All practice questions

A 59-year-old postmenopausal woman with a family history of breast cancer and a recently confirmed BRCA1 pathogenic variant presents to her physician with early satiety, bloating, and increasing abdominal girth for the past month. Physical examination reveals a palpable, fixed, irregular left adnexal mass and a clinically detectable fluid wave indicating ascites. Arrange the following steps in the most appropriate chronological order for the diagnostic workup and standard management of this patient, from initial evaluation to post-remission therapy.

A 24-year-old nulliparous woman presents to the clinic reporting that she has not had a menstrual period for the past 6 months. Her menarche occurred at age 12, and her menses were previously regular, occurring every 28 days. She takes no medications, has no chronic medical conditions, and is sexually active with a male partner. Her vital signs and physical examination are unremarkable. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's secondary amenorrhea, starting with the immediate first step.

A 26-year-old woman evaluates at the urgent care center due to four days of copious, malodorous vaginal discharge associated with mild dysuria. Her medical history is unremarkable, and she recently became sexually active with a new male partner. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Speculum examination demonstrates frothy, yellow-green fluid pooled in the posterior vaginal fornix and several punctate macular hemorrhages on the cervix. A saline microscopy preparation of the fluid reveals multiple motile, pear-shaped, flagellated organisms slightly larger than polymorphonuclear leukocytes. Which of the following is the most appropriate pharmacological intervention?

Review the following four patient profiles. Each patient is seeking a reliable method of contraception. Match each clinical scenario with the most medically appropriate contraceptive method based on the United States Medical Eligibility Criteria (US MEC) for Contraceptive Use.

A 27-year-old female presents to the outpatient clinic reporting an absence of menstruation for the past seven months. She previously experienced predictable cycles every 29 days. She denies hot flashes, nipple discharge, vision changes, or recent alterations in body weight. Physical examination shows a normal female escutcheon, no signs of hyperandrogenism, and an unremarkable bimanual pelvic examination. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting with the mandatory initial test.

Evaluate the following complex patient profiles. Match each clinical scenario with the single most appropriate, highly effective contraceptive method based on the WHO/CDC Medical Eligibility Criteria (MEC).

A 24-year-old healthy female presents to the clinic reporting an absence of menses for the past six months. She previously had regular 28-day menstrual cycles. She does not take any medications, has no chronic medical conditions, and reports no breast discharge, visual changes, or hot flashes. Physical examination reveals a normal body mass index and normal secondary sexual characteristics. Arrange the following diagnostic steps in the most appropriate chronological sequence for the initial evaluation of this patient's secondary amenorrhea, starting with the most immediate first step.

A $26$-year-old nulligravid woman presents to the gynecologist reporting the absence of menses for the past $6$ months. Prior to this, she had regular menstrual cycles occurring every $28$ days. Over the same $6$-month period, she has noted a significant increase in thick, dark hair on her face, chest, and abdomen, as well as a noticeable deepening of her voice. She has also experienced a receding hairline. She has no significant past medical history and takes no medications or supplements. Vital signs are within normal limits. Her BMI is $23 \text{ kg/m}^2$. Physical examination reveals temporal balding, severe hirsutism on the face and trunk, and clitoromegaly. Bimanual pelvic examination is limited by patient discomfort but reveals no obvious adnexal masses. A urine human chorionic gonadotropin test is negative. Serum thyroid-stimulating hormone (TSH) and prolactin levels are within normal limits. Which of the following is the most appropriate next step in the evaluation of this patient?

A 27-year-old primigravid woman at 39 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. She requests and receives epidural anesthesia for pain management. Her labor progresses without complication, and her cervix becomes completely dilated. She is instructed to begin pushing. Three hours later, a vaginal examination reveals the cervix is 10 cm dilated and 100% effaced, and the fetal head is at +2 station in the direct occiput anterior position. The maternal temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 84/min. Uterine contractions occur every 2 to 3 minutes and are strong to palpation. Continuous fetal heart rate monitoring demonstrates a baseline of 135/min, moderate variability, and symmetric, gradual decreases in the fetal heart rate that begin and end with each uterine contraction. The nadir of these decreases coincides precisely with the peak of each contraction. Which of the following is the most appropriate next step in management?

Match the following patient clinical profiles with the most appropriate next step in management.

Diagnostic boundaries in psychiatry often hinge on precise symptom duration and the exact nature of the triggering event. For each of the following patient encounters, determine the single most appropriate DSM-5 diagnosis by differentiating between overlapping clinical features.

A 75-year-old man is brought to the clinic by his daughter for a cognitive evaluation. Over the past 5 months, he has stopped managing his finances, spends most of the day sitting in a recliner, and frequently complains that his memory is 'completely gone.' When the physician asks him to perform serial sevens and recall three objects, he sighs loudly, states 'I just cannot do this anymore,' and refuses to try. Five months ago, he was forced to surrender his driver's license due to worsening macular degeneration. His daughter notes that he has lost 4.5 kg (10 lb) during this period. Neurologic examination is nonfocal. Which of the following is the most likely diagnosis?

A 25-year-old primigravida at 14 weeks gestation is evaluated in the emergency department for sudden-onset palpitations, chest tightness, trembling, and a feeling of impending doom that awoke her from sleep. The episode peaked within 10 minutes and has now resolved. She has had three similar unexpected episodes over the past month. She now refuses to leave her house unless accompanied by her husband, fearing she will have an attack in public. Medical history is notable for a hospitalization at age 19 for a manic episode with psychotic features; she had been stable on lithium but discontinued it 6 months prior to conception.

Her temperature is 37.0°C (98.6°F), blood pressure is 112/70 mm Hg, pulse is 92/min, and respirations are 18/min. Pulse oximetry is 99% on room air. She mentions a chronic, mild sensation of breathlessness over the last few weeks. Physical examination is unremarkable.

Laboratory results:
- TSH: 0.2 $\mu$ IU/mL (normal: 0.4-4.0 $\mu$ IU/mL)
- Free T $_4$: 1.3 ng/dL (normal: 0.8-1.8 ng/dL)

Arterial blood gas analysis on room air:
- pH: 7.45
- PaCO $_2$: 30 mm Hg
- PaO $_2$: 102 mm Hg

The patient's husband is distressed by her avoidance behaviors and demands she be given an intravenous sedative immediately. However, the patient explicitly declines any pharmacotherapy due to fear of teratogenicity. Which of the following is the most appropriate next step in management?

A 46-year-old female accountant is referred to the outpatient psychiatry clinic due to an 8-month history of excessive, uncontrollable worry regarding her finances, job security, and health. She describes feeling constantly "on edge," suffers from severe muscle tension in her neck and shoulders, and struggles with initial insomnia. These symptoms began shortly after she underwent a lumpectomy and localized radiation for estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer. She is currently taking tamoxifen and frequently complains of bothersome, spontaneous hot flashes occurring both during the day and at night. Vital signs are within normal limits. Which of the following is the most appropriate pharmacotherapy for this patient's psychiatric condition?

Evaluate the clinical scenarios below and match each patient to the most appropriate next step in psychiatric management.

A 32-year-old man is evaluated in the psychiatric clinic as part of a court-mandated diversion program following an arrest for assault. During the interview, the patient is superficially charming but shows no remorse for his actions, stating, 'The guy was asking for it.' His medical records show a history of conduct disorder diagnosed at age 14, multiple arrests for theft, and chronic deceitfulness. He is currently prescribed fluoxetine by his primary care physician for mild depressive symptoms. He frequently demands early refills of controlled substances from various providers, although none are currently prescribed. He mentions that during periods of extreme frustration, he occasionally feels 'paranoid that people are out to get me' for a few days, but these feelings quickly resolve. Which of the following are the most appropriate considerations in the evaluation and management of this patient? (Select 2 choices)

Match each clinical presentation of a breast disorder to the most appropriate initial diagnostic workup or management step.

Match each clinical presentation of cognitive decline to its most likely underlying pathophysiologic mechanism.

A 58-year-old woman is admitted to the hospital for management of a deep vein thrombosis. A psychiatric consultation is requested because she refuses her prescribed heparin infusion. The patient states she has a "sixth sense" that hospital medications contain micro-crystals designed to negatively alter her aura. She has lived alone in a rural cabin for 30 years, making a living selling energy-infused stones online. During the interview, she speaks in a vague, overly elaborate manner and appears highly anxious around the nursing staff, attributing her fear to their "disruptive energy fields." Collateral history from her visiting sister confirms that the patient has exhibited these eccentric beliefs and a preference for intense isolation since her early 20s. The sister also notes the patient has experienced fatigue and poor sleep over the past two weeks due to leg pain. Frustrated by the situation, the sister demands that the physician administer the heparin regardless of the patient's objections to prevent a pulmonary embolism.

Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

Match each clinical vignette describing a medication-specific complication, adverse effect, or pharmacokinetic requirement to the most likely offending psychotropic agent used in the context of bipolar disorder.