A 76-year-old woman comes to the office because of a 3-week history of gradually increasing fatigue. During this time she also has had shortness of breath and perspiration when doing housework. She says, “I had to ask my husband to start doing the vacuuming because of my symptoms.” Medical history includes type 2 diabetes mellitus, controlled with diet, and osteoarthritis of the hands and knees. She takes a daily multivitamin and acetaminophen as needed. She does not smoke cigarettes or drink alcoholic beverages. She is 163 cm (5 ft 4 in) tall and weighs 54.5 kg (120 lb); BMI is 21 kg/m2. Vital signs are temperature 37.1°C (98.8°F), pulse 66/min, respirations 18/min, and blood pressure 130/82 mm Hg. Auscultation of the lungs and heart discloses no abnormalities. Results of serum electrolyte concentrations and complete blood count are within the reference ranges. Which of the following studies is most likely to confirm the diagnosis?

A 23-year-old man with HIV infection comes to the office for follow-up after a PPD skin test was placed at his last visit 3 days ago. Today, the PPD test site shows 10 mm of induration. Previous PPD skin tests have been negative. He reports no recent cough, night sweats, or weight loss. His last CD4+ T-lymphocyte count obtained 2 months ago was 350/mm3, and HIV viral load was less than 50 copies/mL. His medications include lamivudine, emtricitabine, and zidovudine. He is 173 cm (5 ft 8 in) tall and weighs 66 kg (145 lb); BMI is 22 kg/m2. Vital signs are normal. Physical examination discloses palpable axillary and posterior cervical lymph nodes bilaterally. Lungs are clear to auscultation. Chest x-ray shows no abnormalities. Which of the following adverse effects of the recommended treatment is most appropriate to discuss with this patient?

A 27-year-old woman with a 9-year history of systemic lupus erythematosus comes to the emergency department because of sharp, left-sided chest pain and mild shortness of breath that began yesterday. The patient also reports mild pain in her left calf for the past 2 days. She reports no recent trauma and has not had cough, fever, or chills. Medical history is otherwise unremarkable and she takes no medications. Vital signs are temperature 37.1°C (98.8°F), pulse 108/min, respirations 20/min, and blood pressure 126/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Auscultation of the chest discloses no abnormalities. There is mild tenderness to palpation over the left calf, which is 2 cm larger in circumference than the right calf. The remainder of the physical examination discloses no abnormalities. Chest x-rays are shown. Which of the following is the most appropriate next step in diagnosis?

A 14-year-old boy is brought to the emergency department by his parents because of the sudden onset of pain in the inguinal region beginning 2 hours ago. He fell from a height of approximately 4 ft yesterday while skateboarding. He did not have inguinal pain at that time. There have been no recent changes in the boy’s health. He is afebrile. Physical examination shows no abdominal scars or bulges. The boy moans with examination of the right inguinal region. Testes are palpable bilaterally, with an enlargement of the right testis. The remainder of the examination shows no abnormalities. Doppler ultrasonography of the right scrotum discloses decreased pulsations on the right side as compared to the left. Which of the following is the most appropriate next step?

A 70-year-old woman with a 5-year history of type 2 diabetes mellitus comes to the office for a routine follow-up examination. Medical history is also significant for isolated systolic hypertension diagnosed 5 years ago. Medications include hydrochlorothiazide and glipizide. The patient smoked one pack of cigarettes daily for 30 years but quit smoking 10 years ago. She does not drink alcoholic beverages. She is not currently in distress. She is 160 cm (5 ft 3 in) tall and weighs 68 kg (150 lb); BMI is 27 kg/m2. Vital signs are temperature 37.1°C (98.8°F), pulse 82/min, respirations 16/min, and blood pressure 170/82 mm Hg. Physical examination discloses no abnormalities. Results of fasting laboratory studies obtained in preparation for today’s visit are shown:

Decreasing which of the following is the most appropriate goal for preventing stroke in this patient?

A 6-year-old girl is brought to the office by her father for a well-child visit. The father says, “My daughter has been healthy, but at least once weekly, she sits up in bed around 4 or 5 am and screams ‘Daddy—come back!’ I go to her room and comfort her but she keeps asking to spend the rest of the night with me and my wife.” These episodes began after the girl became lost during a school picnic 1 month ago. The police found her wandering alone in the park several hours after she became lost. The father says she was not injured but was very frightened. She does not sleepwalk but occasionally wets the bed during the nighttime episodes. Physical examination discloses no abnormalities. Which of the following is the most appropriate next step?

A 78-year-old woman is brought to the emergency department by ambulance because of a 6-hour history of severe, progressive back pain that radiates to her abdomen. She rates the pain as a 7 on a 10-point scale. She called an ambulance because she was too weak to walk. She reports no recent trauma. Medical history is remarkable for hypertension and breast cancer. Her only medication is atenolol. She is 173 cm (5 ft 8 in) tall and weighs 100 kg (220 lb); BMI is 34 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 122/min, respirations 26/min, and blood pressure 142/96 mm Hg. Chest is clear to auscultation. Abdomen is soft with hypoactive bowel sounds. There is mild palpable paraspinous tenderness in the lumbar region. Neurologic examination shows no abnormalities. X-rays of the lumbar spine are shown. Which of the following is the most appropriate next step?

A 50-year-old man with a history of alcohol use disorder is admitted to the hospital because of a 3-day history of progressive upper abdominal pain and vomiting. He rates the pain as a 9 on a 10-point scale and notes that it radiates to his back. He has not had blood or coffee ground material in his vomitus. He has had similar episodes in the past for which he did not seek medical treatment. Medical history is otherwise unremarkable and the patient takes no medications. He had been drinking a fifth of vodka daily before the pain began. BMI is 20 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 28/min, and blood pressure 140/100 mm Hg. Pulse oximetry on 2 L/min of oxygen via nasal cannula shows an oxygen saturation of 94%. Physical examination shows scleral icterus, jaundice, and palmar erythema. Abdomen is nondistended and is tender to palpation above the umbilicus. CT scan of the abdomen shows vertebral compression of L1 of indeterminate age, atelectasis at the bases of both lungs, a small, nodular liver, a small amount of ascites, splenomegaly, distention of the gallbladder with no calculi, calcifications in the pancreas, and a 2-cm simple cyst in the upper pole of the left kidney. There is no free air. Results of serum laboratory studies obtained on admission are shown:

Which of the following is the most likely cause of this patient’s abdominal pain?

A 55-year-old man, who was diagnosed with a primary lung carcinoma 9 months ago, comes to the office with his daughter for a consultation. At the time of diagnosis, thoracic nodes were positive for metastasis. The patient received radiation therapy and is currently receiving chemotherapy. During the past 2 months, new metastases have been found in bone and the liver. His medical history is significant for Hodgkin disease in his 20s and for resection of a malignant melanoma 3 years ago. Today, the daughter says the patient has announced that he does not wish to continue his chemotherapy; he says it is not doing any good and it makes him feel sick all the time. You frequently have had discussions with him about the expectations of a new experimental chemotherapy protocol, and he also has told you that he wants to stop treatment. The daughter says to you, “Isn’t there anything you can do to convince him to continue his treatment?” The patient says, “I’ve thought about this and I have made up my mind. I don’t want any more chemotherapy.” Regarding his treatment, which of the following is the most appropriate next step?

A 4-year-old child is brought to the office by his mother for a routine well-child examination. The patient’s asthma has been managed for the past year, during which time he has had three exacerbations of asthma despite daily use of inhaled fluticasone. The mother observes that every time her child has an exacerbation, he receives an oral dose of prednisone as soon as he comes to the office. She wonders whether she could keep prednisone at home and give him this medicine under telephoned supervision by a physician. A randomized, double-blind, placebo-controlled trial of independent parental administration of prednisone in acute exacerbations of asthma is reviewed. One hundred fifty patients were enrolled in this 1-year study, and 138 patients (92%) completed the study. The study’s intervention consisted of the parents in the case group administering 2 mg/kg (up to 60 mg) of oral prednisone at the outset of a presumed asthma exacerbation if one dose of the child’s usual acute asthma medicine did not appear to improve the child’s condition. The outcome measure was the number of outpatient visits for acute asthma exacerbations during the study period. Results of the study are shown:

Analysis of the results yields a chi-square value of 0.47, with a p-value of 0.50. The best interpretation of these data is that the observed differences in the number of patients who make outpatient visits after administration of prednisone vs. placebo are the result of which of the following?

A 12-year-old boy is in the hospital because of a 10-cm, full-thickness (third-degree) burn of the left leg. He is scheduled for a skin graft. If a layer of epidermis is removed for a split-thickness graft, which of the following is the most accurate conclusion regarding the donor site?

A 32-year-old woman is being evaluated because of a 3-week history of heaviness and stiffness of the right arm and a tendency to drop things. She also has noticed some blurring of vision in the left eye. These symptoms developed while she was recovering from a minor “cold” with runny nose and a dry cough. She recalls several previous self-limited symptoms of mild weakness, tingling, or stiffness involving her other limbs and a brief period of mild incontinence when she was in her 20s, but all episodes resolved within a few weeks, and she attributed them to stress. Physical examination today shows decreased visual acuity in the left eye with failure of the pupil to constrict in response to light. She has increased tone in the muscles of the right arm and both lower legs, with poor performance on finger-to-nose testing. Her superficial abdominal reflexes are absent. Muscle stretch reflexes are increased at the right biceps, triceps, and brachioradialis, as well as at both knees and ankles. She has bilateral ankle clonus and extensor plantar reflexes. MRI of the brain shows bilateral high-intensity signals in the periventricular white matter and cerebellar peduncles. Which of the following treatments is most likely to improve the course of this disease?

A 50-year-old woman comes to the office because, she says, “My right hand feels asleep when I wake up in the morning.” She also describes numbness occurring in the first three fingers when she is driving. She has a history of hypertension, gout, and hypothyroidism, but she has not been seen by a physician for more than 2 years. Physical examination discloses diminished sensation over the involved area but no loss of motor function. The most appropriate diagnostic study is determination of which of the following?

A 42-year-old clerical worker comes to the health center because of a 5-week history of mild pain at the lateral aspect of her right elbow. The pain radiates to the wrist and is aggravated by grasping and motion. Which of the following is the most appropriate initial management?

A 25-year-old man comes to the office because he and his wife have been unable to achieve a pregnancy after 3 years of unprotected intercourse. Her infertility work-up has been normal. He is a factory worker and admits to “drinking too much alcohol.” He also complains of difficulty maintaining an adequate erection. Physical examination discloses gynecomastia and atrophic testicles. The man’s karyotype shows 47,XXY (Klinefelter syndrome). Which of the following is the most appropriate next step to correct his erectile dysfunction?

Item 1 of 2

Which of the following is the most appropriate diagnostic study?

Item 2 of 2

Which of the following is the most appropriate initial management?

An 85-year-old woman is brought to the emergency department by her daughter because of a 2-month history of intermittent episodes of dizziness when rising from a supine position. Her daughter says, “Today, she almost passed out when she stood up. I think she’s gotten so weak that she shouldn’t live on her own anymore.” The daughter is visiting from another state and had not seen her mother during the past 6 months. A neighbor checks on the patient weekly and brings her groceries. The patient says she has always been generally healthy and has not received care from a physician during the past 20 years. She takes no medications. Today she appears frail and pale, but she is alert and oriented to person, place, and time. She is 165 cm (5 ft 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. Vital signs are temperature 37.0°C (98.6°F); pulse 85/min supine, 90/min standing; respirations 12/min; and blood pressure 110/72 mm Hg supine, and 100/66 mm Hg standing. The abdomen is soft, and the spleen tip is palpable. The remainder of the physical examination is noncontributory. Results of laboratory studies are shown:

Peripheral blood smear is obtained and shown. Which of the following is the most likely diagnosis?

A 26-year-old Asian American woman comes to the office because of a 3-day history of shortness of breath on exertion, chest pain with deep inspiration, and an occasional dry cough. She says she has felt warm, but she does not think she has had a fever; she has been taking acetaminophen since the symptoms began. Medical history is unremarkable. Her only medication is a low-dose oral contraceptive that she has taken for the past 2 years. She does not smoke cigarettes. Vital signs are temperature 37.2°C (99.0°F), pulse 104/min, respirations 24/min, and blood pressure 115/65 mm Hg. Auscultation of the lungs discloses decreased breath sounds, decreased fremitus, and increased resonance on percussion at the apex of the left lung. Chest x-ray is pending. Which of the following is the most likely explanation for this patient’s condition?

A 2-year-old girl is brought to the office by her father because of a 4-hour history of pain and decreased mobility in her right arm that began suddenly after her older brother swung her around by her arms. The father says, “I put ice on the arm and gave her ibuprofen, but she still won’t move it.” Growth and development have been normal. Vital signs are normal. The child is tearful. She holds her right arm flexed and pronated at her side. Physical examination of the right upper extremity shows no deformity, edema, or ecchymosis. Grip strength in the right hand is normal. Radial and ulnar pulses are strong bilaterally. X-rays of the right upper extremity are obtained and shown. Which of the following is the most appropriate initial management?

An 18-year-old woman with spina bifida comes to the office for a preemployment physical examination. Medical history is significant for a ventriculoperitoneal shunt placed at age 10 years. The patient uses an intermittent urinary catheter every 5 to 6 hours. Medical history is otherwise unremarkable and her only current medication is oxybutynin. She is sitting in a wheelchair but reports that she can walk short distances with the use of crutches. She is not in acute distress. Vital signs are temperature 37.2°C (99.0°F), pulse 88/min, respirations 14/min, and blood pressure 110/78 mm Hg. Lungs are clear to auscultation. Cardiac examination discloses a grade 2/6 systolic ejection murmur audible at the lower left sternal border. Abdominal examination discloses no abnormalities. The office nurse collects a urine specimen for the preemployment drug screen. She notes that the urine is cloudy and spins it for the physician to review. The physician notes that the urine shows occasional erythrocytes and 15–20 leukocytes/hpf. Which of the following is the most appropriate next step in management?

A 13-year-old girl is brought to the office by her parents for a follow-up examination 4 months after diagnosis of type 1 diabetes mellitus and chronic autoimmune (Hashimoto) thyroiditis. Medical history is otherwise unremarkable. Medications are an insulin pump and levothyroxine. Menarche has not yet occurred. Family history is significant for type 1 diabetes mellitus and chronic autoimmune thyroiditis in multiple family members. The patient’s BMI is at the 10th percentile. Vital signs are normal. Physical examination discloses no abnormalities. Sexual maturity rating is 2 for breast development. This patient is at increased risk for developing which of the following additional conditions?

A 56-year-old male roofer comes to the office because of persistent back pain that began 12 years ago when he fell from a roof while working. The pain interferes with his ability to complete activities of daily living and the patient has been unable to work since the incident. At that time, he was evaluated by an orthopaedist who identified that he had no acute injury to bone. The patient underwent physical therapy for several weeks without significant relief of his pain. He also states that his pain does not respond to over-the-counter medications. Medical history also is significant for hypertension, for which he takes amlodipine. He lives with his wife and receives disability payments. He has smoked one pack of cigarettes daily for the past 40 years. He drinks one to two glasses of bourbon weekly and smokes marijuana one to two times daily to dull his pain and aid with sleep. Family history is significant for rheumatoid arthritis in his mother. BMI is 27 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 92/min, respirations 12/min, and blood pressure 146/82 mm Hg. Physical examination discloses decreased range of motion in flexion and extension of the back. Neurologic examination discloses no abnormalities. The patient requests pain medication. Which of the following factors in this patient is most likely to influence therapy?

A 38-year-old woman, gravida 3, para 2, is admitted to the hospital at 39 weeks’ gestation in active labor and gives birth to a 4220-g (9-lb 5-oz) female newborn via spontaneous vaginal delivery. Labor was uncomplicated; the first stage lasted 12 hours and the second stage lasted 1 hour. A second-degree midline perineal laceration was sustained during delivery, but delivery was otherwise uncomplicated. The placenta is delivered intact 15 minutes after the delivery with no abnormalities. Epidural analgesia was administered for labor and delivery. Medical history is otherwise unremarkable and she takes no medications except for prenatal vitamins. As the perineal laceration is being repaired, approximately 500 mL of blood with clots flows copiously from the vagina. Vital signs are temperature 36.7°C (98.1°F), pulse 96/min, respirations 18/min, and blood pressure 108/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Which of the following factors in this patient’s history most increased her risk for developing this condition?

A 40-year-old female physician is brought to the emergency department requesting zolpidem pills 6 hours after ingesting several oxycodone pills. Her father died 1 month ago. She is tearful but says she will be “OK,” and she asks the physician not to tell anyone in her practice. After expressing empathy about the loss of her father, which of the following is the most appropriate next step?

A 47-year-old woman comes to the office because of a 2-month history of a red, tender area on her right breast. She says the affected skin seems to have changed in texture during this period. Two courses of antibiotic therapy have not changed the appearance of the lesion. She has not had fever or chills. Vital signs are normal. Physical examination shows a 5-cm, erythematous, indurated area on the medial aspect of the right breast, between the 2 and 6 o’clock positions. The nipple appears normal. No masses are palpated in either breast, and there is no lymphadenopathy. Mammography shows no masses in either breast. Which of the following is the most appropriate next step in diagnosis?

A 55-year-old man comes to the office for follow-up 3 months after undergoing a left upper lobectomy for stage 2 non-small cell lung cancer. He reports ongoing fatigue since the operation that has prevented him from returning to work as an auto mechanic. He has been sleeping well. He has not had pain, depressed mood, shortness of breath, or weight loss. Medical history also is significant for osteoarthritis of the knees. His only medication is ibuprofen. BMI is 25 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 84/min, respirations 18/min, and blood pressure 120/60 mm Hg. The patient is not in acute distress. Lungs are clear to auscultation. Results of laboratory studies are shown:

Which of the following is the most appropriate initial management of this patient’s fatigue?

A 45-year-old woman comes to the office for a routine examination. She underwent cholecystectomy 5 years ago and has no other history of serious illness. She takes no medications. Menses occur at regular 30-day intervals and last 5 days. Pap smears during the past 10 years have shown no abnormalities. Her mother was diagnosed with endometrial cancer at the age of 68 years, and her father was diagnosed with colon cancer at the age of 65 years. The patient has smoked one-half pack of cigarettes daily for the past 25 years. She says she wants to stop smoking in the future but is not yet ready. BMI is 30 kg/m2. Vital signs are normal. Physical examination shows no abnormalities. Which of the following is the most appropriate statement or question to this patient to address her smoking history?

A 4-month-old boy is brought to the clinic by his mother for follow-up 8 days after being discharged from the hospital, where he underwent treatment for a 1-day history of profuse watery diarrhea and refusal to eat or drink. During his 2-day hospital stay, he was treated with intravenous and oral rehydration. At the time of discharge, the diarrhea had resolved and he was tolerating liquids well. Since discharge, he has not had any diarrhea, he has been feeding well, and he has had six wet diapers daily. He appears well. He is at the 50th percentile for length, weight, and head circumference. Vital signs are normal. Physical examination discloses no abnormalities. Results of serum laboratory studies obtained on the day of admission, at discharge, and today are shown:

Without additional treatment, which of the following is most likely to develop in this patient?

A 68-year-old man with leukemia is being treated in the oncology ward of the hospital. He tells the physician that he wants to stop his chemotherapy because he is tired of the nausea and vomiting associated with it. He has no other acute treatment needs requiring inpatient hospital admission. He says he knows he will die if he stops the chemotherapy. Medical history also is significant for schizophrenia and post-traumatic stress disorder. He is a US Navy veteran, and he receives disability checks from the US Department of Veterans Affairs, which he uses to pay rent on his apartment and buy food. He has lived independently for the past 10 years. He believes that he is a “warlock” and keeps a large knife, which he calls his “sword,” under his pillow at home for “protection.” His sister states that he has had this belief for the past 15 years. He takes no medications for his psychiatric conditions and is not interested in treatment. At the age of 20 years, he was charged with assault after being involved in a bar fight. At the age of 35 years, he attempted suicide by drug overdose. He has not harmed himself or anyone else since these episodes. Which of the following is the most appropriate action by the physician regarding this patient’s request to stop his current treatment?

A 36-year-old woman, gravida 4, para 3, aborta 1, is brought to the emergency department because of a 2-hour history of increasingly severe lower abdominal pain that began 6 hours after undergoing an induced abortion at 13 weeks’ gestation. She has not had fever, chills, or pain with urination, and she has voided without difficulty since the procedure. Uterine evacuation was uncomplicated. Vital signs are temperature 37.8°C (100.0°F), pulse 105/min, respirations 18/min, and blood pressure 110/66 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination shows moderate diffuse tenderness over the lower abdomen without rebound. Pelvic examination shows a small amount of blood in the vaginal vault and a closed cervical os. Pelvic ultrasonography shows no retained products of conception. Which of the following is the most appropriate next step in diagnosis?

A 32-year-old woman with a history of major depressive disorder is brought to the emergency department by her roommate 4 hours after ingesting an unknown quantity of aspirin in an apparent suicide attempt. The patient reports ringing in her ears and nausea, but she has not vomited. Medical history otherwise is unremarkable and she takes no medications. Vital signs are temperature 38.0°C (100.4°F), pulse 110/min, respirations 24/min, and blood pressure 100/68 mm Hg. Pulse oximetry on oxygen at 2 L/min via nasal cannula shows an oxygen saturation of 99%. The patient is awake and tearful. Physical examination discloses no abnormalities. Results of laboratory studies are shown:

Which of the following is the most appropriate initial step in management?

Investigators are conducting a study to examine the relationship between a diagnosis of major depressive disorder and patients’ perception of discrimination. The office staff members of a primary care clinic inform the research assistants which clinic patients have a diagnosis of major depressive disorder and should be asked to participate in the study. These patients are approached by the research assistants and asked to participate in the study. To determine eligibility, the research assistants ask the potential participants about their age, education level, marital status, and diagnosis of major depressive disorder. In addition, the research assistants record the gender of each potential participant. Which of the following study elements is a violation of the privacy of patient data?

An 84-year-old woman, who resides in a nursing care facility, is admitted to the hospital for gastrostomy tube replacement. One day ago, the tube was dislodged while she was being bathed. She has severe dementia, Alzheimer type, and has required a gastrostomy tube for nutrition for 1 year. She does not have an advance directive. Her nephew, who is her health care proxy, asks that the tube not be replaced, but he expresses concern that this decision may go against the patient’s wishes. Which of the following is the most appropriate response to the nephew?

A 3-year-old girl is brought to the clinic by her mother after the mother noticed a firm mass in the child’s abdomen while bathing her today. The patient’s medical history is remarkable for cerebral palsy with feeding dysfunction. Medications are baclofen and levetiracetam. She uses a wheelchair for mobility and is fed through a gastrostomy tube. For the past 2 weeks, she has had decreased stool volume with small liquid bowel movements. She has not had vomiting or feeding intolerance. She is at the 25th percentile for height and the 5th percentile for weight; BMI is at the 3rd percentile. Vital signs are normal. The patient appears alert and happy. Abdomen is distended and a large, firm mass is palpated in the left lower quadrant. Muscle tone is increased throughout all extremities and there is clonus in both ankles. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate next step in evaluation?

A 68-year-old woman with chronic obstructive pulmonary disease (COPD) comes to the office because of a 6-week history of shortness of breath. She is unable to walk more than two blocks without beginning to wheeze and having to stop to rest. Her symptoms previously were controlled with an albuterol inhaler. She has never required hospitalization for COPD symptoms and has not had any exacerbations during the past year. She takes no other medications. She smoked one pack of cigarettes daily for 40 years but quit 6 months ago. Vital signs are temperature 37.1°C (98.8°F), pulse 90/min, respirations 16/min, and blood pressure 140/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Cardiopulmonary examination discloses a prolonged expiratory phase; no wheezing, crackles, or rhonchi are heard. Addition of which of the following is the most appropriate next step in pharmacotherapy?

A 58-year-old man comes to the office because of a 1-year history of generalized weakness, hand tremors, and difficulty walking. His wife says that during this time, he has had difficulty initiating movements and has moved more slowly. Medical history is remarkable for peptic ulcer disease and chronic obstructive pulmonary disease. He sustained a concussion while playing football at age 17 years. Medications are atorvastatin and amlodipine. Vital signs are temperature 37.0°C (98.6°F), pulse 68/min, respirations 14/min, and blood pressure 115/70 mm Hg. Examination shows infrequent blinking and facial movement. Voice is low-pitched, and speech is mildly slurred. A resting tremor of the hands is more noticeable on the right than the left. There is cogwheel rigidity of both wrists. Muscle strength is 5/5 in all extremities. Gait is wide-based and shuffling. Treatment with which of the following is most likely to alleviate this patient’s tremor?

A 72-year-old man, who was admitted to the hospital 4 days ago for treatment of a stroke, now is being evaluated because of abnormal results of his most recent laboratory studies. The patient has had no additional symptoms since admission. Medical history is remarkable for hypertension. Routine medications are amlodipine and losartan; on admission, his dosages of amlodipine and losartan were decreased, and 81-mg aspirin and atorvastatin were initiated. He also was placed on a low-sodium diet on admission. He does not smoke cigarettes or drink alcoholic beverages. Vital signs are temperature 36.8°C (98.2°F), pulse 72/min, respirations 16/min, and blood pressure 150/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. The patient is not in distress. Physical examination discloses moist mucous membranes and right upper extremity hemiparesis that is unchanged from his examination 1 day ago. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies obtained on admission 4 days ago, 1 day ago, and today are shown:

Which of the following is the most appropriate next step in management?

A 36-year-old woman comes to the emergency department because of a 4-hour history of right-sided abdominal pain and nausea. Medical history is remarkable for a laparoscopic cholecystectomy for acute cholecystitis 10 years ago. She takes no medications. She runs 4.8 kilometers (3 miles) daily. She has smoked one pack of cigarettes daily for 18 years. Her last menstrual period was 6 weeks ago. BMI is 24 kg/m2. Her temperature is 38.2°C (100.7°F), pulse is 94/min, respirations are 20/min, and blood pressure is 120/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Abdominal examination discloses rebound tenderness in the right upper quadrant and tenderness over the right flank. Bowel sounds are decreased. Results of laboratory studies are shown:

Ultrasonography of the abdomen shows fluid in the right flank area and an inflammatory mass in the right upper quadrant. Abdominal laparoscopy shows a dense inflammatory mass with matted bowels in the right upper quadrant; the cecum is not present in either the right or left lower quadrant of the abdomen. The sigmoid colon is visualized in the left lower quadrant. The most appropriate next step in management is operative resection of which of the following structures?

A 56-year-old woman, gravida 2, para 2, is admitted to the hospital because of a 6-day history of profuse vaginal bleeding. Menopause occurred 6 years ago. She has hypertension treated with chlorthalidone. She lives alone and is unemployed. She attended school through the sixth grade. She is 157 cm (5 ft 2 in) tall and weighs 95 kg (210 lb); BMI is 38 kg/m2. Temperature is 37.1°C (98.8°F), pulse is 72/min, respirations are 14/min, and blood pressure is 144/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. The uterus and adnexa are not palpable. Pelvic examination shows a moderate amount of dark blood in the vaginal vault; there is no active bleeding. Endometrial biopsy specimen shows complex endometrial hyperplasia with cellular atypia. Which of the following physician statements is most appropriate to convey the biopsy results to the patient?

A 78-year-old man is brought to the emergency department (ED) by police 30 minutes after his neighbors reported that they had not seen or heard from him in 2 days. On arrival, he appears dehydrated and is confused. Intravenous fluid therapy is begun. His electronic medical record shows that the patient has type 2 diabetes mellitus, hypertension, and osteoarthritis. His medications are insulin, metformin, lisinopril, and ibuprofen. His niece has been caring for him since his wife died 6 months ago. The patient’s temperature is 37.9°C (100.2°F), pulse is 92/min, respirations are 18/min, and blood pressure is 164/79 mm Hg. Physical examination shows several ecchymoses over the shoulders, upper extremities, and abdomen. There is a sacral decubitus ulcer. Results of laboratory studies are shown:

His medical record shows five previous hospitalizations for similar symptoms and physical findings during the past 6 months; the ulcer has worsened since his last admission. Six hours after admission today, the patient’s condition has stabilized, and his mental status has mildly improved. He is now oriented to person and place but not to time. He is unable to draw the face of a clock correctly. He names three objects correctly but can recall only one of them after 5 minutes. He does not remember when he was brought to the ED or the names of his daily medications. He becomes tearful and tells the physician that he misses his wife and wants to “join her.” When the physician informs the patient that she would like to transfer him to an assisted living facility, he asks to be discharged to his niece’s care instead. Which of the following historical factors is most appropriate to consider when determining this patient’s decision-making capacity?

A 52-year-old woman is admitted to the hospital because of a 3-day history of fever, increased urinary frequency, and pain with urination. She says she feels unwell. Temperature is 39.0°C (102.2°F), pulse is 120/min, respirations are 20/min, and blood pressure is 100/60 mm Hg. Physical examination shows mild suprapubic tenderness and left costovertebral angle tenderness. Urinalysis shows more than 100 WBCs/hpf. Gram stain of the urine shows numerous gram-negative bacilli. Results of the blood culture obtained on admission are positive after 7 hours of incubation. A rapid polymerase chain reaction test using this blood culture detects multi-drug–resistant Klebsiella pneumoniae. In addition to standard precautions, which of the following types of precautions is most appropriate for this patient?

A 62-year-old man comes to the office because of a 2-month history of progressively worsening pain in his right thigh. He now is able to bear only minimal weight on the leg and has required use of a cane. He has not sustained any trauma. He also reports having blood in his urine during the past 2 weeks, but he has not had pain with urination. BMI is 27 kg/m2. Temperature is 37.2°C (99.0°F), pulse is 76/min and regular, respirations are 20/min, and blood pressure is 140/70 mm Hg. Physical examination discloses tenderness to palpation of the right femur just above the knee. Abdominal examination discloses no abnormalities. Urinalysis shows 10–20 RBCs/hpf. X-ray of the right thigh shows a lytic lesion of the bone just above the knee that is associated with a hairline fracture. Which of the following is the most appropriate next step in management?

A 64-year-old woman remains hospitalized 1 day after elective total knee arthroplasty. Medical history is remarkable for osteoarthritis, hypertension, and hypothyroidism. Her medications are amlodipine, clonidine, as-needed ibuprofen, levothyroxine, and metoprolol. Medication review was performed on admission, and a nurse confirmed the patient’s medication list verbally, taking notes and later entering them into the electronic medical record (EMR). The nurse writes down clonidine in her notes with a dose of “0.3 mg,” but while entering the amounts into the EMR, she records the dose as “3 mg.” Before discharge, the nurse administers the patient’s home medications at the dosages recorded in the EMR. Fifteen minutes after taking the medications, the patient becomes lightheaded and has syncope upon standing. After stabilizing the patient, a multidisciplinary group convenes to determine how this error occurred. Which of the following tools is most appropriate to use to analyze this error?

A 12-hour-old female newborn is being evaluated in the hospital nursery because of yellowing of her skin and eyes since birth. The patient was born via spontaneous vaginal delivery at 38 weeks’ gestation to a 24-year-old woman whose pregnancy course was complicated by gestational diabetes and a fall during the third trimester, for which she did not receive medical treatment. Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. The newborn has been breast-feeding without difficulty. She is 53 cm (21 in; 90th percentile) long and weighs 4500 g (9 lb 11 oz; 95th percentile); head circumference is 38 cm (15 in; 95th percentile). Temperature is 37.0°C (98.6°F), pulse is 160/min, and respirations are 50/min. Pulse oximetry on room air shows an oxygen saturation of 98%. The patient is crying but is not in distress. Physical examination discloses a small hematoma on the posterior scalp, yellowish discoloration of the face and trunk, and conjunctival icterus. The remainder of the physical examination discloses no abnormalities. Results of laboratory studies are shown:

Direct antiglobulin test is positive. Which of the following factors in this patient’s history most increased her risk for developing her condition?

A 40-year-old male long-distance truck driver comes to the emergency department because of a 2-day history of persistent sharp chest pain and shortness of breath that were sudden in onset. He returned home from a 7-day road trip this morning. He has smoked two packs of cigarettes daily for the past 20 years. He was treated in the emergency department 3 years ago for thrombophlebitis of the left leg. Today, BMI is 35 kg/m2. Temperature is 37.0°C (98.6°F), pulse is 110/min and regular, respirations are 22/min, and blood pressure is 138/86 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92% at rest. Lungs are clear to auscultation. Cardiac examination shows a grade 2/6 nonradiating murmur at the apex. There is 2+ edema of the left lower extremity with no calf tenderness, and a negative Homans sign. Resting ECG shows sinus tachycardia and x-ray of the chest shows no abnormalities. Arterial blood gas analysis while the patient breathes room air is shown:

The most appropriate immediate management is administration of which of the following?

A 28-year-old man with HIV infection comes to the emergency department because of a 3-week history of nonproductive cough and fever with temperatures to 39.0°C (102.2°F). He also reports a weight loss of 6.8 kg (15 lb) during the past 3 months. Medical history otherwise is unremarkable. The patient previously took antiretroviral therapy and trimethoprim-sulfamethoxazole but stopped taking both 6 months ago because of adverse effects; he currently takes no medications. He is 175 cm (5 ft 9 in) tall and weighs 62 kg (136 lb); BMI is 20 kg/m2. Temperature is 39.0°C (102.2°F), pulse is 98/min, respirations are 22/min, and blood pressure is 116/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 86%. Physical examination shows white plaques on the buccal mucosa. Auscultation of the lungs discloses coarse breath sounds bilaterally. The remainder of the physical examination discloses no abnormalities. The patient’s most recent CD4+ T-lymphocyte count obtained 6 months ago was 75/mm3. Chest x-ray shows bilateral interstitial infiltrates without consolidation. Which of the following studies is most likely to confirm the diagnosis?

A 13-year-old girl is admitted to the hospital because of a 2-week history of fever; intermittent weakness; involuntary movements of her face, arms, and legs; and moderate joint pain. The pain started in her left knee, then occurred in her right knee; then there was pain in both ankles followed by the wrists and the elbows. Two weeks ago, she had a faint, pink, expanding rash on her trunk for 3 days; the rash had sharp edges, was clear at the center, and resolved spontaneously. She receives no medications. She is at the 75th percentile for height and 60th percentile for weight; BMI is at the 56th percentile. Temperature is 37.8°C (100.0°F), pulse is 82/min, respirations are 16/min, and blood pressure is 118/62 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. Cardiac examination discloses a grade 3/6 diastolic murmur best heard at the apex. There is mild swelling of the right wrist and tenderness to palpation of the left elbow and right wrist. Neurologic examination discloses intermittent, involuntary grimaces and an inability to maintain constant right handgrip strength. Which of the following is the most likely mechanism of this patient’s condition?

During the night shift at a teaching hospital, a 68-year-old woman with metastatic ovarian cancer is found unresponsive and pulseless by the charge nurse. The charge nurse, who is covering for the patient’s bedside nurse while she takes her dinner break, calls a code, and the attending physician and resident from the intensive care unit (ICU) respond. Cardiopulmonary resuscitation is initiated, and cardiac monitoring shows pulseless electrical activity (PEA). No one in the room is certain of the patient’s code status. The hospital’s electronic health record is temporarily unavailable due to maintenance, and the patient’s order for life-sustaining treatment cannot be accessed. The team continues with the resuscitation efforts while the charge nurse calls the patient’s family to confirm her code status. The ICU attending physician intubates the patient while the resident pages the on-call cardiologist to perform emergent pericardiocentesis. The charge nurse returns after reaching the patient’s daughter and states, “They want everything done.” At the same time, the patient’s bedside nurse returns from her break to find the resuscitation in progress. She calmly but forcefully informs the group that the patient, who had full decision-making capacity, had completed the paperwork for do-not-resuscitate status earlier that afternoon. The team reassesses the patient’s status, finds that she remains in PEA arrest, and stops resuscitation efforts. Which of the following is the most important leadership characteristic in this clinical scenario?

A 7-year-old girl is brought to the office by her mother for a follow-up examination 1 month after an increased blood pressure reading was noted during a well-child examination. Medical history also is remarkable for birth at 32 weeks’ gestation that required a 2-month admission in the neonatal intensive care unit. The patient otherwise has been healthy and currently receives no medications. She is at the 30th percentile for height and weight; BMI is at the 50th percentile. Temperature is 37.6°C (99.7°F), pulse is 120/min, and respirations are 22/min. Four-limb blood pressure measurements are 140/64 mm Hg in the right upper extremity, 132/60 mm Hg in the left upper extremity, 100/50 mm Hg in the right lower extremity, and 98/54 mm Hg in the left lower extremity. Which of the following is most likely to be found on physical examination of this patient?