Questions 1-50

Question 1

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 previously normal 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, but a microscopic examination is negative 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 of AKI. Furthermore, she is taking a 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

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 of rheumatic 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 is necessary 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

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 to ask 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

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 with clear 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 at all. 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

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 heparin and 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

6. A 27-year-old male requests your advice 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

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 muscle

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 A-glucosidase inhibitors.

Question 8

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 not manage the sensation of shortness of breath in a dying patient.

Question 9

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 most likely 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

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 Medicine utilize 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 at least 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

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

12. A 32-year-old meat cutter comes to your office with 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 Norovirus infections 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

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 four parathyroid 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 less than 50 years old or symptomatic patients, such as those with a fragility fracture, parathyroidectomy is the treatment of choice. If a patient is older, is a poor surgical candidate, or has asymptomatic disease, long-term monitoring with treatment focused on reducing bony complications can be considered (SOR C).

Question 14

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 been found to be one of the most common hereditary causes of thrombophilia.

Question 15

15. Which one of the following is most consistent with a diagnosis of asthma?

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 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 FEV1 and a decreased FEV1/FVC ratio indicates airflow obstruction. A reduced FVC with a normal or increased FEV1/FVC ratio is consistent with a restrictive pattern of lung function.

Question 16

16. A 43-year-old female presents to your 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 onset of 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 strongest in 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

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 fluids at 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 intestines.

Question 18

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 generalized maculopapular 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 appropriate next 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 sterile pyuria 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 have some kidney involvement, acute interstitial nephritis is uncommon. Measuring postvoid residual urine volume is indicated if an obstructive cause for the AKI is suspected. Starting an antibiotic to cover methicillin-resistant Staphylococcus aureus (MRSA) is not indicated.

Question 19

19. Which one of the following medications is 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

20. An abandoned infant is brought to the hospital for evaluation. Based on the presence of a dried umbilical cord remnant and her overall appearance, you believe her 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 used for 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 administered intravenously or intramuscularly is the recommended treatment.

Question 21

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 that the 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

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

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 y-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, as well as for severe congenital malformations. Identification and vaccination of unimmunized women immediately after childbirth or abortion is recommended. The use of y-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 immunity there is a very low likelihood that this patient will be exposed to rubella.

Question 24

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 A-blocker
C) A B-blocker
D) A calcium channel blocker
E) A thiazide diuretic

Answer 24

ANSWER: E
An adult patient with a confirmed systolic blood pressure greater than 139 mm Hg or a diastolic blood pressure greater than 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 less than 140/90 mm Hg. This goal blood pressure is further reduced to less than 130/80 mm Hg for patients who also have diabetes mellitus or renal disease. The same guidelines note that elevated systolic blood pressure is a much more important cardiovascular disease risk factor than diastolic blood pressure in persons older than age 50.

Medication is commonly required to reach the goal blood pressure, and most patients will often require two or more drugs. In the absence of compelling indications for use of a specific class of drugs, thiazide-type diuretics are recommended for initial treatment. Examples of compelling indications include ACE inhibitors for patients with heart failure, diabetes mellitus, or high coronary disease risk, or B-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 B-blockers for patients with a history of migraine or tachycardia, calcium channel blockers for patients with Raynaud’s syndrome, and A-blockers for patients with benign prostatic hyperplasia.

Question 25

25. An otherwise healthy 1-year-old male is brought to your office because 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 less than 90%. Corticosteroids have not been shown to be of benefit.

Question 26

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 of clinical fractures among patients who have had a hip fracture (SOR A). While long-term use of bisphosphonates 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 less than 35 mL/min or other evidence of acute renal impairment.

Question 27

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 greater than 30%. (This patient’s creatinine increased by 20%.) The current dosage of lisinopril is appropriate, as the blood pressure meets the diabetic goal of less than 130/80 mm Hg. Small increases in creatinine have been associated with long-term preservation of renal function, and may be a marker of changes in intraglomerular pressure.

Question 28

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 been present 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

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 it may be prolonged or worsened by oral contraceptive use. It does not increase the risk of developing skin malignancies.

Question 30

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 O2 saturation 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 oxygen saturation 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 is the 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 that will 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

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 of patients who have a glomerular filtration rate less than 60 mL/min, and is independently associated with increased mortality and an increased prevalence of cardiovascular disease. In patients with stage 4 chronic kidney disease, current guidelines recommend monitoring of serum calcium and phosphate levels every 3–6 months and bone-specific alkaline phosphatase activity every 6–12 months with the goal of normalizing these values. The other metabolic abnormalities listed are less common than hyperparathyroidism.

Question 32

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 more than a third of the victims. The virus is usually spread by inhalation of dried 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

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 drug exposure than with infectious agents.

The lesions of EM are usually pruritic, but not universally so. 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 of fingers, that occurs in response to an intense inflammatory process such as 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 or red 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

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 more costly 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 determined by 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

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 is poor 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 be avoided whenever possible in nursing-home patients.

Question 36

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 ovary syndrome are associated with an increased risk for endometrial carcinoma, including obesity, hyperinsulinemia, diabetes mellitus, anovulatory cycles, and high androgen levels.

Question 37

37. Which one of the following cardiac rhythm abnormalities is most common in patients with anorexia nervosa?

A) Atrial fibrillation
B) Ventricular fibrillation
C) Sinus bradycardia
D) Sinus tachycardia
E) Paroxysmal supraventricular tachycardia

Answer 37

ANSWER: C
Sinus bradycardia is almost universally present in patients with anorexia nervosa. It is hypothesized that this is due to vagal hyperactivity resulting from an attempt to decrease the amount of cardiac work by reducing cardiac output. It is also possible that the bradycardia can be accounted for by low serum T3 levels, a common finding in persons with chronic malnutrition. Sinus tachycardia may occur with refeeding in patients with anorexia. Other arrhythmias may also occur but are less frequent.

Question 38

38. An asymptomatic 32-year-old male requests screening for sexually transmitted diseases. A nucleic acid amplification test is performed on a urine sample, and the results are positive for gonorrhea and negative for Chlamydia. The patient has no known drug allergies.

Which one of the following is the recommended treatment for this patient?

A) Ceftriaxone (Rocephin), 125 mg intramuscularly

B) Ceftriaxone, 250 mg intramuscularly

C) Ceftriaxone, 250 mg intramuscularly, plus azithromycin (Zithromax), 1 g orally

D) Ceftriaxone, 125 mg intramuscularly, plus doxycycline, 100 mg orally twice daily for 7 days

E) Ciprofloxacin (Cipro), 500 mg orally

Answer 38

ANSWER: C
The recommended treatment regimen for gonorrhea is ceftriaxone, 250 mg intramuscularly. The 125-mg regimen is no longer recommended because of treatment failures and limited effectiveness in pharyngeal infections. In addition, the patient should be given azithromycin, 1 g orally, because of the high incidence of coinfection with Chlamydia, even if testing is negative, and to decrease the risk for cephalosporin resistance.

Question 39

39. Which one of the following vaccines is CONTRAINDICATED in immunocompromised adults?

A) Herpes zoster
B) Human papillomavirus
C) Meningococcal
D) Pneumococcal polysaccharide
E) Tdap

Answer 39

ANSWER: A
The herpes zoster vaccine is the only live-attenuated virus vaccine listed, and is therefore the one contraindicated in immunodeficient patients. Human papillomavirus, Tdap, meningococcal, and pneumococcal polysaccharide vaccines are not live or live-attenuated vaccines, and may be given to immunocompromised patients.

Question 40

40. You are the attending physician at a long-term care facility. A new resident, an 85-year-old female, presents for an initial evaluation. Upon reviewing her history, you find that she is on 18 different medications. Until you can obtain additional history and medical records, you decide to stop or decrease some of her medications and monitor her response.

Which one of the following would be most appropriate to stop or decrease initially?

A) Sertraline (Zoloft), 25 mg daily

B) Acetaminophen/diphenhydramine (Tylenol PM), 500 mg/25 mg daily

C) Dipyridamole/aspirin (Aggrenox), 200 mg/25 mg daily

D) Digoxin, 0.125 mg every other day

E) Omeprazole (Prilosec), 20 mg daily

Answer 40

ANSWER: B
Polypharmacy is common in the elderly population, but the use of numerous medications is necessary in some elderly patients. However, some medications have been identified as having a considerably higher potential to cause problems when prescribed to elderly patients.

In the case described, acetaminophen/diphenhydramine would be an appropriate medication to stop initially. The older antihistamines cause many adverse CNS effects such as cognitive slowing and delirium in older patients. These effects are more pronounced in elderly patients with some degree of preexisting cognitive impairment. The anticholinergic properties of older antihistamines produce effects such as dry mouth, constipation, blurred vision, and drowsiness. The sedative effect of older antihistamines also increases the risk of falls. Hip fracture and subsequent death have been reported in patients who use older antihistamines such as diphenhydramine.

Sertraline is an SSRI, a preferred class for the treatment of depression in the elderly compared to the tricyclic antidepressants, which are associated with several side effects. Dipyridamole is associated with hypotension in elderly patients, but it benefits some individuals by preventing strokes. It can be used in the elderly, but patients should be monitored for side effects. Therefore, until further information is obtained, it is appropriate to continue the dipyridamole/aspirin in this patient.

When used in elderly patients with heart failure, digoxin should be given in a dosage no greater than 0.125 mg daily; the low dosage used in this individual should not be considered inappropriate until the reason for its use is clarified. While omeprazole can cause problems in the elderly with long-term use, 20 mg/day is a relatively low dose and the decision to discontinue its use should be delayed until more history is available.

Question 41

41. A 25-year-old primigravida asks about pain management during labor. You inform her that use of regional analgesia during labor

A) increases the likelihood of cesarean delivery

B) increases the risk for instrument-assisted vaginal delivery

C) provides less pain relief than opioid analgesia

D) lowers 1-minute Apgar scores

Answer 41

ANSWER: B
Regional analgesia in laboring patients increases the risk of vacuum- or forceps-assisted delivery (relative risk = 1.42; 95% confidence interval, 1.28–1.57; 23 trials; n = 735). Multiple randomized, controlled trials have compared regional analgesia with no analgesia. In a meta-analysis, no statistically significant impact was found on the risk of cesarean delivery, maternal satisfaction with pain relief, long-term backache, or immediate effect on neonatal status as determined by Apgar scores. Regional analgesia provides better pain relief than opioid analgesia.

Question 42

42. A 28-year-old female visits your office because she is worried about episodic abdominal pain and altered bowel habits that have been present intermittently for the past year. She describes the character of her abdominal pain as “crampy,” and says it can become quite severe. Defecation brings some relief, but she sometimes must pass several loose, watery stools before the pain resolves. She occasionally notes mucus in her stool and sometimes feels that evacuation is incomplete even though she is unable to pass more stool. Her body weight is stable, and findings on the abdominal examination are completely normal.

Which one of the following diagnostic tests does current evidence support in this case?

A) Hydrogen breath testing
B) Testing for celiac disease
C) Stool testing for ova and parasites
D) Thyroid function testing
E) CT of the abdomen

Answer 42

ANSWER: B
This patient suffers from diarrhea-predominant irritable bowel syndrome (IBS). Her symptoms meet the Rome III criteria for diagnosis with no alarm features. A CBC, serum chemistries, thyroid function studies, stool testing for ova and parasites, and abdominal imaging are all low-yield tests that are not recommended for routine diagnostic evaluation of IBS (SOR C). The association between IBS and bacterial overgrowth in the small intestine is not clear, so routine hydrogen breath testing is not recommended. Routine testing for celiac disease, however, should be considered in patients with diarrhea-predominant or mixed-presentation IBS (SOR C). A systematic review that included more than 4000 patients found that 4% of those with diarrhea-predominant or mixed-presentation IBS had biopsy-proven celiac disease.

Question 43

43. Which one of the following conditions presents an unacceptable health risk for combined oral contraceptive use?

A) Migraine with aura
B) Endometrial hyperplasia
C) Breastfeeding 1–6 months post partum
D) Chronic hepatitis C
E) Previous laparoscopic banding weight-loss surgery

Answer 43

ANSWER: A
The World Health Organization (WHO) publishes the medical eligibility criteria for contraceptive use as a guideline for the appropriate use of contraceptives. There are four categories that define the appropriateness of contraceptive use in women with certain medical problems:

Category 1: A condition for which there is no restriction for the use of the contraceptive method.

Category 2: A condition for which the advantages of using the method generally outweigh the theoretical
or proven risks.

Category 3: A condition for which the theoretical risk or proven risks usually outweigh the advantages of using the method.

Category 4: A condition that represents an unacceptable health risk if the contraceptive method is used.

A history of migraine with aura is classified as category 4 for oral contraceptives. Women with a history of migraines are 2–4 times as likely to have a stroke compared to women without migraines, and women who have an aura associated with their migraines are at even higher risk. Migraine without aura is classified as category 2 in women younger than 35 and category 3 in women 35 or older. Nonmigrainous headaches are category 1, as is chronic hepatitis C.

Combined oral contraceptive use does not appear to increase the rate or severity of cirrhotic fibrosis and there is no increased risk for hepatocellular carcinoma. Combined oral contraceptives are not recommended for use in women with acute hepatitis C. Breastfeeding is considered category 2 by the CDC and category 3 by WHO. There is conflicting evidence about the effects on the volume of breast milk in women who are on combined oral contraceptives, but the concerns are mainly during the first month of the postpartum period. There have not been any demonstrated adverse health effects in infants exposed to combined oral contraceptives through breast milk. Laparoscopic banding weight-loss surgery is category 1 for combined oral contraceptive use. Evidence shows no significant decrease in the effectiveness of oral contraceptives in women who have had this surgery. Combined oral contraceptive use in patients with endometrial hyperplasia is category 1. Combined oral contraceptives have been used to decrease the risk for endometrial cancer.

Question 44

44. A 56-year-old male with diabetes mellitus, hypertension, and chronic renal insufficiency presents for follow-up of his chronic medical conditions. Results of his most recent metabolic panel included an estimated glomerular filtration rate of 30 mL/min/1.73 m2 (N >60) and a calcium level of 10.4 mg/dL (N 8.5–10.2). Medication reconciliation reveals he is not taking the sevelamer (Renagel, Renvela) prescribed by the consulting nephrologist.

You explain to the patient that he should be taking sevelamer to lower his serum calcium.

The drug accomplishes this by

A) blocking the effect of parathyroid hormone

B) blocking excessive vitamin D levels, thus decreasing intestinal calcium absorption and
increasing renal calcium excretion

C) blocking intestinal absorption of phosphate, which lowers parathyroid hormone secretion

D) directly blocking excessive calcium absorption in the intestines

E) directly increasing the renal excretion of both calcium and phosphate

Answer 44

ANSWER: C
This patient has secondary hyperparathyroidism, a common cause of hypercalcemia in patients with chronic renal insufficiency. Sevelamer is a newer synthetic agent in the therapeutic class of phosphate binders, which includes calcium acetate. Decreasing serum phosphate lowers the feedback stimulation of parathyroid hormone secretion by the parathyroid gland, which is often excessive in chronic renal insufficiency. Normalizing parathyroid levels improves serum calcium levels.

Question 45

45. A 16-year-old afebrile, otherwise healthy female presents with a 4-day history of right ear pain. She says she has spent a fair amount of time swimming recently. Traction on the pinna causes pain. The erythema and inflammation is limited to the ear canal but there is too much edema to easily visualize the tympanic membrane.

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

A) Amoxicillin
B) Amoxicillin/clavulanate (Augmentin)
C) Amoxicillin/clavulanate plus acetic acid 2% topically
D) Ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex) topically

Answer 45

ANSWER: D
Acute otitis externa is treated with topical antibiotics. Although no preparation has been shown to be most effective, a fluoroquinolone does not create a risk of ototoxicity if the tympanic membrane is not intact. Topical corticosteroids may hasten symptom reduction. Oral antibiotics are not appropriate unless the infection has spread beyond the ear canal, or if the patient has diabetes mellitus or is immunocompromised.

Question 46

46. An obese 10-year-old male with tonsillar hypertrophy is brought to your office because of snoring. There is no history of recent or past visits for tonsillitis. Polysomnography shows moderate obstructive sleep apnea syndrome.

Which one of the following is the treatment of choice for this patient?

A) Continuous positive airway pressure (CPAP)
B) Intranasal corticosteroids
C) Extended antibiotic therapy
D) Adenotonsillectomy

Answer 46

ANSWER: D
Childhood obstructive sleep apnea syndrome has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities. Adenotonsillectomy is the treatment of choice. Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment. Intranasal corticosteroids may also be helpful, but the benefit appears small.

Question 47

47. For which type of renal calculus is acidification of the urine indicated?

A) Cystine
B) Uric acid
C) Calcium oxalate
D) Calcium phosphate

Answer 47

ANSWER: D
Urine pH is an important factor in the production of kidney stones. Uric acid, cystine, and calcium oxalate stones tend to form in acidic urine, whereas struvite (magnesium ammonium phosphate) and calcium phosphate stones form in alkaline urine. Urine should be acidified for prevention of calcium phosphate and struvite stones. Cranberry juice or betaine can lower urine pH.

Question 48

48. An 11-year-old male is brought to your office for evaluation of bilateral posterior heel pain that has occurred for the past few months. He plays basketball and soccer several times a week and the pain begins several minutes into each of these activities. There is no pain at rest or with walking. The patient has not noticed any numbness, tingling, or weakness.

On examination you find no swelling or tenderness of the heel or Achilles tendon. Reflexes, strength, and range of motion at the ankle are intact, but he does have bilateral posterior heel pain when you passively dorsiflex the ankles.

Which one of the following is the most likely diagnosis?

A) Achilles tendinopathy
B) Calcaneal apophysitis
C) Plantar fasciitis
D) Heel pad syndrome
E) Tarsal tunnel syndrome

Answer 48

ANSWER: B
Calcaneal apophysitis, also known as Sever disease, is the most common etiology of heel pain in children, usually occurring between 5 and 11 years of age. It is thought that in these children the bones grow faster than the muscles and tendons. A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area. There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain. Radiography is usually normal and therefore does not often aid in the diagnosis, but it may reveal a fragmented or sclerotic calcaneal apophysis. Treatment involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices.

Plantar fasciitis and heel pad syndrome cause pain on the plantar surface of the heel rather than posteriorly. Achilles tendinopathy causes tenderness to palpation of the Achilles tendon. Tarsal tunnel syndrome related to compression of the posterior tibial nerve causes neuropathic pain and numbness in the posteromedial ankle and heel.

Question 49

49. A 75-year-old male comes to your office for a routine follow-up visit for hypertension. He is asymptomatic but your evaluation reveals atrial fibrillation. An echocardiogram is normal except for mild left ventricular hypertrophy.

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

A) No anticoagulation
B) Medical cardioversion
C) Anticoagulation with aspirin
D) Anticoagulation with warfarin

Answer 49

ANSWER: D
This patient’s age and his history of hypertension give him a CHADS2 score of 2, which implies that the patient is at a higher risk of thromboembolism and should be anticoagulated with warfarin and not aspirin. The patient should be fully anticoagulated for a minimum of 3 weeks prior to any attempt at cardioversion.

Question 50

50. A 63-year-old male presents for a preoperative evaluation prior to total knee arthroplasty. He underwent coronary artery angioplasty and stent placement 3 years ago following an episode of angina and an abnormal exercise stress test. His current medications include aspirin, atorvastatin (Lipitor), and lisinopril (Prinivil, Zestril). He runs 2 miles three times/week without difficulty. He has no history of heart failure, diabetes mellitus, kidney disease, or cerebrovascular disease. An EKG and preoperative blood tests, including kidney function tests, are normal.

Which one of the following is indicated prior to surgery to decrease this patient’s perioperative risk?

A) Performing noninvasive cardiac stress testing
B) Continuing his statin therapy
C) Discontinuing aspirin
D) Starting a B-blocker
E) Starting clopidogrel (Plavix)

Answer 50

ANSWER: B
This patient has a Revised Cardiac Risk Index (Goldman Index) score of 1, placing him in a low-risk group for perioperative cardiac complications. Low-risk patients who are able to walk for 2 blocks or climb a flight of stairs without stopping to rest (4 METS) do not need noninvasive cardiac testing. Patients in this risk group who are already on a B-blocker should continue it, but adding one preoperatively may increase risk. Stopping aspirin therapy in patients with coronary stents places them at risk for perioperative cardiac events. Surgical bleeding is somewhat increased in patients on aspirin, but differences in the severity of bleeding events and mortality in surgical patients on low-dose aspirin versus controls are minimal. Stopping clopidogrel in patients who have recently undergone coronary stent placement (6 weeks for bare-metal stents, 1 year for drug-eluting stents) markedly increases risk, but there is no need to start clopidogrel in other patients. Perioperative statin therapy should be continued for all patients undergoing surgery. For patients undergoing vascular therapy, statins have been associated with an improvement in postoperative cardiac outcomes.