1.“An 83-year-old woman is brought to the office by her son for a routine follow-up visit.

She was
recently seen in the local emergency room for a fall from a chair that caused large bruises on
her arms and a headache. A CT scan of the head was normal, and she was discharged home.
Her other medical problems include hypertension, type 2 diabetes, hearing loss, coronary artery
disease, aortic stenosis, gastroesophageal reflux disease, transient ischemic attack, and
osteoporosis. She does not use tobacco, alcohol, or drugs She has been living at home with her
son for the past six months. Her family history is noncontributory Her medications include
glyburide, metformin, aspirin, metoprolol, lisinopril, ranitidine, and acetaminophen Her
temperature is 36.1 C (97 F}, blood pressure is 100/60 mm Hg, pulse is 100/min, and
respirations are 16/min. She does not recall falling dov.in and seems withdrawn and quieter
than at her last office visit three months ago She has lost nearly 10 lbs since the previous office
visit A brief examination shows dry mucus membranes, normal jugular venous pressure, clear
lung fields, and a grade 2/6 crescendo-decrescendo systolic murmur at the right second
intercostal area radiating to the carotids that peaks in midsystole. There is no peripheral edema.
She is placed in a treatment room and started on intravenous fluids.”

Which of the following is the most appropriate next step in the management of this patient?

A. Ask the son to leave the room and further examine the patient for more bruises.
B. Obtain a CT scan of the chest, abdomen, and pelvis to rule out malignancy and follow up
outpatient.
C. Recommend nutritional supplements during meal times.
D. Review the patient's medication schedule with her son and discharge her after the
intravenous fluids.
E. Start the patient on a selective serotonin blocker and ask psychiatry for help evaluating
mental competency.

Correct Answer is - A
2. “A 32-year-old man with type 1 diabetes comes to the emergency department with malaise,
fatigue, and abdominal pain His wife says that over the past 24 hours he has consumed large
amounts of water and urinated frequently On physical examination, the patient has dry mucous
membranes. Laboratory testing confirms diabetic ketoacidosis. Shortly after admission, the
patient suffers a seizure after accidentally receiving a bolus of insulin 10 times the amount
indicated. He is transferred to the intensive care unit, where he experiences a ventricular
arrhythmia and dies despite resuscitative measures. His wife is inconsolable and says that she
plans to sue the hospital for her husband's death. The hospital administration enlists a team to
perform a root cause analysis.”

Which of the following is the first step in performing this analysis?

A. Ask the patient's wife for permission to perform an autopsy

B. Contact hospital risk management
C. Create a flow chart of causal factors
D. Gather data on the origin and progression of the insulin order
E. Require that all future insulin orders be double-checked by an on-unit pharmacist

Correct answer is - D
3. An 80-year-old Caucasian female is being discharged from the hospital after surgical repair of
the right hip fracture. She fractured her right hip after falling down the steps in her home. She
has a past history of osteoporosis, hypertension controlled with thiazide diuretics and
metoprolol, diabetes mellitus treated with metformin, and hypercholesterolemia controlled with
simvastatin. She suffered from an acute myocardial infarction six years ago, but she has not had
any complications or recurrence of symptoms She has a 50-year-old daughter who lives near
her house. You advise the patient to consider an alternate living arrangement; however, she
clearly expresses her desire to live by herself in her own home. She does not want to live in her
daughter's house or in a nursing home.

Which of the following is the most appropriate next step?

A. Inform her that nursing home is the only available option for her
B. Ask her to live with her daughter for a few weeks
C. Ask the patient to prepare advanced directives
D. Get home assessment by a nurse
E. Ask the daughter to convince her mother to stay with her

Correct Answer is - D
4. A 46-year-old truck driver comes to the office due to fatigue. He has consumed energy drinks
during the past 3 months to complete his driving routes. He sleeps most of the day on
weekends and avoids his wife and kids. The patient says, "I even slept through my son's
baseball game I felt really bad about that." He has a history of chronic back and knee pain due
to a motorcycle accident. The patient's medications include naproxen He drinks a few beers with
friends but has not socialized much lately The patient's wife says that he is never there for her
and they fight constantly. He has no history of manic symptoms or other psychiatric history.
Physical examination and routine laboratory studies are unremarkable. Mental status
examination shows depressed mood and sad affect. The patient says he has had thoughts of
suicide but would never do anything because of his children. He is diagnosed with depression
and started on sertraline. He returns for a 3-week follow-up, reporting little change. The patient
says, "Some days I think I'm feeling a little better, but other days are really bad. I don't know
about these pills. I've been taking them and don't have any side effects, but still feel pretty bad."

Which of the following is the most appropriate response?

A. Are you having any difficulty taking the medication regularly?

B. I understand you are still struggling, but it takes time for these medicines to take full effect.
C. It can be frustrating when improvement is slow, but we can add another medication to boost
your response
D. We can consider switching to another antidepressant because you are not improving
E. We can stop the medication and try psychotherapy instead.

Correct Answer is - B
5.A 75-year-old woman is admitted to the intensive care unit due to worsening shortness of
breath. Medical history is significant for systolic heart failure with decreased left ventricular
ejection fraction on recent echocardiogram. Evaluation reveals acute hypoxic respiratory failure
due to cardiogenic pulmonary edema. The patient also has a history of three-vessel coronary
artery disease, diabetes mellitus, and chronic kidney disease. Her heart disease is not
amenable to any intervention or surgery due to her poor functional status, and she has been
treated with maximal medical therapy as tolerated. She was hospitalized a month ago due to an
exacerbation of congestive heart failure and was discharged to a nursing facility after
responding to treatment. The patient has limited mobility and requires assistance for activities of
daily living. In the intensive care unit, her symptoms slowly improve with noninvasive
positive-pressure ventilation, ionotropic therapy, and intravenous diuretic treatment, but her
kidney function gradually deteriorates. The critical care physician and nephrologist recommend
that all treatments be stopped and that the patient receive comfort care only. The patient's son
agrees and says, "The time has come to let go " The patient, however, wants "everything to be
done" and even to receive cardiorespiratory resuscitation if required.

Which of the following is the most appropriate course of action?

A. Advise son to authorize a do-not-resuscitate order for patient

B. Continue management with aggressive life-prolonging treatments
C. Document the futility of treatment and treat with comfort-care measures only
D. Transfer patient to hospice facility for end-of-life care
E. Transfer patient to another hospital due to disagreement between patient and physician

Correct answer is - A
6. A 24-year-old man comes to the office for a follow-up visit. His paternal grandfather died at
age 45 from Huntington disease. The patient says, "I don't know if my father has the condition
because whenever I bring it up he shuts down and doesn't want to talk about it. I know that if my
father has the disease I could be at risk and so could my sister, who is 2 years younger. I don't
want to spend the next 20 years worrying about whether I will get sick." The physician educates
the patient about the course and genetics of Huntington disease and orders genetic testing at
the patient's request. The results are positive for Huntington disease. Despite the physician's
recommendation that the patient consider disclosing these results to family members, he
refuses, stating that he prefers to keep this information from his family, which includes his father,
sister, and wife. The patient explains that he doesn't want them to worry.

Which of the following is the most appropriate course of action?

A. Explain that the physician is obligated to inform the father as he most likely has the condition
B. Explain that the physician is obligated to inform the wife due to impact on future pregnancies
C. Explain that the physician is obligated to notify the sister because she is at risk
D. Provide support and agree 'with the patient's decision not to disclose as the illness is
incurable
E. Reassure the patient that even though disclosure is recommended, his decision will be
respected

Correct answer is - E​
7. “A 41-year-old man is brought to the emergency department by ambulance after a motor
vehicle accident He was driving a car with his 6-year-old daughter in the back seat when they
were broadsided by a large truck traveling at high speed The patient is conscious during transit
to the emergency department. He appears oriented to date and time, and informs paramedics
that he is a Jehovah's Witness and does not want blood transfusions for himself or his daughter.
Soon after, he begins moaning and writhing and is clearly in distress. He complains of feeling
nauseated and thirsty. A facemask is placed to administer oxygen Initial assessment
indicates his temperature is 37 C (98 6 F), blood pressure is 100/58 mm Hg, pulse is 132/min
and thready, and respirations are 34/min. There are numerous lacerations on his scalp, trunk,
abdomen, and extremities. The patient's skin is cool and clammy Chest auscultation shows
tachypnea and tachycardia but is otherwise normal. His abdomen is diffusely tender to palpation
and guarding is present Rectal examination is normal. The patient's blood pressure begins to
drop rapidly and approaches 60/15 mm Hg The trauma surgeon advises that an immediate
exploratory laparotomy is warranted to ascertain the source of the internal bleeding.
Hemoglobin is 5.5 g/dl.”

Given the circumstances, which of the following is the most appropriate next step?

A. Administer intravenous fluids and vasopressors

B. Ask patient's wife to authorize blood transfusion for her husband
C. Halt further intervention due to patient's religious affiliation
D. Petition court to authorize blood transfusion for patient
E. Proceed with immediate blood transfusion

Correct answer is A
8.This 6-year-old female presents with severe trauma following a motor vehicle accident,
resulting in a significant crush injury to the chest, accompanied by extensive bleeding. Upon
initial assessment, she is unconscious, with vital signs indicating hemodynamic instability and
respiratory distress. Notably, her blood pressure is critically low (72/38 mm Hg), pulse rate is
elevated (154 bpm), and respiratory rate is increased (42/min). The patient is intubated, and
chest tubes have been placed following external examination of the chest wound. Despite the
administration of intravenous fluids via two large-bore catheters, her hemodynamic status
continues to deteriorate. Her hemoglobin level is measured at 6 g/dL, suggesting substantial
blood loss.

Which of the following is the most appropriate next step?

A. Call patient's mother to authorize blood transfusion

B. Consult with hospital ethics committee for guidance
C. Continue intravenous fluids and do not give blood transfusion
D. Petition court to authorize blood transfusion for patient
E. Proceed with immediate blood transfusion

Correct answer is - E
9. A 12-year-old boy with Down syndrome is brought to the emergency department by
ambulance after being in a motor vehicle collision. The patient was a restrained, rear seat
passenger who required extrication from the vehicle. Temperature is 36.1 C (97 F), blood
pressure is 89/60 mm Hg, pulse is 128/min, and respirations are 24/min. The patient is
unconscious and has a cervical neck collar in place. Multiple lacerations to his face, arms, and
abdomen are noted. A large hematoma is noted across the upper pelvis His 17-year-old sister,
who was driving the boy to music class, is present. The sister has several contusions from the
airbag but is otherwise alert and oriented. She is distressed about her brother and says that he
has severe impairment in intellectual functioning and requires constant supervision The sister
states that their parents are on a flight, but they are due to land in the next 30 minutes and can
then be contacted by phone. The grandparents, who also live with them, do not have mobile
phones but are expected to arrive in the emergency department within the next 5-10 minutes.

Which of the following is the best next step in management of this patient?

A. Delay treatment until parental consent is obtained

B. Obtain consent from the grandparents
C. Obtain consent from the sister
D. Petition the court for consent
E. Provide treatment without seeking consent

Correct answer is - E
10. A 2-week-old boy is brought to the office for a weight check. The infant was born via
spontaneous vaginal delivery to a 26-year-old primigravida following an uncomplicated
pregnancy. Apgar scores were 9 at 1 minute and 9 at 5 minutes. Birth weight Was 3. 7 kg (8
lb 4 oz) The boy is breastfed exclusively every 3-4 hours and sleeps approximately 15 hours a
day Weight today is 3.9 kg (8 lb 8 oz) On physical examination, the baby is alert and quiet in his
mother's lap. The examination is unremarkable. Anticipatory guidance is given regarding the
infant's expected feeding and elimination habits as well as upcoming developmental milestones.
The issue of vaccinations is raised, and the mother adamantly states that she is unwilling to
have her child vaccinated. She says, "I know you might disagree with me, but I feel that shots
can make my son autistic. I refuse to let him be exposed to them." A prolonged discussion
regarding vaccine risks and benefits does not change her beliefs. She is given additional written
information regarding immunization facts.

Which of the following is the best next step in management of this family?

A. Contact child protective services

B. Offer passive immunoprophylaxis as a substitute to vaccination
C. Propose an alternate vaccine schedule
D. Provide additional education at next Welll-child visit
E. Transfer the child's care to another provider

Correct answer is - D
A 65-year-old man is brought to the emergency department by his wife because of a 3-day
history of severe right-sided flank pain, fever, and vomiting. He has a history of gout, benign
prostate hyperplasia, and type 2 diabetes mellitus treated with allopurinol, tamsulosin, and
metformin. Urinalysis shows pyuria, leukocyturia, and WBC casts. Results of blood and urine
cultures are pending. The patient is diagnosed with pyelonephritis and admitted for empiric
treatment with broad-spectrum antibiotics. After 4 days, his symptoms have continued to
worsen. He is somnolent and not oriented to person, place, or time. Temperature is 39.0°C
(102.2°F), pulse is 130/min, respirations are 24/min, and blood pressure is 60/30 mm Hg. He is
transferred to the intensive care unit and vasopressor therapy is initiated. The physician informs
the patient's wife that her husband has developed urosepsis as a complication of his urinary
tract infection and that advanced life support may become necessary. A written advance
directive provided by the patient's primary care physician includes a do-not-intubate (DNI) order,
which was verbally confirmed by the patient upon admission. There is no medical power of
attorney. The patient's wife says she wants full life support in case of cardiorespiratory arrest.
Which of the following is the most appropriate response by the physician?

A)“If you can confirm that this decision is in your husband's best interest, I will provide
full life support.”

B)“I can only intubate your husband if you obtain a court order to revoke his advance
directive.”

C)will perform cardiopulmonary resuscitation if needed, but I cannot intubate your

husband.

D)“This may be difficult for you, but your request is unethical. You should respect your
husband's wishes.”

E)“I have to respect your husband's wishes and will only provide comfort measures.”

Correct answer - C
A 36-year-old woman is brought to the emergency department by her sister 1 hour after
she was found unconscious at home. She appears lethargic. Her temperature is 37°C
(98.6°F), pulse is 80/min, respirations are 5/min, and blood pressure is 120/70 mm Hg.
Urine toxicology screening is positive for alcohol, benzodiazepines, and barbiturates.
The patient's condition improves with supportive treatment, and she is admitted for
psychiatric evaluation. Three days later, a physician colleague approaches the physician
who treated the patient in the lobby of the hospital and states, “I just want to know what
happened. I'm her neighbor and childhood friend, and I'm worried about her.” Which of
the following responses by the treating physician is the most appropriate?

A)"You can find the information in the electronic medical record."

B)"Why don't you go ahead and ask her directly? She is currently in the psychiatric ward."

C)"Her urine toxicology screening was positive for alcohol, benzodiazepines, and
barbiturates."

D)"I'm not the right person to ask. Please ask her primary care physician."

E)"I understand your concern, but I am unable to provide information about this
situation."

F)"Let's go to my office to discuss her situation privately."

Correct answer - E
A 46-year-old woman with a history of previously well-controlled HIV infection comes to
the physician for follow-up after a health maintenance examination last week. She is
currently unemployed and lives in a low-income neighborhood with her 3 children. For
the past 3 years, her HIV RNA viral load was undetectable, but last week, her viral load
was 8,391 copies/mL (N < 50). Current medications include dolutegravir, tenofovir, and
emtricitabine. On questioning, she says that she misses her medications every other
day. Which of the following responses by the physician is most appropriate?

A)"Let's talk about what makes it difficult for you to take your medications."

B)"I would like to check whether the virus has become resistant to your drugs."

C)"Are you aware that it is essential to take your medications every day?"

D)"You should know that skipping doses will make your HIV harder to treat."

E)"The social worker can help subsidize next month's medications."

F)"We should go over the instructions on how to take your medications again."

Correct answer is - A
A 15-year-old girl is brought to the physician by her mother for an annual well-child
examination. Her mother complains that the patient has a poor diet and spends most of
the evening at home texting her friends instead of doing homework. She has been
caught smoking cigarettes in the school bathroom several times and appears
indifferent to the dean's threats of suspension. Two weeks ago, the patient allowed a
friend to pierce her ears with unsterilized safety pins. The mother appeals to the
physician to lecture the patient about her behavior and “set her straight.” The patient
appears aloof and does not make eye contact. Her grooming is poor. Upon questioning
the daughter about her mood, the mother responds “She acts like a rebel. I can't wait
until puberty is over.” Which of the following is the most appropriate response?

A)"What do you think of your mother's version of events? How does it make you feel?"

B)"I am very concerned that your daughter is displaying signs of depression, and I'd
suggest that she is seen by a psychiatrist."

C)"Let's run a routine urine toxicology screen to make sure your daughter is not doing
drugs."

D)"Would it be possible for you to step out for a few moments so that I can interview
your daughter alone?"

E)"I sympathize with you, but I'm afraid if you want to change your daughter's behavior
you would have to change her peer group."

F)"Your daughter displays normal signs of puberty. Being overly critical of your daughter
is not helpful."

Correct answer is -D
A 59-year-old man comes to the physician for a follow-up examination after being
diagnosed with localized prostate cancer 3 weeks ago. The physician is delayed
because of an emergency with another patient; miscommunication between the
physician and his staff created further delays. When he enters the patient's room, the
patient angrily expresses, “Do you realize that I waited 45 minutes in the waiting room,
despite arriving on time, and that I've now waited another half an hour in this exam
room? I am dying; do you have no respect for my time?” Which of the following is the
most appropriate response by the physician?

A)I'm very sorry for the delay. I had a very sick patient who required immediate care."

B)"You have a right to be frustrated, but shouting at me is not appropriate. I am afraid I

will have to ask you to leave."

C)"Let me apologize on behalf of my staff, who is responsible for most of the delay. I
can assure you, there will be consequences for this."

D)"I can understand your distress and would not blame you if you choose to transfer
care to another physician."

E)"I understand that you are frustrated and angry, and I apologize for the inconvenience.
Let's talk about your concerns.

Correct answer is - E
A 50-year-old man with hypertension comes to the physician for a follow-up evaluation.
His blood pressure is 146/98 mm Hg. The physician wishes to prescribe lisinopril. The
patient says that his blood pressure is high when he is “anxious” and requests
alprazolam instead of lisinopril. Which of the following is the most appropriate initial
response by the physician?

A)“I would recommend fluoxetine because alprazolam can cause dependence.”

B)“I would recommend consultation with a psychiatrist.”

C)“Anxiety can cause temporary spikes in blood pressure, but it does not cause a
long-term increase in blood pressure.”

D)“What have you heard about the use of alprazolam to treat high blood pressure?”

E)“Lisinopril is more effective to treat hypertension. If you do not control your high blood
pressure, you may develop a stroke.”

Correct Answer is - D
A 27-year-old man comes to the physician 2 weeks after undergoing successful repair
of a torn medial collateral ligament in his left knee. There were no complications. He
was discharged with prescriptions for oxycodone and acetaminophen. He reports
severe pain that prevents him from participating in physical therapy and wakes him
from sleep. He has a history of illicit drug use. Physical examination of the left knee
shows a healing incision; there is no joint effusion, erythema, or evidence of wound
dehiscence, and his gait is normal. When the physician recommends switching to
ibuprofen for pain, the patient becomes visibly angry and demands a refill of oxycodone.
Which of the following is the most appropriate response to this patient's request?

A)Prescribe a long-acting opioid for better pain relief if he is willing to sign a pain
contract

B)Request further information about which drugs he has taken recently and in the past

C)Request consent for urine test to assess current drug use

D)Prescribe a short course of oxycodone and schedule a follow-up appointment in one

week

E)Refer to a substance use counselor for addiction counseling

A previously healthy 73-year-old man comes to the physician at his wife's insistence
because of a skin lesion on his back. He lives with his wife and works for a high-profile
law firm where he represents several major clients. Physical examination shows a
7-mm, brownish-black papule with irregular borders. When the physician starts to
mention possible diagnoses, the patient interrupts her and says that he does not want
to know the diagnosis and that she should just do whatever she thinks is right. A biopsy
of the skin lesion is performed and histological examination shows clusters of
infiltrative melanocytes. Upon repeat questioning, the patient reaffirms his wish to not
know the diagnosis. Which of the following is the most appropriate response from the
physician?

A)"I have a moral obligation as a physician to inform you about the diagnosis."

B)"I would like to do further testing to investigate how far this cancer has spread."

C)"I don't have to tell you, but I will have to tell your wife so we can plan your therapy."

D)"I'll have to consult with the ethics committee to determine further steps."

E)"I would like to know more about why you don't want to hear your test results."

Correct answer - E
A 79-year-old man with a history of prostate cancer is brought to the emergency
department because of lower abdominal pain for 1 hour. He has not urinated for 24
hours. Abdominal examination shows a palpable bladder that is tender to palpation. A
pelvic ultrasound performed by the emergency department resident confirms the
diagnosis of acute urinary retention. An attempt to perform transurethral catheterization
is unsuccessful. A urology consultation is ordered and the urologist plans to attempt
suprapubic catheterization. As the urologist is called to see a different emergency
patient, she asks the emergency department resident to obtain informed consent for the
procedure. The resident recalls a lecture about the different modes of catheterization,
but he has never seen or performed a suprapubic catheterization himself. Which of the
following statements by the emergency department resident is the most appropriate?

A)“I will make sure the patient reads and signs the informed consent form.”

B)“I would be happy to obtain informed consent on your behalf, but I'm not legally
allowed to do so during my residency.”

C)“Suprapubic catheterization is not the treatment of choice for this patient.”

D)“I would prefer that you obtain informed consent when you become available again.”

E)“I will ask the patient to waive informed consent because this is an urgent procedure.”

Correct answer - D
A 26-year-old man comes to the emergency department because of a 1-week history of
fever, throat pain, and difficulty swallowing. Head and neck examination shows an
erythematous pharynx with purulent exudates overlying the palatine tonsils.
Microscopic examination of a throat culture shows purple, spherical bacteria arranged
in chains. Treatment with amoxicillin is initiated. A day later, a physician colleague from
another department approaches the physician in the lobby of the hospital and asks
about this patient, saying, “Did you see him? What does he have? He’s someone I play
football with and he hasn’t come to play for the past 5 days. I’m worried about him.”
Which of the following is the most appropriate action by the physician?

A)Inform the colleague that she cannot divulge any information about the patient

B)Inform the colleague that he should ask the patient's attending physician

C)Tell her colleague that she cannot tell him the diagnosis but that his friend was
treated with antibiotics

D)Tell her colleague the patient's case file number so he can look it up himself

E)Ask the colleague to meet in her office so they can discuss the patient in private

Correct answer is A)