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Question 1 of 12
1. Question
A 65-year-old Caucasian male presents to your office and complains of a hearing impairment. He is a manager and runs his own business. He noticed that it is now difficult for him to understand his employees during business meetings. He hears well and speaks fluently while on the phone or when talking to his wife, but he poorly understands ‘the people talking on TV shows’. His past medical history is insignificant. He is physically active, and works out in the gym three times a week. He does not smoke or consume alcohol. He is not taking any medications. You perform a speech discrimination test that turns out to be normal. Which of the following actions will most likely reveal an impaired speech discrimination in this patient?
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Question 2 of 12
2. Question
A 32-year-old woman comes to the physician complaining of one year of nasal congestion and runny nose. She also feels mucus dripping down her throat that sometimes makes her cough. She has tried over-the-counter saline spray with mild relief. The patient cannot identify any precipitating factors and feels that her nasal passages are constantly blocked. Physical examination shows boggy-appearing nasal turbinates with mild erythema. Which of the following is the best next step in management of this patient?
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Question 3 of 12
3. Question
A 72-year-old Caucasian male comes to your office. He is complaining of hoarseness for the past six months. He says the hoarseness has been gradually worsening, and now he has developed difficulty in swallowing, pain in both ears, and exertional shortness of breath. He adds that he recently had a couple of episodes of hemoptysis. On examination, significant cervical lymphadenopathy is present. Chest x-ray is normal. Flexible fiberoptic endoscopy shows a laryngeal mass involving both supra glottic and infra glottic regions, as well as the vocal cords. The biopsy report reveals squamous cell carcinoma. The surgery and otolaryngology team, after careful review of all the findings, declare the lesion inoperable. At this time, what is the most appropriate treatment option for your patient?
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Question 4 of 12
4. Question
A 55-year-old woman with amyotrophic lateral sclerosis comes to the clinic for follow-up due to dysphagia. Since the diagnosis 2 years ago, the patient’s functional status has severely declined. NPO was advised, and a percutaneous gastrostomy tube was inserted a year ago after a modified barium swallow study revealed aspiration and ineffective clearance due to weak cough. The patient craves being able to take food by mouth, often asking her husband to spoon-feed her saying, “I would give anything to eat a cheeseburger again.” However, her husband is very reluctant after a frightening episode of coughing and cyanosis when he fed her a piece of steak. The patient uses a motorized wheelchair because of limb weakness and noninvasive positive pressure ventilation at night because of diaphragm dysfunction. She has recently completed an advance directive and will not be resuscitated during cardiac or respiratory arrest. Which of the following is the most appropriate response to the patient’s request to eat?
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Question 5 of 12
5. Question
The following vignette applies to the next 2 items.
A 72-year-old woman comes to the emergency department due to right ear pain and drainage for the past 2 days. She saw her primary care physician a week ago for decreased hearing in the right ear and underwent aural irrigation to remove impacted cerumen. Medical history is notable for hypertension, diabetes mellitus, and rheumatoid arthritis. Current medications include hydrochlorothiazide, enalapril, metformin, and methotrexate. Temperature is 37.2 C (99 F), blood pressure is 146/74 mm Hg, pulse is 100/min, and respirations are 16/min. There is marked tenderness with movement of the right earlobe. Purulent discharge and granulation tissue are noted on the floor of the right external auditory canal at the osseocartilaginous junction. The tympanic membrane appears intact.
Item 1 of 2
Which of the following is the most likely cause of this patient’s acute findings?
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Question 6 of 12
6. Question
Item 2 of 2
Which of the following is the most appropriate initial treatment for this patient’s condition?
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Question 7 of 12
7. Question
A 44-year-old woman comes to the office due to severe, episodic dizziness for the last year. During the episodes, she feels the room is spinning and she is unable to walk. The episodes last for 1-2 hours and resolve spontaneously. She has also noticed periodic decreased hearing and a ringing sensation in her left ear. The patient has chronic tension headaches and frequently takes aspirin to cope with the pain. She does not smoke or drink alcohol. Blood pressure is 130/83 mm Hg and pulse is 74/min standing and 128/85 mm Hg and 76/min supine. What is the most likely diagnosis in this patient?
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Question 8 of 12
8. Question
A 49-year-old woman comes to the emergency department due to hearing loss. Upon awakening this morning, she was unable to hear out of her right ear. She also hears a loud ringing noise in her right ear. The patient has no ear pain or dizziness. This has never occurred before. She has no other medical conditions and takes no medications. Vital signs are within normal limits. On examination, the ear canals and tympanic membranes are clear. There is no middle ear effusion. Weber tuning fork examination lateralizes to the left. Air conduction is greater than bone conduction bilaterally. The remainder of the neurologic examination is normal. Which of the following is the most appropriate next step in management of this patient?
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Question 9 of 12
9. Question
A 4-year-old girl is brought to the emergency department with sore throat, fever, and refusal to eat or drink for the past 12 hours. For the past 10 days, the patient has had symptoms of intermittent fever, runny nose, and cough. Her condition seemed to be improving but then got worse yesterday, progressing to fever up to 39.5 C (103.1 F). The patient also started tugging at her right ear and saying that it hurt. Shortly afterward, she began refusing all food and drink. The patient has no other chronic medical conditions and is up to date with immunizations. Temperature is 38.9 C (102 F), blood pressure is 90/50 mm Hg, and pulse is 110/min. On examination, the patient appears ill. She is not making tears when she cries. The voice sounds muffled. The patient can lie flat to breathe, and there is no stridor. Bilateral tympanic membranes are clear. The nose has some clear rhinorrhea. Trismus limits examination of the oropharynx. Tender anterior cervical adenopathy is worse on the right side. Which of the following physical examination findings in this patient most strongly indicates a need for surgical intervention?
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Question 10 of 12
10. Question
A 76-year-old woman is brought to the physician by her son. He is concerned that his mother, who was previously outgoing, does not want to leave her home. She lives alone and works as a part-time volunteer at a local library. Although she continues to work shelving books, she has stopped attending her weekly meetings at a senior center where she socialized with friends. The patient also seems quieter and more difficult to engage in conversation when he calls her on the telephone. One week ago, he found her sitting on a chair pulled up close to the television. She did not notice his presence immediately but then smiled and nodded as if following the conversation. He became concerned when she asked about her grandchild’s upcoming birthday party even though he had just told her the details. Her past medical history is significant for hypertension. The patient reports that her sleep and appetite are fine. She does not use tobacco, alcohol, or illicit drugs. Her medications include valsartan and hydrochlorothiazide. Which of the following is the most likely diagnosis?
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Question 11 of 12
11. Question
A 56-year-old man comes to the office due to feeling “dizzy” over the past 2 weeks. He works in a warehouse and says he experiences a brief, severe spinning sensation when looking up at objects on a high shelf. Vital signs are normal. Examination shows normal hearing. Ocular movements in a sitting position are normal, but when the patient’s head is rotated to the right side off the examination table, he develops vertigo and rotatory nystagmus. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient’s symptoms?
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Question 12 of 12
12. Question
A 21-year-old man comes to the office due to pain and itching in his left ear. The symptoms began after a swimming party and have progressively worsened. The patient has also noted scant discharge on his pillow when waking in the morning. There is no associated hearing loss, tinnitus, or vertigo. Medical history is unremarkable and he takes no medications. Vital signs are normal without fever. Pain is elicited when the auricle is pulled superiorly or the tragus is pressed inward. The ear canal is edematous and erythematous, with soft cerumen and yellowish debris. There is no periauricular erythema or lymphadenopathy. Following gentle removal of debris from the canal under direct visualization, the tympanic membrane is fully inspected and appears normal. Which of the following is the most appropriate next step in management of this patient?
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