CK- UWSA 3- Block 4

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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:

Hematocrit	22%
Platelets	80,000/mm³
Leukocytes	2,600/mm³

Cortisol, serum	5 µg/dL (normal: 8-20)

C-reactive protein (CRP)	32 mg/L
Erythrocyte sedimentation rate	100 mm/h

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. Autoimmune adrenalitis
B. Chronic myeloid leukemia
C. Disseminated histoplasmosis
D. Mixed connective tissue disease
E. Secondary amyloidosis

Correct

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Question 8 of 40

8. Question

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:


Complete blood count
Hemoglobin	12 g/dL
Platelets	205,000/mm³
Leukocytes	3,000/mm³
Neutrophils	30%
Lymphocytes	70%

Urinalysis
Leukocyte esterase	negative
Nitrites	negative

Influenza A	positive
Influenza B	negative

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. Bone marrow evaluation
B. Genetic testing
C. Neutrophil myeloperoxidase levels
D. Repeat complete blood count in a month
E. Serum B12 level

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Question 9 of 40

9. Question
A 15-year-old boy is brought to the office by his mother due to delayed puberty. He has had no significant growth of facial, axillary, or pubic hair and has experienced no change in genital characteristics since childhood. The patient has been consistently measured at the 60th percentile for height and weight and has followed normal developmental milestones. Examination shows mild gynecomastia. Laboratory results show a prepubertal testosterone level with elevated FSH and LH. Karyotype is 47,XXY. Which of the following is the most appropriate statement in discussing these test results?
- A. “I have test results for your son. However, we should wait until his father is available to discuss them further.”
- B. “I need to talk with your son privately to discuss this diagnosis.”
- C. “Your child has an inherited condition. Family members should be tested as well.”
- D. “Your child’s symptoms are due to a genetic condition that could not have been prevented.”
- E. “Your son has a chromosomal disorder. Unfortunately, there is no treatment available.”
Correct

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Question 10 of 40

10. Question
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. Compared with men, women have a significantly lower mean BMI
- B. Men and women have similar mean levels of HbA1c and SBP
- C. There is no significant difference in log triglycerides between men and women
- D. Women are 26% more likely to have lower LDL-c levels than men
- E. Women have significantly higher mean DBP and significantly lower mean TC compared with men
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Question 11 of 40

11. Question
An 83-year-old woman is brought to the office by her daughter due to a skin lesion. The patient has Alzheimer disease with progressive dementia and moved into her daughter’s house 6 months ago for closer care. The daughter noticed the lesion on the patient’s back during bathing and has become concerned due to its slow enlargement. She reports no itching or pain at the lesion. Skin examination findings are shown in the exhibit. Which of the following is the most appropriate next step in diagnosis of the patient?
- A. Excisional biopsy with narrow margin
- B. Excisional biopsy with wide margin
- C. Incisional biopsy
- D. No additional testing needed
- E. Shave biopsy
Correct

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Question 12 of 40

12. Question
A 47-year-old man is evaluated in the office for abdominal pain. The patient has a prolonged history of restricting subtype anorexia nervosa and recently started a nutritional rehabilitation program. As his oral intake has increased, the patient has experienced worsening postprandial fullness and epigastric pain. The symptoms are often relieved by emesis. The patient prefers liquid rather than solid food. His weight is 51% of the ideal body weight with a BMI of 14 kg/m². Physical examination is notable for cachexia and epigastric fullness. There is no rebound tenderness. CT scan of the abdomen with oral and intravenous contrast reveals distension of the stomach and proximal duodenum with abrupt delay in contrast passage at the third portion of the duodenum. There is abnormal narrowing of the angle between the superior mesenteric artery and the aorta. Which of the following is the most appropriate next step in management of this patient’s abdominal symptoms?
- A. Endoscopic stent placement
- B. Exploratory laparotomy
- C. Laparoscopic surgical decompression
- D. Mesenteric artery embolization
- E. Reassurance and slow nutritional rehabilitation
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Question 13 of 40

13. Question
A 65-year-old woman comes to the office due to a 2-month history of epigastric discomfort, bloating, and early satiety. The patient’s symptoms are constant but worsen after meals. She has had no weight loss, vomiting, or changes in bowel habits but has experienced dysphagia. Medical history includes type 2 diabetes mellitus and hypertension; both were diagnosed 10 years ago and have been well-controlled. Medications include oral antihypertensive and antidiabetic therapy, aspirin, and a statin. The patient drinks a glass of wine on most evenings and does not use tobacco. Vital signs are normal. Examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?
- A. Abdominal ultrasound
- B. CT scan of the abdomen and pelvis
- C. Esophagogastroduodenoscopy
- D. Trial of a proton pump inhibitor
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Question 14 of 40

14. Question
A 38-year-old woman comes to the emergency department in the winter for evaluation of dyspnea and chest discomfort. She describes breathlessness associated with a tight sensation. The symptoms began 4 hours ago soon after she woke up and intensified over the next 30 minutes. Medical history is significant for Hodgkin lymphoma 15 years ago that was treated successfully with chemotherapy and mediastinal radiation. Temperature is 36.5 C (97.7 F), blood pressure is 168/94 mm Hg, pulse is 82/min, and respirations are 20/min. Pulse oximetry shows 97% on room air. On examination, the patient appears anxious and mildly diaphoretic. Cardiac auscultation is normal. Jugulovenous distension and peripheral edema are absent. The lungs are clear throughout. ECG demonstrates normal sinus rhythm with no acute ST-T segment changes. Serum troponin I is 1.12 ng/mL (normal: <0.04). Chest x-ray shows no acute abnormalities. Which of the following is the most likely diagnosis?
- A. Acute coronary syndrome
- B. Constrictive pericarditis
- C. Pulmonary embolism
- D. Restrictive cardiomyopathy
- E. Type A aortic dissection
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Question 15 of 40

15. Question
A 63-year-old man is seen in the oncology clinic for newly diagnosed non–small cell lung cancer. Medical history includes chronic obstructive pulmonary disease with moderate airflow limitation. The patient developed vague chest discomfort, increased cough, and episodic hemoptysis 6 months ago. Staging evaluation revealed a primary mass in the left upper lobe, involvement of ipsilateral hilar nodes, but no metastatic lesions. Based on large registry data and center experience, he has an 80% chance of cure with surgical resection followed by chemotherapy. The patient is anxious about his diagnosis and has been lying awake at night while ruminating about his future. His respiratory symptoms are mostly stable, but he reports slightly worsened dyspnea over the past few weeks. The patient remains active with no trouble completing daily household tasks and continues to participate in social gatherings with his friends. The oncology clinic works closely with the palliative care department. Which of the following best represents the services that should be offered to the patient?
- A. Curative oncologic treatment and palliative care offered together
- B. Curative oncologic treatment offered without palliative care
- C. Palliative care offered only if the patient develops metastatic disease
- D. Palliative care offered only if the patient develops more severe symptoms
- E. Palliative care offered only if the patient elects to enter hospice
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Question 16 of 40

16. Question
A 22-year-old woman comes to the emergency department due to a 3-week history of watery diarrhea. She also has had nausea, vomiting, and crampy upper abdominal pain. The patient has no fever and no blood or mucus in her stool. She underwent kidney transplantation for chronic glomerulonephritis 3 years ago. Current medications include a stable immunosuppressive regimen. The patient is a veterinary student. Temperature is 36.8 C (98.2 F), blood pressure is 106/74 mm Hg, pulse is 100/min, and respirations are 16/min. The abdomen is soft, nontender, and nondistended. Stool testing is negative for fecal leukocytes and occult blood. A comprehensive metabolic panel and complete blood cell count are also unremarkable. Stool studies are pending. What is the most likely causal pathogen in this patient?
- A. Clostridioides difficile
- B. Cryptosporidium parvum
- C. Cytomegalovirus
- D. Listeria monocytogenes
- E. Salmonella Enteritidis
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Question 17 of 40

17. Question
A 50-year-old man comes to the office because he wants to quit smoking. He has tried quitting on his own unsuccessfully, but now he wants to do “everything possible” to increase his chances of success. The patient is a business consultant who flies to a different city every week. Medical history is unremarkable. Physical examination is normal. The physician prescribes varenicline and nicotine replacement therapy. Adding which of the following behavioral interventions would be most effective for achieving long-term smoking cessation in this patient?
- A. Ask the patient to call an in-office counselor when cravings become severe
- B. Give the patient self-help pamphlets and audio recordings to use on an airplane
- C. Have an in-office counselor call the patient regularly at prearranged times to check on progress
- D. Have the patient come to the office for intensive counseling when he is in town
- E. Instruct the patient to call 800-QUIT-NOW right before lighting a cigarette
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Question 18 of 40

18. Question
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:

Total cholesterol

205 mg/dL

HDL

45 mg/dL

LDL

110 mg/dL

Triglycerides

250 mg/dL

Hemoglobin A1c

6.8%

Glucose

115 mg/dL

Creatinine

1.1 mg/dL

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. Amlodipine
- B. Gemfibrozil
- C. Glimepiride
- D. Lisinopril
- E. Rosuvastatin
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Question 19 of 40

19. Question
A 28-year-old man comes to the office due to dizziness. Over the past month, the patient has had 3 episodes in which he felt he was whirling around in circles; the most recent episode was 7 days ago. He also reports a low humming noise and a sensation of fullness in his right ear during these episodes. The patient is currently writing his PhD dissertation and stays up very late working. Each of the episodes started during the evening after he had been writing for several hours. Symptoms resolved after sleeping. The patient is otherwise healthy and takes no medications. Vital signs are within normal limits. Neurologic examination is normal. MRI of the brain is normal. Audiometry shows low-frequency hearing loss in the right ear. Which of the following is the most appropriate next step in management?
- A. Canalith repositioning maneuvers
- B. Daily low-dose diazepam therapy
- C. Daily topiramate therapy
- D. Diet and lifestyle modifications
- E. Short course of oral prednisone therapy
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Question 20 of 40

20. Question
A 30-year-old woman comes to the emergency department due to a 4-week history of progressively worsening nausea, vomiting of undigested food, early satiety, and an unintentional 2.3-kg (5.1-lb) weight loss. The patient has no abdominal pain. The symptoms started after a recent flu-like illness that included fever, generalized body aches, nausea, and malaise. Her only other medical concern is major depression, for which she takes sertraline. Vital signs are normal. Examination discloses mild epigastric tenderness to palpation and is otherwise normal. Complete blood count and comprehensive metabolic panel are normal. Upper gastrointestinal endoscopy reveals retained gastric contents but no obstruction. CT enterography shows a distended stomach with no obstruction. A gastric emptying study using a solid meal reveals significant delay in stomach emptying at 4 hours. What is the most appropriate next step in management of this patient?
- A. Discontinue sertraline therapy
- B. Frequent small meals with low fat and low fiber
- C. Infrequent concentrated meals with high fat and high fiber
- D. Initiate oral proton pump inhibitor therapy
- E. Percutaneous feeding tube placement into the jejunum
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Question 21 of 40

21. Question

A 12-year-old girl is brought to the urgent care by her parents due to dark urine for the past day. The patient has had no lower abdominal pain or dysuria. She has no chronic medical conditions but had an upper respiratory tract infection a few days ago that resolved; she took acetaminophen as needed during her illness. She had one prior episode of red-tinged urine last year, also after a mild respiratory illness. Temperature is 37.2 C (99 F), blood pressure is 142/87 mm Hg, pulse is 85/min, and respirations are 22/min. Physical examination shows a tired-appearing girl with nasal discharge. The abdomen is soft and nontender with no suprapubic or costovertebral angle tenderness. In addition to laboratory confirmation of hematuria, which of the following laboratory values are expected in this patient?

Option	Complement	UA findings
A	Normal	4+ protein, WBC casts
B	Low	4+ protein, muddy brown casts
C	Normal	1+ protein, RBC casts
D	Low	1+ protein, RBC casts
E	Normal	2+ protein, muddy brown casts
F	Low	2+ protein, WBC casts

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Question 22 of 40

22. Question
A 66-year-old woman comes to the emergency department due to difficulty moving her face. The patient had no unusual symptoms this morning, but just before lunch she felt that the left side of her face was “melting.” At lunchtime, she could not sip her iced tea out of a straw. The symptoms continued to worsen over the next few hours, so the patient came to the emergency department. Vital signs are within normal limits. On examination, the extraocular movements are intact, and the conjunctivae are clear. The external auditory canals are clear, and tympanic membranes are normal. Examination of the face is shown in the exhibit. Muscle strength is 5/5 in all 4 extremities. Deep tendon reflexes are normal. There is no Babinski sign. Sensation over the face and body are normal. Which of the following is the best next step in management?
- A. Dix-Hallpike maneuver
- B, Eyelid closure evaluation
- C. Fluoroscopic swallowing evaluation
- D. Spirometry for bedside vital capacity
- E. Weber test with tuning fork
Correct

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Question 23 of 40

23. Question
A 14-year-old boy with Down syndrome is brought to the office due to new-onset behavioral changes. At baseline, the patient has severe intellectual disability and difficulty communicating. He lives at home with his parents and a caregiver and attends a special school. His mother reports that the patient is usually quiet and social but has become aggressive recently. The patient occasionally bangs his head on a pillow and is verbally abusive to his caregiver. Review of systems is positive for constipation but negative for fever, vomiting, and appetite changes. Vital signs are within normal limits. Physical examination shows normal dentition, tonsils and adenoids, and ear canals. Abdomen is distended but soft and nontender. Digital rectal examination shows normal tone and guaiac-negative stool in the rectal vault. The remainder of the examination, including neurologic examination, shows no abnormalities. Blood cell counts, serum chemistry studies, and urinalysis are within normal limits. Which of the following is the most appropriate next step in management of this patient?
- A. Begin daily low-dose antipsychotic therapy
- B. Behavioral modifications with appropriate rewards and consequences
- C. Initiate scheduled benzodiazepine therapy
- D. Obtain abdominal x-ray
- E. Obtain MRI of the brain
Correct

Incorrect
Question 24 of 40

24. Question
A group of students conducted a case-control study to evaluate the association between severe exposure to electromagnetic fields from cell phone use and brain cancer. Cases (n = 50) were adults age 21-45 with brain cancer, and controls (n = 200) were adults age 21-45 without brain cancer. All participants completed a structured questionnaire to collect data on demographics, general health, and level of exposure to electromagnetic fields from cell phone use. A total of 27 cases and 99 controls had a severe exposure to electromagnetic fields from cell phone use (odds ratio of 1.2 with a 95% confidence interval of 0.64-2.23). The students reported that severe exposure to electromagnetic fields from cell phone use was 1.2 times more common in adults with brain cancer than in adults without brain cancer, and that severe exposure to electromagnetic fields from cell phone use is significantly associated with brain cancer. Based on this information, which of the following is true about the students’ conclusion?
- A. The students are correct because the confidence interval excludes 0
- B. The students are correct because the estimated odds ratio is greater than 1.0
- C. The students are incorrect because case-control studies cannot estimate risk
- D. The students are incorrect because the findings are not statistically significant
Correct

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Question 25 of 40

25. Question
A 65-year-old man comes to the hospital due to acute onset of pain in both feet that began 6 hours ago. He has never had similar symptoms before. The patient reports no chest pain, dyspnea, palpitations, or leg claudication. Medical history is significant for hypertension and hypercholesterolemia. He has no history of surgical procedures. The patient has a 30-pack-year smoking history. Temperature is 37.1 C (98.8 F), blood pressure is 140/90 mm Hg, pulse is 90/min and regular, and oxygen saturation is 96% on room air. Heart sounds are normal; there are no murmurs or additional heart sounds. The lungs are clear to auscultation, and the abdomen is soft and nontender. A pulsatile mass is palpated in the epigastrium. Femoral and popliteal pulses are intact. There is no lower extremity edema. Examination of the feet shows cool skin with multiple cyanotic toes. Which of the following is the most likely cause of these symptoms?
- A. Acute arterial atheroemboli
- B. Antiphospholipid antibody syndrome
- C. Aortoiliac stenosis
- D. Inferior vena cava obstruction
- E. Nonocclusive arterial ischemia
- F. Thromboangiitis obliterans
Correct

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Question 26 of 40

26. Question
A newborn girl is evaluated in the delivery room immediately after birth. She was born to a 25-year-old primigravida via vaginal delivery at 39 weeks gestation. The pregnancy was complicated by poorly controlled gestational diabetes mellitus. The delivery was uncomplicated, and the amniotic fluid was clear. The patient does not cry on delivery and is taken immediately to the warmer. There are minimal spontaneous movements, and the trunk and extremities are cyanotic. Which of the following is the most appropriate next step in management of this patient?
- A. Begin chest compressions
- B. Initiate positive pressure ventilation
- C. Initiate tactile stimulation
- D. Intubate and administer surfactant
- E. Provide supplemental oxygen
Correct

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Question 27 of 40

27. Question

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:

Complete blood count
Hemoglobin	10.4 g/dL
Mean corpuscular volume	72 fL
Leukocytes	8,000/mm³
Neutrophils	60%
Eosinophils	10%
Lymphocytes	30%

Serum albumin	3.4 g/dL
Serum amylase	91 U/L

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

A. Antiendomysial antibodies
B. Bronchoalveolar lavage
C. CT scan of the abdomen with oral contrast
D. Stool analysis for ova and parasites
E. Upper gastrointestinal endoscopy
F. Urinary 5-hydroxyindoleacetic acid level

Correct

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Question 28 of 40

28. Question

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:

Complete blood count
Hemoglobin	12 g/dL
Hematocrit	36%
Platelets	180,000/mm³
Leukocytes	9,000/mm³

Serum chemistry
Sodium	136 mEq/L
Potassium	3.8 mEq/L
Chloride	104 mEq/L
Bicarbonate	20 mEq/L
Creatinine	0.8 mg/dL

Alkaline phosphatase	70 U/L (normal: 17-88 in first trimester)
Aspartate aminotransferase (SGOT)	12 U/L
Alanine aminotransferase (SGPT)	24 U/L
Amylase	21 U/L
Lipase	32 U/L (normal: 21-76 in first trimester)

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

A. 24-hour urine total protein collection
B. Dietary modification and pyridoxine supplementation
C. Observation and reassurance only
D. Quantitative serum β-hCG level
E. Ultrasound of the right upper quadrant

Correct

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Question 29 of 40

29. Question
A 57-year-old man comes to the office to discuss his pain medication. Over the past 2 years, he has required an escalating dose of extended-release oxycodone to control abdominal pain from chronic pancreatitis, with the most recent dose increase being 3 months ago. The next scheduled prescription renewal is in 3 weeks, but the patient has run out of the medication because he has been taking it more frequently than prescribed due to worsening pain. He also used a fentanyl patch from a friend and requests a prescription for fentanyl 200 mcg/hr transdermal patches, which is equivalent to a dose escalation from his current dose of oxycodone. Vital signs are normal. On examination, the patient is alert and has mild epigastric tenderness. Previous urine drug tests have all been appropriately positive for oxycodone and negative for other substances. The state prescription drug monitoring database reveals no irregularities. A signed controlled substance agreement is on file. The physician recommends evaluation by the patient’s gastroenterologist, but the patient refuses, saying “All I need is the fentanyl patch. If you won’t prescribe it, I’ll find another doctor.” Which of the following is the most appropriate response to the patient?
- A. “Are you taking the opioid medications for any other purposes besides helping you with the pain?”
- B. “Taking someone else’s opioid medication violates the controlled substance agreement; I would like you to find another doctor within the next 30 days.”
- C. “Unless you see the gastroenterologist to evaluate your pain, I cannot manage your pain any further.”
- D. “Your need for increasing amounts of medication concerns me. How do you feel about seeing an addiction specialist?”
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Question 30 of 40

30. Question
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. Measure TSH level
- B. Obtain growth hormone level
- C. Reassure and follow up routinely
- D. Send Prader-Willi genetic testing
- E. Switch to low-fat milk and reduce meal frequency
Correct

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Question 31 of 40

31. Question
A 25-year-old woman, gravida 2 para 1, comes to the emergency department due to vaginal bleeding. Her last menstrual period was 13 weeks ago, and 2 weeks ago the patient had a positive home urine pregnancy test. Yesterday, she began having intense lower abdominal cramps along with vaginal bleeding. The patient reports soaking 8 pads overnight, and she noticed some tan-colored tissue intermixed with large blood clots. Temperature is 37.3 C (99.1 F), blood pressure is 108/80 mm Hg, and pulse is 102/min. The abdomen is soft and nontender to palpation. On pelvic examination, there is a small amount of bright red blood coming from the cervix. The cervix is closed, and the uterus is 6-week-sized, retroverted, and slightly tender to palpation. A pelvic ultrasound reveals a heterogenous endometrium measuring 2 cm, a simple cyst in the right adnexa, and a small amount of free fluid in the posterior cul-de-sac. Hemoglobin is 10.9 mg/dL and maternal blood type is O, Rh negative. Which of the following is the most appropriate next step in management of this patient?
- A. Anti-D immune globulin
- B. Broad-spectrum antibiotics
- C. Diagnostic laparoscopy
- D. Mifepristone and misoprostol
- E. Suction curettage
Correct

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Question 32 of 40

32. Question
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. Assay for diphtheria toxin
- B. Barium swallow test
- C. CT scan of the neck
- D. Laryngoscopy
- E. Lumbar puncture
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Question 33 of 40

33. Question
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?
- A. Monoamniotic twin pregnancy
- B. No indication for cesarean delivery
- C. Position of presenting twin
- D. Uncontrolled chronic hypertension
- E. Vaginal bleeding
Correct

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Question 34 of 40

34. Question
A 62-year-old man comes to the emergency department due to recurrent left-sided weakness. The patient experienced similar symptoms a month ago, when he was found to have a small ischemic stroke in the right middle cerebral artery territory. Evaluation revealed an atherosclerotic stenosis in the right internal carotid artery, and a percutaneous stent was placed 2 weeks later. The patient did not follow up after stent placement but reports that his weakness was improving. On waking today, he noticed worsening of the left-sided weakness and new slurring of speech. Medical history includes hypertension, type 2 diabetes mellitus, and chronic tobacco use. Temperature is 37.1 C (98.8 F), blood pressure is 142/86 mm Hg, and pulse is 80/min and regular. Physical examination shows left-sided facial droop, dysarthria, and left-sided hemiplegia. Which of the following is the most likely cause of this patient’s current symptoms?
- A. Carotid artery dissection
- B. Carotid baroreceptor stimulation
- C. Carotid in-stent thrombosis
- D. Carotid intimal hyperplasia
- E. Cerebral hyperperfusion
Correct

Incorrect
Question 35 of 40

35. Question
A 24-year-old man is brought to the emergency department after an attacker soaked him with gasoline and set him on fire. The patient has burns to >65% of his body. He was intubated at the scene. Medical history is unknown. Temperature is 37.6 C (99.7 F), blood pressure is 117/70 mm Hg, and pulse is 135/min. Oxygen saturation is 96% on 40% FiO₂ with volume-controlled mechanical ventilation. On examination, the patient is intubated and sedated. He has deep partial- and full-thickness burns to his face, neck, chest, and upper and lower back. There are also deep and superficial partial-thickness burns to his extremities. He is administered intravenous fluids and admitted to the burn intensive care unit. Some 24 hours later, the high peak pressure alarm sounds multiple times on his ventilator, the patient’s lungs become difficult to ventilate, and he is increasingly hypotensive. Auscultation demonstrates clear lungs. Heart sounds are normal. The abdomen is soft and nondistended. Chest x-ray reveals no significant infiltrates or consolidations. What is the best next step in management of this patient?
- A. Administer intravenous furosemide
- B. Administer nebulized albuterol
- C. Increase the positive end-expiratory pressure
- D. Increase the tidal volume
- E. Perform a thoracic escharotomy
Correct

Incorrect
Question 36 of 40

36. Question
A 65-year-old woman comes to the emergency department due to gradually worsening abdominal pain. The patient underwent laparotomy and lysis of intraabdominal adhesions to treat small bowel obstruction 3 weeks ago. The surgery and immediate postoperative course were uncomplicated, and she was discharged after she began tolerating a diet. Over the past several days, the patient has had increasing diffuse abdominal discomfort without fever, nausea, or vomiting. She is able to eat and pass gas. Medical history includes hypertension and hysterectomy for uterine leiomyomas. Home medications are amlodipine and hydrocodone as needed. Temperature is 37 C (98.6 F), blood pressure is 126/78 mm Hg, and pulse is 66/min. Physical examination shows a well-healed surgical incision. The abdomen is distended but soft with mild diffuse tenderness. Bowel sounds are normoactive in all quadrants. Digital rectal examination reveals brown stool in the rectal vault. An abdominal x-ray is obtained and is shown in the exhibit. Which of the following is the best next step in management?
- A. CT scan of the abdomen with contrast
- B. Fluoroscopic small bowel follow-through study
- C. Nasogastric tube suction and bowel rest
- D. Oral laxatives and tap water enema
- E. Urgent exploratory laparotomy
Correct

Incorrect
Question 37 of 40

37. Question
An 18-year-old man is brought to the emergency department after passing out in a gym. Before the patient started his workout, he collapsed. There was no seizure-like activity, and he spontaneously regained consciousness within a minute. The patient reports no chronic medical conditions. Blood pressure is 106/60 mm Hg and pulse is 58/min. On physical examination, the patient appears thin and younger than the stated age. Heart sounds are normal. ECG shows sinus bradycardia and a QTc of 500 msec. Echocardiography reveals decreased left ventricular wall thickness, reduced cardiac chamber volumes, and small pericardial effusion. Ventricular systolic function is normal. Based on the findings, this patient should be further evaluated for which of the following conditions?
- A. Androgenic steroid use
- B. Chagas disease
- C. Eating disorder
- D. Hypothyroidism
- E. Sarcoidosis
Correct

Incorrect
Question 38 of 40

38. Question
A 40-year-old woman comes to the office for follow-up regarding depression. She has been prescribed paroxetine for the past year. The patient reports doing well overall but has been more stressed by her job as a security guard. For the past 2 weeks, she has had to work longer hours due to a coworker quitting and frequently alternates between day and night shifts. During this time, the patient has had some periods of anxiety and restlessness, often accompanied by a headache and muscle aches, which she attributes to her sleep schedule and having to stand while working. She says, “I usually fall asleep right when I get home and wake up just in time for the next shift. Sometimes I forget which day it is because they’ve all started to blur together.” Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate statement?
- A. “Changing your sleep schedule frequently is challenging; I recommend starting melatonin to help switch between day and night shifts.”
- B. “I’m concerned that your job is causing you to feel stressed and physically unwell; have you considered taking some time off?”
- C. “Many people experience stress from time to time; let’s continue to monitor your symptoms and follow-up in 1 month.”
- D. “The symptoms you’re describing may be due to increased thyroid hormones; we can order bloodwork to check your levels.”
- E. “You’ve had a lot of schedule changes in the past few weeks; how have you been taking your medication during this time?”
Correct

Incorrect
Question 39 of 40

39. Question
A 56-year-old woman with a history of schizophrenia is hospitalized for right upper quadrant abdominal pain and diagnosed with cholecystitis. The patient is initially treated with antibiotics, and a scheduled cholecystectomy is planned. On day 2 of hospitalization, she reports that she feels much better. The patient does not want to undergo surgery and instead prefers to go home with oral antibiotics. She says, “I know that God is on my side and will take care of me.” The patient lives in a group home and is prescribed risperidone daily, although she states that she missed 2 doses in the past week due to abdominal pain. Her brother lives nearby and helps with errands and transportation to appointments. On examination, the patient is alert and fully oriented. She reports hearing voices commenting on her behaviors “all the time” and states she is “used to them now.” The patient has no suicidal ideation. Which of the following is the best next step in management?
- A. Ask the patient for permission to discuss treatment recommendations with her brother
- B. Discuss with the patient’s treating psychiatrist her condition and her request to leave the hospital
- C. Inquire about the patient’s understanding of the potential health risks of leaving the hospital
- D. Obtain consent for hospitalization from the patient’s brother due to medication nonadherence and psychosis
- E. Recommend continued hospitalization to the patient and proceed with involuntary hospitalization if she declines
- F. Respect the patient’s wishes and discharge her with a scheduled follow-up visit in 1 week
Correct

Incorrect
Question 40 of 40

40. Question
A 40-year-old woman, gravida 5 para 0 aborta 4, at 35 weeks gestation comes to labor and delivery triage after not feeling her baby move over the past 24 hours. The patient has eaten little all day and skipped dinner due to nausea. Her last ultrasound at 32 weeks gestation showed a fetus in breech position measuring at the 15th percentile and placenta previa. The patient has no chronic medical conditions and has had no prior surgeries. She takes a prenatal vitamin daily and has no medication allergies. Blood pressure is 132/86 mm Hg and pulse is 90/min. BMI is 20 kg/m². The patient has gained 20 lb (9.1 kg) during the pregnancy. The abdomen is gravid, soft, and nontender. A nonstress test shows a baseline fetal heart rate in the 130s with moderate variability and no decelerations. There are no accelerations after an hour of monitoring despite vibroacoustic stimulation. Tocodynamometry shows no contractions. Which of the following is the most appropriate next step in management of this patient?
- A. Biophysical profile
- B. Cesarean delivery
- C. Continuation of nonstress test
- D. Contraction stress test
- E. Umbilical artery flow velocimetry
Correct

Incorrect

Total cholesterol	205 mg/dL
HDL	45 mg/dL
LDL	110 mg/dL
Triglycerides	250 mg/dL
Hemoglobin A1c	6.8%
Glucose	115 mg/dL
Creatinine	1.1 mg/dL

CK- UWSA 3- Block 4

CK- UWSA 3- Block 4

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

Hematocrit

22%

Platelets

80,000/mm3

Leukocytes

2,600/mm3

Cortisol, serum

5 µg/dL (normal: 8-20)

C-reactive protein (CRP)

32 mg/L

Erythrocyte sedimentation rate

100 mm/h

8. Question

Complete blood count

Hemoglobin

12 g/dL

Platelets

205,000/mm3

Leukocytes

3,000/mm3

Neutrophils

30%

Lymphocytes

70%

Urinalysis

Leukocyte esterase

negative

Nitrites

negative

Influenza A

positive

Influenza B

negative

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?

9. Question

10. Question

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

11. Question

12. Question

13. Question

14. Question

15. Question

16. Question

17. Question

18. Question

Total cholesterol

205 mg/dL

HDL

45 mg/dL

LDL

110 mg/dL

Triglycerides

250 mg/dL

Hemoglobin A1c

6.8%

Glucose

115 mg/dL

Creatinine

1.1 mg/dL

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?

19. Question

20. Question

21. Question

Option

Complement

UA findings

80,000/mm³

2,600/mm³

205,000/mm³

3,000/mm³

8,000/mm³