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Question 1 of 26
1. Question
A 34-year-old previously healthy man comes to the office due to severe back pain. Two days ago, the patient was working on the lawn and experienced sudden-onset low back pain while moving a bag of soil. The pain worsens with movement and radiates to his left leg. He also reports weakness of the left leg. He has had some improvement in the pain after taking NSAIDs and resting. Physical examination shows spasm of lower paraspinal muscles. There is weakness of left ankle dorsiflexion and toe extension. Ankle and knee reflexes are normal. Sensory examination shows loss of pinprick sensation over the dorsum of the left foot. Rectal tone is normal, and the remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient’s current condition?
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Question 2 of 26
2. Question
A 24-year-old woman comes to the office due to yellowing of the eyes that was first noted by her college roommate yesterday. The patient otherwise feels well and has no symptoms. She has no chronic medical conditions. The patient recently completed a prolonged fast in observance of a religious holiday. Her only medication is an oral contraceptive. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 76/min. Scleral icterus is present. Cardiopulmonary examination is normal. The abdomen is soft, nondistended, and nontender without hepatosplenomegaly or masses. Laboratory results are as follows:
Complete blood count
Hemoglobin
13 g/dL
Reticulocytes
1%
Liver function studies
Total bilirubin
3.3 mg/dL
Direct bilirubin
0.3 mg/dL
Alkaline phosphatase
70 U/L
Aspartate aminotransferase (SGOT)
12 U/L
Alanine aminotransferase (SGPT)
24 U/L
Which of the following is the most appropriate diagnostic step in management?
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Question 3 of 26
3. Question
An 81-year-old man comes to the office due to dizziness and near falls. The patient’s daughter reports that, over the past 2 weeks, the patient has stated that he experiences intermittent lightheadedness and he sometimes “appears wobbly” and almost falls, most notably in the morning after getting out of bed. Medical history is significant for hypertension and Alzheimer dementia. He takes amlodipine and was recently started on quetiapine for aggressive behavior toward caregivers and delusions that his daughter has been cloned. Temperature is 37 C (98.6 F), blood pressure is 105/66 mm Hg, and pulse is 95/min. Pulse oximetry is 96% on room air. The patient is awake, alert, and oriented to person and place. Heart sounds are regular and without murmurs. The lungs are clear to auscultation bilaterally. Strength is 5/5 in the upper and lower extremities. Reflexes are normal. ECG shows normal sinus rhythm. Which of the following is the most likely cause of this patient’s symptoms?
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Question 4 of 26
4. Question
A 52-year-old woman comes to the office due to intermittent pain on the right side of the face for 3 weeks. The intense, sharp pain on the right cheek and lips lasts several seconds and recurs several times a day. The patient is afraid to brush her teeth or drink cold water because both trigger the pain. She is pain free between episodes. She has a history of hypertension, type 2 diabetes mellitus, and seasonal allergies. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 136/84 mm Hg, and pulse is 80/min. No rash or facial asymmetry is noted. The remainder of the neurologic examination shows no abnormalities. Which of the following is the most likely cause of this patient’s current condition?
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Question 5 of 26
5. Question
A 62-year-old man comes to the office due to difficulty swallowing solids and liquids. His symptoms have progressively worsened over the past 3 months. The patient also has occasional regurgitation of undigested food and a nighttime cough that disturbs his sleep. He has never had similar symptoms. The patient has lost 4.5 kg (10 lb) during this period but has no other medical conditions and takes no medications. He has a 20-pack-year history but quit smoking 10 years ago. He drinks wine on the weekends. Vital signs are normal, and physical examination is unremarkable. Chest x-ray reveals a widened mediastinum, and barium swallow study shows a dilated esophagus with tapering of the distal esophagus. Which of the following is the best next step in management of this patient?
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Question 6 of 26
6. Question
An 89-year-old man is brought to the office by his daughter for a routine visit. The daughter says she is worried about her father’s continued insistence on driving. The patient has had 2 minor accidents in the past 6 months, one in which he hit a mailbox while backing up in the dark and another in a supermarket parking lot where he backed into another car that was also backing out. The patient has not gotten lost while driving. Medical history includes mild cognitive impairment, hypertension, diminished hearing, osteoarthritis, and benign prostatic hyperplasia. Corrected vision is 20/40 in both eyes. Current medications include lisinopril, hydrochlorothiazide, and as-needed ibuprofen. He does not drink alcohol. Vital signs are normal. Physical examination shows decreased range of motion in his neck and mild pain in his hands and knees bilaterally. Mini-Mental State Examination is 23/30, 1 point lower than his score last year. Which of the following is the most appropriate next step in management of this patient?
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Question 7 of 26
7. Question
A 61-year-old farmer is brought to the emergency department after he was found unresponsive in the barn. The patient was last seen appearing normal 3 hours ago. Medical history is unavailable. The paramedics administered naloxone en route without any subsequent change in mental status. Blood pressure is 190/110 mm Hg, pulse is 58/min, and respirations are 10/min and irregular. On physical examination, he does not respond to painful stimuli. There is no evidence of trauma to the head or neck. The pupils are midsized and do not respond to light. Cardiopulmonary examination is normal. The arms and legs are rigid and held straight out; the toes are pointing downward. Bilateral extensor plantar reflexes are present. Which of the following is the most likely diagnosis in this patient?
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Question 8 of 26
8. Question
A 46-year-old man comes to the office due to a sensation of right upper quadrant fullness. The patient has had obesity since early adolescence. Medical history includes type 2 diabetes mellitus and hypertension. Current medications include metformin, candesartan, and hydrochlorothiazide. The patient does not use tobacco, alcohol, or recreational drugs. His father has type 2 diabetes mellitus. Temperature is 36.7 C (98 F), blood pressure is 138/90 mm Hg, pulse is 72/min, and respirations are 16/min. BMI is 36 kg/m2. Physical examination is notable for acanthosis nigricans over the neck creases and hepatomegaly. Laboratory results are as follows:
Albumin
4.0 mg/dL
Total bilirubin
1.0 mg/dL
Direct bilirubin
0.3 mg/dL
Alkaline phosphatase
100 U/L
Aspartate aminotransferase (SGOT)
122 U/L
Alanine aminotransferase (SGPT)
131 U/L
Blood glucose (fasting)
168 mg/dL
Viral hepatitis serologies, antimitochondrial antibodies, antinuclear antibodies, serum ceruloplasmin, and transferrin saturation are normal. Which of the following is the most likely pathophysiologic mechanism responsible for this patient’s increased liver enzymes?
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Question 9 of 26
9. Question
A quality assurance committee is conducting an assessment of diagnostic errors related to myocardial infarction (MI) in the emergency department. The committee finds that clinicians were 4 times more likely to miss MI in women age 60-70 compared to men of the same age. Women were more likely to have a chief complaint of episodic substernal chest pressure exacerbated by mental stress and were incorrectly diagnosed with gastroesophageal reflux disease. Which of the following factors is most likely responsible for this finding?
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Question 10 of 26
10. Question
A 56-year-old woman comes to the office for a routine health maintenance evaluation. The patient is physically well but reports feeling upset that she had to place her 79-year-old father in a nursing home. She says, “I’ve cared for him since he developed Alzheimer disease 5 years ago, but I couldn’t manage him at home anymore.” The patient’s medical conditions include hypertension and type 2 diabetes mellitus. She underwent menopause at age 51. She does not use tobacco or alcohol and takes yoga classes 3 times a week. Blood pressure is 140/85 mm Hg and pulse is 77/min. BMI is 32 kg/m2. Physical examination is unremarkable. The patient expresses concern about developing Alzheimer disease like her father and asks if there is anything to do. Which of the following is the most appropriate response to the patient?
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Question 11 of 26
11. Question
A 74-year-old man comes to the office due to 3 months of “problems of old age.” He has daily temporal headaches and feels quite fatigued. Intermittently, the patient’s ears ring and his eyes become blurry. Both feet feel as if someone is “sticking them with electric pins.” The patient used to smoke cigarettes but now uses vaporized nicotine. His medical history is unremarkable. Temperature is 36.6 C (97.8 F), blood pressure is 128/74 mm Hg, and pulse is 88/min. He is well appearing. There is moderate cervical lymphadenopathy. Cardiopulmonary examination is normal. Hepatosplenomegaly is present. Funduscopy shows dilated, segmented, and tortuous retinal veins. There are sensory deficits in his feet, but reflexes and strength are intact. Laboratory results are as follows:
Complete blood count
Hemoglobin
9.6 g/dL
Platelets
136,000/mm3
Leukocytes
6,200/mm3
Serum chemistry
Glucose
108 mg/dL
Sodium
141 mEq/L
Potassium
3.6 mEq/L
Blood urea nitrogen
18 mg/dL
Creatinine
0.9 mg/dL
Serum protein electrophoresis reveals a sharp IgM spike. Which of the following is the most likely diagnosis for this patient?
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Question 12 of 26
12. Question
A 22-year-old woman comes to the emergency department due to continuous gum bleeding after a mouth injury a few hours ago. She was playing doubles tennis and was accidentally struck on her bottom lip by her partner’s racquet. The patient has a history of bruising with minor trauma and of heavy menstruation with crampy pain. She has no other medical conditions and takes no medications other than occasional ibuprofen. The patient does not use tobacco, alcohol, or illicit drugs; she eats a balanced diet. Her mother also had a history of “bleeding issues.” Blood pressure is 120/70 mm Hg and pulse is 80/min. Oropharyngeal examination shows blood oozing from a gum abrasion. A fading ecchymosis is present on the right calf, but there are no other skin abnormalities. The remainder of the physical examination is normal. Laboratory results are as follows:
Complete blood count
Hemoglobin
10.2 g/dL
Mean corpuscular volume
76 µm3
Platelets
150,000/mm3
Coagulation studies
PT
12 sec
INR
1
Activated PTT
44 sec
Which of the following is the most likely cause of this patient’s bleeding problem?
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Question 13 of 26
13. Question
A 35-year-old, previously healthy man is evaluated due to swelling of the face, abdomen, and legs over the past 4 weeks. Facial edema is worse on awakening. The patient has gained 7 kg (15.4 lb) over this period. Temperature is 37.1 C (98.8 F), blood pressure is 133/75 mm Hg, pulse is 82/min, and respirations are 14/min. Physical examination shows periorbital edema, moderate ascites, and 2+ bilateral pitting lower extremity edema. Cardiopulmonary examination demonstrates no abnormalities. Laboratory results are as follows:
Serum
Creatinine
0.9 mg/dL
Total protein
4.5 g/dL
Albumin
2.3 g/dL
PT
11 sec
This patient is at the greatest risk for developing which of the following?
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Question 14 of 26
14. Question
A 30-year-old family physician moves from Florida to a town in the Colorado mountains to establish a medical practice. On the night of arrival, she experiences headache and has difficulty falling asleep. The next day she develops fatigue, nausea, dizziness, and mild dyspnea on exertion. She has no chronic medical conditions. Temperature is 37.2 C (99 F), blood pressure is 116/68 mm Hg, pulse is 90/min, and respirations are 20/min. Pulse oximetry shows 90% on ambient air. Medication with which of the following effects is most appropriate to improve her symptoms?
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Question 15 of 26
15. Question
A 43-year-old woman comes to the office due to lower extremity edema that has developed over the last 2 weeks. She has no cough, shortness of breath, chest pain, or leg pain. Medical history is significant for diet-controlled type 2 diabetes mellitus and hypertension. Her antihypertensive regimen was recently adjusted to improve blood pressure control. Blood pressure is 133/80 mm Hg and BMI is 27 kg/m2. Physical examination shows bilateral pedal edema but is otherwise unremarkable. Which of the following is most likely responsible for this patient’s symptoms?
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Question 16 of 26
16. Question
A 56-year-old woman comes to the office due to diarrhea. For the past several months, she has had fecal urgency and 5-6 watery bowel movements daily and occasionally at night. She has had no fever, weight loss, nausea, abdominal pain, or visible blood in the stool. The patient eliminated dairy products from her diet with no effect on her symptoms. Medical history includes hypertension and knee osteoarthritis, for which she takes hydrochlorothiazide and naproxen. Vital signs are normal. BMI is 33 kg/m2. The abdomen is nondistended, soft, and nontender. Bowel sounds are normal. Stool testing for occult blood is negative. Colonoscopy is grossly normal; random biopsies demonstrate lymphocytic infiltration of the lamina propria and a thickened subepithelial collagen band. Which of the following is the most likely diagnosis?
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Question 17 of 26
17. Question
A 45-year-old woman is evaluated for fatigue and exertional dyspnea. She has had difficulty walking for more than 1 or 2 blocks without becoming short of breath. She uses 2 pillows to sleep. Past medical history is significant for hyperlipidemia, hypertension, and type 2 diabetes mellitus. The patient smoked a pack a day for 15 years but quit 10 years ago. She does not use alcohol or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is 55 kg/m2. On physical examination, jugular venous distension is difficult to visualize due to a thick neck. Lungs are clear to auscultation without wheezes or crackles. Heart sounds are distant. The abdomen is obese and nontender. There is trace bilateral lower-extremity edema. Neurological examination is within normal limits. Chest x-ray is of poor quality due to under-penetration but shows no obvious abnormalities. ECG shows low-voltage QRS complexes but no significant ST-segment or T-wave abnormalities. Laboratory results are as follows:
Complete blood count Hemoglobin 16.0 g/dL Platelets 224,000/mm3 Leukocytes 6,600/mm3 Arterial blood gases pH 7.3 PaO2 70 mm Hg PaCO2 59 mm Hg Which of the following is the predominant cause of this patient’s dyspnea?
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Question 18 of 26
18. Question
An 84-year-old woman is brought to the emergency department due to 2 weeks of progressive confusion. She has a history of mild dementia and lives in an assisted living facility. Her caregiver reports that during the past several months she has become progressively weaker, and she has fallen down on several occasions and is now using a walker. In her usual state, the patient recognizes most of the staff, converses appropriately, and performs daily activities with minimal assistance; however, for the past week, she has been more confused and sleeping most of the time. She has also developed a mild headache. The patient has had no fever, vomiting, or urinary symptoms. Her other medical problems include hypertension and osteoarthritis. Blood pressure is 138/76 mm Hg and pulse is 74/min and regular. She is somnolent but arousable. The patient does not recognize her caregiver and gives several inaccurate answers but is able to follow simple instructions. Muscle strength is 4/5 on the right side and 3/5 on the left. Plantar reflex is upgoing on the left. Which of the following is the most likely diagnosis?
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Question 19 of 26
19. Question
A 35-year-old woman comes to the office with a 1-month history of right foot pain. She started her job as a waitress 3 months ago. The pain is worse in the morning and toward the end of her shift. Examination of the feet while standing reveals flat arches. Upon sitting, the arches re-form. She has no bony abnormalities, swelling, or skin changes over the feet and ankles. There is sharp pain on palpation over the anteromedial region of the right heel, which is worsened when the big toes are dorsiflexed at the metatarsal phalangeal joints. Palpation of the posterior heel or tapping inferior to the medial malleolus does not reproduce the pain. Strength and sensation in the foot are normal. Which of the following is the best next step in diagnosis?
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Question 20 of 26
20. Question
A 34-year-old woman comes to the office after a recent hospitalization. Over the past several months, the patient has had worsening weakness, anorexia, nausea, and abdominal discomfort. Two weeks ago, she had a syncopal episode; evaluation found a low serum cortisol level and subnormal response to ACTH stimulation. The patient was treated in the hospital and was discharged on oral hydrocortisone therapy. Since discharge, she has had intermittent episodes of light-headedness and nausea but reports improvement in other symptoms. Her husband adds that the patient consumes excessive amounts of salty foods. Temperature is 36.9 C (98.4 F), blood pressure is 108/66 mm Hg supine and 98/60 mm Hg upright, and pulse is 88/min supine and 102/min upright. Physical examination reveals hyperpigmentation of the oral mucosa and palmar creases. Cardiopulmonary and abdominal examination shows no abnormalities. Laboratory results are as follows:
Complete blood count
Hemoglobin
12.8 g/dL
Platelets
205,000/mm3
Leukocytes
7,800/mm3
Serum chemistry
Sodium
130 mEq/L
Potassium
5.5 mEq/L
Creatinine
0.8 mg/dL
Glucose
110 mg/dL
Which of the following is the most appropriate next step in management of this patient?
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Question 21 of 26
21. Question
A 60-year-old man comes to the office for evaluation of a 6-month history of intermittent chest pain. He describes substernal tightness and pain that occur when he walks quickly or climbs stairs. The symptoms last about 10 minutes and slowly fade away with rest. These episodes do not happen at rest. The patient has a history of coronary artery disease with coronary artery bypass grafting surgery 7 years ago. Other medical conditions include hypertension and hyperlipidemia. Blood pressure is 140/78 mm Hg and pulse is 78/min and regular. There are no murmurs on cardiac auscultation. The lungs are clear bilaterally. A treadmill stress test is performed. Seven minutes into the test, the patient develops chest pain and the treadmill is stopped. Sublingual nitroglycerin is administered, which almost immediately relieves the patient’s pain. What is the predominant mechanism responsible for the rapid pain relief in this patient?
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Question 22 of 26
22. Question
A 65-year-old man comes to the physician for fatigue, poor appetite, and lower-leg swelling. Past medical history is significant for hypertension, type 2 diabetes mellitus, chronic cough, chest infections, and lower-extremity peripheral artery disease. The patient has a 40-pack-year smoking history. He does not use alcohol or illicit drugs. Physical examination shows a barrel-shaped chest, with bilateral scattered wheezing on auscultation. The patient’s abdomen is distended, and the liver edge is palpated 4 cm below the right costal margin. There is 2+ pitting edema and dilated, tortuous superficial veins over both lower extremities. Manual pressure on the abdomen causes persistent distension of the jugular veins. His serum sodium level is 135 mEq/L, and creatinine is 1.2 mg/dL. An abnormality of which of the following is most likely the cause of this patient’s edema?
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Question 23 of 26
23. Question
A 40-year-old man comes to the office due to exertional dyspnea of 6 months duration. He occasionally expectorates mucoid sputum. He has no fever, night sweats, weight loss, or loss of appetite. The patient’s past medical history is otherwise unremarkable. He is married and has 2 children. His father died of nonalcoholic liver cirrhosis at age 58. The patient smoked <1/2 pack of cigarettes daily for 15 years but stopped after becoming short of breath. He does not use alcohol or recreational drugs. Vital signs are normal, and pulse oximetry is 97% on room air. Breath sounds are decreased bilaterally. There are no crackles or wheezes. Laboratory results are as follows:
Albumin 4.2 g/dL Total bilirubin 1.0 mg/dL Alkaline phosphatase 96 U/L Aspartate aminotransferase (SGOT) 44 U/L Alanine aminotransferase (SGPT) 55 U/L Which of the following is the most likely diagnosis?
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Question 24 of 26
24. Question
A 46-year-old woman comes to the office due to pain in her hands and knees. The patient has had pain and stiffness in her hands over the past several months that causes difficulty gripping a coffee cup or holding a pen. Over the past 2 weeks, she has also had pain in her knees. The symptoms are worse in the mornings or after prolonged immobility but gradually improve with physical activity over an hour. The patient has no other medical conditions and takes no medications. She does not use tobacco, alcohol, or illicit drugs, and works as a paralegal. Vital signs are within normal limits. Physical examination shows mild swelling and tenderness of the small joints of the hands. There is a nontender nodule near the right elbow over the back of the forearm. Examination of the remainder of the joints is normal. Erythrocyte sedimentation rate is 45 mm/hr. This patient’s current pathologic process is most likely to involve which of the following structures?
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Question 25 of 26
25. Question
A 62-year-old woman comes to the office due to progressive gait unsteadiness. The patient’s legs feel stiff, and she frequently stumbles and has to hold handrails while descending stairs. She also has had tingling and numbness in the hands and an occasional electric shock–like sensation in the spine. She has had no bowel or bladder incontinence. The patient has fibromyalgia and continues to have shoulder and neck pain despite a recent dosage increase in duloxetine. Other medical conditions include depression and hypothyroidism. She does not use tobacco, alcohol, or illicit drugs. Examination of the cranial nerves is normal. Upper extremity muscle strength is decreased, with mild wasting of intrinsic hand muscles. Lower extremity tone and reflexes are increased bilaterally. Sensation is grossly intact. Which of the following is the most likely cause of this patient’s current condition?
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Question 26 of 26
26. Question
A 52-year-old man comes to the office due to upper extremity weakness and pain in his shoulders and upper back since shoveling snow 3 weeks ago. His left arm also has started to feel heavy, and he has difficulty dressing and undressing because he lacks the strength to pull clothes over his head. The patient has not had similar symptoms before and recalls no other trauma to the area. He has a history of hypertension and hypothyroidism. Vital signs are within normal limits. Physical examination of the shoulder joints shows no deformity, and passive range of motion is full with no pain. There is moderate weakness of left shoulder abduction, but strength in the other muscle groups is normal. Decreased sensation to light touch and pinprick is present on the left lateral forearm. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in evaluation of this patient’s symptoms?
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