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Which of the following is the most appropriate management? Which of the following is the most appropriate management? (A) Cryotherapy (A) Finasteride (B) Excisional biopsy (B) Scheduled voiding (C) Reevaluate in 3 months (C) Tamsulosin (D) Superficial shave biopsy (D) Urodynamic testing Item 6 A 64-year-old man is evaluated during a routine well- Item 9 ness visit. He received a tetanus toxoid, reduced diph- A 48-year-old man is evaluated during a follow-up visit for theria toxoid, and acellular pertussis vaccine 5 years obesity. He has been unsuccessful in losing weight despite ago; the live attenuated herpes zoster vaccine 4 years several weight loss diets, including structured meal plans, ago; and the influenza and COVID-l9 vaccines during nutritionist referral, and weight loss medications. He walks the most recent influenza season. He had an episode of 15 minutes daily but finds exercise difficult because of herpes zoster 2 years ago. Medical history is otherwise joint pain. Medical history is significant for type 2 diabetes unremarkable. He takes no medications and does not mellitus, hypertension, obstructive sleep apnea, and osteo- smoke cigarettes. arthritis. Medications are metformin, empagliflozin, lira- glutide, lisinopril, hydrochlorothiazide, topical diclofenac, Which of the following is the most appropriate vaccine to and acetaminophen. He uses continuous positive airway administer to this patient? pressure ventilation at night. On physical examination, blood pressure is 148/80 mm (A) Quadrivalentmeningococcalconjugate vaccine Hg, and pulse rate is 95/min; other vital signs are normal. (B) Recombinant (inactivated) herpes zoster vaccine BMI is 40. Crepitus in his knees bilaterally is noted, along (C) 23-Valentpneumococcalpolysaccharidevaccine with tenderness of the medial joint line. The remainder of (D) No vaccines are indicated the examination is normal.

Item 6 A 64-year-old man is evaluated during a routine well- Item 9 ness visit. He received a tetanus toxoid, reduced diph- A 48-year-old man is evaluated during a follow-up visit for theria toxoid, and acellular pertussis vaccine 5 years obesity. He has been unsuccessful in losing weight despite ago; the live attenuated herpes zoster vaccine 4 years several weight loss diets, including structured meal plans, ago; and the influenza and COVID-l9 vaccines during nutritionist referral, and weight loss medications. He walks the most recent influenza season. He had an episode of 15 minutes daily but finds exercise difficult because of herpes zoster 2 years ago. Medical history is otherwise joint pain. Medical history is significant for type 2 diabetes unremarkable. He takes no medications and does not mellitus, hypertension, obstructive sleep apnea, and osteo- smoke cigarettes. arthritis. Medications are metformin, empagliflozin, lira- glutide, lisinopril, hydrochlorothiazide, topical diclofenac, Which of the following is the most appropriate vaccine to and acetaminophen. He uses continuous positive airway administer to this patient? pressure ventilation at night. On physical examination, blood pressure is 148/80 mm (A) Quadrivalentmeningococcalconjugate vaccine Hg, and pulse rate is 95/min; other vital signs are normal. (B) Recombinant (inactivated) herpes zoster vaccine BMI is 40. Crepitus in his knees bilaterally is noted, along (C) 23-Valentpneumococcalpolysaccharidevaccine with tenderness of the medial joint line. The remainder of (D) No vaccines are indicated the examination is normal. Whidr ofthe following is the moot appropriate managpment Item 7 of this paflenf s obesity? A 21-year-old woman is evaluated during a routine well- (A) Bariatricsurgery ness visit. She has no concerns and is asymptomatic. Med- ical history is unremarkable. Family history is negative (B) Exercise, 150 minutes weekly for premature cardiovascular disease. She does not smoke (C) Phentermine-topiramate cigarettes. She takes no medications. (D) Very-low-caloriediet

Whidr ofthe following is the moot appropriate managpment Item 7 of this paflenf s obesity? A 21-year-old woman is evaluated during a routine well- (A) Bariatricsurgery ness visit. She has no concerns and is asymptomatic. Med- ical history is unremarkable. Family history is negative (B) Exercise, 150 minutes weekly for premature cardiovascular disease. She does not smoke (C) Phentermine-topiramate cigarettes. She takes no medications. (D) Very-low-caloriediet 138

Self-Assessment Test UI t-6, tr Item 10 A 25 year-old man is evaluated fbr a 2-day history of no active joint symptoms; her rheumatoid arthritis is it.t remission. On physical examination. vital signs are normal. (u a rapidly spreading pruritic rash on his chest, back, 'lhere is chronic synovial hypertrophy of the metacarpo E t upper arms and legs. Medical history is signif)cant for UI acne vuigaris treated with tretinoin cream. Hc started phalangeal joints. Hand joints are not warm or sr.t,ollen. o I,l sulfamethoxazole trimethoprim ftrr his acne 9 days there is medial joint line tenderness and crepitus in right t knee. ago. 'Ihe rash on his back is shou,n. o vt Which of the following is the most appropriate perioperative medication management? (A) Continue methotrexate and adalimumab (B) Continue methotrexate and hold adalimurnab (C) Hold methotrexate and adalimumab (D) Hold methotrexate and continue adalimunrab

UI t-6, tr Item 10 A 25 year-old man is evaluated fbr a 2-day history of no active joint symptoms; her rheumatoid arthritis is it.t remission. On physical examination. vital signs are normal. (u a rapidly spreading pruritic rash on his chest, back, 'lhere is chronic synovial hypertrophy of the metacarpo E t upper arms and legs. Medical history is signif)cant for UI acne vuigaris treated with tretinoin cream. Hc started phalangeal joints. Hand joints are not warm or sr.t,ollen. o I,l sulfamethoxazole trimethoprim ftrr his acne 9 days there is medial joint line tenderness and crepitus in right t knee. ago. 'Ihe rash on his back is shou,n. o vt Which of the following is the most appropriate perioperative medication management? (A) Continue methotrexate and adalimumab (B) Continue methotrexate and hold adalimurnab (C) Hold methotrexate and adalimumab (D) Hold methotrexate and continue adalimunrab Item 12 A 78-year-old man is evaluated for a 3-year history of ery- thema and flaking on the scalp and face. On physical examination, ill-deflned greasy, yellow to erythematous patches with slight scale are noted on the eyebrows, nose, and medial aspects of the cheeks. Similar changes on the scalp are shown.

Item 12 A 78-year-old man is evaluated for a 3-year history of ery- thema and flaking on the scalp and face. On physical examination, ill-deflned greasy, yellow to erythematous patches with slight scale are noted on the eyebrows, nose, and medial aspects of the cheeks. Similar changes on the scalp are shown. 'lhe rash is also found on his neck, chest, and proximal limbs. Conjunctivae, oral mucosa. and urethral meatus are There are no additional skin or nail changes. normal, and there are no oral lesions. Anterior and posterior cervical lymphadenopathy is present. 'lhe remainder of the Which of the following is the most appropriate examination is normal. treatment? (A) Clindamycin lotion Which of the following is the most likely diagnosis? (B) Clobetasolointment (A) Drug induced hypersensitivity syndrome (C) 5 Fluorouracil cream (U) Exanthematous drug cruption (D) Oral ketoconazole (C) Fixed drug eruption (E) Zinc pyrithione shampoo (D) I Iypersensitivity vasculitis

'lhe rash is also found on his neck, chest, and proximal limbs. Conjunctivae, oral mucosa. and urethral meatus are There are no additional skin or nail changes. normal, and there are no oral lesions. Anterior and posterior cervical lymphadenopathy is present. 'lhe remainder of the Which of the following is the most appropriate examination is normal. treatment? (A) Clindamycin lotion Which of the following is the most likely diagnosis? (B) Clobetasolointment (A) Drug induced hypersensitivity syndrome (C) 5 Fluorouracil cream (U) Exanthematous drug cruption (D) Oral ketoconazole (C) Fixed drug eruption (E) Zinc pyrithione shampoo (D) I Iypersensitivity vasculitis Item 13 tr Item 11 A 62 year old woman is seen for a preoperative evaluation A 34-year-old man is evaluated for an B month history of erectile dysfunction and decreased libido. He reports an beftrre right knee arthroplasty. She has osteoarthritis of absence of early-morning erections. He reports no depres the knee and also has a history of rheumatoid arthritis. sive or anxiety-related symptoms. Medical history is signif- Medications are topical diclofenac, me thotrexate, {blic acid, icant for a single episode of depression. His only medication and adalimumab. Other than the right knee, she reports is sertraline, initiated 9 months ago. 139

Self-Assessment Test tn (D Physical examination flndings, including vital signs, tn are normal. t^ (D Laboratory studies show an early morning serum total (n l,I testosterone level of 560 ngldl (19.4 nmol/L). .D Which of the following is the most appropriate management? .D UI (A) Sex therapy counseling (B) Startintramusculartestosterone (C) Start oral tadalafll (D) Taper sertraline Item 14 A 27-year old woman is evaluated for contraceptive coun- seling. She is nulliparous. Medical history is signiflcant for migraine with aura. She is sexually active and has a history of multiple male partners. She is a nonsmoker. She takes no Conjunctivae are red and injected. There are erosions and medications. flaccid bullae in the oropharynx. The rash involves 20olo of her body surface area. Carbamazepine has been discontinued. Which ofthe following is the most appropriate contractptive option for this patient? Which of the following is the most likely diagnosis? (A) Combined hormonal oral contraceptive pills (A) Acute generalized er1rthematous pustulosis (B) Combined hormonal vaginal ring (B) Drug-inducedhypersensitivityreaction (C) Levonorgestrel-releasing intrauterine device (C) Erythroderma (D) Male condoms (D) Stevens-Johnson/toxic epidermal necrolysis overlap syndrome

Item 14 A 27-year old woman is evaluated for contraceptive coun- seling. She is nulliparous. Medical history is signiflcant for migraine with aura. She is sexually active and has a history of multiple male partners. She is a nonsmoker. She takes no Conjunctivae are red and injected. There are erosions and medications. flaccid bullae in the oropharynx. The rash involves 20olo of her body surface area. Carbamazepine has been discontinued. Which ofthe following is the most appropriate contractptive option for this patient? Which of the following is the most likely diagnosis? (A) Combined hormonal oral contraceptive pills (A) Acute generalized er1rthematous pustulosis (B) Combined hormonal vaginal ring (B) Drug-inducedhypersensitivityreaction (C) Levonorgestrel-releasing intrauterine device (C) Erythroderma (D) Male condoms (D) Stevens-Johnson/toxic epidermal necrolysis overlap syndrome Item 15 A 4S-year-old man is evaluated during a follow-up visit Item 17 for type 2 diabetes mellitus. Over the past 3 months, his A 36-year-old man is evaluated for a 2-day history of right- hemoglobin A," has remained at 8.3%. Medications are eye redness with a yellow discharge. When he awoke this metformin and liraglutide. The patient is not following a morning, his right eye was matted with a small amount of speciflc diet and does not exercise. He states he is not fully yellow crust. He reports no pain or change in visual acuity. satisfled with his Iifestyle but is ambivalent about change. He does not wear contact lenses. He has no other symptoms or medical problems, and he takes no medications. Which of the following is the most appropriate initial On physical examination, the right eye shows diffuse, management step? circumferential conjunctival erythema with yellow crust- ing on the eyelashes. Visual acuity is 20/20 bilaterally. The (A) Add pioglitazone remainder of the examination is normal. (B) Motivational interviewing After a discussion of the risks and benefits of treatment, (C) Refer to a dietitian the patient prefers pharmacologic treatment. (D) Refer to a supervised exercise program Which of the following is the most appropriate topical treatment?

Item 15 A 4S-year-old man is evaluated during a follow-up visit Item 17 for type 2 diabetes mellitus. Over the past 3 months, his A 36-year-old man is evaluated for a 2-day history of right- hemoglobin A," has remained at 8.3%. Medications are eye redness with a yellow discharge. When he awoke this metformin and liraglutide. The patient is not following a morning, his right eye was matted with a small amount of speciflc diet and does not exercise. He states he is not fully yellow crust. He reports no pain or change in visual acuity. satisfled with his Iifestyle but is ambivalent about change. He does not wear contact lenses. He has no other symptoms or medical problems, and he takes no medications. Which of the following is the most appropriate initial On physical examination, the right eye shows diffuse, management step? circumferential conjunctival erythema with yellow crust- ing on the eyelashes. Visual acuity is 20/20 bilaterally. The (A) Add pioglitazone remainder of the examination is normal. (B) Motivational interviewing After a discussion of the risks and benefits of treatment, (C) Refer to a dietitian the patient prefers pharmacologic treatment. (D) Refer to a supervised exercise program Which of the following is the most appropriate topical treatment? tr Item 16 A 32 year-old woman is evaluated in the emergency depart- (A) Ofloxacin (B) Olopatadine ment for a rapidly spreading rash involving her trunk, (C) Prednisolone extremities, and face that started 48 hours ago. She has intense skin pain, ulcerations in her mouth and vagina, (D) Trimethoprim-polymyxin gritty sensation in her eyes, and fever. She began taking carbamazepine 12 days ago for trigeminal neuralgia. Her medical history is otherwise unremarkable, and she takes no other medications. Item 18 A 24-year-old person is evaluated as an add on patient for tr On physical examination, the patient appears ill and a right wrist growth. He describes a small soft mass on the in pain. Temperature is 40 "C (104 'F), blood pressure is ventral aspect of the wrist that he flrst noticed 6 months 110/65 mm Hg, pulse rate is 110/min, and respiration rate is ago. It has not enlarged, and it does not cause any symptoms l8/min. BMI is 33. Skin flndings are shown (see top of next or limitations. 'lhe patient is new to the practice and has column). indicated on the intake form that his gender is transgender

tr Item 16 A 32 year-old woman is evaluated in the emergency depart- (A) Ofloxacin (B) Olopatadine ment for a rapidly spreading rash involving her trunk, (C) Prednisolone extremities, and face that started 48 hours ago. She has intense skin pain, ulcerations in her mouth and vagina, (D) Trimethoprim-polymyxin gritty sensation in her eyes, and fever. She began taking carbamazepine 12 days ago for trigeminal neuralgia. Her medical history is otherwise unremarkable, and she takes no other medications. Item 18 A 24-year-old person is evaluated as an add on patient for tr On physical examination, the patient appears ill and a right wrist growth. He describes a small soft mass on the in pain. Temperature is 40 "C (104 'F), blood pressure is ventral aspect of the wrist that he flrst noticed 6 months 110/65 mm Hg, pulse rate is 110/min, and respiration rate is ago. It has not enlarged, and it does not cause any symptoms l8/min. BMI is 33. Skin flndings are shown (see top of next or limitations. 'lhe patient is new to the practice and has column). indicated on the intake form that his gender is transgender 140

Self-Assessment Test UI o, tr CONI male. He responds to questioning that he would prefer to be addressed as'he" or'him." On physical examination, vital signs are normal. A soft, during the most recent influenza season. She received two doses ofthe recombinant herpes zoster vaccine 3 years ago. Medical history is significant for stage 4 chronic kidney dis- (l, tr nontender 0.5-cm mass is present on the ventral aspect of ease and type 2 diabetes mellitus. r/t the wrist, consistent with a ganglion cyst. The wrist has full .u vt range of motion, and there is no erythema or induration. Which of the following is the most appropriate vaccine to vt adminisftr to this patient? Which of the following is the most appropriate next step in (l, (A) Tetanus and diphtheria toxoids booster r/t patient management? (B) 13-Valent pneumococcal conjugate vaccine (A) Obtain a hormonal and surgical history (C) 23-Valent pneumococcal polysaccharide vaccine (B) Obtain a social and sexual history (D) No vaccines are indicated (C) Perform a genital examination (D) Screen for sexually transmitted infections (E) Expectantmanagement Item 21 An B1-year old man is seen for a preoperative evaluation tr before total right hip arthroplasty. Medical history is signif- Item 19 icant for mild cognitive impairment, COPD, chronic kidney A 7S-year-old woman is evaluated for a rapidly growing, disease, diabetes mellitus, and hypertension. Medications painful nodule on the right dorsal hand that appeared are topical NSAIDs, albuterol and tiotropium inhalers, met 6 weeks ago. Medical history is unremarkable, and she takes formin, and lisinopril. no medications. On physical examination, vital signs are normal. Oxy- gen saturation is 95'2, breathing ambient air. BMI is 24. The Skin flndings are shown. patient is alert and oriented. Decreased right hip range of motion, especially internal rotation, is present. Cardiac examination is normal. Pulmonary examination reveals distant breath sounds without wheezing.

tr CONI male. He responds to questioning that he would prefer to be addressed as'he" or'him." On physical examination, vital signs are normal. A soft, during the most recent influenza season. She received two doses ofthe recombinant herpes zoster vaccine 3 years ago. Medical history is significant for stage 4 chronic kidney dis- (l, tr nontender 0.5-cm mass is present on the ventral aspect of ease and type 2 diabetes mellitus. r/t the wrist, consistent with a ganglion cyst. The wrist has full .u vt range of motion, and there is no erythema or induration. Which of the following is the most appropriate vaccine to vt adminisftr to this patient? Which of the following is the most appropriate next step in (l, (A) Tetanus and diphtheria toxoids booster r/t patient management? (B) 13-Valent pneumococcal conjugate vaccine (A) Obtain a hormonal and surgical history (C) 23-Valent pneumococcal polysaccharide vaccine (B) Obtain a social and sexual history (D) No vaccines are indicated (C) Perform a genital examination (D) Screen for sexually transmitted infections (E) Expectantmanagement Item 21 An B1-year old man is seen for a preoperative evaluation tr before total right hip arthroplasty. Medical history is signif- Item 19 icant for mild cognitive impairment, COPD, chronic kidney A 7S-year-old woman is evaluated for a rapidly growing, disease, diabetes mellitus, and hypertension. Medications painful nodule on the right dorsal hand that appeared are topical NSAIDs, albuterol and tiotropium inhalers, met 6 weeks ago. Medical history is unremarkable, and she takes formin, and lisinopril. no medications. On physical examination, vital signs are normal. Oxy- gen saturation is 95'2, breathing ambient air. BMI is 24. The Skin flndings are shown. patient is alert and oriented. Decreased right hip range of motion, especially internal rotation, is present. Cardiac examination is normal. Pulmonary examination reveals distant breath sounds without wheezing. Which of the following assessments would best predict surgery-related morbidity and mortality? (A) Chest radiography (B) ECG (C) Frailty assessment (D) Spirometry

Which of the following assessments would best predict surgery-related morbidity and mortality? (A) Chest radiography (B) ECG (C) Frailty assessment (D) Spirometry Item 22 A 4S-year-old man is evaluated during a routine visit. He reports no symptoms, and his medical and family history are unremarkable. He does not smoke cigarettes, and he engages in moderate exercise for 150 minutes per week and consumes a Mediterranean diet. He takes no medications. On physical examination, blood pressure is 120/78 mm Hg; other vital signs are normal. BMI is 25. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis? (A) Actinic keratosis Which of the following is the most appropriate cardiovascular disease assessment? (B) Basal cell carcinoma (C) Keratoacanthoma (A) Calculating cardiovascular disease risk (D) Bodermagangrenosum (B) Carotidarteryultrasonography (E) Sporotrichosis (C) ECG (D) Exercise stress test (E) No cardiovascular disease assessment Item 20 A 65-year-old woman is evaluated during a routine health examination. She received the 23-valent pneumococcal polysaccharide vaccine 4 years ago; the tetanus toxoid, Item 23 A 65-year-old man is seen for a preoperative medical tr reduced diphtheria toxoid, and acellular pertussis vaccine evaluation 2 weeks before total left shoulder arthroplasty. 2 years ago; and the influenza and COVID 19 vaccines Medical history is signiflcant for COPD. He was hospitalized

Item 22 A 4S-year-old man is evaluated during a routine visit. He reports no symptoms, and his medical and family history are unremarkable. He does not smoke cigarettes, and he engages in moderate exercise for 150 minutes per week and consumes a Mediterranean diet. He takes no medications. On physical examination, blood pressure is 120/78 mm Hg; other vital signs are normal. BMI is 25. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis? (A) Actinic keratosis Which of the following is the most appropriate cardiovascular disease assessment? (B) Basal cell carcinoma (C) Keratoacanthoma (A) Calculating cardiovascular disease risk (D) Bodermagangrenosum (B) Carotidarteryultrasonography (E) Sporotrichosis (C) ECG (D) Exercise stress test (E) No cardiovascular disease assessment Item 20 A 65-year-old woman is evaluated during a routine health examination. She received the 23-valent pneumococcal polysaccharide vaccine 4 years ago; the tetanus toxoid, Item 23 A 65-year-old man is seen for a preoperative medical tr reduced diphtheria toxoid, and acellular pertussis vaccine evaluation 2 weeks before total left shoulder arthroplasty. 2 years ago; and the influenza and COVID 19 vaccines Medical history is signiflcant for COPD. He was hospitalized 141

Self-Assessment Test atl o lrll 6 months ago for COPD exacerbation. He reports no changes Oral mucosa is normal. ta E in cough or sputum production. He has no shortness of l '' UI cONI 5r.r15 or t'ever. Screening for obstructive sleep (D apnea (OSA) Which of the following is the most likely diagnosis? I UI Ut with the STOP-BANG questionnaire categorizes the patient : as low risk lor OSA. He has a 30 pack-year history of ciga (A) Drug induced hypersensitivity syndrome .D rette smoking but quit smoking 6 years ago. Medications are (B) Erythroderma -1

atl o lrll 6 months ago for COPD exacerbation. He reports no changes Oral mucosa is normal. ta E in cough or sputum production. He has no shortness of l '' UI cONI 5r.r15 or t'ever. Screening for obstructive sleep (D apnea (OSA) Which of the following is the most likely diagnosis? I UI Ut with the STOP-BANG questionnaire categorizes the patient : as low risk lor OSA. He has a 30 pack-year history of ciga (A) Drug induced hypersensitivity syndrome .D rette smoking but quit smoking 6 years ago. Medications are (B) Erythroderma -1 { .D inhaled tiotropium. beclomethasone, and albuterol. (C) Lichen planus (a On physical examination, vital signs are normal. Oxy- (D) Pemphigus vulgaris : gen saturation is 94'X, breathing ambient air. There are (E) Stevens Johnson syndrome ; decreased breath sounds throughout and an increased expi 1 ratory phase. Left shoulder range of motion is painful and ; restricted. The remainder of the examination is normal. Item 25 I Which of the following is the most appropriate A 23-year old woman is evaluated for a 1 week history of j perioperative pulmonary assessment? vaginal discharge and odor. The patient is sexually active I with men, and her last sexual encounter was 2 weeks ago. (A) Arterial blood gas analysis She takes an oral contraceptive pill for contraception. Her last l

{ .D inhaled tiotropium. beclomethasone, and albuterol. (C) Lichen planus (a On physical examination, vital signs are normal. Oxy- (D) Pemphigus vulgaris : gen saturation is 94'X, breathing ambient air. There are (E) Stevens Johnson syndrome ; decreased breath sounds throughout and an increased expi 1 ratory phase. Left shoulder range of motion is painful and ; restricted. The remainder of the examination is normal. Item 25 I Which of the following is the most appropriate A 23-year old woman is evaluated for a 1 week history of j perioperative pulmonary assessment? vaginal discharge and odor. The patient is sexually active I with men, and her last sexual encounter was 2 weeks ago. (A) Arterial blood gas analysis She takes an oral contraceptive pill for contraception. Her last l (B) Chest radiography menstrual period was 3 weeks ago. Medical history is other (c) Spirometry wise unremarkable. and she takes no other medications. l (D) No further testing The external genitalia examination is normal. Pelvic li examination shows a thin, gray homogenous discharge with a mild odor. The cervix is normal appearing, without discharge. Bimanual examination is unremarkable. tr Item 24 A 62 year-old man is evaluated in the emergency depart- Vaginal pH is 5.0. Wet mount shows 307, clue cells. There are no hyphae on a potassium hydroxide preparation. Whiff ment for a rash that developed over his entire body test result is positive. A pregnancy test result is negative. during the past week. He w'as discharged from the hos- pital 15 days ago lor a COPD exacerbation. He received Which ofthe following is the most appropriate management? prednisone for 5 days and levofloxacin for 7 days. Medical history is signiflcant for chronic plaque psoriasis that he (A) Nucleic acid ampliflcation test for bacterial vaginosis does not treat. Medications are tiotropium and salmeterol (B) Oral azithromycin fluticasone. (C) Oral fluconazole On physical examination, the patient appears ill and (D) Oral metronidazole is bundled in blankets and shivering. Temperature is 37'C (98.6 'F)l other vital signs are normal. The rash covers 90'7, ofbody surface area. Representative skin and nail flndings Item 26 are shown. A 4S-year-old woman is evaluated for 4 month history **&.' of persistent rhinorrhea, frontal headache, loss of smell, and malaise. She has self-treated with saline irrigation and antihistamine/decongestants. On physical examination, vital signs are normal. Nasal turbinates are swollen, and thick yellow nasal discharge is noted. Maxillae and forehead are tender to palpation. the remainder of the examination is normal.

(B) Chest radiography menstrual period was 3 weeks ago. Medical history is other (c) Spirometry wise unremarkable. and she takes no other medications. l (D) No further testing The external genitalia examination is normal. Pelvic li examination shows a thin, gray homogenous discharge with a mild odor. The cervix is normal appearing, without discharge. Bimanual examination is unremarkable. tr Item 24 A 62 year-old man is evaluated in the emergency depart- Vaginal pH is 5.0. Wet mount shows 307, clue cells. There are no hyphae on a potassium hydroxide preparation. Whiff ment for a rash that developed over his entire body test result is positive. A pregnancy test result is negative. during the past week. He w'as discharged from the hos- pital 15 days ago lor a COPD exacerbation. He received Which ofthe following is the most appropriate management? prednisone for 5 days and levofloxacin for 7 days. Medical history is signiflcant for chronic plaque psoriasis that he (A) Nucleic acid ampliflcation test for bacterial vaginosis does not treat. Medications are tiotropium and salmeterol (B) Oral azithromycin fluticasone. (C) Oral fluconazole On physical examination, the patient appears ill and (D) Oral metronidazole is bundled in blankets and shivering. Temperature is 37'C (98.6 'F)l other vital signs are normal. The rash covers 90'7, ofbody surface area. Representative skin and nail flndings Item 26 are shown. A 4S-year-old woman is evaluated for 4 month history **&.' of persistent rhinorrhea, frontal headache, loss of smell, and malaise. She has self-treated with saline irrigation and antihistamine/decongestants. On physical examination, vital signs are normal. Nasal turbinates are swollen, and thick yellow nasal discharge is noted. Maxillae and forehead are tender to palpation. the remainder of the examination is normal. Which of the following is the most appropriate diagnostic test to perform next? (A) CT of the sinuses (B) MRI of the sinuses (C) Nasal swabbing for culture (D) Plain radiography of the sinuses

Which of the following is the most appropriate diagnostic test to perform next? (A) CT of the sinuses (B) MRI of the sinuses (C) Nasal swabbing for culture (D) Plain radiography of the sinuses llem 27 A 42 year old man is evaluated for premature ejaculation. He reports that during sexual intercourse, he ejaculates within 30 seconds after vaginal penetration, which causes him signiflcant psychological distress. He has no decrease in libido or difficulty maintaining an erection. Medical history is positive for depressive symptoms predating the onset of premature ejaculation. He takes no medications. 142

Self-Assessment Test vt Which of the following is the most appropriate treatment? history is signiflcant for hypertension, degenerative joint Fc, disease, and hypothyroidism. There has been no recent q, (A) Clomipramine change in her clinical status or medications. Review of sys- (B) Paroxetine tems is negative. Medications are levothyroxine, chlorthali- Ut UI (C) Squeeze technique done, and lisinopril. (u vt (D) Start-stoptechnique On physical examination, vital signs are normal. BMI is ut (E) Topical anesthetic 22.There is restricted and painful range of right hip motion. The remainder of the physical examination is normal. (l, t/t Two months ago, thyroid-stimulating hormone mea Item 28 surement and serum electrolytes were normal. No other Iaboratory flndings are available. A S4-year-old asymptomatic woman is evaluated during a wellness visit. She has a 35 pack-year smoking history but quit smoking 12 years ago. She has no medical problems and Which of the following is the most appropriate preoperative laboratory testing for this patient? takes no medications. Physical examination, including vital signs, is unre (A) Coagulation studies and platelet count markable. (B) Hemoglobin and serum creatinine (C) Thyroid-stimulating hormone and free thyroxine Which of the following is the most appropriate lung cancer (D) Urinalysis screening stratery for this patient? (A) Annualchestradiography (B) Annual low-dose CT of the chest Item 31 (C) One-time low-dose CT of the chest A 39-year-old woman comes to the offlce to discuss bariatric (D) No screening is indicated surgery. She has been unable to lose weight with diet and exercise, including supervised weight loss programs. She has tried naltrexone bupropion and phentermine-topiramate Item 29 with modest success, but the weight returned after med- A 32 year old man is evaluated for a 2 year history of nail ication discontinuation. Medical history is signiflcant for changes. Medical history is otherwise unremarkable. Fam- type 2 diabetes mellitus. Medications are metformin and ily history is signiflcant for plaque psoriasis in his brother. liraglutide. He takes no medications. On physical examination, vital signs are normal. BMI is Nine of 10 flngernails are dystrophic. Nail flndings are 4.5. The remainder of the examination is normal. shown. Which of the following is the most appropriate treatment for this patient? (A) Gastric banding (B) Intragastricballoon (C) Orlistat (D) Sleeve gastrectomy

vt Which of the following is the most appropriate treatment? history is signiflcant for hypertension, degenerative joint Fc, disease, and hypothyroidism. There has been no recent q, (A) Clomipramine change in her clinical status or medications. Review of sys- (B) Paroxetine tems is negative. Medications are levothyroxine, chlorthali- Ut UI (C) Squeeze technique done, and lisinopril. (u vt (D) Start-stoptechnique On physical examination, vital signs are normal. BMI is ut (E) Topical anesthetic 22.There is restricted and painful range of right hip motion. The remainder of the physical examination is normal. (l, t/t Two months ago, thyroid-stimulating hormone mea Item 28 surement and serum electrolytes were normal. No other Iaboratory flndings are available. A S4-year-old asymptomatic woman is evaluated during a wellness visit. She has a 35 pack-year smoking history but quit smoking 12 years ago. She has no medical problems and Which of the following is the most appropriate preoperative laboratory testing for this patient? takes no medications. Physical examination, including vital signs, is unre (A) Coagulation studies and platelet count markable. (B) Hemoglobin and serum creatinine (C) Thyroid-stimulating hormone and free thyroxine Which of the following is the most appropriate lung cancer (D) Urinalysis screening stratery for this patient? (A) Annualchestradiography (B) Annual low-dose CT of the chest Item 31 (C) One-time low-dose CT of the chest A 39-year-old woman comes to the offlce to discuss bariatric (D) No screening is indicated surgery. She has been unable to lose weight with diet and exercise, including supervised weight loss programs. She has tried naltrexone bupropion and phentermine-topiramate Item 29 with modest success, but the weight returned after med- A 32 year old man is evaluated for a 2 year history of nail ication discontinuation. Medical history is signiflcant for changes. Medical history is otherwise unremarkable. Fam- type 2 diabetes mellitus. Medications are metformin and ily history is signiflcant for plaque psoriasis in his brother. liraglutide. He takes no medications. On physical examination, vital signs are normal. BMI is Nine of 10 flngernails are dystrophic. Nail flndings are 4.5. The remainder of the examination is normal. shown. Which of the following is the most appropriate treatment for this patient? (A) Gastric banding (B) Intragastricballoon (C) Orlistat (D) Sleeve gastrectomy Item 32 A 76-year old woman is seen for a preoperative medical tr evaluation before elective total ankle arthroplasty. She has heart failure with reduced ejection fraction and COPD. She has no chest pain, presyncope, or change in weight. Medi Toenails are not involved. The remainder of the skin cations are tiotropium, budesonide, and albuterol inhalers; and hair examination is normal. furosemide; metoprolol; lisinopril; and 2 L/min of oxygen via nasal cannula during exertion. Which of the following is the most likely diagnosis? On physical examination, blood pressure is 145/80 mm (A) Chronic paronychia Hg, pulse rate is 109/min, respiration rate is 24lmin, and (B) Lichen planus oxygen saturation is 90% breathing ambient air. Jugular venous pressure is elevated. There is an Sa and agrade 216 (C) Nail psoriasis systolic murmur at the lower left sternal border. Breath (D) Onychomycosis sounds are distant without crackles. A recent transthoracic echocardiogram showed an ejection fraction of 4Ook, moderate to severe right ventricle

Item 32 A 76-year old woman is seen for a preoperative medical tr evaluation before elective total ankle arthroplasty. She has heart failure with reduced ejection fraction and COPD. She has no chest pain, presyncope, or change in weight. Medi Toenails are not involved. The remainder of the skin cations are tiotropium, budesonide, and albuterol inhalers; and hair examination is normal. furosemide; metoprolol; lisinopril; and 2 L/min of oxygen via nasal cannula during exertion. Which of the following is the most likely diagnosis? On physical examination, blood pressure is 145/80 mm (A) Chronic paronychia Hg, pulse rate is 109/min, respiration rate is 24lmin, and (B) Lichen planus oxygen saturation is 90% breathing ambient air. Jugular venous pressure is elevated. There is an Sa and agrade 216 (C) Nail psoriasis systolic murmur at the lower left sternal border. Breath (D) Onychomycosis sounds are distant without crackles. A recent transthoracic echocardiogram showed an ejection fraction of 4Ook, moderate to severe right ventricle tr Item 3O A 69-year old woman is seen for a preoperative medical dysfunction, pulmonary artery systolic pressure of 65 mm Hg, and tricuspid regurgitation. ECG shows right bundle evaluation before total right hip arthroplasty. Medical branch block.

tr Item 3O A 69-year old woman is seen for a preoperative medical dysfunction, pulmonary artery systolic pressure of 65 mm Hg, and tricuspid regurgitation. ECG shows right bundle evaluation before total right hip arthroplasty. Medical branch block. 143

Self-Assessment Test vt .D UI ut tr CONT, Which of the following is the most appropriate preoperative management of this patient? the buccal mucous and the hard and soft palates. There is n<r conjunctir,al. urethral, or perineal involr.ement. .D l^ (A) Cancel surgery gt Which of the following is the most likely diagnosis? (B) lncreasefurosemicle .D (C) lnitiatc tadalafil (A) Bullous pemphigoid { (D) Start continuous oxygen therapy (lJ) Dermatilis herpclilormis .D (C) Pemphigus vulgaris UI (D) Stevens Johnson sl,ndrome Item 33 (E) Toric epidern.ral necrolysis A 33 year old woman is evaluated during a preconception counseling visit. She is nulliparous. Her last menstrual period was 2 weeks ago. She is asymptomatic, without Item 35 medical problems. She received her measles, mumps, and A S2-year-old man is evaluated for decreased hearing and a rubella vaccine during childhood and an influenza vaccine 4 year history of tinnitus without vertigo. The patient does during the most recent influenza season. She received the not notice hearing loss but has come for evaluation based tetanus toxoid, reduced diphtheria toxoid, and acellular on his wife's recommendation. He has no history of noise pertussis (Tdap) vaccine 6 years ago. She is unsure whether exposures. He takes no medications. she had chickenpox. She is sexually active with her hus On physical examination, the whispered voice test band only. Her last Pap smear was obtained 1 year ago and suggests left hearing loss. Otoscopy reveals no cerumen was normall human papillomavirus testing was negative. impaction or other blockage ofthe external auditory canal. She does not smoke cigarettes or drink alcohol. Her only Tympanic membranes appear normal. Placement of a medication is a prenatal vitamin. 256 Hz vibrating tuning fork midline on the forehead results A pregnancy test result is negative. in a louder sound in the right ear. For each ear, the tuning lork sound is louder when placed in front of the external Which of the following is the most appropriate ear canal compared with placement on the mastoid process. management? (A) Administer the Tdap vaccine Which of the following is the most likely cause of hearing (B) Obtain nucleic acid ampliflcation test for chlamydia loss in this patient?

UI ut tr CONT, Which of the following is the most appropriate preoperative management of this patient? the buccal mucous and the hard and soft palates. There is n<r conjunctir,al. urethral, or perineal involr.ement. .D l^ (A) Cancel surgery gt Which of the following is the most likely diagnosis? (B) lncreasefurosemicle .D (C) lnitiatc tadalafil (A) Bullous pemphigoid { (D) Start continuous oxygen therapy (lJ) Dermatilis herpclilormis .D (C) Pemphigus vulgaris UI (D) Stevens Johnson sl,ndrome Item 33 (E) Toric epidern.ral necrolysis A 33 year old woman is evaluated during a preconception counseling visit. She is nulliparous. Her last menstrual period was 2 weeks ago. She is asymptomatic, without Item 35 medical problems. She received her measles, mumps, and A S2-year-old man is evaluated for decreased hearing and a rubella vaccine during childhood and an influenza vaccine 4 year history of tinnitus without vertigo. The patient does during the most recent influenza season. She received the not notice hearing loss but has come for evaluation based tetanus toxoid, reduced diphtheria toxoid, and acellular on his wife's recommendation. He has no history of noise pertussis (Tdap) vaccine 6 years ago. She is unsure whether exposures. He takes no medications. she had chickenpox. She is sexually active with her hus On physical examination, the whispered voice test band only. Her last Pap smear was obtained 1 year ago and suggests left hearing loss. Otoscopy reveals no cerumen was normall human papillomavirus testing was negative. impaction or other blockage ofthe external auditory canal. She does not smoke cigarettes or drink alcohol. Her only Tympanic membranes appear normal. Placement of a medication is a prenatal vitamin. 256 Hz vibrating tuning fork midline on the forehead results A pregnancy test result is negative. in a louder sound in the right ear. For each ear, the tuning lork sound is louder when placed in front of the external Which of the following is the most appropriate ear canal compared with placement on the mastoid process. management? (A) Administer the Tdap vaccine Which of the following is the most likely cause of hearing (B) Obtain nucleic acid ampliflcation test for chlamydia loss in this patient? (C) Obtain Pap smear (A) Conductive hearing loss, left ear (D) Obtain varicella antibody titer (B) Conductive hearing loss, right ear (C) Sensorineural hearing loss, left ear (D) Sensorineural hearing loss, right ear tr Item 34 A 51 year old man is evah.rated in the emergencJ' depart ment tbr a 2 clay history of sloughing skin in his mouth and on his facc, ncck. trunk. :u.td lrnrs. His eyes are una{fected, and he reports no dysuria. l{e has no other symptoms. Item 36 A 57-year-old man is evaluated fbr a 2 day history ol mild tr to moderate burning left flank pain rn,ith an associated rash Medical history is significant ltrr rosacea treated lt,ith doxy that appeared shortly after pain tinset. cycline for the past 6 n.ronths. Skin findings are shorvn. On physical examination. the patient is not toxic appearing. Vital signs are norrnal. The rash is shou'n. ;E--'

(C) Obtain Pap smear (A) Conductive hearing loss, left ear (D) Obtain varicella antibody titer (B) Conductive hearing loss, right ear (C) Sensorineural hearing loss, left ear (D) Sensorineural hearing loss, right ear tr Item 34 A 51 year old man is evah.rated in the emergencJ' depart ment tbr a 2 clay history of sloughing skin in his mouth and on his facc, ncck. trunk. :u.td lrnrs. His eyes are una{fected, and he reports no dysuria. l{e has no other symptoms. Item 36 A 57-year-old man is evaluated fbr a 2 day history ol mild tr to moderate burning left flank pain rn,ith an associated rash Medical history is significant ltrr rosacea treated lt,ith doxy that appeared shortly after pain tinset. cycline for the past 6 n.ronths. Skin findings are shorvn. On physical examination. the patient is not toxic appearing. Vital signs are norrnal. The rash is shou'n. ;E--' tIlF Other areas of involvement include the face. neck. chest, ancl proximal arms. [,.rosions are also noted across 144

Self-Assessment Test vt 6' tr CONT. Which of the following is the most appropriate treatment? E (l, tr (A) Topical acyclovir tt ,tl (B) Valacyclovir €, vt (C) Valacyclovir and gabapentin t (D) Valacyclovir and prednisone €, vt

vt 6' tr CONT. Which of the following is the most appropriate treatment? E (l, tr (A) Topical acyclovir tt ,tl (B) Valacyclovir €, vt (C) Valacyclovir and gabapentin t (D) Valacyclovir and prednisone €, vt tr Item 37 A 66-year old woman is evaluated in the emergency department for severe aching pain and visual blurring in the right eye that began 2 hours ago. She describes seeing halos around lights, accompanied by a throb- bing, periocular, right sided headache and nausea. She reports no other symptoms. Medical history is significant for depression and hyperopia. iler only medication is paroxetine. On physical examination. blood pressure is 160194 mm IIg and pulse rate is 102/min. The right pupil Which of the following is the most likely diagnosis? is 4 mm in diameter and responds minimally to direct (A) Hemangioma light. There is diff'use conjunctival injection, and the cornea appears cloudy. Visual acuity is 20/60. The globe is tense (B) Keratoacanthoma and tender to palpation. There is no erythema or edema of (C) Nodular melanoma eyelids or surrouncling eye structures. Funduscopic exam (D) Pigmented basal cell carcinoma ination shows cupping of the optic disc. Examination of the left eye is unremarkable; visual acuity is 20/30. Item 40 Which of the following is the most likely diagnosis? A 2S-year-old woman is seen during a routine visit. She is (A) Acute angle-closure glaucoma in the third trimester of a normal pregnancy. She is up to date on all of her immunizations and received the tetanus (B) Bacterial keratitis toxoid, reduced diphtheria toxoid, and acellular pertussis- (C) Orbital cellulitis vaccine during her flrst pregnancy 24 months ago and the (D) Scleritis inactivated influenza vaccine just before the start of the current pregnancy. She has no medical problems. She takes a multivitamin and folic acid but no other medications or Item 38 supplements.

tr Item 37 A 66-year old woman is evaluated in the emergency department for severe aching pain and visual blurring in the right eye that began 2 hours ago. She describes seeing halos around lights, accompanied by a throb- bing, periocular, right sided headache and nausea. She reports no other symptoms. Medical history is significant for depression and hyperopia. iler only medication is paroxetine. On physical examination. blood pressure is 160194 mm IIg and pulse rate is 102/min. The right pupil Which of the following is the most likely diagnosis? is 4 mm in diameter and responds minimally to direct (A) Hemangioma light. There is diff'use conjunctival injection, and the cornea appears cloudy. Visual acuity is 20/60. The globe is tense (B) Keratoacanthoma and tender to palpation. There is no erythema or edema of (C) Nodular melanoma eyelids or surrouncling eye structures. Funduscopic exam (D) Pigmented basal cell carcinoma ination shows cupping of the optic disc. Examination of the left eye is unremarkable; visual acuity is 20/30. Item 40 Which of the following is the most likely diagnosis? A 2S-year-old woman is seen during a routine visit. She is (A) Acute angle-closure glaucoma in the third trimester of a normal pregnancy. She is up to date on all of her immunizations and received the tetanus (B) Bacterial keratitis toxoid, reduced diphtheria toxoid, and acellular pertussis- (C) Orbital cellulitis vaccine during her flrst pregnancy 24 months ago and the (D) Scleritis inactivated influenza vaccine just before the start of the current pregnancy. She has no medical problems. She takes a multivitamin and folic acid but no other medications or Item 38 supplements. A 66-year-old woman is evaluated during a wellness visit. Which of the following is the most appropriate She reports no symptoms. She does not recall the last time vaccination? she had a Pap smear, and medical records from her previ ous physician are not available. She has no history ofsex- (A) Humanpapillomavirus ually transmitted infection, gynecologic cancer, or surgical (B) Influenza history. (C) Tetanus toxoid, reduced diphtheria toxoid, and acel- lular pertussis Which of the following is the most appropriate cervical (D) No vaccinations are indicated cancer screening stratery for this patient? (A) Cervical biopsy (B) Cervical cytology with human papillomavirus testing Item 41 A77 year old man is sec'n tbr a preoperative medical evalu- tr (C) Colposcopy ation befbre elective aortof'emoral bypass. Ile has exercise- (D) Discontinue cervical cancer screening lin-riting claudication despite participation in supervised exercisc programs and pharmacologic intervention. Medical history is also significant f<rr hypertension. hyperlipidemia, diabetes mellitus, and aortic stenosis. His last echocardio- Item 39 gram 2 years ago showed moderate aortic stenosis with A 48-year-old man is evaluated for a 2-month history of a preserved left ventricular ejection fraction. Medicuticlns are painless lesion on his left shoulder that has been increas- atorvastatin, aspirin, metoprolol. benazepril, amlodipine, ing in size and is now 2 cm in diameter. Medical history is metfbrmin, liraglutide, and cilostazol. unremarkable. On physical examination, vital signs are normal. Skin flndings are shown (see top of next column). Cardiac examination reveals a grade 3i 6 systolic ejection

A 66-year-old woman is evaluated during a wellness visit. Which of the following is the most appropriate She reports no symptoms. She does not recall the last time vaccination? she had a Pap smear, and medical records from her previ ous physician are not available. She has no history ofsex- (A) Humanpapillomavirus ually transmitted infection, gynecologic cancer, or surgical (B) Influenza history. (C) Tetanus toxoid, reduced diphtheria toxoid, and acel- lular pertussis Which of the following is the most appropriate cervical (D) No vaccinations are indicated cancer screening stratery for this patient? (A) Cervical biopsy (B) Cervical cytology with human papillomavirus testing Item 41 A77 year old man is sec'n tbr a preoperative medical evalu- tr (C) Colposcopy ation befbre elective aortof'emoral bypass. Ile has exercise- (D) Discontinue cervical cancer screening lin-riting claudication despite participation in supervised exercisc programs and pharmacologic intervention. Medical history is also significant f<rr hypertension. hyperlipidemia, diabetes mellitus, and aortic stenosis. His last echocardio- Item 39 gram 2 years ago showed moderate aortic stenosis with A 48-year-old man is evaluated for a 2-month history of a preserved left ventricular ejection fraction. Medicuticlns are painless lesion on his left shoulder that has been increas- atorvastatin, aspirin, metoprolol. benazepril, amlodipine, ing in size and is now 2 cm in diameter. Medical history is metfbrmin, liraglutide, and cilostazol. unremarkable. On physical examination, vital signs are normal. Skin flndings are shown (see top of next column). Cardiac examination reveals a grade 3i 6 systolic ejection 145

Self-Assessment Test vr (D ffi murmur at the right upper sternal border that radiates to initiated ledipasvir-sofosbuvir. Her medical history is UI g the right carotid artery. The lower extremities are cool, with otherwise unremarkable, and she takes no other medi U) (D coNl no palpable pulses. cations. t/t Transthoracic echocardiography findings are compat t^ Skin flndings on the low back are shown. ible with severe calcific aortic stenosis with left ventricular .D ejection fraction of 45oL, meeting the criteria for val'",ular intervention. o UI Which of the following is the most appropriate recommendation regarding surgery? (A) Aortic valve replacement prior to aortofemoral bypass (B) Aortic valve replacement plus aortofemoral bypass (C) Percutaneous balloon valvuloplasty prior to aorto- femoral bypass (D) Percutaneous balloon valvuloplasty plus aortofemoral bypass Item 42 A 20 year old woman is evaluated for a 2-day history of sore throat, nonproductive cough, nasal congestion, headache, The volar wrists have lesions similar to those on the and malaise. She has no other medical problems and does back. There is no lymphadenopathy. not smoke. On physical examination, vital signs are norrnal. The Which of the following is the most likely diagnosis? nasal mucosa is boggy and inflamed, with clear discharge. The pharynx is erythematous. Tonsils are normal appear- (A) Lichen planus ing. Tympanic membranes are clear. The remainder of the (B) Pityriasis rosea examination is unremarkable. (C) Psoriasis A SARS-CoV-2 rapid antigen test result is negative. (D) Secondary syphilis

Item 42 A 20 year old woman is evaluated for a 2-day history of sore throat, nonproductive cough, nasal congestion, headache, The volar wrists have lesions similar to those on the and malaise. She has no other medical problems and does back. There is no lymphadenopathy. not smoke. On physical examination, vital signs are norrnal. The Which of the following is the most likely diagnosis? nasal mucosa is boggy and inflamed, with clear discharge. The pharynx is erythematous. Tonsils are normal appear- (A) Lichen planus ing. Tympanic membranes are clear. The remainder of the (B) Pityriasis rosea examination is unremarkable. (C) Psoriasis A SARS-CoV-2 rapid antigen test result is negative. (D) Secondary syphilis Which of the following is the most appropriate treatment? (A) Acetaminophen Item 45 (B) Amoxicillin A 39-year-old woman is evaluated for a 6 month history of irregular, heavy menstrual periods. She reports hav- (C) Guaifenesin ing a menstrual period every 6 to 8 weeks and that her (D) Intranasal zinc periods now last 9 days and are heavier than usual. She has no other symptoms. She birthed two children. Her Iast Pap smear was obtained 3 year ago and was normal; Item 43 human papillomavirus testing was negative. Medical A 50 year-old woman is evaluated during a routine well- history is otherwise unremarkable, and she takes no ness visit. Medical and family histories are unremarkable. medications. She is in a long-term monogamous sexual relationship. On physical examination, vital signs are normal. BMI When tested l0 years ago, she was HIV negative. She takes is 36. The bimanual pelvic examination shows blood in the no medications. cervical os and normal flndings. Laboratory studies reveal a normal complete blood Which of the following is the most appropriate infectious count. A pregnancy test result is negative. disease screening test for this patient?

Which of the following is the most appropriate treatment? (A) Acetaminophen Item 45 (B) Amoxicillin A 39-year-old woman is evaluated for a 6 month history of irregular, heavy menstrual periods. She reports hav- (C) Guaifenesin ing a menstrual period every 6 to 8 weeks and that her (D) Intranasal zinc periods now last 9 days and are heavier than usual. She has no other symptoms. She birthed two children. Her Iast Pap smear was obtained 3 year ago and was normal; Item 43 human papillomavirus testing was negative. Medical A 50 year-old woman is evaluated during a routine well- history is otherwise unremarkable, and she takes no ness visit. Medical and family histories are unremarkable. medications. She is in a long-term monogamous sexual relationship. On physical examination, vital signs are normal. BMI When tested l0 years ago, she was HIV negative. She takes is 36. The bimanual pelvic examination shows blood in the no medications. cervical os and normal flndings. Laboratory studies reveal a normal complete blood Which of the following is the most appropriate infectious count. A pregnancy test result is negative. disease screening test for this patient? (A) Hepatitis C antibody assay Which of the following is the most appropriate management? (B) Nucleic acid ampliflcation test for chlamydia and gon- orrhea (A) Obtain a follicle stimulating hormone level (C) Syphilis enzyme immunoassay test (B) Obtain a Pap smear (D) No testing is indicated (C) Obtain an endometrial biopsy (D) Start oral contraceptive pills

(A) Hepatitis C antibody assay Which of the following is the most appropriate management? (B) Nucleic acid ampliflcation test for chlamydia and gon- orrhea (A) Obtain a follicle stimulating hormone level (C) Syphilis enzyme immunoassay test (B) Obtain a Pap smear (D) No testing is indicated (C) Obtain an endometrial biopsy (D) Start oral contraceptive pills Item 44 A S8-year-old woman is evaluated for a 5-week history of Item 46 an itchy rash on the low back. She was recently diagnosed A 56-year old man is evaluated during a follow-up visit with hepatitis C virus infection, for which she has just for diabetes mellitus, hypertension, and hyperlipidemia. 145

Self-Assessment Test (a (u His father had a myocardial infarction before the age of Skin findings on the volar aspect of the wrist are 55 years, as did his younger brother. Has a 3S-pack-year shown. E (u smoking history but quit smoking 3 months ago. He is sedentary. He has no other medical problems, including t tt no history of gastrointestinal bleeding, upper gastroin- (l, ( testinal pain, uncontrolled hypertension, chronic kidney tl disease, NSAID use, or thrombocytopenia. Medications are varenicline, metformin, lisinopril, hydrochlorothiazide, = ( (u and atorvastatin. On physical examination, vital signs are normal. BMI is 28. The remainder of the physical examination is normal. His 10-year atherosclerotic cardiovascular disease risk is 25% using the Pooled Cohort Equations.' The patient receives counseling on therapeutic life- style changes, including diet, exercise, and weight con- trol and encouragement regarding continued smoking cessation.

(a (u His father had a myocardial infarction before the age of Skin findings on the volar aspect of the wrist are 55 years, as did his younger brother. Has a 3S-pack-year shown. E (u smoking history but quit smoking 3 months ago. He is sedentary. He has no other medical problems, including t tt no history of gastrointestinal bleeding, upper gastroin- (l, ( testinal pain, uncontrolled hypertension, chronic kidney tl disease, NSAID use, or thrombocytopenia. Medications are varenicline, metformin, lisinopril, hydrochlorothiazide, = ( (u and atorvastatin. On physical examination, vital signs are normal. BMI is 28. The remainder of the physical examination is normal. His 10-year atherosclerotic cardiovascular disease risk is 25% using the Pooled Cohort Equations.' The patient receives counseling on therapeutic life- style changes, including diet, exercise, and weight con- trol and encouragement regarding continued smoking cessation. Which of the following is the best advice regarding Which of the following is the most appropriate diagnostic antithrombotic therapy for this patient? test? (A) Aspirin and clopidogrel (A) Mineral oil preparation of skin scraping (B) Clopidogrel (B) Potassium hydroxide preparation ofskin scraping (C) Low-dose aspirin (C) Shave biopsy (D) Rivaroxaban (D) Wood lamp examination (E) No antithrombotic therapy

Which of the following is the best advice regarding Which of the following is the most appropriate diagnostic antithrombotic therapy for this patient? test? (A) Aspirin and clopidogrel (A) Mineral oil preparation of skin scraping (B) Clopidogrel (B) Potassium hydroxide preparation ofskin scraping (C) Low-dose aspirin (C) Shave biopsy (D) Rivaroxaban (D) Wood lamp examination (E) No antithrombotic therapy Item 49 Item 47 A 28-year-old woman is evaluated for a painless breast A 46-year-old woman is seen for a routine evaluation lump she noticed 1 week ago. Medical history is otherwise after Roux-en-Y gastric bypass surgery 2 months ago. unremarkable. Her grandmother was diagnosed with breast She is doing well and has lost 13.6 kC (30 lb). She recently cancer at age72 years. Her only medication is a combined initiated an exercise program. She has type 2 diabetes hormonal contraceptive pill. mellitus and hypertension. Her current medications are Breast examination reveals a 1 cm, nontender, smooth, metformin, low dose insulin glargine, chlorthalidone, mobile, round mass on the medial aspect of the right breast. lisinopril, atorvastatin, vitamin Brr, vitamin D, thiamine, The overlying skin is normal. There is no lymphadenopathy. calcium, and a multivitamin with iron and folate. The left breast is normal. On physical examination, blood pressure is 132/ 78 mm Hg; the remainder of the physical examination is Which of the following is the most appropriate normal. management? Home glucose monitoring data for the previous (A) Breastultrasonography 7 days show average fasting blood glucose of 108 mg/dl (6.0 mmol/L). She has experienced no episodes of hypo- (B) Mammography glycemia. (C) Repeat clinical breast examination in 6 weeks (D) No further evaluation is indicated Which ofthe following medications should be discontinued for this patient? Item 50 (A) Atorvastatin A 27-year old woman is evaluated for a 2-week history of (B) Insulin glargine hives that burn and sting. Individual wheals resolve with (C) Lisinopril darkening of the skin in 1 to 2 days. She also has associated (D) Metformin fever and joint pain. Medical history is otherwise unremark- (E) Vitamin D and calcium able. Other than acetaminophen for fever and joint pain, she takes no medications. On physical examination, temperature is 38.3 "C (101 'F); other vital signs are normal. There are 2- to 3-cm Item 48 wheals with pale red flares on the arms, Iegs, upper chest, A 44-year-old woman is evaluated for a 4-week history of and back. There is faint hyperpigmentation in areas where worsening rash. She used clobetasol cream for 1week, but wheals have resolved. The remainder of the examination the rash worsened. is normal.

Item 49 Item 47 A 28-year-old woman is evaluated for a painless breast A 46-year-old woman is seen for a routine evaluation lump she noticed 1 week ago. Medical history is otherwise after Roux-en-Y gastric bypass surgery 2 months ago. unremarkable. Her grandmother was diagnosed with breast She is doing well and has lost 13.6 kC (30 lb). She recently cancer at age72 years. Her only medication is a combined initiated an exercise program. She has type 2 diabetes hormonal contraceptive pill. mellitus and hypertension. Her current medications are Breast examination reveals a 1 cm, nontender, smooth, metformin, low dose insulin glargine, chlorthalidone, mobile, round mass on the medial aspect of the right breast. lisinopril, atorvastatin, vitamin Brr, vitamin D, thiamine, The overlying skin is normal. There is no lymphadenopathy. calcium, and a multivitamin with iron and folate. The left breast is normal. On physical examination, blood pressure is 132/ 78 mm Hg; the remainder of the physical examination is Which of the following is the most appropriate normal. management? Home glucose monitoring data for the previous (A) Breastultrasonography 7 days show average fasting blood glucose of 108 mg/dl (6.0 mmol/L). She has experienced no episodes of hypo- (B) Mammography glycemia. (C) Repeat clinical breast examination in 6 weeks (D) No further evaluation is indicated Which ofthe following medications should be discontinued for this patient? Item 50 (A) Atorvastatin A 27-year old woman is evaluated for a 2-week history of (B) Insulin glargine hives that burn and sting. Individual wheals resolve with (C) Lisinopril darkening of the skin in 1 to 2 days. She also has associated (D) Metformin fever and joint pain. Medical history is otherwise unremark- (E) Vitamin D and calcium able. Other than acetaminophen for fever and joint pain, she takes no medications. On physical examination, temperature is 38.3 "C (101 'F); other vital signs are normal. There are 2- to 3-cm Item 48 wheals with pale red flares on the arms, Iegs, upper chest, A 44-year-old woman is evaluated for a 4-week history of and back. There is faint hyperpigmentation in areas where worsening rash. She used clobetasol cream for 1week, but wheals have resolved. The remainder of the examination the rash worsened. is normal. 147

Self-Assessment Test yr .D Which of the following is the most likely diagnoeis? accommodation. Visual acuity is 20160 in the left eye and vl 2Ol20 in the right eye. Nondilated funduscopic examination vt (A) Chronic idiopathic urticaria (D is normal. vt (B) Hereditaryangioedema lrr (C) Urticarial drug reaction Which of the following is the most likely diagnosis? (D (D) Urticarialvasculitis (A) Age-related macular degeneration CD vr (B) Central retinal artery occlusion Item 51 (C) Central retinal vein occlusion A 56-year-old man is evaluated for erectile dysfunction that (D) Retinal detachment began insidiously l year ago. He reports that his libido and mood are good. He is in a monogamous relationship with his wife. He runs on a treadmill for 30 to 45 minutes three to Item 54 four times weekly, and he has no cardiovascular symptoms. A 36-year-old wbman is evaluated for a 3-month history The patient's medical history is also signiflcant for coronary of white patches around the eyes, legs, and feet. Medical artery bypass graft surgery 4 years ago, hyperlipidemia, and history is otherwise unremarkable, and she takes no hypertension. Medications are metoprolol, losartan, aspirin, medications. and atorvastatin. On physical examination, vital signs are normal. Skin On physical examination, vital signs are normal. BMI findings are shown. is 24. The remainder of the examination is unremarkable. Laboratory studies show an early moming serum total testosterone level of 380 ng/dl (13.18 nmol/L). Which of the following is the most appropriate management? (A) ECG (B) Exercise stress test (C) Intramusculartestosterone (D) Oral sildenafil

Self-Assessment Test yr .D Which of the following is the most likely diagnoeis? accommodation. Visual acuity is 20160 in the left eye and vl 2Ol20 in the right eye. Nondilated funduscopic examination vt (A) Chronic idiopathic urticaria (D is normal. vt (B) Hereditaryangioedema lrr (C) Urticarial drug reaction Which of the following is the most likely diagnosis? (D (D) Urticarialvasculitis (A) Age-related macular degeneration CD vr (B) Central retinal artery occlusion Item 51 (C) Central retinal vein occlusion A 56-year-old man is evaluated for erectile dysfunction that (D) Retinal detachment began insidiously l year ago. He reports that his libido and mood are good. He is in a monogamous relationship with his wife. He runs on a treadmill for 30 to 45 minutes three to Item 54 four times weekly, and he has no cardiovascular symptoms. A 36-year-old wbman is evaluated for a 3-month history The patient's medical history is also signiflcant for coronary of white patches around the eyes, legs, and feet. Medical artery bypass graft surgery 4 years ago, hyperlipidemia, and history is otherwise unremarkable, and she takes no hypertension. Medications are metoprolol, losartan, aspirin, medications. and atorvastatin. On physical examination, vital signs are normal. Skin On physical examination, vital signs are normal. BMI findings are shown. is 24. The remainder of the examination is unremarkable. Laboratory studies show an early moming serum total testosterone level of 380 ng/dl (13.18 nmol/L). Which of the following is the most appropriate management? (A) ECG (B) Exercise stress test (C) Intramusculartestosterone (D) Oral sildenafil Item 52 A 65-year-old man is evaluated during a follow-up visit for hypertension. He reports that he eats fruits, nuts, and vegetables daily and red meat once weekly. He drinks artifi- cially sweetened soda daily and one alcoholic beverage most evenings with dinner. He does not smoke cigarettes. He lives alone and does not maintain social relationships and describes himself as lonely. Depression screening is negative.

Item 52 A 65-year-old man is evaluated during a follow-up visit for hypertension. He reports that he eats fruits, nuts, and vegetables daily and red meat once weekly. He drinks artifi- cially sweetened soda daily and one alcoholic beverage most evenings with dinner. He does not smoke cigarettes. He lives alone and does not maintain social relationships and describes himself as lonely. Depression screening is negative. ln addition to traditional risk factors, which of the + following is also a contributor to cardiovascular risk in this patient? (A) Alcoholconsumption (B) Artiflcially sweetened soda consumption (C) Red meat consumption (D) Social isolation tr Item 53 A 68-year-old woman is evaluated for reduced vision and flashing lights in her left eye that began this morning. This was preceded by floaters in her left eye, flrst appearing several days ago and now with increasing frequency. She Which of the fo[o\Ming tests should be obtained? has no other symptoms. Medical history is signiflcant for (A) Antinuclearantibody myopia. She takes no medications. On physical examination, she has an inferior visual (B) Hepatitis C antibody fleld defect in her left eye. Visual fields in the right eye are (C) HIV testing normal. Pupils are equally round and reactive to light and (D) Thyroid-stimulatinghormone 148

Self-Assessment Test t^ (C) Pregnancytest o, Item 55 A 60-year-old woman is evaluated for bone health during a (D) Transvaginal ultrasonography o, routine wellness visit. Her mother was treated for a hip frac- F t! ture after a fall at the age of65 years. the patient is sedentary tt and has a 3O-pack-year history of cigarette smoking but Item 58 o v! tt quit smoking 2 months ago. She has no medical problems A 26-year-old woman is evaluated for a L-week history of a and takes no medications. pruritic rash on the chin. She has no other medical problems Physical examination flndings, including vital signs, and takes no medications. =(u t/t are normal. Her weight is 56 kg (123 lb); BMI is 21. Skin findings are shown. Which of the following is the most appropriate next step in management? (A) Assess fracture risk with a clinical assessment tool (B) Bone mineral density measurement (C) Initiatealendronate (D) Serumvitamin D measurement

t^ (C) Pregnancytest o, Item 55 A 60-year-old woman is evaluated for bone health during a (D) Transvaginal ultrasonography o, routine wellness visit. Her mother was treated for a hip frac- F t! ture after a fall at the age of65 years. the patient is sedentary tt and has a 3O-pack-year history of cigarette smoking but Item 58 o v! tt quit smoking 2 months ago. She has no medical problems A 26-year-old woman is evaluated for a L-week history of a and takes no medications. pruritic rash on the chin. She has no other medical problems Physical examination flndings, including vital signs, and takes no medications. =(u t/t are normal. Her weight is 56 kg (123 lb); BMI is 21. Skin findings are shown. Which of the following is the most appropriate next step in management? (A) Assess fracture risk with a clinical assessment tool (B) Bone mineral density measurement (C) Initiatealendronate (D) Serumvitamin D measurement tr Item 56 A 76 year-old woman is seen tbr a preoperative medical evaluation before elective cholecystectomy. Medical his- tory is signiflcant for nonvalvular atrial flbrillation, hyper- tension, and diabetes mellitus. Medications are warfarin, metoprolol. and met formin.

Which of the following is the most appropriate next step in management? (A) Assess fracture risk with a clinical assessment tool (B) Bone mineral density measurement (C) Initiatealendronate (D) Serumvitamin D measurement tr Item 56 A 76 year-old woman is seen tbr a preoperative medical evaluation before elective cholecystectomy. Medical his- tory is signiflcant for nonvalvular atrial flbrillation, hyper- tension, and diabetes mellitus. Medications are warfarin, metoprolol. and met formin. Which of the follo\,ving is the most appropriate perioperative management of this patient's warfarin? Which of the following is the most appropriate treatment? (A) Withhold warfarin 2 days prior to surgery; restart (A) Mupirocin ointment 2 days after surgery (B) Oral cephalexin (B) Withhold warfarin 5 days prior to surgery; bridge with low-molecular weight heparin (C) Oral doxycycline (C) Withhold warfarin 5 days prior to surgery; restart (D) Oral valacyclovir 12 hours after surgery (E) Triamcinolonecream (D) Withhold warfarin 5 days prior to surgery; restart 5 days after surgery Item 59 A 49-year-old man is evaluated for influenza immunization.

Which of the follo\,ving is the most appropriate perioperative management of this patient's warfarin? Which of the following is the most appropriate treatment? (A) Withhold warfarin 2 days prior to surgery; restart (A) Mupirocin ointment 2 days after surgery (B) Oral cephalexin (B) Withhold warfarin 5 days prior to surgery; bridge with low-molecular weight heparin (C) Oral doxycycline (C) Withhold warfarin 5 days prior to surgery; restart (D) Oral valacyclovir 12 hours after surgery (E) Triamcinolonecream (D) Withhold warfarin 5 days prior to surgery; restart 5 days after surgery Item 59 A 49-year-old man is evaluated for influenza immunization. tr Item 57 A 32-year old woman is evaluated for acute onset of right Two weeks ago, he underwent surgical resection for stage III colon cancer. He will begin a 3-month course of adjuvant chemotherapy in 3 weeks. He is doing well postswgically. lower quadrant abdominal pain that began 1 day ago. She All other immunizations are up to date. He has no other reports some vaginal spotting but no discharge, fever, nau- medical problems and takes no medications. sea, or vomiting. She is sexually active with her husband and uses a levonorgestrel releasing intrauterine device for contraception. Medical history is otherwise unremarkable, Which of the following is the preferred influenza and she takes no medications. immunization stratery? On physical examination, blood pressureislO2lT4 mn (A) Defervaccination until completion of chemotherapy I Ig and pulse rate is 95/min; other vital signs are normal. (B) High-dose vaccine Abdominal examination reveals tenderness in the right (C) Nasalsprayvaccine lower quadrant with no guarding. Pelvic examination reveals a normal appearing cervix with a small amount (D) Standard-dose inactivated vaccine ofblood in the vault and tenderness in the right adnexa. Complete blood count is normal.

tr Item 57 A 32-year old woman is evaluated for acute onset of right Two weeks ago, he underwent surgical resection for stage III colon cancer. He will begin a 3-month course of adjuvant chemotherapy in 3 weeks. He is doing well postswgically. lower quadrant abdominal pain that began 1 day ago. She All other immunizations are up to date. He has no other reports some vaginal spotting but no discharge, fever, nau- medical problems and takes no medications. sea, or vomiting. She is sexually active with her husband and uses a levonorgestrel releasing intrauterine device for contraception. Medical history is otherwise unremarkable, Which of the following is the preferred influenza and she takes no medications. immunization stratery? On physical examination, blood pressureislO2lT4 mn (A) Defervaccination until completion of chemotherapy I Ig and pulse rate is 95/min; other vital signs are normal. (B) High-dose vaccine Abdominal examination reveals tenderness in the right (C) Nasalsprayvaccine lower quadrant with no guarding. Pelvic examination reveals a normal appearing cervix with a small amount (D) Standard-dose inactivated vaccine ofblood in the vault and tenderness in the right adnexa. Complete blood count is normal. Which of the following is the most appropriate initial Item 6O A 65-year-old man is evaluated during a routine wellness tr diagnostic test? examination. He reports no symptoms. Medical problems include atrial fibrillation, hypertension, and hypothy- (A) CT of the abdomen and pelvis roidism. He has as a 40 pack-year history of smoking. Fle (B) Nucleic acid amplification test fbr chlamydia and has one alcoholic drink nightly. Current medications are gonorrhea rivaroxaban, levothlroxine, hydrochlorothiazide, metoprolol,

Which of the following is the most appropriate initial Item 6O A 65-year-old man is evaluated during a routine wellness tr diagnostic test? examination. He reports no symptoms. Medical problems include atrial fibrillation, hypertension, and hypothy- (A) CT of the abdomen and pelvis roidism. He has as a 40 pack-year history of smoking. Fle (B) Nucleic acid amplification test fbr chlamydia and has one alcoholic drink nightly. Current medications are gonorrhea rivaroxaban, levothlroxine, hydrochlorothiazide, metoprolol, 149

Self-Assessment Test t/t o lll and atorvastatin. The patient also takes p-carotene, fish oil, significant for atrial flbrillation. hypertension, and peripheral a,t E vitamin E, and large doses of biotin. The patient expresses no vascular disease. Medications are rivaroxaban, metoprolol, ur coNT 6.ri.. to quit smoking at this time. o ur losartan, and atorvastatin. tr On physical examination, vital signs are normal. The Which ofthe following is the most appropriate physical examination documents osteoarthritis of the kree (D recommendation regarding this patient's supplements? and an irregular heart rhythm. Laboratory studies show a serum creatirrine level of o (A) Stop biotin 1.0 mg/dl (es.+ pmol/L) and an estimated glomerular filtra ut (B) Stop B carotene tion rate greater than 60 ml/min/1.73 m2. (C) Stop flsh oil (D) Stop vitamin E Which ofthe following is the most appropriate perioperative (E) Stop all supplements management of the patient's rivamxaban? (A) Continue rivaroxaban until day of surgery (B) Withhold rivaroxaban 3 days before surgery Item 61 (C) Withhold rivaroxaban 3 days before surgery; bridge A 29-year-old woman is evaluated for a 6-month history of with low-molecular weight heparin acne that worsens during menses. She has been using topi- (D) Withhold rivaroxaban 7 days before surgery cal benzoyl peroxide wash and topical tretinoin cream, but there has been no improvement. She reports no hirsutism or (E) Withhold rivaroxaban 7 days before surgery; bridge virilization symptoms. Menses are regular. She has no other with low molecular-weight heparin medical problems and takes no additional medications. Skin flndings are shown. Item 53 A 37-year-old man is evaluated during a pre employment examination. He is starting a new job as a medical assistant in a primary care offlce. Within the past 2 years, he com- pleted his hepatitis B vaccination and the measles, mumps, and rubella vaccine series and received the tetanus and diphtheria toxoids and COVID-l9 vaccines. He received the influenza vaccine during the most recent influenza season. He has no medical conditions and takes no medications. laboratory studies are positive for the hepatitis B sur face antibody and rubella and varicella IgG antibody.

t/t o lll and atorvastatin. The patient also takes p-carotene, fish oil, significant for atrial flbrillation. hypertension, and peripheral a,t E vitamin E, and large doses of biotin. The patient expresses no vascular disease. Medications are rivaroxaban, metoprolol, ur coNT 6.ri.. to quit smoking at this time. o ur losartan, and atorvastatin. tr On physical examination, vital signs are normal. The Which ofthe following is the most appropriate physical examination documents osteoarthritis of the kree (D recommendation regarding this patient's supplements? and an irregular heart rhythm. Laboratory studies show a serum creatirrine level of o (A) Stop biotin 1.0 mg/dl (es.+ pmol/L) and an estimated glomerular filtra ut (B) Stop B carotene tion rate greater than 60 ml/min/1.73 m2. (C) Stop flsh oil (D) Stop vitamin E Which ofthe following is the most appropriate perioperative (E) Stop all supplements management of the patient's rivamxaban? (A) Continue rivaroxaban until day of surgery (B) Withhold rivaroxaban 3 days before surgery Item 61 (C) Withhold rivaroxaban 3 days before surgery; bridge A 29-year-old woman is evaluated for a 6-month history of with low-molecular weight heparin acne that worsens during menses. She has been using topi- (D) Withhold rivaroxaban 7 days before surgery cal benzoyl peroxide wash and topical tretinoin cream, but there has been no improvement. She reports no hirsutism or (E) Withhold rivaroxaban 7 days before surgery; bridge virilization symptoms. Menses are regular. She has no other with low molecular-weight heparin medical problems and takes no additional medications. Skin flndings are shown. Item 53 A 37-year-old man is evaluated during a pre employment examination. He is starting a new job as a medical assistant in a primary care offlce. Within the past 2 years, he com- pleted his hepatitis B vaccination and the measles, mumps, and rubella vaccine series and received the tetanus and diphtheria toxoids and COVID-l9 vaccines. He received the influenza vaccine during the most recent influenza season. He has no medical conditions and takes no medications. laboratory studies are positive for the hepatitis B sur face antibody and rubella and varicella IgG antibody. Which of the following is the most appropriate vaccine to administer to this patient? (A) Hepatitis A vaccine (B) Quadrivalent meningococcal conjugate vaccine (C) Tetanus toxoid, reduced diphtheria toxoid, and acel- lular pertussis vaccine (D) No vaccines are indicated

Which of the following is the most appropriate vaccine to administer to this patient? (A) Hepatitis A vaccine (B) Quadrivalent meningococcal conjugate vaccine (C) Tetanus toxoid, reduced diphtheria toxoid, and acel- lular pertussis vaccine (D) No vaccines are indicated Item 64 No features ofhyperandrogenism are noted. A 32-year old woman telephones the office to request emer- gency contraception after an episode ofunprotected sexual Which of the following is the most appropriate intercourse 4 days ago. She reports no syrnptoms. Medical management? history is unremarkable, and she takes no medications. She is out of town and is unable to come into the office for (A) Hormonemeasurements several days. (B) Pelvicultrasonography Her last recorded BMI is 28, and she reports no change (C) Progesterone eluting intrauterine device in weight since her last visit 6 months ago. (D) Spironolactone (E) Topical metronidazole cream Which of the following is the most appropriate emergency contraceptive option for this patient? (A) Combined hormonal oral contraceptive pill

Item 64 No features ofhyperandrogenism are noted. A 32-year old woman telephones the office to request emer- gency contraception after an episode ofunprotected sexual Which of the following is the most appropriate intercourse 4 days ago. She reports no syrnptoms. Medical management? history is unremarkable, and she takes no medications. She is out of town and is unable to come into the office for (A) Hormonemeasurements several days. (B) Pelvicultrasonography Her last recorded BMI is 28, and she reports no change (C) Progesterone eluting intrauterine device in weight since her last visit 6 months ago. (D) Spironolactone (E) Topical metronidazole cream Which of the following is the most appropriate emergency contraceptive option for this patient? (A) Combined hormonal oral contraceptive pill tr Item 62 A 66-year-oldwoman is seen for a preoperative medical eval (B) Levonorgestrel oral contraceptive pill (C) Subdermalcontraceptiveimplant uation before total right knee arthroplasty. Medical history is (D) Ulipristal acetate oral contraceptive pill 150

Self-Assessment Test vt o, tr Item 55 A 28-year-old woman is evaluated in the emergency depart cancer. She is willing to undergo colorectal cancer screening but does not want colonoscopy. (u ment 3 hours after sustaining a burn of the Ieft arm while burning leaves in her backyard. Which of the following is the most appropriate colorectal v! v! screening strategl for this patient? q, On physical examination, vital signs are normal. Skin t! Ut flndings on the left arrn are shown. (A) Fecal immunochemical test every 1to 2 years (B) CTcolonographyeverylOyears o (C) Serum circulating methylated SEPTg DNA measurement ttt everylto2years (D) Sigmoidoscopy every 2 years

tr Item 55 A 28-year-old woman is evaluated in the emergency depart cancer. She is willing to undergo colorectal cancer screening but does not want colonoscopy. (u ment 3 hours after sustaining a burn of the Ieft arm while burning leaves in her backyard. Which of the following is the most appropriate colorectal v! v! screening strategl for this patient? q, On physical examination, vital signs are normal. Skin t! Ut flndings on the left arrn are shown. (A) Fecal immunochemical test every 1to 2 years (B) CTcolonographyeverylOyears o (C) Serum circulating methylated SEPTg DNA measurement ttt everylto2years (D) Sigmoidoscopy every 2 years Item 68 A 48-year-old woman is evaluated during a routine exam- ination. She reports that her last menstrual period was more than 12 months ago. She states she has occasional hot flushes. She has no genitourinary symptoms. Medical his- tory is unremarkable, and she takes no medications. Physical examination flndings, including vital signs, are normal. A pregnancy test result is negative.

Item 68 A 48-year-old woman is evaluated during a routine exam- ination. She reports that her last menstrual period was more than 12 months ago. She states she has occasional hot flushes. She has no genitourinary symptoms. Medical his- tory is unremarkable, and she takes no medications. Physical examination flndings, including vital signs, are normal. A pregnancy test result is negative. Which ofthe following isthe most appropriate management? The affected area blanches with pressure. Pain is pres- ent without application of pressure. (A) Obtain serum follicle-stimulating hormone level (B) Obtain serum prolactin level Which of the following is the classification of this patient's (C) Obtain serum thyroid-stimulating hormone level burn? (D) No further evaluation (A) First degree (B) Second-degree, superflcialpartial thickness Item 59 (C) Second-degree, deep partial-thickness A 36-year-old woman is evaluated for darkening of the (D) Ttrira degree cheeks and forehead that began during pregnancy and has persisted. She is 6 months postpartum. Medical history is otherwise unremarkable, and she takes no medications. Item 66 Skin flndings are shown. A 38-year-old man is evaluated for a 4-day history of bilat eral eye redness, watery discharge, and pruritus as well as rhinitis and sneezing. He has no other symptoms. He expe- riences similar symptoms around the same time each year. He does not wear contact lenses. Medical history is other wise unremarkable, and he takes no medications. On physical examination, there is swelling and erythema of the conjunctiva bilaterally associated with clear, watery discharge. The remainder of the examination is normal.

Which ofthe following isthe most appropriate management? The affected area blanches with pressure. Pain is pres- ent without application of pressure. (A) Obtain serum follicle-stimulating hormone level (B) Obtain serum prolactin level Which of the following is the classification of this patient's (C) Obtain serum thyroid-stimulating hormone level burn? (D) No further evaluation (A) First degree (B) Second-degree, superflcialpartial thickness Item 59 (C) Second-degree, deep partial-thickness A 36-year-old woman is evaluated for darkening of the (D) Ttrira degree cheeks and forehead that began during pregnancy and has persisted. She is 6 months postpartum. Medical history is otherwise unremarkable, and she takes no medications. Item 66 Skin flndings are shown. A 38-year-old man is evaluated for a 4-day history of bilat eral eye redness, watery discharge, and pruritus as well as rhinitis and sneezing. He has no other symptoms. He expe- riences similar symptoms around the same time each year. He does not wear contact lenses. Medical history is other wise unremarkable, and he takes no medications. On physical examination, there is swelling and erythema of the conjunctiva bilaterally associated with clear, watery discharge. The remainder of the examination is normal. Which of the following is the most appropriate topical treatment? (A) Antibiotic (B) Antihistamine with mast cell-stabilizing properties (C) Glucocorticoid (D) Mast cell stabilizing agent (E) NSAID Which ofthe following is the most appropriate management? (A) Hydrocortisonecream Item 67 (B) Monobenzyletherofhydroquinone (C) Oral tranexamic acid A S8-year-old woman is evaluated during a routine wellness visit. She has no symptoms. She has never been screened (D) Sunscreen and sun avoidance for colorectal cancer. Family history is negative for colon (E) thyroid-stimulatinghornone

Which of the following is the most appropriate topical treatment? (A) Antibiotic (B) Antihistamine with mast cell-stabilizing properties (C) Glucocorticoid (D) Mast cell stabilizing agent (E) NSAID Which ofthe following is the most appropriate management? (A) Hydrocortisonecream Item 67 (B) Monobenzyletherofhydroquinone (C) Oral tranexamic acid A S8-year-old woman is evaluated during a routine wellness visit. She has no symptoms. She has never been screened (D) Sunscreen and sun avoidance for colorectal cancer. Family history is negative for colon (E) thyroid-stimulatinghornone 151

Self-Assessment Test vt (D Item 70 (C) Delal.surgery for 9 months t^ A 24-year-old man is evaluated during a routine health (D) Proceed with surgery nolt U! (D examination. He received the tetanus toxoid, reduced diph- t/t lr! theria toxoid, and acellular pertussis vaccine and one dose J (D of the quadrivalent meningococcal conjugate vaccine when Item 73 he was 18 years old, before starting college. He received the A 3S-year-old woman is evaluated for a 3 week history of o influenza and COVID-l9 vaccines during the most recent pruritic rash on several areas, including the hands. There is UI influenza season. He has not received the human papillo- no facial involvement. mavirus vaccine series. He does not smoke cigarettes. Skin flndings are shown. Which of the following is the most appropriate vaccination strates/ for this patient? (A) Administer a second dose of quadrivalent meningo- coccal conjugate vaccine (B) Administer the human papillomavirus vaccine series (C) Administer the 23-valent pneumococcal polysaccha- ride vaccine (D) No vaccines are indicated at this time tr Item 71 An 1B-year old man is evaluated in the emergency depart ment fbr severe right sided scrotal pain that started sud denly 4 hours ago and has progressed. He is nauseated but reports no other symptoms. He has no history of trauma. He has no other medical problems and takes no medications. On physical examination. the patient is in distress. Temperature is 36.9 'C (98.4 "F). blood pressure is 1461 92 mm Hg, pulse rate is 102rmin. and respiration rate is 16/min. The right testis is elevated, and the overlying scrotal skin is erythematous and warm. The epididymis cannot be distinguished from the testis owing to severe scrotal srtell ing and pain. Cremasteric reflex is absent on the right and intact on the left.

tr Item 71 An 1B-year old man is evaluated in the emergency depart ment fbr severe right sided scrotal pain that started sud denly 4 hours ago and has progressed. He is nauseated but reports no other symptoms. He has no history of trauma. He has no other medical problems and takes no medications. On physical examination. the patient is in distress. Temperature is 36.9 'C (98.4 "F). blood pressure is 1461 92 mm Hg, pulse rate is 102rmin. and respiration rate is 16/min. The right testis is elevated, and the overlying scrotal skin is erythematous and warm. The epididymis cannot be distinguished from the testis owing to severe scrotal srtell ing and pain. Cremasteric reflex is absent on the right and intact on the left. Which of the following is the most appropriate management? (A) lmmediatesurgicalexploration (B) lntramuscular ceftriaxone and oral doxycycline Which of the following is the most likely diagnosis? (C) Scr<-rta1 elevation (A) Bed bug bites (D) Ultrasonography of the scrotum (B) Dyshidrosis (C) Impetigo Item 72 (D) Scabies A 68 year old man is seen for a preoperative medical eval uation before elective cervical laminectomy for chronic radicular pain without neurologic deficits. Medical history is significant for hyperlipidemia and hypertension. He Item 74 A 65 year old man is seen for a preoperatir,e medical eval tr had a cerebrovascular accident 3 weeks ago due to small uation prior to total knee arthroplast!. He has compensated vessel atherosclerosis. Medications are rosuvastatin, lisino alcoholic cirrhosis without a history of variceal hemorrhage, pril. atenolol, aspirin. and dipyridamole. ascites. and encephalopathy. I le has been abstinent from alco On physical examination. vital signs are normal. BMI is hol fbr 9 months. tlis onl-v medication is topical diclofenac. 31. Neurologic examination is normal. On physical cxamination. r'ital signs are normal. Scat terecl spider angiomas are noted on the shoulders. There is Which of the following is the most appropriate no evidence ol'ascites. The right knee has evidence ofosteo recommendation regarding surgery? arthritis, with restricted range o{' motion. Mental status examination is normal. (A) Avoid surgery f{is calculatcd Model for End stage Liver Disease score (B) Delay surgery Ibr 1 month is 14.

Which of the following is the most appropriate management? (A) lmmediatesurgicalexploration (B) lntramuscular ceftriaxone and oral doxycycline Which of the following is the most likely diagnosis? (C) Scr<-rta1 elevation (A) Bed bug bites (D) Ultrasonography of the scrotum (B) Dyshidrosis (C) Impetigo Item 72 (D) Scabies A 68 year old man is seen for a preoperative medical eval uation before elective cervical laminectomy for chronic radicular pain without neurologic deficits. Medical history is significant for hyperlipidemia and hypertension. He Item 74 A 65 year old man is seen for a preoperatir,e medical eval tr had a cerebrovascular accident 3 weeks ago due to small uation prior to total knee arthroplast!. He has compensated vessel atherosclerosis. Medications are rosuvastatin, lisino alcoholic cirrhosis without a history of variceal hemorrhage, pril. atenolol, aspirin. and dipyridamole. ascites. and encephalopathy. I le has been abstinent from alco On physical examination. vital signs are normal. BMI is hol fbr 9 months. tlis onl-v medication is topical diclofenac. 31. Neurologic examination is normal. On physical cxamination. r'ital signs are normal. Scat terecl spider angiomas are noted on the shoulders. There is Which of the following is the most appropriate no evidence ol'ascites. The right knee has evidence ofosteo recommendation regarding surgery? arthritis, with restricted range o{' motion. Mental status examination is normal. (A) Avoid surgery f{is calculatcd Model for End stage Liver Disease score (B) Delay surgery Ibr 1 month is 14. 152

Self-Assessment Test ut €, lJl t-aboratorv studies: Which of the following is the most appropriate bl uemogo6in 11 g/dl (110 g/L) treatment? E (u C0Nl p1^1.1.1 90,000/pL (90 x 10e/L) "orrr, (A) Ketoconazole cream E INR 1.3 vt Totalbilirubin 2.0 mg/dl (34.2 pmol/L) (B) Mupirocin ointment ra o .,I Creatinine 1.2 mg/dl (106.1 pmol/L) (C) Prednisone vt (D) Triamcinolonecream Which of the following is the most appropriate E perioperative management? t (A) Counsel patient on increased surgical risk due to cirrhosis llem 77 (B) Frozen plasma prior to surgery A 65-year-old man is evaluated during a follow-up visit for (C) Livertransplantation evaluation type 2 diabetes mellitus. He feels well. He reports no chest pain or shortness of breath. Medical history is also signifl- (D) No additional testing or intervention cant for atrial flbrillation, dyslipidemia, and hypertension. Medications are metformin, Iiraglutide, lisinopril, meto- prolol, rivaroxaban, and atorvastatin. Item 75 Physical examination flndings, including vital signs, A 3S-year-old woman is seen in the office to discuss phar- are normal. macotherapy for obesity. She has not lost signiflcant weight His 1O-year atherosclerotic cardiovascular disease risk over the past 6 months despite dietary counseling, commer- is 24% using the Pooled Cohort Equations. cial weight loss programs, and exercise. Medical history is significant for nephrolithiasis, insomnia, hypertension, and Which of the following is the best advice regarding aspirin irritable bowel syndrome with diarrhea. Medications are therapy for this patient? hydrochlorothiazide and loperamide. On physical examination, vital signs are normal. BMI is (A) Aspirin, 81mg/d 39. The remainder of the examination is normal. (B) Aspirin, 81 mg/d, and omeprazole (C) Aspirin,325 mg/d Which of the following is the most appropriate (D) No aspirin management? (A) Liraglutide (B) Naltrexone-bupropion (C) Orlistat Item 78 A 50 year-old man is evaluated during a follow-up visit tr (D) Phentermine-topiramate I month after being hospitalized for deep venous throm- bosis of the right leg. He is no longer taking apixaban because he received only a 14-day supply after Ieaving Item 76 the hospital and his symptoms had improved after fln- ishing the supply. He thought he had flnished a course of A 56-year-old man is evaluated for worsening erythema therapy. and pruritus that began 3 days ago. Ten days ago, bacitra- On physical examination, vital signs and the remainder cin ointment was used following excision of a dysplastic of the physical examination are normal. nevus on his upper back; it was stopped 3 days ago. Two weeks ago, he was treated with amoxicillin for community- Which of the following steps should be taken now to acquired pneumonia. Medical history is otherwise unre- promote medication adherence? markable, and he takes no medications. Skin findings are shown. (A) Patienteducation ) (B) Recommend a pill box t (C) Screen for low health literacy (D) Select an anticoagulant with the lowest copayment ;

ut €, lJl t-aboratorv studies: Which of the following is the most appropriate bl uemogo6in 11 g/dl (110 g/L) treatment? E (u C0Nl p1^1.1.1 90,000/pL (90 x 10e/L) "orrr, (A) Ketoconazole cream E INR 1.3 vt Totalbilirubin 2.0 mg/dl (34.2 pmol/L) (B) Mupirocin ointment ra o .,I Creatinine 1.2 mg/dl (106.1 pmol/L) (C) Prednisone vt (D) Triamcinolonecream Which of the following is the most appropriate E perioperative management? t (A) Counsel patient on increased surgical risk due to cirrhosis llem 77 (B) Frozen plasma prior to surgery A 65-year-old man is evaluated during a follow-up visit for (C) Livertransplantation evaluation type 2 diabetes mellitus. He feels well. He reports no chest pain or shortness of breath. Medical history is also signifl- (D) No additional testing or intervention cant for atrial flbrillation, dyslipidemia, and hypertension. Medications are metformin, Iiraglutide, lisinopril, meto- prolol, rivaroxaban, and atorvastatin. Item 75 Physical examination flndings, including vital signs, A 3S-year-old woman is seen in the office to discuss phar- are normal. macotherapy for obesity. She has not lost signiflcant weight His 1O-year atherosclerotic cardiovascular disease risk over the past 6 months despite dietary counseling, commer- is 24% using the Pooled Cohort Equations. cial weight loss programs, and exercise. Medical history is significant for nephrolithiasis, insomnia, hypertension, and Which of the following is the best advice regarding aspirin irritable bowel syndrome with diarrhea. Medications are therapy for this patient? hydrochlorothiazide and loperamide. On physical examination, vital signs are normal. BMI is (A) Aspirin, 81mg/d 39. The remainder of the examination is normal. (B) Aspirin, 81 mg/d, and omeprazole (C) Aspirin,325 mg/d Which of the following is the most appropriate (D) No aspirin management? (A) Liraglutide (B) Naltrexone-bupropion (C) Orlistat Item 78 A 50 year-old man is evaluated during a follow-up visit tr (D) Phentermine-topiramate I month after being hospitalized for deep venous throm- bosis of the right leg. He is no longer taking apixaban because he received only a 14-day supply after Ieaving Item 76 the hospital and his symptoms had improved after fln- ishing the supply. He thought he had flnished a course of A 56-year-old man is evaluated for worsening erythema therapy. and pruritus that began 3 days ago. Ten days ago, bacitra- On physical examination, vital signs and the remainder cin ointment was used following excision of a dysplastic of the physical examination are normal. nevus on his upper back; it was stopped 3 days ago. Two weeks ago, he was treated with amoxicillin for community- Which of the following steps should be taken now to acquired pneumonia. Medical history is otherwise unre- promote medication adherence? markable, and he takes no medications. Skin findings are shown. (A) Patienteducation ) (B) Recommend a pill box t (C) Screen for low health literacy (D) Select an anticoagulant with the lowest copayment ; I

ut €, lJl t-aboratorv studies: Which of the following is the most appropriate bl uemogo6in 11 g/dl (110 g/L) treatment? E (u C0Nl p1^1.1.1 90,000/pL (90 x 10e/L) "orrr, (A) Ketoconazole cream E INR 1.3 vt Totalbilirubin 2.0 mg/dl (34.2 pmol/L) (B) Mupirocin ointment ra o .,I Creatinine 1.2 mg/dl (106.1 pmol/L) (C) Prednisone vt (D) Triamcinolonecream Which of the following is the most appropriate E perioperative management? t (A) Counsel patient on increased surgical risk due to cirrhosis llem 77 (B) Frozen plasma prior to surgery A 65-year-old man is evaluated during a follow-up visit for (C) Livertransplantation evaluation type 2 diabetes mellitus. He feels well. He reports no chest pain or shortness of breath. Medical history is also signifl- (D) No additional testing or intervention cant for atrial flbrillation, dyslipidemia, and hypertension. Medications are metformin, Iiraglutide, lisinopril, meto- prolol, rivaroxaban, and atorvastatin. Item 75 Physical examination flndings, including vital signs, A 3S-year-old woman is seen in the office to discuss phar- are normal. macotherapy for obesity. She has not lost signiflcant weight His 1O-year atherosclerotic cardiovascular disease risk over the past 6 months despite dietary counseling, commer- is 24% using the Pooled Cohort Equations. cial weight loss programs, and exercise. Medical history is significant for nephrolithiasis, insomnia, hypertension, and Which of the following is the best advice regarding aspirin irritable bowel syndrome with diarrhea. Medications are therapy for this patient? hydrochlorothiazide and loperamide. On physical examination, vital signs are normal. BMI is (A) Aspirin, 81mg/d 39. The remainder of the examination is normal. (B) Aspirin, 81 mg/d, and omeprazole (C) Aspirin,325 mg/d Which of the following is the most appropriate (D) No aspirin management? (A) Liraglutide (B) Naltrexone-bupropion (C) Orlistat Item 78 A 50 year-old man is evaluated during a follow-up visit tr (D) Phentermine-topiramate I month after being hospitalized for deep venous throm- bosis of the right leg. He is no longer taking apixaban because he received only a 14-day supply after Ieaving Item 76 the hospital and his symptoms had improved after fln- ishing the supply. He thought he had flnished a course of A 56-year-old man is evaluated for worsening erythema therapy. and pruritus that began 3 days ago. Ten days ago, bacitra- On physical examination, vital signs and the remainder cin ointment was used following excision of a dysplastic of the physical examination are normal. nevus on his upper back; it was stopped 3 days ago. Two weeks ago, he was treated with amoxicillin for community- Which of the following steps should be taken now to acquired pneumonia. Medical history is otherwise unre- promote medication adherence? markable, and he takes no medications. Skin findings are shown. (A) Patienteducation ) (B) Recommend a pill box t (C) Screen for low health literacy (D) Select an anticoagulant with the lowest copayment ; I t Item 79 A 62-year-old woman is evaluated in the hospital for venous tr I thromboembolism (WE) prophylaxis. The patient has locally I invasive ovarian cancer and will undergo total abdominal I hysterectomy and bilateral salpingo oophorectomy. She has i no personal or family history of WE. She is otherwise well L and takes no medication. On physical examination, vital signs are normal. BMI L is 33. Ascites is present. The remainder of the physical examination is unremarkable. L Intermittent pneumatic compression is initiated. I t 153 L I

Self-Assessment Test yt .D ut UI tr CONT, Which of the following is the most appropriate additional WE prophylaxis for this patient? Item 82 A 34-year-old woman is evaluated for preconception coun- .D UI (A) Insertion of an inferior vena cava filter seling. She received two doses of the human papillomavirus UI (B) Low-molecular weight heparin (LMWH) for 7 days (HPV) vaccine before 15 years of age; the tetanus toxoid, (D reduced diphtheria toxoid, and acellular pertussis (Tdap) (C) LMWH for 30 days vaccine 5 years ago; and the influenza and COVID-19 vac- (D) No additional prophylaxis cines during the most recent influenza season. She has no (D UI medical problems and takes no medications. Laboratory studies reveal a negative rubella antibody

ut UI tr CONT, Which of the following is the most appropriate additional WE prophylaxis for this patient? Item 82 A 34-year-old woman is evaluated for preconception coun- .D UI (A) Insertion of an inferior vena cava filter seling. She received two doses of the human papillomavirus UI (B) Low-molecular weight heparin (LMWH) for 7 days (HPV) vaccine before 15 years of age; the tetanus toxoid, (D reduced diphtheria toxoid, and acellular pertussis (Tdap) (C) LMWH for 30 days vaccine 5 years ago; and the influenza and COVID-19 vac- (D) No additional prophylaxis cines during the most recent influenza season. She has no (D UI medical problems and takes no medications. Laboratory studies reveal a negative rubella antibody tr Item 8O A 66-year-old man is evaluated in the emergency depart titer and a positive varicella antibody titer. A pregnancy test result is negative. ment for sudden onset of perineal pain that began 1 day ago. He also reports urinary frequency, urgency. and hes Which of the following is the most appropriate vaccination itancy, and fever and chills. He is not sexually active. strategr for this patient? Medical history is otherw,ise unremarkable, and he takes (A) Additional dose of HPV vaccine no medications. (B) Measles, mumps, and rubella vaccine On physical examination, temperature is 38.7 'C (tOt.S 'F); other vital signs are normal. On digital rectal (C) Tdapvaccine examination, the prostate is tender, enlarged, and boggy. (D) No vaccines are indicated at this time The remainder of the examination is unremarkable.

tr Item 8O A 66-year-old man is evaluated in the emergency depart titer and a positive varicella antibody titer. A pregnancy test result is negative. ment for sudden onset of perineal pain that began 1 day ago. He also reports urinary frequency, urgency. and hes Which of the following is the most appropriate vaccination itancy, and fever and chills. He is not sexually active. strategr for this patient? Medical history is otherw,ise unremarkable, and he takes (A) Additional dose of HPV vaccine no medications. (B) Measles, mumps, and rubella vaccine On physical examination, temperature is 38.7 'C (tOt.S 'F); other vital signs are normal. On digital rectal (C) Tdapvaccine examination, the prostate is tender, enlarged, and boggy. (D) No vaccines are indicated at this time The remainder of the examination is unremarkable. Which of the following is the most appropriate next Item 83 management step? A 26 year old man is evaluated for a 2 month history of hair loss with no erythema, scaling, or pruritus. Medical history (A) CT of the prostate is unremarkable, and he takes no medication. (B) Nitrofurantoin Skin flndings are shown. (C) Prostatic massage fbllowed by urine culture (D) Trimethoprim sulfamethoxazole (E) Urinary catheter placement Item 81 A 64-year old man is evaluated for a 1 month history of a pruritic and irritated wart like growth on his back. The warty lesion has been present for over a year, but the irrita- tion and redness are new. There are scattered seborrheic keratoses throughout trunk. Skin flndings are shown.

Item 81 A 64-year old man is evaluated for a 1 month history of a pruritic and irritated wart like growth on his back. The warty lesion has been present for over a year, but the irrita- tion and redness are new. There are scattered seborrheic keratoses throughout trunk. Skin flndings are shown. Which of the following is the most appropriate treatment? Which of the following is the most likely diagnosis? (A) Cryotherapy (A) Alopecia areata (B) Mupirocin ointment (B) Androgenicalopecia (C) Topical 5-fluorouracil (C) Discoid Iupus erythematosus (D) Topicaltriamcinolone acetonide (D) Tinea capitis 154

Self-Assessment Test t o, tr Item 84 A 4S-year old man is seen for a preoperative medical eval- Item 87 An 18 year-old man is evaluated during a preparticipation E (l, uation before undergoing an elective hernia repair. He is physical examination for his college soccer team. He is otherwise well. History and physical examination are per- asymptomatic. He describes no limitation in his exercise ut tt (u formed. Complete blood count, coagulation studies, chest capacity, palpitations, syncope, presyncope, dyspnea, or l,t ut radiography, and electrocardiography are not obtained. chest discomfort. He has exercise-induced bronchospasm. His only medication is abudesonide-formoterol inhalerthat (u This preoperative evaluation stratery is most in keeping he uses before exercise. He does not smoke, drink alcohol, vt with which of the following? or use any drugs. There is no family history of cardiac dis ease or sudden death. (A) Defensive medicine Physical examination flndings, including vital signs (B) High value care and cardiac auscultation, are normal. (C) Lean quality improvement model (D) Medical rationing Which of the following is the most appropriate test to perform? (A) Chest radiography Item 85 (B) Echocardiography A 46-year-old woman is evaluated for a 2-week history of (C) Spirometry vaginal discharge and itching. She reports no other vaginal or urinary symptoms. She is sexually active with one male (D) No testing is indicated partner. She has a levonorgestrel-releasing intrauterine device for contraception. Medical history is otherwise unre- Item 88 markable, and she takes no medications. Speculum examination shows gray frothy discharge. A 72 year-old man is evaluated for a 6-month history of a The cervix is normal appearing, without purulent discharge. painful lesion on the left ear that is increasing in size. Medi- Bimanual examination is unremarkable. cal history is otherwise unremarkable. Laboratory studies reveal a vaginal pH of5.0. There are Skin flndings are shown. no hyphae on potassium hydroxide preparation. Tricho- monad nucleic acid amplification test result is positive. A pregnancy test result is negative.

t o, tr Item 84 A 4S-year old man is seen for a preoperative medical eval- Item 87 An 18 year-old man is evaluated during a preparticipation E (l, uation before undergoing an elective hernia repair. He is physical examination for his college soccer team. He is otherwise well. History and physical examination are per- asymptomatic. He describes no limitation in his exercise ut tt (u formed. Complete blood count, coagulation studies, chest capacity, palpitations, syncope, presyncope, dyspnea, or l,t ut radiography, and electrocardiography are not obtained. chest discomfort. He has exercise-induced bronchospasm. His only medication is abudesonide-formoterol inhalerthat (u This preoperative evaluation stratery is most in keeping he uses before exercise. He does not smoke, drink alcohol, vt with which of the following? or use any drugs. There is no family history of cardiac dis ease or sudden death. (A) Defensive medicine Physical examination flndings, including vital signs (B) High value care and cardiac auscultation, are normal. (C) Lean quality improvement model (D) Medical rationing Which of the following is the most appropriate test to perform? (A) Chest radiography Item 85 (B) Echocardiography A 46-year-old woman is evaluated for a 2-week history of (C) Spirometry vaginal discharge and itching. She reports no other vaginal or urinary symptoms. She is sexually active with one male (D) No testing is indicated partner. She has a levonorgestrel-releasing intrauterine device for contraception. Medical history is otherwise unre- Item 88 markable, and she takes no medications. Speculum examination shows gray frothy discharge. A 72 year-old man is evaluated for a 6-month history of a The cervix is normal appearing, without purulent discharge. painful lesion on the left ear that is increasing in size. Medi- Bimanual examination is unremarkable. cal history is otherwise unremarkable. Laboratory studies reveal a vaginal pH of5.0. There are Skin flndings are shown. no hyphae on potassium hydroxide preparation. Tricho- monad nucleic acid amplification test result is positive. A pregnancy test result is negative. Which of the following is the most appropriate treabnent? (A) Oral azithromycin (B) Oral fluconazole (C) Oral metronidazole (D) Topical metronidazole gel

t o, tr Item 84 A 4S-year old man is seen for a preoperative medical eval- Item 87 An 18 year-old man is evaluated during a preparticipation E (l, uation before undergoing an elective hernia repair. He is physical examination for his college soccer team. He is otherwise well. History and physical examination are per- asymptomatic. He describes no limitation in his exercise ut tt (u formed. Complete blood count, coagulation studies, chest capacity, palpitations, syncope, presyncope, dyspnea, or l,t ut radiography, and electrocardiography are not obtained. chest discomfort. He has exercise-induced bronchospasm. His only medication is abudesonide-formoterol inhalerthat (u This preoperative evaluation stratery is most in keeping he uses before exercise. He does not smoke, drink alcohol, vt with which of the following? or use any drugs. There is no family history of cardiac dis ease or sudden death. (A) Defensive medicine Physical examination flndings, including vital signs (B) High value care and cardiac auscultation, are normal. (C) Lean quality improvement model (D) Medical rationing Which of the following is the most appropriate test to perform? (A) Chest radiography Item 85 (B) Echocardiography A 46-year-old woman is evaluated for a 2-week history of (C) Spirometry vaginal discharge and itching. She reports no other vaginal or urinary symptoms. She is sexually active with one male (D) No testing is indicated partner. She has a levonorgestrel-releasing intrauterine device for contraception. Medical history is otherwise unre- Item 88 markable, and she takes no medications. Speculum examination shows gray frothy discharge. A 72 year-old man is evaluated for a 6-month history of a The cervix is normal appearing, without purulent discharge. painful lesion on the left ear that is increasing in size. Medi- Bimanual examination is unremarkable. cal history is otherwise unremarkable. Laboratory studies reveal a vaginal pH of5.0. There are Skin flndings are shown. no hyphae on potassium hydroxide preparation. Tricho- monad nucleic acid amplification test result is positive. A pregnancy test result is negative. Which of the following is the most appropriate treabnent? (A) Oral azithromycin (B) Oral fluconazole (C) Oral metronidazole (D) Topical metronidazole gel Item 86 EI An 82-year-old woman is seen for a preoperative medical patient evaluaiion before undergoing cataract surgery' The of breath is wtreetctrair bound. Shi reports stable shortness exertion' Medical history is sig Which of the following is the most lftely diagnosis? with minimal to moderate nificant for hypertension, chronic kidney disease' COPD' (A) Basal cell carcinoma joint disease. Medications are albuterol' (B) Bowen disease ".Ja.g"".."iive ipotio-pi"*, and beclomethasone inhalers; lisinopril; (C) Seborrheickeratosis metoprolol; and oxygen by nasal cannula, 2 L/min contin- uously. (D) Squamous cell carcinoma 6n physical examination, blood pressure is 150/85 mm i"t. it gzl-in, respiration rate is.24lmin' and Hg, pulse o*'yg".t trtrrt"tion is 947, on 2 L/min of oxygen by nasal ,rir'. gteath tounds are distant, with an occasional can- wheeze' Item 89 A l9-year-old woman is evaluated in the emergency depart- tr menifor a 3-day history ofprogressively severe sore throat' She cannot t*"llo*Iiquids due to pain and has drooling' Which of the following is the most appropriate preoperative testing for this patient? On physical examination, temperature is 38'5 "C (tot.g "p), Uiood pressure is 110/70 mm Hg, pulse rate is 110/ min, and respiration rate is 25lmin' There is no stridor' (A) Chest radiograPhY She is patient has (B) ECG Jtoofi"g. The oropharynx is hyperemic, and the (C) EchocardiograPhY Jimc.tffi, opening her mouth fully' The uvula is engorged' Antibiotics are initiated. (D) No testing is indicated 155

: t \ Self-Assessment Test t/l .D in (C) Nystatin cream Which of the following is the most appropriate next step vt UI tr CONT. management? (D) Oral itraconazole (E) Terbinaflnecream , l .D (A) ICU admission t UI (B) Intravenousmethylprednisolone \ (D (C) Neck CT with contrast (D) Rapid antigen detection test Item 92 A S9-year-old woman is evaluated in the hospital for tr ! 1

.D (A) ICU admission t UI (B) Intravenousmethylprednisolone \ (D (C) Neck CT with contrast (D) Rapid antigen detection test Item 92 A S9-year-old woman is evaluated in the hospital for tr ! 1 .D vl postoperative ileus following a hysterectoml' Sfe reports : iloit""i"g nausea and abdominal fullness' Her last bowel \ Item 90 -or".n..tlt was on the morning of surgery' She has been l A 33-year-old woman is evaluated for a 6-month history of is using hydrocodone for pain. Her only other medication bilateral breast pain that begins before her menstrual period prophylactic ' 'O; physicallow -molecular-weight heparin' and resolves after the onset of menstruation' She reports examination, vital signs are normal' There no other breast symptoms, masses, or nipple discharge' is a healinghysterectomy incision. The abdomen is diflusely Medical history is otherwise unremarkable. Family history tender without guarding; bowel sounds are decreased' is signiflcant for breast cancer in her grandmother at age Comprehensive metabolic profile is normal' oz yiars.Her only medication is a combined hormonal oral Plain abdominal radiograph shows mildly dilated ! Ioops of small and large bowel with air fluid levels and air I contraceptive Pill. On physical examination, vital signs are normal' Bilat- throughout the colon. I !

.D vl postoperative ileus following a hysterectoml' Sfe reports : iloit""i"g nausea and abdominal fullness' Her last bowel \ Item 90 -or".n..tlt was on the morning of surgery' She has been l A 33-year-old woman is evaluated for a 6-month history of is using hydrocodone for pain. Her only other medication bilateral breast pain that begins before her menstrual period prophylactic ' 'O; physicallow -molecular-weight heparin' and resolves after the onset of menstruation' She reports examination, vital signs are normal' There no other breast symptoms, masses, or nipple discharge' is a healinghysterectomy incision. The abdomen is diflusely Medical history is otherwise unremarkable. Family history tender without guarding; bowel sounds are decreased' is signiflcant for breast cancer in her grandmother at age Comprehensive metabolic profile is normal' oz yiars.Her only medication is a combined hormonal oral Plain abdominal radiograph shows mildly dilated ! Ioops of small and large bowel with air fluid levels and air I contraceptive Pill. On physical examination, vital signs are normal' Bilat- throughout the colon. I ! eral breast examination results are normal, with no masses l or nipple discharge. There is no lymphadenopathy' Which of the foltowing is the most appropriate l 1

eral breast examination results are normal, with no masses l or nipple discharge. There is no lymphadenopathy' Which of the foltowing is the most appropriate l 1 A pregnancy test result is negative. management? I (A) CT of the abdomen Which of the following is the most appropriate ) management? (B) Decrease opioid use 1 (C) Methylnaltrexone I (A) BreastultrasonograPhY i (D) Nasogastric tube Placement t (B) Initiate danazol I (E) Neostigmine 1 (C) Mammography ! (D) Patient education and reassurance I

(C) Methylnaltrexone I (A) BreastultrasonograPhY i (D) Nasogastric tube Placement t (B) Initiate danazol I (E) Neostigmine 1 (C) Mammography ! (D) Patient education and reassurance I Item 91 Item 93 A randomized controlled screening trial for prostate cancer tr 1 1 t 1 is reviewed. Men who were screened with a prostate-specific A S5-year-old woman is evaluated for 3-month history t l of mildly pruritic rash on her feet, with thickening and antigen blood test were compared with men who were not discoloration of several toenails. She states that she is not screened. Results were analyzed according to their original I

is reviewed. Men who were screened with a prostate-specific A S5-year-old woman is evaluated for 3-month history t l of mildly pruritic rash on her feet, with thickening and antigen blood test were compared with men who were not discoloration of several toenails. She states that she is not screened. Results were analyzed according to their original I 1 concerned about the toenails because polish covers them. group assignment. Approximately 1.3 deaths from prostate : She has no other medical problems. cancer were prevented over 13 years per 1000 men screened. ! Skin flndings are shown. Overall mortality was not reduced by screening. Men in the screened population were more likely to undergo repeated l biopsies and report higher levels of anxiety, and they had l greater rates of infection and bleeding complications. I j Which of the following is most likely responsible for these l results? I

greater rates of infection and bleeding complications. I j Which of the following is most likely responsible for these l results? I ) (A) Classifizing outcomes by overall mortality i (B) Lead-time bias l (C) Overdiagnosis 'l (D) Selection bias \ l \ Item 94 A 58 year old man is evaluated lbr a 2-day history of non- tr I 1 !

(B) Lead-time bias l (C) Overdiagnosis 'l (D) Selection bias \ l \ Item 94 A 58 year old man is evaluated lbr a 2-day history of non- tr I 1 ! Upon removing the toenail polish, several nails are dys- radiating, right-sided scrotal pain and swelling. The pain l trophic, with subungual keratosis and discoloration. began insidiously and has slowly worsened in intensity. He I also reports dysuria and frequency but no fever or hema- I

Upon removing the toenail polish, several nails are dys- radiating, right-sided scrotal pain and swelling. The pain l trophic, with subungual keratosis and discoloration. began insidiously and has slowly worsened in intensity. He I also reports dysuria and frequency but no fever or hema- I Which of the following is the most appropriate treatment turia. He has no previous history of scrotal pain, trauma, \ I for this patient's rash? or urologic procedures. He is sexually active only with his wife and has no history of sexually transmitted infections. (A) Adalimumabinjection Medical history is otherwise unremarkable, and he takes no I (B) Clobetasolcream \ medications. 1 i 156 i \ l

Self-Assessment Test ta Physical examination, including pelvic examination, o, se..,;'*"ll,f isi::l::il:l#;#11',,:;?ill,?ilil;ff CONr 5a.u1r1 pain relievcd with elevation il is normal. ts E of,the scr<ltur.n. Cre- A pregnancy test result and chlamydia screening are g, masteric reflex is nonnal. negative. E tl UI (l, Which of the following is the most appropriate Which of the following is the most appropriate UI tl management? (A) Dopplerultrasonographyolthe scrotum management? gq, (A) Acetaminophen rrt (B) [ntramuscular ceftriaxone and oral doxycycline (B) Combined hormonal oral contraceptive pill (C) Intramuscular ceftriaxone and oral levofloxacin (C) Copper intrauterine device placement (D) Oral levofloxacin (D) Transvaginal ultrasonography :

ta Physical examination, including pelvic examination, o, se..,;'*"ll,f isi::l::il:l#;#11',,:;?ill,?ilil;ff CONr 5a.u1r1 pain relievcd with elevation il is normal. ts E of,the scr<ltur.n. Cre- A pregnancy test result and chlamydia screening are g, masteric reflex is nonnal. negative. E tl UI (l, Which of the following is the most appropriate Which of the following is the most appropriate UI tl management? (A) Dopplerultrasonographyolthe scrotum management? gq, (A) Acetaminophen rrt (B) [ntramuscular ceftriaxone and oral doxycycline (B) Combined hormonal oral contraceptive pill (C) Intramuscular ceftriaxone and oral levofloxacin (C) Copper intrauterine device placement (D) Oral levofloxacin (D) Transvaginal ultrasonography : Item 95 Item 97 An 18 year old woman is evaluated lor sunburn of the dor A 65-year old man is evaluated during a wellness visit. sal hands and dorsal f'eet with burning and pruritus that He has a 50 pack year smoking history but quit smoking began 6 hours after walking on the beach. Medical history is 7 years ago. He is up to date on colorectal and lung cancer signiflcant for acne. Medications are drospirenone ethinyl screening. He prefers not to be screened for prostate cancer. estradiol oral contraceptive, doxycycline, and tretinoin He has not been screened for abdominal aortic aneurysm. cream. On physical examination, vital signs are normal. BMI is 35. Skin flndings on the feet are shown. I Which of the following is the most appropriate screening test? i (A) Abdominal auscultation and palpation (B) Abdominal CT (C) Abdominal ultrasonography (D) Magnetic resonance angiography of the abdomen

Item 95 Item 97 An 18 year old woman is evaluated lor sunburn of the dor A 65-year old man is evaluated during a wellness visit. sal hands and dorsal f'eet with burning and pruritus that He has a 50 pack year smoking history but quit smoking began 6 hours after walking on the beach. Medical history is 7 years ago. He is up to date on colorectal and lung cancer signiflcant for acne. Medications are drospirenone ethinyl screening. He prefers not to be screened for prostate cancer. estradiol oral contraceptive, doxycycline, and tretinoin He has not been screened for abdominal aortic aneurysm. cream. On physical examination, vital signs are normal. BMI is 35. Skin flndings on the feet are shown. I Which of the following is the most appropriate screening test? i (A) Abdominal auscultation and palpation (B) Abdominal CT (C) Abdominal ultrasonography (D) Magnetic resonance angiography of the abdomen : Item 98 A 4O-year old man is evaluated for a 5-day history of sore throat and fever. He has no cough or nasal congestion. Med- ical history is otherwise unremarkable. He does not smoke. On physical examination, temperature is 38.5'C (101.3.F). The oropha4mx is erythematous, with enlarged tonsils with purulent exudate. The anterior cervical lymph nodes are ten- der and enlarged. The remainder of the physical examination is normal.

: Item 98 A 4O-year old man is evaluated for a 5-day history of sore throat and fever. He has no cough or nasal congestion. Med- ical history is otherwise unremarkable. He does not smoke. On physical examination, temperature is 38.5'C (101.3.F). The oropha4mx is erythematous, with enlarged tonsils with purulent exudate. The anterior cervical lymph nodes are ten- der and enlarged. The remainder of the physical examination is normal. Which of the following is the most appropriate next step in management? (A) Penicillin VK Which of the following is the most likely diagnosis? (B) Rapid antigen detection test for group A Streptococcus (A) Bullous pemphigoid (C) Throat culture (B) Photoallergic drug reaction (D) No testing or therapy (C) Phototoxic drug reaction (D) Porphyria cutanea tarda Item 99 A i34 year-old woman is evaluated in the emerger.rcy depart Item 96 ment lbr fever and a painful rash that began 2 days ago. The A 24-year-old woman is evaluated for a 2 year history of rash now involves her face, neck, trunk. ancl arms. She is on painful menstrual periods, causing her to miss work once day 6 of a 7 day course of sulfirmethorazole trimethoprin.r or twice a month. She reports no abnormal vaginal bleeding lbr treatment ol'a recently incised and drained abscess on or discharge. Her last menstrual period was l week ago. She hcr left leg. is sexually active with men and uses condoms for contra- On physical cxaminatiorr, the patient appears ill and ception. Her last sexual intercourse was 2 months ago. She in pain. 'femperirture is 40 "C (10.1 'F), blood pressure is does not desire pregnancy at this time. Her last Pap smear 117162 mm Hg, pulse rate is 122,/min. and respiration rate is obtained 1 year ago was normal. Medical history is other- 16tmin. Representative skin findings of her right:rrnr and hancl wise unremarkable. and she takes no medications. are sholr,.n (see top of next page).

Which of the following is the most appropriate next step in management? (A) Penicillin VK Which of the following is the most likely diagnosis? (B) Rapid antigen detection test for group A Streptococcus (A) Bullous pemphigoid (C) Throat culture (B) Photoallergic drug reaction (D) No testing or therapy (C) Phototoxic drug reaction (D) Porphyria cutanea tarda Item 99 A i34 year-old woman is evaluated in the emerger.rcy depart Item 96 ment lbr fever and a painful rash that began 2 days ago. The A 24-year-old woman is evaluated for a 2 year history of rash now involves her face, neck, trunk. ancl arms. She is on painful menstrual periods, causing her to miss work once day 6 of a 7 day course of sulfirmethorazole trimethoprin.r or twice a month. She reports no abnormal vaginal bleeding lbr treatment ol'a recently incised and drained abscess on or discharge. Her last menstrual period was l week ago. She hcr left leg. is sexually active with men and uses condoms for contra- On physical cxaminatiorr, the patient appears ill and ception. Her last sexual intercourse was 2 months ago. She in pain. 'femperirture is 40 "C (10.1 'F), blood pressure is does not desire pregnancy at this time. Her last Pap smear 117162 mm Hg, pulse rate is 122,/min. and respiration rate is obtained 1 year ago was normal. Medical history is other- 16tmin. Representative skin findings of her right:rrnr and hancl wise unremarkable. and she takes no medications. are sholr,.n (see top of next page). 157

Self-Assessment Test vlt .D Item 101 D ui A 56 year old woman is evaluated for a 2-year history of UI (D worsening hot flashes and night sweats. She reports that U) (,t the night sweats awaken her several times nightly, result- (D ing in fatigue and missed work. History is significant for hypertension and hysterectomy at age 48 years for uterine flbroids. She has no history of venous thromboembolism. (D (,I Findings on screening mammography 1 year ago were neg- ative. Family history is signiflcant for breast cancer in her grandmother, diagnosed at age 75 years. The patient's only medication is amlodipine. On physical examination, blood pressure is 134/82 mm Hg; other vital signs are normal. The remainder of the exam- ination is unremarkable. ao Which of the following is the most appropriate treatment? (A) Oral estrogen and progesterone (B) Oral gabapentin (C) Transdermalestrogen (D) Transdermal estrogen and oral progesterone

vlt .D Item 101 D ui A 56 year old woman is evaluated for a 2-year history of UI (D worsening hot flashes and night sweats. She reports that U) (,t the night sweats awaken her several times nightly, result- (D ing in fatigue and missed work. History is significant for hypertension and hysterectomy at age 48 years for uterine flbroids. She has no history of venous thromboembolism. (D (,I Findings on screening mammography 1 year ago were neg- ative. Family history is signiflcant for breast cancer in her grandmother, diagnosed at age 75 years. The patient's only medication is amlodipine. On physical examination, blood pressure is 134/82 mm Hg; other vital signs are normal. The remainder of the exam- ination is unremarkable. ao Which of the following is the most appropriate treatment? (A) Oral estrogen and progesterone (B) Oral gabapentin (C) Transdermalestrogen (D) Transdermal estrogen and oral progesterone Item 1O2 A 44-year old woman is evaluated for redness, tearing, and irritation ofthe right eye that began 1 day ago. She reports no eye pain, photophobia, or change in vision. Her left eye is uninvolved. She has no other symptoms. Medical history is otherwise unremarkable, and she takes no medications. On physical examination, visual acuity is20l2O in both ln Tlte rash is notecl on her face. neck, back. trunk. and eyes. Pupils are equally round and reactive to light and llJ proxinral legs. involving 25'){, of her body surface area. accommodation. The right eye is shown. coNT lhg abscess site on the left leg is healing without signs of infection.

Item 1O2 A 44-year old woman is evaluated for redness, tearing, and irritation ofthe right eye that began 1 day ago. She reports no eye pain, photophobia, or change in vision. Her left eye is uninvolved. She has no other symptoms. Medical history is otherwise unremarkable, and she takes no medications. On physical examination, visual acuity is20l2O in both ln Tlte rash is notecl on her face. neck, back. trunk. and eyes. Pupils are equally round and reactive to light and llJ proxinral legs. involving 25'){, of her body surface area. accommodation. The right eye is shown. coNT lhg abscess site on the left leg is healing without signs of infection. Which of the following is the most appropriate management? (A) Begin high dose intravenous glucocorticoids (B) Beginintravenousimmunoglobuiin (C) Discontinuesullamethoxazole trimethoprim (D) Obtain skir.r biopsy

Item 1O2 A 44-year old woman is evaluated for redness, tearing, and irritation ofthe right eye that began 1 day ago. She reports no eye pain, photophobia, or change in vision. Her left eye is uninvolved. She has no other symptoms. Medical history is otherwise unremarkable, and she takes no medications. On physical examination, visual acuity is20l2O in both ln Tlte rash is notecl on her face. neck, back. trunk. and eyes. Pupils are equally round and reactive to light and llJ proxinral legs. involving 25'){, of her body surface area. accommodation. The right eye is shown. coNT lhg abscess site on the left leg is healing without signs of infection. Which of the following is the most appropriate management? (A) Begin high dose intravenous glucocorticoids (B) Beginintravenousimmunoglobuiin (C) Discontinuesullamethoxazole trimethoprim (D) Obtain skir.r biopsy tr Item 1OO A 72 year-old woman is seen fbr a preoperative medical eval There is no preauricular lymphadenopathy uation prior to a henticolectomy fbr newly diagnosed stage II colon cancer. Five months ago. she underwent drug-eluting Which of the following is the most likely diagnosis? coronary artery stent placement for stable ischemic heart disease and is now asymptomatic. I\4edications are mcto- (A) Episcleritis prolol, aspirin. clopidogrel. benazepril. and aton,astatin. (B) Herpes simplex keratitis Physical cxamination findings, including vital signs, (C) Scleritis are normal. (D) Uveitis Which of the following is the most appropriate preoperative (E) Viralconjunctivitis management of this patient's dual antiplatelet therapy? (A) Continue aspirin lnd clopidogrel Item 1O3 (B) Continue aspirin and r,t,ithhold clopidogrel A 44 year old man is evaluated for a 6 week history of a mildly itchy rash in his armpits. (C) Withholcl aspirin and clopiclogrel The rash is conflned to the axillae. There is some flne (D) Withhold aspirin and continue clopidogrel scale. Skin findings are shown (see top ofnext page).

tr Item 1OO A 72 year-old woman is seen fbr a preoperative medical eval There is no preauricular lymphadenopathy uation prior to a henticolectomy fbr newly diagnosed stage II colon cancer. Five months ago. she underwent drug-eluting Which of the following is the most likely diagnosis? coronary artery stent placement for stable ischemic heart disease and is now asymptomatic. I\4edications are mcto- (A) Episcleritis prolol, aspirin. clopidogrel. benazepril. and aton,astatin. (B) Herpes simplex keratitis Physical cxamination findings, including vital signs, (C) Scleritis are normal. (D) Uveitis Which of the following is the most appropriate preoperative (E) Viralconjunctivitis management of this patient's dual antiplatelet therapy? (A) Continue aspirin lnd clopidogrel Item 1O3 (B) Continue aspirin and r,t,ithhold clopidogrel A 44 year old man is evaluated for a 6 week history of a mildly itchy rash in his armpits. (C) Withholcl aspirin and clopiclogrel The rash is conflned to the axillae. There is some flne (D) Withhold aspirin and continue clopidogrel scale. Skin findings are shown (see top ofnext page). 158

Self-Assessment Test v! Which of the following is the most appropriate management? 6' F (A) Behavioralcounseling q, (B) Review benefits of a healthy diet E U! (C) Review benefits of exercise Ut o UI (D) Review consequences of hypertension vl o t/t Item 106 A 50 year-old man is evaluated during a routine wellness visit. He has no medical problems and takes no medications. the patient is engaged in a discussion about the benefits and harms of prostate cancer screening, after wl-rich he expresses no pref'erence for or against prostate cancer screening.

o t/t Item 106 A 50 year-old man is evaluated during a routine wellness visit. He has no medical problems and takes no medications. the patient is engaged in a discussion about the benefits and harms of prostate cancer screening, after wl-rich he expresses no pref'erence for or against prostate cancer screening. According to the U.S. Preventive Services Task Force, which ofthe following is the most appropriate prostate screening stratery for this patient? (A) Digital rectal examination (B) Digital rectal examination and prostate specific antigen (PSA)testing (C) PSA testing (D) No screening Which of the following is the most appropriate diagnostic test? Item 107 (A) Hemoglobin A,. A 37 year oldwomanisevaluated lbra2 monthhistoryofa (B) Mineral <-ril preparation of skin scraping persistent facial skin rash that becomes more prominent and (C) Potassium hydroxide preparation ol skin scraping stings, burns, and itches within a f'ew minutes of sunlight (D) Wood lamp evaluation exposure, exercise, drinking alcohol, or eating spicy fbods. Skin Iindings are shown.

According to the U.S. Preventive Services Task Force, which ofthe following is the most appropriate prostate screening stratery for this patient? (A) Digital rectal examination (B) Digital rectal examination and prostate specific antigen (PSA)testing (C) PSA testing (D) No screening Which of the following is the most appropriate diagnostic test? Item 107 (A) Hemoglobin A,. A 37 year oldwomanisevaluated lbra2 monthhistoryofa (B) Mineral <-ril preparation of skin scraping persistent facial skin rash that becomes more prominent and (C) Potassium hydroxide preparation ol skin scraping stings, burns, and itches within a f'ew minutes of sunlight (D) Wood lamp evaluation exposure, exercise, drinking alcohol, or eating spicy fbods. Skin Iindings are shown. tr Item 104 A 68 -v-etrr old man undergoes l preoperativc meclicirl evaluation befirre total knee arthropllsty. Mcdical his tory is significant lirr hvpertension. l-rl,perlipidenria, degenerative joint disease. ancl psoriasis. Meclications are amlodipine, rnetoprolol, methotrexdte. folic acid. ancl atorvilstatir-1. Or-r 1rl-rysical exarnination. r,ital signs are nonnal. Small. scattered psoriatic plac;ues are noted on the elbows, knees. and sacrum. Iixilminatirin of'the left knee sl-runs linritecl range of'motion. Jhe renrainder of the physical erlr.nir.rution is non-nal.

tr Item 104 A 68 -v-etrr old man undergoes l preoperativc meclicirl evaluation befirre total knee arthropllsty. Mcdical his tory is significant lirr hvpertension. l-rl,perlipidenria, degenerative joint disease. ancl psoriasis. Meclications are amlodipine, rnetoprolol, methotrexdte. folic acid. ancl atorvilstatir-1. Or-r 1rl-rysical exarnination. r,ital signs are nonnal. Small. scattered psoriatic plac;ues are noted on the elbows, knees. and sacrum. Iixilminatirin of'the left knee sl-runs linritecl range of'motion. Jhe renrainder of the physical erlr.nir.rution is non-nal. Which of the following is the most appropriate perioperative medication management? (A) Withholcl methotrexate 2 rt,eeks belirre surgcry (B) Witl-rholcl nretoirrrlol and atrirvastittin on clrry crf surgery (C) Withhold uretopnrkrl and nrethotrexate on chy of surgery (D) Cor.rtinue all medicatiot'ts Item 105 A 28 year-old man is evaluated during a fbllow up visit fbr hypertension and diabetes mellitus. He works two jobs and eats fast fbod fbr most meals. He reports that he does not have time to exercise. He states that he is unhappy with his life style. Medications are amlodipine and hydrochlorothiazide. 159

Self-Assessment Test vr .D Which of the following is the most appropriate D UI treatment? UI .D U! (A) Oral chloroquine UT (B) Topical clobetasol cream .D (C) Topical metronidazole cream { .D (D) Topical tacrolimus cream UI

Self-Assessment Test vr .D Which of the following is the most appropriate D UI treatment? UI .D U! (A) Oral chloroquine UT (B) Topical clobetasol cream .D (C) Topical metronidazole cream { .D (D) Topical tacrolimus cream UI Item 108 A 52 year-old woman is evaluated during a follow up visit for type 2 diabetes mellitus. She reports that she is unable to lose weight. She has implemented a healthier diet and exercise. Medical history is also signiflcant for depression and epilepsy, both well controlled. Medi- cations are metformin, glimepiride, bupropion, and Which of the following is the most likely diagnosis? topiramate. (A) Dysplastic nevus On physical examination, vital signs are normal. BMI (B) Pigmented actinic keratosis is 36. (C) Pigmented basal cell carcinoma Which of the following medication changes is most likely (D) Seborrheickeratosis to promote weight loss in this patient? (A) Switch bupropion to paroxetine (B) Switch bupropion to venlafaxine Item 1 11 (C) Switch glimepiride to liraglutide A 64 year old man is seen for a preoperative evaluation before a complex open ventral hernia repair. Medical his (D) Switch glimepiride to sitagliptin tory is significant for COPD. He stoppecl smoking 9 months (E) Switch topiramate to carbamazepine ago. He has dyspnea when walking rapidly on a flat surface. His symptoms are currently stable, with minimal cough and sputum production. Medications include inhaled tiotro Item 109 pium and as nceded albuterol. Spironretry results from A 26-year old woman is evaluated during a routine exam- 4 months ago slrow an FVC/FEV, rati<-r of 0.5 and an FEV, ination. She had gestational diabetes during a pregnancy of 60'X, of predicted. Screening for obstructive sleep apnea 4 years ago, but her 12-week postpartum oral glucose tol is negative. erance test was normal. A copper intrauterine device (lUD) On physical examination, vital signs are normal. Oxy- for contraception was placed at that time. A Pap smear gen saturation is 94% breatl.ring ambient air. Chest shows obtained I year ago was normal. She received the human diminished breath sounds r.r,ithout wheezes. Other than a papillomavirus (HPV) vaccine as a child. She is sexually Iarge ventral hernia, the remainder of the physical exam active with her husband and has no sexual or vaginal con- ination is normal. cerns. Medical history is otherwise unremarkable, and she takes no medications. Which of the following is mostly likely to reduce On physical examination, vital signs are normal. postoperative pulmonary complications in this BMI is 20. The remainder of the examination is unre patient? markable. (A) Perioperative prophylactic respiratory physio therapy Which of the following is the most appropriate (B) Postoperativeincentivespirometry management? (C) Postoperative nasogastric tube decompression (A) Cervical cltology and HPV testing (D) Preoperative chlorhexidine oral washes (B) Hemoglobin A," test (C) Nucleic acid amplification test for chlamydia (D) Replace copper IUD Item 1 12 A 23-year old man is evaluated at an urgent care center for a 5-day history of right ear pain associated with otorrhea, Item 1 10 pruritus, and diminished hearing. He reports no rash or A 55 year old man is evaluated for a painless spot on his other symptoms. He has no other medical problems and back that his wife noticed. He is unaware how long the spot takes no medications. has been there. Medical history is unremarkable, and he On physical examination, vital signs are normal. There takes no medications. is discomfort when pulling on the right ear pinna. Findings Skin flndings are shown (see top of next column). on otoscopy are shown (see top ofnext page).

Item 108 A 52 year-old woman is evaluated during a follow up visit for type 2 diabetes mellitus. She reports that she is unable to lose weight. She has implemented a healthier diet and exercise. Medical history is also signiflcant for depression and epilepsy, both well controlled. Medi- cations are metformin, glimepiride, bupropion, and Which of the following is the most likely diagnosis? topiramate. (A) Dysplastic nevus On physical examination, vital signs are normal. BMI (B) Pigmented actinic keratosis is 36. (C) Pigmented basal cell carcinoma Which of the following medication changes is most likely (D) Seborrheickeratosis to promote weight loss in this patient? (A) Switch bupropion to paroxetine (B) Switch bupropion to venlafaxine Item 1 11 (C) Switch glimepiride to liraglutide A 64 year old man is seen for a preoperative evaluation before a complex open ventral hernia repair. Medical his (D) Switch glimepiride to sitagliptin tory is significant for COPD. He stoppecl smoking 9 months (E) Switch topiramate to carbamazepine ago. He has dyspnea when walking rapidly on a flat surface. His symptoms are currently stable, with minimal cough and sputum production. Medications include inhaled tiotro Item 109 pium and as nceded albuterol. Spironretry results from A 26-year old woman is evaluated during a routine exam- 4 months ago slrow an FVC/FEV, rati<-r of 0.5 and an FEV, ination. She had gestational diabetes during a pregnancy of 60'X, of predicted. Screening for obstructive sleep apnea 4 years ago, but her 12-week postpartum oral glucose tol is negative. erance test was normal. A copper intrauterine device (lUD) On physical examination, vital signs are normal. Oxy- for contraception was placed at that time. A Pap smear gen saturation is 94% breatl.ring ambient air. Chest shows obtained I year ago was normal. She received the human diminished breath sounds r.r,ithout wheezes. Other than a papillomavirus (HPV) vaccine as a child. She is sexually Iarge ventral hernia, the remainder of the physical exam active with her husband and has no sexual or vaginal con- ination is normal. cerns. Medical history is otherwise unremarkable, and she takes no medications. Which of the following is mostly likely to reduce On physical examination, vital signs are normal. postoperative pulmonary complications in this BMI is 20. The remainder of the examination is unre patient? markable. (A) Perioperative prophylactic respiratory physio therapy Which of the following is the most appropriate (B) Postoperativeincentivespirometry management? (C) Postoperative nasogastric tube decompression (A) Cervical cltology and HPV testing (D) Preoperative chlorhexidine oral washes (B) Hemoglobin A," test (C) Nucleic acid amplification test for chlamydia (D) Replace copper IUD Item 1 12 A 23-year old man is evaluated at an urgent care center for a 5-day history of right ear pain associated with otorrhea, Item 1 10 pruritus, and diminished hearing. He reports no rash or A 55 year old man is evaluated for a painless spot on his other symptoms. He has no other medical problems and back that his wife noticed. He is unaware how long the spot takes no medications. has been there. Medical history is unremarkable, and he On physical examination, vital signs are normal. There takes no medications. is discomfort when pulling on the right ear pinna. Findings Skin flndings are shown (see top of next column). on otoscopy are shown (see top ofnext page). 160

Self-Assessment Test t 6' Physical examination flndings, including vital signs, F are normal. E o Which of the following supplements can be recommended UI It as most likely to help the patient meet her therapeutic goal? o UI UI (A) VitaminA (B) Vitamin C (u (C) Vitamin D with calcium lrt (D) Vitamin E (E) No vitamin or supplement

t 6' Physical examination flndings, including vital signs, F are normal. E o Which of the following supplements can be recommended UI It as most likely to help the patient meet her therapeutic goal? o UI UI (A) VitaminA (B) Vitamin C (u (C) Vitamin D with calcium lrt (D) Vitamin E (E) No vitamin or supplement Item 1 15 A 24 year old woman is evaluated for a 5 year history of atopic dermatitis. She continues to have mild flares every few weeks on her arms. Her only medication is topical clo- Using an otoscope and a wire ear loop, debris is betasol cream. removed from the canal. Skin flndings are shown.

Item 1 15 A 24 year old woman is evaluated for a 5 year history of atopic dermatitis. She continues to have mild flares every few weeks on her arms. Her only medication is topical clo- Using an otoscope and a wire ear loop, debris is betasol cream. removed from the canal. Skin flndings are shown. Which of the following is the most appropriate additional treatment? (A) Ciprofloxacin dexamethasone otic drops (B) Intravenousceftriaxone (C) Topicalclotrimazole (D) Valacyclovir Item I 13 A 58 year old man is evaluated for decreased libido and erectile dysfunction that began insidiously over the past 6 months. He is not having nocturnal or early morning erections. His medical history is otherwise unremarkable. On physical examination, vital signs are normal. BMI is 24. There is no gynecomastia. Distribution of pubic hair is normal. Testes are normal sized. Laboratory studies show an B:00 eru serum total testosterone level of 200 ng/dl (O.g+ nmol/L) and a thyroid-stimulating hormone level of 3.6 pU/mL (3.6 mUiL).

Item I 13 A 58 year old man is evaluated for decreased libido and erectile dysfunction that began insidiously over the past 6 months. He is not having nocturnal or early morning erections. His medical history is otherwise unremarkable. On physical examination, vital signs are normal. BMI is 24. There is no gynecomastia. Distribution of pubic hair is normal. Testes are normal sized. Laboratory studies show an B:00 eru serum total testosterone level of 200 ng/dl (O.g+ nmol/L) and a thyroid-stimulating hormone level of 3.6 pU/mL (3.6 mUiL). Which of the following is the most appropriate management? (A) Measure serum free testosterone level (B) Measure serum luteinizing hormone level Which of the following is the most appropriate treatment? (C) Repeat B:00 ,qu serum total testosterone measurement (D) Start intramuscular testosterone therapy (A) Add calcipotriene cream (E) Start sildenafll (B) Replace clobetasol cream with ketoconazole cream : (C) Replace clobetasol cream with tacrolimus ointment I (D) Replace clobetasol cream with triamcinolone cream Item 1 14 A S8-year old woman comes to the office for a routine follow Item 1 15 tr :

Which of the following is the most appropriate management? (A) Measure serum free testosterone level (B) Measure serum luteinizing hormone level Which of the following is the most appropriate treatment? (C) Repeat B:00 ,qu serum total testosterone measurement (D) Start intramuscular testosterone therapy (A) Add calcipotriene cream (E) Start sildenafll (B) Replace clobetasol cream with ketoconazole cream : (C) Replace clobetasol cream with tacrolimus ointment I (D) Replace clobetasol cream with triamcinolone cream Item 1 14 A S8-year old woman comes to the office for a routine follow Item 1 15 tr : up visit. Medical history is signiflcant for hypertension, hyperlipidemia, and diabetes mellitus. She remains asymp A72-year old man is admitted to the hospital with cellulitis tomatic and active. Medications are metformin, empagli- of the right lower extremity. He has no other medical prob- t flozin, chlorthalidone, and atorvastatin. She consumes a lems and takes no medications. heart-healthy diet, exercises 150 minutes weekly, and does On physical examination, temperature is 38.7 'C i not smoke. She drinks one glass of red wine nightly. She (101.8'F), blood pressure is 150/80 mm Hg, pulse rate is recently began taking vitamins A, C, E, and D with calcium 111/min, and respiration rate is 22lmin. There is extensive for primary prevention of cardiovascular disease. erythema, warmth, swelling and tenderness extending from 161

Self-Assessment Test t/r (D UI (a (D tr CONT, the midcalf to the left medial malleolus and dorsomedial aspect of the right fbot. There is no fluctuance or drainage. Doppler ultrasound olthe right lower extremity shows time of discharge, physical examination shows no evidence of volume overload and laboratory studies are normal.

UI (a (D tr CONT, the midcalf to the left medial malleolus and dorsomedial aspect of the right fbot. There is no fluctuance or drainage. Doppler ultrasound olthe right lower extremity shows time of discharge, physical examination shows no evidence of volume overload and laboratory studies are normal. t^ (a no evidence of deep venous thrombosis or fluid collection. Which of the following factors is fundamental to a Intravenous cefazolin is initiated. successful transition of care for this patient? o Which of the following is the most appropriate management (A) Discharge planning by the hospital physician .D tt for preventing venous thromboembolism? (B) Explicit communication with the primary care physician (C) Medication reconciliation by the daughter (A) Direct oral anticoagulant (D) Scheduling of follow up laboratory evaluation (B) lntermittent pneumatic compression (lPC) (C) IPC and direct oral anticoagulant (D) IPC and lorv molecular weight heparin (LMWH) Item 120 (E) LMWH A 62 year old woman is evaluated for a 6 month history of intermittent, painful sores on the back of her hands that worsen with sun exposure. She has no other medical prob- Item 11 7 lems and takes no medications. Skin findings are shown. A 30 year-old man is evaluated during a routine wellness : visit. He is asymptomatic, has no ongoing medical prob lems, and does not use tobacco products. Previous screening for hepatitis C virus and HIV infections were negative. His immunizations are up to date. On physical examination, blood pressure is 120/70 mm Hg. The remainder of the examination is normal.

t^ (a no evidence of deep venous thrombosis or fluid collection. Which of the following factors is fundamental to a Intravenous cefazolin is initiated. successful transition of care for this patient? o Which of the following is the most appropriate management (A) Discharge planning by the hospital physician .D tt for preventing venous thromboembolism? (B) Explicit communication with the primary care physician (C) Medication reconciliation by the daughter (A) Direct oral anticoagulant (D) Scheduling of follow up laboratory evaluation (B) lntermittent pneumatic compression (lPC) (C) IPC and direct oral anticoagulant (D) IPC and lorv molecular weight heparin (LMWH) Item 120 (E) LMWH A 62 year old woman is evaluated for a 6 month history of intermittent, painful sores on the back of her hands that worsen with sun exposure. She has no other medical prob- Item 11 7 lems and takes no medications. Skin findings are shown. A 30 year-old man is evaluated during a routine wellness : visit. He is asymptomatic, has no ongoing medical prob lems, and does not use tobacco products. Previous screening for hepatitis C virus and HIV infections were negative. His immunizations are up to date. On physical examination, blood pressure is 120/70 mm Hg. The remainder of the examination is normal. Which of the following is the most appropriate screening for this patient? (A) Diabetes mellitus (B) Hazardous alcohol drinking (C) Obstructive sleep apnea (D) Thyroid dysfunction Skin punch biopsy results are pending. i Item 118 Which ofthe following is the most appropriate diagnostic test? A 33 year old woman is evaluated for a 4 day history of (A) Antinuclearantibody increased vaginal discharge and itching. She is sexually active with men and has one partner. She takes an oral con (B) Anti tissue transglutaminase antibody traceptive pill for contraception. Her last menstrual period (C) Bullous pemphigoid antibodies was 3 weeks ago and was normal. Medical history is oth (D) Plasma and urine porphyrin levels erwise unremarkable. and she takes no other medication. External genital examination reveals excoriations. Item 121 Speculum examination reveals thick, white, odorless dis- charge. The cervix is normal appearing. Bimanual examina A 65 year-old woman is evaluated during a wellness visit. tion is unremarkable. She received the tetanus toxoid, reduced diphtheria toxoid. A pregnancy test result is negative. and acellular pertussis vaccine 7 years ago; the 23 valent pneumococcal polysaccharide vaccine 6 years ago; the two dose recombinant herpes zoster vaccine (spaced 7 months Which ofthe following is the most appropriate management? apart) 3 years ago; and the influenza vaccine during the most (A) Intravaginalclotrimazole recent influenza season. She has also been vaccinated against (B) Oral fluconazole COVID-l9. Her medical history is unremarkable. She is a cur- (C) Oral metronidazole rent smoker with a 35 pack-year history and is planning to quit. She does not use alcohol or recreational drugs. She has (D) Saline and potassium hydroxide wet mounts no plans for international travel. She takes no medications. After a discussion of risks and beneflts, the patient wants to receive all age appropriate vaccinations. Item 119 A 92 year old r,r,oman is being discharged home in the care Which of the following is the most appropriate vaccine to of her daughter after treatment fbr heart tailure. Medical his administer at this visit? tory is also significant for hypertension and hyperlipidemia. Outpatient medications are lisinopril, carvedilol, atorvasta- (A) Recombinant herpes zoster vaccine tin, and furosemide. She is currently asymptomatic. At the (B) Tetanus and diphtheria toxoids vaccine

Which of the following is the most appropriate screening for this patient? (A) Diabetes mellitus (B) Hazardous alcohol drinking (C) Obstructive sleep apnea (D) Thyroid dysfunction Skin punch biopsy results are pending. i Item 118 Which ofthe following is the most appropriate diagnostic test? A 33 year old woman is evaluated for a 4 day history of (A) Antinuclearantibody increased vaginal discharge and itching. She is sexually active with men and has one partner. She takes an oral con (B) Anti tissue transglutaminase antibody traceptive pill for contraception. Her last menstrual period (C) Bullous pemphigoid antibodies was 3 weeks ago and was normal. Medical history is oth (D) Plasma and urine porphyrin levels erwise unremarkable. and she takes no other medication. External genital examination reveals excoriations. Item 121 Speculum examination reveals thick, white, odorless dis- charge. The cervix is normal appearing. Bimanual examina A 65 year-old woman is evaluated during a wellness visit. tion is unremarkable. She received the tetanus toxoid, reduced diphtheria toxoid. A pregnancy test result is negative. and acellular pertussis vaccine 7 years ago; the 23 valent pneumococcal polysaccharide vaccine 6 years ago; the two dose recombinant herpes zoster vaccine (spaced 7 months Which ofthe following is the most appropriate management? apart) 3 years ago; and the influenza vaccine during the most (A) Intravaginalclotrimazole recent influenza season. She has also been vaccinated against (B) Oral fluconazole COVID-l9. Her medical history is unremarkable. She is a cur- (C) Oral metronidazole rent smoker with a 35 pack-year history and is planning to quit. She does not use alcohol or recreational drugs. She has (D) Saline and potassium hydroxide wet mounts no plans for international travel. She takes no medications. After a discussion of risks and beneflts, the patient wants to receive all age appropriate vaccinations. Item 119 A 92 year old r,r,oman is being discharged home in the care Which of the following is the most appropriate vaccine to of her daughter after treatment fbr heart tailure. Medical his administer at this visit? tory is also significant for hypertension and hyperlipidemia. Outpatient medications are lisinopril, carvedilol, atorvasta- (A) Recombinant herpes zoster vaccine tin, and furosemide. She is currently asymptomatic. At the (B) Tetanus and diphtheria toxoids vaccine 162

L L Self-Assessment Test t L UI (C) 13 Valent pneumococcal conjugate vaccine Which of the following is the most appropriate o L (D) 23 Valent pneumococcal polysaccharide vaccine management? o L (A) Chest CT angiography E t! I Item 122 (B) Elevate head of'the bed and limit sedating medications UI (l, L UI (C) Start albuterol vt A 72-year-old man is evaluated lor recurrent urinary tract L infections (UTIs). He is currently asymptomatic. Seven days (D) Start bilevel positive airway pressure ventilation ago, he presented with dysuria, urgency, and suprapubic (E) Start empiric antibiotics =(l, t pain. A urine culture was obtained, and he was started on t/t t t empiric trimethoprim-sulfamethoxazole. This is his third UTI in 12 months. All previous urine cultures grew Esch- Item 125 I 5 erichia coli sensitive to trimethoprim sulfamethoxazole. A 26-year-old man is evaluated for redness of the left eye t All episodes were treated with a 7-day course of antibiotics, accompanied by yellow discharge and crusting on the eye L with rapid resolution of symptoms. Medical history is oth lids for the past 2 days. The symptoms are most noticeable erwise unremarkable, and he takes no other medications. upon awakening. He reports some visual blurring that clears t I

L Self-Assessment Test t L UI (C) 13 Valent pneumococcal conjugate vaccine Which of the following is the most appropriate o L (D) 23 Valent pneumococcal polysaccharide vaccine management? o L (A) Chest CT angiography E t! I Item 122 (B) Elevate head of'the bed and limit sedating medications UI (l, L UI (C) Start albuterol vt A 72-year-old man is evaluated lor recurrent urinary tract L infections (UTIs). He is currently asymptomatic. Seven days (D) Start bilevel positive airway pressure ventilation ago, he presented with dysuria, urgency, and suprapubic (E) Start empiric antibiotics =(l, t pain. A urine culture was obtained, and he was started on t/t t t empiric trimethoprim-sulfamethoxazole. This is his third UTI in 12 months. All previous urine cultures grew Esch- Item 125 I 5 erichia coli sensitive to trimethoprim sulfamethoxazole. A 26-year-old man is evaluated for redness of the left eye t All episodes were treated with a 7-day course of antibiotics, accompanied by yellow discharge and crusting on the eye L with rapid resolution of symptoms. Medical history is oth lids for the past 2 days. The symptoms are most noticeable erwise unremarkable, and he takes no other medications. upon awakening. He reports some visual blurring that clears t I On physical examination, vital signs are normal. Digital with blinking. The right eye is uninvolved. He reports no t rectal examination reveals a nontender prostate with no bog- giness. The remainder of the examination is unremarkable. other symptoms. He does not wear contact lenses. Medical history is unremarkable, and he takes no medications. t Urine culture shows growth of E. coli sensitive to On physical examination, there is diffuse circumferen t trimethoprim sulflamethoxazole. tial conjunctival erythema of the left eye that is most notice I able peripherally. A small amount of dried, yellow discharge Which of the following is the most appropriate management? is noted on the superior and inferior eyelashes. Visual acuity t is 20/30 in both eyes. The remainder of the examination is I (A) CToftheprostate I 5 unremarkable. (B) Prostatic massage followed by urine culture I L (C) Six-week course of trimethoprim sulfamethoxazole Which of the following is the most likely diagnosis? (D) No additional treatment L (A) Acutebacterial conjunctivitis I (B) Blepharitis t Item 123 (C) Hyperacutebacterialconjunctivitis L A 40 year-old woman is evaluated during a routine well- (D) Scleritis I ness visit. She asks about breast cancer screening. She has (E) Viralconjunctivitis I no medical problems or concerning family history, includ, L ing no history ofbreast cancer, and has no risk factors for breast cancer. Item 126 t I On physical examination, breast examination is normal. A 65-year-old woman is evaluated for a mole beneath the right eye that has been present for several months but L Which of the following is the most reasonable breast appears to be growing. cancer screening management stratery for this patient? Skin flndings are shown. L (A) Breast MRI (B) Digital breast tomosynthesis : (C) Mammography (D) Shared decision making

On physical examination, vital signs are normal. Digital with blinking. The right eye is uninvolved. He reports no t rectal examination reveals a nontender prostate with no bog- giness. The remainder of the examination is unremarkable. other symptoms. He does not wear contact lenses. Medical history is unremarkable, and he takes no medications. t Urine culture shows growth of E. coli sensitive to On physical examination, there is diffuse circumferen t trimethoprim sulflamethoxazole. tial conjunctival erythema of the left eye that is most notice I able peripherally. A small amount of dried, yellow discharge Which of the following is the most appropriate management? is noted on the superior and inferior eyelashes. Visual acuity t is 20/30 in both eyes. The remainder of the examination is I (A) CToftheprostate I 5 unremarkable. (B) Prostatic massage followed by urine culture I L (C) Six-week course of trimethoprim sulfamethoxazole Which of the following is the most likely diagnosis? (D) No additional treatment L (A) Acutebacterial conjunctivitis I (B) Blepharitis t Item 123 (C) Hyperacutebacterialconjunctivitis L A 40 year-old woman is evaluated during a routine well- (D) Scleritis I ness visit. She asks about breast cancer screening. She has (E) Viralconjunctivitis I no medical problems or concerning family history, includ, L ing no history ofbreast cancer, and has no risk factors for breast cancer. Item 126 t I On physical examination, breast examination is normal. A 65-year-old woman is evaluated for a mole beneath the right eye that has been present for several months but L Which of the following is the most reasonable breast appears to be growing. cancer screening management stratery for this patient? Skin flndings are shown. L (A) Breast MRI (B) Digital breast tomosynthesis : (C) Mammography (D) Shared decision making tr Item 124 A 66 year old man is evaluated in the postanesthesia care unit after undergoing elective lumbar laminectomy. He has snoring and oxygen desaturations. Medical history is signiflcant for obesity, hypertension, and diabetes mellitus. Medications are metoprolol, amlodipine, metfbrmin (with- held preoperatively), and hydromorphone. On physical examination, temperature is 37'C (98.7'1"), blood pressure is 149188 mrn Hg, pulse rate is B9/min, and respiration rate is 16/min. While awake and upright, oxygen Which of the following is the most likely diagnosis? saturations are 95')(, on 2 L of oxygen and 93'l,, breathing (A) Malignant melanoma room air; while sleeping supine, oxygen saturation inter mittently dips to 8B'2, on 2 L of oxygen. BMI is 42. His neck (B) Pigmented basal cell carcinoma is large. On pulmonary examination, lungs are clear. lhe (C) Seborrheickeratosis abdomen is soft and protuberant, with a large pannus. (D) Squamous cell carcinoma

tr Item 124 A 66 year old man is evaluated in the postanesthesia care unit after undergoing elective lumbar laminectomy. He has snoring and oxygen desaturations. Medical history is signiflcant for obesity, hypertension, and diabetes mellitus. Medications are metoprolol, amlodipine, metfbrmin (with- held preoperatively), and hydromorphone. On physical examination, temperature is 37'C (98.7'1"), blood pressure is 149188 mrn Hg, pulse rate is B9/min, and respiration rate is 16/min. While awake and upright, oxygen Which of the following is the most likely diagnosis? saturations are 95')(, on 2 L of oxygen and 93'l,, breathing (A) Malignant melanoma room air; while sleeping supine, oxygen saturation inter mittently dips to 8B'2, on 2 L of oxygen. BMI is 42. His neck (B) Pigmented basal cell carcinoma is large. On pulmonary examination, lungs are clear. lhe (C) Seborrheickeratosis abdomen is soft and protuberant, with a large pannus. (D) Squamous cell carcinoma 163