CK- UWSA 3- Block 2

A 7-year-old boy is brought to the clinic for evaluation of a dry cough for 2 months.  He has no fever, headache, rhinorrhea, or congestion.  The patient’s cough is worse at night than during the day.  The patient sleeps with a humidifier, but he still wakes often at night and has fallen asleep at school on occasion.  The patient’s teacher reports that he coughs and becomes short of breath while playing outside during recess.  He has had no recent illnesses or sick contacts.  His mother has given cough suppressants and honey with no improvement.  The patient has no chronic medical conditions and takes no medications.  His father has seasonal allergies.  Vitals signs are normal.  Height and weight are at the 30th percentile.  Cardiopulmonary examination is normal.  Which of the following is the most appropriate next step in evaluation of this patient?

A 37-year-old woman, gravida 1 para 1, is evaluated on the postpartum unit for fever.  The patient underwent a prolonged labor induction for postterm gestation and is now postoperative day 2 after a cesarean delivery for arrest of descent.  She has a low appetite, but no nausea or vomiting.  The patient has been resistant to ambulation due to lower abdominal pain, which is minimally improved with pain medication.  Prepregnancy BMI was 34 kg/m².  The patient gained 17.2 kg (38 lb) this pregnancy.  Temperature is 100.8 F (38.2 C), pulse is 110/min, and respirations are 16/min.  Cardiovascular examination is regular and tachycardic.  There is bilateral breast engorgement and tenderness.  The uterus is tender and bowel sounds are hypoactive, but there is no rebound, rigidity, or guarding.  The skin incision is well-approximated; there is induration and serosanguinous discharge on the right side of the incision, but no erythema or purulent drainage.  The remainder of the physical examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

A 35-year-old man comes to the office due to cough, chest discomfort, and shortness of breath for the past 4 weeks.  The patient has been taking ibuprofen without improvement in his symptoms.  He also has had profound fatigue, weight loss, and occasional hemoptysis.  The patient recently emigrated from Eastern Europe; he says he was treated for a lung infection a year ago in his home country.  Temperature is 37.5 C (99.5 F), blood pressure is 115/75 mm Hg, and pulse is 95/min and regular.  On examination, the patient appears comfortable at rest.  Both lung bases are clear to auscultation.  There is no peripheral edema.  Chest x-ray reveals an enlarged cardiac silhouette.  What is the most likely cause of this imaging finding?

A 41-year-old man comes to the office due to 3 weeks of worsening bilateral vision impairment, intermittent floaters, a sensation of flashing lights, and photosensitivity.  He also reports headaches, dizziness, and tinnitus with no hearing loss.  The patient had a scaly rash on the extremities and trunk a month ago that spontaneously resolved.  He was treated for gonorrhea 4 years ago but reports no other chronic medical conditions.  Vital signs are within normal limits.  Physical examination demonstrates bilaterally decreased visual acuity.  Funduscopy shows findings of posterior uveitis.  There are whitish patches with erosion on the oral mucosa and scattered enlarged lymph nodes.  Neurologic examination shows neck stiffness but no focal weakness or sensory loss.  Which of the following is most likely to reveal the underlying cause of this patient’s current condition?

A 30-year-old man comes to the office for follow-up.  The patient has had almost daily abdominal pain for the past 2 years.  The pain causes a frequent urgency to defecate, which produces only mucus or minimal soft stool.  He was diagnosed with irritable bowel syndrome after a thorough work-up.  Despite appropriate dietary modification and initiation of as-needed antispasmodic therapy and loperamide antidiarrheal therapy, the patient continues to have bothersome abdominal discomfort that often interferes with his daily activities.  He has no other medical conditions.  Physical examination shows no abnormalities.  Which of the following pharmacotherapy options would be most beneficial for this patient?

A 6-year-old boy is brought to the office by his mother for assessment of anxiety.  His mother says, “He has started rubbing and picking at his skin.  He stayed home with me before starting school and I am concerned this is caused by anxiety.”  The patient started kindergarten a few months ago and is struggling to keep up in class.  He can copy shapes but is unable to write letters or count to 10.  His teacher noted that the patient tends to stay to himself and speaks very little.  Medical history is significant for feeding difficulty as an infant, requiring supplemental feeding.  The patient was able to sit at age 18 months and to walk at age 3 years.  Vital signs are within normal limits.  He is currently tracking on the 10th percentile for height and 90th percentile for weight.  Physical examination is significant for an overweight child with a narrow forehead, almond-shaped eyes, and red excoriations over the left hand and arm.  The patient is noted to have small hands and genitalia.  He makes little eye contact and begins to cry when the physician asks him questions.  Which of the following is likely to be found on diagnostic testing?

A 25-year-old man comes to the emergency department for right knee pain following a motorcycle collision that occurred earlier in the day.  Immediately after the accident, the patient noted severe pain and marked swelling in his right knee.  Pain was minimally relieved by rest, ice, and over-the-counter analgesia.  The patient can bear weight, but he feels that the knee is “giving out.”  He particularly has difficulty walking down stairs.  Vital signs are normal.  X-rays of the right knee demonstrate an avulsion fracture of the anterolateral tibial plateau.  MRI of the knee would most likely reveal which of the following?

Patient Information

Age: 28 years

Gender: F, self-identified

Race/Ethnicity: unspecified

Site of Care: emergency department

History

Reason for Visit/Chief Concern: “I’m having a severe panic attack.”

History of Present Illness:

• started having chest pain, shortness of breath, pounding heart, and sweating 1 hour ago

• has also had lightheadedness

Past Medical History:

• panic disorder diagnosed 3 years ago; inadequate response to cognitive-behavioral therapy; began taking fluoxetine and clonazepam 2 months ago

• endometriosis well controlled with oral contraceptive pills and as-needed nonsteroidal anti-inflammatory drugs

Allergies:

• no known drug allergies

Family History:

• noncontributory

Psychosocial History:

• smokes cigarettes occasionally; no alcohol or recreational drug use

• married, no children

• works as a graphic designer

Physical Examination

• Appearance: anxious

• Pulmonary: clear lungs

• Cardiac: regular rhythm; normal S₁ and S₂

• Neurologic: fully oriented; no focal deficits

• Mental Status: cooperative; nondepressed mood; no suicidal ideation

Diagnostic Studies

• Chest x-ray: no infiltrate, consolidation, or effusion

• ECG: sinus tachycardia; no ST-segment elevation or depression

Question: Which of the following is the best next step in management of this patient?

A 48-year-old woman is being evaluated for abnormal urinalysis result.  The patient was initially seen 2 weeks ago as a new patient.  She was found to have undiagnosed hypertension and type 2 diabetes mellitus, and appropriate treatments have been started.  Urinalysis sent during initial evaluation revealed numerous yeasts without leukocyte esterase or white blood cells.  The patient reports no suprapubic or flank pain, dysuria, frequency, or urgency.  She also has had no vaginal discharge or pruritus.  Temperature is 37 C (98.6 F), blood pressure is 142/80 mm Hg, and pulse is 70/min.  Physical examination shows no abdominal or costovertebral tenderness.  External genitalia and pelvic examinations are normal.  Which of the following is the best next step in management of this patient’s urinary condition?

A 77-year-old woman is admitted to the intensive care unit for unwitnessed out-of-hospital cardiac arrest.  She required 30 minutes of cardiopulmonary resuscitation before spontaneous circulation was restored.  The patient was endotracheally intubated prior to transport to the hospital and has been comatose for the past 7 days, despite being weaned off sedation.  Hemodialysis was initiated 2 days ago due to anuria, believed to be a result of ischemic tubular necrosis.  On examination, the patient is unresponsive to any stimulus.  Pupils are not reactive to light.  Brain imaging reveals diffuse cerebral edema.  During the family meeting to discuss her poor prognosis and goals of care, the patient’s children express uncertainty and disagreement regarding their mother’s wishes regarding end-of-life care.  The patient has no advance directive for health care on file.  Which of the following recommendations from the physician is most appropriate at this time?

A 66-year-old woman comes to the office with increasing right groin pain for the past 2 weeks.  The pain is worse with weight bearing but, lately, has been present at rest.  She has had no fever or other joint pain.  The patient had a right femoral neck fracture after a fall 8 months ago, which was treated with open reduction and internal fixation with a screw.  Medical history also includes hypertension and type 2 diabetes mellitus.  Vital signs are within normal limits.  Physical examination shows painful but intact passive range of motion of the right hip joint.  No tenderness to palpation of the hip is present.  Sensation in the lower extremities is intact.  Which of the following is the most likely cause of this patient’s hip pain?

A 54-year-old man comes to the office for follow-up after a recent colonoscopy.  Six weeks ago, the patient was hospitalized due to abdominal pain in the left lower quadrant; CT scan of the abdomen revealed focal thickening of the sigmoid wall.  He has never had similar symptoms.  The symptoms resolved with treatment, and the patient underwent outpatient colonoscopy a week ago, which revealed sigmoid colon findings as shown in the exhibit.  He now feels well and reports no residual symptoms.  Physical examination is normal.  Which of the following is the most appropriate recommendation for preventing future complications from this patient’s condition?

A 38-year-old man comes to the emergency department due to chest pain.  The patient reports nonexertional, central chest discomfort radiating to his neck that has increased over the past several days.  He has had no dyspnea, cough, or palpitations.  He was diagnosed with bicuspid aortic valve in childhood but has not seen a physician in 20 years.  The patient takes no medications and does not use tobacco, alcohol, or recreational substances.  Family history is significant for his father requiring aortic valve surgery at an early age.  Blood pressure is 130/80 mm Hg on both arms and pulse is 78/min.  Physical examination demonstrates an ejection click best heard at the cardiac apex that is accompanied by a brief ejection murmur.  The lungs are clear to auscultation.  There is no chest wall tenderness.  ECG shows sinus rhythm with no ST-segment or T-wave changes.  Serum troponin is normal.  Chest x-ray reveals no infiltrate, consolidation, or effusion.  Which of the following additional tests is most appropriate at present?

A 16-year-old girl comes to the office for a high school sports physical.  The patient has no chronic medical conditions but reports that she has had little appetite, intermittent abdominal pain, and difficulty sleeping for the past 2 weeks.  She says, “I think I may have lost 3-4 pounds.  I feel anxious and depressed for no reason and wake up several times a night.”  The patient does well in school.  She has been looking forward to playing basketball but feels some pressure to play well to earn an athletic college scholarship next year.  The patient has a history of depression at age 12 following her parent’s divorce that was treated with psychotherapy.  She takes no medications.  The patient drinks alcohol at parties.  She does not use tobacco.  She smoked cannabis daily but quit 3 weeks ago in anticipation of the basketball season coming up soon.  Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 10/min.  BMI is 18.5 kg/m².  Physical examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

A 12-year-old girl is brought to the emergency department due to episodes of anxiety, tachycardia, and diaphoresis.  She has been sleeping poorly for the last 2 weeks and has developed a desquamating rash, which her mother attributes to profuse sweating.  The patient has elevated urinary catecholamines; however, extensive evaluation for pheochromocytoma is unrevealing.  Measuring levels of which of the following substances is the best next step in management of this patient?

A 2-year-old boy is brought to the office by his mother due to behavioral issues.  The mother has noticed that over the past 2 months, his behavior “has taken a turn for the worse.”  When the patient does not get what he wants, he responds by crying, screaming, and throwing himself onto the floor.  For example, yesterday, he started to cry and roll on the floor after his mother refused to give him another cookie; she tried to sit at his level and calmly discuss his frustration, but he pushed her away.  These episodes have occurred 2 or 3 times per week, with each episode lasting about 10 minutes.  The patient is otherwise doing well.  He sleeps 12 hours overnight and eats 3 meals and 2 snacks every day.  Growth and development are appropriate for age; he has no medical conditions.  The patient lives with his parents and a 3-month-old sister.  Which of the following is the most appropriate advice to the mother regarding the patient’s behavior?

A 25-year-old woman comes to the office due to blurry vision in both eyes for the past week.  The patient works as a nurse and first noticed the vision change when she had difficulty reading telemetry monitors.  She has had no eye pain, redness, or discharge.  The patient also reports increased thirst and urination.  Medical history includes type 1 diabetes mellitus diagnosed 2 years ago and currently managed with a basal-bolus insulin regimen.  The patient states she recently started overnight shifts and has not been able to take insulin as prescribed.  Blood glucose level as measured at home ranges from 200 to 300 mg/dL.  The patient’s most recent ophthalmology evaluation was 3 months ago and was unremarkable, with visual acuity measured as 20/20.  Vital signs are normal.  On physical examination, extraocular movements and pupillary responses are normal.  There is no conjunctival edema or erythema.  Visual acuity using a Snellen chart is 20/50.  The fundus appears grossly normal on ophthalmoscopic examination, and tonometry readings are normal.  Point-of-care hemoglobin A1c is 9.0%.  Which of the following is the best next step in management of this patient’s vision change?

A 12-year-old boy is brought to the office by his father for follow-up evaluation of chest and abdominal discomfort.  For the past 6 months, the boy has had a sensation of food sticking in his chest associated with a burning feeling after eating, particularly with solid food.  He has also vomited on several occasions after eating solid food, so he restricts his diet mainly to soft food such as yogurt and mashed potatoes.  Omeprazole was prescribed 8 weeks ago, but the symptoms persist.  Vital signs are normal for age.  Physical examination is normal apart from eczematous patches on bilateral antecubital fossae and behind both knees.  Which of the following is the most appropriate next step in evaluation of this patient?

A 24-year-old man comes to the emergency department due to a severe lip laceration.  During a recreational boxing match, the patient received a punch to the right side of the face that split his upper lip and threw his head backward so that he lost his balance and fell; he did not lose consciousness.  He has generalized soreness from the fight, but the worst pain is in the right upper lip and right neck.  Vital signs are normal.  Multiple bruises are present on the face and upper body.  On the right upper lip, there is a 3-cm, jagged laceration involving the orbicularis muscle.  No bony tenderness exists in the face or the midline posterior cervical spine.  The neck is supple; a right carotid bruit is present.  Neurologic examination is normal.  In addition to repair of the lip laceration, which of the following is the most appropriate next step in management?

A 28-year-old man comes to the office for follow-up of a wrist sprain sustained in a motor vehicle collision a week ago.  He reports long-standing problems with distracted driving, which has resulted in several misdemeanors for not slowing down in a school zone and for speeding.  Although his mood is usually good, he has felt “unstable” because his girlfriend broke up with him 2 weeks ago after he abruptly quit his job and lost his health insurance.  The patient previously worked on an assembly line and was given warnings for having quality-control issues and not meeting minimum quotas.  He says, “It wasn’t a good fit anyway.  The job was boring and none of my supervisors respected me.”  The patient shares that, throughout his childhood, his parents often became upset when he forgot to do his chores, and he struggled with completing assignments and keeping up with peers, which made him feel angry that he was “never good enough.”  Questions must be repeated at times during the evaluation.  The patient’s thought process is logical but circumstantial.  Which of the following is the most likely diagnosis?

A 55-year-old man with a history of hypertension, type 2 diabetes mellitus, and irritable bowel disease is hospitalized for treatment of community-acquired pneumonia.  The patient receives appropriate treatment, and his respiratory status and symptoms improve.  However, on the fourth day of hospitalization, he has abdominal cramping followed by 4 episodes of watery diarrhea.  Vital signs and physical examination are normal.  Which of the following is the best next step?

A researcher hypothesizes that long-term treatment with an immunosuppressive medication used to treat plaque psoriasis in adults may cause a very rare but serious progressive neurologic disease that develops years after treatment.  The researcher wants to conduct a study to investigate the potential association between treatment with the immunosuppressive medication and the very rare neurologic disease.  Which of the following study designs would be most appropriate to achieve the researcher’s goal?

A 39-year-old woman, gravida 2 para 1, at 24 weeks gestation comes to the office for a prenatal visit.  She feels well and has no symptoms.  Fetal movement is normal.  The patient has no chronic medical conditions.  Prepregnancy BMI was 24 kg/m², and she has gained 9.1 kg (20.1 lb) this pregnancy.  Vital signs are normal.  Fundal height is 29 cm.  Fetal heart tones are 156/min on Doppler ultrasound.  Urinalysis shows 2+ glucose and trace protein.  After undergoing glucose tolerance testing, the patient is diagnosed with gestational diabetes mellitus.  She is counseled on the appropriate diet and exercise regimen.  In addition to monitoring fasting blood glucose measurements, which of the following is the best next step in management of this patient?

A 34-year-old woman comes to the office for medical evaluation.  She recently returned to the United States after completing a government project in India.  The patient reports no symptoms.  She has a history of hypothyroidism and takes levothyroxine and a combined estrogen/progestin oral contraceptive pill.  The patient drinks a glass of wine nightly and does not smoke cigarettes or use recreational drugs.  Immunizations are up to date.  Vital signs and physical examination are normal.  Complete blood count, serum chemistry studies, and liver aminotransferases are within normal limits.  Interferon gamma release assay is positive.  Tuberculosis symptom screening and chest x-ray are negative.  Treatment options for latent tuberculosis are discussed, and a prescription for daily rifampin for 4 months is given.  Which of the following additional recommendations is most appropriate for this patient during the treatment course?

A 46-year-old woman comes to the emergency department due to severe pain in her left buttock near the anus.  The pain is particularly worse when passing stool.  Although the patient is uncertain when the discomfort first began, she notes that the pain has increased significantly over the past 24 hours.  She has never experienced symptoms like this.  Two years ago, the patient was diagnosed with type 2 diabetes mellitus, which has been controlled with oral medication.  Temperature is 37.7 C (99.9 F), blood pressure is 125/82 mm Hg, and pulse is 89/min.  A well-defined, 2-cm, hot, tender, mass is located between the anus and the left ischial tuberosity.  The mass fluctuates on palpation.  What is the most appropriate next step in management of this patient?