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Question 1 of 32
1. Question
A 74-year-old woman is brought by ambulance to the emergency department due to confusion. She is accompanied by her daughter, who lives with her. The patient was diagnosed with aplastic anemia a year ago. Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions. The patient is alert and oriented to person only; she is unable to respond to other questions. Complete blood count shows severe pancytopenia. The patient has an advance directive, signed 9 months ago, in which she designated a friend as her health care proxy. The friend is contacted by phone and tells the physician that the patient did not want to undergo any more blood transfusions. The patient’s daughter adamantly insists that the patient receive a blood transfusion, saying, “I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life.” In deciding whether to perform the blood transfusion, which of the following should the physician consider to have the highest priority?
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Question 2 of 32
2. Question
A 25-year-old man is brought to the emergency department by his wife after vomiting at a party. The patient admits to drinking 4 glasses of wine and some vodka and says he feels better now. Temperature is 37.8 C (100 F), blood pressure is 100/50 mm Hg, pulse is 106/min, and respirations are 14/min. Physical examination is remarkable for blood-tinged vomitus on the patient’s shirt and shoes. Abdominal examination reveals epigastric tenderness on palpation. On mental status examination, the patient is alert, cooperative, and fully oriented. Blood alcohol level is 70 mg/dL (0.07% blood alcohol content). The physician recommends laboratory evaluation, including complete blood count, comprehensive metabolic panel, amylase, and lipase. The patient insists that he is fine and wants to go home. Which of the following is the most appropriate course of action?
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Question 3 of 32
3. Question
A 52-year-old woman comes to the clinic to discuss the results of a recent abdominal CT scan. The patient says, “I hope the scan can tell me why I’ve been losing so much weight. What does it show?” The physician shares that the imaging is suggestive of pancreatic cancer. Upon hearing this, the patient begins to cry while holding her head in her hands. Which of the following is the most appropriate response by the physician?
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Question 4 of 32
4. Question
An 80-year-old man is brought to the emergency department by his son due to acute shortness of breath. The patient reports a chronic cough and a 13.6-kg (30-lb) weight loss over the past 6 months. Chest x-ray demonstrates a large mass in the right lung and an associated pleural effusion. The patient is hospitalized and undergoes bronchoscopy with biopsy; the pathology report comes back as bronchogenic carcinoma. When the physician initiates a private discussion about the biopsy results, the patient says, “I prefer not to be told anything. You can discuss everything with my son. I trust his judgment.” The patient is cognitively intact without signs of mental illness. Which of the following is the most appropriate response by the physician?
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Question 5 of 32
5. Question
A 2-month-old girl is brought to the office for a well-child visit. The patient was born at term with no complications. She is exclusively formula fed and gaining weight well. Examination is unremarkable today. The mother is informed that several vaccinations are due at this visit. She becomes upset and mentions that her older son, who did follow a standard vaccine schedule, had a “bad reaction” to his last set of shots and had a cough for weeks. She wants to defer immunizations for her daughter at this time. The mother says, “I know you won’t agree with me, but I have been reading that these reactions are actually very harmful to the immune system.” Which of the following is the most appropriate response?
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Question 6 of 32
6. Question
A 33-year-old man comes to the office due to back pain. He has a 2-week history of moderate pain in the lumbar area that started after a long day of yard work. There is no associated fever, motor weakness, or urinary symptoms. The patient has no history of acute trauma and medical history is unremarkable. Examination shows normal lower extremity strength, sensation, and reflexes. Straight-leg raising test is negative. The patient says, “My brother had similar pain last year and his MRI scan showed a bulging disc. Can you order that test for me?” The clinician offers options for symptomatic relief but recommends against performing any imaging studies. Which of the following is the most likely effect of this recommendation?
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Question 7 of 32
7. Question
A 31-year-old woman comes to the emergency department for evaluation of nausea, vomiting, and abdominal pain over the past 2 days. The triage nurse notes that the patient’s legal name differs from what was written on the intake form. While reviewing the patient’s electronic medical record, you see that the patient’s sex is listed as male and that multiple pronouns have been used to describe the patient in prior notes. In addition to introducing yourself to the patient, which of the following is the most appropriate initial statement?
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Question 8 of 32
8. Question
A 24-year-old man comes to the office because of mood changes. He has felt depressed, irritable, and anxious nearly every day for 2 months. The patient has difficulty getting out of bed in the mornings and staying focused at work. He has no medical conditions and takes no medications. The patient drinks 3 or 4 beers daily and more on weekends. The physician provides education about the link between alcohol and mood changes. The patient responds, “But it really helps me to unwind and relax after a long workday and makes it easier to fall asleep. It’s also how I hang out with my friends on weekends. I can’t see quitting.” Which of the following is the most appropriate statement by the physician at this time?
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Question 9 of 32
9. Question
A 62-year-old man with amyotrophic lateral sclerosis comes to the office for follow-up. The patient was diagnosed 8 months ago after experiencing bilateral arm weakness. He notes no worsening or new physical symptoms. The patient has no mood depression or anhedonia. Vital signs are within normal limits. Cardiopulmonary examination is normal. Neurologic examination is consistent with prior evaluation; moderate atrophy and weakness of the upper extremities are present, and reflexes are 3+ in the upper and lower limbs. The patient states that he is glad that the physical examination remains unchanged but shares that he has “felt distant” from his wife since being diagnosed. Which of the following is the most appropriate response?
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Question 10 of 32
10. Question
A 57-year-old woman with a history of type 2 diabetes mellitus and asthma comes to the office for a preventive visit during influenza season. The patient belongs to an ethnic minority group and is accompanied by her daughter. The patient’s medical conditions are well controlled, and she currently has no symptoms. The provider explains that she is at high risk for complications from seasonal influenza and recommends that she get the seasonal influenza vaccine. The patient says, “I don’t trust that vaccine. It’s from the government, so I don’t think it’s safe for people like me.” Which of the following actions by the physician is most appropriate?
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Question 11 of 32
11. 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 12 of 32
12. Question
An 18-year-old woman comes to the office to discuss test results. She was evaluated one week ago for recurrent vulvovaginal discharge and reported being sexually active with two partners, using oral contraceptives sometimes. The patient was counseled on safe sexual practices and tested for sexually transmitted diseases. The results have returned as positive for HIV. She has no significant medical history and takes no medications other than oral contraceptives. The patient’s family history is significant for a mother with schizophrenia and a paternal uncle with alcohol use disorder who lives in the home with them. On hearing her test results and the recommendation to start antiretroviral therapy, she is visibly upset. Which of the following is the most important intervention to promote adherence to treatment in this patient?
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Question 13 of 32
13. Question
A 29-year-old woman comes to the emergency department due to abdominal pain and fever. This morning, while crossing a street, she was struck in the stomach by a motorcyclist. On arrival, the patient tells the triage nurse that she does not have medical insurance. She has no chronic medical conditions. Temperature is 38 C (100.4 F), blood pressure is 109/82 mm Hg, and pulse is 88/min. The abdomen is distended with bruising, rebound tenderness, and guarding. The patient is told she needs exploratory surgery to treat her condition. She refuses and states angrily, “I’m suffering and I’m not going to be a guinea pig for this system. If I had insurance, you’d give me something that would actually cure me.” In addition to clarifying the details of the surgical procedure with the patient, which of the following is the most appropriate response by the physician?
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Question 14 of 32
14. Question
A 68-year-old man comes to the office for follow-up of type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient’s diabetes and hypertension are inadequately controlled, requiring multiple modifications to his medication regimen. Extended counseling is provided regarding today’s changes and the overall long-term care plan. The patient’s next appointment is in a month for a routine health maintenance examination. As the physician is getting ready to leave the room at the end of the scheduled appointment time, the patient states, “Doc, my urinary stream has been slow for the past 6 months, and I’ve been waking up twice overnight to use the bathroom. Can we talk about this today?” Which of the following is the most appropriate response by the physician?
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Question 15 of 32
15. Question
A 71-year-old woman with metastatic non-small cell lung cancer is admitted to the intensive care unit for malignant airway obstruction with post-obstructive pneumonia and sepsis. Her oncologist calls the admitting physician to provide sign out, saying, “Her disease has been progressing. Our plan was to start a third-line chemotherapy regimen next week.” Despite receiving antibiotics and supportive care, she has rapid deterioration of her respiratory status with a very high likelihood of dying in the intensive care unit. When the physician discusses the patient’s condition, the patient and family say, “Whatever might have a chance of working, we want everything to be done.” Which of the following is the most appropriate response?
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Question 16 of 32
16. Question
A 52-year-old woman undergoes a fine needle aspiration procedure for evaluation of a thyroid nodule. The physician completes the biopsy successfully without complication. However, a week later, the physician is concerned because no pathology results are seen in the electronic medical record. Upon contacting the laboratory, the physician learns that the specimen was never received. The physician inquires further among his staff and learns that the staff member normally in charge of transporting specimens was absent the day the procedure was performed, and a temporary off-site assistant had filled in for the staff member. The patient is scheduled to come to the office the following day to receive her results. After informing the patient of the need for a repeat procedure due to sample misplacement, which of the following additional statements by the physician would be most appropriate?
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Question 17 of 32
17. Question
A 49-year-old woman comes to the office due to worsening hot flashes and night sweats over the past year. The patient’s menstrual periods have been irregular for the past 2 years, and her last menstrual cycle was a year ago. She has no chronic medical conditions and has had no surgeries. BMI is 23 kg/m2. Vital signs are normal. The neck is supple and without thyromegaly. The remainder of the examination is normal. The patient says, “This is awful. I turn red and sweat in the middle of work meetings and then have to leave to cool down. I’m wondering if hormones could help.” Which of the following is the most appropriate response to this patient?
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Question 18 of 32
18. Question
An 18-year-old man comes to the office for a follow-up visit. He was seen in the emergency department 3 months ago because of panic attacks related to cocaine use. The patient subsequently stopped using cocaine and has had no recurrent anxiety symptoms. He graduated from high school, started a new job, and has been considering applying to community college. At today’s visit, the patient reports that he used cocaine at a friend’s house this past weekend. He says, “I really messed up. I feel like a failure.” The patient has no history of illness. He is in no physical discomfort. Which of the following is the most appropriate statement by the physician at this time?
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Question 19 of 32
19. Question
A 68-year-old woman comes to the office to discuss lipid-lowering therapy. She was prescribed rosuvastatin 6 months ago following a transient ischemic attack, but her pharmacy sent a notice to the physician a week ago that she has not filled her prescription for the past 3 months. The patient otherwise feels well and has had no recurrent neurologic symptoms. When asked why she is not taking her medication, she says, “I feel great without it. The ministroke was the scariest thing that ever happened to me, and now that I have put it behind me, I don’t want the medication to remind me about my problem all over again.” Which of the following is the most appropriate response to this patient’s statement?
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Question 20 of 32
20. Question
A 60-year-old man comes to the office for surgical consultation of multivessel coronary artery disease. After reviewing prior records and completing a thorough evaluation, the surgeon discusses the recommendation for a coronary artery bypass graft, describing the indications for the operation and providing an overview of the surgery, including risks and benefits. The surgeon then discusses what the patient can expect during the recovery period. Which of the following additional disclosures is a necessary component of an informed consent discussion by the surgeon?
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Question 21 of 32
21. Question
A 28-year-old woman, gravida 2 para 1, comes to the emergency department for evaluation of vaginal bleeding. The patient has had bright red spotting for the past 24 hours but no contractions or leakage of fluid. She is at 31 weeks gestation by last menstrual period and has not had prenatal care this pregnancy. Her first pregnancy ended in an uncomplicated spontaneous vaginal delivery at term. Vital signs and fetal heart rate tracing are normal. Physical examination shows a nontender uterus consistent in size with 31 weeks gestation. A pelvic ultrasound reveals a complete placenta previa. The findings are discussed with the patient, and she states that she would still like to have a vaginal delivery. The physician says, “Unfortunately, the only safe option for delivery is a cesarean delivery.” The physician’s statement is an example of which of the following ethical principles?
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Question 22 of 32
22. Question
A 56-year-old man comes to the office for follow-up of type 2 diabetes mellitus. He has an extensive family history of complicated type 2 diabetes, and multiple family members have required lower extremity amputations for nonhealing ulcers. The patient has tried multiple oral medications and his most recent hemoglobin A1c is 9.6%. He is now being considered for basal insulin therapy. After an extended discussion of injection technique, the patient tells the clinician that he does not want to initiate insulin. He says, “My diabetes is my own fault. My mother always said I was too fat and was going to get diabetes like my dad. Maybe if I stop eating too much, I wouldn’t have to waste your time giving me insulin.” Which of the following is the most appropriate response to this patient’s statement?
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Question 23 of 32
23. Question
A 57-year-old man comes to the office accompanied by his wife due to low mood and sleep disturbances for the past 2 months. The patient has also had a loss of interest in his hobbies, concentration difficulties that are affecting his work, and low energy. The patient has no suicidal thoughts. Psychiatric history is significant for a period of depression in his 20s treated with psychotherapy. Medical history is noncontributory. Vital signs and physical examination are within normal limits. The patient has a depressed affect with restricted range and soft speech. Treatment options are discussed, including psychotherapy and antidepressant medications. The patient responds that he is willing to consider psychotherapy but does not believe medication is necessary. His wife says, “I don’t think he understands how serious this is—he’s in danger of losing his job. I’ll make sure he takes the medication.” Which of the following is the most appropriate next step in management of this patient?
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Question 24 of 32
24. 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 discussions regarding advance care planning and appointment of a surrogate decision maker are initiated, 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 best response?
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Question 25 of 32
25. Question
A 59-year-old man comes to the office for follow-up. The patient had an acute myocardial infarction 1 month ago, and a drug-eluting stent was placed successfully. He has no cardiovascular symptoms, but he does have hypertension and hyperlipidemia and a 40-pack-year smoking history. Blood pressure is 132/86 mm Hg and pulse is 68/min. BMI is 30.8 kg/m2. Physical examination is unremarkable. The patient says, “I can’t wait to get back to work, but at the same time, I’m concerned about having another heart attack. I have a high-pressure job, but I need to find time to exercise. Plus, I know I should stop smoking and lose at least 20 pounds.” Which of the following is the most appropriate response by the physician at this time?
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Question 26 of 32
26. Question
A 25-year-old woman comes to the office for an initial evaluation of low mood. Since moving to a new apartment 3 weeks ago, the patient has felt sad and has not been sleeping well. She says, “My landlord won’t allow pets in the building. I miss my dog so much. I know my mood would improve if I could get a letter from you saying my dog can live with me.” The patient’s dog is currently staying with her parents, who live a few miles away from her. Which of the following statements by the physician is the most appropriate?
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Question 27 of 32
27. Question
A 73-year-old woman with congestive heart failure is being prepared for discharge from the hospital. The patient has heart failure with reduced ejection fraction and has been admitted to the hospital twice in the past 60 days. Medical history is notable for ischemic heart disease, chronic obstructive pulmonary disease, and hypertension. Vital signs are normal. Pulmonary examination shows normal respiratory effort and no crackles, and there is no peripheral edema. The patient asks to stay in the hospital for a few additional days and says, “I feel fine right now, but I am worried that if I go home, I might end up back in the hospital again.” Which of the following is the most appropriate response to this patient’s request?
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Question 28 of 32
28. Question
A 16-year-old girl comes to the office due to malodorous vaginal discharge. The patient arrives with her mother, who stays in the examination room for the evaluation. The patient has had increased vaginal discharge for the past 2 days but no abnormal vaginal bleeding or abdominal or pelvic pain. She is sexually active with a new partner and uses a progestin-releasing subdermal implant for contraception. Her last menstrual period was 2 weeks ago. She has no chronic medical conditions and takes no medications. Vital signs are normal. The patient appears anxious. Abdominal examination shows no tenderness or palpable masses. When the pelvic examination is attempted, the patient says that she is “embarrassed and anxious” and refuses the examination. Which of the following is the most appropriate course of action?
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Question 29 of 32
29. Question
A resident physician is on her way to morning signout after her overnight shift and gets into an elevator crowded with nurses and other hospital staff members. The medical student on the team gets on the elevator and asks the resident how her shift went. During the conversation, the student is careful not to mention the patient’s name, asking, “Did the patient in Room 232 get her CT scan?” Which of the following is the most appropriate response to the student?
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Question 30 of 32
30. Question
A 45-year-old woman comes to the office for a routine follow-up. The patient feels well overall but mentions that climbing the last flight of stairs to her 3rd-floor apartment has become harder. She says, “Sometimes I have to stop at the landing to catch my breath.” Medical history includes cocaine use disorder in remission for the past 4 years; it is otherwise unremarkable. The patient does not use alcohol or illicit drugs. She has a 25-pack-year smoking history and has been counseled to quit smoking in the past. The patient says, “I’ve tried to quit several times. I can cut down to a few cigarettes or half a pack for a day or two, but then it’s just too difficult.” Which of the following is the most appropriate response by the physician regarding this patient’s smoking?
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Question 31 of 32
31. Question
A 37-year-old woman, gravida 2 para 1, at 8 weeks gestation comes to the clinic to establish prenatal care. The patient has had mild nausea, but no vomiting or vaginal bleeding. She has no chronic medical conditions and has had no surgeries. Her only medication is a prenatal vitamin. The patient’s prior pregnancy ended in a spontaneous vaginal delivery at 38 weeks gestation. BMI is 32 kg/m2. Physical examination is unremarkable. Ultrasound confirms an 8-week intrauterine pregnancy with normal cardiac activity. Although the patient’s last delivery was at a hospital, she is now considering a planned home birth. Which of the following is the most appropriate statement to this patient?
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Question 32 of 32
32. Question
A 70-year-old woman comes to the office for evaluation of headaches. She has been having a severe, persistent headache for the past 2 weeks that is worse in the morning and always lingers throughout the day. The patient frequently feels nauseated but has no vomiting. Medical history is significant for major depressive disorder and a prior suicide attempt at age 45; the patient is currently taking an antidepressant and has been in remission for the past year. MRI of the head reveals a mass with surrounding edema in the left cerebral hemisphere that is consistent with glioblastoma multiforme. The patient returns to the office with her son to discuss the results. Before the physician has a chance to share the findings, the son asks to speak in private and requests that the physician not reveal the results to his mother. Which of the following is the most appropriate response to the patient’s son?
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