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Question 1 of 40
1. Question
A 46-year-old woman comes to the office to establish care. She has not seen a physician in several years and takes no medication. The patient has recently been experiencing a significant amount of stress due to her mother’s recent diagnosis of metastatic breast cancer. She expresses sadness due to her mother’s condition but has had no suicidal or homicidal ideation or substantial loss of interest or pleasure in performing her activities. She lives at home with her mother, who is widowed, and no other family members live nearby. Due to her mother’s worsening condition, the patient has needed to personally assist her with activities of daily living and transportation to medical appointments. The patient works at a large company and states that she is having increasing difficulty fulfilling her commitments at work. She has used up all her sick and vacation days, and her supervisor cannot give her additional time off. The patient is tearful and states, “I’m really hoping you can help me. I am going through so much stress. I just need a few weeks off work so I can look after my dying mother.” Which of the following is the most appropriate response by the physician?
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Question 2 of 40
2. Question
A 64-year-old woman comes to the office for a health maintenance visit. Her medical issues include hypothyroidism treated with levothyroxine and postmenopausal vaginal dryness treated with estrogen cream. The patient exercises 3 times a week and eats a well-balanced diet. She does not use tobacco and drinks a glass of wine 3-5 days a week. She works as a volunteer at her local public library. The patient’s 88-year-old father has Alzheimer disease and was recently placed in a nursing facility. She mentions that it has been difficult to see her father decline and was upset when he failed to recognize her at her last visit. She says, “I do crossword puzzles every day because I am afraid I will develop Alzheimer disease” and mentions that she has seen information on the internet and television describing beneficial effects from ginkgo biloba, fish oil, and vitamins. The patient asks, “Will any of these supplements help prevent dementia?” Which of the following is the most appropriate advice for this patient?
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Question 3 of 40
3. Question
Officials at a public health department are interested in working with physicians and pharmacists to address the regional epidemiology of opioid use. Recently, new regulations were implemented in the area that require clinicians to review a prescription drug monitoring database when prescribing opioid medications. The secure database contains detailed records of all controlled substance prescriptions (provider name, date, quantity, pharmacy) that a patient has filled over the past 2 years; it can be accessed through a link contained in the electronic medical record. Which of the following best characterizes the optimal use of this database?
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Question 4 of 40
4. Question
A physician receives a phone call from his sister requesting an antidepressant prescription for her 16-year-old son. She explains that he saw a psychiatrist who prescribed the medication for depression a year ago. The boy has been doing well on the medication and has not seen the psychiatrist for more than 6 months. She is concerned that the psychiatrist will be unwilling to refill the prescription without seeing him for a follow-up appointment. The sister is reluctant to schedule an appointment due to cost and inconvenience and asks the physician to do her this favor. As far as the physician knows, his nephew has no medical problems and does well in school. He was unaware of his nephew’s history of depression until now. Which of the following is the most appropriate course of action?
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Question 5 of 40
5. Question
A 5-year-old boy is brought to the office by his father for a follow-up visit after being discharged from the hospital for an asthma exacerbation 2 days ago. This was the patient’s third admission in 4 months; during the second hospitalization, he required transfer to the pediatric intensive care unit. The father shares that the patient was doing well on the day of discharge but that his cough has worsened since then despite taking all the medications as prescribed. The physician notes the smell of cigarette smoke on the father’s clothes and asks if he is aware that exposure to smoke can worsen asthma symptoms in children. The father replies, “That’s what the doctors in the hospital kept telling me, but that can’t be true because my other kids are just fine. I’ve thought about quitting before, but it’s just not an option right now.” Which of the following is the most appropriate response?
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Question 6 of 40
6. Question
A 70-year-old man is brought to the emergency department by ambulance after his neighbor found him confused and feverish at home. The patient has diabetes mellitus; on arrival, finger-stick glucose is >400 mg/dL. Temperature is 39.5 C (103.1 F), blood pressure is 90/60 mm Hg, pulse is 118/min, and respirations are 20/min. The patient is oriented to person but not place or time. On physical examination, the perineum is erythematous, warm, and tender to palpation; areas of skin sloughing associated with malodorous discharge are present. CT scan of the abdomen and pelvis reveals necrotizing infection of the perineum. Intravenous fluids, insulin, and antibiotics are administered. The surgical team is consulted. The patient repeatedly says, “I just want to go home. Don’t cut me.” Which of the following is the best next step in management?
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Question 7 of 40
7. Question
A 32-year-old business executive comes to the psychiatrist for treatment of depression. He has a 4-month history of increasing sadness, sleep disturbance, low energy and motivation, and impaired concentration, and states that he is on the verge of losing his job. He responds well to antidepressant medication and continues on the medication for a year without complication; the last chart entry documents that his depression is in remission. Three months later, the patient phones the psychiatrist to inform her that he is doing well, has decided to discontinue the medication, and no longer feels the need for follow-up. A year later, the patient, who is single, meets the psychiatrist at a local gathering and invites her for a dinner date. The psychiatrist is likewise single and interested in dating. Which of the following is the most appropriate course of action?
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Question 8 of 40
8. Question
A 78-year-old man is brought to the emergency department for evaluation of fever, cough, and shortness of breath. His wife reports he has been coughing for 2 days, but his breathing worsened today. The patient has a history of Alzheimer disease, with a Montreal Cognitive Assessment (MOCA) score of 24 during a visit to his primary care physician 3 weeks ago. Temperature is 38.7 C (101.7 F), blood pressure is 86/42 mm Hg, pulse is 122/min, and respirations are 20/min. Pulse oximetry shows an oxygen saturation of 92% on room air. On examination, the patient is awake, alert, and oriented but appears in mild respiratory distress. He has dry mucous membranes and bibasilar rhonchi on auscultation. He is moving all extremities, following commands, and his speech is clear. Chest x-ray shows bilateral pneumonia. The wife has the patient’s living will with her, which includes signed do-not-resuscitate (DNR) and do-not-intubate (DNI) forms. Which of the following is the best next step in confirming the goals of care?
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Question 9 of 40
9. Question
A 32-year-old man with type 1 diabetes comes to the emergency department with malaise, fatigue, and abdominal pain. His wife says that over the past 24 hours he has consumed large amounts of water and urinated frequently. On physical examination, the patient has dry mucous membranes. Laboratory testing confirms diabetic ketoacidosis. Shortly after admission, the patient suffers a seizure after accidentally receiving a bolus of insulin 10 times the amount indicated. He is transferred to the intensive care unit, where he experiences a ventricular arrhythmia and dies despite resuscitative measures. His wife is inconsolable and says that she plans to sue the hospital for her husband’s death. The hospital administration enlists a team to perform a root cause analysis. Which of the following is the first step in performing this analysis?
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Question 10 of 40
10. Question
A 3-day-old boy is brought to the office by his mother for a weight check. The patient was born via spontaneous vaginal delivery to a 26-year-old primigravida following an uncomplicated pregnancy. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. The patient is breastfed exclusively every 3-4 hours and sleeps approximately 15 hours a day. On physical examination, he is alert and quiet in his mother’s lap. The examination is unremarkable. Anticipatory guidance is given regarding the patient’s expected feeding and elimination habits, as well as upcoming developmental milestones. The topic of vaccinations is raised, and the mother adamantly states that she is unwilling to have her child vaccinated. She says, “I know you might disagree with me, but I feel that vaccines can make my son autistic. I refuse to let him be exposed to them.” A prolonged discussion regarding vaccine risks and benefits does not change her beliefs. She is given additional written information regarding immunization facts. Which of the following is the best next step in management of this family?
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Question 11 of 40
11. Question
A 74-year-old woman is brought to the emergency department by ambulance due to confusion. Her son reports that the patient has had chills and poor appetite for 3 days and became difficult to arouse today. She was ambulatory before this episode and does not use a walker or cane. The patient has no chronic medical conditions except for mild urinary incontinence. Temperature is 39 C (102.2 F), blood pressure is 74/33 mm Hg, pulse is 134/min, and respirations are 24/min. She is lethargic but opens her eyes with verbal stimuli. Examination reveals erythema, warmth, and swelling of the left anterior leg and foot without fluctuance and a strong dorsalis pedis pulse. The patient is given antibiotics and an intravenous fluid bolus but remains hypotensive. The physician thinks she will benefit from vasopressor therapy. The son, who is the patient’s power of attorney, presents copies of her advance directive with a signed do-not-resuscitate (DNR) form. He asks the physician to respect the patient’s wishes and hold off any resuscitation efforts. Which of the following is the best next step in management?
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Question 12 of 40
12. Question
A 49-year-old woman comes to the urgent care clinic due to flu-like symptoms. For the last 3 days, the patient has had nasal congestion, coughing, and a low-grade fever. Medical history is negative for underlying cardiopulmonary disease, but she has a history of chronic back pain due to a work-related injury 5 years ago. Her only medication is hydrocodone-acetaminophen, which she takes on a regular schedule 3 times daily. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 37.2 C (99 F); vital signs are otherwise normal. Examination shows boggy, erythematous nasal mucosae. Lung examination is normal. Moderately exaggerated lumbar lordosis is present with bilateral lumbar paraspinal tenderness. The patient ambulates with the assistance of a walker, but lower extremity motor strength, sensation, and reflexes are normal. Straight-leg raising test is negative. Bedside influenza screening is negative, and she is counseled in over-the-counter medications for her acute illness. Prior to release from the clinic, the patient reports that she has a regularly scheduled pain management follow-up appointment the next day but says, “I’m worried that I might miss my appointment because I’m sick. As long as I’m here, can you give me my hydrocodone prescription?” Which of the following is the most appropriate response to the patient’s request?
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Question 13 of 40
13. Question
A physician at a large academic medical center is conducting clinical research on a novel hepatitis C therapy. Patients with a history of untreated hepatitis C are referred from clinics in the community and are randomly assigned to either the novel therapy or standard therapy group. Every participant receives regular follow-up visits and a small monetary compensation for their time. Recruitment of patients has been slow, and a research associate proposes to expand recruitment to the state prison close to the academic institution. Which of the following is the most appropriate response to this suggestion?
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Question 14 of 40
14. Question
A 73-year-old man is brought to the emergency department from a nursing home due to fever and decreased mental status that began this morning. He has Lewy body dementia and is being treated for metastatic prostate cancer. Temperature is 39 C (102.2 F), blood pressure is 82/40 mm Hg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 90% on nonrebreather. The patient is arousable but sleepy. He is oriented to person only. He answers questions with only yes or no. Chest x-ray reveals right lower lobe pneumonia. His wife arrives at the bedside and says, “He has a DNR. He has an advance directive that says he does not want to be resuscitated.” Which of the following is the most appropriate next step in management of this patient?
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Question 15 of 40
15. Question
A 59-year-old obese woman with a history of type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD) is admitted with COPD exacerbation. Management is complicated by difficulty controlling the patient’s blood glucose, with levels of 100-300 mg/dL throughout the day. On her second hospital day, a 7 x 3 cm abscess of her left buttock is found and requires incision and drainage. Following the procedure, the surgeon instructs the overnight hospitalist to obtain serial ultrasound examinations to monitor the abscess. During the course of signing out, the hospitalist expresses concern about the patient’s fluctuating blood sugars, provides details on the status of her COPD, and mentions the drainage of the abscess but forgets to mention the need for follow-up ultrasound examination. Due to this oversight, the abscess is not reexamined for several days and worsens significantly, requiring more extensive surgical intervention. Following a review of the adverse outcome, the hospital administration forms a committee to improve patient handoffs between medical staff members. Which of the following interventions would most significantly improve the quality of patient handoffs?
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Question 16 of 40
16. Question
A 63-year-old man admitted for urolithiasis complicated by a urinary tract infection is treated with intravenous antibiotics. The patient is a Russian-speaking immigrant who lives with his son. During the night, the nurse sees that one of his intravenous catheters is infiltrated and cannot be used. The nurse is unable to secure a second peripheral intravenous line and notes that the patient is becoming progressively hypotensive with a blood pressure of 105/50 mm Hg and pulse of 89/min. He calls the medical resident covering the patient for assistance. The resident has little experience placing peripheral intravenous lines but has placed several internal jugular lines, including 5 independently, during his intensive care rotations. The resident asks the patient in English for consent of immediate central line placement. During the attempt to insert the internal jugular line, the patient develops a large pneumothorax. In the root cause analysis of this adverse event, which of the following could be the most important patient-related factor?
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Question 17 of 40
17. Question
A pharmaceutical company sales representative comes into the office to provide information on a new discount program for the company’s antidepressant medication. One of the office staff members performs a search of the practice electronic record system; she finds 2 patients on the schedule for the following week who are taking the drug and provides the names and addresses to the sales representative so that he can send information about the program. Later that day, when the clinician is notified of what happened, she immediately instructs the sales representative to not contact the patients and delete their information from his laptop computer. Which of the following is the most appropriate next step in addressing this situation?
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Question 18 of 40
18. Question
A 62-year-old man comes to the office due to weight loss, persistent cough, hemoptysis, and dyspnea, after having cancelled several previous appointments. The patient has been under stress lately as he is going through a divorce, and he recently had to postpone his retirement plans when several business deals fell through. He has a history of substance abuse, with episodes of residential treatment for cocaine and alcohol abuse. He no longer uses cocaine but continues to use alcohol daily “to relax.” During the visit, a chest x-ray shows a suspicious mediastinal mass. The physician explains the need for a chest CT scan and tissue biopsy. The patient says, “My whole life is going to crap. I suppose you’re going to tell me to stop smoking. What do you know? You doctors are all the same. Do this, don’t do that; meanwhile, you go home in your fancy cars to your fancy homes. Well, you know what? I’m going to keep smoking and get drunk as hell tonight!” Which of the following is the most appropriate response to the patient?
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Question 19 of 40
19. Question
A 66-year-old woman comes to the clinic for follow-up of sarcoidosis. Over the past year, her lung function has worsened significantly, and her probability of survival at 12 months is below 50%. When the physician suggests they talk about advance care planning and appointment of a surrogate decision maker, the patient replies, “Why would I want to sign away my life on a piece of paper? The Lord will take me when the time is right.” Which of the following is the most appropriate response?
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Question 20 of 40
20. Question
A 55-year-old man attends a fundraising dinner for a science museum. When introductions are made at the dinner table, he learns that he is seated next to a physician. They engage in friendly discussion during dinner, and afterward the man privately asks the physician about a skin lesion on his upper back. The lesion has been growing over the past several months, and it bleeds intermittently when he showers. The physician looks at the lesion quickly and tells the man that the lesion is most likely benign. They do not see each other again; the lesion is subsequently diagnosed by a dermatologist as a malignant melanoma. The man files a lawsuit against the physician. Which of the following most accurately describes whether the physician is liable for medical malpractice?
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Question 21 of 40
21. Question
A 17-year-old girl is brought to the office by her mother due to worsening right leg pain over the past 2 weeks. The patient is a cross-country runner on her high school team and shares that she has a statewide competition next week. Physical examination reveals point tenderness over the anterior tibia. Radiographs show a linear lucency along the anterior tibia consistent with a tibial stress fracture. The physician shares the diagnosis and treatment recommendations, including a pneumatic splint, non–weight-bearing rest, and a referral to orthopedic surgery. Her mother states, “If she does well in this competition, she could get a full scholarship for college, but her coach won’t let her run without a doctor’s note. I understand the risks of her running with this injury, and I’m willing to accept them.” The patient becomes tearful, stating that she promises to rest before and after the competition, and says, “Can you write a note saying that I can run in this one race?” Which of the following is the most appropriate response by the physician?
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Question 22 of 40
22. Question
A mother brings her 7-year-old son to the pediatrician for a check-up. He was born 8 weeks premature and has a history of asthma. The physician has cared for the child from birth but is part of a large group practice in which other physicians may see the patient on occasion due to scheduling issues. Over the years, the physician has become close to the patient’s mother, who confided that she is unhappily married and is seeking a divorce. The physician and the patient’s mother started dating last year but have kept the relationship hidden from the patient. He has been too embarrassed to discuss the situation with his colleagues. The physician now feels increasingly concerned about the ethics of treating the patient as the relationship with the mother has intensified. At today’s visit, the mother insists that he continue as the child’s physician because she trusts him the most. After the visit, the physician approaches one of his colleagues for advice. Which of the following is the best advice to give the physician at this time?
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Question 23 of 40
23. Question
A 33-year-old woman is transferred to the university medical center from a small community hospital due to acute pyelonephritis with sepsis. She has a history of recurrent urinary tract infections due to urinary retention related to a spinal cord injury in childhood. On arrival, the patient is febrile and lethargic. She provides no additional history, and the only information available is from poorly legible handwritten notes from the originating hospital. The patient is admitted to the intensive care unit with orders to give imipenem and vancomycin. Overnight, the patient develops a rash and severe respiratory distress requiring brief mechanical ventilation. The following morning, a transcribed physician note from the originating hospital arrives by fax and indicates that the patient has an allergy to multiple antibiotics, including imipenem. When discussing events with the patient and her family, which of the following statements is associated with reduced malpractice liability for the treating clinician?
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Question 24 of 40
24. Question
A 35-year-old woman comes to the office for evaluation. Her medical problems include migraine headaches, chronic back pain, asthma, and depression. The patient has had extensive diagnostic workup of her back pain, including several imaging studies, that was unrevealing. At today’s visit, she is seen by another physician in the same group, as her primary physician is currently on personal leave. The patient is mildly depressed and reports continued headaches and back pain. During the course of the appointment, the patient discloses that her primary physician asks her to undress at every visit so he can examine her breasts. She also mentions that they were in a consensual sexual relationship that she stopped because the physician was not willing to divorce his wife to be with her. The treating physician contacts the patient’s primary physician to discuss concerns about the patient’s report. The primary physician admits to a brief sexual relationship over a year ago when he first began treating her as a patient. However, he denies there has ever been any inappropriate behavior in the office, stating, “She is a psych patient and is always upset; you can’t trust what she is saying.” Which of the following is the best next course of action?
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Question 25 of 40
25. Question
A 46-year-old man is admitted to the hospital with constant mid-epigastric pain for the past 5 days. He has a history of intravenous drug use, alcohol use disorder, and chronic pancreatitis and continues to drink heavily. He has had 3 recent admissions for pancreatitis in the past 4 months and is well known to the hospital staff. After several days, the patient’s condition stabilizes and plans are made to discharge him and refer him back to his primary care physician for a posthospitalization visit within a few days of the hospitalization. When contacted, the primary care physician says, “I do not want to continue to be involved in this patient’s care. He does not take his medications consistently and exhibits drug-seeking behaviors, and he was verbally abusive to my office staff at his last appointment when he did not receive a prescription for opioid pain medications.” Which of the following is the most appropriate step at this time?
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Question 26 of 40
26. Question
An 18-year-old woman comes to the office for follow-up of genetic testing. The patient was admitted to the hospital 2 weeks ago for a seizure and on examination was found to have myoclonus. Due to concern for a genetic syndrome, testing was performed while she was inpatient. The patient is told that her results are consistent with myoclonic epilepsy with ragged red fibers (MERRF), a rare mitochondrial disease that can present in late childhood or early adulthood. Family history is unknown because the patient and her sister were adopted together at age 2 and 3, respectively, and have no contact with their biological family. The patient is encouraged to share the results with her sister so that she can attend genetic counseling. She reacts angrily to this and states that her sister abandoned her to move across the country with her boyfriend after becoming pregnant a few months ago. She says, “I don’t want to talk to her. My sister only cares about herself. She hasn’t even bothered to check in on me.” Which of the following is the most appropriate initial statement?
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Question 27 of 40
27. Question
A 52-year-old man comes to the office for a routine follow-up appointment. The patient has a history of well-controlled hypertension and hyperlipidemia. He has a 35-pack-year smoking history and reports that he continues to smoke about 10-15 cigarettes daily. Family history is significant for lung cancer in his mother. His father died following a stroke at age 65. When asked about whether he has considered quitting, the patient replies that he is not ready to stop smoking. He says, “I know I probably should, but I’m just too stressed at work to give up my cigarettes right now. To be honest, I’m probably smoking closer to a pack a day.” Which of the following is the most appropriate response to the patient?
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Question 28 of 40
28. Question
A hospital committee is tasked with promoting optimal use of health care resources such as imaging and laboratory studies to improve quality of care and health care value. The committee finds significant variation in physician orders for common laboratory tests for inpatients, including complete blood count and iron panel tests. As a first step to improving the laboratory ordering process, the committee develops a testing protocol designed to promote an evidence-based approach to anemia workup. The protocol will be integrated into the electronic medical record and will be automatically activated whenever a patient diagnosis of anemia is documented. Which of the following approaches in designing the protocol is most recommended to improve health care quality?
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Question 29 of 40
29. Question
A 19-year-old woman comes to the office for an initial health maintenance evaluation. She has no health concerns but would like to be tested for sexually transmitted infections because she recently started a new relationship. The patient met her partner at a museum a few months ago after moving to the area for college. She found out later that her 40-year-old partner is her art history professor for the class she is taking this semester. They have agreed not to tell anyone about their relationship, including her parents and sister, because the professor is married and is planning to get a divorce soon. The patient states that they will tell everyone “when the time is right.” Which of the following is the most important determining factor as to whether this patient is in an abusive relationship?
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Question 30 of 40
30. Question
A 35-year-old woman at 38 weeks gestation is admitted to the hospital after prelabor rupture of membranes at home. The vaginal delivery is uneventful, and the patient and newborn are doing well. When the physician informs her that she will be discharged tomorrow, she states that she has 2 young children and feels overwhelmed at the thought of returning home. The patient asks if her hospitalization can be extended by an additional 24 hours. Vital signs and physical examination are unremarkable. The patient is not depressed. Her insurance covers only a 2-day hospital admission for an uncomplicated vaginal delivery. Which of the following is the most appropriate response to this patient’s concerns?
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Question 31 of 40
31. Question
A 52-year-old man comes to the office accompanied by his wife to discuss the results of a routine screening colonoscopy in which several polyps were removed. He has a history of knee pain for which he takes glucosamine and chondroitin and multiple food allergies managed with dietary modifications. He does not use tobacco, alcohol, or illicit drugs. The patient adheres to a vegetarian diet and exercises regularly. Family history is not significant and he takes no medications. Physical examination is normal. His mood is good and he is looking forward to his eldest son’s upcoming graduation from college. The physician informs the patient that biopsy of a polyp showed cancerous cells, and stage 1 colorectal cancer is diagnosed. Surgical resection is recommended, and the physician explains that surgery is considered curative for localized colon cancer. The patient prefers to treat his condition nonsurgically and says, “Positive energy from natural light and foods can cure me. I will be fine.” He shows the physician results of his Internet research on natural fruit therapy and believes that “the fruit enzymes will eat the cancer cells.” The patient’s wife disagrees with his decision and is in favor of surgery. Which of the following is the most appropriate course of action?
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Question 32 of 40
32. Question
A 43-year-old man is brought to the emergency department after suffering serious injuries during a fight at a local bar. The patient smells heavily of alcohol, slurs his words, and has difficulty standing and walking. It is unclear if he experienced a loss of consciousness. Physical examination reveals numerous contusions and lacerations on his face that will require suturing. The patient has unilateral pupil dilation in the right eye and appears sleepy. When he is told that a head CT scan is needed for further evaluation, he rouses and becomes belligerent. The patient begins to shout and curse, claiming that the staff is harassing him and that he will sue the hospital for violation of his civil rights. Which of the following is the most appropriate course of action?
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Question 33 of 40
33. Question
A 79-year-old woman is brought to the office by her daughter for a follow-up visit after a fall. Two days ago, her knees gave out while standing up from bed, and she fell to the floor. There was no loss of consciousness, and evaluation in the emergency department revealed no significant trauma. The patient has a history of frequent falls and has been prescribed a walker but does not use it consistently. Other chronic medical problems include hypertension, type 2 diabetes mellitus, osteoarthritis, and obesity. The patient uses oxygen therapy for idiopathic pulmonary fibrosis. She lives with her daughter and performs basic activities of daily living independently. The patient no longer drives; her daughter shops for food for her and takes her to family events and church services. Her daughter says, “I am working 2 jobs and am finding less time to care for my mother. I worry that she may fall again and break her hip. I have also found that sometimes she forgets to take her medications.” Blood pressure is 156/80 mm Hg and pulse is 72/min. Gait is unsteady but no focal weakness or sensory loss is present. The patient’s daughter would like to learn more about home health services for her mother. Which of the following conditions qualifies this patient for home health services?
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Question 34 of 40
34. Question
A 76-year-old man with chronic obstructive pulmonary disease is admitted overnight to the hospital due to worsening shortness of breath over the past 3 days. The following morning, a resident physician on the primary team introduces herself and asks the patient how he has been feeling. The patient whistles in response and says, “Wow, a doctor who’s beautiful and smart. I’m the luckiest patient in the world.” The resident feels uncomfortable but smiles and asks him again how he is feeling today. The patient shares how he has been and the symptoms he is experiencing. During the physical examination, as the resident leans over the bed to auscultate the lungs, the patient reaches up and hugs her. He says, “I just had to give you a hug. I couldn’t stop myself.” The resident finishes the examination and leaves the room. She immediately reports the incident to her supervising physician. Which of the following is the most appropriate next step for the supervising physician to take?
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Question 35 of 40
35. Question
A 65-year-old man is hospitalized due to 3 days of shortness of breath that progressively worsened until he was unable to walk up the flight of stairs to his apartment. The patient is diagnosed with an exacerbation of chronic obstructive pulmonary disease. Chest x-ray reveals a hilar mass, and a subsequent CT scan confirms the presence of a 3-cm mass in the left hilum, suggestive of lung cancer. The patient’s sister, who is at the hospital visiting, tells the physician, “My brother doesn’t really care about his health. He smokes and eats a lot of junk food. He refuses to exercise and does not take his medications every day. It’s no wonder he got sick.” The patient responds, “I know I should try to live healthier, but it’s hard to break old habits. What’s the point of living longer if I can’t enjoy anything?” When discussing the recommendation of a bronchoscopy and biopsy, he says, “I don’t want to hear the results. I’d prefer to just keep living my life.” Which of the following is the most appropriate response to this patient’s request?
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Question 36 of 40
36. Question
A 28-year-old man comes to the office for a routine health maintenance examination. The patient is seen by his primary care physician, who has known him since childhood and also cares for the patient’s 26-year-old wife, who is pregnant. The wife also sees a high-risk obstetrician for serial ultrasound examinations due to complications of Rh(D) alloimmunization. The wife is Rh(D)-negative; her husband is Rh(D)-positive. Her medical records indicate that she has had a prior pregnancy with a different partner that resulted in an elective termination. During the visit, the patient discusses how excited he and his wife are to become new parents. He mentions that he has done some research about Rh sensitization and has read about cases similar to his wife’s. He asks how his wife could have this problem considering this is the couple’s first child. Which of the following is the most appropriate response?
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Question 37 of 40
37. Question
A physician working at a tertiary care hospital is diagnosed with early pancreatic cancer. The physician continues to work and immediately becomes involved in pancreatic cancer research fundraising. In addition to sharing the diagnosis with patients and asking them to donate to fundraising efforts for a national cancer institute, the physician also petitions hospital administrators to expand its clinical research activities surrounding pancreatic cancer management. The physician is a member of the local city council and has advocated for a rezoning policy that would allow a cancer research center to be built in the city. Which of the following best characterizes the appropriateness of the physician’s actions?
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Question 38 of 40
38. Question
A 3-day-old boy is brought to the office for follow-up after hospital discharge. He was delivered vaginally at 40 weeks gestation to a 28-year-old primigravid mother. All maternal prenatal laboratory results were normal, and Group B Streptococcus culture was negative. Maternal history is significant for lactose intolerance, celiac disease, and shellfish and egg allergies. Birth weight was 3.5 kg (7.7 lb); discharge weight yesterday was 3.35 kg (7.4 lb) and weight today is 3.26 kg (7.2 lb), a 7% decrease from birth weight. Physical examination reveals a crying infant who is easily consoled when held. Cardiopulmonary examination is normal. The Moro reflex is symmetric and the infant has a strong suck. There is an erythema toxicum rash on the trunk. The remainder of the examination is normal. The mother tearfully says, “I would like to continue to breastfeed exclusively, but the baby is still losing weight. He wants to feed all the time, especially at night. My husband thinks we should give the baby formula. What do you think?” Which of the following is the best recommendation for this patient?
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Question 39 of 40
39. Question
A 32-year-old woman with type I diabetes mellitus comes to a clinic serving uninsured patients of low socioeconomic status. The patient has had unstable glucose levels despite following her insulin regimen, which includes multiple daily injections. Her recent HbA1c was 9%, and her home glucose log shows several readings >200 mg/dL and many as low as 50 mg/dL. The option of an insulin pump has been discussed with the patient previously, but she is unable to afford one. The physician has recently started enrolling eligible patients with type I diabetes mellitus for a clinical trial in which an insulin pump and supplies are paid for by the pharmaceutical company sponsoring the study. The company also provides a small stipend for participating in the trial. Which of the following is the most appropriate course of action?
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Question 40 of 40
40. Question
A physician is appointed to be the medical director of a primary care practice in an underserved area. The practice serves a significant number of patients who are on government-subsidized insurance programs due to low income, or those who have commercial insurance plans with high deductibles and copayments. The clinic has a high rate of missed appointments with many patients lost to follow-up, negatively impacting the clinic’s quality metrics for chronic disease management benchmarks. It is a major priority of the clinic to increase patient retention and improve follow-up rates. Which of the following arrangements is most likely to promote health care access while also reducing the likelihood of medical insurance fraud?
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