STEP 3 – UWSA 1 – BLOCK 4

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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 23-year-old woman, gravida 0 para 0, comes to the office for a routine visit. She has had irregular menstrual periods for the past 2 years. Many times, the bleeding lasts over 10 days and is heavy. The patient’s last menstrual period was 4 months ago. Menarche was at age 14. She is sexually active with her boyfriend and uses condoms for contraception. The patient has no chronic medical conditions or previous surgeries. She smokes a pack of cigarettes a day and drinks alcohol occasionally. Her last Pap test and sexually transmitted infection testing 6 months ago were normal. The patient’s mother has type 2 diabetes mellitus and hypertension. Her older sister has Down syndrome. Blood pressure is 144/88 mm Hg and pulse is 76/min. BMI is 37 kg/m². Physical examination shows normal hair growth and no acne. The thyroid is not enlarged and has no nodules. There are no abdominal striae. The external genitalia are normal, and the uterus is small and nontender with no palpable adnexal masses. Urine pregnancy test is negative.

Item 1 of 2

Which of the following is the best next step in management of this patient?

A. Karyotype analysis
B. Pelvic ultrasound
C. Serum 17-hydroxyprogesterone
D. Serum dehydroepiandrosterone sulfate
E. Serum FSH

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Question 13 of 40

13. Question

Item 2 of 2

The patient’s pelvic ultrasound shows a normal uterus and bilateral, polycystic-appearing ovaries. Laboratory results are as follows:

17-hydroxyprogesterone, serum	124 ng/dL (normal: <200)
Prolactin, serum	12 ng/mL (normal: <20)
Testosterone, serum	85 ng/dL (normal: 20-70)
TSH, serum	3.8 µU/mL (normal: 0.5-5)

Which of the following is the best next step in evaluation of this patient?

A. CA-125 and alpha-fetoprotein
B. Low-dose dexamethasone suppression test
C. Oral glucose tolerance test
D. Plasma aldosterone/renin ratio
E. Thyroid function tests

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Question 14 of 40

14. Question
A 46-year-old woman comes to the emergency department after experiencing several episodes of a ”funny sensation” in her chest. These episodes started yesterday after a friend’s birthday party where the patient drank about 2 glasses of wine. She has no significant medical history. The patient works as a librarian, rides a bicycle 3 times a week, and jogs occasionally. There is no family history of coronary artery disease or stroke. On examination, she is in no acute distress. Blood pressure is 132/88 mm Hg, pulse is 122/min and irregular, and oxygen saturation is 98% on room air. Heart sounds reveal a soft S1 and a 3/6 holosystolic murmur best heard at the apex with radiation to the axilla. The lungs are clear to auscultation. There is no peripheral edema. ECG is consistent with atrial fibrillation with rapid ventricular response. The next morning, the patient’s pulse is 78/min and regular. Repeat ECG confirms normal sinus rhythm. She feels well. Echocardiography demonstrates mitral valve prolapse with severe mitral regurgitation, mild pulmonary regurgitation, and a left ventricular ejection fraction of 50%. Which of the following is the most appropriate statement to this patient?
- A. Adequate medical therapy can help you avoid surgery.
- B. You need laboratory testing to determine the cause of your atrial fibrillation.
- C. You need long-term antiarrhythmic and blood-thinning medication.
- D. You need to avoid alcohol and should return immediately if the symptoms recur.
- E. You should be evaluated for mitral valve surgery.
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Question 15 of 40

15. Question
A 62-year-old female complains of irritated, dry, ”gritty” eyes for the last several months. At times, her eyes are very sensitive to bright lights. She denies any fatigue, joint pain, weight loss, dry mouth, or difficulty swallowing. Her past medical history is significant for hypertension and hypothyroidism. She does not smoke or consume alcohol. Laboratory studies show a TSH level of 4.3 µU/mL, hemoglobin of 13.2 g/dL, platelet count of 150,000/mm³, serum creatinine level of 1.1 mg/dL, and ESR of 12 mm/hr. The antinuclear antibody (ANA) test is negative. Which of the following is the best treatment for this patient?
- A. Methylcellulose eye drops
- B. Topical cyclosporine
- C. Topical corticosteroids
- D. Topical antimicrobials
- E. Systemic corticosteroids
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Question 16 of 40

16. Question
A 61-year-old female comes to your office complaining of right knee pain that limits her daily activities. She denies fever, chills, rash, or nocturnal pain. She has a past medical history of rheumatoid arthritis that has been treated for years with methotrexate and non-steroidal anti-inflammatory agents (NSAIDs). She has also received corticosteroids intermittently for disease flare-ups. She was started on infliximab recently, which has improved her morning stiffness and general well-being. Her other medical problems include hypertension and type 2 diabetes mellitus. She does not smoke cigarettes or consume alcohol. On examination, there are some deformities involving the small joints of both hands along with atrophy of the interosseous muscles. The right knee is swollen. There is pain on passive flexion of the right knee, but no joint laxity is present. Joint aspiration reveals clear fluid containing 1,000 leukocytes/mL with 30% neutrophils. Which of the following is the most likely cause of this patient’s current presentation?
- A. Gouty arthritis
- B. Osteonecrosis
- C. Osteoarthritis
- D. Infectious arthritis
- E. Reactive arthritis
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Question 17 of 40

17. Question
A 67-year-old man comes to the office due to 2 days of left-sided burning chest pain. The patient has never had similar symptoms. He has had no nausea, vomiting, palpitations, or shortness of breath. The patient has a history of hypertension, type 2 diabetes mellitus, and a right total knee replacement 2 years ago due to osteoarthritis. He was treated with external beam radiation therapy for localized prostate cancer 3 years ago. The patient smokes a pack of cigarettes daily and drinks beer occasionally. Temperature is 36.7 C (98.1 F), blood pressure is 143/92 mm Hg, and heart rate is 78/min. BMI is 24.5 kg/m². Physical examination reveals scattered vesicles over the seventh left intercostal space. While discussing treatment options, which of the following should be emphasized?
- A. A short course of steroids promotes more rapid healing
- B. Although commonly prescribed, no treatment has proven benefit
- C. Early treatment may decrease the risk for long-term complications
- D. Early treatment prevents the rash from occurring again
- E. Early treatment prevents the rash from systemic dissemination
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Question 18 of 40

18. Question
A 42-year-old Caucasian male comes to clinic with a two week history of right groin discomfort. He describes the sensation as a nagging pain that lasts for a couple of hours. Sometimes, he feels a tender fullness in his right groin. His past medical history is significant for asthma and hypertension. He uses an inhaled corticosteroid daily and albuterol as needed for wheezing and shortness of breath. For his hypertension, he takes valsartan and hydrochlorothiazide. He is a construction worker, and his job responsibilities include lifting heavy objects. Which of the following statements is most accurate regarding femoral hernias?
- A. Femoral hernias pass through the internal inguinal ring.
- B. Femoral hernias can descend into the scrotum.
- C. Femoral hernias lie medial to the femoral vein.
- D. Femoral hernias pass above the inguinal ligament.
- E. Femoral hernias pass through the obturator foramen.
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Question 19 of 40

19. Question
A 29-year-old woman comes to the office due to inability to conceive despite appropriately timed, unprotected intercourse for the past 4 months. Menarche was at age 13; menses occur every month and last for 4-7 days. The patient takes nonsteroidal anti-inflammatory medication several times a day during her menstrual periods due to cramping. She has had no abnormal Pap tests and has a remote history of Chlamydia trachomatis cervicitis but has had negative sexually transmitted infection testing since then. The patient and her husband have no chronic medical conditions or previous surgeries. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 25 kg/m². Physical examination shows a soft, nontender abdomen with no masses. Pelvic examination reveals a cervix with no discharge; a small, mobile, anteverted uterus; no cervical motion tenderness; and no palpable adnexal masses. Which of the following is the best next step in management of this patient?
- A. Antimüllerian hormone level
- B. Day 21 progesterone level
- C. Hysterosalpingography
- D. Reassurance and no additional testing indicated at this time
- E. Semen analysis
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Question 20 of 40

20. Question
A 25-year-old woman comes to the office due to joint pain. The patient was feeling well until 4 days ago, when she acutely developed a fever and generalized malaise. At that time, she noticed pain in her right wrist, right ankle, and the small joints of the right hand. The fever has now resolved, but the joint pain has worsened. The patient has had no chest pain, cough, abdominal pain, dysuria, hematuria, or rash. Her last menstrual period was a week ago, and she uses a copper intrauterine device for contraception. Medical history is otherwise unremarkable. Her mother has rheumatoid arthritis, and her paternal uncle has Crohn disease. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 112/71 mm Hg, and pulse is 94/min. Examination shows prominent tenderness to palpation at the right wrist and along the right extensor hallucis longus tendon with passive extension. A 5-mm, hemorrhagic pustule is noted on the sole of the right foot. Which of the following is the best diagnostic test for this patient’s condition?
- A. Antinuclear antibody screen
- B. Antistreptococcal antibody titers
- C. Rheumatoid factor and cyclic citrullinated peptide antibodies
- D. Transesophageal echocardiography
- E. Vaginal nucleic acid amplification test
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Question 21 of 40

21. Question
An 88-year-old female nursing home resident is admitted to the hospital because of fever, chills, and cough. She was recently discharged after an episode of aspiration pneumonia. She has lost ten pounds over the last four months. She has advanced dementia and requires constant assistance with her activities of daily living. She speaks in short sentences and does not recognize her caregivers. She is also incontinent of urine. Her other medical problems include hypertension, coronary artery disease, chronic atrial fibrillation, type 2 diabetes mellitus, and mild intermittent asthma. She has had multiple ischemic strokes in the past with some residual left-sided hemiparesis. She had coronary artery bypass surgery fifteen years ago. Her temperature is 37.8°C (100°F), blood pressure is 152/87 mmHg, heart rate is 82/min, and oxygen saturation is 92% on 2 liters of oxygen via nasal cannula. Her BMI is 18.5 kg/m². On examination, the mucous membranes are dry and coarse rhonchi are heard over the right lower lung field. A stage 3 coccygeal pressure ulcer and a stage 2 right heel ulcer are noted. Blood cultures are sent and she is started on broad-spectrum antibiotics. Further testing in the hospital reveals severe dysphagia. Her daughter is asking about nutritional support for her mother because she is losing weight. Which of the following best addresses her concerns?
- A. Percutaneous endoscopic gastrostomy (PEG) tube placement prevents aspiration and recurrent pneumonia
- B. PEG tube placement does not prolong life in patients with advanced dementia
- C. PEG tube placement offers a significant advantage in managing pressure ulcers
- D. A high-calorie liquid diet and avoidance of solid foods would improve nutrition and may prevent aspiration
- E. Appetite stimulation with megestrol would address the weight loss issue
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Question 22 of 40

22. Question
A 62-year-old man comes to the emergency department due to shortness of breath and weakness. Over the past 4 days, he has had progressive difficulty walking due to bilateral leg weakness and has stumbled and fallen several times. The patient has also had tingling and numbness of his hands and feet as well as palpitations and light-headedness when he stands suddenly. For the past day, his hands have been weak, and he has had difficulty swallowing. The patient has had no fever, chest or abdominal pain, or bowel/bladder dysfunction. He has no prior medical history besides occasional episodes of nasal congestion. The patient has never been hospitalized and takes no medications. He smokes a pack of cigarettes and drinks 2 or 3 cans of beer a day. Which of the following is most expected on physical examination of this patient?
- A. Bilateral papilledema
- B. Cogwheel rigidity
- C. Extensor plantar response
- D. Hyporeflexia
- E. Spinal cord sensory level
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Question 23 of 40

23. Question
A 56-year-old male is scheduled for a right adrenalectomy after an MRI of the abdomen showed a 5 cm mass. He initially presented with weight gain, headaches, and fatigue. He was also recently diagnosed with type 2 diabetes mellitus and started on oral hypoglycemic agents. His other medical problems include non-ulcer dyspepsia and systolic/diastolic hypertension. His pre-operative 24-hour urine cortisol excretion was 3 times the normal value and his serum ACTH level was 4 pg/mL (normal 9-52 pg/mL). Plasma fractionated metanephrines were 1.5 times the normal value. Twelve hours after surgery, the patient complains of abdominal discomfort and has one episode of non-bilious vomiting. His blood pressure is 72/40 mmHg and heart rate is 95/min, regular. Which of the following is the most likely cause of this patient’s current condition?
- A. Retroperitoneal bleed
- B. Postoperative ileus
- C. Catecholamine surge
- D. Pituitary apoplexy
- E. Adrenal gland atrophy
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Question 24 of 40

24. Question
A 64-year-old woman with advanced knee osteoarthritis comes to the office for preoperative assessment prior to right knee arthroplasty. The patient also has rheumatoid arthritis, which was diagnosed 15 years ago and is managed with methotrexate and adalimumab. She has taken short courses of oral glucocorticoids for acute flares; her last steroid course was approximately a year ago. The patient has difficulty climbing stairs due to joint pain but can walk 1 or 2 blocks on level ground without chest pain or shortness of breath. Blood pressure is 122/78 mm Hg, pulse is 80/min, and respirations are 16/min. Oxygen saturation is 99% on ambient air. BMI is 24 kg/m². Oropharyngeal, cardiopulmonary, abdominal, and neurologic examinations are unremarkable. There are chronic deformities of the hand joints and wrists but no active synovitis. The right knee shows significant periarticular bony hypertrophy. Which of the following is most appropriate in the preoperative assessment of this patient?
- A. Cervical spine radiographs
- B. Cosyntropin stimulation test
- C. C-reactive protein level
- D. Pharmacologic cardiac stress testing
- E. Pulmonary function testing
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Question 25 of 40

25. Question
A 72-year-old male has experienced three episodes of severe dizziness over the last two weeks. He describes ”almost passing out” each time, but denies any associated chest pain, shortness of breath, headaches, weakness or numbness. His past medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include lisinopril, hydrochlorothiazide, metformin, and simvastatin. At his primary care provider’s office, he is found to have a blood pressure of 124/78 mmHg and heart rate of 123/min, irregularly irregular. The decision is made to transfer him to the emergency department for further evaluation. During the transfer, he experiences another episode of severe dizziness. Vital signs on arrival are blood pressure 122/72 mmHg and heart rate 53/min, regular. Physical examination reveals a faint systolic murmur over the left sternal border. The lungs are clear to auscultation. There is trace peripheral edema. Neurological examination shows good muscle strength bilaterally. An EKG reveals sinus rhythm at 55 beats per minute and no acute ST segment or T wave changes. Which of the following is the most likely diagnosis?
- A. Transient ischemic attack
- B. Unstable angina
- C. Ventricular tachyarrhythmia
- D. Sick sinus syndrome
- E. Vasovagal presyncope
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Question 26 of 40

26. Question
A 72-year-old man is brought to the office by his wife due to a hand tremor for the past 3-4 months. The tremor is most noticeable when he watches television and reads the newspaper. He has a long-standing history of type 2 diabetes mellitus, hypertension, and stage 2 chronic kidney disease. The patient is concerned that he may have Parkinson disease because he heard about it on television and read about it online. The presence of which of the following additional findings is most consistent with a diagnosis of idiopathic Parkinson disease in this patient?
- A. Asymmetric hand rigidity
- B. Frequent falls
- C. Gaze palsy
- D. Orthostatic hypotension
- E. Tremor suppression with alcohol
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Question 27 of 40

27. Question
A 68-year-old male with a past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and transient ischemic attacks is admitted to the hospital for chest pain. He complains of episodic substernal chest pain that radiates down his left arm for approximately 25-30 minutes. The pain is not related to exertion. He denies having palpitations, shortness of breath, nausea, vomiting, or sweating. He had a carotid endarterectomy five years ago. He has smoked one-half pack of cigarettes per day for the last 30 years and drinks alcohol occasionally. He has a strong family history of hypertension, stroke, and myocardial infarction. After his initial evaluation, an ECG is obtained that shows non-specific ST segment abnormalities in the inferior and lateral leads. The cardiac troponin T level is negative. A cardiac catheterization is performed, showing 50% atherosclerotic stenosis of the proximal left anterior descending artery and 70% atherosclerotic stenosis of the distal right coronary artery. No intervention is undertaken. On the third day of hospitalization, the patient continues to complain of occasional chest pain. His BUN level is 42 mg/dL and his serum creatinine level is 1.9 mg/dL (in comparison to a BUN of 19 mg/dL and a creatinine of 0.9 mg/dL on the day of admission). Physical examination now shows a purple discoloration of his right third toe. Which of the following additional laboratory findings would you most expect in this patient?
- A. Proteinuria and waxy casts on urinalysis
- B. "Muddy brown" casts on urinalysis
- C. Eosinophilia and eosinophiluria
- D. Hematuria
- E. Crystalluria
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Question 28 of 40

28. Question

A 78-year-old man is brought to the emergency department from a nursing home due to 3 days of increased sleepiness. Medical history is significant for ischemic stroke, dementia, and hypertension. He is incontinent of urine and is completely dependent on caregivers for his activities of daily living. Temperature is 38.1 C (100.6 F), blood pressure is 110/58 mm Hg, and pulse is 102/min. On examination, the patient appears somewhat somnolent but is easily arousable to verbal stimuli and provides single-word answers. Pupils are equal and reactive to light. Mucous membranes are dry. The lungs are clear to auscultation and the abdomen is soft and nontender. Laboratory findings are as follows:

Leukocytes	16,500/mm³
Hemoglobin	15.2 g/dL
Platelets	344,000/mm³
Sodium	124 mEq/L
Potassium	4.4 mEq/L
Chloride	94 mEq/L
Bicarbonate	20 mEq/L
Blood urea nitrogen	46 mg/dL
Creatinine	1.2 mg/dL
Glucose	124 mg/dL

Urinalysis shows large leukocyte esterase, trace protein, and 50-100 WBCs/hpf. Which of the following is the most appropriate treatment for this patient’s electrolyte abnormalities?

A. 3% hypertonic saline solution
B. Normal saline infusion
C. Sodium bicarbonate infusion
D. Vasopressin receptor antagonist
E. Water restriction

Correct

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Question 29 of 40

29. Question
A 48-year-old woman comes to the office due to several months of vague abdominal discomfort and bloating. Her abdomen has also grown in size despite no changes to diet or activity level. The patient has a history of recurrent urinary tract infections. She is otherwise healthy but has recently had irregular menstruation, which she attributes to menopause. Family history is notable for colon cancer in her father. Temperature is 37.1 C (98.8 F), blood pressure is 142/88 mm Hg, and pulse is 78/min. BMI is 20 kg/m². Mucosal pallor is present. Cardiopulmonary examination is normal. Abdominal palpation reveals a nontender mass in the right flank that moves with respiration. Which of the following is the most likely cause of this patient’s current abdominal finding?
- A. Ascending colon neoplasm
- B. Ovarian cystic lesion
- C. Polycystic kidney disease
- D. Pyonephrosis
- E. Renal cell carcinoma
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Question 30 of 40

30. Question

A 38-year-old woman comes to the emergency department with severe upper abdominal pain. She describes the pain as crampy and radiating between her shoulder blades. The pain started 5 hours ago and has gradually increased in intensity. The patient feels nauseated and has vomited twice since the onset of symptoms. Medical history is significant for peptic ulcer disease, nephrolithiasis, and pelvic inflammatory disease. Medications include omeprazole. The patient drinks a fifth of liquor most days of the week and reports drinking approximately twice this amount the evening prior to her symptom onset. She smokes tobacco occasionally and uses no illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 134/78 mm Hg, pulse is 112/min, and respirations are 14/min. The heart rate is regular in rhythm, and lungs are clear to auscultation bilaterally. The abdomen is nondistended and tender in the epigastric area without guarding or rebound. The extremities are warm and without edema. The remainder of the physical examination is normal. Laboratory results are as follows:

Serum chemistry
Sodium	136 mEq/L
Potassium	4.2 mEq/L
Chloride	98 mEq/L
Bicarbonate	26 mEq/L
Blood urea nitrogen	8 mg/dL
Creatinine	0.6 mg/dL
Calcium	9.4 mg/dL
Glucose	97 mg/dL

Liver function studies
Total protein	7.7 g/dL
Albumin	4.3 g/dL
Total bilirubin	0.3 mg/dL
Direct bilirubin	0.1 mg/dL
Alkaline phosphatase	70 U/L
Aspartate aminotransferase	37 U/L
Alanine aminotransferase	49 U/L
Lipase	872 U/L (normal 0-160 U/L)

The patient is admitted to the hospital and treated with intravenous fluids and hydromorphone as needed. The nausea and vomiting is treated with antiemetics. Vital signs improve several hours after admission. The following day the patient reports that her pain has resolved and that she has not vomited or felt nauseated since she came to the hospital. She asks when she will be allowed to start eating again. Which of the following is the most appropriate next step regarding management of this patient’s nutrition?

A. Continue bowel rest for 24-48 hours with serial laboratory testing
B. Order a abdominal CT scan with contrast
C. Place a central intravenous catheter for initiation of parenteral nutrition
D. Place a nasojejunal feeding tube for initiation of enteral nutrition
E. Start oral feeding with a low-fat, soft diet

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Question 31 of 40

31. Question
A 62-year-old man comes to the office for follow-up after a recent hospitalization. Three weeks ago, he experienced coughing and difficulty breathing and was diagnosed with community-acquired pneumonia. The patient was admitted for antibiotic therapy, and his hospital course was complicated by an episode of severe right knee pain and swelling. Synovial fluid aspirated from the affected joint revealed uric acid crystals. The joint pain improved with treatment in the hospital, and the patient currently has no joint symptoms. In the past, he has had similar episodes of joint pain involving the right foot and left knee and is worried that it may recur. His other medical conditions include hypertension and hyperlipidemia. The patient has completed the prescribed antibiotics, and his only current medications are ramipril and atorvastatin. He drinks 1 or 2 beers on the weekend and does not smoke. Blood pressure is 129/78 mm Hg and pulse is 82/min. Lungs are clear on auscultation. Right knee examination shows full, pain-free range of motion with no erythema, warmth, or swelling. The remainder of the examination is normal. Laboratory results show a serum creatinine level of 1 mg/dL and serum uric acid level of 10.5 mg/dL. After a detailed discussion, the patient elects to begin preventive therapy in addition to lifestyle modifications, and allopurinol is prescribed. Which of the following additional interventions is most appropriate for this patient?
- A. Low-dose colchicine
- B. Oral prednisone taper
- C. Thiazide diuretic
- D. Uricosuric agent
- E. Urine alkalization therapy
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Question 32 of 40

32. Question
A 21-year-old student comes to the university health clinic due to left knee pain. For the last 3 weeks, she has had aching, poorly localized anterior knee pain that is worse when standing up from a low chair or when sitting in class for extended periods. The patient plays on a club softball team but is unable to play through a complete game due to the pain. Her medical history is unremarkable, and her only medication is an oral contraceptive. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 118/70 mm Hg, and pulse is 68/min. BMI is 17 kg/m². Inspection of the knee and leg is normal with no erythema, swelling, or obvious deformity. Active and passive range of motion is normal. Quadriceps strength is normal and symmetric, but squatting reproduces the pain. No focal tenderness is noted on palpation of the knee. Which of the following should be recommended to the patient at this time?
- A. A glucocorticoid injection would speed resolution of your pain.
- B. Calcium and vitamin D supplementation can prevent recurrence of your problem.
- C. Exercises to strengthen your hip and thigh muscles will likely correct your problem.
- D. Using a shock-absorbing shoe insert would relieve your pain.
- E. X-ray of the knee joint would likely diagnose the cause of your problem.
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Question 33 of 40

33. Question
A 54-year-old man comes to the office for a follow-up examination 2 weeks after he had an ischemic stroke. At the time of the stroke, he was also found to be in atrial fibrillation with rapid ventricular response, which was controlled with metoprolol. He currently has no symptoms. Medical history is significant for coronary artery disease, heart failure, type 2 diabetes mellitus, hypertension, hyperlipidemia, and peptic ulcer disease. He had a cardiac catheterization with stent placement in the left anterior descending artery 3 years ago. His left ventricular ejection fraction measured 2 weeks ago by echocardiography was 35%. He had an episode of upper gastrointestinal bleeding requiring hospitalization 3 years ago without any recurrence. He has a 40 pack-year smoking history but quit several years ago. Family history is significant for a stroke in his father at age 61 and diabetes mellitus in his mother. Blood pressure is 151/87 mmHg and pulse is 74/min and irregularly irregular. BMI is 30 kg/m². On examination, no carotid bruits are heard on neck auscultation, the lungs are clear to auscultation, and there is no peripheral edema. Neurologic examination shows mild left-sided hemiparesis that does not interfere with walking. His last HbA1c was 8.1%. Which of the following places this patient at the highest risk of stroke in the future?
- A. Diabetes mellitus
- B. Heart failure
- C. Hypertension
- D. Previous smoking
- E. Previous stroke
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Question 34 of 40

34. Question
A 58-year-old woman is brought to the emergency department with fevers and weakness. A week ago, she developed intermittent fevers with soaking night sweats. She also has experienced chills, malaise, and weight loss. The patient has used intravenous drugs over the past year and reports sharing needles. Medical history includes congestive heart failure, hypertension, and asthma. A recent echocardiogram showed a left ventricular ejection fraction of 30%. The patient’s medications include lisinopril, metoprolol, and inhaled albuterol. Temperature is 38.6 C (101.5 F), blood pressure is 130/75 mm Hg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for a right-sided holosystolic murmur. The patient is admitted for further treatment, and blood cultures quickly grow methicillin-resistant Staphylococcus aureus. Echocardiography confirms the diagnosis of infective endocarditis. Treatment with intravenous antibiotics is initiated, and the patient’s blood cultures clear within 3 days. However, peripheral venous access is lost on hospital day 4 and is unable to be regained. The patient undergoes placement of a central line for further treatment with antibiotics. An hour later, she is found hypotensive and tachycardic, with a blood pressure of 90/50 mm Hg and a heart rate of 126/min. A chest x-ray obtained shortly after the line placement is shown below.

Which of the following mechanisms is likely most responsible for this patient’s hypotension?
- A. Decreased cardiac contractility
- B. Decreased systemic vascular resistance
- C. Decreased venous return
- D. Increased pulmonary vascular resistance
- E. Intravascular volume depletion
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Question 35 of 40

35. Question
A 38-year-old male is brought to the emergency department after being involved in a bar fight. He has a small laceration on his right arm, a large bruise around his left eye, and several bruises in the epigastric region. There is also a laceration on his right hand that resulted from punching someone in the teeth. On physical examination, his blood pressure is 127/78 mmHg and heart rate is 82/min. There is mild upper abdominal tenderness without guarding or rebound. Chest x-ray is clear. Abdominal ultrasound does not show any intraabdominal fluid. Which of the following antibiotics is most appropriate for this patient?
- A. Cephalexin
- B. Amoxicillin-clavulanate
- C. Ciprofloxacin
- D. Clindamycin
- E. Dicloxacillin
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Question 36 of 40

36. Question
Based on a meta-analysis of several cohort studies, investigators estimate the annual risk of gastrointestinal bleeding in patients with a recent peptic ulcer-related gastrointestinal bleed to be 5 per 1,000 patients. The annual risk increases to 25 per 1,000 patients for patients started on low-dose aspirin therapy for cardiovascular prevention. What is the number needed to harm in this group of patients if they are started on aspirin?
- A. 5
- B. 10
- C. 20
- D. 50
- E. 100
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Question 37 of 40

37. Question
A 62-year-old male complains of two days of right arm pain. He denies fever, chills, joint pain, or rash. He also denies recent trauma. He has no significant past medical history. His family history is significant for hypertension, type 2 diabetes mellitus, and stroke. He has smoked one pack of cigarettes per day for the last 30 years. On physical examination, his blood pressure is 152/91 mmHg, heart rate is 86/min, and oxygen saturation is 94% on room air. His BMI is 31 kg/m². There is pitting edema of the right arm and tortuous, engorged superficial veins over the right shoulder. The tip of the spleen is palpable below the left costal margin. His leukocyte count is 12,500/mm³, hemoglobin is 19.5 g/dL, and platelet count is 650,000/mm³. Which of the following is the most accurate test to diagnose this patient’s condition?
- A. Leukocyte alkaline phosphatase
- B. Serum erythropoietin level
- C. Serum B12 binding capacity
- D. Karyotype analysis
- E. Genetic mutation analysis
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Question 38 of 40

38. Question
A 36-year-old woman, gravida 1 para 1, comes to the office for evaluation of vaginal pruritus. She also has experienced worsening discomfort during sexual intercourse that is no longer relieved with over-the-counter lubricants. Six months ago, the patient had a vacuum-assisted vaginal delivery complicated by a third-degree perineal laceration that required extensive repair. She was placed on stool softeners for 6 weeks after the delivery. She has had 2 urinary tract infections since the delivery but has no chronic medical conditions or previous surgeries. The patient has no history of abnormal Pap tests but did have a Trichomonas vaginalis infection several years ago, which was treated with metronidazole. She has been exclusively breastfeeding her infant since delivery; the infant is healthy and meets all developmental milestones. The patient takes a prenatal vitamin daily and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/70 mm Hg and pulse is 84/min. BMI is 24 kg/m². On pelvic examination, the perineal laceration repair is nontender and appropriately healed. The vaginal mucosa appears pale and thin; vaginal discharge is minimal and has a pH of 5.6. A rectovaginal examination reveals normal rectal sphincter tone. Wet mount microscopy shows no protozoa or clue cells. Which of the following is the best next step in management of this patient?
- A. Prescribe a course of metronidazole
- B. Prescribe a topical antifungal
- C. Prescribe a topical estrogen
- D. Recommend antihistamines
- E. Recommend cessation of breastfeeding
Correct

Incorrect

Question 39 of 40

39. 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 the Next Item, you will not be able to add or change an answer.

A 31-year-old woman, gravida 2 para 2, comes to the office due to fatigue, anxiety, and palpitations. She feels warm all the time, but when she takes her temperature it is consistently normal. The patient had an uncomplicated vaginal delivery 2 months ago and has not resumed normal menses. She states, “I hardly make any breast milk, and I have had to add in some formula.” The patient has had a 10-kg (22-lb) weight loss since delivery, which she thinks is “expected.” She had similar symptoms for 2 months after delivery of her first child, but her symptoms are more severe this time. Medical history is otherwise unremarkable. The patient smoked cigarettes briefly as a teenager but quit 15 years ago and does not use alcohol or illicit drugs. Her mother had a ”thyroid operation” when she was young, and her father had a stroke and has hypertension. Blood pressure is 136/67 mm Hg and pulse is 120/min. The thyroid gland is diffusely enlarged. The heart has a regular tachycardia with normal heart sounds. The hands show a fine tremor with warm, moist palms. Laboratory results are as follows:

TSH	0.01 µU/mL
Antithyroid peroxidase antibody	positive
Erythrocyte sedimentation rate	27 mm/hr

Item 1 of 2

Which of the following is the best treatment for this patient?

A. Atenolol
B. Methimazole
C. Prednisone
D. Radioiodine therapy
E. Thyroidectomy

Correct

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Question 40 of 40

40. Question
Item 2 of 2

Appropriate treatment is planned. The patient asks about the long-term consequences of her condition. Which of the following statements best addresses her concerns?
- A. Curative treatment with surgery or radioiodine therapy is eventually needed in most patients.
- B. There is a high risk of nonthyroid manifestations, such as eye problems.
- C. There is an increased risk of persistent goiter and chronic thyroid dysfunction.
- D. There is a significant long-term risk of thyroid nodules that may harbor malignancy.
- E. This is a transient condition, and there is no risk of long-term thyroid abnormalities.
Correct

Incorrect

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12. 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.

Item 1 of 2

Which of the following is the best next step in management of this patient?

13. Question

Item 2 of 2

The patient’s pelvic ultrasound shows a normal uterus and bilateral, polycystic-appearing ovaries. Laboratory results are as follows:

17-hydroxyprogesterone, serum

124 ng/dL (normal: <200)

Prolactin, serum

12 ng/mL (normal: <20)

Testosterone, serum

85 ng/dL (normal: 20-70)

TSH, serum

3.8 µU/mL (normal: 0.5-5)

Which of the following is the best next step in evaluation of this patient?

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28. Question

Leukocytes

16,500/mm3

Hemoglobin

15.2 g/dL

Platelets

344,000/mm3

Sodium

124 mEq/L

Potassium

4.4 mEq/L

Chloride

94 mEq/L

Bicarbonate

20 mEq/L

Blood urea nitrogen

46 mg/dL

Creatinine

1.2 mg/dL

Glucose

124 mg/dL

Urinalysis shows large leukocyte esterase, trace protein, and 50-100 WBCs/hpf. Which of the following is the most appropriate treatment for this patient’s electrolyte abnormalities?

29. Question

30. Question

Serum chemistry

Sodium

136 mEq/L

Potassium

4.2 mEq/L

Chloride

98 mEq/L

Bicarbonate

26 mEq/L

16,500/mm³

344,000/mm³