AAFP free questions

Question 1

What to monitor on amiodarone therapy

Answer 1

TSH and free T4 every 6 months

Question 2

Pediatric asthma is the most commonly encountered chronic illness, occurring in nearly one out of seven individuals. Short-acting β-agonists in the form of metered-dose inhalers are clearly favored for acute exacerbations, as well as for intermittent asthma. Treatment for persistent asthma requires the use of inhaled corticosteroids, with short-acting β-agonists used for exacerbations. For patients not well controlled with those options, either a long-acting β-agonist or a leukotriene receptor antagonist may be added. While both cromolyn and nedocromil are fairly devoid of adverse effects, their use is limited because of a lack of efficacy in the prevention of acute asthma exacerbations.

Question 3

Palpitations are a common symptom in ambulatory care. Cardiac causes are the most worrisome so it is important to distinguish cardiac from noncardiac causes. Patients with a history of cardiovascular disease, palpitations that affect their sleep, or palpitations that occur at work have an increased risk of an underlying cardiac cause (positive likelihood ratio 2.0–2.3) (SOR C). Psychiatric illness, adverse effects of medications, and substance abuse are other common causes.

Palpitations that are worse in public places and those of very short duration (<5 minutes), especially if there is a history of anxiety, are often related to panic disorder. However, even a known behavioral issue should not be presumed to be the cause of palpitations, as nonpsychiatric causes are found in up to 13% of such cases. The use of illicit substances such as cocaine and methamphetamine can cause palpitations that are associated with dry mouth, pupillary dilation, sweating, and aberrant behavior. Excessive caffeine can also cause palpitations.

Question 4

A Wood’s lamp may assist with the diagnosis of certain skin conditions. This patient’s presentation is consistent with erythrasma caused by a Corynebacterium minutissimum infection, and use of an ultraviolet light would reveal a coral pink color. Pale blue fluorescence occurs with Pseudomonas infections, yellow with tinea infections, and totally white with vitiligo. A lime green fluorescence is not characteristic of a particular skin condition.

Question 5

Annual HPV screening in patients age 21–29 years has very little effect on cancer prevention and leads to an increase in procedures and treatments without significant benefit. In this age group there is a high prevalence of high-risk HPV infections but a low incidence of cervical cancer. If this patient were due for a Papanicolaou (Pap) test and results were ASC-US with a positive high-risk HPV or a higher grade abnormality, colposcopy would be recommended. Current recommendations are for a Pap test with cytology every 3 years for women age 21–29 years with normal results, and the frequency does not change with an increased number of normal screens. HPV is the most common sexually transmitted infection (STI) and up to 79% of sexually active women contract HPV infection in their lifetime, so the lack of other STIs does not preclude the possibility of an HPV infection.

Question 6

The first step in the management of severe hypertension is determining whether a hypertensive emergency is present. A thorough history and physical examination are crucial (SOR C). Severe hypertension (blood pressure >180 mm Hg systolic or >110 mm Hg diastolic) with end-organ damage constitutes a hypertensive emergency. A physical examination should center on evaluating for papilledema, neurologic deficits, respiratory compromise, and chest pain. If end-organ damage is present the patient should be hospitalized for monitored blood pressure reduction and further diagnostic workup. If end-organ damage is not present and the physical examination is otherwise normal, a 30-minute rest with reevaluation is indicated. Approximately 30% of patients will improve to an acceptable blood pressure without treatment (SOR C). Home medications should then be adjusted with outpatient follow-up and home blood pressure monitoring (SOR A). Short-acting antihypertensives are indicated if mild symptoms are noted such as headache, lightheadedness, nausea, shortness of breath, palpitations, anxiety, or epistaxis. Diagnostic testing is not immediately indicated for asymptomatic patients (SOR C). A basic metabolic panel or other testing should be considered if mild symptoms are present. Aggressive lowering of blood pressure can be detrimental and a gradual reduction over days to weeks is preferred (SOR C).

Question 7

The American Society of Anesthesiologists (ASA) has recently revised its physical status classification system. A healthy patient would be classified as ASA I, while a patient with mild systemic disease would be classified as ASA II. All patients who are having major surgery should be offered preoperative laboratory testing, including a CBC and renal function testing. For patients who are ASA III or IV and have chronic liver disease or take anticoagulants, coagulation testing should be considered. There is no compelling evidence to support either a chest radiograph or an EKG as part of a routine preoperative evaluation.

Question 8

The recommended treatment for metatarsal stress fractures is no weight bearing for a few days, possibly using a posterior splint, transitioning to a walking boot or short leg cast, and then a rigid-soled shoe in 4–6 weeks. Callus formation on a radiograph and a lack of point tenderness signify adequate healing, and immobilization can be discontinued. Other recommended conservative therapy includes modified rest for 6–8 weeks with continuation of activities of daily living and limited walking. Normal activity can be resumed after 2–3 weeks with no pain. Additionally, the use of NSAIDs, ice, and stretching, as well as cross-training is recommended. Resuming regular activity after only 1 week of pain-free rest would not be recommended. Fractures of the fifth metatarsal should be carefully investigated to rule out a Jones fracture that may require orthopedic treatment. Treatment of the more common second and third metatarsal stress fractures is relatively straightforward.

Question 8

It is important to distinguish serious illness from benign causes of proteinuria, which are the most common etiology in children. Confirming the presence of proteinuria is the next step in this case because functional (exercise/stress-induced) and orthostatic proteinuria are common types of proteinuria and are transient. A 24-hour urine for protein is a possible option, but would be impractical and burdensome for a healthy-acting 11-year-old. The pediatric nephrology panel of the National Kidney Foundation reported that a spot protein/creatinine ratio is a reliable test for ruling out proteinuria. A specialist referral, blood analysis, and ultrasonography are unnecessary unless persistent proteinuria is identified.

Question 9

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 10

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 11

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 12

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 13

Somatic symptom disorder (formerly called somatization disorder) usually begins in the teens or twenties and is characterized by multiple unexplained physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history. These patients also commonly abuse alcohol, narcotics, or other drugs.

Patients with illness anxiety disorder are overly concerned with bodily functions, and can often provide accurate, extensive, and detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain. Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic, or gastrointestinal symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and scanning.

Question 14

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 15

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 16

The U.S. Preventive Services Task Force recommends against screening for cervical cancer for women
younger than 21, for women over the age of 65 who have had adequate screening in the recent past and
are not at high risk, and for women who have had a hysterectomy with removal of the cervix and no
history of CIN 2 or 3 or cervical cancer (USPSTF D recommendation). Women between the ages of 21
and 65 can be screened every 3 years with cytology alone, or the interval can be increased to 5 years after
age 30 by using a combination of cytology and HPV testing (USPSTF A recommendation). The history
of HPV vaccination is not a factor in screening decisions. Other organizations such as the American
Cancer Society and the American College of Obstetricians and Gynecologists have similar guidelines.

Question 17

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 17

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 18

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 19

Methicillin-resistant Staphylococcus aureus (MRSA) is the predominant cause of suppurative skin and
soft-tissue infection. While community-acquired strains have been susceptible to many antibiotics,
clindamycin is associated with Clostridium difficile enterocolitis, trimethoprim/sulfamethoxazole is usually
used orally only for outpatient treatment, and doxycycline and minocycline are often effective clinically
but seldom used for serious infections. Resistance to quinolones is increasing and may emerge during
treatment. Vancomycin given parenterally is generally still the drug of choice for hospitalized patients.

Question 20

This patient has a peripheral neuropathy. A review of the patient’s history and specific laboratory testing was performed to evaluate for the most common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In this patient, the mildly elevated total protein and erythrocyte sedimentation rate, which suggest a monoclonal gammopathy such as MGUS (monoclonal gammopathy of unknown significance) or multiple myeloma, should direct her workup. Serum protein electrophoresis is indicated to assess for this.

Other less common causes of peripheral neuropathy include carcinoma causing a paraneoplastic syndrome, lymphoma, sarcoidosis, AIDS, and genetic disorders such as Charcot-Marie-Tooth disease. Approximately 25% of patients with peripheral neuropathy have no clearly defined cause after a thorough evaluation and are diagnosed with idiopathic polyneuropathy.

Answer 20

MRI of the lumbar spine can identify central lesions causing spinal cord or nerve root compression but is not indicated in the evaluation of peripheral neuropathy. Serum angiotensin converting enzyme levels and a chest radiograph can assist in the diagnosis of sarcoidosis, which can cause peripheral neuropathy but is less likely in this patient. Cerebrospinal fluid analysis is important in assessing for chronic inflammatory demyelinating polyradiculoneuropathy, a more rare cause of peripheral neuropathy.

Question 21

The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method.

Question 22

Due to the disease prevalence and impact, effectiveness of screening instruments, and benefits of available treatment, the U.S. Preventive Services Task Force (USPSTF) recommends screening for major depressive disorder when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF has made no recommendations regarding screening for bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, or schizophrenia.

Question 23

This patient’s cat is well more than 10 days after the bite, so rabies vaccine is not necessary. Azithromycin is indicated for cat scratch disease, but the presentation does not suggest this. Severe infections may require incision, drainage, and intravenous antibiotics. A surgery consultation is recommended to evaluate for tendon sheath or joint infection.

Question 24

In the treatment of active tuberculosis, direct observational therapy (DOT) involves providing the antituberculosis drugs directly to patients and watching them swallow the medication. It is the preferred care management strategy for all patients with tuberculosis. The use of DOT does not guarantee the ingestion of all doses of every medication, as patients may miss appointments, may not actually swallow the pills, or may regurgitate the medication, sometimes deliberately. Due to these limitations, the use of DOT does not remove the need to monitor patients for signs of treatment failure. DOT is effective in a wide variety of settings, including in the community with health nurses. It even shows benefit when the observation makes use of telehealth settings or mobile phones. Among the important benefits of DOT are that it has been shown to decrease both the acquisition and transmission of drug-resistant tuberculosis and to increase treatment success in HIV-positive patients.

Question 24

The patient is experiencing an acute cognitive change from baseline, indicating possible delirium. The Confusion Assessment Method (CAM) is a delirium diagnosis tool useful for evaluating acute cognitive changes. The other tests listed, including the Mini-Mental State Examination, Mini-Cog, Montreal Cognitive Assessment, and Saint Louis Mental Status exam, test chronic baseline cognitive function and are not designed to test for acute changes.

Question 25

Reported cure rates for trigger finger after corticosteroid injection range from 54% to 86%. Corticosteroid injection for the other conditions listed results in temporary pain relief, but the underlying conditions are not improved by the injection.

Question 26

Because of concerns about the growing epidemic of obesity in this population, the American Academy of Pediatrics now recommends screening for elevated serum cholesterol levels in children 9–11 years of age (SOR C). This patient should also be screened annually for depression beginning at 11 years of age and continuing through 21 years of age. Universal screening for iron deficiency anemia is recommended at 12 months of age and again at 15–30 months of age if the patient is determined to be high risk. HIV screening is recommended in adolescents 16–18 years of age, and age 21 is now the recommended starting age for screening for cervical dysplasia. Universal screening for diabetes mellitus is not recommended for children or adolescents.

Question 27

Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.

Question 28

This patient has hyperactive delirium. The first step in management is to determine and treat the underlying cause if possible. There are multiple causes of delirium such as medications, infections, metabolic abnormalities, and underlying diseases. The first step in treatment is behavioral management with strategies to orient the patient. Haloperidol or antipsychotics may be used if the patient is at risk of harm. Lorazepam and anticholinergics should both be avoided, as they can worsen delirium. Restraints can also worsen the agitation and should not be used. Mirtazapine is an antidepressant and is not used in the treatment of delirium.

Question 29

This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension, and to manage her weight. Exercise stress testing is not specifically indicated for this patient. Current recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or more days per week.

Question 30

Early systemic Lyme disease may manifest with facial nerve palsy, and treatment should include corticosteroids. The evidence for efficacy of antivirals for facial nerve palsy is lacking, especially beyond 3–4 days after onset. But in this case, specific treatment to eradicate the Lyme disease is also indicated, in order to prevent later, more severe systemic complications.

Question 31

Patients with a history of cryptorchidism are at high risk for the development of testicular cancer, especially if orchiopexy is performed after puberty. If sonography shows a hypoechoic mass, a testicular biopsy is contraindicated, since it may contaminate the scrotum or alter the lymphatic drainage. Radical inguinal orchiectomy is both diagnostic and therapeutic. Watchful waiting would not be an option in this high-risk patient. CT of the chest, abdomen, and pelvis, and measurement of the tumor markers are useful for staging and as an indication of tumor burden, but they are not diagnostic.

Question 32

Premature adrenarche without development of secondary sex characteristics is usually idiopathic and does not lead to an abnormal pattern of development. Reassurance and surveillance over the next 3–6 months would be most appropriate at this time. Laboratory studies and radiography warrant consideration if the patient develops secondary sex characteristics before the age of 8, or if her height velocity increases rapidly during the surveillance period.

Question 33

Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy are the most common cause of hypertension in preadolescent children. Preadolescent children with hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the first choice of imaging in this age group. Renin and aldosterone levels are indicated if there is a reason to suspect primary hyperaldosteronism, such as unexplained hypokalemia. Measurement of 24-hour urinary fractionated metanephrines and normetanephrines is used to diagnose pheochromocytomas, which are rare and usually present with a triad of symptoms including headache, palpitations, and sweating. Doppler ultrasonography of the renal arteries is useful for diagnosing renal artery stenosis, which should be suspected in patients with coronary or peripheral atherosclerosis or young adults, especially women 19–39 years of age, who are more at risk for renal artery stenosis due to fibromuscular dysplasia. Sleep studies are indicated in patients who are obese or have signs or symptoms of obstructive sleep apnea.

Question 34

Topiramate increases the risk of kidney stones. It is a carbonic anhydrase inhibitor, which induces a metabolic acidosis that leads to hypercalciuria and the formation of calcium phosphate stones. The risk of kidney stones is not increased by escitalopram, levothyroxine, lisinopril, or metformin.

Question 35

The fifth metatarsal has the least cortical thickness of all of the metatarsals. There are strong ligaments and capsular attachments on the proximal fifth metatarsal that can put significant stress on this area of the bone, leading to fractures. Nondisplaced tuberosity fractures can generally be treated with compressive dressings such as an Aircast or Ace bandage, with weight bearing and range-of-motion exercises as tolerated. Minimally displaced (<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a short leg walking boot. If the displacement is >3 mm, an orthopedic referral is warranted.

Question 36

When psychogenic erectile dysfunction (ED) coexists with depression, treatment of the underlying mood disorder is often an appropriate first step (SOR C). An antidepressant that is less likely to worsen the ED, such as bupropion, mirtazapine, or fluvoxamine, should be chosen. Antidepressants that are more likely to cause sexual side effects should be avoided, including SSRIs, SNRIs, and tricyclic and tetracyclic antidepressants. Phosphodiesterase-5 inhibitors are the first line of treatment for ED (SOR A) and can be used effectively in men with depression, in combination with treatments for mood disorders. Ref: Yuan J, Zhang R, Yang Z, et al: Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: A systematic review and network meta-analysis.

Question 37

HPV vaccine is currently recommended for males and females at age 11. Catch-up vaccination is recommended until age 21 in males and 26 in females. Children who receive the first dose of the vaccine before the age of 15 and receive two doses are considered adequately vaccinated. If the first dose is given after age 15, a three-dose series is recommended. Ref: Immunization schedules: Recommended immunization schedule for children and adolescents aged 18 years or younger,

Question 38

The classic facial dysmorphologies associated with fetal alcohol syndrome are a smooth philtrum, shortened palpebral fissures, and a thin vermilion border of the upper lip. Two out of these three characteristics are required for the diagnosis of fetal alcohol syndrome. Low-set ears and a central chin dimple are not associated findings.

Question 39

Screening for developmental dysplasia of the hip (DDH) is somewhat controversial because the benefit of treatment remains somewhat unclear. Despite the widespread practice of screening for DDH, ethical newborn practices are difficult to determine. The American Academy of Family Physicians and the U.S. Preventive Services Task Force have found insufficient evidence to recommend routine screening for DDH. The American Academy of Pediatrics, however, recommends routine screening of all newborns with physical examination maneuvers, and targeted screening ultrasonography for infants who were breech in the third trimester, have a family history of DDH, or have a personal history of instability. Given this, decisions should be individualized. Additional risk factors include female sex, firstborn status, oligohydramnios, and a large-for-gestational-age infant.

Question 40

Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition and early imaging is associated with worse overall outcomes and is likely to identify minor abnormalities even in asymptomatic patients. Imaging for acute low back pain should be reserved for cases that are suspicious for cauda equina syndrome, malignancy, fracture, or infection. In the absence of red flags such as progressive motor or sensory loss, new urinary retention or overflow incontinence, a history of cancer, a recent invasive spinal procedure, or significant trauma relative to age, imaging is not warranted regardless of whether radiculopathy is present, unless symptoms persist despite a trial of at least 6 weeks of medical management and physical therapy.

Question 41

Prophylactic antibiotics should be given for all closed-fist injuries unless the skin has not been penetrated, and for puncture wounds caused by cat bites. The antibiotic should have both aerobic and anaerobic activity and include Pasteurella coverage for animal bites and Eikenella coverage for human bites. Suggested regimens include amoxicillin/clavulanate. If the patient is allergic to penicillin, clindamycin plus levofloxacin or moxifloxacin, which has anaerobic coverage, can be used. Azithromycin, cephalexin, and metronidazole are not first-line antibiotics following a cat bite.

Question 42

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 43

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 44

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 45

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 46

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 47

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 48

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 49

Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be administered (SOR B). The therapeutic response to NSAIDs is often remarkable. Acetaminophen has not been shown to be a superior analgesic for acute rheumatic fever. Gabapentin is not indicated, especially considering that the pain does not have a neuropathic etiology. Opioids would not be considered first-line treatment because of their adverse effects and the dramatic response of NSAIDs alone.

Question 50

Diagnosing attention-deficit disorder in adults requires symptoms that interfere with social, academic, or occupational functioning and are present in more than one setting. DSM-5 states that a history of symptoms before age 12 is required for the diagnosis. DSM-IVspecified that symptoms must have been present before age 7.

Question 51

Patients with a peanut allergy can have reactions to infinitesimal amounts of peanut protein, including residue on the lips of other people. This patient has successfully interrupted the course of anaphylaxis. Diphenhydramine can help reduce subsequent symptoms, and prednisone is generally given, although its value is unproven. However, the patient is at risk of a biphasic reaction and should go to an emergency department where additional epinephrine and resuscitation facilities are available. The American Academy of Pediatrics guideline recommends that all peanut-allergic patients who require a dose of adrenaline be observed in an emergency department. Patients who have not already had a full allergy evaluation need to see an allergist, but this patient’s peanut allergy has been established. Peanut-allergic patients tend to have accidental exposure about once every 5 years in spite of efforts at avoidance.

Question 52

In the first 3 to 4 days of illness, viral rhinosinusitis cannot be distinguished from early acute bacterial rhinosinusitis. If the patient seems to be improving and then symptoms start to worsen on days 5–10 of the illness (double sickening), acute bacterial rhinosinusitis should be suspected. The color of the nasal discharge should not be used as the sole indication for antibiotic therapy. One study showed that unilateral predominance with purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis. After 10 days of upper respiratory symptoms, the probability of acute bacterial rhinosinusitis is 60%. Antibiotic therapy should be considered if the patient does not improve after 7–10 days from the onset of symptoms or if the symptoms worsen at any time. According to most guidelines, the first-line antibiotic for treatment of adults with sinusitis is amoxicillin/clavulanate. Respiratory fluoroquinolones are not recommended as first-line medications, as they offer no additional benefits and have significant side effects. Second and third-generation cephalosporins, trimethoprim/sulfamethoxazole, and macrolide antibiotics are no longer recommended for initial therapy. This is due to high rates of resistance in Streptococcus pneumoniae and Haemophilus influenzae .

Question 53

Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. A sweat chloride level of 20 mEq/L rules out cystic fibrosis. Normal serum calcium excludes DiGeorge’s syndrome. The battered child generally presents with more than just a single recurring medical problem. β-Thalassemia would be indicated by a microcytic anemia.

Question 54

Childhood constipation is a very common problem encountered in outpatient practice. Most childhood constipation is functional, which appears to be the case with this patient. She has no evidence of organic disease, and she had a change in lifestyle that caused her to retain stool, resulting in a cycle of constipation. Polyethylene glycol is easily tolerated, safe, and easy to use. For this reason, it is the first-line therapy. A daily dose should resolve this issue, although it is likely that the child will need another course of treatment, as functional constipation is likely to recur. It is not reasonable in this case to provide no treatment, as the child is uncomfortable. An enema would be unnecessary since oral therapies are very likely to be effective. Behavioral therapies have not been shown to be as effective as laxatives for functional constipation, and stringent therapy that is not related to food intake is likely to increase the stress surrounding going to the toilet. There is no role for imaging in a case where the suspicion of an organic cause is so low.

Question 55

Key diagnostic features of autism spectrum disorder include deficits in social communication and interaction across multiple contexts and restricted, repetitive patterns of behavior, interests, or activities. The DSM-5 , which came out in 2013, created an umbrella diagnosis of autism spectrum disorder to consolidate four previously separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Any individuals with a previous diagnosis of one of these disorders should now be given a diagnosis of autism spectrum disorder.

Question 56

Cardiovascular disease, in particular ischemic heart disease, has now become the leading cause of human deaths worldwide. It was once considered a disease of the wealthy, but now more than 80% of deaths from noncommunicable diseases occur in low- to middle-income countries. The other conditions listed remain among the top 10 causes of human deaths worldwide, along with stroke, lower respiratory infections, COPD, diabetes mellitus, and road deaths.

Question 57

This patient has symptoms consistent with hyperthyroidism, which could be caused by any of the options listed. TSH is suppressed and free T4 and free T3 are elevated in all of these conditions. Only Graves disease, however, will cause high radioactive iodine uptake on a thyroid scan. Uptake will be low in the other conditions.

Answer 57

Postpartum thyroiditis Silent thyroiditis Subacute thyroiditis Graves disease Exogenous thyroid ingestion

Question 58

Given this patient’s age, lack of symptoms, and possible family history, the presence of asymptomatic bilateral hilar lymphadenopathy most likely represents stage 1 pulmonary sarcoidosis. Because the patient does not have any symptoms and stage 1 sarcoidosis resolves in most cases, the most prudent course is to reevaluate her in 6 months with a careful history, a physical examination, and a chest radiograph. Given the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a lung biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but would be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.

Question 59

This patient presents with typical vasomotor symptoms that can begin in perimenopause and affect sleep quality. Hormone therapy is the gold standard for treatment of vasomotor symptoms. Combination estrogen and progesterone therapy is highly effective for vasomotor symptoms and provides protection against uterine neoplasia. Although micronized progesterone decreases vasomotor symptoms there are no long-term studies to assess the safety of progestin-only treatment for menopausal symptoms. Compounded bioidentical hormone therapy creates safety concerns and is not a first-line therapy due to limited government regulation and monitoring, the potential for overdosing and underdosing, impurities or lack of sterility, and the lack of labeling describing risks. Testosterone alone is not FDA-approved for use in women. Additionally, it has not been shown to be beneficial for treatment of vasomotor symptoms in combination with hormone therapy and is associated with significant side effects. It may be useful for hypoactive sexual desire in postmenopausal women. There is insufficient data to recommend the use of herbal remedies such as black cohosh.

Question 60

Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White syndrome (WPW). Catheter ablation has a very high immediate success rate (96%–98%). The most significant risk associated with the procedure is permanent atrioventricular block, which occurs in approximately 0.4% of procedures. Adenosine and amiodarone are used for the acute management of supraventricular tachycardia, but not for long-term management. Node-blocking medications such as diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk of ventricular fibrillation.

Question 61

The CDC’s Advisory Committee on Immunization Practices recommends that patients with egg allergy receive influenza vaccination. Previously unvaccinated patients ages 6 months to 8 years should receive two doses of either trivalent or quadrivalent vaccine separated by 1 month.

Question 62

The cause of hip pain is generally determined from the patient’s history and physical examination. A positive flexion, abduction, external rotation (FABER) test that produces pain at the sacroiliac joint, lumbar spine, and posterior hip is associated with sacroiliac joint dysfunction. The log roll test involves passive supine internal and external rotation of the hip. When this test is positive for pain it is associated with piriformis syndrome. While femoroacetabular impingement may be associated with a positive FABER test, it would produce pain in the groin. Greater trochanteric pain syndrome results in lateral hip pain rather than posterior pain. Osteoarthritis is usually associated with a limited range of motion and groin pain.

Question 63

Patients who have a venous thromboembolism (VTE) require anticoagulation therapy for treatment and prevention of recurrence. The risk of recurrence is greatest in the first year after the event and remains elevated indefinitely. The risk for VTE recurrence is dependent on patient factors, such as active cancers and thrombophilia. Current guidelines recommend treatment for at least 3 months. In patients who have a reversible provoking factor such as surgery, anticoagulation beyond 3 months is not recommended.

Question 64

The recommended first-line treatment for primary focal hyperhidrosis is topical 20% aluminum chloride. It should be applied to affected areas nightly for 6–8 hours and works by obstructing the eccrine sweat glands and destroying secretory cells. Iontophoresis and botulinum toxin are alternative first- or second-line therapies for palmar and plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or face. Topical 2% glycopyrrolate must be compounded by a pharmacy and is indicated only for craniofacial hyperhidrosis. Oral anticholinergics such as oxybutynin can be considered if other first-line treatments fail. However, up to 10% of patients will stop taking these medications due to side effects such as dry mouth, constipation, urinary retention, and blurred vision. Microwave technology is a newer treatment option that has shown some promising results but should not be recommended as a first-line treatment. Sympathetic denervation should be used only if other less invasive therapies have already been tried.

Question 65

This patient presents with acute epididymitis. Typical symptoms develop gradually over 1–2 days with posterior scrotal pain and swelling. Additional symptoms may include fever, hematuria, dysuria, and urinary frequency. The pain may radiate to the lower abdomen. Physical examination findings may include tenderness of the epididymis and testis along with swelling of the scrotum. Elevation of the scrotum may decrease the pain (Prehn sign). Typical ultrasound findings include hyperemia, swelling, and increased blood flow to the epididymis. With testicular torsion the pain is often sudden in onset and severe, with associated nausea and vomiting and no other urologic symptoms. A physical examination often demonstrates a high-riding testis that may lie transversely in the scrotum. The cremasteric reflex may be absent. Ultrasound findings would demonstrate decreased or absent blood flow with testicular torsion. In sexually active adults <35 years of age, gonorrhea and Chlamydia are the most common causative organisms of acute epididymitis. Ceftriaxone, 250 mg intramuscularly or intravenously once, with oral doxycycline, 100 mg twice daily for 10 days, would be the appropriate treatment for acute epididymitis (SOR C). In men over the age of 35 or those with a history of recent urinary tract surgery or instrumentation, enteric organisms are the most likely cause and monotherapy with oral levofloxacin or ofloxacin for 10 days would be the recommended treatment.

Question 66

Written self-management plans have been shown to decrease respiratory-related hospitalizations in patients with COPD. Although regular physical activity has clear health benefits, the methods are so varied in studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in COPD patients. Although FEV1 is important for predicting hospitalizations for a population, it is not accurate enough to be useful in an individual patient. Daily oxygen therapy does not help to postpone the first hospitalization. Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep apnea, but not those with COPD alone.

Question 67

Somatic symptom disorders account for approximately 5% of primary care visits. Effective pharmacologic treatment includes sertraline and other SSRI-based therapy in addition to cognitive-behavioral therapy (SOR B). Bupropion, monoamine oxidase inhibitors such as selegiline, anticonvulsants such as topiramate, and antipsychotics such as clozapine are ineffective.

Question 68

The TSH reference range is lower during pregnancy because of the cross-reactivity of the -subunit of hCG. Levels of hCG peak during weeks 7–13 of pregnancy, and hCG has mild TSH-like activity, leading to slightly high free T4 levels in early pregnancy. This leads to a feedback decrease in TSH.

Question 69

This patient’s laboratory results and back pain suggest multiple myeloma (MM). He has a normocytic anemia and evidence of renal insufficiency, which can indicate MM. The laboratory findings along with worsening back pain indicate a need to order serum protein electrophoresis to look for MM. Flow cytometry is generally used in patients with an elevated WBC count and suspected lymphoma. The remainder of this patient’s CBC is normal, which makes a bone marrow issue less likely. His mean corpuscular volume is also normal, making vitamin B12 deficiency less likely. A haptoglobin level could be ordered, but protein electrophoresis is a better choice because the peripheral smear demonstrated no evidence of a hemolytic problem.

Question 70

Breast cancer survivors should undergo a history and physical examination every 3–6 months for the first 3 years after treatment, then every 6–12 months for the next 2 years, and then annually thereafter (SOR C). Papanicolaou testing guidelines do not change for patients with a history of breast cancer. Screening should be repeated every 3–5 years according to American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. Mammograms of both breasts or the remaining breast are recommended no more often than yearly (SOR A). Breast MRI is not recommended on a regular basis unless the patient has a high risk of recurrence, a significant family history of breast or ovarian cancer, or a personal history of Hodgkin’s disease (SOR C). While it is important to be alert for signs of cardiotoxicity due to prior chemotherapy, echocardiography is indicated only if the patient has cardiac symptoms. Routine echocardiography is not recommended (SOR C)

Question 71

Several decision support tools can help guide the decision to order imaging of an injured knee, such as the Ottawa Knee Rule, the Pittsburgh Knee Rule, and American College of Radiology (ACR) criteria. The inability to take four or more steps immediately after an injury or in the emergency setting is an indication for radiography in all three rules. Age is an indication for radiography in acute knee pain in patients over 55 years of age according to the Ottawa rule, or under 12 or over 50 years of age according to the Pittsburgh rule. The patient’s sex does not factor into the criteria for imaging. Bony tenderness is an indication for imaging according to the ACR and Ottawa rules, but only if isolated over the proximal fibula or over the patella without other bony tenderness. The inability to flex the knee to 90° is also an indication for imaging according to the ACR and Ottawa rules.

Question 72

Injection of glucocorticoids (usually mixed with a local anesthetic) into the subacromial space may be considered in patients with rotator cuff tendinitis if the pain is significant enough to interfere with sleep and/or function despite adequate analgesia. An intra-articular injection is appropriate for a patient with severe shoulder osteoarthritis. A corticosteroid injection into the biceps or deltoid insertions is not appropriate. An acromioclavicular injection is appropriate for acromioclavicular arthritis but not for rotator cuff tendinitis.

Question 73

Tamsulosin promotes passage of ureter stones that are 5–10 mm in diameter. The number needed to treat is five patients to cause the expulsion of one stone (SOR B). There was no difference in the percentage of patients passing stones smaller than 5 mm when comparing tamsulosin to placebo, as these stones have a high rate of spontaneous passage without any intervention. Naproxen and promethazine are sometimes used for the management of pain and nausea associated with stones, but they have not been shown to facilitate stone expulsion. Ciprofloxacin and nitrofurantoin are used to treat urinary tract infections but have not been shown to facilitate stone expulsion.

Question 74

This patient has severe community-acquired pneumonia based on clinical criteria, including an elevated respiratory rate, confusion, and hypotension requiring aggressive fluid resuscitation. Corticosteroids such as methylprednisolone have been shown to improve clinical outcomes such as length of stay, duration of antibiotic treatment, and the risk of developing adult respiratory distress syndrome. The preferred choice of antibiotic treatment for patients in the intensive-care unit is a -lactam antibiotic (ceftriaxone, cefotaxime) or ampicillin/sulbactam, plus a macrolide alone or a macrolide and a respiratory fluoroquinolone. The addition of levofloxacin is not necessarily preferred over just ceftriaxone and azithromycin. Clindamycin is not indicated in the absence of risk factors for anaerobic infection such as aspiration or alcoholism. Oseltamivir is not indicated in the absence of known or suspected influenza infection.

Question 75

Postpartum thyroiditis is defined as a transient or persistent thyroid dysfunction that occurs within 1 year of childbirth, miscarriage, or medical abortion. Release of preformed thyroid hormone in the bloodstream initially results in hyperthyroidism. During the hyperthyroid phase, radioactive iodine uptake will be low, which can help to confirm the diagnosis. Pregnancy and breastfeeding are contraindications to radionuclide imaging. Thyroid peroxidase antibody levels are elevated with chronic autoimmune thyroiditis (Hashimoto’s thyroiditis), and patients present with symptoms of hypothyroidism. The Endocrine Society and American Association of Clinical Endocrinologists do not recommend routine thyroid ultrasonography in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland. Thyrotropin receptor antibody levels are positive in Graves disease.

Question 76

This is a classic presentation for acute poststreptococcal glomerulonephritis (APSGN), with the onset of gross hematuria associated with hypertension and systemic edema. This is most commonly seen in school-age children, usually 1–2 weeks after an episode of pharyngitis or 3–4 weeks after an episode of impetigo, caused by so-called nephritogenic strains of Group A -hemolytic Streptococcus. The hematuria is caused by immune complex–mediated glomerular injury. Bacteriuria may be seen in both upper and lower urinary tract infections, but may also be a spurious finding, especially with the combined presence of epithelial cells. The classic finding on microscopic urinalysis for acute glomerulonephritis is the presence of RBC casts. WBC casts are seen with acute pyelonephritis. The presence of urinary eosinophils indicates acute interstitial nephritis. Calcium oxalate makes up the most common type of kidney stones. Antibiotics prescribed for antecedent pharyngitis do not prevent APSGN. Treatment is supportive, controlling blood pressure and edema with a thiazide or a loop diuretic. The prognosis for resolution and full recovery of the vast majority of patients with APSGN is excellent, especially in the pediatric age group.

Question 77

Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute migraine beyond their effect on nausea. Most outpatient clinics do not have the ability to administer intravenous metoclopramide, which is the preferred treatment. However, most clinics do have the ability to administer intramuscular prochlorperazine or promethazine. Due to concerns about oversedation, misuse, and rebound, treatment with parenteral opiates is discouraged but may be an option if other treatments fail. Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of success in the treatment of acute migraine. Sumatriptan is contraindicated within 24 hours of the use of rizatriptan.

Question 78

Solar lentigines occur on sun-exposed skin and are known commonly as liver spots. A biopsy should be performed if they grow rapidly, change rapidly, are painful, itch, bleed easily, heal poorly, or have an atypical or suspicious appearance. If no suspicious changes or symptoms are present there are various options for treatment, including topical therapy with hydroquinone or retinoids, or ablative therapy with chemical peels, cryotherapy, intense pulsed light, or laser therapies.

Question 79

For women at high risk of developing preeclampsia, the U.S. Preventive Services Task Force (USPSTF) recommends starting low-dose aspirin after 12 weeks gestation (B recommendation). While calcium appears to be helpful in preventing preeclampsia for women with a diet deficient in calcium, the evidence is not yet conclusive. The USPSTF recommendation does not address the use of fish oil, magnesium gluconate, vitamin C, or vitamin D for the prevention of preeclampsia.

Question 80

This patient has a calcaneal stress fracture as suggested by the history of increased running on a hard surface, improvement with rest, and a positive calcaneal squeeze on examination. A delay in diagnosis increases the risk of delayed union. MRI is the preferred imaging modality because radiographs often do not detect a calcaneal stress fracture. A C-reactive protein level could be indicated if there were symptoms or signs of infection or autoimmune illness. The clinical picture does not suggest a neurologic condition, so nerve conduction velocity testing is not appropriate. While there are some case reports of the diagnosis of stress fractures using ultrasonography, this is not the preferred imaging method. Ref: Tu P: Heel pain: Diagnosis and management. Am Fam Physician 2018;97(2):86-

Question 81

This patient presents with morbid obesity complicated by several obesity-related conditions. Bariatric surgery has been shown to result in greater weight loss compared to nonsurgical interventions (SOR A). It has also been shown to be highly effective in treating obesity-related comorbid conditions such as diabetes mellitus (SOR A). Patients with a BMI 40 kg/m2 should be referred for consideration of bariatric surgery (SOR B). While worksite intervention, exercise therapy, behavioral therapy, and pharmacotherapy are appropriate treatments for obesity, these interventions are all less effective than bariatric surgery.

Question 82

Dysmenorrhea affects 50%–90% of females and the great majority of cases are primary dysmenorrhea, or pain that occurs in the absence of pelvic pathology. After a complete history confirming cyclic cramping pelvic pain beginning around the start of menses and a negative urine pregnancy test, empiric treatment should be offered (SOR C). First-line treatment is an NSAID at moderate to maximum dosing, such as naproxen, 500 mg every 12 hours. Any NSAID can be used and should be started 1–2 days before the onset of menses and continued through the first several days of bleeding. A secondary benefit to NSAID use is a reduction in heavy menstrual bleeding. Combined estrogen/progestin oral contraceptives may also be used as first-line therapy or in conjunction with NSAIDs. While screening for sexually transmitted infections is important for sexually active adolescents, it is not indicated in the evaluation of dysmenorrhea. Neither pelvic examination nor imaging is indicated when the history is consistent with primary dysmenorrhea. If there is evidence of secondary dysmenorrhea (due to pelvic pathology or a recognized medical condition), then an examination and imaging are indicated. Family physicians are able to manage the majority of cases of primary dysmenorrhea. If there is no improvement in treatment after 3 months, referral to a gynecologist may be indicated.

Question 83

Symptoms of serotonin syndrome range from mild to life-threatening and typically appear minutes to hours after ingestion of serotonergic medications. SSRIs are the most commonly associated class of medication due to their widespread use. The Hunter Serotonin Toxicity Criteria are the most commonly used diagnostic tool. This patient has a history of serotonergic medication use, signs of inducible clonus, agitation, and diaphoresis, as well as hyperthermia. It is likely that the addition of dextromethorphan precipitated this episode. This patient’s history does not suggest an overdose of methylphenidate, and there is little evidence in this scenario for a serious infectious process. Malignant hyperthermia generally appears over a longer period of time and does not typically induce clonus. There are few, if any, choices for medication therapy of concomitant attention-deficit/hyperactivity disorder and depression that do not increase the risk of serotonin syndrome, so patients on these regimens should be educated about the symptoms of serotonin syndrome and common causative agents.

Question 84

Although behavioral interventions are the mainstay of treatment for insomnia, they often need to be supplemented by pharmacologic therapy. When both doxepin and extended-release melatonin fail to provide benefit, a member of the Z-drug class should be tried next. Among the Z-drugs only eszopiclone provides an early peak onset and a long half-life, with a 1-hour approximate time to peak and a 6-hour half-life. While zaleplon has an equally short time to peak of 1 hour, it also has a 1 hour half-life. Antihistamines, including diphenhydramine and doxylamine, as well as atypical antipsychotics such as olanzapine, are not indicated unless used primarily to treat another condition.

Question 85

The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV. Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200 cells/μL. Hepatitis B vaccine is recommended but would not be necessary for patients such as this one with natural immunity or confirmed immunity from vaccination.

Question 86

Hypertriglyceridemia, defined as triglyceride levels 500 mg/dL, increases the risk of pancreatitis. It does not increase the risk of asthma, chronic kidney disease, gallstones, or hypothyroidism. Patients with hypertriglyceridemia should initiate therapeutic lifestyle modifications and should be treated with fibrates or niacin to help reduce the risk of pancreatitis.

Question 87

For children up to 4 years of age who only have wheezing with respiratory infections, using an inhaled corticosteroid (IC) daily when a respiratory infection develops reduces exacerbations and the use of systemic corticosteroid therapy. It is uncertain if ICs affect growth, but they would be less likely to do so than systemic corticosteroids. Antibiotic therapy should be reserved for bacterial infections. Montelukast is indicated for the prevention of asthma and allergic rhinitis. The use of antihistamine decongestant preparations in children is not recommended due to potential side effects and minimal benefit.

Question 88

This patient has a nondisplaced radial head fracture. Current evidence supports a brief period of immobilization followed by early range-of-motion exercises to avoid decreased range of motion. This results in good outcomes in 85%–95% of patients. Immobilization for 6 weeks using either a long arm posterior splint or a long arm cast is not necessary. More advanced or displaced fractures may require a referral to an orthopedist for cast placement or operative repair, but nondisplaced radial head fractures can be managed by primary care physicians.

Question 89

This patient has an acute febrile illness and meets criteria for systemic inflammatory response syndrome (SIRS) and decompensated shock. Shock is a medical emergency requiring urgent treatment to prevent death or other complications. The four types of shock are differentiated based on clinical signs. Correct treatment hinges on accurate determination of the type of shock. This patient demonstrates high-output shock typical of septic shock. Initial treatment of septic shock begins with fluid resuscitation using isotonic crystalloid by an intravenous or intraosseous route. Recent guidelines recommend a minimum of 30 mL/kg of isotonic crystalloid, with a preference for lactated Ringer’s solution over normal saline. Hypotonic solutions, such as half-normal saline, should never be administered as a bolus. There is no indication for epinephrine or dobutamine in this patient. Norepinephrine can be indicated for septic shock that has not responded to fluid resuscitation.

Question 90

Mastalgia is a common symptom requiring evaluation in the primary care setting. Cyclic mastalgia accounts for about two-thirds of all breast pain and is thought to be caused by increased sensitivity of the breast tissues to hormonal stimulation during the luteal phase of the menstrual cycle. Topical NSAIDs such as diclofenac are the first-line pharmacologic treatment for mastalgia (SOR B). Danazol is the only drug that is approved by the FDA for treatment of mastalgia, but it is poorly tolerated due to menorrhagia, muscle cramps, weight gain, and other androgenic effects. Goserelin is only indicated for severe, refractory mastalgia. Tamoxifen is more effective and better tolerated than danazol, but is associated with hot flashes, vaginal discharge, venous thromboembolism, endometrial cancer, and teratogenicity.

Question 91

Complex regional pain syndrome (CRPS) usually develops after an injury, often a fracture, to a distal extremity, although it can present without prior injury. The diagnosis is made clinically using the history and physical examination. Its pathophysiology is poorly understood. Ultrasonography or MRI may be used to rule out other diagnoses but are not necessary for the diagnosis of CRPS. Nerve injury can be seen on nerve conduction testing with type 2 CRPS, also known as causalgia, but nerve injury is not always identified with type 1 CRPS, also known as reflex sympathetic dystrophy. Nerve conduction testing is not necessary for making the diagnosis, and both types of CRPS are treated with the same approach. A technetium 99m bone scan may reveal increased bone resorption at the site, but it is neither sensitive nor specific for CRPS.

Question 92

Patients with end-stage renal disease and diabetes mellitus need careful monitoring of glucose because insulin requirements are difficult to predict and there is an increased risk of hypoglycemia in this setting. The optimal hemoglobin A1c has not been established but maintaining a value between 6% and 9% does decrease mortality. With close monitoring, insulin is preferred for most individuals. Sulfonylureas such as glimepiride and glyburide are associated with a high risk of hypoglycemia and should be avoided in these patients. Metformin should be avoided in those with a glomerular filtration rate <30 mL/min/1.73 m2. Pioglitazone should also be avoided in chronic kidney disease due to the risk of fluid retention and precipitating heart failure.

Question 93

This patient has a stage 2 pressure ulcer. It is recommended that pressure ulcers not be cleaned with povidone/iodine, Dakin’s solution, hydrogen peroxide, wet-to-dry dressings, or any solutions that may impede granulation tissue formation. These sites should be cleaned with either saline or tap water and covered with hydrocolloid, foam, or another nonadherent dressing that promotes a moist environment.

Question 94

Patients with rheumatoid arthritis being treated with anti-tumor necrosis factor therapy are at increased risk for septic arthritis. The most common cause of septic arthritis in adults is Staphylococcus aureus, followed by Streptococcus species. Escherichia coli causes about a fourth of the cases in the elderly. Fungal and mycobacterial causes such as Candida albicans or Mycobacterium tuberculosis are less common but must be considered in immunocompromised patients.

Question 95

Family physicians are often asked to provide primary care for organ transplant recipients. Pregnancy should be avoided during the 12 months following transplantation because of the increased risk of preterm delivery and graft rejection. Female fertility typically increases post transplant. The use of an IUD avoids interactions with medications, does not increase the risk of infection, and is not affected by typical immunosuppressive therapies. The remaining options are incorrect because of their higher failure and discontinuation rates. The CDC cites failure rates with typical use of 9% for combined oral contraceptives and the etonogestrel/ethinyl estradiol vaginal ring, 6% for injectable progesterone, 0.2% for levonorgestrel IUDs, and 0.08% for the copper IUD. Barrier method failure rates exceed 18%. Combined oral contraceptives and the vaginal ring also have potential estrogen-related side effects, and injectable progesterone use increases the risk for osteoporosis.

Question 96

There are several types of chronic headaches, and they often respond to different treatments. Migraine is very prevalent and is characterized by headaches that are periodic, often unilateral, and frequently pulsatile. Migraine is familial and typically starts in childhood, adolescence, or young adulthood, and the headaches decrease in frequency over time. Some are associated with aura, which causes visual disturbances. In mild cases, over-the-counter medications may control symptoms. For most patients, however, treatment to control the attack can include triptans such as sumatriptan, and/or ergot alkaloids such as ergotamine. Treatment to prevent attacks may also be appropriate, and could include a β-blocker, antiepileptic drugs, or amitriptyline. Tension headaches are usually bilateral and are typically described as dull or aching, but patients often describe tightness or pressure. They are not associated with symptoms such as throbbing, nausea, or photophobia. Tension headaches are more frequent than migraine but patients often treat them at home without seeking medical treatment. Frequent or persistent tension headaches can be treated with several drugs used for anxiety or depression, including amitriptyline. Stronger analgesics and ergotamine are not helpful.

Answer 96

Cluster headache is another type of chronic headache. This occurs most frequently in adult males, and often occurs over a period which may extend over many weeks, with repeated episodes or clusters. It most often occurs at night, and may recur several times during the night. The headache is unilateral and is associated with orbital pain and vasomotor phenomenon such as blocked nasal passages, rhinorrhea, conjunctival injection, and miosis. The headache can be treated with inhalation of 100% oxygen, and the headache cycle can be terminated with verapamil. Ergotamine or sumatriptan can be used at night to prevent attacks. There are also variants of cluster headaches, including chronic paroxysmal hemicrania, which resembles cluster headache but has some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.

Question 97

Cognitive-behavioral therapy for chronic insomnia is known to be superior to pharmacologic therapies (SOR A) and can be effectively administered by primary care physicians (SOR B). An important component of cognitive-behavioral therapy is sleep hygiene education to identify behaviors that can interfere with sleep, such as pets in the bedroom, caffeine consumption after 4 p.m., exercising within 2 hours of bedtime, and nicotine use. It is also important to identify factors that can facilitate sleep, such as maintaining an environment conducive to sleep, including a cool room and a comfortable bed. Addressing misunderstandings about normal sleep, reinforcing factual sleep-related information, and addressing stimulus control, such as limiting use of the bedroom to sleep and sex and delaying going to bed until sleepy, are among the other key components of a comprehensive cognitive-behavioral therapy program for chronic insomnia.

Question 98

This patient has diarrhea-predominant irritable bowel syndrome (IBS). There are many treatments available, with varying degrees of evidence. SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS. Polyethylene glycol is a treatment for constipation and would not help this patient. Acupuncture has not been shown to be superior to sham acupuncture in improving IBS symptoms. Neomycin has been shown to improve symptoms in constipation-predominant IBS but would not be helpful in diarrhea-predominant IBS. Soluble fiber such as psyllium improves symptoms and decreases abdominal pain scores in patients with IBS. Insoluble fiber has not been shown to improve any IBS outcomes.

Question 99

Though symptoms of generalized anxiety disorder (GAD) overlap with other psychiatric and medical conditions, the case presented is most consistent with GAD. SSRIs are first-line therapy for GAD (SOR B). Benzodiazepines such as lorazepam can improve anxiety-related symptoms, but due to the side effects and addiction potential they are recommended for short-term use (SOR B). Bupropion is approved for the treatment of depression but is not used to treat GAD. Quetiapine may be considered as second-line therapy for GAD (SOR B). Methylphenidate is first-line therapy for attention-deficit/hyperactivity disorder but is not indicated to treat GAD. Psychotherapy, especially cognitive-behavioral therapy, is also first-line treatment for GAD (SOR A), and exercise can also improve symptoms (SOR B).

Question 100

Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal spirometry indicates a disease process that disrupts gas transfer in the lungs without causing lung restriction or airflow obstruction. Common causes include chronic pulmonary emboli, heart failure, connective tissue disease with pulmonary involvement, and primary pulmonary hypertension. Asthma, bronchiectasis, COPD, and pulmonary fibrosis are associated with abnormalities on spirometry.

Question 101

Patients with an artificial heart valve should be given antibiotic prophylaxis prior to dental procedures to prevent infectious endocarditis. The organisms that most frequently cause infectious endocarditis include Staphylococcus aureus (31%), Streptococcus viridans (17%), coagulase-negative staphylococci (11%), Enterococcus (11%), Streptococcus bovis (7%), and other streptococci (5%). Amoxicillin is the preferred medication for prophylaxis. Clindamycin or azithromycin can be used in patients with a penicillin allergy. If the penicillin allergy is not associated with anaphylaxis, angioedema, or urticaria, then cephalexin would be an appropriate antibiotic choice. Ciprofloxacin, doxycycline, rifampin, and trimethoprim/sulfamethoxazole are not used for bacterial endocarditis prophylaxis.

Question 102

Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition. Examples include childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex. Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications. Examples include routine Papanicolaou tests and screening for hypertension, diabetes mellitus, or hyperlipidemia. Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. Examples include screening patients with diabetes for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin.

Question 103

The Centers for Disease Control and Prevention (CDC) provides specific recommendations for backup contraception after IUD insertion. According to the CDC guidelines, this patient does not need to use backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts, the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

Question 104

Elderly patients, especially those taking hydrochlorothiazide, are at risk for developing hyponatremia while taking carbamazepine. Carbamazepine is one of the medications that can cause the syndrome of inappropriate antidiuretic hormone secretion, as it interferes with the ability to dilute the urine. It does not lead to the other derangements listed (SOR A).

Question 105

Prazosin is an α-adrenergic receptor antagonist and is recommended for the treatment of nightmares in posttraumatic stress disorder (SOR A). It is thought to reduce sympathetic outflow in the brain. Although clonidine may be tried, evidence of its effectiveness is sparse (SOR C). Clonazepam, propranolol, and divalproex have not been recommended.

Question 106

Oral corticosteroids are not indicated in the treatment of plaque psoriasis. All of the other options are indicated only if topical treatments fail. Of the options listed, the combination of a topical corticosteroid and topical calcipotriene is considered the most appropriate for this patient. Another option would be to add topical tazarotene to the topical corticosteroid. However, when tazarotene is used as monotherapy it often fails to clear plaques and increases the incidence of skin irritation.

Question 107

This patient presents with signs and symptoms that suggest age-related macular degeneration. Smoking is a modifiable risk factor and smokers should be counseled to quit (SOR C). The patient should be referred to an ophthalmologist for further evaluation and management. Watchful waiting would not be appropriate. Vitamin supplements with Age-Related Eye Disease (AREDS) and AREDS2 formulations have been shown to delay visual loss in patients with age-related macular degeneration (SOR A). Age-related macular degeneration is not reversible but treatment can delay progression or stabilize the changes (SOR A).

Question 108

The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay. Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.

Question 109

This child’s presentation appears most consistent with bites from an insect. Having multiple exposures on skin often not covered by clothing would be typical of household fleas or bedbugs. Tick bites are typically identified by the presence of an actively feeding insect or a single papular lesion. Similarly, brown recluse spider bites would not be expected to be multiple or recurrent. A chigger is the larval form of a mite, which is an eight-legged arthropod. The larval form has only six legs, and tends to crawl into spaces near constricted clothing and cause welts from their bites along the neckline, waistline, sock line, or more rarely on the genitals. A scabies infestation often presents as an eczematous rash in semi-protected folds of skin such as the web spaces of fingers, the umbilicus, the axillae, or the genital region.

Question 110

Employing a presumptive approach rather than a participatory approach significantly increases the likelihood that a patient, parent, or guardian will accept a recommended vaccine. This strategy implies that accepting the immunization is the usual or normal choice. The correct option in this scenario presumes the patient will accept the immunization, while the remainder of the options ask if they will.

Question 111

According to an international consensus statement, there are three criteria for diagnosing sarcoidosis: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings. The main exceptions to the need for histologic confirmation are the presence of bilateral hilar adenopathy in an asymptomatic patient (stage I) and the presentation of sarcoid-specific Lofgren syndrome—with fever, erythema nodosum, and bilateral hilar adenopathy that can be diagnosed based on clinical presentation alone. An asymptomatic patient with stage I sarcoidosis (bilateral hilar lymphadenopathy on chest radiography) without suspected infection or malignancy does not require an invasive tissue biopsy because the results would not affect the recommended management, which is monitoring only. Treatment is not indicated because spontaneous resolution of stage I sarcoidosis is common. Reliable biomarkers for diagnosing sarcoidosis do not exist. Although the serum angiotensin converting enzyme level may be elevated in up to 75% of untreated patients, this lacks sufficient specificity, has large interindividual variability, and fails to consistently correlate with disease severity, all of which limit its clinical utility. Pathologic evidence of noncaseating granulomas from the most accessible and safest biopsy site should be pursued only if there is an indication for treatment, such as significant symptomatic or progressive stage II or III pulmonary disease or serious extrapulmonary disease. If treatment is indicated, corticosteroids are the first-line treatment for sarcoidosis. Second- and third-line treatments include methotrexate, azathioprine, leflunomide, and biologic agents.

Question 112

This patient has a peripheral neuropathy. A review of the patient’s history and specific laboratory testing was performed to evaluate for the most common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In this patient, the mildly elevated total protein and erythrocyte sedimentation rate, which suggest a monoclonal gammopathy such as MGUS (monoclonal gammopathy of unknown significance) or multiple myeloma, should direct her workup. Serum protein electrophoresis is indicated to assess for this. Other less common causes of peripheral neuropathy include carcinoma causing a paraneoplastic syndrome, lymphoma, sarcoidosis, AIDS, and genetic disorders such as Charcot-Marie-Tooth disease. Approximately 25% of patients with peripheral neuropathy have no clearly defined cause after a thorough evaluation and are diagnosed with idiopathic polyneuropathy. MRI of the lumbar spine can identify central lesions causing spinal cord or nerve root compression but is not indicated in the evaluation of peripheral neuropathy. Serum angiotensin converting enzyme levels and a chest radiograph can assist in the diagnosis of sarcoidosis, which can cause peripheral neuropathy but is less likely in this patient. Cerebrospinal fluid analysis is important in assessing for chronic inflammatory demyelinating polyradiculoneuropathy, a more rare cause of peripheral neuropathy.

Question 113

The annual failure rate of combined oral contraceptive pills with typical use is 7%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 4% for injectable progestin, 13% for male condoms, and 22% for the withdrawal method.

Question 114

Due to the disease prevalence and impact, effectiveness of screening instruments, and benefits of available treatment, the U.S. Preventive Services Task Force (USPSTF) recommends screening for major depressive disorder when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF has made no recommendations regarding screening for bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, or schizophrenia.

Question 115

Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.

Question 116

Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be administered (SOR B). The therapeutic response to NSAIDs is often remarkable. Acetaminophen has not been shown to be a superior analgesic for acute rheumatic fever. Gabapentin is not indicated, especially considering that the pain does not have a neuropathic etiology. Opioids would not be considered first-line treatment because of their adverse effects and the dramatic response of NSAIDs alone.

Question 117

This patient has acute chest syndrome (ACS), a serious vaso-occlusive complication of sickle cell disease (SCD). Its cause may be multifactorial, but infections are common and antimicrobials are indicated. However, the clinical course of ACS is significantly different from infectious pneumonia in patients without SCD, due to the damaged microvasculature that occurs in ACS. Studies have shown that atypical pathogens predominate in ACS and it is therefore important to treat all patients with ACS with antibiotics that cover Mycoplasma and Chlamydophila. Viral infections are also common, especially in children with ACS. Other possible pathogens include Staphylococcusaureus, Streptococcus pneumoniae, and Haemophilus influenzae. Therefore, the use of a third-generation cephalosporin along with azithromycin is the recommended antibiotic coverage. In addition to antimicrobials, treatment includes supportive care with supplemental oxygen, intravenous fluids, pain control, and incentive spirometry. Depending on the degree of anemia seen, a simple blood transfusion or exchange transfusion is often indicated as well. Consultation with a hematologist is recommended in the care of patients with ACS. Even with appropriate care, mortality rates in ACS are as high as 3%.

Question 118

Recommendations to screen for vitamin D deficiency apply only to patients at risk and not to the general population. This patient’s obesity and her clothing style, which limits sun exposure to the skin, puts her at increased risk. Additionally, this patient’s muscle aches may be a symptom of vitamin D deficiency. The recommended test for this condition is a 25-hydroxyvitamin D level. A 1,25-dihydroxyvitamin D level is recommended to monitor, not diagnose, certain conditions. Parathyroid hormone, calcium, and alkaline phosphatase levels are poor indicators of vitamin D status.

Question 119

Absorption of levothyroxine is impaired by several gastrointestinal conditions, including atrophic gastritis, chronic proton pump inhibitor use, and Helicobacter pylori infection. Treatment of H. pylori infection reverses this effect, and following eradication of the infection a reduction of the levothyroxine dosage by 30% or more will often be required.

Question 120

Acute uncomplicated cystitis responds well to 3 days of trimethoprim/sulfamethoxazole, 160/800 mg twice daily. Increasing resistance to fluoroquinolones has been seen and they are therefore less likely to be successful. Because of the association with tendon rupture they are also not considered first-line treatment. β-Lactam agents have similar resistance issues. Azithromycin is not indicated for urinary tract infections. Ibuprofen alone has produced good symptom relief, but antibiotics are frequently needed for a definitive cure. The presence of diabetes or prediabetes should not change treatment (SOR A, SOR C).

Question 121

The European Society of Cardiology 2016 Guidelines for Atrial Fibrillation state that the benefits of oral anticoagulation outweigh the risks in the majority of patients with atrial fibrillation who meet CHA2DS2-VASc criteria for oral anticoagulation. This includes the elderly and patients with cognitive impairment, frailty, or frequent falling. Oral anticoagulation is superior to aspirin for the prevention of stroke, while the bleeding risk with aspirin is not different than that of oral anticoagulation. Use of the CHA2DS2-VASc criteria significantly increases the number of patients eligible for anticoagulation therapy compared with the CHADS2 scoring system. If there is concern about bleeding risk, particularly in patients older than 65 years of age, the HAS-BLED scoring system has been well validated, with a score of 3 or more indicating that a patient has a high likelihood of hemorrhage. This patient’s HAS-BLED score is 1 (age) and her estimated risk of major bleeding with 1 year of anticoagulation is 1.88%–3.3%. Her adjusted stroke risk is high (4.8% per year), as she has a CHA2DS2-VASc score of 4 (age ≥75, female, history of hypertension).

Question 122

In addition to aspirin, a high-intensity statin, and sublingual nitroglycerin as needed, patients with chronic stable angina may be treated with β-blockers, calcium channel blockers, and/or long-acting nitrates. β-Blockers and heart rate–lowering calcium channel blockers should be avoided in this patient who already has bradycardia. Ranolazine, which affects myocardial metabolism, is not used as a first-line agent. Ivabradine is not a first-line agent and is used only in patients with heart failure. A long-acting nitrate or a dihydropyridine calcium channel blocker would be appropriate for this patient.

Question 123

This patient has signs and symptoms of cubital tunnel syndrome, which is the second most common peripheral neuropathy. Symptoms develop because of ulnar nerve compression in the upper extremity, leading to sensory paresthesias in the ulnar digits and intrinsic muscular weakness. Vague motor problems, including poor coordination of the fingers and hand clumsiness, are frequent complaints. Provocative testing includes demonstration of Tinel’s sign over the cubital tunnel, and the elbow flexion test with paresthesias elicited over the ulnar nerve. Carpal tunnel syndrome causes paresthesias in the distal median nerve distribution. Wartenberg’s syndrome reflects compression of the superficial radial nerve. Pronator syndrome is a proximal median nerve neuropathy, while anterior interosseous nerve syndrome, a rare clinical entity, causes paresis or paralysis of the flexor pollicis longus, and the flexor digitorum profundus of the index and long fingers.

Question 124

If atrial fibrillation is converted back to sinus rhythm, the likelihood of the patient staying in sinus rhythm is best predicted from the diameter of the left atrium on the patient’s echocardiogram. Significant left atrium enlargement means the patient is unlikely to stay in sinus rhythm after successful conversion. Other factors that predict a lack of success in maintaining sinus rhythm after cardioversion include a longer time in atrial fibrillation before cardioversion, or the presence of underlying heart disease, especially rheumatic heart disease.

Question 125

Fractures of the clavicle are common in young individuals, usually from sports injuries or direct trauma. Eighty percent of these fractures occur in the midclavicle. Unless significantly displaced, these fractures do not require referral. They can be treated with just a sling for 2–6 weeks. A sling is more comfortable and less irritating than a figure-of-eight bandage. Passive range of motion of the shoulder is indicated as soon as the pain allows. Physical therapy may be started at 4 weeks after the injury.

Question 126

In a patient with cancer, deep vein thrombosis of the leg or a pulmonary embolus is considered to be cancer-associated thrombosis. Low molecular weight heparin (LMWH), such as enoxaparin, should be chosen over the other anticoagulant options listed. (LMWH over warfarin is a Grade 2B recommendation; LMWH over dabigatran is a Grade 2C recommendation; LMWH over rivaroxaban is a Grade 2C recommendation; and LMWH over apixaban or edoxaban is a Grade 2C recommendation).

Question 127

This child has gastroesophageal reflux. This is a normal physiologic process that occurs in infants. Most reflux events are caused by transient lower esophageal sphincter relaxation that is triggered by postprandial gastric distention. This relaxation can continue into childhood, but with growth and an upright eating position it generally improves. Reflux in infants can be treated by implementing body position changes while awake, lower volume feedings if they are overfed, thickening agents, and antiregurgitant formula. It is recommended to avoid the use of medication in infants that have regurgitation that is effortless, painless, and not affecting growth. When the infant is not growing well or appears to be in pain, it would be appropriate to initiate pharmacotherapy with an acid-suppressing medication. Abdominal ultrasonography would be indicated if there were forceful vomiting and concerns about possible pyloric stenosis.

Question 128

Although the FDA has not approved the use of antipsychotics for aggressive behavior associated with dementia, they are often used to treat refractory behavioral and psychological symptoms of dementia. Their off-label use should be considered only when nonpharmacologic therapies are ineffective and the behaviors pose a risk of harm to the patient or others (SOR C), and the drug should be discontinued if there is no evidence of symptom improvement (SOR A). In a meta-analysis of three atypical antipsychotics, only aripiprazole showed small average reductions in behavioral and psychological symptoms of dementia. Olanzapine has demonstrated inconsistent results and ziprasidone is ineffective. Diphenhydramine is an anticholinergic agent and could exacerbate behaviors. Mirtazapine is indicated for depression. The American Geriatrics Society recommends against the use of benzodiazepines in older adults as a first choice for insomnia, agitation, or delirium.

Question 129

There are three situations when a breach of confidentiality is justified: abuse of a vulnerable person (child or elderly), a public health risk (communicable disease), or substantial danger to the patient or others. While Chlamydia is not usually considered life-threatening or dangerous, it is communicable. Contacting sexual partners to notify and treat them to stem the spread of disease is recommended.

Question 130

Sepsis is a severe life-threatening disorder that has a 25%–30% mortality rate. Early aggressive management has been shown to decrease the mortality rate. The initial step in the management of sepsis is respiratory stabilization. Fluid resuscitation should be started and followed by vasopressor therapy if there is an inadequate blood pressure response. Antibiotics should be initiated within 1 hour of presentation. Other interventions in early goal-directed therapy that have been shown to improve mortality rates include blood transfusions, low-dose corticosteroid therapy, and conventional (not intensive) glycemic control with a target glucose level of <180 mg/dL. Intensive management of glucose in critically ill adult patients (a target glucose level of 80–110 mg/dL) has been shown to increase mortality.

Question 131

This child presents with oppositional defiant disorder (ODD). To meet the DSM-5 criteria for ODD, the child must demonstrate at least four symptoms from any of the following categories: angry/irritable mood (often loses temper, is often touchy or easily annoyed, is often angry and resentful), argumentative/defiant behavior (often argues with authority figures or with adults, often actively defies or refuses to comply with requests from authority figures, often deliberately annoys others, often blames others for his/her mistakes or misbehavior), and vindictiveness (has been spiteful or vindictive at least twice within the past 6 months). These behaviors must be directed toward at least one person other than a sibling. Behavioral problems associated with conduct disorder are more severe, including aggression toward animals or other persons, destruction of property, and a pattern of theft or deceit. The person’s conduct frequently leads to conflict with authority figures.

Answer 131

Attention-deficit/hyperactivity disorder involves difficulty in following rules, struggles with authority figures, and possibly annoying others. In ODD, however, defiance of authority figures occurs in settings other than those where sustained attention or sitting quietly is required. Bipolar disorder can include irritability and negative affect but the argumentative, defiant behavior or vindictiveness that occur in ODD do not routinely occur in mood disorders. Intermittent explosive disorder involves repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which the person reacts grossly out of proportion to the situation. Road rage, domestic abuse, throwing or breaking objects, or other temper tantrums may be signs of intermittent explosive disorder. Serious aggression toward others does not occur in ODD.

Question 132

This patient’s history fits the diagnosis of functional dyspepsia. Two subtypes of this disorder have been described. The first, epigastric pain syndrome, is described as intermittent pain and burning in the epigastrium. The second, postprandial distress syndrome, is more typical of the symptoms this patient describes: postprandial fullness and early satiety. Although there is considerable benefit from reassurance and “naming” a patient’s condition, empiric treatment is also warranted. Patients with epigastric pain syndrome are more likely to respond to proton pump inhibitors or H2-blockers. Patients with predominantly postprandial distress symptoms are more likely to improve with a motility agent such as metoclopramide. Sucralfate, antacids, and selective antidepressants have not been shown to be more effective than placebo in functional dyspepsia, whereas tricyclic antidepressants and buspirone have shown some benefit and are reasonable next steps for this patient.

Question 133

Community-acquired pneumonia in children is treated based on age. The most likely etiologic agents in a school-age child are Mycoplasma pneumoniae , Chlamydia pneumoniae , and Streptococcus pneumoniae . Group A Streptococcus and Haemophilus influenzae are less common causes. Staphylococcus aureus that is methicillin-resistant has become increasingly common. The preferred treatment for community-acquired pneumonia is a macrolide antibiotic such as azithromycin. In children ages 5–16, Mycoplasma pneumonia tends to have a gradual onset of symptoms and seldom causes respiratory distress. Signs and symptoms may vary. The patient may develop a rash, musculoskeletal symptoms, or gastrointestinal symptoms. Radiographs may reveal bronchopneumonia, nodular infiltrates, hilar adenopathy, pleural effusions, or plate-like atelectasis. Ear pain may be due to bullous myringitis, although this may be viral as well. Laboratory findings may not be helpful, as the WBC count may be normal or slightly elevated. There may be thrombocytosis, an elevated erythrocyte sedimentation rate, an elevation of cold agglutinins, or an elevated reticulocyte count. A Coombs test is seldom needed, although it might be helpful at times. The diagnosis is generally made on a clinical basis.

Question 134

In young patients with hypertension it is important to consider secondary causes in addition to the more common essential hypertension. This patient’s relatively young age and elevated home blood pressure readings despite drug therapy warrant further evaluation. The initial evaluation showed hypokalemia, which suggests an endocrine cause of hypertension, specifically hyperaldosteronism. Other potential causes of secondary hypertension include coarctation of the aorta, renal artery stenosis, thyroid disorders, obstructive sleep apnea, pheochromocytoma, and Cushing syndrome. Each of these presents with clinical findings that help to distinguish them from other potential causes, and the laboratory evaluation would depend on the suspected cause.

Question 135

Based on her clinical presentation and classic ophthalmopathy, this patient has Graves disease. Unlike radioactive iodine, methimazole has been shown to decrease the risk of development or progression of ophthalmopathy in Graves disease (SOR B). Atenolol is used for symptomatic control in hyperthyroidism. Cholestyramine can help lower thyroid hormone acutely but is not a long-term treatment. Prednisone is used for severe hyperthyroidism and not long-term treatment. Atenolol, cholestyramine, and prednisone do not have any effect on the long-term complications of Graves disease.

Question 136

Accepted mood stabilizers used for maintenance therapy in patients with bipolar disorder include lithium, valproate, lamotrigine, and some atypical antipsychotics such as olanzapine, quetiapine, and risperidone. The atypical antipsychotics are associated with weight gain and adverse metabolic changes. Annual testing for diabetes mellitus is recommended. Long-term maintenance therapy with a mood stabilizer is recommended in patients with bipolar I disorder due to the high risk of recurrent mania. Monotherapy with antidepressants is contraindicated. Although the typical antipsychotics may cause QT prolongation, atypical antipsychotics such as quetiapine do so much less frequently, and most SSRIs do not cause this. Coadministration with sertraline is not contraindicated.

Question 137

Conservative treatment is the recommended initial management for olecranon bursitis when there is no history of trauma or signs of septic bursitis. Aspiration of the bursal fluid is not recommended initially due to the risk of iatrogenic infection, but can be considered for symptomatic relief if there is significant enlargement or symptoms, or for diagnosis and culture if septic bursitis is suspected. Antibiotics are not recommended for aseptic bursitis and should be delayed in septic bursitis until after aspiration for culture. MRSA coverage may be indicated if the patient is at high risk for MRSA infection. An intrabursal corticosteroid injection is not routinely recommended for bursitis unless an underlying inflammatory condition is suspected, such as gout or rheumatoid arthritis. An intrabursal hyaluronic acid injection is not a recommended treatment for bursitis.

Question 138

Generally, the goal for patients with vertebral compression fractures is early mobilization when tolerated. Bed rest is ordered only if movement is not tolerated. The evidence for back bracing is limited but it can be used after weighing the risks and benefits. Current evidence supports initial conservative treatment before considering vertebroplasty or kyphoplasty (SOR C). Neurosurgical consultation is not required in this case.

Question 139

There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. Clinically useful statistics for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratio. The likelihood ratio indicates how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%. The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.

Question 140

The 2013 American College of Cardiology/American Heart Association cholesterol guideline suggests statin therapy for individuals with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or greater. The U.S. Preventive Services Task Force and the National Institute for Health and Care Excellence recommend statin therapy when the patient’s 10-year risk of cardiovascular disease is 10% or greater. While international guidelines differ somewhat, other major guidelines would support similar recommendations.

Question 141

Constitutional growth delay, defined as delayed but eventually normal growth in an adolescent, is usually genetic. If evaluation of the short adolescent male reveals no evidence of chronic disease, if his sexual maturity rating is 2 or 3, and if his height is appropriate for his skeletal age he can be told without endocrinologic testing that he will begin to grow taller within a year or so. His adult height may be below average but cannot be predicted reliably. Average sexual maturity ratings for a male of 14.3 years are 4 for genitalia and 3–4 for pubic hair. The history and physical examination would have given clues to any illnesses or nutritional problems.

Question 142

Family physicians should know about health risks associated with adverse childhood experiences (ACEs). Many risk factors are associated with cumulative ACEs. As ACEs increase so do the risks for alcoholism, drug abuse, depression, suicide attempts, smoking, poor self-rated health, ≥50 sex partners, sexually transmitted disease, physical inactivity, severe obesity, and several chronic medical conditions that are leading causes of death in adults. Of the options listed, this child is at greatest risk for alcoholism.

Question 143

α1-Blockers such as doxazosin, prazosin, and tamsulosin have been shown to hasten the passage of ureteral stones (level 2 evidence). They are probably more effective than calcium channel blockers (level 2 evidence). β-Blockers, phosphodiesterase inhibitors such as sildenafil, 5-α-reductase inhibitors such as finasteride, and thiazide diuretics have not been shown to hasten stone passage. However, thiazide diuretics have been shown to decrease stone formation in patients with hypercalciuria.

Question 144

In 2013 nearly 180,000 bariatric surgery procedures were performed in the United States. Bariatric surgery does result in reduced all-cause mortality and more weight loss. National Institutes of Health Consensus Development Conference eligibility criteria include comprehension of risks, benefits, expected outcomes, alternatives, and required lifestyle changes, including required postoperative lifelong supplements, diet changes, and follow-up appointments.

Question 145

Posterior midline fissures cause pain during and after defecation. Most are caused by the passage of hard stool and when stretched cause bleeding. Conservative therapy consisting of bulk agents and stool softeners usually allows these to heal. Internal hemorrhoids can cause bleeding with the passage of stool but are typically painless. External hemorrhoids can bleed with trauma but typically cause pain with thrombosis, independent of bowel movements. Anal fistulas and perirectal abscesses may intermittently drain purulent material. Abscesses can cause continuous pain, and a perianal mass may be noted on examination.

Question 146

This patient’s MRSA bacteremia is considered uncomplicated due to the effectiveness of the antibiotic therapy and the lack of endocarditis or implanted prostheses such as heart valves. Therefore, the Infectious Diseases Society of America recommends that follow-up cultures of blood samples be obtained 2–4 days after the initial cultures and as needed thereafter to document clearance of bacteremia (SOR A; Quality of Evidence II).

Question 147

GLP-1 agonists are contraindicated in patients with medullary thyroid cancer or multiple endocrine neoplasm syndrome, or with a family history of these conditions. They are not associated with heart failure, coronary artery disease, or hypothyroidism. They have been associated with pancreatitis in rare cases, but this is not a contraindication to prescribing them.

Question 148

Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia, Korea, China, and Vietnam. The belief is that one’s illness must be drawn out of the body, and the red marks produced by rubbing the skin with a coin are evidence of the body’s “release” of the illness. These marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the illness itself.

Question 149

Recent guidelines have suggested that hypotension (a systolic blood pressure <90 mm Hg or a diastolic blood pressure <60 mm Hg, for 15 minutes or longer) should be treated with thrombolysis in patients who are not at high risk for bleeding. Patients who have other indicators of cardiopulmonary impairment without signs of hypotension should be given anticoagulation therapy and aggressive supportive care, but should not be treated with thrombolytic therapy. If the patient’s condition continues to deteriorate as evidenced by the development of hypotension or other clinical indicators of cardiopulmonary compromise, thrombolysis may be considered.

Question 150

This patient has osteomyelitis until proven otherwise. A radiograph of his right foot is the best initial test to look for evidence of this diagnosis. In most treatment settings, radiography is much easier to obtain than ultrasonography, CT, MRI, or technetium 99m bone scintigraphy. In addition, it is generally considerably less expensive than the other options listed. A radiograph also allows the physician to rule out other bony pathologies. MRI is useful if the radiograph is inconclusive, and is more helpful than radiography for determining bony versus soft-tissue infection. CT may be used in cases where MRI is contraindicated. Ultrasonography is not useful for evaluating bony lesions. Bone scintigraphy has low sensitivity, particularly in the setting of recent trauma or surgery.

Question 151

According to the guidelines of the American Academy of Pediatrics, elemental iron supplementation (2 mg/kg per day) should begin at 1 month of age for exclusively breastfed infants born before 37 weeks gestation and should continue until 12 months of age, unless the infant had multiple blood transfusions.

Question 152

All staff, visitors, and nursing home residents should observe strict handwashing practices when a resident has a MRSA infection. Barrier precautions for wounds and medical devices should also be initiated. Surveillance cultures are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the spread of MRSA. Isolating the patient is not practical or cost effective.

Question 153

Achilles tendinopathy is among the most common injuries in middle-aged distance runners. Oral NSAIDs may be helpful for temporary pain relief, but they contribute little to recovery from this injury. Corticosteroid injection is contraindicated due to the risk of tendon rupture. Surgical debridement and fixation in a walking boot may be considered as a last resort for difficult cases, but the most effective treatment overall is eccentric calf-strengthening exercises.

Question 154

Screening for colorectal cancer (CRC) is recommended for average-risk individuals beginning at age 50 (SOR A). Individuals at higher risk include those with a personal history of adenomatous polyps, CRC, inflammatory bowel disease, genetic cancer syndromes, or a family history of either adenomatous polyps or CRC. Patients with a first degree relative with CRC or adenomatous polyps discovered before age 60, or two or more first degree relatives at any age with CRC or advanced adenoma, should undergo colonoscopy screening starting at age 40 or 10 years before the youngest age a family member was diagnosed, whichever comes first. The maximum surveillance interval for these patients is 5 years (SOR C). Patients with a single first degree relative diagnosed at age 60 or older, and patients with two affected second degree relatives, should undergo screening starting at age 40 by any recommended method, and at the same intervals for average-risk individuals (SOR C). Patients with small, distal hyperplastic polyps are considered to have a normal colonoscopy (SOR C). There is no need for referral to a gastroenterologist or interval fecal immunochemical testing (FIT) following an adequate colonoscopy.

Question 155

Infantile hemangiomas usually appear by 4 weeks of age and stop growing by 5 months of age. As many as 70% leave residual skin changes, including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring. Systemic corticosteroids were the mainstay of treatment for hemangiomas during infancy until 2008, when the FDA approved oral propranolol for this indication. Intralesional corticosteroids can be effective for small, bulky, well localized lesions in infants. Laser therapy can also be used to treat early lesions or residual telangiectasia. Once involution is complete, however, as is the case with this child, elective surgical excision is the treatment of choice, producing better outcomes.

Question 156

First-line agents for hypertension include ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Hydrochlorothiazide would be relatively contraindicated due to the patient’s gout. Losartan, an angiotensin receptor blocker, should not be added because the patient is taking an ACE inhibitor. Metoprolol succinate, a β-blocker, is not a first-line agent for blood pressure unless there is another indication such as systolic heart failure or migraine prophylaxis.

Question 157

Penile enlargement in an 8-year-old male is a sign of precocious puberty. Isolated sparse pubic and axillary hair growth and axillary odor is referred to as premature adrenarche, and represents high levels of dehydroepiandrosterone rather than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty. The isolated findings of premature adrenarche are generally considered benign. An 8-year-old with breast buds and a 10-year-old with menarche are within the normal range of expected pubertal development. Penile enlargement typically represents full activation of the hypothalamic-pituitary-gonadal axis and warrants endocrinologic evaluation in boys younger than 9 years of age.

Question 158

According to the American College of Rheumatology criteria, this patient has systemic lupus erythematosus, with photosensitivity, arthritis, a positive antinuclear antibody test, and a positive anti–double-stranded DNA test. She has a mild form of the disease. Hydroxychloroquine reduces arthritis pain in lupus patients (SOR A) and is the preferred initial treatment for lupus arthritis. Cyclosporine and azathioprine are indicated for severe lupus or lupus nephritis. Mycophenolate is indicated for refractory lupus or lupus nephritis. Rituximab is indicated for severe refractory lupus.

Question 159

In otherwise healthy stable patients with upper gastrointestinal bleeding, a transfusion of red cells is recommended when the hemoglobin level falls below 7.0 g/dL. In hypotensive patients with severe bleeding, a blood transfusion before the hemoglobin level reaches 7.0 g/dL is needed to prevent significant decreases below this level that would occur with just fluid resuscitation. In hemodynamically stable patients with known cardiovascular disease and significant upper gastrointestinal bleeding, 8.0 g/dL should be the threshold for a blood transfusion.

Question 160

Elevated levels of NT-proBNP are known to indicate an increased likelihood of heart failure, and lower levels can rule out heart failure. However, certain patient characteristics can lead to higher levels of NT-proBNP even in healthy individuals. The use of one normal cutoff level for elevated NT-proBNP may not be appropriate. Even healthy female patients and those >65 years of age will have higher levels of NT-proBNP than younger male patients (SOR A). NT-proBNP is negatively correlated with kidney function as measured by the estimated glomerular filtration rate (GFR) and albumin levels. Patients with a low GFR or a low level of albumin have higher NT-proBNP levels (SOR A). Interestingly, grip strength is negatively correlated with NT-proBNP as well. A higher BMI is associated with a lower NT-proBNP. Thus, the utility of NT-proBNP to rule out heart failure in obese patients is decreased (SOR A).

Question 161

NSAIDs such as ibuprofen should be used as first-line treatment for the control of pleuritic pain (SOR B). NSAIDs do not have the analgesic potency of narcotics, but they do not cause respiratory suppression and do not change the patient’s sensorium. Corticosteroids should be reserved for patients who cannot take NSAIDs. Colchicine is used to treat pericarditis but not pleuritic pain.

Question 162

Randomized, controlled studies yield stronger evidence than other types of studies, especially case-control or cohort studies, because randomization provides the greatest safeguard against unanticipated study bias. Evidence obtained from randomized, controlled studies is considered level 1 (strongest) by the U.S. Preventive Services Task Force. Evidence obtained from nonrandomized, controlled studies is considered level 2a, well-designed case-control and cohort studies are considered level 2b, and reports of expert committees or respected authorities are considered level 3 (weakest).

Question 163

Legionella should be considered as a pathogen for community-acquired pneumonia when the patient has a history of a hotel stay or cruise ship travel within the past couple of weeks. Travel to or residence in Southeast Asia or East Asia is a risk factor for avian influenza, exposure to farm animals or parturient cats is a risk factor for Coxiella burnetii infection, exposure to bird or bat droppings is a risk factor for Histoplasma capsulatum infection, and travel to or residence in desert Southwest states with deer mouse exposure is a risk factor for Hantavirus infection.

Question 164

In 2016 the CDC changed the recommendation for the number of HPV vaccine doses for children ages 11–14. Children in this age group need only two doses of HPV vaccine 6–12 months apart. However, if they received two doses of HPV vaccine less than 5 months apart, they still need to have the third dose. Children and young adults over the age of 14 and those with certain immunocompromising conditions still require three doses of HPV vaccine. There is no indication for a booster dose at a later date, nor is there clinical data to support using titers to gauge immunogenicity to HPV.

Question 165

A fractured hip is possible and must be ruled out since there is difficulty bearing weight and the leg is externally rotated. Examination of a patient with severe dementia can be extremely difficult. Other findings with a fractured hip would include pain elicited on rotation and groin pain when applying an axial load. If the hip radiograph is negative, MRI of the knee may be considered.

Question 166

Informed consent to treat is considered an important ethical and legal part of caring for children and adolescents. Some situations can become confusing when trying to balance the need for treatment, a child’s consent, and a parent or guardian’s permission. In most states, 18 is the age when legal decisions can be made; however, in some states 21 years old is the age of legal consent. Children below the age of majority must have proof of permission to treat from a parent or guardian for non-emergent care. This does not apply to emergency situations in which a delay in care could result in serious harm. Another exception to parental consent is when a child is considered emancipated under state law. This can happen with a court order, or (in some states) if the child is married, is a parent, is in the military, or is living independently. Either biologic parent can consent to treatment unless one of them is explicitly denied guardianship. If a child presents with a non-emergent condition and does not have evidence of permission from a parent or guardian, permission should be sought before the physician interaction takes place.

Question 167

By definition, a pulmonary nodule is a circumscribed, round lesion that may measure up to 3 cm in size and is surrounded by aerated lung. Management is based on the size of the nodule and the probability of malignancy. Risk factors for lung cancer include a previous malignancy, a positive smoking history, and age ≥65. Only 1% of nodules between 2 mm and 5 mm in size are malignant. Nodules <8 mm are difficult to biopsy, and a PET scan is not reliable. The risk of surgery outweighs the benefits in nodules of this size. For a low-risk patient with a nodule 4 mm to <8 mm in size, a repeat noncontrast CT at 12 months is recommended. If it is unchanged, no further follow-up is needed.

Question 168

Female pattern hair loss is categorized as diffuse and nonscarring. It presents with parietal hair thinning with preservation of the frontal hairline. Minoxidil 2% produces regrowth of hair in female pattern hair loss (SOR B). Oral finasteride is appropriate only for men with male pattern hair loss (SOR A). Hydroxychloroquine is used for inflammatory hair loss associated with discoid lupus erythematosus, which is focal and scarring. Topical corticosteroids are appropriate for alopecia areata (SOR B) but not for female pattern hair loss. Griseofulvin is used to treat tinea capitis, which presents as focal scale with erythema.

Question 169

A recent review from the Agency for Healthcare Research and Quality (AHRQ) found the frequency of adverse events in older adults taking SSRIs such as sertraline and escitalopram was similar to placebo (SOR B). SSRIs also have lower discontinuation rates than tricyclic antidepressants such as amitriptyline or nortriptyline during treatment of up to 12 weeks (SOR B). Evidence suggests that SNRIs including duloxetine and venlafaxine cause more adverse events and greater discontinuation of therapy during treatment of up to 12 weeks when compared to placebo (SOR B). A randomized, controlled trial involving duloxetine demonstrated an increased risk of treatment withdrawal due to adverse events and an increased risk of falls over 12–24 weeks. Venlafaxine was compared to no antidepressant use in a large cohort study that had a median treatment period of 364 days and was associated with an increased risk of falls, fractures, and mortality.

Question 170

The Joint Commission for Hospital Accreditation now requires a patient spiritual assessment upon hospital admission. Using the FICA Spiritual History Tool or HOPE questions for making the spiritual assessment is appropriate for the physician. HOPE is a mnemonic for sources of Hope, Organized religion, Personal spirituality and practices, and Effects on medical care and end-of-life issues. The FICA tool includes questions in the categories of Faith and beliefs, Importance, Community, and how to Address these issues when providing care. It is very appropriate for a physician to conduct a spiritual assessment in older, hospitalized patients with critical or terminal illnesses. Some patients may consider themselves spiritual but not necessarily religious.

Question 171

This patient has confirmed peripheral artery disease (PAD) with an abnormal ankle-brachial index. Guideline-directed therapy for PAD includes low-dose aspirin, moderate- to high-intensity statin therapy, an ACE inhibitor or angiotensin receptor blocker, a structured exercise program, and smoking cessation. Apixaban is a novel oral anticoagulant that is used for stroke prevention in nonvalvular atrial fibrillation as well as treatment of deep vein thrombosis and pulmonary embolism. Apixaban is not used for the treatment of PAD.

Question 172

This patient has physical findings and a history consistent with impetigo, a skin infection caused by Staphylococcus aureus and/or Streptococcus pyogenes . Since she has only one lesion, systemic antibiotics are not required as they would be for a patient with extensive disease or multiple lesions. Although bacitracin and neomycin are commonly used, they are much less effective for impetigo than mupirocin, despite some reports of resistance to mupirocin (level A-1 evidence).

Question 173

Patellofemoral pain syndrome is one of the most common causes of knee pain in children, particularly adolescent girls. Pain beneath the patella is the most common symptom. Squatting, running, and other vigorous activities exacerbate the pain. Walking up and down stairs is a classic cause of the pain, and pain with sitting for an extended period is also common. The physical examination reveals isolated tenderness with palpation at the medial and lateral aspects of the knee, and the grind test is also positive. Osgood-Schlatter disease is seen in skeletally immature patients. Rapid growth of the femur can cause tight musculature in the quadriceps across the knee joint. It typically appears between the ages of 10 and 15, during periods of rapid growth. Pain and tenderness over the tibial tubercle and the distal patellar tendon is the most common presentation. The pain is aggravated by sports participation, but also occurs with normal daily activities and even at rest.

Answer 173

Growing pains most often affect the thigh and quadriceps and occur during late afternoon or evening, or wake the patient at night. The joints are not affected. The pain typically goes away by morning, and may sometimes occur the day after vigorous or unusual activity. Patellar tendinopathy is an overuse injury often seen in those who participate in jumping sports such as volleyball, and is also related to frequent stops and starts in football players. It typically causes infrapatellar pain, and findings include extensor mechanism malalignment, weakness of ankle flexors, and tightness of the hamstring, heel cord, and/or quadriceps. Sever’s disease is an overuse syndrome most often seen between the ages of 9 and 14, and is related to osteochondrosis at the insertion of the Achilles tendon on the calcaneal tuberosity. It occurs during periods of rapid growth, causes heel pain during and after activity, and is relieved with rest. It is often related to beginning a new sport or the start of a season.

Question 174

Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.

Question 175

Urinary tract infection (UTI) is the most common bacterial infection in women. The annual incidence of UTI in women is 12%. Women who have had a UTI in the past are usually quite adept at diagnosing their own subsequent UTIs. Prospective studies have shown that women who suspect they have a UTI are more than 85% accurate based on culture results (SOR B). This is more accurate than dipstick testing, which has a sensitivity of 75% and a specificity of 82%. Nonpregnant female patients who have typical UTI symptoms without signs of pyelonephritis (i.e., fever and nausea) or vaginitis can be treated safely and effectively by phone. Urine culture testing is not indicated for uncomplicated UTIs. It has been found that the traditional criterion for infection (100,000 colony-forming units/mL) is not sensitive for women with a UTI. Urine testing should be reserved for patients suspected of having pyelonephritis. There are three first-line antibiotics for uncomplicated UTI. These include nitrofurantoin for 5 days, trimethoprim/sulfamethoxazole for 3 days, and fosfomycin as a single dose (SOR A). Fluoroquinolones are second-line agents and are best reserved for more serious infections such as pyelonephritis. Urinary analgesics can be helpful with UTI symptoms but are not the preferred method of treatment, as antibiotics rapidly reduce the symptoms of infection.

Question 176

Exercise-based therapy is the foundation for treating knee osteoarthritis. Foot orthoses can be helpful for anterior knee pain but this patient’s pain is located medially. The benefit of hyaluronic acid injections is controversial, and recommendations vary; recent systematic reviews do not support a clinically significant benefit. Weight loss is recommended for patients with a BMI >25.0 kg/m2. Wearing a knee brace has shown little or no benefit for reducing pain or improving knee function.

Question 177

This patient is suffering from acute urinary retention, likely due to mild benign prostatic hyperplasia exacerbated by pain medication and a lack of activity. Acute urinary retention could also possibly be due to irritation of sympathetic and/or parasympathetic nerves near the spine. Placing an indwelling bladder catheter is appropriate. It would also be reasonable, although impractical in the short term, to teach the patient or his caretakers to intermittently catheterize him. The likelihood of a successful return to voiding spontaneously will increase over time. However, the risk of catheter-associated urinary tract infection is estimated to be about 5% per day. Therefore, catheter removal and a trial of spontaneous voiding should be attempted after 48–72 hours. There is good evidence that starting an α-blocking medication such as tamsulosin during the time the catheter is in place will nearly double the success of the trial of spontaneous voiding. Finasteride in isolation is not recommended and oxybutynin would be contraindicated.

Question 178

A wealth of evidence-based research has established the benefits of probiotics, especially in children. Probiotics, particularly Saccharomyces boulardii , have been shown to prevent the antibiotic-associated diarrhea that occurs in 5%–30% of children who receive antibiotics (SOR A). The number needed to treat to prevent one case of diarrhea is 10. Probiotics reduce the pain associated with irritable bowel syndrome (IBS) but have not been shown to be helpful in reducing diarrhea or constipation in pediatric IBS patients (SOR A). In breastfed infants, probiotics reduce daily crying time by up to an hour. Similar benefits have not been found in formula-fed infants or infants who are combining breastfeeding and formula. Probiotics have not been shown to prevent colic in any infants. Other benefits of probiotics include the prevention of eczema and upper respiratory infections (SOR A). However, their use has not been shown to prevent allergies and asthma.

Question 179

Acute mountain sickness (AMS) occurs in at least 25% of persons traveling to destinations over 8000 feet above sea level. Risk factors include rapid ascent, living at low altitudes (<2000 ft), a prior history of altitude illness, and strenuous physical exertion during the ascent. AMS is most often manifested by headache, fatigue, lightheadedness, and/or nausea. The best way to prevent AMS is gradual ascent, but medications may also be effective in prophylaxis, especially if a rapid ascent such as in motorcycling, driving, or flying to altitude is planned. The drug of first choice in preventing AMS is acetazolamide, a carbonic anhydrase inhibitor, starting the day before ascent. It is, however, contraindicated in patients with sulfa allergy. The second-line drug for prevention is dexamethasone, which should be used for prophylaxis in sulfa-allergic patients. It is also used in the treatment of AMS and high-altitude cerebral or pulmonary edema, but immediate descent of at least 2000 feet is imperative if either of those more serious complications develop. While advocated as a prophylactic and treatment option for AMS, the results for ginkgo are mixed and it is therefore not recommended for use in this situation. Smoking cessation and physical conditioning are both good ideas for this patient, but neither will reduce his risk for developing AMS.

Question 180

Family physicians should be familiar with age-appropriate cancer screening recommendations. Deaths from cervical cancer have been significantly reduced through screening. HPV testing is not recommended for screening in average-risk women younger than 30 years old. Cytology without HPV testing is recommended for screening every 3 years for an average-risk 21-year-old female.

Question 181

Patients with systemic sclerosis (SS) in its final stages often develop a restrictive lung disease (SOR C). Interstitial lung disease and pulmonary artery hypertension are common. While the restrictive pattern is similar to idiopathic pulmonary fibrosis, this condition is characteristic of SS and is not idiopathic. Emphysema presents with an obstructive pattern on pulmonary function tests. Pulmonary edema can develop from cardiac malfunction and heart failure, but it is not present in this patient. Sarcoidosis is not related to SS. There is a 10-year mortality of 42% in patients with SS who have an FVC <50%. Cyclophosphamide may be helpful in some cases to improve lung function, decrease dyspnea, and improve the patient’s quality of life (SOR B).

Question 182

This patient has type 2 diabetes mellitus and presents with new-onset edema in her lower extremities, the most common presenting symptom of nephrotic syndrome (NS). Patients with NS may also report foamy urine, exertional dyspnea or fatigue, and significant fluid-associated weight gain. A 24-hour urine collection for protein (not creatinine) can be used to diagnose proteinuria, but the collection process is cumbersome and the specimen is often collected incorrectly. The protein-to-creatinine ratio from a single urine sample is commonly used to diagnose nephrotic-range proteinuria. The role of a renal biopsy in patients with NS is controversial and there are no evidence-based guidelines regarding indications for a biopsy. Renal ultrasonography may be appropriate to assess for underlying conditions and/or disease complications if the glomerular filtration rate is reduced. There is no data to support using MRI in the diagnosis and management of nephrotic syndrome.

Question 183

Vaccine delay and vaccine hesitancy are on the rise in the United States, so family physicians should be familiar with the nuances of vaccine catch-up schedules as well as contraindications. Rotavirus vaccine has age restrictions and should not be initiated after 14 weeks and 6 days of age. In addition, the rotavirus series must be complete by 8 months of age. These age restrictions are intended to ensure the vaccine is administered when it will be of maximal benefit to children given the slightly increased risk of intussusception after vaccine administration. Hepatitis B vaccine should be administered at routine intervals. Haemophilus influenzae type b, inactivated poliovirus, and pneumococcal conjugate can all be administered to this patient today. However, these vaccines have complex follow-up intervals based on the age at prior doses and age at catch-up. Therefore, the clinician should consult the CDC catch-up vaccine schedule to verify dosing intervals.

Question 184

Colon cancer arises from adenomatous polyps, and generally requires at least 5 years of growth before malignant transformation. Villous adenomas carry a threefold increased risk for becoming malignant compared with other adenomatous types such as tubular or tubulovillous adenomas. The larger the polyp the greater the chance of malignancy, although malignant polyps <1.5 cm are rare. Hamartomas (juvenile polyps) and inflammatory polyps (often associated with inflammatory bowel disease) are benign. Hyperplastic polyps are the most common histologic type by far, but only rarely become cancerous.

Question 185

The American Diabetes Association recommends screening for all asymptomatic adults with a BMI >25.0 kg/m2 who have one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 35. Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c ≥6.5%, a fasting plasma glucose level ≥126 mg/dL, a 2-hour plasma glucose level ≥200 mg/dL, or, in a symptomatic patient, a random blood glucose level ≥200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.

Question 186

Neonatal early-onset sepsis (EOS) has an incidence of 0.5 per 1000 live births according to the CDC, and group B Streptococcus (GBS) remains the most common cause. Risk factors for neonatal EOS include maternal GBS, prolonged rupture of membranes, intrauterine inflammation or infection, and the combination of inflammation and infection, commonly known as maternal chorioamnionitis, or triple I. Updated guidelines from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists replaced traditional guidelines on prevention of neonatal EOS from the CDC. Current guidelines recommend either categorical risk factor assessment, use of the neonatal EOS calculator, or enhanced observation. However, categorical risk factor assessment, similar to 2002 and 2010 CDC guidelines, would result in blood cultures and administration of antibiotics to any newborn where there was a maternal intrapartum fever. The other two approaches, particularly use of the neonatal EOS calculator, have been demonstrated to decrease antibiotic administration. This calculator uses a multivariate approach to determining neonatal EOS risk, combining information from both the delivery and postpartum assessment of the newborn. Enhanced observation utilizes frequent clinical assessment and is thought to similarly reduce antibiotic administration. The AAP guidelines suggest C-reactive protein levels and CBCs have poor predictive value in identifying neonatal EOS and should not be used to guide management. Blood cultures are frequently obtained with co-administration of antibiotics and there is no data to suggest that blood cultures alone would reduce antibiotic administration.

Question 187

This patient has signs and symptoms consistent with primary adrenal insufficiency (PAI). In Western countries autoimmunity is responsible for 90% of these cases. Because the corticotropin (ACTH) stimulation test has a higher degree of sensitivity and specificity than morning cortisol and ACTH concentrations, it is the preferred test in all patients with possible primary adrenal insufficiency. Serum aldosterone paired with plasma renin activity is used to screen for adrenal hyperplasia in hypertensive patients and also for establishing the existence of mineralocorticoid insufficiency in patients with PAI. Once the diagnosis is established, 21-hydroxylase antibodies and 17-hydroxylase progesterone levels are used to determine the etiology of PAI.

Question 188

Validated clinical prediction rules can be used to estimate the pretest probability of deep vein thrombosis (DVT) and pulmonary embolism in a patient with dyspnea and chest pain, and to guide further evaluation (SOR C). Factors used for calculating the pretest probability include elevated heart rate without hemoptysis, a diagnosis of cancer, recent surgery/immobilization, previous thromboembolism, and signs and symptoms of DVT. Based on these rules the patient described in the scenario has a low score and therefore a low probability of pulmonary embolism. A D-dimer level is the next most appropriate test for this low-probability scenario. Compression ultrasonography would be the next test for a patient with an intermediate or high pretest probability for DVT. CT angiography would be the next test for a clinically stable patient with an intermediate or high pretest probability of pulmonary embolism. A ventilation-perfusion scan would be the next test if a CT angiogram were indicated in a patient with a contraindication such as contrast allergy, renal disease, or pregnancy. Echocardiography would be the next test for a critically ill patient with a high pretest probability of pulmonary embolism.

Question 189

NSAIDs, acetaminophen, and muscle relaxants are effective for the treatment of acute low back pain (SOR A). There is moderate-quality evidence that nonbenzodiazepine muscle relaxants are beneficial in the treatment of acute low back pain. There is also moderate-quality evidence that NSAIDs combined with nonbenzodiazepine muscle relaxants may have additive benefit for decreasing pain. Bed rest is not helpful in the treatment of acute back pain and is not recommended (SOR A). There is no evidence that lumbar support is helpful. Oral corticosteroids have not been found to be beneficial for isolated low back pain, but there is questionable benefit when there are associated radicular symptoms. There are several low-quality trials that show acupuncture has minimal or no benefit over sham treatment in acute back pain.

Question 190

In patients ≥65 years of age treated with medication for type 2 diabetes mellitus, hemoglobin A1c values of 7%–8% have shown the greatest reduction in mortality in multiple studies. It is suggested that frequent hypoglycemia is associated with lower hemoglobin A1c values, and that presents a greater risk. Values over 9% are associated with greater mortality (SOR B). Thus, while the risk of complications increases linearly with hemoglobin A1c, mortality has a V-shaped curve.

Question 191

Medication and/or a walking program have been shown to improve functional capacity in patients with symptomatic peripheral artery disease (PAD). However, this patient has critical limb ischemia and needs urgent revascularization. Endovascular therapy of isolated disease below the knee is not recommended. These patients should undergo femoral-tibial bypass. Warfarin is not recommended for the treatment of PAD.

Question 192

When an otherwise healthy patient’s alkaline phosphatase level is elevated, it is helpful to determine whether the source of elevated isoenzymes is the liver or bone. One method is fractionation of the alkaline phosphatase by electrophoresis. A gamma-glutamyl transferase or 5 -nucleotidase level can also indicate whether the elevation of the alkaline phosphatase is from the liver. These enzymes are rarely elevated in conditions other than liver disease. Severe vitamin D deficiency can lead to osteomalacia with an elevated alkaline phosphatase.

Question 193

The U.S. Preventive Services Task Force does not recommend routine physical examinations but recommends blood pressure screenings every 3–5 years for adults 18–39 years of age who are at low risk for hypertension. Mammograms are not recommended until age 40. Lead screening is recommended for at-risk individuals between 6 months and 6 years of age. Colorectal cancer screening for average-risk individuals is recommended at age 45. Counseling on tobacco use and other substance abuse is recommended as part of all routine preventive care.

Question 194

In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Norepinephrine is the preferred drug for shock due to sepsis. Its relative safety suggests that it be used as an initial vasopressor. It is a potent vasoconstrictor and inotropic stimulant and is useful for shock. As a first-line therapy norepinephrine is associated with fewer adverse events, including arrhythmia, compared to dopamine. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.

Question 195

Long-acting reversible contraception (LARC) includes the copper IUD, levonorgestrel IUDs, and subdermal implants. LARCs can be placed at any point in the patient’s menstrual cycle (SOR A). There should be evidence that the patient is not pregnant prior to placement.

Question 196

This patient has shoulder impingement syndrome (with a positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test). However, the negative drop-arm rotator cuff test is evidence against a complete rotator cuff tear with a negative drop-arm rotator cuff test, and the absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy. Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem, and cessation of play is not necessary since other treatment options are available. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function. Surgery is a potential option if other treatments fail and a significant tear is proven, but is not preferable as an initial treatment.

Question 197

The 2014 evidence-based guideline from the panel members appointed to the Eighth Joint National Committee (JNC 8) makes few suggestions regarding preferred initial agents for the treatment of hypertension. Of the options listed, only hydrochlorothiazide is a reasonable option for first-line treatment. Verapamil is rarely used for blood pressure control.

Question 198

The patient described has polymyalgia rheumatica (PMR). The hallmark of this condition is the rapid and often dramatic response, typically within a few days, to low-dose corticosteroids. In fact, the lack of response to low-dose prednisone in such a case should prompt the physician to consider another diagnosis. A related condition, giant cell arteritis, is associated with transient or even permanent vision loss, typically unilateral but sometimes bilateral. This condition usually presents with headache and tenderness of the affected artery, most commonly the temporal artery. Prompt recognition and the initiation of high-dose corticosteroids are keys to preventing blindness. The other options listed are not pertinent to the management of PMR. While prompt response to low-dose corticosteroids confirms the diagnosis, they are usually continued for 1–2 years, with gradual tapering beginning several months after initiation of treatment (SOR C).

Question 199

Postexposure prophylaxis after exposure to invasive meningococcal disease is indicated for any close contact regardless of immunization status. Close contacts include those exposed in households, dormitories, or day care centers, and those who have direct contact with oral secretions. There are several options for prophylaxis, including ciprofloxacin, 500 mg orally one time; azithromycin, 500 mg orally one time; ceftriaxone, 250 mg intramuscularly one time; or rifampin, 600 mg orally twice daily for 2 days. Treatment should begin as soon as possible after exposure but no later than 14 days. While rifampin can be used for postexposure prophylaxis, a one-time dose is not adequate. This patient is at risk of infection due to his close contact with the source patient. Postexposure prophylaxis is indicated even for vaccinated patients.

Question 200

This patient’s symptoms and findings suggest dermatomyositis. This disease is distinguished from autoimmune myopathies and polymyositis by distinct dermatologic findings, including Gottron’s sign (nonpalpable macules over the extensor surface of joints). Patients may also have dilated nail-fold capillaries and ragged, thickened cuticles. Distal onycholysis is most commonly associated with onychomycosis, while hyperkeratotic plaques are not a feature of dermatomyositis. Polygonal papules on the wrist flexor surfaces are seen in lichen planus.

Question 201

This patient has the classic presentation for roseola infantum, which is caused by human herpesvirus 6. The typical history includes a high fever in a child with either mild upper respiratory symptoms or no other symptoms. After the fever subsides, a rash will appear. The rash is self-limited and no treatment is required. Pityriasis rosea typically presents with a single herald patch that is oval-shaped and scaly with central clearing, followed by a symmetric rash on the trunk in a typical distribution along the Langer lines. The rash may last up to 12 weeks and no treatment is required. Erythema infectiosum is caused by parvovirus B19 and is also known as fifth disease. The child will typically have mild symptoms then an erythematous facial rash that has a “slapped cheek” appearance. This is sometimes followed by pink patches and macules in a reticular pattern. Once the rash appears the child is no longer contagious. Molluscum contagiosum is caused by a poxvirus and is characterized by scattered flesh-colored papules with umbilicated centers. Atopic dermatitis typically presents as scaly, erythematous plaques, commonly on the flexor surfaces of the extremities.

Question 202

Abnormal uterine bleeding can be a sign of endometrial cancer in premenopausal women, who account for 20% of cases of endometrial cancer. The American College of Obstetricians and Gynecologists recommends that women with abnormal uterine bleeding should be evaluated for endometrial cancer if they are older than 45 years or if they have a history of unopposed estrogen exposure (SOR C). Most guidelines recommend either transvaginal ultrasonography or endometrial biopsy as the initial study in the evaluation of endometrial cancer. Transvaginal ultrasonography is often preferred as the initial study because of its availability, cost-effectiveness, and high sensitivity. If bleeding persists despite normal transvaginal ultrasonography a tissue biopsy should be performed. The listed hormonal treatment options may be appropriate once cancer is ruled out. An FSH level can help determine whether someone is menopausal or approaching menopause, in which case they will likely be missing periods. Continued observation would only delay the diagnosis.

Question 203

This patient is experiencing a manic or hypomanic episode. Therapeutic options include lithium, anticonvulsants such as divalproex, and antipsychotic medications such as olanzapine. Benzodiazepines such as lorazepam may be of minimal benefit. SSRIs such as sertraline can aggravate mania. Bupropion would help treat an associated depression and trazodone could possibly help the patient sleep, but these medications are ineffective for treating a manic/hypomanic episode.

Question 204

This patient has a Jones fracture. The treatment plan for this type of fracture needs to account for the activity level of the patient. It has been shown that active patients have shorter healing times and return to activity sooner with surgical management. A competitive dancer would be best managed with surgery. If the nonsurgical option is chosen the patient is given an initial posterior splint and followed up in 3–5 days, then placed in a short non–weight-bearing cast for 6 weeks, at which time a repeat radiograph is taken. If the radiograph shows healing, the patient can return to gradual weight bearing. If the radiograph does not show proper healing, then the period of non–weight bearing is extended.

Question 205

Functional ovarian cysts are estimated to be present in approximately 15% of menstruating women and are often found incidentally on a pelvic examination or on diagnostic imaging performed for other reasons. The majority of these lesions resolve spontaneously within two or three menstrual cycles and management should consist of follow-up ultrasonography 8–12 weeks after the cyst is identified. Cysts that are particularly symptomatic, have less than simple features, are >10 cm in size, or that persist longer than 12 weeks should be referred for consideration of diagnostic removal (cystectomy or oophorectomy depending on patient characteristics). Patients who carry a BRCA gene or who have a family history of ovarian cancer should also be considered for invasive testing sooner. Serum CA-125 testing is difficult to interpret in premenopausal patients, who frequently have elevated levels without evidence of a malignancy. In postmenopausal women with an ovarian cyst a CA-125 level >35 U/mL should prompt referral for removal.

Question 206

In patients who present with an ear discharge and have ventilation tubes in place, antibiotic eardrops (with or without corticosteroids) can resolve the discharge and improve the illness-related quality of life more quickly than oral antibiotics, corticosteroid eardrops, or saline rinses. The antibiotic eardrops of choice are fluoroquinolones, which are not ototoxic.

Question 207

Sex education programs have been associated with a reduction in the rates of sexually transmitted infections in adolescents. Clinicians should meet with adolescents privately to provide confidentiality. Adolescents should be screened for obesity and provided appropriate behavioral counseling. Cervical cancer screening should begin at age 21.

Question 208

The U.S. Preventive Services Task Force (USPSTF) recommends screening for asymptomatic bacteriuria with a urine culture for pregnant women at 12–16 weeks gestation or at the first prenatal visit if it occurs later (B recommendation). The USPSTF recommends against screening for asymptomatic bacteriuria in men and nonpregnant women (D recommendation). The Infectious Diseases Society of America (IDSA) guidelines for asymptomatic bacteriuria recommend that pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive (B-I recommendation). The IDSA also recommends screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate (B-I recommendation) and also before other urologic procedures for which mucosal bleeding is anticipated (A-III recommendation). The IDSA’s recommendation for the Choosing Wisely campaign is to not treat asymptomatic bacteriuria with antibiotics. The only exceptions to this recommendation include pregnant women, patients undergoing prostate surgery or other invasive urologic surgery, and kidney or kidney pancreas organ transplant patients within the first year of receiving the transplant. Screening for asymptomatic bacteriuria is not recommended for long-term care residents or patients with indwelling bladder catheters without symptoms of a UTI (catheter-associated asymptomatic bacteriuria).

Question 209

The U.S. Preventive Services Task Force (USPSTF) recommends screening for abdominal aortic aneurysm in men between the ages of 65 and 75 who have ever smoked (B recommendation). This should be performed one time, using abdominal duplex ultrasonography. There may be a small benefit for screening men who have never smoked, and the USPSTF recommends selectively offering screening to this group (C recommendation). The evidence is insufficient to assess the benefits and harms in women who have ever smoked (I recommendation), and the USPSTF recommends against screening for women who have never smoked (D recommendation).

Question 210

Evaluation of the pleural fluid is important to assist in determining the cause of the effusion. Protein, glucose, LDH, and cell counts should be measured in the pleural fluid. This can help determine if the effusion is exudative or transudative. A pleural protein to serum protein ratio >0.5 or a pleural fluid LDH to serum LDH ratio >0.6 suggests an exudative effusion. Lower ratios suggest a transudative process. With transudates, the pleural fluid pH is typically between 7.40 and 7.55, with fewer than 1000 WBCs, and the glucose level is similar to the serum glucose level. Cirrhosis with ascites is a cause of transudative effusion. Pleural effusions associated with malignancy, pneumonia, viral illness, and asbestosis tend to be exudative.

Question 211

Concerns about addiction and respiratory depression often limit the use of opioids or lead to inadequate dosages in patients with a terminal illness who are experiencing pain at the end of life (SOR C). Sedation (ranging from full consciousness to complete loss of consciousness) usually precedes respiratory depression. Opioid use and dosages can therefore be effectively managed with close monitoring for sedation, allowing patients to receive adequate medication to control pain. Close monitoring allows clinicians to identify advancing sedation before it is compounded by continued opioid administration that could lead to clinically significant respiratory depression (SOR C).

Question 212

For primary preventive interventions for the management of lipids, the 10-year atherosclerotic cardiovascular disease risk estimate is useful as a starting point for shared decision-making with patients. Specifically, it is a helpful tool when deciding on the use and intensity of statin therapy. The coronary artery calcium score can refine the risk assessment even further for those at intermediate predicted risk (7.5% to <20%) or borderline predicted risk (5% to <7.5%). For those at intermediate or borderline risk with a coronary artery calcium score of 0, it would not be reasonable to start a statin. If the coronary artery calcium score is 100 or greater, starting a statin is acceptable in patients 55 years of age.

Question 213

Oral antibiotics are recommended for acne that is resistant to topical treatments. Oral isotretinoin is indicated for severe nodular acne or moderate acne resistant to other treatments. Since this patient has not tried any therapies, these two options would not yet be appropriate. Topical antibiotics are recommended only in combination with benzoyl peroxide. Appropriate treatments would be topical benzoyl peroxide, a topical retinoid, and oral contraceptives. Antiandrogen therapies such as spironolactone are not indicated solely for acne vulgaris, although they may be appropriate for concomitant conditions such as polycystic ovary syndrome.

Question 214

Treatment of adult obesity with bariatric surgery is becoming more common. In addition to counseling patients about surgical options and the risks and benefits of surgery, the family physician is in a position to provide both long-term support and postsurgical medical management. Bariatric surgery does result in greater weight loss than nonsurgical interventions and is highly effective in treating comorbidities of obesity, particularly diabetes mellitus. Bariatric surgery also reduces obesity-related mortality. After bariatric surgery the patient’s postoperative medications may require adjustments and NSAIDs should be avoided. Patients should be encouraged to eat three meals and one or two snacks daily. Very dry foods, bread, and fibrous vegetables are most likely to cause problems. Fluids should be avoided during meals and for 15–30 minutes before and after meals. Those desiring pregnancy should wait 12–18 months after surgery. Recommended laboratory studies include a CBC, a metabolic profile, a folic acid level, iron studies, a parathyroid hormone level, a lipid profile, vitamin B12 levels, 24-hour urinary calcium excretion, and 25-hydroxyvitamin D levels. It is recommended that bone density measurements be done every 2 years.

Question 215

Plasma sodium concentration measurements can be unreliable in patients with severe hyperlipidemia or hyperproteinemia (pseudohyponatremia). The other electrolyte abnormalities do not cause hyponatremia.

Question 216

A chest radiograph is appropriate in the initial evaluation of hemoptysis (SOR C). If the chest radiograph does not indicate a cause, then CT or CT angiography with intravenous contrast should be performed (SOR C). CT has become the preferred modality over bronchoscopy because it is more effective in determining the etiology. If CT does not identify the cause, bronchoscopy would be the next step. In addition, other tests including a sputum Gram stain, acid-fast bacillus smear, or sputum cytology can be useful depending upon the clinical situation. If there are concerns about the possibility of immunologic, rheumatologic, or vasculitic disease, testing for immunologic antibodies such as antineutrophil cytoplasmic antibody (ANCA) can be ordered.

Question 217

Cigarette smoking, increasing age, and exogenous estrogen, particularly at the supraphysiologic doses used in contraceptives, all increase risk for vascular events such as venous thromboembolism and stroke. The use of estrogen-containing contraception in smokers ≥35 years is contraindicated because of this risk. All of the contraceptive options listed contain estrogen except for the etonogestrel implant. Other progestin-only contraceptive options that could be considered include depot medroxyprogesterone acetate, the levonorgestrel-releasing IUD, and progestin-only oral contraceptive pills.

Question 218

Cigarette smoking, increasing age, and exogenous estrogen, particularly at the supraphysiologic doses used in contraceptives, all increase risk for vascular events such as venous thromboembolism and stroke. The use of estrogen-containing contraception in smokers ≥35 years is contraindicated because of this risk. All of the contraceptive options listed contain estrogen except for the etonogestrel implant. Other progestin-only contraceptive options that could be considered include depot medroxyprogesterone acetate, the levonorgestrel-releasing IUD, and progestin-only oral contraceptive pills.

Question 219

This patient has symptomatic iron deficiency anemia. Because she has had a gastric bypass, she is not able to absorb oral iron adequately and therefore needs intravenous iron replacement. A blood transfusion may help temporarily but will not restore her iron stores, so it is not indicated if she does not respond to intravenous iron, consultation with a hematologist may be indicated.

Question 220

Oxycodone often is not detected by an immunoassay test and unexpected results require follow-up with a more accurate test such as gas chromatography/mass spectrometry or high-performance liquid chromatography. Codeine can be detected more accurately, but substituting codeine for oxycodone would be inappropriate. Pain management is reasonable if the patient is requiring large amounts of opiates, has failed treatment, or has a history of drug abuse. A pain management agreement should be initiated at the beginning of treatment with an opiate.

Question 221

Because of their favorable side-effect profile and low cost, SSRIs are the first-line agents for late-life depression. SNRIs may be used as second-line agents when remission is not obtained with an SSRI. Tricyclic antidepressants work as well as SSRIs and may be considered in recalcitrant cases, but side effects may be troublesome, especially in this age group. The use of stimulants in depressed older adults has not been well studied. Second-generation antipsychotic agents may be used as an add-on to an SSRI or SNRI medication when the depression is resistant. Side effects and long-term safety may be issues with this approach.

Question 222

Simplifying medication regimens, including using combination medications to decrease the number of pills a patient must take, has been shown to improve medication adherence in clinical trials (SOR B). Taking antihypertensive medications before bed has not been shown to improve adherence. Prescribing brand name medications increases costs, which may decrease adherence. Unless specific side effects are a concern, changing medications or adding another agent would not be likely to improve adherence.

Question 223

Given the obesity epidemic in the United States, an awareness of therapies that affect weight is imperative for family physicians. This patient is taking medications that help with weight loss (metformin) and medications that are weight neutral (lisinopril, simvastatin, and fluoxetine). Glipizide, however, causes weight gain, and switching to an SLGT2 inhibitor such as canagliflozin can help promote weight loss. Likewise, the patient could use a GLP-1 receptor agonist such as exenatide or an amylin mimetic (pramlintide) for weight loss benefits. Sulfonylureas, thiazolidinediones, and insulins all promote weight gain (SOR A). Fluoxetine and sertraline are weight neutral, whereas paroxetine can cause weight gain (SOR B). The statins are weight neutral in general, and switching to atorvastatin should not affect weight. ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, thiazides, and β-adrenergic blockers are all weight neutral. In this patient with diabetes mellitus, an ACE inhibitor would be preferable to carvedilol in terms of renal protection (SOR A).

Question 224

Thrombocytopenia is a relatively common dyscrasia often discovered through routine laboratory studies. There are many causes of thrombocytopenia but medication-induced thrombocytopenia should always be considered. In this case the patient is taking an H2-blocker that may cause blood dyscrasias. The offending agent should be stopped and a repeat level should be obtained in 2–4 weeks for patients with mild asymptomatic thrombocytopenia (platelet count 100,000–150,000/mm3) and in 1–2 weeks for moderate thrombocytopenia (platelet count 50,000–100,000/mm3) (SOR C). Prednisone is the first-line treatment for immune thrombocytopenic purpura (SOR C); however in this situation, it is reasonable to look for other causes first. If the thrombocytopenia is worse on repeat testing (<100,000/mm3) it is reasonable to consider consultation for further evaluation and to consider a bone marrow biopsy. If the platelet count improves, continued monitoring is indicated until it returns to normal. Platelet transfusions are not indicated in stable, nonbleeding patients unless the platelet count drops below 10,000/mm3.

Question 225

Amyloidosis is defined as the extracellular deposition of the fibrous protein amyloid at one or more sites. It may remain undiagnosed for years. Features that should alert the clinician to the diagnosis of primary amyloidosis include unexplained proteinuria, peripheral neuropathy, enlargement of the tongue, cardiomegaly, intestinal malabsorption, bilateral carpal tunnel syndrome, and orthostatic hypotension. Amyloidosis occurs both as a primary idiopathic disorder and in association with other diseases such as multiple myeloma.

Question 226

This patient has severe asthma that is not responding to a moderate dose of an inhaled corticosteroid, a leukotriene inhibitor, and a long-acting β-agonist. The next appropriate step is to add a stronger dose of inhaled corticosteroid. Methotrexate and azithromycin are considered inappropriate therapies. Theophylline and low-dose oral prednisone are considered appropriate steps if the patient does not respond to high doses of an inhaled corticosteroid. Other reasonable options for the treatment of severe asthma would be a muscarinic antagonist such as tiotropium, or assessing for the presence of IgE-dependent allergic asthma that may respond to omalizumab.

Question 227

The U.S. Preventive Services Task Force (USPSTF) recommends that all women planning or capable of pregnancy take a daily folic acid supplement containing 0.4–0.8 mg (400–800 μg) (A recommendation). A manual breast examination by the clinician or patient is not recommended by the USPSTF. Cervical cytology (a Papanicolaou test) is recommended every 5 years if results are normal and it is combined with negative high-risk HPV testing (A recommendation). Chlamydia screening is recommended yearly for all sexually active females under age 25 and older individuals at higher risk. For women who are over 25 and not at increased risk the USPSTF makes no recommendation for or against screening (C recommendation). This patient was screened for lipid disorders 3 years ago. While the best screening interval for lipids is not clearly defined, there is no clear recommendation to repeat screening lipids at this time. The USPSTF makes no recommendation for or against screening for lipid disorders in women who are not at increased risk for coronary heart disease (C recommendation).

Question 228

CT angiography (CTA) is the recommended imaging modality for the diagnosis of visceral ischemic syndromes because of its 95%–100% accuracy. Images of the origins and length of the vessels can be obtained rapidly, characterize the extent of stenosis or occlusion and the relationship to branch vessels, and aid in the assessment of options for revascularization. Endoscopy is most useful for diagnosing conditions other than mesenteric ischemia. The value of ultrasonography is extremely dependent on the skills of the technologist. In addition, adequate imaging can be difficult to obtain in patients with obesity, bowel gas, and heavy calcification in the vessels. Angiography with selective catheterization of mesenteric vessels is now used after a plan for revascularization has been chosen. MR angiography takes longer to perform than CTA, lacks the necessary resolution, and can overestimate the degree of stenosis.

Question 229

After a shoulder dislocation, normal activity can resume when motion and strength in both arms is equal. Immobilization of the shoulder after a dislocation is recommended for at least 1 week. Recurrent shoulder dislocations are more common in younger patients and should be immobilized for 3 weeks in patients under 30 years of age. In patients over 30 years of age, 1 week of immobilization will limit the amount of joint stiffness. Prolonged immobilization is a risk factor for developing adhesive capsulitis (frozen shoulder). Gentle range-of-motion exercises should be performed during the immobilization period to limit the risk of adhesive capsulitis. Recurrent dislocations, rotator cuff injuries, shoulder impingement syndrome, and acromioclavicular joint injuries are not reduced by gentle range-of-motion exercises.

Question 230

Expert panel guideline recommendations suggest fluoxetine should be the first-line pharmacotherapy option for adolescents after a trial of psychotherapy. The patient should be monitored weekly for side effects for a month after starting fluoxetine. If fluoxetine is ineffective, sertraline and citalopram are recommended as alternatives. Venlafaxine should be avoided in adolescents because it is associated with a statistically increased risk of suicidal behavior or ideation.

Question 231

Most pericarditis is presumed to be viral in origin. Enteroviruses, herpesviruses, adenovirus, and parvovirus B19 are common agents. Tuberculosis infection is also possible in this patient, considering the high prevalence of tuberculosis in sub-Saharan Africa. Candida infection is much less common, especially in an HIV-negative patient. Post–myocardial infarction syndrome, secondary metastatic tumor, and drug reaction are infrequent causes, especially in a previously healthy patient. Ibuprofen may be used to treat pericarditis.

Question 232

Atrial fibrillation is the most common cardiac arrhythmia and can be a source of morbidity and mortality. If this is suspected, a 12-lead EKG should be obtained to confirm the diagnosis. Patients need evaluation for possible cardioversion, rate versus rhythm control, and anticoagulation. The first-line agent to achieve a target heart rate of <80 beats/min would be either a β-blocker or a nondihydropyridine calcium channel blocker. This patient has significant COPD, which eliminates the use of a nonselective β-blocker such as propranolol. A nondihydropyridine calcium channel blocker such as verapamil or diltiazem would be a better choice. Adding digoxin could be considered if the initial therapy is unsuccessful in controlling the heart rate. Amiodarone has significant toxicity and is usually not recommended unless the first-line options fail.

Question 233

A history of gestational diabetes mellitus (GDM) is the greatest risk factor for future development of diabetes mellitus. It is thought that GDM unmasks an underlying propensity to diabetes. While a healthy pregnancy is a diabetogenic state, it is not thought to lead to future diabetes. This patient’s age is not a risk factor. Obesity and family history are risk factors for the development of diabetes, but having GDM leads to a fourfold greater risk of developing diabetes, independent of other risk factors (SOR C). It is thought that 5%–10% of women who have GDM will be diagnosed with type 2 diabetes within 6 months of delivery. About 50% of women with a history of GDM will develop type 2 diabetes within 10 years of the affected pregnancy.

Question 234

Value is often defined as quality divided by cost. As such, the value that a health care system provides increases as the quality of that care increases, the costs of the care decrease, or both. Value-based reimbursement is a system of health care reimbursement that seeks to motivate health care systems and/or providers to increase the value of their services rather than just seeking to increase the quantity of their services. An example of this type of payment incentive is the Center for Medicare and Medicaid Services’s move to establish a program called value-based purchasing. This program increases reimbursement rates for high-value hospitals and decreases reimbursement rates for hospitals that provide lower-value services.

Question 235

Spinal extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this. Spinal flexion that decreases lordosis has the opposite effect and will usually improve the pain, as will sitting. Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin. Pain in the lateral hip is more typical of trochanteric bursitis.

Question 236

Dysphagia alone or with unintentional weight loss is the most common presenting symptom of esophageal cancer. Adenocarcinoma is the most common esophageal cancer in developed nations, and risk factors include GERD, obesity, and tobacco abuse. Upper endoscopy is the recommended diagnostic tool (SOR B). If cancer is confirmed, CT and PET scanning are useful for staging.

Question 237

When evaluating bilateral lower extremity edema, one should first look for systemic etiologies that would result in edema, such as hepatic, renal, or cardiac failure. In patients with obesity or a history of loud snoring, daytime drowsiness, or unrestful sleep, obstructive sleep apnea is likely. These patients can be diagnosed through polysomnography. Echocardiography is also recommended to detect pulmonary hypertension. Chronic venous insufficiency would be associated with skin changes such as hemosiderin deposits or venous ulcerations. If these findings are present, duplex ultrasonography should be ordered. If there is suspected arterial insufficiency an ankle-brachial index can be determined. For those with a low likelihood of deep vein thrombosis (DVT), a D-dimer assay can be ordered, but duplex ultrasonography is a more definitive test. For those with negative ultrasonography, magnetic resonance venography may be needed to rule out a pelvic or thigh DVT. Patients with suspected lymphedema can usually be diagnosed clinically, although lymphoscintigraphy may be required.

Question 238

Adult patients with acute bronchitis rarely require a chest radiograph to rule out pneumonia. Indications for a chest radiograph include dyspnea, tachypnea, tachycardia, temperature >100.0°F, bloody sputum, or signs of focal consolidation on lung auscultation. In patients with bronchitis the cough lasts an average of 18 days, so a chest radiograph would not be indicated after only 14 days. Smoking does not influence the need for a chest radiograph, and wheezing is common in uncomplicated acute bronchitis.

Question 239

This patient has subclinical hypothyroidism and should have a TSH level repeated in 1–3 months, as TSH may fluctuate in patients without thyroid disease and return to normal on subsequent testing. In a patient with a normal free T4 the TSH level must be >10 μU/mL for a diagnosis of hypothyroidism. Mild TSH elevations may be a normal manifestation of aging.

Question 240

This patient should have his aortic valve replaced. He meets criteria for severe aortic stenosis with a transthoracic velocity ≥4.0 m/sec and an aortic valve area <1.0 cm2. Symptomatic patients with severe aortic stenosis have 2-year mortality rates of more than 50%. After valve replacement the 10-year survival rate is almost identical to that of patients without aortic stenosis. Watchful waiting with monitoring for symptoms and periodic echocardiograms is indicated for asymptomatic patients with moderate to severe aortic stenosis who have a normal ejection fraction. There is no medical treatment that delays the progression of aortic valve disease or improves survival. Measures to reduce cardiovascular risk, including treatment of hypertension, are indicated. Rate-slowing calcium channel blockers and β-blockers that depress left ventricular function should be avoided if possible. ACE inhibitors may improve symptoms in patients with aortic stenosis who are not surgical candidates.

Question 241

A diagnosis of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) generally starts with the discovery of hyponatremia and is confirmed after all other possible causes are excluded. The root cause is the pathologic secretion of antidiuretic hormone (ADH), which can occur in response to some drugs and a variety of conditions, including infections, tumors, and dysregulation in the nervous system involving sympathetic tone and baroreflex response. Inappropriate release of ADH increases free water reabsorption, which increases circulating blood volume, dilutes sodium, and lowers hematocrit and hemoglobin. Urine output is often lowered because of this reabsorption, and the urine is more concentrated (urine osmolality > plasma osmolality) with sodium levels >20 mEq/L. Modest weight gain may be noted as a result of the increased blood volume. Polydipsia also causes dilution of serum sodium and hemodilution but results in dilution of urine. Excessive beer drinking may result in hyponatremia and hypokalemia (beer potomania) as a result of overhydration with a fluid containing inadequate solute. Laboratory testing for sodium can be falsely reduced in a hyperglycemic state. A simple calculation can correct for this: Corrected (Na+) = Measured (Na+) + (2.4 × glucose (mg/dL) – 100 mg/dL)/100 mg/dL.

Question 242

This patient has classic signs and symptoms of viral bronchiolitis, likely due to respiratory syncytial virus (RSV). A chest radiograph is not indicated in a patient with a classic presentation and no focal findings on examination. Most concerning is his history of low urine output, suggesting inadequate oral intake. This is often related to a high respiratory rate and copious nasal secretions. The patient requires hospitalization for monitoring of his respiratory status and supportive care, including intravenous or nasogastric rehydration. At this time the infant does not require supplemental oxygen, as his oxygen saturation is above 90%. Many medications have been studied for the treatment of bronchiolitis in children and most have been found to not provide benefit with regard to the need for hospitalization, length of hospitalization, or disease resolution. Medications that are NOT recommended include inhaled bronchodilators, inhaled epinephrine, inhaled or systemic corticosteroids, and antibiotics.

Question 243

Puncture wounds to the foot commonly get infected. Most soft-tissue infections from puncture wounds are caused by gram-positive organisms. Staphylococcus aureus is the most common, followed by other staphylococcal and streptococcal species. When the puncture wound is through the rubber sole of an athletic shoe, Pseudomonas is the most frequent pathogen. Ciprofloxacin is the only oral antibiotic that has antipseudomonal activity, and would be the most appropriate choice.

Question 244

Back pain that regularly occurs at night and awakens a child is usually associated with tumors or infections, such as osteomyelitis, discitis, osteoid osteoma, osteoblastoma, and spinal cord tumors. Other possible symptoms associated with nighttime back pain include fever, malaise, and weight loss. Back pain that occurs at night is an indication for immediate medical evaluation.

Question 245

Although pharmacologic therapy is the mainstay of treatment for hypertension in adults, there are several nonpharmacologic options that have been shown to lower blood pressure. Moderate exercise 3–4 times per week for 40 minutes or more has been shown to lower high blood pressure, with the greatest effect seen when patients exercise 150 minutes or more per week. Limiting sodium intake to 2400 mg/day decreases blood pressure, and further effects are seen when it is limited to 1500 mg/day. Alcohol should be limited to no more than two drinks per day in men, and one drink per day in women. Magnesium and coenzyme Q10 do not lower blood pressure.

Question 246

Salmonella is a common cause of gastroenteritis. Transmission is most often associated with eggs, poultry, undercooked ground meat, and dairy products from contaminated animals, or produce contaminated by their waste. Salmonella infection is usually associated with nausea, vomiting, diarrhea, and fever starting 6–48 hours after ingestion of contaminated water or food. Stools are usually moderate-volume, loose, and nonbloody, although they can be large-volume watery stools with blood. While Salmonella can cause severe infection, it is usually self-limited. Antibiotics should not be routinely used to treat uncomplicated Salmonella gastroenteritis and may prolong the duration of Salmonella excretion in stool. Antibiotic treatment should be reserved for patients who are severely ill or suspected of being bacteremic. The threshold for treatment should also be decreased in those who are considered to be at higher risk for severe illness and invasive disease, such as infants, the elderly, patients with sickle cell disease, and immunosuppressed patients. Chronic fecal carriers of Salmonella may also benefit from treatment. If treatment is required, ciprofloxacin, ampicillin, ceftriaxone, and trimethoprim/sulfamethoxazole are all treatment options.

Question 247

Diagnostic error is important because it is very common. Anchoring bias, also known as premature closure, is defined by the Agency for Healthcare Research and Quality as relying on an initial diagnostic impression despite subsequent information to the contrary. This is the most frequent single cause of diagnostic error. In this case, once the diagnosis of dehydration and acute kidney injury were made, clinicians became “anchored” to that diagnosis and did not consider other possibilities until much later. Hindsight bias and outcome bias occur when looking back at a case while knowing the result and outcome. Commission and omission bias relate to the tendency toward action rather than inaction and the tendency toward inaction rather than action, respectively.

Question 248

This patient is at high risk for malignancy based on his age, sex, and lymphadenopathy for more than 4–6 weeks. Fine-needle aspiration is an acceptable first-line test to evaluate for a reactive node versus malignancy. Further testing may be necessary to confirm the diagnosis. Watchful waiting could delay the diagnosis of a malignancy in a patient at high risk and would not be appropriate. Due to the duration of his symptoms and presentation, lymphadenitis is unlikely and antibiotics would not be appropriate. Corticosteroids are not recommended until a diagnosis is confirmed, as they may interfere with the cytology. While medications can cause lymphadenopathy, lisinopril has not been associated with this problem.

Question 249

Mammographic screening is not recommended at the age of 38. The U.S. Preventive Services Task Force (USPSTF) recommends against routine mammographic screening for breast cancer between the ages of 40 and 49, but promotes a policy of individualized shared decision making. Mammography every 2 years is recommended for women between the ages of 50 and 74 (B recommendation). The USPSTF recommends any of several familial risk stratification tools for use in women who have a family member with breast, ovarian, tubal, or peritoneal cancer, to assess for an increased risk of a BRCA1 or BRCA2 mutation. If the screen is positive, a referral for genetic counseling is recommended to determine if BRCA testing is indicated (B recommendation). MRI of the breasts is not recommended for screening by the USPSTF but is recommended by some organizations as an adjunct to mammography for women determined to be at high risk of breast cancer, such as those with a BRCA mutation.

Question 250

A single dose of oral dexamethasone improves symptoms in children with mild croup when compared with placebo. It is as effective for reducing croup symptoms as nebulized budesonide and is less distressing for the child. There is currently no evidence from randomized, controlled trials to support the use of humidification or a helium-oxygen mixture to reduce the symptoms of croup.

Question 251

This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension, and to manage her weight. Exercise stress testing is not specifically indicated for this patient. Current recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or more days per week.

Question 252

This patient has pneumonia based on the clinical presentation and the physical findings of fever, cough, and abnormal lung findings. A fever would not be a typical finding in pulmonary embolus or heart failure. An upper respiratory infection is unlikely given the abnormal lung findings that suggest a lower respiratory tract infection. This would not be a typical presentation for acute leukemia.

Question 253

Early systemic Lyme disease may manifest with facial nerve palsy, and treatment should include corticosteroids. The evidence for efficacy of antivirals for facial nerve palsy is lacking, especially beyond 3–4 days after onset. But in this case, specific treatment to eradicate the Lyme disease is also indicated, in order to prevent later, more severe systemic complications. For facial nerve palsy, treatment with doxycycline or amoxicillin for 14 days is effective. Patients with more severe neurologic manifestations of Lyme disease, such as altered mental status, meningoencephalitis, or other cranial nerve palsies, require longer courses of antibiotics, usually intravenously. A single-dose treatment with doxycycline or amoxicillin is recommended as prophylaxis in asymptomatic patients after a known tick bite. This is only recommended for tick attachment longer than 36 hours, or of unknown duration.

Question 254

Patients with a history of cryptorchidism are at high risk for the development of testicular cancer, especially if orchiopexy is performed after puberty. If sonography shows a hypoechoic mass, a testicular biopsy is contraindicated, since it may contaminate the scrotum or alter the lymphatic drainage. Radical inguinal orchiectomy is both diagnostic and therapeutic. Watchful waiting would not be an option in this high-risk patient. CT of the chest, abdomen, and pelvis, and measurement of the tumor markers are useful for staging and as an indication of tumor burden, but they are not diagnostic.

Question 255

The initial “destructive” phase of subacute thyroiditis presents with signs, symptoms, and laboratory findings of overt hyperthyroidism; however, a radioactive iodine uptake scan is negative in this phase. Graves disease and toxic multinodular goiter also present with overt hyperthyroidism, but radioactive iodine uptake is high. Factitious thyrotoxicosis is associated with low TSH and elevated or normal free T4 and total T3, but a goiter is not present. A TSH-secreting pituitary adenoma results in elevated TSH, free T4, and total T3.

Question 256

Agitation and delirium are common end-of-life symptoms. It is important to assess for treatable causes, including constipation, urinary retention, uncontrolled pain, and adverse medication effects. The antipsychotic medication risperidone is effective for treating agitation and nausea at this stage, but dosing is much lower than when this medication is used for psychiatric disorders. Benzodiazepines can provoke increased agitation and should be used with caution; however, they can be useful for treating significant end-of-life anxiety. Generally, a longer-acting form such as lorazepam would be a better choice than short-acting alprazolam. Amitriptyline and diphenhydramine can both cause urinary retention, potentially leading to delirium and agitation.

Question 257

Patellofemoral pain syndrome is a common cause of anterior knee pain, especially in women. It is worse with running downhill or going down stairs. It is not associated with a knee effusion. The examination is often positive for an apprehension test over the patella. A torn meniscus can cause medial joint line tenderness as well as a positive McMurray’s test, defined as a click and/or pain when moving the knee from flexion to extension with valgus stress. Prepatellar bursitis causes anterior knee pain, usually associated with tenderness, swelling, and redness over the prepatellar bursa. Osgood-Schlatter syndrome causes anterior knee pain over the tibial tuberosity. Pes anserine bursitis causes medial knee pain just distal and slightly posterior to the joint space.

Question 258

Of the options given, only a GLP-1 agonist such as liraglutide could be used for this patient because of his comorbidities of chronic kidney disease and heart failure. Metformin is contraindicated in males with a creatinine level >1.5 mg/dL and in females with a creatinine level >1.4 mg/dL. SGLT2 inhibitors are not as safe or effective if the patient’s estimated glomerular filtration rate (eGFR) is <50 mL/min/1.73 m2, and it is not recommended in patients with an eGFR <30 mL/min/1.73 m2. The initiation of rosiglitazone is contraindicated in patients with established New York Heart Association class III or class IV heart failure.

Question 259

Microscopic colitis is characterized by intermittent secretory diarrhea in older patients, although all ages can be affected. The cause is unknown, but there is some evidence that more than 6 months of NSAID use increases the risk. Only a biopsy from the transverse colon can confirm the diagnosis. Two histologic patterns are found: lymphocytic colitis and collagenous colitis. The other diagnostic studies listed do not confirm the diagnosis.

Question 260

Sympathomimetic agents can elevate blood pressure and intraocular pressure, may worsen existing urinary obstruction, and adversely interact with -blockers, methyldopa, tricyclic antidepressants, and oral hypoglycemic agents and MAOIs. They also speed up the heart rate. First-generation nonprescription antihistamines can enhance the anticholinergic and sedative effects of other medications.

Question 261

The initial tests used in the workup for suspected hemochromatosis are a serum ferritin level and transferrin saturation. A transferrin saturation >45% and a serum ferritin level >300 ng/mL in men or >200 ng/mL in women are indicative of iron overload and highly suggestive of hereditary hemochromatosis. A serum iron level is ordered as part of transferrin saturation testing, but an elevated iron level by itself is not as sensitive or specific as the other tests. Other etiologies of iron overload should be ruled out, including liver disease, alcohol abuse, and metabolic syndrome. If no secondary etiologies are found, genetic testing would be appropriate to identify HFE mutations indicating hereditary hemochromatosis. Genetic testing should not be performed in a patient without iron overload or a family history of hereditary hemochromatosis. MRI may help determine the risk of developing cirrhosis, and a liver biopsy is used to determine the amount of liver damage.

Question 262

This patient has posttraumatic stress disorder (PTSD). She was exposed to threatened death and injury (DSM-5 criterion A) and exhibits multiple symptoms from several clusters of the DSM-5 criteria for PTSD (reliving of the traumatic event [criterion B], avoidance of trauma-related stimuli [criterion C], negative thoughts or feelings that began or worsened after the trauma [criterion D], and trauma-related arousal and reactivity that began or worsened after the trauma [criterion E]). She has symptoms that have caused distress and functional impairment for more than 1 month and are not triggered by medication or substance use (criteria F–H). Individual, trauma-focused psychotherapy has strong evidence for benefit in the treatment of PTSD and is recommended as the first-line treatment. If psychotherapy is not available or preferred by the patient, pharmacotherapy is then recommended. Among the options listed, fluoxetine has the strongest evidence of efficacy as monotherapy for PTSD. There is a lack of evidence for the efficacy of benzodiazepines such as clonazepam, antiepileptics such as divalproex, and atypical antipsychotics such as quetiapine and risperidone. Furthermore, risks outweigh any potential benefits from these medications.

Question 263

Telemedicine can be helpful in the management of many chronic conditions, including diabetes mellitus. Medicare and most private insurers pay for telemedicine visits at the same rate as in-person visits. Teleretinal screening performed at the primary care provider’s office should be considered in patients with diabetes as a cost-effective option for improving retinopathy screening rates (SOR B). Eyecare specialists can remotely evaluate the retinal photos for timely completion of annual retinopathy screening. Counseling about the importance of retinal screening, digital reminders, office-wide prize drawings, and sharing office space with an ophthalmologist have not been proven to be effective in increasing retinal screening rates in patients with diabetes.

Question 264

The prompt recognition of heatstroke is critical to effective treatment. Heatstroke is characterized by a core temperature >40°C (104°F) in association with neurologic abnormalities such as headache, confusion, altered mental status, irritability, and seizure. Exercise-associated collapse, previously called heat syncope, generally occurs immediately after strenuous exercise and is more associated with hydration status. Heat edema is a benign condition manifested by mild swelling in the extremities and facial flushing in a patient with a normal temperature. Heat exhaustion may involve neurologic symptoms but is associated with a lower temperature (38.3°C–40.0°C [101°F–104°F]) and thus a better outcome. Like heatstroke, heat injury can be associated with a temperature >40°C, but does not involve neurologic symptoms. Instead, kidney, muscle, or liver injury may be present.

Question 265

Paget disease of bone is the second most common metabolic bone disorder after osteoporosis and has a lifetime prevalence of 1%–2% in the United States. Only 30%–40% of patients have symptoms such as bone pain at diagnosis. Most patients are diagnosed after an incidental finding of elevated alkaline phosphatase (ALP) on routine laboratory studies or by plain films performed for another reason. When an elevated ALP level is found in an asymptomatic patient, other liver function tests such as a gamma-glutamyl transaminase level should be performed to evaluate for hepatobiliary pathology. If negative, this should be followed by plain radiography of the skull and tibia, and an enlarged view of the pelvis to assess for lytic lesions and cortical thickening. If plain radiography is consistent with Paget disease of bone, a radionuclide bone scan is performed to assess the full extent of the disease. Bisphosphonates are the first-line treatment in active disease, which is signified by bone pain, hearing loss, and lytic lesions. Right upper quadrant ultrasonography, a full-body CT scan, and a HIDA scan would not be the most appropriate next step in the evaluation.

Question 266

This patient’s tuberculosis (TB) screening test is positive, and the next step in the evaluation involves determining whether he has a latent infection or active disease. Diagnosis of latent TB requires ruling out active disease by assessing the patient clinically with a history, physical examination, and chest radiograph. If this evaluation does not suggest active disease, sputum studies are not needed. Interferon-gamma release assays (IGRA), which are blood tests used to screen for TB infection, are more accurate than tuberculin skin testing, so a tuberculin skin test is not needed. Treatment should not be started until a determination of latent versus active TB is made.

Question 267

The central role of inflammation in the progression of coronary disease is well recognized and the use of an anti-inflammatory medication may improve outcomes in these patients. The low-dose colchicine (LoDoCo2) trial evaluated colchicine, 0.5 mg daily, versus placebo in patients with chronic coronary artery disease and found a 30% risk reduction in cardiovascular deaths, spontaneous myocardial infarctions, ischemic stroke, and ischemia-driven revascularization. It did not find any observable difference with regard to new-onset atrial fibrillation, deep vein thrombosis, diabetes mellitus, or pulmonary embolism. Of note, the trial excluded individuals with heart failure or renal impairment. At one time, azithromycin had shown some evidence in the secondary prevention of cardiovascular disease, but subsequent trials did not show the same benefit. Studies of fish oil capsules that contain marine omega-3 fatty acid supplements mixed with EPA/DHA formulations have failed to show cardiovascular benefit in patients with known cardiovascular disease. Similarly, niacin does not reduce overall mortality, cardiovascular mortality, or noncardiovascular mortality. The benefits of niacin therapy in the prevention of cardiovascular disease events are not well proven.

Question 268

Although many providers assume short-term systemic corticosteroids are safe, evidence shows multiple negative effects including elevated blood glucose and blood pressure, mood and sleep disturbance, and an increased risk of sepsis and venous thromboembolism. There are adequate trials to support the use of systemic corticosteroids within 3 days of the onset of Bell’s palsy (SOR A). Adequate studies recommend against prescribing systemic corticosteroids for acute bronchitis in the absence of underlying asthma or COPD, or acute sinusitis (SOR B). There is insufficient evidence (SOR B) to support the routine use of systemic corticosteroids for patients with acute pharyngitis or lumbar radiculopathy.

Question 269

Phytophotodermatitis is an inflammation and/or discoloration of the skin caused by contact with specific plants followed by exposure to sunlight. Limes are commonly associated with this phenomenon. Addison’s disease causes generalized hyperpigmentation and has an insidious onset along with other constitutional symptoms such as anorexia, nausea, and weakness. An allergic reaction would likely be pruritic and a chemical burn would be expected to be painful. Cellulitis would also be uncomfortable and would likely be associated with erythema.

Question 270

Factors associated with a higher risk of heat-related deaths include being confined to bed, not leaving home daily, and being unable to care for oneself. Living alone during a heat wave is associated with an increased risk of death, but this increase is not statistically significant. Among medical conditions, the highest risk is associated with preexisting psychiatric illnesses, followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease. A lower risk of heat-related deaths has been noted in those who have working air conditioning, visit air-conditioned sites, or participate in social activities. Those who take extra showers or baths and who use fans have a lower risk, but this difference is not statistically significant.

Question 271

Permission for the release of patient information should always be in writing. Although the actual medical record is the property of the physician, the information in the chart is the property of the patient. Ethically and legally, patients have a right to the information in their medical records, and it cannot be withheld from the patient or a third party (at the request of the patient), even if medical bills are unpaid or the physician is concerned about the patient.

Question 272

A hydrocele of the tunica vaginalis testis occurs frequently at birth but usually resolves in a few weeks or months. No treatment is indicated during the first year of life unless there is a clinically evident hernia. A simple scrotal hydrocele without communication with the peritoneal cavity and no associated hernia should be excised if it has not spontaneously resolved by the age of 12 months. Aspirating the mass for diagnostic or therapeutic reasons is not recommended, since a loop of bowel may be injured. Removing the fluid is ineffectiveas it will quickly reaccumulate.

Question 273

The use of herbal and nutritional supplements has become commonplace in the United States. Unfortunately, there is insufficient research for most herbal remedies, in terms of both efficacy and safety. However, there is a significant body of evidence from randomized, controlled trials and various meta-analyses showing benefit from the use of kava in the short-term treatment of anxiety disorders (up to 24 weeks), including generalized anxiety disorder (SOR A). The other remedies listed have only single studies or anecdotal evidence attesting to benefit for patients with anxiety. At best, information about them is limited, and there are often conflicting results. Safety concerns about kava have been addressed by recent randomized, controlled trials demonstrating that kava has a safety profile similar to those of FDA-approved treatments for anxiety disorders. Care should be taken with any concurrent use of kava and medications metabolized by the liver, and patients should be discouraged from using alcohol while taking kava. Physicians should be aware of all remedies their patients are taking, even if they are not prescribed. In addition, it is important to be aware of remedies that have evidence supporting their use.

Question 274

Entrapment of the posterior tibial nerve or its branches as the nerve courses behind the medial malleolus results in a neuritis known as tarsal tunnel syndrome. Causes of compression within the tarsal tunnel include varices of the posterior tibial vein, tenosynovitis of the flexor tendon, structural alteration of the tunnel secondary to trauma, and direct compression of the nerve. Pronation of the foot causes pain and paresthesias in the medial aspect of the ankle and heel, and sometimes the plantar surface of the foot. The usual site for a stress fracture is the shaft of the second, third, or fourth metatarsals. A herniated nucleus pulposus would produce reflex and sensory changes. Plantar fasciitis is the most common cause of heel pain in runners and often presents with pain at the beginning of the workout. The pain decreases during running only to recur afterward. Diabetic neuropathy is usually bilateral and often produces paresthesias and burning at night, with absent or decreased deep tendon reflexes

Question 275

This patient most likely has periodontitis of the tooth’s roots with cellulitis, complicated by an apical abscess. This infection is caused by anaerobic oral bacteria. Penicillin VK, amoxicillin or amoxicillin/clavulanate is preferred for antibiotic treatment, but this patient is allergic to penicillin. Clindamycin is a good choice to cover the likely pathogens. Doxycycline, trimethoprim/sulfamethoxazole, ciprofloxacin, and cephalexin have limited effectiveness against anaerobes and would not be indicated.

Question 276

Certain drugs can affect taste more than smell, but this does not include the bisphosphonates. Olfactory disorders may be associated with deficiencies of vitamins A, B6, B12, and trace metals, but not with vitamin D deficiency. Celiac disease is not known to cause a decreased ability to smell. Rare tumors involving the olfactory region of the brain can affect smell, and are best detected by MRI.

Question 277

This is a classic incidentaloma. Nodules are detected in up to 50% of thyroid sonograms and carry a low risk of malignancy (<5%). If the TSH level is normal, nuclear scanning and further thyroid studies are not necessary. Nodules smaller than 1 cm are difficult to biopsy and thyroid surgery is not indicated for what is almost certainly benign disease. It is reasonable to follow small nodules with clinical examinations and periodic sonograms.

Question 278

Gilbert syndrome is an autosomal dominant disease characterized by indirect hyperbilirubinemia caused by impaired glucuronyl transferase activity. The workup includes studies to exclude hemolysis (CBC, reticulocyte count, and haptoglobin) and liver disease (AST, ALT, alkaline phosphatase, and prothrombin time). Alcoholic liver disease is associated with a greater elevation of AST than of ALT. Dubin-Johhnson syndrome is a benign liver disease distinguished by direct or conjugated hyperbilirubinemia. Imaging studies are not required to confirm Gilbert syndrome; such studies are more useful for conditions involving conjugated hyperbilirubinemia. Other causes of indirect hyperbilirubinemia include hematoma, infection, cardiac disease, rhabdomyolysis, living at high altitude, thyrotoxicosis, and some medications.

Question 279

Red cell distribution width (RDW) is a measure of the variability of size of the red cells. It is particularly useful in distinguishing anemic disorders, especially iron deficiency anemia (high RDW, normal to low mean corpuscular volume) and uncomplicated heterozygous thalassemia (normal RDW, low mean corpuscular volume).

Question 280

Topical mupirocin is as effective as cephalexin or amoxicillin/clavulanate in the treatment of impetigo, which is most often caused by Staphlococcal species. Oral penicillin V, oral erythromycin, and topical bacitracin are less effective than mupirocin. Topical treatment is well suited to this localized lesion. Topical disinfectants such as hydrogen peroxide are no more effective than placebo.

Question 281

Temporomandibular joint (TMJ) disorders occur in a large number of adults. The etiology is varied, but includes dental malocclusion, bruxism (teeth grinding), anxiety, stress disorders, and, rarely, rheumatoid arthritis. Dental occlusion problems, once thought to be the primary etiology, are not more common in persons with TMJ disorder. While dental splints have been commonly recommended, the evidence for and against their use is insufficient to make a recommendation either way. Physical therapy modalities such as iontophoresis or phonophoresis may benefit some patients, but there is no clearly preferred treatment. Radiologic imaging is unnecessary in the vast majority of patients, and should therefore be reserved for chronic or severe cases. In fact, the majority of patients with TMJ disorders have spontaneous resolution of symptoms, so noninvasive symptomatic treatments and tincture of time are the best approach for most.

Question 282

Acute interstitial nephritis (AIN) is often drug-induced. Discontinuation of medications that are likely to cause AIN is the most important first step in management. If these medications are withdrawn early, most patients can be expected to recover normal renal function. Of the medications listed, ibuprofen is the most likely offending agent, because all NSAIDs are known to be associated with AIN. Development of AIN usually becomes evident approximately 2 weeks after starting a medication and is not dose-related. Other medications strongly associated with AIN include various antibiotics (particularly cephalosporins, penicillins, sulfonamides, aminoglycosides, and rifampin), diuretics, and miscellaneous medications such as allopurinol.

Question 283

In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine currently are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.

Question 284

Chronic cough is defined as a cough lasting at least 8 weeks. If a thorough history (with attention to ACE inhibitor use), a physical examination, and a plain-film chest radiograph do not suggest an obvious cause for the cough, experts suggest that the three most common etiologies are gastroesophageal reflux, persistent postnasal drip, and unrecognized asthma. Treating a chronic cough empirically with a high-dose proton pump inhibitor for 2–3 months is considered a reasonable choice before further investigations are attempted. Ordering an esophageal pH probe or esophagogastroduodenoscopy would also be considered appropriate. Postnasal drip is often due to allergic rhinitis or another noninfectious condition and some guidelines recommend empiric nasal corticosteroid sprays and/or first-generation oral antihistamine use. CT of the chest and bronchoscopy may become necessary if the evaluation and treatment for these three common conditions does not improve the patient’s symptoms. Since there are no symptoms of bacterial sinusitis, the use of a broad-spectrum antibiotic is not justified.

Question 285

Effective treatments for chronic orthostatic hypotension include fludrocortisone, midodrine, and physostigmine (SOR B). Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate therapies.

Question 286

Several studies have demonstrated that SSRIs are safe and effective in treating depression in patients with coronary disease, particularly those with a history of previous episodes of depression. Medications have performed significantly better than intensive interpersonal psychotherapy in this setting. Electroconvulsive therapy is not considered first-line therapy in the absence of severe symptoms. While it may be effective for sleep disturbance, amitriptyline has potential cardiac side effects and is unlikely to be effective for the treatment of depression in low doses.

Question 287

Migraine is the most likely diagnosis in this scenario, because the patient is young and female; the headaches are unilateral, infrequent, and throbbing; the headaches are associated with nausea and vomiting; and sleep offers relief. Symptoms of sinusitis usually include fever, facial pain, and a purulent nasal discharge. The pain of cerebral tumor tends to occur daily and becomes more frequent and severe with time. Furthermore, the prevalence of brain tumor is far less than that of migraine. The pain of muscle tension headache is described as a pressure or band-like tightening, often in a circumferential or cap distribution. This headache also has a pattern of daily persistence, often continuing day and night for long periods of time. Cluster headache is more common in males, and presents as a very severe, constant, agonizing orbital pain, usually beginning within 2 or 3 hours after falling asleep.

Question 288

After several unsuccessful attempts to remove an object deep in the ear canal of an uncooperative child, it is best to refer the patient to an otolaryngologist for removal under anesthesia. Additional attempts are very unlikely to succeed, especially with the techniques listed. A loop curette cannot be safely placed behind a foreign body that is close to the tympanic membrane. A round, hard object cannot be grasped with forceps. Acetone can be used to dissolve Styrofoam foreign bodies, but it would not dissolve a plastic bead.

Question 289

β-Blockers are recommended to reduce mortality in symptomatic patients with heart failure (SOR A). The role that digoxin will ultimately play in heart failure is unclear. The Digitalis Investigation Group study revealed a trend toward increased mortality among women with heart failure who were taking digoxin, but digoxin levels were higher among women than men. There is no evidence that warfarin decreases mortality in patients with heart failure. There is also no evidence that amiodarone decreases mortality from heart failure in patients with no history of atrial fibrillation. Calcium channel blockers should be used with caution in patients with heart failure because they can cause peripheral vasodilation, decreased heart rate, decreased cardiac contractility, and decreased cardiac conduction.

Question 290

Age-related macular degeneration is the most common cause of blindness in the older population. It occurs more frequently in light-skinned individuals than in dark-skinned individuals. Risk factors include smoking and hypertension.

Question 291

Croup is a viral illness and is not treated with antibiotics. Racemic epinephrine may be used acutely, but rebound can occur. Albuterol has not been shown to be helpful. Oral or intramuscular dexamethasone, 0.6 mg/kg as a single dose, and nebulized budesonide have been shown to reduce croup scores and shorten hospital stays.

Question 292

Papanicolaou (Pap) tests are intended to screen for cervical cancer, but most abnormal Pap tests are associated with precancerous lesions or with no abnormality. The category of atypical glandular cells not otherwise specified (AGC-NOS) has a benign sound to it, although it is associated with a 17% rate of cancer (8% carcinoma in situ and 9% invasive carcinoma). High-grade squamous intraepithelial lesion (HSIL), which would seem worse intuitively, has only a 3% associated cancer rate. AGC-NOS is associated with higher rates of cancer than the other choices listed.

Question 293

Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive behaviors that impair everyday functioning. SSRIs such as fluoxetine and fluvoxamine are FDA-approved and considered first-line agents in the treatment of this condition. None of the other agents listed is recommended for the treatment of obsessive-compulsive disorder. Lithium is useful in bipolar disease and depression, alprazolam is used in generalized anxiety and panic disorder, and amitriptyline is used in depression and chronic pain syndromes. Valproic acid is primarily an anti-epileptic agent

Question 294

The p-value is a level of statistical significance, and characterizes the likelihood of achieving the observed results of a study by chance alone, and in this case that likelihood is 5%. (In this case, 5% or less of the results can be achieved by chance alone and still be significant.) The confidence interval is a measure of variance and is derived from the test data. The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%. The a or type I error is akin to the error of false-positive assignment; the B or type II error is analogous to the false-negative rate, or 1 - specificity, and cannot be calculated from the information given.

Question 295

Recent American Society of Anesthesiologists guidelines recommend the following restrictions on diet prior to surgery for pediatric patients: 8 hours for solid food, 6 hours for formula, 4 hours for breast milk, and 2 hours for clear liquids. These changes have resulted in decreased numbers of canceled cases and pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction.

Question 296

The FDA has approved more than 90% of the drugs available from Canada. Most of these drugs come from the same manufacturers as drugs in the U.S. Health Canada takes longer, on average, to approve a drug for release than does the FDA, and most drugs discontinued for safety reasons by the FDA between 1992 and 2001 had not been approved for use in Canada. Websites advertising Canadian drugs may be selling counterfeit drugs from unregulated sources.

Question 297

Henoch-Schonlein purpura typically follows an upper respiratory tract infection, and presents with low-grade fever, fatigue, arthralgia, and colicky abdominal pain. The hallmark of the disease is the rash, which begins as pink maculopapules, progresses to petechiae or purpura, which are clinically palpable, and changes in color from red to dusty brown before fading. Arthritis, usually involving the knees and ankles, is present in two-thirds of cases, and gastrointestinal tract involvement results in heme-positive stools in 50% of cases. Laboratory findings are not specific or diagnostic, and include indications of mild to moderate thrombocytosis, leukocytosis, and anemia, and an elevated erythrocyte sedimentation rate. Treatment is typically symptomatic and supportive, although corticosteroids are indicated in the rare patient with life-threatening gastrointestinal or central nervous system manifestations. Systemic juvenile-onset rheumatoid arthritis usually presents with an evanescent salmon-pink rash. Rocky Mountain spotted fever does not present with arthritis and the rash begins distally on the legs. Iron ingestion does not typically cause a rash, fever, or arthritis. Disseminated anthrax does not present with a rash and joint symptoms.

Question 298

The key indicator of postherpetic neuralgia is persistent pain 3–6 months after an episode of herpes zoster. Studies show that patients who present for treatment of herpes zoster within 72 hours will benefit from antiviral therapy such as famciclovir to reduce the pain and decrease the risk of postherpetic neuralgia. Treating zoster pain with tricyclic antidepressants in low dosage (10–25 mg amitriptyline) may also decrease risk. While steroids added to antiviral therapy may be of benefit in short-term therapy, they do not reduce pain at 6 months.

Question 299

This patient has several clinical features of vitamin B12 deficiency. Some patients with significant vitamin B12 deficiency have levels in the lower range of normal, as this patient does. Vitamin B12 is a cofactor in the synthesis of both methionine and succinyl coenzyme A, and vitamin B12 deficiency leads to the accumulation of methylmalonic acid and homocysteine, which are the precursors of these compounds. An elevated level of these substances is therefore more sensitive than a low vitamin B12 level for vitamin B12 deficiency. Homocysteine is also elevated in folic acid deficiency, however, so a methylmalonic acid level is recommended if vitamin B12 deficiency is a concern and serum vitamin B12 levels are 150–400 pg/mL. A reduced haptoglobin level is useful to confirm hemolytic anemia. An elevated free erythrocyte protoporphyrin level may occur in lead poisoning or iron deficiency. An elevated angiotensin converting enzyme level is found in sarcoidosis.

Question 300

Kawasaki disease, or mucocutaneous lymph node syndrome, is a common form of vasculitis in childhood. It is typically self-limited, with fever and acute inflammation lasting 12 days on average without therapy. However, if untreated, this illness can result in heart failure, coronary artery aneurysm, myocardial infarction, arrhythmias, or occlusion of peripheral arteries. It is most common in those under the age of 5 years. To diagnose this disease, fever must be present for 5 days or more with no other explanation. In addition, at least four of the following symptoms must be present: 1) nonexudative conjunctivitis that spares the limbus; 2) changes in the oral membranes such as diffuse erythema, injected or fissured lips, or “strawberry tongue”; 3) erythema of palms and soles, and/or edema of the hands or feet followed by periungual desquamation; 4) cervical adenopathy in the anterior cervical triangle with at least one node larger than 1.5 cm in diameter; and, 5) an erythematous polymorphous rash, which may be targetoid or purpuric in 20% of cases. The disease must be distinguished from toxic shock syndrome, streptococcal scarlet fever, Stevens-Johnson syndrome, juvenile rheumatoid arthritis, measles, adenovirus infection, echovirus infection, and drug reactions. Treatment significantly diminishes the risk of complications. Current recommendations are to hospitalize the patient for treatment with intravenous immune globulin. In addition, aspirin is used for both its anti-inflammatory and antithrombolitic effects. While prednisone is used to treat other forms of vasculitis, it is considered unsafe in Kawasaki disease, as a previous study showed an extraordinarily high rate of coronary artery aneurysm with its use.

Question 301

Celiac sprue is a condition of acquired malabsorption that resolves when the patient is exposed to a gluten-free diet. Gluten is a substance found in wheat, rye, and barley, but not in corn or rice products. Children with this sensitivity will develop inflammation and destruction of the microvilli in the small intestine as a result of an immune response to gluten. Patients with celiac sprue often present as this child has, between 4 and 24 months of age with impaired growth, diarrhea, and abdominal distention. An iron deficiency anemia can occur with impairment of iron absorption from the small intestine. Lesser cases of malabsorption are common, and this condition often goes unrecognized into adolescence or adulthood. Serologic tests, and ultimately a biopsy of the small intestine, can confirm the diagnosis.

Question 302

Seventy to ninety percent of patients with acute appendicitis have leukocytosis, but this is also a characteristic of other conditions, and thus has poor specificity for acute appendicitis. The urinalysis may exhibit microscopic pyuria or hematuria in a patient with acute appendicitis, but these findings may also be present with urinary tract disease. Plain radiographs of the abdomen are of limited value in diagnosing acute appendicitis. Ultrasonography can be useful, especially in ruling out gynecologic problems, but is technician-dependent and is not as specific nor sensitive as CT scanning, which has a sensitivity, specificity, and overall accuracy in excess of 90%. In cases where the CT scan is indeterminate, patients should be admitted to the hospital for close observation with repeated physical examinations to monitor clinical status.

Question 303

The patient has symptoms, signs, and laboratory findings consistent with a diagnosis of Waldenström’s macroglobulinemia. This illness is due to an uncontrolled proliferation of lymphocytes and plasma cells, which produce IgM proteins with kappa light chains. The average age at the time of diagnosis is 65 years. Weakness, fatigue, weight loss, bleeding, and recurrent infections are common presenting symptoms. Physical findings include pallor, hepatosplenomegaly, and lymphadenopathy. Typical laboratory findings include moderate anemia and monoclonal IgM peaks on serum electrophoresis. Bence-Jones protein is seen in 80% of cases, but is typically absent in monoclonal gammopathy of undetermined significance. Unlike in multiple myeloma, lytic bone lesions are not seen, and marrow biopsy reveals mostly lymphocytes. Sarcoidosis usually presents with hilar lymphadenopathy and a polyclonal gammopathy. Non-Hodgkin’s lymphoma presents with similar symptoms, lymphadenopathy, and hepatosplenomegaly, but generally lacks a monoclonal gammopathy and Bence-Jones proteinemia, and has distinctive malignant lymphocytes on bone marrow biopsy.

Question 304

This presentation is consistent with a common injury called a “fight bite.” Radiographs are needed to determine if there is a distal metacarpal fracture so that it can be treated appropriately. Because human bites commonly cause infection, prophylactic antibiotics are recommended with any break in the skin. If the skin break is superficial, this is sufficient. Deeper wounds should be explored by a surgeon, but superficial wounds should not be probed indiscriminately.

Question 305

The etiology of prepubertal labial adhesions is idiopathic. The adhesions may be partial or complete; in some cases only a small pinhole orifice may be seen that allows urine to exit from the fused labia. This problem may be asymptomatic, but the patient may also have a pulling sensation, difficulty with voiding, recurrent urinary tract infections, or vaginitis. If there is enough labial fusion to interfere with urination, treatment should be undertaken. The use of topical estrogen cream twice daily at the point of the midline fusion will usually result in resolution of the problem.

Question 305

Stress fractures of the femoral neck are most commonly seen in military recruits and runners. They present with persistent groin pain, and limited hip flexion and internal rotation. Radiographs may be normal early. Iliotibial band syndrome also occurs in runners and presents with stinging pain over the lateral femoral epicondyle. Osteitis pubis occurs in distance runners and presents with pain in the anterior pelvic area and tenderness over the symphysis pubis. Pelvic inflammatory disease is associated with abdominal pain and fever.

Question 306

According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass index (BMI). Mild is a BMI >17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of 15.0–15.9 kg/m2, and extreme is a BMI <15.0 kg/m2. Recurrent episodes of binge eating or purging behavior help differentiate restricting type from binge-eating/purging type, but do not indicate severity. Orthostatic changes in pulse or blood pressure and refusal to eat are criteria for inpatient hospitalization, but are not part of the classification of severity according to the DSM-5. Amenorrhea can be a clinical sign of anorexia nervosa but is not part of the classification of severity.

Question 307

Behavioral symptoms such as agitation and wandering become common as Alzheimer’s disease progresses. Cholinesterase inhibitors may improve some of these symptoms. If they persist, use of a psychotropic agent may be necessary. Atypical agents can help control problematic delusions, hallucinations, severe psychomotor agitation, and combativeness. Typical agents help control these same problems, but are used more as second-line therapy in those who do not respond to atypical agents. Mood-stabilizing drugs can help control these symptoms as well, and may also be useful alternatives to antipsychotic agents for controlling severe agitated, repetitive, and combative behaviors. Benzodiazepines are used to manage insomnia, anxiety and agitation. Some behaviors, such as wandering and pacing, are not amenable to drug therapy.

Question 308

There are a number of alternatives to the bisphosphonates. Unfortunately, efficacy data is not encouraging for most of them. Intravenous zoledronic acid has been shown to reduce both hip fracture risk and vertebral fracture risk. Teriparatide reduces vertebral fracture risk but not hip fracture risk. The same is true for raloxifene and calcitonin salmon.

Question 309

While the exact etiology of nausea and vomiting in pregnancy remains unclear, there are few data to support the theory that psychological factors play a role. Although nausea is usually a self-limited condition, other causes must be ruled out. Secondary causes are more likely to be present if the onset of symptoms occurs after 9 weeks' gestation. Several pharmacologic treatments are proven safe and are superior to placebo in relieving symptoms and preventing hospitalization. Metoclopramide is more effective than placebo and has not been associated with an increased risk of adverse effects on the fetus.

Question 310

This patient has iron deficiency anemia. There are several substances that decrease the absorption of iron, including antacids, soy protein, calcium, tannin (which is in tea), and phytate (which is found in bran). Since an acidic environment increases iron absorption, ascorbic acid (vitamin C) can enhance absorption of an iron supplement

Question 311

Results of randomized clinical trials demonstrate that medications such as SSRIs, tricyclic antidepressants, and monoamine oxidase inhibitors alleviate the symptoms of post-traumatic stress disorder (PTSD) and are associated with improvements in overall functioning. SSRIs are a first-line medication because they are safer and better tolerated than other types of psychotropic medications. Sertraline and paroxetine are the only agents that have been approved by the FDA for the treatment of PTSD.

Question 312

Even though the patient’s DEXA has improved and she is technically osteopenic, she still has risk factors for osteoporosis, including recent smoking, low BMI, and a prior fragility fracture. She should continue her current regimen.

Question 313

The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in the elderly, including primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric population, cerebrovascular disease is the most common cause of seizures, with about 10% of stroke victims developing epileptic seizures. Seizures are more common following hemorrhagic strokes compared to nonhemorrhagic strokes.

Question 314

Amitriptyline, doxepin, MAO inhibitors, and clomipramine should be avoided in nursing-home patients. SSRIs are the most appropriate first-line pharmacologic treatment for depression in nursing-home residents. Other classes of non-tricyclic antidepressants may be effective and appropriate, but the evidence for this is not as good as the evidence for SSRIs.

Question 315

Shift-work insomnia is the only circadian sleep disorder listed. It may respond to bright-light therapy. Alcoholism is a behavioral disorder that may respond to gradual discontinuance. Inadequate sleep hygiene (use of stimulants at night, sleeping other than at bedtime, etc.) may respond to habit changes. Sleep-related myoclonus is an intrinsic sleep disorder and can be treated with levodopa or clonazepam.

Question 316

Thalamotomy and pallidotomy, contralateral to the side of the body that is most affected, are most effective for the treatment of disabling unilateral tremor and dyskinesia from Parkinson’s disease.

Question 317

Hypertrophic pyloric stenosis is the most likely diagnosis in this case. If it is allowed to progress untreated, there may be signs of malnutrition, constipation, oliguria, and profound hypochloremic metabolic alkalosis. The latter is a characteristic sign of pyloric obstruction. As the child vomits chloride and hydrogen-rich gastric contents, hypochloremic alkalosis sets in. Pneumonia is not a common problem with pyloric stenosis, as it can be with congenital tracheoesophageal fistulae for example. After feeding, there may be a visible peristaltic wave that progresses across the abdomen. However, since the point of obstruction is proximal to the small and large intestines and affected infants lose weight, the abdomen is usually flat rather than distended, especially in the malnourished infant. Currant jelly stool is a common clinical manifestation of intussusception. Mild jaundice with elevated indirect bilirubin is seen in about 5% of infants with pyloric stenosis, but is not a characteristic sign.

Question 318

The rash described is typical of herpes zoster. This commonly occurs in older individuals who have had chickenpox in childhood. The treatment of choice for acute herpes zoster is oral antiviral agents. Acyclovir, valacyclovir, and famciclovir have all been shown to be efficacious with 7 days of oral treatment. Studies suggest that valacyclovir may be superior to acyclovir in decreasing both acute and postherpetic pain. Famciclovir appears to be equal in efficacy to valacyclovir. Topical acyclovir may be effective for more limited forms of herpes simplex, but is usually not effective for herpes zoster. Topical and oral corticosteroids may have some use for combatting the inflammatory process, and may decrease the incidence of postherpetic neuralgia in certain individuals. Topical capsaicin may be useful in treating the pain of acute herpes zoster infection, as well as postherpetic neuralgia.

Question 319

Dribbling and increased post-void residual volume (>100 mL) are signs of overflow incontinence. Overflow incontinence can be caused by outflow obstruction (e.g., prostate hypertrophy, urethral constriction, fecal impaction) or, as in this case, by detrusor muscle denervation caused by diabetic or other neuropathies. Excess urine output from hyperglycemia would result in frequent urination, but not urinary retention. Atrophic vaginitis and cystoceles are usually associated with stress incontinence. Asymptomatic bacteriuria is unlikely because the patient does not have any evidence of infection

Question 320

The failure to provide immunizations because of perceived contraindications is one of the most common reasons for an inadequately protected population. A PPD may be falsely negative if administered 2-30 days after MMR administration, not the reverse. If the patient is immunodeficient or pregnant, rather than a household contact, then MMR is contraindicated. Breastfeeding is not a contraindication.

Question 321

The Mini-Mental State Examination, developed by Folstein in 1975, has become a standard tool for rapid clinical assessment of cognitive impairment. The score is known to be affected by the patient’s educational attainment. Given the same level of cognitive impairment, those with higher education levels score somewhat better than those with less education. Race, sex, and socioeconomic status per se do not affect patients’ scores.

Question 322

In older adults, coprescription of clarithromycin or erythromycin with a statin that is metabolized by CYP 3A4 (atorvastatin, simvastatin, lovastatin) increases the risk of statin toxicity. The other antibiotics listed do not interact with statins.

Question 323

Intranasal decongestants such as phenylephrine should not be used for more than 3 days, as they cause rebound congestion on drug withdrawal. When used for several months or more, these agents can cause a form of rhinitis, rhinitis medicamentosa, that can be extremely difficult to treat.

Question 324

Influenza has a very abrupt onset, and a fever with a nonproductive cough is almost always present. Unconfirmed cases are referred to as influenza-like illness (ILI) or suspected influenza. Patients with confirmed cases tend to say they have never been so ill. Mycoplasma pneumonia can spread among family members, but it is milder and has a more indolent onset and a longer incubation period. Bacterial bronchitis is an overdiagnosed, supposed complication of upper respiratory infections, and is not contagious. While the phrase cold and flu is often used, upper respiratory infections are not so febrile or prostrating, and coryza is the dominant syndrome sooner or later. Legionella can have point-source epidemics, but the incubation period is longer, symptoms vary from mild illness to life-threatening pneumonia, and diarrhea is prominent in many cases. Reference: Thibodeau KP, Viera AJ: Atypical pathogens and challenges in community-acquired pneumonia. Am Fam Physician

Question 325

The most common pediatric vasculitis is Henoch-Schonlein purpura. It is an IgA-mediated small-vessel vasculitis that classically presents with the triad of nonthrombocytopenic palpable purpura, colicky abdominal pain, and arthritis. Kawasaki disease is manifested by conjunctival injection, mucosal erythema, rash, and lymphadenopathy. Takayasu arteritis has numerous manifestations, including night sweats, fatigue, weight loss, myalgia, and arthritis. Later findings may include hypertension, skin lesions, and cardiac disorders. Wegener granulomatosis causes constitutional symptoms also, including weight loss and fatigue, with later findings including respiratory problems, ophthalmologic lesions, neuropathies, glomerulonephritis, and skin lesions. Polyarteritis nodosa is another disease that causes constitutional symptoms such as fatigue, fever, and myalgias. It also causes skin lesions, gastrointestinal symptoms such as postprandial abdominal pain, and cardiac lesions.

Question 326

This patient probably has the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). SIADH can be caused by CNS tumors, various infections such as meningitis, and pneumonia. Several drugs can cause this condition, including amiodarone, carbamazepine, SSRIs, and chlorpromazine. In this fairly asymptomatic patient, initial management should be free water restriction. As she is hemodynamically stable, she does not need normal saline. Moreover, administration of normal saline may exacerbate the hyponatremia, as the sodium may be rapidly excreted while the water is retained. If she had a rapid onset and neurologic symptoms such as seizures, hypertonic saline could be given. Correction should be slow, with a goal of no more than a 1-2 mmol/L/hr increase in the sodium level; a normal sodium level should not be reached within the first 48 hours of treatment. Demeclocycline is appropriate for patients who cannot adhere to the requirement for fluid restriction, or who have recalcitrant hyponatremia despite restriction.

Question 327

Marfan's syndrome is an autosomal dominant disease manifested by skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller than 72 in and women taller than 70 in who have two or more manifestations of Marfans disease should be screened by echocardiography for associated cardiac abnormalities. Any of these athletes who have a family history of Marfan's syndrome should be screened, whether they have manifestations themselves or not. If there is no family history, echocardiography should be performed if two or more of the following are present: cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 standard deviation below the mean, myopia, or an ectopic lens. Patients with Marfan's syndrome who have echocardiographic evidence of aortic abnormalities should be placed on beta-blockers and monitored with echocardiography every 6 months.

Question 328

Treatments available for childhood nocturnal enuresis include nonpharmacologic and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the bed-wetting alarm has a higher success rate (75%) and a lower relapse rate (41%).

Question 329

The Ottawa Ankle Rules are widely accepted guidelines for appropriate evaluation of ankle and midfoot injuries occurring in adults age 19 or older presenting for the first time in a clinical setting. The guidelines utilize the historical and physical findings to determine which radiographic studies, if any, are indicated. Patients who were able to bear weight immediately following their injury and who can take 4 steps independently in a clinical setting require radiographic study only when the following criteria are met: pain is present in the malleolar zone and bony tenderness of the posterior edge or tip of either malleolus is elicited (ankle radiograph), or pain is present in the midfoot zone and bony tenderness of either the base of the fifth metatarsal or the navicular region is present.

Question 330

Once therapy is initiated, children with bacterial conjunctivitis should be allowed to remain in school. Careful hand hygiene is important, however, and behavior must be appropriate to maintain adequate hygiene. No specific length of treatment or evidence of clinical response is required before returning to school.

Question 331

Chagas disease is caused by Trypanosoma cruzi, and is estimated to infect some 300,000 persons in the United States. Potential consequences include cardiomyopathy, heart failure, and fatal cardiac arrhythmias. The CDC has designated Chagas disease as a neglected parasitic infection, based on the number of people estimated to be infected in the United States, the potential severity of the illness, and the ability to prevent and treat this disease. This infection is considered neglected because relatively little attention has been devoted to its surveillance, prevention, and/or treatment. It is most common in those who live in rural, impoverished areas in Mexico or central America, where the vector of the disease, the kissing bug, is found. Trichomoniasis can lead to infertility and poor birth outcomes. Toxocariasis and toxoplasmosis cause developmental defects in children. Cysticercosis can lead to epilepsy in young adults. Some of these sequelae develop years after an initial mild infection.

Question 332

A number of medications can cause thrombocytopenia, but heparin is a more likely cause than enalapril, furosemide, labetalol, or insulin. Even the small doses of heparin used to flush intravenous lines can be a source of thrombocytopenia.

Question 333

In patients with head and neck lymphadenopathy, supraclavicular nodes are the most likely to be malignant. Lymphadenopathy of these nodes should always be investigated, even in children. Overall, the prevalence of malignancy with this presentation is unknown, but rates of 54%–85% have been seen in biopsy series reports.

Question 334

Both ectopic pregnancy and spontaneous or therapeutic abortion pose a significant risk for fetomaternal hemorrhage. Thus, administration of RHO immune globulin (RhoGAM) is recommended in any Rh-negative patient who is unsensitized (D antibody screen–negative prior to administration of RhoGAM). If the estimated gestational age is 12 weeks or less, 50 mcg of RhoGAM is recommended. If the estimated gestational age is greater than 12 weeks, 300 µg of RhoGAM is recommended

Question 335

Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest in children and in women of childbearing age (especially pregnant women).

Question 336

When a person is Rh negative, this indicates that they do not have type D antigen on their red blood cells. If a woman is exposed to Rh D antigen–positive red blood cells, she can have an immune response of variable strength. This may occur in the setting of pregnancy (transplacental fetomaternal transfusion), or exposure outside of pregnancy (e.g., transfusion with mismatched blood). If a maternal antibody screen for D antigen is positive, this indicates that the current fetus MAY be at risk for hemolytic disease. The level of risk is determined by the antibody titer. For example, an antibody titer of 1:4 poses much less risk to the fetus than a titer of 1:64. Determination of the blood type of the father is helpful if paternity is certain. If the father is homozygous Rh negative, there is no risk of alloimmunization to the fetus and the fetus is NOT at risk for hemolytic disease. In this scenario, maternal sensitization occurred either from a prior pregnancy with a different partner or from another source (e.g., transfusion). If the father is heterozygous or homozygous Rh positive, then the fetus IS at risk. If paternity is uncertain, a polymerase chain reaction can be performed on 2 mL of amniotic fluid or 5 mL of chorionic villi to accurately determine the fetal Rh status

Question 337

Iron and vitamin B12 deficiencies develop in more than 30% of patients after Roux-en-Y gastric bypass. The incidence of pulmonary embolus is 1%–2%. The incidence of dumping syndrome is very low.

Question 338

It is important to screen for anemia during late infancy. Iron deficiency is the most common cause of anemia in this age group. There is evidence that persistent iron deficiency in childhood may have a negative impact on cognitive development. A therapeutic trial of iron is the best approach to the treatment of iron deficiency in late infancy. If the anemia fails to respond, investigating other causes of anemia is indicated.

Question 339

Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk.

Question 340

The scabies mite is predominantly transmitted by direct personal contact. Infestation from indirect contact with clothing or bedding is believed to be infrequent. Hats are frequent transmitters of head lice, but not scabies

Question 341

Contraindications to treatment with electrosurgery include the use of a pacemaker and the treatment of melanoma. All the other lesions listed can be treated with electrosurgery.

Question 342

When draining a felon, a volar longitudinal incision or a high lateral incision is recommended. Incisions that are not recommended are the “fish-mouth” incision, the “hockey stick” (or “J”) incision, and the transverse palmar incision.

Question 343

When Crohn’s disease affects primarily the distal small intestine (regional enteritis), a most characteristic clinical pattern emerges. A young person, usually in the second or third decade, will present with a period of episodic abdominal pain, largely postprandial and often periumbilical, occasionally with low-grade fever and mild diarrhea. Anorexia, nausea, and vomiting may also be present. Weight loss is frequent. Some patients may be aware of tenderness in the right lower quadrant and even of a palpable mass in that region.

Question 344

When family dynamics lead to conflict during an office visit, it is best for the physician to attempt to remain neutral by avoiding triangulation, which occurs when the two sides in conflict each attempt to align with a third party. Priority should be given to the patient’s right to privacy and confidentiality, and the physician should ask permission from the patient to discuss his or her health issues with other people. Physicians should always remember who they are primarily responsible to.

Question 345

DRESS is an acronym for Drug Reaction with Eosinophilia and Systemic Symptoms. The hallmark of DRESS syndrome is erythroderma accompanied by fever, lymphadenopathy, elevation of liver enzymes, and eosinophilia. The offending medication should be discontinued immediately and treatment with corticosteroids should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine, and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS syndrome has the highest mortality rate. Stevens-Johnson syndrome is characterized by a vesiculobullous rash with mucocutaneous involvement, and erysipelas is a painful localized rash with well-demarcated borders. Red man syndrome is associated with vancomycin.

Question 346

Celiac disease is thought to be greatly underdiagnosed in the United States. Antibody tests indicate that the prevalence is approximately 1:250 among adult Americans of European ancestry. Approximately 7% of type 1 diabetics have celiac disease. A number of other autoimmune syndromes have been associated with celiac disease, including thyroid disease and rheumatoid arthritis. There is no reported association with type 2 diabetes. Gastrointestinal involvement may manifest as diarrhea, constipation, or other symptoms of malabsorption, such as bloating, flatus, or belching. Fatigue, depression, fibromyalgia-like symptoms, aphthous stomatitis, bone pain, dyspepsia, gastroesophageal reflux, and other nonspecific symptoms may be present and can make the diagnosis quite challenging. Dermatitis herpetiformis is seen in 10% of patients with celiac disease. Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires esophagogastroduodenoscopy with a biopsy of the distal duodenum to detect characteristic villous flattening.

Question 347

Gallstones are frequently discovered on a diagnostic workup for an unrelated problem. Only 1%–2% of persons with asymptomatic gallstones will require cholecystectomy in a given year, and two-thirds of patients with asymptomatic gallstones will remain symptom free over a 20-year period. The longer the patient remains asymptomatic, the more likely that no symptoms will develop in the future. This patient may have had gallstones for several years, and the best management would be to do nothing unless symptoms develop.

Question 348

ACE inhibitors can significantly worsen renal failure in patients with hypertension caused by renovascular disease. Hyperkalemia is an associated problem. Captopril renography is a useful diagnostic screening test. The other agents are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACE inhibitors in cases of significant renovascular disease.

Question 349

It has been shown that congestive heart failure (CHF) patients treated with ACE inhibitors survive longer, and all such patients should take these agents if tolerated. Warfarin and/or antiarrhythmic drugs should be given only to selected CHF patients. Verapamil may adversely affect cardiac function and should be avoided in patients with CHF. Hydralazine can be used, but because of its side effect profile would be a second-line agent.

Question 350

This patient has bipolar II disorder. She has a history of hypomanic episodes as well as major depression, with no history of a manic or mixed episode. Among the pharmacologic options listed, only divalproex and lithium are indicated for treating bipolar depression or acute mania, and for maintenance. They should be given as single agents, however, not in combination with other drugs. No evidence supports combination therapy or the addition of an antidepressant in the acute phase of depression. In a study of patients with bipolar II disorder, initially adding paroxetine or bupropion to the mood stabilizer was no more effective than using lithium or valproate. An SSRI or bupropion can be added if a therapeutic dosage of a mood stabilizer does not resolve symptoms and the patient is not in a mixed state. Tricyclic antidepressants and antidepressants with dual properties, such as venlafaxine, should be avoided because they may induce mania. Aripiprazole is indicated for acute mania but not for bipolar depression.

Question 351

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial funded by the National Heart, Lung, and Blood Institute concluded that in patients with diabetes mellitus and advanced coronary artery disease, coronary artery bypass graft surgery was superior to percutaneous coronary intervention (PCI) in that it significantly reduced rates of death and myocardial infarction, although stroke rates were higher in the 30-day perioperative period. The FREEDOM trial suggested that these outcomes are similar whether PCI is performed without stents, with bare-metal stents, or with drug-eluting stents. These results were consistent with reports from other smaller or retrospective studies of revascularization in patients with diabetes mellitus.

Question 352

Ingestion of grapefruit juice can increase absorption and serum levels of statins, leading to an increased risk of muscle injury. The mechanism for this is believed to be the cytochrome p-450 pathway. Starfruit juice and pomegranate juice can have a similar effect. These juices contain an irreversible inhibitor of intestinal CYP3A4, and increase the bioavailability of atorvastatin, lovastatin, and simvastatin. Rosuvastatin and fluvastatin utilize the CYP2C9 system for metabolism, so the effect on these drugs is minimal. Grapefruit juice reduces CYP3A4 activity by 50% within 4 hours of ingestion, and activity is reduced by 30% for as long as 24 hours after ingestion. Several studies document that consuming 600 mL of double-strength juice for 3 days produces a more than tenfold increase in the area under the curve for simvastatin and lovastatin, but only a 250% increase in atorvastatin.

Question 353

Metronidazole, vancomycin, and fidaxomicin are the three medications recommended for treatment of Clostridium difficile colitis infections. Only metronidazole is effective intravenously, because its biliary excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the bloodstream. Treatment for this condition with vancomycin and fidaxomicin is oral. Imipenem/cilastatin, ciprofloxacin, and meropenem have not been shown to be effective for C. difficile infection.

Question 354

Calcaneal apophysitis, also called Sever’s disease, is a common cause of heel pain in young athletes, especially those who participate in basketball, soccer, track, and other sports that involve running. Typically the heel apophysis closes by age 15. Treatment options include activity modification, the use of ice packs and/or moist heat, stretching, analgesics, and orthotic devices. The use of therapeutic ultrasound on the active bone growth plates in children is contraindicated.

Question 355

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents defines hypertension in children as a systolic or diastolic blood pressure above the 95th percentile for the patient’s sex, age, and height on several different readings. Although it is appropriate to have this finding confirmed in the outpatient setting, 130 mm Hg is still at the 99th percentile for systolic blood pressures in this patient. Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography.

Question 356

For a healthy nonsmoker with no chronic disease who is not in a high-risk group, pneumococcal vaccine is recommended once at age 65, or as soon afterward as possible. Persons that should be immunized before age 65 include patients with chronic lung disease, cardiovascular disease, diabetes mellitus, chronic liver disease, cerebrospinal fluid leaks, cochlear implants, immunocompromising conditions, or asplenia, and residents of nursing homes and long-term care facilities. The Advisory Committee on Immunization Practices of the CDC updated the recommendations for pneumococcal vaccination in 2011 to include immunization for persons age 50–64 in the following categories: Alaska Natives, Native Americans living in areas of increased risk, persons with asthma, and smokers.

Question 357

NSAIDs, pyridoxine, and diuretics have been shown to be no more effective than placebo in the treatment of patients with carpal tunnel syndrome. Splinting, physical therapy, and corticosteroid injections have all been shown to result in short-term improvement. Patients with persistent symptoms achieve the best long-term relief with surgery.

Question 358

A number of pretest probability scoring systems are available for assessing venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism. Although the Wells clinical prediction rule is widely used, other tools such as the Hamilton score and the AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) score are also available. The Wells rule divides patients suspected of having a DVT into low, intermediate, and high-risk categories, with a 5%, 17%, and 53% prevalence of DVT, respectively. This patient has a Wells score of 0 (+1 for calf circumference increase >3 cm, +1 for pitting edema, –2 for a likely alternative diagnosis of gastrocnemius strain) and is therefore at low risk. A negative D-dimer assay has a high negative predictive value for DVT, so the diagnosis can be ruled out in a patient who has a low pretest probability and a negative D-dimer result. A negative D-dimer assay does not rule out DVT in a patient with a moderate to high pretest probability (SOR C).

Question 359

This patient presents with a classic description of supraventricular tachycardia (SVT). The initial management of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient initial measures should include vagal maneuvers (SOR C), intravenous adenosine or verapamil (SOR B), intravenous diltiazem or β-blockade, intravenous antiarrhythmics, or cardioversion in refractory cases. While digoxin is occasionally useful in atrial fibrillation with a rapid ventricular rate, it is not recommended for SVT. Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT, not just those refractory to suppressive drug therapies. Observational studies have shown that this therapy results in improved quality of life and lower cost as compared to drug therapy (SOR B).

Question 360

Acute respiratory distress syndrome (ARDS) may be caused by pulmonary sepsis or sepsis from another source, or it may be due to acute pulmonary injury, including inhalation of smoke or other toxins. Inflammatory mediators are released in response to the pulmonary infection or injury. The syndrome has an acute onset and is manifested by rapidly developing profound hypoxia with bilateral pulmonary infiltrates. The mortality rate in patients with ARDS may be as high as 55%. Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival. Patients with ARDS should be started at lower tidal volumes (6 mL/kg) instead of the traditional volumes (10–15 mL/kg) (SOR A). These patients also often require higher positive end-expiratory pressure settings (SOR B). Fluid management should be conservative to allow for optimal cardiorespiratory and renal function and to avoid fluid overload. However, the routine use of central venous or pulmonary artery pressure catheters is not recommended due to the potential complications associated with their use (SOR A). While surfactant is commonly used in children with ARDS, it does not improve mortality in adults (SOR A).

Question 361

First-line treatment for diabetic peripheral neuropathy, according to the American Diabetes Association, is tricyclic antidepressants. Anticonvulsants are second line and opioids are third line. Many medications have been found to be effective, including the tricyclics, duloxetine, pregabalin, oxycodone, and tramadol (SOR A). Among the tricyclics, amitriptyline, imipramine, and nortriptyline have been found to be the most effective (SOR A). For an uninsured patient, the tricyclics are also the most affordable.

Question 362

The child described has facial features characteristic of fetal alcohol syndrome. Fetal alcohol spectrum disorders (FASD) are caused by the effects of maternal alcohol consumption during pregnancy. Fetal alcohol syndrome is the most clinically recognized form of FASD and is characterized by a pattern of minor facial anomalies, including a thin upper lip, a smooth philtrum, and a flat nasal bridge; other physical anomalies, such as clinodactyly; prenatal and postnatal growth retardation; and functional or structural central nervous system abnormalities. Children with Down syndrome have hypotonia, a flat face, upward and slanted palpebral fissures and epicanthic folds, and speckled irises (Brushfield spots); varying degrees of mental and growth retardation; dysplasia of the pelvis; cardiac malformations; a simian crease; short, broad hands; hypoplasia of the middle phalanx of the 5th finger; and a high, arched palate.

Answer 362

Marfan syndrome is characterized by pectus carinatum or pectus excavatum, an arm span to height ratio >1.05, a positive wrist and thumb sign, limited elbow extension, pes planus, and aortic ascendens dilatation with or without aortic regurgitation. The bilateral renal agenesis seen with Potter syndrome leads to death shortly after birth. Other anomalies include widely separated eyes with epicanthic folds, low-set ears, a broad and flat nose, a receding chin, and limb anomalies. Finally, Prader-Willi syndrome is characterized by severe hypotonia at birth, obesity, short stature (responsive to growth hormone), small hands and feet, hypogonadism, and mental retardation.

Question 363

Children with diabetes mellitus are at increased risk for retinopathy, nephropathy, and hypertension. They are also more likely to have immune-mediated disorders such as celiac disease and hypothyroidism. For all children and adolescents with type 1 diabetes mellitus, the American Diabetes Association recommends screening for hypothyroidism, nephropathy, hypertension, celiac disease, and retinopathy. Screening for dyslipidemia should be considered if there is a family history of hypercholesterolemia or cardiac events before age 55.

Question 364

The most likely diagnosis is septic arthritis of the hip. Ultrasonography is highly sensitive for the effusion seen in septic arthritis, which can be aspirated to confirm the diagnosis (SOR A). It is important to diagnose this problem as soon as possible. Clinical features of septic arthritis include an oral temperature >38.5°C (101.3°F), refusal to bear weight on the affected leg, an erythrocyte sedimentation rate >40 mm/hr, a peripheral WBC count >12,000/mm3, and a C-reactive protein level >20 mg/L. If ultrasonography is negative, a bone scan should be done. CT of the hip is indicated to visualize cortical bone. MRI is especially valuable for osteomyelitis.

Question 365

Asymptomatic gallstones are not usually an indication for prophylactic cholecystectomy, as most patients remain asymptomatic throughout their lives, and only 1%–4% develop symptoms or complications from gallstones each year. Only 10% of patients found to have asymptomatic gallstones develop symptoms within the first 5 years after diagnosis, and only 20% within 20 years. In the past, cholecystectomy was recommended for diabetic patients with asymptomatic gallstones, based on the assumption that autonomic neuropathy masked the pain and signs associated with acute cholecystitis, and that patients would therefore develop advanced disease and more complications. More recent evidence has shown that these patients have a lower risk of major complications than previously thought. Prophylactic cholecystectomy is not recommended in renal transplant patients with asymptomatic gallstones. One study found that 87% of these patients remained asymptomatic after 4 years, with only 7% developing acute cholecystitis and requiring subsequent uncomplicated laparoscopic cholecystectomy. Other studies have shown that the presence of gallstone disease does not negatively affect graft survival.

Answer 365

Patients with hemoglobinopathies are at a significantly increased risk for developing pigmented stones. Gallstones have been reported in up to 70% of sickle cell patients, up to 85% of hereditary spherocytosis patients, and up to 24% of thalassemia patients. In sickle cell patients, complications from asymptomatic gallstones have been reported to be as high as 50% within 3–5 years of diagnosis. This has been attributed largely to the diagnostic challenge associated with symptomatic cholelithiasis versus abdominal sickling crisis. In the past these patients were managed expectantly because of the significant morbidity and mortality associated with open operations. The operative risk for these patients (especially sickle cell patients) has been lowered by laparoscopic cholecystectomy, along with improved understanding of preoperative hydration and transfusion, improved anesthetic technique, and better postoperative care. Prophylactic laparoscopic cholecystectomy in these patients prevents future diagnostic confusion, as well as the mortality and morbidity risk associated with emergency surgery. Furthermore, cholecystectomy can and should be performed at the time of splenectomy, whether open or laparoscopic. Studies have shown no significant differences in progression to symptoms from silent gallstones in cirrhotic patients compared with noncirrhotic patients. Expectant management is therefore recommended in patients with cirrhosis.

Question 366

The criteria for chronic fatigue syndrome include fatigue for 6 months and a minimum of four of the following physical symptoms: impaired memory, postexertional malaise, muscle pain, polyarthralgia, tender lymph nodes, sore throat, new headaches, and unrefreshing sleep. Both cognitive-behavioral therapy and graded exercise therapy have been shown to improve fatigue levels, anxiety, work/social adjustment, and postexertional malaise (SOR A). Treatments that have not been shown to be effective include methylphenidate, melatonin, and galantamine. Citalopram has not been shown to be effective in the absence of a comorbid diagnosis of depression.

Question 367

There are many drugs that can induce a syndrome resembling systemic lupus erythematosus, but the most common offenders are antiarrhythmics such as procainamide. Hydralazine is also a common cause. There is a genetic predisposition for this drug-induced lupus, determined by drug acetylation rates. Polyarthritis and pleuropericarditis occur in half of patients, but CNS or renal involvement is rare. While all patients with this condition have positive antinuclear antibody titers and most have antibodies to histones, antibodies to double-stranded DNA and decreased complement levels are rare, which distinguishes drug-induced lupus from idiopathic lupus. The best initial management for drug-induced lupus is to withdraw the drug, and most patients will improve in a few weeks. For those with severe symptoms, a short course of corticosteroids is indicated. Once the offending drug is discontinued, symptoms seldom last beyond 6 months.

Question 368

If a metal foreign body is present on the cornea for more than 24 hours a rust ring will often be present in the superficial layer of the cornea. This material is toxic to the cornea and should be removed as soon as possible, but it is not an emergency. The proper removal of a rust ring requires the use of a slit lamp and specialized ophthalmic equipment. Referral to an eye specialist within 24–48 hours is the best management in this case.

Question 369

Workers and children at child care centers should receive postexposure prophylaxis if one or more cases of hepatitis A is found in a child or worker. Hepatitis A vaccine is preferred over immunoglobulin because of its long-lasting effect, ease of administration, and efficacy. Children younger than 1 year of age should receive immunoglobulin. Family members should receive prophylaxis only during an outbreak and if their child is still in diapers.

Question 370

In general, recommended preoperative testing is based on the patient’s medical history and risk factors, the risk associated with the planned surgery, and the patient’s functional capacity. In the case of cataract surgery, however, randomized, controlled trials have established a lack of benefit from preoperative testing for patients in their normal state of health (SOR A).

Question 371

Cefazolin is the recommended prophylactic antibiotic for most patients undergoing orthopedic procedures such as total joint replacement, unless the patient has a β-lactam allergy (SOR A).

Question 372

A medial meniscus tear is the most likely diagnosis in a patient older than 40 who was bearing weight when the injury occurred, was unable to continue the activity, and has a positive Thessaly test. This test is performed by having the patient stand on one leg and flex the knee to 20°, then internally and externally rotate the knee. The presence of swelling immediately after the injury makes an internal derangement of the knee more likely, so osteoarthritis is less probable. This patient is able to bear weight, so a fracture is also not likely. Either a collateral ligament tear or an anterior cruciate ligament tear is possible, but these are not as common in this situation.

Question 373

Orthostatic hypotension is defined as a documented drop in blood pressure of at least 20 mm Hg systolic or 10 mm Hg diastolic that occurs within 3 minutes of standing. When symptomatic it is often described as lightheadedness or dizziness upon standing. Etiologies to consider include iatrogenic, neurologic, cardiac, and environmental causes, plus many others alone or in combination. Since orthostatic hypotension may result in syncope, leading to falls and substantial injury, identifying it and taking corrective steps can produce a significant benefit.

Question 374

This patient most likely has schizotypal personality disorder. These patients have problems with social and interpersonal relationships, which are marked by significant anxiety and discomfort, and they also exhibit odd thinking, speech, and perceptions. This disorder is classified as being in the cluster A personality disorder group. Patients with disorders in this group exhibit odd or eccentric personalities, and the group includes paranoid, schizoid, and schizotypal personality disorders. Cluster B disorders are characterized by dramatic, emotional, or erratic personalities, and include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C disorders include avoidant, obsessive-compulsive, and dependent personality disorders. Patients with disorders in this group exhibit mainly anxious or fearful behaviors.

Question 375

The Ottawa ankle rules are 99% sensitive and 58% specific for identifying a fracture. They state that ankle radiography should be performed when a patient presents with pain in the malleolar region and has either point tenderness over the tip of the malleolus or the posterior edge of the affected bone (distal 6 cm), or is unable to bear weight at the time of injury and while being evaluated in the emergency department or office. Inability to bear weight is defined as the inability to take four steps. A limp when weight is transferred to the affected extremity still counts as being able to bear weight.

Question 376

Erysipelas is caused primarily by group A Streptococcus, with a rare case caused by group C or G. Most cases of erysipelas involve the face, but the lesions can occur anywhere on the body. Penicillin is an effective treatment.

Question 377

Some hypothyroid patients who are treated with appropriate dosages of levothyroxine and whose TSH levels are in the appropriate range continue to have persistent symptoms such as fatigue, depressed mood, and weight gain. If the TSH is in the appropriate range then no adjustment is necessary and annual serum TSH testing is recommended. Patients who remain symptomatic on an appropriate dosage of levothyroxine, as determined by a TSH <2.5 mIU/L, are not likely to benefit from combination triiodothyronine/thyroxine therapy (SOR A). Desiccated thyroid hormone preparations are not recommended by the American Association of Clinical Endocrinologists for the treatment of hypothyroidism. A meta-analysis of 11 randomized, controlled trials of combination T3/T4 therapy versus T4 monotherapy showed no improvements in pain, depression, or quality of life (SOR A).

Question 378

Treating basal cell carcinoma with Mohs micrographic surgery leads to the lowest recurrence rate. Because of its cost and limited availability, however, this procedure should be limited to tumors with a higher risk for recurrence. Risk factors include larger size, more invasive histologic subtypes (micronodular, infiltrative, and morpheaform), and sites associated with a higher risk of recurrence. High-risk locations include the “mask” areas of the face, which include the central face, eyelids, eyebrows, periorbital area, nose, lips (cutaneous and vermilion), chin, mandible, preauricular and postauricular skin/sulci, temple, and ear. Other high-risk sites include the genitalia, hands, and feet. Moderate-risk locations include the cheeks, forehead, scalp, and neck. All other areas, including the trunk and extremities, are low-risk areas. Even with a low-risk location, a lesion that is ≥20 mm in size has a high risk of recurrence. With a moderate-risk location a lesion ≥10 mm in size carries a higher risk of recurrence, and a lesion ≥6 mm in size is considered high risk in a high-risk location.

Question 379

Tinea capitis is an infection of the scalp caused by a variety of superficial dermatophytes. The treatment of choice for this infection is oral griseofulvin. It has the fewest drug interactions, a good safety record, and anti-inflammatory properties. Terbinafine has equal effectiveness and requires a significantly shorter duration of therapy, but it is only available in tablet form. Since tinea capitis most commonly occurs in children, tablets would have to be cut and/or crushed prior to administration. Oral itraconazole, fluconazole, and ketoconazole have significant side effects. Topical antifungals such as ketoconazole and miconazole are ineffective against tinea capitis. Topical acyclovir is used in the treatment of herpesvirus infections, and oral cephalosporins are used in the treatment of bacterial skin infections.

Question 380

While it would increase the risk of urinary infection, indwelling catheter placement is most likely to provide immediate relief of this patient’s urinary retention. It will minimize or prevent further contamination of his decubitus ulcer with urine. Prostatectomy may relieve the urethral obstruction, but this patient is likely to remain incontinent due to his vascular dementia. Doxazosin or finasteride would likely be inadequate in this situation. Tolterodine is not indicated for overflow incontinence.

Question 381

Intertrigo is skin inflammation caused by skin-on-skin friction. It is facilitated by moisture trapped in deep skinfolds where air circulation is limited. When intertrigo does not respond to usual conservative measures, including keeping the skin clean and dry, evaluation for infection is recommended. A Wood’s light examination, KOH preparation, and exudate culture can assist in identifying causative organisms. The moist, damaged skin associated with intertrigo is a fertile breeding ground for various microorganisms, and secondary cutaneous infections are commonly observed in these areas. Candida is the organism most commonly associated with intertrigo. In the interdigital spaces dermatophytes (e.g., Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum) are more common. Staphylococcus aureus may present alone or with group A β-hemolytic Streptococcus (GABHS). Pseudomonas aeruginosa, Proteus mirabilis, or Proteus vulgaris also may occur alone or simultaneously.

Question 382

SGLT2 inhibitors inhibit SGLT2 in the proximal nephron. This blocks glucose reabsorption by the kidney, increasing glucosuria. The advantages of this medication include no hypoglycemia, decreased weight, decreased blood pressure, and effectiveness at all stages of type 2 diabetes mellitus. Disadvantages are that it increases the risk of genitourinary infections, polyuria, and volume depletion and increases LDL-cholesterol and creatinine levels. GLP-1 receptor agonists work by activating the GLP-1 receptors, causing an increase in insulin secretion, a decrease in glucagon secretion, slowing of gastric emptying, and increasing satiety. DPP-4 inhibitors inhibit DPP-4 activity, which increases postprandial active incretin concentration. This increases insulin secretion and decreases glucagon secretion. Meglitinides act by closing the ATP-sensitive K+ channels on the B-cell plasma membranes, which increases insulin secretion. "-Glucosidase inhibitors inhibit intestinal "-glucosidase, which slows intestinal carbohydrate digestion and absorption.

Question 383

Spironolactone is now recommended for treating resistant hypertension, even when hyperaldosteronism is not present. A longer-acting diuretic such as chlorthalidone is also recommended for treating hypertension, particularly in resistant cases with normal renal function. There is no benefit to switching from an ACE inhibitor to an ARB. Nitrates have some effect on blood pressure but are recommended only for patients with coronary artery disease.

Question 384

Chronic excessive alcohol intake produces functional changes in neurotransmitter activity that can lead to a net increase in excitatory neuroreceptor activity when the person stops drinking. Withdrawal can be divided into four levels of severity: minor, major, seizures, and delirium tremens. Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting, and/or insomnia 6–24 hours after the patient’s last drink. Major withdrawal occurs 10–72 hours after the last drink and can include the signs and symptoms of minor withdrawal, as well as visual and auditory hallucinations, diaphoresis, tachycardia, and elevated blood pressure. Alcoholic seizure generally occurs within 2 days of the last drink and may be the only sign of withdrawal, although approximately one-third of these patients will progress to delirium tremens. The onset of delirium tremens can occur anytime within 3–10 days following the last drink. The defining clinical finding is delirium, but the findings seen in milder forms of alcohol withdrawal can also be present, and may be more severe. Fever is most often seen with delirium tremens and is less common with less severe forms of alcohol withdrawal.

Question 385

The combination of the vasodilators hydralazine and isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and an ACE inhibitor (or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in African-Americans with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures. Digoxin, a long-time standard for the treatment of heart failure, is useful in reducing the symptoms of heart failure but has not been shown to improve survival. Amlodipine and other calcium channel blockers do not have a direct role in the treatment of heart failure.

Question 386

The main use of atropine in cases of cardiac arrest is for symptomatic bradycardia. It has little effect with complete heart block and Mobitz type II atrioventricular block. It is not recommended or effective for cardiac arrest with pulseless electrical activity or in cases of asystole. It has been removed from these algorithms by the ACLS committee. During an acute myocardial infarction or acute cardiac ischemia, an increase in heart rate may increase the amount of ischemia.

Question 387

Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive, and equivalent doses can be easily calculated if the patient must later be switched to another medication. Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not recommended as first-line therapy because they are expensive and can produce tolerance relatively quickly (SOR B). Methadone is another second-line option and tolerance is usually less of a problem. It is inexpensive and long-acting but also has unique pharmacokinetics. It has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Methadone can prolong the QT interval, especially in patients who are taking other QT-prolonging medications (SOR B). Buprenorphine is a partial opioid agonist that is usually used for treatment of patients with opioid addictions. Although it can be effective for treatment of pain, it is expensive and requires special prescriber training, so it is currently not recommended as a first-line agent for treatment of chronic pain (SOR C).

Question 388

This patient has carpal tunnel syndrome. Initial conservative approaches for mild to moderate symptom relief include full-time splinting for 8 weeks (SOR B) and oral corticosteroids. However, studies suggest that local corticosteroid injections offer symptom relief for 1 month longer than oral corticosteroid therapy and some individuals experience relief for up to 1 year. Severe or chronic symptoms usually require surgical intervention for nerve decompression. Physical therapy is not recommended, and full rest is unlikely in a person in a high-risk occupation for overuse syndromes.

Question 389

Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic hypertension, left ventricular hypertrophy, and a normal ejection fraction (50%–55%).

Question 390

Nonalcoholic fatty liver disease is characterized by the accumulation of fat in hepatocytes. It is associated with insulin resistance, central adiposity, increased BMI, hypertension, and dyslipidemia. An incidentally discovered elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests the presence of nonalcoholic fatty liver disease. The goal of therapy is to prevent or reverse hepatic injury and fibrosis. Diabetes mellitus, hypertension, dyslipidemia, and other comorbid conditions should be appropriately managed. A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with nonalcoholic fatty liver disease. Weight loss has been shown to both normalize AST levels and improve hepatic histology. Vitamin E has been shown to improve AST levels but has no impact on liver histology, and pentoxifylline, simvastatin, and L-carnitine have not been shown to consistently improve either AST levels or liver histology (SOR B).

Question 391

The only FDA-approved oral treatment for acne rosacea is doxycycline at a subantimicrobial dosage (40 mg daily). This does not contribute to antibiotic resistance, even when used over several months, and is better tolerated than higher dosages. Other antibiotics have limited and low-quality supporting evidence of efficacy and may lead to antibiotic resistance.

Question 392

The American Academy of Dermatology recommends against the routine use of topical antibiotics for clean surgical wounds, based on randomized, controlled trials. Topical antibiotics have not been shown to reduce the rate of infection in clean surgical wounds compared to the use of nonantibiotic ointment or no ointment. Studies have shown that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care. Topical antibiotics can aggravate open wounds, hindering the normal wound-healing process. In addition, there is a significant risk of developing contact dermatitis, as well as a potential for antibiotic resistance. Antibiotic treatment should be reserved for wounds that show signs of infection.

Question 393

The American Academy of Asthma, Allergy, and Immunology recommends that asthma not be diagnosed or treated without spirometry. Once the diagnosis is confirmed, treatment should commence with a short-acting β-agonist as needed, followed by stepwise treatment based on the severity of asthma.

Question 394

This patient has diabetes insipidus, which is caused by a deficiency in the secretion or renal action of arginine vasopressin (AVP). AVP, also known as antidiuretic hormone, is produced in the posterior pituitary gland and the route of secretion is generally regulated by the osmolality of body fluid stores, including intravascular volume. Its chief action is the concentration of urine in the distal tubules of the kidney. Both low secretion of AVP from the pituitary and reduced antidiuretic action on the kidney can be primary or secondary, and the causes are numerous. Patients with diabetes insipidus present with profound urinary volume, increased frequency of urination, and thirst. The urine is very dilute, with an osmolality <300 mOsm/L. Further workup will help determine the specific type of diabetes insipidus and its cause, which is necessary for appropriate treatment. Low levels of aldosterone, plasma renin activity, or angiotensin would cause abnormal blood pressure, electrolyte levels, and/or renal function. Insulin deficiency results in diabetes mellitus.

Question 395

A reduction of the pain caused by abdominal palpation when the abdominal muscles are tightened is known as Carnett’s sign. If the cause of the pain is visceral, the taut abdominal muscles may protect the locus of pain. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.

Question 396

The concept of a medical home was first suggested by the American Academy of Pediatrics in 1967 to describe the ideal care of children with disabilities. In 2004 the Future of Family Medicine Project adapted this concept to describe how primary care should be based on “continuous, relationship-centered, whole-system, comprehensive care for communities.” In 2007 all of the major primary care organizations collaborated to define the foundational principles of the patient-centered medical home (PCMH). These principles include the following: Comprehensiveness: Most preventive, acute, and chronic care for individual patients can be performed at the PCMH. Patient Centered: The PCMH provides care that is relationship-based, with an orientation toward the whole person. Coordination: The PCMH coordinates care for patients across all elements of the health care system. Accessibility: The PCMH works to provide patients with timely access to providers. Quality: The PCMH continuously works to improve care quality and safety.

Question 397

Mild cognitive impairment is an intermediate stage between normal cognitive function and dementia. Motor function remains normal. The presence of the APO E4 allele is a risk factor, but is not necessary for a diagnosis. Patients have essentially normal functional activities but there is objective evidence of memory impairment, and the patient may express concerns about cognitive decline.

Question 398

Conjugate vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae have been highly effective in reducing the incidence of bacterial meningitis in young children and are now routinely recommended for infants and older patients who fall into appropriate risk groups (SOR B). Escherichia coli and Listeria monocytogenes also cause meningitis in young children, but there is not currently a routine vaccine for these pathogens. Likewise, Borrelia burgdorferi and Mycoplasma pneumoniae can cause aseptic meningitis, but there is no routine vaccine.

Question 399

Targets for uric acid levels in patients with gout vary according to published guidelines but range from 5 to 6 mg/dL. Patients may be symptom-free at higher levels but risk joint damage even without acute episodes (SOR A).

Question 400

After confirmation of anemia and microcytosis on a CBC, a serum ferritin level is recommended (SOR C). If the ferritin level is consistent with iron deficiency anemia, identifying the underlying cause of the anemia is the priority. A common cause of iron deficiency anemia in premenopausal adult women is menstrual blood loss. If the serum ferritin level is not consistent with iron deficiency anemia, the next stage of the evaluation should include a serum iron level, total iron-binding capacity (TIBC), and transferrin saturation (SOR C). Iron deficiency anemia is still probable if the serum iron level and transferrin saturation are decreased and TIBC is increased. It is more likely anemia of chronic disease if the serum iron level is decreased and the TIBC and transferrin saturation are decreased or normal. Other laboratory tests that may help in differentiating the cause of microcytosis include hemoglobin electrophoresis, a reticulocyte count, and peripheral blood smears.

Question 401

It is recommended that an implanted cardioverter-defibrillator be deactivated when it is inconsistent with the care goals of the patient and family. In about one-quarter of patients with an implanted cardioverter-defibrillator, the defibrillator delivers shocks in the weeks preceding death. For patients with advanced irreversible disease, defibrillator shocks rarely prevent death, may be painful, and are distressing to caregivers and family members. Advance care planning discussions should include the option of deactivating the implanted cardioverter-defibrillator when it no longer supports the patient’s goals.

Question 402

Except for persistent pubertal gynecomastia, medication use and substance use are the most common causes of nonphysiologic gynecomastia. Common medication-related causes include the use of antipsychotic agents, antiretroviral drugs, or prostate cancer therapies. Spironolactone also has a high propensity to cause gynecomastia; other mineralocorticoid receptor antagonists, such as eplerenone, have not been associated with similar effects. Discontinuing the contributing agent often results in regression of breast tissue within 3 months.

Question 403

The Advisory Committee on Immunization Practices (ACIP) periodically makes recommendations for routine or postexposure immunization for a number of preventable diseases, including tetanus. Since 2005, the recommendation for tetanus prophylaxis has included coverage not only for diphtheria (Td) but also pertussis, due to waning immunity in the general population. The current recommendation for adults who require a tetanus booster (either as a routine vaccination or as part of treatment for a wound) is to use the pertussis-containing Tdap unless it has been less than 5 years since the last booster in someone who has completed the primary vaccination series. In this scenario, no additional vaccination is needed at this time, since the patient is certain of completing the primary vaccinations and received a tetanus booster within the previous 5 years. Had the interval been longer than 5 years, then a single dose of Tdap would be appropriate unless his previous booster was Tdap. Tetanus immune globulin is recommended in addition to tetanus vaccine for wounds that are tetanus-prone due to contamination and tissue damage in persons with an uncertain primary vaccine history. Plain tetanus toxoid (TT) is usually indicated only when the diphtheria component is contraindicated, which is uncommon.

Question 404

Patients with repeated EKGs showing a QTc interval >480 ms with a syncopal episode, or >500 ms in the absence of symptoms, are diagnosed with long QT syndrome if no secondary cause such as medication use is present. This syndrome occurs in 1 in 2000 people and consists of cardiac repolarization defects. It is associated with polymorphic ventricular tachycardia, including torsades de pointes, and sudden cardiac death. It may be treated with p-blockers and implanted cardioverter defibrillators.

Question 405

The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels >14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels (<13 mg/dL). If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide. Intravenous pamidronate, a bisphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. Glucocorticoids are useful in the treatment of hypercalcemia associated with certain malignancies (multiple myeloma, leukemia, several lymphomas, and breast cancer) or with vitamin D intoxication. The onset of action, however, takes several days, with the effect lasting days to weeks.

Question 406

For patients started on empiric antibiotic therapy at hospital admission, the CDC recommends an antibiotic time-out 48 hours after the initial order to determine if it can be stopped or needs to be changed. The dose, route, and duration should also be reviewed. The rationale is that antibiotics are often ordered empirically at the time of admission, while cultures and other studies are also being ordered. The original empiric order should be reassessed, incorporating the results of these studies while considering the evolving clinical status of the patient. Studies show this reassessment with antibiotic modification does not reliably occur.

Question 407

Transvaginal ultrasonography is the preferred initial test for a patient with painless postmenopausal bleeding, although endometrial biopsy is an option if transvaginal ultrasonography is not available. Transvaginal ultrasonography showing an endometrial thickness <3–4 mm would essentially rule out endometrial carcinoma (SOR C). An endometrial biopsy is invasive and has low sensitivity for focal lesions. Saline infusion hysterography should be considered if the endometrial thickness is greater than the threshold, or if an adequate measurement cannot be obtained by ultrasonography. If hysterography shows a global process, then a histologic diagnosis can usually be obtained with an endometrial biopsy, but if a focal lesion is present hysteroscopy should be considered as the next diagnostic step. Colposcopy is not indicated given the patient’s normal Papanicolaou smear.

Question 408

Systemic corticosteroid therapy reduces the hospital length of stay in patients with acute COPD exacerbations (SOR A). Oral therapy has been shown to be as effective as the intravenous route in patients who can tolerate oral intake (SOR B). A randomized, controlled trial has demonstrated that 5-day courses of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A). Inhaled corticosteroids are beneficial in some COPD patients but nebulizers generally do not offer significant advantages over metered-dose inhalers in most patients.

Question 409

Irritable bowel syndrome (IBS) symptoms improve with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

Question 410

While anyone, even previously healthy individuals, may benefit from treatment of symptomatic clinical influenza infection with antiviral agents, not everyone who has been exposed but is asymptomatic requires chemoprophylaxis. However, persons at higher risk for complications from influenza should be considered for preventive treatment. Those at highest risk include children under the age of 2 years, pregnant women (including women less than 2 weeks post partum), adults over the age of 65, the morbidly obese (BMI >40 kg/m2), and Native or Alaskan Americans. If persons at high risk for influenza complications are not treated prophylactically with antiviral agents after exposure, then they should receive prompt treatment as soon as possible after developing signs and symptoms of influenza infection.

Question 411

The Infectious Diseases Society of America recommends that penicillin remain the treatment of choice for group A streptococcal pharyngitis because of its proven efficacy, safety, narrow spectrum, and low cost. Penicillin-resistant group A Streptococcus has never been documented. Amoxicillin is often used in place of penicillin V as oral therapy for young children, primarily because of acceptance of the taste of the suspension. The other options listed are all possible regimens for group A streptococcal pharyngitis but penicillin is still considered the treatment of choice.

Question 412

While all of the conditions listed are in the differential diagnosis, the most likely in this patient is Rocky Mountain spotted fever (RMSF) (SOR C). It is transmitted by ticks and occurs throughout the United States, but is primarily found in the South Atlantic and South Central states. It is most common in the summer and with exposure to tall vegetation from activities such as camping, hiking, or gardening. The diagnosis is based on clinical criteria that include fever, hypotension, rash, myalgia, vomiting, and headache (sometimes severe). The rash associated with RMSF usually appears 2–4 days after the onset of fever and begins as small, pink, blanching macules on the ankles, wrists, or forearms that evolve into maculopapules. It can occur anywhere on the body, including the palms and soles, but the face is usually spared. Mucocutaneous lymph node syndrome is a similar condition in children (usually <2 years old), but symptoms include changes in the lips and oral cavity, such as strawberry tongue, redness and cracking of the lips, and erythema of the oropharyngeal mucosa. Leptospirosis is usually accompanied by severe cutaneous hyperesthesia. The patient with scarlet fever usually has prominent pharyngitis and a fine, papular, erythematous rash. Toxic shock syndrome may present in a similar fashion, but usually in postmenarchal females.

Question 413

Morphine should be avoided in patients with renal insufficiency because the toxic metabolites morphine-3-glucuronide and morphine-6-glucuronide are not eliminated by the kidneys. Accumulation of these metabolites causes neuroexcitatory effects, including confusion, sedation, respiratory depression, and myoclonus.

Question 414

Viruses cause 80% of infectious conjunctivitis cases and viral conjunctivitis usually requires no treatment. Bacterial conjunctivitis is associated with mattering and adherence of the eyelids. Topical antibiotics reduce the duration of bacterial conjunctivitis but have no effect on viral conjunctivitis. Allergic conjunctivitis would be more likely if the patient reported itching. Antibiotics or corticosteroids would not be helpful in this patient, and would not prevent complications. The majority of cases of viral conjunctivitis are caused by adenoviruses, which cause pharyngeal conjunctival fever and epidemic keratoconjunctivitis. Pharyngeal conjunctival fever is characterized by high fever, pharyngitis, and bilateral eye inflammation. Keratoconjunctivitis occurs in epidemics, and is associated with a watery discharge, hyperemia, and ipsilateral lymphadenopathy in >50% of cases.

Question 415

The Society of Hospital Medicine recommends that urinary catheters not be placed or left in place for managing incontinence or for staff convenience, or for monitoring output in patients who are not critically ill. The Infectious Diseases Society of America recommends using patient weight to monitor diuresis. Acceptable indications for an indwelling catheter include critical illness, obstruction, hospice care, and perioperatively for <2 days for urologic procedures.

Question 416

Statin drugs are effective for preventing stroke, which should be the key goal in this high-risk patient. They may stabilize the intimal wall. Rapid lowering of blood pressure could cause brain injury by reducing blood flow in patients with carotid stenosis. Any evidence of hypoperfusion needs to be corrected immediately. Combination therapy with aspirin and clopidogrel is associated with an increased risk of bleeding and is not recommended for stroke prevention. Patients over age 70 have worse outcomes with carotid stenting than with endarterectomy. Occult patent ductus arteriosus has not been shown to be a significant risk factor for stroke.

Question 417

Common features of acute adrenal insufficiency include fatigue and lack of energy, weight loss, hypotension, loss of appetite, nausea, and vomiting. Other features such as dry skin, hyperpigmentation, and abdominal pain are seen to varying degrees. Common laboratory findings include electrolyte disturbances, hyponatremia, hyperkalemia, hypercalcemia, azotemia, anemia, and eosinophilia. Patients can also have unexplained hypoglycemia. Patients with advanced-stage cancer (especially of the lung or breast) may develop acute adrenal insufficiency from metastatic infiltration of the adrenal glands. Intravenous hydrocortisone is the treatment of choice in the management of adrenal crisis. For managing hypotension, dopamine is recommended for patients with sepsis, dobutamine for those in cardiogenic shock, and packed RBCs for those with hemorrhagic shock. Broad-spectrum antibiotics are part of the therapy for sepsis, but are not first-line agents for hypotension (SOR B).

Question 418

There are many patient-related historical factors that may affect the safety and choice of hormonal contraception, but very few physical factors are likely to be found on examination that would not otherwise have been identified. Obtaining a thorough medical history is standard practice, but the Choosing Wisely campaign recommends against requiring a pelvic or other physical examination prior to prescribing oral contraceptives. It is unnecessary to wait to begin hormonal contraception until after the next menses, as inadvertent exposure to oral contraception will not harm an early pregnancy. Prescribing a 1-year supply of hormonal contraceptives improves adherence and lowers cost. There is broad consensus that sexually transmitted infection screening and Papanicolaou testing should not be required to prescribe contraception.

Question 419

A nondisplaced spiral fracture of the distal tibial shaft (toddler’s fracture) should be suspected in children from 9 months to 3 years of age who present with pain in the distal third of the tibia after minor or even unnoticed injury. Toddler’s fractures can have subtle radiographic findings and may not be visible on initial radiographs, so repeat radiography to look for healing is appropriate. Standard treatment is immobilization of the affected leg. While the fracture may heal without immobilization, reassurance alone is not recommended given the unclear diagnosis. If repeat radiography is negative and symptoms have resolved, reassurance may then be appropriate. For children with possible septic arthritis, laboratory studies should be considered, but in this case there are no signs of infection. Bone scintigraphy is more sensitive than radiography and can be considered if follow-up radiography is negative and symptoms persist. Toddler’s fractures routinely heal without complication, so referral to an orthopedic surgeon at this time would be premature.

Question 420

Treatment of orthostatic hypotension begins with identifying and addressing the underlying cause(s) when possible. This may include correcting a reversible medical condition or discontinuing an offending medication. Nonpharmacologic measures should be initiated next and typically include increasing fluid and sodium intake, improving physical fitness, wearing compression garments, and avoiding hot and humid environments. When additional treatment is needed, first-line medication options include midodrine or droxidopa, which act by increasing peripheral vascular resistance. Off-label use of atomoxetine or pyridostigmine may be considered as adjunct therapy but these medications are not part of the initial management. The α-antagonist clonidine typically causes a decrease in blood pressure through central action on the sympathetic nervous system. In patients with autonomic dysfunction, however, clonidine can increase venous return without a blood pressure–lowering effect and therefore improve orthostatic hypotension, but it should only be considered a supplementary treatment. The α-sympathomimetic medication phenylephrine may also be considered as a second-line option, but it is not part of the initial management of orthostatic hypotension.

Question 421

Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Initiative for Health and Care Excellence, and the American College of Chest Physicians all recommend that in addition to smoking cessation, COPD should be treated initially with either a long-acting β-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist with either of those inhaled medications then combination therapy should be initiated. An inhaled corticosteroid (ICS) can be added to the LABA/LAMA regimen for triple therapy if symptoms continue. Long-term use of an ICS as monotherapy is not recommended due to a slight increase in the incidence of pneumonia.

Question 422

Adrenal incidentalomas usually do not produce overt hormone excess, but mild autonomous cortisol secretion (MACS) is present in up to 30%–50% of cases. This mild secretion of cortisol may predispose patients to metabolic syndrome, osteoporosis, and cardiovascular events. MACS can be ruled out with an overnight 1-mg dexamethasone suppression test. The remainder of the evaluation can be based on CT findings and clinical symptoms. An ACTH stimulation test is used to evaluate for adrenal insufficiency, which is not caused by an adenoma. If no hypertension or hypokalemia are present, the serum aldosterone and plasma renin activity paired values may not be necessary. Testing for metanephrines is indicated only if pheochromocytoma is suspected. If no clinical symptoms of pheochromocytoma (such as hypertension, sweating, or headaches) are present and the lesions are <10 Hounsfield units on CT, pheochromocytoma and malignancy are very unlikely. A PET scan would not be indicated in this scenario.

Question 423

The most important aspect of infection prevention in treating a superficial wound is cleaning and irrigation. Studies have shown that irrigation with tap water provides similar outcomes compared to sterile saline (SOR B). Antiseptic solutions such as hydrogen peroxide are no more effective than tap water, can be caustic to wound tissue, and may delay healing (SOR C). Antibiotics should be used for treatment of wound infections; however, non-infected wounds do not routinely require antibiotic prophylaxis unless there is an increased risk of infection. Risk factors for wound infection include bite wounds, delayed presentation, retained foreign material, insufficient cleaning, puncture or crush wounds, open fractures, significant immunocompromise, and joint, cartilage, or tendon involvement. Patients with three or more doses of tetanus toxoid with the most recent vaccination within the past 5 years do not require a tetanus booster or tetanus immune globulin for prophylaxis, regardless of the type of wound.

Question 424

The duration and characterization of this patient’s cough are most suggestive of pertussis. Of the options listed, azithromycin is the most appropriate for management of pertussis. Azithromycin is most effective for treatment and minimizing spread of the disease within 21 days of symptom onset. Sulfamethoxazole/trimethoprim and other macrolides, such as erythromycin and clarithromycin, are also acceptable options. Continued supportive care only does not provide the advantages of cure and minimization of community spread that are accomplished by initiating azithromycin. Symptomatic treatment with over-the-counter medication is appropriate but such supportive care does not replace the therapeutic advantages of azithromycin. This patient’s objection to routine vaccination should be explored as priorities allow. He should be vaccinated against pertussis with Tdap as soon as feasible, but the vaccination would not provide immediate treatment of his current episode of pertussis. Doxycycline has shown benefit in other bacterial infections but does not provide effective treatment of pertussis. Based upon the duration of symptoms, quality of his cough, and lack of documented fevers, this patient is not likely to have influenza, so oseltamivir would not be appropriate.

Question 425

This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers under 2 years of age typically have a varus angle at the knee (bowlegs). This transitions to physiologic genu valgus, which gradually normalizes by around 6 years of age. As this condition is physiologic, therapies such as surgical intervention, special bracing, and exercise programs are not indicated.

Question 426

Many types of exercise programs are beneficial for older adults, including simply walking for 30 minutes three times a week. However, a meta-analysis of progressive resistance training programs in nursing homes showed that there were significant improvements in muscle strength, chair-to-stand time, stair climbing, gait speed, and balance. This is seen even in those with advanced age, disabilities, chronic diseases, or extremely sedentary lifestyles.

Question 427

Acute diverticulitis can be treated using oral antibiotics on an outpatient basis in 90% of cases. In fact, there is good evidence that those with uncomplicated diverticulitis (no signs of abscess, fistula, phlegmon, obstruction, bleeding, or perforation) can be treated without the use of antibiotics, using only bowel rest and close follow-up. Among patients who require hospitalization, it is estimated that <10% of cases will require surgical intervention. Thus, the majority of patients hospitalized with this condition, even those with complicated diverticulitis, will respond well to bowel rest and intravenous antibiotics. Indications for surgery include generalized peritonitis, unconfined perforation, uncontrolled sepsis, an undrainable abscess, and failure of conservative management. CT-guided percutaneous drainage of an accessible abscess is a well-proven treatment to avoid the use of open surgery. Prevention of future episodes of diverticulitis increasingly revolves around the use of daily oral medications. Some experts recommend considering surgery to remove a section of bowel after a patient’s third admission for diverticulitis.

Question 428

SSRIs are the most commonly used medications for postpartum depression. They have fewer side effects and are considered safer than tricyclic antidepressants, especially in depressed women who may be at increased risk for medication overdose (SOR C). In one study, infant serum levels of sertraline and paroxetine were undetectable. It is also recommended that a woman with postpartum depression be started on a medication that she had taken previously with a good response, unless there is evidence of potential harm to her infant (SOR C). Tricyclic antidepressants are excreted into breast milk and there is some concern regarding potential toxicity to the newborn. Phenytoin, diazepam, and zolpidem are not antidepressants. Phenytoin and diazepam are Category D for use in pregnant women. Diazepam is potentially toxic to infants and can accumulate in breastfed infants, and it is not recommended for lactating women (SOR C). Zolpidem is category B in pregnancy and probably acceptable for use in lactating women if clinically indicated.

Question 429

Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups. Topical calcineuron inhibitors such as pimecrolimus are a second-line therapy, but carry a warning of a possible link to lymphomas and skin malignancies and are not recommended for children under 2 years of age. Oral antihistamines are not effective for the pruritus associated with atopic dermatitis. Probiotic use is not supported by available evidence.

Question 430

This patient has acute low back pain of moderate severity. If acetaminophen and NSAIDs are ineffective when used alone, the most appropriate next step is a combination of both medications. Acetaminophen/NSAID combinations have been shown to be more effective for acute pain than either agent alone. CBD oil does not have a specific indication for acute pain, and low-quality studies show mixed results. Diclofenac topical gel is an appropriate treatment option for acute, non–low back musculoskeletal pain. This patient describes her pain as mild to moderate in severity, so other options should be tried before prescribing opioids such as hydrocodone/acetaminophen or oxycodone.

Question 431

All unvaccinated household contacts and sexual contacts should receive postexposure prophylaxis following significant exposure to hepatitis A within the previous 2 weeks. Healthy individuals 12 months to 40 years of age should receive the hepatitis A vaccine as prophylaxis. Infants younger than 12 months of age should receive immune globulin as postexposure prophylaxis. Individuals >40 years of age, as well as immunocompromised patients, should receive both hepatitis A vaccine and immune globulin.

Question 432

Maturity-onset diabetes of the young (MODY) is a form of diabetes mellitus in nonobese young adults (under age 30) who have preserved pancreatic β-cell function. Nearly 80% of patients with MODY are misdiagnosed as having type 1 or type 2 diabetes. These patients exhibit no signs of insulin resistance (metabolic syndrome, acanthosis nigricans, skin tags, androgenic alopecia), are not obese, have positive C-peptide levels, and have a strong family history of diabetes. MODY does not respond to metformin, but because β-cell function is preserved, the hyperglycemia does respond to sulfonylureas. While exercise and a balanced diet of appropriate portions and low carbohydrates are also necessary in patients with MODY, a ketogenic diet is not specifically indicated. Insulin is required only during pregnancy.

Question 433

This image shows typical hyphae of pityriasis versicolor, a superficial infection caused by yeasts in the genus Malassezia. Of the listed therapies, topical selenium sulfide would be the most appropriate first-line treatment. Topical antifungals such as terbinafine and miconazole are other first-line options. Oral fluconazole can be used, but oral therapy is usually reserved for when topical treatment is impractical or unsuccessful. Topical nystatin cream and oral nystatin are ineffective, and topical corticosteroids such as triamcinolone may temporarily suppress symptoms while exacerbating the infection.

Question 434

A MET is the amount of energy used by the body per minute of activity. Light intensity is <3 METs and includes activities such as sitting at a desk, light housework, casual walking, and stretching. Moderate intensity is 3.0–5.9 METs and includes brisk walking, water aerobics, and ballroom dancing. Vigorous intensity is 6 METs and is represented by activities such as high-intensity interval training, jogging, and heavy gardening.

Question 435

This patient has a classic presentation of croup, which peaks in the fall and winter months. There may not be any particular history of sick contacts and it does not present with a prodrome, in contrast to respiratory syncytial virus. The diagnosis of croup is purely clinical and does not require laboratory studies, viral cultures, or imaging (SOR C). The treatment of croup includes corticosteroids such as dexamethasone in mild cases (SOR A) and the addition of epinephrine in moderate to severe cases (SOR A). The inhalation of humidified air does not improve outcomes (SOR B) nor does nebulized albuterol.

Question 436

This child displays characteristics of oppositional defiant disorder (ODD). The DSM-5 criteria for a diagnosis of ODD include frequently losing one’s temper, being easily annoyed, antagonism toward authority figures, deliberately annoying others, placing blame on others, and being spiteful or vindictive. These symptoms must occur for at least 6 months, cause distress or negative impacts, and not occur exclusively with substance use or in the course of a psychotic, depressive, or bipolar disorder. Treatment of common comorbid mental health conditions can be associated with improvement in ODD, so it is important to evaluate for attention-deficit/hyperactivity disorder, depression, and anxiety disorders, as well as ODD. Given the persistence of symptoms and maternal concern in this patient, reassurance alone would not be appropriate. Patients with ODD have a high risk of developing other mental health conditions later, and early therapy is recommended. While positive reinforcement is an important parenting strategy for children with ODD, it would not be expected to be effective in isolation. Medication is rarely indicated for ODD, and not as monotherapy. Parent management therapy is an important part of ODD treatment, but therapy should generally include both child therapy and parent training.

Question 437

A semen analysis is the first step in the evaluation of male infertility. In males with oligozoospermia (especially if the sperm count is <10 million/mL), the American Urological Association recommends an endocrine evaluation with an FSH level and early morning total testosterone levels. The results of that testing can dictate next steps. A CBC and a basic metabolic panel have no role in the evaluation of male infertility. Antisperm antibody testing is rarely recommended and should only be considered in consultation with a fertility specialist. Scrotal ultrasonography is not recommended in individuals with a normal physical examination and should only be performed in individuals with palpable varicoceles on physical examination. A testicular biopsy is not usually required to help differentiate between obstructive and nonobstructive azoospermia.

Question 438

The U.S. Preventive Services Task Force (USPSTF) recommends screening for hypertension with office blood pressure measurement in adults 18 years of age (A recommendation). Adults 40 years of age and those 18 years of age with risk factors should receive annual hypertension screening. Less frequent screening is recommended for adults 18–39 years of age without risk factors. The USPSTF found insufficient evidence to recommend an ankle-brachial index (I recommendation) or a coronary artery calcium score (I recommendation) for cardiovascular screening, even in patients with traditional risk factors such as male sex, older age, current smoking, and overweight/obesity status. Cardiovascular screening with an EKG is not recommended (D recommendation). The USPSTF did not find adequate evidence to suggest that adding a resting or exercise EKG helped guide treatment decisions to reduce cardiovascular events in asymptomatic adults. It identified some evidence that small to moderate harms may exist, such as unnecessary invasive procedures. The USPSTF recommends abdominal duplex ultrasonography (B recommendation) for men 65–75 years of age who have ever smoked, which is usually defined as 100 cigarettes or more in a lifetime. The only appropriate screening test for the patient in this scenario is blood pressure measurement.

Question 439

It is uncommon for people to experience severe reactions, including anaphylaxis, after influenza vaccination. This is true even for those with egg allergies, despite the fact that embryonic chicken eggs are used to grow most influenza vaccine viruses. Influenza vaccine is safe to administer regularly to those who have only had hives after exposure to eggs. If more serious allergic symptoms occur with egg exposure, such as respiratory distress or anaphylaxis, influenza vaccine should be administered in an inpatient or supervised outpatient setting. Premedication with diphenhydramine or prednisone is not recommended. Referral to an allergist for desensitization would not be recommended for this patient.

Question 440

This patient presents with lateral hip pain and symptoms of greater trochanteric pain syndrome, which can include bursitis as well as gluteus medius tendinopathy or tears. She exhibits a Trendelenburg gait, which indicates gluteus muscle weakness. Both femoroacetabular impingement and labral tears generally cause anterior hip pain. Femoroacetabular impingement is one of the most common causes of hip pain in young adults and is usually caused by a cam deformity and/or a pincer deformity of the hip joint. Labral tears are usually associated with a history of trauma or sports-related injury. Hamstring injuries and sacroiliac joint dysfunction generally cause posterior hip pain. Hamstring strains are also associated with a history of trauma, sports-related injury, or overuse.

Question 441

The American Medical Association Code of Medical Ethics offers helpful guidance for making difficult decisions, including triage and reassessment decisions, when health care resources are limited during crisis situations. Explaining triage decision policies and procedures and providing patients who are denied initial resources a process for appealing decisions is a recommended process and the most ethically sound option of those listed. It is also recommended to make triage decisions based on medical need rather than social worth, and to allocate limited resources first to prevent premature death and then to those with the greatest duration of benefit after recovery. When unable to distinguish need based on medical factors, a random process or lottery is recommended rather than a first-come, first-served process since patients with obstacles to care who cannot present first would be unfairly disadvantaged. Reassessment of whether continued treatment is likely to be beneficial should occur periodically. Providing palliative care when treatment has been withdrawn is a necessary ethical practice.

Question 442

Breastfeeding provides many health benefits to both the mother and the infant. Maternal benefits include a decreased risk of developing cardiometabolic disease, including diabetes mellitus, hypertension, and cardiovascular disease; a decreased risk of breast cancer and ovarian cancer; and a decreased risk of postpartum depression. A link has not been established between breastfeeding and a reduced risk of developing colon cancer or lung cancer or osteoarthritis later in life. While breastfeeding may reduce the infant’s risk of respiratory disease, this is not an expected benefit for the mother.

Question 443

This patient has the female athlete triad, a syndrome characterized by low energy availability relative to needs, disordered menses (delayed menarche, oligomenorrhea, or secondary amenorrhea), and decreased bone mineral density. This patient exhibits at least two components of the triad, although only one is required for diagnosis. Low energy availability relative to needs can be related to an eating disorder or to exercising beyond caloric supply. This leads to functional hypothalamic amenorrhea, which results in low circulating estrogen levels and then reduced bone mineral density. Anemia would be secondary to the low energy availability rather than the cause of this spectrum of issues. This patient does not have a history consistent with anorexia nervosa. Vitamin D deficiency would not cause the menstrual irregularities she has noted.

Question 444

Patients found to have a PVC burden >10% are at risk for PVC-induced dilated cardiomyopathy (PVC-CM). In fact, a PVC burden of 16% has a sensitivity of almost 80% for PVC-CM. Echocardiography should be performed in patients with a PVC burden >10%. Treatment with anti-arrhythmic drugs or radiofrequency ablation reverses cardiomyopathy and its associated increase in morbidity, mortality, and health care spending. Further evaluation for ischemic heart disease may be performed if the patient has risk factors for ischemia. Symptomatic palpitations may be treated with β-blockers or calcium channel blockers, even in patients with lower PVC burdens and no cardiomyopathy. Left heart catheterization would not be appropriate.

Question 445

This patient is showing signs of delirium, which is common in hospice patients. Delirium should be considered in anyone with disturbances of cognitive function, altered attention, fluctuating consciousness, or acute agitation. The mainstay of management is the diagnosis and treatment of any conditions that may cause delirium. Medications that may cause delirium should be discontinued or reduced if possible. Antipsychotic medications are the drug of choice to improve delirium. Central nervous system depressants such as benzodiazepines and barbiturates should be avoided because they can make delirium worse. Nortriptyline has anticholinergic side effects and can also cause delirium. Mirtazapine would not be helpful for treating delirium.

Question 446

Respiratory syncytial virus (RSV) bronchiolitis is responsible for approximately 2.1 million health care encounters annually in the United States. The child in this case has a typical presentation of RSV bronchiolitis. The diagnosis can be made clinically, although specific testing for RSV is often used in the hospital setting to segregate RSV-infected patients from others. Management is primarily supportive, especially including maintenance of hydration and oxygenation. Bronchodilators, corticosteroids, and antiviral agents do not have a significant impact on symptoms or the disease course. Ribavirin is not recommended for routine use due to its expense, conflicting data on effectiveness, and potential toxicity to exposed health care workers. Antibiotics are of no benefit in the absence of bacterial superinfection.

Question 447

Mesenteric ischemia presents with pain disproportionate to the findings on examination, often with nausea, vomiting, or diarrhea. Air within the wall of dilated loops of small bowel (pneumatosis intestinalis) and evidence of acidosis also suggest bowel ischemia. Cholangitis most likely would be associated with a more substantial elevation of the amylase and/or lipase levels, as well as elevated bilirubin and/or alkaline phosphatase levels. Pancreatitis would also be associated with higher amylase and/or lipase levels. Acute appendicitis often has a vague presentation in older patients, presenting without fever and not localizing to the right lower quadrant as it does in younger patients. However, the leukocytosis is usually not as dramatic as in this case, there is usually no elevation of the amylase or lipase levels, and imaging does not show air within the small bowel.

Question 448

All of the drugs listed are used to treat motor symptoms in patients with Parkinson’s disease. However, the best evidence supports the use of carbidopa/levodopa, non-ergot dopamine agonists such as pramipexole or ropinirole, or monoamine oxidase-B inhibitors such as selegiline or rasagiline for initial management of patients with early disease (SOR A).

Question 449

Knowledge of endemic fungi capable of causing infection in otherwise healthy patients can be very helpful in ensuring an appropriate evaluation. Coccidioidomycosis is a common infection in the southwestern United States. In addition to the symptoms in this patient, coccidioidomycosis can also present with a rash such as erythema nodosum. Histoplasmosis is most common in the Midwest and with low-level exposure symptoms are usually mild or absent. Blastomycosis is also present in the Midwest, as well as in the Atlantic and southeastern states. Symptoms include an abrupt onset of fever, chills, pleuritic chest pain, arthralgias, and myalgias. The cough is initially nonproductive but frequently becomes purulent. Cryptococcosis and mucormycosis are more opportunistic infections occurring in immunocompromised hosts.

Question 450

Medical conditions that decrease responsiveness to warfarin and reduce the INR include hypothyroidism, visceral carcinoma, increased vitamin K intake, diabetes mellitus, and hyperlipidemia. Conditions that increase responsiveness to warfarin, the INR, and the risk of bleeding include vitamin K deficiency caused by decreased dietary intake, malabsorption, scurvy, malnutrition, cachexia, small body size, hepatic dysfunction, moderate to severe renal impairment, hypermetabolic states, fever, hyperthyroidism, infectious disease, heart failure, and biliary obstruction (SOR B, SOR C).

Question 451

The sulfonylureas are the oral hypoglycemic agents most likely to cause hypoglycemia, with glyburide more likely to cause low glucose levels than glipizide, due to its longer half-life. The use of these agents should be rare in elderly patients with diabetes mellitus.

Question 452

Most Hispanic immigrants have received the bacille Calmette-Guérin (BCG) vaccine. Although past practice has been to interpret skin test results without regard to BCG status, false-positive tests in this population are common. Interferon-y release assays are preferred to tuberculin skin testing in immigrants who have been vaccinated with BCG.

Question 453

Among the constellation of history and physical findings that can be found in patients with heart failure, none provides a proof-positive diagnosis alone, as most are found in other disease states as well. Each of the options listed raises the possibility of heart failure but the only one that has a specificity >90% is the third heart sound, which is 99% specific for the diagnosis of heart failure. Other findings with >90% sensitivity include a displaced point of maximal impulse, interstitial edema or venous congestion on a chest radiograph, jugular vein distention, and hepatojugular reflux. The other options listed here have specificities for heart failure that fall within the range of 65%–80%.

Question 454

Ulcerative colitis (UC) is a lifelong condition that results in a waxing and waning autoimmune inflammation of the colon. Clinical symptoms are inadequate for assessing the need for ongoing therapy. For this reason, once a patient with UC has achieved remission with a specific medication, that medication should be continued indefinitely unless the disease resurfaces. Sulfasalazine is one of the most effective agents for this purpose, is usually well tolerated, and is considered first-line therapy for ulcerative colitis. There is no apparent reason to consider a higher order of therapy (azathioprine) in this patient or to refer her for colectomy. Patients with UC who have had a history of moderate or extensive involvement of the colon, however, are at markedly increased risk for the development of colorectal cancer. Current guidelines recommend beginning screening colonoscopy 10 years after the initial diagnosis and continuing every 2–5 years, with the interval based on the findings.

Question 455

Tramadol lowers the seizure threshold and should be avoided in patients with seizures. It is considered a second-line treatment for mild to moderate pain (SOR B). A history of heart failure, ventricular dysrhythmias, or hypertension is not a contraindication to its use.

Question 456

Suspected COPD should be confirmed by spirometry in stable patients, based on a postbronchodilator FEV1/FVC ratio <70% of predicted (SOR C). While guidelines for the treatment of COPD differ slightly among the leading national and international organizations, most have come to a consensus on using this criterion for the diagnosis (SOR C).

Question 457

The concentration of lithium into the thyroid gland inhibits iodine uptake, iodotyrosine coupling, and thyroid hormone secretion. Thyroglobulin structure is also affected by lithium. The effect can be significant enough to produce a state of hypothyroidism and/or goiter, and studies have shown that as many as two-thirds of patients develop hypothyroidism within 10 years of beginning lithium treatment. Routine monitoring of TSH and T4 every 6–12 months is a recommended standard for all patients receiving lithium treatment. Lithium administration would not be expected to directly affect any of the other blood levels listed, so the indications for obtaining these tests are the same as for other patients.

Question 458

based on the patient’s symptoms rather than documented evidence of infection (SOR C). In healthy premenopausal women with no history of a urinary tract functional abnormality, current pregnancy, or another underlying condition that may increase the risk of treatment failure, infection can be presumed based on symptoms. Patients with acute uncomplicated cystitis are not febrile and have no vaginal symptoms. Men and children, as well as women who do not meet these criteria, require in-person evaluation. A urine dipstick has relatively low sensitivity and specificity for urinary tract infection (SOR A). Negative dipstick results do not reliably rule out infection in a patient with strongly positive symptoms. A midstream culture is as good as or better than a urinary catheter–obtained specimen (SOR B). However, neither of these is required for the diagnosis or treatment of uncomplicated acute cystitis.

Question 459

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all adults for tobacco use, advise smoking cessation, and provide behavioral therapy and FDA-approved pharmacotherapy if appropriate (A recommendation). Varenicline is an FDA-approved pharmacotherapy that is an effective option for smoking cessation with or without behavioral therapy. Although clonidine has been used for smoking cessation it is considered a second-line agent and is not FDA approved for smoking cessation. The USPSTF concluded that there was not enough evidence on the effect on smoking cessation to recommend an electronic nicotine delivery system (I recommendation). Abrupt and complete (“cold-turkey”) nicotine withdrawal is less effective than pharmacotherapy (nicotine replacement therapy, bupropion hydrochloride, and varenicline). There is a lack of evidence regarding the efficacy of hypnotherapy.

Question 460

This patient has heavy menstrual bleeding, associated anemia, and morbid obesity, all of which need to be taken into consideration when choosing contraception. Medroxyprogesterone acetate can contribute to weight gain and thus should not be the first choice in this individual. The norelgestromin/ethinyl estradiol transdermal system is not recommended in patients with a weight over 90 kg and thus is not an option for this patient. The levonorgestrel-releasing intrauterine system would be the best option, given the associated significant decrease in menstrual blood loss after the first 3 months of insertion and equal effectiveness in obese and non-obese patients. Although a diaphragm is an option, it will not decrease her menstrual blood loss.

Question 461

Most watery diarrhea is self-limited and testing is not indicated. A diagnostic workup is usually reserved for patients with severe dehydration or illness, diarrhea persisting for more than 3–7 days, fever, bloody stool, immunosuppression, or a history suggesting nosocomial infection or an outbreak. Indiscriminate use of laboratory testing is inefficient and not cost-effective.

Question 462

Motion sickness is a syndrome that includes nausea and other symptoms, including vague subtle symptoms of stomach awareness, malaise, fatigue, and irritability. The most effective medication is scopolamine; transdermal scopolamine is more effective than oral scopolamine.

Question 463

Acetaminophen is the analgesic of choice for short-term treatment of mild to moderate pain in patients with stage 3–5 chronic kidney disease. Chronic nonterminal pain requires initial treatment with nonopioid analgesics. NSAIDs should be avoided because of the risk of nephrotoxicity.

Question 464

Anxiety, shortness of breath, paresthesia, and carpopedal spasm are characteristic of hyperventilation. Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is elevated and pCO2 is depressed. Low pH is characteristic of acidosis, either respiratory or metabolic, and elevated pH with elevated pCO2 is characteristic of metabolic alkalosis with respiratory compensation.

Question 465

This patient suffers from secondary amenorrhea (defined as the cessation of regular menses for 3 months or irregular menses for 6 months). The most common causes of secondary amenorrhea are polycystic ovary syndrome, primary ovarian failure, hypothalamic amenorrhea, and hyperprolactinemia. With a normal physical examination, negative pregnancy test, and no history of chronic disease, a hormonal workup is indicated, including TSH, LH, and FSH levels (SOR C). A hormonal challenge with medroxyprogesterone to provoke withdrawal bleeding is used to assess functional anatomy and estrogen levels (SOR C). However, it has poor specificity and sensitivity for ovarian function and a poor correlation with estrogen levels. Pelvic ultrasonography is indicated in the workup of primary amenorrhea to confirm the presence of a uterus and detect structural abnormalities of the reproductive organs. Likewise, karyotyping can be used for patients with primary amenorrhea, as conditions such as Turner’s syndrome and androgen insensitivity syndrome are due to chromosomal abnormalities. A CBC and metabolic panel would not be initial considerations in the workup of amenorrhea unless the patient has a known chronic disease which may affect the results.

Question 466

In the frail elderly, it may be difficult to distinguish relative starvation due to decreased or inadequate caloric intake from cachexia, which is due to an inflammatory response with elevated cytokines. Appetite is decreased early in cases of cachexia but remains normal in the early stages of starvation. Likewise, albumin decreases early in cases of cachexia and later in starvation. Due to the inflammatory changes, cachexia is resistant to refeeding.

Question 467

This patient’s symptoms are most consistent with a viral upper respiratory infection. There is no curative treatment so management should be focused on symptoms. Most over-the-counter cough and cold preparations, including the ingredients dextromethorphan and diphenhydramine, have no evidence of benefit and carry a risk of harm in children and should not be recommended. Albuterol is only helpful for cough in patients with wheezing. Buckwheat honey has limited evidence of effectiveness but appears to carry no risk of harm and may be recommended for symptom management.

Question 468

Localized or generalized lymphadenopathy is a common complaint in children. Most cases are benign and related to infections or connective tissue disorders. Initial management involves watchful waiting for up to 4 weeks (SOR C). Evidence to support treatment with antibiotics is lacking and should be reserved for patients who show evidence of local inflammation. Malignancy should be excluded if lymphadenopathy persists beyond 4 weeks, or if other symptoms develop, such as fever, night sweats, weight loss, hepatosplenomegaly, or orthopnea. In this situation, the evaluation should include a CBC, blood smear, erythrocyte sedimentation rate, and chest radiography (SOR C).

Question 469

Pessaries are considered first-line treatment for pelvic organ prolapse (SOR C). Ring pessaries provide support and are the initial choice in most circumstances. Sexual intercourse can still occur with a ring pessary, which can be inserted and removed by the patient. Space-occupying pessaries are associated with more vaginal discharge and irritation and do not allow for sexual intercourse. While they can improve stress and urge urinary incontinence, Kegel exercises do not treat pelvic organ prolapse. Surgery, including hysterectomy or hysteropexy that conserves the uterus, can be considered after first-line treatment with a pessary.

Question 470

All oral NSAIDs increase the risk of myocardial infarction (relative risk versus placebo from 1.5 for ibuprofen to 1.7 for celecoxib), with the exception of naproxen. Cardiac risks are greater in older patients, those with a history of cardiac events, and with higher dosages.

Question 471

This patient most likely has plantar fasciitis. Stretching exercises are effective in reducing heel pain caused by plantar fasciitis. Clinical trials regarding pain relief with the use of night splints are conflicting and thus inconclusive. The American College of Foot and Ankle Surgeons does not advocate for or against acupuncture to treat plantar fasciitis, as the studies available are of low quality. Extracorporeal shock wave therapy is only recommended after conservative therapies fail and for chronic plantar fasciitis. Platelet-rich plasma injections may be indicated in refractory plantar fasciitis but are not considered first-line therapy for an acute presentation.

Question 472

n order to make a diagnosis, personality disorders must meet specific criteria as outlined in the DSM-5. Other mental disorders, substance use or exposure, and medical conditions must also be excluded. This patient has avoidant personality disorder, which is characterized by social inhibition, fears of inadequacy, and hypersensitivity to criticism or rejection. It often presents in early adulthood. Persons with avoidant personality disorder may avoid new or unfamiliar situations, such as this patient who is unwilling to seek a new job. Persons with antisocial personality disorder exhibit a lack of respect for the rights of others, as well as deceitfulness, aggressiveness, and recklessness. Psychopathy and sociopathy are alternate terms. Borderline personality disorder is marked by instability in interpersonal relationships and self-image, impulsivity, reactivity of mood, and self-destructive behavior. Dependent personality disorder is described as an excessive need to be taken care of, intense fear of being alone, and extreme reliance on others for motivation and direction. Persons with histrionic personality disorder demonstrate excessive emotionality and attention-seeking behavior, often overestimating the closeness of interpersonal relationships and alienating others with hypersexual or hyperemotional reactions.

Question 473

This patient presents with symptomatic hyperglycemia in a catabolic state. In such cases insulin therapy is the most reliable way to control hyperglycemia and reverse catabolism. Oral metformin would not be adequate to control this degree of hyperglycemia and might not be tolerated well, given that the current symptoms include nausea and weight loss. Similarly, both empagliflozin, which increases glucosuria and volume contraction, and liraglutide, which decreases gastric emptying and is likely to exacerbate nausea, are likely to be poorly tolerated in this situation. While rapid and effective treatment is essential to prevent further complications, hospitalization is not necessary since the patient has no evidence of diabetic ketoacidosis.

Question 474

The signs of retinal vein occlusion typically include sudden painless loss of vision or distortion of vision. Redness is not typical and should cause the clinician to suspect an alternate diagnosis. Tortuous and dilated retinal veins are the most common finding on funduscopic examination. Patients also often have multiple cotton-wool spots, although these are not specific to retinal vein occlusion. An afferent pupillary defect often occurs on the affected side. Diabetes mellitus and hypertension are both risk factors for retinal vein occlusion, increasing the likelihood in this patient.

Question 475

The patient’s history and physical findings are all consistent with a keloid, which is a benign overgrowth of scar tissue at sites of trauma to the skin, such as acne, burns, surgery, ear piercing, tattoos, and infections. Common locations include the earlobes, jawline, nape of the neck, scalp, chest, and back. Lesions are sometimes asymptomatic, but often are associated with hypersensitivity, pain, and pruritus. The incidence is higher in Blacks, Hispanics, and Asians. Intralesional corticosteroid injections are first-line therapy. Silicone gel sheeting, topical imiquimod, and intralesional fluorouracil can be used when first-line therapy fails, but these methods are more often associated with recurrence. Laser therapy and surgical excision are associated with a high rate of recurrence when used as monotherapy.

Question 476

Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids. Pseudoephedrine can cause a false-positive test for amphetamines (SOR A).

Question 477

Bartonella henselae is the organism that causes cat-scratch disease. IgG titers over 1:256 strongly suggest active or recent infection. IgM elevation suggests acute disease but production of IgM is brief. Lymph node biopsy is reserved for cases where node swelling fails to resolve or the diagnosis is uncertain. The organism is difficult to culture and cultures are not recommended. Nontuberculous mycobacteria do not cause cat-scratch disease (SOR C).

Question 478

Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for the treatment of hirsutism in premenopausal women (SOR C). Women should avoid becoming pregnant while on spironolactone because of the potential for teratogenic effects. In addition to having side effects, prednisone is only minimally helpful for reducing hirsutism by suppressing adrenal androgens. Leuprolide, although better than placebo, has many side effects and is expensive. Metformin can be used to treat patients with polycystic ovary syndrome, but this patient does not meet the criteria for this diagnosis.

Question 479

Stretching is often included in comprehensive treatment programs for musculoskeletal injuries and chronic conditions, making the determination of how much of the benefit is derived specifically from the stretching component difficult. Trials using different stretching techniques have demonstrated measurable benefit from a tailored stretching program for each of the options listed, with the exception of joint contracture. This mobility-impairing condition results from post-healing shortness of noncontractile tissues that are not easily released with stretching. When applied to healing tissues, stretching is thought to increase muscle length and align collagen fibers, thereby increasing range of motion and flexibility post healing. A program that includes static, dynamic, and proprioceptive neuromuscular facilitation (PNF) stretching increases range of motion post knee replacement. Static and PNF stretching increases range of motion in osteoarthritis of the knee. A program of precontraction and static stretching increases hamstring flexibility following a strain. A yearlong stretching program for relief of chronic neck pain has been shown to have a benefit equal to that of strengthening exercises or manual therapy.

Question 480

Fiber is ineffective in the treatment of adult irritable bowel syndrome (IBS) (SOR A). Symptoms do improve, however, with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

Question 481

The diagnosis of pelvic inflammatory disease (PID) is based primarily on the clinical evaluation. Significant consequences can occur if treatment is delayed. Physicians should therefore treat on the basis of clinical judgment without waiting for confirmation from laboratory or imaging tests (SOR B). No single symptom, physical finding, or laboratory test is sensitive or specific enough to definitively diagnose PID (SOR C). Clinical diagnosis alone based on the history, physical examination, and office laboratory results is 87% sensitive, transvaginal ultrasonography is 30% sensitive, and laparoscopy is 81% sensitive but unnecessarily invasive and not cost-effective. A study examining the diagnostic performance of CT in acute PID concluded that the overall sensitivity of CT is poor.

Question 482

Stimulants are preferred over nonstimulant medications for adults with attention-deficit disorder. Stimulant medications can aggravate psychosis, tics, or hypertension and are therefore contraindicated in patients with these problems. The main side effects of these drugs include insomnia, dry mouth, weight loss, headaches, and anxiety. They are classified as schedule II drugs due to their potential for abuse. The risk for serious adverse cardiovascular events is very low, although these drugs can increase resting heart rate and elevate both systolic and diastolic blood pressure.

Question 483

Elevated blood pressure may have a protective effect in the initial period after an ischemic stroke, and studies have shown adverse outcomes when it is lowered in the acute period. Blood pressure usually will spontaneously decrease without treatment in the first several hours after presentation, and antihypertensive treatment should not be started in the first 24 hours after an acute stroke unless blood pressure exceeds 220/120 mm Hg, or treatment is warranted because of another medical condition such as acute myocardial infarction. Tighter blood pressure control becomes more important after the first 24 hours.

Question 484

Fortunately, emergency tracheotomy is not often necessary, but should one be necessary the best site for the incision is directly above the cricoid cartilage, through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is actually above the trachea. However, it is below the vocal cords and bypasses any laryngeal obstruction. The thyrohyoid membrane lies well above the vocal cords, making this an impractical site. The area directly below the cricoid cartilage—which includes the second, third, and fourth tracheal rings, as well as the thyroid isthmus—is the preferred tracheotomy site under controlled circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede the procedure in an emergency.

Question 485

Thiazide diuretics have proven efficacy in the treatment of hypertension in all age groups and sexes. When used as antihypertensive agents, the reduction in adverse cardiovascular outcomes equals that of a-blockers, calcium channel blockers, and ACE inhibitors. Successful thiazide treatment of hypertension is especially effective in preventing heart failure or strokes. Unlike the other options listed, thiazide diuretics have also been shown to slow cortical bone loss in postmenopausal females and to reduce the incidence of osteoporosis and hip fractures in those who take it continuously. This protective beneficial side effect disappears within 4 months following discontinuation of thiazide therapy. As with all medications there are potential disadvantages of thiazide use, including excessive urinary losses of potassium and sodium and possible increases in serum glucose levels.

Question 486

This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have shown that septic arthritis should be considered highly likely in a child who has a fever >38.7°C (101.7°F), refuses to bear weight on the affected leg, has a WBC count >12,000 cells/mm3, and has an ESR >40 mm/hr. If several or all of these conditions exist, aspiration of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful when the diagnosis is unclear based on the initial evaluation, or if other etiologies need to be excluded.

Question 487

Improving quality and efficiency in medicine is best done using a systems approach. One of the tools for improving a system of care is to utilize the “Plan-Do-Check-Act” cycle of continuous quality improvement. This cycle includes a planning stage to identify an improvement strategy. An implementation stage is followed by a time of evaluation for effectiveness. Finally, a decision is made to adopt or abandon the initial strategy. The cycle is then repeated as many times as necessary to attain the desired results.

Question 488

Nausea and vomiting are common in early pregnancy and can affect the health of both the pregnant woman and the fetus. Mild cases of nausea and vomiting can be controlled with lifestyle and dietary changes. It is recommended that patients eat frequent small meals consisting of dry and bland foods, avoid spicy and fatty foods, eat high-protein snacks, and eat crackers in the morning before rising. If the nausea and vomiting are not controlled with dietary modifications, the first-line treatment is vitamin B6, 10–25 mg, and doxylamine, 12.5 mg, 3–4 times per day. The other antiemetics can also be used in pregnancy, but vitamin B6 and doxylamine should be tried first because of the balance of safety and efficacy.

Question 489

Women over the age of 50 require at least 1200 mg of calcium a day. Inadequate calcium intake is common, particularly in older women, and is associated with increased bone loss and an increased fracture risk. Supplements should be considered when dietary intake is inadequate. Calcium carbonate is the least expensive and most commonly used supplement, but it is constipating and stomach acid improves its absorption. Calcium gluconate and calcium lactate are rarely used for fracture prevention or calcium supplementation. Bone meal and oyster shell calcium are primarily composed of calcium carbonate but may contain lead or other contaminants since they are derived from natural sources. In addition, their absorption without stomach acid is erratic. Calcium citrate is less dependent on stomach acidity for absorption and it may be used with long-term gastric acid suppression agents. It may be taken without regard to food or meals.