ITE 2022 Flashcards
A 50-year-old male presents with chronic abdominal pain. A workup leads you to suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small duodenal ulcer. The endoscopist also notes some small esophageal varices without red wale signs.
Further evaluation confirms that the patient has compensated cirrhosis in the setting of alcohol use disorder. He readily accepts this diagnosis and enters an Alcoholics Anonymous program. His ulcer symptoms resolve with antibiotic therapy for Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his esophageal varices would be
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1–2 years
ANSWER: E
Primary prevention of variceal hemorrhage is an important consideration in the management of patients with cirrhosis. Although this patient’s varices were diagnosed incidentally, patients with cirrhosis and clinically significant portal hypertension should be screened for varices every 2–3 years with esophagogastroduodenoscopy (EGD). EGD can be deferred in patients with platelet counts <150,000/mm3 and transient elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of bleeding. Findings associated with a high risk of bleeding include small varices in patients with decompensated cirrhosis, small varices with red wale signs (thinning of the variceal wall), and medium to large varices. Patients with small varices not meeting these criteria have a low risk of hemorrhage and do not require prophylaxis. They should be rescreened with EGD every 1–2 years.
For patients requiring treatment due to high-risk features, options for primary prophylaxis of hemorrhage include nonselective -blockers such as propranolol or endoscopic variceal ligation. Treatment decisions are based on patient preference, other potential contraindications, and local resources. The need for repeat endoscopy in these cases will depend on the clinical circumstances. If nonselective -blockers are used, they should be continued indefinitely. Octreotide is only given intravenously for acute hemorrhage. There is no evidence that omeprazole slows the progression of esophageal varices.
Once hemolysis is excluded, the most common cause of unconjugated hyperbilirubinemia is
A) alcoholic liver disease
B) biliary tract disease
C) fatty liver disease
D) Gilbert syndrome
E) Wilson disease
ANSWER: D
Unconjugated hyperbilirubinemia can be defined as an elevated indirect bilirubin level. While unconjugated hyperbilirubinemia is most commonly seen in hemolysis, another common cause is Gilbert syndrome, which stems from a genetic defect that affects how the liver processes bilirubin. Alcoholic liver disease, biliary tract disease, fatty liver disease, and Wilson disease do not lead to unconjugated hyperbilirubinemia.
A 27-year-old male presents to establish care after relocating to the community. He was diagnosed with β-thalassemia major at birth and has been transfusion-dependent since early childhood. His microcytic anemia is stable with blood transfusions every 4 weeks, but his most recent DEXA scan indicates an advancement from osteopenia to osteoporosis.
In addition to bisphosphonates, calcium, and vitamin D, which one of the following medications may improve his bone density?
A) Hydroxyurea (Hydrea)
B) Vitamin C
C) Zinc
D) Deferoxamine (Desferal)
E) Luspatercept (Reblozyl)
ANSWER: C
In addition to bisphosphonates, calcium, and vitamin D, zinc supplementation is recommended to improve bone density in patients with thalassemia and osteoporosis (SOR C). Though hydroxyurea is an indicated therapy to minimize the frequency of blood transfusions needed in transfusion-dependent thalassemia, it does not improve bone density (SOR C). Vitamin C supplementation does not improve bone health in patients with thalassemia and osteoporosis. Deferoxamine infusions are indicated when ferritin levels are >1000 ng/mL in patients with transfusion-dependent thalassemia to reduce iron overload (SOR C). Luspatercept reduced transfusion burden by 33% in a phase 3, randomized study but is not indicated to improve bone density.
An obese 40-year-old female with diabetes mellitus sees you for evaluation of painful, deep-seated nodules in both axillae. On examination you note nodules in the axillae with purulent drainage and associated scarring.
This condition is associated with which one of the following?
A) Amyotrophic lateral sclerosis
B) Crohn’s disease
C) Dermatitis herpetiformis
D) Systemic lupus erythematosus
E) Trauma
ANSWER: B
The patient has hidradenitis suppurativa, a chronic folliculitis affecting intertriginous areas in the axillae and the groin that may also occur around the anus and nipples. Treatment depends on severity and ranges from topical to systemic antibiotics. Hidradenitis suppurativa is associated with obesity, diabetes mellitus, Crohn’s disease, arthritis and spondyloarthropathy, metabolic syndrome, polycystic ovary syndrome, pyoderma gangrenosum, and trisomy 21. There are three stages: stage I is single or multiple abscesses without sinus tracts or scarring, stage II is abscess recurrence with sinus tracts and scarring and widely separated lesions, and stage III is diffuse abscesses with interconnecting sinus tracts. Amyotrophic lateral sclerosis has no typical skin manifestation. Dermatitis herpetiformis is associated with celiac disease and has clusters of pruritic lesions. Systemic lupus erythematosus has cutaneous manifestations of a malar rash and may involve subcutaneous lesions without scarring. Hidradenitis suppurativa is not associated with trauma.
A 43-year-old female with lifelong asthma asks if she would be a candidate for treatment with a biologic agent such as omalizumab (Xolair). A CBC reveals mild eosinophilia, indicating type 2 inflammatory asthma.
In which one of the following patient scenarios should biologic treatment for asthma be considered?
A) Any patient with poorly controlled, severe asthma
B) A patient with severe non–type 2 asthma that is poorly controlled despite adherence to
optimal therapy with long-term controller medication
C) A patient with type 2 inflammatory asthma that is poorly controlled despite therapy with
as-needed inhaled albuterol (Proventil, Ventolin) and low-dose inhaled corticosteroids
D) A patient with severe type 2 inflammatory asthma that is poorly controlled despite
adherence to optimal therapy with long-term controller medication
ANSWER: D
Biologic therapy for asthma targets type 2 inflammation pathways. According to the 2019 Global Initiative for Asthma (GINA) guidelines, diagnosis and management of severe asthma includes determination of the asthma phenotype to assess for type 2 inflammation. Type 2 asthma includes allergic and eosinophilic asthma. Non–type 2 asthma is driven by neutrophils and is associated with smoking and obesity. Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy. Biologic therapy may be considered in patients with severe type 2 inflammatory asthma who continue to have significant symptoms despite adherence to optimal therapy, including high-dose inhaled corticosteroids and a long-acting -agonist.
Cardiac stress testing would be most appropriate for which one of the following patients?
A) A 57-year-old female who is scheduled for a knee replacement and has dyspnea when walking up a few stairs
B) A 60-year-old male with diabetes mellitus who was admitted to the hospital for chest pain and acute stroke and has a normal EKG and troponin levels
C) A 66-year-old male with diabetes and hypertension without cardiac symptoms who would like to stratify his risk for heart disease
D) A 68-year-old female with coronary artery disease who is scheduled for a knee replacement and does not have cardiac symptoms when walking up a flight of stairs
E) A 79-year-old male who is scheduled for a transcatheter aortic valve replacement for severe aortic stenosis and has dyspnea when walking up a few stairs
ANSWER: A
In the setting of acute symptoms, cardiac stress testing is indicated when there is an intermediate probability of acute coronary syndrome. Cardiac stress testing is also indicated in a preoperative assessment when surgery is at least a moderate risk and the patient cannot reach 4 METs of exertion (climbing a single flight of stairs) without cardiac symptoms. Cardiac stress testing is contraindicated after a recent stroke or TIA and in patients with severe symptomatic aortic stenosis. It is not indicated in asymptomatic patients with no history of revascularization.
A 45-year-old male sees you for a routine visit. His medical history includes hypertension treated with hydrochlorothiazide, amlodipine (Norvasc), and losartan (Cozaar). He also has type 2 diabetes treated with metformin and empagliflozin (Jardiance). Laboratory findings are significant for an LDL-cholesterol level of 167 mg/dL and you prescribe simvastatin (Zocor), 80 mg daily. At a follow-up visit 3 months later he tells you that he stopped taking the simvastatin after a week due to muscle pain and weakness.
Which one of the following medications in this patient’s current regimen most likely contributed to his risk for developing statin-induced myopathy?
A) Amlodipine
B) Empagliflozin
C) Hydrochlorothiazide
D) Losartan E) Metformin
ANSWER: A
Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. In patients on statin therapy, concurrent use of other medications that are also metabolized by this system, including amiodarone, calcium channel blockers such as amlodipine, certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy. In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9), and this patient’s other medications are metabolized by different mechanisms (empagliflozin) or not significantly metabolized (hydrochlorothiazide and metformin).
A 12-year-old female is brought to your office for a routine well child examination. The U.S. Preventive Services Task Force recommends screening this patient for which one of the following?
A) Anemia
B) Depression
C) Diabetes mellitus
D) Dyslipidemia
E) HIV
ANSWER: B
The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents and adults starting at age 12. The USPSTF states that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children 6–24 months of age (I recommendation) and does not offer recommendations regarding other age groups. There are no USPSTF recommendations regarding universal screening for diabetes mellitus in children or adolescents. The American Academy of Pediatrics now recommends screening for dyslipidemia in children once between 9 and 11 years of age, but the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years of age (I recommendation). HIV screening is recommended in adolescents and adults 15–65 years of age (A recommendation).
A 70-year-old female who is an established patient at your practice calls you late on a Saturday afternoon. Earlier in the day she misjudged the location of a bench at a neighbor’s house and sat down hard on the porch floor. She felt immediate pain in her back. She went home and took naproxen, 440 mg, and sustained-release acetaminophen, 1300 mg, 3 hours ago. She still describes her pain as unbearable, rating it as 10 on a scale of 10. You agree to meet her in the emergency department, where you confirm an acute T12 vertebral compression fracture.
Of the following, the most appropriate treatment option for this patient’s acute pain is a short course of
A) prescription-strength NSAIDs
B) methadone
C) transdermal fentanyl
D) immediate-release oxycodone (Roxicodone)
ANSWER: D
The most appropriate treatment for this patient’s acute pain following a T12 vertebral compression fracture is round-the-clock class II narcotics. Subcutaneous calcitonin can also be useful for relieving pain from vertebral fractures. NSAIDs and acetaminophen are usually insufficient during the acute phase of a vertebral compression fracture, and this patient has already tried these. Methadone or transdermal fentanyl can be used, but plasma levels of methadone may take 5–7 days to stabilize and fentanyl takes 24–48 hours to take effect.
A 75-year-old male sees you for evaluation of a unilateral resting tremor of his right hand. The tremor resolves if he is touched on the hand by someone. His wife notes that he seems to drag his feet now, but he has no history of falls.
Which one of the following has been shown to delay progression of his disease?
A) No currently available pharmacologic agents
B) Amantadine
C) Carbidopa/levodopa (Sinemet)
D) Rasagiline (Azilect)
E) Ropinirole
ANSWER: A
There are no currently available medications that have been shown to delay progression of Parkinson’s disease. However, guidelines recommend initiating the treatment of motor symptoms when they begin to affect the functions of daily life or decrease the quality of life. The first-line treatment for motor symptoms is carbidopa/levodopa due to its effectiveness for tremors, rigidity, and bradykinesia. It is a myth that delaying the use of levodopa will prevent a lack of efficacy later in the course of the illness, as what appears to be a lack of efficacy actually represents progression of the disease.
Amantadine can be used for patients under 65 years of age who are only experiencing tremors. Monoamine oxidase inhibitors such as rasagiline and non-ergot dopamine agonists such as ropinirole are not as effective as carbidopa/levodopa for motor symptoms, but they do not cause the dyskinesias and motor fluctuations seen with levodopa. Monoamine oxidase inhibitors are considered first-line therapy for patients under age 65 with mild motor symptoms.
A 28-year-old female presents with a 2.5-cm pruritic, erythematous, oval macule on her left thigh. She was seen at an urgent care facility 2 days ago for a urinary tract infection (UTI) and was treated with sulfamethoxazole/trimethoprim (Bactrim). Her UTI symptoms have improved. She reports that she was called earlier this morning and told that her infection was caused by Escherichia coli. The patient reports a similar lesion in the same area about a year ago at the time of her last UTI.
You explain this is most likely secondary to
A) an immunologic reaction to E. coli
B) erythema multiforme
C) nummular eczema
D) the Shiga toxin sometimes produced by E. coli
E) the sulfamethoxazole/trimethoprim used to treat the infection
ANSWER: E
This is a typical history for a fixed drug eruption (FDE), which is an immunologic reaction that recurs upon re-exposure to the offending drug. It is most likely related to T-lymphocytes at the dermal-epidermal junction. Sulfonamides and anticonvulsants are the most frequently cited medications, but tetracycline and penicillins have also been reported to cause FDE. FDE is not caused by bacteria. Erythema multiforme does not present as an isolated, recurrent macule and generally has central clearing. Nummular eczema is a coin-shaped, very pruritic patch but does not fit this clinical scenario. Shiga toxin–producing Escherichia coli are rarely found in extra-intestinal sites.
A 72-year-old female presents with progressive hand pain and stiffness. She is a seamstress and is concerned because sewing has been more difficult over the past 6 months. She recalls that her mother’s hands were misshapen, but her mother never received a diagnosis. You examine her hands, which are shown below.
Which one of the following would be the most appropriate pharmacotherapy?
A) Colchicine (Colcrys)
B) Diclofenac (Zorvolex)
C) Hydroxychloroquine (Plaquenil)
D) Infliximab (Remicade) injections
E) Methotrexate (Trexall)
ANSWER: B
This patient presents with erosive osteoarthritis that involves the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints with sparing of the metacarpophalangeal (MCP) joints. The primary goals for treating osteoarthritis are to control symptoms such as pain and stiffness and optimize function in order to preserve quality of life. Topical or oral NSAIDs are the most appropriate pharmacotherapy for osteoarthritis of the hand. Colchicine and methotrexate have not been studied for the treatment of osteoarthritis and their use for this condition is not recommended. Colchicine is indicated for the treatment of gout, which is usually pauciarticular and asymmetrical, and methotrexate is effective for rheumatoid arthritis. Conventional synthetic and biologic disease-modifying medications such as hydroxychloroquine and infliximab have not been shown to be effective in the treatment of osteoarthritis. These medications are appropriate for the treatment of systemic lupus erythematosus and rheumatoid arthritis, which have examination findings that involve the MCP and PIP joints but spare the DIP joints.
Which one of the following medications for the treatment of type 2 diabetes has been associated with ketoacidosis?
A) Dapagliflozin (Farxiga)
B) Liraglutide (Victoza)
C) Metformin
D) Pioglitazone (Actos)
E) Sitagliptin (Januvia)
ANSWER: A
SGLT2 inhibitors such as dapagliflozin have increasingly been shown to be associated with diabetic ketoacidosis under certain circumstances. Liraglutide, metformin, pioglitazone, and sitagliptin are not associated with diabetic ketoacidosis.
A 48-year-old male with schizophrenia presents for a new patient visit after recently relocating to your area. He has been stable on clozapine (Clozaril) for the past 15 years and asks you to refill his prescription. He has been told the earliest available appointment with a local psychiatric provider is in 3 months.
Under the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program, which one of the following is required to prescribe clozapine to this patient?
A) A signed patient consent form
B) Serum clozapine levels
C) Creatinine levels
D) Neutrophil counts
E) Specialty training in psychiatry
ANSWER: D
Clozapine is a highly effective antipsychotic medication, but its use is limited due to its association with severe drug-induced neutropenia, also referred to as agranulocytosis. Patients must be enrolled in the national Clozapine Risk Evaluation and Mitigation Strategy (REMS) program to receive treatment, and all prescribers and pharmacies must be certified by this program in order to dispense clozapine. The patient’s absolute neutrophil count must be submitted at least every 30 days, or more frequently as determined by stability in treatment. A signed patient consent form should be obtained but is not a part of the Clozapine REMS monitoring system. Monitoring serum clozapine levels and creatinine levels may be appropriate but is not part of the Clozapine REMS program. Family physicians can prescribe clozapine if registered and certified in the Clozapine REMS program, which includes passing a brief knowledge assessment, but specialty training in psychiatry is not required.
A 32-year-old female comes to your office because of chronic diarrhea, abdominal cramping, and bloating. She has had these symptoms for many years but has never discussed them in depth with a physician. A thorough history and physical examination are most consistent with irritable bowel syndrome (IBS). You order IgA tissue transglutaminase (tTG) antibody and fecal calprotectin testing to rule out other conditions and both are negative. She has expressed an interest in nonpharmacologic measures as initial management of her IBS.
Which one of the following should you recommend initially, given that it has the best evidence of benefit for her condition?
A) A gluten-free diet
B) A low-FODMAP diet
C) Soluble fiber
D) Prebiotics
E) Probiotics
ANSWER: C
This patient has diarrhea-predominant irritable bowel syndrome (IBS-D) and may benefit from validation of her symptoms and a clear diagnosis that has several substantiated treatment options. A 2021 clinical guideline from the American College of Gastroenterology (ACG) is based on a systematic review performed by a committee of experts in this field. Based on this review, soluble fiber (but not insoluble fiber) has good evidence for the alleviation of global IBS symptoms and is recommended strongly as a first-line intervention. In contrast, a gluten-free diet has not been shown to be beneficial for IBS. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has low-quality evidence supporting its benefit but merits a trial in patients who do not have an adequate response to fiber supplementation. The ACG has not commented on prebiotics as a treatment for IBS. A 2018 systematic review concluded that while there are small individual studies suggesting benefit for prebiotics (and probiotics) there is inadequate long-term consistent evidence to support their routine use. Probiotics have mixed and low-quality evidence for benefit in IBS. Because of the inconsistent data the ACG recommends against their use.
Which one of the following disorders is caused by an underlying mechanism of osteochondrosis rather than apophysitis?
A) Legg-Calvé-Perthes disease
B) Osgood-Schlatter disease
C) Sever’s disease
D) Sinding-Larsen-Johansson syndrome
ANSWER: A
Osteochondrosis refers to degenerative changes in the epiphyseal ossification areas of growing bones. Legg-Calvé-Perthes disease is a type of osteochondrosis that affects the femoral head. Patients with Legg-Calvé-Perthes disease should be referred to an orthopedist and instructed to avoid all weight-bearing activities until reossification occurs. Osteochondrosis should be differentiated from apophysitis because the etiologies and management strategies differ. Apophysitis is a traction injury to the cartilage and bony attachments of tendons in growing children. Osgood-Schlatter disease, Sever’s disease, and Sinding-Larsen-Johansson syndrome are apophysitis disorders that affect the anterior tibial tubercle, posterior heel, and inferior patellar pole, respectively. Treatment of apophysitis involves stretching, activity modification, icing, and limited use of NSAIDs.
A 40-year-old female presents with several pruritic, thickened, scaly areas on her lower back, knees, and elbows. She says that when she tries to remove the scales they often bleed.
Which one of the following would be the most appropriate pharmacologic therapy for this patient?
A) Clobetasol propionate 0.05% lotion (Clobex)
B) Selenium sulfide 2.5% lotion
C) Permethrin cream (Nix)
D) Terbinafine cream 1%
E) Loratadine (Claritin), 10 mg daily
ANSWER: A
This patient has psoriasis that is characterized by plaques on her extensor extremities and limited bleeding with removal of the scales (Auspitz sign). First-line treatment for localized plaques is topical corticosteroid therapy, such as clobetasol propionate lotion. Antifungals such as selenium sulfide lotion and terbinafine cream are used to treat dermatophytosis infections including tinea pedis and tinea versicolor. Permethrin cream is indicated for treatment of scabies and lice. Loratadine, an oral antihistamine, is used to treat urticaria.
A 17-year-old cross country runner sees you to discuss the results of pulmonary function tests to evaluate his episodic shortness of breath and chest tightness. He had previously been diagnosed with exercise-induced asthma and prescribed albuterol (Proventil, Ventolin), which provided minimal relief. You tell him that the pulmonary function tests revealed normal expiratory findings including normal FEV1 and FVC and a flattened inspiratory flow loop.
The test most likely to confirm a diagnosis for this patient’s shortness of breath is
A) a sleep study
B) chest radiography
C) chest CT
D) esophagogastroduodenoscopy
E) nasolaryngoscopy
ANSWER: E
This patient has vocal cord dysfunction, sometimes called paradoxical vocal fold motion, a condition in which the vocal cords close during inspiration when they should be open. It is not entirely understood why this occurs but it is associated with other conditions including asthma, GERD, and anxiety disorders. It typically causes sudden, severe shortness of breath and often has a trigger such as exercise, gastroesophageal reflux, inhalation of an irritant, or stress. Symptoms may include chest or throat tightness, inspiratory stridor, and wheezing predominantly over the upper airway. In less severe situations the voice may be impacted, and patients sometimes also describe a chronic cough that occurs separately from more acute symptoms. Vocal cord dysfunction is confirmed by direct visualization of the vocal cords during inspiration via nasolaryngoscopy. Pulmonary function tests are often performed as part of the assessment for shortness of breath and, if performed while the patient is experiencing symptoms, will show a flattened inspiratory flow loop. Treatment is primarily focused on therapeutic breathing maneuvers and vocal cord relaxation techniques. A speech therapist may assist in instructing patients in these techniques. Associated conditions should also be treated to help prevent vocal cord dysfunction. A sleep study, chest radiography, chest CT, and esophagogastroduodenoscopy would not confirm a diagnosis of vocal cord dysfunction.
A 62-year-old male is found to have an alkaline phosphatase (ALP) level of 152 U/L (N 32–91). Laboratory studies performed last year showed an ALP level of 134 U/L. The review of systems today is negative, including for pain, nausea, and dyspnea. You note that his AST and ALT levels are in the normal range, and a gamma-glutamyl transaminase level is also normal.
Which one of the following would be the most appropriate next step in the evaluation?
A) Plain radiography of the skull, pelvis, and tibia
B) Right upper quadrant ultrasonography
C) A full-body CT scan
D) A HIDA scan
E) A radionuclide bone scan
ANSWER: A
Paget disease of bone is the second most common metabolic bone disorder after osteoporosis and has a lifetime prevalence of 1%–2% in the United States. Only 30%–40% of patients have symptoms such as bone pain at diagnosis. Most patients are diagnosed after an incidental finding of elevated alkaline phosphatase (ALP) on routine laboratory studies or by plain films performed for another reason. When an elevated ALP level is found in an asymptomatic patient, other liver function tests such as a gamma-glutamyl transaminase level should be performed to evaluate for hepatobiliary pathology. If negative, this should be followed by plain radiography of the skull and tibia, and an enlarged view of the pelvis to assess for lytic lesions and cortical thickening. If plain radiography is consistent with Paget disease of bone, a radionuclide bone scan is performed to assess the full extent of the disease. Bisphosphonates are the first-line treatment in active disease, which is signified by bone pain, hearing loss, and lytic lesions. Right upper quadrant ultrasonography, a full-body CT scan, and a HIDA scan would not be the most appropriate next step in the evaluation.
A 37-year-old male presents for a physical evaluation prior to starting a new job in a hospital. He recently immigrated from Uganda. An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) is positive. He is otherwise healthy. He has not had any cough, fever, unintended weight loss, or night sweats.
Which one of the following is the most appropriate next step?
A) Tuberculin skin testing
B) Inducing sputum for mycobacterial culture
C) Chest radiography
D) Proceeding with treatment for latent tuberculosis
E) Proceeding with treatment for active tuberculosis
ANSWER: C
This patient’s tuberculosis (TB) screening test is positive, and the next step in the evaluation involves determining whether he has a latent infection or active disease. Diagnosis of latent TB requires ruling out active disease by assessing the patient clinically with a history, physical examination, and chest radiograph. If this evaluation does not suggest active disease, sputum studies are not needed. Interferon-gamma release assays (IGRA), which are blood tests used to screen for TB infection, are more accurate than tuberculin skin testing, so a tuberculin skin test is not needed. Treatment should not be started until a determination of latent versus active TB is made.
An 11-year-old female is brought to your office by her parent who is concerned that the child’s spine might be curved. The most appropriate evaluation for scoliosis at this point is
A) comparing the length from the pelvic brim to the pelvic floor on the left and the right
B) scoliometer measurement with the patient bent over to 90°
C) scoliometer measurement with the patient upright and arms to her side
D) determination of the Cobb angle with the patient bent over to 90°
E) determination of the Cobb angle with the patient upright and arms to her side
ANSWER: B
The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°–7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis.
The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°.
A 69-year-old male with a history of diabetes mellitus presents to your clinic with concerns of mild vision problems. His brother lost his vision due to glaucoma and encouraged the patient to seek care.
Which one of the following is most consistent with the typical vision changes of glaucoma?
A) Central vision loss with peripheral sparing
B) Halos and decreased night vision
C) Intermittent complete blackening of the visual field
D) Patchy peripheral vision blurring
E) Sudden scattered floaters
ANSWER: D
Glaucoma and other common eye conditions cause a range of visual disturbances. Glaucoma is typically associated with blurring of peripheral vision as elevated pressure in the eye pushes on the periphery of the ophthalmic nerve. Central vision loss with peripheral sparing is classically seen with macular degeneration. Halos and decreased night vision are classic problems for patients with cataracts. Intermittent complete blackening of the visual field may be seen with ischemia associated with stroke or temporal arteritis. Sudden scattered floaters should raise concern for retinal detachment.
A 67-year-old male presents for follow-up of ongoing chest pain that he experiences when walking up hills. His medical history is significant for hypertension and coronary artery disease. Four months ago he had a positive exercise stress test and underwent coronary angiography, which showed diffuse atherosclerotic disease but no lesions suitable for percutaneous intervention. His current medications include aspirin, 81 mg; atorvastatin (Lipitor), 80 mg; and metoprolol succinate (Toprol-XL), 100 mg. His vital signs include a blood pressure of 120/66 mm Hg and a pulse rate of 68 beats/min. Recent laboratory studies are significant for an LDL-cholesterol level of 58 mg/dL, a triglyceride level of 120 mg/dL, and a troponin level of 0.05 ng/mL (N <0.04).
The addition of which one of the following agents would decrease this patient’s all-cause mortality risk?
A) Clopidogrel (Plavix), 75 mg daily
B) Colchicine (Colcrys), 0.6 mg daily
C) Icosapent ethyl (Vascepa), 2 g twice daily
D) Isosorbide mononitrate, 30 mg daily
E) Rivaroxaban (Xarelto), 2.5 mg twice daily
ANSWER: E
This patient presents with stable angina and documented coronary atherosclerosis. His slight troponin elevation is a marker of elevated risk. The addition of low-dose rivaroxaban to aspirin has been shown to decrease cardiac and all-cause mortality in patients with coronary artery disease (CAD) and may be offered to this patient (SOR A). Dual antiplatelet therapy with clopidogrel and aspirin is recommended for 1 year after stenting but is not recommended in patients with stable angina who do not have stents. Colchicine has been associated with decreased cardiac events in patients with CAD but may increase all-cause mortality. Icosapent ethyl has been shown to decrease cardiac events but not mortality in patients with hypertriglyceridemia >150 mg/dL. Isosorbide mononitrate may be indicated to improve angina symptoms but does not improve mortality risk.
An 80-year-old female is brought to the emergency department after her family finds her on the floor at her home. They state that she has been confused and not acting like herself for the past 5–7 days. She lives independently and cares for herself, and she is active in a senior church group.
The patient is unable to explain why she was on the floor, so the history is obtained from the family. There are no other associated symptoms and no known inciting incident. There have been no recent medication changes and the family is unaware of any fever or chills. The patient has not had episodes like this in the past.
Her past medical history is notable for controlled blood pressure and a TIA several years ago with no residual neurologic deficit or impairment. A physical examination is negative except for her confusion, and there are no focal neurologic findings. Imaging shows no acute process.
Which one of the following is the most likely explanation for these findings?
A) Alzheimer’s disease
B) Delirium
C) Ischemic stroke
D) Mild neurocognitive disorder
E) Vascular dementia
ANSWER: B
This patient presents with acute altered mental status. Delirium should always be considered in this setting because it is both common and frequently overlooked (SOR C). There are multiple potential causes of this patient’s acute altered mental status, including but not limited to systemic infections, metabolic disturbances, medications, systemic conditions, and central nervous system insults such as ischemic stroke. The clinical examination does not indicate the focal neurologic changes of a stroke, and this patient’s TIA was several years ago with no subsequent chronic cognitive changes.
The history and examination in this case do not suggest the presence of chronic cognitive changes indicative of conditions such as Alzheimer’s disease, mild neurocognitive disorder, or vascular dementia. Alzheimer’s disease has an insidious and gradual onset of cognitive symptoms. In vascular dementia, the symptoms begin after cerebrovascular events. Importantly, in the setting of acute mental status changes, the Choosing Wisely campaign recommends not presuming a diagnosis of dementia in an older adult with acute symptoms of confusion without first assessing for delirium.
A 45-year-old male presents for follow-up of a recent positive HIV test. He has not had any symptoms. An initial laboratory evaluation is significant for the following:
HIVviralload 124,000copies/mL CD4lymphocytecount 289cells/μL HepatitisCantibody negative Anti-HBs positive Anti-HBc positive HBsAg negative
Renal function is normal. He has an upcoming appointment with the comprehensive HIV clinic to initiate antiretroviral therapy.
Which one of the following would be appropriate to recommend today?
A) Prophylactic emtricitabine/tenofovir (Truvada)
B) Prophylactic sulfamethoxazole/trimethoprim (Bactrim)
C) Hepatitis B vaccine
D) Herpes zoster vaccine (Shingrix)
E) Meningococcal B (MenB) vaccine
ANSWER: D
The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV. Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200cells/ L.HepatitisBvaccineisrecommendedbutwouldnotbenecessaryforpatientssuchasthis one with natural immunity or confirmed immunity from vaccination.
Which one of the following medical conditions is most likely the result of severely elevated triglycerides?
A) Asthma
B) Chronic kidney disease
C) Gallstones
D) Hypothyroidism
E) Pancreatitis
ANSWER: E
Hypertriglyceridemia, defined as triglyceride levels 500 mg/dL, increases the risk of pancreatitis. It does not increase the risk of asthma, chronic kidney disease, gallstones, or hypothyroidism. Patients with hypertriglyceridemia should initiate therapeutic lifestyle modifications and should be treated with fibrates or niacin to help reduce the risk of pancreatitis.
A 74-year-old male whom you have not seen for several years presents with fatigue, an 8-lb weight loss, and musculoskeletal pain for the last 6 months. He had been in good health before these symptoms started. He states that he has a “deep ache” in his lower back, hips, and shoulders that awakens him at night. Plain films of the lumbar spine ordered by an orthopedic surgeon revealed osteopenia and degenerative disease with osteophytes. A bone scan was within normal limits for his age. The only abnormalities you detect on a thorough physical examination are tenderness to percussion over the scapulae, lumbar vertebrae, and posterior pelvis, and a mildly enlarged but smooth prostate.
Of the
A) B) C) D) E)
following, the most likely diagnosis is
carcinoma of the prostate metastatic to bone hyperparathyroidism
multiple myeloma
osteomalacia
Laboratory Findings
Hematocrit Hemoglobin Meancorpuscularvolume PSA Calcium Phosphorus Albumin Globulin Alkalinephosphatase BUN Creatinine
31%(N40–50) 10.3g/dL(N14.0–17.0) 90 μm3 (N 80–100) 4.6ng/mL(N0.0–4.0) 10.9mg/dL(N9.0–10.5) 4.2mg/dL(N3.0–4.5) 3.0g/dL(N3.5–5.5) 6.7g/dL(N2.0–3.5)
86 U/L (N 30–92)
26 mg/dL (N 8–20) 2.5mg/dL(N0.7–1.5)
polymyalgia rheumatica
ANSWER: C
The combination of a high globulin-to-albumin ratio, anemia, renal insufficiency, and hypercalcemia in a patient with diffuse musculoskeletal pain is highly suggestive of multiple myeloma. Serum and urine immunoelectrophoresis would be the next test to order. Carcinoma of the prostate metastatic to bone should be seen on a bone scan and the PSA level would be much higher. Hyperparathyroidism is part of the differential diagnosis, but a low phosphorus level would be expected. An elevated alkaline phosphatase level would be expected in osteomalacia. Polymyalgia rheumatica is more common in women and would not be associated with elevated calcium and globulins and this degree of anemia.
A 26-year-old recreational baseball player presents with recurrent right shoulder pain that tends to gradually worsen during play and is relieved by rest. His other daily activities have not been affected and he has no nighttime pain.
Examination of the right shoulder reveals a normal appearance, no tenderness to palpation, normal abduction strength, and a positive painful arc at 90°. The drop-arm rotator cuff test is negative, the Hawkins impingement sign is mildly positive, the empty-can supraspinatus test is moderately positive, and the Gerber liftoff test is negative. Radiographs of the right shoulder are normal.
Which one of the following would be appropriate at this time to provide long-term pain relief?
A) Complete shoulder rest with temporary use of a shoulder sling
B) Recommending that he permanently stop playing baseball
C) A subacromial corticosteroid injection
D) Physical therapy
E) Referral for arthroscopic surgery
ANSWER: D
This patient has shoulder impingement syndrome (with a positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test). However, the negative drop-arm rotator cuff test is evidence against a complete rotator cuff tear with a negative drop-arm rotator cuff test, and the absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy. Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem, and cessation of play is not necessary since other treatment options are available. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function. Surgery is a potential option if other treatments fail and a significant tear is proven, but is not preferable as an initial treatment.
In the U.S. legal system, which one of the following is a required finding to determine that medical malpractice has occurred?
A) Conflict of interest
B) A financial charge rendered to the patient
C) A causal relationship between breach of duty and injury to the patient
D) Presentation of the case to a grand jury
E) Testimony from an expert witness for the plaintiff
ANSWER: C
For a physician to be found guilty of medical malpractice in the United States, the plaintiff must show that the physician acted negligently in providing care and that the negligence resulted in injury. Determining this requires proof of the following four legal components: (1) a professional duty owed to the patient; (2) a breach of said duty; (3) an injury caused by the breach; and (4) resulting damages. Although physicians are legally required to disclose conflicts of interest, having a conflict of interest is not an essential element in a malpractice decision. Malpractice may occur even if the patient is not rendered a financial charge, provided that the four essential criteria are met. Medical malpractice cases that are not settled or otherwise dismissed proceed to a jury trial, not to a grand jury. Grand juries are part of the criminal indictment process and are not relevant to medical malpractice cases. While expert witness testimony is often used in a malpractice case, typically to help establish whether there has been a breach of a professional standard of care, such testimony is not a requirement for a medical malpractice decision.
A 30-year-old male presents to your office after sustaining a scratch to the eye while playing with his 2-year-old nephew. A penlight examination reveals sensitivity to light and mild conjunctival irritation with no foreign body. Pupillary response, extraocular movements, and visual acuity are all normal. Fluorescein staining reveals a 3-mm corneal abrasion.
Which one of the following would be the most appropriate management?
A) Patching the affected eye
B) Patching the unaffected eye
C) Prednisolone ophthalmic drops
D) Tetracaine ophthalmic drops
E) Oral naproxen
ANSWER: E
Corneal abrasions are a common cause of acute eye pain and are often evaluated in primary care settings. Small (4 mm), uncomplicated abrasions typically heal within 1–2 days and usually respond to oral analgesics such as acetaminophen or NSAIDs. A 2013 review reported effective pain relief and earlier return to work with use of topical NSAIDs, although a 2017 Cochrane review subsequently found that evidence may be lacking to support their use, especially considering the higher cost when compared to oral options.
A 17-year-old female has a positive urine drug screen for cannabis. She does not use marijuana but recently attended a party where others were smoking it.
How long after passive exposure to cannabis smoke can an otherwise cannabis-naïve person test positive for it on a drug screen?
A) Never
B) Up to 24 hours
C) 3 days
D) 1 week
E) 1 month
ANSWER: B
A urine drug screen may be positive for cannabis for up to 24 hours after exposure to secondhand cannabis smoke in an enclosed space. The urine drug screen can be positive for 4–5 days after a single use of cannabis and for a month after cessation in someone who uses it daily.
A 45-year-old male with no known medical history presents as a new patient for a physical examination. A review of symptoms is negative. He notes that his father died in his fifties of heart disease, but the patient does not know any further details. An examination is notable for a systolic murmur at the lower left sternal border.
Which one of the following additional findings in this patient would be most consistent with hypertrophic cardiomyopathy?
A) Decreased intensity of the murmur when supine
B) Decreased intensity of the murmur with the Valsalva maneuver
C) Elevated jugular venous distention
D) Elevated pulse pressure
E) A differential in blood pressure between the arms
ANSWER: A
Hypertrophic cardiomyopathy (HCM), formerly known as idiopathic hypertrophic subaortic stenosis, is a common and underdiagnosed form of inherited heart disease with a prevalence of 1:500 in the United States and worldwide. HCM is associated with a systolic murmur at the lower left sternal border with an intensity that changes along with changes to preload of the heart. Lying down increases preload, which decreases the murmur. The Valsalva maneuver decreases preload and increases the murmur. Advanced HCM may cause heart failure and jugular venous distention, but at that stage symptoms would be expected. Elevated pulse pressures are classically seen with aortic insufficiency rather than HCM. Differential blood pressures in the arms would not be expected with HCM.
A 62-year-old male presents with a 3-day history of left lower quadrant pain and a low-grade fever. Findings on CT are consistent with acute diverticulitis. The patient has a history of intolerance to metronidazole (Flagyl).
If antibiotics are given, the preferred agent for this patient would be
A) amoxicillin/clavulanate (Augmentin)
B) azithromycin (Zithromax)
C) cephalexin (Keflex)
D) ciprofloxacin (Cipro)
E) doxycycline
ANSWER: A
The traditional approach to outpatient management of acute diverticulitis consists of clinical diagnosis (with or without imaging), antibiotics, and bowel rest. Two cohort studies found no difference in the effectiveness of outpatient treatment of diverticulitis with amoxicillin/clavulanate or with metronidazole plus a fluoroquinolone. Azithromycin is more appropriate for Campylobacter or Escherichia coli infections that cause lower gastrointestinal bleeding. Cephalexin is not an appropriate treatment, and ciprofloxacin monotherapy will not provide adequate coverage. Doxycycline is a treatment for watery diarrhea caused by Vibrio cholerae and Yersinia infections.
A 20-year-old female comes to your office for routine follow-up after recently finishing neck irradiation treatment for Hodgkin’s lymphoma. Her past medical history is otherwise significant for allergic rhinitis and GERD. She feels generally well after treatment. A physical examination is unremarkable.
Which one of the following should be performed to monitor for complications from radiation?
A) No routine follow-up surveillance
B) Parathyroid hormone levels
C) Swallow studies
D) Carotid artery ultrasonography
E) Neck CT
ANSWER: D
Patients who have been treated with neck irradiation for lymphoma require follow-up surveillance with carotid artery ultrasonography every 10 years. There is evidence that asymptomatic carotid artery disease is more common in patients who have been treated with radiation for Hodgkin’s lymphoma compared to the general population.
You are evaluating a couple for infertility. The semen analysis demonstrates oligozoospermia on two separate samples. The history and physical examination of the male partner are otherwise unremarkable.
Which one of the following would be the most appropriate next step in the evaluation of his oligozoospermia?
A) A CBC with differential and a basic metabolic panel
B) FSH and early morning total testosterone levels
C) Antisperm antibody testing
D) Scrotal ultrasonography
E) Referral for a testicular biopsy
ANSWER: B
A semen analysis is the first step in the evaluation of male infertility. In males with oligozoospermia (especially if the sperm count is <10 million/mL), the American Urological Association recommends an endocrine evaluation with an FSH level and early morning total testosterone levels. The results of that testing can dictate next steps. A CBC and a basic metabolic panel have no role in the evaluation of male infertility. Antisperm antibody testing is rarely recommended and should only be considered in consultation with a fertility specialist. Scrotal ultrasonography is not recommended in individuals with a normal physical examination and should only be performed in individuals with palpable varicoceles on physical examination. A testicular biopsy is not usually required to help differentiate between obstructive and nonobstructive azoospermia.
You see a 15-year-old male for a well child check. He does not have any health concerns and his developmental and social histories are unremarkable. His vital signs include a height of 152 cm (60 in), a weight of 79 kg (174 lb), a blood pressure of 133/80 mm Hg, a heart rate of 85 beats/min, and a respiratory rate of 14/min.
Which one of the following would be the most appropriate next step in management?
A) Discussing healthy lifestyle changes, with follow-up at the next annual visit
B) Repeating blood pressure measurements two more times during this visit
C) Checking blood pressure in the upper and lower extremities and starting an angiotensin
receptor blocker
D) Screening for hyperlipidemia, diabetes mellitus, fatty liver, and kidney disease only
E) Screening for hyperlipidemia, diabetes, fatty liver, and kidney disease, and referral for intensive weight management and dietary therapy
ANSWER: B
Hypertension in children up to age 12 is defined by a blood pressure at the 95th percentile or higher based on age, height, and sex. Starting at age 13, hypertension can be defined in absolute numbers of 130/80 mm Hg or higher. Diagnosing hypertension in children and adolescents requires careful evaluation, and it is recommended to recheck the blood pressure twice during the same visit using auscultation and average the values to determine the final blood pressure. If this results in a persistent hypertensive blood pressure level, initial lifestyle modifications should be recommended, and blood pressure should be rechecked in 1–2 weeks. Ambulatory blood pressure monitoring should be considered at that time, particularly if the blood pressure is borderline. If blood pressure remains high, a targeted evaluation for secondary hypertension and an evaluation for hyperlipidemia, diabetes mellitus, and renal disease should be performed, as well as checking upper and lower extremity blood pressures to evaluate for possible coarctation of the aorta. Referral to intensive programming for weight management and diet therapy would be appropriate at that time, particularly in children with obesity. Medication should not be started for asymptomatic stage 1 hypertension unless lifestyle modifications are unsuccessful.
The results of a meta-analysis of lung cancer screening using low-dose CT were as follows: the pooled lung cancer–specific mortality rate in the control group was 2.12%, the estimated lung cancer–specific mortality rate in the screened population was 1.72%, and the absolute risk reduction for lung cancer mortality was 0.4% (2.12% minus 1.72%).
What is the number needed to screen to prevent one death due to lung cancer?
A) 5 B) 23 C) 47
D) 200 E) 250
ANSWER: E
The absolute risk reduction (ARR) in this meta-analysis was 0.4%. The number needed to screen is the reciprocal of the ARR. The number needed to screen would equal 1 divided by the ARR (1/ARR), or 1/0.004, which equals 250. Based upon this meta-analysis, 250 individuals would need to be screened to prevent one lung cancer death.
A 61-year-old male is found to have a 2-cm right adrenal incidentaloma on CT. He has no history of hypertension, electrolyte abnormalities, headaches, flushing, or sweating.
Which one of the following studies should be performed in patients found to have an adrenal incidentaloma?
A) An ACTH stimulation test
B) A dexamethasone suppression test
C) Paired serum aldosterone and plasma renin activity
D) Serum or urine metanephrines
E) A PET scan
ANSWER: B
Adrenal incidentalomas usually do not produce overt hormone excess, but mild autonomous cortisol secretion (MACS) is present in up to 30%–50% of cases. This mild secretion of cortisol may predispose patients to metabolic syndrome, osteoporosis, and cardiovascular events. MACS can be ruled out with an overnight 1-mg dexamethasone suppression test. The remainder of the evaluation can be based on CT findings and clinical symptoms.
A 57-year-old male who uses tobacco presents with cough and dyspnea. His symptoms were previously controlled with an albuterol (Proventil, Ventolin) inhaler once or twice a month. After a 3-week trial of a tiotropium (Spiriva) inhaler his symptoms are better, but he is still having frequent episodes of coughing and dyspnea. He has been smoking 1–2 packs of cigarettes a day since age 13 and is not interested in quitting.
On examination he is afebrile, his vital signs are stable, and his oxygen saturation is 95% on room air. His lung sounds are diminished, and the remainder of the examination is unremarkable. His in-office peak flow is 300 L/min. You suspect he has moderate COPD and recommend pulmonary function tests but he declines.
In addition to continuing tiotropium, which one of the following medications would you recommend adding to his current regimen?
A) An oral antibiotic
B) An oral corticosteroid
C) An inhaled corticosteroid
D) An inhaled long-acting β-agonist
E) A nebulized short-acting β-agonist
ANSWER: D
Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Initiative for Health and Care Excellence, and the American College of Chest Physicians all recommend that in addition to smoking cessation, COPD should be treated initially with either a long-acting -agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist with either of those inhaled medications then combination therapy should be initiated. An inhaled corticosteroid (ICS) can be added to the LABA/LAMA regimen for triple therapy if symptoms continue. Long-term use of an ICS as monotherapy is not recommended due to a slight increase in the incidence of pneumonia.
You see a 30-year-old male for a routine health maintenance visit. The physical examination is normal, but he mentions that he has an overwhelming urge to keep checking and rechecking doors to make sure they are locked. He senses that something dangerous will happen if he does not do this. These thoughts and behaviors have become very distressing to him, and have started to interfere with his work and home life.
Which one of the following would be most appropriate at this time?
A) Alprazolam (Xanax)
B) Risperidone (Risperdal)
C) Sertraline (Zoloft)
D) Referral for psychodynamic psychotherapy
ANSWER: C
Treatment of OCD requires the integration of various approaches to maximize the outcome. Most patients experience substantial improvement using a combination of pharmacotherapy, particularly SSRIs, and cognitive behavioral therapy. Benzodiazepines such as alprazolam are capable of relieving generalized anxiety, but do not affect obsessions or compulsions. Antipsychotics such as risperidone may be added to an SSRI as second-line pharmacotherapy. Traditional psychodynamic psychotherapy is not effective for OCD.
A patient’s office spirometry results reveal a normal FEV1/FVC ratio and a decreased FVC. Which one of the following is the most likely explanation for these findings?
A) A normal pattern
B) A mixed pattern
C) A restrictive pattern
D) A reversible obstructive pattern
E) An irreversible obstructive pattern
ANSWER: C
Forced vital capacity (FVC) is the total amount of air that can be expelled from full lungs. A decreased FVC on spirometry indicates a restrictive pattern. FEV1 is the volume of air (in liters) that is exhaled in the first second during forced exhalation after maximal inspiration. A normal FEV1/FVC ratio and normal FVC would indicate a normal pattern. A decreased FEV1/FVC ratio with a decreased FVC is consistent with a mixed pattern. A reduced FEV1/FVC ratio indicates an obstructive pattern. A bronchodilator is then utilized to determine whether the obstructive pattern is reversible or irreversible.
A 56-year-old male was recently diagnosed with hypertension and started on lisinopril (Zestril). At a follow-up visit his blood pressure remains elevated and his serum creatinine level has increased from 0.9 mg/dL to 1.8 mg/dL (N 0.7–1.3). He has no other known medical issues and has a normal BMI.
Which one of the following should be ordered to confirm the most likely cause of his hypertension?
A) Renin and aldosterone levels
B) A TSH level
C) 24-hour urinary free cortisol
D) 24-hour urinary fractionated metanephrines and normetanephrines
E) CT angiography of the abdomen and pelvis
ANSWER: E
Resistant hypertension occurs in 5%–10% of adults with hypertension. In this patient, renal artery stenosis is suggested by the increase in creatinine of more than 50% after starting an ACE inhibitor. CT angiography, renal artery duplex ultrasonography, and MR angiography are appropriate diagnostic tests for renal artery stenosis. Other causes of resistant hypertension include hyperaldosteronism (diagnosed with renin and aldosterone levels), thyroid disorders (diagnosed with TSH levels), Cushing syndrome (diagnosed with 24-hour urinary free cortisol), and pheochromocytoma (diagnosed with 24-hour urinary fractionated metanephrines and normetanephrines).
Which one of the following oral conditions shows the most significant response to oral antivirals?
A) Behçet’s syndrome
B) Hand-foot-and-mouth disease
C) Herpangina
D) Herpes gingivostomatitis
E) Vincent’s angina
ANSWER: D
Herpes gingivostomatitis is the enanthem associated with a primary herpes simplex virus 1 infection, and it is the only condition listed here that is treated with antivirals such as acyclovir or valacyclovir. Behçet’s syndrome is an inflammatory condition presenting with oral and genital aphthous ulcerations. The cause is unknown and it is frequently managed with topical or systemic corticosteroids or colchicine. Hand-foot-and-mouth disease and herpangina are caused by coxsackie or enterovirus and supportive care is most appropriate for both of these. Vincent’s angina (also known as trench mouth or necrotizing ulcerative gingivitis) is a bacterial infection of the gingiva associated with poor hygiene. It is treated with systemic antibiotics such as metronidazole or amoxicillin/clavulanate.
A 72-year-old male presents for follow-up of a recent emergency department (ED) visit for chest pain that was diagnosed as costochondritis. He has a history of hypertension and chronic atrial fibrillation. A CBC in the ED was significant for a hemoglobin level of 11.1 g/dL (N 13.5–17.5) and a mean corpuscular volume of 104 μm3 (N 80–100). Follow-up laboratory studies showed the following:
Peripheralsmear normalotherthanmacrocytosis Reticulocyteindex 1.7%(N0.5–2.5) VitaminB12 512pg/mL(N190–950)
Folate 12pg/mL(N2.7–17)
Which one of the following is the most likely cause of this patient’s anemia?
A) Anemia of chronic disease
B) Chronic alcohol use
C) Gastrointestinal bleeding
D) Hemolysis
E) Myelodysplastic syndrome
ANSWER: B
Chronic alcohol use is one of the most common causes of macrocytic anemia. This patient’s normal peripheral smear and reticulocyte index <2% in the setting of anemia suggest decreased red blood cell production, which may be related to alcohol use or nutritional deficiency. Vitamin B12 and folate levels in the normal range rule out deficiencies in these vitamins, though patients with low-normal vitamin B12 and folate levels may warrant testing of homocysteine and methylmalonic acid levels. Anemia of chronic disease is typically characterized by a normocytic or microcytic anemia and a low reticulocyte count. Blood loss and hemolytic anemia are typically associated with a reticulocyte index >2%. Myelodysplastic syndrome is not suggested by the peripheral smear and is less common than anemia related to alcohol use disorder.
A healthy 80-year-old female sees you for a routine visit. She is active and follows a healthy diet. She is enthusiastic about vitamin supplements and asks you regularly about their benefits. Her laboratory chemistry profile demonstrates a persistent calcium level elevation at 10.9 mg/dL (N 8.5–10.2).
You review her prescription medications and do not find any associated with hypercalcemia. You also review her calcium and vitamin D intake. Because you know about her tendency to take supplements, you consider other vitamins that may contribute to the hypercalcemia.
Excessive intake of which one of the following would be the most likely explanation for these findings?
A) Vitamin A
B) Vitamin B1
C) Vitamin C
D) Vitamin E
E) Vitamin K
ANSWER: A
Vitamin A intoxication can cause hypercalcemia. This includes analogs of vitamin A such as those used to treat acne. The excessive intake of vitamin A is associated with multisystem effects that can include bone resorption and hypercalcemia. Sources of preformed vitamin A include supplements as well as animal sources such as liver, fish liver oil, dairy, and eggs. Vitamin A toxicity should be considered in unexplained cases of parathyroid hormone–independent hypercalcemia. Vitamins B1, C, E, and K are not associated with hypercalcemia.
