ITE 2021

Question 1

A 23-year-old male with opioid use disorder requests buprenorphine therapy. He is still actively using immediate-release oxycodone (Roxicodone) and he took a dose 2 hours ago.
This patient should begin buprenorphine induction
A) now
B) in 2 hours
C) 8–12 hours after his last opioid use
D) 24 hours after his last opioid use
E) 1 week after his last opioid use

Answer 1

ANSWER: C
Buprenorphine is a partial opioid agonist. In order to reduce the risk of precipitated withdrawal, buprenorphine induction should begin once the patient is exhibiting signs of mild to moderate withdrawal, usually 8–12 hours after the last opioid use. Waiting until a patient goes through full withdrawal increases the chances that the patient will revert back to using opioids.

Question 2

A 57-year-old female with diabetes mellitus comes to your office for a routine follow-up. Her current medications include metformin (Glucophage), 1000 mg twice daily. She tells you that she does not exercise regularly and finds it difficult to follow a healthy diet. A hemoglobin A1c today is 7.5%. She does not want to add medications at this time, but she does want to get her hemoglobin A1c below 7%, which is the goal that was previously discussed.
Which one of the following would be the most effective way to improve glucose control for this patient?
A) Discuss the components of a healthy diabetic diet and encourage her to follow it more closely
B) Discuss the importance of regular exercise and encourage her to exercise 30–45 minutes daily
C) Recommend that she check her glucose level 1–3 times daily to help determine what adjustments need to be made
D) Start her on an additional medication
E) Refer her to a diabetes educator for medical nutrition therapy

Answer 2

ANSWER: E
Counseling by a diabetic educator or team of educators for medical nutrition therapy lowers hemoglobin A1c by 0.2–0.8 percentage points in patients with type 2 diabetes. While a healthy diabetic diet and regular exercise are important, simply reminding the patient of that fact is not likely to be as successful as comprehensive diabetic education. According to the Society of General Internal Medicine in the Choosing Wisely campaign, patients with type 2 diabetes who are not on insulin therapy should not check their blood glucose level daily. An additional medication will likely decrease the hemoglobin A1c, but this patient has expressed a desire to avoid additional medication, is near goal, and is not currently managing her diabetes with adequate lifestyle changes, so it would be appropriate to respect her wishes and pursue proven interventions that do not require medication.

Question 3

Which one of the following antihypertensive medications is LEAST likely to exacerbate erectile dysfunction?
A) Clonidine (Catapres)
B) Doxazosin (Cardura)
C) Hydrochlorothiazide
D) Losartan (Cozaar)
E) Metoprolol

Answer 3

ANSWER: D
Angiotensin receptor blockers (ARBs) such as losartan are least likely to cause or exacerbate erectile dysfunction. ARBs may have a favorable effect on erectile dysfunction by inhibiting vasoconstriction activity of angiotensin. Clonidine, -blockers, hydrochlorothiazide, and -blockers are more likely to negatively affect erectile function.

Question 4

A 3-year-old male has developed multiple large areas of bullous impetigo on the legs, buttocks, and trunk after being bitten numerous times by ants. Which one of the following would be the most appropriate treatment?
A) Topical mupirocin ointment
B) Oral azithromycin (Zithromax)
C) Oral tetracycline
D) Oral trimethoprim/sulfamethoxazole (Bactrim)
E) Intramuscular penicillin G benzathine (Bicillin L-A)

Answer 4

ANSWER: D
Impetigo may be caused by Streptococcus pyogenes or Staphylococcus aureus, but bullous impetigo is caused exclusively by S. aureus. Oral trimethoprim/sulfamethoxazole is an appropriate treatment for skin infections caused by S. aureus, including susceptible cases of methicillin-resistant S. aureus (MRSA). Topical mupirocin ointment is not practical in very widespread cases or in cases with large bullae. Neither azithromycin nor penicillin is a preferred treatment for impetigo, due to a high rate of treatment failure. Tetracycline should be avoided in children under 8 years of age due to a propensity to cause permanent staining of the teeth.

Question 5

A 60-year-old male with diabetes mellitus and hypertension sees you for routine follow-up. He has no acute health concerns during today’s visit. His current medications include metformin (Glucophage), lisinopril (Prinivil, Zestril), and hydrochlorothiazide. He smokes cigarettes and has a 40-pack-year smoking history. His vital signs and a physical examination are normal. An in-office dipstick urinalysis reveals 1+ blood and trace protein but is otherwise normal.
Which one of the following would be the most appropriate follow-up?
A) Repeat dipstick urinalysis in 3 months
B) Microscopic urinalysis
C) Renal ultrasonography
D) CT urography
E) Referral for cystoscopy

Answer 5

ANSWER: B
Microscopic hematuria, also known as microhematuria, is defined as 3 RBCs/hpf on microscopy. Dipstick analysis alone is insufficient to diagnose microscopic hematuria, as blood that is seen on dipstick analysis may represent a false-positive result caused by myoglobinuria, hemoglobinuria, dehydration, exercise, menstrual blood, or povidone-iodine, as opposed to true hematuria. Thus, when the presence of blood is suggested by dipstick urinalysis, confirmation with microscopic analysis should be obtained. The current guideline from the American Urological Association (AUA) stratifies further workup for microscopic hematuria based on the patient’s overall risk of genitourinary malignancy, rather than automatic referral for cystoscopy and CT urography for all adults 35 years old with microhematuria, as was recommended in the previous AUA guideline. According to the current guideline, further evaluation may include renal ultrasonography, CT urography, and/or cystoscopy, depending on the patient’s level of risk. Patients who are at low risk also may be given the option to repeat a urinalysis in 6 months. For this patient the next step would be microscopic urinalysis to determine the presence of hematuria, and, if present, to quantify it. If microscopic urinalysis confirms the presence of hematuria, then CT urography and cystoscopy would be indicated, as his age, male sex, and smoking history place him at increased risk of malignancy. Repeating the dipstick analysis in 3 months would be inappropriate in this situation, as the presence or absence of true microscopic hematuria needs to be clarified because of his high-risk history.

Question 6

A 33-year-old gravida 2 para 1 presents to the hospital at 35 weeks estimated gestation with premature rupture of membranes. A decision is made to manage the pregnancy expectantly and delay delivery unless signs of infection or fetal distress are noted.
Based on current evidence, expectant management rather than immediate delivery increases the risk of which one of the following complications?
A) Cesarean delivery
B) Antepartum or postpartum maternal hemorrhage
C) Time spent in the neonatal intensive-care unit
D) Neonatal sepsis
E) Perinatal or infant mortality

Answer 6

ANSWER: B
While historically the optimal management of premature rupture of membranes between 34 and 36 weeks has been unclear, based on the PPROMT (Preterm Pre-labour Rupture of the Membranes close to Term) trial published in 2015, expectant management appears to be associated with better neonatal outcomes. Expectant management decreases the risk of cesarean delivery, neonatal respiratory distress, mechanical ventilation, time spent in the neonatal intensive-care unit, and time spent in the hospital. Expectant management did increase the risk of maternal antepartum or postpartum hemorrhage and intrapartum fever. No differences were found between immediate delivery and expectant management in the risk of neonatal sepsis, pneumonia, or perinatal or infant mortality.

Question 7

A 57-year-old male recently diagnosed with acute lymphoblastic leukemia presents to the emergency department with intractable nausea, vomiting, and myalgias. His first chemotherapy infusion was administered earlier in the day.
Which one of the following electrolyte disturbances would be consistent with tumor lysis syndrome?
A) Hypocalcemia B) Hypokalemia C) Hyponatremia
D) Hypophosphatemia E) Hypouricemia

Answer 7

ANSWER: A
Tumor lysis syndrome is a common complication of chemotherapy in hematologic malignancies, such as acute leukemia. Homeostasis is overwhelmed with phosphorus, potassium, calcium, and uric acid released into the bloodstream due to acute cell lysis. Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome. Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream. Sodium electrolyte levels are not as likely to be affected.

Question 8

Which one of the following is needed to calculate the number needed to treat (NNT)?
A) Number needed to harm
B) Pretest probability
C) Absolute risk reduction
D) Relative risk reduction
E) Likelihood ratio

Answer 8

The number needed to treat (NNT) is calculated as: 1/absolute risk reduction (ARR),

Question 9

A 30-year-old male comes to your office for evaluation of hand weakness. On examination you detect weakness when he tries to bring his thumb and index finger together. For confirmation you ask him to try to hold on to a piece of paper between his thumb and index finger while you try to pull it away. He is unable to resist when you pull on the paper.
The most likely explanation for these findings is an injury to the
A) brachial plexus
B) median nerve
C) musculocutaneous nerve
D) radial nerve
E) ulnar nerve

Answer 9

ANSWER: E
Initial general neurovascular assessment of an upper extremity injury includes evaluating for radial pulse and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism is indicative of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential brachial plexus injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index finger, and long finger. Weakness of supination of the forearm would indicate a potential musculocutaneous nerve injury. Weakness of active wrist extension would indicate a potential radial nerve injury.

Question 10

A 70-year-old female sees you for a Medicare annual wellness visit. Her past medical history includes hypertension treated with enalapril (Vasotec). She states that she “couldn’t be better” and says that she has no new symptoms or health concerns. She has a blood pressure of 159/90 mm Hg, a temperature of 36.7°C (98.1°F), a heart rate of 76 beats/min, a respiratory rate of 17/min, and an oxygen saturation of 98% on room air. On examination you note a new harsh systolic murmur that is heard best at the second right intercostal space and can also be heard over the right carotid artery. A transthoracic echocardiogram reveals severe aortic stenosis.
Which one of the following should you recommend for this patient?
A) Antibiotic prophylaxis for dental procedures
B) Transesophageal echocardiography
C) Repeat echocardiography in 6 months
D) Referral for aortic valve replacement

Answer 10

ANSWER: C
This patient has severe aortic stenosis that is asymptomatic. Watchful waiting is recommended for most asymptomatic patients. In asymptomatic patients with severe aortic stenosis, monitoring with serial echocardiography is recommended every 6–12 months. Antibiotic prophylaxis is not indicated unless the patient has undergone aortic valve replacement or has a history of endocarditis. Transesophageal echocardiography is not indicated in this situation. Aortic valve replacement is indicated to decrease mortality in patients with symptomatic aortic stenosis.

Question 11

After a thorough history and examination you determine that a 30-year-old male has an upper respiratory infection with a persistent cough. He is afebrile and is otherwise healthy.
The best treatment for symptomatic relief of his persistent cough would be intranasal
A) antibiotics
B) antihistamines
C) corticosteroids
D) ipratropium (Atrovent)
E) saline

Answer 11

ANSWER: D
Upper respiratory tract infections are the most common acute illness in the United States. Symptoms are self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise, and a low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis, antitussives and expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics, antihistamines, corticosteroids, and saline would not improve this patient’s cough.

Question 12

A 20-year-old male presents with a painful second finger after his right hand was stepped on 3 days ago while he was playing basketball. He has marked pain as well as numbness of the distal finger. There are no open wounds and the skin color and nail appear normal other than moderate edema of the fingertip. A radiograph reveals a distal phalanx fracture.
Which one of the following would be the most appropriate next step?
A) Treat symptomatically with ice and an anti-inflammatory medication
B) Tape the first and second digits together until symptoms resolve
C) Splint the affected digit for 2–4 weeks
D) Remove the nail to evaluate for a nail bed injury
E) Refer to a hand surgeon

Answer 12

ANSWER: C
Tuft fractures are the most common type of distal phalanx fracture. They rarely require orthopedic referral but often result in up to 6 months of hyperesthesia, pain, and numbness. Treatment involves splinting the affected digit for 2–4 weeks, followed by range of motion and strengthening exercises. Symptomatic treatment may also be involved, but splinting is needed. Taping digits would likely not provide enough stability for the second digit distal phalanx, which extends beyond the first digit. Patients with distal finger injuries need careful physical examination to evaluate for a nail bed injury, but in this case there is no evidence of nail bed damage or laceration.

Question 13

A 72-year-old female with a history of type 2 diabetes and hypertension presents to your clinic because of fatigue and depression for the last 5–6 months. She has gained about 7 kg (15 lb) and now has a BMI of 32 kg/m2. A physical examination is otherwise unremarkable. Laboratory studies reveal a TSH level of 8.2 U/mL (N 0.4–4.0). A repeat test 1 month later shows a TSH level of 7.4 U/mL and a free T4 level of 1.6 ng/dL (N 0.8–2.8).
Treatment of this patient with L-thyroxine
A) has no proven benefit
B) can increase grip strength
C) can increase her energy level
D) can help improve depression symptoms
E) can reduce her BMI

Answer 13

ANSWER: A
Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4 level. It is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST (Thyroid Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of randomized, controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle strength, fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A), and up to 60% of cases resolve within 5 years without intervention in older adults.
Appropriate management of an elevated TSH level includes repeat testing in 1–3 months along with a free T4 level. If SCH is diagnosed, levels should be monitored yearly. Only 2%–4% of patients with SCH develop overt hypothyroidism.

Question 14

A 72-year-old male with a history of hypertension, heart failure, and chronic kidney disease sees you for evaluation of gradually worsening lumbar pain. The pain worsens with walking but improves when he sits. He says that the pain radiates to the buttocks and down the right leg, especially with activity. He has not had any fevers, chills, or new urinary symptoms. MRI indicates severe degenerative changes resulting in moderate to severe canal stenosis at the L4-L5 level.
Which one of the following would be most appropriate at this point?
A) Oral diclofenac, 75 mg twice daily
B) Oral pregabalin (Lyrica), 75 mg twice daily
C) Physical therapy
D) Referral to an orthopedic surgeon for elective surgical resolution
E) Referral to a neurosurgeon for urgent surgical resolution

Answer 14

ANSWER: C
Lumbar spinal stenosis is a common cause of low back pain in older adults, with varying reports of prevalence but at least 10% in most studies. It is the most common reason for lumbar spinal surgery in the United States. Management of this condition is delayed due to the lack of strong evidence for definitively efficacious nonsurgical approaches, and by high rates of major complications with surgical approaches. Focused physical therapy has the best evidence for initial management. Given this patient’s cardiac and renal comorbidities, chronic use of oral NSAIDs is likely to cause significant harm. While some oral pain medications may be considered, pregabalin has not been found to be any more effective than placebo. Both orthopedic and neurosurgical subspecialists perform lumbar spinal surgeries across the United States. In this case, there is no indication for urgent or emergent surgical management. Given the high complication rate, elective surgical management should be considered only after more conservative options have been found ineffective.

Question 15

A 28-year-old female presents with a depressed mood and sleep disturbance. She tells you that this has occurred for the past 4 years but only during the winter months. Her past medical history and a physical examination are unremarkable.
Which one of the following interventions has the strongest evidence for preventing recurrence of her condition?
A) Exercise
B) Light therapy
C) Cognitive-behavioral therapy
D) Bupropion (Wellbutrin XL)
E) Fluoxetine (Prozac)

Answer 15

ANSWER: D
This patient has seasonal affective disorder (SAD) that has recurred and is likely to continue to recur. Bupropion is the only medication beneficial for prevention of SAD. Light therapy and SSRIs are helpful for treating this disorder but do not prevent it. Exercise and cognitive-behavioral therapy are beneficial adjuncts to treatment but would not prevent recurrence.

Question 16

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 16

ANSWER: C
This patient most likely has peroneal tendinopathy, which is a degeneration of the peroneal tendon that involves pain or tenderness in the lateral calcaneus below the ankle along the path to the base of the fifth metatarsal. Initial treatment options include activity modification, decreasing pressure to the affected area, anti-inflammatory or analgesic medications, and eccentric exercises. Calcaneal apophysitis, or Sever’s disease, is a common growth-related injury that typically affects adolescents between 8 and 12 years of age. Symptoms often present after a growth spurt or starting a new high-impact sport or activity, and common examination findings include tight heel cords and a positive calcaneal squeeze test. A calcaneal stress fracture, which most commonly occurs immediately inferior and posterior to the posterior facet of the subtalar joint, involves pain that intensifies with activity and often worsens to include pain at rest. It typically follows an increase in weight-bearing activity or a switch to running or walking on a hard surface. Plantar fasciitis is characterized by sharp, shooting pain in the arch and medial aspect of the foot that often is worse upon arising and taking the first few steps of the morning. Examination of the foot reveals tenderness at the site and pain with dorsiflexion of the toes. Tarsal tunnel syndrome involves entrapment of the posterior tibial nerve and causes a burning, tingling, or shooting pain and numbness that radiates into the plantar aspect of the foot, often into the toes. The pain associated with tarsal tunnel syndrome typically worsens with activity and is relieved with rest.

Question 17

A 30-year-old female with type 2 diabetes and obesity sees you for follow-up. She has experienced several episodes of symptomatic hypoglycemia, and because of this she stopped all of her medications except metformin (Glucophage). Her hemoglobin A1c has increased to 8.4%.
Which one of the following would be the best additional treatment for this patient?
A) Basal insulin (Lantus)
B) Rapid-acting insulin (Humalog)
C) Exenatide (Byetta)
D) Glipizide (Glucotrol)
E) Repaglinide

Answer 17

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

Question 18

A 43-year-old female comes to your clinic for a routine health maintenance examination. She has a past medical history of diarrhea-predominant irritable bowel syndrome (IBS-D), recurrent urinary tract infections (UTIs), and bacterial vaginosis. She has no new health concerns today. She does not take any medications on a regular basis, and states that she prefers natural supplements to prescription medications. She says that she has heard that oral probiotics are beneficial and asks if they might be the right choice for her.
Which one of the following is the best evidence-based approach to counseling her about oral probiotics?
A) There is no evidence that they will improve her IBS
B) There is no evidence that they will decrease the risk of Clostridioides (Clostridium)
difficile diarrhea when she is treated for a UTI
C) There is strong evidence that they will decrease the risk of antibiotic-associated diarrhea
when she is treated for a UTI
D) There is strong evidence that they will decrease the risk of UTI recurrence
E) There is strong evidence that they will decrease the risk of bacterial vaginosis recurrence

Answer 18

ANSWER: C
For this 43-year-old patient, there is strong evidence based on Cochrane reviews that the use of probiotics may reduce the risk of both antibiotic-associated diarrhea more generally, and Clostridioides (Clostridium) difficile diarrhea specifically, when antibiotics are used (level of evidence A). Evidence is not as strong for their impact in adults over the age of 65. The preponderance of evidence for the effective use of probiotics is with diarrhea-predominant irritable bowel syndrome, and systematic reviews have generally supported their use for this condition. There is little evidence that probiotics decrease the incidence or recurrence of urinary tract infections. Topical, not oral, preparations of probiotics have good evidence for reducing the risk of recurrent bacterial vaginosis.

Question 19

A 70-year-old female with a history of coronary artery disease, a femorofemoral bypass 3 years ago, and hypertension sees you for a follow-up visit. She has intermittent right arm pain that is worse with exercise. The pain increases with all arm exercises and improves with rest. The patient’s blood pressure is 140/70 mm Hg in the left arm and 120/64 mm Hg in the right arm.
Which one of the following would be the most appropriate next step?
A) Radiographs of the right shoulder
B) Arterial duplex ultrasonography of the upper extremities
C) MR angiography
D) No imaging, and referral to physical therapy

Answer 19

ANSWER: B
This patient has peripheral artery disease (PAD) of the right arm. PAD of the upper extremities is characterized by pain with exertion and can cause gangrene and ulceration. It is more common in patients who have had lower extremity occlusive disease. A blood pressure differential of 15 mm Hg between arms suggests stenosis and warrants further testing. Initial testing in symptomatic patients includes arterial duplex ultrasonography of the upper extremities. CT angiography and MR angiography may be appropriate to clarify the diagnosis or plan intervention. Neither radiography nor physical therapy would be appropriate.

Question 20

Which one of the following has been shown to be an appropriate therapeutic intervention for nonspecific low back pain?
A) Bed rest
B) A lumbar brace
C) Muscle relaxants
D) Shoe insoles
E) Yoga

Answer 20

ANSWER: E
Nonspecific low back pain is a condition with no distinct etiology to explain the patient’s associated symptoms. Physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention in the treatment of nonspecific low back pain. The Choosing Wisely campaign states that bed rest should not be recommended for low back pain, and lumbar supports or braces should not be prescribed for the long-term treatment or prevention of low back pain. Studies have consistently shown that NSAIDs combined with muscle relaxants have no benefit over NSAIDs alone. Interventions such as shoe insoles have shown little benefit.

Question 21

An otherwise healthy 21-year-old male sees you for follow-up after a hospitalization for pneumonia. This was his second pneumonia infection of the year. He reports a history of multiple sinus infections and upper respiratory infections over the years that were treated with antibiotics on an outpatient basis. Laboratory studies reveal a normal CBC and a decreased IgA level. A trial of pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) reveals no measurable response.
This presentation is most consistent with
A) selective IgA deficiency
B) common variable immunodeficiency
C) severe combined immunodeficiency
D) DiGeorge syndrome
E) Wiskott-Aldrich syndrome

Answer 21

ANSWER: B
Common variable immunodeficiency (CVID) is the only immunodeficiency condition listed that can present later in life, while severe combined immunodeficiency, DiGeorge syndrome, and Wiskott-Aldrich syndrome typically present prior to 6 months of age. CVID is a condition of impaired humoral immunity and thus should be considered in a patient this age in the setting of recurrent bacterial infections such as sinusitis or pneumonia. The blunted response to a vaccination challenge implies impaired IgG antibody response, which differentiates CVID from a selective IgA deficiency. Because severe combined immunodeficiency is associated with significant abnormalities of both T-cell and B-cell function, it presents very early in life with multiple severe, opportunistic infections, and failure to thrive. DiGeorge syndrome is associated with multiple other physical abnormalities such as cardiac malformations and dysmorphic facial features. Wiskott-Aldrich syndrome is linked to the X chromosome (primarily affecting males) and associated with eczema and thrombocytopenia.

Question 22

A 55-year-old female with type 2 diabetes sees you because of early satiety, nausea, vomiting, bloating, and postprandial fullness that is sometimes accompanied by upper abdominal pain. Since these symptoms have developed she has also noted increasing difficulty with blood glucose control.
Which one of the following would be the best study for confirming the most likely diagnosis?
A) Gastric emptying scintigraphy with a solid meal
B) Hepatobiliary scintigraphy (HIDA)
C) An upper gastrointestinal series with small-bowel follow-through
D) Abdominal ultrasonography
E) Abdominal CT

Answer 22

ANSWER: A
Gastroparesis is a complication of diabetes mellitus, and presents with nausea, vomiting, early satiety, bloating, postprandial fullness, and/or upper abdominal pain. Gastric emptying scintigraphy with a solid meal is the first-line study for confirming the diagnosis. Hepatobiliary scintigraphy (HIDA) is used to evaluate biliary dyskinesia and is not indicated in this patient. An upper gastrointestinal radiographic series, abdominal ultrasonography, and CT of the abdomen can help to rule out obstructive pathology, biliary tract disease, and other gastrointestinal conditions but would not confirm the diagnosis. The patient should also undergo esophagogastroduodenoscopy to exclude obstruction.

Question 23

The administrator in your practice recently attended a quality improvement conference. He would like to start a clinic-wide program to focus on lead screening in asymptomatic children 5 years of age and younger.
After reviewing U.S. Preventive Services Task Force guidelines, which one of the following should you tell the practice administrator?
A) There is insufficient evidence to recommend for or against lead screening in children 5 years of age and younger
B) All children 5 years of age and younger should undergo lead screening
C) All children who live in housing built before 1978 should undergo lead screening
D) There are accurate and reliable screening questionnaires to guide lead screening

Answer 23

ANSWER: A
The U.S. Preventive Services Task Force (USPSTF) has found adequate evidence that questionnaires and other clinical prediction tools to identify asymptomatic children with elevated blood lead levels are inaccurate. The USPSTF went on to conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years of age and younger. Although children living in older housing with lead-based paint are at higher risk of elevated blood lead levels than those living in housing built after 1978, the USPSTF does not recommend routine screening in asymptomatic children based on this risk factor.

Question 24

A 3-year-old male is brought to your office by his mother because he stepped on a large wooden splinter that broke off at the surface of his left foot and since then he has been avoiding walking on that foot. On examination the bottom of the left heel is red and inflamed.
Which one of the following would be most appropriate initially to visualize the splinter?
A) Radiography
B) Fluoroscopy
C) Ultrasonography
D) CT E) MRI

Answer 24

ANSWER: C
Foreign bodies can be challenging to both detect and remove, especially in younger children. Ultrasonography is good for detecting radiolucent material such as wood or vegetation. MRI can also be used but is more expensive and not as readily available, and may be dangerous if metal is present. There is no radiation exposure with either of these modalities. Plain radiography creates minimal exposure to radiation and can detect radiopaque materials such as glass and metal but cannot detect vegetative materials. Fluoroscopy would be an option to detect radiopaque materials, but not a wooden splinter. CT would not be used for initial evaluation given the cost and high level of radiation exposure. In addition, like plain radiography, CT does not adequately detect radiolucent material.

Question 25

A 55-year-old male sees you because of a second flare of gout. He has also had an elevated blood pressure at the last few visits to your clinic and is hypertensive again today. In addition to treating his gout flare, which one of the following would be the most appropriate agent to treat his hypertension in light of his presenting problem? A) Atenolol (Tenormin) B) Hydralazine C) Hydrochlorothiazide D) Lisinopril (Prinivil, Zestril) E) Losartan (Cozaar)

Answer 25

ANSWER: E The 2020 American College of Rheumatology guideline for the management of gout generated numerous recommendations, including the management of concurrent medications in patients with gout. In such patients, losartan is the preferred antihypertensive agent when possible (SOR C). Hydrochlorothiazide should typically be changed to another agent, such as losartan, when feasible in patients with gout (SOR C). Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations, with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril as antihypertensive treatment in patients with gout.

Question 26

Which one of the following is the preferred method of diagnosing lymphoma in a 60-year-old male who presents with weight loss, unexplained fever, and axillary adenopathy? A) CT of the chest, pelvis, and abdomen pre- and post-contrast B) A PET-CT scan C) A bone scan D) A bone marrow aspiration and biopsy E) An open lymph node biopsy

Answer 26

ANSWER: E An open lymph node biopsy is the preferred method for making the diagnosis of lymphoma. Although fine-needle aspiration and core needle biopsy are often part of the initial evaluation of any adenopathy, neither will provide adequate tissue for the diagnosis of lymphoma. A PET-CT scan may be used for staging. A bone scan or CT alone is not part of the usual diagnostic evaluation

Question 27

A 30-year-old female who is an established patient calls your office to request a test for COVID-19. The patient spent several hours inside the home of another individual who just received a positive COVID-19 test result. She states that her sense of taste seems diminished, but she has no respiratory symptoms and otherwise feels well. Which one of the following is the typical incubation period for COVID-19? A) 1day B) 5 days C) 14 days D) 30 days

Answer 27

ANSWER: B SARS-CoV-2 is a respiratory coronavirus that is responsible for COVID-19. Knowledge of the natural history of the viral infection will inform testing strategies and many other aspects of counseling of patients. The incubation period measures the time from exposure to symptom onset. The typical incubation period for COVID-19 is approximately 4–5 days, though it can range from 1–14 days.

Question 28

A 45-year-old female with a 4-year history of type 2 diabetes is taking only metformin (Glucophage) and maintaining a hemoglobin A1c of 6.6%. Her LDL-cholesterol level is 94 mg/dL. She has no complications related to diabetes and her medical history is otherwise unremarkable. Which one of the following should be added to her current medication regimen? A) A DPP-4 inhibitor B) An SGLT2 inhibitor C) A low-intensity statin D) A moderate-intensity statin E) A high-intensity statin

Answer 28

ANSWER: D All patients between 40 and 75 years of age with diabetes mellitus and an LDL-cholesterol level 70 mg/dL should begin taking a moderate-intensity statin. It is not necessary to calculate a 10-year risk for atherosclerotic cardiovascular disease because the results do not alter the recommendation. This patient’s hemoglobin A1c is <7%, which is acceptable, and she does not need additional hypoglycemic medications. She has no diabetes-specific risk-enhancing conditions such as a long duration of illness, chronic kidney disease, retinopathy, neuropathy, or an ankle-brachial index <0.9. Older age and risk-enhancing conditions may require increasing the statin to high-intensity dosages. A DPP-4 inhibitor, an SGLT2 inhibitor, and a low-intensity statin would not be appropriate for this patient at this time.

Question 29

A 23-year-old primigravida comes to your office for her initial obstetric visit. She is at 13 weeks gestation based on the dates of her last menstrual period. She is a nonsmoker and does not drink alcohol or use illicit substances. Her vital signs are remarkable for a blood pressure of 142/92 mm Hg and a BMI of 32 kg/m2. She says that she has been diagnosed with hypertension in the past but has not taken any medications for it. In addition to a prenatal vitamin, which one of the following would you recommend for her? A) No additional medications B) Aspirin C) Ferrous sulfate D) Folic acid E) Labetalol (Trandate)

Answer 29

ANSWER: B The U.S. Preventive Services Task Force (USPSTF) recommends prescribing low-dose aspirin after 12 weeks gestation for asymptomatic women at high risk for preeclampsia. Women at high risk include those with a history of preeclampsia, chronic hypertension, multiple pregnancy, type 1 or 2 diabetes, renal disease, autoimmune disease, or any combination of these. Many women become iron deficient in pregnancy but not all will require additional iron supplementation beyond what is available in the prenatal vitamin. The USPSTF found insufficient evidence to recommend for or against routine iron supplementation for pregnant women. Additional folic acid is recommended for women with increased risk for neural tube defects (NTDs), and while obesity increases the risk for NTD it is not an indication alone for a higher dosage of folic acid than the levels found in prenatal vitamins. In pregnant patients with chronic hypertension, treatment with antihypertensive medications is recommended only when the blood pressure is >150/100 mm Hg, because aggressive blood pressure lowering may result in placental hypoperfusion.

Question 30

A 45-year-old female presents with a lesion on her mid-back (shown below) that measures 1.2 mm in diameter. A punch biopsy confirms nodular basal cell carcinoma. She is otherwise healthy and does not take any daily medications. She is concerned about the cosmetic appearance after treatment. Which one of the following would be the most appropriate treatment strategy? A) No further management B) Topical fluorouracil 5% (Efudex) C) Cryotherapy D) Curettage and electrodesiccation E) Standard excision with 4-mm margins

Answer 30

ANSWER: E Surgical excision is indicated for the management of larger basal cell carcinomas. Although this patient had a punch biopsy, that is not considered curative and excision with wide margins is indicated. Topical therapy and cryotherapy are reserved for patients who decline surgery or for cases in which surgery is contraindicated. The combination of curettage and electrodesiccation is a management option, but the cosmetic results are not as desirable as with excision.

Question 31

A 68-year-old female comes to your office for a follow-up visit for diabetes mellitus. Her home glucose monitor record shows a range of 68–125 mg/dL. Her medications include atorvastatin (Lipitor), 40 mg daily; metformin (Glucophage), 750 mg twice daily; and insulin glargine (Lantus), 10 U nightly. Laboratory studies are remarkable for a hemoglobin A1c of 5.8% and a creatinine level of 0.98 mg/dL (N 0.6–1.1). She maintains healthy lifestyle behaviors such as walking 30 minutes 5 days per week and avoiding sweetened beverages. Which one of the following would be the most appropriate treatment plan? A) Continue the current medication regimen B) Increase the insulin glargine dosage C) Increase the metformin dosage D) Discontinue insulin glargine E) Discontinue metformin

Answer 31

ANSWER: D According to the ACCORD (Action to Control Cardiovascular Risk in Diabetes) and ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) trials, aggressive management of diabetes mellitus to achieve a hemoglobin A1c <6.5% increases the risk of patient harm and does not provide clinical benefit. The American Diabetes Association recommends metformin as first-line therapy, which is supported by the STEPS criteria: safety, tolerability, effectiveness, price, and simplicity. Insulin glargine increases the risk of hypoglycemia, which this patient reports. In addition, it is expensive and more complex to administer insulin compared to an oral medication. Since this patient is on a starting dosage of insulin glargine and her hemoglobin A1c is well below 6.5%, she should discontinue insulin glargine and maintain metformin as a first-line choice that is well tolerated.

Question 32

A 78-year-old male with terminal lung cancer and long-standing COPD is admitted to a regular medical-surgical care unit pending transfer to the hospice unit within the next day. You are called about worsening anxiety and dyspnea. The patient is alert and anxious. He has a blood pressure of 150/94 mm Hg, a pulse rate of 96 beats/min, a respiratory rate of 24/min, and an oxygen saturation of 93% on 2 L/min of oxygen via nasal cannula. Which one of the following would be most effective in this situation? A) 40% oxygen by venti-mask B) Dexamethasone C) Hyoscyamine (Anaspaz) D) Lorazepam (Ativan) E) Morphine sulfate

Answer 32

ANSWER: E Opiates are the most effective agents for treating dyspnea and the resultant anxiety in patients with terminal cancer. Higher levels of oxygen are indicated if the patient’s oxygen saturation is <92% and with caution in patients with COPD so as not to suppress respiratory drive. Dexamethasone, hyoscyamine, and lorazepam have a frequent role in patients such as this one, but morphine sulfate or a similar fast-acting opiate is the drug of choice (SOR B).

Question 33

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 33

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 B-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 34

A 42-year-old female presents to your office with heavy menstrual periods and pelvic pressure. Her symptoms began several years ago and have gradually worsened. Laboratory findings are notable for a mild microcytic anemia. Pelvic ultrasonography identifies a 7-cm submucosal mass. She wants to avoid a hysterectomy but desires a treatment that will provide symptom relief, decrease the volume of the mass, and have a sustained effect. Which one of the following would be most appropriate for this patient? A) Expectant management B) A GnRH agonist C) A selective estrogen receptor modulator D) A levonorgestrel-releasing IUD (Mirena) E) Uterine artery embolization and occlusion

Answer 34

ANSWER: E This patient presents with a symptomatic fibroid. Although she does not express a desire to maintain fertility, she prefers uterine preservation. The Agency for Healthcare Research and Quality Effective Health Care Program review found consistent evidence that uterine artery embolization and occlusion is effective for reducing fibroid size, with lasting effects up to 5 years and moderate evidence for reducing bleeding and improving quality of life. Expectant management is an appropriate option only for patients who have asymptomatic fibroids. GnRH agonists are effective for providing symptom relief and reducing fibroid size, but their use results in a hypoestrogenized state and should not be continued long term for a sustained effect in premenopausal women. Treatment with a selective estrogen receptor modulator such as raloxifene does not affect fibroid size or bleeding patterns. There is limited data regarding the efficacy of a levonorgestrel-releasing IUD for the treatment of uterine fibroids.

Question 35

A 58-year-old male with a history of a neurogenic bladder comes to your office as a new patient. He recently elected to have placement of a chronic indwelling urethral catheter rather than performing intermittent catheterization at home, and he asks how to reduce his risk of urinary tract infections (UTIs). His last UTI was approximately 1 year ago and required intravenous antibiotics. Which one of the following is most effective for preventing UTIs in patients with chronic indwelling urethral catheters? A) Routine daily hygiene of the meatal surface with soap and water B) Daily periurethral cleaning with iodine C) Daily oral antibiotics based on prior urine culture sensitivities D) Routine instillation of an antimicrobial solution into the drainage bag E) Regularly scheduled catheter exchanges at fixed intervals

Answer 35

ANSWER: A Although use of chronic indwelling urethral catheters should be avoided whenever possible, there are still some patients that will require one. Prevention of catheter-associated urinary tract infections (CAUTIs) is important. The most important measure to prevent CAUTIs is routine cleaning of the meatal surface with soap and water while bathing or showering. Use of specific periurethral antiseptics or instillation of antiseptics into the drainage bag does not reduce rates of CAUTI. Daily oral antibiotics are not indicated to prevent CAUTIs. Catheters and drainage bags should only be changed when clinically indicated, such as when there is an infection or obstruction.

Question 36

A 68-year-old male presents with a burn on his lower leg after trying to light a bonfire with kerosene. Examination of the affected leg reveals the presence of blistering, along with a denuded central area that does not blanch with pressure. The underlying fat and connective tissue are not involved. Which one of the following is the proper classification of this burn? A) Superficial burn B) Superficial partial-thickness burn C) Deep partial-thickness burn D) Full-thickness burn

Answer 36

ANSWER: C Decisions regarding the management of burn wounds depend on first identifying the depth of the burn. Superficial burns are red, painful, and blanching, and they do not blister. Superficial partial-thickness burns blister and blanch with pressure. Deep partial-thickness burns blister, but do not blanch with pressure. Full-thickness burns extend through the entire dermis and into the underlying tissues, and they are dry and leathery. Patients with deep partial-thickness or full-thickness burns should be evaluated by a burn specialist.

Question 37

A 71-year-old female with a history of well controlled hypertension, diabetes mellitus, and osteoporosis presents with a 2-day history of fever, chills, and a productive cough. She lives at home with her husband, who has not noted any confusion but says she has been weak and unable to bathe herself. On examination the patient has a temperature of 38.2°C (100.8°F), a blood pressure of 110/68 mm Hg, unlabored respirations at a rate of 22/min, and an oxygen saturation of 94% on room air. You note that she has good air entry, there are no abnormal breath sounds, and there is no egophony or increased fremitus. The cardiovascular examination is unremarkable. Laboratory Findings WBCs                                14,000/mm3 (N 4500–11,000) Hemoglobin                           12.5 g/dL (N 14.0–17.5) Platelets                              250,000/mm3 (N 150,000–350,000) Creatinine                             1.0 mg/dL (N 0.6–1.2) BUN                                 14 mg/dL (N 8–23) Posteroanterior and lateral chest radiographs show an infiltrate in the right middle lobe. Which one of the following would be the most appropriate treatment for this patient? A) Azithromycin (Zithromax) B) Amoxicillin plus metronidazole (Flagyl) C) Amoxicillin/clavulanate (Augmentin) plus azithromycin D) Azithromycin plus levofloxacin E) Clindamycin (Cleocin) plus doxycycline

Answer 37

ANSWER: C Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other health care setting, and it is a significant cause of morbidity and mortality in adults. This patient has CAP in the presence of a significant comorbidity (diabetes mellitus). After CAP is diagnosed the first decision to make is whether hospitalization is needed. In all patients with CAP, mortality and severity prediction scores should be used to determine inpatient versus outpatient care (SOR A). This patient has a CURB-65 score of 1 (age 65 years), so she can be treated as an outpatient. For outpatients with comorbidities, amoxicillin/clavulanate is a possible treatment option, but it should be paired with a macrolide. Macrolides such as azithromycin are the treatment of choice for previously healthy outpatients with no history of antibiotic use within the past 3 months. Azithromycin monotherapy, amoxicillin plus metronidazole, azithromycin plus levofloxacin, or clindamycin plus doxycycline would not be appropriate treatment strategies for this patient with a significant comorbidity.

Question 38

An 8-year-old female is brought to your office because of left arm pain after she fell down on the sidewalk while roller skating. She has pain, swelling, and a mild deformity of her distal forearm over the radius. Posteroanterior and lateral radiographs confirm an incomplete compression fracture of the distal radius. In addition to a short arm splint, which one of the following would be appropriate management of this fracture? A) Ultrasonography in 3 weeks B) Repeat radiography in 4 weeks C) Return to activity in 4 weeks if she is pain free D) Follow-up and reevaluation in 6 weeks E) Referral to an orthopedist

Answer 38

ANSWER: C This patient has a compression fracture of the distal radius, also known as a buckle fracture. There is no cortical disruption and these are inherently stable fractures. Radiography or ultrasonography may be used as the initial imaging study if a buckle fracture is suspected. Treatment consists of short arm immobilization, which is most easily performed with a removable splint or wrist brace. The Choosing Wisely campaign states that these fractures do not require repeat imaging if there is no longer any tenderness or pain with palpation after 4 weeks of splinting, and the patient can return to full activity as tolerated. These fractures do not require referral to an orthopedist and can be managed in the office.

Question 39

While on rounds in the newborn nursery, you receive a call about a 2-day-old infant born at 39 weeks gestation. According to the American Academy of Pediatrics standard treatment guidelines for infants at high risk of bilirubin encephalopathy, the infant has an elevated total serum bilirubin level that is approaching the threshold for initiating phototherapy. Which one of the following additional factors would be the strongest indication for phototherapy in this infant? A) East Asian ethnicity B) Exclusive breastfeeding C) A positive direct antibody titer (Coombs test) D) A sibling with a history of neonatal jaundice E) Untreated maternal group B streptococcal colonization

Answer 39

ANSWER: C Although up to 84% of term newborns experience neonatal jaundice, severe hyperbilirubinemia (total serum bilirubin level >20 mg/dL) occurs in <2% of term infants. Prompt identification and management of severe hyperbilirubinemia is critical due to the risk of neurologic injury from untreated bilirubin toxicity. Acute bilirubin encephalopathy develops in 1 in 10,000 infants, and kernicterus (chronic bilirubin encephalopathy) occurs in 1 in 100,000 infants and can lead to permanent neurodevelopmental delay. Neonates at high risk of bilirubin toxicity are treated with phototherapy to decrease bilirubin levels through the breakdown of unconjugated bilirubin into byproducts that are excreted into stool and urine. In infants at even higher risk, exchange transfusion may be indicated. Treatment guidelines published by the American Academy of Pediatrics stratify infants according to risk. Risk factors for toxicity include earlier gestational age at birth, hemolysis, sepsis, acidosis, G6PD deficiency, lethargy, asphyxia, temperature instability, acidosis, and hypoalbuminemia. Of the options listed, hemolysis, which is associated with a positive direct antibody titer (Coombs test), is the most significant risk factor for developing acute bilirubin encephalopathy, and therefore impacts the treatment threshold for initiation of phototherapy. While East Asian race, exclusive breastfeeding, and a sibling with a history of neonatal jaundice are risk factors for severe hyperbilirubinemia, they do not impact the phototherapy treatment threshold. Similarly, untreated maternal group B Streptococcus colonization may increase an infant’s risk of developing neonatal sepsis, although it is not a direct risk factor for bilirubin encephalopathy.

Question 40

An obese 32-year-old male is admitted to the hospital with a new onset of acute pancreatitis. A lipid panel reveals a triglyceride level of 1150 mg/dL and an HDL-cholesterol level of 30 mg/dL. Other laboratory studies are normal. His 10-year risk of atherosclerotic cardiovascular disease is <5%. His family history is positive for recurrent pancreatitis in his father and paternal grandfather. In addition to lifestyle modifications, which one of the following would be most appropriate for this patient after he is discharged? A) Atorvastatin (Lipitor) B) Colesevelam (Welchol) C) Ezetimibe (Zetia) D) Fenofibrate (Tricor) E) Omega-3-acid ethyl esters (Lovaza)

Answer 40

ANSWER: D Fibrates reduce the likelihood and recurrence of pancreatitis due to severe hypertriglyceridemia when triglyceride levels are 500 mg/dL, measured in a fasting or nonfasting state (SOR A). This patient’s risk of atherosclerotic cardiovascular disease is <7.5% and his LDL-cholesterol level is within normal range, so initiating a statin or ezetimibe is not indicated. Colesevelam may be used to reduce LDL-cholesterol and glucose levels but is not considered a first-line treatment. Omega-3-acid ethyl esters will reduce the triglyceride levels but this patient has severe hypertriglyceridemia, so fibrate therapy is recommended to prevent recurrent pancreatitis.

Question 41

A 23-year-old gravida 1 para 1 who is a single mother of a 3-day-old infant comes to your office for a newborn follow-up. She reports some sleep disturbance, mild depression without suicidal ideation, and financial concerns. Her past medical history is significant for persistent depressive disorder. The U.S. Preventive Services Task Force recommends which one of the following to help prevent perinatal depression in patients such as this? A) Exercise B) Amitriptyline C) Sertraline (Zoloft) D) Referral for cognitive-behavioral therapy

Answer 41

ANSWER: D The U.S. Preventive Services Task Force (USPSTF) recommends counseling interventions to prevent perinatal depression in patients who are at risk. This patient has risk factors for perinatal depression, including young age, single motherhood, and a history of depression. Other risk factors include low socioeconomic status and depressive symptoms. The USPSTF found that the benefits of counseling interventions outweigh the harms. The USPSTF could not find evidence that exercise, amitriptyline, or sertraline were beneficial.

Question 42

A 34-year-old male sees you because he was recently informed that a partner he had unprotected sex with last month has been diagnosed with HIV. You would advise this patient to initiate ongoing antiretroviral therapy A) immediately, because HIV testing is not necessary prior to initiation B) at the time of diagnosis of HIV infection C) when his CD4 cell count drops to <200 cells/ L D) when his CD4 cell count drops to <500 cells/ L E) when he develops an AIDS-defining illness

Answer 42

ANSWER: B Antiretroviral therapy (ART) should be prescribed at the time of diagnosis of HIV infection unless the patient has expressed a desire to not initiate treatment. ART should not be delayed until the CD4 cell count drops to a predetermined level or until an AIDS-defining illness occurs. It is recommended to initiate prophylaxis for Pneumocystis pneumonia when the CD4 cell count drops below 200 cells/ L.

Question 43

A 58-year-old male sees you for evaluation of left ankle pain after he slipped on some ice in his driveway last night. He felt immediate pain over the lateral ankle, which started swelling over the next hour. He elevated his foot, applied ice, and took ibuprofen. This morning the ankle remains swollen and also appears bruised. He is able to walk on it with some pain. On examination you note typical findings of an ankle sprain. He asks you for medication to manage his pain. Which one of the following medications has the best evidence for providing pain relief while also minimizing side effects? A) Topical diclofenac gel (Pennsaid) B) Topical menthol gel C) Oral hydrocodone/acetaminophen (Lortab) D) Oral ibuprofen E) Oral tramadol

Answer 43

ANSWER: A In 2020 the American College of Physicians and the American Academy of Family Physicians published a guideline regarding the treatment of acute pain from musculoskeletal injuries (non–low back related). This systematic review found good evidence to support the recommendation that topical NSAIDs be used as first-line therapy to reduce pain and improve physical function. Topical NSAIDs were the only intervention that improved multiple outcomes and were not associated with a statistically significant increase in the risk for adverse events. Oral NSAIDs and acetaminophen were recommended as second-line therapies, as they were found to be effective for pain relief but were associated with an increased risk for adverse events. Topical menthol gel was not found to be effective as monotherapy but may be considered when combined with a topical NSAID. The guideline specifically recommends avoidance of opioids, including tramadol, noting a prevalence of 6% for prolonged opioid use resulting from an initial prescription. Nonpharmacologic approaches with evidence of benefit include specific acupressure and use of a transcutaneous electrical nerve stimulation (TENS) uni

Question 44

A 7-year-old male is brought to the urgent care clinic with a 2-day history of fever and sore throat, with no associated cough. His temperature is 38.3°C (100.9°F) and a rapid antigen test confirms a group A -hemolytic Streptococcus infection. A prescription for penicillin is sent to the pharmacy, but the medication is never picked up due to a lack of transportation. The patient is brought to your office 2 weeks later with a fever, joint pain, shortness of breath, and chest pain. His vital signs are significant for a temperature of 38.8°C (101.8°F) and a heart rate of 118 beats/min. On examination the patient’s affect is appropriate, he has a 3/6 holosystolic murmur heard best over the apex, and he has tenderness and swelling of his knees bilaterally and of his left ankle. An antistreptolysin O titer is positive, his erythrocyte sedimentation rate is 124 mm/hr (N <10), and a chest radiograph is significant for cardiomegaly. Which one of the following would be the most appropriate therapy? A) Hydroxychloroquine (Plaquenil) B) Methylprednisolone acetate (Depo-Medrol) C) Naproxen D) Intravenous immunoglobulins E) Plasmapheresis

Answer 44

ANSWER: C Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria (carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate). NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be indicated for management

Question 45

A 51-year-old female presents with concerns about a change in her cognition. She says she has difficulty retrieving words, loses her train of thought, and goes into a room and forgets why she came there. She also has had more frequent hot flashes and sleep disturbances. She still menstruates but has noticed a change from her previous pattern. A physical examination is unremarkable, and recent laboratory tests were all normal, including vitamin B12 and thyroid studies. Cognitive testing is normal. Which one of the following would be the most appropriate next step? A) Reassurance only B) CT of the head C) MRI of the brain D) Hormone therapy E) Referral to a neurologist

Answer 45

ANSWER: A Women experience subjective cognitive difficulties during their menopausal transition. This may include retrieving numbers or words, losing one’s train of thought, forgetting appointments, and forgetting the purpose of behavior such as entering a room. Clinical studies of these women showed intact cognitive test performance. The treatment consists of patient education and reassurance, since studies have shown that 62% of women report subjective cognitive problems during their menopausal transition. Imaging and referral to a neurologist are not indicated, and there are no trials that support the use of hormone therapy.

Question 46

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 46

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 47

A 45-year-old male presents to your office with intermittent chest pain for the past few days, although he is currently pain free after taking aspirin at home. He tells you that while running this morning he had pain every time he ran uphill. The pain is a dull ache on his left chest wall. He has no other associated symptoms and no significant past medical history or family history. His vital signs are stable and a physical examination is unremarkable. An EKG performed at this visit is shown below, along with a previous EKG. Which one of the following would be most appropriate at this point? A) An exercise stress test B) Stress echocardiography C) Coronary CT angiography D) Referral to a cardiologist E) Transportation via ambulance to the emergency department LBBB

Answer 47

ANSWER: E This patient presents with risk factors for coronary artery disease, including male sex and activity-related chest pain. He also has a new left bundle branch block, which necessitates a trip to the emergency department for urgent evaluation. If there were no EKG changes the patient would be at moderate risk for acute coronary syndrome, and further evaluation with an exercise stress test, stress echocardiography, or coronary CT angiography would be indicated. Referral to a cardiologist would lead to further delay and would not be appropriate.

Question 48

An asymptomatic 53-year-old female recently underwent a right breast lumpectomy and radiation therapy with curative intent. Over the next 5 years routine surveillance should include A) annual unilateral left breast mammography B) annual bilateral mammography C) annual bilateral mammography and radionuclide bone scans D) biannual bilateral mammography E) biannual bilateral mammography and annual radionuclide bone scans

Answer 48

ANSWER: B Primary care physicians should ensure that their patients who have undergone treatment for breast cancer follow the recommendations of their oncologist, as well as receive a history evaluation and health maintenance examination every 3–6 months for 3 years, every 6–12 months for 2 more years, and then on an annual basis. For ongoing surveillance only annual mammography is recommended (SOR A), which is bilateral in breast-conserving therapy and unilateral following a mastectomy. Other surveillance testing such as radionuclide bone scans, PET scans, and biomarkers should not be performed in asymptomatic patients who received curative treatment.

Question 49

A 42-year-old transgender male comes to your office for a routine health maintenance examination. The patient’s current medications include testosterone enanthate (Xyosted), 100 mg subcutaneously every 7 days, for gender affirmation, and medroxyprogesterone acetate (Depo-subQ Provera 104), 104 mg subcutaneously every 12 weeks, for contraception. The patient has no current chronic health conditions and no current sexual partners, but he has previously been sexually active with men and women. Which one of the following health conditions is more likely to occur in this patient compared to a female cisgender patient? A) Anemia B) Cervical cancer C) Dyslipidemia D) Kidney disease E) Venous thromboembolism

Answer 49

ANSWER: C Transgender describes persons whose experienced or expressed gender differs from their sex assigned at birth. In the United States approximately 150,000 youth and 1.4 million adults identify as transgender, though many believe these numbers underestimate the actual prevalence. Transgender men who take testosterone may experience increased muscle mass and decreased fat mass, male pattern baldness, increased sexual desire, clitoromegaly, decreased fertility, deepening of the voice, cessation of menses, acne, and a significant increase in body hair, particularly on the face, chest, and abdomen. Risks of testosterone therapy include more atherogenic lipid profiles, an increase in blood pressure, and erythrocytosis (rather than anemia). Severe liver dysfunction is unusual at therapeutic dosages but is a concern at dosages above the recommended therapeutic range. Testosterone therapy has not been associated with cervical cancer, kidney disease, or venous thromboembolism (VTE). Estrogen-based therapies for male-to-female transgender patients do carry an increased risk for VTE. It is not clear whether increased blood pressure and dyslipidemia in these patients translates into an increase in cardiovascular events. Even so, when identified, treatment such as antihypertensive drugs and statins to address these risk factors is recommended as for any other patient.

Question 50

A 72-year-old female presents with pain, swelling, and decreased range of motion in her right great toe for several months. There is no history of injury or overuse. On examination the metatarsophalangeal joint is swollen and mildly tender, but not red. Dorsiflexion and plantar flexion are approximately 30°. A radiograph shows joint space narrowing and a small bone spur. Recommended management at this time would be A) stretching and strengthening exercises B) a rigid shoe insert C) ibuprofen D) a corticosteroid injection E) surgical referral

Answer 50

ANSWER: B Hallux rigidus affects as many as 50% of women and 40% of men by the age of 70. It is usually due to osteoarthritis of the metatarsophalangeal (MTP) joint and presents as decreased range of motion, swelling, and pain. With progression of the condition, flare-ups become more frequent and more severe, and it can be mistaken for gout. Initial treatment is restriction of motion across the MTP joint. A stiffening shoe insert does relieve pain and most patients see improvement without surgery. Custom orthotics, rigid inserts, or hard-soled shoes are options that are more effective than NSAIDs. Corticosteroid injections, preferably administered with ultrasound guidance, and surgery are reserved for those who fail to respond to more conservative measures. Stretching and strengthening exercises are recommended for plantar fasciitis more so than for hallux rigidus

Question 51

A 12-year-old male with type 1 diabetes is brought to your office for routine follow-up. Laboratory work performed prior to the appointment shows an LDL-cholesterol level of 120 mg/dL. In addition to counseling the patient on a heart-healthy diet and daily physical activity, which one of the following would you recommend? A) No additional measures B) Fish oil supplements C) Atorvastatin (Lipitor) D) Ezetimibe (Zetia) E) Gemfibrozil (Lopid)

Answer 51

ANSWER: C Pediatric type 1 diabetes is recognized as a high-risk condition for the future development of cardiovascular disease. Current guidelines recommend initiating a statin, in addition to education regarding a healthy diet and physical activity, for pediatric patients in this high-risk category with an LDL-cholesterol level >100 mg/dL. Statins such as atorvastatin are recommended for first-line treatment according to multiple studies that demonstrate their efficacy and benefits in reduction of cardiovascular morbidity and mortality, along with long-term studies demonstrating their safety. Fish oil supplements, ezetimibe, and gemfibrozil would not be appropriate recommendations for this patient at this time.

Question 52

You are reviewing and updating your routine health care examination electronic health record templates to include formal recommendations from the U.S. Preventive Services Task Force. You also consider age-specific causes of mortality in order to create corresponding preventive strategies. Which one of the following is the leading cause of mortality among people 45–64 years of age? A) Accidents B) Diabetes mellitus C) Heart disease D) Malignancy E) Suicide

Answer 52

ANSWER: D The leading cause of mortality among people aged 45–64 years is malignancy. The U.S. Preventive Services Task Force generally recommends a focus on cancer screening in this age group. Accidents are the third most common cause of mortality in people 45–64 years of age, but they are the leading cause of mortality among people 15–44 years of age, and preventive recommendations reflect interventions to prevent accidents. Diabetes mellitus is the sixth most common cause of mortality in people 45–54 years of age, and the fifth most common cause in people 55–64 years of age. Heart disease is the second most common cause of mortality in people 45–64 years of age, but it is the leading cause of mortality in people 65 years of age and older. Suicide is the fourth most common cause of mortality in adults 45–54 years of age, and the eighth most common cause in adults 55–64 years of age

Question 53

A 44-year-old male with diabetes mellitus, hypertension, obesity, and chronic pain is on chronic opiate therapy. He comes to your office because of a lack of sex drive, decreasing strength, low overall energy levels, and hot flashes. After ruling out other causes you confirm that he has a low total testosterone level on two separate early morning laboratory tests. He would like to start testosterone therapy. Which one of the following would be the most appropriate next step? A) Order a PSA level and perform a digital rectal examination B) Order LH and FSH levels C) Order chromosomal studies D) Discuss risks and benefits of testosterone replacement therapy and start low-dose replacement E) Inform him that testosterone replacement therapy would not be beneficial for him because of its high risk

Answer 53

ANSWER: B After confirming low testosterone with two morning laboratory tests, the next step is to attempt to determine the cause of the low testosterone. Checking LH and FSH levels is recommended to evaluate for primary hypogonadism. If primary hypogonadism is present, chromosomal studies should be considered. Before initiating testosterone therapy, checking the patient’s PSA level and performing a digital rectal examination are recommended, but in this case the initial workup is not yet complete. It is crucial to discuss the risks and benefits of treatment, and as with all medications, it is recommended to start with the lowest dose needed. However, starting treatment in this case is premature. Evidence for testosterone replacement therapy is not as robust as desired and it does carry risks, but as long as there are no contraindications it can be initiated after a discussion of the risks and benefits.

Question 54

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 54

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 55

The mother of a 6-month-old infant is concerned that her child’s feet are “deformed.” On examination the heel bisector line is between the third and fourth digits on the right foot and on the third digit on the left foot. You attempt to flex the feet, and both appear to be rigid. Which one of the following would you recommend as a corrective intervention? A) Night splints B) Adjustable orthotic shoes C) Braces D) Physical therapy E) Surgical correction

Answer 55

ANSWER: B Adjustable orthotic shoes in infants who are not yet walking can be effective for the treatment of metatarsus adductus (SOR B). These orthotics can be adjusted to apply an abduction force on the forefoot while maintaining the heel in a neutral position. Night splints, braces, and physical therapy are not indicated or proven to correct this deformity. Surgery has high complication rates and is rarely indicated to treat metatarsus adductus

Question 56

A patient begins to cry when you tell her that the mammogram she had yesterday shows an abnormality requiring further imaging. The most appropriate response at this time is to A) tell her there is no need to cry B) quickly reassure her that this is most likely benign C) reassure her that most breast cancers have a long survival rate D) wait to specifically address her emotional response until after you have given her more complete information E) stop giving information and address her apparent sadness prior to continuing

Answer 56

ANSWER: E Delivering life-altering news is a difficult but common task for family physicians, who should respect the patient’s individual preferences for receiving bad news and allow adequate time to deliver the information in a private setting with limited interruptions. The physician should accept the patient’s response and acknowledge it at that time, most appropriately with a statement that shows empathy for the emotion. This should be done prior to attempting to immediately reassure her about the prognosis or giving more information. Although telling the patient there is no need to cry may seem reassuring, it is not acknowledging and accepting her response of crying or sadness.

Question 57

A 15-year-old female is brought to your office by her parents for evaluation because they are concerned about her restrictive eating patterns and weight loss. The patient is unconcerned about these issues and says that she feels well and does not need any evaluation. Her parents tell you that for the past 6 months she has had an increasingly restricted diet to the point that she now drinks only water and eats only vegetables and roasted chicken or turkey. They report that she looks much thinner now than she did 6 months ago, but they are uncertain how much weight she has lost. She says that she does not feel depressed or anxious and she is doing well in school. On examination she has a height of 163 cm (64 in) and a weight of 43 kg (95 lb), with a BMI of 16 kg/m2 . She has a pulse rate of 52 beats/min and a blood pressure of 102/68 mm Hg while seated and 84/58 mm Hg while standing. Evaluation of her teeth shows significant erosion of the enamel. When considering the psychotherapy aspect of care for this patient, which one of the following is preferred for treatment of her condition? A) Cognitive-behavioral therapy B) Dialectical behavioral therapy C) Family therapy D) Interpersonal therapy E) Psychodynamic therapy

Answer 57

ANSWER: C This patient has anorexia nervosa, likely a combination of the restrictive subtype and the binge-eating and purging subtype, given the dental findings on examination. This condition is difficult to treat and carries significant risk of mortality, with an estimated aggregate mortality of 5.6% per decade. Coexisting psychiatric conditions are common, with major depression, anxiety disorders, obsessive-compulsive disorder, and trauma-related disorders predominating. Medical complications include disorders of the esophagus and stomach related to repeated vomiting; cardiovascular conditions associated with bradycardia, orthostatic hypotension, and arrhythmias; renal disease due to chronic dehydration and electrolyte abnormalities; and osteoporosis and bone marrow abnormalities. Treatment may be provided in inpatient or outpatient settings, depending on the severity of disease. Psychotherapy is the foundation of treatment and parental involvement is key for children and adolescents. Parents or guardians typically have a high level of distress around their child’s condition and family therapy helps provide consistent support for treatment goals set by the care team. Other types of one-on-one therapy may be appropriate to augment family therapy and for adolescents with specific comorbidities. Psychotropic drugs have not been consistently and clearly shown to add benefit to psychotherapy, although they are often prescribed.

Question 58

A 50-year-old male has an acute upper respiratory infection and cough that has improved but has not resolved completely. He presents to your office today with a 2-day history of chest pain that began gradually. The pain is worse when he is supine, takes deep breaths, or coughs, and he says the pain is relieved when he leans forward while sitting. He is afebrile and his vital signs are normal. An EKG confirms your impression of acute pericarditis, a troponin level is normal, and he does not appear acutely ill. You treat him as an outpatient with ibuprofen, 600 mg three times daily, and omeprazole (Prilosec) for gastrointestinal protection. The patient returns for follow-up 7 days later and tells you that the pain is somewhat improved but still present. He remains afebrile and his other vital signs are normal. On examination he still has a pericardial friction rub but no gallops or murmurs, and his lungs are clear. Which one of the following would be most appropriate at this time? A) Continue his current medications and add colchicine (Colcrys) B) Continue his current medications and add prednisone C) Discontinue his current medications and start aspirin D) Discontinue his current medications and start indomethacin E) Admit him to the hospital and consult a cardiologist

Answer 58

ANSWER: A In a patient with acute pericarditis, after determining that the patient is not at high risk for complications, does not have acute myocardial injury, and is an appropriate candidate for outpatient treatment, there are several options for treatment. Any of the NSAIDs alone are effective in many patients, but some patients do not respond sufficiently, so the addition of colchicine would be the treatment of choice. Colchicine alone is also an appropriate initial treatment, but in case of insufficient response to NSAIDs, the combination is the most effective treatment. Corticosteroids are best reserved for pericarditis related to a connective tissue disease, but they are not recommended in viral or idiopathic pericarditis or in pericarditis in patients with post–acute myocardial infarction pericarditis. Consultation with a cardiologist would be recommended for patients with pericarditis that is severe, is refractory to treatment, or has an unclear etiology.

Question 59

A 55-year-old female presents with swelling and some redness in the area of her right ankle that had a gradual onset over the past week. She has not had any injury, fever, or other signs of systemic illness and has no pain. Her past medical history is significant for type 2 diabetes with polyneuropathy that is moderately well controlled, hypertension, hyperlipidemia, and a BMI of 35 kg/m2 . On examination her right ankle and foot are slightly larger than the left, exhibit faint erythema, and feel slightly warmer than the left. No pain is noted with palpation, and her ankle ligaments appear to be intact. Pedal pulses are 2+ bilaterally and she has no calf pain or swelling. Which one of the following would be the most appropriate next step? A) Reassure her that the lack of pain indicates the absence of a serious disease process B) Prescribe antibiotics for presumed cellulitis C) Recommend compression stockings, leg elevation, and monitoring D) Provide an ankle stabilizing brace E) Obtain bilateral weight-bearing foot radiographs

Answer 59

ANSWER: E Acute Charcot neuropathy is a commonly missed diagnosis, and the diagnosis is delayed in up to 25% of cases. The diagnosis should be considered in patients over age 40 with neuropathy and obesity who present with unilateral foot swelling. There may be associated erythema and warmth, and pain may be absent. In a patient with suspected acute Charcot neuropathy, bilateral weight-bearing radiographs are recommended to detect fractures of the midfoot. Acute Charcot neuropathy is frequently painless, and its consequences can be severe, so it would be inappropriate to counsel a patient that lack of pain means the absence of serious disease. Charcot neuropathy is commonly misdiagnosed as cellulitis. In this patient’s presentation, cellulitis is not a clear diagnosis, and Charcot neuropathy needs to be considered before initiating treatment for cellulitis. Compression stockings and leg elevation are appropriate for peripheral edema when other causes of edema have been evaluated and addressed, but in this case the swelling is lower on the leg than what compression stockings would usually treat, and further evaluation is required prior to treatment. There is no evidence for ankle sprain or instability in this patient, so an ankle brace would not be appropriate.

Question 60

A 34-year-old male began a sexual relationship with a woman 3 months ago and the relationship ended on friendly terms last week. He received a call yesterday from the woman, who said she had developed a rash that resulted in a diagnosis of syphilis and that he should be evaluated and treated if appropriate. He has no symptoms and a serologic test for syphilis is negative. He has no known drug allergies. Which one of the following would be most appropriate at this time? A) Daily self-inspection of the penis to identify a chancre B) Observation with a repeat serologic test for syphilis in 6 weeks C) Azithromycin (Zithromax), 2 g orally as a single dose D) Penicillin G benzathine (Bicillin L-A), 2.4 million units intramuscularly as a single dose E) Penicillin G benzathine, 2.4 million units intramuscularly once weekly for 3 weeks

Answer 60

ANSWER: D The evidence suggests that this patient did not have syphilis prior to this lone contact and a diagnosis of syphilis cannot be confirmed by examination or testing at this point. He should be treated presumptively for early syphilis, even though the serologic test result is negative, because he had sexual contact within the past 90 days with a person who was diagnosed with secondary syphilis. The same is true for individuals exposed to sex partners diagnosed with primary or early latent syphilis during the same time period. When the contact occurred more than 90 days before confirmation of a negative serologic test result, no treatment is necessary. The recommended treatment for individuals such as this patient and for those with primary or secondary syphilis is a single dose of penicillin G benzathine, 2.4 million units. For patients with a penicillin allergy, oral treatment with doxycycline, 100 mg twice daily; tetracycline, 500 mg four times daily; or azithromycin, 2 g as a single dose, has been effective as an alternate treatment option but should only be used when penicillin is contraindicated and should be followed by close monitoring of serologic tests.

Question 61

A 50-year-old male with newly diagnosed type 2 diabetes asks how to reduce his risk of diabetic retinopathy progression. You tell him that in addition to maintaining good glycemic control, the risk can be reduced by A) corticosteroid eye drops B) an ACE inhibitor C) aspirin therapy D) blood pressure control E) lipid management

Answer 61

ANSWER: D The risk of diabetic retinopathy progression can be modified by good glycemic control, maintaining a hemoglobin A1c <7%, maintaining a blood pressure <140/90 mm Hg, and undergoing periodic eye examinations. Corticosteroid eye drops are not appropriate to reduce the risk of diabetic retinopathy. ACE inhibitors are used to help prevent nephropathy. Aspirin therapy and lipid management have no effect on the progression of diabetic retinopathy.

Question 62

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 62

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 63

A 29-year-old male tells you that several years ago he was physically assaulted while walking home from work. Since the assault he has experienced insomnia, anhedonia, irritability, and vivid flashbacks and intrusive thoughts about the assault. Using a screening tool and structured interview you make a diagnosis and discuss treatment. Which one of the following would be the best evidence-based recommendation for initial treatment? A) Alprazolam (Xanax) B) Clonazepam (Klonopin) C) Escitalopram (Lexapro) D) Dialectical behavioral therapy E) Individual trauma-focused psychotherapy

Answer 63

ANSWER: E Posttraumatic stress disorder (PTSD) is regularly seen in primary care practices, with estimated incidences of 8%–20% in the general population. Expert guidelines recommend screening adults at risk of PTSD, such as this patient who was exposed to a traumatic event, with standardized screening tools and then using a structured interview tool if the screen is positive. Once the diagnosis is established, individual trauma-focused psychotherapy is the intervention that demonstrates the most significant benefit. Pharmacotherapy may be used if psychotherapy is not effective or available. Recommended options include fluoxetine, paroxetine, venlafaxine, or sertraline. Benzodiazepines and escitalopram are not recommended in the treatment of PTSD. Dialectical behavioral therapy is used in the treatment of borderline personality disorder.

Question 64

A 62-year-old male is scheduled for CT of the chest with intravenous contrast in the next 48 hours. He has a long-standing history of degenerative joint disease in the right knee, coronary artery disease, and type 2 diabetes. His current medications are low-dose aspirin, metformin (Glucophage), and naproxen. In addition to discontinuing metformin prior to the procedure, which one of the following would you recommend for prevention of contrast-induced nephropathy? A) Discontinue aspirin B) Discontinue naproxen C) Start acetylcysteine D) Start mannitol (Osmitrol)

Answer 64

ANSWER: B In order to prevent contrast-induced nephropathy, NSAIDs such as naproxen should be withheld for 24–48 hours prior to a procedure involving venous or arterial administration of radiocontrast material. Avoidance of volume depletion and other nephrotoxic agents is also recommended. Aspirin in low doses (up to 325 mg) does not impact renal function and therefore does not play a role in the development of contrast-induced nephropathy. Administration of acetylcysteine or mannitol has not been shown to reduce the incidence of contrast-induced nephropathy. Pre- and postprocedural hydration with normal saline is recommended in patients at high risk for developing contrast-induced nephropathy, such as those with underlying chronic kidney disease, heart failure, proteinuria, sepsis, hypovolemia, or hypotension. Metformin does not cause contrast-induced nephropathy but should be withheld due to the potential, mostly theoretical, risk of developing lactic acidosis, especially if contrast-induced nephropathy were to develop (SOR B).

Question 65

You are covering a weekend shift in the local intensive-care unit. When providing care for a very ill adult patient with hypoproliferative thrombocytopenia who is not currently bleeding, prophylactic platelet transfusion should be considered if the platelet count is below a threshold of A) 10,000/ L B) 20,000/ L C) 25,000/ L D) 50,000/ L E) 100,000/ L

Answer 65

ANSWER: A The threshold for transfusing platelets to prevent spontaneous bleeding in the setting of hypoproliferative thrombocytopenia in most adults is <10,000/ L (SOR A). A platelet count <20,000/ L is the threshold for use of elective central venous catheter placement. For elective diagnostic lumbar puncture, major elective non-neuraxial surgery, and interventional procedures, the threshold is a platelet count <50,000/ L. For neuraxial surgery a threshold <100,000/ L is recommended.

Question 66

A 15-year-old female is brought to your office for a routine wellness check. Her only concerns are that she has never menstruated and she is not growing as fast as her peers. She is very active and plays volleyball on a travel team. An examination reveals that her height is now at the 25th percentile, although it was at the 90th percentile when she was 8 years old. She has breast buds that do not extend beyond the areola and her pubic hair is fine and sparse. Laboratory findings include a negative pregnancy test and a normal CBC, metabolic panel, TSH level, and prolactin level. She has an estradiol level of 12 pg/mL (N 25–75), an LH level of 40 mIU/mL (N 5–20), and an FSH level of 50 mIU/mL (N 3–20). The most likely diagnosis is A) congenital adrenal hyperplasia B) constitutional delay of puberty C) pituitary adenoma D) polycystic ovary syndrome E) primary ovarian insufficiency

Answer 66

ANSWER: E Primary amenorrhea is the lifelong absence of menses. If menarche has not occurred by age 15, or no menses have occurred 3 years after the development of breast buds, an evaluation is recommended. The patient’s history should include a review of eating and exercise habits, sexual activity, changes in body weight, perfectionistic tendencies, substance abuse, chronic illness, and timing of breast and pubic hair development. A family history of late growth spurts or late menses may indicate constitutional delay, which manifests as short stature that continues on the same percentile until puberty, when there is a delayed growth spurt to achieve normal height. A physical examination should note trends in height, weight, and BMI. An evaluation should be performed to look for signs of virilization, which would indicate androgen excess found in congenital adrenal hyperplasia, polycystic ovary syndrome, Cushing syndrome, or adrenal tumors. Laboratory testing is usually initiated with a pregnancy test and prolactin, LH, FSH, and TSH levels. Primary ovarian insufficiency is associated with low estradiol levels and high levels of LH and FSH. Generally, the LH/FSH ratio is <1. Patients with congenital adrenal hyperplasia will have low estrogen, LH, and FSH levels. Virilization is generally noted in congenital adrenal hyperplasia, and a 17-hydroxyprogesterone level should be obtained to assess for this condition. Functional hypothalamic amenorrhea will also cause low levels of LH, FSH, and TSH. While polycystic ovary syndrome is associated with low estrogen, LH, and FSH levels, prolactin may be elevated. A pituitary adenoma will cause the prolactin level to be elevated.

Question 67

A 42-year-old male presents with a 3-month history of epigastric pain, bloating, and occasional vomiting after eating. He has not had any weight loss, blood in the stools, or difficulty swallowing. He does not report any significant acid reflux symptoms. Which one of the following would be the best management strategy for this patient? A) Implement lifestyle changes and follow up in 3 months B) Test for Helicobacter pylori and treat if positive C) Initiate a 2-month trial of proton pump inhibitor therapy D) Order esophagogastroduodenoscopy E) Order a barium swallow

Answer 67

ANSWER: B This patient presents with dyspepsia but does not have any alarm symptoms such as weight loss, blood in the stools, or difficulty swallowing. An important cause of dyspepsia is gastric infection with Helicobacter pylori. In patients younger than 55 years of age with no alarm symptoms, a test-and-treat strategy is effective and safe, with esophagogastroduodenoscopy reserved for patients not meeting these criteria (SOR A). Lifestyle interventions and proton pump inhibitor therapy are more effective for GERD. A barium swallow would not be appropriate for this patient at this time.

Question 68

A healthy 36-year-old female who is a nonsmoker sees you for a routine well woman examination. She has been sexually active with five partners in the last 2 years. She has never had an abnormal Papanicolaou (Pap) smear. Last year’s Pap test with high-risk HPV co-testing was negative. You review her immunization status and note that she received the influenza vaccine last fall. Which one of the following vaccines that this patient has never previously received would you recommend for her? A) Hepatitis A vaccine B) HPV vaccine (Gardasil 9) C) Meningococcal polysaccharide conjugate vaccine (Menactra) D) Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) E) Recombinant zoster vaccine (Shingrix)

Answer 68

ANSWER: B The only vaccine indicated for this patient would be the HPV vaccine, which the CDC recommends as a routine vaccination for all patients starting at 11 or 12 years of age through 26 years of age but can also be considered in adults 27–45 years of age who have not previously received the vaccine and are most likely to benefit. Routine vaccination for hepatitis A is recommended only for patients who are at high risk of hepatitis A infection, but that is not the case with this patient. Meningococcal polysaccharide conjugate vaccine is not routinely recommended for patients 24 years of age. The CDC recommends pneumococcal polysaccharide vaccine (PPSV23) for all adults 65 years of age, but also for those 2 years of age at high risk of disease, including patients who smoke. However, this patient does not have any high-risk conditions and is not a smoker, so PPSV23 would not be appropriate. The recombinant zoster vaccine is approved for adults 50 years of age.