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Question 1 of 40
1. Question
A 37-year-old man with a history of bipolar disorder is brought to the emergency department by family members after they prevented him from going to a gun range, where he had planned to shoot himself. On admission to the psychiatric unit, the patient reports being very depressed about breaking up with his girlfriend. In addition, she has recently posted photos of herself with her new boyfriend on social media. Since then, the patient has felt worthless and hopeless, believing that his life is not worth living. On his third day in the hospital he is taken off 1-to-1 constant observation and changed to 30-minute checks. That evening, he asks to speak with his former girlfriend by phone. Following the phone call, the patient does not come out for dinner and is not seen in his room. He is found hanging from a sheet fastened as a noose around the hinge of the bathroom door. He is unresponsive and appears pale. A staff member begins cardiopulmonary resuscitation while awaiting the rapid response team’s arrival. Despite resuscitative measures, the patient remains unresponsive and dies. In responding to this incident, which of the following is the most appropriate next step for the hospital to prevent such occurrences in the future?
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Question 2 of 40
2. Question
A 39-year-old woman has started using the encrypted email within her hospital’s electronic health record system to contact her primary care physician about health concerns. She works as an attorney and has a history of sarcoidosis, gastroesophageal reflux disease, and tension headaches. The patient frequently sends long updates on her symptoms to her physician with medical questions referencing articles she finds on the internet, often 5-10 times a day. Her physician, who has treated her over the past 5 years, has been spending increasing amounts of time responding to her concerns. During this time, she has also no-showed for 2 of her scheduled in-person appointments. When the physician is suddenly called out of the office due to a family emergency, the patient becomes frustrated by the lack of response to her emails and sends the physician several messages complaining about lack of availability. On returning, what would be the best response for the physician to give the patient?
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Question 3 of 40
3. Question
An emergency physician recently began working at a local community hospital. The emergency department is very busy and is part of a larger training program for emergency medicine residents. At times the physician works with residents but is not their direct supervisor. During the third week on the job, the physician meets the emergency medicine chief resident, who comes in infrequently to cover for other residents but is busy primarily with a nonclinical research project. He has an excellent reputation in the program and is near the end of his final year. At the end of the shift the physician sees the chief resident in the locker room; although the physician cannot be sure, it appears that the chief resident is snorting a substance behind his locker door. The following week the physician sees him snorting a white powder in the bathroom. The physician confronts the chief resident and asks if he is using drugs. He initially denies drug use but then says, “Please don’t tell anyone about this. They’ll kick me out, and I’ve worked so hard to get here. I’ll do anything you say – stop, get help, sign up for treatment.” The physician is ethically obligated to do which of the following?
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Question 4 of 40
4. Question
A 4-year-old girl is brought to the office by her mother for evaluation of vaginal discharge. The mother states that the discharge started about 2 days ago; she has also noticed that her daughter has been scratching and pulling at her underwear. The mother tried using baby wipes, diaper cream, and an over-the-counter ointment each time her daughter went to the bathroom, with no relief of symptoms. The patient has no chronic medical conditions or previous surgeries. Her vaccinations are up to date. She takes no daily medications and has no known drug allergies. The patient lives with her mother, mother’s boyfriend, and 1-year-old stepbrother. She attends day care 3 days a week. Vital signs are normal. On inspection of the external genitalia, the vulva is edematous and erythematous; a malodorous discharge is at the vaginal introitus. There is no hymenal notching, tearing, or bleeding. Perianal inspection reveals no hemorrhoids, anal fissures, or tags. Mild eczema is seen behind the knees and on the arms. The pH of the discharge is 6, and wet-mount microscopy reveals pear-shaped motile organisms. The mother asks about the cause of the girl’s symptoms. Which of the following is the most appropriate response?
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Question 5 of 40
5. Question
A group of university researchers is conducting a study to determine whether a ketogenic drink improves cognition in mild cognitive impairment. Cognition, plasma ketone response, and metabolic profile will be assessed before and 6 months after supplementation with a drink containing ketogenic medium-chain triglyceride 15 g twice daily (n = 39) or placebo (n = 44). The research proposal has been approved by the university institutional review board (IRB). After enrollment starts, the researchers decide to simplify the consent form and reduce it from 5 to 2 pages to help participants understand the purpose, benefits, and risks related to participation in the study. Which of the following is true concerning the need to resubmit the study protocol to the IRB?
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Question 6 of 40
6. Question
A 32-year-old woman with obesity comes to the office for follow-up of hypothyroidism. The patient’s most recent TSH level is 0.6 µU/mL with her current dosage of levothyroxine. She requests that the physician increase the dosage to help her lose weight. After explaining the negative health consequences of thyrotoxicosis that would result from increasing the dosage, the physician offers to discuss alternate strategies to achieve a healthy weight. The patient declines these alternate options and wishes to obtain a copy of her records so she can take them to a different physician for a second opinion. After today’s visit, the patient has an account balance of several hundred dollars. Which of the following is the most appropriate response by the physician?
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Question 7 of 40
7. Question
An 18-month-old boy is brought to urgent care due to a burn. His mother says that he sustained the burn 45 minutes earlier while bathing and that “the water was hotter than I realized.” The patient has no other medical conditions and takes no medications. He lives with his mother, father, and 8-year-old sister. The patient’s weight and length are at the 50th percentile. Vital signs are normal for age. The patient appears uncomfortable on examination but is easily consoled by his sister. He has well-demarcated areas of erythema on his lower abdomen, lower back, and lower extremities, but flexural areas and the center of the buttocks are spared. There are no blisters and no splash marks. In addition to basic wound care for the burn, which of the following is the most appropriate next step in management of this patient?
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Question 8 of 40
8. Question
A 55-year-old woman with poorly controlled type 2 diabetes mellitus is admitted to the hospital for pyelonephritis. Urine and blood cultures grow Escherichia coli susceptible to ciprofloxacin. By day 3 of hospitalization, the patient’s clinical status has significantly improved. Because of the blood culture result, the attending hospitalist phones an infectious disease specialist and requests advice regarding the optimal duration of antibiotic therapy and the need for repeat blood culture. In the event of unforeseen short-term complications, which of the following is the most likely effect of this informal (“curbside”) consultation on physician liability?
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Question 9 of 40
9. Question
A 74-year-old man is brought to the emergency department after being found unconscious at home. Emergency medical personnel report that he was in complete heart block when they arrived. The patient’s history is significant for a myocardial infarction 12 years ago, with subsequent congestive heart failure. He has been admitted to the hospital twice over the past 3 months, once for decompensated heart failure and once for atrial fibrillation with rapid ventricular response. In reviewing the home medications brought in by his wife, the physician notes that the patient is taking aspirin; dabigatran; furosemide; apixaban; lisinopril; extended-release metoprolol; and atenolol. The wife reports that he takes these medications regularly and they were all prescribed by his doctors. He sees a primary care physician and a cardiologist, who work within the same hospital system. The patient’s son, a pharmacist, expresses disappointment after learning of his father’s complete heart block and prescription for 2 different beta blockers and oral anticoagulants. Which of the following actions would be most helpful in preventing the medical error that led to this patient’s outcome from occurring again in the future?
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Question 10 of 40
10. Question
A 68-year-old man with a history of paroxysmal atrial fibrillation, rheumatoid arthritis, and heart failure with reduced ejection fraction is admitted for total hip arthroplasty due to fracture from a mechanical fall. During surgery, the patient develops bleeding, and the surgeon requests packed red blood cells in anticipation of potential transfusion. The blood bank requires a confirmatory patient blood sample for type and cross-matching and sends an empty collection tube prelabeled with patient name and date of birth. The anesthesiologist draws the patient’s blood into the tube and returns it to the blood bank, which confirms blood type and releases the blood products. However, the surgical nurse discovers that the name on the blood products belongs to a different patient. Internal investigation of the incident reveals that the collection tube sent by the blood bank was prelabeled with the wrong patient information. Which of the following is most likely to describe an active error in this case?
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Question 11 of 40
11. Question
A 33-year-old woman comes to the office due to dyspareunia. The pain started about a year ago after the birth of her second child. When the patient saw her obstetrician for follow-up 4 months ago, he reassured her that everything was normal and her pain would improve shortly. She has no other medical issues and her vital signs are within normal limits. Pelvic examination reveals an abnormal episiotomy scar with contracture around the perineum secondary to scarring. This is the fifth patient in the past 12 months the physician has seen with the same examination findings; all 5 are patients of the same obstetrician. Previously, after seeing the second of those patients, the physician had contacted the obstetrician to discuss his rationale for the procedure, and the obstetrician had responded, “It is an acceptable and safe procedure that generally has excellent results. Both of those patients’ symptoms should get better soon. I appreciate your concern, but I am a specialist and I know what I am doing.” Which of the following is the most appropriate course of action?
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Question 12 of 40
12. Question
A 75-year-old man is hospitalized with a severe pneumococcal pneumonia. After 48 hours of hospitalization, he begins to recover. On the 3rd day of hospitalization, he suddenly develops chest pain while being prepared for discharge. An emergency CT reveals a pulmonary embolus. After reviewing the patient’s chart, it becomes apparent that although he had no contraindications, he was not placed on anticoagulant thromboprophylaxis. The patient’s wife arrives and asks if this complication could have been prevented. Which of the following is the best response to her question?
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Question 13 of 40
13. Question
A 30-year-old man comes to the office to receive genetic testing results for Huntington disease. His father was diagnosed at age 39 and died 10 years later after experiencing progressive and disabling neurologic deterioration. At previous visits, the patient underwent genetic counseling and ultimately decided to get tested last month because he wanted to understand his risk for developing Huntington disease. His older sister and younger brother are apparently healthy and have not sought testing. The patient is married, and he and his wife are thinking about having a baby. As the physician prepares to discuss the test results, the patient says, “Actually I’ve changed my mind, doc. I don’t want to know the results.” Which of the following is the most appropriate response to this patient?
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Question 14 of 40
14. Question
A 12-year-old boy is brought to the emergency department by his grandmother due to worsening fever, sore throat, headache, and nausea that began yesterday. He is up to date on vaccinations and has no chronic medical conditions. The grandmother cares for the child after school while his mother is at work. The boy’s father died of leukemia 3 years ago, and his mother is healthy. Temperature is 39.4 C (102.9 F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 14/min. Oxygen saturation is 95% on room air. The patient is awake, alert, and in mild discomfort. On examination of the oropharynx, pharyngeal erythema and exudate are noted. The uvula is deviated to the right, and the left soft palate is depressed downward. The patient has no pooling of oral secretions and is able to swallow. There is bilateral anterior cervical lymphadenopathy. Lung fields are clear to auscultation bilaterally with good air entry. A small peritonsillar abscess is suspected, and the proposed treatment, including needle aspiration, is discussed with the grandmother. Which of the following is the best next step in management of this patient?
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Question 15 of 40
15. Question
An 87-year-old man is brought to the primary care office by his daughter for an annual examination. The patient states that he feels well except for “feeling my age a bit more these days.” The daughter says her father appears thinner and his appetite has decreased; he eats only a small amount of food when she cooks for him and primarily prefers to eat from local restaurants. The patient has a history of longstanding hypertension, for which he has taken hydrochlorothiazide for several years, and uses glasses for reading and distance vision. He has fallen at home twice in the past year, in the bathroom and bedroom, but sustained no major injuries. The patient lives with his daughter, who works full-time during the week, in a two-story home. He is independent with most activities of daily living and drinks one alcoholic beverage 3 or 4 times a week. Blood pressure is 152/87 mm Hg without orthostatic changes, and pulse is 81/min. BMI is 19 kg/m2. The patient is alert and fully oriented, and able to remember 3 out of 3 objects after 5 minutes. Muscle strength is globally decreased, gait is slow but nonataxic, and the patient requires extended time and use of arm support to rise from a chair. The remainder of the examination, including visual acuity testing, is normal. Which of the following interventions should be performed next to optimize this patient’s health outcomes?
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Question 16 of 40
16. Question
The following vignette applies to the next 2 items.
A 72-year-old man is brought to the emergency department (ED) due to a sudden onset of severe difficulty in breathing. He has chronic obstructive pulmonary disease, and is on 2 liters of oxygen at all times. While in the ED, he develops progressive hypoxic respiratory failure, and is intubated by the ED physician. His son comes to the hospital an hour later and gets very upset. He pulls you to one side of the room and says, “Please remove the tube. He never wanted to live like this.” The patient does not have any advance directives for his health care. He regains consciousness for a few seconds while you are having a discussion with his son, but he is unable to state his wishes regarding life-sustaining treatment.
Item 1 of 2
Which of the following is the most appropriate next step in the management of this patient?
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Question 17 of 40
17. Question
Item 2 of 2
The patient’s whole family shows up in the hospital two hours later. He has two sons and three daughters who appear extremely concerned by the recent events. They all live in the same town and are very close to their parents. The patient lives alone. After prolonged discussions, the two sons agree and wish to proceed with the withdrawal of mechanical ventilation. The daughters are adamant about continuing life-sustaining treatment. The daughters tell you, “Our dad never said that he didn’t want to live”. Which of the following is the most appropriate next step in the management of this patient?
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Question 18 of 40
18. Question
A 55-year-old man comes to the physician with fatigue, polyuria, and polydipsia. He is morbidly obese and has recently lost about 2.27 kg (5 lb) unintentionally. The patient has blurred vision but no abdominal pain, hematuria, melena, or bruising. Vital signs are within normal limits, and physical examination is unremarkable. The patient’s blood glucose is 287 mg/dL, measured by a finger-stick. The patient is diagnosed with type 2 diabetes mellitus, is started on medications, and is greatly relieved to receive a diagnosis. He returns 2 weeks later feeling much better and brings a fruit basket for the physician to express his gratitude. Which of the following is the most appropriate response to this patient’s gift?
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Question 19 of 40
19. Question
A 14-year-old girl is brought to the clinic due to behavioral changes over the last 2-3 months. She has become increasingly angry and easily annoyed, arguing with teachers at school and her mother at home and refusing to do her chores. The patient was previously an honor roll student, but her grades have dropped significantly and she is now failing most subjects. When asked why her grades have dropped, the patient says, “It’s been really hard to focus on what the teacher is saying and I have trouble remembering to turn in my homework.” Her mother reports that the girl has gained 18.1 kg (40 lb) in the last 3 months. The patient’s father is currently unemployed and abuses alcohol. To help with finances, the family moved in with the girl’s aunt and uncle 9 months ago. The patient became sexually active 3 months ago, has had 4 lifetime partners, and uses no birth control. She smokes marijuana several times a week but does not use tobacco or alcohol. BMI is 33 kg/m2. On mental status examination, the patient appears fidgety and avoids eye contact during the examination. She still enjoys playing with her little brother and has no thoughts of death or suicide. Which of the following is the most likely explanation for this patient’s change in behavior?
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Question 20 of 40
20. Question
An 80-year-old Caucasian female is being discharged from the hospital after surgical repair of the right hip fracture. She fractured her right hip after falling down the steps in her home. She has a past history of osteoporosis, hypertension controlled with thiazide diuretics and metoprolol, diabetes mellitus treated with metformin, and hypercholesterolemia controlled with simvastatin. She suffered from an acute myocardial infarction six years ago, but she has not had any complications or recurrence of symptoms. She has a 50-year-old daughter who lives near her house. You advise the patient to consider an alternate living arrangement; however, she clearly expresses her desire to live by herself in her own home. She does not want to live in her daughter’s house or in a nursing home. Which of the following is the most appropriate next step?
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Question 21 of 40
21. Question
A 60-year-old man comes to the office for surgical consultation of multivessel coronary artery disease. After reviewing prior records and completing a thorough evaluation, the surgeon discusses the recommendation for a coronary artery bypass graft, describing its indications and providing an overview of the surgery, including risks and benefits of the operation. The surgeon then discusses what the patient can expect during the recovery period. Which of the following additional disclosures is a necessary component of an informed consent discussion by the surgeon?
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Question 22 of 40
22. Question
A 79-year-old woman with acute-onset shortness of breath is brought to the emergency department by her husband and adult son. The patient has had 2 recent hospitalizations for aspiration pneumonia over the previous 6 months. Medical history includes Alzheimer disease, hypertension, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease. Temperature is 37.8 C (100 F), blood pressure is 85/60 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry is 70% on room air and 85% on 100% nonrebreather mask. Examination shows dry mucous membranes, right lung base crackles, and tachycardic heart sounds. She is stuporous and minimally responsive. Intravenous fluids and antibiotics are administered, but her respiratory status continues to deteriorate. The patient has designated the son as her medical power of attorney. The son states that his mother would not want to be intubated and requests that she be made comfortable. The husband agrees, but when the patient’s daughter arrives, she insists that “everything should be done” and that “Mom would not want to die like this.” Which of the following is the most appropriate next step in management of this patient?
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Question 23 of 40
23. Question
A 47-year-old woman comes to a multidisciplinary community health center. She is uninsured, and the center’s social worker counsels the patient regarding options for insurance enrollment. The patient reports high levels of stress due to financial constraints and the recent deaths of her sister and mother from breast cancer. She wishes to establish care with a primary care physician to be screened for breast cancer and discuss cancer prevention. The patient is eligible to enroll in a private health insurance plan through the Health Insurance Marketplace exchange. She states, “Every dollar counts right now. I’m scared the doctor will charge me a big fee to get a mammogram.” Which of the following best describes this patient’s expected out-of-pocket spending to obtain a mammogram?
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Question 24 of 40
24. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A quality improvement committee based at a primary care clinic wishes to improve screening and follow-up of patients with obesity. Currently, 30% of patient encounters include documentation of BMI, and 10% of patients with BMI ≥30 kg/m2 are scheduled for weight management follow-up appointments. The committee sets a goal to increase BMI documentation to 40% and BMI follow-up to 30% in 3 months. It decides to test the effectiveness of a clinical decision support tool in achieving this goal. The tool is designed for clinical providers and integrated into the electronic medical record; it includes a BMI calculator and a prompt to arrange follow-up when BMI is ≥30 kg/m2. An email introducing the tool and its purpose is circulated to all clinical providers.
Item 1 of 2
After the tool is implemented for 3 months, which of the following is the most appropriate next action according to the Plan-Do-Study-Act paradigm?
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Question 25 of 40
25. Question
Item 2 of 2
Three months after implementation of the tool, the committee analyzes patient charts to determine changes in obesity screening and follow-up. They find that obesity documentation now occurs in 32% of patients and that follow-up is arranged for 12% of patients with BMI ≥30 kg/m2. The clinic’s providers report that, while the tool functions properly, they often overlook it because patient vital sign measurement, including weight, and arrangement of follow-up appointments are typically part of medical assistant workflow. Which of the following is the most appropriate subsequent action?
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Question 26 of 40
26. Question
A 29-year-old man comes to the office for a health maintenance evaluation. He has been feeling well with no physical symptoms; he mentions that his grandfather recently died of Huntington disease. The patient says, “My dad refuses to get tested. If he has the disease, I could be at risk. I don’t want to spend the next 20 years worrying about whether I will get sick.” The patient is married, and his wife is 8 weeks pregnant. The physician shares information about the genetics and course of Huntington disease and refers the patient for genetic counseling. The patient decides to get predictive testing done to plan for his future. The results are positive for Huntington disease, and the patient decides he is not going to share this information with anyone, including his father and wife. Which of the following is the most accurate statement concerning this patient’s results?
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Question 27 of 40
27. Question
A physician opens a new primary care practice in a medical office building adjacent to a local hospital. The practice belongs to an accountable care network that includes numerous primary care and specialist physicians. Due to participation in the accountable care network, the physician receives bonuses earned for meeting evidence-based quality targets, including appropriate referrals of eligible patients for screening and treatment of breast cancer, colon cancer, obesity, and skin cancer. Which of the following referrals for medical management and health maintenance is ethically appropriate?
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Question 28 of 40
28. Question
A 65-year-old man remains hospitalized on the surgical intensive care unit 3 weeks after a small bowel resection secondary to ischemic bowel disease. The postoperative course was complicated by wound dehiscence and sepsis. The patient is slowly recovering now but still has an open abdominal wound and a tracheostomy. He is alert and oriented and has given the physician permission to speak with family members. The patient’s son and daughter are visiting today. They are both very upset and approach the physician to discuss their concerns. The daughter says, “My father should be better by now.” The son says, “I can’t understand how you allowed him to get an infection. Aren’t there precautions to prevent this from happening?” They demand that his abdomen be closed immediately and the patient transferred to a different hospital. Which of the following is the most appropriate response to the patient’s family?
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Question 29 of 40
29. Question
A 22-year-old man is found not breathing in his apartment by his parents, who checked on him when he did not answer his phone. Paramedics transport the patient to the hospital, and he is pronounced dead on arrival in the emergency department. He has no history of medical conditions. Physical examination of the body shows no signs of trauma. After giving the parents time to process the death and expressing condolences, which of the following is the most appropriate statement to be made by the emergency physician?
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Question 30 of 40
30. Question
A 56-year-old man comes to the office for follow-up of type 2 diabetes mellitus. He has an extensive family history of complicated type 2 diabetes, and multiple family members have required lower extremity amputations for nonhealing ulcers. The patient has tried multiple oral medications and his most recent hemoglobin A1c is 9.6%. He is now being considered for basal insulin therapy. After an extended discussion of injection technique, the patient tells the clinician that he does not want to initiate insulin. He says, “My diabetes is my own fault. My mother always said I was too fat and was going to get diabetes like my dad. Maybe if I stop eating too much, I wouldn’t have to waste your time giving me insulin.” Which of the following is the most appropriate response to this patient’s statement?
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Question 31 of 40
31. Question
A 1-month-old boy is brought to the office for a routine well-child examination. The patient has been taking 3 oz of formula every 4 hours and sleeping well between feeds. He was born via vaginal delivery to a 20-year-old primiparous birth mother who received appropriate prenatal care. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. He was adopted shortly after birth by his 2 fathers as part of a planned open adoption. To date, the birth mother has chosen to have no further contact with the baby. The patient has no known birth family history of developmental delay, autism, or psychiatric disorders. Vital signs, growth measurements, and physical examination are normal. In comparing children of gay and lesbian parents with those of heterosexual parents, which of the following statements is most accurate?
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Question 32 of 40
32. Question
A 39-year-old woman with a family history of cancer undergoes genetic screening. She tests positive for a gene known to cause hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome. The patient is anxious about her diagnosis but is consoled after a detailed discussion with her physician regarding cancer screening. At a follow-up visit, she mentions that she is being considered for a promotion at work. The patient states that she fears being passed over for promotion due to her test results. The physician explains that medical information cannot be released to her employer without her permission, but the patient remains worried. Which of the following is the most appropriate next step in management?
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Question 33 of 40
33. Question
A mother brings her 4-year-old son to the clinic for evaluation of 2 days of abdominal pain. She moved to the United States from Vietnam 3 years ago with her husband and children and cannot speak or understand English. She is fluent in Vietnamese. Her husband is fluent in English but is currently out of town on business. The boy is accompanied by his 7-year-old sister, who is fluent in Vietnamese and learning English in elementary school. The treating physician is unable to speak or understand Vietnamese, and there is no Vietnamese interpreter available in the clinic. They are joined by a family friend, who is fluent in both languages. The boy has stable vital signs and does not appear to be in distress. Which of the following is the most appropriate choice to communicate with this patient?
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Question 34 of 40
34. Question
A physician has partnered with a large pharmaceutical company to conduct clinical trials on a new cholesterol-lowering medication. The physician is preparing to travel to a conference where he will be a faculty guest lecturer and present the potential benefits of this new medication to physician attendees. The pharmaceutical company offers to provide him with pre-made presentation slides, reimbursement for travel expenses, and a modest honorarium. According to American Medical Association guidelines for physician behavior, which of the following is appropriate to accept from the pharmaceutical company?
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Question 35 of 40
35. Question
A 58-year-old man comes to the office for follow-up. The patient is under the physician’s care for management of diabetes and hypertension and was recently hospitalized for a diabetic foot infection. In the hospital, he received antibiotic therapy and his insulin regimen was adjusted to optimize glycemic control. The patient has been well since hospital discharge and is compliant with his medications. He has returned to work full-time but worries about his health and hopes the physician might be able to see him for a same-day appointment should he experience any discomfort. Physical examination is unremarkable. Toward the end of the visit, the patient presents the physician with a watch as a gift, saying, “It wasn’t expensive; it is just a small token of my appreciation for your excellent care.” Which of the following is the most appropriate course of action regarding the gift?
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Question 36 of 40
36. Question
An 8-year-old boy is brought to the emergency department by his parents for evaluation of a facial injury. The patient was playing ice hockey with his friends and skated into the goal post. He was briefly unconscious and sustained a facial laceration. During triage, the nurse notes a 2-cm laceration across the forehead. The patient is otherwise alert and fully oriented. Vital signs are within normal limits. The parents state that they are very concerned about their son and decided to come to the closest emergency department; however, they are worried their insurance will not provide coverage for the visit at this private facility. The hospital is a large, for-profit, adult hospital that does not have admitting services for children. Which of the following is the most appropriate next step in management of this patient?
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Question 37 of 40
37. Question
A 28-year-old woman, gravida 2 para 1, comes to the emergency department for evaluation of vaginal bleeding. The patient has had bright red spotting for the past 24 hours but no contractions or leakage of fluid. She is at 31 weeks gestation by last menstrual period and has not had prenatal care this pregnancy. Her first pregnancy ended in an uncomplicated spontaneous vaginal delivery at term. Vital signs and fetal heart rate tracing are normal. Physical examination shows a nontender uterus consistent in size with 31 weeks gestation. A pelvic ultrasound reveals a complete placenta previa. The findings are discussed with the patient, and she states that she would still like to have a vaginal delivery. The physician says, “Unfortunately, the only safe option for delivery is a cesarean delivery.” The physician’s statement is an example of which of the following ethical principles?
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Question 38 of 40
38. Question
A 75-year-old woman is admitted to the intensive care unit due to worsening shortness of breath. Medical history is significant for systolic heart failure with a left ventricular ejection fraction of 10% on recent echocardiogram. Evaluation reveals acute hypoxic respiratory failure due to cardiogenic pulmonary edema. The patient also has a history of three-vessel coronary artery disease, diabetes mellitus, and chronic kidney disease. Her heart disease is not amenable to any intervention or surgery due to her poor functional status, and she has been treated with maximal medical therapy as tolerated. She was hospitalized a month ago due to an exacerbation of congestive heart failure and was discharged to a nursing facility after responding to treatment. The patient has limited mobility and requires assistance for activities of daily living. In the intensive care unit, her symptoms slowly improve with noninvasive positive-pressure ventilation, ionotropic therapy, and intravenous diuretic treatment, but her kidney function gradually deteriorates. The critical care physician and nephrologist recommend that all treatments be stopped and that the patient receive comfort care only. The patient’s son agrees and says, “The time has come to let go.” The patient, however, wants “everything to be done” and even to receive cardiorespiratory resuscitation if required. Which of the following is the most appropriate course of action?
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Question 39 of 40
39. Question
An 18-year-old woman who recently immigrated to the United States comes to the office for a pre-employment physical. She is looking forward to starting a job as a nursing aide and also plans to enroll in night classes to become a registered nurse. The patient is engaged to be married and is planning on returning to her country to visit her family next month and to undergo a “female circumcision.” She says that this matter is very important because it is considered a rite of passage in her culture. Her family feels strongly that she should undergo the procedure in preparation for marriage. Two of the patient’s older sisters have already undergone the procedure. Her medical history is unremarkable and physical examination reveals no abnormalities. Which of the following is the most appropriate response?
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Question 40 of 40
40. Question
A 65-year-old woman is admitted to hospice due to stage IV breast cancer metastatic to the brain, liver, lung, and thoracic vertebrae. The patient has discontinued all antineoplastic treatment; her pain is adequately controlled. Additional medical history includes type 2 diabetes mellitus with most recent hemoglobin A1c of 8.8%, dyslipidemia, hypertension, major depression, and a seizure disorder due to brain metastasis. Medications include rosuvastatin, basal insulin, lisinopril, levetiracetam, sertraline, and oxycodone. Temperature is 37 C (98.6 F), blood pressure is 125/84 mm Hg, pulse is 76/min, and respirations are 14/min. Pulse oximetry is 95% on room air. On examination, the patient is awake and responds appropriately to questions. Heart rate is regular; no murmur is present. There is no pedal or pretibial edema. The lungs are clear. Which of the following is the most appropriate medication change for this patient?
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