Rheum
A 48-year-old woman is evaluated for sicca.
She has a 2-year history of Sjögren syndrome.
Chewing sugarless gum and taking frequent
small sips of water are increasingly less helpful
for oral dryness. Current medications are
artificial tears and ophthalmic cyclosporine.
She has no other concerning symptoms.
On physical examination, vital signs are
normal. Other than dry oral mucosa, the
examination is normal.
Which of the following is the most
appropriate treatment?
Cevimeline
Hydroxychloroquine
Low-dose prednisone
Rituximab
Cevimeline
A 70-year-old woman is evaluated in follow-up for peripheral artery disease. She walks 2 miles daily, and her symptoms force her to stop several times. Medical history is otherwise significant for hypertension and hyperlipidemia. She has a 50-pack-year smoking history but quit 10 years ago. Medications are aspirin, cilostazol, lisinopril, and amlodipine. She was prescribed atorvastatin, but she took the medication for only 1 week after reading that muscle ache is an adverse effect.
Which of the following is the most appropriate treatment?
Atorvastatin
Colestipol
Ezetimibe
Icosapent ethyl
Atorvastatin
A 72-year-old woman is hospitalized for subacute onset of jaundice that developed 5 days ago on the second day of a cruise to Central America. She has no known liver disease and reports consuming fewer than three drinks per week. She has no abdominal pain, nausea, or vomiting. Five weeks ago she was treated with amoxicillin-clavulanate for an episode of acute diverticulitis.
On physical examination, vital signs are normal. Icterus and jaundice are observed. There are no signs of chronic liver disease. Mental status is normal, and no asterixis is seen.
Alkaline phosphatase -200 U/L
Alanine aminotransferase -57 U/L
Aspartate aminotransferase -70 U/L
Total bilirubin 15 mg/dL (256.5 μmol/L)
INR 1.0
Right-upper-quadrant ultrasound shows no gallbladder stones or biliary dilation, a normal-size liver, and no masses.
Which of the following is the most likely diagnosis?
Autoimmune hepatitis
Drug-induced liver injury
Hepatitis A virus infection
Primary biliary cholangitis
Drug induced liver injury
A 34-year-old woman with fistulizing Crohn disease is evaluated in the ICU 10 days after she was admitted with surgical complications. She has been unable to be weaned from mechanical ventilation. Tube feedings were initiated 48 hours after ICU admission but have not advanced above 50% of her nutritional goal because of recurrent abdominal distention and emesis. She has lost 1.8 kg (4 lb) over the last week. The ileostomy bag contains gas and liquid feces. Medications are low-molecular-weight heparin, metoclopramide, fentanyl, piperacillin-tazobactam, mesalamine, and oral budesonide.
On physical examination, vital signs are normal. BMI is 20. She is intubated, on mechanical ventilation, and a nasogastric feeding tube is in place. She has a healing abdominal surgical wound and an ileostomy. Bowel sounds are present, and the abdomen is distended.
Abdominal radiograph reveals gas throughout the small bowel and no evidence of obstruction.
Which of the following is the most appropriate management?
Add megestrol acetate
Add methylnaltrexone
Increase fiber in the enteral diet
Stop enteral nutrition; start parenteral nutrition
Stope enteral nutrition and start parenteral
A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports that he is still working full time and walks about a half mile to and from work each day.
On physical examination, vital signs are normal. Examination is notable for hepatomegaly.
Complete blood count is normal. On serum chemistry testing, alkaline phosphatase and aminotransferase levels are elevated; bilirubin and creatinine levels are normal.
CT scan of the chest, abdomen, and pelvis shows hepatomegaly with multiple metastatic lesions and abdominal carcinomatosis with a small amount of ascites. No other abnormalities are noted. Liver biopsy reveals adenocarcinoma.
The patient is diagnosed with metastatic cancer from an unknown primary.
Which of the following is the most appropriate management?
Measure serum CA-19-9, CA-15-3, and CA-125 antigens
Obtain a gene expression array PET
Upper endoscopy, wireless capsule endoscopy, and colonoscopy
No additional testing; initiate combination chemotherapy
No additional testing , initiate combination chemotherapy
This patient has advanced metastatic adenocarcinoma from a cancer of unknown primary (CUP). Diagnostic efforts should focus on identifying whether a patient is among the approximately 20% of patients with CUP who have a more favorable prognosis and who can benefit from a specific treatment strategy. A biopsy obtained from the site that can be sampled in the safest, least invasive manner is performed, and specimens are evaluated by immunohistochemical stains consistent with the tumor's pattern of presentation to attempt to establish a diagnosis of a more treatable subtype of CUP (for example, germ cell tumor or lymphoma). The clinical evaluation should not involve an exhaustive search for a primary site because detection of an asymptomatic and occult primary tumor does not improve outcome
A 52-year-old woman is evaluated at a follow-
up visit. Dermatomyositis was diagnosed 4
weeks ago; she was positive for anti-Mi-2
antibodies. Prednisone has improved
heliotrope and photosensitive rashes and
proximal muscle weakness. She is currently
asymptomatic. Current medication is
prednisone, 60 mg/d. She is participating in
physical therapy.
On physical examination, vital signs are
normal. There is no rash. Muscle strength is
normal.
Serum creatine kinase A level is 200 U/L,
decreased from 520 U/L 1 month ago.
Results of screening colonoscopy,
mammography, and cervical cancer screening are all normal.
Which of the following is the most
appropriate treatment?
Add hydroxychloroquine
Add methotrexate
Add rituximab
Continue current therapy
Methotrexate
A 35-year-old man is evaluated for exertional dyspnea. His history is otherwise unremarkable.
On physical examination, vital signs and oxygen saturation are normal. Central venous pressure is elevated. A left parasternal impulse is present. A grade 2/6 systolic murmur is heard at the second left intercostal space, and a diastolic flow rumble is heard at the left sternal border. Fixed splitting of the S2 is present. The remainder of the physical examination is normal.
An ECG demonstrates sinus rhythm with right axis deviation and incomplete right bundle branch block. A transthoracic echocardiogram demonstrates a 1.5-cm ostium secundum atrial septal defect, with moderate right heart enlargement. Left ventricular cavity size and function are normal. The estimated right ventricular systolic pressure is 30 mm Hg.
Which of the following is the most appropriate management?
Atrial septal defect closure
Cardiopulmonary exercise testing
Coronary angiography
Echocardiographic surveillance
ASD closure
A 64-year-old man is evaluated in the emergency department for ascites. He has diabetes mellitus and cirrhosis associated with hemochromatosis, as well as a history of hepatic encephalopathy. Current medications are metformin, canagliflozin, lactulose, and rifaximin.
On physical examination, blood pressure is 106/76 mm Hg and pulse rate is 60/min; other vital signs are normal. The patient is alert. Jaundice, spider telangiectasia, and palmar erythema are present. Jugular venous distension and peripheral edema are present. Cardiac sounds are indistinct and lung sounds are diminished. Ascites is present.
Abdominal ultrasound shows a cirrhotic liver, splenomegaly, and abdominal ascites.
Paracentesis with analysis of ascitic fluid shows a leukocyte count of 100/μL (100 × 109/L), albumin level of 2.2 g/dL (22 g/L), and total protein level of 2.6 g/dL (26 g/L). Serum albumin level is 3.5 g/dL (35 g/L).
Which of the following is the most appropriate management?
Ascitic fluid cytology
Ascitic fluid triglyceride measurement
Echocardiography
Liver biopsy
Echocardiography
A 44-year-old woman is evaluated for daytime sleepiness of 1 year's duration. She sleeps 8 to 9 hours nightly. She naps during the day. She has chronic musculoskeletal back pain and depression. Medications are venlafaxine and sustained-release oxycodone.
On physical examination, respiration rate is 12/min; the remainder of the vital signs are normal. She has antalgic gait and limited trunk flexion due to pain. Oropharyngeal airway is patent. Nasal, lung, and heart examinations are normal. There is no peripheral edema.
Polysomnography documents central sleep apnea without obstructive sleep apnea.
Which of the following is the most appropriate treatment?
Adaptive servo-ventilation
Continuous positive airway pressure
Modafinil
Pain rehabilitation program
A 51-year-old man is evaluated following biopsy of the prostate gland. His father died of prostate cancer at the age of 60 years, and his mother was diagnosed with breast cancer at the age of 45 years.
Biopsy of the prostate revealed adenocarcinoma with bilateral gland involvement; his Gleason score was 9. Bone scan confirmed multiple osseous metastatic lesions.
Which of the following is the most appropriate management?
Cystoscopy
PET/CT
Prostate-specific antigen density measurement
Referral to a genetic counselor
Referral to a genetic counselor
A 39-year-old woman is evaluated for newly
discovered neutropenia. She has a 10-year
history of severe, difficult-to-control rheumatoid
arthritis. She has no sicca symptoms. Current
medications are prednisone, methotrexate,
folic acid, and adalimumab.
On physical examination, vital signs are
normal. There are rheumatoid nodules over
the olecranon processes. The spleen tip is
palpable. Joint examination reveals ulnar
deviation, subluxation at the
metacarpophalangeal joints, reduced range of
motion at the wrists, and bilateral swelling of
the wrists and left ankle.
Absolute neutrophil
count - 1100/uL (1.1 x109/L)
Leukocyte count- 3800/ML (3.8 x109/L)
Lymphocyte count- Normal
Platelets- Normal
Urinalysis- Normal
Which of the following is the most likely diagnosis?
AAA amyloidosis
Felty syndrome
Sjögren syndrome
Systemic lupus erythematosus
Felty syndrome
A 71-year-old man is evaluated for a 6-month history of exertional chest pain. The pain has increased in frequency and now occurs earlier during his exercise regimen. The pain is relieved by sublingual nitroglycerin. He underwent coronary artery bypass graft surgery 4 years ago. History is also significant for hypertension and hyperlipidemia. Medications are metoprolol, lisinopril, atorvastatin, and aspirin.
Physical examination findings, including vital signs, are normal.
ECG shows left bundle branch block.
Which of the following is the most appropriate test?
Dobutamine echocardiography
Exercise ECG
Exercise single-photon emission CT
Vasodilator single-photon emission CT
Vasodilator single photon emission CT
48-year-old man is evaluated for follow-up of cirrhosis due to hepatitis C virus (HCV) infection. He has ascites responsive to furosemide and spironolactone and recent-onset hepatic encephalopathy treated with lactulose. He has a MELD-Na (Model for End-Stage Liver Disease–sodium) score of 12. He takes no additional medications.
On physical examination, vital signs are normal. Physical examination reveals spider angiomas, abdominal distention, and a palpable liver edge below the right costal margin.
Laboratory studies:
Prothrombin time 14.6 s
Total bilirubin 2.6 mg/dL (44.5 μmol/L)
Creatinine 0.8 mg/dL (70.7 μmol/L)
HCV DNA 600,000 U/mL
Which of the following is the most appropriate management?
Initiate protease inhibitor–based direct-acting antiviral therapy
Initiate rifaximin therapy
Limit dietary protein
Refer for liver transplantation
Refer for Liver transplantation
A 67-year-old man is evaluated before airline travel. He is planning a trip to Hawaii next month. He has COPD and becomes dyspneic when walking short distances on level ground. Results of his last pulmonary function test indicated an FEV1 of 40% of predicted. He has not yet required oxygen supplementation. Medications are tiotropium, salmeterol, and fluticasone and albuterol inhalers.
On physical examination, respiration rate is 16/min. Auscultation of the lungs reveals a prolonged expiratory phase with no wheezes.
Which of the following is the most appropriate next step?
High-altitude simulation test
Recommend against air travel
Resting pulse oximetry
No further testing needed
A 58-year-old woman is evaluated for a 6-week history of fatigue, anorexia, and abdominal distention. She has lost 2.3 kg (5 lb) over the past week. For the past 4 days, she has been so debilitated that she has difficulty ambulating due to abdominal pain and fatigue; she has been bedbound for the past 48 hours. Prior to this, she had been working full time and running approximately 12 miles per week. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. Abdominal examination reveals distention with normal bowel sounds. The liver edge is palpable 4 cm below the right costal margin. Stool sample is guaiac-positive.
Laboratory studies:
Hemoglobin -9.7 g/dL (97 g/L)
Bilirubin -2.3 mg/dL (39.3 µmol/L)
Creatinine - 0.9 mg/dL (79.6 µmol/L)
Contrast-enhanced CT scan demonstrates a mass in the descending colon and hepatomegaly with multiple metastatic lesions. A colonoscopy identifies a mass in the left colon, and a biopsy shows adenocarcinoma
Which of the following is the most appropriate management?
Fluorouracil
Fluorouracil and oxaliplatin
Hemicolectomy
Supportive, comfort-oriented care
Fluorouracil and oxaliplatin
A 27-year-old woman is evaluated for a 4-year history of progressive achy and stiff low back pain that wakes her up at night and a 2-year history of intermittent, severe, sharp bilateral buttock pain. She has stiffness for 90 minutes each morning. Exercise and ibuprofen help relieve pain. She has a history of unilateral uveitis. She has no children.
On physical examination, vital signs are normal. Range of motion of the lumbar spine is decreased in all directions. The eye examination, occiput-to-wall distance, chest expansion, and peripheral joints are normal.
Laboratory studies reveal an elevated blood C-reactive protein level and negative HLA-B27 antigen result.
Radiographs of the pelvis and lumbar spine are normal.
Which of the following is the most appropriate diagnostic test to perform next?
Bone scanning
CT of pelvis
MRI of pelvis
Rheumatoid factor and anti–cyclic citrullinated peptide antibodies
MRI pelvis
A 74-year-old man is evaluated in the hospital for a 6-month history of progressive fatigue and exertional dyspnea, along with increasing peripheral edema and abdominal girth over the past 3 months. He also has coronary artery disease, for which he had a coronary artery bypass graft at age 62 years. Medications are metoprolol, low-dose aspirin, and atorvastatin.
On physical examination, vital signs are normal. Jugular venous distention with prominent waveforms is noted. There is no discernable fall in the central venous pressure during inspiration. An early diastolic sound is present. The liver is enlarged and pulsatile. Ascites is present, and peripheral edema extends to the knees bilaterally.
On chest radiograph, sternotomy wires and vascular clips are seen, and small bilateral pleural effusions are present.
Which of the following is the most likely diagnosis?
Cardiac tamponade
Chronic liver disease
Constrictive pericarditis
Restrictive cardiomyopathy
Constrictive pericarditis
A 58-year-old woman is evaluated for treatment of hepatitis C virus (HCV) infection. She has unresectable metastatic pancreatic adenocarcinoma. She requests treatment of her HCV infection.
On physical examination, vital signs are normal. She has jaundice, icterus, and cachexia.
Which of the following is the most appropriate management?
HCV antiviral treatment
HCV viral load measurement and genotyping
Testing for hepatitis B virus and HIV infections
No further HCV-related testing or treatment
No further HCV related testing or treatment
An 84-year-old man is evaluated 3 days after he was admitted to the ICU with a right lower lobe infiltrate and presumed sepsis. Prior to admission, the patient had vomited, aspirated, and developed respiratory distress. In the emergency department, temperature was 38.3 °C (100.9 °F); tachypnea, tachycardia, hypoxemia, and hypotension were also present. Chest radiograph on admission showed an infiltrate in the right lower lobe. Intravenous fluids, supplemental oxygen by nasal cannula, and broad-spectrum antibiotics were given. Over the next 24 hours, the patient improved rapidly.
On today's physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 138/80 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Oxygen saturation is 95% with the patient breathing ambient air.
The patient's leukocyte count is 6,000/μL (6 × 109/L) with a normal differential.
Sputum and blood cultures are negative.
Which of the following is the most appropriate antibiotic management?
Continue antibiotics for 4 additional days
Continue antibiotics for 7 additional days
Continue antibiotics for 10 additional days
Discontinue antibiotics
Discontinue antibiotics
The 2019 community-acquired pneumonia (CAP) guideline from the American Thoracic Society and the Infectious Diseases Society of America recommends standard empiric treatment for CAP in patients with suspected aspiration pneumonia. Many patients with aspiration pneumonitis experience rapid resolution of symptoms within 24 to 48 hours. In these patients, removal of antibiotics and supportive care alone is preferred. Because this patient improved clinically within 24 hours of admission, aspiration pneumonitis is likely and it is safe to discontinue therapy.
A 58-year-old man is evaluated for possible smoldering myeloma. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs and other examination findings are normal.
Serum protein electrophoresis and immunofixation show an IgA protein spike of 3.5 g/dL (35 g/L). Bone marrow biopsy reveals 50% clonal plasma cells.
Whole-body low-dose CT scan is negative for bone lesions.
Which of the following is the most appropriate imaging test to perform next?
Bone scan
Skeletal survey
Whole-body MRI
No further testing
Whole body MRI
A 58-year-old man is evaluated at a follow-up visit. He has had rheumatoid arthritis for 5 years. Increasing morning stiffness, fatigue, increasing joint pain, and swelling of small hand joints have developed in the past 6 months. His disease activity score shows moderate activity. He also has coronary artery disease, COPD, and a history of diverticulitis. Current medications are aspirin, lisinopril, metoprolol, a tiotropium inhaler, methotrexate, and sulfasalazine.
On physical examination, blood pressure is 136/84 mm Hg. BMI is 29. Multiple metacarpophalangeal joints are tender to palpation, and there is active synovitis.
Result of an interferon-gamma release assay is negative.
Hand radiographs show joint-space narrowing and three new erosions
Which of the following is the most appropriate treatment?
Abatacept
Adalimumab
Anakinra
Tocilizumab
Tofacitinib
Adalimumab
A 78-year-old woman is evaluated 4 months after placement of a drug-eluting stent for treatment of chronic stable angina pectoris. She is asymptomatic. She has hypertension, gastroesophageal reflux disease, and a history of several colonic angiodysplasias treated with electrocoagulation 8 months ago. Medications are pravastatin, aspirin, clopidogrel, metoprolol, hydrochlorothiazide, ferrous sulfate, and omeprazole.
On physical examination, blood pressure is 132/72 mm Hg, pulse rate is 78/min, and respiration rate is 20/min. BMI is 17. Scattered ecchymoses are evident over both lower extremities.
Results of laboratory studies show a hematocrit of 34%.
Which of the following is the most appropriate initial management?
Assess platelet reactivity
Discontinue aspirin and clopidogrel
Discontinue clopidogrel
Discontinue omeprazole
Discontinue Clopidogrel
A 56-year-old man is evaluated for right-upper-quadrant abdominal pain of several months' duration. He otherwise has been well. He does not drink alcohol, has not been exposed to other hepatotoxins, and takes no medications.
On physical examination, vital signs are normal. Abdominal examination reveals hepatosplenomegaly. The remainder of the physical examination is normal
Laboratory studies:
Platelet count -109,000/μL (109 × 109/L)
Alkaline phosphatase -450 U/L
Alanine aminotransferase -105 U/L
Aspartate aminotransferase -103 U/L
Chest radiograph shows bilateral hilar lymphadenopathy. Result of an interferon-γ release assay is negative.
Abdominal ultrasound shows a slightly enlarged, mildly nodular liver, with normal bile ducts. Spleen is 14 cm in length. Liver biopsy reveals changes of non-necrotizing hepatic granulomas without hepatic fibrosis.
Culture results of liver biopsy specimens are negative for fungal, Brucella, and Coxiella burnetii infections
Which of the following is the most appropriate diagnostic test to perform next?
CT of abdomen
Hepatobiliary iminodiacetic acid scintigraphy
Magnetic resonance cholangiopancreatography
Upper endoscopy
Upper endoscopy
A 25-year-old man is evaluated in the emergency department for worsening shortness of breath and right-side pleuritic chest pain, which developed 1 hour ago. He has an 8-pack-year history of smoking cigarettes. His medical history is otherwise unremarkable, including the absence of lung disease. He is a professional scuba diver.
On physical examination, blood pressure is 150/70 mm Hg, pulse rate is 105/min, and respiration rate is 30/min. Oxygen saturation is 92% with the patient breathing ambient air. There are decreased breath sounds, reduced expansion, and hyperresonance to percussion on the right side.
Chest radiograph reveals a large right pneumothorax and no signs of tension.
Smoking cessation counseling and an offer of varenicline are planned at the time of discharge.
Which of the following is the most appropriate additional pneumothorax management?
Catheter thoracostomy followed by pleurodesis
Needle aspiration
Observation
Supplemental oxygen and observation
Catheter thoracostomy followed by pleurodesis
A 78-year-old man is hospitalized with dyspnea, light-headedness, palpitations, and intermittent chest pain progressing over the past 7 days. Medical history is notable for atherosclerotic cardiovascular disease, hypertension, and hyperlipidemia. Medications are lisinopril, atorvastatin, metoprolol, and aspirin.
On physical examination, blood pressure is 91/53 mm Hg and pulse rate is 107/min; oxygen saturation is 93% breathing ambient air. Conjunctivae are pale. The remainder of the examination is normal.
Laboratory studies:
Haptoglobin
<10 mg/dL (100 mg/L)
Hemoglobin
6.7 g/dL (67 g/L)
Leukocyte count
9500/μL (9.5 × 109/L)
Platelet count
315,000/μL (315 × 109/L)
Reticulocyte count
11% of erythrocytes
A direct antiglobulin test is strongly positive for anti-IgG and weakly reactive for anticomplement. The blood bank reports all available units are incompatible.
Which of the following is the most appropriate immediate treatment?
Combination prednisone plus rituximab
Erythrocyte transfusion
Emergent splenectomy
Methylprednisolone
Rituximab
Erythrocyte transfusion