CK- UWSA 3 – Block 1

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A randomized controlled trial compared the effectiveness of a new drug (new-umab) versus the standard of care (standard-umab) for moderate to severe plaque psoriasis. Patients age 18-75 with stable (for >6 months) moderate to severe chronic plaque psoriasis involving ≥10% body surface area with a Psoriasis Area Severity Index (PASI) score ≥12 were randomly assigned to receive subcutaneous injections of new-umab (a single 18-mg dose) or standard-umab (a single 45-mg dose). A 5% significance level is chosen. The primary end point was a ≥90% reduction from baseline in the PASI score at week 12. Data on safety were also collected. An excerpt of study results is shown below.

	Clinical response at week 12
Outcomes	New-umab (N = 50)	Standard-umab (N = 50)	p-value	NNT	NNH
PASI90 (n, %)	20 (40)	15 (30)	0.294	10	–
SAE (n, %)	11 (22)	2 (4)	0.007	–	6
NNH = number needed to harm; NNT = number needed to treat; PASI90 = Psoriasis Area Severity Index score ≥90; SAE = serious adverse event.

Based on these data, which of the following is the most appropriate conclusion regarding the occurrence of severe adverse events (SAEs)?

A. About 6 of 100 patients treated for 12 weeks with new-umab will have a severe adverse event
B. Of 10 patients (on average) treated for 12 weeks with new-umab instead of standard-umab, 6 will experience a severe adverse event
C. On average, for every 6 patients treated for 12 weeks with new-umab instead of standard-umab, 1 will experience a severe adverse event
D. Patients treated with new-umab are 6.0 times more likely to have a severe adverse event compared to patients treated with standard-umab

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Question 10 of 40

10. Question
A 72-year-old man is brought to the office after an episode of passing out. Over the past 6 months, the patient has had several short spells of feeling unsteady on his feet, almost as if he were on a boat, along with double vision and numbness of the bilateral limbs. He has not found a consistent trigger, but the events usually occur when he is fatigued. Today, the patient was working under his car in the garage and became severely dizzy when he went from kneeling to standing. He felt his knees giving away and he collapsed. The patient lost consciousness transiently; he was not confused after regaining consciousness but felt nauseated. Medical history is significant for hypertension, diabetes mellitus, and hyperlipidemia. Blood pressure is 144/92 mm Hg while supine and 140/88 mm Hg when upright and pulse is 70/min and regular. On physical examination, the patient appears comfortable with moist mucous membranes and no pallor. Heart and lung sounds are normal. There is bilateral horizontal nystagmus but no other neurologic findings. Which of the following is most likely to reveal the cause of this patient’s symptoms?
- A. Ambulatory ECG monitoring
- B. Audiometry
- C. CT angiography of the head and neck
- D. Dix-Hallpike maneuver
- E. Tilt-table testing
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Question 11 of 40

11. Question
A 19-year-old woman comes to the office due to painful neck swelling. The patient noticed a lump on the left side of her neck about a week ago that has progressively enlarged and become more painful. She has also had intermittent fever up to 39.5 C (103.1 F). The patient has no prior medical conditions and takes no medications. She works as a pet groomer and has not traveled recently. On physical examination, a large, tender, firm, and lobulated mass is noted on the left side of the patient’s neck, with erythematous overlying skin. Oropharyngeal examination is normal. CT scan of the neck reveals diffuse left cervical lymphadenopathy with surrounding inflammatory changes, as shown in the exhibit. Which of the following is the best next step in management of this patient?
- A. Azithromycin
- B. Nasopharyngeal endoscopy
- C. Penicillin V
- D. Symptomatic treatment
- E. Tuberculin skin testing
Correct

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Question 12 of 40

12. Question
A 45-year-old woman comes to the office for follow-up of type 2 diabetes mellitus. In the past year, her hemoglobin A1c has been steadily rising despite careful adherence to a multidrug regimen. In addition, the patient has gained approximately 10 kg (22 lb) since relocating to the United States 2 years ago from her native Costa Rica to work as a software engineer. She prepares her own breakfast and dinner at home most days and eats a small, midday snack from the office break room. Vital signs are normal. BMI is 36 kg/m². Hemoglobin A1c is 7.8%. Which of the following is the most appropriate next step in management of this patient?
- A. Advise the patient to adopt a Mediterranean-style diet
- B. Discuss lower-calorie alternatives for the patient’s dietary staples
- C. Provide Spanish language handouts with easy-to-follow meal plans
- D. Recommend eliminating American-style snacks when at work
- E. Recommend using a reduced-calorie commercial meal preparation service
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Question 13 of 40

13. Question
44-year-old woman comes to the office for evaluation of exertional dyspnea and “noisy breathing” that worsen with exercise. She has no sputum production or hoarseness. She has smoked 2 packs of cigarettes a day since age 20. A trial of bronchodilators has worsened her symptoms. Temperature is 36.1 C (97 F), blood pressure is 120/80 mm Hg, pulse is 88/min, and respirations are 18/min. BMI is 33.5 kg/m². Pulse oximetry is 97% on room air. On examination, the patient has audible noises on expiration that can be heard without a stethoscope. Lung auscultation demonstrates expiratory wheezes. The patient undergoes pulmonary function testing. The flow-volume loop is shown in the image below:

Which of the following is the most likely explanation for this patient’s symptoms?
- A. Asthma
- B. Pulmonary fibrosis
- C. Thyroid carcinoma
- D. Tracheobronchomalacia
- E. Vocal cord paralysis
Correct

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Question 14 of 40

14. Question
A 75-year-old man comes to the office for a routine health maintenance examination. The patient has no dermatologic symptoms. Medical history is notable only for diet-controlled diabetes mellitus, and he takes no medications. Examination of the face is shown in the exhibit. The skin in the left temporal area is dry and has a rough texture. Which of the following is the most appropriate management of this patient?
- A. Field radiation therapy
- B. Topical 5-fluorouracil
- C. Topical clotrimazole
- D. Topical hydrocortisone
- E. Topical metronidazole
Correct

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Question 15 of 40

15. Question

A 45-year-old man is brought to the emergency department due to a 6-hour history of altered mental status, difficulty seeing, and pain with eye movements. In addition, the patient has nausea, vomiting, and abdominal pain. He is homeless and has a history of bipolar disorder but does not take medications. The patient drinks alcohol daily. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respirations are 26/min. On examination, he appears anxious and confused. Ophthalmic examination shows mydriasis, retinal edema, and hyperemia of the optic discs. Mild epigastric tenderness is present on deep palpation, but physical examination is otherwise normal. The patient is able to move all 4 extremities, and deep tendon reflexes are normal. Laboratory results are as follows:

Serum chemistry
Sodium	138 mEq/L
Potassium	5.1 mEq/L
Chloride	104 mEq/L
Bicarbonate	6 mEq/L
Creatinine	1.0 mg/dL
Calcium	9.6 mg/dL
Glucose	100 mg/dL

Arterial blood gases
pH	7.15
PaO₂	104 mm Hg
PaCO₂	16 mm Hg

Blood, plasma, and serum
Lactic acid, venous blood	2.4 mg/dL

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

A. Initiate hemodialysis
B. Initiate hyperbaric oxygen therapy
C. Obtain CT scan of the abdomen
D. Obtain MRI of the brain
E. Obtain urine ketones

Correct

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Question 16 of 40

16. Question
A 39-year-old woman comes to the emergency department due to chest pain that started 8 hours ago while she was changing her 4-day-old baby’s diaper. The pain, which has been unrelenting and has prevented her from caring for the baby and her 3 other children, is substernal and very uncomfortable, radiating to her neck and left arm. The patient reports no shortness of breath, nausea, vomiting, or sweating. The pain does not worsen with exertion or deep breaths. The patient has no medical history. She is afebrile. Blood pressure is 110/70 mm Hg, pulse is 106/min, and respirations are 18/min. Pulse oximetry reading is 100% on room air. On examination, the patient appears uncomfortable. The lungs are clear to auscultation bilaterally, and heart sounds are normal. The abdomen is soft and nontender with a normal postpartum uterus. There is no lower extremity edema or swelling. Chest x-ray is normal. ECG is shown in the exhibit. Laboratory results are as follows:

D-dimer, plasma

2.67 µg/mL (normal: <0.5)

Troponin T, serum

>80 ng/mL (normal: <0.04)

Which of the following is the most likely diagnosis?
- A. Cardiac tamponade
- B. Complete heart block
- C. Coronary artery dissection
- D. Pericarditis
- E. Pulmonary embolism
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Question 17 of 40

17. Question
A 78-year-old woman is brought to the office by her daughter due to urinary urgency and frequent episodes of urinary incontinence over the past month. There is no report of urinary leakage with coughing or exertion, and the patient has had no fever, chills, abdominal pain, or dysuria. Three months ago, she was prescribed donepezil, which she takes at the maximal dose, for mild Alzheimer dementia. Her daughter reports that the patient’s forgetfulness is about the same, with no behavioral symptoms. The patient lives with her daughter and there have been no safety concerns. Temperature is 36.7 C (98.1 F), blood pressure is 133/80 mm Hg, pulse is 78/min, and respirations are 16/min. Physical examination shows no abdominal or costovertebral angle tenderness. The patient is oriented only to person and place and recalls 1 of 3 objects after 5 minutes. The remainder of the neurologic examination shows no abnormalities. Blood cell counts, serum chemistry studies, and urinalysis are within normal limits. Her daughter takes oxybutynin for overactive bladder and requests that her mother be prescribed the same medication. Which of the following is the most appropriate next step in management of this patient’s urinary symptoms?
- A. Add memantine treatment
- B. Advise pelvic muscle exercises
- C. Discontinue donepezil
- D. Initiate oxybutynin therapy
- E. Start intermittent catheterization
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Question 18 of 40

18. Question
A 57-year-old man with amyotrophic lateral sclerosis is participating in a clinical trial evaluating a novel therapeutic agent. The patient is accompanied by his wife for the initial session. The research coordinator provides a description of the study and tells the wife he is optimistic that the medication will help patients like her husband. He then shares that more participants are needed for the study to be successful and asks if she would like to enroll as a healthy control. In obtaining consent for the wife’s participation, which of the following principles has been violated by the research coordinator?
- A. Beneficence
- B. Confidentiality
- C. Nonmaleficence
- D. Veracity
- E. Voluntariness
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Question 19 of 40

19. Question
A 34-year-old woman with Down syndrome is brought to the office due to behavioral changes over the past several months. She has moderate intellectual disability with limited verbal abilities and lives at a group home. The caregiver states that the patient has become irritable and impulsive. She does not participate in group activities like usual and pays no attention when she is there. The patient sleeps most days and has lost some of her previously learned vocational skills. She has had no constipation or urinary symptoms. Medical history is significant for repaired ventricular septal defect and hypothyroidism treated with levothyroxine. Blood pressure is 134/88 mm Hg and pulse is 74/min. BMI is 28 kg/m². Physical examination shows craniofacial changes and generalized hypotonia consistent with Down syndrome. The remainder of the examination including dentition and ear canals shows no abnormalities. Blood cell counts, serum chemistry studies, TSH level, and urinalysis are within normal limits. Which of the following is the most appropriate next step in management of this patient?
- A. Obtain echocardiography
- B. Obtain polysomnography
- C. Prescribe fluoxetine
- D. Prescribe modafinil
- E. Recommend cognitive-behavioral therapy
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Question 20 of 40

20. Question
A 34-year-old man comes to the office due to episodic shortness of breath. He also reports chest tightness and cough productive of scanty clear sputum, occurring 1 or 2 times per week. The patient’s symptoms seem to worsen at night and on days with a high pollen count and improve when he drinks several cups of coffee. Medical history is significant for allergic rhinitis. Medications include cetirizine and fluticasone nasal spray. He smoked 1 pack of cigarettes daily from age 20 to 25. Examination of the nasal passages shows mild turbinate hypertrophy but no polyps. Pulmonary auscultation reveals clear breath sounds bilaterally with no wheezing. The patient’s spirometry data are shown in the table below:

Prealbuterol
(% predicted)

Postalbuterol
(% predicted)

FVC

90%

96%

FEV₁

61%

79%

FEV₁/FVC ratio

65%

80%

Which of the following medication regimens would be most appropriate for initial management of this patient?
- A. Inhaled long-acting beta agonist as needed
- B. Inhaled low-dose corticosteroid and beta agonist as needed
- C. Inhaled medium-dose corticosteroid and beta agonist twice daily
- D. Inhaled muscarinic antagonist daily
- E. Oral leukotriene receptor antagonist as needed
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Question 21 of 40

21. Question
A US-based pharmaceutical company is planning to conduct a randomized clinical trial to test the effectiveness of a monoclonal antibody in the treatment of a virulent viral infection with high global morbidity and mortality rates. The investigational product is hypothesized to be superior to the other established antiviral treatments, which slow progression of the virus but do not cure the disease or shorten its duration. The trial is being conducted in a large, resource-limited country that has a high disease prevalence and lacks economic and educational infrastructure and adequate access to medications. Which of the following characteristics is most important in protecting the safety of participants?
- A. Administration of an established antiviral drug in the control arm
- B. Administration of an experimental treatment in the control arm
- C. Large sample size with diverse participant population
- D. Payment to individuals who consent to participate in research
- E. Protocol for close monitoring of adverse events in the intervention arm only
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Question 22 of 40

22. Question
A 67-year-old woman comes to the office due to progressively worsening dull, aching pain in the right groin for the past 2 weeks. Walking for longer than 2 minutes or going up more than 2 flights of stairs exacerbates the discomfort. She reports no trauma or overuse. The patient has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. She has been taking alendronate for the past 7 years; other medications include metformin and lisinopril. The patient drinks a shot of vodka daily. Vital signs are normal. BMI is 32 kg/m². Physical examination reveals pain localized to the right groin that is worse with internal and external rotation of the hip. X-ray of the right hip is normal. MRI reveals a stress fracture of the lateral aspect of the subtrochanteric region of right femur and no other significant abnormalities. DEXA scan shows that bone density has increased compared to 5 years ago. Which of the following is the most likely underlying cause of the fracture in this patient?
- A. Age-related degeneration
- B. Alcohol use
- C. Elevated BMI
- D. Medication adverse effect
- E. Metastatic bone lesion
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Question 23 of 40

23. Question
A 6-year-old girl is evaluated for recurrent generalized tonic-clonic seizures. The patient also has had frequent mucocutaneous candidal infections over the past 2 years. Physical examination is significant for stunted growth, dysplastic nails, and hyperpigmented lips. Laboratory testing reveals normal blood cell counts and chemistry studies except for a serum calcium level of 6.2 mg/dL. Parathyroid hormone level is 6 pg/mL (normal: 10-65). Which of the following is the most appropriate management?
- A. Bisphosphonate therapy
- B. Calcium plus calcitriol supplementation
- C. Calcium plus magnesium supplementation
- D. Calcium plus phosphorus supplementation
- E. Intranasal calcitonin therapy
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Question 24 of 40

24. Question

A 26-year-old woman comes to the emergency department due to a 7-day history of worsening abdominal discomfort. In the past 24 hours, she voided only once and says it was a small amount of dark urine. The patient also reports anorexia, weight loss, and fevers for the last month. Vital signs are within normal limits. BMI is 18.2 kg/m². Abdominal examination shows hepatosplenomegaly and mild, diffuse tenderness to deep palpation. The rest of the examination is unremarkable. Serum chemistry results are as follows:

Serum chemistry
Sodium	132 mEq/L
Potassium	5.3 mEq/L
Bicarbonate	20 mEq/L
Blood urea nitrogen	83 mg/dL
Creatinine	4.9 mg/dL
Calcium	10.7 mg/dL
Phosphorus	4.9 mg/dL
Uric acid	6.5 mg/dL

ECG shows sinus rhythm with normal T-wave morphology. CT scan of the abdomen is shown in the exhibit and reveals bulky retroperitoneal lymphadenopathy and bilateral hydronephrosis with normal-thickness renal cortices. One-time straight catherization of the bladder recovers 40 mL of urine. Which of the following is the most appropriate course of action to address this patient’s renal dysfunction?

A. Alkalinizing the urine with sodium bicarbonate
B. Initiating emergency hemodialysis
C. Inserting an indwelling bladder catheter
D. Performing a nuclear renal excretion scan
E. Placing percutaneous nephrostomy tubes

Correct

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Question 25 of 40

25. Question
An 83-year-old man is brought to the emergency department from an assisted living facility due to abdominal pain and fever. Medical history is notable for advanced Alzheimer disease, type 2 diabetes mellitus, and stage 3b chronic kidney disease. Initial evaluation indicates acute cholecystitis with gallbladder perforation and septic shock. Antibiotics and vasopressor therapy are started. The emergency department staff consult the on-call surgeon for emergency surgery. The patient’s records indicate he is full code. The surgeon estimates the perioperative mortality risk for this patient to be very high but lower than for nonsurgical management. However, he chooses to not operate because the patient’s premorbid life expectancy is low and because he has been unable to reach the patient’s daughter, who is the patient’s designated decision maker, to obtain consent, despite repeated phone calls. If the patient subsequently experiences an adverse outcome, which of the following best describes the surgeon’s malpractice liability in this case?
- A. The surgeon is liable because he failed to provide beneficial care
- B. The surgeon is liable because the emergency department staff consulted him for emergency surgery
- C. The surgeon is liable because the patient’s dementia establishes the patient as a vulnerable person
- D. The surgeon is not liable because of the patient’s limited life expectancy
- E. The surgeon is not liable because he made a good faith attempt to obtain consent
- F. The surgeon is not liable because the risk of surgical complications is high
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Question 26 of 40

26. Question
A 62-year-old man with an extensive history of tobacco use comes to the office for follow-up 10 days after undergoing total laryngectomy and unilateral modified radical neck dissection for advanced laryngeal squamous cell carcinoma with erosion completely through the thyroid cartilage. The patient has not yet received chemotherapy, immunotherapy, or radiation therapy. Today the patient is able to communicate well with an electrolarynx. He reports fatigue, irritability, memory difficulties, muscle aches, and tingling in both hands and feet. He says he has also been sleeping more than usual and feels depressed. Appetite is normal, and he has no suicidal ideation. Vital signs are within normal limits. On examination, the patient appears anxious but fully oriented. The surgical site is healing well with no erythema or discharge; the stoma is clean and open with no crusting. Lung and heart sounds are normal. Neurologic examination shows normal recall and attention. Deep tendon reflexes are 3+ in all 4 extremities with normal muscle tone and strength. Babinski sign is absent. Sensation is normal throughout. Which of the following is the best next step in management?
- A. Begin selective serotonin reuptake inhibitor therapy
- B. Begin vitamin B12 supplementation
- C. Obtain MR imaging of the brain
- D. Obtain serum calcium level
- E. Obtain thyroid function studies
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Question 27 of 40

27. Question
A 62-year-old man comes to the office due to left foot pain at night for the past 2 months. The patient describes a gnawing pain across the base of the metatarsal heads that begins shortly after he goes to bed. The pain is often relieved after he gets up and walks around the room or sits at the edge of the bed for a few minutes. Medical history includes diabetes mellitus, hypertension, and chronic kidney disease. The patient is a former smoker with a 20-pack-year history. Blood pressure is 132/70 mm Hg and pulse is 68/min. Physical examination shows normal jugular venous pressure, clear lungs, and normal heart sounds. The left foot appears normal with no redness, swelling, or focal tenderness. The foot joints are normal with a normal foot arch. Bilateral dorsalis pedis pulses are not palpable. Neurologic examination demonstrates absent ankle reflex bilaterally. There is diminished sensation at the tip of the toes bilaterally on monofilament testing. The ankle-brachial index is <0.4 on the left and 0.6 on the right. The most recent hemoglobin A1c was 7.8%. Which of the following is the best next step in management of this patient’s foot pain?
- A. Corticosteroid injection
- B. Duloxetine therapy
- C. Orthotic footwear
- D. Revascularization evaluation
- E. Strict glycemic control
Correct

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Question 28 of 40

28. Question
A 45-year-old man comes to the office for a hypertension follow-up visit. The patient feels well and is currently asymptomatic. The hypertension was diagnosed 3 months ago, at which time the patient had a blood pressure of 160/96 mm Hg; a combination of lisinopril and amlodipine was prescribed. Today, his blood pressure is 158/95 mm Hg. BMI is 27 kg/m². Physical examination is unremarkable. Which of the following is most likely responsible for this patient’s persistently elevated blood pressure?
- A. Diffuse vascular calcification
- B. Inappropriate initial choice of medications
- C. Nonadherence with therapy
- D. Underlying left ventricular hypertrophy
- E. Underlying renal parenchymal disease
Correct

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Question 29 of 40

29. Question
A 58-year-old woman comes to the emergency department due to progressively worsening, mild headaches and right facial numbness with no other weakness, slurred speech, or vision impairment. She has no chronic medical conditions and takes no medication. Noncontrast CT scan of the head reveals an extraaxial, partially calcified left frontal mass. A subsequent contrast MRI redemonstrates the 2-cm extraaxial mass, as shown in the exhibit. What is the most appropriate next step in management of this patient?
- A. Interferon gamma release assay
- B. MRI of the spine
- C. Spinal fluid evaluation
- D. Surgical excision without additional workup
- E. Toxoplasma serology
Correct

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Question 30 of 40

30. Question
A previously healthy 5-year-old boy is brought to the emergency department due to a 2-day history of diarrhea, abdominal cramping, vomiting, and fever. Symptoms started 12 hours after eating a meal at a birthday party. Several other children at the party were ill with similar symptoms as well. The patient has had 4 or 5 nonbloody but mucoid stools per day. Temperature is 38.6 C (101.5 F), blood pressure is 100/68 mm Hg, pulse is 102/min, and respirations are 18/min. On examination, he appears mildly irritable. The oral mucous membranes are dry, and capillary refill is 2 seconds. There is mild, diffuse abdominal tenderness. Laboratory results are as follows:

Complete blood count

Hemoglobin

13 g/dL

Platelets

200,000/mm³

Leukocytes

11,000/mm³

Serum chemistry

Blood urea nitrogen

14 mg/dL

Creatinine

0.8 mg/dL

Multipathogen molecular testing with PCR of the stool is positive for Salmonella species but negative for other pathogens. His parents request antibiotic therapy. What is the most accurate statement about antibiotic therapy in this patient?
- A. Indicated, mainly to decrease the invasive metastatic infection
- B. Indicated, mainly to prevent the duration and severity of illness
- C. Not indicated, due to the risk of developing hemolytic uremic syndrome
- D. Not indicated, due to the risk of extending asymptomatic Salmonella carriage
Correct

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Question 31 of 40

31. Question
A 70-year-old man comes to the emergency department due to right groin pain. The pain started suddenly 8 hours ago and has been accompanied by several episodes of vomiting. The patient says he noticed a bulge in his right groin a few months ago and that it “comes and goes,” but now it is larger and painful. Medical history is significant for hypertension. Temperature is 38.2 C (100.8 F), blood pressure is 125/75 mm Hg, pulse is 115/min, and respirations are 16/min. On examination, the patient appears uncomfortable. The abdomen is diffusely tender to palpation. The right scrotum is edematous and tender. Intravenous fluids and pain medications are administered. Laboratory results show a white blood cell count of 18,000/mm³. Which of the following is the best next step in management?
- A. CT scan of the abdomen and pelvis
- B. Immediate operative repair
- C. Nasogastric tube placement and observation
- D. Reduction of herniated abdominal contents
- E. Scrotal ultrasonography
Correct

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Question 32 of 40

32. Question
A 15-year-old girl comes to the office for a routine health maintenance examination. The patient has no current concerns. She is up to date on her vaccinations. The patient has never had a menstrual period. She does not use tobacco, alcohol, or recreational drugs. The patient is not sexually active. Height is 142 cm (4 ft 8 in) and weight is 45 kg (99.2 lb). BMI is 23 kg/m². Blood pressure is 120/80 mm Hg and pulse is 72/min. Cardiac examination shows a systolic ejection click and a soft systolic murmur heard best along the right sternal border. Peripheral pulses are full. The lungs are clear to auscultation. Breast development is Tanner stage 2; there is scant axillary and pubic hair. The cervix and uterus appear normal. Which of the following therapies is likely to be of most benefit to this patient?
- A. Dopamine agonist
- B. Estrogen and progestin
- C. GnRH agonist
- D. No hormonal therapy indicated
- E. Progestin only
Correct

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Question 33 of 40

33. Question

A 60-year-old man is evaluated for fatigue and generalized weakness. Medical history is significant for chronic kidney disease due to hypertension and type 2 diabetes mellitus. Vital signs are within normal limits. Colonoscopy performed at age 55 was normal except mild sigmoid diverticulosis. Examination shows conjunctival pallor but no evidence of jaundice or scleral icterus. Abdominal examination does not show organomegaly. Laboratory studies are as follows:

Hemoglobin	9.1 g/dL
Leukocytes	6,200/mm³
Platelets	234,000/mm³
Reticulocytes	0.5% of erythrocytes

Vitamin B₁₂ and folic acid level	normal
Ferritin	60 ng/mL (normal: ≥100 ng/mL)
Transferrin saturation	15% (normal: 22%-46%)
Estimated glomerular filtration rate	20 mL/min/1.73 m²
Stool testing for occult blood	negative

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

A. Measure serum hepcidin level
B. Obtain serum erythropoietin level
C. Perform a bone marrow biopsy
D. Provide iron replacement therapy
E. Repeat colonoscopy

Correct

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Question 34 of 40

34. Question
A 15-year-old boy is brought to the emergency department due to 4 days of intermittently having high-grade fevers, along with chills, headache, vomiting, and bilateral flank pain. He has no significant medical history, takes no medications, and has received all age-appropriate vaccinations. The patient traveled with his family to Vietnam for the summer and returned 2 weeks ago. Temperature is 39 C (102.2 F), blood pressure is 96/64 mm Hg, pulse is 120/min, and respirations are 24/min. Physical examination shows a normal oropharynx, clear lungs, normal heart sounds, and normal abdomen. There are no rashes or extremity edema. Laboratory results are as follows:

Complete blood count

Hemoglobin

9 g/dL

Hematocrit

27%

Platelets

110,000/mm³

Leukocytes

9,000/mm³

Neutrophils

84%

Eosinophils

2%

Lymphocytes

14%

Which of the following is most likely to establish a diagnosis in this patient?
- A. Assay for heterophile antibody
- B. Blood cultures
- C. Blood smear
- D. CT scan of the abdomen
- E. Stool cultures
Correct

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Question 35 of 40

35. Question
A 3-month-old female is evaluated in the neonatal intensive care unit for new-onset hypertension. She was born at 26 weeks gestation via spontaneous vaginal delivery. The mother received betamethasone prior to delivery due to preterm labor. The patient was apneic at birth and required intubation. Umbilical venous and arterial catheters were placed for resuscitation and removed the following day. After one week, she was extubated to continuous positive airway pressure and continues to require supplemental oxygen. The patient receives breastmilk via orogastric tube and has had 10 wet diapers and 2 yellow, seedy stools in the past 24 hours. Temperature is 37 C (99 F), pulse is 120/min, and respirations are 45/min. Blood pressure is 120/80 mm Hg in the right arm and 115/75 mm Hg in the right leg. Physical examination shows a well-appearing, alert infant. The anterior fontanelle is flat. Auscultation reveals a normal S1 and S2 with a 3/6 holosystolic murmur at the left sternal border. Breath sounds are coarse bilaterally. The abdomen is soft and nondistended. Brachial and femoral pulses are 2+. Which of the following is the most likely cause of elevated blood pressure in this patient?
- A. Antenatal steroids
- B. Aortic coarctation
- C. Bronchopulmonary dysplasia
- D. Intracranial hemorrhage
- E. Umbilical artery catheterization
Correct

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Question 36 of 40

36. Question
A 15-year-old girl is brought to the office by her mother for a health maintenance evaluation. The mother asks to first speak with the physician privately and expresses concern that her daughter is smoking marijuana. The mother says, “Although my daughter says she’s only tried it once or twice, I frequently smell it in her clothes and hair.” The patient has a history of asthma, managed with an albuterol inhaler as needed. She has no other medical problems. When questioned about drug use during the examination, the patient admits to smoking marijuana and says, “All my friends do it and I’ve never had a bad effect.” Physical examination is unremarkable. Which of the following is the best response to this patient?
- A. “Are you aware that, although marijuana is relatively safe, it can lead to using other drugs that are much more dangerous?”
- B. “I need you to tell me exactly how much and how frequently you are using marijuana.”
- C. “I would like to discuss some of the health effects of smoking marijuana, especially because you have asthma.”
- D. “I’m glad you have had no bad effects, but sometimes marijuana can be laced with other drugs.”
- E. “Some teenage patients smoke marijuana to feel more accepted by their friends; have you had a similar experience?”
Correct

Incorrect
Question 37 of 40

37. Question
A 28-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal appointment after a positive home pregnancy test. Her last menstrual period was 8 weeks ago, and she has had about 3 weeks of increasing fatigue, nausea, and daily vomiting but is still able to eat 2 meals a day. She has no chronic medical conditions and has a history of an appendectomy. Her only medication is a daily prenatal vitamin. She does not use tobacco, alcohol, or recreational drugs. Prepregnancy BMI is 18.5 kg/m². Blood pressure is 108/80 mm Hg, pulse is 90/min, and respirations are 16/min. Cardiopulmonary examination is normal. The abdomen is soft and nontender, and the uterus is palpated just above the pelvic brim. Urine dipstick is negative for glucose, protein, and nitrites. A pelvic ultrasound is performed, and findings are seen in the exhibit. This patient is at greatest risk for which of the following pregnancy complications?
- A. Discordant fetal growth
- B. Fetal dysmaturity
- C. Placenta accreta
- D. Poor maternal weight gain
- E. Uterine rupture
Correct

Incorrect

Question 38 of 40

38. Question

The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.

A cross-sectional study was conducted to evaluate the effect of treatment with protease inhibitors (PIs) on insulin sensitivity, oral glucose tolerance, and serum lipids in patients with HIV-1 infection. The goal of the study was to determine the association between treatment with PIs and insulin sensitivity. A total of 65 patients treated with PIs, 15 therapy-naive patients, and 20 HIV-1–negative controls were tested for insulin sensitivity. An excerpt of study results is shown in the box plots below, with the pathological threshold for insulin sensitivity indicated by a vertical line.

Item 1 of 2

Based on these results, which of the following best describes the percentage of patients treated with PIs who have a level of insulin sensitivity below the pathologic cutoff?

A. Fewer than 25% of patients
B. More than 25% but fewer than 50% of patients
C. More than 50% but fewer than 75% of patients
D. More than 75% of patients
E. Cannot be determined from the given information

Correct

Incorrect

Question 39 of 40

39. Question
Item 2 of 2

An analysis of the data revealed that all assumptions for statistical analysis had been met. Which of the following statistical tests would be most appropriate to determine whether a statistically significant difference in insulin sensitivity exists across all groups?
- A. Analysis of variance
- B. Chi-square test
- C. Correlation analysis
- D. Two-sample t test for means
- E. Two-sample z test for proportions
Correct

Incorrect

Question 40 of 40

40. Question

Patient Information

Age: 49 years

Gender: F

Ethnicity: unspecified

Site of Care: office

History
Reason for Visit/Chief Concern: follow-up for hypertension
History of Present Illness:

hypertension, 4 years
during recent office visits, blood pressure has been persistently high; chlorthalidone added 2 months ago
has since developed increasing constipation but otherwise feels well

Medical History:

hypercholesterolemia
hypertension

Surgical History:

none

Social History:

married, lives with family
former smoker, 20-pack-year history
no alcohol or recreational drug use

Family History:

noncontributory

Medications:

chlorthalidone 25 mg once a day
lisinopril 40 mg once a day
atorvastatin 10 mg once a day

Allergies:

no known drug allergies

Physical Examination

Temp

Pulse

Resp

BP

O₂ Sat

Ht

Wt

BMI

36.5 C

(97.7 F)

72/min

12/min

122/78

mm Hg

99%

on RA

–

34.4 kg/m²

Appearance: sitting comfortably
HEENT: normal
Pulmonary: clear lung sounds
Cardiac: regular rate and rhythm, no murmur
Abdominal: soft, nontender, normal bowel sounds
Extremities: no edema
Musculoskeletal: normal
Skin: normal
Neurologic: cranial nerves normal; normal peripheral sensation, strength, and reflexes
Psychiatric: alert and oriented; affect normal

Laboratory results

Serum Chemistry
Sodium	134 mEq/L (normal: 136-146)
Potassium	4.2 mEq/L (normal: 3.5-5)
Calcium	12.1 mg/dL (normal: 8.4-10.2)
Urea nitrogen	20 mg/dL (normal: 7-18)
Creatinine	1.1 md/dL (normal: 0.6-1.2)
Glucose	137 mg/dL (normal: 70-110)
Albumin	4 g/dL (normal: 3.5-5)

Parathyroid hormone	69 pg/mL (normal: 10-65)

Question: Which of the following is the most likely cause of this patient’s hypercalcemia?

A. Medication-induced volume depletion
B. Occult bone metastasis
C. Parathyroid hormone-related protein secretion
D. Primary hyperparathyroidism
E. Undiagnosed sarcoidosis

Correct

Incorrect

D-dimer, plasma	2.67 µg/mL (normal: <0.5)
Troponin T, serum	>80 ng/mL (normal: <0.04)

	Prealbuterol (% predicted)	Postalbuterol (% predicted)
FVC	90%	96%
FEV₁	61%	79%
FEV₁/FVC ratio	65%	80%

Complete blood count
Hemoglobin	9 g/dL
Hematocrit	27%
Platelets	110,000/mm³
Leukocytes	9,000/mm³
Neutrophils	84%
Eosinophils	2%
Lymphocytes	14%

CK- UWSA 3 – Block 1

CK- UWSA 3 – Block 1

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

pH

7.32

PaCO2

38 mm Hg

PaO2

43 mm Hg

Bicarbonate

19 mEq/L

Complete blood count is normal. Which of the following is best next step in management?

7. Question

Serum chemistry

Potassium

5.4 mEq/L

Blood urea nitrogen

54 mg/dL

Creatinine

2.4 mg/dL

Calcium

6.1 mg/dL

Uric acid

5.5 mg/dL

Which of the following is most helpful in evaluating the cause of this patient’s acute kidney injury?

8. Question

9. Question

Clinical response at week 12

Outcomes

New-umab (N = 50)

Standard-umab (N = 50)

p-value

NNT

NNH

PASI90 (n, %)

20 (40)

15 (30)

0.294

10

–

SAE (n, %)

11 (22)

2 (4)

0.007

–

6

NNH = number needed to harm; NNT = number needed to treat; PASI90 = Psoriasis Area Severity Index score ≥90; SAE = serious adverse event.

Based on these data, which of the following is the most appropriate conclusion regarding the occurrence of severe adverse events (SAEs)?

10. Question

11. Question

12. Question

13. Question

Which of the following is the most likely explanation for this patient’s symptoms?

14. Question

15. Question

Serum chemistry

Sodium

138 mEq/L

Potassium

5.1 mEq/L

Chloride

104 mEq/L

Bicarbonate

6 mEq/L

Creatinine

1.0 mg/dL

Calcium

9.6 mg/dL

Glucose

100 mg/dL

PaCO₂

PaO₂

New-umab
(N = 50)

Standard-umab
(N = 50)

PaO₂

PaCO₂

Prealbuterol
(% predicted)

Postalbuterol
(% predicted)

FEV₁

FEV₁/FVC ratio