Combined ITE Review

Question 1

You are providing end-of-life care for a 53-year-old female with end-stage colon cancer. Her family reports that she is having significant abdominal pain, nausea, and vomiting, and she is not able to tolerate oral intake. You suspect a malignant bowel obstruction.
Which one of the following interventions would be most likely to significantly improve her symptoms?
A) Medical cannabis
B) Dexamethasone
C) Morphine
D) Octreotide (Sandostatin)
E) Polyethylene glycol (MiraLAX)

Answer 1

ANSWER: B
Malignant bowel obstruction is a common issue with gastrointestinal cancers. Corticosteroids can help alleviate these symptoms, which is the focus in end-of-life care. Corticosteroids have numerous beneficial effects in these situations, such as central antiemetic, anti-inflammatory, antisecretory, and analgesic effects. Intravenous dexamethasone is generally recommended at a dosage of 4 mg 3–4 times daily for malignant bowel obstruction because it has much greater anti-inflammatory effect than methylprednisolone. Although octreotide is commonly used for this purpose, there is little evidence to support its use. Medical cannabis can be used to treat nausea and vomiting in end-of-life care but is not effective for bowel obstruction. Morphine can be used to treat pain and end-of-life dyspnea, but not nausea and vomiting. The use of polyethylene glycol for a malignant obstruction could worsen the patient’s symptoms significantly.

Question 2

A 69-year-old male sees you for a routine examination and asks about lung cancer screening. He smoked one pack of cigarettes per day for about 35 years but quit 11 years ago.
According to the U.S. Preventive Services Task Force and the American College of Chest Physicians, which one of the following should you recommend?
A) No screening
B) An annual history and examination focusing on lung symptoms
C) Annual chest radiography
D) Annual low-dose chest CT

Answer 2

ANSWER: D
The U.S. Preventive Services Task Force and the American College of Chest Physicians support screening for lung cancer with annual low-dose CT in patients 50–80 years of age who have a 20-pack-year smoking history and who currently smoke or have smoked within the past 15 years. There is no evidence to support an annual history and physical examination or annual chest radiography as screening tools for lung cancer.

Question 3

To determine compliance with prescribed medications and detect use of illicit substances, your clinic uses urine drug screening with an immunoassay qualitative point-of-care test to monitor patients who are on long-term opioid therapy. Which one of the following is most likely to result in a false-negative result and require confirmatory testing for detection?
A) Cannabis
B) Cocaine
C) Codeine
D) Morphine
E) Oxycodone (OxyContin)

Answer 3

ANSWER: E
Immunoassay drug screenings can be performed at the point of care and are relatively inexpensive. Typical immunoassays can detect nonsynthetic opioids such as morphine and codeine, as well as illicit substances such as amphetamines, cannabinoids, cocaine, and phencyclidine. However, these immunoassays do not reliably detect synthetic or semisynthetic opioids such as oxycodone, oxymorphone, methadone, buprenorphine, and fentanyl, as well as many benzodiazepines. Confirmatory testing is needed in situations with an unexpected negative result in order to distinguish a false negative from a true negative.

Question 4

A 34-year-old female with asthma sees you for routine follow-up. She tells you that she uses her short-acting -agonist (SABA) approximately twice a week.
Which one of the following management strategies would you recommend for prevention of exacerbations?
A) Continued use of a SABA as needed
B) An inhaled corticosteroid (ICS)/long-acting -agonist (LABA) as needed
C) A daily maintenance ICS/LABA
D) A daily maintenance ICS plus a SABA as needed
E) A daily maintenance ICS plus a daily leukotriene receptor antagonist

Answer 4

ANSWER: B
For patients with mild asthma, recent evidence has shown that an inhaled corticosteroid (ICS)/long-acting -agonist (LABA), such as budesonide/formoterol, as needed was as effective at preventing exacerbations as a daily maintenance ICS plus a short-acting -agonist (SABA) at one-fifth of the total corticosteroid dose. In addition, it was more effective at preventing exacerbations than continued use of a SABA alone as needed. A daily maintenance ICS inhaler plus either a LABA or a leukotriene receptor antagonist are
management strategies for persistent asthma.

Question 5

A 67-year-old female who is a retired teacher presents with generalized itching. She tells you that she is convinced that she has acquired a skin infestation from small mites. She gives you a matchbox containing what appears to be crusts, dried blood, and bits of skin as evidence of this problem. A previous physician had obtained a CBC, comprehensive metabolic panel, TSH level, chest radiograph, and drug screen, which were all normal. An examination today reveals excoriations on her arms, abdomen, and legs in easily reached areas. Her skin is not dry and there are no lesions in her axillae or web spaces.
Which one of the following medications would be most likely to help this patient?
A) Cholestyramine (Questran)
B) Hydroxyzine (Vistaril)
C) Ivermectin (Stromectol)
D) Olanzapine (Zyprexa)
E) Prednisone

Answer 5

ANSWER: D
Delusion of infestation is a strong belief by the patient that he or she is afflicted with an insect infestation or an infection by a microorganism. Before making this diagnosis organic causes must be ruled out, including withdrawal from illicit drugs or alcohol. The majority of patients with this condition are female and are either retired or disabled. They have often seen multiple providers and have been told this problem is “in your head.” Management can be difficult, but it is important to thoroughly investigate during the initial visit, including examining samples that the patient presents. Subsequent visits should be supportive, allowing time for the patient to have any concerns addressed. Often the patient will respond to atypical antipsychotic medications such as risperidone or olanzapine.
Cholestyramine is used to treat cholestatic jaundice. Hydroxyzine can be used for itching, particularly from urticaria, but can cause sedation in the elderly. Ivermectin is an option to treat scabies. Prednisone would be appropriate for allergic reactions or inflammatory dermatitis problems.

Question 6

A 68-year-old male with a history of COPD, hypertension, and hyperlipidemia presents with a worsening cough and dyspnea with exertion over the past 3 months. His symptoms were previously well controlled with tiotropium (Spiriva) daily and albuterol (Proventil, Ventolin) as needed, and he has not had any COPD exacerbations in the past year until these symptoms began. He has not had any change in sputum production. Recently he has been using his albuterol inhaler several times a day to help relieve his shortness of breath with exertion.
A physical examination reveals a temperature of 37.0°C (98.6°F), a heart rate of 78 beats/min, a respiratory rate of 16/min, a blood pressure of 144/82 mm Hg, and an oxygen saturation of 95% on room air. A cardiac evaluation reveals a regular rate and rhythm and he has no peripheral edema or cyanosis. His lungs are clear with no wheezes or crackles, and there is a mild prolonged expiratory phase.
According to current GOLD guidelines, which one of the following would be the most appropriate next step in the management of this patient’s symptoms?
A) Add azithromycin (Zithromax)
B) Add inhaled fluticasone (Flovent)
C) Add inhaled salmeterol (Serevent)
D) Add inhaled fluticasone/salmeterol (Advair)
E) Discontinue tiotropium and start inhaled fluticasone

Answer 6

ANSWER: C
COPD is currently the third leading cause of death in the United States and is commonly treated by primary care providers. In patients on monotherapy with a long-acting bronchodilator such as a long-acting muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized, treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.

Question 7

A 6-week-old female is brought to your office by her parents to establish care after the family recently moved from out of state. The infant was born at term after an uncomplicated normal spontaneous vaginal delivery but failed her initial newborn hearing screen in the right ear only. Both parents are confident that she is able to hear out of both ears because she turns her head toward their voices regardless of where they are standing. A physical examination is within normal limits.
Which one of the following would be the most appropriate next step in response to this patient’s abnormal hearing screen?
A) No further testing
B) A bilateral audiology evaluation before 3 months of age
C) A bilateral audiology evaluation at 6 months of age
D) A bilateral audiology evaluation at 12 months of age
E) A bilateral audiology evaluation immediately before entering kindergarten

Answer 7

ANSWER: B
All newborns should have a bilateral hearing screen completed before hospital discharge. For infants that fail the initial hearing screen in one or both ears, a repeat bilateral audiology evaluation should be performed before 3 months of age to ensure early identification of hearing loss and therefore maximize speech perception and development.

Question 8

Which one of the following best explains the pathophysiology of cytokine storm?
A) Anaphylaxis
B) Immune dysregulation
C) Immunodeficiency
D) Normal physiologic response
E) Serum sickness

Answer 8

ANSWER: B
Cytokine storm or cytokine release syndrome is caused by the release of cytokines and is characterized by fever, tachypnea, headache, tachycardia, hypotension, rash, and/or hypoxia. Cytokine storm can be triggered by certain therapies, pathogens, cancers, autoimmune conditions, and monogenic disorders. The normal inflammatory response involves recognition of a pathogen or injury, activation of a proportional response, and a return to homeostasis. However, cytokine storm involves immune dysregulation and immune-cell hyperactivation in which an overabundance of cytokines can cause collateral damage that may be worse than the benefit from the immune response itself. It is not considered a normal physiologic response, and it does not involve histamine release or anaphylaxis. Immune-cell hyperactivation rather than immunodeficiency is involved in cytokine storm. However, it is important to be aware of concurrent immunodeficiency since treatment for the immune hyperactivity can place patients at risk for secondary infections and illness. Serum sickness is associated with delayed hypersensitivity to foreign proteins from animal serums and is not involved in the pathophysiology of cytokine storm.

Question 9

A patient’s office spirometry results demonstrate an obstructive pattern. This would be seen with which one of the following?
A) Asbestosis exposure
B) Cystic fibrosis
C) Idiopathic pulmonary fibrosis
D) Nitrofurantoin exposure
E) Sarcoidosis

Answer 9

ANSWER: B
Office spirometry can be very helpful in the development of a differential diagnosis. The differential can be narrowed with the use of office spirometry, as many conditions create either an obstructive or restrictive pattern. Of the options listed, only cystic fibrosis can cause an obstructive pattern. Other causes of an obstructive pattern include asthma, COPD, 1-antitrypsin deficiency, and bronchiectasis, among others. Common diseases or conditions causing restrictive patterns include adverse reactions to nitrofurantoin, methotrexate, and amiodarone. Chest wall conditions such as kyphosis, scoliosis, and morbid obesity can also cause restrictive patterns. Interstitial lung disease, including idiopathic pulmonary fibrosis, sarcoidosis, and asbestosis, also causes a restrictive pattern (SOR A).

Question 10

A 62-year-old male with hypertension and metabolic syndrome sees you for follow-up. A fasting triglyceride level is 300 mg/dL. You address lifestyle and other potential causes of his elevated triglycerides, including his current medications.
If included in his current regimen, which one of the following hypertension medications would be most likely to contribute to his hypertriglyceridemia?
A) Amlodipine (Norvasc)
B) Diltiazem (Cardizem)
C) Lisinopril (Prinivil, Zestril)
D) Metoprolol

Answer 10

ANSWER: D
Several medications can be secondary causes of hypertriglyceridemia, including -blockers, with the exception of carvedilol. Others include oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, and thiazides. Calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers are not associated with hypertriglyceridemia.

Question 11

A 42-year-old female presents with a several-month history of fatigue, arthralgias in her knees and hips, myalgias, hair loss, and a recent episode of gross hematuria diagnosed at an urgent care center as a urinary tract infection. She has no urinary tract symptoms at this time. A friend of hers who had similar symptoms for months was recently diagnosed with systemic lupus erythematosus (SLE), and the patient asks whether she might have SLE.
Which one of the following would be most helpful in reassuring her that the likelihood of her having SLE is low?
A) Absence of the typical malar rash
B) Absence of RBC casts on microscopic urinalysis
C) A negative serum antinuclear antibody
D) Normal levels of complement C3, C4, and CH50
E) Joint pain limited to large joints

Answer 11

ANSWER: C
The diagnosis of systemic lupus erythematosus (SLE) can be difficult and is often not established for months or even years, due to the significant overlap of symptoms with many other conditions. The American College of Rheumatology has established 11 diagnostic criteria, at least 4 of which must be met over time, to establish a diagnosis of SLE. The vast majority (>95%) of patients with SLE have a positive antinuclear antibody (ANA) test, thus it is sensitive as an initial test in a patient for whom there is clinical suspicion for SLE. However, testing for other immunologic subgroup ANA markers should be performed in a patient with a positive ANA. If one or more of those are positive, then the likelihood of SLE is higher. The majority of patients with a positive ANA do not have SLE but a negative ANA is very unlikely in a patient who has SLE.
The typical malar rash of SLE is one of the 11 clinical criteria but is only present in approximately 30% of patients with SLE. Up to 80% of patients may have some form of cutaneous involvement over the course of the disease but hair loss is not specifically a feature of SLE. Other potentially helpful but nonspecific findings in SLE include proteinuria and RBC cellular casts, both of which are indicators of nephritis, but their absence does not rule it out. The subgroup markers (anti-dsDNA, anti-SmDNA, complement C3, C4, CH50) should only be obtained in patients suspected of having SLE who have a positive ANA. Myalgias or arthralgias and synovitis in two or more joints (not limited to large or small joints) is another one of the clinical diagnostic criteria.

Question 12

Which one of the following cardiovascular medications may lead to hyperthyroidism?
A) Amiodarone
B) Digoxin
C) Flecainide
D) Metoprolol
E) Valsartan (Diovan)

Answer 12

ANSWER: A
Amiodarone-induced thyrotoxicosis (AIT) is a less common cause of hyperthyroidism and can be particularly difficult to accurately diagnose and treat. AIT type 1 is a form of iodine-induced thyrotoxicosis caused by the high iodine content in amiodarone. AIT type 2 is a form of amiodarone-induced thyroiditis. Digoxin, flecainide, metoprolol, and valsartan do not cause hyperthyroidism.

Question 13

A 35-year-old female presents to your office with a feeling of vague fullness in her neck for the last month. She has noticed a gradual onset of fatigue, constipation, and cold intolerance over that time. A few weeks ago the patient took a selfie and was surprised by how puffy her face appeared in the photo.
On examination her thyroid is diffusely enlarged and nontender and feels pebbly on palpation. An HEENT examination, including an eye examination, is otherwise normal.
Which one of the following is the most likely diagnosis?
A) Chronic autoimmune (Hashimoto) thyroiditis
B) Graves disease
C) Lymphadenitis
D) Lymphoma
E) Thyroid cancer

Answer 13

ANSWER: A
This patient’s clinical picture is most consistent with chronic autoimmune thyroiditis, traditionally known as Hashimoto thyroiditis. This diagnosis is suggested by her neck fullness and symptoms of hypothyroidism. Additionally, a nontender goiter that feels like pebbles on examination is classically reported with chronic autoimmune thyroiditis.
Graves disease typically presents with symptoms of hyperthyroidism and, in many patients, orbitopathy (eye bulging). A patient with lymphadenitis typically shows symptoms of a causative infection. Lymphadenitis tends to rapidly enlarge the lymph nodes, which are also typically painful and tender. Lymphoma more commonly presents with fevers, night sweats, unintentional weight loss, itchy skin, and dyspnea.
This patient lacks a discrete thyroid nodule, which makes thyroid cancer less likely. Thyroid nodules are more frequently painful, while the neck fullness in chronic autoimmune thyroiditis is usually painless and nontender.

Question 14

An 8-year-old male is brought to your office because of acute lower abdominal pain. He does not have constipation and has never had abdominal surgery. You suspect acute appendicitis.
Which one of the following imaging modalities would be most appropriate to consider first?
A) Plain radiography
B) Ultrasonography
C) CT without contrast
D) CT with contrast
E) MRI

Answer 14

ANSWER: B
Ultrasonography is recommended as the initial imaging modality to evaluate acute abdominal pain in children. It avoids radiation exposure and is useful for detecting many causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis. Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history of previous abdominal surgery.

Question 15

A 51-year-old patient asks about recommended lung cancer screenings. The U.S. Preventive Services Task Force recommends annual lung cancer screening with low-dose CT for individuals starting at age
A) 45 with a 15-pack-year smoking history
B) 50 with a 20-pack-year smoking history
C) 55 with a 30-pack-year smoking history
D) 60 with a 35-pack-year smoking history
E) 65 with a 40-pack-year smoking history

Answer 15

ANSWER: B
Lung cancer is the second most common cancer in both women and men, after breast cancer for women and prostate cancer for men. It is the leading cause of cancer deaths in the United States, making it important for primary care providers to screen for this disease process. The primary risk factor for lung cancer is tobacco smoking, which accounts for 90% of all lung cancer cases. Lung cancer has a relatively poor prognosis, but early-stage lung cancer is more amenable to treatment and has a better prognosis. Low-dose CT has a reasonable specificity and high sensitivity for lung cancer in patients at high risk. The eligibility criteria were recently updated by the U.S. Preventive Services Task Force due to evidence of mortality benefit, with a recommendation for screening to begin at age 50 for patients with a 20-pack-year smoking history who are current smokers or have quit within the past 15 years.

Question 16

A 4-year-old male is brought to your office by his parents because of a 2-day history of cough and a runny nose, but no fever. The child’s symptoms are not progressing. The patient has a history of wheezing when he has mild respiratory infections. The only findings on examination are yellow nasal discharge and mild wheezing.
The appropriate management with the LEAST amount of risk would be treatment for 10 days with
A) amoxicillin
B) montelukast (Singulair)
C) an antihistamine decongestant
D) an inhaled corticosteroid
E) an oral corticosteroid

Answer 16

ANSWER: D
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 17

You are utilizing shared decision-making with patients while determining whether to recommend starting a statin for the primary prevention of atherosclerotic cardiovascular disease. In which one of the following patients would a screening coronary artery calcium score be most appropriate for guiding this recommendation?
A) A 35-year-old at low (<5%) 10-year risk
B) A 55-year-old at high (20%) 10-year risk
C) A 55-year-old with diabetes mellitus at high (20%) 10-year risk
D) A 60-year-old at low (<5%) 10-year risk
E) A 60-year-old at intermediate (7.5% to <20%) 10-year risk

Answer 17

ANSWER: E
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%).
49
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 18

A 4-year-old male is brought to your office by his mother because of fevers, irritability, runny nose, and cough for the past week. On examination he is noted to have bilateral conjunctivitis; dry cracked lips; a maculopapular rash; edema and erythema of his palms and soles bilaterally; and a nontender, enlarged, right anterior cervical lymph node.
Which one of the following should be included in the evaluation of this patient’s condition?
A) Chest radiography
B) Neck ultrasonography
C) Echocardiography
D) Neck CT
E) Cardiac MRI

Answer 18

ANSWER: C
This patient has the classic clinical manifestations of Kawasaki disease. All patients with Kawasaki disease should undergo echocardiography due to the high risk of coronary artery dilation and aneurysm associated with the disease. Chest radiography, neck ultrasonography, neck CT, and cardiac MRI are not recommended in the evaluation of a patient with Kawasaki disease and would only be recommended if another clinical indication for these studies were present.

Question 19

A 56-year-old male was recently diagnosed with hypertension and started on lisinopril (Zestril). At a follow-up visit his blood pressure remains elevated and his serum creatinine level has increased from 0.9 mg/dL to 1.8 mg/dL (N 0.7–1.3). He has no other known medical issues and has a normal BMI.
Which one of the following should be ordered to confirm the most likely cause of his hypertension?
A) Renin and aldosterone levels
B) A TSH level
C) 24-hour urinary free cortisol
D) 24-hour urinary fractionated metanephrines and normetanephrines
E) CT angiography of the abdomen and pelvis

Answer 19

ANSWER: E
Resistant hypertension occurs in 5%–10% of adults with hypertension. In this patient, renal artery stenosis is suggested by the increase in creatinine of more than 50% after starting an ACE inhibitor. CT angiography, renal artery duplex ultrasonography, and MR angiography are appropriate diagnostic tests for renal artery stenosis. Other causes of resistant hypertension include hyperaldosteronism (diagnosed with renin and aldosterone levels), thyroid disorders (diagnosed with TSH levels), Cushing syndrome (diagnosed with 24-hour urinary free cortisol), and pheochromocytoma (diagnosed with 24-hour urinary fractionated metanephrines and normetanephrines).

Question 20

A 33-year-old female presents to your office concerned about feeling fatigued for the past few months. She says that she feels cold often, has intermittent joint discomfort, and has gained 5 lb. She has not experienced any pain or problems swallowing. She gave birth to her youngest child almost 3 years ago, and she recently started an oral contraceptive. She has not had any recent illnesses. Her family history is significant for rheumatoid arthritis.
A physical examination reveals a mild goiter but is otherwise unremarkable. Her vital signs are stable. A CBC and comprehensive metabolic panel are normal. A TSH level is 6.48 U/mL (N 0.4–4.5) and a thyroid peroxidase antibody level is 378 IU/mL (N <34). A free T4 level is normal.
Which one of the following is the most likely diagnosis for this patient?
A) Drug-induced thyroiditis
B) Hashimoto thyroiditis
C) Postpartum thyroiditis
D) Subacute thyroiditis

Answer 20

ANSWER: B
Thyroiditis, a general term for inflammation of the thyroid gland, is associated with thyroid gland dysfunction. It is classified based on clinical symptoms: painless or painful, acute or subacute, and underlying etiology (medication-induced, infection, radiation-induced, or autoimmune). The most common forms of thyroiditis include Hashimoto, subacute, and postpartum. Thyroiditis often results in a triphasic disease pattern of thyroid dysfunction: hyperthyroidism due to the release of preformed thyroid hormone from damaged thyroid cells followed by hypothyroidism when the thyroid stores are depleted. Eventually normal thyroid function is restored, or the patient develops permanent hypothyroidism. This patient presents with symptoms commonly seen in thyroid disease. Further testing reveals elevated TSH and thyroid peroxidase (TPO) levels. Elevated TPO levels are found in 95% of patients with Hashimoto thyroiditis. In addition, this patient’s family history includes rheumatoid arthritis, another autoimmune disease, making Hashimoto thyroiditis the most likely diagnosis. Treatment is lifelong thyroid hormone therapy.
Several medications are linked to thyroiditis, including lithium, amiodarone, interferon-alfa, interleukin-2, immune checkpoint inhibitors, and tyrosine kinase inhibitors. However, there is no proven link between oral contraceptives and Hashimoto thyroiditis. Postpartum thyroiditis occurs within 1 year of delivery, miscarriage, or medical abortion, not 2–3 years. Subacute thyroiditis is self-limited and often occurs after upper respiratory infections, causing thyroid pain and dysphagia due to inflammatory destruction of thyroid follicles.

Question 21

A 45-year-old female sees you for follow-up 3 days after a visit to the emergency department (ED) for acute abdominal pain due to an initial episode of a kidney stone. Her past medical history and family history are unremarkable. A CT scan in the ED demonstrated a nonobstructing, 4-mm mid-ureteral stone and several smaller stones in both kidneys, measuring up to 2 mm. Laboratory studies in the ED showed a calcium level of 11.4 mg/dL (N 8.0–10.0) and microscopic hematuria on urinalysis but were otherwise normal. She was treated with intravenous hydration and pain control and was discharged home. She passed the stone the next day.
A physical examination today is normal. Follow-up laboratory studies confirm an elevated serum calcium level, along with elevated serum parathyroid hormone and 24-hour urine calcium levels. A DEXA scan and repeat microscopic urinalysis are normal.
At this point, you should
A) prescribe a bisphosphonate
B) prescribe a thiazide diuretic
C) refer her for genetic evaluation
D) refer her for cystoscopy
E) refer her for parathyroidectomy

Answer 21

ANSWER: E
This patient has laboratory evidence of primary hyperparathyroidism, with hypercalcemia and an inappropriately elevated (as opposed to suppressed) parathyroid hormone (PTH) level. An elevated 24-hour urine calcium level further distinguishes primary hyperparathyroidism from familial hypocalciuric hypercalcemia. Treatment of primary hyperparathyroidism with parathyroidectomy has been shown to normalize PTH and calcium levels, decrease kidney stone production, and prevent declines in renal function and bone mineral density. Untreated primary hyperparathyroidism increases overall mortality as well as cardiovascular and cerebrovascular disease risk, in addition to increasing the risk of kidney stone production, renal function decline, and loss of bone mineral density. Parathyroidectomy is indicated in this patient based on her symptomatic hypercalcemia, age <50, and serum calcium level >1 mg/dL above the upper limit of normal. Other potential indications include the presence of osteoporosis, reduced kidney function, or other asymptomatic renal involvement, including silent nephrolithiasis on imaging, nephrocalcinosis, or hypercalciuria.
Patients with primary hyperparathyroidism who are not candidates for surgery may be managed medically. Bisphosphonates may be used to increase bone mineral density. For this patient with a normal DEXA scan, surgical treatment would obviate the possible future need to treat her for bone density loss related to hyperparathyroidism. Thiazides may be used for treating certain hyperparathyroid states due to their impact on reducing calcium excretion and improving bone mineral density, although they are typically avoided in primary hyperparathyroidism because they can worsen hypercalcemia. Genetic evaluation would be warranted for a patient suspected of having multiple endocrine neoplasia type 1 or 2A, although this patient does not have any family history or presenting features to suggest involvement of either of these rare familial syndromes. Cystoscopy may be indicated in the setting of ureteral obstruction but is not necessary in this case.

Question 22

A 45-year-old male presents to the urgent care clinic with a 2-hour history of central chest pain that began at rest with associated shortness of breath. In addition, he has had a mild dry cough and rhinorrhea for a few days but no fever. He has not had any nausea, dizziness, or diaphoresis, and the chest pain does not radiate. He took a low-dose aspirin at home at the insistence of his partner but states that it did not affect the pain. He has no past medical history, takes no medications, consumes 4–6 alcoholic drinks per night, and does not smoke. He has a sedentary job in customer service and walks his dog twice a day. He lives at home with his partner and toddler, who also has a mild cough and runny nose.
On examination the patient has a temperature of 37.0°C (98.6°F), a blood pressure of 150/100 mm Hg, a heart rate of 118 beats/min, a respiratory rate of 14/min, and an oxygen saturation of 98% on room air. The patient is well appearing, and an HEENT examination reveals no jugular vein distention. A cardiovascular examination reveals tachycardia without murmur. There is no chest wall tenderness to palpation. The lung examination reveals decreased breath sounds on the right compared with the left, and there are no crackles or wheezes. There is no lower extremity edema.
A chest radiograph and an EKG are shown below. Laboratory studies including D-dimer and troponin levels, a CBC, and a comprehensive metabolic panel have been ordered and the results are pending.
Which one of the following would be the most appropriate next step in management?
A) Initiation of antibiotics
B) Initiation of heparin infusion
C) Chest tube placement
D) Cardiac catheterization

Answer 22

ANSWER: C
This patient’s chest radiograph is consistent with a large right pneumothorax and complete lung collapse. In addition, there is a leftward mediastinal shift that raises the concern for a tension pneumothorax. The most appropriate next step in management would be placement of a chest tube. The chest radiograph is not consistent with pneumonia, so antibiotics would not be appropriate. While a pulmonary embolus and non–ST-elevation myocardial infarction could have a similar presentation, the abnormal chest radiograph points to the most likely diagnosis, and a heparin infusion would not be indicated. Cardiac catheterization is not the most appropriate next step in the management of a pneumothorax because the focus should be on stabilizing the lung condition and ensuring proper healing before considering invasive procedures.

Question 23

A 55-year-old male presents to your clinic for evaluation of COPD. He has a history of tobacco use and quit smoking 2 years ago. He reports occasional symptoms that limit his activities but has not had any exacerbations or hospitalizations. Pulmonary function tests indicate an FEV1/FVC ratio <0.7 and an FEV1 of 75%. His vital signs are normal.
Which one of the following would be the most appropriate initial pharmacotherapy?
A) Budesonide/formoterol (Symbicort)
B) Ipratropium (Atrovent)
C) Levalbuterol
D) Tiotropium (Spiriva)
E) Umeclidinium/vilanterol (Anoro Ellipta)

Answer 23

ANSWER: D
COPD is a common condition, which led to 3.23 million deaths worldwide in 2019. A variety of treatments are available to alleviate symptoms, and family physicians are well suited to manage this condition through lifestyle modifications and pharmacotherapy. Guidelines suggest that patients with mild disease, as in this patient’s case per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) class 2 findings on pulmonary function tests and no exacerbations, are best managed through once-daily inhalation of a long-acting muscarinic antagonist (LAMA) such as tiotropium. Short-acting medications such as ipratropium and levalbuterol require frequent dosing and lack the mortality benefit seen with LAMAs. The combination of LAMAs and long-acting -agonists (LABAs) can be initiated in those with persistent symptoms but would not be used as initial therapy. Inhaled corticosteroids may be beneficial in those with significant asthma and COPD overlap, but in general corticosteroids should be reserved for those with persistent symptoms despite LAMA and LABA therapy.

Question 24

A previously healthy 58-year-old female sees you for evaluation of increased hair growth on her face and a weight gain of 18 kg (40 lb) over the past year. An examination is significant for a blood pressure of 155/98 mm Hg, a BMI of 34 kg/m2 with a truncal obesity pattern, striae on the sides of the torso and lower abdomen, marked hirsutism, and a rounded, swollen facial appearance. A urine pregnancy test is negative. Liver and renal function tests are normal, as are TSH, electrolyte, testosterone, and DHEA levels. A hemoglobin A1c is 6.2%.
Which one of the following would be most useful to diagnose the condition suggested by this patient’s presentation?
A) A 24-hour urinary free cortisol level
B) 24-hour urinary metanephrines
C) ACTH stimulation testing
D) FSH and LH levels
E) Plasma renin activity testing and an aldosterone level

Answer 24

ANSWER: A
This patient presents with clinical findings strongly suggestive of Cushing disease, which is defined as the excessive production of adrenal cortical hormones. Options for confirmatory testing include 24-hour urinary free cortisol and overnight salivary cortisol levels. Metanephrines are used to diagnose pheochromocytoma. ACTH stimulation testing is used to diagnose adrenal insufficiency. FSH and LH levels test the hypothalamic-pituitary-gonadal axis. Plasma renin activity testing and an aldosterone level are useful in the workup of secondary hypertension to help diagnose hyperaldosteronism.

Question 25

A 56-year-old female with type 2 diabetes is hospitalized with acute epigastric pain, nausea, and vomiting. She reports that several of her diabetes medications were recently changed. Findings on physical examination and laboratory studies are consistent with acute pancreatitis.
Which one of the following classes of medications is the most likely cause?
A) Biguanides
B) GLP-1 receptor agonists
C) Insulin
D) SGLT2 inhibitors

Answer 25

ANSWER: B
GLP-1 receptor agonists should be discontinued in patients suspected to have pancreatitis. Additionally, therapy with GLP-1 receptor agonists should not be restarted once the pancreatitis has resolved. Although pancreatitis has been reported in clinical trials, the causality between GLP-1 receptor agonists and pancreatitis has not been established. Other medication classes such as DPP-4 inhibitors can also cause pancreatitis. Biguanides, insulin, and SGLT2 inhibitors do not cause pancreatitis (SOR C).

Question 26

A 78-year-old male presents to your office for a health maintenance visit at the request of his spouse. He does not have any current symptoms or concerns. He states that he has not seen a physician since he was a teenager. The patient reports breaking his arm as a child but has no other known medical conditions. He has a 30-pack-year history of smoking cigarettes but has not smoked for 10 years. He has one glass of wine with dinner 3–4 times a month and does not use illicit substances. His sexual history consists of sex with only his wife. His family history includes a mother who died of a stroke and a father who died of pancreatic cancer. He walks 2 miles five times a week. His vital signs and a physical examination are normal.
Which one of the following screenings is recommended by the U.S. Preventive Services Task Force for this patient?
A) Hepatitis B testing
B) Prostate-specific antigen testing
C) Abdominal aortic aneurysm ultrasonography
D) A DEXA scan
E) Low-dose CT of the chest

Answer 26

ANSWER: E
The U.S. Preventive Services Task Force (USPSTF) recommends annual screening for lung cancer with low-dose CT of the chest for men and women ages 50–80 with a 20-pack-year smoking history or more, or patients who currently smoke or have quit smoking in the past 15 years (B recommendation). This patient is 78 years old with a 30-pack-year history and he quit smoking only 10 years ago.

Patients at increased risk for hepatitis B virus infection should be tested (B recommendation). This patient does not have a history that is high risk for hepatitis B infection, such as needle-sharing, injecting illicit substances, having sex with other men, and HIV infection, so he does not need to be tested at this time. Shared clinical decision-making to discuss the benefits and harms of prostate-specific antigen (PSA) testing in men ages 55–69 years should be considered. This patient’s age makes PSA testing inappropriate (D recommendation).
According to the clinical evidence, one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography demonstrates moderate benefit for males between the ages of 65–75 who have ever smoked or have smoked at least 100 cigarettes (B recommendation). Smoking history is the strongest predictor for AAA (B recommendation). This patient does have a smoking history, but his age is outside the recommended window for AAA screening. According to the USPSTF, there is insufficient evidence to screen men for osteoporosis (I recommendation), so a DEXA scan would not be appropriate.