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A 32-year-old man comes to the office because of a 2-day history of redness of the right eye. He has not had sensitivity to light or the sensation of a foreign body in the eye. He has no history of serious illness and takes no medications. Examination of the right eye shows erythema and clear discharge. Examination of the left eye shows no abnormalities. The physician prescribes ketorolac ophthalmic solution. Which of the following is the most appropriate way for the physician to write the prescription?

Ketorolac 0.5% solution, 1 drop in right eye, four times daily

A

A 14-year-old girl is brought to the physician by her mother for a well-child examination. Vital signs are within normal limits. On breast examination, the areolae are 3 cm in diameter and form a secondary mound bilaterally. Cardiopulmonary and abdominal examinations show no abnormalities. Pelvic examination shows dark, curly, coarse hair that spreads sparsely over the pubic area but not over the thighs. Which of the following is the most accurate assessment of this patient's development?

Pubic Hair Development: Normal; Breast Development: normal

D

A healthy 19-year-old woman comes to the clinic requesting advice regarding contraception. Menses occur at regular 28-day intervals with heavy flow. She is sexually active and has had three lifetime male partners. She has smoked one-half pack of cigarettes daily for 2 years. She lives in a college dormitory and says that she often does not sleep in her own room and has trouble remembering to take medications regularly. Her only medication is a daily multivitamin. She is 163 cm (5 ft 4 in) tall and weighs 58 kg (128 lb); BMI is 22 kg/m². Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation regarding contraception for this patient?

Subdermal contraceptive implant

D

A previously healthy 17-year-old girl comes to the emergency department because of a 3-day history of moderateright lower quadrant pain, fever, and loss of appetite. She has not had abnormal vaginal discharge. Four months ago,she was treated with oral antibiotics for cystitis. She currently takes no medications. Menses occur at regular 28-dayintervals. Her last menstrual period was 10 days ago. She has been sexually active with two male partners during thepast 6 months and uses condoms inconsistently. Temperature is 38.5°C (101.3°F), pulse is 105/min, respirations are14/min, and blood pressure is 127/82 mm Hg. Abdominal examination shows tenderness to palpation of the lowerquadrants with rebound in the right lower quadrant; there is no distention. Bowel sounds are decreased. Pelvicexamination shows blood-tinged discharge from the cervical os and cervical motion tenderness. There is a 5-cmmass in the right adnexal region. Which of the following is the most likely diagnosis?

Tubo-ovarian abscess

E

A 15-year-old girl is brought to the office because she has never had a menstrual period. She has no history ofserious illness and receives no medications. Growth and development are appropriate for age. Breast developmentbegan at the age of 10 years. She has never been sexually active. She is at the 90th percentile for height, 75thpercentile for weight, and 69th percentile for BMI. Sexual maturity rating is 4 for breast development. Pelvicexamination shows a normal-appearing vagina; the cervix and uterus cannot be palpated. Her serum testosteroneconcentration is 340 ng/dL (N=5–40). Serum concentrations of luteinizing hormone, follicle-stimulating hormone,thyroid-stimulating hormone, 17α-hydroxyprogesterone, and prolactin are within the reference ranges. Serum β-hCGtesting is negative. Pelvic ultrasonography shows no uterus. Her karyotype is 46,XY. Which of the following is themost appropriate next step in management?

Gonadectomy

B

A 50-year-old man returns to the office for a follow-up examination. During the past 2 months, he has had increased blood pressure readings during several checks at the office and at home. He says he has felt well. He has major depressive disorder and gout. Medications are fluoxetine and allopurinol. His maternal grandfather had congestive heart failure and the patient's older brother has hypertension. The patient has smoked one-half pack of cigarettes daily for 32 years. He is 180 cm (5 ft 11 in) tall and weighs 95 kg (210 lb); BMI is 29 kg/m². Pulse is 70/min and blood pressure is 152/90 mm Hg. Physical examination discloses no abnormalities. Which of the following medications is contraindicated in this patient?

Hydrochlorothiazide

C

A 23-year-old woman is brought to the emergency department by her friends 30 minutes after the sudden onset ofnausea, facial flushing, and chest pressure while eating at a Thai restaurant. She does not have any known allergiesto foods or medications. She had asthma during childhood but has not required treatment for 5 years. On arrival, sheis diaphoretic and appears anxious. Temperature is 37.1°C (98.8°F), pulse is 92/min, respirations are 20/min, andblood pressure is 126/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination ofthe neck shows erythema; no masses or nodules are palpated. Cardiopulmonary examination shows noabnormalities. Which of the following is the most likely diagnosis?

Reaction to food additive

D

A 45-year-old woman returns to the office to discuss results of a fine-needle aspiration biopsy of a 0.5-cm rightbreast mass obtained 1 week ago. She is unaccompanied. Medical history is unremarkable and she takes nomedications. Her mother and maternal aunt were diagnosed with breast cancer at the ages of 45 and 52 years,respectively. Physical examination discloses no palpable axillary nodes. The biopsy specimen showed malignantcells. The patient is counseled that she has an excellent chance of cure with lumpectomy and radiation therapy. Sheadamantly refuses this treatment plan and states that she will try natural therapies, including megavitamins andherbal remedies instead. After exploring the reasons behind the patient's decision, which of the following is the mostappropriate response?

Ask the patient if she would be willing to return to the office in 2 weeks to discuss treatment options again

C

A 47-year-old woman comes to the office because of a 2-month history of progressive weakness and numbness ofher right leg. She has a 3-year history of type 2 diabetes mellitus treated with metformin. She has worked as a stockperson in a storeroom for 12 years; she often moves and lifts heavy objects and sometimes crawls into tight spaces.On neurologic examination, muscle strength is 5−/5 in the hip extensor, thigh abductor, hamstring, andgastrocnemius muscles on the right and intact on the left. Muscle strength is intact in the iliopsoas, thigh adductor,quadriceps, and tibial anterior muscles bilaterally. Deep tendon reflexes are 1+ in the right ankle and 2+ in the leftankle. Sensation to light touch is mildly decreased over the lateral and inferior aspects of the right foot. Sensationotherwise is intact. Which of the following is the most likely diagnosis?

S1 radiculopathy

F