Step 3 – NBME 7 – Block 4

A 30-year-old woman is admitted to the hospital because of a 2-day history of fever and left flank pain. For the past 5 days she also has had dysuria and urinary urgency and frequency. Medical history is significant for chronic hepatitis B infection. She takes no medications and has no drug allergies. Her last menstrual period was 7 weeks ago. She is sexually active with one male partner and uses condoms inconsistently. Vital signs are temperature 38.9°C (102.1°F), pulse 118/min, respirations 20/min, and blood pressure 100/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Auscultation of the chest discloses no abnormalities. There is left costovertebral tenderness to palpation. The abdomen is soft; palpation discloses suprapubic tenderness but no masses. Pelvic examination discloses no abnormalities. Results of laboratory studies are shown:

Urine and blood cultures are obtained and results are pending. Which of the following is the most appropriate antibacterial agent to administer?

An 85-year-old man is brought to the office by his daughter who is visiting from out of town because, she says, “I’m concerned about his mind.” The daughter states he has lost interest in participating in family events; he no longer answers his telephone and he rarely calls anyone. He seems to ignore her when she speaks to him and she has to yell at him to get his attention. He lives alone and is independent in all activities of daily living. He is a retired small weapons tester. He says he does not watch television much anymore; he reads magazines instead. He attends church regularly and often meets friends at a social club. Medical history is significant for stable angina and arthritis of his fingers. Medications include sublingual and long-acting nitroglycerin, and amlodipine. The patient appears frail. BMI is 24 kg/m2. Vital signs are normal. Physical examination discloses early bilateral cataracts. The tympanic membranes are well visualized and appear normal for age. Cardiopulmonary examination discloses a grade 2/6 systolic ejection murmur and an S4. There is no peripheral edema. Results of laboratory studies are within the reference ranges. Which of the following screening assessments is most appropriate at this time?

A 39-year-old woman is admitted to the hospital because of a 24-hour history of severe suprapubic abdominal pain and a 3-day history of foul-smelling vaginal discharge. She has been generally healthy and she takes no medications. She is divorced and has been in a monogamous sexual relationship for the past 3 years with her female partner. Her last menstrual period was 4 weeks ago. Vaginal spotting began yesterday. Her menstrual periods occur at normal intervals and usually last for 5 days, with light flow on the first day and heavier flow during subsequent days. She uses one to two tampons daily for heavy flow. Vital signs on admission are temperature 39.1°C (102.5°F), pulse 110/min, respirations 18/min, and blood pressure 90/50 mm Hg. Skin is warm and dry with normal turgor. There is a fine maculopapular rash over her entire body. Neurologic examination discloses no abnormalities. Results of laboratory studies are shown:

Which of the following findings in this patient most strongly indicates a good prognosis?

A 17-month-old girl is brought to the emergency department by her parents following a 3-minute seizure that resolved spontaneously. For the past day, the child has had temperatures to 38.9°C (102.0°F), decreased oral intake, and nonbilious vomiting. She was given acetaminophen twice today for fever. The mother says her daughter fell chasing a ball 3 days ago, but she got up and kept playing. The mother adds, “When my brother was 6 years old, he had seizures when he used to get hot with ear infections, but he outgrew them.” The patient attends day care and her vaccinations are up-to-date, with the last doses given at age 15 months. Now, the child is alert and drinking juice. Temperature is 39.8°C (103.6°F). Physical examination discloses clear rhinorrhea but no other abnormalities. Which of the following historical factors most increased this patient’s risk for her present condition?

A 57-year-old man with type 2 diabetes mellitus is admitted to the hospital because of a 3-day history of pain and redness of the fourth toe on his left foot that has progressed to the point at which he now has difficulty walking. Medical history also is significant for hypertension diagnosed 3 years ago. Medications are daily metformin and lisinopril; the patient states that he forgets to take his metformin occasionally. BMI is 32 kg/m2. Vital signs are temperature 38.9°C (102.0°F), pulse 102/min, respirations 22/min, and blood pressure 85/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination of the left foot discloses bullae with thick, purple, malodorous discharge extending across the entire dorsum of the foot. Palpation of the area elicits no tenderness. The left fourth toe is deep purple to black in color, with a 1-cm ulcer located on the pad of the toe. The toe is cold to touch and is not tender to palpation. Blood cultures are obtained. In addition to initiating broad-spectrum antibiotic therapy, which of the following is the most appropriate initial step in management?

A 58-year-old man, who is recovering in the hospital 6 hours after undergoing an uncomplicated left hemicolectomy for treatment of adenocarcinoma of the descending colon, now reports incisional pain. Medical history also is significant for hypertension, benign prostatic hyperplasia, chronic kidney disease, and degenerative arthritis in both knees. Routine medications are hydrochlorothiazide and occasional oxycodone. The patient smokes one to two cigarettes daily; he has been trying to quit for 3 years and previously smoked one pack daily for 30 years. Vital signs now are temperature 37.2°C (99.0°F), pulse 76/min, respirations 16/min, and blood pressure 130/78 mm Hg. Examination of the surgical incision site shows a dry, intact dressing; palpation of the area discloses tenderness. Results of laboratory studies obtained preoperatively are shown:

Which of the following is the most appropriate pharmacotherapy for this patient’s postoperative pain?

A 75-year-old man is admitted to the hospital because of the sudden onset 10 hours ago of blurred vision and altered mental status. Medical history is significant for hypertension, hyperlipidemia, and anemia. The patient has missed three follow-up appointments during the past 14 months for evaluation of the anemia. Medications are atorvastatin and chlorthalidone. He does not smoke cigarettes. He lives at home with his daughter. BMI is 23 kg/m2. Vital signs are temperature 36.9°C (98.4°F), pulse 74/min, respirations 14/min, and blood pressure 142/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. The patient is oriented to person but not to time or place. Direct ophthalmoscopy shows sausage-shaped dilatations of the retinal veins. Lymph nodes are enlarged in the cervical, axillary, and inguinal regions. Liver edge and spleen tip are both easily palpated; liver span measures an estimated 16 cm by percussion. Results of laboratory studies are shown:

An abnormality in which of the following is the most likely cause of this patient’s symptoms?

A 22-year-old female university student is brought to the clinic by her mother 1 day after the patient was dismissed from class because of disruptive behavior. Her professor said she stood up while he was teaching and announced that class was dismissed. The patient has pressured speech and speaks rapidly; she says she feels “wonderful” and has no idea why she is at the clinic. Her mother says the patient has been sleeping only 1 to 2 hours nightly during the past week. The patient says she has been staying up to work on papers and that her family is tracking her movements through her laptop. She says she feels like a puppet controlled by her family and makes accompanying marionette-like gestures with her arms. The mother also says her daughter has become increasingly hypersexual during the past week, and she spent an entire financial aid check purchasing clothing and a new computer. Medical history is significant for asthma treated with an albuterol metered-dose inhaler. The patient has not had any recent alcohol or drug use. She is unsure of the date of her last menstrual period. BMI is 32 kg/m2. Vital signs are temperature 36.1°C (97.0°F), pulse 115/min, respirations 20/min, and blood pressure 144/79 mm Hg. Physical examination discloses no abnormalities. Urine pregnancy test is positive. Which of the following is the most appropriate pharmacotherapy?

A 79-year-old Mexican American woman is admitted to the hospital for open reduction and internal fixation of a left femoral neck fracture. Medical problems include diabetes mellitus, osteoarthritis, and hearing impairment. She had a cholecystectomy and hysterectomy with bladder suspension. Current medications are metformin and naproxen. On the second postoperative day her appetite is decreased and she is not having bowel movements. Vital signs are temperature 37.1°C (98.8°F) orally, pulse 84/min, respirations 16/min, and blood pressure 156/78 mm Hg. On physical examination the abdomen is distended, soft, and nontender. There is a small amount of stool in the rectal vault that is negative for occult blood. Bowel sounds are diminished and high pitched. Results of laboratory studies are shown:

Upright abdominal x-ray shows a cecal diameter of 14 cm, and ascending and transverse colon diameters of 11 cm. There is no small-bowel dilation and few air-fluid levels. Gas is present in the dilated sigmoid colon and is seen in the rectum. Which of the following is the most likely diagnosis?

A 6-year-old boy is brought to the health center by his mother. She says, “His asthma is getting worse. He uses his albuterol inhaler every day now instead of one or two times per week. We just moved here and we don’t have a doctor yet. Could it be something in our house?” The boy’s medical history is remarkable for asthma since age 3 years, which usually has been controlled with occasional nebulizer treatments and the albuterol inhaler. He has never been hospitalized for asthma. His vaccinations are up-to-date. Height and weight are normal for his age. Vital signs are normal. Physical examination discloses a few scattered expiratory wheezes bilaterally. The mother states that she has just remarried and moved into a newly constructed house with wall-to-wall carpeting. Her son has been jealous of her husband’s two children. The family has had a dog for the past 2 years. The mother does not smoke cigarettes but her husband does smoke cigarettes in the home at times. Which of the following factors is most likely associated with this patient’s worsening condition?

A 6-month-old female infant is brought to the office by her mother because of a rash that appeared 5 days ago. The mother says she first noticed the rash under her daughter’s arms, but that the lesions have spread over her entire body since that time. She also reports a few red bumps on the infant’s right wrist that were not present yesterday. She says her daughter has appeared uncomfortable and has been rubbing herself on the bed sheets. She has not had fever and there have been no changes in her feeding or voiding. The mother has not used any new laundry detergents, creams, or lotions on the infant. The infant is breast-fed. No other family members have had any recent illnesses. Medical history is unremarkable and vaccinations are up-to-date. The infant attends a day-care facility. Vital signs are temperature 37.1°C (98.7°F), pulse 130/min, and respirations 28/min. Physical examination discloses the rash shown in the photograph. Which of the following is the most appropriate pharmacotherapy at this time?

A 7-year-old girl, who was diagnosed with complex partial seizures 4 weeks ago, is brought to the office by her parents for follow-up after starting oxcarbazepine therapy 4 weeks ago. She has not had any seizures since starting therapy. Medical history is otherwise unremarkable and she takes no other medications. The patient is at the 30th percentile for height and the 20th percentile for weight. Vital signs are normal and physical examination discloses no abnormalities. The patient’s parents want to know what safety precautions they should implement in light of the child’s condition. The most appropriate advice is that the patient should be restricted from doing which of the following?

A 14-month-old white girl is brought to the office by her mother for the first time for a well-child visit. Her family has recently moved to the community. Medical records indicate that the child was born at term; pregnancy and delivery were uncomplicated. At age 3 months, a difference in muscle tone was noted between the right and left sides. At age 5 months, decreased movement on the left side and a preference for use of the right hand were noted. At age 8 months, the child was able to sit upright with support. At age 12 months, she was able to stand on her tiptoes with support, and now she is able to take a step with support. Weight is 10 kg (21 lb; 25th percentile), length is 74 cm (29 in; 25th percentile), and head circumference is 46 cm (18 in; 25th percentile). Vaccinations are up-to-date. Vital signs today are temperature 37.0°C (98.6°F), pulse 98/min, and respirations 22/min. The infant interacts well during today’s examination and refers to her mother as “mama.” Physical examination shows increased muscle tone that is more prominent on the left side and in the upper extremities. Deep tendon reflexes are increased bilaterally, and Babinski sign is present on the left with ankle clonus. Which of the following is the most likely conclusion about this patient’s condition?

A 2-week-old female newborn is brought to the clinic for her first well-child examination. She was born to a 32-year-old primigravid woman at 39 weeks’ gestation via cesarean delivery because of breech presentation. The pregnancy otherwise was uncomplicated. Family history is remarkable for rheumatoid arthritis in the newborn’s maternal grandmother and systemic lupus erythematosus in a maternal aunt. At birth, the patient was 49 cm (19 in; 50th percentile) long and weighed 3800 g (8 lb 6 oz; 80th percentile); head circumference was 35 cm (14 in; 75th percentile). Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Since discharge from the hospital, the newborn has been feeding well and has had normal urine and stool output. The mother reports the patient likes to sleep mostly on her side or in her car seat and is very fussy when placed flat on her back. The patient otherwise has been doing well. Today, the patient weighs 3940 g (8 lb 11 oz; 75th percentile). Vital signs are within normal limits. The patient appears well. Physical examination discloses decreased abduction of the left hip; Barlow maneuver is positive. Which of the following factors in this newborn’s history most increased her risk for developing this condition?

A 25-year-old Norwegian man comes to the emergency department because, he says, “I was bitten by a dog yesterday and I want to get rabies shots.” The patient is on vacation in the USA and has been staying with a friend during his visit. He says he has been playing vigorously with his friend’s large dog and was bitten on his left arm when he tried to take the dog’s toy away. He reports that he washed the wound with soap and water. The friend told the patient that the dog is healthy, has never bitten anyone in the past, and received “all of his shots” 2 years ago. The friend and dog live in the middle of a large city and have not traveled. Examination of the patient’s left arm discloses a superficial clean wound with no evidence of infection. The patient plans to return to Norway in 5 days. Which of the following is the most appropriate recommendation to the patient regarding rabies prophylaxis?

A 20-year-old college student is admitted to the hospital because of severe epigastric pain radiating to her back that began suddenly 3 hours ago. She also has had a 2-day history of malaise, generalized aching, swollen glands around her jaw, and fever. Medical history is unremarkable and the patient’s only medication is an oral contraceptive. She does not drink alcoholic beverages, smoke cigarettes, or use illicit drugs. She is sexually active with one partner. She appears moderately ill. Vital signs are temperature 38.3°C (101.0°F), pulse 110/min, respirations 22/min, and blood pressure 100/70 mm Hg. Glands in front of the ears and under the jaw are swollen and tender to palpation. There is exquisite tenderness over the epigastrium. Results of laboratory studies are shown:

Serologic studies for which of the following is most likely to confirm the diagnosis?

A 60-year-old man comes to the emergency department because of severe right flank and back pain that began suddenly 4 hours ago and does not radiate. He rates the pain as a 10 on a 10-point scale and says it is associated with nausea. He reports no recent trauma and has not had chest pain, shortness of breath, or any change in bowel habits. Medical history is significant for coronary artery disease, hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. Medications are metoprolol, fosinopril, 81-mg aspirin, warfarin, atorvastatin, and amlodipine. He has no known medication allergies. Family history is significant for coronary artery disease in both parents and one brother. He rarely drinks alcoholic beverages and does not smoke cigarettes. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min and irregular, respirations 20/min, and blood pressure 180/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Cardiac examination discloses only tachycardia. Examination of the extremities shows trace edema bilaterally. The remainder of the physical examination discloses no abnormalities. Results of initial laboratory studies are shown:

ECG shows atrial fibrillation. CT scan of the abdomen is shown. Results of urinalysis are most likely to show which of the following?

Item 2 of 2

The most significant risk to this patient posed by the recommended arteriography and urokinase therapy is which of the following?

A 67-year-old woman comes to the office for the first time for a periodic health evaluation. While taking her medical history, she informs you that 2 years ago she had a right lumpectomy and radiation therapy for breast cancer. Since that time, she has been in good health with no evidence of cancer recurrence. She says, “Because I had cancer, I have a living will that states that I will not be resuscitated under any circumstance.” Which of the following is the most appropriate response to her comment?

An 85-year-old woman is brought to the emergency department 20 minutes after falling down the stairs. She reports right groin pain and is unable to bear weight. Vital signs are temperature 37.0°C (98.6°F), pulse 85/min, respirations 16/min, and blood pressure 140/93 mm Hg. X-rays of the cervical spine, lumbar spine, pelvis, and hip show no abnormalities. MRI of the pelvis and right hip shows a fracture of the right superior pubic ramus and sacral ala. Which of the following is the most appropriate management?

A 23-year-old woman, gravida 2, para 1, comes to the office for her first prenatal visit. Her last menstrual period was 24 weeks ago. She does not work and reports that she no longer has a relationship with the father of her unborn child. She reports no pain, nausea, vomiting, fever, or any illnesses. She does not take any prenatal vitamins. She says her diet is “fair.” She smokes two packs of cigarettes per day and marijuana once or twice daily; she admits to drinking three to four beers per week. Physical examination is consistent with a 24-week gestation, which is confirmed by ultrasonography. The patient should be counseled regarding which of the following?

A 12-year-old white girl is brought to the emergency department by her parents because of a 2-hour history of severe nosebleed. The parents report that the epistaxis began after their daughter was wrestling with her 9-year-old brother. They say, “This is her third nosebleed this month. She has also been bruising more easily recently.” The patient had been in good health until having a febrile viral illness treated with ibuprofen 3 weeks ago; since then, she has become easily fatigued. Medical history is remarkable for short stature, for which she was referred to an endocrinologist. The parents were informed that karyotype, renal function tests, and determinations of growth hormone concentrations were all normal. Family history is remarkable for a paternal uncle with short stature and mild intellectual developmental disorder. The patient is in the sixth grade and her grades consist of mostly A’s. The patient is 124 cm (4 ft 1 in; <3rd percentile) tall and weighs 20 kg (44 lb; <3rd percentile). Head circumference is normal. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 20/min, and blood pressure 85/55 mm Hg. Physical examination discloses tanned skin with scattered café au lait spots. Tympanic membranes are clear. There is slow oozing of blood from the left naris. Auscultation of the chest discloses no abnormalities. Sexual maturation rating is stage 1 for breast and pubic hair development. Results of complete blood count are shown:

Which of the following is the most appropriate diagnostic study?

A 29-year-old woman comes to the office because of a 3-week history of persistent right leg weakness exacerbated by walking or physical exertion. Medical history is significant for an episode of optic neuritis of the right eye 3 years ago that resolved with intravenous corticosteroid therapy. She currently is taking no medications. Vital signs are temperature 36.7°C (98.0°F), pulse 74/min, respirations 12/min, and blood pressure 120/72 mm Hg. Examination of the cranial nerves discloses residual optic disc pallor on the right. There is a mild right hemiparesis that involves the right lower extremity and hip flexors more than the right upper extremity. Reflexes are brisker on the right, and Babinski sign is present on the right. The remainder of the examination discloses no abnormalities. MRI of the brain shows multiple cerebral white matter lesions. Which of the following is the most appropriate treatment to prevent acute exacerbations of this patient’s condition?

A 64-year-old woman is evaluated in the acute rehabilitation facility 4 days after she was transferred from the hospital following emergent coronary artery bypass grafting. Medical history also is remarkable for coronary artery disease, unstable angina, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. Medications are metoprolol, atorvastatin, clopidogrel, ranitidine, and daily aspirin. The patient has smoked one pack of cigarettes daily for the past 38 years. Since arriving at the facility, she has had difficulty completing rehabilitation exercises because of aching and cramping pain in her calves that develops with any aerobic activity involving the lower extremities. The pain is slightly worse in the right calf. When the patient walks on a treadmill, the pain develops after a distance of one-tenth of a mile and prevents her from continuing. BMI is 31 kg/m2. Temperature is 36.8°C (98.2°F), pulse is 68/min, respirations are 14/min, and blood pressure is 128/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Physical examination discloses central obesity and a healing median sternotomy incision. There are no lesions or edema noted in the lower extremities. Capillary refill time is less than 3 seconds in the toes bilaterally. Neurologic examination discloses no abnormalities. Results of which of the following studies are most likely to be abnormal in this patient?

A 36-year-old man, who was admitted to the hospital 3 days ago for management of opioid withdrawal, wants to be discharged against medical advice. Temperature is 37.7°C (99.9°F), pulse is 88/min, respirations are 18/min, and blood pressure is 155/85 mm Hg. Physical examination shows mild, diffuse piloerection. Pupils measure 3 mm. On mental status examination, he is alert and fully oriented. The patient’s nurse calls the attending physician, who says he has seen the patient already today and will evaluate him again tomorrow. The patient and his roommate insist that the physician has not visited their room today. No other hospital staff members recall seeing the physician today. On review of the patient’s electronic medical record, the nurse sees a note from the physician documenting a 30-minute examination of the patient today. Which of the following is the most appropriate action by the nurse?

A 17-year-old girl is brought to the clinic because of a 1-month history of shortness of breath when talking to friends. She says she cannot “finish a sentence without gasping for air.” She was diagnosed with spinal muscular atrophy 11 years ago, when genetic testing disclosed a mutation of the SMN1 gene. She now is unable to walk. She has no other history of serious illness and takes no medications. Temperature is 37.9°C (100.2°F), pulse is 82/min, respirations are 20/min, and blood pressure is 116/76 mm Hg. Physical examination shows cachexia. Neurologic examination discloses posterior oropharyngeal dysarthria, diffuse atrophy, and fasciculations in all extremities. Muscle strength is 3/5 in the upper extremities and 2/5 in the lower extremities. Deep tendon reflexes are absent throughout. When counseling this patient and her parents regarding her prognosis, it is most appropriate for the physician to inform them that complications from which of the following will pose the greatest risk of death?

A 34-year-old Hispanic man comes to the emergency department (ED) 45 minutes after his husband’s condom broke while the couple was engaged in sexual intercourse. The husband has been HIV positive for the past 14 years. The patient reports no symptoms at this time. He and his spouse have been in a monogamous relationship since they met and have been married for the past 10 years; they use condoms consistently. This is the third time during the past year in which a condom has broken during intercourse; the patient was evaluated in the ED and provided with short-term postexposure prophylaxis on both previous occasions. Medical history otherwise is unremarkable. The patient was last screened for HIV infection 6 months ago and was determined to be HIV negative. He takes no medications. Vital signs are within normal limits. Physical examination, including genitourinary and rectal examinations, discloses no abnormalities. In addition to providing the patient with postexposure prophylaxis, which of the following is the most appropriate next step in management?

Item 1 of 2

The most appropriate conclusion is that there is which of the following?

Item 2 of 2

Investigators determined that with the available sample size, the study had 27% power to detect the observed 2% absolute difference for meningitis between groups. In the context of this study, this means which of the following?

An 18-month-old boy is brought to the office by his 36-year-old mother for a well-child visit. The child, whom you have treated since birth, has multiple congenital anomalies and intellectual developmental disorder. At this visit you note that the mother looks fatigued. When you question her, she says, “It has been a real struggle to take care of my son. He’s just started to sleep through the night, but I’ve been waking up at 3:00 am every day for the past month worrying about things.” Which of the following is the most appropriate next step regarding the mother?

A 48-year-old woman is in the hospital after undergoing total thyroidectomy 2 hours ago. Four weeks ago a 4-cm, firm, nontender nodule was discovered in the patient’s right thyroid lobe during a routine visit to her primary care physician. Thyroid function tests at that time disclosed no abnormalities, but fine-needle aspiration of the nodule showed “papillary cells.” Today, a frozen section of the resected right lobe showed evidence of papillary cancer. Based on this information the left thyroid lobe was also removed during the procedure. Assuming that all the thyroid tissue was successfully removed, determination of which of the following serum concentrations will be the most appropriate screening for recurrent disease during follow-up visits?

A 1-week-old Hispanic American neonate is brought to the office by her parents for a routine well-child visit. The patient’s chart reveals that she failed the newborn otoacoustic emissions (OAE) test. She is scheduled to undergo a follow-up brain stem auditory evoked response test later this week. You recall a recent systematic review concerning newborn screening for hearing loss. It was estimated that the prevalence of significant hearing loss in this group is approximately 3 in 1000. In this literature, it is estimated that the sensitivity of an abnormal OAE test in detecting significant hearing loss is 99%, the specificity is 82%, the positive predictive value is 2%, and the negative predictive value is 100%. The patient’s chart also reveals that the infant was born 5 weeks prematurely. The same review article states that the prevalence of significant hearing loss among infants born prematurely is increased fivefold. Given this information, which of the following is the most accurate statement regarding this newborn’s abnormal OAE?

An 11-year-old girl is brought to the office by her parents because of a 1-week history of sleeping problems. The symptoms began when her brother’s snake got out of its cage and crawled into her bedroom and over her foot. She was not bitten or injured and the snake has since been removed from the house, but she continues to have difficulty falling asleep and awakens frequently during the night. Her school performance continues to be good. Medical history is otherwise unremarkable. She lives with her mother, stepfather, and 8-year-old brother. The patient is 145 cm (4 ft 9 in; 50th percentile) tall and weighs 28 kg (62 lb; 10th percentile); BMI is 16 kg/m2 (25th percentile). Vital signs are temperature 36.4°C (97.5°F), pulse 76/min, respirations 18/min, and blood pressure 108/68 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate management?

A 57-year-old woman comes to the office because of a 3-month history of vulvar itching. She has tried a variety of over-the-counter creams including miconazole and corticosteroid preparations without relief. Medical history is remarkable for cervical intraepithelial neoplasia, for which the patient underwent cone biopsy of the cervix at age 32 years; since that time, Pap smears have been normal. She also has a history of hypertension, psoriasis, and several basal cell carcinomas on her face and back that are believed to have worsened as a result of tanning bed use in the past. Menopause occurred at age 49 years and was uneventful. Current medications include lisinopril and corticosteroid creams for treatment of the psoriasis. BMI is 25 kg/m2. Vital signs are normal. Physical examination discloses an 8-mm, raised, firm, non-pigmented lesion with irregular borders on the right labia majora; biopsy of the lesion is done. Which of the following factors in this patient’s history is most likely related to the development of this condition?

A 45-year-old Hispanic woman comes to the office because of excessive thirst and urination for the past 3 to 4 days and blurred vision today. She says her last health maintenance examination was several years ago. She has a long history of mild asthma and has been treated in the emergency department for asthma three times during the past 2 years; her most recent visit was 10 days ago. She states that her asthma attack at that time was precipitated by “the flu,” which began approximately 2 weeks ago, with fever, cough, and diarrhea, and resolved by the time of her visit. She finished the medication prescribed at the emergency department visit 2 days ago and does not recall the name of the pills, but her asthma is much improved. She uses an albuterol metered dose inhaler daily. She is 163 cm (5 ft 4 in) tall and weighs 66 kg (145 lb); BMI is 25 kg/m2. Vital signs are temperature 37.2°C (98.9°F), pulse 90/min, respirations 18/min, and blood pressure 135/84 mm Hg. Funduscopic findings are shown. Oral mucosa is dry. A few scattered wheezes are heard on forced expiration. Fingerstick blood glucose concentration is 550 mg/dL. Urine dipstick is negative for ketones. Appropriate laboratory studies are ordered. Which of the following is the most likely explanation for this patient’s current condition?

An 18-year-old man is brought to the emergency department by ambulance after he fell overboard while deep-sea fishing 45 minutes ago. He was in the water for 20 minutes before he could be located and rescued. The water temperature was 4.4°C (40.0°F). The patient was apneic at the scene; cardiopulmonary resuscitation was begun and he was intubated. Upon arrival in the emergency department, Glasgow Coma Scale score is 6. Mechanical ventilation is initiated. Vital signs are temperature 30.5°C (86.9°F), pulse 45/min, respirations 20/min on ventilator, and blood pressure 80/44 mm Hg. Pulse oximetry on Fio2 of 1.0 shows an oxygen saturation of 94%; positive end-expiratory pressure is 10 cm H2O. Jugular venous pressure is normal. Auscultation of the lungs discloses crackles throughout both lung fields. Cardiovascular examination discloses bradycardia with a regular rhythm and no murmur. Chest x-ray shows bilateral opacities consistent with pulmonary edema. Which of the following is the most appropriate first step in management?

A 14-year-old girl is brought to the office by her mother because she is concerned that she has not begun menstruating. Menarche occurred in her two older sisters at ages 12 and 13 years and in her mother at age 13 years. The patient’s medical history is unremarkable and she takes no medications. She is not sexually active. She says she does not binge, purge, or restrict her caloric intake. She runs 5 days weekly for a total of 40 to 48 km (25 to 30 mi) and participates on her school’s track and cross country teams. She is 165 cm (5 ft 5 in; 75th percentile) tall and weighs 57 kg (126 lb; 75th percentile); BMI is 21 kg/m2 (>50th percentile). Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 14/min, and blood pressure 120/80 mm Hg. Breast development began at age 12 years. Sexual maturity rating is 3 for breast and pubic hair development. Physical examination shows no breast discharge. Pelvic examination discloses no abnormalities. Which of the following is the most appropriate next step in management?

A 67-year-old man comes to the clinic because of a 1-month history of progressive shortness of breath and nonproductive cough. Initially, he had shortness of breath only when taking long walks. During the past week, however, he has had occasional shortness of breath while at rest. Medical history is significant for hypertension and hyperlipidemia. Medications are hydrochlorothiazide and atorvastatin. He had smoked one pack of cigarettes daily for 25 years but quit 10 years ago. One year ago, he started a new exercise program of walking. He now is retired but was an aircraft mechanic for 10 years and then a construction worker for 30 years. Vital signs are temperature 37.1°C (98.8°F), pulse 88/min, respirations 22/min, and blood pressure 145/85 mm Hg. Auscultation of the lungs discloses end-inspiratory crackles, most prominent in the lower lung fields. Chest x-ray shows reticular-linear, diffuse, irregular opacities in the lower lung fields and a calcified pleural plaque on the right hemi-diaphragm. Results of pulmonary function testing show markedly decreased lung volume and FVC compared with results from 5 years ago. A photomicrograph of a sputum sample is shown. Which of the following is the most likely cause of this patient’s progressive dyspnea?

Investigators at a hospital are studying the role of a new rapid method for identifying microbiologic pathogens from blood cultures. They would like to measure the impact of this new method on a series of outcomes, including length of hospital stay. The distribution of length of stay for patients at this hospital is shown. Based on this graph, which of the following is the most appropriate measure of central tendency and variability?

A 27-year-old woman, gravida 3, para 3, who underwent cesarean delivery at term 2 days ago, now has dyspnea. Pregnancy and delivery were uncomplicated, and the operation was performed under spinal anesthesia. Her first pregnancy ended in cesarean delivery because of breech presentation; her second pregnancy ended in elective cesarean delivery at term. She has no history of serious illness and has no known allergies. Medications are acetaminophen, oxycodone, and prenatal vitamins. Vital signs are temperature 37.0°C (98.6°F), pulse 125/min, respirations 28/min, and blood pressure 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Auscultation of the lungs discloses bilateral basilar crackles. The incision site is clean, dry, and intact. ECG shows sinus tachycardia. Chest x-ray is shown. Which of the following is the most likely diagnosis?

A 55-year-old woman, who is scheduled to undergo a cholecystectomy for chronic cholelithiasis, comes to the clinic for a preoperative examination. Medical history is remarkable for biliary colic, chronic atrial fibrillation, hypertension, and type 2 diabetes mellitus. Medications are metoprolol, warfarin, lisinopril, and metformin. The patient is physically active and appears healthy. BMI is 25 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 96/min and irregular, respirations 16/min, and blood pressure 110/70 mm Hg. Lungs are clear to auscultation. Cardiac examination discloses atrial fibrillation, but heart sounds are otherwise normal. Abdomen is soft and nontender. There is no edema of the extremities. INR obtained 1 week ago was 2.5. Which of the following is the most appropriate management of this patient’s anticoagulation during the perioperative period?

A 72-year-old woman comes to the clinic because of a 1-week history of worsening swelling of her legs and a 2-week history of severe fatigue. She previously had been an active volunteer at her church but now is unable to participate in any activities because of fatigue. During the past week, she has been unable to walk to her mailbox because of her symptoms. She has not had fever, chest pain, or palpitations. Medical history is unknown; she has not been examined in many years. She takes no medications. BMI is 22 kg/m2. Vital signs are temperature 37.8°C (100.1°F), pulse 128/min, respirations 18/min, and blood pressure 104/72mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Auscultation of the lungs discloses crackles in both bases. Cardiac examination discloses an irregularly irregular rhythm and a loud grade 3/6 holosystolic murmur heard best along the left sternal border and the apex of the heart. Examination of the extremities shows 2+ pitting edema from the ankles to the knees bilaterally. Which of the following is the most likely diagnosis?

A 55-year-old woman comes to the office because of a 2-month history of anal drainage and bleeding. She says there is blood on the toilet tissue after every bowel movement. Screening colonoscopy 2 years ago disclosed no abnormalities. Medical history is unremarkable and she takes no medications. Family history is unremarkable. BMI is 23 kg/m2. Vital signs are temperature 37.1°C (98.7°F), pulse 68/min, respirations 14/min, and blood pressure 110/60 mm Hg. Physical examination discloses a 2-cm, flat, reddish lesion in the right anterior position 1 cm from the anal verge; the lesion bleeds to the touch. A biopsy of the lesion discloses adenocarcinoma arising from the perianal apocrine glands. Which of the following is the most appropriate next step in management?

A 29-year-old man with schizophrenia comes to the office for a routine examination. His only medication is risperidone. He does not drink alcohol or use illicit drugs. Vital signs are normal. Physical examination shows no abnormalities. On mental status examination, he has an expansive mood. He pulls out pages of intricately drawn and colored diagrams of triangular shapes and describes the connections among the seven colors of the rainbow, the seven notes on the piano, the seven “special organs of the body,” and the epiphanies he has while meditating on the seventh day of the week. He explains that the special organs will resonate when he plays corresponding keys on the piano. He eats foods whose color corresponds to a specific day of the week. As the interview concludes, the patient asks what the physician thinks of his diagrams and theories. Which of the following is the most appropriate physician response?

A 58-year-old man comes to the office because of a 4-month history of increasingly severe back and rib pain. He has hypertension and hypercholesterolemia. Current medications are atenolol and atorvastatin. He does not smoke cigarettes and does not drink alcoholic beverages. Vital signs are temperature 37.7°C (99.9°F), pulse 75/min, respirations 16/min, and blood pressure 132/86 mm Hg. Pressure applied over the lower rib cage and the hips bilaterally elicits pain. The result of a bone scan is shown. Pathologic examination of this patient’s primary tumor is most likely to show which of the following?

A 6-month-old male infant is brought to the office by his parents to establish care after their family emigrated from a refugee camp in Ethiopia. He was born at term after an uncomplicated pregnancy and has received no medical care. His mother says he has had difficulty gaining weight, although he seems interested in feeding. She also has noticed a hoarse cry. The patient normally has a bowel movement once every 4 days. He has just begun to roll from his back to his stomach and does not yet sit unsupported. The mother says that as a newborn the patient’s weight was normal. Today, the infant is 61 cm (24 in; <2nd percentile) and weighs 6000 g (13 lb 3 oz; <2nd percentile); head circumference is 40.8 cm (16 in; 15th percentile). Vital signs are normal. The patient is hypotonic. Physical examination discloses sparse hair, dry skin, and a reducible umbilical hernia. The fontanel is large and flat. No dysmorphic features are noted. The remainder of the physical examination discloses no abnormalities. Which of the following studies is most likely to establish a diagnosis?

A 68-year-old man is admitted to the hospital after sustaining an ST-segment elevation myocardial infarction. Upon arrival, he emergently undergoes cardiac catheterization. A 100% occlusion is noted in the left anterior descending artery, and an angioplasty is performed with stent placement. Two days later, transthoracic echocardiography shows diminished systolic function and an ejection fraction of 20%. Carvedilol and lisinopril therapy is initiated. The physician recalls a recent study assessing the benefit of Drug X for the treatment of systolic heart failure. In the study, 200 patients aged 50 to 75 years were randomized to receive standard therapy plus either Drug X or placebo. Enrollment criteria included known systolic heart failure documented by echocardiography and symptoms of dyspnea and orthopnea. Study patients were required to have been receiving standard therapy for at least 3 months prior to enrollment. Outcomes measured included readmission to the hospital for heart failure, myocardial infarction, and cardiovascular death. Results of the study are shown:

Which of the following is the most appropriate interpretation of the study results as they apply to this patient if he started therapy with Drug X?

A 10-year-old boy is brought to the office by his mother for a well-child examination. Medical history is unremarkable and he receives no medications. The patient is adopted and the mother does not know all of the patient’s family history, but she says his biological father recently died at age 49 years from a myocardial infarction and his biological paternal grandfather had “cholesterol problems.” The patient is 139 cm (4 ft 7 in; 50th percentile) tall and weighs 32 kg (71 lb; 50th percentile); BMI is 17 kg/m2 (50th percentile). Vital signs are within normal limits and physical examination discloses no abnormalities. Which of the following is the most appropriate next step in management?

A 15-year-old girl is brought to the office because of a 2-week history of episodes of a burning sensation during urination accompanied by a patch of open sores over her vulva. Her only medication is an oral contraceptive. She reports that she is sexually active with her boyfriend, and they use condoms inconsistently. Examination shows clusters of inflamed papules and vesicles in the vagina and over the outer surface of the vulva. The physician informs the patient that she has genital herpes. She covers her face with her hands and exclaims, “My mother is going to kill me if she finds out I’m having sex and now have a sexually transmitted disease!” Which of the following is the most appropriate initial statement by the physician?