NKU: MSN 621 Final Exam Questions and Answers Updated 2025.

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1 Final Exam Study Guide Which of the following is associated with the CD10 antigen? 1. Acute myeloid leukemia 2. Acute lymphocytic leukemia 3. Chronic myeloid leukemia 4. Hodgkin lymphoma A 49... -year-old male with fatigue and easy bruising is found to have terminal deoxynucleotidyl transferase (TdT) positive cells in the blood. He may have which of the following conditions? 1. Acute myelogenous leukemia 2. Hodgkin lymphoma 3. Hairy cell leukemia 4. Acute lymphoblastic leukemia A 67-year-old woman presents with a history of high fevers and productive cough with green sputum for the last 3 days. Her past medical history is unremarkable. The patient received the influenza vaccine this year. She has a smoking history of 25 pack years. She does not drink alcohol or use illicit drugs. Vital signs are temperature 102 °F (38.9 °C), blood pressure 115/70mm Hg, heart rate 101 bpm, respiratory rate 23 breaths/min, and oxygen saturation 91% on room air. On physical examination, her anterior cervical lymph nodes are enlarged and nontender. Chest auscultation reveals crackles in the left lower lobe. Hepatosplenomegaly is present. A chest x-ray shows a left lower lobe consolidation. Laboratory tests show a WBC count of 45000/μL, with lymphocytes being 85%. Empirical pharmacotherapy is initiated, and blood cultures are sent to the lab. Which of the following is the most appropriate step next? 1. Flow cytometry of blood 2. Biopsy of lymph node 3. Bronchoscopy 4. Biopsy of lung tissue A 65-year-old woman with renal cancer presents with dyspnea, fatigue, and dizziness. She is taking warfarin to treat a left leg deep vein thrombosis, and lab results show a hemoglobin of 7.1 g/dL, hematocrit of 22%, platelet count of 109,000 cells/microliter, and INR of 1.45. What is the best next step in treatment? 1. Transfuse packed red blood cells 2. Transfuse platelets 3. Transfuse fresh frozen plasma 4. Administer vitamin K A 60-year-old asymptomatic man is found to have leukocytosis on a preoperative CBC. Physical examination shows the spleen tip to be palpable 2 cm below the left costal margin. Rubbery, nontender lymph nodes up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory data include the following: Hgb 13.3 g/dL (normal 14 to 18); leukocytes 40,000/microliter (normal 4,300 to 10,800); and platelet count 238,000 cells/microliter (normal 150,000 to 400,000). His peripheral blood smear is shown in the accompanying photo. Which of the following is the most likely diagnosis?2 Final Exam Study Guide 1. Acute monocytic leukemia 2. Chronic myelogenous leukemia 3. Chronic lymphocytic leukemia 4. Tuberculosis A 45-year-old asymptomatic man is found to have leukocytosis on a preoperative complete blood count. His physical examination is significant for the spleen tip being palpable 2 cm below the left costal margin. Enlarged, rubbery, nontender lymph nodes up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory workup reveals a hemoglobin of 13.3 g/dL, leukocytes 40,000/microliter, and platelets 238,000/microliter. His peripheral blood smear shows mature lymphocytes with smudge cells. If he fails first-line therapy, which of the following cytogenetic changes would be an indication for stem cell transplant in this patient? 1. Trisomy 12 2. 13q deletion 3. 17p deletion 4. 19p deletion A 59-year-old male patient with a history of non-Hodgkins lymphoma treated with cyclophosphamide, adriamycin, vincristine, and prednisone eight years ago presents with a new diagnosis of myelodysplastic syndrome. Bone marrow biopsy reveals 12% blasts and greater than 10% dysplasia in the erythroid and granulocytic lineages. Fluorescence in situ hybridization (FISH) revealed monosomy 7. He asks you about the risk of transformation into acute myeloid leukemia (AML). What is the risk of treatment-related myelodysplastic syndrome transforming into AML? 1. 50% of patients will transform into AML 2. 2% of patients will transform into AML 3. 10% of patients will transform into AML 4. There is no risk of transformation into AML A 36-year-old woman with a past medical history significant for menorrhagia from uterine fibroids presents with exertional dyspnea and fatigue. Examination shows conjunctival pallor. Laboratory tests reveal a hemoglobin of 6.2 grams/dL, mean corpuscular volume (MCV) 60 fl (normal: 80-100 fl), and normal liver function tests. What is the most likely diagnosis? 1. Anemia of chronic disease 2. Vitamin B12 deficiency 3. Iron deficiency anemia 4. Acute blood loss anemia A 67-year-old woman with a performance status of 0 presents with breathlessness and fatigue. She says she has needed several blood transfusions over the past 3 months. Her hemoglobin is 7.5 g/dL, absolute neutrophil count is 1500 cells/microliter, and platelet count is 119,000 cells/microliter. A bone marrow biopsy reveals myelodysplastic3 Final Exam Study Guide syndrome (MDS) with 6% blasts and cytogenetics positive for a 5q deletion. There are no mutations or other cytogenetic abnormalities. What is the best initial treatment for this patient? 1. An erythropoietin-stimulating agent 2. A thalidomide derivative 3. A hypomethylating agent 4. Allogeneic hematopoietic stem cell transplant A 65-year-old woman presents with an 8-month history of recurrent low-grade fevers, a 3-month history of abdominal fullness, and more recently, fatigue and moderately reduced exercise tolerance. Before this, she was in good health with no major medical conditions. Upon examination, she appeared to be stable and in no acute distress. She has a heart rate of 95 bpm and blood pressure of 128/60 mmHg. She had several palpable cervical and axillary lymph nodes (1-2 cm) that were non-tender and freely mobile. She also had palpable splenomegaly. No other abdominal masses/hepatomegaly appreciated on examination. Her complete blood count showed a leukocyte count of 32,000/mm3, hemoglobin of 9.8 g/dL, platelet count of 145,000/mm3, neutrophil count 1,900/mm3, lymphocyte count 30,000/mm3, elevated LDH, and elevated reticulocyte count. Peripheral blood smear showed an increasing number of mature lymphocytes, spherocytes, and polychromasia with no schistocytes. Which one of the following is the most likely cause of a patient's anemia in this case? 1. Microangiopathic hemolytic anemia 2. Autoimmune hemolytic anemia 3. Myelofibrosis 4. Aplastic anemia A 43-year-old man presents to the clinic for evaluation after abnormalities noted on a routine set of labs. CBC with differential demonstrated hemoglobin 14 g/dL, WBC count 26,000/microL, lymphocytes 21,000/microL, neutrophils 4500/microL, and platelets 260,000/microL. The basic metabolic panel demonstrates normal electrolytes and renal function. LFTs show total bilirubin 1.2 mg/dL and normal liver enzymes. On examination in office, his examination is normal, with no palpable lymph nodes or hepatosplenomegaly. He denies any B symptoms. Peripheral smear shows lymphocytosis with many small lymphocytes and smudge cells. Which of the following is the next best step in the management of this patient? 1. Dexamethasone monotherapy 2. Initiate chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) 3. Rituximab monotherapy 4. Observation and close follow up A 57-year-old patient with lymphoma complains of nausea after starting morphine. Which of the following is most accurate regarding nausea and vomiting due to opioids? 1. Marijuana is the first-line therapy for opioid-associated nausea. 2. Antiemetic drugs are not useful in treating opioid-associated nausea. 3. Nausea and vomiting only occur by oral administration of opioids. 4. After starting opioids, nausea often improves within a few days. A 16-year-old male presents with fatigue, easy bruisability, and weight loss. On examination, hepatosplenomegaly is noted. After a detailed evaluation, the patient is diagnosed with acute lymphocytic leukemia. Which of the following is used in the management of this patient's condition? 1. Dexrazoxane 2. L-asparaginase 3. Imatinib 4. Everolimus A 16-year-old female presents with complaints of fever, lethargy, and night sweats. The patient also reports a 6- kilogram (13.2 pound) weight loss in the past 3 months. On examination, painless, enlarged cervical and4 Final Exam Study Guide supraclavicular lymph nodes are palpated. A fine-needle aspiration biopsy of one of the lymph nodes is shown in the image. The patient's findings are most suggestive of which of the following? 1. Follicular lymphoma 2. Hodgkin lymphoma 3. Non-Hodgkin lymphoma 4. Multiple myeloma A 16-year-old male presents with lethargy, fatigue, and occasional mucosal bleeding. The patient also reports weight loss in the past 5 months. Laboratory analysis reveals a white blood cell count of 32,000 cells/microL. On examination, hepatosplenomegaly is noted. Further evaluation shows findings suggestive of acute lymphocytic leukemia. What is the most likely cause of the patient's mucosal bleeding? 1. Hepatosplenomegaly 2. Decreased platelet count 3. Factor V deficiency 4. Microthrombi formation A healthy patient is administered a subcutaneous injection of purified protein derivative (PPD) on the anterior aspect of the forearm. At 48 hours, 15 mm of induration develops. What is the diagnosis? 1. Active tuberculosis 2. Immunity to tuberculosis 3. Advanced tuberculosis 4. Exposure to tuberculosis A 17-year-old presents with tonsillar hypertrophy, bilateral cervical lymphadenopathy, low-grade fever, and general malaise. Which of the following is the gold standard test for diagnosing this condition? 1. Abdominal CT 2. Epstein-Barr specific antibodies 3. Hepatobiliary iminodiacetic acid scan 4. Blood cultures and complete blood count A 40-year-old woman from the New England area of the United States presents with malaise, headache, rash, and fever. She went hiking in a local park with her family 7 days ago. She has a history of depression and hypothyroidism, for which she takes paroxetine and levothyroxine. Her vitals are temperature 99 °F (37.2 °C), heart rate 80 bpm, respiratory rate 16 breaths/min, and blood pressure 125/75 mm Hg. A rash is noted on her right upper extremity (see image). The rest of the physical exam is unremarkable. What is the recommended treatment for this patient's condition?5 Final Exam Study Guide 1. A 10-day course of penicillin 2. A 7-day course of cefuroxime 3. A 7-day course of amoxicillin 4. A 10-day course of doxycycline A 16-year-old boy with a low-grade fever and a cough is seen in the ER. The clinician sends blood work for the measurement of heterophile antibodies because they suspect which of the following? 1. Rheumatic fever 2. Measles 3. Infectious mononucleosis 4. Pertussis A 17-year-old girl presents with a severe sore throat and fever for 4 days. The patient's voice is muffled, and she prefers not to speak secondary to pain. She has not been able to eat solids for 2 days and has refused to drink for 1 day. Vital signs are temperature 39.8 C (103.6 F), heart rate 140 bpm, respiratory rate 20 breaths/min, and blood pressure 110/70 mmHg. The physical examination shows the tonsils to be 4+ enlarged with partial airway obstruction and grey-white exudates, cervical lymphadenopathy, and splenomegaly. A rapid strep screen is negative. A CBC shows atypical lymphocytes. What is the most appropriate management? 1. Admission for IV antibiotics 2. Admission for IV corticosteroids 3. Admission for hydration and IV antibiotics 4. Admission for hydration and corticosteroids A 35-year-old woman presents with 1 day of sneezing, rhinorrhea, nasal congestion, fatigue, and myalgias. A review of systems reveals mild itching in the eyes and a frontal headache. She smokes 2 packs of cigarettes daily and denies alcohol and illicit drug use. Her history is significant for gastroesophageal reflux disease and irritable bowel syndrome. The patient cannot recall her last vaccination and says that she prefers “natural immunity.” Vital signs are blood pressure 130/75 mmHg, heart rate 105 bpm, temperature 100 F (37.7 C), and respiratory rate 19 breaths/min. Physical examination shows red eyes, erythema of the pharynx, and dry mucous membranes. Which of the following is the next best step in management? 1. Amantadine 2. Oseltamivir 3. Symptomatic management 4. Influenza vaccination A 34-year-old man presents with dizziness, syncope, and increasing fatigue for 2 weeks. He has no significant history and is employed as a forest ranger. Vital signs are temperature 98 °F (36.7 °C), blood pressure 110/80 mm6 Final Exam Study Guide Hg, and heart rate 38 bpm. Physical examination reveals weakness of the right facial muscles. An electrocardiogram (EKG) shows a complete heart block. Which joint is most likely painful? 1. Hip 2. Knee 3. Elbow 4. Spine A 17-year-old woman from Wisconsin presents with arthralgias, progressive confusion, a rash with central clearing over several weeks, and memory loss. She has no significant history and is an avid camper. Her temperature is 100.4 °F (38 °C). What is her most likely diagnosis? 1. Aseptic meningitis 2. Viral encephalitis 3. Cryptococcal meningitis 4. Lyme disease A 38-year-old man presents with one week of numbness and tingling in his extremities, which have been interfering with his sleep. He denies muscle weakness or memory impairment. He is being treated for pulmonary tuberculosis and has completed 8 weeks of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB). On exam, Vital signs are normal. He has diminished breath sounds in the left upper lobe. A chest X-ray shows an improving cavitary lesion in the left lung. Lab tests show his complete blood count, liver enzymes, and renal function are within normal limits. What is the most appropriate next step in management? 1. Add pyridoxine 2. Stop isoniazid 3. Stop rifampin 4. Add metformin A 16-year-old boy presents with fever, fatigue, lymphadenopathy, and sore throat. His medical history is positive for asthma; his father had leukemia. Social history is notable for being involved in multiple school sporting activities. Vital signs are blood pressure 135/85 mm Hg, heart rate 92 bpm, and respiratory rate 16 breaths/min. Physical examination shows exudative pharyngitis and splenomegaly. Rapid streptococcal testing is negative. What is the most appropriate recommendation? 1. Avoid using the corticosteroid inhaler 2. Avoid contact sports for a minimum of 6 weeks 3. Refer for lymph node biopsy 4. Chest x-ray imaging A 33-year-old prison inmate with no chronic medical problems presents for a routine annual checkup. He complains of disturbed sleep, constipation, and weight loss. A review of the systems is negative for cough, shortness of breath, burning urination, abdominal discomfort, or weakness. Examination shows normal vitals, a soft, non-tender abdomen with no organomegaly, normal S1 and S2 with no added sounds, and normal bronchial breathing bilaterally. A purified protein derivative (PPD) test shows an induration of 11 mm. What is the next best step in the management of this patient? 1. Isoniazid for 6 to 9 months 2. Isoniazid and rifampin for 4 months 3. Chest X-ray 4. Reassurance and follow-up in 6 month A healthy 17-year-old boy presents with 3 days of worsening fatigue, rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to eggs and therefore does not receive the annual influenza vaccine. His vitals are blood pressure 125/75 mmHg, heart rate 100 bpm, temperature 100 F (37.7 C), and respiratory rate 187 Final Exam Study Guide breaths/min. Examination demonstrates conjunctivitis, oropharyngeal erythema, and clear breath sounds. Given the likely diagnosis, what is the most appropriate treatment? 1. Amoxicillin-clavulanic acid 2. Amantadine 3. Oseltamivir 4. Symptomatic treatment only An adolescent presents with a sore throat, fever, lymphadenopathy, headache, and splenomegaly. What is the most appropriate management? 1. CT chest/abdomen/pelvis 2. Take a CXR 3. Treat symptomatically 4. Suspect a bacterial etiology A 26-year-old man comes to the emergency department complaining of fatigue, dyspnea, chest pain, and syncope, especially when playing soccer. This has been going on for the past 2 weeks. He has no significant past medical history. He denies smoking, caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for the past year due to headaches that he attributes to "being stressed out from my new job." On examination, vital signs show blood pressure 120/81 mm Hg, heart rate 55 bpm, respiratory rate 18 breaths/min, and O2 99% on room air. Skin examination shows no rashes. An abdominal examination reveals mild epigastric tenderness but no organomegaly. A chest examination shows equal air entry bilaterally with no abnormal sounds. ECG shows P waves and QRS complexes that are independent of each other. Blood tests show antibodies to the organism in the picture. Which of the following is the most appropriate treatment for this patient's case? 1. Hospitalization for close monitoring with telemetry and IV amiodarone 2. Hospitalization for close monitoring with telemetry and IV ceftriaxone 3. Hospitalization for close monitoring with telemetry and triple therapy with clarithromycin, amoxicillin, and lansoprazole 4. Hospitalization for close monitoring with telemetry and IV lansoprazole only A 16-year-old girl presents because she believes she was bitten by a tick while hiking in the woods 4 weeks ago. She mentions swelling in her right ear and general malaise. On exam, she has a 1 x 2 cm bluish-red nodule on the right ear lobe. What is the next best step in management for this patient?8 Final Exam Study Guide 1. Ehrlichiosis serology 2. Arthrocentesis 3. Start corticosteroids therapy 4. Lyme serology A female presents with progressive confusion over weeks with memory loss. She has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of arthralgias. History is otherwise unremarkable except for the fact she is an avid camper. Which of the following is the initial diagnostic test that should be ordered? 1. Serology 2. Culture of synovial fluid 3. PCR 4. CBC A 34-year-old Asian woman reported a history of losing weight and cough over a period of 5 months. On examination, she was anemic and on auscultation left apical crackles were noted. Her chest x-ray revealed left apical shadowing with cavitation. What is the next stage in her management? 1. A chest CT scan and infectious disease serological panel 2. Tuberculin skin test and sputum culture 3. Bronchoscopy and histology of bronchial secretions 4. HIV ELISA test A 17-year-old male patient with no significant past medical history presents with several days of loose, watery stools since returning from a trip to Mexico. He was in Mexico for one week and frequently drank water from the hotel faucet. He describes having up to six brown, non-bloody, loose, watery stools per day. His heart rate is 66 beats per minute, blood pressure 138/72 mmHg, respiratory rate 14 breaths per minute, and temperature 101.4 F (38.6 C). He denies taking any medication and denies any known food intolerances. His most likely condition is associated with which of the following changes? 1. Decreased extracellular and intracellular fluid volume 2. Decreased extracellular fluid volume and unchanged intracellular fluid volume 3. Decreased extracellular and intracellular fluid osmolarity 4. Decreased extracellular fluid osmolarity and increased intracellular fluid osmolarity A 30-year-old woman presents with complaints of abdominal pain and diarrhea for 6 months. She describes her pain as abdominal cramps. She is unable to localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently. She says her pain is worse right before she has a bowel movement and relieves after having a bowel movement. She denies any weight loss, dietary changes, or recent travel. She describes her bowel movements as loose, unformed stools. Given the patient's most likely diagnosis, which of the following would be most likely in this patient? 1. Blood and mucus in her stool 2. Recent problems with increased marital stress 3. Ova in her stool 4. Nocturnal diarrhea A 43-year-old woman presents for evaluation. Her left knee has been painful and swollen for the past week. Her symptoms have worsened, and now she finds it difficult to bear weight. She denies any trauma or falls. She denies any other joint pain, and a review of systems is otherwise negative except for an annular rash that she had on the upper back about 1 month ago that resolved on its own. Medical and family history are unremarkable. Her vital signs are normal. The left knee is erythematous, has an effusion, and is tender. The range of motion is limited in flexion and extension. The rest of the exam is normal. Laboratory evaluation shows a normal complete blood count and liver and renal function. Her erythrocyte sedimentation rate is 44 mm/hr. Rheumatoid factor, ANA, and anti9 Final Exam Study Guide CCP are negative. Synovial fluid analysis reveals 12,000 white blood cells/microliter and no crystals. Bacterial cultures are negative. An x-ray of the knee reveals mild medial joint space narrowing and the presence of an effusion. Magnetic resonance imaging (MRI) of the left knee reveals mild chondromalacia, a large effusion, and fraying of the medial meniscus without any significant tear. What is the next best step in the management? 1. Serological studies for infectious etiology 2. Intra-articular corticosteroid injection 3. Further synovial fluid studies 4. Admit for IV antibiotics An otherwise healthy 17-year-old male presents for an initial evaluation after recently immigrating from Sudan, Africa. He says he has received all the necessary vaccinations, including the BCG vaccine. Further inquiry reveals his sister was treated for tuberculosis seven years ago. He is not sexually active, takes no medications, and does not drink alcohol, use illicit drugs, or smoke cigarettes. What is the most appropriate next step in evaluation? 1. Interferon-gamma release assay 2. Mantoux tuberculin skin test 3. Chest x-ray 4. Induced sputum culture for AFB A 35-year-old man complains of cough and low-grade fever for the past 3 months. The patient developed a fever 3 months ago, which was low-grade and associated with night sweats. He also has had a troublesome cough. He had an episode of hemoptysis, which prompted the visit. His history is significant for HIV infection 8 years ago, for which he has never taken treatment. His vitals are temperature 99 °F (37.2 °C), heart rate 90 bpm, blood pressure 110/70 mm Hg, and respiratory rate 22 breaths/min. His general physical examination reveals the presence of oropharyngeal thrush and mild pallor. Chest examination reveals coarse crackles and bronchial breathing in the left upper lobe. His investigations reveal a WBC count of 3,000 cells/microliter, hemoglobin of 10 gm/dL, platelet count of 150,000 cells/microliter, erythrocyte sedimentation rate of 50 mm per hour, serum creatinine of 0.8 mg/dL and a CD4+ count of 60/microliter. A Mantoux test is performed, which shows no induration. A chest x-ray reveals cavitation and reticulonodular shadowing in the right upper lobe. Sputum demonstrates the presence of acid-fast bacilli. What should be the treatment plan for this patient? 1. Start antiretroviral therapy (ART) and antitubercular treatment (ATT) together 2. Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 6 months 3. Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 2 weeks 4. Start antiretroviral therapy (ART) now and antitubercular treatment (ATT) after 2 weeks A 39-year-old woman is brought to the emergency department with 2 days history of fever, headache, severe myalgias, dry cough, breathlessness, and coryza. She is a school teacher, and many students in her class have been reported sick with “the flu.” Physical examination reveals scattered crackles in both lung fields. Blood tests indicate a white blood cell count of 12,900 cells/microL with 69% lymphocytes. Chest x-ray shows increased interstitial markings on both sides. She has had rheumatoid arthritis, and she takes prednisone. Which of the following tests is most likely to confirm the diagnosis in this patient? 1. Urine Legionella antigen 2. Immunofluorescence antibody staining for influenza from blood 3. Rapid influenza diagnostic test from a throat swab 4. Viral cell cultures for influenza virus from a throat swab A 39-year-old woman is brought to the emergency department with complaints of fever, headache, severe body aches, dry cough, dyspnea, and coryza for the last 2 days. She has had rheumatoid arthritis for the previous 5 years, and she is on oral prednisone therapy. History reveals that she is a school teacher; many of her students have been sick with similar symptoms. Physical examination shows scattered crackles in both lung fields. Laboratory findings indicate a white blood cell (WBC) count of 12,000 cells/microliter with 67% lymphocytes. Chest x-ray10 Final Exam Study Guide (CXR) detects bilateral increased interstitial markings. Which of the following treatments will most likely be given to this patient? 1. Acyclovir 800 mg orally five times daily 2. Clarithromycin 500 mg orally 3 times daily 3. Oseltamivir 75 mg orally 2 times daily 4. Amantadine 100 mg orally 2 times daily A patient is diagnosed with pulmonary tuberculosis. Which of the following is the most common diagnostic histopathological hallmark of the patient's condition? 1. Caseating granuloma 2. Noncaseating granuloma 3. Reed-Sternberg cell 4. Aschoff bodies A 62-year-old man presents with general malaise, occasional cough, and weight loss of 10 lbs (4.5 kg) over the last two months. History is significant for prediabetes managed with diet and cigarette smoking. Physical examination findings include mild edema in the extremities and clubbing bilaterally. Blood work shows mild anemia and sodium of 122 mg/dL. What test should be done next? 1. Bronchoscope 2. Chest MRI 3. Chest radiograph 4. CT chest Chest X-ray of a long-term smoker shows a 2-cm spiculated mass in the right perihilar lung. A barium esophagram shows an extrinsic compression in the region of the carina. Which of the following would be most helpful at this point? 1. Upper endoscopy 2. Mediastinoscopy 3. Chest CT with possible CT-guided biopsy 4. Thoracotomy A 65-year-old man presents with 3 months of progressive shortness of breath and nocturnal cough. He is a smoker and works in a cotton factory. He has one son and one daughter with asthma. On examination, there is a wheeze and coarse end-inspiratory crackles in the chest. A chest X-ray reveals diffuse non-specific changes consistent with lung disease. Spirometry is performed. Which of the following would indicate asthma? 1. FEV1 to FVC ratio of 70% 2. FEV1 to FVC ratio of 80% 3. FEV1 to FVC ratio of 72% 4. FEV1 to FVC ratio of 68% A 65-year-old man presents with a dry cough and wheezing, particularly at night. His history is significant for asthma, and he is on inhaled formoterol and low-dose budesonide twice a day and occasional use of an albuterol inhaler as required. He is now more short of breath with morning drops in his peak flow readings. On physical examination, he is mildly dyspneic but able to complete sentences. On auscultation, there are wheezes scattered in his chest. His peak expiratory flow rate is 70% of predicted. What is the most appropriate next step in management? 1. Start oral theophylline. 2. Add oral corticosteroids. 3. Increase inhaled budesonide dose. 4. Add oral long-acting beta 2 agonists11 Final Exam Study Guide A 35-year-old woman presents to the out-patient department with complaints of cough with whitish sputum production for the past 3 months. She mentions that the cough worsens at night. She has no other complaints. The patient mentions that she has tried chlorpheniramine for a week, and no improvement was noted. She has a history of gastroesophageal reflux disease, for which she takes famotidine. She has been smoking a pack of cigarettes daily for the past 7 years and drinks alcohol socially. Vitals show blood pressure 133/85 mmHg, heart rate 79 bpm, respiratory rate 14 breaths/min, and temperature 98.6 °F (37 °C). Pulmonary examination reveals normal breath sounds bilaterally. A chest x-ray is normal. Which of the following is the best next step in the management of the patient’s condition? 1. Pulmonary function tests 2. Endoscopy 3. Sputum analysis 4. CT scan of the chest A 78-year-old male presents to the clinic with complaints of a cough that started three days ago. The cough is associated with sputum, which is scanty in volume and yellow in color. He also complains of mild headaches and a stuffy nose for the last two days. On further questioning, he reveals that he has had two similar episodes previously, which subsided within a week. A detailed medical history reveals that he was diagnosed with diabetes mellitus twenty years ago and is on metformin. His vital signs show a blood pressure of 100/80 mmHg, a respiratory rate of 14/min, a heart rate of 88/min, and a temperature of 99 F (37.1 C). Auscultation of the chest was performed, which reveals bilateral coarse rhonchi, whereas a chest x-ray is normal. What is the most appropriate next step in the management of his condition? 1. Steroids and antitussives 2. Chest physiotherapy and antitussives 3. Antibiotics and antitussives 4. Analgesics and antitussives A nursing home patient with chronic obstructive pulmonary disease (COPD) and chronic carbon dioxide retention is wheezing. The oxygen saturation drops from 93 to 90. Which of the following would be most appropriate? 1. Increase the oxygen from 2 to 4 liters by nasal cannula 2. Treat with albuterol by nebulizer 3. Give an extra dose of tiotropium 4. Give an extra dose of 2 puffs of beclomethasone A 70-year-old man presents for a follow-up visit. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) and multiple hospital admissions for exacerbations. He uses a budesonide/formoterol combination and tiotropium inhalers. He has a 40-pack-year smoking history. He is up-todate with his influenza and pneumococcal vaccines. What should be advised to decrease his COPD exacerbations? 1. Start him on omalizumab. 2. Start him on mepolizumab. 3. Start him on roflumilast. 4. Move to a warm climate. A middle-aged man presents with an exacerbation of his chronic obstructive pulmonary disease (COPD). He is coughing and moderately short of breath for the past 2 days. He says that his inhalers do work, but he ran out of supplies. He complains of general malaise. You decide to start him on antibiotics after obtaining sputum for Gram stain and culture. Which of the following organisms is involved in COPD exacerbation according to the 2015 Global Initiative for Chronic Obstructive Lung Disease? 1. Moraxella catarrhalis 2. Pseudomonas aeruginosa 3. Escherichia coli 4. Mycobacterium12 Final Exam Study Guide A 65-year-old man presents with worsening shortness of breath and a productive cough for 6 months. His medical history includes hypertension and chronic kidney disease. He has a 30-pack-year smoking history. His vital signs are blood pressure 145/95 mm Hg, heart rate 88 bpm, and oxygen saturation 92% on room air. On physical examination, he is not using his accessory muscles of respiration. On lung auscultation, there is decreased air movement and prolonged expiration. There are no wheezes heard and no S3 or S4 auscultated. There is no jugular vein distention. He has no lower extremity edema and denies chest pain or calf tenderness. Chest x-ray reveals bilateral hyperinflated lung fields. Which of the following is the next best step in evaluation? 1. Chest computed tomography with intravenous contrast 2. Arterial blood gas analysis 3. Spirometry 4. Bronchoalveolar lavage A 16-year-old boy presents with a 2-week history of fever, runny nose, and paroxysms of coughing productive of clear sputum that is worse at night. His past medical history is unremarkable, and he takes no medication. His vitals are blood pressure 110/70 mm Hg, respiratory rate 16 breaths/min, heart rate 102 bpm, temperature 101.8 °F (38.8 °C), and oxygen saturation 98% on room air. The lung examination demonstrates clear breath sounds bilaterally. Initial laboratory results show leukocytosis with lymphocytic predominance. Chest x-ray findings are within normal limits, and PCR from the nasopharyngeal passage is positive for Bordetella pertussis. In addition to an antipyretic, what is the first-line treatment for this patient? 1. Prednisone 2. Azithromycin 3. Trimethoprim-sulfamethoxazole 4. Albuterol metered-dose inhaler A 37-year-old woman presents with complaints of intermittent dry cough and chest tightness since she started a new job as a chambermaid at a hotel 5 weeks ago. Her symptoms worsen at night. She does not have rhinitis, postnasal drip, or a history of allergic rhinitis. She has never smoked and does not take medication. On physical examination, the patient appears comfortable and speaks full sentences without difficulty. Oral and nasal mucosa appear normal. On auscultation, a wheeze is heard in her left lung. Chest x-ray findings are normal. Which of the following is the next best step in identifying the cause of the patient's current symptoms? 1. CT scan of the chest 2. Dermal patch testing to identify trigger allergies 3. Spirometry with pre and post-bronchodilator testing 4. Follow up with albuterol A 65-year-old female with a past medical history of hypertension and high cholesterol presents to the emergency department in winter with a six-day history of cough and a fever. The maximum temperature was 101 F on the day before the presentation. She denies any sick contacts or recent illness. Vital signs on presentation were significant for a heart rate of 102/min, blood pressure 130/84 mmHg, pulse oximetry of 90%, and temperature 99.1 F. The physical exam was notable for an ill-looking female with scattered rhonchi on lung auscultation. The patient reports recent travel on an airplane back from England. She has a dry cough and muscle aches and no other complaints. What is the most appropriate management for the probable condition? 1. Blood work, a chest x-ray, influenza screening, and treatment with antiviral therapy if positive 2. Influenza screening and antiviral therapy 3. Treatment with azithromycin 4. Reassurance and supportive therapy A 28-year-old man with a medical history significant for asthma presents to the primary care office for complaints of cough and shortness of breath for 24 hours. His symptoms started abruptly and are progressively worsening. He denies fevers or chills and has had no known exposure to sick contacts. Vital signs are within normal limits.13 Final Exam Study Guide Physical examination is significant for mild expiratory wheezing. His asthma has been in remission, and he has not used any inhalers for a few years. What is the next best step in the treatment of this patient? 1. Prescribe a course of azithromycin 2. Obtain blood work and a chest x-ray 3. Prescribe albuterol 4. Reassurance A 26-year-old woman G1P0000 at 24 weeks gestation presents to the clinic in October for evaluation of cough, rhinorrhea, and subjective fever for 24 hours. The patient has no significant past medical history and takes only a prenatal vitamin daily. Vital signs show temperature 38 °C (100.4 °F), blood pressure 120/80 mm Hg, heart rate 90 bpm, respirations 18 breaths/min, and oxygen saturation 96% on room air. Physical exam reveals a mildly illappearing gravid female in no acute distress with lung fields that are clear to auscultation bilaterally. Continuous fetal monitoring is normal. Nasal swab ELISA is positive for influenza A. Which of the following is the most appropriate treatment for this patient to decrease the likelihood of progression to viral pneumonia? 1. Zanamivir 2. Symptomatic treatment only 3. Oseltamivir 4. Baloxavir A 35-year-old previously healthy male presents for evaluation of coryza, dry cough, and fever for 4 days duration. The patient reports no significant past medical history, takes no daily medications, and has no known drug allergies. He reports receiving COVID-19 and influenza vaccines this season. Of note, upon obtaining a travel history, the patient stated that he recently returned from Saudi Arabia. He had petted a dog and visited a camel farm while on his trip. His vital signs show a temperature of 101 F (38.3 C), blood pressure of 102/64 mmHg, respiratory rate of 20 breaths per minute, heart rate of 115 beats per minute, and SpO2 of 95% on room air. Significant findings on the exam include tachycardia, tachypnea, and mild use of accessory respiratory muscles. Which of the following diagnoses is most important to consider in this patient? 1. Middle East respiratory syndrome coronavirus (MERS-CoV) 2. Severe acute respiratory syndrome coronavirus (SARS-CoV) 3. Rabies 4. Ebola A 40-year-old male patient comes in with a chief complaint of difficulty breathing. His cardiac function test results are normal. He shows airway hyperresponsiveness to the methacholine challenge test. His lung spirometry test reveals a lower-than-predicted level of forced expiratory volume in the first second (FEV1). Based on the most likely diagnosis, what is the most appropriate first-line therapy for a patient with infrequent episodes of mild symptoms? 1. Albuterol and a low-dose corticosteroid inhaler 2. An inhaler with a combination of formoterol and a corticosteroid 3. Inhaled low-dose corticosteroids 4. Albuterol alone A 44-year-old woman presents with sudden shortness of breath and 10/10 left-sided chest pain, which began two hours ago while she was at work. She has had two episodes of frank hemoptysis en route to the emergency department. She reports a history of deep venous thrombosis three years ago, diagnosed during a prolonged hospital admission after a cholecystectomy. She completed three months of apixaban at that time. She smokes one pack of cigarettes per day, and her medications include a multivitamin and an oral contraceptive pill. Her blood pressure is 70/45 mmHg, heart rate 140 beats per minute, and respiratory rate 40 breaths per minute. Chest auscultation demonstrates clear lung sounds in all fields. The patient's left-sided chest pain is not reproducible, and there is no left chest deformity. An electrocardiogram shows sinus tachycardia without ST-T wave changes, and the initial Ddimer level is elevated. After receiving two liters of normal saline solution, her blood pressure is 80/50 mmHg, heart14 Final Exam Study Guide rate 135 beats per minute, and oxygen saturation 90% on four liters of oxygen via nasal cannula. A bedside transthoracic echocardiography reveals moderate right ventricle hypokinesis with diffuse regional wall motion abnormalities. What is the best next step in treatment? 1. Intravenous heparin 2. Oral apixaban 3. Oral warfarin 4. Intravenous tissue plasminogen activator A 56-year-old man with a past medical history of uncontrolled hypertension, poorly controlled diabetes mellitus and hyperlipidemia presents with a 1-hour history of sudden onset, sharp left shoulder pain. He states that the pain is exacerbated by deep breathing, and coughing. The patient is diaphoretic. He does not take any medication except aspirin which he took today when the chest pain began. On examination, his oxygen saturation is 99% on room air, respiratory rate 20/minute, heart rate 88/min, and blood pressure 110/50 mmHg. A chest x-ray is unremarkable. Which of the following is the next best step in the management of this patient? 1. Refer for exercise stress testing 2. CT chest without contrast 3. X-ray left shoulder 4. EKG A 65-year-old female is evaluated for shortness of breath with exertion and a chronic cough. She is often unable to walk farther than 200 feet without stopping to catch her breath. She is a current smoker with a 33-pack-year smoking history. She has no prior hospitalizations. On physical examination, her vital signs are within normal limits at rest. Auscultation of her lungs reveals bilateral expiratory wheezes. The remainder of her physical examination is normal. Spirometry is performed and shows an FEV1 of 72% of predicted. Her post-bronchodilator FEV1/FVC ratio is 60%. Her modified medical research council (mMRC) dyspnea score is 3. She is counseled on smoking cessation. Which of the following is the most appropriate pharmacological treatment for this patient? 1. Monotherapy with a short-acting bronchodilator as needed 2. Roflumilast 3. Long-acting bronchodilator and an inhaled corticosteroid 4. Short-acting bronchodilator as needed and a long-acting bronchodilator  This patient has an FEV1/FVC ratio of < 0.7 consistent with the diagnosis of chronic obstructive pulmonary disease (COPD). Her post-bronchodilator FEV1 % of predicted is 60%, and she has an mMRC score of 3. According to the 2020 global initiative for chronic obstructive lung disease (GOLD), she falls within GOLD 2, Group B.  A short-acting bronchodilator as needed and a long-acting bronchodilator is indicated in GOLD group B patients.  Long-acting bronchodilators have been shown to improve FEV1, dyspnea, and the number of hospitalizations in patients with COPD. It is indicated in patients who are within GOLD groups B-D.  Monotherapy with a short-acting bronchodilator as needed is not adequate for this patient with moderate disease. Roflumilast is a phosphodiesterase-4 inhibitor used in severe cases, often with an FEV1 < 50% of predicted. Inhaled corticosteroids are reserved for severe to very severe cases of COPD. A 20-year-old male presents with a two month history of cough and right-sided chest pain. On examination, his chest movement on the right side is diminished, the trachea is shifted to the left, and a stony dull percussion note is15 Final Exam Study Guide on the right. His breath sounds are impaired, and vocal fremitus is present. Which of the following is the most likely diagnosis? 1. Right-sided pneumothorax 2. Right-sided pleural effusion 3. Left-sided pneumothorax 4. Left-sided pleural effusion A 45-year-old man presents to the hospital with complaints of dull aching chest pain, exacerbated upon inhalation. The pain worsens and becomes unbearable while coughing and sneezing. He further states that he had a fever two days ago, which responded to acetaminophen. Which of the following is the most likely source of pain in this patient? 1. Respiratory system 2. Cardiovascular system 3. Gastrointestinal system 4. Hepatobiliary system A 65-year-old woman receives palliative care for progressively worsening chronic obstructive pulmonary disease. She has multiple coughing episodes during dinner, and later that night, she develops a fever and respiratory distress. What is the most likely diagnosis? 1. Pulmonary embolism 2. Myocardial infarction 3. Aspiration pneumonia 4. Pneumothorax A patient with lung cancer presented with sudden onset pleuritic chest pain on the left side. She is dyspneic and exhibits tachypnea, tachycardia, and cough. On auscultation, there are decreased breath sounds on the left. After a brief period of stabilization, the patient becomes hemodynamically unstable and develops cyanosis. What is the likely diagnosis? 1. Heart failure 2. Tension pneumothorax 3. Cardiac tamponade 4. Pneumonia A 65-year-old man with metastatic lung cancer presents with complaints of dyspnea, dry cough, and chest pain that is exacerbated on inspiration. His blood pressure is 110/70 mmHg, heart rate 90/min, respiratory rate 26/min, and he is afebrile. A chest x-ray shows hyperinflation of the left lung. The patient has most likely developed which of the following complications? 1. Primary spontaneous pneumothorax 2. Secondary spontaneous pneumothorax 3. Tension pneumothorax 4. Pleural effusion A 25-year-old woman presents with 5 days of painful urination and increased frequency of urination. She has no significant history. Her last menstrual period was two weeks ago, and she is taking combined oral contraceptive pills. She smoked a pack of cigarettes daily for the last 5 years. She does not drink alcohol and denies any illicit drug use. Vital signs are blood pressure 119/78 mm Hg, heart rate 74 bpm, temperature 37.1 C (98.8 F), and respiratory rate 16 breaths/min. Which of the following imaging studies is required in this patient? 1. Ultrasound 2. Intravenous pyelogram 3. CT scan 4. No imaging is needed16 Final Exam Study Guide A man presents with nausea, vomiting, and left flank pain. He feels pain during micturition, and his urine appears cloudy and reddish-brown. His history is significant for hypertension and asthma, which are under control. Which of the following tests is the most sensitive and specific for making a diagnosis? 1. Plain X-ray of kidneys, ureters, and bladder 2. Renal ultrasound 3. Intravenous pyelography 4. Non-contrast abdominal CT A 17-year-old girl presents with left flank, pain, nausea, vomiting, and dysuria that started a day ago. She has no significant history. She is afebrile, and her vital signs are stable. A physical examination demonstrates costovertebral tenderness as well as tenderness in the left flank on palpation. Urinalysis shows 12 RBC/hpf and 2 WBC/hpf. What is the best next step in making a definitive diagnosis? 1. Cystoscopy 2. Procalcitonin 3. Non-contrast CT scan of the abdomen and pelvis 4. Renal nuclear scan A 28-year-old man presents for his annual physical. He has no complaints and feels perfectly healthy. He has no significant history. Vital signs are blood pressure 120/80 mmHg, heart rate 60 bpm, and respiratory rate 15 breaths/min. Physical examination is normal. A urine dipstick test reveals 1+ proteinuria. His 24-hour urinary protein excretion is 1 g/day. The patient's renal function tests are normal. The patient is concerned about these lab findings. Which of the following is the correct response? 1. Transient proteinuria is not indicative of underlying renal disease. 2. Orthostatic proteinuria in young people is a cause for concern. 3. An autoimmune profile needs to be obtained. 4. Proteinuria >5 g/day is associated with an active disease if edema is present A 33-year-old woman presents with worsening left lower quadrant abdominal that she describes as intermittent and sharp. She also reports dysuria and urinary urgency. Her surgical history is significant for gastric bypass surgery 5 years ago, and her social history is negative for recent sexual activity. Vital signs are temperature 99.6 °F (37.5 °C), blood pressure 148/72 mm Hg, and heart rate 86 bpm. The physical examination demonstrates left lower quadrant abdominal tenderness and pain radiating to the left groin and left flank on palpation. Urinalysis shows 100 red blood cells/HPF, and a urine pregnancy test is negative. What is the best next step in management? 1. Kidney, ureter, and bladder (KUB) x-ray 2. Intravenous pyelogram 3. Non-contrast CT of the abdomen and pelvis 4. Course of antibiotics A 37-year-old female patient presents with symptoms of fatigue and ankle swelling. She is found to have mild hypertension but otherwise appears healthy. She has a negative medical, surgical, and family history. Her urine is found to have a smoky, tea-colored appearance. A urine dipstick is positive for blood and protein. This urine finding and her clinical presentation suggest she is likely bleeding from which of the following structures? 1. Bladder 2. Kidney 3. Ureter 4. Urethra A 55-year-old man presents with an inability to void on his own associated with intermittent leakage of urine. The patient denies any known triggers that cause urinary leakage. His history is significant for benign prostatic hyperplasia. The patient is on a maximum dose of tamsulosin. He denies any medication allergies, other medical17 Final Exam Study Guide conditions, history of surgeries, or traumas. Vital signs are normal. Physical examination reveals a distended bladder and suprapubic tenderness. Which of the following is the next best step in management? 1. Obtain a urinalysis 2. Urethral catheterization 3. Prescribe an alpha-adrenergic agonist 4. Suprapubic catheterization A clinician is seeing an 84-year-old man with dementia from a nursing home. He is a poor historian. The nurse caring for him states that he is often found wet with urine. The nurse states that he has no other medical conditions or symptoms. His vital signs are within normal limits. Physical examination reveals a pleasantly demented, frail older male who smells of urine. There is no suprapubic tenderness. What is the next best step in the management of this patient? 1. Insertion of an indwelling Foley catheter 2. Empiric treatment with antibiotics for 3 days 3. Bladder scan 4. Start the patient on oxybutynin A 65-year-old man presents with urinary dribbling. He denies urinary urgency but describes his urinary flow as "not what it used to be". He has a past medical history of coronary artery disease and a stroke without residual deficits. He does not currently take any prescription or over-the-counter medications. Vital signs are normal. On physical examination, he has no difficulties with speech, mobility, or short-term memory. There is no suprapubic tenderness. Urodynamic testing confirms that significant dribbling is present. What is the likely mechanism of his urinary problem? 1. Intrinsic sphincter deficiency 2. Bladder outlet obstruction from prostate enlargement 3. Detrusor hyperactivity 4. Urethral hypermobility A 67-year-old man presents with urinary hesitancy, decreased stream, dribbling, and nocturia 3 times a night. On physical examination, his prostate is enlarged, non-tender, and smooth. The results of a urinalysis and culture are normal. His post-void residual urine volume is 50 mL. Which of the following is the best next step in management? 1. Laser prostatectomy 2. Alfuzosin 3. Oxybutynin 4. Desmopressin A 28-year-old woman presents with burning on urination, urgency, and increased urinary frequency. She is G1P0 at 32 weeks gestation. She has no allergies. Her vital signs are blood pressure 100/60 mm Hg and heart rate 102 bpm. The results of her physical examination are normal. Laboratory tests show her hemoglobin is 11 g/dL, and her WBC count is 12,000/μL. Which of the following is the best treatment option? 1. Tetracycline 2. Cephalexin 3. Erythromycin 4. Ciprofloxacin A 65-year-old man presents with erectile dysfunction. The postage stamp test is positive. Which of the following medications will be beneficial? 1. Ramipril 2. Prednisolone 3. Furosemide 4. Amiodarone18 Final Exam Study Guide A 55-year-old man presents with erectile dysfunction, decreased libido, and lethargy. Laboratory tests show hypogonadism. A long-acting testosterone pellet is implanted. Which of the following must be monitored in addition to the testosterone level and his erectile ability? 1. Muscle mass and weight 2. Prostate-specific antigen (PSA) level 3. Liver function tests 4. Degree of gynecomastia A 54-year-old man presents with erectile dysfunction. A history of present illness reveals the gradual onset of difficulty with achieving and maintaining an erection sufficient for intercourse. He has normal sensations and libido. He has no significant medical history but has not seen a physician in over 10 years. He has been married for 20 years. He has a 25-pack-year smoking history. His physical examination findings are unremarkable. What is(are) the first step(s) to identifying the etiology of his erectile dysfunction? 1. Blood pressure measurement and HbA1c 2. Morning serum testosterone level 3. Stamp test 4. Trial of intracavernosal injection A previously healthy 36-year-old female presents with concerns about involuntary urine loss. The episodes occur when she lifts weights, and she has also noticed leakage of urine when she laughs hard. She does not experience sudden urges to urinate or frequency. She denies dysuria, fevers, and chills. Her vital signs are within normal limits. Her physical exam is unremarkable. Which of the following is the likely cause of her symptoms? 1. Overflow incontinence from a full bladder 2. Intrinsic sphincter deficiency 3. Uterine prolapse 4. Pelvic floor muscle weakness A 17-year-old girl presents with a complaint of urine leakage for the last 2 weeks. She states that she will randomly have urges to urinate, which can not be deferred. She also admits to occasional loss of urine when laughing or coughing. She was diagnosed with myasthenia gravis 2 years ago. Vital signs show blood pressure 119/72 mm Hg, heart rate 75 bpm, respiratory rate 12 breaths/min, and temperature 37.2 °C (99 °F). A physical exam is unremarkable. Urinalysis is negative for leukocyte esterase, nitrites, and red blood cells. Available treatment options are discussed with the patient, and she eventually decides on medical management. Which of the following medications is contraindicated in this patient? 1. Mirabegron 2. Duloxetine 3. Oxybutynin 4. Imipramine A 79-year-old man with a past medical history of hypertension, hyperlipidemia, COPD, and peripheral arterial disease presents to the emergency department with complaints of intermittent blood in the urine, dysuria, and unintentional weight loss of 15 pounds (7 kg) over the last 2 months. He denies having any urgency or frequency. His PSA levels were recently checked and were borderline elevated. He denies having any frequency, urgency, or incontinence. He used to smoke 2 packs per day for 30 years but quit 15 years ago. Urinalysis reveals a large amount of blood but is otherwise unremarkable. CBC reveals a hemoglobin of 9 g/dL but is otherwise unremarkable. CMP shows elevated AST and ALT. What is the next best step in the management of this patient? 1. Continuous bladder irrigation 2. CT scan of the abdomen and pelvis 3. Cystoscopy 4. Tamsulosin19 Final Exam Study Guide A young woman presents to a clinic complaining of low-grade fever, irritation, and a burning sensation while passing urine. A urinalysis is performed, and a urinary tract infection is diagnosed. The provider starts trimethoprim/sulfamethoxazole for 3 days and asks the patient to follow up afterward. What additional instructions are most helpful for this patient? 1. Drink more cranberry juice. 2. After voiding, wipe from back to front. 3. Drink plenty of water. 4. Take extra vitamin C. A 54-year-old female presents to the clinic with acute onset of right flank pain. She describes the pain as crampy and severe, radiating to her right groin. Urinalysis shows 1 white blood cell and 3 red blood cells per high power field. Ultrasound kidney-ureter-bladder does not show any stones. Which of the following is the next best step in the evaluation of this patient? 1. Repeat ultrasound in 24 hours 2. Computed tomography (CT) scan without contrast 3. Intravenous pyelogram 4. Ureteroscopy A 65-year-old woman presents with pain when urinating and lower abdominal discomfort. She is diagnosed with cystitis. She is interested in knowing the most important mode of transmission of microorganisms into the urinary bladder. Which of the following is the most appropriate response? 1. Ascending infection from the perineum 2. From the rectum 3. From sexual activity 4. Normal urinary tract flora A 65-year-old male patient presents to the outpatient clinic for a health check-up advised as a pre-employment requirement at his office. The patient has a past medical history of diabetes and hypertension for 15 years that were previously well controlled with pharmacological intervention and lifestyle modifications until last year when he lost his insurance due to unemployment. The patient has no active complaints. The patient is a former computer programmer who currently leads a sedentary lifestyle. The vital signs are a heart rate of 86 beats per minute, respiratory rate of 14 breaths per minute, and blood pressure of 152/94 mmHg. On examination, he has a soft abdomen and normal breath sounds on auscultation in both lungs. Laboratory work shows hemoglobin 14 g/dl, platelets 295,000/mm3, sodium 139 mEq/L, potassium 4.3 mEq/L, and HbA1c 6.9. Urine analysis shows no cells or casts, and the urine albumin-creatine ratio is 325 mg/g. What is the most appropriate medication to start for this patient? 1. Metoprolol 2. Losartan 3. Chlorthalidone 4. Metolazone A 28-year-old woman presents with complaints of dysuria, nausea, and low-grade fever. The client states the symptoms started 2 weeks ago but have worsened in the past 3 days. The client is sexually active with multiple partners. On examination, left costovertebral tenderness is noted. Which of the following conditions has the client most likely developed? 1. Nephrolithiasis 2. Obstructive pyelonephritis 3. Pyelonephritis 4. Lower urinary tract infection20 Final Exam Study Guide A 70-year-old patient has reflex urinary incontinence due to spinal cord compression. Which of the following is the best way to manage urinary incontinence in this patient? 1. Catheterization 2. Pelvic floor muscle training 3. Antibiotics 4. Fluid restriction An 85-year-old woman presents with signs and symptoms of overflow incontinence. The patient has a past medical history significant for multiple sclerosis. On examination, bladder distension is noted. Which of the following is the best next step in the management of this patient? 1. Intermittent catheterization 2. Suprapubic catheterization 3. Urinary diversion 4. Cystoscopy A 76-year-old woman is admitted to the hospital after experiencing loose stools and disorientation while residing in a nursing home following a stroke. She experiences urine incontinence on her third hospital day. While using the DIAPERS assessment scale for urinary incontinence, which of the following is best described by 'D"? 1. Depression 2. Delirium 3. Dehydration 4. Diplopia A 30-year-old woman presents with her third episode of a painful cyst at the opening of the vagina on the left side. The last episode was treated with incision and drainage, followed by the insertion of a Word catheter. What is the best next step in treatment? 1. Cryotherapy 2. Laser ablation 3. Marsupialization 4. Excision A 27-year-old woman who is 7 weeks postpartum woman presents with right breast pain and swelling. She is breastfeeding her infant exclusively without any difficulty. She first noticed redness on her right breast a week ago, which has worsened. She took ibuprofen and applied ice packs with little relief from the pain. She has a temperature of 99.5 F (37.5 C) and is hemodynamically stable. Examination of her breast shows a patch of erythema extending from the areola to the lateral edge of the breast, with a 2.5 cm area of fluctuance at the lateral border at the 4 o'clock position. What is the most appropriate next diagnostic step? 1. Mammography 2. Fine needle aspiration 3. Core-needle biopsy 4. Breast ultrasound A 33-year-old woman presents with a painful and erythematous right breast. Her history is significant for a normal spontaneous vaginal delivery 4 weeks ago and she is exclusively breastfeeding her infant. Vital signs are temperature 99.7 F (37.6 C), blood pressure 130/70 mmHg, and heart rate 89 bpm. Physical examination reveals an erythematous area on the right breast covering approximately 2 cm by 3 cm at 7 o'clock. The area is tender to palpation, fluctuant, and slightly indurated. The nipple of the right breast is cracked, but milk can be expressed without any difficulty. No visible pus is observed in breast milk. A breast ultrasound confirms a collection of pus in the erythematous part of the right breast. The clinician prescribes antibiotics and recommends fine-needle aspiration of the affected area of the breast. Which is the next best step if the patient does not improve with the recommended therapy?21 Final Exam Study Guide 1. Incision and drainage. 2. Diagnostic mammography. 3. Breast magnetic resonance imaging (MRI) with gadolinium contrast. 4. Repetition of fine-needle aspiration. A 20-year-old woman presents with painful menstrual periods and associated abdominal bloating over the last 6 months. The symptoms are most severe on the first day of her period, and she is concerned because it is causing her to miss work. Her menstrual history reveals regular periods every 28 days that last for 5 days. She denies excessive menstrual blood loss, takes no medication, and denies smoking tobacco or using illicit drugs. Which of the following is considered a first-line treatment for this patient's condition? 1. Tranexamic acid 2. Naproxen 3. Norethindrone 4. Levonorgestrel-releasing intrauterine system A 65-year-old woman presents with vaginal burning, itching, and dyspareunia. She has no significant past medical history. She takes an aspirin a day and calcium supplements. Her pelvic examination shows pallor and thinning of the vaginal mucosa. There is no discharge and a wet mount shows no organisms. What is the best treatment? 1. Vaginal lubricants 2. 2.5% hydrocortisone cream intravaginally 3. Estrogen vaginal cream 4. Ospemifene A 38-year-old woman presents with swelling on the left side of her vulva for the past week. Her review of systems is negative for pain or weight loss. She has no significant past medical history and takes no medications. She reports having regular menstrual cycles and being sexually active with her husband. On examination, there is a 1 cm palpable non-tender fluctuant mass in the left lower vulva, but no erythema or purulent discharge. Which of the following is the most appropriate treatment option? 1. Marsupialization 2. Incision and drainage 3. Antibiotic prescription 4. Observation, no further treatment is required A 44-year-old woman presents with a 2-day history of itching in the vagina, increased vaginal discharge, and pain with urination. A history of present illness reveals that the discharge started a month ago after unprotected sexual intercourse. A review of systems is negative for fever, nausea, constipation, anorexia, and sleep disturbances. Her past medical history is significant for type 2 diabetes mellitus. She irregularly uses intravaginal estriol cream for relief of vaginal dryness. On physical examination, she has vaginal erythema, foamy thick vaginal discharge, and a strawberry-appearing cervix. Which of the following is the most appropriate step in management? 1. Measure the pH of the vaginal fluid. 2. Perform bacterial culture on the vaginal fluid. 3. Recommend a diagnostic trial of not using vaginal estriol cream. 4. Observe the vaginal fluid under a microscope. Lactational breast abscesses are most often caused by which of the following organisms? 1. Listeria monocytogenes 2. Pseudomonas aeruginosa 3. Staphylococcus aureus 4. Escherichia coli22 Final Exam Study Guide A 65-year-old woman presents for a follow-up visit. Her physical examination demonstrated a palpable mass in the upper outer quadrant of the right breast without palpable axillary nodes. Her diagnostic mammogram demonstrates a 1.2 cm spiculated mass in the upper outer quadrant of the right breast. A targeted ultrasound shows a hypoechoic mass measuring 1.3 x 1.1 x 0.8 cm. Breast biopsy reveals a moderately differentiated invasive ductal carcinoma measuring 1.2 cm that is ER/PR positive and HER2/neu negative. What is the best next step? 1. Upfront axillary node biopsy 2. Chemotherapy 3. Mastectomy 4. Lumpectomy and sentinel node biopsy A 35-year-old woman presents with the chief complaint of pelvic pain. She has a history of secondary infertility and has had 1 live birth via Caesarean section. Since childbirth, her symptoms of pelvic pain have worsened. She functions normally with her tasks of daily living except for the inability to comfortably place a tampon and have pain-free vaginal intercourse. The provider performs a pelvic exam and obtains a sample to screen for sexually transmitted infections. Which of the following is the most appropriate next step in management? 1. Refer to a pelvic floor physical therapist for further evaluation 2. Order an ultrasound to detect endometriosis 3. Prescribe vaginal estrogen therapy and plan for follow-up in 1 month 4. Perform a Q-tip test as well as a neuromuscular exam of the pelvis Breast ultrasonography done for a 45-year-old woman shows bilateral microcalcifications. Biopsy specimen analysis is significant for 2 lesions with lobular carcinoma in situ that are considered concordant with the imaging findings. What is the most appropriate management for this patient? 1. Simple mastectomy 2. Modified radical mastectomy with adjuvant tamoxifen 3. Prophylactic tamoxifen and life-long surveillance 4. Lumpectomy followed by radiation therapy A 51-year-old woman presents with irregular, heavy menstrual bleeding for the past 6 months. She reports previously regular cycles every 30 days, lasting 4 to 6 days, with medium flow. She says her cycles are now occurring every 30 to 45 days, lasting 5 to 12 days, with heavy flow and occasional passing of clots. Her BMI is 30.2 kg/m2, and her vital signs are within normal limits. What is the most appropriate next step in evaluating this patient? 1. Luteinizing and follicle-stimulating hormone levels 2. Sonohysterography 3. Endometrial sampling 4. Gonorrhea and chlamydia testing An otherwise healthy 25-year-old nulliparous woman presents with cyclic, "crampy" abdominal pain that starts within a few hours of the onset of menses and usually resolves within 72 hours. Her periods have been regular, with no spotting, and her last one occurred 1 week ago. She is currently sexually active with her husband and is hoping to become pregnant within the next 3 months. What is the best initial pharmacotherapy for this patient? 1. An opioid 2. A selective serotonin reuptake inhibitor 3. A combined oral contraceptive pill 4. A nonsteroidal anti-inflammatory drug (NSAID) A 24-year-old woman presents to the clinic with breast tenderness, which increases before menses. Ultrasound reveals a round, well-circumscribed, anechoic structure, with an imperceptible wall. What is the most likely diagnosis? 1. Simple cyst23 Final Exam Study Guide 2. Complicated cyst 3. Complex cyst 4. Fibroadenoma A 37-year-old woman undergoes a cystoscopy for microscopic hematuria. During the procedure, a 3 cm mass is observed adjacent to the right labia major without overlying skin changes. Further inquiry reveals the mass has developed over the past two weeks, and there is no similar past medical history. It is not tender, not draining, and not bothersome to her. Which of the following is an indication for referral to a gynecologic specialist? 1. Spontaneous discharge from the mass 2. Severe pain when sitting down 3. Asymmetry of the vulva 4. Diminishing size of the mass 58-year-old woman presents with symptoms of vaginal dryness and painful intercourse. The examination shows a thin, fragile vaginal mucosa, with pH 7.0, and a vaginal maturation index of 22. The patient is started on intravaginal estrogen. On follow-up, her symptoms are improving, with pH 4.0, and the vaginal maturation index is 55. What is the mechanism through which her symptoms improved? 1. Estrogen increases the vaginal squamous cells, providing more glycogen availability for lactobacilli that convert glycogen into lactic acid and hydrogen peroxide. 2. Estrogen increases the squamous cells, which then release lactic acid and hydrogen peroxide. 3. Estrogen increases the squamous cells providing more glycogen availability for Gardnerella, which convert glycogen into lactic acid and hydrogen peroxide. 4. Estrogen increases the squamous cells providing more glycogen availability for Gardnerella, which convert glycogen into acetic acid. A 22-year-old woman presents to the clinic with a history of lower abdominal pain for the past six months. There is no history of dysuria and dyspareunia. There is no relevant family history of cancer. The patient noticed that the pain increases during the first two days of her period. The periods are regular and slightly heavier than usual. She has to change 6 to 7 pads per day. The patient’s blood pressure is 120/80 mmHg, pulse 63/minute, and the temperature is 36.1 C. She denies any loss of weight. The pelvic examination shows a globularly enlarged and retroverted uterus. The pregnancy test is negative. She has a recent pelvic ultrasound, which showed some evidence of endometriosis. What is the most likely diagnosis for this patient? 1. Primary dysmenorrhea 2. Secondary dysmenorrhoea 3. Cervical stenosis 4. Endometrial polyp A 35-year-old woman presents with a large, firm, minimally tender subareolar mass in her right breast. She states it has been present for the last month and has continued to grow. While the patient denies a family history of breast cancer, she does have a new 6-month-old child. She denies fevers or chills, and the skin surrounding the mass is devoid of any inflammatory changes. Ultrasound reveals a well-circumscribed hypoechoic cyst-like structure. A fine needle aspiration (FNA) reveals a milky discharge. What is the most appropriate next step in the management of this patient? 1. The patient requires a full course of antibiotics. 2. The patient requires an excisional biopsy. 3. The patient requires a formal incision and drainage of the cyst contents. 4. The patient does not require any further medical interventions. A 32-year-old woman presents with complaints of breast tenderness and swelling for the past 8 days. The patient states she has a hard time changing clothes due to severe breast pain. The patient has a past medical history significant for seasonal allergies. She has a 10 pack-year smoking history. On examination, erythema and swelling24 Final Exam Study Guide are noted near the right areola. An ultrasound reveals a hypoechoic multiloculated fluid collection beneath the right areola. The fluid is aspirated and sent for histopathology. The findings are shown in the figure. Which of the following best describes the findings shown? 1. Abundant anucleated squamous cells, histiocytes, and acute inflammation 2. Sheets of ductal cells with a branching appearance 3. Small epithelial cells arranged as single cells and small linear clusters 4. Atypical ductal epithelium with nuclear polymorphism A 45-year-old woman is diagnosed with hormone receptor (HR) positive lobular carcinoma of the breast. After a detailed evaluation, the client undergoes a radical mastectomy. She is also started with adjuvant therapy with tamoxifen after the procedure. What is the purpose of this therapy? 1. Decreases risk of disease recurrence 2. Increases bone density and prevents osteoporosis 3. Decreases disease-free survival period 4. Reduces future risk of uterine cancer [Show More]

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