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Question 1 of 11
A 71-year-old man with metastatic prostate cancer comes to the office due to progressively worsening back pain. The patient reports pain of 5 on a 10-point scale. The pain is notably worse with movement and limits his activity. He reports no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3 or 4 times a day, and his pain is not controlled. The patient takes androgen deprivation therapy and has also received palliative radiotherapy for multiple lumbar spine metastases recently. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal. Which of the following is the most appropriate initial therapy for this patient’s pain?
Question 2 of 11
A 42-year-old man comes to the office for a routine medical evaluation. He has no known medical conditions but has not seen a health care provider in many years. The patient has had an intermittent, nonproductive cough and otherwise feels well. He takes no medications, drinks alcohol occasionally, and does not use tobacco or illicit drugs. Vital signs are within normal limits. Physical examination shows no scleral icterus or mucosal pallor. The lungs are clear on auscultation and heart sounds are normal. The liver edge is palpable 3 cm below the right costal margin, and the spleen tip is palpable below the left costal margin. There is no skin rash or extremity edema. Laboratory results are as follows:
Complete blood count
Liver function studies
Aspartate aminotransferase (SGOT)
Alanine aminotransferase (SGPT)
Chest x-ray shows mediastinal fullness and bilateral reticulonodular opacities, mostly involving the upper lungs. Which of the following is the most likely underlying cause of this patient’s liver disease?
Question 3 of 11
A 54-year-old man comes to the office due to several episodes of coughing up bloody sputum. The patient has also noticed weight loss, anorexia, constipation, increased thirst, and fatigue. He smoked 2 packs of cigarettes daily for 32 years but quit last month. Vital signs are within normal limits. The patient appears slim and pale. Physical examination is otherwise normal. Laboratory results are as follows:
Blood urea nitrogen
Chest x-ray shows a left-sided hilar mass. Whole-body bone scan is normal. Histopathology of the hilar mass is most likely to reveal which of the following?
Question 4 of 11
A 25-year-old woman, gravida 3 para 0 aborta 2, at 6 weeks gestation comes to the office for a routine prenatal visit. The patient says she feels fine except for mild nausea; she takes no medications other than a prenatal vitamin. Her 2 prior pregnancies ended in first-trimester spontaneous abortions. Prior to this pregnancy, the patient drank alcohol on social occasions, and she does not use tobacco or illicit drugs. She is in a monogamous relationship and has never been diagnosed with or treated for a sexually transmitted infection. Laboratory results are as follows:
Complete blood count
Activated partial thromboplastin time
Urinalysis shows no blood or protein. Sonogram shows a 6-week fetal pole with cardiac motion. Which of the following is the best next step in the management of this patient?
Question 5 of 11
A 25-year-old woman comes to the office due to “chest pain” that began 2 days ago. The pain is described as a constant soreness across the chest, and the patient is unable to sleep prone because of the pain. She is an avid runner and kickboxer and has been unable to maintain her normal exercise routine due to discomfort wearing a sports bra. The patient is sexually active with her husband and recently stopped taking oral contraceptives because the couple are trying to have a child. Her last menstrual period was 3 weeks ago; menses are regular, occur approximately every 28 days, and last for 6 days. The patient takes a daily folic acid supplement and no other medications. Vitals signs are normal. Palpation demonstrates bilateral, nonfocal chest tenderness and diffusely nodular, dense breasts. Which of the following is the most likely diagnosis in this patient?
Question 6 of 11
A 48-year-old woman is evaluated for a painless lump in the right breast, which was first noticed by the patient 3 weeks ago. She has no prior medical problems and has had no mammograms. Her aunt was diagnosed with breast cancer at age 60. Physical examination reveals a 1 x 1.5 cm, firm, mobile mass in the upper outer quadrant of the right breast with no skin or nipple changes. There are no enlarged axillary or cervical lymph nodes. Mammography shows a spiculated mass, and fine-needle aspiration biopsy is positive for invasive ductal carcinoma. The patient undergoes right mastectomy and axillary lymph node dissection. Tumor analysis is negative for estrogen and progesterone receptors but positive for human epidermal growth factor receptor 2 (HER2) gene amplification. Adjuvant therapy containing trastuzumab is planned. Which of the following is most appropriate prior to starting the medication in this patient?
Question 7 of 11
A 78-year-old woman is brought to the hospital for urinary incontinence. The patient has a history of Alzheimer dementia and has been living in a nursing home for the past 3 years. She requires assistance for most of her daily activities. The patient can indicate to the nursing home staff when she needs to use the bathroom. She has been less active for the past week and sleeps most of the time. She also has developed urinary incontinence, which she has never had before. Her temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, and pulse is 76/min. On examination, the patient is somnolent but responsive to voice. She is disoriented but has no focal neurologic deficits. The abdomen is soft and nontender. Genitourinary examination shows thin and pale vaginal mucosa with ill-defined labia minora. Which of the following is the best next step in managing this patient’s urinary incontinence?
Question 8 of 11
A 28-year-old nulliparous woman comes to the office due to malodorous vaginal discharge for the last month. The patient has tried various over-the-counter vaginal douche products with no improvement. Her last menstrual period was 2 weeks ago, and she noticed no change in her symptoms during that time. In addition to the discharge, the patient has had intermittent, crampy abdominal pain and sometimes feels like gas is passing through her vagina. The patient has had no surgeries. Vital signs are normal. Speculum examination shows a malodorous, tan vaginal discharge and a patch of erythema on the posterior vaginal wall. The cervix is nulliparous and has no visible lesions or areas of friability. A sinus with purulent drainage is also present in the perianal skin. Which of the following is the most likely underlying cause of this patient’s presentation?
Question 9 of 11
A 41-year-old woman comes to the office for the evaluation of a lump on her left breast. She feels, “generally well,” and denies having any medical problems. She takes a multivitamin and Tums daily. She stopped smoking after getting married 21 years ago. She drinks wine only on weekends. Her only surgery was a bilateral tubal ligation last year, after giving birth to her fourth child. Physical examination of the left breast reveals a 4 cm lump at the 11 o’ clock position and two axillary nodes on the left side. Mammography shows irregular micro-calcifications. The result of the FNA is suggestive for infiltrating ductal carcinoma. Which of the following is the single most important prognostic factor in this patient?
Question 10 of 11
A 56-year-old woman comes to the office due to epigastric abdominal pain for the past year. The pain worsens after eating and is described as crampy, intermittent, and nonradiating. The patient has had bloating and nausea but no unexpected weight loss, vomiting, constipation, diarrhea, melena, hematochezia, or changes in bowel habits. Medical history is significant for hypertension and hypothyroidism. Family history is unremarkable. She does not use tobacco or alcohol. Temperature is 37.5 C (99.5 F), blood pressure is 142/67 mm Hg, pulse is 80/min, and respirations are 14/min. The patient is not in acute distress. Heart and lung sounds are unremarkable. The abdomen is mildly tender to palpation in the epigastrium without rebound, guarding, or distension. Laboratory results are as follows:
Complete blood count
Mean corpuscular volume
Which of the following is the most likely diagnosis in this patient?
Question 11 of 11
A 69-year-old woman comes to the office for a routine preventive visit. She has no specific concerns and feels well. The patient lives alone, drinks alcohol socially, and does not smoke. Other than an emergency appendectomy 40 years ago, she has no significant medical history. The patient takes no medications and has no personal or family history of cancer or heart disease. She had a normal mammogram and lipid panel 2 years ago and a normal resting ECG and Pap smear with human papillomavirus cotesting at age 65. A colonoscopy 7 years ago showed no lesions. Which of the following studies is most appropriate at this time?
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