Mcq

Question 1

A 52-year-old female with a history of hypertension and hypercholesterolemia presents with mild
edema, weakness, and body aches. Her only medications are atorvastatin (Lipitor) and
chlorthalidone. Her previouslynormal serum creatinine level is now 2.6 mg/dL (N 0.64–1.27).
Her BUN level is 32 mg/dL (N 6–20) and her serum is clear without pigmentation. The urine
dipstick is positive for blood, buta microscopic examination isnegative for WBCs, RBCs, and
casts.
The most likely diagnosis is
A) allergic interstitial nephritis
B) glomerulonephritis
C) hemolysis
D) pyelonephritis
E) rhabdomyolysis

Answer 1

ANSWER: E
This patient with acute kidney injury (AKI) has clinical symptoms and signs consistent with
rhabdomyolysis, a known cause ofAKI. Furthermore, she is takinga medication known to cause
rhabdomyolysis. The urinalysis with a positive dipstick for blood and no RBCs on the microscopic
examination is indicative of either hemolysis or rhabdomyolysis. Darkened, pigmented serum would be
expected with hemolysis, while rhabdomyolysis is associated with clear serum. Urine abnormalities found
in glomerulonephritis include proteinuria and RBC casts, while patients with allergic interstitial nephritis
may have eosinophils and possibly WBC casts. Pyelonephritis is associated with WBCs in the urine, and
if the dipstick is positive for blood there will be RBCs on the microscopic examination.

Question 2

A 36-year-old male with a history of ankylosing spondylitis and atrial fibrillation presents with
a 3-week history of cough with hemoptysis, anorexia, night sweats, and an 11-lb weight loss.
On examination he has rales in the right upper lobe, but there is no lymphadenopathy or
hepatosplenomegaly. A chest radiograph shows a cavitary lesion in the right lung apex, with
mediastinal hilar lymphadenopathy. His chronic disease symptoms have been well controlled
with a combination of meloxicam (Mobic), adalimumab (Humira), esomeprazole (Nexium),
ondansetron (Zofran), docusate sodium (Colace), and amiodarone (Cordarone).
Which one of the patient’s medications is most likely contributing to his current problem?
A) Adalimumab
B) Amiodarone
C) Esomeprazole
D) Meloxicam
E) Ondansetron

Answer 2

ANSWER: A
Tumor necrosis factor (TNF) inhibitors are currently approved by the U.S. Food and Drug Administration
(FDA) for the treatment ofrheumatic diseases such as rheumatoid arthritis, ankylosing spondylitis,
psoriatic arthritis, and juvenile idiopathic arthritis. All drugs in this class carry an FDA black-box warning
about the potential for developing primary tuberculosis or reactivating latent tuberculosis. These drugs are
also associated with an increased risk for invasive fungal infections and opportunistic bacterial and viral
diseases. The FDA also warns of reports of lymphomas and other malignancies in children and adolescents
taking these drugs.
A PPD skin test should be performed prior to initiating PNF-inhibitor therapy. An induration of 5 mm or
greater with tuberculin skin testing should be considered a positive test result when assessing whether
treatment for latent tuberculosis isnecessary prior to PNF-inhibitor use, even for patients previously
vaccinated with bacille Calmette-Guérin (BCG) (SOR B).
Ankylosing spondylitis patients may develop fibrosis of the upper lung fields with long-standing disease,
but esomeprazole, ondansetron, and meloxicam do not cause reactivation of tuberculosis. Amiodarone is
associated with a subacute cough and progressive dyspnea due to pulmonary toxicity (patchy interstitial
infiltrates)

Question 3

You have just finished giving a prescription with instructions to a 28-year-old male from El
Salvador who speaks limited English. You gave the instructions with the aid of an interpreter,
but are concerned that the patient might not fully understand them.
Which one of the following is the best course of action?
A) Refer the patient to a website about his condition
B) Repeat the instructions slowly to the interpreter and ask him or her to speak clearly to
the patient
C) Contact a family member who speaks English and ask him or her to repeat the
instructions to the patient
D) Ask the patient to repeat the instructions to you in his own words

Answer 3

ANSWER: D
To ensure that patients from other cultures understand instructions, it is helpful toask them to repeat the
instructions in their own words. A website would probably not be specific or culturally sensitive to the
patient’s condition. The physician should speak in a normal tone to the patient, and not to the interpreter.
Family members may be used as convenient translators if necessary, but to maintain confidentiality and
reduce miscommunication it is best to use a trained medical interpreter

Question 4

Which one of the following accurately describes the classic rash of erythema migrans?
A) Scattered individual purple macules on the ankles and wrists
B) An annular rash with a bright red outer border and partial central clearing
C) A dry, scaling, dark red rash in the groin, with an active border and central clearing
D) A diffuse eruption withclear vesicles surrounded by reddish macules
E) A migratory pruritic, erythematous, papular eruption

Answer 4

ANSWER: B
An annular rash with a bright red outer border and partial central clearing is characteristic of erythema
migrans. It is important to remember that not all lesions associated with Lyme disease look this way, and
that some patients with Lyme disease may not have any skin lesions atall. Rocky Mountain spotted fever
causes scattered individual purple macules on the ankles and wrists. A dry, scaling, dark red rash in the
groin, with an active border and central clearing, is seen with tinea cruris. A diffuse eruption with clear
vesicles surrounded by reddish macules is found in chickenpox. A migratory pruritic, erythematous,
papular eruption is most consistent with urticaria.

Question 5

A patient with chronic atrial fibrillation treated with dabigatran (Pradaxa) sees you for follow-up.
She says she can no longer afford the dabigatran and would like to switch to warfarin
(Coumadin). She has normal renal function.
Which one of the following would be the most appropriate approach?
A) Start warfarin and stop dabigatran when her INR is 2.0–3.0
B) Start warfarin now and stop dabigatran in 3 days
C) Stop dabigatran, start warfarin, and start low molecular weight heparinand enoxaparin
(Lovenox) every 12 hr until her INR is 2.0–3.0
D) Stop dabigatran for 24 hr and then start warfarin
E) Hospitalize the patient, stop dabigatran, start warfarin, and treat with heparin until her
INR is 2.0–3.0

Answer 5

ANSWER: B
The recommendation for switching to warfarin in a patient treated with dabigatran is to start warfarin 3
days prior to stopping dabigatran. Bridging with a parenteral agent is not necessary. Dabigatran is known
to increase the INR, so the INR will not reflect warfarin’s effect until dabigatran has been withheld for at
least 2 days.

Question 6

A 27-year-old male requests youradvice regarding colon cancer screening. His brother died of
colon cancer, which was diagnosed at the age of 40.
You suggest that he begin colonoscopy screening
A) now
B) at age 30
C) at age 40
D) at age 45
E) at age 50

Answer 6

ANSWER: B
Average-risk adults should be screened for colon cancer starting at 50 years of age, and high-risk adults
either at age 40 or 10 years before the age at which colorectal cancer was diagnosed in the youngest
affected relative.

Question 7

Which one of the following is the major mechanism of action of metformin (Glucophage)?
A) Stimulation of pancreatic insulin release
B) Inhibition of glucose production by the liver
C) Inhibition of carbohydrate absorption in the small intestine
D) Improved insulin sensitivity of skeletal muscl

Answer 7

ANSWER: B
Metformin has multiple mechanisms of action, but its main effect on serum glucose results from inhibition
of gluconeogenesis in the liver. Sulfonylureas and meglitinides stimulate insulin release from the pancreas,
and thiazolidinediones sensitize peripheral tissues to insulin. Carbohydrate absorption in the small intestine
is inhibited by the -glucosidase inhibitors

Question 8

Which one of the following medications is most appropriate for treating moderate to severe
shortness of breath in a hospice patient with lung cancer?
A) Dexamethasone
B) Haloperidol
C) Scopolamine
D) Morphine

Answer 8

ANSWER: D
Morphine effectively decreases the feeling of shortness of breath in hospice patients. Randomized,
controlled trials have shown significant improvements in symptoms without a significant change in oxygen
saturation. Haloperidol can be used for nausea and vomiting (SOR B) and delirium, but is not helpful in
the treatment of shortness of breath. Scopolamine is used to decrease the production of secretions but is
not helpful for treating dyspnea. Corticosteroids will notmanage the sensation of shortness of breath in
a dying patient.

Question 9

A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism
treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic
range. She has no symptoms of hypothyroidism.
Which one of the following is the patient mostlikely to require if she becomes pregnant?
A) A decreased dosage of levothyroxine
B) An increased dosage of levothyroxine
C) The addition of liothyronine (Cytomel)
D) Substitution of desiccated thyroid hormone preparation (Armour Thyroid) for the
levothyroxine

Answer 9

ANSWER: B
Thyroid hormone requirements increase during pregnancy. Most women with hypothyroidism who become
pregnant require an increased levothyroxine dosage (SOR A). A common recommendation is to have
women on fixed daily doses of levothyroxine begin taking nine doses weekly (one extra dose on 2 days
of the week) as soon as the pregnancy is confirmed (SOR B). Thyroid function tests should be repeated
regularly throughout the pregnancy to guide additional dosage adjustments.

Question 10

Which one of the following is considered to be the highest strength of recommendation by the
Strength of Recommendation Taxonomy (SORT) used by family medicine journals?
A) Expert opinion
B) A consensus guideline
C) A retrospective cohort study
D) Multiple good quality randomized, controlled trials

Answer 10

ANSWER: D
Family medicine journals, including American Family Physician, The Journal of Family Practice, and The
Journal of the American Board of Family Medicineutilize the Strength of Recommendation Taxonomy
(SORT) to label key recommendations in clinical review articles. These grades are assigned on the basis
of the quality and consistency of available evidence. The Cochrane Collaboration is an extensive database
of systematic reviews and clinical trials. A Cochrane review with a clear recommendation warrants a
strength of recommendation rating of A. This indicates consistent, good quality, patient-oriented evidence.
Consistent findings from atleast two randomized, controlled studies or a systematic review/meta-analysis
of randomized, controlled trials are also assigned a level A strength of recommendation. Expert opinion
and consensus guidelines are assigned a level C strength of recommendation. SORT also includes a grade
of 1 to 3 for levels of evidence. Retrospective cohort studies are considered level 2

Question 11

Which one of the following tumors is most likely to cause hormonally induced hypercalcemia?
A) Squamous cell carcinoma of the lung
B) Pheochromocytoma
C) Medullary thyroid cancer
D) Prostatic carcinoma

Answer 11

ANSWER: A
Hypercalcemia due to malignancy has a poor prognosis. Up to 80%of cases are due to secretion of
parathyroid hormone–related protein. This is most common with squamous cell carcinomas. Breast cancer,
lymphomas, and multiple myeloma may cause hypercalcemia as a result of osteolytic activity at the site
of the metastasis.
Small cell carcinoma of the lung is a major cause of the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH) and may also cause Cushing syndrome. Prostate cancer can also cause SIADH, and
thyroid cancer can cause Cushing syndrome.

Question 12

A 32-year-old meat cutter comes to your officewith persistent symptoms of nausea, vomiting,
and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His
wife was sick during the first 2 days of the cruise with similar symptoms. On the ship they both
ate the “usual foods” in addition to oysters. Findings on examination are negative, and a stool
specimen is negative for white blood cells.
Which one of the following is the most likely cause of his illness?
A) Escherichia coli
B) Rotavirus
C) Norovirus
D) Hepatitis A
E) Giardia

Answer 12

ANSWER: C
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norovirusinfections due
to waterborne or foodborne spread. In the United States these viruses are responsible for about 90% of all
epidemics of nonbacterial gastroenteritis. The noroviruses are common causes of waterborne epidemics
of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships,
at summer camps, and in schools. Symptomatic treatment by itself is usually appropriate.

Question 13

A 47-year-old postmenopausal female falls while carrying groceries into her house and sustains
a right distal radial fracture. A chemistry panel reveals a calcium level of 11.2 mg/dL (N
8.6–10.6) and further evaluation leads to a diagnosis of primary hyperparathyroidism.
Which one of the following is the best course of treatment for this patient?
A) Estrogen replacement therapy
B) Long-term bisphosphonate therapy
C) Daily furosemide treatment with increased oral fluids
D) Elimination of calcium and vitamin D from the diet
E) Referral to a surgeon for consideration of parathyroidectomy

Answer 13

ANSWER: E
Hyperparathyroidism is usually caused by a single adenoma of one of the fourparathyroid glands. A
minority of cases (10%–15%) are associated with four-gland hyperplasia. Studies that localize the glands,
such as a technetium scan or ultrasonography, help surgeons who are familiar with this condition achieve
a cure rate of 95%–98%, with an estimated complication rate of 1%–3%. For patients

Question 14

Activated protein C resistance (factor V Leiden) is most commonly found in patients with
A) hemolytic anemia
B) carcinoma of the lung
C) familial hypercholesterolemia
D) venous thrombotic disease
E) cystic fibrosis

Answer 14

ANSWER: D
Venous thrombosis, both acute and recurrent, is associated with several hematologic abnormalities, in
addition to the well-known factors of trauma, surgery, malignancy, sepsis, and oral contraceptive use.
Notably, activated protein C resistance (factor V Leiden) has beenfound to be one ofthe most common
hereditary causes of thrombophilia.

Question 15

Which one of the following is most consistent with a diagnosis of asthma?
A) Reduced FEV1and a decreased FEV1/FVC ratio
B) Reduced FEV1and a normal FEV1/FVC ratio
C) Reduced FEV1and an increased FEV1/FVC ratio
D) Reduced FVC and a normal FEV1/FVC ratio
E) Reduced FVC and an increased FEV1/FVC ratio

Answer 15

ANSWER: A
Asthma is typically associated with an obstructive impairment that is reversible with short-acting
bronchodilators. A reduced FEV1and a decreased FEV1/FVC ratio indicates airflow obstruction. A
reduced FVC with a normal or increased FEV
1/FVC ratio is consistent with a restrictive pattern of lung
function

Question 16

A 43-year-old female presents toyour office 2 days after discovering a rash on her back, shown
below. Which one of the following treatments will decrease her chances of developing long-term
sequelae?
A) Amitriptyline
B) Gabapentin (Neurontin)
C) Oral corticosteroids
D) Topical corticosteroids
E) Oral acyclovir (Zovirax)

Answer 16

ANSWER: E
While some studies have shown mixed results, there is good evidence that oral acyclovir reduces the
incidence of herpetic neuralgia when given within 72 hours of the onsetof the rash, and that it reduces the
duration of symptoms (SOR A). Acyclovir, valacyclovir, and famciclovir have also been shown to reduce
the formation of new lesions, reduce viral shedding, and hasten the resolution of lesions. The effect of
acyclovir on preventing neuralgia appears to be strongestin the first month. Oral or topical corticosteroids
can reduce the duration of the rash and pain in the acute phase. Tricyclic antidepressants and gabapentin
can be used to treat the pain of postherpetic neuralgia if it does develop (SOR A

Question 17

You receive a telephone call from the mother of a 5-year-old female. The child has had diarrhea
and a decreased appetite for the past 2 days. She is still playing some. The mother reports no
vomiting, but says her daughter has complained of a dry mouth and does not have tears when
she cries. You suspect that the child may be mildly dehydrated.
Which one of the following would you advise?
A) Increased water intake
B) Clear liquids with sodium, such as chicken broth
C) An over-the-counter oral rehydration solution
D) Intravenous fluids in the emergency department
E) Loperamide (Imodium

Answer 17

ANSWER: C
When children show signs of dehydration from diarrhea, the first step is to assess its extent. In one study,
four factors predicted dehydration: a capillary refill time >2 seconds, the absence of tears, dry mucous
membranes, and an ill general appearance; the presence of two or more of these signs indicates a fluid
deficit of at least 5%. This child has two of the signs, but does not require intravenous fluidsat this point.
Early oral rehydration therapy is recommended and can be started at home. This should be done using an
oral rehydration solution that is designed for children (SOR C). Adult oral rehydration solutions should
not be used in children
Water and other clear liquids, even those with sodium, such as chicken broth, should not replace an oral
rehydration solution because they are hyperosmolar. These fluids do not adequately replace potassium,
bicarbonate, or sodium, and can sometimes cause hyponatremia. Antidiarrheal medications are usually not
recommended for use in children with acute gastroenteritis because they delay the elimination of infectious
agents from the intestine

Question 18

A 42-year-old male with a history of chronic hepatitis C develops left leg cellulitis and is treated
with cephalexin (Keflex). He returns to your office 5 days later for follow-up, and the cellulitis
is responding favorably to treatment. However, the patient has a generalizedmaculopapular rash
and a low-grade fever, which he says began 3 days ago. He also complains of arthralgias. You
admit him to the hospital for further evaluation.
His serum creatinine level is 3.2 mg/dL (N 0.6–1.5), which is elevated from his baseline level
of 0.8 mg/dL. A urinalysis is normal, except for the presence of occasional eosinophils. The
remainder of his evaluation, including liver enzyme levels and renal ultrasonography, is normal.
Which one of the following is the most appropriatenext step in the management of this patient?
A) A postvoid residual urine volume
B) A hepatitis C viral load and genotype
C) Discontinuing cephalexin
D) Antibiotics to cover methicillin-resistant Staphylococcus aureus(MRSA)
E) Aggressive fluid resuscitation with normal saline

Answer 18

ANSWER: C
Acute kidney injury (AKI) is currently defined as either a rise in serum creatinine or a reduction in urine
output. Creatinine must increase by at least 0.3 mg/dL, or to 50% above baseline within a 24–48 hour
period. A reduction in urine output to 0.5 mL/kg/hr for longer than 6 hours also meets the criteria. Acute
interstitial nephritis is an intrinsic renal cause of AKI. These patients are often nonoliguric. A history of
recent medication use is key to the diagnosis, as cephalosporins and penicillin analogues are the most
common causes. Approximately one-third of patients present with a maculopapular rash, fever, and
arthralgias. Eosinophilia and sterilepyuria may also be seen in addition to eosinophiluria. Discontinuation
of the offending drug is the cornerstone of management.
Although up to 30% of patients with chronic hepatitis C infection havesome kidney involvement, acute
interstitial nephritis is uncommon. Measuring postvoid residual urine volume is indicated if an obstructive
cause for the AKI is suspected. Starting anantibiotic to cover methicillin-resistant Staphylococcus aureus
(MRSA) is not indicated

Question 19

Which one of the following medicationsis most likely to cause hypokalemia?
A) Albuterol (Proventil, Ventolin)
B) Doxazosin (Cardura)
C) Erythromycin
D) Felodipine (Plendil)
E) Lisinopril (Prinivil, Zestril)

Answer 19

ANSWER: A
B-Agonists activate potassium uptake by the cells. This includes bronchodilators and tocolytic agents. Other
agents that can induce hypokalemia include pseudoephedrine and insulin. Diuretics, particularly thiazides,
can also cause hypokalemia as a result of the renal loss of potassium.

Question 20

An abandoned infant is brought tothe hospital for evaluation. Based on the presence of a dried
umbilical cord remnant and her overall appearance, you believeher to be no more than 5 days
of age. A thorough examination is normal except for a finding of bilateral conjunctival erythema
and exudate. A Gram stain of the exudate is remarkable for numerous WBCs, very few of which
are noted to contain gram-negative diplococci.
Which one of the following treatment options is most appropriate?
A) Application of moist, warm saline eye compresses
B) Irrigation of both eyes with povidone-iodine (Betadine)
C) One-time application of ophthalmic erythromycin ointment into both eyes
D) Instillation of silver nitrate solution into both eyes
E) Intramuscular injection of ceftriaxone (Rocephin)

Answer 20

ANSWER: E
Infantile gonococcal infection is usually the result of exposure to infected cervical exudate during delivery
and manifests 2–5 days after birth. Ophthalmia neonatorum and sepsis are the most severe gonococcal
infections in newborns and immediate treatment is warranted based on the presumptive diagnosis. Topical
antibiotics are appropriate for prophylaxis, but not for treatment. Silver was usedfor prophylaxis at one
time, but is no longer available. Povidone-iodine has not been studied for prevention. A single dose of
25–50 mg/kg of ceftriaxone administeredintravenously or intramuscularly is the recommended treatment

Question 21

Which one of the following has been shown to have a beneficial effect for symptoms of the
common cold in an adult?
A) Diphenhydramine (Benadryl)
B) Ipratropium (Atrovent) nasal spray
C) Intranasal zinc
D) Intranasal corticosteroids
E) Systemic corticosteroids

Answer 21

ANSWER: B
Ipratropium is the only nasally inhaled anticholinergic recommended by the American College of Chest
Physicians for a cough caused by the common cold. One study showed thatthe nasal formulation decreases
rhinorrhea and sneezing, and a Cochrane review found that ipratropium bromide nasal spray improved
rhinorrhea but did not help nasal stuffiness (SOR B). Antihistamine monotherapy (either sedating or
nonsedating) such as diphenhydramine was no more effective than placebo (SOR A). Corticosteroids have
not been found to be effective for the symptoms of a common cold. Intranasal zinc should not be used
because it may result in the permanent loss of smell.

Question 22

A 50-year-old white male is injured while mountain biking. The CT scan of the patient’s
abdomen shown below is most consistent with which one of the following?
A) Rupture of the spleen
B) Subcapsular hematoma of the spleen
C) Subcapsular hematoma of the kidney
D) Ruptured hollow viscus
E) Herniated vertebral disc

Answer 22

ANSWER: C
The CT scan shows a subcapsular hematoma of the kidney. This is considered a grade I injury and does
not require surgical treatment.

Question 23

A 21-year-old primigravida at 10 weeks gestation has a negative titer for rubella. The best
procedure to follow is to
A) institute a -globulin regimen and maintain it throughout her pregnancy
B) administer rubella vaccine after 12 weeks gestation
C) administer rubella vaccine immediately post partum
D) administer rubella vaccine 12 weeks post partum

Answer 23

ANSWER: C
Rubella has been directly responsible for inestimable pregnancy wastage, aswell as for severe congenital
malformations. Identification and vaccination of unimmunized women immediately after childbirth or
abortion is recommended. The use of -globulin to prevent viremia in nonimmune subjects exposed to
rubella is not recommended. The vaccine should be avoided shortly before or during pregnancy since it
is an attenuated live virus. Because of herd immunitythere is a very low likelihood that this patient will
be exposed to rubella.

Question 24

A postmenopausal female who has recently been diagnosed with hypertension returns for
follow-up 3 months after the initiation of therapeutic lifestyle changes. Her blood pressure has
improved but remains higher than goal at 142/90 mm Hg, and pharmacologic treatment is
indicated. The patient has a family history of osteoporosis.
Which one of the following may slow the demineralization of bone in this patient?
A) An ACE inhibitor
B) An -blocker
C) A -blocker
D) A calcium channel blocker
E) A thiazide diuretic

Answer 24

ANSWER: E
An adult patient with a confirmed systolic blood pressure >139 mm Hg or a diastolic blood pressure >89
mm Hg is hypertensive. JNC-7 guidelines recommend the adoption of healthy lifestyles for all patients,
especially those with hypertension,and the addition of pharmacologic treatment as necessary to reach a
goal blood pressure -blockers post myocardial infarction.
The selection of an agent with favorable side benefits is recommended. Thiazide-type diuretics are useful
in slowing demineralization from osteoporosis, making this the most appropriate choice for this patient.
Other examples of choosing drugs based on side benefits include -blockers for patients with a history of
migraine or tachycardia, calcium channel blockers for patients with Raynaud’s syndrome, and -blockers
for patients with benign prostatic hyperplasia

Question 25

An otherwise healthy 1-year-oldmale is brought to your officebecause of increased respiratory
effort, wheezing, and rhinorrhea. He has no fever. On examination he is found to have an
increased respiratory rate and mild retractions. A chest film shows no foreign body or infiltrates.
His O2
saturation is 94%.
Management should include which one of the following?
A) A trial of nebulized albuterol (AccuNeb)
B) Nebulized epinephrine (Asthmanefrin)
C) Oxygen
D) Antibiotics
E) Corticosteroids

Answer 25

ANSWER: A

This presentation is consistent with bronchiolitis, which is a response to a viral respiratory infection.
American Academy of Pediatrics guidelines for the management of bronchiolitis do not recommend routine
use of any treatment, recommending instead that the choice be based on the specific needs of the child.
If the child responds to a trial of albuterol, then treatment can be continued; otherwise, evidence shows
no benefit. Antibiotics are indicated for signs of bacterial infection. Oxygen is indicated if the O2 saturation
is

Question 26

An 80-year-old female is admitted to your service at a skilled nursing facility 5 days after repair
of a hip fracture. When you review her records you note that she has not received any previous
treatment for osteoporosis. You are considering ordering zoledronic acid (Reclast) to reduce her
risk of another fracture.
Which one of the following should be evaluated before administering zoledronic acid to this
patient?
A) Vitamin D levels
B) Liver enzyme levels
C) Estimated glomerular filtration rate
D) A CBC

Answer 26

ANSWER: C
Secondary prevention of fractures is an important component of care following a hip fracture. Options to
consider include bisphosphonates, calcium supplementation, and vitamin D supplementation.
Bisphosphonates, including zoledronic acid, can reduce rates ofclinical fractures among patients who have
had a hip fracture (SOR A). While long-term use ofbisphosphonates may increase the risk of jaw
osteonecrosis and anemia, a CBC is not necessary before initiating therapy. Contraindications to zoledronic
acid include hypocalcemia and a creatinine clearance

Question 27

A 58-year-old male has a history of type 2 diabetes mellitus that is not well controlled. He has
recently developed mild hypertension that has not been controlled by lifestyle changes. You
prescribe lisinopril (Prinivil, Zestril), 20 mg daily, for the hypertension and 2 months later you
note that his serum creatinine level has increased from 1.25 mg/dL to 1.5 mg/dL (N 0.64–1.27)
and his blood pressure has decreased from 142/88 mm Hg to 128/78 mm Hg.
Which one of the following should you do now?
A) Continue the current dosage of lisinopril
B) Decrease the dosage of lisinopril to 10 mg
C) Increase the dosage of lisinopril to 40 mg
D) Discontinue lisinopril and initiate chlorthalidone
E) Discontinue lisinopril and initiate losartan (Cozaar

Answer 27

ANSWER: A
ACE inhibitors such as lisinopril do not need to be discontinued unless baseline creatinine increases by
>30%. (This patient’s creatinine increased by 20%.) The current dosage of lisinopril is appropriate, as
the blood pressure meets the diabetic goal of

Question 28

A 68-year-old female presents with recent poor oral intake, fatigue, and confusion. Osmotic
demyelination syndrome (central pontine myelinolysis) and permanent neurologic deficits could
result from overly rapid correction of which one of the following abnormalities?
A) Hyperglycemia
B) Hyperkalemia
C) Hypokalemia
D) Hypernatremia
E) Hyponatremia

Answer 28

ANSWER: E
Overly rapid correction of hyponatremia may cause osmotic demyelination syndrome, or central pontine
myelinolysis, sometimes resulting in permanent neurologic deficits after a brief improvement in neurologic
status. Signs and symptoms may include dysarthria, dysphagia, paresis, coma, and seizures. It is believed
that brain volume shrinks because it cannot assimilate the new electrolytes fast enough and water is lost
from the cells. Rapid correction of hypernatremia that has beenpresent for a short time is relatively safe.
Hyperkalemia is a life-threatening condition that should be corrected promptly. Rapid correction of
hypoglycemia is not an issue. Overly rapid correction of hyperglycemia and subsequent cerebral edema
is unusual and is primarily seen in children

Question 29

A 22-year-old primigravida presents for routine prenatal care at 18 weeks gestation. She is
frustrated because of increased pigmentation on her face consistent with melasma (chloasma).
Which one of the following would you recommend for this patient?
A) Use of a high-potency broad-spectrum sunscreen
B) Use of hydroquinone for 4 weeks
C) Postpartum use of oral contraceptives
D) Avoiding future use of topical retinoids
E) Increased surveillance for skin cancer beginning at age 40

Answer 29

ANSWER: A
Melasma is a very common condition in pregnancy and is due to hyperpigmentation related to normal
hormonal changes that accompany pregnancy. It can also be caused by oral contraceptives and is more
common in dark-skinned persons.
High-potency broad-spectrum sunscreens may help prevent melasma, or at least prevent worsening of the
condition (SOR C). Topical retinoids, hydroquinone, and corticosteroids can also be helpful, but are
usually reserved for postpartum use and require months of treatment. Other treatments include azelaic acid,
chemical peels, kojic acid, cryosurgery, and laser treatment (SOR B). Melasma usually improves
spontaneously after delivery, but itmay be prolonged or worsened by oral contraceptive use. It does not
increase the risk of developing skin malignancies

Question 30

A 40-year-old white male was seen 4 weeks ago for a sudden onset of cough and shortness of
breath. At that visit his O2saturation was 92%, but his examination and a chest radiograph were
normal. You prescribed azithromycin (Zithromax) and an albuterol inhaler (Proventil, Ventolin).
Ten days later he was feeling well and his oxygensaturation was 97%. Today he returns to the
office with a dry cough and shortness of breath.
On examination he has rare inspiratory rales that clear with deep breaths, and he has an O2
saturation of 86%. A chest film and a D-dimer test are normal. Pulmonary function tests show
significant restriction that improves only minimally with albuterol. He has not been exposed to
anyone with a similar illness, has no history of asthma, and has no smoking history or
occupational exposure. However, he reports that 2 months ago his home was flooded after a
heavy rain, and he has been tearing out carpeting that was ruined by the flood.
Which one of the following isthe most likely diagnosis?
A) Persistent asthma with acute exacerbations
B) Legionnaires’ disease
C) Pulmonary embolism
D) Hypersensitivity pneumonitis

Answer 30

ANSWER: D
Hypersensitivity pneumonitis can present in acute, subacute, or chronic forms. The case described includes
two episodes of the acute form. The patient was exposed to mold antigens in his flooded home. Within 4–8
hours of exposure, chills, cough, and shortness of breath will be noted, and at times will be dramatic. A
chest film can be normal, even with significant hypoxia. Pulmonary function tests will show restrictive
changes, as compared to the reversible obstructive changes of acute asthma. Blood tests often show an
elevated erythrocyte sedimentation rate. Serum IgG tests for the probable antigen confirm the diagnosis.
Symptoms of acute hypersensitivity pneumonitis resolve over several days, but will suddenly and violently
recur with repeated exposure to the offending antigen. The subacute form begins gradually over weeks or
months, causing a cough and increasing shortness of breath. The chronic form develops over years of
exposure, causing fibrotic changes to the lungs thatwill be evident on radiographs, as well as chronic
crackles on auscultation.
Asthma would be an unlikely diagnosis in this case, with the pulmonary function tests showing restrictive
changes rather than obstructive changes, and little improvement with albuterol. Also, the lack of a previous
history of asthma makes it less likely. Legionnaires’ disease is always possible, but is unlikely in this case
given the sudden onset, quick recovery over several days, and sudden recurrence.Pulmonary embolism
is ruled out by the negative D-dimer test

Question 31

Which one of the following metabolic abnormalities is most likely to be seen in patients with
stage 4 kidney disease?
A) Hyperaldosteronism
B) Hyperparathyroidism
C) Hypothyroidism
D) Hypogonadism
E) Type 2 diabetes mellitus

Answer 31

ANSWER: B

Hyperparathyroidism is present in more than half ofpatients who have a glomerular filtration rate

Question 32

Which one of the following is the usual reservoir for hantavirus?
A) Prairie dogs
B) Jackrabbits
C) Deer mice
D) Ground squirrels

Answer 32

ANSWER: C
Up through July of 2013, the Centers for Disease Control and Prevention had logged 624 cases of
hantavirus pulmonary syndrome in residents of 34 states. The infection killed morethan a third of the
victims. The virus is usually spread by inhalation ofdried aerosolized deer mouse urine or droppings.
Infected deer mice usually have few outward signs. Other hosts include the white-footed mouse, the rice
rat, and the cotton rat. Other rodents have not been shown to carry the virus.

Question 33

The skin lesion shown below is characteristic of which condition often associated with a drug
reaction?
A) Id reaction
B) Erythema multiforme
C) Discoid lupus
D) Granuloma annulare
E) Pyoderma gangrenosum

Answer 33

ANSWER: B
Erythema multiforme (EM) is an acute, often recurrent, inflammatory condition. While it is associated with
many different causes such as drugs,infections, and physical agents, it is most commonly associated with
acute upper respiratory infections, herpes simplex virus, and Mycoplasma pneumoniae.
EM typically occurs in persons 20–40 years of age, with urticarial papules or the classic bull’s-eye or
target lesions (as shown in this case). The distribution is primarily on the hands (both the dorsi and palms),
soles, and extensor aspects of the arms and legs. Lesions may also occur on mucosal surfaces, but in
typical EM these are milder than in the more severe Stevens-Johnson syndrome, which is more commonly
associated with drugexposure than with infectious agents.
The lesions of EM are usually pruritic, but not universallyso. They evolve to the typical target forms over
24–48 hr. The central area is often dusky and may be superficially necrotic or vesicular. Partial target
lesions may resemble urticaria. The lesions usually heal without scarring over a 10- to 14-day period.
An id reaction is a papulovesicular eruption, classically on the sides offingers, that occurs in response to
an intense inflammatory process suchas a fungal infection or acute dermatitis in another anatomic area of
the body. When that condition resolves, so does the id reaction.
Discoid lupus lesions are irregular but roughly round in shape, sharply demarcated, and most commonly
found on the face or scalp. They usually develop an adherent thick scale. The duration may be months or
years.
Granuloma annulare manifests as a ring of firm, flesh-colored orred papules with a more prominent outer
ring forming due to central involution. These lesions may last for months to years. The distribution is
usually on the dorsolateral aspect of the hands or feet.
Pyoderma gangrenosum begins as a tender papule, usually on the lower leg, and evolves to a painful,
necrotic, inflammatory lesion that gradually enlarges up to 10 cm. It usually is a manifestation of an
underlying systemic inflammatory condition such as inflammatory bowel disease. The lesions last for
months to years and heal with scarring.

Question 34

A new home urine test is designed to detect a particular type of cancer. The gold standard test
for this cancer is a biopsy, but a biopsy is morecostly than the urine test, is invasive, and is
associated with a number of adverse side effects. To test the effectiveness of the home urine test,
104 people took the test and then agreed to a biopsy. When the study was concluded, 77 people
tested negative and 27 tested positive on the urine test. Biopsies were positive in 18 individuals,
8 of whom tested negative on the urine test.
What is the negative predictive value of the home urine test, rounded to a whole number?
A) 20%
B) 37%
C) 56%
D) 80%
E) 90%

Answer 34

ANSWER: E
The results of this urine test were that 10 people had the disease and tested positive (true positives); 8
people had the disease but tested negative (false negatives); 17 people did not have the disease (27 – 10)
but tested positive (false positive); 69 people did not have the disease (77 – 8) and tested negative (true
negative). The negative predictive value is determinedby dividing the true negatives (69) by the total
number who tested negative (true plus false negatives = 77). The result is 89.6%, which rounded to a
whole number is 90%.

Question 35

An 85-year-old male is admitted to a nursing home due to weakness, debility, and limitation of
activities of daily living (ADLs) after being hospitalized for acute community-acquired
pneumonia. He previously lived with his wife independently and his goal is to return home when
he is strong enough. He has a history of coronary artery disease, type 2 diabetes mellitus
controlled with diet, hypertension,and chronic diastolic heart failure, but he has no symptoms
related to these chronic problems. His appetite ispoor and he has lost a significant amount of
weight. His admission diet order from the hospital was a cardiac diet.
Which one of the following would be the most appropriate diet for this patient?
A) A regular diet
B) An American Heart Association diet
C) A diet with no added salt
D) An 1800-calorie/day American Diabetes Association diet
E) A diet with no concentrated sweets

Answer 35

ANSWER: A
This patient should be provided with a regular diet, which may promote weight gain in nursing-home
residents with unintentional weight loss. Malnutrition and unintentional weight loss are significant problems
in nursing-home residents and lead to multiple complications, including pressure ulcers and infections. The
American Dietetic Association recommends liberalizing diets to improve nutritional status and quality of
life in older adults. A small study demonstrated equivalent glycemic control in nursing-home residents who
ate a regular diet compared to those who ate a restricted American Diabetes Association diet (SOR C).
Low-salt and low-cholesterol diets are unpalatable and are often associated with protein-energy malnutrition
and postural hypotension in older persons. Special diets should beavoided whenever possible in
nursing-home patients

Question 36

In women with polycystic ovary syndrome, the risk is increased the most for carcinoma of the
A) breast
B) cervix
C) colon
D) endometrium
E) ovary

Answer 36

ANSWER: D
Several disorders that are common in women with polycystic ovarysyndrome are associated with an
increased risk for endometrial carcinoma, including obesity, hyperinsulinemia, diabetes mellitus,
anovulatory cycles, and high androgen levels.