2019

Question 1

A 42-year-old female presents for follow-up after being treated for recurrent respiratory
problems at an urgent care facility. She is feeling a little better after a short course of oral
prednisone and use of an albuterol (Proventil, Ventolin) inhaler. She has had a gradual increase
in shortness of breath, a chronic cough, and a decrease in her usual activity level over the past
year. She has brought a copy of a recent chest radiograph report for your review that describes
panlobular basal emphysema. She does not have a history of smoking, secondhand smoke
exposure, or occupational exposures. Spirometry in the office reveals an FEV1/FVC ratio of
0.67 with no change after bronchodilator administration.
Which one of the following underlying conditions is the most likely cause for this clinical
presentation?
A) 1-Antitrypsin deficiency
B) Bronchiectasis
C) Diffuse panbronchiolitis
D) Interstitial lung disease
E) Left heart failure

Answer 1

ANSWER: A
This patient presents with symptoms of chronic obstructive lung disease, and spirometry confirms airflow
limitation or obstruction with an FEV1/FVC <0.7. Her age, the lack of tobacco smoke or occupational
exposures, and the chest radiograph findings are typical of 1-antitrypsin deficiency. While left heart
failure, interstitial lung disease, bronchiectasis, and diffuse panbronchiolitis are all causes of chronic
cough, they are not necessarily associated with the development of COPD and these spirometry findings.
Furthermore, the radiologic findings in this patient are not consistent with these conditions. Left heart
failure would present with pulmonary edema on a chest radiograph and volume restriction on pulmonary
function testing. Bronchiectasis would present with bronchial dilation and bronchial wall thickening on a
chest radiograph. Interstitial lung disease would present with reticular or increased interstitial markings.
Diffuse panbronchiolitis would present with diffuse small centrilobular nodular opacities along with
hyperinflation.

Question 2

An otherwise healthy 57-year-old male presents with mild fatigue, decreased libido, and erectile
dysfunction. A subsequent evaluation of serum testosterone reveals hypogonadism.
Which one of the following would you recommend at this time?
A) No further diagnostic testing
B) A prolactin level
C) A serum iron level and total iron binding capacity
D) FSH and LH levels
E) Karyotyping

Answer 2

ANSWER: D
In men who are diagnosed with hypogonadism with symptoms of testosterone deficiency and unequivocally
and consistently low serum testosterone concentrations, further evaluation with FSH and LH levels is
advised as the initial workup to distinguish between primary and secondary hypogonadism. If secondary
hypogonadism is indicated by low or inappropriately normal FSH and LH levels, prolactin and serum iron
levels and measurement of total iron binding capacity are recommended to determine secondary causes of
hypogonadism, with possible further evaluation to include other pituitary hormone levels and MRI of the
pituitary. If primary hypogonadism is found, karyotyping may be indicated for Klinefelter’s syndrome.

Question 3

A 4-year-old female is brought to your office because of a history of constipation over the past
several months. Her mother reports that the child has 1–2 bowel movements per week composed
of small lumps of hard stool. She strains to have the bowel movements, and they are painful.
The child eats normally like her two siblings.
Which one of the following would be most effective at this time?
A) Daily fiber supplements
B) Lactulose
C) Magnesium hydroxide (Milk of Magnesia)
D) Polyethylene glycol (MiraLAX)
E) Senna

Answer 3

ANSWER: D
This patient presents with symptoms compatible with functional constipation. Daily use of polyethylene
glycol (PEG) solution has been found to be more effective than lactulose, senna, or magnesium hydroxide
in head-to-head studies. Evidence does not support the use of fiber supplements in the treatment of
functional constipation. No adverse effects were reported with PEG therapy at any dosing regimen.
Low-dose regimens of PEG are 0.3 g/kg/day and high-dose regimens are up to 1.0–1.5 g/kg/day.

Question 4

A 30-year-old female presents with a 5-day history of subjective fever and malaise. She does not
have a thermometer at home but has felt alternately warm and chilled. She has felt generally
unwell and is sleeping more than usual. She has had a decreased appetite but has been drinking
fluids without difficulty. She does not have a runny nose, cough, headache, abdominal pain,
vomiting, diarrhea, joint pain, rash, or pain with urination. Her medical history includes
substance use disorder and she takes buprenorphine/naloxone (Suboxone). She smokes one pack
of cigarettes daily, has 0–2 alcoholic drinks daily, and began using intravenous heroin again 1
week ago.
An examination reveals a blood pressure of 112/68 mm Hg, a pulse rate of 88 beats/min, a
respiratory rate of 16/min, a temperature of 38.9°C (102.0°F), and an oxygen saturation of 95%
on room air. The patient appears fatigued and uncomfortable but nontoxic. Her heart has a
regular rate and rhythm with no murmur. Her lungs are clear to auscultation bilaterally and her
abdomen is soft and nontender. There is no swelling or redness in the extremities and a skin
examination reveals no rashes or lesions.
Which one of the following would be most important at this point?
A) A viral swab
B) An antinuclear antibody level
C) Blood cultures
D) An erythrocyte sedimentation rate
E) A chest radiograph

Answer 4

ANSWER: C
A patient who uses intravenous drugs and has a fever without a clear source must be evaluated for
infectious endocarditis (IE). The first step in this evaluation is to obtain blood cultures. Although this
patient might have a less serious condition, it is critical to evaluate for bacteremia in this situation. If the
concern for IE is high, blood cultures should be obtained and antibiotics may be started while waiting for
results and arranging for urgent echocardiography.
IE in people who inject drugs is more likely to be right-sided, specifically involving the tricuspid valve.
Right-sided IE is less frequently associated with systemic findings of endocarditis such as Janeway lesions
or Roth spots. Patients often do not have a heart murmur.

Question 5

During a newborn examination you note a foot deformity, with the front half of the foot turned
inward. Applying gentle pressure to the forefoot while holding the heel steady brings the heel
and forefoot into alignment.
Which one of the following would you recommend?
A) Observation only
B) Adjustable shoes
C) Serial casting
D) Surgical correction

Answer 5

ANSWER: A
This patient has flexible metatarsus adductus, the most common congenital foot deformity. Flexible
metatarsus adductus usually resolves spontaneously by 1 year of age and does not require treatment. Rigid
metatarsus adductus should be treated with serial casting. Using adjustable shoes is an alternative that is
less expensive than serial casting for motivated parents with children who are not yet walking. Surgical
correction should be reserved for older children who are already walking or for those with persistent
symptomatic metatarsus adductus that is resistant to casting.

Question 6

A 35-year-old female comes to your office for evaluation of a tremor. During the interview you
note jerking movements first in one hand and then the other, but when the patient is distracted
the symptom resolves. Aside from the intermittent tremor the neurologic examination is
unremarkable. She does not drink caffeinated beverages and takes no medications.
Which one of the following is the most likely diagnosis?
A) Parkinson’s disease
B) Cerebellar tremor
C) Essential tremor
D) Physiologic tremor
E) Psychogenic tremor

Answer 6

ANSWER: E
Psychogenic tremor is characterized by an abrupt onset, spontaneous remission, changing characteristics,
and extinction with distraction. Cerebellar tremor is an intention tremor with ipsilateral involvement on
the side of the lesion. Neurologic testing will reveal past-pointing on finger-to-nose testing. CT or MRI
of the head is the diagnostic test of choice. Parkinsonian tremor is noted at rest, is asymmetric, and
decreases with voluntary movement. Bradykinesia, rigidity, and postural instability are generally noted.
For atypical presentations a single-photon emission CT or positron emission tomography may help with
the diagnosis. One of the treatment options is carbidopa/levodopa.
Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head,
voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no
specific diagnostic test but the tremor is treated with propranolol or primidone. Enhanced physiologic
tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of
caffeine use or anxiety.

Question 7

A patient with moderately severe Alzheimer’s disease has been taking quetiapine (Seroquel), 50
mg daily at bedtime, to manage behavioral symptoms related to the dementia. The patient’s
symptoms have been stable on the quetiapine for 6 months. The patient’s spouse is the primary
caregiver and is not aware of any adverse effects. The patient does not have a history of other
psychiatric diagnoses such as schizophrenia or bipolar disorder.
Which one of the following would be the most appropriate intervention at this time?
A) Continue quetiapine at the current dosage
B) Reduce quetiapine to a lower maintenance dosage
C) Taper the quetiapine dosage with the goal of stopping it
D) Start diphenhydramine (Benadryl) while tapering quetiapine with the goal of stopping
it
E) Start lorazepam (Ativan) while tapering quetiapine with the goal of stopping it

Answer 7

ANSWER: C
Behavioral and psychological symptoms of dementia include delusions, hallucinations, aggression, and
agitation. Antipsychotics are frequently used for treatment of these symptoms and are continued
indefinitely. For patients who have been taking antipsychotics for 3 months and whose symptoms have
stabilized, or for patients who have not responded to an adequate trial of an antipsychotic, it is
recommended that the drug be tapered slowly (SOR B).
Physicians should collaborate with the patient and caregivers when deciding whether to use an
antipsychotic. This is recommended because antipsychotic medications have adverse effects, including an
increased overall risk of death, cerebrovascular events, extrapyramidal symptoms, gait disturbances, falls,
somnolence, edema, urinary tract infections, weight gain, and diabetes mellitus. The risk of these harms
increases with prolonged use in the elderly.
One tapering method to consider is to reduce the daily dose to 75%, 50%, and 25% of the original dose
every 2 weeks until stopping the medication. This reduction pace can be slowed for some patients.
Diphenhydramine and lorazepam are on the Beers list of potentially inappropriate medications to use in
older patients and would not be recommended.

Question 8

A healthy 35-year-old female presents to your office to discuss an upcoming trip to Bangladesh.
She currently feels well and has no health problems. She is a nurse and will be traveling with
a church group to work in a clinic for 1 month. This area is known to have a high prevalence
of tuberculosis (TB). She is worried about contracting TB while she is there and asks for
recommendations regarding TB screening. She had a negative TB skin test about 1 year ago at
work. A TB skin test today is negative.
Assuming she remains asymptomatic, which one of the following would you recommend?
A) Prophylactic treatment with isoniazid starting 1 month prior to departure and continuing
throughout her trip
B) Prophylactic treatment with rifampin (Rifadin) starting 1 month prior to departure and
continuing throughout her trip
C) A repeat TB skin test 2 months after she returns
D) A chest radiograph 2 months after she returns
E) An interferon-gamma release assay (IGRA) 6 months after she returns

Answer 8

ANSWER: C
Individuals who travel internationally to areas with a high prevalence of tuberculosis (TB) are at risk for
contracting the disease if they have prolonged exposure to individuals with TB, such as working in a health
care setting. The CDC recommends either a TB skin test or an interferon-gamma release assay prior to
leaving the United States. If the test is negative, the individual should repeat the testing 8–10 weeks after
returning. A chest radiograph in asymptomatic individuals or prophylactic treatment at any point is not
recommended. Isoniazid and rifampin are options for treatment of latent TB.

Question 9

A nulliparous 34-year-old female comes to your office for evaluation of fatigue, hair loss, and
anterior neck pain. These symptoms have been gradually worsening for the past few months.
Her past medical history is unremarkable. She has gained 5 kg (11 lb) since her last office visit
18 months ago. Examination of the thyroid gland reveals tenderness but no discrete nodules. Her
TSH level is 7.5 U/mL (N 0.4–4.2), her T4 level is low, and her thyroid peroxidase antibodies
are elevated.
Which one of the following would be the most appropriate next step?
A) Continue monitoring TSH every 6 months
B) Begin thyroid hormone replacement and repeat the TSH level in 6–8 weeks
C) Begin thyroid hormone replacement and repeat the TSH level along with a T3 level in
6–8 weeks
D) Order ultrasonography of the thyroid
E) Order fine-needle aspiration of the thyroid

Answer 9

This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most
appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8
weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no
need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid
examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient
presents with severe thyroid pain and systemic symptoms.

Question 10

A 35-year-old male presents with depression that started when his wife asked him for a divorce
last month. A depression screen is positive and he has some passive suicidal ideation. He does
not have any prior history of suicide attempts or a specific plan. He does not have any health
issues, a family history of mental health issues, or a history of adverse childhood events.
You would be most concerned that the patient will die from suicide if he
A) has limited support from his family
B) has no religious affiliation
C) has a history of “cutting” as an adolescent
D) has easy access to firearms
E) was hospitalized for an appendectomy 2 months ago

Answer 10

D
Easy access to a lethal means of suicide is a major risk factor for a successful suicide attempt. It is
important to eliminate access to firearms, drugs, or toxins for a patient with any suicidal ideation. Other
risk factors include, but are not limited to, a family history of suicide, previous suicide attempts, a history
of mental disorders, a history of alcohol or substance abuse, and physical illness. Another risk factor in
this patient is loss of a personal relationship. A history of borderline personality disorder (associated with
cutting) is not a risk for successful suicide. Any support from family or friends is helpful, even if it is
limited.

Question 11

A 49-year-old African-American male sees you for a routine health maintenance examination.
His past medical history is significant for sarcoidosis. He has noticed some fatigue and shortness
of breath over the last several months, but he is asymptomatic today. His vital signs are normal
except for an irregular pulse. An EKG performed in the office is shown below. (2nd degree heart block)
Which one of the following would be most appropriate at this point?
A) Observation only
B) Amiodarone (Cordarone)
C) Apixaban (Eliquis)
D) Metoprolol succinate (Toprol-XL)
E) A cardiology assessment for placement of a pacemaker

Answer 11

ANSWER: E
This patient’s EKG shows type II second degree (Mobitz type II) atrioventricular (AV) block. Conduction
disturbances are one of the most common manifestations of cardiac sarcoidosis. In addition to AV block,
supraventricular and ventricular arrhythmias can be seen. Mobitz type II AV block is treated with
pacemaker placement. Metoprolol could be used for treatment of nonsustained ventricular tachycardia,
apixaban for anticoagulation in patients with atrial fibrillation or atrial flutter, and amiodarone for either
supraventricular or ventricular tachycardias.

Question 12

A 70-year-old male presents to your office for follow-up after he was hospitalized for acute
coronary syndrome. He has not experienced any pain since discharge and is currently in a
supervised cardiac rehabilitation exercise program. His medications include aspirin, lisinopril
(Prinivil, Zestril), and metoprolol, but he was unable to tolerate atorvastatin (Lipitor), 40 mg
daily, because he developed muscle aches.
Which one of the following would you recommend?
A) Evolocumab (Repatha)
B) Ezetimibe/simvastatin (Vytorin)
C) Fenofibrate (Tricor)
D) Niacin
E) Omega-3 fatty acid supplements

Answer 12

ANSWER: B
High-intensity statin therapy is recommended for patients younger than 75 years of age with known
coronary artery disease. For those who are intolerant of high-intensity statins, a trial of a
moderate-intensity statin is appropriate. There is evidence to support ezetimibe plus a statin in patients with
acute coronary syndrome or chronic kidney disease. Omega-3 fatty acids, fibrates, and niacin should not
be prescribed for primary or secondary prevention of atherosclerotic cardiovascular disease because they
do not affect patient-oriented outcomes. PCSK9 inhibitors such as evolocumab are injectable monoclonal
antibodies that lower LDL-cholesterol levels significantly and have produced some promising results, but
more studies are needed to determine when this would be cost effective.

Question 13

A 50-year-old male presents with difficulty straightening his left ring finger. Examination of the
affected hand reveals a nodule of the palmar aponeurosis and associated fibrous band that limits
full extension of the fourth finger. He is unable to fully extend both the metacarpophalangeal
(MCP) joint and the proximal interphalangeal (PIP) joint, with MCP and PIP contractures
estimated at 40° and 20°, respectively.
Which one of the following would be the most appropriate management strategy?
A) Observation until the PIP contracture is >90°
B) Serial intralesional injection with a corticosteroid
C) Cryosurgery of the fibrous nodule
D) Referral for physical therapy
E) Referral for surgical release of the contracture

Answer 13

ANSWER: E
This patient has Dupuytren’s disease with a contracture of the affected finger. Surgical release is indicated
when the metacarpophalangeal joint contracture reaches 30° or with any degree of contracture of the
proximal interphalangeal joint. Intralesional injection may reduce the need for later surgery in a patient
with grade 1 disease, but not if there is a contracture. There is no evidence to support the use of physical
therapy or cryosurgery.

Question 14

A 44-year-old female presents for a pretravel consultation and asks about medication options for
traveler’s diarrhea. She will be on an organized tour traveling to a country with a very low risk
for this problem. She plans to take all precautions to further reduce her risk but would also like
you to recommend a medication she can take.
Which one of the following would be an appropriate recommendation?
A) A short course of azithromycin (Zithromax) if she develops diarrhea
B) Loperamide (Imodium) daily, starting 1 day prior to travel and continued until 1 day
after returning home
C) Probiotics daily, starting 1 week prior to travel and continued until 1 week after
returning home
D) Ciprofloxacin (Cipro) daily, starting 2 weeks prior to travel and continued until 4 weeks
after returning home
E) Bismuth subsalicylate daily, starting 2 weeks prior to travel and continued until 4 weeks
after returning home

Answer 14

ANSWER: A
Traveler’s diarrhea is the most common infection in international travelers. A short course of antibiotics
can be taken after a traveler develops diarrhea and usually shortens the duration of symptoms (SOR A).
Azithromycin is preferred to treat severe traveler’s diarrhea. Rifaximin or fluoroquinolones may be used
to treat severe nondysenteric traveler’s diarrhea. Prophylactic antibiotics are not routinely recommended.
For patients at high risk, bismuth subsalicylate reduces the risk but does not need to be initiated prior to
travel. There is insufficient evidence for the use of probiotics to prevent traveler’s diarrhea. Loperamide
can be used with or without antibiotics after symptoms develop but is not recommended for prophylaxis.

Question 15

A 69-year-old female presents to your office with a 5-day history of cough and low-grade fever.
She has a past history of hypertension and obstructive sleep apnea. Her daughter brought her in
this morning because of worsening symptoms. The patient’s temperature is 37.4°C (99.3°F),
her blood pressure is 110/74 mm Hg, her pulse rate is 88 beats/min, her respiratory rate is
36/min, and her oxygen saturation is 95% on room air. She is alert and oriented to person,
place, and time. A CBC and basic metabolic panel are normal except for an elevated WBC count
of 12,500/mm3 (N 4300–10,800). A chest radiograph shows a right lower lobe infiltrate.
This patient has a higher risk of mortality and should be considered for inpatient treatment due
to her
A) female sex
B) underlying hypertension
C) respiratory rate
D) elevated WBC count
E) abnormal chest radiograph

Answer 15

ANSWER: C
There are several decision support tools to assist in predicting 30-day mortality for patients with
community-acquired pneumonia. Calculating the number of high-risk markers can aid in deciding whether
to admit the patient to the hospital. The risk of mortality increases with a respiratory rate 30/min,
hypotension, confusion or disorientation, a BUN level 20 mg/dL, age >65 years, male sex, or the
presence of heart failure or COPD.

Question 16

A 78-year-old male is brought to your office by his daughter. She is concerned that her father
is no longer attending his weekly cribbage and bingo games, has stopped bathing regularly, and
is eating much less.
Which one of the following would be most appropriate at this time?
A) Administering the CAGE screening questionnaire
B) Administering the PHQ-9 screening questionnaire
C) A trial of megestrol
D) A trial of nortriptyline (Pamelor)
E) MRI of the brain

Answer 16

ANSWER: B
This elderly patient is exhibiting classic signs of depression. The PHQ-2 has a similar sensitivity to the
PHQ-9, but the PHQ-9 has a higher specificity in diagnosing depression (91%–94% compared to
78%–92%) and can assist in diagnosing depression. In addition to the PHQ-2 and PHQ-9 there are specific
screening tools for use in the elderly population, including the Geriatric Depression Scale and the Cornell
Scale for Depression in Dementia. Somatic issues and dementia can make it more difficult to screen for
and diagnose depression in this population. The CAGE questionnaire screens for substance abuse.
Megestrol is used to stimulate the appetite, but in this patient the appetite symptoms are likely secondary
to depression so treating the depression would be a more appropriate starting point. The tricyclic
nortriptyline is used to treat depression but is not first-line therapy, especially in the elderly. In general,
a more extensive medical history and a physical examination are indicated before ordering MRI of the
brain.

Question 17

The U.S. Preventive Services Task Force recommends which one of the following for
prevention of falls in community-dwelling adults 65 years of age who are at increased risk for
falls?
A) Empirical vitamin D supplementation
B) Psychological evaluation and treatment programs
C) In-home environmental evaluation and modification
D) Regular participation in an exercise program

Answer 17

ANSWER: D
The U.S. Preventive Services Task Force (USPSTF) recommends exercise interventions to prevent falls
in community-dwelling adults 65 years of age who are at increased risk for falls (B recommendation).
This recommendation is based on several studies that demonstrated improved fall-related outcomes for
individuals from this population who participated in exercise programs. Strength and resistance exercises
were specifically identified as beneficial. The evidence exists to support group-based exercises is less
convincing.
It is also recommended that clinicians selectively offer multifactorial interventions to prevent falls in this
population, based on the possible small benefit and minimal risk (C recommendation). The USPSTF
recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years
of age with the caveat that this applies only to those who are not known to have osteoporosis or vitamin
D deficiency (D recommendation).

Question 18

A 30-year-old gravida 1 para 0 develops erythematous patches with slightly elevated scaly
borders during her first trimester. There was a 2-cm herald patch 2 weeks before multiple
smaller patches appeared. The rash on the back has a “Christmas tree” pattern. She has not had
any prenatal laboratory work.
This condition is associated with
A) no additional pregnancy risk
B) a small-for-gestational-age newborn
C) congenital cataracts
D) multiple birth defects
E) spontaneous abortion

Answer 18

ANSWER: E
This patient has classic pityriasis rosea. This is generally a benign disease except in pregnancy. The
epidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible to
pityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate of
spontaneous abortion in the first 15 weeks of gestation. It is not associated with an increased risk for a
small-for-gestational-age newborn, congenital cataracts, or multiple birth defects.

Question 19

A 57-year-old male with diabetes mellitus and hypertension presents with a 1-month history of
pain in his hands and elbows. His hands are shown below. On examination they are tender and
he has soft swelling of the wrists, metacarpophalangeal (MCP) joints, and proximal
interphalangeal (PIP) joints. Plain films show mild, diffuse bony erosions in the MCP and PIP
joints.
Which one of the following is the most likely diagnosis?
A) Dermatomyositis
B) Osteoarthritis
C) Psoriatic arthritis
D) Rheumatoid arthritis
E) Systemic lupus erythematosus

Answer 19

ANSWER: D
This patient’s clinical findings and radiographs indicate a diagnosis of inflammatory arthritis, most likely
rheumatoid arthritis. Symmetric small-joint inflammatory arthritis is typical of rheumatoid arthritis and
systemic lupus erythematosus (SLE), but bony erosions are not seen in SLE. Psoriatic arthritis can also
affect small joints but is typically not symmetric. Dermatomyositis can present with a thick, bright red rash
over the metacarpophalangeal (MCP) and interphalangeal joints (Gottron’s sign) but is typically associated
with proximal muscle weakness rather than joint pain or erosions that can be seen on radiographs.
Osteoarthritis does not typically cause the soft-tissue swelling seen in the image. It usually affects the distal
and proximal interphalangeal joints while sparing the MCP joints, and it results in osteophytes and joint
space narrowing that can be seen on radiographs.

Question 20

A 77-year-old Spanish-speaking female with end-stage heart failure has elected hospice care to
be provided at home for the duration of her life. A trained interpreter is available for assistance
when you see the patient and is present in the room.
Which one of the following is considered a best practice when using interpreters?
A) Addressing the patient directly when speaking
B) Seating the interpreter closest to the clinician, slightly in front of the patient, to observe
body language when translating
C) Asking the interpreter to serve as a witness for a consent form for hospice
D) Explaining to the interpreter the entire care plan, then having him or her repeat it back
to the patient
E) Explaining in full detail all possible scenarios for symptom management and what to
expect

Answer 20

ANSWER: A
When professional interpreters participate in patient care it is important to speak directly in the first person,
using “I” statements rather than statements that start with “tell her” (SOR C). It is ideal to seat the
interpreter next to or slightly behind the patient, so that the patient is the focus of the interaction.
Sentence-by-sentence interpretation can prevent miscommunication errors, as opposed to expecting the
interpreter to remember every detail of a complex care plan. It is not appropriate for the medical
interpreter to also serve as a witness to consent. Focusing on three or fewer key points rather than
over-communicating multiple complex issues increases the likelihood that the patient will comprehend the
plan of care.

Question 21

Which one of the following treatments has been shown to improve the quality of life for a patient
with tinnitus?
A) Antidepressant therapy
B) Ginkgo biloba
C) Niacin
D) Vitamin B12
E) Cognitive-behavioral therapy

Answer 21

ANSWER: E
Treatments to reduce awareness of tinnitus and tinnitus-related distress include cognitive-behavioral
therapy, acoustic stimulation, and educational counseling. No medications, supplements, or herbal
remedies have been shown to substantially reduce the severity of tinnitus.

Question 22

A 28-year-old female who was recently diagnosed with polycystic ovary syndrome presents to
discuss treatment of irregular menses. She has 2–3 menstrual periods every 6 months that happen
at irregular times and can often produce heavy bleeding. She is not obese and has no significant
acne or hirsutism. She does not desire pregnancy and her primary goal is to decrease the heavy
menstrual bleeding.
Which one of the following would be the most effective initial recommendation?
A) Dietary modifications aimed at weight loss
B) Clomiphene
C) Metformin (Glucophage)
D) Spironolactone (Aldactone)
E) Placement of a levonorgestrel IUD (Mirena)

Answer 22

ANSWER: E
Polycystic ovary syndrome can significantly affect multiple organ systems, and menstrual irregularities
from anovulatory cycles are very common. Treatment should be based on the patient’s goals and modified
based on her desire for fertility. In a patient who is not interested in near-term fertility and whose goal is
to control menstrual irregularities, a levonorgestrel IUD is most likely to reduce the frequency, duration,
and volume of bleeding. Metformin is used to treat insulin resistance, dietary modifications are used to
treat obesity, spironolactone can be used to treat hirsutism or acne, and clomiphene is used to induce
ovulation and fertility.

Question 23

A 6-month-old male is brought to the urgent care center with a 3-day history of rhinorrhea,
cough, and increased respiratory effort. His temperature is 37.5°C (99.5°F), his heart rate is
120 beats/min, his respiratory rate is 42/min, and his oxygen saturation is 96% on room air. On
examination the child appears well hydrated with clear secretions from his nasal passages, there
is diffuse wheezing heard bilaterally, and there is no nasal flaring or retractions. The mother
states that the child has a decreased appetite but is drinking a normal amount of fluids.
Which one of the following would be the most appropriate management for this patient?
A) Supportive therapy only
B) Bronchodilators
C) A corticosteroid taper
D) Epinephrine
E) Nebulized hypertonic saline

Answer 23

ANSWER: A
This patient’s symptoms and the examination suggest viral bronchiolitis. Supportive therapy, including
adequate hydration, is recommended for treatment. Treatment with bronchodilators, epinephrine,
hypertonic saline, or corticosteroids is not indicated (SOR A).

Question 24

In asymptomatic patients with sarcoidosis, which one of the following organ systems should be
examined yearly to detect extrapulmonary manifestations of the disease?
A) Cardiac
B) Neurologic
C) Ocular
D) Integumentary

Answer 24

ANSWER: C
Sarcoidosis has numerous extrapulmonary manifestations. Because inflammation of the eye can result in
permanent impairment and is often asymptomatic, patients require yearly eye examinations as well as
additional monitoring with disease flares. Although skin involvement is common it is usually readily
apparent and rarely has serious sequelae. Cardiac sarcoidosis can potentially lead to progressive heart
failure and sudden death, but evaluation is needed only in patients who are symptomatic. Similarly,
evaluation for neurologic involvement is needed only in patients who are symptomatic.

Question 25

In addition to a thorough history and physical examination, the routine evaluation of patients
presenting with syncope should include
A) a CBC, comprehensive metabolic panel, TSH level, and urinalysis
B) orthostatic blood pressure measurements and an EKG
C) cardiac stress testing
D) echocardiography and Doppler ultrasonography of the carotid arteries
E) CT or MRI of the brain

Answer 25

ANSWER: B
Orthostatic blood pressure measurement and an EKG are indicated in the routine evaluation of patients with
syncope. All other testing should be directed by findings obtained in the history and on the physical
examination.

Question 26

A 67-year-old male presents for a Medicare wellness visit. He underwent basic laboratory work
prior to the office visit. He is feeling well and does not have any concerns or symptoms. His
blood pressure is 127/76 mm Hg, his heart rate is 64 beats/min, and he is afebrile. A
comprehensive metabolic panel is unremarkable. A CBC shows the following results:
WBCs                                7500/mm3 (N 4100–10,900)
RBCs                                 4.05 million/mm3 (N 4.70–6.10)
Hemoglobin                           12.9 g/dL (N 14.0–18.0)
Hematocrit                            39% (N 42–52)
Mean corpuscular volume                82 m3 (N 80–95)
Platelets                              197,000/mm3 (N 130,000–448,000)
Which one of the following would be the most appropriate next step in the workup of this
patient?
A) A serum ferritin level
B) A serum transferrin receptor–ferritin index
C) Oral iron supplementation, and a repeat CBC in 4 weeks
D) Referral to a gastroenterologist

Answer 26

ANSWER: A
Anemia is often diagnosed incidentally on laboratory testing and is often asymptomatic. It is associated
with increased morbidity and mortality in older adults, and is often caused by nutritional deficiencies,
chronic kidney disease, occult blood loss from gastrointestinal malignancies, or chronic inflammation.
However, in many patients the cause remains unknown. A detailed history and physical examination are
indicated. In patients with normocytic or microcytic anemia, a serum ferritin level should be ordered. A
low serum ferritin level is associated with iron deficiency and should be further evaluated so the underlying
cause can be addressed. A serum transferrin-receptor–ferritin index should be determined for patients with
a serum ferritin level between 46 and 100 ng/mL to distinguish between iron deficiency anemia and other
types of anemia. Referring this patient to a gastroenterologist would not be indicated at this time.

Question 27

A 57-year-old male presents with left posterior heel pain that started several weeks ago. An
examination reveals a nodular appearance at the site of insertion of the Achilles tendon to the
calcaneus, and local tenderness of the distal tendon.
Which one of the following would be the safest and most appropriate initial management?
A) Local injection with a corticosteroid
B) Local injection with platelet-rich plasma
C) Physical therapy with eccentric calf-strengthening exercises
D) Immobilization of the ankle in a cast or boot for 4–6 weeks
E) Surgical debridement of the calcification about the distal tendon

Answer 27

ANSWER: C
This patient has typical symptoms and findings of Achilles tendinopathy. The best management involves
eccentric calf-strengthening exercises. A local injection with corticosteroids or with platelet-rich plasma
is ineffective and may increase the risk of a tendon rupture. Immobilization and surgical debridement may
be considered if more conservative therapies have failed.

Question 28

A 35-year-old gravida 2 para 2 reports diminished sexual arousal since initiating antidepressant
therapy with sertraline (Zoloft). She has normal menstrual cycles and does not have any other
symptoms.
Which one of the following would you recommend?
A) Black cohosh, 40 mg daily
B) Bupropion (Wellbutrin), 150 mg twice daily
C) Ethinyl estradiol, 0.5 mg daily
D) Ospemifene (Osphena), 60 mg daily
E) A testosterone patch, 300 g applied twice weekly

Answer 28

ANSWER: B
Bupropion can improve antidepressant-related sexual arousal dysfunction (SOR B). Black cohosh is
considered a safe alternative for treating menopausal vasomotor symptoms, but not for treating sexual
arousal dysfunction in women who are premenopausal. Ethinyl estradiol may be taken to improve sexual
dysfunction related to menopausal symptoms. Vaginal estrogen therapy is recommended over oral estrogen
when vaginal dryness is the primary symptom. Ospemifene is indicated for dyspareunia related to vulvar and vaginal atrophy due to menopause. Testosterone has proven to be effective for treating menopause-related low sexual desire but the evidence is limited due to the lack of long-term data. The Endocrine Society recommends consideration of a 3- to 6-month course of testosterone specifically for
postmenopausal women with low sexual desire.

Question 29

A 67-year-old male presents to your office for evaluation of chronic redness, flaking, and
discomfort of his eyelids. Additionally, his eyes feel irritated, dry, and sandpapery at times. He
has had difficulties with these symptoms on and off throughout his life but they have worsened
lately. He has not had any vision changes and does not wear contact lenses.
On examination his eyelids appear red and mildly swollen with yellow crusting at the bases of
the eyelashes. You note bilateral mild conjunctival injection. Visual acuity is intact, as are pupil
reactions and extraocular movements.
Which one of the following treatments is appropriate first-line therapy for this condition?
A) Warm compresses and gentle cleansing with a mild shampoo
B) Sodium sulfacetamide eye drops
C) Topical betamethasone
D) Oral acyclovir (Zovirax)
E) Oral cephalexin (Keflex)

Answer 29

ANSWER: A
This patient has blepharitis, a chronic inflammation of the eyelids. Seborrhea is a common cause in older
adults. In younger patients including children, colonization with Staphylococcus may be a contributing
factor. Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of
tear films, which leads to dry eyes and irritation. Other diagnoses to consider in this patient include
conjunctivitis, preseptal cellulitis, and Sjögren’s syndrome. Conjunctivitis typically involves the
conjunctiva and an eye discharge but less involvement of the eyelids is present. Cellulitis is an acute rather
than chronic condition and involves more pain and swelling. Sjögren’s syndrome causes dry eye but not
inflammatory changes of the lid.
The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried
secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization
load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral
antibiotics can be considered for more severe cases.

Question 30

A patient with a BMI of 32 kg/m2 has type 2 diabetes that is currently controlled by lifestyle
interventions, including moderate-intensity physical activity and healthy low-calorie meals. The
patient asks about nonnutritive sweeteners, containing few or no calories.
According to the American Diabetes Association, which one of the following would be the most
appropriate advice?
A) Sucrose (table sugar) is preferred
B) Nonnutritive sweeteners are acceptable to use
C) Nonnutritive sweeteners worsen glucose control
D) Sucralose-based sweeteners, such as Splenda, should be avoided
E) Sweeteners with aspartame, such as Equal, should be avoided

Answer 30

ANSWER: B
Nonnutritive sweeteners contain few or no calories. According to the American Diabetes Association,
nonnutritive sweeteners may be acceptable to use instead of nutritive sweeteners such as sucrose. They
should be used in moderation if they are used.
The use of nonnutritive sweeteners can help to reduce overall intake of carbohydrates and calories. They
do not significantly affect glycemic control. Research is inconsistent regarding the effects of nonnutritive
sweeteners on weight loss, but most systematic reviews and meta-analyses demonstrate a benefit.
There is no recommendation to avoid sucralose or aspartame in patients with type 2 diabetes. Beverages
sweetened with sugar are associated with an increased risk of type 2 diabetes.

Question 31

A 32-year-old female presents with a 4-month history of nasal drainage, congestion, and loss
of her sense of smell. She reports having a cold about 4 months ago that never resolved. On
examination the nasal turbinates are swollen and you note mucopurulent drainage on the right.
Which one of the following is the most likely cause of her symptoms?
A) Chronic rhinosinusitis
B) Granulomatosis with polyangiitis (Wegener’s granulomatosis)
C) Nasal polyposis
D) Sarcoidosis
E) Seasonal allergic rhinitis

Answer 31

ANSWER: A
The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of two of four
cardinal symptoms, which include nasal drainage, nasal obstruction, facial pain or pressure, and hyposmia
or anosmia, along with objective signs on examination or radiographic studies. This patient has three
cardinal symptoms of chronic rhinosinusitis and objective evidence on the physical examination. No nasal
polyps were seen on the examination. Granulomatosis with polyangiitis and sarcoidosis can both present
similarly but are uncommon causes of chronic rhinosinusitis. Allergic rhinitis can be associated with
chronic rhinosinusitis but would also present with allergic symptoms.

Question 32

A 52-year-old female with metastatic breast cancer is hospitalized for treatment of complications
from her cancer treatment. She has developed a new onset of back pain that has been
progressively worsening over the past few hours. The pain is worse when she is lying down and
is not responsive to pain medication.
Which one of the following would be the most appropriate next step to address this patient’s
back pain?
A) Increase the dosage of her immediate-release morphine
B) Increase the dosage of her sustained-release morphine
C) Order cyclobenzaprine
D) Order an urgent MRI
E) Order a physical therapy consultation for mobility

Answer 32

ANSWER: D
Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm
the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset
progressive back pain that is worse when the patient is lying down. It is most commonly associated with
breast cancer and develops in approximately 5% of all patients with cancer. Once the diagnosis is
confirmed, an urgent management approach is needed. Corticosteroids and neurosurgical intervention can
preserve motor and sensory function. Attempting to alleviate the pain would not address this emergency.

Question 33

A 78-year-old female with Alzheimer’s disease is accompanied to an office visit by her daughter.
The daughter has asked to complete an advance directive giving her medical power of attorney.
Which one of the following would indicate that the patient lacks capacity to make decisions with
regard to completing her medical directive?
A) A dementing illness
B) Inconsistent answers to questions
C) Lack of orientation to time
D) Asking that her son make medical decisions for her instead of her daughter
E) A score of 24/30 on the Mini-Mental State Examination

Answer 33

ANSWER: B
In order for patients to show they have the capacity to make a decision they must demonstrate an
understanding of the situation, including the risks, benefits, and consequences of the decision or refusal
of care. If a patient gives inconsistent answers to questions after multiple explanations, this indicates that
there is a lack of understanding and would meet one of the criteria to determine that the patient lacks the
capacity to make that decision. The presence of dementia can be associated with an increased incidence
of having a lack of capacity; however, a diagnosis of dementia by itself does not indicate that the patient
lacks the capacity to make a decision. While disorientation to time or a lower score on the Mini-Mental
State Examination is associated with an increased risk of lacking capacity, these findings alone would not
be enough to determine that the patient lacks capacity. The patient asking that her son be her medical
decision maker instead of her daughter would not be an indication that she lacks capacity.

Question 34

A 72-year-old male with a past history of hypertension, COPD, and pulmonary embolism
presents with nonspecific symptoms including fatigue and syncope. You suspect he has
pulmonary hypertension.
Which one of the following would be the most appropriate initial test?
A) Pulmonary function tests
B) Chest CT with contrast
C) Echocardiography
D) A coronary calcium scan
E) Right heart catheterization

Answer 34

ANSWER: C
According to national guidelines echocardiography is the preferred initial noninvasive testing modality
when pulmonary hypertension is suspected (SOR C). Pulmonary function tests provide helpful information
in regard to pulmonary capacity but are not necessarily diagnostic of pulmonary hypertension. CT of the
chest with contrast will not provide pulmonary pressures but may assist in the detection of pulmonary
emboli. A coronary calcium scan may be indicated to evaluate for coronary artery disease but it is not a
diagnostic test for pulmonary hypertension. Although right heart catheterization would provide pulmonary
pressure values it is considered more invasive than echocardiography and is not always necessary for
making the diagnosis.

Question 35

A 19-year-old female member of a college cross-country team presents with a 1-week history
of right knee pain. She does not have any acute injury to the knee. An examination reveals no
deformity and she has a normal gait. She has tenderness and subtle swelling localized 1 cm distal
to the right medial joint line, and examinations of the knee and hip are otherwise normal.
Which one of the following is the most likely diagnosis?
A) Fibular head stress fracture
B) Iliotibial band syndrome
C) Medial meniscal tear
D) Pes anserine bursitis
E) Tibial apophysitis (Osgood-Schlatter disease)

Answer 35

ANSWER: D
This patient has medial knee pain related to repetitive use, most likely caused by pes anserine bursitis.
Iliotibial band syndrome is often related to overuse but causes pain in the lateral knee. The fibular head
is also lateral to the knee joint. Osgood-Schlatter disease is also often related to overuse but causes pain
at the insertion of the patellar ligament on the midline proximal tibia. A medial meniscal tear would
localize to the medial joint line rather than distal to the joint line and would more likely be associated with
positive findings from other examinations, such as a McMurray test.

Question 36

A 52-year-old female sees you because of a vaginal discharge. An examination reveals a
malodorous, greenish-yellow, frothy discharge, and inflammation of the cervix and vagina.
Which one of the following is the most likely diagnosis?
A) Atrophic vaginitis
B) Irritant/allergic vaginitis
C) Bacterial vaginosis
D) Trichomoniasis
E) Vulvovaginal candidiasis

Answer 36

ANSWER: D
Trichomoniasis classically presents as a greenish-yellow, frothy discharge with a foul odor. Erythema and
inflammation of the vagina and cervix are often present and can include punctate hemorrhages (strawberry
cervix). Atrophic vaginitis may cause a thin, clear discharge and is usually associated with a thin, friable
vaginal mucosa. Irritant/allergic vaginitis causes burning and soreness with vulvar erythema but usually
does not cause any significant discharge. Bacterial vaginosis more commonly presents as a thin,
homogenous discharge with a fishy odor and no cervical or vaginal inflammation. Vulvovaginal candidiasis
presents with white, thick, cheesy, or curdy discharge.

Question 37

The father of a healthy 14-year-old male calls you about a recent mumps outbreak in your
community. The child never received the MMR vaccine because the parents declined the
immunization despite extensive counseling about the topic.
You advise the father that
A) mumps typically starts with a cough, coryza, and conjunctivitis
B) mumps causes a pruritic rash with fluid-filled blisters
C) mumps can cause orchitis, possibly resulting in decreased fertility
D) Koplik spots or whitish papules in the mouth are pathognomonic for mumps
E) the MMR vaccine is not recommended for patients in this age range

Answer 37

ANSWER: C
Prodromal symptoms of mumps include myalgia, fatigue, loss of appetite, fever, and headache. Parotitis
is the most common manifestation. Infertility, meningitis, and encephalitis are serious complications of
orchitis. Measles is characterized by cough, coryza, conjunctivitis, and Koplik spots. Varicella is
characterized by a pruritic rash with fluid-filled blisters. MMR vaccine is indicated for this child.

Question 38

A 42-year-old female with diabetes mellitus comes to your office because of recurrent yeast
infections. She is taking numerous agents in an attempt to lower her glucose level.
Which one of the following classes of antidiabetic agents is associated with an increased risk for
candidiasis?
A) Biguanides such as metformin (Glucophage)
B) DPP-4 inhibitors such as sitagliptin (Januvia)
C) SGLT2 inhibitors such as empagliflozin (Jardiance)
D) GLP-1 receptor agonists such as liraglutide (Victoza)
E) Sulfonylureas such as glipizide (Glucotrol)

Answer 38

ANSWER: C
SGLT2 inhibitors are known to cause an increased risk of yeast vaginitis because their mechanism of action
involves blocking renal uptake of glucose, which results in an increase in glucosuria (SOR A). Common
side effects of metformin include gastrointestinal upset. DPP-4 inhibitors have very few side effects.
GLP-1 receptor agonists typically cause nausea and early satiety and weight loss. Sulfonylureas are
associated with weight gain and hypoglycemia.

Question 39

A gravida 2 para 0 at 34 weeks gestation presents to your office because of diffuse itching. She
does not have any known allergies other than seasonal allergies, and she does not have any new
contacts. An examination is normal other than some scattered excoriations, and there is no other
distinct rash. She has tried moisturizers but her symptoms have not improved.
Which one of the following would be most appropriate at this point?
A) Monitoring for the development of a rash
B) Liver function tests and serum bile acid levels
C) Topical corticosteroids
D) Oral antihistamines
E) Varicella-zoster immune globulin

Answer 39

ANSWER: B
Whenever a pregnant woman presents with pruritus without a primary rash, it is important to evaluate her
for intrahepatic cholestasis of pregnancy. This diagnosis is associated with increased fetal mortality and
warrants increased antenatal surveillance as well as possible induction by 35–37 weeks gestation. It is most
appropriate to check for elevation of liver function tests and serum bile acids. Emollients, topical
corticosteroids, and oral antihistamines can all be helpful for pruritus and certain rashes, but in this patient
it is most important to promptly look for the cause of the pruritus. Varicella-zoster immune globulin would
be indicated if she had no immunity to varicella and had been exposed to varicella or if she had a rash that
was suspected to be chickenpox.

Question 40

When titrating the dosage of opioids, the CDC recommends that you should also consider
prescribing naloxone when the opioid dosage reaches what morphine milligram equivalent
(MME) per day threshold?
A) 30
B) 50
C) 80
D) 90
E) 100

Answer 40

ANSWER: B
To mitigate the risk of opioid harm, it is essential to understand morphine milligram equivalents (MME).
The evidence shows that the risk of an opioid overdose increases at the threshold of 50 MME/day. It is
therefore recommended by the CDC that a prescription for naloxone be ordered when an opioid dosage
reaches 50 MME/day, which is a high dosage. In general one should avoid prescribing 90 MME/day
because of the substantially higher risk of an overdose at this dosage level.

Question 41

A 62-year-old female with stage 3 chronic kidney disease and an estimated glomerular filtration
rate of 37 mL/min/1.73 m2 is found to have a mildly low ionized calcium level. Which one of
the following would you expect to see if her hypocalcemia is secondary to her chronic kidney
disease?
A) Elevated parathyroid hormone (PTH) and elevated phosphorus
B) Elevated PTH and low phosphorus
C) Low PTH and elevated phosphorus
D) Low PTH and low phosphorus

Answer 41

ANSWER: A
Chronic kidney disease–mineral and bone disorder (CKD-MBD) is found in many patients with CKD and
is associated with an increased risk of bone fractures and cardiovascular events due to vascular
calcification. In patients with CKD, phosphate is not appropriately excreted and the subsequent
hyperphosphatemia leads to secondary hyperparathyroidism and binding of calcium. Decreased production
of calcitriol in patients with CKD also leads to hypocalcemic hyperparathyroidism. Patients with CKD
stages 3a–5 should have phosphorus, calcium, parathyroid hormone, and 25-hydroxyvitamin D levels
checked regularly, and consultation with a nephrologist or endocrinologist should be obtained if
CKD-MBD is suspected.

Question 42

A 1-day-old newborn is brought to your office for a routine examination. His parents report that
he is well. The prenatal course and delivery were unremarkable. An examination is normal
except for a 1-cm wide dimple on the sacrum, 1 cm superior to the anus. The dimple has a tuft
of dark hair.
At this point you would recommend
A) a follow-up examination in 1 month
B) ultrasonography
C) MRI
D) a fistulogram/sinogram
E) a dermatology consultation

Answer 42

ANSWER: B
Recognizing clinically significant abnormalities on the newborn examination is important. Newborns with
small sacral dimples located far from the anal verge, without other skin findings such as hair, do not need
imaging to rule out spinal dysraphism (tethered cord). While the exact parameters of what is considered
large (>0.5 cm diameter) and close (within 2.5 cm of the anal verge) can easily be found in reference
materials, the dimple described here is clearly concerning and needs imaging. Ultrasonography can
accurately and safely detect spinal dysraphism in these cases.

Question 43

A 63-year-old female sees you for evaluation of recurrent right foot swelling and redness. She
has a history of obesity and type 2 diabetes with retinopathy, nephropathy, and peripheral
neuropathy. She presented with similar symptoms 2 weeks ago and was diagnosed with cellulitis
and treated with a 10-day course of amoxicillin/clavulanate (Augmentin). Her symptoms seemed
to initially improve with this therapy along with elevation of the foot but then worsened. She
does not have any pain in the foot, fever, or chills. She does not recall any trauma or other
inciting event.
The patient’s vital signs include a temperature of 37.1°C (98.8°F), a pulse rate of 72 beats/min,
and a blood pressure of 124/82 mm Hg. Her right foot appears swollen, red, and warm to the
touch, and is not tender to palpation. There are no open sores or calluses. Her dorsalis pedis
pulse is 2+. Monofilament testing confirms a diagnosis of peripheral neuropathy. A WBC count
is normal. Radiographs reveal soft-tissue edema with no other abnormalities.
The most appropriate treatment at this point would be
A) immobilization
B) antibiotics
C) bisphosphonates
D) corticosteroids
E) surgical repair

Answer 43

ANSWER: A
This patient has acute Charcot neuroarthropathy, an inflammatory condition that occurs in obese patients
with peripheral neuropathy and ultimately leads to foot deformities (the classic rocker-bottom foot) and
resultant ulcerations and infections. Its clinical appearance can easily be initially mistaken for cellulitis.
However, the absence of tenderness and other signs of infection such as fever, an elevated WBC count,
and inflammatory markers is not consistent with cellulitis. Radiography is an appropriate initial imaging
modality but the results are often interpreted as normal early in the disease process. MRI is the modality
of choice for a definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent
soft-tissue edema, joint effusion, and microtrabecular or stress fractures.
The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which
increases the total surface area of contact to the entire lower extremity, distributing pressure away from
the foot. Immobilization is typically required for at least 3–4 months but in some cases may be needed for
up to 12 months. Bisphosphonates were found to be ineffective as adjunctive therapy in acute Charcot
neuroarthropathy. Corticosteroids and antibiotics have no role in the treatment of Charcot foot but would
be appropriate therapy for cellulitis or gout, which are important alternative diagnoses to consider. The
role of surgery is more controversial but may be indicated in the acute phase of Charcot neuroarthropathy
in patients with severe dislocation or instability.

Question 44

A 38-year-old female with a 6-month history of mild shortness of breath associated with some
intermittent wheezing during upper respiratory infections presents for follow-up. You previously
prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler, which she says helps her
symptoms. You suspect asthma. Pulmonary function testing reveals a normal FEV1/FVC ratio
for her age.
Which one of the following would be the most appropriate next step?
A) Consider an alternative diagnosis
B) Assess her bronchodilator response
C) Perform a methacholine challenge
D) Prescribe an inhaled corticosteroid
E) Proceed with treatment for COPD

Answer 44

ANSWER: C
Spirometry is central to confirming the diagnosis of asthma, which is characterized by a reversible
obstructive pattern of pulmonary function. In this case the patient’s FEV1/FVC ratio is normal, which
neither confirms nor rules out asthma. A methacholine challenge is recommended in this scenario to assess
for the airway hyperresponsiveness that is the hallmark of asthma. Methacholine is a cholinergic agonist.
Bronchoconstriction (defined as a reduction in FEV1 20%) observed at low levels of methacholine
administration (<4 mg/mL) is consistent with asthma. If the FEV1/FVC ratio is reduced on initial
spirometry, a bronchodilator response should be tested. A fixed or partially reversible obstructive pattern
suggests an alternative diagnosis such as COPD, and full reversal after bronchodilator use is consistent
with asthma. Inhaled corticosteroids are not appropriate for intermittent asthma.

Question 45

An 80-year-old former smoker sees you for a 6-month follow-up for hypertension. He is taking
carvedilol (Coreg), amlodipine (Norvasc), and low-dose aspirin. His home blood pressure
readings have been 130–150/80–90 mm Hg. Over the last 4 months he has developed pain in his
thighs when walking to his mailbox a block away. The pain resolves after he sits for a few
minutes.
On examination he has a blood pressure of 135/85 mm Hg, a heart rate of 72 beats/min, a BMI
of 26 kg/m2, and an oxygen saturation of 95% on room air. Examinations of the heart and lungs
are normal. There is dependent rubor of both legs but posterior tibial pulses are palpable. No
ulcerations are noted. You obtain ankle-brachial indices of 0.85 on the left and 0.80 on the right.
You prescribe a daily walking program.
Which one of the following additional measures would be most appropriate for this patient?
A) Add atorvastatin (Lipitor)
B) Add clopidogrel (Plavix)
C) Add lisinopril (Prinivil, Zestril) to achieve a goal blood pressure <120/80 mm Hg
D) Discontinue aspirin and start warfarin (Coumadin)
E) Refer to a vascular surgeon

Answer 45

ANSWER: A
Management of asymptomatic peripheral artery disease (PAD) should initially be conservative and should
include a walking program (SOR A), smoking cessation, and a healthy diet. Statins should be started for
all patients with PAD regardless of their LDL-cholesterol levels (SOR A). High-intensity statins should
be used if tolerated. A single antiplatelet agent is recommended for patients with PAD. Both aspirin and
clopidogrel are effective in the reduction of stroke, but the combination of the two is recommended only
after revascularization surgery.
Blood pressure control is indicated in patients with PAD but no antihypertensive class is clearly superior
to another, although there is some evidence that ACE inhibitors may have additional benefits in terms of
walking and pain. In an 80-year-old patient, lowering blood pressure below 120/80 mm Hg can be
associated with significant side effects, including a greater risk of falls. Anticoagulants have not been
shown to reduce the risk of major cardiovascular events in patients with PAD and they increase the risk
of life-threatening bleeding. Referral to a vascular surgeon or for angiography is indicated if conservative
therapy fails or symptoms worsen acutely, pain occurs at rest, or the patient develops ulcerations or loss
of tissue.

Question 46

An 84-year-old male nursing home resident with dementia is noted to have a weight loss of about
5% in the past 6 months. Which one of the following would be most appropriate?
A) Avoiding dietary restrictions
B) An appetite stimulant
C) Vitamin B12, vitamin D, and selenium supplements
D) An omega-3 fatty acid supplement
E) Tube feeding

Answer 46

ANSWER: A
Effective interventions for weight loss in nursing home patients include providing meals in a pleasant,
home-like environment. Avoiding dietary restrictions has low quality evidence of effectiveness. There is
high quality evidence that initiating tube feedings in patients with severe dementia is not only ineffective
but may lead to problems such as decubitus ulcers and aspiration. There is low to very low evidence of
the effectiveness for prescribing appetite stimulants, selenium, vitamin B, or vitamin D supplements unless
there is a documented deficiency. Neither quality of life nor survival is improved.

Question 47

According to the most recent American College of Cardiology/American Heart Association
guidelines, hypertension is defined as a blood pressure reading greater than
A) 120/80 mm Hg
B) 130/80 mm Hg
C) 135/85 mm Hg
D) 140/90 mm Hg
E) 150/90 mm Hg

Answer 47

ANSWER: B
The latest American College of Cardiology/American Heart Association guidelines promote a radical
change in the management of hypertension, which they now define as a blood pressure 130/80 mm Hg.
Elevated blood pressure is defined as a systolic pressure of 120–129 mm Hg and a diastolic pressure <80
mm Hg. A blood pressure of 130–139/80–89 mm Hg is classified as stage 1 hypertension and a systolic
pressure 140 mm Hg or a diastolic pressure 90 mm Hg is classified as stage 2 hypertension.

Question 48

A 26-year-old G2P1001 at 30 weeks gestation was recently diagnosed with gestational diabetes
and is ready to start testing her blood glucose at home. Which one of the following is the
recommended goal for fasting blood glucose in this patient?
A) <75 mg/dL
B) <95 mg/dL
C) <120 mg/dL
D) <150 mg/dL
E) <180 mg/dL

Answer 48

ANSWER: B
The goal fasting blood glucose level in patients with gestational diabetes is <95 mg/dL. A fasting glucose
level <80 mg/dL is associated with increased maternal and fetal complications. The goal 2-hour
postprandial glucose level is <120 mg/dL and the goal 1-hour postprandial glucose level is <140 mg/dL.

Question 49

A 67-year-old male diagnosed with polymyalgia rheumatica is started on long-term prednisone
therapy. Which one of the following is the recommended first-line agent to prevent
steroid-induced osteoporosis?
A) Alendronate (Fosamax)
B) High-dose vitamin D
C) Raloxifene (Evista)
D) Teriparatide (Forteo)

Answer 49

ANSWER: A
Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term
glucocorticoid therapy, defined as >2.5 mg of prednisone for a duration of 3 months or longer. The
American College of Rheumatology recommends pharmacologic treatment for these patients, as well as
for patients receiving glucocorticoids who have a bone mineral density T-score –2.5 at either the spine
or the femoral neck and are either male and 50 years of age or female and postmenopausal. Therapy is
also recommended in patients 40 years of age who do not meet these criteria but have a 10-year risk of
major osteoporotic fracture of at least 20% or a risk of hip fracture of at least 3% according to the FRAX
tool.
Oral bisphosphonates are recommended as first-line agents for preventing glucocorticoid-induced
osteoporotic fractures, although intravenous bisphosphonates can be used if patients are unable to use the
oral forms. Supplementation of calcium (800–1000 mg) and vitamin D (400–800 IU) is also recommended.
Raloxifene and teriparatide are options when bisphosphonate therapy fails or is contraindicated (SOR A).

Question 50

At a routine well child check, the mother of an 18-month-old female expresses concern about
the child’s development. Which one of the following should prompt consideration of a
developmental delay?
A) A vocabulary of less than six words
B) Failure to point to pictures or body parts when named
C) Inability to follow one-step directions
D) Inability to run well
E) Inability to copy a vertical line

Answer 50

ANSWER: C
At 18 months of age a child should follow one-step directions. Approximately 90% of 18-month-olds say
at least three words, and 50%–90% say six words. The ability to point to body parts or pictures after they
are named is expected at 2 years of age. Not walking at 18 months would be a red flag for delay, but
running well may not yet be accomplished. At 18 months a child would be expected to scribble
spontaneously but not to copy a vertical line.

Question 51

Which one of the following is the strongest indication for formal allergy testing?
A) Erythema and tenderness surrounding an insect sting for 24 hours
B) A fever for 3 days followed by a diffuse urticarial rash in a child
C) A diffuse whole-body rash following ingestion of trimethoprim/sulfamethoxazole
(Bactrim) in a patient with no documented drug allergies
D) Recurrent or persistent upper respiratory symptoms
E) Persistent epigastric pain following ingestion of tomato products

Answer 51

ANSWER: D
Despite 10%–30% of the population being affected by allergic disease, allergy testing does have limitations
and is most useful in certain clinical situations. Allergy testing can be helpful in patients with persistent
sinus infections, allergic rhinitis, and poorly controlled asthma. Allergy testing for insect stings is indicated
only following systemic/anaphylactic or large local reactions, not with limited localized reactions. Three
days of fever followed by a diffuse urticarial rash likely represents a rash associated with a limited viral
illness. Allergy testing for penicillin has a negative predictive value of 95%–98%. Testing for allergy to
other antibiotics has a much lower sensitivity and specificity but does have limited use to help guide
medication choices in patients with multiple allergies and when limited antibiotic options are available.
Persistent epigastric pain following the ingestion of tomato products is more indicative of acid reflux
symptoms rather than a tomato allergy.

Question 52

A 22-year-old male presents to your office the morning after falling onto his outstretched right
hand as he tripped while leaving a bar. He has a deep, dull ache in the right wrist on the radial
side. The pain is worsened by gripping and squeezing. On examination there is some wrist
fullness and the wrist is tender to palpation over the anatomic snuffbox. Radiographs of the wrist
are negative.
Which one of the following would be most appropriate at this time?
A) Rest, ice, compression, elevation, and NSAIDs with no specific follow-up
B) Rest, ice, compression, elevation, and NSAIDs with a follow-up examination in 2 weeks
C) Placement of a thumb spica splint, with a follow-up examination in 2 weeks
D) CT of the wrist to detect an occult fracture
E) Ultrasonography of the wrist to detect a ligament injury

Answer 52

ANSWER: C
The history, symptoms, and physical examination findings in this case suggest a scaphoid fracture. The
scaphoid bone is the most commonly fractured carpal bone and a fall on an outstretched hand can produce
enough force to cause this fracture. This fracture is most common in males 15–30 years of age.
The finding of anatomic snuffbox tenderness is highly sensitive but not specific for a scaphoid fracture.
Initial radiographs often do not demonstrate a fracture. When there is a high clinical suspicion for a
scaphoid fracture but radiographs are negative, it is reasonable to immobilize in a thumb spica splint and
reevaluate in 2 weeks.

Treatment for a sprain with or without follow-up would not be ideal in a situation where a scaphoid
fracture is suspected. MRI or bone scintigraphy can be considered if the patient desires or needs an
immediate diagnosis, but CT and ultrasonography are not appropriate imaging modalities for this fracture.

Question 53

A 54-year-old male develops chest pain while running. He is rushed to the emergency
department of a hospital equipped for percutaneous coronary intervention. An EKG shows 3 mm
of ST elevation in the anterior leads. He is diaphoretic and cool with ongoing chest pain. His
blood pressure is 80/50 mm Hg, his pulse rate is 116 beats/min, and his oxygen saturation is
98% on room air.
You would immediately administer
A) a -blocker
B) dual antiplatelet therapy and an anticoagulant
C) intravenous fibrinolytic therapy
D) an intravenous vasopressor

Answer 53

ANSWER: B
This patient is likely experiencing an acute anterior wall myocardial infarction with possible incipient
cardiogenic shock. Along with initiating the hospital’s protocol for myocardial infarction, immediate
treatment should include dual antiplatelet therapy with a 325-mg dose of nonenteric aspirin, a P2Y12
inhibitor (clopidogrel, prasugrel, or ticagrelor), and an anticoagulant (unfractionated heparin or
bivalirudin). Given the possibility of cardiogenic shock, -blockers should not be used. Unless more than
a 2-hour delay in percutaneous coronary intervention is expected, fibrinolytics should not be administered.
An intravenous vasopressor is not indicated.

Question 54

A 38-year-old female presents for follow-up of a second hospitalization in the past 3 months for
acute hepatitis, thrombocytopenia, and alcohol withdrawal symptoms treated with
benzodiazepines. She says that prior to her hospitalization a week ago she had been drinking a
half pint of vodka daily. She reports that her drinking has gradually increased over the past 10
years but increased significantly 6 months ago after she lost her job at a bar and grill. She knows
her alcohol consumption is causing damage to her liver and tells you that her aunt died of
alcoholic cirrhosis this year. Despite this knowledge she does not want to stop drinking at this
time. She has looked into several alcohol cessation programs in the area but does not think that
they are a good fit for her.
She currently lives with her boyfriend who also uses alcohol and cocaine regularly. She is not
currently speaking to her mother because they “don’t see eye to eye.” She tells you that she has
not consumed alcohol since her discharge from the hospital 2 days ago. She reports that her
abdominal pain, nausea, and vomiting have resolved and she is feeling well.
The most likely diagnosis is
A) alcohol intoxication
B) alcohol withdrawal
C) alcohol use disorder in early remission
D) severe alcohol use disorder

Answer 54

ANSWER: D
This patient presents with 6 out of 11 symptoms of alcohol use disorder within a 12-month period,
including a strong desire or urge to use alcohol, recurrent alcohol use that has contributed to the inability
to fulfill work obligations, continued alcohol use despite interpersonal problems with her family, continued
alcohol use despite knowledge that it is causing physical damage to her liver, development of a tolerance
to the effects of alcohol over time, and withdrawal symptoms that require treatment with benzodiazepines.
Mild alcohol use disorder is defined by the presence of 2–3 of the 11 symptoms documented in the DSM-5,
whereas 3–5 symptoms indicate moderate alcohol use disorder and 6 or more symptoms indicate severe
alcohol use disorder. This patient has severe alcohol use disorder that is currently active. Early remission
is defined as the absence of symptoms for at least 3 months but less than 12 months. She is not currently
intoxicated, and she does not currently have withdrawal symptoms related to her alcohol use over a week
ago.

Question 55

A 67-year-old male presents to your office because of fatigue and a syncopal episode. His vital
signs in the office are normal. An examination reveals a harsh systolic murmur best heard over
the second right intercostal space radiating to the neck. Echocardiography confirms your
suspected diagnosis.
Which one of the following is the only treatment that improves mortality with this condition?
A) -Blockers
B) Antimicrobial prophylaxis for bacterial endocarditis
C) Aortic valve replacement
D) Mitral valve repair
E) Ventricular septal defect closure

Answer 55

ANSWER: C
This patient has symptomatic severe aortic stenosis. The only treatment that improves this condition is
aortic valve replacement (SOR B). Transcutaneous aortic valve replacement may be an alternative for
patients who are not candidates for surgery. -Blockers must be used with caution due to the risk of
depressing left ventricular systolic function. They have not been shown to improve mortality. Antimicrobial
prophylaxis is not indicated unless a patient has undergone valve replacement or has a history of
endocarditis (SOR C). Atrial fibrillation is common in patients with aortic stenosis and rate control is
important. Symptomatic mitral valve regurgitation may require mitral valve intervention. However, these
murmurs are holosystolic, high pitched, and best heard at the cardiac apex. A ventricular septal defect can
cause a loud holosystolic murmur with an associated thrill heard best at the third/fourth interspace along
the sternal border.

Question 56

A 28-year-old white female comes to your office at 37 weeks gestation with a 24-hour history
of painful vesicles on the vulva. She does not have a past history of similar lesions. You make
a presumptive diagnosis of genital herpes.
Of the following, the most sensitive and specific test is
A) exfoliative cytology (Tzanck test)
B) a polymerase chain reaction (PCR) test
C) an enzyme-linked immunosorbent assay (ELISA)
D) HSV serology (IgG/IgM)

Answer 56

ANSWER: B
When genital herpes occurs during pregnancy, the best method of diagnosis is either a tissue culture or a
polymerase chain reaction (PCR) test, which is more sensitive. Enzyme-linked immunosorbent assays are
sensitive, but not as sensitive or specific as PCR.

Question 57

A 27-year-old white female with a history of mania sees you because of polyuria and increased
thirst over the past month. She has taken lithium, 1800 mg daily, for 3 years and her mania is
well controlled. She has not lost weight and there is no family history of her current problem.
There are no orthostatic blood pressure changes.
Laboratory Findings
Serum sodium                          145 mEq/L (N 135–145)
Serum potassium                       4.5 mEq/L (N 3.5–5.0)
Serum glucose                         92 mg/dL
Serum creatinine                        0.9 mg/dL (N 0.6–1.5)
Serum lithium                          1.38 mEq/L (therapeutic range 0.5–1.5)
Urine volume                          6.85 L/24 hr
Urine osmolality                        161 mOsm/kg H2O
There is no significant change in urine osmolality in response to the administration of
vasopressin. Which one of the following is the most likely cause of this patient’s problem?
A) Drug-induced nephrogenic diabetes insipidus
B) Borderline diabetes mellitus
C) Panhypopituitarism
D) Psychogenic water drinking

Answer 57

ANSWER: A
Polyuria occurs in 20%–70% of patients on long-term lithium therapy, even when plasma lithium levels
are in the therapeutic range. This is a result of impaired renal concentrating ability that is resistant to
vasopressin (nephrogenic diabetes insipidus). Inappropriate antidiuretic hormone secretion causes
hyponatremia and fluid retention. The diuresis associated with diabetes mellitus is a result of the osmotic
effect of increased serum glucose, which is not present in this case. Patients with hypothalamic or pituitary
injuries may develop central diabetes insipidus, which responds to exogenous vasopressin. Psychogenic
water drinking occurs in psychiatric patients, but would not be expected to cause impairment of renal
concentration or hypernatremia.

Question 58

A 40-year-old female sees you because of burning upper abdominal and chest pain and an acidic
taste in her mouth after nearly every meal. She has pain at night that sometimes keeps her
awake, but she does not have any nausea, vomiting, difficulty swallowing, bloating, bloody
stools, or weight loss. She does not smoke.
Which one of the following would be the most appropriate next step?
A) Test for Helicobacter pylori and treat if present
B) Start a 4- to 8-week trial of a proton pump inhibitor
C) Order abdominal ultrasonography
D) Schedule esophagogastroduodenoscopy
E) Refer to a surgeon to consider fundoplication

Answer 58

ANSWER: B
Patients with symptoms typical for GERD can be treated conservatively initially unless there are warning
signs such as anemia, weight loss, evidence of bleeding or obstruction, dysphagia, or persistent symptoms
despite maximal treatment, or the patient is age 50 or over. In the absence of any of these concerns,
medical therapy with a proton pump inhibitor can be initiated. While H2 histamine blockers can also treat
reflux symptoms they are somewhat less effective, and stepwise therapy may increase costs.
Routine testing for Helicobacter pylori in patients with GERD alone is not recommended because treating
H. pylori has been shown in some studies to increase esophagitis and GERD symptoms. However, in the
presence of dyspepsia (fullness, bloating, nausea), which can be associated with GERD, testing for and
treating H. pylori is expected to be beneficial. This patient has classic signs and symptoms of GERD and
abdominal ultrasonography would not be likely to reveal any helpful findings. In the presence of warning
signs, esophagogastroduodenoscopy would be indicated to evaluate for a more serious pathology. Surgical
intervention for GERD should be reserved for patients who fail maximal medical therapy or patients who
are unable to take proton pump inhibitors.

Question 59

A 36-year-old male went skiing last year for the first time and when he made it to the top of the
mountain he developed a headache, nausea, and dizziness, but no respiratory difficulty. That
night he had difficulty sleeping. He asks for your recommendation on preventing a recurrence
of the problem when he goes skiing again this year.
Which one of the following medications would you recommend he start the day before his ascent
and continue until his descent is complete?
A) Acetazolamide (Diamox Sequels)
B) Aspirin
C) Dexamethasone (Decadron)
D) Tadalafil (Adcirca)
E) Zolpidem (Ambien)

Answer 59

ANSWER: A
Acetazolamide is the preferred agent for preventing acute mountain sickness (AMS). Multiple trials have
demonstrated its efficacy in preventing AMS. Dexamethasone is a first-line treatment for acute mountain
sickness of any severity but is a second-line drug for prevention because of its side-effect profile. Tadalafil
is advised as a second-line treatment after nifedipine for the prevention and treatment of high-altitude
pulmonary edema. Zolpidem may help with sleep but not AMS, and aspirin is not recommended for
prevention of AMS.