CK- UWSA 3- Block 4

A 48-year-old woman comes to the office due to 2 months of worsening fatigue, a 10-kg (22-lb) unintentional weight loss, and recurrent low-grade fevers.  She was diagnosed with rheumatoid arthritis 5 years ago and has been on anti–tumor necrosis factor (TNF) therapy for a year.  The patient was ruled out for tuberculosis prior to starting the TNF inhibitor, and she has not traveled recently from her home state of Indiana.  Temperature is 37.9 C (100.2 F), blood pressure is 100/70 mm Hg and pulse is 96/min.  On physical examination, the patient is thin and ill appearing.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender with hepatosplenomegaly.  There is generalized muscle weakness, normal range of motion, and no active joint swelling or tenderness.  Laboratory results are as follows:

High-resolution CT scan of the chest and abdomen reveals a diffuse reticulonodular infiltrate of both lung fields with mediastinal lymphadenopathy, hepatosplenomegaly, retroperitoneal lymphadenopathy, and bilateral adrenal gland enlargement.  Which of the following is the most likely cause of this patient’s current condition?

A 15-month-old girl is brought to the clinic for evaluation of persistent fevers.  Her symptoms began 4 days ago with fever and fussiness.  The patient vomited once but has had no diarrhea or cough.  She has no chronic medical conditions and takes no medications aside from acetaminophen for the fever.  Weight is stable at the 15th percentile.  Temperature is 39 C (102.2 F), pulse is 120/min, and respirations are 20/min.  The patient is alert.  Bilateral conjunctivae are clear, and tympanic membranes appear normal.  The oropharynx is clear without ulcerations.  The neck is supple, and there is no lymphadenopathy.  Cardiopulmonary examination is unremarkable.  Abdominal examination shows no palpable liver or spleen, and there are no skin lesions.  Laboratory results are as follows:

A manual peripheral smear reveals a normal morphologic appearance of erythrocytes and platelets.  Granulocytes are decreased, and the few segmented neutrophils visualized contain 4-5 nuclear lobes.  Which of the following is the best next step in evaluation of this patient’s neutropenia?

A cross-sectional study is conducted to examine differences between women and men with type 2 diabetes mellitus with regard to cardiometabolic risk factors, pharmacologic treatment, and achievement of risk factor control.  A total of 6,637 individuals (40% women) participated in the study.  Linear and Poisson regression analyses were used to examine sex differences (women − men) in cardiometabolic risk factor levels, treatment, and control.  Results on cardiometabolic risk factor levels are presented below:

Based on these results, which of the following conclusions is strongly justified?

A 40-year-old man comes to the office to follow up on type 2 diabetes mellitus, which was diagnosed a year ago.  The patient feels well and has no specific concerns.  Current management includes dietary modification, exercise, and metformin, which he takes as prescribed.  The patient does not smoke and drinks 1 or 2 glasses of wine 3 times a week.  Temperature is 36.7 C (98.1 F), blood pressure is 122/76 mm Hg, and pulse is 80/min.  BMI is 29 kg/m².  Fasting laboratory results are as follows:

Urine albumin/creatinine ratio is 15 mg/g (normal: <30).  The addition of which of the following is most appropriate in management of this patient?

A 16-year-old boy comes to the office due to intermittent nausea, watery diarrhea, and a bloating sensation for the past several months.  The patient has also had episodic periumbilical pain, especially after a meal, and has lost 2.3 kg (5.1 lb) since the symptoms started.  He emigrated from rural Thailand with his family approximately 8 months ago.  Shortly after arriving in the United States, the patient developed dry cough, shortness of breath, and wheezing that spontaneously resolved after several days; otherwise, he has no medical conditions.  The patient is afebrile, and other vital signs are within normal range.  Bilateral breath sounds are normal.  Heart sounds are normal with no murmur.  The abdomen is soft and nontender, and bowel sounds are normal.  Laboratory results are as follows:

Which of the following is the most appropriate diagnostic study for this patient?

A 34-year-old woman, gravida 2 para 1, at 12 weeks gestation comes to the emergency department due to nausea and vomiting.  The patient had been feeling well; however, over the past day, she developed severe nausea and she has vomited several times.  She has also had upper abdominal pain that is worse after she tries to eat solid food.  She has had no diarrhea or constipation.  The patient’s first pregnancy resulted in an uncomplicated delivery at term gestation.  She has no chronic medical conditions or prior surgeries.  The patient’s only medication is a prenatal vitamin.  BMI is 34 kg/m².  Blood pressure is 146/88 mm Hg and pulse is 96/min.  Fetal heart tones are 170/min on Doppler.  Cardiopulmonary examination is normal.  On abdominal examination, there is right upper quadrant and midepigastric discomfort to deep palpation; no palpable masses are present.  Laboratory results are as follows:

Urinalysis is normal.  Which of the following is the best next step in management of this patient?

An 18-month-old boy is brought to the clinic for a well-child check.  His parents say that he has been generally well but are concerned because he seems hungry despite frequent feedings.  The patient eats portions of meals, as well as 2 or 3 small fruit snacks throughout the day and whole cow’s milk from a cup.  He has been voiding and stooling well.  The patient was born at 27 weeks gestation and was admitted to the neonatal intensive care unit for the first 9 weeks of life.  His global developmental milestones are at the level expected for a 15-month-old child, and he continues to show steady improvement since starting early intervention therapies a year ago.  Vitals are normal.  On examination, the patient is alert, active, and without obvious deformities.  His growth chart is below.

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

A 4-year-old boy is brought to the office due to a progressively increasing sore throat, difficulty eating solid foods, neck pain, and fever with chills for 2 days.  The patient has had a cough and runny nose for a week.  He has no chronic medical conditions, and immunizations are up to date.  Temperature is 38.9 C (102 F), blood pressure is 110/60 mm Hg, pulse is 130/min, and respirations are 28/min.  Oxygen saturation is 98% by pulse oximetry.  On examination, the voice is muffled.  The patient has tender anterior cervical lymphadenopathy.  He sits upright, holding his neck stiff and straight, and has difficulty opening his mouth.  The posterior oropharynx appears erythematous.  The uvula is in the midline.  Lung fields are clear with good air entry.  Neurologic examination shows no abnormalities.  What is the best next step in management of this patient?

A 31-year-old woman, gravida 3 para 2, at 29 weeks gestation with a monochorionic, monoamniotic twin pregnancy presents with contractions.  The contractions began this morning and are painful, occurring every 3 to 4 minutes.  She has had no leakage of fluid.  Her past medical history includes chronic hypertension.  The patient has had only intermittent prenatal care, but her prior 2 pregnancies ended with spontaneous vaginal deliveries at term.  External fetal monitoring shows category I tracing for both fetuses.  Tocodynamometer shows contractions every 3 minutes.  Blood pressure is 135/90 mm Hg, pulse is 105/min, and respirations are 18/min.  On physical examination, the cervix is 5 cm dilated and there is mucous-like vaginal discharge that is lightly blood tinged.  Ultrasound shows that the presenting twin is in vertex, occiput anterior position.  The second twin has a vertex presentation, and the placenta is located at the fundus.  Urine dipstick shows 1+ protein.  A cesarean delivery is recommended.  Which of the following is the indication for cesarean delivery in this patient?