MSN 621 Final Exam

A 37-year-old woman presents to her clinic with complaints of aching pain in the breast for six months which is worse before her periods. She is apprehensive as her mother-in-law has been recently diagnosed with breast cancer. On examination, the breasts feel lumpy with greenish discharge from the right nipple. Ultrasound reveals focal areas of thickening of the parenchyma and multiple small cysts. Core biopsy reveals cystically dilated ducts, with a few ducts showing atypical epithelial hyperplasia surrounded by dense fibrosis. Which of the following best estimates the patient's risk of breast cancer?

1 to 2 times the normal population

A 40-year-old woman from the New England area of the United States presents with complaints of malaise, headache, rash, and fever. She went hiking in a local park with her family 7 days ago. She has a history of depression and hypothyroidism, for which she takes paroxetine and levothyroxine. She was an occasional smoker but quit 5 years ago. On examination, her temperature is 99 F (37.2 C), heart rate is 80 bpm, respiratory rate is 16 breaths/min, and blood pressure is 125/75 mmHg. A rash is noted on her right upper extremity (see image). The rest of her physical exam is unremarkable. What is the recommended treatment for this patient's condition? (see photo)

10-day course of doxycycline

A 45-year-old asymptomatic man is found to have leukocytosis on a preoperative complete blood count. His physical examination is significant for the spleen tip being palpable 2 cm below the left costal margin. Enlarged, rubbery, nontender lymph nodes up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory workup reveals a hemoglobin of 13.3 g/dL, leukocytes 40,000/microliter, and platelets 238,000/microliter. His peripheral blood smear shows mature lymphocytes with smudge cells. If he fails first-line therapy, which of the following cytogenetic changes would be an indication for stem cell transplant in this patient?

17p deletion

A 34-year-old Asian woman reported a history of losing weight and cough over a period of 5 months. On examination, she was anemic and on auscultation left apical crackles were noted. Her chest x-ray revealed left apical shadowing with cavitation. What is the next stage in her management?

Tuberculin skin test and sputum culture

A 17-year-old female presents with fever and low abdominal pain. The patient admits to unprotected sexual intercourse. There are cervical motion tenderness and an adnexal mass. Select the most likely diagnosis.

Tubo-ovarian abscess

A 59-year-old male patient with a history of non-Hodgkins lymphoma treated with cyclophosphamide, adriamycin, vincristine, and prednisone eight years ago presents with a new diagnosis of myelodysplastic syndrome. Bone marrow biopsy reveals 12% blasts and greater than 10% dysplasia in the erythroid and granulocytic lineages. Fluorescence in situ hybridization (FISH) revealed monosomy 7. He asks you about the risk of transformation into acute myeloid leukemia (AML). What is the risk of treatment-related myelodysplastic syndrome transforming into AML

50% of patients will transform into AML

A 67-year-old female with a performance status of 0, is brought to the clinic with symptomatic anemia and has required several transfusions over the past 2 to 3 months. Currently, her hemoglobin is 7.5 g/dL, absolute neutrophil count 1500/microL and platelet count is 119,000/microL. She had a bone marrow biopsy performed that reveals myelodysplastic syndrome (MDS) with 6% blasts and cytogenetics positive for 5q deletion. She did not have any mutations or other cytogenetic abnormalities. Which of the following is the best initial course of treatment?

A thalidomide derivative

A 49-year-old male with fatigue and easy bruising is found to have terminal deoxynucleotidyl transferase (TdT) positive cells in the blood. He may have which of the following conditions

Acute lymphoblastic leukemia

Which of the following is associated with the CD10 antigen?

Acute lymphocytic leukemia

A 38-year-old man presents with numbness and tingling in his extremities for the past week. He says his hands have been feeling unusual, and that this interferes with his sleep. He has no muscle weakness or memory impairment. His past medical history includes pulmonary tuberculosis, for which he takes isoniazid, rifampin, pyrazinamide, and ethambutol. All his vital signs are within normal limits. Examination reveals diminished breath sounds in the left upper lobe. A chest x-ray shows a cavitating lesion in the left lung. What is the most appropriate next step in the management of this patient?

Add pyridoxine

A 17-year-old female presents with a severe sore throat. She has been sick with a fever for four days. The patient's voice is muffled, and she prefers not to speak secondary to pain. She has not been able to eat solids for 2 days and has refused to drink for 1 day. Vital signs show a temperature of 39.8 C, heart rate 140 beats/min, respiratory rate 20, and blood pressure 110/70 mmHg. The exam shows the tonsils to be four-plus enlarged with partial airway obstruction and grey-white exudates. It is associated with cervical lymphadenopathy and splenomegaly. A rapid strep screen is negative. A CBC shows atypical lymphocytes. What is the most appropriate management?

Admission for hydration and corticosteroids

A 57-year-old patient with lymphoma complains of nausea after starting morphine. Which of the following is most accurate regarding nausea and vomiting due to opioids?

After starting opioids, nausea, often improves within a few days

A 40-year-old male patient comes in with a chief complaint of difficulty breathing. His cardiac function test results are normal. He shows airway hyperresponsiveness to the methacholine challenge test. His lung spirometry test reveals a lower-than-predicted level of forced expiratory volume in the first second (FEV1). Based on the most likely diagnosis, what is the most appropriate first-line therapy for a patient with infrequent episodes of mild symptoms?

Albuterol alone

A 78-year-old male presents to the clinic with complaints of a cough that started three days ago. The cough is associated with sputum, which is scanty in volume and yellow in color. He also complains of mild headaches and a stuffy nose for the last two days. On further questioning, he reveals that he has had two similar episodes previously, which subsided within a week. A detailed medical history reveals that he was diagnosed with diabetes mellitus twenty years ago and is on metformin. His vital signs show a blood pressure of 100/80 mmHg, a respiratory rate of 14/min, a heart rate of 88/min, and a temperature of 99 F (37.1 C). Auscultation of the chest was performed, which reveals bilateral coarse rhonchi, whereas a chest x-ray is normal. What is the most appropriate next step in the management of his condition?

Antibiotics and antitussives

A 65-year-old woman presents with pain when urinating and lower abdominal discomfort. She is diagnosed with cystitis. She is interested in knowing the most important mode of transmission of microorganisms into the urinary bladder. Which of the following is the most appropriate response?

Ascending infection from the perineum

A 65-year-old woman receives palliative care for progressively worsening chronic obstructive pulmonary disease. She has multiple coughing episodes during dinner, and later that night, she develops a fever and respiratory distress. What is the most likely diagnosis?

Aspiration pneumonia

A 65-year-old woman presents with an 8-month history of recurrent low-grade fevers, a 3-month history of abdominal fullness, and more recently, fatigue and moderately reduced exercise tolerance. Before this, she was in good health with no major medical conditions. Upon examination, she appeared to be stable and in no acute distress. She has a heart rate of 95 bpm and blood pressure of 128/60 mmHg. She had several palpable cervical and axillary lymph nodes (1-2 cm) that were non-tender and freely mobile. She also had palpable splenomegaly. No other abdominal masses/hepatomegaly appreciated on examination. Her complete blood count showed a leukocyte count of 32,000/mm3, hemoglobin of 9.8 g/dL, platelet count of 145,000/mm3, neutrophil count 1,900/mm3, lymphocyte count 30,000/mm3, elevated LDH, and elevated reticulocyte count. Peripheral blood smear showed an increasing number of mature lymphocytes, spherocytes, and polychromasia with no schistocytes. Which one of the following is the most likely cause of a patient's anemia in this case?

Autoimmune hemolytic anemia

A 16-year-old patient presents to the hospital with fever, fatigue, lymphadenopathy, and sore throat. Exudative pharyngitis is noted on the throat examination. However, rapid strep testing is negative. His blood pressure is 135/85 mmHg, the pulse rate is 92/min regular, and his respiratory rate is 16/min. Past medical history is positive for asthma, and his father had leukemia. Social history is notable for being involved in multiple school sporting activities. What is the most appropriate piece of advice for this patient?

Avoid contact sports for a minimum of 6 weeks

A 16-year-old male presents with lethargy, fatigue, and occasional mucosal bleeding. The patient also reports weight loss in the past 5 months. Laboratory analysis reveals a white blood cell count of 32,000 cells/microL. On examination, hepatosplenomegaly is noted. Further evaluation shows findings suggestive of acute lymphocytic leukemia. What is the most likely cause of the patient's mucosal bleeding?

Decreased platelet count

A 30-year-old female presents to her provider complaining of a swelling on the left side of her vulva. She reports that this is the third time she develops a recurrence of this problem. She asks what is her diagnosis and she wonders what should be the best treatment to be done for her to prevent this swelling from recurring again and again?

Bartholian's gland abscess, marsupialization

A 65-year-old male with a past medical history of coronary artery disease and a stroke without residual deficits complains of urinary dribbling. He denies urinary urgency but describes his urinary flow as "not what it used to be". He does not currently take any prescription or over-the-counter medications. He has no apparent difficulties with speech, mobility, or short-term memory. His vital signs are within normal limits. The physical exam does confirm that significant dribbling is present. There is no suprapubic tenderness and his neurologic exam is normal. The rest of the physical exam is also unremarkable. What is the likely mechanism of his urinary problem?

Bladder outlet obstruction from prostate enlargement

A clinician is seeing an 84-year-old male with dementia from a nursing home. He is a poor historian. The nurse taking care of him states that he is often found wet with urine. The nurse states that he does not have any other medical conditions or symptoms. His vital signs are within normal limits. Physical examination reveals a pleasantly demented, frail older male who smells of urine. There is no suprapubic tenderness. What is the next best step in the management of this patient?

Bladder scan

A 65-year-old female with a past medical history of hypertension and high cholesterol presents to the emergency department in winter with a six-day history of cough and a fever. The maximum temperature was 101 F on the day before the presentation. She denies any sick contacts or recent illness. Vital signs on presentation were significant for a heart rate of 102/min, blood pressure 130/84 mmHg, pulse oximetry of 90%, and temperature 99.1 F. The physical exam was notable for an ill-looking female with scattered rhonchi on lung auscultation. The patient reports recent travel on an airplane back from England. She has a dry cough and muscle aches and no other complaints. What is the most appropriate management for the probable condition?

Blood work, a chest x-ray, influenza screening, and treatment with antiviral therapy if positive

A 79-year-old man with a past medical history of hypertension, hyperlipidemia, COPD, and peripheral arterial disease presents to the emergency department with complaints of intermittent blood in the urine, dysuria, and unintentional weight loss of 15 pounds (7 kg) over the last 2 months. He denies having any urgency or frequency. His PSA levels were recently checked and were borderline elevated. He denies having any frequency, urgency, or incontinence. He used to smoke 2 packs per day for 30 years but quit 15 years ago. Urinalysis reveals a large amount of blood but is otherwise unremarkable. CBC reveals a hemoglobin of 9 g/dL but is otherwise unremarkable. CMP shows elevated AST and ALT. What is the next best step in the management of this patient?

CT scan of the abdomen and pelvis

A 65-year-old woman with a past medical history of hypertension, well-controlled diabetes mellitus, and transient ischemic attacks presents to the clinic for abdominal bloating for the last four months. Abdominal distension is noted on examination. Further evaluation by a CT scan abdomen shows liver lesions, ascites, and pleural effusion with lung lesions. The biopsy of the lesions is consistent with primary ovarian cancer. CA-125 is elevated. She is negative for BRCA 1 and BRCA 2. Which of the following is the most appropriate first-line therapy for this patient?

Carboplatin with paclitaxel

A client is diagnosed with pulmonary tuberculosis. Which of the following is the most common diagnostic histopathological hallmark of the client's condition?

Caseating granuloma

A 22-year-old woman presents with severe lower abdominal pain, nausea, and vomiting that started two hours ago. She also reports fever, dyspareunia, and mucopurulent vaginal discharge for the last five days. Her blood pressure is 100/70 mmHg, respiratory rate 20 breaths/min, temperature 101 F (38.3 C), and heart rate 96 beats/min. Pelvic examination is consistent with severe pelvic inflammatory disease. What is the most appropriate initial treatment for this patient?

Ceftriaxone plus doxycycline plus metronidazole

A 62-year-old man presents with general malaise, occasional cough, and weight loss of 10 lbs (4.5 kg) over the last two months. History is significant for prediabetes managed with diet and cigarette smoking. Physical examination findings include mild edema in the extremities and clubbing bilaterally. Blood work shows mild anemia and sodium of 122 mg/dL. What test should be done next?

Chest radiograph

A 33-year-old inmate is brought to the clinic for a routine annual checkup. The patient says that he has been in good health and does not have any medical problems. He, however, does complain of disturbed sleep, constipation, and weight loss. A review of systems is negative for cough, shortness of breath, burning urination, abdominal discomfort, or weakness. Examination shows normal vitals, a soft, nontender abdomen with no organomegaly, normal S1 and S2 with no added sounds, and normal bronchial breathing bilaterally. A purified protein derivative test shows an induration of 11 mm. What is the next best step in the management of this patient?

Chest x-ray

Chest X-ray of a long-term smoker shows a 2-cm spiculated mass in the right parahilar lung. A barium esophagram shows an extrinsic impression in the region of the carina. Which of the following choices would be most helpful at this point?

Chest x-ray with possible CT-guided biopsy

A 60-year-old asymptomatic man is found to have leukocytosis on a preoperative CBC. Physical examination shows the spleen tip to be palpable 2 cm below the left costal margin. Rubbery, nontender lymph nodes up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory data include the following: Hgb: 13.3 g/dL (normal 14 to 18) Leukocytes: 40,000/microL (normal 4300 to 10,800) Platelet count: 238,000 (normal 150,000 to 400,000) His peripheral blood smear is shown in the accompanying photo. Which of the following is the most likely diagnosis? (see photo)

Chronic lymphocytic leukemia

An 18-year-old white female presents for a wellness examination. After some questioning, she admits to heavy menstrual cycles that are 28 days apart and last 7-8 days. She reports the passage of clots and on her heaviest days, having to change her pads every 1-2 hours. She is not sexually active and denies any significant past medical history. She does admit to an episode of heavy bleeding after tooth extraction for braces when she was 13 years old. The physical examination is unremarkable except for scattered ecchymoses on her bilateral shins. Which of the following is the most appropriate step in the diagnosis of this patient?

Coagulopathy studies

A 38-year-old woman with regular menstrual cycles presents for postcoital vaginal bleeding. She has never had a Pap smear but consents to have one done today. The cervical smear report reads, "atypical squamous cells, cannot rule out a high-grade squamous intraepithelial lesion (HSIL)." What is the best next step in the management of this patient?

Colposcopy and biopsy

A 54-year-old female presents to the clinic with acute onset of right flank pain. She describes the pain as crampy and severe, radiating to her right groin. Urinalysis shows 1 white blood cell and 3 red blood cells per high power field. Ultrasound kidney-ureter-bladder does not show any stones. Which of the following is the next best step in the evaluation of this patient?

Computed tomography (CT) scan without contrast

A 50-year-old woman with metastatic ovarian cancer requires at least 12 hours of active nursing care because of a worsening condition. What is the best description for this patient's level of hospice service under the Medical Hospice Benefit?

Continuous home hospice care

A 49-year-old female presents for an annual physical exam. Her medical history is significant for diabetes mellitus that is well controlled on metformin 500 mg twice a day. She otherwise has no complaints except for pain during intercourse. She also has been moody recently. She has been married for 15 years and has no trouble in the marriage. Which of the following most accurately describes the hormonal events associated with menopause?

Decreased estradiol production

A 17-year-old male patient with no significant past medical history presents with several days of loose, watery stools since returning from a trip to Mexico. He was in Mexico for one week and frequently drank water from the hotel faucet. He describes having up to six brown, non-bloody, loose, watery stools per day. His heart rate is 66 beats per minute, blood pressure 138/72 mmHg, respiratory rate 14 breaths per minute, and temperature 101.4 F (38.6 C). He denies taking any medication and denies any known food intolerances. His most likely condition is associated with which of the following changes?

Decreased extracellular fluid volume and unchanged intracellular fluid volume

A 76-year-old woman is admitted to the hospital after experiencing loose stools and disorientation while residing in a nursing home following a stroke. She experiences urine incontinence on her third hospital day. While using the DIAPERS assessment scale for urinary incontinence, which of the following is best described by 'D"?

DELIRIUM

A 16-year-old female patient presents to the hospital with a complaint of vaginal pain and dyspareunia that started two weeks ago. She also complains of mild lower abdominal pain. A detailed medical history reveals that she has had multiple sexual partners in the last six months. Her vital signs show a blood pressure of 100/70 mmHg, respiratory rate of 20 breaths/min, temperature of 101 F (38.3 C), and heart rate of 96 beats/min. A pelvic examination is performed, which reveals cervical motion tenderness and uterine tenderness. A nucleic acid amplification test performed is negative. What is the most appropriate first-line treatment for the patient?

Doxycycline and ceftriaxone

A young female presents to a clinic complaining of low-grade fever, irritation, and a burning sensation while passing urine. A urinalysis is performed, and a urinary tract infection is diagnosed. The provider starts trimethoprim/sulfamethoxazole for three days and asks the client to follow up afterward. What additional instructions are most helpful for this patient?

Drink plenty of water

A 67-year-old woman presents with new-onset vaginal bleeding. She reports first sexual intercourse at age 14, smoking 1/2 pack of cigarettes for the last 35 years, and a history of vaginal intraepithelial neoplasia treated with laser ablation. On pelvic exam, a lesion is seen by separating both labia minora without having to place a speculum. Which lymphatic chain is the suspected malignancy most likely to spread to first?

Inguinal lymph nodes

A 56-year-old man with a past medical history of uncontrolled hypertension, poorly controlled diabetes mellitus and hyperlipidemia presents with a 1-hour history of sudden onset, sharp left shoulder pain. He states that the pain is exacerbated by deep breathing, and coughing. The patient is diaphoretic. He does not take any medication except aspirin which he took today when the chest pain began. On examination, his oxygen saturation is 99% on room air, respiratory rate 20/minute, heart rate 88/min, and blood pressure 110/50 mmHg. A chest x-ray is unremarkable. Which of the following is the next best step in the management of this patient?

EKG

A 21-year-old woman presents to the office with complaints of fever and abdominal pain for 24 hours. The pain is located on the right lower quadrant and is non-radiating. She reports vaginal discharge but denies any vaginal bleeding, nausea, vomiting, or trauma. She is passing flatus. The patient is unmarried and has had multiple sexual partners in the past. Her last menstrual period was three weeks ago. On examination, the temperature is 101 F, the pulse is 94/min, and the blood pressure is 124/86 mmHg. There is cervical motion tenderness, and the speculum examination shows whitish vaginal discharge. Complete blood count with differential shows leukocytosis. The urine pregnancy test is negative. She is treated with ceftriaxone and doxycycline. Which of the following is the most likely complication of this condition?

Ectopic pregnancy

A 15-year-old female presents to the hospital with a complaint of intermenstrual bleeding that started four months ago. She also complains of dyspareunia and vaginal discharge. On further questioning, she gives a history of lower abdominal pain and fever. Her vital signs show blood pressure 120/70 mmHg, respiratory rate 14/min, heart rate 84/min, and temperature 101 F (38.8 C). A pelvic examination performed shows cervical motion tenderness and uterine tenderness. A blood test was ordered, which showed a white cell count of 18,000 per microliter of blood. What other conditions are in the primary differential diagnosis?

Ectopic pregnancy, appendicitis, and pyelonephritis

A 51-year-old female presents with a chief complaint of irregular, heavy menstrual bleeding for the past six months. She reports previously regular cycles every 30 days, lasting 4 to 6 days, with medium flow. She reports her cycles are now occurring every 30 to 45 days, lasting anywhere from 5 to 12 days, with heavy flow and the occasional passing of clots. On exam, her BMI is 30.2, and her vitals are within normal limits. Along with a pelvic examination, what is the next most appropriate step in evaluating this patient?

Endometrial sampling

A 25-year-old woman with no previous history of abnormal Pap tests is being evaluated. Which of the following is the most appropriate Pap test frequency for this patient?

Every three years

A healthy patient is administered a subcutaneous injection of purified protein derivative (PPD) on the anterior aspect of the forearm. At 48 hours, 15 mm of induration develops. What is the diagnosis?

Exposure to TB

A 65-year-old male patient presents with the complaint of increasing shortness of breath and nocturnal cough. His condition has been progressively worsening over the past three months. He is a smoker and works in a cotton factory. He has one son and one daughter with asthma. On examination, there is a wheeze and coarse end-inspiratory crackles in the chest. A chest radiograph reveals diffuse non-specific changes consistent with lung disease. Spirometry is performed on him. Which of the following would indicate asthma?

FEV1 to FVC ratio of 68%

A 24-year-old woman presents to the office for evaluation of a tender breast swelling. The patient states she noticed the swelling last week while taking a shower. She is sexually active and uses oral contraceptive pills regularly. The patient is concerned as her mother died from metastatic breast cancer 2 years ago. On examination, a 2x1 cm size lump is present in the upper lateral quadrant of the right breast. The lump is rubbery in texture and is mobile. A biopsy is performed, and the histopathology findings are shown in the figure. What is the most likely diagnosis? (see photo)

Fibroadenosis with dystrophic calcifications

A 67-year-old female presents with a history of high fevers and productive cough with green sputum for the last three days. The patient received the influenza vaccine this year. Her past medical history is unremarkable. She has a smoking history of 25 pack years. She does not drink alcohol or use illicit drugs. Temperature is 102F, blood pressure is 115/70mmHg, the pulse is 101/min, and respirations are 23/min. Her oxygen saturation is 91% on room air. On examination, her anterior cervical lymph nodes are enlarged and nontender. Chest auscultation reveals crackles in the left lower lobe. Hepatosplenomegaly is present. A chest x-ray shows a developing left lower lobe consolidation. Labs show a WBC count of 45000, with lymphocytes being 85%. Empirical pharmacotherapy is initiated, and blood cultures are sent to the lab. Which of the following is the most appropriate step next?

Flow cytometry of blood

A 17-year-old male presents with a two-day history of fever, runny nose, and cough productive of clear sputum. His past medical history is unremarkable, and he takes no medication. His blood pressure is 110/70 mmHg, respiratory rate 16 breaths per minute, heart rate 102 beats per minute, temperature 101.8 F (38.8 C), and oxygen saturation 98% on room air. The lung examination demonstrates clear breath sounds bilaterally. In addition to an antipyretic, what is the most appropriate treatment for this patient?

Guafenesin

A 17-year-old presents with tonsil hypertrophy, new-onset snoring, bilateral cervical lymphadenopathy, low-grade fever, and general malaise. Two days ago, the patient developed severe abdominal pain and anorexia, unaffected by eating or drinking. He has had a recent bowel movement. Which of the following is the gold standard test in diagnosing his condition?

Heterophil antibody test

A 16-year-old female presents with complaints of fever, lethargy, and night sweats. The patient also reports a 6-kilogram (13.2 pound) weight loss in the past 3 months. On examination, painless, enlarged cervical and supraclavicular lymph nodes are palpated. A fine-needle aspiration biopsy of one of the lymph nodes is shown in the image. The patient's findings are most suggestive of which of the following? (see photo)

Hodgkin lymphoma

A 26-year-old male comes to the emergency department complaining of fatigue, dyspnea, chest pain, and syncope, especially when playing soccer. This has been going on for the past 2 weeks. He has no significant past medical history. He denies smoking, caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for the past year due to headaches that he attributes to "being stressed out from my new job." On examination, BP: 120/81 mmHg, HR: 55 bpm, RR: 18/min, and O2: 99% on room air. Skin examination: no rashes, abdominal examination: mild epigastric tenderness but no organomegaly, chest examination: equal air entry bilaterally with no abnormal sounds. ECG shows P waves and QRS complexes that are independent of each other. Blood tests show antibodies to the organism in the picture. Which of the following is the most appropriate treatment for this patient's case? (see photo)

Hospitalization for close monitoring with telemetry and IV ceftriaxone

A 65-year-old male patient presents to the clinic with complaints of a dry cough and wheezing, particularly at night. He has had asthma. Six months ago, his symptoms were well-controlled on inhaled fomoterol and low dose budesonide twice a day and occasional use of an albuterol inhaler as required. However, now he is more short of breath with morning dipping of his peak flow readings. On examination, he is mildly dyspneic but able to complete sentences. On auscultation, there are wheezes scattered in his chest. His peak expiratory flow rate is 70% of predicted. What is the most appropriate next step in the management of this patient?

Increase inhaled budesonide dose

A 16-year-old boy with a low-grade fever and a cough is seen in the ER. The clinician sends blood work for the measurement of heterophile antibodies because they suspect which of the following?

Infectious mononucleosis

An otherwise healthy 17-year-old male presents for an initial evaluation after recently immigrating from Sudan, Africa. He says he has received all the necessary vaccinations, including the BCG vaccine. Further inquiry reveals his sister was treated for tuberculosis seven years ago. He is not sexually active, takes no medications, and does not drink alcohol, use illicit drugs, or smoke cigarettes. What is the most appropriate next step in evaluation?

Interferon gamma release assay

A 41-year-old female patient presented to the clinician for contraception. She had 3 children, all born through standard vaginal delivery. She stated that her family was complete, and was sure that she does not want another child. Her blood pressure was 150/90, and her pulse was at 89 beats/minute. She smoked half a pack of cigarettes daily. What would be an ideal contraceptive in this case?

Intrauterine device

A 44-year-old woman presents with sudden shortness of breath and 10/10 left-sided chest pain, which began two hours ago while she was at work. She has had two episodes of frank hemoptysis en route to the emergency department. She reports a history of deep venous thrombosis three years ago, diagnosed during a prolonged hospital admission after a cholecystectomy. She completed three months of apixaban at that time. She smokes one pack of cigarettes per day, and her medications include a multivitamin and an oral contraceptive pill. Her blood pressure is 70/45 mmHg, heart rate 140 beats per minute, and respiratory rate 40 breaths per minute. Chest auscultation demonstrates clear lung sounds in all fields. The patient's left-sided chest pain is not reproducible, and there is no left chest deformity. An electrocardiogram shows sinus tachycardia without ST-T wave changes, and the initial D-dimer level is elevated. After receiving two liters of normal saline solution, her blood pressure is 80/50 mmHg, heart rate 135 beats per minute, and oxygen saturation 90% on four liters of oxygen via nasal cannula. A bedside transthoracic echocardiography reveals moderate right ventricle hypokinesis with diffuse regional wall motion abnormalities. What is the best next step in treatment?

Intravenous tissue plasminogen activator

A 36-year-old woman with a past medical history significant for menorrhagia from uterine fibroids presents with exertional dyspnea and fatigue. Examination shows conjunctival pallor. Laboratory tests reveal a hemoglobin of 6.2 grams/dL, mean corpuscular volume (MCV) 60 fl (normal: 80-100 fl), and normal liver function tests. What is the most likely diagnosis?

Iron deficiency anemia

A 26-year-old female presents to the office for a health maintenance visit. The patient has no active complaints but states that she experienced dysuria a couple of weeks ago, which resolved by drinking plenty of water. The patient is sexually active with two partners and wants to know about female contraceptive methods. She says she does not want to take oral contraceptive pills and wants to try a female barrier contraceptive method like a cervical cap. She wants to know more about this contraceptive technique. What should be the adequate response by the clinician?

It increases the risk of the urinary tract and vaginal infections

A 37-year-old female patient presents with symptoms of fatigue and ankle swelling. She is found to have mild hypertension but otherwise appears healthy. She has a negative medical, surgical, and family history. Her urine is found to have a smoky, tea-colored appearance. A urine dipstick is positive for blood and protein. This urine finding and her clinical presentation suggest she is likely bleeding from which of the following structures?

Kidney

A 34-year-old forest ranger, previously healthy, presents with dizziness, syncope, and increasing fatigue for 2 weeks. Vital signs are the temperature of 98°F (36.7°C), blood pressure of 110/80 mm Hg, and a heart rate of 38 beats per minute with a regular pulse. No murmur is noted. The neurological exam reveals a Bell palsy. An electrocardiogram (EKG) shows a complete heart block. Which joint is most likely painful?

Knee

A 16-year-old male presents with fatigue, easy bruisability, and weight loss. On examination, hepatosplenomegaly is noted. After a detailed evaluation, the patient is diagnosed with acute lymphocytic leukemia. Which of the following is used in the management of this patient's condition

L-asparaginase

A 17-year-old female presents with lower abdominal pain and vaginal bleeding. She states that she just missed her period and has been sexually active. She has a past medical history of gonorrhea and trichomonas, which have been treated successfully. She is allergic to penicillin. The physical exam reveals mild tenderness to palpation in the right lower quadrant. The pelvic exam reveals the presence of blood, but no masses are felt. Her urinary human chorionic gonadotropin (hCG) is positive. Blood hCG level is 1,000 IU. The patient remains stable while waiting for an ultrasound. If this is an ectopic pregnancy, what blood hCG level will be seen in 48 hours?

Less than 2,000 IU

A 65-year-old male patient presents to the outpatient clinic for a health check-up advised as a pre-employment requirement at his office. The patient has a past medical history of diabetes and hypertension for 15 years that were previously well controlled with pharmacological intervention and lifestyle modifications until last year when he lost his insurance due to unemployment. The patient has no active complaints. The patient is a former computer programmer who currently leads a sedentary lifestyle. The vital signs are a heart rate of 86 beats per minute, respiratory rate of 14 breaths per minute, and blood pressure of 152/94 mmHg. On examination, he has a soft abdomen and normal breath sounds on auscultation in both lungs. Laboratory work shows hemoglobin 14 g/dl, platelets 295,000/mm3, sodium 139 mEq/L, potassium 4.3 mEq/L, and HbA1c 6.9. Urine analysis shows no cells or casts, and the urine albumin-creatine ratio is 325 mg/g. What is the most appropriate medication to start for this patient?

Losartan

A female presents with progressive confusion over weeks with memory loss. She has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of arthralgias. History is otherwise unremarkable except for the fact she is an avid camper. What is her most likely diagnosis?

Lyme disease

A 35-year-old previously healthy male presents for evaluation of coryza, dry cough, and fever for 4 days duration. The patient reports no significant past medical history, takes no daily medications, and has no known drug allergies. He reports receiving COVID-19 and influenza vaccines this season. Of note, upon obtaining a travel history, the patient stated that he recently returned from Saudi Arabia. He had petted a dog and visited a camel farm while on his trip. His vital signs show a temperature of 101 F (38.3 C), blood pressure of 102/64 mmHg, respiratory rate of 20 breaths per minute, heart rate of 115 beats per minute, and SpO2 of 95% on room air. Significant findings on the exam include tachycardia, tachypnea, and mild use of accessory respiratory muscles. Which of the following diagnoses is most important to consider in this patient?

Middle east respiratory coronavirus (MERS-CoV)

A middle-aged male presents to the emergency department with an exacerbation of his chronic obstructive pulmonary disease (COPD). He has been coughing and been moderately short of breath for the past 2 days. He says that his inhalers do work, but he ran out of supplies. He complains of general malaise. After examining him, you decide to start him on antibiotics. However, you first decide to send the sputum for gram stain and culture. According to the 2015 Global Initiative for Chronic Obstructive Lung Disease report, which of the following organisms is most likely to be involved in COPD exacerbation?

Moraxella catarrhalis

A 42-year-old patient comes to the clinic for her annual appointment. She currently feels well. Her vital signs are within normal limits. She is up to date on her screenings and vaccinations. She does not smoke or take illicit drugs. She drinks a glass of wine every day before dinner. She is sexually active and takes oral contraceptive pills. She has 3 children through normal vaginal deliveries, who are all healthy. Family history is insignificant. Past medical problems include anxiety and obesity. Which of the following is a protective factor in this patient for the development of ovarian cancer?

Multiparity

A 25-year-old G0P0 female presents with intermittent abdominal pain. She states that the pain starts before her period, is "crampy" in nature, and lasts for a few days after, and has been occurring intermittently since menarche. Her periods have been regular, with no spotting or pain in between periods. Her last period was a week ago. She has no other health issues and takes no medications. She has had no previous surgeries in the past. She is currently sexually active with her husband and is interested in starting a family shortly. What is the first line of treatment for this patient?

NSAIDS

A 33-year-old obese female presents in late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, which waxes and wanes over time. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery five years ago. She is not sexually active. Her temperature is 99.6 deg F, blood pressure is 148/72 mmHg, and the pulse is 86/min. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 102 red blood cells/high power field. A urine pregnancy test is negative. What is the next best step in management?

Non-contrast CT abdomen/pelvis

A male patient presents to the emergency department with complaints of nausea, vomiting, and left flank pain. The patient says that he feels pain during micturition, and his urine appears cloudy and reddish-brown. He has hypertension and asthma, which are under control. Which of the following tests is the most sensitive and specific for making a diagnosis in this patient?

Non-contrast abdominal CT

A 17-year-old female presents with abdominal pain, nausea, vomiting, and dysuria that started a day ago. On further questioning, she admits that the pain is more in the area of her left flank. A detailed medical history reveals no known medical conditions. She is afebrile, and her vital signs are stable. A physical examination demonstrates costovertebral tenderness as well as tenderness in the left flank on palpation. Urinalysis shows 12 red blood cells and two white blood cells per high power field. What is the best next step in making a definitive diagnosis?

Non-contrast computed tomography (CT) scan abdomen and pelvis with a kidney, ureter, and bladder (KUB)

A 43-year-old man presents to the clinic for evaluation after abnormalities noted on a routine set of labs. CBC with differential demonstrated hemoglobin 14 g/dL, WBC count 26,000/microL, lymphocytes 21,000/microL, neutrophils 4500/microL, and platelets 260,000/microL. The basic metabolic panel demonstrates normal electrolytes and renal function. LFTs show total bilirubin 1.2 mg/dL and normal liver enzymes. On examination in office, his examination is normal, with no palpable lymph nodes or hepatosplenomegaly. He denies any B symptoms. Peripheral smear shows lymphocytosis with many small lymphocytes and smudge cells. Which of the following is the next best step in the management of this patient?

Observation and close follow up

A 48-year-old woman presents with a swelling on the left side of her vulva. The patient says she noticed this swelling one week ago. She denies any pain, or history of weight loss. She reports having regular menstrual cycles and being sexually active with her husband. She has no past medical history and takes no medications. On examination, there is no erythema, or purulent discharge. Which of the following is the most appropriate treatment option?

Observation, no further treatment is required

A 35-year-old woman presents with sneezing, rhinorrhea, nasal congestion, fatigue, and myalgias. She developed these complaints one day back and decided to seek immediate care. A review of symptoms reveals mild itching in the eyes and a frontal headache. She admits to smoking two packs of cigarettes daily; however, she denies alcohol and illicit drug use. The patient's medical history is significant for gastroesophageal reflux disease and irritable bowel syndrome. The patient cannot recall her last vaccination and says that she prefers "natural immunity." Her blood pressure is 130/75 mmHg, pulse is 105/min, temperature 100 F (37.7 C), and respiratory rate is 19/min. Examination shows red eyes, erythema over the pharynx, and dry mucous membranes. Which of the following is the next best step in the management of this patient?

Oseltamivir

A 39-year-old woman is brought to the emergency department with complaints of fever, headache, severe body aches, dry cough, dyspnea, and coryza for the last 2 days. She has had rheumatoid arthritis for the last 5 years, and she is on oral prednisone therapy. History reveals that she is a school teacher, and many of her students have been sick with similar symptoms. Physical examination shows scattered crackles in both lung fields. Laboratory findings indicate a white blood cell (WBC) count of 12,000 cells/mm3 with 67% lymphocytes. Chest x-ray (CXR) detects bilateral increased interstitial markings. Which of the following treatment is most likely to be given to this patient?

Oseltamivir 75 mg orally 2 times daily

A 36-year-old woman presents to the clinic for her annual visit. She is sexually active, has no children, and her medications include oral contraceptive pills and a daily multivitamin. Her menses are regular, with mild cramps. She does not smoke tobacco or drink alcohol. Her family history is significant for a mother diagnosed at 45 years of age with ovarian cancer. Physical exam, including bimanual exam, is normal. She asks the clinician about ovarian cancer screening. Which of the following best describes this screening?

Ovarian cancer screening may be offered to women at high risk

A 17-year-old female presents with a complaint of leakage of urine for the last two weeks. She states that she will randomly have urges to urinate, which can not be deferred. She also admits to occasional loss of urine when laughing or coughing. She was diagnosed with myasthenia gravis two years ago. Vital signs show a blood pressure of 119/72 mmHg, a pulse of 75 beats per minute, a respiratory rate of 12/min, and a temperature of 37.2 C (99 F). A physical exam is unremarkable. Urinalysis is negative for leukocyte esterase, nitrites, and red blood cells. Available treatment options are discussed with the patient and she eventually decides on medical management. Which of the following medications is contraindicated in this patient?

Oxybutinin

A 49-year-old female (G2 P2) with a history of fibrocystic breast disease presented with a left breast mass that she found a month ago on self-examination. The patient faithfully had obtained routine mammograms since age 40. This year, after reporting the mass and with spot films obtained as recommended by the radiologist, a new cluster of microcalcifications was identified on the report: "spot compression" assessment identified a 3-cm mass and noted "s/p breast augmentation." The radiologist interpreted the spot films to be benign. His report stated that "15% of breast cancers are not detected by a mammogram, and breast self-exam is recommended monthly from 40 years of age." The provider recommended a 6-month follow-up. When the patient complied, the radiologist's report again noted calcifications believed to be nonmalignant. Six months later, the patient presented with bloody nipple discharge from her left breast with apparent "eczema-like" lesions on the areola. Which differential diagnosis should be included for further assessment?

Paget disease

A 24-year old female has a pap smear showing a precancerous lesion on her cervix. What is the most likely infection that caused this pathology?

Papilloma virus strains 16 & 18

A 23-year-old female presents to the hospital with a complaint of mucopurulent vaginal discharge that started a month ago. She also complains of fever and intermenstrual bleeding. On further questioning, she gives a history of mild and continuous lower abdominal pain. A detailed medical history reveals that she was treated for a similar condition last year. Her vital signs show blood pressure 100/60 mmHg, respiratory rate 18/min, heart rate 96/min, and temperature 101 F (38.8C). A pelvic examination performed shows cervical motion tenderness and uterine tenderness. A blood test was ordered, which shows a white cell count of 17,000 per microliter of blood. What is the most likely initial complication of her condition?

Pelvic abscess

A previously healthy 36-year-old female presents with concerns about involuntary urine loss. The episodes occur when she lifts weights, and she has also noticed leakage of urine when she laughs hard. She does not experience sudden urges to urinate or frequency. She denies dysuria, fevers, and chills. Her vital signs are within normal limits. Her physical exam is unremarkable. Which of the following is the likely cause of her symptoms?

Pelvic floor muscle weakness

A 31-year-old female attends the clinics with a complaint of being unable to conceive. She has been having regular unprotected intercourse for the last 18 months but still unable to conceive. Her periods are regular every 28 days which last for 4-5 days. She has a history of lower abdominal pain starting a day before her menstruation. She has been taking paracetamol and mefenamic acid with minimal relief. She has no other relevant history, and she is a teetotaler and denies smoking. On examination, her blood pressure is 123/76 mmHg, and her pulse is 81 bpm, her body mass index is 29 kg/m2. On bimanual pelvic examination, there is tenderness on the left side for her abdomen. What the most appropriate next step in management?

Pelvic ultrasound

An 18-year-old female patient presents to the clinic with complaints of lower abdominal pain and fever for two days. She also reports cervical discharge for one week. She has a history of multiple sexual partners and unprotected sexual intercourse. She denies any nausea or vomiting. On examination, her temperature is 101 F (38.3 C). Abdominal examination reveals tenderness on the left lower quadrant. Bimanual examination shows cervical motion tenderness. What is the best next step in the management of this patient?

Perform a beta HCG test

A 17-year-old female patient presents to the hospital with a complaint of lower abdominal pain for the past week. She complains of vaginal discharge and dyspareunia. On further questioning, she reveals that the pain is mild and continuous. A detailed medical history reveals that she started living with her boyfriend recently. Her vital signs show a blood pressure of 100/70 mmHg, respiratory rate of 20 breaths/min, temperature of 101 F (38.3 C), and heart rate of 101 beats/min. A pelvic examination performed reveals cervical motion tenderness. Laboratory investigations show a white cell count of 17,000 per microliter of blood. What are the most likely causative organisms?

Polymicrobial infection

A 28-year-old male patient with a past medical history significant for asthma presents to the primary care office for complaints of cough, shortness of breath for 24 hours duration. His symptoms started abruptly and are progressively worsening. He denies fevers or chills and has had no known exposure to sick contacts. Vital signs are within normal limits. Physical examination is significant for mild expiratory wheezing. His asthma is well controlled, and he has not used any inhalers for a few years. What is the next best step in the management of this patient?

Prescribe albuterol

A 33-year-old woman presents with an absence of menstruation, vaginal dryness, and night sweats for the past six months. Her menstrual history is remarkable for menarche at 13 years of age, with regular menstrual periods every 28 days, lasting for five days on average until six months ago. Two home pregnancy tests have been negative in the past week. She has smoked ten cigarettes daily for the last ten years. She denies drinking alcohol or using illicit drugs. Past medical history is positive for several urinary tract infections managed successfully with antibiotics. Physical examination is unremarkable. Her breasts are of normal size, and no acne or hirsutism is noted. Laboratory tests show follicle-stimulating hormone (FSH) of 51 mIU/L, luteinizing hormone (LH) of 71 mIU/L, and estradiol (E2) of 8 pg/ml. A serum beta-hCG test today is negative. Which of the following is most likely the cause of this patient's amenorrhea?

Primary ovarian insufficiency

A 65-year-old female is evaluated for shortness of breath with exertion and a chronic cough. She is often unable to walk farther than 200 feet without stopping to catch her breath. She is a current smoker with a 33-pack-year smoking history. She has no prior hospitalizations. On physical examination, her vital signs are within normal limits at rest. Auscultation of her lungs reveals bilateral expiratory wheezes. The remainder of her physical examination is normal. Spirometry is performed and shows an FEV1 of 72% of predicted. Her post-bronchodilator FEV1/FVC ratio is 60%. Her modified medical research council (mMRC) dyspnea score is 3. She is counseled on smoking cessation. Which of the following is the most appropriate pharmacological treatment for this patient?

Short-acting bronchodilator as needed and a long-acting bronchodilator

A patient past her reproductive years has carcinoma in situ of the cervix with cone biopsy showing squamous cell carcinoma with invasion 1 mm beyond the basement membrane. There is no lymphovascular space invasion. What is the next best step?

Simple hysterectomy

A 35-year-old female presents to the out-patient department with complaints of cough with whitish sputum production for the past three months. She mentions that the cough worsens at night. She has no other complaints. The patient mentions that she has tried chlorpheniramine for a week, and no improvement was noted. She has a history of gastroesophageal reflux disease, for which she takes famotidine. She has been smoking a pack of cigarettes a day for the past seven years and drinks alcohol socially. Vitals show a blood pressure of 133/85 mm Hg, pulse of 79/min, respiratory rate of 14/min, and temperature of 98.6 F (37 C). Pulmonary examination reveals normal breath sounds bilaterally. A chest x-ray is normal. Which of the following is the best next step in the management of the patient's condition?

Pulmonary function tests

A 39-year-old woman is brought to the emergency department with 2 days history of fever, headache, severe myalgias, dry cough, breathlessness, and coryza. She is a school teacher, and many students in her class have been reported sick with "the flu." Physical examination reveals scattered crackles in both lung fields. Blood tests indicate a white blood cell count of 12,900 cells/microL with 69% lymphocytes. Chest x-ray shows increased interstitial markings on both sides. She has had rheumatoid arthritis, and she takes prednisone. Which of the following tests is most likely to confirm the diagnosis in this patient?

Rapid influenza diagnostic test from a throat swab

A 30-year-old female patient presents with complaints of abdominal pain and diarrhea for six months. She describes her pain as abdominal cramps. She is unable to localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently. She states her pain is worse right before she has a bowel movement and relieves after having a bowel movement. She describes her bowel movements as loose, unformed stools. Given the patient's most likely diagnosis, which of the following would be most likely in this patient?

Recent problems with marriage resulting in divorce

A healthy 17-year-old male presents with three days of worsening fatigue, rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to eggs and therefore does not receive the annual influenza vaccine. His blood pressure is 125/75 mmHg, pulse 100 beats per minute, temperature 100 F (37.7 C), and respiratory rate 18 breaths per minute. Examination demonstrates conjunctivitis, oropharyngeal erythema, and clear breath sounds. Given the likely diagnosis, what is the most appropriate treatment?

Symptomatic treatment only

A 55-year-old male with a past medical history of benign prostatic hyperplasia presents due to the clinic with complaints of inability to void on his own associated with intermittent leakage of urine. The patient denies any known triggers that cause urinary leakage. The patient is on a maximum dose of tamsulosin. He denies any medication allergies, other medical conditions, history of surgeries, or traumas. Vitals are within normal limits. Physical examination reveals a distended bladder and suprapubic tenderness. Which of the following is the next best step in management?

Urethral catheterization

A 45-year-old man presents to the hospital with complaints of dull aching chest pain, exacerbated upon inhalation. The pain worsens and becomes unbearable while coughing and sneezing. He further states that he had a fever two days ago, which responded to acetaminophen. Which of the following is the most likely source of pain in this patient?

Respiratory system

A 20-year-old man presents to the clinic with two months history of cough and right-sided chest pain. On examination, his chest movement on the right side is diminished, the trachea is shifted to the left, and a stony dull percussion note is present on the right side. His breath sounds are impaired, and vocal fremitus is present. Which of the following is the most likely diagnosis?

Right sided pleural effusion

A 24-year-old female has a sudden onset of low abdominal pain. She passes a clot per vagina and collapses. She is brought to the emergency department where fluid resuscitation is initiated. The abdomen is slightly distended and the left adnexa shows a tender soft mass. Ultrasound only is remarkable for fluid in the pouch of Douglas. The clot is examined and only shows decidua and coagulated blood without trophoblastic tissue or chorionic villi. What is the most probable diagnosis?

Ruptured ectopic pregnancy

A 22-year-old woman presents to the clinic with a history of lower abdominal pain for the past six months. There is no history of dysuria and dyspareunia. There is no relevant family history of cancer. The patient noticed that the pain increases during the first two days of her period. The periods are regular and slightly heavier than usual. She has to change 6 to 7 pads per day. The patient's blood pressure is 120/80 mmHg, pulse 63/minute, and the temperature is 36.1 C. She denies any loss of weight. The pelvic examination shows a globularly enlarged and retroverted uterus. The pregnancy test is negative. She has a recent pelvic ultrasound, which showed some evidence of endometriosis. What is the most likely diagnosis for this patient?

Secondary dysmenorrhea

A 65-year-old man with metastatic lung cancer presents with complaints of dyspnea, dry cough, and chest pain that is exacerbated on inspiration. His blood pressure is 110/70 mmHg, heart rate 90/min, respiratory rate 26/min, and he is afebrile. A chest x-ray shows hyperinflation of the left lung. The patient has most likely developed which of the following complications?

Secondary spontaneous pneumothorax

A 25-year-old woman presents to the emergency department with a history of mild lower abdominal pain and vaginal spotting for the past 6 hours. She is unmarried and had three sexual partners in the last 2 months. She never used any contraception besides condoms. Her menstrual cycles are regular with 28 days cycle and the last menstrual period was 6 weeks ago. On examination, she is hemodynamically stable with marked rebound tenderness in the left lower quadrant with minimal guarding. Urinary beta hCG is positive and serum beta hCG is 600 mIU/mL. Transvaginal ultrasound shows an empty uterus and normal adnexa. What should be the most appropriate next step to confirm the diagnosis?

Serial beta HCG measurements

A female presents with progressive confusion over weeks with memory loss. She has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of arthralgias. History is otherwise unremarkable except for the fact she is an avid camper. Which of the following is the initial diagnostic test that should be ordered?

Serology

A 43-year old female presents for evaluation. Her left knee has been painful and swollen for the past week. Her symptoms have been worsening, and now she finds it difficult to bear weight. She denies any trauma or fall. She denies any other joint pain, and a review of systems is otherwise negative except for an annular rash that she had on the upper back about one month ago that resolved on its own. Past medical history and family history are unremarkable. On exam, vitals are normal. The left knee is erythematous, has an effusion, and is tender. The range of motion is limited in flexion and extension. The rest of the exam is normal. Laboratory evaluation shows normal complete blood count, liver function, and renal function. ESR is 44 mm/hr. Rheumatoid factor, ANA, Anti-CCP are negative. Synovial fluid analysis reveals 12,000 WBC/mm3 and no crystals. Bacterial cultures are negative. X-ray of the knee reveals mild medial joint space narrowing and the presence of effusion. MRI of the left knee reveals mild chondromalacia, a large effusion, and fraying of the medial meniscus without any significant tear. What is the next best step in the management of this case?

Serum studies

A 65-year-old male is evaluated for worsening shortness of breath and a productive cough for 6 months. He is a current smoker with a 30-pack-year smoking history. His other medical history includes hypertension and chronic kidney disease. On examination, his blood pressure is 145/95 mmHg, pulse 88/min, and oxygen saturation of 92% on room air. He does not have accessory muscle use. On lung auscultation, there is decreased air movement and prolonged expiration. There are no wheezes detected. No S3 or S4 auscultated. There is no jugular vein distention. He has no lower extremity edema and denies chest pain or calf tenderness. Chest x-ray reveals bilateral hyperinflated lung fields. Which of the following is the next best step in the diagnosis of this patient's condition?

Spirometry

A 37-year-old woman presents with complaints of intermittent dry cough and chest tightness since she started a new job as a chambermaid at a hotel 5-weeks ago. Her symptoms are worst at night. She does not have any rhinitis, postnasal drip, or history of allergic rhinitis. She has never smoked and doe not take any medicine. On physical examination, the patient appears comfortable and speaks full sentences without any problem. Oral and nasal mucosa appears normal. On auscultation of lungs, wheeze is reported in the left lung. The chest x-ray report comes out normal. Which of the following is the next best step in identifying the cause of the patient's current symptoms?

Spirometry with pre and post-bronchodilator testing

A 35-year-old male is seen in the outpatient department with complaints of cough and low-grade fever for the past 3 months. The patient developed fever 3 months back, which was low grade and associated with night sweats. He also has had a troublesome cough. He had an episode of hemoptysis, which prompted the visit. His history is significant for HIV infection 8 years ago, for which he has never taken treatment. Examination reveals a temperature of 99 F, a pulse of 90 beats per minute, a blood pressure of 110/70 mmHg, and a respiratory rate of 22 breaths per minute. His general physical examination reveals the presence of oropharyngeal thrush and mild pallor. Chest examination reveals coarse crackles and bronchial breathing in the left upper lobe. His investigations reveal a WBC count of 3,000 per microL, hemoglobin of 10 gm/dl, platelet count of 150,000 per microL, erythrocyte sedimentation rate of 50 mm per hour, serum creatinine of 0.8 mg/dl and a CD4+ count of 60 per microL. A Mantoux test is performed, which shows no induration. A chest x-ray reveals cavitation and reticulonodular shadowing in the right upper lobe. Sputum demonstrates the presence of acid-fast bacilli. What should be the management plan for this patient?

Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 2 weeks

A 70-year-old man with severe chronic obstructive pulmonary disease (COPD) has had multiple hospital admission for exacerbations. He is an ex-smoker of 40 pack years. He takes budesonide/formoterol combination and tiotropium inhalers. He is up-to-date with his Influenza and pneumococcal vaccine. What should be advised to decrease his COPD exacerbations?

Start him on roflumilast

A patient with lung cancer presented with sudden onset pleuritic chest pain on the left side. She is dyspneic and exhibits tachypnea, tachycardia, and cough. On auscultation, there are decreased breath sounds on the left. After a brief period of stabilization, the patient becomes hemodynamically unstable and develops cyanosis. What is the likely diagnosis?

Tension pneumothorax

A 17-year-old female sex worker presents to the hospital with a complaint of vaginal discharge that started two months ago. She also complains of intermenstrual bleeding and lower abdominal pain. On further questioning, she reveals that she has been active with multiple partners lately. Her vital signs show blood pressure 100/80 mmHg, respiratory rate 18 breaths/min, heart rate 88 beats/min, and temperature 101 F (38.3 C). A pelvic examination shows cervical discharge, cervical motion tenderness, and uterine tenderness. A blood test is ordered, which shows a white cell count of 17,500 per microliter of blood. What is the most likely mechanism leading to the spread of the causative organism?

Thinning of cervical mucus

A 65-year-old female presents with complaints of decreased libido. She has been happily married for 30 years and has no relationship issues. She is physically active and exercises 30 minutes daily. She complains of vaginal dryness and painful intercourse. She also complains of frequent vaginal itching. She has tried vaginal lubricants with mild symptomatic relief. On examination, the vaginal mucosa is pale and dry. She has a past medical history of diabetes mellitus that is well controlled with metformin. Family history is significant for colon cancer in her maternal aunt. Which of the following would be the most effective treatment for this patient's symptoms?

Topical estrogen preparation

A 65-year-old female with renal cancer presents with dyspnea, fatigue, and dizziness. She is on warfarin to treat a left leg deep vein thrombosis. Her hematocrit is 22%, hemoglobin is 7.1 g/dL, platelets 109,000/mL, PT 1.3, PTT 36, INR 1.45, and WBC 12,000 mm3. What is the next step in the management of the patient?

Transfuse packed red blood cells

A 28-year-old male runner presents to the clinic for his annual physical. The patient states that he has no complaints and feels perfectly healthy. The patient has no significant past medical history. His blood pressure is 120/80 mmHg, pulse rate is 60/min, and respiratory rate is 15 breaths/min. Physical examination is unremarkable. A urine routine examination is performed, which reveals 1+ proteinuria. 24-hour urinary protein is 1 g/day. The patient's renal function tests are normal. The patient is concerned about these lab findings. Which of the following is the correct response?

Transient proteinuria is not indicative of underlying renal disease

A 26-year-old woman presents with sudden onset severe right lower quadrant abdominal pain. Examination reveals extreme tenderness on palpation. She has no history of smoking, alcohol consumption, or illicit drug use. She has a medical history of 2 previous elective abortions followed by a D & C. Her menstrual cycle started this morning and reports it was ten days before it was due. She states that this is unusual for her. A urine pregnancy test is positive. Blood pressure is 86/60 mmHg, pulse rate is 100/min, and the respiratory rate is 16/min. Two large-bore needles are placed on each arm, and IV fluids are begun. Which of the following is the most appropriate next step in the management of this patient?

Transvaginal ultrasound

A 65-year-old woman with a BMI of 32 kg/m2 comes to the clinician with a complaint of two episodes of vaginal bleeding in the past 40 days. She has a past medical history of hypertension and diabetes mellitus type 2. On both occasions, light spotting lasted for three days. She experienced menopause at the age of 56 years. Currently, she is afebrile and hemodynamically stable with an unremarkable physical examination. She takes metformin and lisinopril. What is the first-line imaging study to evaluate a patient with this complaint?

Transvaginal ultrasound

An adolescent presents to you with sore throat, fever, lymphadenopathy, and splenomegaly. He also complains of headache but has been previously well. Which should be done?

Treat symptomatically

A patient with chronic obstructive pulmonary disease (COPD) and chronic carbon dioxide retention in a nursing home is wheezing. The oxygen saturation drops from 93 to 90. Which of the following would be most appropriate?

Treat with albuterol by nebulizer

A 17-year-old female presents to the clinic with a 1-week history of low-grade fever and abdominal pain. She has presented multiple times in the last year with urinary tract infections. The patient says she has had multiple sexual partners over the last year and uses barrier protection inconsistently. On examination, the patient has diffuse lower abdominal tenderness with no guarding or rigidity. She also has cervical motion tenderness and mucopurulent vaginal discharge on pelvic examination. Culture and gram staining are negative for any organism. What is the organism most likely responsible for the patient's presentation?

chlamydia

A 25-year-old woman presents to the clinic with nausea, pelvic pain, and vaginal discharge. The client is sexually active and has multiple sexual partners. Her blood pressure is 110/70 mmHg, her pulse rate is 110/min, and her temperature is 102 F (38.8 C). On examination, adnexal tenderness is noted. Which of the following complications is most likely to occur if this client's condition is left untreated?

infertility

A 16-year-old patient presents because she believes she was bitten by a tick while hiking in the woods a few days ago. She mentions swelling in her right ear and general malaise. On exam, she has a 1 x 2 cm bluish-red nodule on the right ear lobe. What is the next best step in management for this patient?

lyme serology

A 20-year-old woman presents for extremely painful menstrual periods and associated abdominal bloating over the last 6 months. The symptoms are most severe on the first day of her period, and she is concerned because it is causing her to miss work. Her menstrual history reveals regular menstrual periods every 28 days that last for 5 days. She denies excessive menstrual blood loss. She is otherwise fit and healthy. She takes no medication and denies smoking tobacco or using illicit drugs. She drinks alcohol occasionally. She admits that she is trying to conceive and does not use any method of contraception. Her BMI is 25 kg/m2. Which of the following is the best initial treatment for this patient?

naproxen

A 35-year-old nulliparous woman presents for a check-up. She currently has no symptoms. She does not smoke or ingest illicit drugs. She drinks one glass of wine after dinner every night. Her vitals are within the normal range. She is sexually active with her husband and uses contraceptive pills. Menarche was at 14. Menses are regular, with normal flow and mild cramps. Her past medical problems include obesity. Her BMI is 30 kg/m2. Family history is significant for breast cancer in the paternal grandmother and ovarian cancer in the mother. She is up to date with her screenings and vaccinations. After her family history, which of the following is the most important risk factor for the development of ovarian cancer in this patient?

nulliparity

A 65-year-old female presents to the clinic with complaints of vaginal bleeding, vague abdominal pain, and nausea. She says she has not been feeling well for the past few months. She has class 2 obesity and denies any weight loss and has not seen a healthcare provider for at least five years. She has a 30-pack-year history of smoking and drinks three to four alcoholic beverages daily. She is on no medications and denies any allergies. A physical exam is unremarkable except for the presence of blood clots at the cervical os. Which of the following risk factors would raise the suspicion of uterine cancer?

obesity

A 65-year-old nulligravid woman presents to the clinic with complaints of vaginal bleeding and vague abdominal pain. She says she has not been feeling well for the past three months. She denies any weight loss and has not seen a healthcare provider for the past five years. She smokes one pack of cigarettes per day, and her BMI is 29 kg/m2. She has a history of multiple sexual partners and was diagnosed with endometriosis when she was 20 years old. She is on no medications and denies any allergies. The physical exam is unremarkable except for the presence of blood clots at the cervical os. Which of the following risk factors would raise suspicion of her condition?

obesity

A 26-year-old woman G1P0000 at 24 weeks gestation presents to the clinic in October for evaluation of cough, rhinorrhea, and subjective fever for 24 hours. The patient has no significant past medical history and takes only a prenatal vitamin daily. Vital signs show oral temperature 38 C (100.4 F), blood pressure 120/80 mmHg, pulse 90/minute, respirations 18/minute, and oxygen saturation 96% on room air. Physical exam reveals a mildly ill-appearing gravid female in no acute distress with lung fields that are clear to auscultation bilaterally. Continuous fetal monitoring is normal. Nasal swab ELISA is positive for influenza A. Which of the following is the most appropriate treatment for this patient to decrease the likelihood of progression to viral pneumonia?

oseltamivir

Which of the following is the best modality for diagnosing a 1x1 cm cystic breast mass in a 35-year-old female presenting with a painful mobile lump of fewer than 6 months duration?

ultrasound