General Internal Medicine MCQ Quiz Questions

1. A 43-year-old woman is evaluated during an initial visit. She has brought with her a written list of health problems, including headaches, muscle pain and weakness, abdominal pain, diarrhea, sinusitis, and frequent urinary tract infection. She also reports problems with sexual intimacy. For the past 4 years, her health problems have interfered with her ability to work. Previous treatments for headache have included venlafaxine, verapamil, propranolol, and gabapentin. For each of these, she reports no relief or an intolerance to the medication. Previous evaluation by a neurologist, gastroenterologist, and rheumatologist yielded no diagnosis of her medical problems. Previous laboratory studies, including complete blood count; erythrocyte sedimentation rate; serum B-₁₂/folate, electrolyte, creatinine, blood urea nitrogen, and thyroid-stimulating hormone levels; liver chemistry tests; serum lipid panel; serum rheumatoid factor and antinuclear antibody assays; heterophile antibody testing; and urinalysis, were normal. Results of MRI of the head, colonoscopy, and CT of the abdomen were negative. She has not had any tick exposures or bites nor any memory of experiencing an expanding red rash. The patient describes health problems in response to each portion of the general review of systems. When she is asked if she feels depressed, she becomes visibly angry. The physical examination, including vital signs, is normal. Which of the following is the most appropriate management option for this patient?

Repeated MRI of the head

Cognitive behavioral therapy

Enzyme-linked immunosorbent assay for Borrelia burgdorferi

Lumbar puncture and cerebral fluid analysis

Switch from nortriptyline to venlafaxine

Based on the patient's extensive list of symptoms and negative findings on previous evaluations and laboratory studies, it is unlikely that her symptoms are due to a specific medical condition. The patient's anger when asked about depression suggests that her symptoms may be related to a psychological or psychiatric condition. Cognitive behavioral therapy (CBT) is a form of psychotherapy that has been shown to be effective in treating a range of conditions, including chronic pain, headaches, and depression. Therefore, CBT would be the most appropriate management option for this patient. Repeated MRI of the head, enzyme-linked immunosorbent assay for Borrelia burgdorferi, lumbar puncture and cerebral fluid analysis, and switching medications are not indicated based on the information provided.

Explanation

Based on the patient's extensive list of symptoms and negative findings on previous evaluations and laboratory studies, it is unlikely that her symptoms are due to a specific medical condition. The patient's anger when asked about depression suggests that her symptoms may be related to a psychological or psychiatric condition. Cognitive behavioral therapy (CBT) is a form of psychotherapy that has been shown to be effective in treating a range of conditions, including chronic pain, headaches, and depression. Therefore, CBT would be the most appropriate management option for this patient. Repeated MRI of the head, enzyme-linked immunosorbent assay for Borrelia burgdorferi, lumbar puncture and cerebral fluid analysis, and switching medications are not indicated based on the information provided.

2. A 24-year-old woman with Down's syndrome is evaluated for hair loss. Hair comes out in patches when she washes or brushes it. She feels well and has had no recent stressors or changes in her routine. She takes no medications. She is not fatigued and has had no recent change in weight. On examination, she has a well-demarcated bald patch in the occipital area. The area shows a small oval patch of smooth skin with no scale or redness. Wood's light examination is negative. Which of the following is the most likely diagnosis?

Telogen effluvium

Trichotillomania

Tinea capitis

Alopecia areata

The most likely diagnosis in this case is alopecia areata. This is supported by the presence of a well-demarcated bald patch in the occipital area, which is characteristic of alopecia areata. The absence of scale, redness, or positive findings on Wood's light examination also suggests alopecia areata rather than tinea capitis. Trichotillomania, which is hair loss caused by compulsive hair pulling, is less likely given the absence of any recent stressors or changes in routine. Telogen effluvium, which is hair shedding caused by a disruption in the hair growth cycle, is also less likely given the well-demarcated patch of hair loss.

Explanation

The most likely diagnosis in this case is alopecia areata. This is supported by the presence of a well-demarcated bald patch in the occipital area, which is characteristic of alopecia areata. The absence of scale, redness, or positive findings on Wood's light examination also suggests alopecia areata rather than tinea capitis. Trichotillomania, which is hair loss caused by compulsive hair pulling, is less likely given the absence of any recent stressors or changes in routine. Telogen effluvium, which is hair shedding caused by a disruption in the hair growth cycle, is also less likely given the well-demarcated patch of hair loss.

3. A 20-year-old male college student is having trouble sleeping because of an itchy rash on his hands and inner aspect of his arm. His pruritus has been recurring for several years, becoming more severe in the winter despite his use of a daily moisturizer. His history is remarkable for seasonal allergies, and the only medication he uses is a nasal corticosteroid in the fall. The physical examination, including vital signs, is normal, exception for the skin examination, shown in Figure-

Which of the following is the most appropriate treatment for this patient's condition?

Topical corticosteroids

Topical tacrolimus

Oral antibiotics

Topical antifungals

Oral corticosteroids

The most appropriate treatment for this patient's condition is topical corticosteroids. The patient's symptoms of an itchy rash on his hands and inner aspect of his arm, which worsens in the winter, suggest a chronic dermatitis. Topical corticosteroids are the mainstay of treatment for dermatitis and can help reduce inflammation, itching, and redness. The fact that the patient has been using a daily moisturizer without improvement suggests that moisturizers alone are not sufficient in this case.

Explanation

The most appropriate treatment for this patient's condition is topical corticosteroids. The patient's symptoms of an itchy rash on his hands and inner aspect of his arm, which worsens in the winter, suggest a chronic dermatitis. Topical corticosteroids are the mainstay of treatment for dermatitis and can help reduce inflammation, itching, and redness. The fact that the patient has been using a daily moisturizer without improvement suggests that moisturizers alone are not sufficient in this case.

4. A 72-year-old man is evaluated for decreased central vision, poor night vision, and floaters. The patient has a 20-year history of type 2 diabetes mellitus controlled with oral medications, a 20-pack-year smoking history, and hypertension. The patient has not had an eye examination in over 5 years but was told at that time that he had some early changes in his eyes due to diabetes. On physical examination, the blood pressure is 135/89 mm Hg. The ophthalmoscopic examination shows microaneurysms, cotton-wool spots, dilated retinal vessels, and new formation of retinal vessels. Neurologic evaluation is remarkable for decreased sensation in the lower extremities. Laboratory studies include a hemoglobin A_1C of 7.9% and a fasting plasma glucose level of 160 mg/dL (8.88 mmol/L). Which of the following is the most appropriate next step in the treatment of this patient's vision?

Daily aspirin

Enalapril

Laser photocoagulation

Vitrectomy

Insulin

Laser photocoagulation is the most appropriate next step in the treatment of this patient's vision because the ophthalmoscopic examination findings suggest proliferative diabetic retinopathy. Laser photocoagulation is the standard treatment for proliferative diabetic retinopathy as it helps to seal off leaking blood vessels and prevent the growth of abnormal blood vessels. This treatment can help preserve vision and prevent further complications. Other options such as daily aspirin, enalapril, vitrectomy, or insulin are not the first-line treatments for proliferative diabetic retinopathy.

Explanation

Laser photocoagulation is the most appropriate next step in the treatment of this patient's vision because the ophthalmoscopic examination findings suggest proliferative diabetic retinopathy. Laser photocoagulation is the standard treatment for proliferative diabetic retinopathy as it helps to seal off leaking blood vessels and prevent the growth of abnormal blood vessels. This treatment can help preserve vision and prevent further complications. Other options such as daily aspirin, enalapril, vitrectomy, or insulin are not the first-line treatments for proliferative diabetic retinopathy.

5. Which of the following conditions is most commonly associated with chronic, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs)?

Hypertension

Peptic ulcer disease

Asthma

Diabetes mellitus

Chronic, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is most commonly associated with the development of peptic ulcer disease. NSAIDs can irritate the stomach lining and inhibit the production of protective gastric mucus, leading to ulcers. While NSAIDs can also have effects on blood pressure and asthma, the strongest and most common association is with peptic ulcer disease. Diabetes mellitus is not typically related to NSAID use.

Explanation

Chronic, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is most commonly associated with the development of peptic ulcer disease. NSAIDs can irritate the stomach lining and inhibit the production of protective gastric mucus, leading to ulcers. While NSAIDs can also have effects on blood pressure and asthma, the strongest and most common association is with peptic ulcer disease. Diabetes mellitus is not typically related to NSAID use.

6. A 30-year-old man was evaluated for a 4-day history of acute unilateral eye pain with a foreign-body sensation in the eye. He reported no antecedent trauma, and the pain was worse in the morning on awakening. The medical history was noncontributory. On physical examination, there was conjunctival erythema of the affected eye, with no evidence of a foreign body. Results of fluorescein staining indicated a corneal ulcer. The patient was prescribed pain medication and was counseled to call the next day if there was no resolution or worsening of symptoms. The patient calls the next day, stating that his pain has gotten progressively worse and there is a mucopurulent discharge from his eye. Which of the following possible patient factors is likely to be helpful in establishing a diagnosis?

History of diabetes mellitus

Contact lens use

Swimming

History of chronic allergic conjunctivitis

History of systemic lupus erythematosus

Contact lens use is likely to be helpful in establishing a diagnosis because it increases the risk of corneal ulcers. Contact lenses can cause microtrauma to the cornea, which can lead to the development of ulcers. Additionally, contact lens use can increase the risk of infection, which can also cause symptoms such as eye pain and discharge. Therefore, considering the patient's symptoms and the presence of a corneal ulcer, contact lens use is a relevant factor to consider in the diagnosis.

Explanation

Contact lens use is likely to be helpful in establishing a diagnosis because it increases the risk of corneal ulcers. Contact lenses can cause microtrauma to the cornea, which can lead to the development of ulcers. Additionally, contact lens use can increase the risk of infection, which can also cause symptoms such as eye pain and discharge. Therefore, considering the patient's symptoms and the presence of a corneal ulcer, contact lens use is a relevant factor to consider in the diagnosis.

7. A 55-year-old woman is evaluated during a routine visit and seeks medication to help her lose weight. The patient had begun to put on weight after menopause at age 49 years. She has tried multiple diets but has failed to maintain the weight loss she initially achieves with each diet. She does not smoke or drink alcohol. Her medical history is significant for hypertension, for which she takes three medications. On physical examination, the pulse rate is 65/min, and the blood pressure is 142/90 mm Hg. The BMI is 33. The remainder of the physical examination is normal. Which of the following medications is the most appropriate treatment for this patient?

Sibutramine

Phentermine

Mirtazapine

Orlistat

Orlistat is the most appropriate treatment for this patient because it is a weight loss medication that works by inhibiting the absorption of dietary fat. This patient has a BMI of 33, which indicates obesity, and has failed to maintain weight loss with multiple diets. Additionally, she has hypertension, which may be exacerbated by her weight. Orlistat can help her achieve and maintain weight loss, which can improve her overall health and potentially reduce her blood pressure. Sibutramine and phentermine are both appetite suppressants, but they are contraindicated in patients with hypertension. Mirtazapine is an antidepressant that can cause weight gain.

Explanation

Orlistat is the most appropriate treatment for this patient because it is a weight loss medication that works by inhibiting the absorption of dietary fat. This patient has a BMI of 33, which indicates obesity, and has failed to maintain weight loss with multiple diets. Additionally, she has hypertension, which may be exacerbated by her weight. Orlistat can help her achieve and maintain weight loss, which can improve her overall health and potentially reduce her blood pressure. Sibutramine and phentermine are both appetite suppressants, but they are contraindicated in patients with hypertension. Mirtazapine is an antidepressant that can cause weight gain.

8. A 37-year-old man is evaluated during a routine visit and reports feeling depressed. He meets the criteria for major depression and generalized anxiety disorder. The medical history is otherwise noncontributory. The physical examination, including vital signs, is normal. Laboratory studies are unremarkable. Which of the following is the most appropriate treatment option for this patient?

Paroxetine

Bupropion

Clonazepam

Risperidon

Paroxetine is the most appropriate treatment option for this patient because it is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat major depression and generalized anxiety disorder. It is effective in improving mood and reducing anxiety symptoms. Bupropion is an atypical antidepressant that may be considered as an alternative, but it is not the most appropriate initial treatment option for this patient. Clonazepam is a benzodiazepine used to treat anxiety disorders, but it is not the first-line treatment for depression. Risperidone is an antipsychotic medication used for the treatment of schizophrenia and bipolar disorder, and it is not indicated for the treatment of depression or anxiety disorders.

Explanation

Paroxetine is the most appropriate treatment option for this patient because it is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat major depression and generalized anxiety disorder. It is effective in improving mood and reducing anxiety symptoms. Bupropion is an atypical antidepressant that may be considered as an alternative, but it is not the most appropriate initial treatment option for this patient. Clonazepam is a benzodiazepine used to treat anxiety disorders, but it is not the first-line treatment for depression. Risperidone is an antipsychotic medication used for the treatment of schizophrenia and bipolar disorder, and it is not indicated for the treatment of depression or anxiety disorders.

9. A 60-year-old man is evaluated for a 3-month history of persistent left lower facial pain in the mandibular region that has worsened and been unresponsive to treatment with acetaminophen, 4 g four times daily, over the past 3 weeks. He describes the pain as "electrical" in nature, often triggered by dental manipulation or extreme temperature exposure. His dentist found no oral or dental cause for the pain but treated him with a 14-day course of amoxicillin for presumptive sinusitis without improvement. The physical examination, including a complete neurologic evaluation, is normal. Laboratory studies and CT of the sinuses are normal. Which of the following is the most cost-effective and efficacious treatment for this patient?

Narcotic analgesia

Gabapentin

Tricyclic antidepressants

Carbamazepine

Tetrahydrocannabinol analogs

Carbamazepine is the most cost-effective and efficacious treatment for this patient. The patient's symptoms, such as persistent left lower facial pain that is described as "electrical" and triggered by dental manipulation or extreme temperature exposure, are consistent with trigeminal neuralgia. Carbamazepine is the drug of choice for treating trigeminal neuralgia and has been shown to be effective in reducing pain in this condition. Other options such as narcotic analgesia, gabapentin, tricyclic antidepressants, and tetrahydrocannabinol analogs may be used in certain cases, but carbamazepine is the most appropriate initial treatment for this patient.

Explanation

Carbamazepine is the most cost-effective and efficacious treatment for this patient. The patient's symptoms, such as persistent left lower facial pain that is described as "electrical" and triggered by dental manipulation or extreme temperature exposure, are consistent with trigeminal neuralgia. Carbamazepine is the drug of choice for treating trigeminal neuralgia and has been shown to be effective in reducing pain in this condition. Other options such as narcotic analgesia, gabapentin, tricyclic antidepressants, and tetrahydrocannabinol analogs may be used in certain cases, but carbamazepine is the most appropriate initial treatment for this patient.

10. Which of the following is NOT a common symptom of hypothyroidism?

Fatigue

Weight gain

Constipation

Tachycardia

Hypothyroidism is a condition characterized by an underactive thyroid gland, which leads to a deficiency of thyroid hormones. These hormones play a crucial role in regulating metabolism, energy levels, and various bodily functions. Common symptoms of hypothyroidism include fatigue, weight gain, constipation, cold intolerance, dry skin, and hair loss. Tachycardia, which is a rapid heart rate, is not typically associated with hypothyroidism. In fact, hypothyroidism can sometimes cause bradycardia, which is a slow heart rate.

Explanation

Hypothyroidism is a condition characterized by an underactive thyroid gland, which leads to a deficiency of thyroid hormones. These hormones play a crucial role in regulating metabolism, energy levels, and various bodily functions. Common symptoms of hypothyroidism include fatigue, weight gain, constipation, cold intolerance, dry skin, and hair loss. Tachycardia, which is a rapid heart rate, is not typically associated with hypothyroidism. In fact, hypothyroidism can sometimes cause bradycardia, which is a slow heart rate.

11. A 68-year-old man is evaluated in the emergency department with a 5-day history of shortness of breath. He describes being jarred in an elevator 5 days earlier and sustaining a large bruise on his right flank. That evening, he had trouble sleeping from the pain, but finally managed to rest while sitting in a recliner. Over the past 5 days he has had progressive shortness of breath; originally it was related to exertion, but it now occurs at rest. He continues to sleep in the recliner for comfort. He does not smoke. On physical examination, an ecchymosis is evident on his right flank. He is mildly dyspneic with conversation. BMI is 25.7. Temperature is 38.3 °C (100.9 °F), pulse rate is 112/min, respiration rate is 26/min, and blood pressure is 142/72 mm Hg bilaterally. Pulse oximetry is 93% on room air. The trachea is midline, and jugular venous pressure is 6 cm. Lungs are dull to percussion, and there are decreased breath sounds on the right side of the chest. Cardiovascular point of maximal impulse is at the fifth intercostal space, midclavicular line. He has tachycardia. No rubs, murmurs, or gallops are heard, and there is no evidence of edema. The electrocardiogram shows sinus tachycardia without acute ST- or T-wave changes. Which of the following is the most likely diagnosis?

Pneumonia

Pulmonary Embolism

Hemothorax

Pleural effusion

Chylothorax

The most likely diagnosis in this case is hemothorax. The patient's history of sustaining a large bruise on his right flank after being jarred in an elevator suggests trauma to the chest, which can cause hemothorax. The progressive shortness of breath, decreased breath sounds on the right side of the chest, and dullness to percussion in the lungs are consistent with hemothorax. The presence of tachycardia and mild dyspnea also support this diagnosis. The absence of acute ST- or T-wave changes on the electrocardiogram rules out other cardiac causes.

Explanation

The most likely diagnosis in this case is hemothorax. The patient's history of sustaining a large bruise on his right flank after being jarred in an elevator suggests trauma to the chest, which can cause hemothorax. The progressive shortness of breath, decreased breath sounds on the right side of the chest, and dullness to percussion in the lungs are consistent with hemothorax. The presence of tachycardia and mild dyspnea also support this diagnosis. The absence of acute ST- or T-wave changes on the electrocardiogram rules out other cardiac causes.

12. An 18-year-old woman is evaluated for acne. She has had intermittent outbreaks of acne over the past 5 years. She is currently a college student who experiences stress associated with her studies. Because of her busy schedule, she often eats fast food and snacks on chocolate bars. She has tried over-the-counter topical salicylic acid and antibiotic medications to treat her acne without benefit. She is sexually active and uses barrier contraception. On physical examination, she has comedonal acne with open (blackheads) and closed (whiteheads) comedones on her face. There are no nodular lesions. Which of the following is the most appropriate management strategy for this patient's acne?

Avoidance of fast foods and chocolate

Topical retinoid medications

Oral corticosteroids

Oral tetracycline

The most appropriate management strategy for this patient's acne is the use of topical retinoid medications. This is because she has comedonal acne, which is characterized by open and closed comedones. Topical retinoids are effective in treating this type of acne by unclogging pores and preventing the formation of new comedones. Additionally, the patient has already tried over-the-counter topical salicylic acid and antibiotic medications without benefit, indicating the need for a stronger treatment option.

Explanation

The most appropriate management strategy for this patient's acne is the use of topical retinoid medications. This is because she has comedonal acne, which is characterized by open and closed comedones. Topical retinoids are effective in treating this type of acne by unclogging pores and preventing the formation of new comedones. Additionally, the patient has already tried over-the-counter topical salicylic acid and antibiotic medications without benefit, indicating the need for a stronger treatment option.

13. A 35-year-old woman is evaluated for a red right eye that is also tearing; her symptoms have developed over the past 24 hours. Her vision is not altered, and she denies eye pain, trauma to the eye, changes in visual acuity, or pruritus. On physical examination, the right conjunctiva is diffusely red, and the eye is tearing with clear discharge. The left eye appears normal. The vision is 20/20 in both eyes. Which of the following is the most appropriate next step in the management of this patient?

Topical antibiotics

No further treatment

Topical antihistamines

Urgent referral to an ophthalmologist

Topical corticosteroids

No further treatment is the most appropriate next step in the management of this patient because the patient's symptoms and physical examination findings are consistent with viral conjunctivitis, which is a self-limiting condition that does not require specific treatment. The absence of eye pain, trauma, changes in visual acuity, or pruritus further supports the diagnosis of viral conjunctivitis. Topical antibiotics, topical antihistamines, and topical corticosteroids are not indicated in viral conjunctivitis. Urgent referral to an ophthalmologist is not necessary in this case as the patient's symptoms are mild and self-limiting.

Explanation

No further treatment is the most appropriate next step in the management of this patient because the patient's symptoms and physical examination findings are consistent with viral conjunctivitis, which is a self-limiting condition that does not require specific treatment. The absence of eye pain, trauma, changes in visual acuity, or pruritus further supports the diagnosis of viral conjunctivitis. Topical antibiotics, topical antihistamines, and topical corticosteroids are not indicated in viral conjunctivitis. Urgent referral to an ophthalmologist is not necessary in this case as the patient's symptoms are mild and self-limiting.

14. A 37-year-old man is evaluated for frontal headaches, nasal congestion, and mucopurulent nasal drainage that have persisted intermittently for several years. He also has fatigue, a nighttime cough, and decreased sense of smell. Over the past 4 months, he has received three successive courses of antibiotics for worsening symptoms—initially with weeklong courses of trimethoprim–sulfamethoxazole and doxycycline. Most recently, he completed a 3-week course of amoxicillin–clavulanate in combination with a nasal steroid inhaler, nasal saline irrigation, and an oral decongestant. This treatment regimen provided only partial relief. He has no history of allergic rhinitis, eczema, or drug allergy. On physical examination, he is afebrile. The turbinates are edematous, with yellowish mucus between the right middle turbinate and lateral nasal wall. The septum is deviated to the right but with no nasal polyps. Percussion of his right maxillary sinus elicits mild tenderness. Which of the following is the most appropriate management for this patient's condition?

Allergy testing

Nasal swab cultures

Sinus MRI

Sinus CT

Sinus Radiography

The most appropriate management for this patient's condition is Sinus CT. This is because the patient has chronic symptoms of frontal headaches, nasal congestion, and mucopurulent nasal drainage that have persisted for several years. He has also received multiple courses of antibiotics with only partial relief. Sinus CT can help evaluate the sinuses for any structural abnormalities or chronic sinusitis, which may be the underlying cause of the patient's symptoms. Allergy testing and nasal swab cultures may be considered in certain cases, but in this patient, they are not indicated based on the history and physical examination findings. Sinus MRI and sinus radiography are less commonly used for evaluating chronic sinusitis.

Explanation

The most appropriate management for this patient's condition is Sinus CT. This is because the patient has chronic symptoms of frontal headaches, nasal congestion, and mucopurulent nasal drainage that have persisted for several years. He has also received multiple courses of antibiotics with only partial relief. Sinus CT can help evaluate the sinuses for any structural abnormalities or chronic sinusitis, which may be the underlying cause of the patient's symptoms. Allergy testing and nasal swab cultures may be considered in certain cases, but in this patient, they are not indicated based on the history and physical examination findings. Sinus MRI and sinus radiography are less commonly used for evaluating chronic sinusitis.

15. Which of the following is NOT a common symptom of hyperthyroidism?

Weight loss

Heat intolerance

Tremors

Bradycardia

Hyperthyroidism is a condition characterized by an overactive thyroid gland, which leads to an excess of thyroid hormones. These hormones play a crucial role in regulating metabolism, energy levels, and various bodily functions. Common symptoms of hyperthyroidism include weight loss, heat intolerance, tremors, anxiety, palpitations, and increased sweating. Bradycardia, which is a slow heart rate, is not typically associated with hyperthyroidism. In fact, hyperthyroidism can sometimes cause tachycardia, which is a rapid heart rate.

Explanation

Hyperthyroidism is a condition characterized by an overactive thyroid gland, which leads to an excess of thyroid hormones. These hormones play a crucial role in regulating metabolism, energy levels, and various bodily functions. Common symptoms of hyperthyroidism include weight loss, heat intolerance, tremors, anxiety, palpitations, and increased sweating. Bradycardia, which is a slow heart rate, is not typically associated with hyperthyroidism. In fact, hyperthyroidism can sometimes cause tachycardia, which is a rapid heart rate.

16. A 67-year-old woman is evaluated because she is worried that her memory is not what it used to be. She has trouble remembering where she places her keys and purse and sometimes has difficulty remembering where she parked her car on shopping trips. She is otherwise well and is fully independent in performing her activities of daily living. She denies depression or anhedonia and plays a round of golf each week. Her medical history includes hypertension and hypothyroidism well controlled with hydrochlorothiazide, lisinopril, and levothyroxine. She takes no herbal supplements, and her only other medications are low-dose enteric-coated aspirin, calcium, and vitamin D. On physical examination, her Mini–Mental State Examination score is 28/30. The remainder of her examination is unremarkable. Her most recent laboratory studies of 4 months ago, including complete blood count, mean corpuscular volume, liver chemistry tests, and serum creatinine, electrolyte, blood urea nitrogen, calcium, and thyroid-stimulating hormone levels, were normal. Which of the following is the most appropriate management option for this patient?

Donepezil

Depression screening

MRI of the head

Rapid plasma reagin, serum folate, and B12 measurement

The most appropriate management option for this patient is to perform a rapid plasma reagin (RPR) test, as well as measure serum folate and B12 levels. This is because the patient is experiencing memory difficulties, which could be due to various causes including vitamin deficiencies or syphilis infection. The RPR test will help to rule out syphilis as a potential cause, while measuring serum folate and B12 levels will help to identify any deficiencies that could be contributing to the memory problems. This approach allows for a targeted and specific evaluation of potential underlying causes.

Explanation

The most appropriate management option for this patient is to perform a rapid plasma reagin (RPR) test, as well as measure serum folate and B12 levels. This is because the patient is experiencing memory difficulties, which could be due to various causes including vitamin deficiencies or syphilis infection. The RPR test will help to rule out syphilis as a potential cause, while measuring serum folate and B12 levels will help to identify any deficiencies that could be contributing to the memory problems. This approach allows for a targeted and specific evaluation of potential underlying causes.

17. A 22-year-old woman is evaluated for acne on her face that has worsened over the past few weeks and includes inflammatory and small nodular lesions. The patient has a history of moderate-to-severe acne outbreaks occurring since she was age 14 years. Her parents and siblings also had serious acne. She has been taking topical retinoid and antibiotic preparations with no improvement. She is otherwise healthy. She takes combined oral contraceptives for birth control and has regular menses. On physical examination, she has several papulonodular lesions on the face. The lesions are tender, and some have pustules. Which of the following is the most appropriate next step in the management of this patient?

Change to a barrier method of contraception

Prescribe oral tetracycline

Prescribe oral isotretinoin

Prescribe a course of oral corticosteroids

Explanation

18. A 54-year-old woman undergoes urgent preoperative evaluation before resection of a partially obstructing mass in the descending colon. She has lost 9 kg (20 lb) over the past 6 months. Her history includes moderately severe chronic obstructive pulmonary disease (COPD) but no known coronary artery disease. She smokes 1 pack of cigarettes daily. Her only medication is a combined ipratropium–albuterol oral inhaler. On physical examination, she appears ill. The blood pressure is normal. Weight is 48.9 kg (108 lb). Oxygen saturation is 88% on room air. On cardiopulmonary examination, the lungs are clear, with distant breath sounds and a prolonged expiratory phase, and the heart has a regular rhythm without murmur or gallop. On abdominal examination, high-pitched bowel sounds are heard, and a 6-cm mass, tender to palpation, is detected in the left lower quadrant of the abdomen. Laboratory tests are normal except for a hemoglobin of 10.0 g/dL (100 g/L) and a serum albumin level of 2.9 g/dL (29 g/L). The chest radiograph shows only changes consistent with COPD, and the electrocardiogram is normal. In addition to routine use of scheduled bronchodilator treatments and supplemental oxygen, which of the following strategies is most appropriate in preventing postoperative pneumonia in this patient?

Intravenous hyperalimentation

Prophylactic corticosteroids

Prophylactic antibiotics

Incentive spirometry

Enteral hyperalimentation

Incentive spirometry is the most appropriate strategy to prevent postoperative pneumonia in this patient. This patient has several risk factors for postoperative pneumonia, including weight loss, COPD, and smoking. Incentive spirometry helps to improve lung function and prevent atelectasis, which can lead to pneumonia. It involves deep breathing exercises using a spirometer device to encourage deep inhalation and prevent lung collapse. Intravenous hyperalimentation and enteral hyperalimentation are not indicated in this patient as she does not have severe malnutrition. Prophylactic corticosteroids and antibiotics are not recommended for routine use in preventing postoperative pneumonia.

Explanation

Incentive spirometry is the most appropriate strategy to prevent postoperative pneumonia in this patient. This patient has several risk factors for postoperative pneumonia, including weight loss, COPD, and smoking. Incentive spirometry helps to improve lung function and prevent atelectasis, which can lead to pneumonia. It involves deep breathing exercises using a spirometer device to encourage deep inhalation and prevent lung collapse. Intravenous hyperalimentation and enteral hyperalimentation are not indicated in this patient as she does not have severe malnutrition. Prophylactic corticosteroids and antibiotics are not recommended for routine use in preventing postoperative pneumonia.

19. A 42-year-old woman is evaluated during a routine examination. She has been married and monogamous for 21 years. Her history includes celiac sprue, which was diagnosed at age 25 years and for which she maintains a gluten-free diet that limits her symptoms. She also has mild rosacea and frequent urinary tract infections. Her mother was recently diagnosed with hypothyroidism, but the patient reports no fatigue or hot or cold intolerance, and she has had no changes in weight, hair, skin, and nails. The patient exercises regularly. She reports no polyuria or polydipsia. On physical examination, the patient is fair-skinned. BMI is 18.9, and weight has been stable. The pulse rate is 68/min, and blood pressure is 102/66 mm Hg. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate management for this patient?

TSH measurement

Bone density test

Chalamydia trachomatis infection

Diabetes screening

Colon cancer screening

The patient is a 42-year-old woman with a history of celiac sprue, mild rosacea, and frequent urinary tract infections. She has no symptoms of hypothyroidism or diabetes. The most appropriate management for her would be a bone density test. Celiac sprue is associated with decreased bone mineral density, and since the patient has had the condition for a long time, it is important to assess her bone health. The other options, such as TSH measurement, chlamydia infection testing, diabetes screening, and colon cancer screening, are not indicated based on the patient's history and symptoms.

Explanation

The patient is a 42-year-old woman with a history of celiac sprue, mild rosacea, and frequent urinary tract infections. She has no symptoms of hypothyroidism or diabetes. The most appropriate management for her would be a bone density test. Celiac sprue is associated with decreased bone mineral density, and since the patient has had the condition for a long time, it is important to assess her bone health. The other options, such as TSH measurement, chlamydia infection testing, diabetes screening, and colon cancer screening, are not indicated based on the patient's history and symptoms.

20. A 77-year-old man who wears glasses is evaluated for symptoms of increasing visual glare when he is out at night, but he reports no problems with bright sunlight, reading, or watching television. He no longer drives because he lives in a downtown condominium and prefers to walk and use public transportation. His history is negative for diabetes, corticosteroids, and cigarette smoking. His corrected visual acuity is 20/25 in each eye. Direct ophthalmoscopy reveals bilateral red reflexes with central opacities, but the optic disks and retinal vessels are normal. Which of the following is the most appropriate management for this patient's visual symptoms?

Cataract extraction

Vitamin E supplementation

β-Carotene supplementation

Monitoring of visual status

Topical ophthalmic prostaglandin

The most appropriate management for this patient's visual symptoms is monitoring of visual status. The patient is experiencing increasing visual glare at night, which can be a symptom of cataracts. However, since the patient reports no problems with bright sunlight, reading, or watching television, and his corrected visual acuity is 20/25 in each eye, cataract extraction may not be necessary at this time. Vitamin E or β-Carotene supplementation is not indicated as there is no evidence of a deficiency or specific indication for these supplements. Topical ophthalmic prostaglandin is not indicated as there is no mention of increased intraocular pressure or glaucoma. Therefore, the most appropriate management is to monitor the patient's visual status.

Explanation

The most appropriate management for this patient's visual symptoms is monitoring of visual status. The patient is experiencing increasing visual glare at night, which can be a symptom of cataracts. However, since the patient reports no problems with bright sunlight, reading, or watching television, and his corrected visual acuity is 20/25 in each eye, cataract extraction may not be necessary at this time. Vitamin E or β-Carotene supplementation is not indicated as there is no evidence of a deficiency or specific indication for these supplements. Topical ophthalmic prostaglandin is not indicated as there is no mention of increased intraocular pressure or glaucoma. Therefore, the most appropriate management is to monitor the patient's visual status.