Questions 1-50

Question 1

1. A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his right ear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameter and has a horny plug in the center.

The most likely diagnosis is

A) Bowen’s disease
B) basal cell carcinoma
C) keratoacanthoma
D) Kaposi’s sarcoma
E) seborrheic keratosis

Answer 1

ANSWER: C

Keratoacanthoma is a relatively common lesion in the elderly, but is difficult to distinguish from squamous cell carcinoma. However, it is easily distinguished from Bowen’s disease, basal cell carcinoma, Kaposi’s sarcoma, and seborrheic keratosis. Most keratoacanthomas undergo a benign self-healing course but may leave a large, unsightly scar. Treatment is almost always preferred, both for cosmetic reasons and to prevent the rare case of malignant transformation. Proper treatment for a lesion with this appearance is excisional biopsy in order to distinguish between keratoacanthoma and squamous cell carcinoma.

Question 2

2. An 8-year-old male is brought to the emergency department with an acute asthma attack that began 48 hours earlier. His mother initiated his asthma action plan when the attack began, starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with a spacer every 3–4 hours. In the emergency department the child is alert, with a respiratory rate of 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peak flow is 40% of the predicted value.

Which one of the following should you do next?

A) Continue the current albuterol treatment but switch to a nebulizer

B) Administer high-dose albuterol via nebulizer every 20 minutes for 1 hour

C) Administer intravenous corticosteroids within the first hour

D) Administer magnesium sulfate intravenously

E) Prescribe high-dose mucolytics and chest physiotherapy

Answer 2

ANSWER: D

Repeated doses of a short-acting B2-agonist and correction of hypoxia are the main elements of initial emergency department treatment for acute asthma exacerbations in children. Nebulizer treatments are no better than a metered-dose inhaler with a spacer (SOR A). High-dose nebulized albuterol every 20 minutes for 1 hour has not been shown to be beneficial. In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization (SOR A). Oral administration of corticosteroids is as effective as the intravenous route for reducing the need for hospital admission (SOR A). Mucolytics and chest physiotherapy have not been shown to be effective in children with acute asthma attacks.

Question 3

3. A 56-year-old male with type 2 diabetes mellitus has normal cardiac and renal function but has failed to achieve adequate control of his diabetes with diet and multiple oral agents. His BMI is 30.1 kg/m2 and his hemoglobin A1c level is 9.1%.

Which one of the following is most likely to be beneficial in combination with insulin and diet therapy in this patient?

A) Acarbose (Precose)
B) Glimepiride (Amaryl)
C) Metformin (Glucophage)
D) Pioglitazone (Actos)
E) Repaglinide (Prandin)

Answer 3

ANSWER: C

Metformin has been found to reduce cardiovascular risk in patients with type 2 diabetes mellitus. It also decreases the risk of weight gain, and unlike some oral agents it does not significantly increase the risk of hypoglycemia. It should be continued when insulin is initiated in patients with no renal impairment (SOR B).

Question 4

4. You see a 78-year-old male in the hospital the day after his hip-replacement surgery. He has not voided in the past 12 hours. A urethral catheter is placed and 500 mL of urine is removed from his bladder.

Which one of the following is most likely to improve the success rate of a voiding trial?

A) Using a specialized catheter coudé instead of a standard catheter

B) Leaving the catheter in place for at least 2 weeks

C) Immediately removing the catheter to prevent a urinary tract infection

D) Starting tamsulosin (Flomax), 0.4 mg daily, at the time of catheter insertion

E) Starting antibiotic prophylaxis at the time of catheter insertion

Answer 4

ANSWER: D

Urinary retention is a common problem in hospitalized patients, especially following certain types of surgery. Starting an 4-blocker at the time of insertion of the urethral catheter has been shown to increase the success of a voiding trial (SOR A). Voiding trial success rates have not been shown to be improved by leaving the catheter in for 2 weeks, immediate removal of the catheter, using a specialized catheter, or antibiotic prophylaxis.

Question 5

5. A 22-year-old college student comes to your office to discuss her several-year history of abdominal pain and constipation. It has gotten worse since she returned to school this fall. She describes crampy pain and bloating that eases after defecation. Her bowel movements are firm and difficult to pass, and occur about every 3 days on average. Her symptoms have not included vomiting, weight loss, blood in the stool, or melena. Her menses are regular and she is an otherwise healthy young woman. Her family history is negative for any gastrointestinal or genitourinary diseases. On examination you find her abdomen to be soft and without masses, with no tenderness to palpation.

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

A) A therapeutic trial of increased soluble fiber intake
B) A therapeutic trial of lubiprostone (Amitiza)
C) Abdominal ultrasonography
D) Abdominal CT
E) Colonoscopy

Answer 5

ANSWER: B

This patient’s symptoms are consistent with irritable bowel syndrome (IBS). Her history, physical examination, and laboratory evaluation did not show any evidence of peptic ulcer disease, celiac disease, thyroid disease, or inflammatory bowel disease. Red flags include unintentional and unexplained weight loss, rectal bleeding, a family history of bowel or ovarian cancer, and a change in bowel habits to looser and/or more frequent stools persisting for more than 6 weeks in a person over 60. The patient does not have any of these findings and therefore does not require any additional testing to confirm the diagnosis of IBS.

Patients should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, physical activity, and dietary intake. A Cochrane review showed that soluble fiber such as psyllium is not effective for IBS. Lubiprostone is effective for constipation-predominant IBS.

Question 6

6. Which one of the following is a proven strategy to reduce anterior cruciate ligament tears in high-school athletes?

A) The use of neoprene knee sleeves by all athletes competing in high-risk sports

B) Consistent inclusion of long-distance running in practice sessions

C) Structured exercises stressing balance, muscle strength, and proprioception

D) Prohibiting girls from playing on boys’ sports teams

E) Increased enforcement of penalties involving dangerous plays

Answer 6

ANSWER: C

Several prospective trials have shown significant benefits from the use of sports-specific training of the hips and legs in preventing anterior cruciate ligament (ACL) injuries. These programs focus on plyometrics (repetitive actions that rapidly load and contract a targeted muscle group), strength training, and balance exercises, along with consistent feedback about proper landing technique. One such study was able to reduce the frequency of ACL injuries in female high-school soccer players by 88%. Although the risk of ACL injuries in female athletes is up to 10 times that of males, there is no data to show that restricting their participation in male-dominated sports is a successful strategy to prevent injuries.

Question 7

7. A 70-year-old female presents with recurrent episodes of cough, voluminous sputum, and dyspnea. She is a nonsmoker and has never smoked, except for a few cigarettes in her teens. Her past, family, and occupational histories do not suggest a cause for pulmonary or liver disease. Her examination is within normal limits except for the lung examination, which reveals crackles at both lung bases on auscultation. A chest radiograph shows nonspecific markings at both bases.

The most appropriate next step in her workup would be

A) a PPD skin test
B) high-resolution CT
C) an a1-antitrypsin level
D) referral for bronchoscopy

Answer 7

ANSWER: B

The symptoms of this patient fit the criteria for bronchiectasis, and the gold standard for diagnosis is high-resolution chest CT. The chest film does not suggest pulmonary tuberculosis, so a PPD would not be appropriate initially (although tuberculosis can be a cause of bronchiectasis). Bronchoscopy may eventually be necessary, but not at this point in the investigation. This patient’s age, the absence of findings of emphysema, and the lack of a family history of emphysema or liver disease make the diagnosis of a1-antitrypsin deficiency unlikely.

Question 8

8. A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever. On examination she has tenderness over the maxillary sinus on the left.

Which one of the following would be most appropriate for treatment of this patient’s condition?

A) Intranasal saline flushes
B) Intranasal antihistamines
C) Oral antihistamines
D) Oral antibiotics
E) Reassurance only

Answer 8

ANSWER: D

While there are several guidelines for the clinical diagnosis of acute bacterial sinusitis (ABS), there is general agreement that patients with a duration of symptoms of at least 10 days without improvement should be treated with antibiotics, including both children and adults (SOR C). Signs and symptoms may include nasal drainage and congestion, facial pressure and/or pain, sinus tenderness, and headache. Recommendations for the duration of treatment vary.

One set of guidelines calls for empiric treatment with amoxicillin alone; another recommends going directly to amoxicillin/clavulanate. Suggested alternatives include a “respiratory” quinolone or the combination of a third-generation cephalosporin and clindamycin, particularly in patients with penicillin allergy. Due to the increasing emergence of resistant Streptococcus and Haemophilus species, neither trimethoprim/sulfa- methoxazole nor macrolides are now recommended for empiric treatment of ABS.

Data regarding the efficacy of other measures such as nasal irrigation and the use of decongestants is limited and variable. The most recent guidelines do not recommend the use of decongestants, whether oral or topical.

Question 9

9. A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized by flat-topped violaceous papules 3–4 mm in size. The lesions are located primarily on the volar wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared she went to the emergency department and was treated for “possible scabies,” but the treatment has made little or no difference.

Which one of the following treatments is indicated at this time?

A) Clobetasol (Cormax, Temovate) 0.05% ointment
B) Permethrin 5% cream
C) Tacrolimus (Protopic) 0.1% ointment
D) Triamcinolone 0.1% cream

Answer 9

ANSWER: A

This patient has classic lichen planus, with pruritic, symmetrically distributed papular lesions. The violaceous flat-topped papules, usually 3–6 mm in size, are distinct and so characteristic in appearance that a biopsy is usually not necessary to make the diagnosis. First-line treatment is with high-potency topical corticosteroids such as clobetasol, as mid-potency topical agents such as triamcinolone are ineffective. Topical calcineurin inhibitors, including tacrolimus, can be used in cases not responding to topical corticosteroids. While scabies can masquerade as a variety of other dermatoses, retreatment with a scabicide is not indicated in this patient.

Question 10

10. Which one of the following children should be referred immediately for evaluation of speech delay?

A) A 12-month-old who babbles but speaks no words

B) An 18-month-old who does not understand action words

C) A 2-year-old who has a vocabulary of 25 words

D) A 2-year-old who is unable to follow three-step directions

E) A 3-year-old who has a vocabulary of 50 words

Answer 10

ANSWER: E

Because speech-language therapy is effective for primary expressive language disorders, referral as early as possible is critical (SOR A). Red flags suggesting the need for immediate evaluation include no babbling in a 12-month-old, not saying “mama” or “dada” at 18 months, a vocabulary of less than 25 words at age 2, and using less than 200 words at age 3. Children should be able to follow two-step commands by 2 years of age (SOR A).

Question 11

11. A 23-year-old female presents with recurrent unprovoked epistaxis. The patient’s mother is known to have hereditary hemorrhagic telangiectasia.

Contrast echocardiography is recommended to screen for which one of the following frequently associated conditions?

A) Atrioseptal defect
B) Ventricular septal defect
C) Aortic root aneurysm
D) Pulmonary arteriovenous malformation
E) Myocardial perfusion defects

Answer 11

ANSWER: D

Pulmonary arteriovenous malformations are found in 15%–30% of patients with hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. All patients with possible or confirmed HHT should be screened for pulmonary arteriovenous malformations with contrast echocardiography (SOR C). While contrast echocardiography is used to detect atrioseptal and ventricular septal defects, neither of these conditions is particularly prevalent in HHT. Aortic aneurysms and myocardial perfusion defects are also not associated with HHT.

Question 12

12. A 65-year-old male who has been in good health presents to your office with a 2-day history of a sensation of pressure and hearing loss in his left ear. A physical examination and a thorough neurologic examination are both unremarkable. Both tympanic membranes are normal. An audiogram shows a 30-decibel hearing loss at three consecutive frequencies in the left ear, with normal hearing on the right. Placing a vibrating tuning fork in the midline of the forehead reveals sound lateralizing to the right ear.

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

A) CT
B) A CBC, metabolic profile, and thyroid studies
C) Nifedipine (Procardia)
D) Acyclovir (Zovirax)
E) Oral corticosteroids

Answer 12

ANSWER: E

When a patient presents with sudden hearing loss it is important to distinguish between sensorineural and conductive hearing loss. Patients should be asked about previous episodes, and the workup should include both an assessment for bilateral hearing loss and a neurologic examination. Sudden sensorineural hearing loss is diagnosed by audiometry demonstrating a 30-decibel hearing loss at three consecutive frequencies, with no other cause indicated from the physical examination.

Evaluation for retrocochlear pathology may include auditory brainstem response, MRI, or follow-up audiometry. Routinely prescribing antiviral agents, thrombolytics, vasodilators, vasoactive substances, or antioxidants is not recommended. Oral corticosteroids may be offered as initial therapy, and hyperbaric oxygen therapy may be helpful within 3 months of diagnosis. The guidelines also strongly recommend against routine laboratory tests or CT of the head as part of the initial evaluation.

Question 13

13. Which one of the following is true concerning the use of hemoglobin A1c levels to diagnose diabetes mellitus?

A) A level >6.0% is diagnostic of diabetes mellitus

B) Results can be misleading in patients with sickle cell disease

C) The test is equally sensitive in African-Americans and whites

D) The test is useful to diagnose diabetes during pregnancy

Answer 13

ANSWER: B

Hemoglobin A1c (HbA1c) levels of 6.0%–6.5% indicate an increased risk for diabetes mellitus, and levels >6.5% can be used to diagnose diabetes. Hemoglobinopathies and conditions causing hemolysis can cause HbA1c measurements to be falsely low. The opposite effect is seen in African-Americans, who have higher HbA1c levels than whites along the continuum of glycemia. Other tests should be used in patients with conditions that affect HbA1c, including pregnancy.

Question 14

14. A 50-year-old female presents for evaluation of dyspnea that tends to occur with exercise. She has a 40–pack-year history of smoking and has been diagnosed with exercise-induced asthma. She denies any other medical problems. You perform spirometry and find that the expiratory loop is normal and that she has a flattened inspiratory loop.

What is the most likely diagnosis?

A) Vocal cord dysfunction
B) COPD
C) Asthma
D) Restrictive lung disease

Answer 14

ANSWER: A

Vocal cord dysfunction is a disorder in which the vocal cords move toward midline during inspiration or expiration, leading to varying degrees of obstruction. It is commonly misdiagnosed as exercise-induced asthma. There are a number of precipitating factors, including exercise, psychological conditions, irritants, rhinosinusitis, and gastroesophageal reflux disease. Spirometry generally will show a normal expiratory loop with a flattened inspiratory loop. In asthma and COPD the FEV1/FVC ratio is decreased, resulting in a concave shape in the expiratory portion of the flow-volume curve. The inspiratory loops are generally normal. Patients with restrictive lung disease have a normal FEV1/FVC ratio with a reduced FVC.

Question 15

15. A previously healthy 27-year-old female presents with dysuria and urinary urgency and frequency. She also complains of right flank pain, fevers and chills, and nausea without vomiting. She has a decreased appetite, but has been able to drink liquids.

On examination she has a temperature of 38.4°C (101.2°F), a heart rate of 102 beats/min, and a blood pressure of 126/82 mm Hg. She has mild suprapubic tenderness and right costovertebral angle tenderness. A urinalysis shows microscopic pyuria, hematuria, and a positive leukocyte esterase test. Additional laboratory studies are notable for leukocytosis with a left shift, but are otherwise normal, including a negative pregnancy test. The patient does not have allergies to any antibiotics.

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

A) Outpatient management with oral amoxicillin

B) Outpatient management with oral ciprofloxacin (Cipro)

C) Outpatient management with oral nitrofurantoin (Macrodantin)

D) Inpatient management with intravenous ceftriaxone (Rocephin)

E) Inpatient management with intravenous levofloxacin (Levaquin)

Answer 15

ANSWER: B

Most cases of uncomplicated acute pyelonephritis, including the one described here, can be managed in the outpatient setting. Findings that might prompt consideration of inpatient management include comorbid conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac disease), hemodynamic instability, male sex, metabolic derangements, pregnancy, severe pain, a toxic appearance, an inability to take liquids by mouth, or a temperature >39.4°C (103.0°F).

Nitrofurantoin for 5 days is an appropriate treatment for an uncomplicated urinary tract infection, but not for pyelonephritis. Amoxicillin is generally not considered first-line treatment for pyelonephritis because of a high prevalence of resistance to oral B-lactam antibiotics, and it should only be chosen if susceptibility results for the urinary isolate are known and indicate likely activity. Fluoroquinolones, such as ciprofloxacin, are the preferred empiric antibiotic treatment for outpatient treatment of pyelonephritis, as long as the local prevalence of resistance to community-acquired Escherichia coli is less than or equal to 10%.

Question 16

16. An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives in place.

Should it become necessary, the patient’s decision-making capacity is determined by

A) the spouse or next of kin
B) the attending physician
C) a consulting psychiatrist
D) the hospital ethics committee
E) a judge, at the request of hospital social services or the physician

Answer 16

ANSWER: B

The attending physician is responsible for determining capacity and incapacity for decision making. The extent, cause, and probable duration of any incapacity should be documented in the clinical record.

Question 17

17. A 67-year-old female presents with the inability to smell. She is in good health, and her only medical problem is osteoporosis, treated with alendronate (Fosamax). She says she has no sinus or nasal symptoms. A physical examination is normal including an ear, nose, and throat examination.

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

A) Discontinuing the alendronate
B) An anti-tissue transglutaminase antibody test
C) A serum vitamin D level
D) MRI of the brain

Answer 17

ANSWER: D

Certain drugs can affect taste more than smell, but this does not include the bisphosphonates. Olfactory disorders may be associated with deficiencies of vitamins A, B6, B12, and trace metals, but not with vitamin D deficiency. Celiac disease is not known to cause a decreased ability to smell. Rare tumors involving the olfactory region of the brain can affect smell, and are best detected by MRI.

Question 18

18. The American Heart Association recommends a goal blood pressure of less than or equal to 130/80 mm Hg for patients with

A) heart failure
B) pulmonary hypertension
C) atrial fibrillation
D) angina pectoris
E) chronic kidney disease

Answer 18

ANSWER: E

The American Heart Association recommends a goal blood pressure of 130/80 mm Hg or less for the treatment of hypertension in patients with diabetes mellitus, chronic kidney disease, or coronary artery disease.

Question 19

19. A 78-year-old female has chronic symptomatic orthostatic hypotension, likely related to diabetic autonomic dysfunction, which has failed to respond to nonpharmacologic treatment. Her current medications include metformin (Glucophage), 1000 mg twice daily; atorvastatin (Lipitor), 40 mg daily; aspirin, 81 mg daily; and insulin glargine (Lantus), 24 units at bedtime.

Which one of the following would be the most effective therapy for her orthostatic hypotension?

A) Clonidine (Catapres)
B) Midodrine
C) Pseudoephedrine
D) Terbutaline
E) Theophylline

Answer 19

ANSWER: B

Effective treatments for chronic orthostatic hypotension include fludrocortisone, midodrine, and physostigmine (SOR B). Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate therapies.

Question 20

20. A 34-year-old white female who works as an engineer for a major corporation complains of fatigue, low energy, and a depressed mood. She states that she has felt this way for most of her life. She feels depressed most of the time but denies any recent stresses or significant losses in her life. She reports that she is doing well at work and that she recently received a promotion. She has no interests other than her job and states that she has no happy thoughts and that her self-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies. She has had no sleep disturbance, change in appetite, or difficulty concentrating. She is taking no medications and denies substance abuse. Results of a recent medical evaluation required by her employer were all normal, including a physical examination, EKG, multiple chemical profile, CBC, urinalysis, and TSH level.

Which one of the following is the most likely diagnosis?

A) Major depression
B) Dysthymic disorder
C) Bipolar disorder
D) Cyclothymia
E) Adjustment disorder with depressed mood

Answer 20

ANSWER: B

Dysthymic disorder is characterized by depressed mood for at least 2 years in addition to at least two of the following: change in appetite, alteration in sleep, low energy, low self-esteem, poor concentration, or feelings of hopelessness. There must be no history of a manic or hypomanic episode, substance abuse, a chronic psychotic disorder, or an organic cause.

Symptoms of major depression are similar to those of dysthymia and can occasionally be difficult to distinguish from dysthymia. This patient’s lifelong history of a depressed mood not triggered by any particular depressing event, and the predominance of patient complaints as opposed to objective signs, indicate that major depression is not the diagnosis in this case.

Bipolar disorder is characterized by major depression with periods of mania. Cyclothymia is characterized by dysthymia with periods of hypomania. Adjustment disorder with depressed mood is characterized by impaired social or occupational functioning or abnormal symptoms within 3 months of a stressor.

Question 21

21. A 35-year-old female immigrant from a rural village in Southeast Asia visits your clinic shortly after arriving in the United States. She presents with a 1-week history of low-grade fever and a nonproductive cough, and has crackles but no signs of consolidation or pleural effusion on examination. You order a chest radiograph and see several oval infiltrates, 1–2 cm in size.

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

A) Ascaris lumbricoides
B) Enterobius vermicularis (pinworm)
C) Taenia saginata
D) Taenia solium
E) Diphyllobothrium latum

Answer 21

ANSWER: A

This patient has the classic pulmonary manifestations of Ascaris infection, which develop during the transpulmonary passage of Ascaris larvae (SOR C). The larvae produce a syndrome of transient eosinophilic pulmonary infiltrates, commonly referred to as Löffler syndrome. Ascaris infection is the most common worldwide cause of this syndrome. Symptoms develop when larvae are within the lungs, approximately 9–12 days after ingestion of Ascaris eggs. Patients may develop the following symptoms and signs:

• an irritating, nonproductive cough and burning substernal discomfort
• dyspnea and blood-tinged sputum
• urticaria during the first few days of the illness (15% of patients)
• fever, which infrequently exceeds 38.3°C (101.0°F)
• crackles and wheezing, with no signs of consolidation
• hepatomegaly

The acute symptoms generally subside within 5–10 days, depending upon the severity of the illness. The chest radiograph may show round or oval infiltrates ranging in size from several millimeters to several centimeters in both lung fields; these lesions are more likely to be present when blood eosinophilia exceeds 10%. The infiltrates are migratory and may become confluent in perihilar areas, and usually clear completely after several weeks.

Taenia does not infiltrate the lungs, but forms cysts in the muscles. Diphyllobothrium latum, the fish tapeworm, does not cause pulmonary problems. Enterobius (pinworm) does not migrate from the gastrointestinal tract into other organs.

Question 22

22. A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post partum after an uncomplicated delivery.

Which one of the following would be most effective?

A) Lanolin cream
B) Expressed breast milk
C) Tea bag compresses
D) Hydrogel dressing
E) Education on positioning

Answer 22

ANSWER: E

Nipple pain with breastfeeding is extremely common, with some studies reporting a prevalence of up to 96%. Preventing or alleviating nipple pain is important for comfort, but also for promoting breastfeeding in general. The best intervention for nipple pain is education on proper positioning and attachment of the infant. Topical remedies may also be effective, although no one topical agent has been shown to be clearly superior, and none is as effective as education on positioning and latch-on.

Question 23

23. A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints are affected.

The most likely cause of this problem is

A) varicella-zoster virus
B) measles (rubeola) virus
C) parvovirus B19
D) adenovirus
E) human immunodeficiency virus (HIV)

Answer 23

ANSWER: C

Also known as erythema infectiosum or fifth disease, parvovirus B19 infection is a fairly common cause of an exanthematous rash and arthritis in younger women. This infection should be particularly suspected in health-care workers who have frequent contact with children. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.

Question 24

24. For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix) and spironolactone (Aldactone). On examination his temperature is 38.0°C (100.4°F), his blood pressure is 100/60 mm Hg, and his heart rate is 92 beats/min and regular. Examination of the heart and lungs is normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal examination is normal, and the stool is negative for occult blood.

You perform diagnostic paracentesis and send a sample of the fluid for analysis. Which one of the following findings would best support the suspected diagnosis of spontaneous bacterial peritonitis?

A) pH less than 7.2
B) Bloody appearance
C) Neutrophil count >250/mL
D) Positive cytology
E) Total protein >1 g/dL

Answer 24

ANSWER: C

Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis.

Question 25

25. A 67-year-old female has a bone density study that indicates a T score of –3.5. You prescribe alendronate (Fosamax) but at her next visit she says she cannot tolerate the side effects and asks about other therapies.

Which one of the following has the best evidence for prevention of both vertebral fractures and hip fractures?

A) Calcitonin-salmon (Miacalcin)
B) Raloxifene (Evista)
C) Teriparatide (Forteo)
D) Zoledronic acid (Reclast)

Answer 25

ANSWER: D

There are a number of alternatives to the bisphosphonates. Unfortunately, efficacy data is not encouraging for most of them. Intravenous zoledronic acid has been shown to reduce both hip fracture risk and vertebral fracture risk. Teriparatide reduces vertebral fracture risk but not hip fracture risk. The same is true for raloxifene and calcitonin salmon.

Question 26

26. A 65-year-old Asian male with a long history of cigarette smoking presents with weakness, lethargy, and mental confusion. A physical examination is normal. There are no signs of dehydration, edema, or pigmentary changes.

Laboratory Findings
Serumsodium. . . . . . . . . . . 122 mEq/L (N 135–145)
Urineosmolality. . . . . . . . . .280 mOsm/kg H2O (N 50–1400)
Plasmaosmolality. . . . . . . . 260mOsm/kgH2O(N285–295)
Urinesodium. . . . . . . . . . . . 25mEq/L
BUN. . . . . . . . . . . . . . . . . . . 4mg/dL(N8–25)
Serumpotassium. . . . . . . . .4.1mEq/L(N3.5–5.0)

The most likely diagnosis is

A) sodium depletion

B) syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

C) primary polydipsia

D) adrenal insufficiency

Answer 26

ANSWER: B

The syndrome of inappropriate secretion of antidiuretic hormone should be suspected in any patient who has hyponatremia and excretes urine that is hypertonic relative to plasma. A urine sodium concentration >20 mEq/L combined with a low BUN level provides further support for the diagnosis. Additional findings may include weakness, lethargy, mental confusion, and weight gain.

Sodium depletion usually causes clinical features of dehydration, an elevated BUN level, and a urine sodium concentration less than 20 mEq/L. Primary polydipsia almost invariably results in dilute urine with low osmolality when compared to serum. Renal failure is unlikely with a BUN level of 4 mg/dL. Adrenal insufficiency is also unlikely, as most patients will have skin pigmentation, weight loss, and hypotension. A normal serum potassium level is also inconsistent with the diagnosis of adrenal insufficiency.

Question 27

27. A 38-year-old female has spontaneous rupture of the membranes with thick meconium just prior to delivery of a male infant at 40 weeks gestation. Oropharyngeal suctioning of the infant is performed prior to delivery of the shoulders. Upon delivery the infant is noted to have spontaneous respirations, a heart rate of 120 beats/min, cyanosis of the hands and feet, and good tone.

Which one of the following would be most appropriate in the immediate management of the newborn?

A) Intubation and tracheal suctioning below the vocal cords

B) Suctioning of the stomach to remove any swallowed meconium

C) Positive pressure ventilation

D) Expectant management only

Answer 27

ANSWER: D

Endotracheal suctioning of vigorous infants born through meconium-stained amniotic fluid is not recommended (SOR C). Although infants born through thick meconium are more likely to develop aspiration syndrome, endotracheal suctioning does not provide any benefit over expectant management in preventing this condition or other respiratory problems. Endotracheal suctioning may be useful if the infant is not vigorous or shows signs of respiratory depression.

Suctioning of the infant’s stomach can be done electively but is not required for immediate management. Positive pressure ventilation is indicated for ventilatory support of newborns with respiratory depression who are not born through meconium-stained amniotic fluid.

Question 28

28. An 84-year-old female presents for follow-up of multiple chronic medical problems. She is usually accompanied by her daughter, who lives nearby, but today is brought in by her son and daughter-in-law, who live out of town. They are supportive, but are insistent that the patient see a specialist for a problem that she has previously decided not to pursue further. The patient wants to avoid conflict but does not want to see any other physicians.

Which one of the following is the most appropriate way to deal with this situation?

A) Speak with the son and daughter-in-law privately
B) Maintain neutrality and avoid triangulation
C) Call the daughter to discuss the situation
D) Try to talk your patient into seeing the specialist
E) Schedule the appointment to appease the family, then cancel it later

Answer 28

ANSWER: B

When family dynamics lead to conflict during an office visit, it is best for the physician to attempt to remain neutral by avoiding triangulation, which occurs when the two sides in conflict each attempt to align with a third party. Priority should be given to the patient’s right to privacy and confidentiality, and the physician should ask permission from the patient to discuss his or her health issues with other people. Physicians should always remember who they are primarily responsible to.

Question 29

29. A 50-year-old male presents to your office with erythroderma and fever. He has not had a sore throat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril (Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has a blood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6°C (101.5°F). The skin is remarkable for marked erythema over 90% of the body, with tenderness to touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted in the neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.

A CBC shows a WBC count of 15,000/mm3 (N 4300–10,800) with 20% eosinophils. A metabolic profile shows an AST (SGOT) level of 100 U/L (N 10–40) and an ALT (SGPT) level of 110 U/L (N 10–55), but is otherwise normal.

Which one of the following is the most likely diagnosis?

A) Stevens-Johnson syndrome
B) Erysipelas
C) Red man syndrome
D) Toxic shock syndrome
E) Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)

Answer 29

ANSWER: E

DRESS is an acronym for Drug Reaction with Eosinophilia and Systemic Symptoms. The hallmark of DRESS syndrome is erythroderma accompanied by fever, lymphadenopathy, elevation of liver enzymes, and eosinophilia. The offending medication should be discontinued immediately and treatment with corticosteroids should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine, and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS syndrome has the highest mortality rate.
Toxic shock syndrome should be suspected in patients with erythroderma, hypotension, and laboratory evidence of end-organ involvement (elevated liver enzymes or kidney function studies, anemia, thrombocytopenia, or elevation of creatine kinase). Treatment with intravenous clindamycin, which inhibits toxin synthesis, should be undertaken immediately.

Stevens-Johnson syndrome is characterized by a vesiculobullous rash with mucocutaneous involvement, and erysipelas is a painful localized rash with well-demarcated borders. Red man syndrome is associated with vancomycin.

Question 30

30. An unconscious 22-year-old male is brought into the emergency department. His respiratory rate is 8/min, his pulse rate is 60 beats/min and regular, and his pupils are miotic.

The most likely cause of his condition is

A) organophosphate poisoning
B) scopolamine overdose
C) narcotics overdose
D) benzodiazepine overdose

Answer 30

ANSWER: C

In cases of drug overdose, several critical physical findings must be evaluated. The most important is the size of the pupils. Tolerance rarely reduces the miotic effects of narcotic medications. A patient who is comatose, with decreased breathing, a slow pulse, and small pupils should be strongly suspected of having overdosed on a narcotic. Naloxone should be administered to reverse these effects. The response to treatment with naloxone is irregular. Cerebral infarction in the pontine angle, organophosphate poisoning, phenothiazine overdose, and treatment for glaucoma can also cause constricted pupils, but these associations are seen much less frequently than narcotics overdose.

Question 31

31. A 39-year-old male with a history of alcoholism presents to your office with complaints of abdominal pain, vomiting, and nausea following a recent binge. He has eaten little since the onset of his symptoms 3 days ago. Laboratory findings suggest alcoholic ketoacidosis. His serum bicarbonate level is 16.3 mEq/L (N 22.0–26.0).

In addition to thiamine, what other treatment should be provided for this patient?

A) Bicarbonate and insulin
B) Glucagon (GlucaGen) and hydrocortisone
C) Normal saline and glucose
D) N-acetylcysteine and pyridoxine (vitamin B6)

Answer 31

ANSWER: C

Alcoholic ketoacidosis generally occurs in a patient who has been drinking heavily without eating. Blood glucose levels are usually low or normal, and volume depletion associated with nausea, vomiting, and abdominal pain is the norm. Patients typically have high osmolal and anion gaps. Treatment of alcoholic ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine and glucose. Only in the rare presence of marked acidemia (pH less than 7.10) is the administration of bicarbonate thought to be necessary. Though insulin levels may be low, hyperglycemia is seldom found. N-acetylcysteine and pyridoxine are not used for the treatment of alcoholic ketoacidosis. Levels of glucagon and hydrocortisone are typically elevated in patients with alcoholic ketoacidosis.

Question 32

32. A previously normotensive 20-year-old primigravida is admitted to the hospital at 39 weeks gestation with a headache, a blood pressure of 170/110 mm Hg, and proteinuria. Which one of the following is the most effective agent for preventing eclamptic seizure while preparing for expedited delivery?

A) Benzodiazepines
B) Fosphenytoin (Cerebyx)
C) Magnesium sulfate
D) Nimodipine

Answer 32

ANSWER: C

Magnesium sulfate has a long history of use for preventing seizures in preeclampsia and eclampsia, and a recent Cochrane review confirmed that it is the preferred agent. Benzodiazepines and fosphenytoin are secondary agents that can be used if magnesium sulfate fails, but they are not as effective. Nimodipine was also shown to be less effective than magnesium sulfate. Delivery is indicated, but magnesium sulfate must also be administered (SOR A).

Question 33

33. A 71-year-old white male with COPD and lung cancer is discharged from the hospital. In addition to a medical diagnosis, which one of the following criteria is used to determine whether Medicare will pay for his home oxygen therapy?

A) Oxygen saturation
B) PCO2
C) FEV1
D) The patient’s finances

Answer 33

ANSWER: A

Medicare eligibility for home oxygen therapy is based on oxygen saturation. To qualify for continuous long-term oxygen therapy the patient must have a PaO2 less than or equal to 55 mm Hg or an SaO2 less than or equal to 88 mm Hg.

Question 34

34. Which one of the following findings on examination of the head, oral cavity, and neck is associated with diabetes mellitus?

A) Parotid enlargement
B) Tooth erosion
C) Diffuse melanin pigmentation
D) Cobblestone oral mucosa
E) Painful oral ulcers

Answer 34

ANSWER: A

Sialadenosis, bilateral noninflammatory enlargement of the parotid gland, is associated with diabetes mellitus. Periodontal bleeding and inflammation, candidiasis, and delayed wound healing also are associated with diabetes mellitus.

Tooth erosion can be an oral manifestation of gastroesophageal reflux disease or bulimia. Cobblestone oral mucosa is seen in Crohn’s disease. Diffuse melanin pigmentation is an oral finding of Addison’s disease. Painful oral ulcers occur in several conditions, including Behçet syndrome, aphthous ulcers, pemphigus, and pemphigoid.

Question 35

35. A 53-year-old female is concerned about a skin lesion that has recently been changing in size and shape. On examination she is found to have a 7-mm, asymmetric, darkly pigmented lesion with some color variegation and irregular borders.

Which one of the following skin biopsy techniques is most appropriate for confirming the diagnosis?

A) A shave biopsy
B) Electrodesiccation and curettage
C) Elliptical excision
D) Mohs surgery

Answer 35

ANSWER: C

This lesion is suspicious for melanoma, based on the asymmetry, irregular border, color variegation, and size larger than 6 mm. In addition, a history of evolution of the lesion, with changes in size, shape, or color, has been shown in some studies to be the most specific clinical finding for melanoma. The preferred method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small margin of normal-appearing skin. The depth of the lesion is crucial to staging and prognosis, so shave biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an appropriate treatment for melanoma. Mohs surgery is sometimes used to treat melanomas, but is not used for the initial diagnosis.

Question 36

36. A 22-year-old female in her second trimester of pregnancy presents with a 48-hour history of a sore throat. She has also had coryza and a nonproductive cough. A physical examination reveals a temperature of 37.3°C (99.2°F) and a blood pressure of 110/70 mm Hg. A HEENT examination reveals tonsillar and pharyngeal erythema with no exudate. There is no adenopathy. Her chest is clear.

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

A) Reassurance and symptomatic treatment only
B) A routine throat culture
C) A rapid antigen detection test for Streptococcus
D) Azithromycin (Zithromax) for 5 days
E) Penicillin V for 10 days

Answer 36

ANSWER: A

Most episodes of pharyngitis are caused by viral rather than bacterial infections. The use of clinical decision rules for diagnosing group A B-hemolytic streptococcal pharyngitis improves quality of care while reducing unwarranted treatment and overall cost (SOR A). The original Centor score used four signs and symptoms to estimate the probability of acute streptococcal pharyngitis in adults with a sore throat, and was later modified by adding age as a fifth criterion. One point each is assigned for (1) absence of cough, (2) swollen, tender anterior cervical nodes, (3) temperature >38.0°C (100.4°F), and (4) a tonsillar exudate and swelling. One point is added for patients between the ages of 3 and 14 years, and a point is subtracted for patients over the age of 45. The cumulative score determines the likelihood of streptococcal pharyngitis and the need for antibiotics, and guides testing strategies. Patients with a score of zero or 1 are at very low risk for streptococcal pharyngitis and do not require testing or antibiotic therapy. Patients with a score of 2–3 should be tested using a rapid antigen test or throat culture, and a positive result warrants antibiotic therapy. Patients with a score of 4 or higher are at high risk for streptococcal pharyngitis, and empiric treatment may be considered. This patient’s score is zero, and no testing or treatment is warranted.

Question 37

37. A 34-year-old female has a history of many years of diffuse pain, debilitating fatigue, and disrupted sleep. You suspect she may have fibromyalgia. Laboratory tests and imaging studies have been negative. She is confused about why she is in so much pain even though “everything is normal.”

What do you tell her is currently thought to be the etiology of fibromyalgia?

A) Diffuse inflammation of soft tissues

B) A chronic viral infection

C) An exaggerated response to tactile stimuli by the central nervous system

D) A malfunction of pain receptors in the dermis, causing excess sensitivity

E) A psychological disorder in which the patient imagines the pain

Answer 37

ANSWER: C

The understanding of fibromyalgia has been rapidly expanding in recent years, primarily due to the use of functional magnetic resonance imaging (fMRI). The hallmark of fibromyalgia is an exaggerated response to painful stimuli, or an attribution of pain to a stimulus that is normally not painful. Early research focused on peripheral tissues as the source of this condition. However, the cause has now been recognized as an abnormality in the central nervous system, which can be seen on fMRI. This physical brain abnormality differentiates fibromyalgia from psychogenic conditions such as conversion disorder and malingering.

Any evidence of an actual abnormality of the peripheral tissue on physical examination, blood tests, or an imaging study in a patient suspected to have fibromyalgia should raise the suspicion that another diagnosis is also present. It is estimated that up to 25% of patients who have a definable rheumatologic condition such as lupus or rheumatoid arthritis also suffer from fibromyalgia. Many patients who develop fibromyalgia started having symptoms in the wake of a viral infection (especially Epstein-Barr virus). However, these viral illnesses are believed to trigger a genetic predisposition rather than being a necessary cause of this condition.

Question 38

38. A 12-year-old African-American male is brought to your office by his parents because he has been limping for the past month. He says he has pain in the groin and knee, but the pain is poorly localized. On examination he is noted to be obese, with normal findings on examination of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait is antalgic.

The most likely cause of this problem is

A) unreported trauma
B) aseptic necrosis of the femoral head
C) reactive arthritis
D) juvenile rheumatoid arthritis
E) slipped capital femoral epiphysis

Answer 38

ANSWER: E

Slipped capital femoral epiphysis is often misdiagnosed, as the symptoms are frequently vague. It is the most common hip disorder in adolescents, with the age range being 9 to 15 years. It occurs when the proximal femoral epiphysis slips posteriorly and inferiorly on the femoral neck through the growth plate. The typical presentation is a limping child who may have pain in the groin, hip, thigh, or knee. Very often the pain is vague and poorly localized. It occurs more often in boys, with African-Americans and Pacific Islanders having a higher rate of involvement, possibly due to increased levels of obesity in these population groups.

Physical findings vary, depending on the severity of the slippage. A child with a severe slip may not be able to bear weight. Obligatory external rotation of the involved hip is noted when the hip is passively flexed to 90°. Radiographs are needed to diagnose unstable slipped capital epiphysis, and should include frog-leg lateral views and anteroposterior views of both hips.

Another cause of hip pain in adolescent patients is apophyseal avulsion fractures. Clinical features include pain after a sudden, forceful movement. Hip apophysitis presents as activity-related hip pain with a history of overuse and negative radiographs. In children under the age of 10 years, transient synovitis is also a common cause of hip pain. It occurs after a viral illness and is associated with negative radiographs but positive laboratory tests. Fractures may be seen in children on occasion, but there will be a history of trauma. Septic arthritis is an infrequent cause of hip pain in children, but patients have a history of fever with elevation of the WBC count and inflammatory joints. The diagnosis would be confirmed by joint aspiration. Legg-Calvé-Perthes disease is also infrequent, and features include vague hip pain with decreased internal rotation of the hip. The diagnosis is based on findings from radiographs or MRI.

Question 39

39. Of the following cardiovascular parameters, which one increases with normal aging?

A) Maximum heart rate
B) Heart rate variability
C) Left ventricular ejection fraction
D) Arterial wall elasticity
E) Blood pressure

Answer 39

ANSWER: E

It can be difficult to determine the point at which changes of normal aging are more appropriately considered disease processes. Although the direction of expected change is generally well understood, variables such as the level of fitness and overall health of an individual affect the degree of change. As the body ages, the measured left ventricular ejection fraction, heart rate variability, and maximum heart rate trend downward, the walls of the major aorta and major arteries stiffen, and the vasodilator capacity of most smaller vessels is reduced (SOR A). The arterial wall changes increase peripheral resistance and result in an increase in blood pressure. Positive adaptive changes have been shown in older adults who engage in regular aerobic exercise, however, and these changes can be measured after only 3 months of moderate-intensity exercise (SOR A).

Question 40

40. A 68-year-old male with type 2 diabetes mellitus has failed to control his diabetes with diet and exercise. His most recent serum creatinine level was 1.9 mg/dL (N 0.6–1.5).

Which one of the following agents is most likely to cause symptomatic hypoglycemia in this patient?

A) Glimepiride (Amaryl)
B) Glipizide (Glucotrol)
C) Glyburide (DiaBeta)
D) Metformin (Glucophage)
E) Repaglinide (Prandin)

Answer 40

ANSWER: C

Older patients are at higher risk for hypoglycemia caused by oral antidiabetic agents. Glyburide is associated with a significantly greater risk of symptomatic hypoglycemia than other second-generation sulfonylurea hypoglycemic agents.

Metformin decreases liver production of glucose and is not associated with hypoglycemia. Even so, this patient’s creatinine elevation is a contraindication to metformin use, as it increases the risk of lactic acidosis.

Glimepiride, glipizide, and repaglinide stimulate insulin release and increase the risk of hypoglycemia. However, the risk of symptomatic hypoglycemia is substantially lower compared to the risk associated with glyburide in patients with similar hemoglobin A1c values (SOR B).

Question 41

41. A healthy 47-year-old female presents with a 3-day history of moderately severe low back pain after attempting to lift a heavy container of potting soil in her garden. She has no history of back problems. Her pain is in the right lower back with radiation to the buttock. She denies urinary or bowel incontinence, urinary retention, and numbness or tingling. A physical examination confirms low back muscular strain.

Which one of the following interventions has been shown to be beneficial in this situation?

A) Bed rest
B) Massage therapy
C) Lumbar traction
D) Prednisone
E) Cyclobenzaprine (Flexeril)

Answer 41

ANSWER: E

Acute low back pain is one of the most common presenting symptoms in family medicine practices. In the absence of red flags such as fever, a history of cancer, or neurologic deficits, patients can be successfully treated with conservative therapy. Interventions that have been shown to be beneficial include non-benzodiazepine muscle relaxers (SOR A). They are most effective in the first 1–2 weeks but can be used for up to 4 weeks. Additional beneficial treatments include physical therapy, acetaminophen, and NSAIDs. Bed rest is inadvisable for patients with low back pain (SOR A). Patients who stay active have better outcomes than those who stay at rest.

There is no good evidence that oral corticosteroids are beneficial for acute back pain, and insufficient evidence that massage therapy is effective. Lumbar traction provides no benefit in acute low back pain (SOR B).

Question 42

42. A 40-year-old male complains of a cough that has persisted for more than 3 months. He is otherwise asymptomatic. A chest radiograph and pulmonary function tests are normal.

Which one of the following is the most likely cause?

A) Bronchiectasis
B) Tuberculosis
C) Sarcoidosis
D) Asthma
E) Gastroesophageal reflux disease

Answer 42

ANSWER: E

Gastroesophageal reflux disease is one of the most common causes of chronic cough. Patients with “silent” gastroesophageal reflux may not have the classic symptoms of heartburn and regurgitation. The diagnosis is based on resolution of the cough with an empiric trial of a proton pump inhibitor, although a chest radiograph should be obtained in all patients with a chronic cough to exclude bronchiectasis, tuberculosis, and sarcoidosis. Asthma is another frequent cause of chronic cough, but it can be ruled out with normal pulmonary function tests.

Question 43

43. A 45-year-old male asks you to evaluate his cardiovascular health status. He is currently asymptomatic, but wants to do everything he can to prevent heart disease and to understand his potential cardiovascular risk. His Framingham score indicates that he is at low risk (10-year risk less than 6%), and his physical examination is normal.

He asks which laboratory and imaging tests he should have, and you recommend a lipid profile. According to the American College of Cardiology Foundation and the American Heart Association, which one of the following should also be recommended for this patient at this time?

A) Lipoprotein and apolipoprotein levels
B) A C-reactive protein level
C) Measurement of cardiac calcium
D) An ankle-brachial index
E) No further testing

Answer 43

ANSWER: E

The American College of Cardiology Foundation/American Heart Association guidelines for early cardiovascular assessment do not recommend lipoprotein and apolipoprotein levels. A C-reactive protein level can help to determine the need for statin therapy in men 50 and older and women 60 and older whose LDL-cholesterol levels are less than 130 mg/dL and who are not on lipid-lowering medication, hormone therapy, or immunosuppressive therapy, and who do not have clinical coronary heart disease, diabetes mellitus, chronic kidney disease, severe inflammatory disease, or contraindications to statins. A C-reactive protein level may also be reasonable in younger patients with intermediate, but not low, cardiovascular risk.
Measurement of cardiac calcium levels is reasonable in patients whose cardiovascular risk is intermediate (10-year risk 10%–20%) or low-to-intermediate (10-year risk 6%–10%). An ankle-brachial index is reasonable for intermediate-risk, but not low-risk, patients. At this point in time, the patient described here does not meet any recommended criteria for further testing.

Question 44

44. In an adult who has a critical illness but no history of cardiac disease, the threshold for transfusion of red blood cells should be a hemoglobin level of

A) 6 g/dL
B) 7 g/dL
C) 8 g/dL
D) 9 g/dL
E) 10 g/dL

Answer 44

ANSWER: B

The threshold for transfusion of red blood cells should be a hemoglobin level of 7 g/dL in adults and most children.

Question 45

45. A 67-year-old female hospitalized with pneumonia develops the rapid onset of dyspnea, pleuritic chest pain, tachypnea, and hypoxemia not responding to oxygen and requiring intubation. A physical examination is notable for rales throughout both lung fields with no peripheral edema noted. A chest radiograph shows bilateral pulmonary infiltrates. Her BNP level is 90 ng/L.

Which one of the following is the most likely reason for her worsening clinical situation?

A) Heart failure
B) Hypersensitivity pneumonitis
C) Acute respiratory distress syndrome
D) Pulmonary embolus
E) Pneumothorax

Answer 45

ANSWER: C

This patient demonstrates classic findings for acute respiratory distress syndrome (ARDS). In many cases ARDS must be differentiated from heart failure. Heart failure is characterized by fluid overload (edema), jugular venous distention, a third heart sound, an elevated BNP level, and a salutary response to diuretics. A BNP level less than 100 pg/mL can help rule out heart failure (SOR A). In addition, a patient with ARDS would not have signs of left atrial hypertension and overt volume overload.

Hypersensitivity pneumonitis is usually preceded by exposure to an inciting organic antigen such as bird feathers, mold, or dust. Pulmonary embolus, while certainly in the differential, is unlikely to cause such dramatic radiographic findings. Pneumothorax would be seen on the chest radiograph.

Question 46

46. A 64-year-old male with a previous history of hypertension and atrial fibrillation presents with an acute onset of ataxia, headache, mild confusion, and restlessness. His only current medications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his blood pressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature 36.7°C (98.1°F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. His INR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.

Which one of the following should be performed urgently?

A) Neurosurgical consultation for posterior cerebellar hematoma decompression

B) A reduction in blood pressure to 140/90 mm Hg

C) Administration of vitamin K, 10 mg intravenously

D) Administration of mannitol (Osmitrol), 0.5–1.0 mg/kg intravenously

E) Induction of hypothermia to achieve a body temperature of 34.4°C (94.0°F)

Answer 46

ANSWER: A

Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical consultation. Guidelines have been developed by the American Heart Association for lowering blood pressure in patients with a systolic blood pressure >180 mm Hg, or a mean arterial pressure >130 mm Hg. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear. Patients with an INR >1.5 should receive therapy to replace vitamin K–dependent factors and have their warfarin withheld.

Question 47

47. You prescribe enalapril (Vasotec) for a 68-year-old male with heart failure. At a follow-up visit 6 weeks later the patient’s serum creatinine level is 2.5 mg/dL (N 0.6–1.5) and his serum potassium level is 5.7 mEq/L (N 3.4–4.8). His baseline values were normal.

Which one of the following is a side effect of ACE inhibitors that is the most likely cause of these changes in renal function?

A) Toxicity to the proximal renal tubules
B) Impaired autoregulation of glomerular blood flow
C) Microangiopathic arteriolar thrombosis
D) Rhabdomyolysis
E) Interstitial nephritis

Answer 47

ANSWER: B

Blood flow to the kidney is autoregulated so as to sustain pressure within the glomerulus. This is influenced by angiotensin II–related vasoconstriction. ACE inhibitors can impair the kidney’s autoregulatory function, resulting in a decreased glomerular filtration rate and possibly acute renal injury. This is usually reversible if it is recognized and the offending agent stopped. NSAIDs can exert a similar effect, but they can also cause glomerulonephritis and interstitial nephritis. Statins, haloperidol, and drugs of abuse (cocaine, heroin) can cause rhabdomyolysis with the release of myoglobin, which causes acute renal injury. Thrombotic microangiopathy is a rare mechanism of injury to the kidney, and may be caused by clopidogrel, quinine, or certain chemotherapeutic agents.

Question 48

48. A 46-year-old African-American female sees you because of a history of excessive uterine bleeding and irregularity in her menstrual cycle. She has three children and had a tubal ligation after her last delivery. A pelvic examination does not reveal any pathology to explain her symptoms. Further laboratory evaluation indicates that she is mildly anemic. You perform an endometrial biopsy in the office that confirms your suspicion of endometrial hyperplasia without atypia.

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

A) Elective hysterectomy
B) Hysteroscopic endometrial laser ablation
C) High-dose oral estrogen supplementation
D) Antifibrinolytic therapy
E) Progestational drugs

Answer 48

ANSWER: E

Medical therapy with progestational drugs is the treatment of choice for menorrhagia due to endometrial hyperplasia without atypia. Progestins convert the proliferative endometrium to a secretory one, causing withdrawal bleeding and the regression of hyperplasia. The most commonly used form is cyclic oral medroxyprogesterone, given 14 days per month, but implanted intrauterine levonorgestrel is the most effective (SOR A) and also provides contraception.

High-dose estrogen supplementation would further stimulate the endometrium. Estrogen is useful in cases where minimal estrogen stimulation is associated with breakthrough bleeding. The anti-fibrinolytic agent tranexamic acid prevents the activation of plasminogen and is given at the beginning of the cycle to decrease bleeding. Side effects and cost limit this treatment option, however. It may be most useful in women with bleeding disorders or with contraindications to hormonal therapy.

NSAIDs, which decrease prostaglandin levels, reduce menstrual bleeding but not as effectively as progestins. While mefenamic acid is marketed for menstrual cramps and bleeding, all NSAIDs have a similar effect in this regard.

If medical management fails, hysteroscopic endometrial ablation is an option for reducing uterine bleeding but is considered permanent and obviously will impair fertility. Hysterectomy is reserved for severe and chronic bleeding that is not relieved by other measures.

Question 49

49. The diagnosis of Osgood-Schlatter disease (osteochondritis of the tibial tubercle apophysis) is best made on the basis of findings from

A) the history and examination
B) evaluation by an orthopedic specialist
C) radiographs
D) ultrasonography
E) MRI

Answer 49

ANSWER: A

Osgood-Schlatter disease is an inflammatory condition that is a common cause of knee pain in children and adolescents. The diagnosis is usually based on clinical findings, although radiographs may be necessary to rule out fractures or other problems if findings are not typical. MRI, ultrasonography, and orthopedic referral are not usually needed. The problem is typically self-limited and responds to activity modification, over-the-counter analgesics, stretching, and physical therapy.

Question 50

50. A 35-year-old primigravid schoolteacher awakens with a rash clinically consistent with varicella early in the 38th week of her pregnancy. She had a negative varicella titer early in her pregnancy. The clinical course is mild and all vesicles have either crusted over or healed 1 week later. She has an uncomplicated labor and vaginal delivery at 40 weeks gestation, and delivers a healthy-appearing male.

Of the following options, which one is the most appropriate initial management for the newborn?

A) Intravenously administered varicella immune globulin

B) A weight-appropriate dose of intravenous acyclovir (Zovirax)

C) Varicella vaccine

D) Combination treatment with varicella vaccine, intravenous acyclovir, and varicella immune globulin

C) Close observation only

Answer 50

ANSWER: E

The result of neonatal varicella infection can be catastrophic, with a fatality rate approaching 30%. Maternal immunity is ideal, but since varicella vaccination is contraindicated during pregnancy the best alternative is advising the patient to avoid contact with infected individuals until safe postpartum immunization is possible. Maternal varicella infection is particularly problematic during weeks 13–20 of pregnancy (resulting in a 2% risk of congenital varicella in the newborn) and when the onset of maternal symptoms occurs from 5 days before until 2 days after delivery.

Administration of varicella immune globulin to the expectant mother has not been shown to benefit the fetus or infant, but because pregnancy can increase the risk of serious complications in the mother the Advisory Committee on Immunization Practices (ACIP) recommends that administration to pregnant women be considered following known exposure. The ACIP also recommends that term infants born within the 7-day window described above, as well as all preterm infants, receive varicella immune globulin, and that those who develop any signs of varicella infection also be given intravenous acyclovir. Term infants delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive immunity for protection and the expected benign course generally requires only observation.