMI is 18 kg/m². She appearslethargic. She is oriented to person, place, and time but speaks slowly with slurred speech. Vital signs are normal. Examination ofthe skin shows no abnormalities. Pupils are pinpoint and react sluggishly.Which of the following is the most appropriate next step in management?

C

"I am concerned that you are abusing pain medicine. I would like for you to consider a substance use disorder

A 35-year-old woman comes to the office for follow-up of chronic pelvic pain. The patient has had deep pelvic pain sinceundergoing 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. Allsubsequent cancer follow-up has been negative. Medical history otherwise is unremarkable. The patient has taken oxycodone forher pain for 3 years, but she now reports that the oxycodone only partially relieves her pain. She requests either an increased dose ofoxycodone or a change in her prescription to controlled-release morphine, which was recently given to her by a friend. She hassmoked one pack of cigarettes daily for the past 15 years. She does not drink alcoholic beverages. BMI is 18 kg/m2. She appearslethargic. She is oriented to person, place, and time but speaks slowly with slurred speech. Vital signs are normal. Examination ofthe skin shows no abnormalities. Pupils are pinpoint and react sluggishly. Urine toxicology screening is positive for diazepam, methadone, and oxycodone. The patient returns to the office 1 week laterto discuss these results. Which of the following is the most appropriate opening remark?

A

Chlamydial cervicitis

A 24-year-old woman, gravida 1, para 1, comes to the office because she and her husband have been trying to conceive forthe 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 intrauterinedevice (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 otheroccasions. 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 increasedher risk for development of her condition?

C

Ankle brachial index

Patient InformationAge: 62 yearsGender: M, self-identifiedEthnicity: white, self-identifiedSite of Care: officeHistoryReason 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 worstPast Medical History: hypertension, mild angina, type 2 diabetes mellitusMedications: lisinopril, metoprolol, furosemide, glyburide, lovastatinAllergies: no known drug allergiesPsychosocial History: has smoked one-half pack of cigarettes daily for 44 yearsPhysical ExaminationTemp 36.0°C (96.8°F) Pulse 72/minResp 14/minBP 140/90 mmHgO2Sat -Height 164 cm (5 ft 5 in)Weight 90 kg (198 lb)BMI 33 kg/m² Appearance: no acute distressHEENT: funduscopic shows grade 2/4 arteriovenous nickingNeck: no jugular venous distentionPulmonary: clear to auscultation; mildly diminished lung soundsCardiac: no bruits; distant heart soundsAbdominal: obese; no tenderness, guarding, masses, bruits, or hepatosplenomegalyExtremities: no joint erythema, edema, or warmth; no hair on toes; no femoral bruits; dorsalis pedis, radial, and femoralpulses intactNeurologic: sensation to vibration intactQuestion: Which of the following is the most appropriate diagnostic study?

A

A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism

In determining the usefulness of a D-dimer assay in ruling out pulmonary embolism as a diagnosis in a 27-year-old womanwith pleuritic chest pain and nonproductive cough, a recent study in the medical literature is reviewed. The study evaluatesthe use of D-dimer assay in 1500 patients (705 female and 795 male) ranging in age from 19 years to 57 years (mean age is36 years), whose examining physicians had a low clinical suspicion that the patients had pulmonary embolism. All patients inthe study underwent a D-dimer assay, followed by CT angiography of the chest to confirm or exclude the diagnosis ofpulmonary embolism. Study results are shown:D-Dimer Positive and CT Angiography Positive: 88D-Dimer Negative and CT Angiography Positive: 0D-Dimer Positive and CT Angiography Negative: 312D-Dimer Negative and CT Angiography Negative: 1100Total CT Angiography Positive: 88Total CT Angiography Negative: 1412Total D-Dimer Positive: 400Total D-Dimer Negative: 1100Which of the following is the most appropriate conclusion about this data in regard to patients with low clinical suspicion forpulmonary embolism?

D

It is inappropriate because the physician would not be stating the truth

A 45-year-old man is admitted to the hospital because of a 6-hour history of bilateral vision loss. He is otherwiseasymptomatic. He has no history of serious illness and takes no medications. Vital signs are within normal limits. Physicalexamination findings are consistent with psychogenic blindness. A medical student on the patient's treatment team suggeststo the attending physician that they administer a placebo 0.9% saline injection to the patient but tell the patient it is a newmedication that will "confirm a diagnosis of blindness by temporarily recovering your vision." Which of the following bestdescribes the appropriateness of the medical student's suggestion?

D

Infant HIV infection was the only significantly associated factor

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' gestationvia cesarean delivery because of chorioamnionitis. The infant had fetal distress that was documented by fetal monitoringduring 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 Bvaccination on the second day of life. The infant's weight today is 3912 g (8 lb 10 oz); physical examination shows noabnormalities. 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 isplanned for the infant regarding HIV. To determine the risk of HCV transmission, a recently published study of risk factorsfor 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 Transmission155 Mothers with HIV and HCV InfectionFactor: Gestational Age <37 weeks - HCV Transmission 8.4%, RR 1.0, 95% CI -Factor: Gestational Age ≥37 weeks - HCV Transmission 8.3%, RR 0.99, 95% CI 0.32 to 3.06, p Value 0.99Factor: No Cesarean Delivery - HCV Transmission 6.0%, RR 1.0, 95% CI -Factor: With Cesarean Delivery - HCV Transmission 13.3%, RR 2.21, 95% CI 0.69 to 7.06, p Value0.24Factor: No Chorioamnionitis - HCV Transmission 7.0%, RR 1.0, 95% CI -Factor: With Chorioamnionitis - HCV Transmission 33.3%, RR 4.77, 95% CI 0.86 to 26.3, p Value 0.21Factor: Did not use Fetal Electrode - HCV Transmission 7.0%, RR 1.0, 95% CI —Factor: Used of Fetal Electrode - HCV Transmission 3.3%, RR 0.66, 95% CI 0.09 to 4.89, p Value 0.99Factor: Infant Not HIV-infected - HCV Transmission 5.4%, RR 1.0 95% CI —Factor: Infant HIV-infected - HCV Transmission 17.1%, RR 3.19, 95% CI 1.14 to 8.93, p Value 0.04RR=relative risk; CI=confidence intervalBased on these data, which of the following is the most appropriate conclusion regarding the five potential risk factors fortransmission of HCV?

C

Place masks on the patient and yourself and then continue to evaluate him

A 45-year-old man comes to the community health center because of a 1-week history of fever, chills, sweating, mildshortness of breath, and nonproductive cough. Medical history is remarkable for AIDS and pneumonia 3 years ago thatrequired hospitalization. Today, he says that he lost his job 6 months ago and cannot afford to buy his antiretroviralmedications. Vital signs are temperature 38.6°C (101.5°F), pulse 82/min, respirations 20/min, and blood pressure116/72 mmHg. Pulse oximetry on room air shows an oxygen saturation of 97%. The health center is very busy with severalpatients waiting to be evaluated. Which of the following is the most appropriate next step?

C

No further evaluation is necessary

A 45-year-old man comes to the office for a follow-up examination 2 days after he was seen in the emergency department fora generalized tonic-clonic seizure. He was prescribed chlordiazepoxide upon being discharged but did not fill theprescription. 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 anyalcoholic beverages for the past 5 days. He takes no medications. The patient says that his seizures usually occur after heabstains from alcohol for a period of time. Vital signs are normal. Physical examination shows scattered spider angiomata onhis chest and abdomen. Liver is enlarged, smooth, and nontender. CT scan of the head with contrast done in the emergencydepartment 2 days ago showed no abnormalities. Which of the following is the most appropriate next step?

E

The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension

A case-control study is conducted to assess risk factors predicting inpatient mortality among geriatric patients withcommunity-acquired pneumonia. Results of the study include the odds ratios shown below, which were calculated from amultivariable logistic regression equation:Predictor Variables:Hypotension (systolic blood pressure ≤100 mm Hg) - Odds Ratio: 3.32, 95% CI (1.65 to 5.11)Hypoxemia (PO2 ≤ 50 mm Hg) - Odds Ratio: 2.43, 95% CI (1.55 to 3.32)Lung infiltrate present on chest x-ray at time of admission - Odds Ratio: 1.35, 95% CI (0.76 to 2.24)When the other covariates are controlled, which of the following is the most appropriate conclusion regarding these data?

A

Serum free metanephrine concentration

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 mostfrequently in the afternoon. He does not have any new stressors in his life. Medical history is significant for hypertension andtype 2 diabetes mellitus. Medications are lisinopril and metformin. Family history is significant for hyperparathyroidism inan aunt and the death of an uncle from medullary thyroid cancer. The patient's BMI is 33 kg/m². Vital signs are temperature36.9°C (98.4°F), pulse 74/min, respirations 18/min, and blood pressure 138/92 mm Hg. Physical examination discloses noabnormalities. Results of serum laboratory studies are shown:Calcium 9.8 mg/dLUrea nitrogen 15 mg/dLCreatinine 1.0 mg/dLNa+ 140 mEq/LK+ 3.8 mEq/LCl− 102 mEq/LHCO3 −28 mEq/LECG shows no abnormalities. Which of the following is the most appropriate diagnostic study at this time?

C

"Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up."

A 19-year-old woman is referred to the office by her counselor for evaluation of possible depression. The counselor describesthe 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 hehad "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." Sheis still sad and often tearful about her ex-boyfriend, but she has not had alterations in her sleep habits, appetite, weight, orenergy level. She has not had any thoughts about death. Medical history is unremarkable and she takes no medications. BMIis 24 kg/m². Vital signs are normal and physical examination discloses no abnormalities. Which of the following is the mostappropriate initial response to this patient's self-deprecating description?

B

Displacement of the nucleus pulposus

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. Thepain 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 hasbeen unable to find a comfortable position and has been sleeping in a recliner. Medical history is unremarkable and he takesno medications. He has smoked one pack of cigarettes daily for the past 25 years, and he drinks a six-pack of beer on Fridayand Saturday nights. BMI is 27 kg/m². He appears uncomfortable and stands during the physical examination. Vital signs arenormal. Straight-leg raise test is positive on the right, with loss of right ankle reflex. The remainder of the physicalexamination discloses no abnormalities. Which of the following is the most likely explanation for this patient’s symptoms?

A

Vascular dementia

A 71-year-old woman is brought to the emergency department by her daughter for evaluation of her mental status. Thedaughter says, "I visited mom today for the first time in 6 months; her memory has worsened, her bills are unpaid, and herhouse is unusually messy." The patient says, "I'm perfectly healthy." Medical history is significant for hypertensiondiagnosed more than 25 years ago, and two small strokes occurring 3 years and 7 months ago. The daughter gives you threeempty 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 doesnot 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 thefollowing is the most likely underlying cause of the patient's symptoms?

E

Instructing the patient to stop driving

A 45-year-old woman with a history of seizure disorder comes to the office because she has had seizures daily for the past 3weeks, despite adhering to her medication regimen. Medical history is also significant for borderline hypertension for thepast year and alcohol use disorder. 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 parentsand in all of her grandparents, heart disease in her sister, and death of her paternal grandfather of complications from alcoholuse disorder. 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 hospitalappointments. BMI is 22 kg/m². Vital signs are temperature 37.1°C (98.8°F), pulse 80/min, respirations 16/min, and bloodpressure 138/86 mm Hg. Physical examination discloses no abnormalities. Serum phenobarbital concentration is obtainedand results are pending. Which of the following is the priority in management at today's visit?

D

90%

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%) and60 men (30%) ages 30 to 60 years, with baseline blood pressure measurements of 150/95 mm Hg or higher. The investigatorsdefined antihypertensive therapy as effective if the treatment resulted in a blood pressure measurement below140/90 mm Hg. When designing the study, the investigators set the probability of wrongly finding that Drug X is moreeffective than the standard therapy as 1%; they set the probability of wrongly finding that the effectiveness of the two drugsis the same as 10%. Which of the following is the most accurate estimate of the statistical power in this study?

D

Essepro should not be prescribed because the patient has severe liver disease

Essepro™ (lesystolol) Reduces Blood Pressure SignificantlyNo significant interactions with commonly used medications were observed. No significant interactions with hydrochlorthiazide, furosemide, losartan orlisinopril. No significant interactions with digoxin, warfarin or simvastatin. Drugs that inhibit CYP2C9 can increase plasma levels of Essepro. Patients on Essepro who are also treated with drugs that inhibit or induce this enzyme shhould be monitored closely, and dosage of Essepro may need to be adjusted based on blood pressure response.Important Safety InformationPatients treated with Essepro should be advised against sudden discontinuation of therapy. When discontinuing therapy, dosage should be gradually tapered over 2 weeks. Essepro is contraindicated i patients with bradycardia, heart block greater than first degree, cardiogenic shock, decompensated cardiac failure, severe hepatic impairment, and in patients who are hypersensitive to any component of this product. Essepro should be used with caution in patients with peripheral vascular disease, renal impairment or thyrotoxicoses. Caution should be used in diabetics, as beta blockers may mask some manifestations of hypoglycemia. In general, patients with bronchospastic disease should not receive beta blockers.A 65-year-old woman comes to the office for blood pressure medication management. Medical history is significant for poorlycontrolled hypertension, psoriasis, and psoriatic arthritis previously treated with methotrexate. Additional medical history issignificant for alcohol use disorder and elevated liver function tests. Medications include enalapril, spironolactone, and topicalcorticosteroids. Vital signs are normal except for a blood pressure of 160/104 mm Hg. Physical examination discloses thick, scalyplaques on the scalp, buttocks, and upper and lower extremities. There are several spider angiomata on the chest and abdomen. Theabdomen is distended and a fluid wave is noted. She has 2+ lower extremity edema. The patient says she would like to try a newdrug called Essepro to treat her hypertension because she can get a 3-month supply of the medication for free.66. Which of the following is the most appropriate response to the patient's request for the medication?

D

Mucosal edema

A 19-year-old woman comes to her university's health center because of a 1-week history of nasal stuffiness, occasional clearrhinorrhea, and a mild sore throat. Two days ago, she began to feel hot, but she has not taken her temperature. Medicalhistory is unremarkable and her only medication is an oral contraceptive. She has no history of allergies. She does not smokecigarettes. BMI is 22 kg/m². Vital signs are temperature 38.1°C (100.6°F), pulse 88/min, respirations 16/min, and bloodpressure 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 upperincisors. The left frontal sinus does not transilluminate. Cardiopulmonary examination discloses no abnormalities. Which ofthe following is the most likely underlying mechanism of this patient's sinusitis?

B

Polymyositis

A 40-year-old woman comes to the office because of a 2-month history of fatigue, and generalized aching and weakness ofthe proximal muscles of all four extremities. The patient initially noticed the weakness only while she was getting in and outof her car, but during the past 2 weeks, the weakness has progressed, so that she now has difficulty combing her hair. Sincethe symptoms began, she also has had aching of the joints in her hands that has responded partially to ibuprofen. She wasadopted and family history is unknown. She has two teenaged children who are well. She appears uncomfortable. She is 170cm (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 examinationdiscloses cracking of the skin of both hands that involves the tips and lateral sides of several fingers. The muscles of theupper arms and legs are somewhat tender to pressure. Results of serum laboratory studies show a creatine kinaseconcentration of 600 U/L and a lactate dehydrogenase concentration of 800 U/L. Results of complete blood count are withinthe reference ranges. Which of the following is the most likely diagnosis?

C

13

A new diagnostic test for HIV infection is developed. The new serum biomarker concentration is measured in 711 men andwomen, 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:Serum Biomarker Concentration >100 U/mL Positive for HIV 120 Negative for HIV 10Serum Biomarker Concentration 76–100 U/mL Positive for HIV 100 Negative for HIV 130Serum Biomarker Concentration 51–75 U/mL Positive for HIV 75 Negative for HIV 75Serum Biomarker Concentration 26–50 U/mL Positive for HIV 30 Negative for HIV 60Serum Biomarker Concentration 0–25 U/mL Positive for HIV 11 Negative for HIV 200Total Number of Positive for HIV = 336Total Number of Negative for HIV = 375Which of the following is the likelihood ratio that is associated with a serum biomarker concentration greater than 100 U/mL?

C

Fine-needle aspiration of the nodule

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 apalpable nodule in the right lobe of the thyroid gland. Serum thyroid-stimulating hormone concentration is within thereference range. Ultrasonography of the thyroid gland confirms a solid, 1-cm nodule. Which of the following is the mostappropriate next step in evaluation?

B

Serologic study for Coccidioides immitis

A 35-year-old man was admitted to the hospital 3 days ago because of pneumonia, but he has shown no clinical improvementdespite ceftriaxone and azithromycin therapy. Upon admission, the patient exhibited blood-streaked sputum and chest x-rayshowed hilar adenopathy. Medical history is otherwise unremarkable. The patient is a construction worker and he returnedhome 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 pressure110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. PPD skin test is nonreactive. Acid-fastsmears of three sputum samples were all negative. Complete blood count at the time of admission showed a normal leukocytecount with 15% eosinophils. Results of blood culture have been negative since admission. Which of the following is mostlikely to provide a diagnosis?

D

Initiate a family meeting to discuss the parents' concerns with their son

A 25-year-old man is brought to the office by his parents. The patient has Down syndrome and mild intellectualdevelopmental disorder. He is their only child, and they are concerned that his current lifestyle is increasing his risk forcoronary artery disease and stroke. The patient has a systolic murmur and also underwent surgical repair of an atrial septaldefect at 1 year of age. He has smoked one pack of cigarettes daily for 5 years. He lives in a group home and works about25 hours each week in a fast-food restaurant. He has a few friends and is romantically involved with a woman from hischurch 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. Agrade 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 yourassistance in obtaining legal guardianship of their son. Which of the following is the most appropriate initialrecommendation?

D

Over-the-counter cold medication

A 45-year-old woman comes to the office because of a 3-day history of nasal congestion, headache, sore throat, and generalmalaise. She has developed a cough during the past 24 hours that is mildly productive of clear sputum. Except for occasionalseasonal allergies, she has no previous history of medical problems. She takes no medications on a regular basis but duringthe past 3 days she has been taking an over-the-counter oral cold medication. She follows a strict low-fat vegetarian diet andshe drinks three to four glasses of wine per week. She jogs 3 miles a day when she is not sick. Vital signs today aretemperature 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 is54 kg (120 lb); BMI is 19 kg/m². On physical examination she appears slightly anxious. Nasal mucosa is erythematous andswollen, and sinuses are nontender. Posterior pharynx is also erythematous but there are no exudates. Lungs are clear onauscultation and cardiac examination is normal. Repeat blood pressure measurement at the end of the examination is142/96 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 herelevated blood pressure?

E

No additional study is indicated

A 41-year-old woman comes to the emergency department because of a 3-day history of fever and a 2-day history ofworsening flank pain with frequent and painful urination. She describes the pain as constant and says it worsens when shecoughs or lies on her right side. She rates the pain as a 5 on a 10-point scale; ibuprofen has provided moderate relief of herpain. She also reports intermittent nausea but has not had vomiting or change in bowel habits. Medical history is significantfor several uncomplicated urinary tract infections, most recently 8 months ago. Each infection resolved with antibiotictherapy. She currently takes no medications aside from her recent use of ibuprofen. She is sexually active with one malepartner and uses condoms regularly. Vital signs are temperature 39.4°C (103.0°F), pulse 76/min, respirations 20/min, andblood pressure 128/74 mm Hg. Auscultation of the chest discloses normal S1 and S2. Abdomen is soft with normal bowelsounds. There is guarding on the right lateral side and tenderness to compression over the right costophrenic angle. Results oflaboratory studies are shown:Serum:Urea nitrogen 18 mg/dL Creatinine 0.9 mg/dL Blood:Hemoglobin 12.8 g/dLWBC 20,000/mm3Neutrophils, segmented 80%Lymphocytes 15%Eosinophils 2%Monocytes 3%Urine:Specific gravity 1.015 (N=1.003–1.029) Protein Negative Occult blood Negative Leukocyte esterase PositiveWBC Too numerous to countCasts OccasionalUrine and blood cultures are obtained and sent for analysis. Antibiotic therapy is initiated. Which of the following is the mostappropriate next step?

E

Sympathetic underactivity

A 41-year-old woman is brought to the emergency department by her husband because of nausea and dizziness that begansuddenly 4 hours ago. She says she feels like the room is spinning. She has not vomited. She recalls receiving a blow to theleft side of her neck 1 week ago when her dog jumped on her, but she has had no ill effects from that incident. Medicalhistory is unremarkable. She takes no medications. Vital signs are normal. Physical examination shows mild ptosis of the lefteyelid. The right pupil measures 4 mm in diameter and the left pupil measures 2 mm in diameter. Both pupils are reactive tolight. 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 andlower extremities. Which of the following pathophysiologic processes most accurately explains this patient's left-sided ptosisand decreased pupil size?

F

Urine protein concentration

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) weightgain. Medical history is significant for sickle cell trait and mild anemia. She has been taking 800 mg of ibuprofen three timesdaily for Achilles tendinitis diagnosed 1 month ago. She has smoked five cigarettes daily for the past 15 years, and she drinksone to five beers on weekends. She experimented with cocaine briefly 16 years ago, but she has never used intravenousdrugs. She has been in a monogamous sexual relationship for the past 12 years. Today, vital signs are temperature37.2°C (99.0°F), pulse 88/min, respirations 16/min, and blood pressure 145/95 mm Hg. Physical examination disclosesperiorbital edema but no jugular venous distention. Lungs are clear to auscultation. Cardiac examination discloses an S1 andS2 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 ofthe following studies are most likely to be abnormal in this patient?

E

Topiramate

A 54-year-old woman comes to the office because she has had intermittent shooting pain over her right cheek and jaw duringthe past 3 weeks. Each episode of pain lasts for 1 second or less. The pain is often triggered by cold air, chewing, tactilestimulation, and brushing her teeth. She has had no trauma to the face or head. Medical history is remarkable for tensionheadaches, 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 ofsensation. The remainder of the physical examination shows no abnormalities. CT scan of the head with and without contrastshows no abnormalities. Which of the following is the most appropriate pharmacotherapy at this time?

D

Measurement of lower extremity compartment pressures

A 25-year-old man, who was admitted to the hospital 5 hours ago because of nausea, light-headedness, and muscle aches thatbegan after he completed a marathon, now reports worsening pain in his right leg. On admission, the patient reported onlymild muscle aching, but he now rates the pain in his right lower extremity as a 9 on a 10-point scale. Laboratory studies onadmission were notable for a serum creatine kinase concentration of 10,000 U/L and a serum creatinine concentration of 1.7mg/dL. Since admission the patient has received 5 L of 0.9% saline and his nausea and light-headedness have resolved. He isalert and fully oriented. Vital signs are temperature 36.9°C (98.5°F), pulse 88/min, respirations 16/min, and blood pressure126/82 mmHg. Pulse oximetry on room air shows an oxygen saturation of 97%. Cardiopulmonary and abdominalexaminations disclose no abnormalities. Passive flexion of the toes elicits pain over the anterior portion of the right lowerextremity below the knee. Distal pulses are present in the lower extremities bilaterally. The remainder of the physicalexamination discloses no abnormalities. Results of laboratory studies obtained 1 hour ago are shown:Serum:Urea nitrogen 12 mg/dLCreatinine 1.2 mg/dL Na+ 140 mEq/L K+ 4.0 mEq/LCl− 100 mEq/LHCO3 −24 mEq/LBlood:Hemoglobin 14.0 g/dLWBC 14,000/mm3Neutrophils, segmented 60%Which of the following is the most appropriate next step in management?

C

Systemic hypertension

A 9-year-old boy is brought to the office by his parents to establish care after recently moving to the area. The patient has notbeen evaluated by a physician in 4 years. He has been generally healthy. Medical history is significant for pneumonia at age3 years. He takes no medications. He is at the 25th percentile for height, weight, and BMI. Vital signs are temperature37.0°C (98.6°F), pulse 82/min, respirations 20/min, and blood pressure 112/74 mm Hg. Cardiac examination discloses agrade 3/6 systolic murmur audible along the left sternal border at the third and fourth intercostal spaces. Femoral pulses areweak and brachial pulses are strong; there is a radiofemoral delay. Chest x-ray discloses mild cardiomegaly with leftventricular prominence. ECG shows left ventricular hypertrophy. This patient is at greatest risk for which of the followingcomplications?

C

Serial serum β-hCG concentrations

A 25-year-old woman comes to the office because of a 2-day history of right lower quadrant abdominal pain and vaginalspotting. She describes the abdominal pain as cramping and rates it as a 4 on a 10-point scale. Medical history isunremarkable and the patient takes no medications. Menses are typically irregular but she thinks her last menstrual periodwas approximately 5 weeks ago. She is sexually active with one male partner and they use condoms occasionally. Vital signsare temperature 37.2°C (99.0°F), pulse 90/min, respirations 16/min, and blood pressure 110/65 mm Hg. Abdominalexamination discloses tenderness to palpation of the right lower quadrant. Pelvic examination discloses dark blood in thevaginal vault. Hematocrit is 36%. Urine pregnancy test is positive. Pelvic ultrasonography shows a thickened endometriallining and no adnexal masses. Which of the following is the most appropriate next step in management?

E

History of psychosis

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-lb11-oz) term female newborn. She has been breast-feeding her daughter since birth. The patient says that she cries frequentlyfor no reason, is irritable, and is worried about her infant's long-term health. The patient reports having no appetite. She saysthat 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 followingthe birth of her first child; she had no similar symptoms after the births of her second and third children. Which of thefollowing factors in this patient's history most strongly indicates a poor prognosis?

C

Recommend diet and low-impact exercise

A 47-year-old man comes to the office to establish care. He recently moved to the area and has not been evaluated by aphysician for more than 3 years. He reports a 1-year history of bilateral knee pain that worsens after prolonged standing, buthe otherwise has felt well. Medical history is unremarkable and his only medication is acetaminophen as needed for his kneepain. Family history is significant for hypothyroidism in his mother and myocardial infarction in a paternal uncle at age55 years. The patient drinks five to six beers weekly and does not smoke cigarettes. BMI is 32 kg/m² . Vital signs aretemperature 36.1°C (97.0°F), pulse 78/min, respirations 12/min, and blood pressure 138/89 mm Hg. The patient is not indistress. Physical examination discloses no abnormalities. Results of fasting serum lipid studies obtained in preparation fortoday's visit are shown:CholesterolTotal 264 mg/dLHDL 54 mg/dLLDL 170 mg/dLTriglycerides 200 mg/dLWhich of the following is the most appropriate next step in management regarding the patient's laboratory study results?

C

Do endotracheal intubation

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 withspironolactone. He drinks eight to ten alcoholic beverages daily. While you are obtaining additional history, the patientvomits a large volume of bright red blood and becomes difficult to arouse. Vital signs are temperature 36.0°C (96.8°F), pulse110/min, respirations 12/min, and blood pressure 90/50 mm Hg. Following initiation of intravenous fluids, which of thefollowing is the most appropriate immediate management?

C

Pain reduction

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? Why not the other choices?

C

Order echocardiography

A 45-year-old man returns to the office for ongoing treatment of tuberculous pericarditis. Pericardiocentesis 9 weeks agoshowed a serosanguineous effusion; culture of the effusion was positive for Mycobacterium tuberculosis, and therapy withisoniazid, rifampin, and ethambutol was initiated. During the past 2 weeks, he has had increasing shortness of breath onminimal exertion, cough, pain in the right upper quadrant, and swelling of the lower extremities. BMI is 26 kg/m² . Vital signstoday are temperature 37.0°C (98.6°F), pulse 100/min, respirations 22/min, and blood pressure 105/65 mm Hg. Physicalexamination discloses 10 cm of jugular venous distention. Lungs are clear to auscultation and percussion. Cardiacexamination 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-Tchanges. Chest x-ray today is unchanged from the x-ray obtained at the time of diagnosis, which showed resolution of apicaland perihilar infiltrates and a normal-sized heart. Which of the following is the most appropriate next step in management?

E

Compression stockings

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

Stage of disease

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 16 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?

E

Lowering blood pressure

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 CholesterolTotal - 202 mg/dLHDL - 33 mg/dLLDL - 137 mg/dLTriglycerides - 158 mg/dLGlucose - 104 mg/dLBlood Hematocrit - 46%Hemoglobin - 15.6 g/dLWBC - 9800/mm³Pharmacotherapy should be directed toward which of the following?

D

Prescribe metronidazole therapy

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?

D

Antiretroviral therapy

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 25kg/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:BloodCD4+ T-lymphocyte count - 128/mm³Hematocrit - 36%Hemoglobin - 12.0 g/dLWBC - 1400/mm³Neutrophils, segmented - 79%Eosinophils - 3%Lymphocytes - 11%Monocytes - 7%Platelet count - 124,000/mm³Which is of the following is the most appropriate clinical intervention at this time?

A

Recommend behavioral therapy

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. 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

Incision and drainage

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

The sons of their daughters will be at risk for a clinically evident coagulation disorder

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?

C

Recommend beginning a weight loss program

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?

D

Endometrial biopsy

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?

C

Smoking cessation program

A 36-year-old woman 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. The patient works as an advertising executive. 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?

C

Adjustment of the ventilator settings

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 11⁄2 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

Oral docusate

A 32-year-old woman comes to the office because of a 2-week history of burning rectal pain and bleeding. She says, "The pain is like being burned with a hot poker." The pain is at its worst when she has a bowel movement and for approximately 20 minutes after defecation. She rates the pain at its worst as an 8 on a 10-point scale. She has noticed small amounts of bright red blood on the toilet paper when wiping, as well as drops of blood on her underwear. Medical history is unremarkable and she takes no medications. BMI is 28 kg/m². Vital signs are normal. Abdominal examination discloses no abnormalities. The patient has pain during rectal examination. Anoscopy shows a small tear in the anal mucosa. Test of the stool for occult blood is positive. Which of the following is the most appropriate next step in management?

D

Prescribe rifampin

A 16-year-old girl is brought to the office by her mother because she is concerned that she may have contracted meningitis from her soccer teammate, who was diagnosed with meningococcal meningitis and admitted to the hospital yesterday. The patient's soccer team traveled to a neighboring state to participate in a tournament 1 week ago and she shared a hotel room with the girl who was hospitalized. The patient feels well but is concerned she may have "caught the same bug." Medical history is remarkable for asthma. Medications include inhaled albuterol. Vital signs are temperature 37.2°C (98.9°F), pulse 64/min, respirations 16/min, and blood pressure 107/58 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate intervention for this patient at this time?

D

Transfusion of packed red blood cells

A 27-year-old nulligravid woman comes to the office because of a 1-month history of daily vaginal bleeding associated with lower abdominal pain and, more recently, shortness of breath. Three days ago, she also developed aching pain of her sternum, which she rates as a 10 on a 10-point scale. During the 6 months prior to her current symptoms, the patient's menstrual periods occurred regularly but were heavy in flow. Her current bleeding has required changing her sanitary pad every 2 hours. Medical history is significant for sickle cell anemia. Medications include hydroxyurea (500 mg daily). The patient appears younger than her stated age. She is 162 cm (5 ft 4 in) tall and weighs 54 kg (120 lb); BMI is 21 kg/m². Vital signs are temperature 37.7°C (99.8°F), pulse 99/min, respirations 19/min, and blood pressure 129/79 mm Hg. Auscultation of the chest discloses coarse breath sounds in both lung bases and a grade 2/6 systolic murmur heard best at the second left intercostal space. Results of laboratory studies are shown:BloodHematocrit - 18.0%Hemoglobin - 5.7 g/dLRBC - 3.8 million/mm³WBC - 3000/mm³Reticulocyte count - <0.4% of red cellsWhich of the following is the most appropriate management of this patient's sternal pain?

E

Obtain a swallowing evaluation

A 67-year-old man with Parkinson disease is admitted to the hospital for treatment of pneumonia. The patient's daughter, who is visiting the patient, says he has had increased lethargy for the past day and decreased ambulation during the past 6 months. She also says that there are times during the day when his tremors increase in severity, although he continues to care for himself at home. Medical history is also remarkable for hypertension. Medications include hydrochlorothiazide, atenolol, levodopa, and carbidopa. He is 168 cm (5 ft 6 in) tall and weighs 78 kg (172 lb); BMI is 28 kg/m². Vital signs are temperature 38.9°C (102.0°F), pulse 60/min supine and 68/min standing, respirations 22/min, and blood pressure 100/60 mm Hg supine and 80/50 mm Hg standing. The patient appears ill and older than his stated age. He is fully oriented but lethargic. Auscultation of the chest discloses rhonchi in the right mid lung field. Abdominal examination discloses no abnormalities. Neurologic examination discloses masked facies, bradykinesia, and cogwheel rigidity; gait was not assessed on admission. Chest x-ray shows a right lower lobe infiltrate. ECG shows no abnormalities. Appropriate intravenous antibiotic therapy is initiated. Prior to discharge, which of the following is the most appropriate step?

B

Metoprolol

A 47-year-old man is admitted to the hospital through the emergency department because of the sudden onset of palpitations, left-sided chest pain, light-headedness, and shortness of breath that began while he was watching television 2 hours ago. Medical history is remarkable for paroxysmal atrial fibrillation. The patient is 180 cm (5 ft 11 in) tall and weighs 82 kg (180 lb); BMI is 25 kg/m². ECG obtained in the emergency department showed atrial fibrillation with narrow QRS complex. Pulse was 146/min. Physical examination was remarkable for rapid heart rate. The patient was given oxygen via nasal cannula and intravenous metoprolol 5 mg every 5 minutes for a total of 15 mg. His pulse slowed to 90/min. Two hours after admission, he is pain free but his pulse is now 160/min. Blood pressure is 122/78 mm Hg. In order to decrease the patient's pulse, which of the following should be administered intravenously?

E

Echocardiography

A 23-year-old man comes to the clinic to establish care after moving to the area for his first job since graduating from college. He has felt well. Medical history is remarkable for Hodgkin lymphoma diagnosed 10 years ago, which was treated with radiation therapy and a chemotherapy regimen of vinblastine, doxorubicin, methotrexate, and prednisone. BMI is 20 kg/m². Vital signs are within normal limits. The patient appears well. Physical examination discloses no abnormalities. Which of the following screening studies is most appropriate to include in this patient's annual examinations?

C

Refer the patient to a child psychiatrist

A 5-year-old boy returns to the office with his mother to discuss results of studies done to evaluate his behavior of eating dirt. The patient sits quietly while his mother answers questions about his health. She says her son seems healthy, although he does not seem to be as active as other children his age. He has said his head hurts three or four times during the past 2 weeks. He has not had fever, sweats, or chills. She says he has a good appetite but has had a habit of eating sand and dirt since age 3 years. She says, "I don't know where he gets that habit. I used to eat dirt, but I stopped years ago. I try to stop him from eating dirt, but I'm not around much since I work two jobs." The patient takes no medications. Vaccinations are up-to-date. Height, weight, and BMI are at the 50th percentile. Vital signs are normal. Physical examination discloses no abnormalities except for symmetrical nontender cervical adenopathy. Results of laboratory studies, including serum zinc, lead, and iron concentrations, are within the reference ranges. Serologic testing confirms toxoplasmosis. In addition to prescribing pyrimethamine and sulfadiazine therapy, which of the following is the most appropriate next step in management?

D

MRI of the thoracic spine

A 55-year-old woman is brought to the office by her husband because of increasingly severe pain in her mid back for the past week. She says the pain is especially severe with walking. Her husband says she has been favoring her right leg for the past 3 days. Ibuprofen no longer controls the pain. She enjoys gardening but had to discontinue it 1 week ago because of the pain. She has not had bowel or bladder dysfunction. She underwent a right mastectomy 3 years ago for carcinoma and has been taking tamoxifen since that time. She is 173 cm (5 ft 8 in) tall and weighs 66 kg (145 lb); BMI is 22 kg/m². Vital signs are temperature 38.0°C (100.4°F), pulse 90/min, respirations 15/min, and blood pressure 118/72 mm Hg. Strength is 3/5 in all muscle groups of the right lower extremity and 5/5 in the left lower extremity. Achilles and patellar reflexes are hyperactive on the right and normal on the left. Sensation to pinprick and temperature is decreased in the left lower extremity to the level of the inguinal ligament. Sensation to vibration is decreased in the right lower extremity. Reflexes and sensation are otherwise intact. Rectal sphincter tone is normal. Which of the following is the most appropriate next step?

D