A
B
C
D
100
A 67-year-old man is evaluated because of a 2-year history of multiple scaly spots on the forehead, cheeks, ears, and hands. The lesions are asymptomatic but unsightly. Medical history is unremarkable except for significant lifetime sun exposure and several painful, blistering sunburns as a child.
The lesions are thin and have a rough, sandpaper-like quality when palpated. Representative lesions on the hands are shown.
What is the most appropriate treatment?
Topical fluorouracil cream
Cryotherapy
Photodynamic therapy
Topical imiquimod cream
100
A 29-year-old woman is evaluated for a 2-week history of left-sided back pain. The pain begins in the lumbar spine and radiates through the left buttock and hip into the thigh. The pain is sharp and shooting. She is 19 weeks pregnant with her first child. The pregnancy is uncomplicated. Her only medication is a prenatal vitamin.
On physical examination, she walks with a limp favoring the left leg. Hip range of motion is normal. There is no pain with hip flexion, abduction, or external rotation. There is left-sided hip and leg pain with straight leg raise of both the left and right legs. There is no pain with flexion or extension of the lumbar spine.
What is the most likely diagnosis?
Radiculopathy of the sciatic nerve
Osteoarthritis of the hip
Round ligament pain
Sacroiliitis
100
A 45-year-old man is evaluated for generalized dull, throbbing pain in the left shoulder. He also reports an intermittent catching sensation with movement and a feeling of shoulder joint instability. There is no history of trauma. He is an avid weightlifter.
On physical examination, there is no pain with palpation of the left shoulder; palpation of the biceps tendon elicits crepitus but no pain. Passive range of motion is within normal limits, and active range of motion is limited by pain. Pronation of the forearm and abduction and external rotation of the left arm reproduce pain. Clicking in the glenohumeral joint is noted with passive rotation of the arm in an abducted position. Tests for rotator cuff injury are negative. Strength is 5/5 throughout the left arm.
What is the most likely diagnosis?
Labral tear
Acromioclavicular joint degeneration
Adhesive capsulitis
Biceps tendinopathy
100
A 58-year-old woman is evaluated for a 1-week history of urinary incontinence and increased urinary frequency. She reports having a sudden urge to urinate and needing to rush to the bathroom. There is often leakage of urine before she reaches the toilet. She has had no dysuria, nocturia, or hematuria. She has been postmenopausal for 4 years and had three vaginal deliveries between 24 and 30 years of age.
On physical examination, vital signs are normal. Pelvic examination is normal.
What is the most appropriate management?
Urinalysis
Bladder training with timed voiding
Pelvic floor muscle training
Topical vaginal estrogen
200
A 37-year-old woman is evaluated for a 4-day history of acute-onset, right-sided neck pain with radiation to the right arm. The pain worsens when she turns her head to the right and with right lateral flexion, and it improves when she lies down. She also notes a sporadic tingling sensation on the lateral aspect of the right hand. She has not had any other symptoms. She reports recreational use of oral opioids.
On physical examination, active and passive range of motion of the neck are severely limited by pain. Right upper extremity muscle strength and reflexes are normal. There is no cervical spine tenderness. Pain is reproduced by applying downward pressure to the patient's head while it is bent to the right and extended (Spurling test). Pain is relieved by lifting her right arm above her head.
What is the most appropriate management?
Neck exercises
Cervical collar
MRI of the cervical spine
Oxycodone
Radiography of the cervical spine
200
An 84-year-old woman is brought to the office by her son for evaluation of dementia. He reports that since the patient's husband died 8 months ago, she has neglected her personal hygiene, naps during the day, has difficulty sleeping at night, and has lost interest in going out. She takes no medications.
On physical examination, vital signs are normal. BMI 1 year ago was 26; today, BMI is 24. She appears sad and has a blunted affect. Neurologic examination is without focal motor deficits. On the Mini-Cog assessment of cognitive function, the patient cannot recall two of three words and did not attempt to draw a clock face due to fatigue.
What is the most appropriate diagnostic test to perform next?
Depression assessment
Comprehensive neuropsychological evaluation
MRI of the brain
Vitamin B12 measurement
200
A 57-year-old woman is evaluated for worsening right shoulder pain of several months' duration, which she describes as a dull ache deep within the shoulder. She has had difficulty with fastening her bra behind her back and with performing overhead activities.
On physical examination, there is no pain with palpation of the right shoulder. During full passive abduction of the right arm, pain occurs at 90 degrees. She is able to lower her arm smoothly from a fully abducted position. Resisted abduction strength and forward flexion strength are 4/5; strength is otherwise 5/5 in the right arm. The remainder of the shoulder examination is normal.
What is the most appropriate next step in management?
Physical therapy
Glucocorticoid injection
MRI of the right shoulder
Sling immobilization
200
A 40-year-old woman is evaluated for constant worry about work and family, feeling on edge, irritability, difficulty concentrating at work, and insomnia. These symptoms have developed over the past 7 months and have resulted in family discord and absenteeism from work. The patient has a history of alcohol use disorder that has been in remission for 18 months. She is otherwise well, and her only medication is an oral contraceptive.
On physical examination, vital signs are normal. Score on the Generalized Anxiety Disorder-7 instrument is 16.
Thyroid-stimulating hormone level is 2 µU/mL (2 mU/L).
The patient is offered cognitive behavioral therapy but prefers a trial of medication.
What is the most appropriate management?
SSRI
Alprazolam
Repeat the Generalized Anxiety Disorder-7 assessment in 1 month
Amitriptyline
300
A 58-year-old man is evaluated at a follow-up appointment. He is feeling well and has no symptoms. Medical history is significant for hypertension and type 2 diabetes mellitus. He exercises by walking 4 miles daily. He has never smoked and drinks one or two glasses of wine per day. Current medications are lisinopril, metformin, canagliflozin, and aspirin. He is also receiving maximum-dose therapy with atorvastatin and ezetimibe. His baseline LDL cholesterol level before starting atorvastatin and ezetimibe was 220 mg/dL (5.70 mmol/L).
On physical examination, blood pressure is 124/73 mm Hg. BMI is 28.
Laboratory studies:
Hemoglobin A1c 6.9%
HDL cholesterol 35 mg/dL (0.91 mmol/L)
LDL cholesterol 140 mg/dL (3.63 mmol/L)
Total cholesterol 190 mg/dL (4.92 mmol/L)
Triglycerides 100 mg/dL (1.13 mmol/L)
What is the most appropriate additional treatment?
Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody
Fenofibrate
Icosapent ethyl
Niacin
300
A 34-year-old woman is evaluated for concerns about long-term stressors. She reports ongoing court battles with her former spouse over child custody. She also describes frustration about her current living situation stemming from arguments with her roommate about rent payments. She was previously treated by a psychiatrist for major depression but terminated the relationship because she and the psychiatrist “did not see eye to eye” about treatment options; she becomes angry when discussing this situation. She takes no medications.
What is the most likely diagnosis?
Personality disorder
Bipolar disorder
Generalized anxiety disorder
Schizophrenia
300
A 63-year-old man is evaluated in the emergency department for confusion after being found by his wife. He recently visited an urgent care center for symptoms of an upper respiratory tract infection and was prescribed codeine-guaifenesin. His wife reports that he took the medicine as directed.
On physical examination, respiration rate is 10/min. All other vital signs are normal. The patient is somnolent. Miotic pupils and shallow inspirations are noted.
Treatment with naloxone rapidly improves mental status and respiration.
What pharmacogenetic variant is the most likely cause of this patient's adverse drug reaction?
Polymorphism of a cytochrome P450 gene
Polymorphism of thiopurine methyltransferase gene
Presence of HLA-B*57:01 allele
Presence of HLA-B*58:01 allele
300
A 38-year-old woman is evaluated after a recent diagnosis of systemic exertion intolerance disease. She fulfilled the diagnostic criteria of fatigue of at least 6 months' duration with substantial reduction in pre-illness activities, postexertional malaise, unrefreshing sleep, and cognitive impairment. She reports no pain, depressed mood, anhedonia, snoring, or daytime hypersomnolence. Medical history is significant for migraine and irritable bowel syndrome with predominant diarrhea. Medications are sumatriptan, topiramate, loperamide, and nortriptyline.
What is the most appropriate management?
Pacing strategies
Modafinil
Pregabalin
Sertraline
400
A 64-year-old man is evaluated in the emergency department for low back pain and difficulty climbing stairs that has worsened over the past several days. The pain radiates into his legs bilaterally. He has not urinated in the past 24 hours. He has a history of prostate cancer treated with external beam radiation therapy.
On physical examination, vital signs are normal. Ankle reflexes and patellar reflexes are decreased bilaterally. Dorsiflexion and plantar flexion weakness are present bilaterally, as is mild but detectable weakness of the major muscle groups of the legs and thighs. There is no spinal tenderness.
Whatis the most likely diagnosis?
Cauda equina syndrome
Piriformis syndrome
Radiation-induced pelvic insufficiency fracture
Vertebral compression fracture
400
A 53-year-old woman is evaluated during a follow-up appointment for a multiyear history of chronic back pain in the setting of osteoporotic compression fractures. In addition to nonpharmacologic treatment, including exercise, she has previously undergone vertebroplasty, facet joint injections, medial branch blocks with radiofrequency ablation, and transforaminal epidural glucocorticoid injections. Her pain is not well controlled with gabapentin, topical lidocaine patches, and an oral NSAID, resulting in interference with work and leisure activities. Other medications include zoledronic acid, vitamin D, and calcium.
There are no changes noted on her physical examination from previous visits.
Opioid therapy is being considered.
What is the most appropriate next step in management?
Opioid risk assessment
Calcitonin
Thoracic and lumbar radiography
Urine drug screening
400
A 54-year-old man is evaluated before starting statin therapy for dyslipidemia. He also has hypertension. He reports no exertional chest pain or dyspnea. Therapeutic lifestyle changes have been implemented. His only medication is losartan.
On physical examination, vital signs and other findings are normal. BMI is 24.
His 10-year risk for atherosclerotic cardiovascular disease is 8.0%.
What is the most appropriate test to perform before starting statin therapy?
Aminotransferase measurement
Creatine kinase measurement
Fasting blood glucose measurement
Treadmill stress testing
400
A 40-year-old man is evaluated for episodic dizziness. Three years ago, he developed left ear sensorineural hearing loss confirmed by audiometry, with associated tinnitus. For the past 6 months, he has had episodes of “room spinning” that last from 30 minutes to several hours; episodes are associated with nausea and sometimes vomiting. He experiences disequilibrium intermittently. MRI of the brain performed 6 months ago was normal. The patient is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. The Dix-Hallpike maneuver on the left side causes dizziness without vertigo or nystagmus.
What is the most likely diagnosis?
Meniere disease
Benign paroxysmal positional vertigo
Labyrinthitis
Vertebrobasilar stroke
Vestibular migraine
500
A 40-year-old man undergoes cardiac risk evaluation. He is asymptomatic but leads a sedentary lifestyle.
On physical examination, vital signs are normal. BMI is 27. The remainder of the examination is normal.
Laboratory studies:
Total cholesterol 180 mg/dL (4.66 mmol/L)
LDL cholesterol 100 mg/dL (2.59 mmol/L)
HDL cholesterol 40 mg/dL (1.03 mmol/L)
Fasting plasma glucose 98 mg/dL (5.43 mmol/L)
Calculated risk for atherosclerotic cardiovascular disease using the Pooled Cohort Equations is 1.4%.
What is the most appropriate management?
Intensive diet and exercise counseling
Low-dose aspirin
Moderate-intensity statin therapy
Treadmill stress exercise testing
500
A 72-year-old woman is evaluated for an intense urge to empty her bladder and inability to get to the bathroom fast enough. She rushes to the bathroom six to eight times per day and wakes several times in the night to urinate. She has no hematuria or dysuria. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. BMI is 25. Pelvic examination is normal except for mild anterior wall prolapse.
Findings on urinalysis are unremarkable.
What is the most appropriate management?
Bladder training with timed voiding
Mirabegron
Oxybutynin
Pelvic floor muscle training
500
A 45-year-old man is evaluated after admission to the hospital for pneumonia. He has a history of T4 paraplegia from a motor vehicle accident 20 years ago. He performs intermittent bladder catheterization for urinary retention. He has no other medical conditions and takes no medications.
On physical examination, temperature is 37.3 °C (99.2 °F), blood pressure is 108/70 mm Hg, pulse rate is 99/min, and respiration rate is 20/min. Oxygen saturation is 92% on 2 L of oxygen by nasal cannula. BMI is 33. The patient is supine in a hospital bed. He has crackles and reduced breath sounds in the right lower lobe. The skin over the back, buttocks, and lower extremities shows no evidence of pressure injury. He is asensate below T4.
What is the most appropriate measure to prevent pressure injury in this patient?
Hourly repositioning
Alternating air mattress
Local skin care with emollients
Nutritional supplementation
Static mattress overlay
500
A 50-year-old man is evaluated for worsening depressive symptoms. He has major depressive disorder, which was previously well controlled with fluoxetine, 20 mg daily.
On physical examination, vital signs are normal. The patient appears anxious and tired. He becomes tearful when discussing his current situation.
Repeat score on PHQ-9 is 15; his previous score was 8.
What is the most important next step in management?
Inquire about suicidal ideation
Add olanzapine
Administer the Mood Disorder Questionnaire
Increase fluoxetine