Questions 1-50

Question 1

50. A 25-year-old female with hypothyroidism sees you for preconception counseling. Her thyroid problem has been well managed with levothyroxine (Synthroid), 75 :g daily, but she asks your advice about changing her treatment to something more natural now that she is planning to become pregnant.

Which one of the following is the best recommendation for this patient?

A) Continue the current dosage of levothyroxine
B) Reduce the current dosage of levothyroxine to 50g daily
C) Change to a comparable dosage of combination levothyroxine/L-triiodothyronine
D) Change to a comparable dosage of desiccated thyroid

Answer 1

Item 50
ANSWER: A
Untreated hypothyroidism during pregnancy impairs fetal development and increases the risk of spontaneous miscarriage, prematurity, preeclampsia, gestational hypertension, and postpartum hemorrhage. These risks are mitigated by appropriate levothyroxine treatment. Levothyroxine/L- triiodothyroxine combinations and desiccated thyroid preparations have the potential to correct maternal hypothyroidism, but the T4 level may still be too low to provide the transplacental delivery necessary for optimal fetal health. The most appropriate pregnancy planning advice is to continue the current dosage of levothyroxine with a plan for monthly monitoring of TSH and T4 during pregnancy, with the expectation that an increase in dosage may be required as the pregnancy progresses.

Question 2

49. A 36-year-old male laborer presents to an urgent care center 5 hours after falling off a ladder. He was 7–8 feet off the ground, and he fell directly on his anterolateral leg as he landed. Weight bearing is painful. Foot pulses are normal, as is a sensorineural examination of the foot and leg. The anterolateral lower leg is quite tender but only slightly swollen, and there is exquisite pain in that area with passive plantar flexion of the great toe. Radiographs of the lower leg and ankle are negative.

In addition to ice, elevation, and analgesia, which one of the following would be most appropriate?

A) Scheduled oral muscle relaxants
B) A 6-day oral corticosteroid taper
C) Physical therapy referral for early mobilization and ultrasound therapy
D) A short leg splint and non–weight bearing for 5–7 days
E) Urgent orthopedic referral for possible fasciotomy

Answer 2

Item 49
ANSWER: E
This patient most likely has acute compartment syndrome and must be urgently evaluated by an orthopedic surgeon. Typically, compartment pressure can be measured using a needle attached to a manometer, and if the pressure is elevated (usually >40 mm Hg) urgent fasciotomy is necessary to prevent muscle necrosis. If the classic “Five Ps” (pain, paresthesia, pallor, pulselessness, and paralysis) are all present, the outcome will most certainly be bad, even limb-threatening. Early identification with a high index of suspicion and urgent referral for fasciotomy is necessary to prevent tragic results.

Before the classic findings develop, patients will have tenderness out of proportion to the physical appearance of the injury and, most importantly, severe pain in the involved compartment with passive stretching of the involved muscles.

While rest, immobilization, non–weight bearing, and analgesia are all appropriate measures, none of these is sufficient treatment for this urgent problem.

Question 3

48. A disheveled 89-year-old male with dementia who relies on a caregiver for bathing, dressing, shopping, and meal preparation is brought in for continued evaluation of weight loss. No medical cause has been found at this point. On examination a large purplish bruise is noted over his posterior leg and a more faded greenish-yellow bruise is noted over his abdomen, which his caregiver explains by saying that he has fallen several times recently. The patient is also noted to have a large sacral decubitus ulcer.

Which one of the following should you suspect as the cause of bruising in this patient?

A) Senile purpura
B) Thrombocytopenia
C) Leukemia
D) Elder abuse
E) Cushing syndrome

Answer 3

Item 48
ANSWER: D
This patient has numerous red flags for elder abuse, including unexplained weight loss, reliance on a caregiver, a disheveled appearance, a pressure ulcer, and bruising in locations that are not typically associated with unintentional trauma from falls. Although the other listed causes of bruising are possible, in this scenario the index of suspicion should be highest for elder abuse.

Question 4

47. A 78-year-old male experiences two episodes of near-syncope within several hours. You order an EKG, which is shown below.

Which one of the following does this EKG show?

A) Atrial fibrillation with a slow ventricular response
B) Sinus bradycardia
C) Complete heart block
D) 2:1 Mobitz AV block

Answer 4

Item 47
ANSWER: C
The EKG reveals P waves unrelated to the QRS complex, in that the PR interval is variable and random. With atrial fibrillation there is no P wave. Sinus bradycardia has a P wave associated with each QRS complex and a fixed PR interval. With 2:1 AV block there would be two P waves followed by a QRS. Mobitz-type blocks have a consistent PR interval, often with a widened QRS.

Question 5

46. A 49-year-old white female is concerned because she has painful, cold fingertips that sometimes turn white when she is hanging out her laundry. Which one of the following medications has been shown to be useful for this patient’s condition?

A) Propranolol
B) Nifedipine (Procardia)
C) Ergotamine/caffeine (Cafergot)
D) Cilostazol (Pletal)

Answer 5

Item 46
ANSWER: B
There is no currently approved treatment for Raynaud’s disease. However, patients with this disorder reportedly experience subjective symptomatic improvement with dihydropyridine calcium channel antagonists, with nifedipine being the calcium channel blocker of choice. “1-Antagonists such as prazosin or terazosin are also effective. B-Blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol are contraindicated. Drugs such as ergotamine preparations can produce cold sensitivity, and should therefore be avoided in patients with Raynaud’s disease. Cilostazol is indicated for intermittent claudication but not for Raynaud’s disease.

Question 6

45. A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running.

An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated.

Which one of the following is the most likely diagnosis?

A) Sesamoid fracture
B) Gout
C) Morton’s neuroma
D) Cellulitis

Answer 6

Item 45
ANSWER: A
Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury.

Gout often involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton’s neuroma typically causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized.

Sesamoiditis is often hard to differentiate from a true sesamoid fracture. Radiographs should be obtained, but at times they are nondiagnostic. Fortunately, treatment is similar for both conditions, unless the fracture is open or widely displaced. Limiting weight bearing and flexion to control discomfort is the first step. More complex treatments may be needed if the problem does not resolve in 4–6 weeks.

Question 7

44. One week after a complete and adequate baseline screening colonoscopy, a 51-year-old female with no history of previous health problems visits you to review the pathology report on the biopsy specimen obtained from the solitary 8-mm polyp discovered in her sigmoid colon. The report confirms that this was a hyperplastic polyp. Her family history is negative for colon cancer.

Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient?

A) 1 year
B) 2 years
C) 5 years
D) 10 years

Answer 7

Item 44
ANSWER: D
There is substantial evidence that small (less than 10 mm) hyperplastic polyps found in the rectum or sigmoid colon are not neoplastic. Data obtained from numerous studies provides considerable evidence of moderate quality that individuals with no significant findings other than rectal or sigmoid hyperplastic polyps of this size should be included in the same low-risk cohort as those who have an unremarkable colonoscopy. For patients at low risk the recommended interval between screening colonoscopies is 10 years. Reductions in this interval are recommended for patients with one or two small tubular adenomas (5–10 years) or those with three or more tubular adenomas (3 years); the interval for more extensive disease is best individualized but can be as often as annually in unusual cases.

Question 8

43. You are treating an 18-year-old college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis.

Which one of the following intranasal medications is considered optimal treatment for this condition?

A) Glucocorticoids
B) Cromolyn sodium
C) Decongestants
D) Antihistamines

Answer 8

Item 43
ANSWER: A
Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety. Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms. Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.
Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause somnolence and a bitter taste. Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea. Overall, they are not as effective as topical glucocorticoids.

Question 9

42. A 71-year-old female with a history of hypertension and osteoporosis presents to your office for preoperative clearance for upcoming eye surgery. She complains of progressively worsening fatigue over the past 8–10 months. She says she often feels dizzy but denies a history of syncope. Her current medications include alendronate and hydrochlorothiazide. You obtain the EKG shown below as part of her preoperative evaluation.

Which one of the following would be most appropriate at this point?

A) Clearance for eye surgery with no further evaluation
B) An exercise treadmill test
C) A 48-hour Holter monitor
D) A 7-day event monitor
E) Referral to a cardiologist for pacemaker placement

Answer 9

Item 42
ANSWER: E
This patient has documented bradycardia on an EKG and a diagnosis of sick sinus syndrome. She has symptomatic end-organ hypoperfusion resulting from her slow heart rate. In addition to lightheadedness and fatigue, other manifestations can include palpitations, angina, heart failure, oliguria, TIA, or stroke. In a symptomatic patient with documented bradycardia, permanent pacemaker placement is recommended (SOR C).

If a patient is symptomatic but bradycardia is not evident on the EKG, prolonged monitoring is recommended with a 48-hour Holter monitor. The next step would be longer monitoring with an event monitor.

Evidence of sick sinus syndrome may be seen with exercise treadmill testing. Patients with chronotropic incompetence may be unable to achieve target heart rates with exercise. However, the exercise treadmill test is not standardized to diagnose sick sinus syndrome.

Question 10

41. A 4-year-old male is brought to your office by his parents who are concerned that he is increasingly “knock-kneed.” His uncle required leg braces as a child, and the parents are worried about long-term gait abnormalities. On examination, the patient’s knees touch when he stands and there is a 15° valgus angle at the knee. He walks with a stable gait.

Which one of the following should you do now?

A) Refer to orthopedics for therapeutic osteotomy
B) Refer to physical therapy for customized bracing
C) Prescribe quadriceps-strengthening exercises
D) Provide reassurance to the patient and his family

Answer 10

Item 41
ANSWER: D
This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers under 2 years of age typically have a varus angle at the knee (bowlegs). This transitions to physiologic genu valgus, which gradually normalizes by around 6 years of age. As this condition is physiologic, therapies such as surgical intervention, special bracing, and exercise programs are not indicated.

Question 11

40. A 56-year-old male is brought to the emergency department by his wife because of a 3-day history of fever up to 102.1°F (38.9°C). He complains of headache, body aches, and a cough. His wife notes that he seems to be confused at times, and mentions that he has type 2 diabetes mellitus.

On examination the patient’s temperature is 38.7°C (101.7°F), heart rate 113 beats/min, blood pressure 96/64 mm Hg, respiratory rate 24/min, and oxygen saturation 93% on room air. You administer 2 L of oxygen via nasal cannula and his oxygen saturation rises to 98%. A CBC, blood cultures, and a basic metabolic panel are ordered, as well as a chest radiograph and urinalysis.

In addition to starting antibiotics, which one of the following would be most appropriate at this point?

A) A bolus of normal saline
B) Bicarbonate therapy
C) Vasopressin (Pitressin)
D) Hydrocortisone intravenously
E) Norepinephrine

Answer 11

Item 40
ANSWER: A
This patient exhibits signs of possible sepsis, including fever, altered mental status, tachycardia, and tachypnea. Confirmation of a documented infection would establish the diagnosis, but treatment should be started before the infection is confirmed. Initial management includes respiratory stabilization. This patient responded to oxygen supplementation, but if he had not, mechanical ventilation would be indicated. The next appropriate step is fluid resuscitation. A bolus of intravenous fluids at 20 mL/kg over 30 minutes or less is recommended (SOR A). Vasopressors should be started if a patient does not respond to intravenous fluids as evidenced by an adequate increase in mean arterial pressure and organ perfusion (SOR B). First-line agents include dopamine and norepinephrine. Vasopressin may be added but has not been shown to improve mortality. Bicarbonate therapy is not usually recommended to improve hemodynamic status. Hydrocortisone may be used in patients who do not respond to fluids and vasopressors.

Question 12

39. A 62-year-old female with type 2 diabetes mellitus routinely has fasting blood glucose levels in the 80–100 mg/dL range and her hemoglobin A1c level is 7.8%. She has been diligently monitoring her blood glucose levels and all are acceptable with the exception of elevated bedtime readings. She currently is on insulin glargine (Lantus), 18 U at night.

Which one of the following changes would be most appropriate for this patient?

A) Adding rapid-acting insulin at breakfast
B) Adding rapid-acting insulin at lunch
C) Adding rapid-acting insulin at dinner
D) Increasing the nightly insulin glargine dose
E) Increasing the insulin glargine dosage and giving two-thirds in the morning and one-third
at night

Answer 12

Item 39
ANSWER: C
This patient continues to have an elevated hemoglobin A1c and bedtime hyperglycemia. The addition of a rapid-acting insulin at dinner would be the next step in management. For patients exhibiting blood glucose elevations before dinner, the addition of rapid-acting insulin at lunch is preferred. For patients with elevations before lunch, rapid-acting insulin with breakfast would most likely improve glucose control. Increasing or splitting the insulin glargine would be unlikely to improve management.

Question 13

38. Azithromycin (Zithromax) is prescribed for a 65-year-old male with coronary artery disease. This drug should be used with caution in this patient due to an increased risk for

A) an adverse effect on left ventricular function
B) peripheral edema
C) elevation of systolic blood pressure
D) fatal arrhythmias

Answer 13

Item 38
ANSWER: D
In March of 2013 the FDA issued a safety warning regarding azithromycin and its potential to lead to serious and even fatal arrhythmias, particularly in at-risk patients. Risk factors include hypokalemia, hypomagnesemia, a prolonged QT interval, and the use of certain medications to treat abnormal heart rhythms. The mechanism of action is prolongation of the QT interval, leading to torsades de pointes (level of evidence 2, SOR A).

The FDA recommends that physicians consider the risk of torsades de pointes and fatal heart rhythms associated with azithromycin when considering antibiotic treatment options, particularly in patients who are already at risk for cardiovascular events.

Question 14

37. A 39-year-old female presents with a 4-month history of gradually worsening left elbow pain. She does not recall an injury but frequently lifts and holds her 10-month-old son in her left arm. She has tenderness over the lateral epicondyle. Her elbow range of motion is normal but she has pain with supination and pronation. The remainder of the examination is normal.

For long-term pain relief, the best evidence supports which one of the following?

A) Expectant/conservative management
B) Physical therapy
C) Oral anti-inflammatory agents
D) A corticosteroid injection

Answer 14

Item 37
ANSWER: A
Lateral epicondylitis is a common condition characterized by degeneration of the extensor carpi radialis muscle tendon originating in the lateral epicondyle. It is a self-limited condition and usually resolves within 12–18 months without treatment. It is not an inflammatory condition and anti-inflammatory agents have not been found to be beneficial. Corticosteroid injections have been found to be associated with poor long-term outcomes, as well as high recurrence rates. Neither physical therapy, bracing, nor splinting is proven to provide long-term pain relief. Approximately 90%–95% of all patients with lateral epicondylitis show improvement at 1 year despite the type of therapy utilized (SOR A).

Question 15

36. A 65-year-old female presents with an 11-mm lesion on her nasolabial fold. You perform a shave biopsy that confirms basal cell carcinoma.

Which one of the following would be the most appropriate treatment of this lesion?

A) Excision with wide margins
B) Electrodesiccation and curettage
C) Mohs micrographic surgery
D) Cryotherapy
E) Imiquimod (Aldara) cream

Answer 15

Item 36
ANSWER: C
Basal cell carcinoma is the most common invasive malignant cutaneous neoplasm in humans. The tumor rarely metastasizes but it can advance by direct extension and can destroy normal tissue. Approximately 85% of all basal cell carcinomas occur on the head and neck, with 25%–30% on the nose. Lesions on the nose, eyelid, chin, jaw, and ear have higher recurrence rates than lesions in other locations. A biopsy is necessary to make a definitive diagnosis prior to treatment. Excision is preferred for larger tumors with well-defined borders, but wide margins are not necessary. It is very difficult to perform this surgery with a primary closure around the nose. For lesions around the nose, especially those >1 cm, Mohs micrographic surgery is the preferred treatment. This is a microscopically controlled technique that facilitates removal of the entire lesion with the least amount of tissue removed.

Imiquimod is an immune response modifier that can be used on superficial basal cell carcinomas but should not be used for a site with a high risk of recurrence. Electrodesiccation and curettage is effective for smaller nodular basal cell carcinomas. Cryotherapy is not recommended.

Question 16

35. A 50-year-old female with a history of refractory hypertension presents with abdominal pain. Her laboratory results are significant for a positive Helicobacter pylori antibody. You decide to initiate treatment for her H. pylori infection with sequential therapy using the following drug regimen: rabeprazole (Aciphex) plus amoxicillin, followed by clarithromycin (Biaxin) plus tinidazole (Tindamax). She is currently on multiple medications for her hypertension.

Which one of her antihypertensive agents would be most affected by the treatment regimen described?

A) Amlodipine (Norvasc)
B) Clonidine transdermal (Catapres-TTS)
C) Hydrochlorothiazide
D) Metoprolol tartrate (Lopressor)
E) Ramipril (Altace)

Answer 16

Item 35
ANSWER: A
Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of calcium channel blockers metabolized by this enzyme, thus increasing their levels. This can lead to hypotension, edema, and acute kidney injury due to decreased renal perfusion. It is preferable to choose a different antibiotic regimen for patients on a dihydropyridine calcium channel blocker such as amlodipine, but if another antibiotic cannot be used, either temporarily stopping the calcium channel blocker or empirically lowering the dosage should be considered.

Question 17

34. A 56-year-old male with diabetes mellitus and hypertension presents with a 6-month history of generalized pruritus. He reports that he scratches frequently. On examination his skin is dry and scaly. He has multiple linear excoriations and thickened skin on his forearms, legs, and neck.

Which one of the following is the most likely cause of his pruritus?

A) Contact dermatitis
B) Chronic urticaria
C) Lichen simplex chronicus
D) Scabies

Answer 17

Item 34
ANSWER: C
This patient has lichen simplex chronicus, consisting of lichenified plaques and excoriations that result from excessive scratching. Treatment focuses on stopping the itch-scratch cycle. Topical corticosteroids under an occlusive dressing or intralesional corticosteroids can be helpful. Scabies lesions are small, erythematous papules that are frequently excoriated. Contact dermatitis is usually associated with direct skin exposure to an allergen or irritant and is typically localized to the area of exposure. Chronic urticaria causes a typical circumscribed, raised, erythematous lesion with central pallor.

Question 18

33. The parents of a 4-year-old male bring him in for evaluation because of behavioral problems in his preschool. They report that he is inattentive, hyperactive, and impulsive, has difficulty remaining seated, always seems to be moving, frequently interrupts others, and talks incessantly. His teacher also told them that he never plays quietly, has difficulty taking turns, and intrudes often in other children’s play.

Which one of the following is recommended by the American Academy of Pediatrics for initial management in this child’s case?

A) Behavioral treatment alone
B) Methylphenidate (Ritalin) alone
C) Atomoxetine (Strattera) alone
D) Methylphenidate combined with behavioral treatment
E) Methylphenidate combined with atomoxetine

Answer 18

Item 33
ANSWER: A
According to the American Academy of Pediatrics, preschool-age children with ADHD should receive behavioral therapy alone, administered by a parent and/or teacher. Initially prescribing behavioral therapy alone is supported by strong overall evidence and also by a study finding that many preschool-age children with moderate to severe dysfunction had improved symptoms with behavioral therapy alone. If significant improvement is not observed, then methylphenidate can be added. Medications combined with behavioral therapy should be prescribed in elementary school–age children. Evidence for the use of stimulants is strong, and evidence for the use of atomoxetine is sufficient, but not as strong as for the stimulants.

Question 19

32. Which one of the following findings on pulmonary function testing is most consistent with restrictive lung disease?

A) Reduced FEV1 and a decreased FEV1/FVC ratio

B) Reduced FEV1 and a normal FEV1/FVC ratio

C) Reduced FEV1 and an increased FEV1/FVC ratio

D) Reduced FVC and an increased FEV1/FVC ratio

E) Decreased diffusing capacity of the lung for carbon monoxide (DLCO)

Answer 19

Item 32
ANSWER: D
A full set of pulmonary function tests consists of spirometry, helium lung volume measurements, and the measurement of diffusing capacity of the lung for carbon monoxide (DLCO). A bronchodilator challenge will allow assessment of reversible airway obstruction. A methacholine challenge test can also be used to look for airway hyperreactivity. A reduced FVC with either a normal or increased FEV1/FVC ratio is consistent with restrictive lung disease. There are three basic categories of restrictive lung disease: intrinsic lung disease, chest wall deformities, and neuromuscular disorders. A reduced FEV1 and decreased FEV1/FVC ratio is seen in obstructive lung disease (asthma, COPD). The DLCO is the measure of the diffusion of carbon monoxide across the alveolar-capillary membrane. Reduced values are obtained when interstitial fibrosis is extensive, or when the capillary surface is compromised by vascular obstruction or nonperfusion, or is destroyed (as in emphysema).

Question 20

31. A 43-year-old asymptomatic male is found to have slightly elevated ALT (SGPT) and AST (SGOT) levels on laboratory work prior to donating blood. He feels well and is otherwise healthy.

Which one of the following should be ordered to evaluate the patient for hereditary hemochromatosis?

A) A serum iron panel, including a serum ferritin level and transferrin saturation
B) An A-fetoprotein (AFP) level
C) HFE genetic testing
D) Hepatic ultrasonography
E) A liver biopsy

Answer 20

Item 31
ANSWER: A
Initial testing with serum ferritin levels and transferrin saturation is indicated when hereditary hemochromatosis is suspected. Normal values for these tests exclude iron-mediated organ dysfunction. Genetic testing is indicated if the serum ferritin level is >300 ng/mL in men or >200 ng/mL in women, or if transferrin saturation is ≥45%. A liver biopsy would be indicated to determine hepatic iron content and histopathology if the ferritin level were ≥1000 ng/mL or liver transaminases were elevated in a patient who is homozygous for C282Y. An A-fetoprotein level and hepatic ultrasonography would be indicated to detect hepatocellular carcinoma if the condition has already advanced to cirrhosis.

Question 21

30. Which one of the following is the most accurate imaging study for assessing early osteomyelitis?

A) Plain radiography
B) Ultrasonography
C) CT
D) MRI
E) A bone scan

Answer 21

Item 30
ANSWER: D
Osteomyelitis is a serious complication of diabetic foot infections and is present in up to 20% of mild to moderate infections and in 50%–60% of severe infections. While a bone biopsy and/or bone cultures are definitive for making the diagnosis, radiologic studies can also be helpful. Plain radiography may show bony destruction but has a sensitivity for osteomyelitis ranging from 28% to 75%, depending on the timing of the examination and the severity of the infection. It may take weeks for these infections to become apparent on plain radiographs. The sensitivity of triple-phase technetium bone scans is up to 90% but they have low specificity for osteomyelitis. The 90% sensitivity and 80% specificity of MRI is superior to all other imaging modalities.

Question 22

29. A 57-year-old female is hospitalized for hypotension. She has stage IV breast cancer with extensive visceral and skeletal metastases. For the past 2 weeks she has had fatigue, nausea, and anorexia. She also reports a 3-lb weight loss during this time. She decided to stop chemotherapy 1 month ago.

The patient appears pale with a pulse rate of 78 beats/min and a blood pressure of 82/54 mm Hg. Her physical examination is unremarkable except for lower thoracic spine tenderness on percussion. Laboratory studies reveal a serum sodium level of 132 mEq/L, a potassium level of 5.2 mEq/L, and a hemoglobin level of 10.5 g/L. Chest radiographs reveal scattered pulmonary metastatic lesions. The patient is started on intravenous fluid resuscitation with normal saline. On day 2 her blood pressure continues to remain low despite aggressive fluid replacement.

Which one of the following should be administered next to manage her hypotension?

A) Broad-spectrum antibiotics
B) Dobutamine
C) Dopamine
D) Hydrocortisone
E) Packed RBCs

Answer 22

Item 29
ANSWER: D
Common features of acute adrenal insufficiency include fatigue and lack of energy, weight loss, hypotension, loss of appetite, nausea, and vomiting. Other features such as dry skin, hyperpigmentation, and abdominal pain are seen to varying degrees. Common laboratory findings include electrolyte disturbances, hyponatremia, hyperkalemia, hypercalcemia, azotemia, anemia, and eosinophilia. Patients can also have unexplained hypoglycemia. Patients with advanced-stage cancer (especially of the lung or breast) may develop acute adrenal insufficiency from metastatic infiltration of the adrenal glands. Intravenous hydrocortisone is the treatment of choice in the management of adrenal crisis. For managing hypotension, dopamine is recommended for patients with sepsis, dobutamine for those in cardiogenic shock, and packed RBCs for those with hemorrhagic shock. Broad-spectrum antibiotics are part of the therapy for sepsis, but are not first-line agents for hypotension (SOR B).

Question 23

28. A 75-year-old male with a history of hypertension sees you after experiencing an episode of numbness on his right side and loss of strength in his right arm. The numbness and weakness resolved spontaneously within 20 minutes. Carotid Doppler ultrasonography and cerebral angiography both reveal significant carotid stenosis.

In addition to starting aspirin, which one of the following would be the most appropriate next step for this patient?

A) Aggressive lowering of blood pressure
B) Clopidogrel (Plavix)
C) Carotid artery stenting
D) Evaluation for occult patent ductus arteriosus
E) High-dose statin therapy

Answer 23

Item 28
ANSWER: E
Statin drugs are effective for preventing stroke, which should be the key goal in this high-risk patient. They may stabilize the intimal wall. Rapid lowering of blood pressure could cause brain injury by reducing blood flow in patients with carotid stenosis. Any evidence of hypoperfusion needs to be corrected immediately. Combination therapy with aspirin and clopidogrel is associated with an increased risk of bleeding and is not recommended for stroke prevention. Patients over age 70 have worse outcomes with carotid stenting than with endarterectomy. Occult patent ductus arteriosus has not been shown to be a significant risk factor for stroke.

Question 24

27. A 75-year-old female is evaluated in the emergency department in the evening for heart failure. She is acutely symptomatic with dyspnea. Vital signs include a pulse rate of 96 beats/min, a blood pressure of 140/90 mm Hg, and an oxygen saturation of 94% on room air. A chest radiograph shows mild pulmonary congestion.

Which one of the following would be most appropriate regarding placement of an indwelling urinary catheter for accurate measurement of urine output and for patient comfort?

A) Avoiding indwelling urinary catheter placement

B) Placement of an indwelling urinary catheter only until initial diuresis is completed

C) Placement of an indwelling urinary catheter and removal when the patient is transferred out of the emergency department

D) Placement of an indwelling urinary catheter until 6:00 a.m. tomorrow

E) Placement of an indwelling urinary catheter and removal within 24 hours

Answer 24

Item 27
ANSWER: A
The Society of Hospital Medicine recommends that urinary catheters not be placed or left in place for managing incontinence or for staff convenience, or for monitoring output in patients who are not critically ill. The Infectious Diseases Society of America recommends using patient weight to monitor diuresis. Acceptable indications for an indwelling catheter include critical illness, obstruction, hospice care, and perioperatively for less than 2 days for urologic procedures.

Question 25

26. A 29-year-old female presents with redness of her left eye. She has just returned from a summer beach vacation with her children and woke up with a red eye. Your examination reveals a watery discharge, a hyperemic conjunctiva, and a palpable preauricular lymph node. Her cornea is clear on fluorescein staining.

Which one of the following is most appropriate for this patient?

A) Reassurance only
B) Culture-guided antibiotic therapy
C) Quinolone eyedrops
D) Corticosteroid/antibiotic eyedrops
E) Urgent ophthalmologic referral

Answer 25

Item 26
ANSWER: A
Viruses cause 80% of infectious conjunctivitis cases and viral conjunctivitis usually requires no treatment. Bacterial conjunctivitis is associated with mattering and adherence of the eyelids. Topical antibiotics reduce the duration of bacterial conjunctivitis but have no effect on viral conjunctivitis. Allergic conjunctivitis would be more likely if the patient reported itching. Antibiotics or corticosteroids would not be helpful in this patient, and would not prevent complications.

The majority of cases of viral conjunctivitis are caused by adenoviruses, which cause pharyngeal conjunctival fever and epidemic keratoconjunctivitis. Pharyngeal conjunctival fever is characterized by high fever, pharyngitis, and bilateral eye inflammation. Keratoconjunctivitis occurs in epidemics, and is associated with a watery discharge, hyperemia, and ipsilateral lymphadenopathy in >50% of cases.

Question 26

25. A 76-year-old male with metastatic cancer, diabetes mellitus, and stage IV chronic renal disease develops confusion and myoclonus. His current medications include enalapril (Vasotec), 10 mg/day; glipizide (Glucotrol), 10 mg/day; and morphine sulfate, 30 mg every 4 hours for pain. The morphine was started 4 weeks ago and the dosage was gradually increased until the pain was controlled.

Which one of the following is the most likely cause of his symptoms?

A) A drug-drug interaction
B) Metastasis to the lumbar spine
C) Diabetic neuropathy
D) Toxic metabolites of morphine

Answer 26

Item 25
ANSWER: D
Morphine should be avoided in patients with renal insufficiency because the toxic metabolites morphine-3-glucuronide and morphine-6-glucuronide are not eliminated by the kidneys. Accumulation of these metabolites causes neuroexcitatory effects, including confusion, sedation, respiratory depression, and myoclonus.

Fentanyl and methadone are considered the safest opioids to use in patients with end-stage renal disease, but they require careful titration, dosage adjustments as necessary, continued monitoring, and an awareness of possible interactions with other medications that patients may be taking.

Question 27

24. A 7-year-old Hispanic female has a 3-day history of a fever of 104.0°F (40.0°C), muscle aches, vomiting, anorexia, and headache. Over the past 12 hours she has developed a painless maculopapular rash that includes her palms and soles but spares her face, lips, and mouth. She has recently returned from a week at summer camp in Texas. Her pulse rate is 140 beats/min, and her blood pressure is 70/40 mm Hg.

Which one of the following is the most likely diagnosis?

A) Mucocutaneous lymph node syndrome
B) Leptospirosis
C) Rocky Mountain spotted fever
D) Scarlet fever
E) Toxic shock syndrome

Answer 27

Item 24
ANSWER: C
While all of the conditions listed are in the differential diagnosis, the most likely in this patient is Rocky Mountain spotted fever (RMSF) (SOR C). It is transmitted by ticks and occurs throughout the United States, but is primarily found in the South Atlantic and South Central states. It is most common in the summer and with exposure to tall vegetation from activities such as camping, hiking, or gardening. The diagnosis is based on clinical criteria that include fever, hypotension, rash, myalgia, vomiting, and headache (sometimes severe). The rash associated with RMSF usually appears 2–4 days after the onset of fever and begins as small, pink, blanching macules on the ankles, wrists, or forearms that evolve into maculopapules. It can occur anywhere on the body, including the palms and soles, but the face is usually spared.

Mucocutaneous lymph node syndrome is a similar condition in children (usually less than 2 years old), but symptoms include changes in the lips and oral cavity, such as strawberry tongue, redness and cracking of the lips, and erythema of the oropharyngeal mucosa. Leptospirosis is usually accompanied by severe cutaneous hyperesthesia. The patient with scarlet fever usually has prominent pharyngitis and a fine, papular, erythematous rash. Toxic shock syndrome may present in a similar fashion, but usually in postmenarchal females.

Question 28

23. The Infectious Diseases Society of America recommends which one of the following as the drug of choice for group A streptococcal pharyngitis?

A) Azithromycin (Zithromax)
B) Cefadroxil
C) Cephalexin (Keflex)
D) Clindamycin (Cleocin)
E) Penicillin

Answer 28

Item 23
ANSWER: E
The Infectious Diseases Society of America recommends that penicillin remain the treatment of choice for group A streptococcal pharyngitis because of its proven efficacy, safety, narrow spectrum, and low cost. Penicillin-resistant group A Streptococcus has never been documented. Amoxicillin is often used in place of penicillin V as oral therapy for young children, primarily because of acceptance of the taste of the suspension. The other options listed are all possible regimens for group A streptococcal pharyngitis but penicillin is still considered the treatment of choice.

Question 29

22. Which one of the following ethnic groups in the United States is at greatest risk for complications from influenza?

A) African-American
B) Asian-American
C) Mexican-American
D) Native American
E) Scandinavian-American

Answer 29

Item 22
ANSWER: D
While anyone, even previously healthy individuals, may benefit from treatment of symptomatic clinical influenza infection with antiviral agents, not everyone who has been exposed but is asymptomatic requires chemoprophylaxis. However, persons at higher risk for complications from influenza should be considered for preventive treatment. Those at highest risk include children under the age of 2 years, pregnant women (including women less than 2 weeks post partum), adults over the age of 65, the morbidly obese (BMI >40 kg/m2), and Native or Alaskan Americans. If persons at high risk for influenza complications are not treated prophylactically with antiviral agents after exposure, then they should receive prompt treatment as soon as possible after developing signs and symptoms of influenza infection.

Question 30

21. Which one of the following medications used for anxiety has also been shown to reduce the symptoms of irritable bowel syndrome?

A) Buspirone
B) Clonazepam (Klonopin)
C) Divalproex sodium (Depakote)
D) Risperidone (Risperdal)
E) Citalopram (Celexa)

Answer 30

Item 21
ANSWER: E
Irritable bowel syndrome (IBS) symptoms improve with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

Question 31

20. A 67-year-old male is admitted to your inpatient service with a week-long acute exacerbation of COPD. He also has hypertension and type 2 diabetes mellitus. After 24 hours of intravenous fluids and intravenous methylprednisolone, he is now tolerating oral intake.

Which one of the following corticosteroid regimens is best for this patient at this time?

A) Continue intravenous methylprednisolone until his COPD is back to baseline, then switch to oral methylprednisolone for a 14-day total course of treatment

B) Switch to oral prednisone for a 14-day total course of treatment, including the initial 24-hour intravenous treatment

C) Switch to oral prednisone for 4 more days of treatment

D) Use only inhaled corticosteroids by nebulizer

E) Discontinue corticosteroid treatment altogether after 24 hours

Answer 31

Item 20
ANSWER: C
Systemic corticosteroid therapy reduces the hospital length of stay in patients with acute COPD exacerbations (SOR A). Oral therapy has been shown to be as effective as the intravenous route in patients who can tolerate oral intake (SOR B). A randomized, controlled trial has demonstrated that 5-day courses of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A). Inhaled corticosteroids are beneficial in some COPD patients but nebulizers generally do not offer significant advantages over metered-dose inhalers in most patients.

Question 32

19. A 58-year-old postmenopausal female presents with a recent onset of painless vaginal bleeding. Her last menses occurred 8 years ago and she has had no bleeding until now. She reports that her Papanicolaou smears have always been normal, with the last one obtained a year ago. A pelvic examination today is normal.

Which one of the following management options is the preferred next diagnostic step?

A) Colposcopy with endocervical curettage
B) Transvaginal ultrasonography
C) Saline infusion sonohysterography
D) Hysteroscopy

Answer 32

Item 19
ANSWER: B
Transvaginal ultrasonography is the preferred initial test for a patient with painless postmenopausal bleeding, although endometrial biopsy is an option if transvaginal ultrasonography is not available. Transvaginal ultrasonography showing an endometrial thickness less than 3–4 mm would essentially rule out endometrial carcinoma (SOR C). An endometrial biopsy is invasive and has low sensitivity for focal lesions. Saline infusion hysterography should be considered if the endometrial thickness is greater than the threshold, or if an adequate measurement cannot be obtained by ultrasonography. If hysterography shows a global process, then a histologic diagnosis can usually be obtained with an endometrial biopsy, but if a focal lesion is present hysteroscopy should be considered as the next diagnostic step. Colposcopy is not indicated given the patient’s normal Papanicolaou smear.

Question 33

18. An 84-year-old male is walking across the street and has to hurry to avoid oncoming traffic. He suddenly develops extreme pain in his knee and falls down, and has to be carried to the sidewalk.

The following day he comes to the emergency department. He is comfortable when placed in a knee immobilizer, but is very tender just above the patella. He can bend his knee but when he tries to straighten his leg it is so weak that he cannot move it at all. Radiographs of the knee are shown below.

What is the most likely diagnosis?

A) Patellar tendon rupture
B) Quadriceps tendon rupture
C) Tibial plateau fracture
D) Patellar subluxation
E) Lumbar radiculopathy

Answer 33

Item 18
ANSWER: B
Quadriceps tendon rupture can be partial or complete. When complete, as in this case, the patient has no ability to straighten the leg actively. A similar pattern is seen with patellar tendon rupture, but in this situation the patella is retracted superiorly by the quadriceps. Quadriceps rupture often produces a sulcus sign, a painful indentation just above the patella. If the patient is not examined soon after the injury, the gap in the quadriceps can fill with blood so that it is no longer palpable. The clinical examination is usually diagnostic for this condition, but this patient’s radiograph shows some interesting findings, especially on the lateral view. A small shard of the patella has been pulled off and has migrated superiorly with the quadriceps. The hematoma filling the gap in the quadriceps is the same density as the muscle, but wrinkling of the fascia over the distal quadriceps provides a clue that it is no longer attached to the superior margin of the patella.

Tibial plateau fractures are intra-articular, so they produce a large hemarthrosis. They are evident on a radiograph in almost all cases. Pain inhibits movement of the knee, but the extreme weakness evident in this case would not be seen.

Patellar subluxation is obvious acutely, when the patella is displaced laterally. More often, the patient comes in after the patella has relocated. Findings then include tenderness along the medial retinaculum, sometimes a joint effusion, and a positive apprehension sign when the patella is pushed gently laterally.

Lumbar radiculopathy can cause weakness of the quadriceps if it involves the third lumbar root, but complete paralysis would not occur. Other findings would include lumbar pain radiating to the leg, possibly with paresthesias and fasciculations if there were significant neurologic impairment.

Question 34

17. Which one of the following intravenous agents is the best INITIAL management for hypercalcemic crisis?

A) Furosemide
B) Pamidronate
C) Hydrocortisone
D) Saline

Answer 34

Item 17
ANSWER: D
The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels >14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels ( less than 13 mg/dL). If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide.
Intravenous pamidronate, a bisphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. Glucocorticoids are useful in the treatment of hypercalcemia associated with certain malignancies (multiple myeloma, leukemia, several lymphomas, and breast cancer) or with vitamin D intoxication. The onset of action, however, takes several days, with the effect lasting days to weeks.

Question 35

16. A previously healthy 16-year-old male presents to your office after having a syncopal episode at the start of track practice. An EKG revealed a QTc of 520 ms. This was confirmed on a subsequent EKG.

This finding is associated with which one of the following rhythm abnormalities?

A) Sinus arrest
B) Third degree atrioventricular block
C) Paroxysmal supraventricular tachycardia
D) Polymorphic ventricular tachycardia
E) Atrial fibrillation with a rapid ventricular response

Answer 35

Item 16
ANSWER: D
Patients with repeated EKGs showing a QTc interval >480 ms with a syncopal episode, or >500 ms in the absence of symptoms, are diagnosed with long QT syndrome if no secondary cause such as medication use is present. This syndrome occurs in 1 in 2000 people and consists of cardiac repolarization defects. It is associated with polymorphic ventricular tachycardia, including torsades de pointes, and sudden cardiac death. It may be treated with B-blockers and implanted cardioverter defibrillators.

Question 36

15. A large wooden splinter went deep into the forearm of a 24-year-old male while he was working in a horse barn, and he has required local anesthesia and a small incision to remove it completely. After thorough wound cleansing, you inquire about his tetanus status. He is certain that he received all of his primary childhood vaccines and a “tetanus booster” at age 20, but does not know which vaccine he received.

Which one of the following is the best choice for this patient regarding tetanus immunization at this time?

A) TT (tetanus toxoid)
B) Td (tetanus toxoid with reduced diphtheria)
C) Tdap (tetanus toxoid with reduced diphtheria and acellular pertussis)
D) TIG (tetanus immune globulin)
E) No immunization

Answer 36

Item 15
ANSWER: E
The Advisory Committee on Immunization Practices (ACIP) periodically makes recommendations for routine or postexposure immunization for a number of preventable diseases, including tetanus. Since 2005, the recommendation for tetanus prophylaxis has included coverage not only for diphtheria (Td) but also pertussis, due to waning immunity in the general population. The current recommendation for adults who require a tetanus booster (either as a routine vaccination or as part of treatment for a wound) is to use the pertussis-containing Tdap unless it has been less than 5 years since the last booster in someone who has completed the primary vaccination series.

In this scenario, no additional vaccination is needed at this time, since the patient is certain of completing the primary vaccinations and received a tetanus booster within the previous 5 years. Had the interval been longer than 5 years, then a single dose of Tdap would be appropriate unless his previous booster was Tdap. Tetanus immune globulin is recommended in addition to tetanus vaccine for wounds that are tetanus-prone due to contamination and tissue damage in persons with an uncertain primary vaccine history. Plain tetanus toxoid (TT) is usually indicated only when the diphtheria component is contraindicated, which is uncommon.

Question 37

14. A 50-year-old male with difficult-to-control hypertension seeks your advice regarding progressive breast enlargement. Your examination reveals bilateral firm, glandular tissue in a concentric mass around the nipple-areola complex. You diagnose gynecomastia.

Which one of the following antihypertensive medications is most likely to cause this problem?

A) Doxazosin (Cardura)
B) Hydrochlorothiazide
C) Lisinopril (Prinivil, Zestril)
D) Losartan (Cozaar)
E) Spironolactone (Aldactone)

Answer 37

Item 14
ANSWER: E
Except for persistent pubertal gynecomastia, medication use and substance use are the most common causes of nonphysiologic gynecomastia. Common medication-related causes include the use of antipsychotic agents, antiretroviral drugs, or prostate cancer therapies. Spironolactone also has a high propensity to cause gynecomastia; other mineralocorticoid receptor antagonists, such as eplerenone, have not been associated with similar effects. Discontinuing the contributing agent often results in regression of breast tissue within 3 months.

Question 38

13. An elderly male who has an implanted cardioverter-defibrillator is admitted to long-term care. He has several chronic comorbidities, including hypertension, a previous stroke, coronary artery disease, osteoarthritis, advanced chronic systolic heart failure, chronic kidney disease with a calculated glomerular filtration rate of 20 mL/min/1.73 m2, diabetes mellitus, and hypercholesterolemia.

The patient’s quality of life has declined to the point that he wishes to receive only palliative care. He does not want aggressive treatments, including hospitalization, except for reasons of comfort. He has decided he does not wish to be resuscitated, including CPR or intubation.

When considering his goals, and after consultation with the patient and his spouse, which one of the following would be most appropriate for managing his defibrillator?

A) Adjust the defibrillator to deliver shocks only for ventricular fibrillation

B) Adjust the defibrillator to deliver shocks only for a heart rate >140 beats/min

C) Remove the defibrillator generator

D) Deactivate the defibrillator

E) Make no change to the defibrillator

Answer 38

Item 13
ANSWER: D
It is recommended that an implanted cardioverter-defibrillator be deactivated when it is inconsistent with the care goals of the patient and family. In about one-quarter of patients with an implanted cardioverter-defibrillator, the defibrillator delivers shocks in the weeks preceding death. For patients with advanced irreversible disease, defibrillator shocks rarely prevent death, may be painful, and are distressing to caregivers and family members. Advance care planning discussions should include the option of deactivating the implanted cardioverter-defibrillator when it no longer supports the patient’s goals.

Question 39

12. A 30-year-old female sees you because of increasing fatigue. She has no chronic medical problems and reports no recent acute illnesses. She recalls being told that she was mildly anemic after the birth of her daughter 3 years ago. The anemia resolved after 3 months of oral iron supplementation. The patient’s menstrual periods are regular and last approximately 6 days, with heavy bleeding for the first 3 days then moderate to mild flow for approximately 3 days. She denies epistaxis, black stools, or other signs of bleeding.

On examination her temperature is 36.7°C (98.1°F), pulse rate 93 beats/min, respiratory rate 16/min, and blood pressure 116/58 mm Hg. The remainder of her physical examination is unremarkable. A CBC is notable for a hemoglobin level of 10.9 g/dL (N 12.0–16.0) and a mean corpuscular volume of 70 :m3 (N 78–102).

Which one of the following serum levels would be most appropriate for further evaluating her microcytic anemia at this point?

A) Ferritin
B) Folate
C) Erythropoietin
D) Hemoglobin A1c
E) TSH

Answer 39

Item 12
ANSWER: A
After confirmation of anemia and microcytosis on a CBC, a serum ferritin level is recommended (SOR C). If the ferritin level is consistent with iron deficiency anemia, identifying the underlying cause of the anemia is the priority. A common cause of iron deficiency anemia in premenopausal adult women is menstrual blood loss. If the serum ferritin level is not consistent with iron deficiency anemia, the next stage of the evaluation should include a serum iron level, total iron-binding capacity (TIBC), and transferrin saturation (SOR C). Iron deficiency anemia is still probable if the serum iron level and transferrin saturation are decreased and TIBC is increased. It is more likely anemia of chronic disease if the serum iron level is decreased and the TIBC and transferrin saturation are decreased or normal. Other laboratory tests that may help in differentiating the cause of microcytosis include hemoglobin electrophoresis, a reticulocyte count, and peripheral blood smears.

Question 40

11. To prevent joint damage from gout, uric acid levels should be lowered by medication to

A) less than 6.0 mg/dL
B) less than 8.0 mg/dL
C) less than 10.0 mg/dL
D) a level that keeps the patient symptom-free for 6 months

Answer 40

Item 11
ANSWER: A
Targets for uric acid levels in patients with gout vary according to published guidelines but range from 5 to 6 mg/dL. Patients may be symptom-free at higher levels but risk joint damage even without acute episodes (SOR A).

Question 41

10. Routine vaccination against which one of the following organisms has significantly reduced the risk of bacterial meningitis among young children?

A) Borrelia burgdorferi
B) Escherichia coli
C) Haemophilus influenzae
D) Listeria monocytogenes
E) Mycoplasma pneumoniae

Answer 41

Item 10
ANSWER: C
Conjugate vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae have been highly effective in reducing the incidence of bacterial meningitis in young children and are now routinely recommended for infants and older patients who fall into appropriate risk groups (SOR B). Escherichia coli and Listeria monocytogenes also cause meningitis in young children, but there is not currently a routine vaccine for these pathogens. Likewise, Borrelia burgdorferi and Mycoplasma pneumoniae can cause aseptic meningitis, but there is no routine vaccine.

Question 42

9. A healthy 24-year-old male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough. On examination his temperature is 37.2°C (99.0°F). His pharynx is red without exudates, and there are no anterior cervical nodes. His tympanic membranes are normal, and his chest is clear.

Which one of the following would be most appropriate at this point?

A) Analgesics and supportive care only
B) A rapid strep test
C) A throat culture and empiric treatment with penicillin
D) Azithromycin (Zithromax)

Answer 42

Item 9
ANSWER: A
The Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts to develop evidence-based guidelines for evaluating and treating adults with acute respiratory disease. According to these guidelines, the most reliable clinical predictors of streptococcal pharyngitis are the Centor criteria. These include tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. The presence of three or four of these criteria has a positive predictive value of 40%–60%, and the absence of three or four of these criteria has a negative predictive value of 80%.
Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and should therefore not be tested or treated with antibiotics.

Question 43

8. Mild cognitive impairment is characterized by which one of the following?

A) Localized motor dysfunction
B) Impairment in at least one activity of daily living
C) Impairment in at least one instrumental activity of daily living
D) The presence of the APO E4 allele
E) Objective evidence of memory decline

Answer 43

Item 8
ANSWER: E
Mild cognitive impairment is an intermediate stage between normal cognitive function and dementia. Motor function remains normal. The presence of the APO E4 allele is a risk factor, but is not necessary for a diagnosis. Patients have essentially normal functional activities but there is objective evidence of memory impairment, and the patient may express concerns about cognitive decline.

Question 44

7. Which one of the following is one of the five basic principles of the patient-centered medical home?

A) Utilizing the latest research and advances in treatment and diagnosis

B) Coordinating a patient’s care across all elements of the health care system

C) Acting as a gatekeeper to limit access to specialist care

D) Serving as the base of a pyramid in support of a complex health care system

E) Transitioning away from delivering care in an office, and focusing on meeting patients
in their own homes

Answer 44

Item 7
ANSWER: B
The concept of a medical home was first suggested by the American Academy of Pediatrics in 1967 to describe the ideal care of children with disabilities. In 2004 the Future of Family Medicine Project adapted this concept to describe how primary care should be based on “continuous, relationship-centered, whole-system, comprehensive care for communities.” In 2007 all of the major primary care organizations collaborated to define the foundational principles of the patient-centered medical home (PCMH). These principles include the following:

Comprehensiveness: Most preventive, acute, and chronic care for individual patients can be performed at the PCMH.

Patient Centered: The PCMH provides care that is relationship-based, with an orientation toward the whole person.

Coordination: The PCMH coordinates care for patients across all elements of the health care system.

Accessibility: The PCMH works to provide patients with timely access to providers.

Quality: The PCMH continuously works to improve care quality and safety.

Question 45

6. A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a supine position, you palpate the tender area of her lower abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies.

Which one of the following is the most likely diagnosis?

A) Appendicitis
B) A hematoma within the abdominal wall musculature
C) Diverticulitis
D) Pelvic inflammatory disease
E) An ovarian cyst

Answer 45

Item 6
ANSWER: B
A reduction of the pain caused by abdominal palpation when the abdominal muscles are tightened is known as Carnett’s sign. If the cause of the pain is visceral, the taut abdominal muscles may protect the locus of pain. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.

Question 46

5. A 36-year-old female presents with a several-week history of polyuria and intense thirst. She currently takes no medications. On examination her blood pressure and pulse rate are normal, and she is clinically euvolemic. Laboratory tests, including serum electrolyte levels, renal function tests, and plasma glucose, are all normal. A urinalysis is significant only for low specific gravity. Her 24-hour urine output is >5 L with low urine osmolality.

The most likely cause of this patient’s condition is a deficiency of

A) angiotensin II
B) aldosterone
C) renin
D) insulin
E) arginine vasopressin

Answer 46

Item 5
ANSWER: E
This patient has diabetes insipidus, which is caused by a deficiency in the secretion or renal action of arginine vasopressin (AVP). AVP, also known as antidiuretic hormone, is produced in the posterior pituitary gland and the route of secretion is generally regulated by the osmolality of body fluid stores, including intravascular volume. Its chief action is the concentration of urine in the distal tubules of the kidney. Both low secretion of AVP from the pituitary and reduced antidiuretic action on the kidney can be primary or secondary, and the causes are numerous.

Patients with diabetes insipidus present with profound urinary volume, increased frequency of urination, and thirst. The urine is very dilute, with an osmolality less than 300 mOsm/L. Further workup will help determine the specific type of diabetes insipidus and its cause, which is necessary for appropriate treatment.

Low levels of aldosterone, plasma renin activity, or angiotensin would cause abnormal blood pressure, electrolyte levels, and/or renal function. Insulin deficiency results in diabetes mellitus.

Question 47

4. A 15-year-old male is brought to the office for a well child visit. His parents report that he has had a nighttime cough and wheezing for the past several months. He is otherwise healthy and up-to-date on all of his immunizations. You suspect that he has asthma.

Which one of the following would be most appropriate at this point?

A) Treat empirically with a short-acting B-agonist
B) Perform spirometry
C) Order radiologic testing
D) Start an inhaled corticosteroid
E) Start a leukotriene inhibitor

Answer 47

Item 4
ANSWER: B
The American Academy of Asthma, Allergy, and Immunology recommends that asthma not be diagnosed or treated without spirometry. Once the diagnosis is confirmed, treatment should commence with a short-acting B-agonist as needed, followed by stepwise treatment based on the severity of asthma.

Question 48

3. A 52-year-old male has a skin lesion removed from his arm with appropriate sterile precautions. Which one of the following would be most appropriate to use on this surgical wound?

A) Petrolatum
B) Silver sulfadiazine (Silvadene) cream
C) Mupirocin (Bactroban) ointment
D) Polymyxin B/bacitracin ointment (Polysporin)
E) Triple-antibiotic (neomycin/polymyxin B/bacitracin) ointment

Answer 48

Item 3
ANSWER: A
The American Academy of Dermatology recommends against the routine use of topical antibiotics for clean surgical wounds, based on randomized, controlled trials. Topical antibiotics have not been shown to reduce the rate of infection in clean surgical wounds compared to the use of nonantibiotic ointment or no ointment. Studies have shown that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care.

Topical antibiotics can aggravate open wounds, hindering the normal wound-healing process. In addition, there is a significant risk of developing contact dermatitis, as well as a potential for antibiotic resistance. Antibiotic treatment should be reserved for wounds that show signs of infection.

Question 49

2. A 44-year-old male with papulopustular rosacea sees you for follow-up. You have been treating his condition with topical azelaic acid (Finacea), and although his condition is improved he is not satisfied with the results.

You suggest adding which one of the following oral medications?

A) Clarithromycin (Biaxin)
B) Clindamycin (Cleocin)
C) Doxycycline
D) Erythromycin
E) Metronidazole (Flagyl)

Answer 49

Item 2
ANSWER: C
The only FDA-approved oral treatment for acne rosacea is doxycycline at a subantimicrobial dosage (40 mg daily). This does not contribute to antibiotic resistance, even when used over several months, and is better tolerated than higher dosages. Other antibiotics have limited and low-quality supporting evidence of efficacy and may lead to antibiotic resistance.

Question 50

1. A 52-year-old female with morbid obesity is incidentally noted to have mildly elevated AST (SGOT) levels. She does not consume alcohol and denies using recreational drugs. A workup for chronic viral hepatitis and hemochromatosis is negative.

Which one of the following is most likely to improve her hepatic condition?

A) Pentoxifylline
B) Simvastatin (Zocor)
C) L-carnitine
D) Vitamin E
E) Weight loss

Answer 50

Item 1
ANSWER: E
Nonalcoholic fatty liver disease is characterized by the accumulation of fat in hepatocytes. It is associated with insulin resistance, central adiposity, increased BMI, hypertension, and dyslipidemia. An incidentally discovered elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests the presence of nonalcoholic fatty liver disease. The goal of therapy is to prevent or reverse hepatic injury and fibrosis. Diabetes mellitus, hypertension, dyslipidemia, and other comorbid conditions should be appropriately managed.

A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with nonalcoholic fatty liver disease. Weight loss has been shown to both normalize AST levels and improve hepatic histology. Vitamin E has been shown to improve AST levels but has no impact on liver histology, and pentoxifylline, simvastatin, and L-carnitine have not been shown to consistently improve either AST levels or liver histology (SOR B).