A
An 86-year-old woman is evaluated in the hospital after admission from her nursing home for a gluteal pressure injury. She has advanced Alzheimer dementia and is bedbound and noncommunicative. Nutritional status is judged to be adequate and has been maintained by assistance with feeding. The nursing home treated the pressure injury with hydrocolloid dressings.
On physical examination, vital signs are normal. BMI is 23. The patient is resting on an air-fluidized mattress. Skin examination shows a 5-cm × 6-cm area of full-thickness tissue loss with visible subcutaneous fat over the right gluteus; no tendon, muscle, or bone is visibly exposed. There is no erythema or fluctuance in the surrounding tissue and no purulent drainage. The remainder of the examination is normal.
What is the most appropriate treatment?
Pressure offloading
Ascorbic acid supplementation
Hyperbaric oxygen
Piperacillin-tazobactam
Switch to gauze dressings
A study compares a new treatment for symptom reduction in fibromyalgia versus treatment with pregabalin over a 1-year period. The target symptom reduction on a standard symptom inventory was reached in 30% of patients in the new treatment group and 25% of patients in the pregabalin group. However, 15% of patients in the new treatment group had to discontinue the treatment because of adverse effects; treatment was discontinued for this reason in 5% of patients in the pregabalin group.
What is the number needed to treat for one patient to benefit from the new medication for fibromyalgia?
20
10
30
40
A 27-year-old man is evaluated during a follow-up visit. He recently visited the emergency department for a burn sustained while setting off fireworks at a party while intoxicated. He has a history of depression but never followed up for treatment. Since that time, he reports that his mood has improved remarkably, and he is able to stay up “all night if I need to” to catch up on work. He has elaborate plans for starting his own cybersecurity business, running for city council, and working on an invention to prevent power grid failures. Medical history is otherwise unremarkable.
On physical examination, vital signs and other examination findings are normal. He has an elevated mood, is very talkative, and laughs somewhat inappropriately at the circumstances that led to the accident. He has a difficult time focusing on questions and is easily distracted by events in the corridor.
What following is the most likely diagnosis?
Bipolar 1 disorder
ADHD
Personality disorder
Schizophrenia
A 68-year-old woman is evaluated in the hospital for agitated delirium. She has metastatic non–small cell lung cancer. She was admitted to the hospital 5 days ago with acute hypoxic respiratory failure, and she opted for a comfort-directed care strategy. She is currently receiving oxygen through nasal cannula and parenteral opioids for dyspnea and bone pain. She became agitated 2 days ago, and after a thorough search excluded reversible causes, she was treated with intravenous haloperidol. Response to haloperidol was initially positive but is now waning. Her only other medication is morphine.
On physical examination, pulse rate is 121/min, respiration rate is 26/min, and oxygen saturation is 93% breathing 3 L/min oxygen by nasal cannula. The patient is not oriented or responding appropriately to questions. She is agitated and is attempting to climb out of bed.
What is the most appropriate next step in management?
Add parenteral lorazepam
Change haloperidol to olanzapine
Stop haloperidol
Stop morphine
A 43-year-old man is evaluated for cough. His symptoms started 12 days ago with headache, runny nose, cough, subjective fever, and fatigue. The headache, runny nose, and fever have improved, but the cough has persisted. He reports no shortness of breath. Medical history is significant for major depressive disorder treated with fluoxetine.
On physical examination, temperature is 37.4 °C (99.4 °F), blood pressure is 128/89 mm Hg, and respiration rate is 16/min. The oropharynx is clear and without exudates. Lungs are clear bilaterally.
Testing for SARS-CoV-2 is negative.
What is the most appropriate next step in management?
Education and reassurance
Albuterol inhaler
Azithromycin
Chest radiography
Dextromethorphan
A 38-year-old woman is evaluated for a 3-month history of depressed mood. She meets the diagnostic criteria for major depression. She reports no suicidal ideation or episodes of mania or hypomania. Her most troublesome symptoms at this time are difficulty concentrating at work and low self-esteem. She is in a new relationship, and there is the possibility of becoming sexually active at some point in the future. She has a copper intrauterine device for contraception. She has obesity and prediabetes and has experienced some success with weight reduction, but since the onset of depression, she has struggled with overeating. Medical history is also significant for hyperlipidemia and juvenile myoclonic epilepsy. Medications are atorvastatin and levetiracetam.
The patient would like to avoid an additional medication, if possible, but wishes to be provided with effective treatment.
What is the most appropriate management?
Cognitive behavioral therapy
Bupropion
Paroxetine
Reassurance
A 32-year-old man is evaluated in the emergency department for low back pain of several weeks' duration. The pain is in the lumbar area and does not radiate. He has no other symptoms. Medical history is significant for injection drug use.
On physical examination, temperature is 37.4 °C (99.4 °F); other vital signs are normal. Pain is present with gentle palpation of L3 and L4. The pain worsens with hyperextension or flexion of the spine. Marks from injection drug use are seen on the forearms. The remainder of the examination is normal.
Interferon-γ release assay, HIV test results, and blood and urine cultures are pending.
What is the most appropriate next step in management?
MRI of the lumbar spine
CT of the lumbar spine
Empirical antibiotic therapy
Radiography of the lumbar spine
A 72-year-old man is evaluated during an annual physical examination. The patient is a widower and has one daughter, from whom he is estranged. He has not completed an advance directive. His father died of complications of stroke after a prolonged hospital stay.
The patient mentions that he does not want to die like his father did, “hooked up to machines.” He is worried that he will receive aggressive care at the end of life, which he does not want.
The physician engages the patient in a discussion of health care preferences and goals for future care.
What best describes this interaction between the patient and his physician?
Advance care planning
Creation of a living will
Execution of an advance directive
Identification of a health care proxy
A 29-year-old man is evaluated for fatigue and difficulty concentrating. He finds himself worrying frequently and reports that he loses energy easily during the week, worries about being evaluated negatively at work, and sometimes snaps at his coworkers when he is particularly tense. These symptoms have been present most days of the week for the past year. Family and personal medical history is otherwise noncontributory, and he takes no medications.
On physical examination, vital signs and other findings are normal.
Results of laboratory studies show normal thyroid function. A urine drug screen is negative.
Which of the following is the most likely diagnosis?
Generalized anxiety disorder
ADHD
Panic attacks
Social anxiety disorder
A 42-year-old man is seen for a routine evaluation. Medical history is unremarkable. He takes no medications.
On physical examination, vital signs are normal. BMI is 35. The remainder of the physical examination is normal.
Laboratory studies reveal an LDL cholesterol level of 128 mg/dL (3.32 mmol/L) and triglyceride level of 348 mg/dL (3.93 mmol/L).
His 10-year risk for atherosclerotic cardiovascular disease based on the Pooled Cohort Equations is 2.4%.
What is the most appropriate management?
Recommend lifestyle interventions
Initiate fibrate therapy
Initiate statin therapy
Recommend omega-3 fatty acid supplements
A 47-year-old man is evaluated in the hospital after treatment for acute alcoholic pancreatitis. During the hospitalization, he is diagnosed with moderately severe alcohol use disorder. Medical history includes hypertension. He has been prescribed antihypertensives in the past but struggled with medication adherence; he recognizes this as a potential problem. Medical history is otherwise unremarkable, and screens for depression, other mood disorders, and additional substance use disorders are negative. He takes no medications at the present time.
He agrees to attend a 12-step facilitation program after hospital discharge, but he is concerned that it will not help sufficiently.
What is the most appropriate additional treatment?
Injectable naltrexone
Bupropion
Lorazepam
Oral naltrexone
A 79-year-old woman is evaluated for weight loss. She is brought to the office by her niece, with whom she moved in 3 months ago. There are several adult family members in the home. The patient is able to ambulate short distances in the home with a walker. She does not toilet independently and requires assistance with feeding, bathing, and dressing. Current medical problems include type 2 diabetes mellitus, hypertension, and osteoarthritis. Medications are metformin, losartan, atorvastatin, and acetaminophen.
On physical examination, vital signs are normal. BMI is 22. The patient is disheveled. She speaks very little and only to answer yes-or-no questions. Dry mucous membranes are noted. The perineum is soiled with caked feces and urine, and skin in the area is erythematous. An early stage 2 sacral decubitus ulcer is noted. There is bruising on the right upper arm. The remainder of the examination is normal.
What is the most appropriate management?
Adult Protective Services referral
Enteral nutritional supplementation
Hwalek-Sengstock Elder Abuse Screening test
Hydrocolloid wound dressing
An 89-year-old woman is evaluated in follow-up after discharge from a rehabilitation facility. Two weeks ago, she fractured her right hip after falling in her home when she tripped rushing to the bathroom to urinate during the night. Urinary urgency continues to be a problem. She has a history of hypertension, coronary artery disease, and insomnia. Her home medications are amlodipine, aspirin, calcium, lisinopril, metoprolol, and diphenhydramine as needed for sleep.
On physical examination, vital signs and other findings are normal. The incision at the right hip is healing well with no signs of infection.
What is the most appropriate medication management to reduce this patient's risk for falls?
Stop diphenhydramine
Start oxybutynin
Start vitamin D
Stop metoprolol
A 28-year-old woman is evaluated for a 2-month history of left-sided neck and shoulder pain and paresthesia in her left arm from her fingers to her shoulder. Her symptoms worsen with overhead arm activity. She takes no medications.
On physical examination, she has full range of motion in her left neck, shoulder, elbow, and wrist. Muscle bulk, tone, and strength in the upper extremities are normal bilaterally. Neurologic examination reveals normal reflexes and sensation in the upper extremities bilaterally. Upper extremity pulses are full and equal. There is no cyanosis, swelling, or edema.
What is the most likely diagnosis?
Neurogenic thoracic outlet syndrome
Arterial thoracic outlet syndrome
Cervical radiculopathy
Venous thoracic outlet syndrome
A 74-year-old man undergoes follow-up evaluation 4 weeks after an urgent care visit for benign paroxysmal positional vertigo. He is concerned about an upcoming trip and the possibility of falling. He has had no recent falls but did have a near fall. Medical history is significant for atrial fibrillation. Current medications are metoprolol, apixaban, and meclizine.
On physical examination, blood pressure and pulse rate are normal and without orthostatic changes. Cardiac examination reveals an irregular rhythm. Screening neurologic examination is normal.
The Timed Up and Go Test result is prolonged (16 seconds).
The patient undergoes canalith repositioning with the Epley maneuver.
What is the most appropriate additional management to reduce this patient's risk for falls?
Discontinue meclizine
Discontinue metoprolol
Prescribe a four-prong cane
Prescribe vitamin D
A 34-year-old woman is evaluated for a 3-month history of dry cough. She does not use tobacco. A chest radiograph obtained 1 month ago was normal. The patient has a history of seasonal rhinitis. Since the onset of the cough, she has used fluticasone nasal spray daily without improvement. She has no other symptoms.
Vital signs and physical examination are normal.
What is the most appropriate next step in management?
Spirometry
Ambulatory pH monitoring
Chest CT
Omeprazole
Sputum eosinophil evaluation
A 45-year-old man is evaluated during a routine examination. He does not exercise. He has never smoked and drinks one to two beers, 4 nights per week. There is no family history of premature atherosclerotic cardiovascular disease. For the purpose of calculating the patient's risk for atherosclerotic cardiovascular disease, the patient reports that he is Black.
On physical examination, blood pressure is 124/78 mm Hg. BMI is 28, and waist circumference is 106 cm (42 in).
Laboratory studies:
Fasting blood glucose 106 mg/dL (5.9 mmol/L)
LDL cholesterol148 mg/dL (3.83 mmol/L)
HDL cholesterol38 mg/dL (0.98 mmol/L)
Triglycerides 160 mg/dL (1.81 mmol/L)
His calculated 10-year risk for atherosclerotic cardiovascular disease (ASCVD) is 4.3%.
What is the most appropriate treatment?
Recommend intensive diet and exercise regimen
Initiate fenofibrate
Initiate moderate-intensity statin therapy
Recommend decreased alcohol intake
A 29-year-old woman requests advice after receipt of a direct-to-consumer genetic test result that included BRCA gene analysis. She has no breast symptoms and has not undergone any previous breast cancer screening. Her mother was diagnosed with breast cancer at age 48 years and ovarian cancer at age 60 years; she died at age 62 years. The patient's sister was recently diagnosed with breast cancer at age 41 years and is still living. The genetic test report is negative for BRCA1 and BRCA2 variants. Family members have not undergone genetic testing.
On physical examination, vital signs, breast examination, and other findings are normal.
What is the most appropriate management?
Genetic counseling
Clinical BRCA genetic test
MRI of the breast
Reassurance and no further testing
A 33-year-old woman is evaluated in the emergency department after a friend found her unresponsive and called emergency medical services. She is now alert and reports that she had used heroin hours earlier, as well as oxycodone and clonazepam just before this episode. She was treated in another local emergency department 2 months ago for a similar accidental polysubstance overdose.
What is the most appropriate measure for preventing an overdose-related death in this patient?
Intranasal naloxone
Oral clonidine
Naltrexone
Transdermal buprenorphine
A 62-year-old woman is evaluated for a change in her abdominal and pelvic pain symptoms. The patient has been followed for 3 years for medically unexplained symptoms. Her typical symptoms have included chronic pelvic pain of unknown cause and migrating upper abdominal pain. An extensive evaluation, including endoscopy, advanced imaging, and laboratory evaluation, has been negative. Her symptoms have been stable for the past 2 years until recently. Her new abdominal symptom is central boring pain that has been present for 6 weeks and is associated with anorexia, diarrhea, and a 2-kg (4.4-lb) weight loss. She is currently taking no medications.
On physical examination, vital signs are normal. The mid-abdomen is tender to deep palpation.
What is the most appropriate initial management?
CT of the abdomen and pelvis
Depression screening
Exploration of psychosocial stressors
Nortriptyline