Several studies have evaluated the association between beta blocker use and mortality in patients with acute myocardial infarction without either heart failure or left ventricular systolic dysfunction.  Results have been generally consistent in confirming that, among survivors of hospitalization with acute myocardial infarction who did not have heart failure or left ventricular systolic dysfunction as recorded in the hospital, the use of beta blockers was not associated with a lower risk of death at any point up to a year.  Results from 4 recent observational studies are as follows:

Which of the following statements best explains the results of the meta-analysis study?

A 2-month-old girl is brought to the office for a routine health visit.  The parents have no concerns; the patient is breastfeeding exclusively.  She urinates and stools frequently and sleeps on her back in a bassinet.  The patient was born to a 29-year-old primigravida at 40 weeks gestation by cesarean delivery for breech presentation.  The pregnancy was otherwise uncomplicated.  Birth weight was large for gestational age at 4 kg (8 lb 13 oz); current weight is 5.1 kg (11 lb 3 oz).  Physical examination shows an infant sleeping comfortably in the prone position on her father’s chest.  The patient begins to cry when turned over for supine examination, and the mother requests to feed the infant prior to completing the full examination.  Prior to passing the patient to the mother, the examiner notes asymmetric gluteal skinfolds and an increased number of thigh creases on the right compared with the left.

Item 1 of 3

Which of the following additional findings would most likely be present on examination?

Item 2 of 3

A complete physical examination shows a palpable clunk of the right hip during attempted dislocation.  Ultrasonography of both hips reveals a dislocated right hip with a flat acetabulum.  Which of the following is the best next step in management of this patient?

Item 3 of 3

Appropriate treatment is obtained.  At a follow-up visit, one of the parents asks, “What are the long-term concerns for this condition?  I am worried that she will not be able to sit, crawl, or walk.”  Which of the following is the best response?

An 82-year-old woman is brought to the office by her son for evaluation of behavioral changes.  The patient is a retired teacher who has lived alone since her husband died 6 months ago from complications of esophageal cancer.  Her son, who visits her several times a year, became concerned when he found his mother had changed since his visit 2 months earlier.  He says, “She used to like cooking and volunteering at church, and she could take care of herself and the house.  Now, all she does is sleep and watch TV.  Her clothes are too loose for her now, and the house is dirty—there are piles of trash everywhere.”  The patient says, “My husband’s gone and it’s all my fault.  I’ll suffer the rest of my days to make up for what I did.”  Medical history includes osteoarthritis and hyperlipidemia.  On physical examination, heart and lung sounds are normal.  Gait is slow but steady.  There are no focal neurologic findings.  On mental status examination, the patient makes intermittent eye contact and requires questions to be repeated multiple times.  She is fully oriented and recalls 2 of 3 objects after 5 minutes.  The patient speaks slowly with frequent pauses.

Item 1 of 2

Which of the following is the most likely diagnosis of this patient?

Item 2 of 2

The patient is admitted to the psychiatric unit for further evaluation and treatment.  Additional history indicates a previous episode of depression in her 40s treated with sertraline, as well as a myocardial infarction 5 years ago from which she recovered completely.  In the hospital, she is minimally verbal.  The patient pushes her food away, saying she does not deserve to eat, and refuses to drink any liquids.  Temperature is 37.2 C (99 F), blood pressure is 90/60 mm Hg, pulse is 108/min, and respirations are 18/min.  On mental status examination, the patient stares blankly ahead.  Her speech is slow and barely audible.  She nods her head “yes” when asked if she is having thoughts of suicide.  Which of the following is the most appropriate treatment?

A 29-year-old woman comes to the office due to 6 months of increased urinary frequency that began after she was treated with antibiotics for uncomplicated cystitis.  The patient urinates every 30 minutes during most of the day.  The patient thought the urination frequency and mild discomfort she was having at that time were due to the infection.  However, her symptoms progressed and she now feels constant lower abdominal pain relieved only during urination.  The patient has tried to treat her symptoms with cranberry juice, but it has not helped.  She reports no fevers, chills, hematuria, abnormal vaginal discharge, or vulvar pruritus.  She has a history of depression controlled with a selective serotonin reuptake inhibitor but has had no previous surgeries.  The patient’s Pap tests have all been normal and she has no history of sexually transmitted infections.  She is using a transdermal patch for contraception.  She drinks alcohol once or twice a week but does not use tobacco or illicit drugs.  Blood pressure is 110/60 mm Hg and pulse is 68/min.  BMI is 27 kg/m².  Abdominal examination reveals moderate suprapubic tenderness but no masses, rebound, or guarding.  Pelvic examination reveals tenderness along the urethra but no urethral or cervical discharge.  Post-void residual urine volume is normal.  Laboratory results are as follows:

Which of the following is the most likely diagnosis in this patient?

A 32-year-old woman, gravida 1 para 0, comes to the emergency department at 36 weeks gestation due to increasing shortness of breath and fatigue.  The patient says she feels breathless even when walking across a room.  At night she feels “smothered” and has to sleep upright in a chair.  She has had no chest pain or palpitations and reports normal fetal movements.  The patient has no previous medical problems and her pregnancy has been uneventful.  She takes a multivitamin daily, is a nonsmoker, and has not consumed alcohol since conception.  Temperature is 36.7 C (98 F), blood pressure is 118/64 mm Hg, pulse is 108/min, and respirations are 24/min.  Pulse oximetry shows 94% on ambient air.  Jugular venous pressure is 10 cm H₂O at a 45-degree incline.  Bibasilar lung crackles are present.  Cardiac examination reveals a laterally displaced and diffuse apical impulse, a grade 2/6 holosystolic murmur at the apex radiating to the axilla, and an S3 gallop.  The patient has bilateral lower extremity pitting edema.  Blood cell count and serum chemistry studies are within normal limits.  ECG shows sinus tachycardia with no significant ST-T changes.  Echocardiography shows left ventricular enlargement and global hypokinesis with an ejection fraction of 20% and moderate mitral regurgitation.  She has some symptom improvement with intravenous furosemide.  Which of the following additional therapies is most appropriate at present?

A group of scientists conducts a study to quantify changes in bone mineral density (BMD) score among patients before and after they switch from brand to generic alendronate.  A chart review of postmenopausal women age >50 is conducted, and patients on alendronate are included.  The mean change in BMD scores is defined as the difference between BMD before and BMD after the switch (difference in BMD = BMD_before − BMD_after).  The researchers hypothesize that patients will have a significantly reduced BMD score after the switch and conduct a 1-sided t-test.  Results of the study show the following mean changes in BMD scores:

BMD = bone mineral density.

Which of the following is the correct conclusion about the null hypothesis at the 5% significance level?

A 24-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit.  She is at 12 weeks gestation by her last menstrual period.  The patient is gaining weight appropriately and feels well except for mild nausea.  She was diagnosed with systemic lupus erythematosus (SLE) 3 years ago, when she experienced pain in her hand joints and had a photosensitive malar rash.  The patient has been doing well on hydroxychloroquine with no symptoms for the past 2 years.  She has also been taking aspirin 81 mg daily “because I heard it would prevent blood clots.”  The patient has no history of miscarriage, deep venous thrombosis, or other thrombotic events.  Physical examination is normal.  Laboratory results show normal blood counts, renal function, electrolytes, and urinalysis.  Additional results are as follows:

The patient asks what effects her SLE may have on her pregnancy and if there are any preventive measures that she can take.  Which of the following is the best response to this patient?

A 29-year-old man comes to the office accompanied by his wife due to irritability and moodiness that are causing difficulties at work and at home.  The patient was fired from his job 2 weeks ago after having an argument in which he yelled at his boss and impulsively slammed a door.  The patient says, “I hated that job.  I would have gotten fired anyway because my productivity was so low.  I always feel restless and am easily distracted at work.  When I have a new idea I get a burst of energy and lose patience with the boring stuff.  I can’t tolerate a desk job; I am better when I am moving.”  His wife adds, “He is always irritable and has had a low frustration tolerance for as long as I have known him.  This is not the first job he’s lost because of it.  I see it at home too.”  The patient has a history of behavioral problems since childhood and recalls that he was frequently in trouble for talking loudly, leaving his desk, and bothering his peers during class.  In college he briefly attended counseling for anxiety and depression after he was placed on academic probation.  He says, “I guess it was my own fault because I would always procrastinate and then hand in my work at the last minute.”  The patient has no medical problems.  He drinks 1-2 beers three times a week and smokes marijuana several times a month to “help me relax.”  Vital signs and physical examination are normal.  On mental status examination the patient is cooperative, mildly restless, and talkative.  His mood is irritable.  He has no suicidal ideation or psychotic features.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

Further history indicates that inattentive symptoms have had a significant impact throughout the patient’s life.  He consistently underperformed academically and took 6 years to graduate college.  His work history has been characterized by multiple jobs that he has held, each for a year or less.  He typically quits abruptly when he feels bored or is fired for poor performance.  At home, his wife is frustrated by his disorganization, forgetfulness, and failure to follow through with any home projects.  She says, “He is always good at getting started but never finishes anything.”  A diagnosis of attention-deficit disorder is made and a long-acting stimulant medication is initiated.  This patient is at greatest risk for which of the following complications of treatment?

A 31-year-old man comes to the office due to a 3-month history of progressive tiredness, weight gain, and lethargy.  He has exercised daily with a personal fitness trainer for several years but stopped going to the gym a few weeks ago due to fatigue and muscle aches.  The patient has also experienced erectile dysfunction and a significant loss of libido.  He states, “I have tried to take extra supplements and vitamins to boost my energy, but I do not feel any different.”  The patient’s medical history is unremarkable; he takes a fish oil capsule daily but no prescription medications.  He drank 1 or 2 beers a day following workouts and does not use tobacco or illicit drugs.  The patient and his sister were adopted; she has hypothyroidism treated with levothyroxine but family history is otherwise unavailable.  Blood pressure is 136/90 mm Hg and pulse is 62/min and regular.  BMI is 26 kg/m².  The thyroid is normal on palpation.  The testes are small and soft.  Delayed muscle relaxation is noted on deep tendon reflex testing.  The rest of the examination is unremarkable.  Fasting (8:00 AM) laboratory results are as follows:

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

A 58-year-old man comes to the office for an initial evaluation.  The patient was unhappy with his previous medical care and says, “My previous doctor told me that my blood pressure was high and prescribed pills, but I felt okay, so I didn’t take any.”  However, for the past month, he has been taking chlorthalidone daily after his brother started hemodialysis due to renal failure from hypertension.  The patient has had no chest pain, palpitations, shortness of breath, lightheadedness, headache, or focal weakness or numbness.  He takes no other medications and has no drug allergies.  He drinks 1 or 2 glasses of wine most days.  Temperature is 36.1 C (97 F), blood pressure is 150/88 mm Hg, and pulse is 80/min.  BMI is 28 kg/m².  Apical impulse is displaced to the left and downward.  The remainder of the examination shows no abnormalities.  ECG shows left ventricular hypertrophy with repolarization abnormalities.  Laboratory results are as follows:

The estimated glomerular filtration rate is 41 mL/min/1.73 m².  Renal ultrasonography shows bilateral, symmetric, small, and echogenic kidneys with no hydronephrosis.  According to the patient’s medical records from the previous outpatient facility, serum creatinine was 1.4 mg/dL and 1.8 mg/dL 12 and 6 months ago, respectively.

Item 1 of 2

Which of the following is the strongest risk factor for accelerated renal disease in this patient?

Item 2 of 2

The patient receives education about hypertension and its effects on various organ systems, and medication adherence is reinforced.  Lisinopril is added to his treatment regimen.  The patient returns to the office 2 weeks later for follow-up.  He reports feeling well and has no symptoms.  Blood pressure is 128/78 mm Hg and pulse is 76/min.  Physical examination has not changed significantly.  Laboratory results are as follows:

Which of the following is currently the most appropriate management for this patient?