Questions 1-50

Question 1

1. A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea, cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia.

What is the most likely etiologic agent?

A) Staphylococcus species
B) Chlamydia trachomatis
C) Respiratory syncytial virus
D) Parainfluenza virus

Answer 1

ANSWER: B

Chlamydial pneumonia is usually seen in infants 3–16 weeks of age, and these patients frequently have been sick for several weeks. The infant appears nontoxic and is afebrile, but is tachypneic with a prominent cough. The physical examination will reveal diffuse crackles with few wheezes, and conjunctivitis is present in about 50% of cases. A chest film will show hyperinflation and diffuse interstitial or patchy infiltrates.

Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever, and initially may have an expiratory wheeze simulating bronchiolitis. Signs of abdominal distress, tachypnea, dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present. The WBC count will show a prominent leukocytosis.

Respiratory syncytial virus infections start with rhinorrhea and pharyngitis, followed in 1–3 days by a cough and wheezing. Auscultation of the lungs will reveal diffuse rhonchi, fine crackles, and wheezes, but the chest film is often normal. If the illness progresses, coughing and wheezing increase, air hunger and intercostal retractions develop, and evidence of hyperexpansion of the chest is seen. In some infants the course of the illness may be similar to that of pneumonia. Rash or conjunctivitis may occur occasionally, and fever is an inconsistent sign. The WBC count will be normal or elevated, and the differential may be normal or shifted either to the right or left. Chlamydial infections can be differentiated from respiratory syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the mild wheezing. There may also be eosinophilia.

Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.

Question 2

2. A 36-year-old obese female presents to your office with a chief complaint of amenorrhea. On examination you note hirsutism and body acne. She is on no medications and a pregnancy test is negative. Serum testosterone is at the upper limits of normal and TSH is within normal limits.

In addition to weight loss and exercise, which one of the following would be the most appropriate initial management?

A) High-dose combined oral contraceptives
B) Progestin-only contraceptives
C) Metformin (Glucophage)
D) Levothyroxine (Synthroid)

Answer 2

ANSWER: C

This patient has polycystic ovary syndrome, which is characterized by hyperandrogenism on clinical and laboratory evaluations, polycystic ovaries on pelvic ultrasonography, and ovulatory dysfunction. Hyperandrogenism and either polycystic ovaries or ovulatory dysfunction are necessary to make the diagnosis. The first-line recommendation in obese patients is lifestyle modification, but metformin may improve abnormal menstruation (SOR A). Low-dose combined oral contraceptives are more frequently used to reduce the risk of endometrial cancer in patients with chronic anovulation and the resulting unopposed estrogen secretion. This patient does not have thyroid dysfunction, so levothyroxine is not indicated.

Question 3

3. A factory worker sustains a forced flexion injury of the distal interphalangeal (DIP) joint, resulting in a small bone fragment at the dorsal surface of the proximal distal phalanx (mallet fracture). Which one of the following is the most appropriate management strategy?

A) Buddy taping and early range of motion
B) Splinting the DIP joint in extension
C) Splinting the DIP joint in flexion
D) Referral for surgical repair

Answer 3

ANSWER: B

The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in extension (SOR B). The usual duration of splinting is 8 weeks. It is important that extension be maintained throughout the duration of treatment because flexion can affect healing and prolong the time needed for treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar to those of surgical treatment and therefore is generally preferred.

Question 4

4. Which one of the following drugs is NOT effective for maintenance therapy in bipolar disorders?

A) Haloperidol
B) Lamotrigine (Lamictal)
C) Lithium
D) Quetiapine (Seroquel)
E) Valproate sodium (Depacon)

Answer 4

ANSWER: A

Lithium, valproate, lamotrigine, and some antipsychotics (including quetiapine) are effective treatments for both acute depression and maintenance therapy of bipolar disorders. Haloperidol is an effective treatment for acute mania in bipolar disorders, but not for maintenance therapy or acute depression.

Question 5

5. A 30-year-old ill-appearing male presents with right hand and arm pain and a rapidly expanding area of redness. On examination he has a temperature of 38.9°C (102.0°F), a pulse rate of 120 beats/min, and a blood pressure of 116/74 mm Hg. He also has erythema from the dorsal hand to the elbow, violaceous bullae on the dorsal hand and wrist, and severe pain with dorsiflexion of the wrist or fingers.

Which one of the following is the most appropriate initial step in the management of this patient?

A) Oral dicloxacillin and outpatient follow-up within the next 24 hours

B) Intravenous metronidazole

C) Consultation with an infectious disease specialist for antibiotic management

D) Immediate surgical consultation for operative debridement

E) Incision and drainage with wound cultures in the emergency department

Answer 5

ANSWER: D

This patient has physical findings consistent with a necrotizing skin and soft-tissue infection, or necrotizing fasciitis. Severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration, are strong indications of necrotizing fasciitis. Antimicrobial therapy is essential but is not sufficient by itself; aggressive surgical debridement within 12 hours reduces the risk of amputation and death.

Question 6

6. Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum levels of

A) cortisol
B) creatine phosphokinase
C) creatinine
D) LDH
E) TSH

Answer 6

ANSWER: E

Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a patient on amiodarone have baseline thyroid function tests (free T4, TSH) with follow-up testing every 6 months to monitor for these conditions. Hyperadrenalism and hypoadrenalism are not associated with amiodarone treatment.

Question 7

7. A mother brings her 2-year-old daughter to your office because the child is not using her left arm. Earlier in the day the mother left the toddler under the supervision of her 12-year-old sister while she went to the store. When she returned the toddler was playing with toys using only her right arm, and was holding the left arm slightly pronated, flexed, and close to her body. The older daughter was unaware of any injury to the girl’s arm, and the child does not seem distressed or traumatized.

Physical examination of the child’s clavicle, shoulder, wrist, and hand do not elicit any signs of pain or change in function. She does seem to have some tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow.

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

A) Plain radiographs of the affected elbow

B) Ultrasonography of the affected elbow

C) Evaluation by an orthopedic surgeon within 24 hours

D) Attempted reduction of the subluxed radial head

E) Placement in a splint and follow-up in the office if there is no improvement in the next
1–2 weeks

Answer 7

ANSWER: D

Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in children 1–4 years of age, although it can be encountered before 1 year of age and in children as old as 9 years of age. The mechanism of injury is partial displacement of the radial head when the child’s arm undergoes axial traction while in a pronated and fully extended position. The classic history includes a caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is recalled.

As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt reduction of the radial head before moving on to imaging studies. With the child’s elbow in 90° of flexion, the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction, then a plain radiograph is recommended.

Question 8

8. A 12-year-old male uses a short-acting bronchodilator three times per week to control his asthma. Lately he has been waking up about twice a week because of his symptoms.

Which one of the following medications would be most appropriate?

A) Inhaled medium-dose corticosteroids
B) A scheduled short-acting bronchodilator
C) A scheduled long-acting bronchodilator
D) A leukotriene inhibitor

Answer 8

ANSWER: A

This patient has moderate persistent asthma. Although many parents are concerned about corticosteroid use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close growth plates and are the most effective treatment with the least side effects. Scheduled use of a short-acting bronchodilator has been shown to cause tachyphylaxis, and is not recommended. The same is true for long-acting bronchodilators. Leukotriene use may be beneficial, but compared to those using inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring systemic corticosteroids.

Question 9

9. Which one of the following is the most appropriate first-line therapy for primary dysmenorrhea?

A) Combined monophasic oral contraceptives
B) Combined multiphasic oral contraceptives
C) Subdermal etonogestrel (Nexplanon)
D) Intramuscular medroxyprogesterone (Depo-Provera)
E) NSAIDs

Answer 9

ANSWER: E

The first-line treatment for primary dysmenorrhea should be NSAIDs (SOR A). They should be started at the onset of menses and continued for the first 1–2 days of the menstrual cycle. Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized, controlled trials demonstrating pain improvement (SOR B). They may be a good choice if the patient also desires contraception. Although combined oral contraceptives and intramuscular and subcutaneous progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis, they are not first-line therapy for primary dysmenorrhea.

Question 10

10. While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ultrasonography. The most appropriate next step in the evaluation of this finding is a

A) serum calcitonin level
B) serum free T3 level
C) serum TSH level
D) serum thyroglobulin level
E) radionuclide thyroid scan

Answer 10

ANSWER: C

Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules less than 1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American Thyroid Association’s guidelines recommend that TSH be the initial evaluation (SOR A) and that this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended.

Question 11

11. Which one of the following medications should be started at a low dosage and titrated slowly to minimize the risk of Stevens-Johnson syndrome?

A) Carbamazepine (Tegretol)
B) Divalproex (Depakote)
C) Lamotrigine (Lamictal)
D) Lithium
E) Ziprasidone (Geodon)

Answer 11

ANSWER: C

Lamotrigine is an anti-epileptic medication that is often used in bipolar disorder. It can cause Stevens-Johnson syndrome, which is a severe disorder of the skin and mucous membranes. This most commonly occurs in children or when the drug is initiated at a high dosage, and is also more likely to occur in patients taking divalproex. To decrease the risk of Stevens-Johnson syndrome, it is recommended that lamotrigine therapy be started at a dosage of 25 mg daily and titrated every 2 weeks until the goal dosage is reached.

Question 12

12. You are the medical director of a long-term-care facility that has 60 residents. Several patients experience fever, cough, and upper respiratory symptoms. Two of these patients test positive for influenza A (H1N1) virus.

Which one of the following is recommended by the Centers for Disease Control and Prevention (CDC) for this situation?

A) Chemoprophylaxis with appropriate medications for all residents

B) Treatment initiated on an individual basis once testing confirms that a resident has
influenza

C) Prophylaxis only for staff who have had direct patient contact with a resident with
laboratory-confirmed infection

D) No chemoprophylaxis for staff or residents who have been appropriately vaccinated

Answer 12

ANSWER: A

The occurrence of two or more laboratory-confirmed cases of influenza A is considered an outbreak in a long-term care facility. The CDC has specific recommendations for managing an outbreak, which include chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation is recommended; however, it cannot be strictly enforced due to residents’ rights.

Question 13

13. Information derived from which one of the following provides the best evidence when selecting a specific treatment plan for a patient?

A) Meta-analyses
B) Prospective cohort studies
C) Expert opinion
D) Consensus guidelines

Answer 13

ANSWER: A

In general, the strongest evidence for treatment, screening, or prevention strategies is found in systematic reviews, meta-analyses, randomized controlled trials (RCTs) with consistent findings, or a single high-quality RCT. Second-tier levels of evidence include poorer quality RCTs with inconsistent findings, cohort studies, or case-control studies. The lowest quality of evidence comes from sources such as expert opinion, consensus guidelines, or usual practice recommendations.

Question 14

14. Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time?

A) An allergy evaluation
B) Low-dose antihistamines
C) Hydrocortisone cream 0.5%
D) A sepsis workup
E) Observation only

Answer 14

ANSWER: E

This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No testing is usually necessary because of the distinct appearance of the lesions. The cause is unknown.

Question 15

15. American Urological Association guidelines define asymptomatic microscopic hematuria as
    which one of the following in the absence of an obvious benign cause?

A) greater than or equal to 1 RBCs/hpf
B) greater than or equal to 3 RBCs/hpf
C) greater than or equal to 10 RBCs/hpf
D) A positive dipstick reading for blood

Answer 15

ANSWER: B

The American Urological Association guidelines define asymptomatic microscopic hematuria (AMH) as greater than or equal to 3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause (SOR C). A positive dipstick does not define AMH, and evaluation should be based solely on findings from microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH.

Question 16

16. A 70-year-old male with widespread metastatic prostate cancer is being cared for through a local hospice. Surgery, radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. Over the past few days he has been experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min.

Which one of the following would be best at this point?

A) Morphine
B) Oxygen
C) Albuterol (Proventil, Ventolin)
D) Haloperidol

Answer 16

ANSWER: A

Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment and other measures may be appropriate in specific circumstances. For example, inhaled bronchodilators or glucocorticoids may be helpful in patients with COPD, and diuresis may be helpful in patients with heart failure. The evidence for oxygen in patients with hypoxemia is not clear, but there is no benefit from oxygen for nonhypoxemic patients.

Question 17

17. A 30-year-old female with a history of prolonged QT syndrome presents with severe acute bacterial sinusitis. Which one of the following antibiotics should be avoided?

A) Amoxicillin
B) Clarithromycin (Biaxin)
C) Amoxicillin/clavulanate (Augmentin)
D) Moxifloxacin (Avelox)
E) Cefuroxime (Ceftin)

Answer 17

ANSWER: B

A number of medications can cause or exacerbate prolonged QT syndrome, which can lead to torsades de pointes. This can be associated with syncope or degenerate into a sustained ventricular tachycardia or ventricular fibrillation. Clarithromycin interferes with the delayed rectifier potassium current, which results in the accumulation of potassium ions in cardiac myocytes and thereby delays cardiac repolarization. This leads to prolongation of the QT interval and therefore the risk of fatal arrhythmia. Clarithromycin is metabolized by the cytochrome P450 3A enzyme. When using clarithromycin it is important to avoid any other medications that may inhibit this enzyme, leading to higher clarithromycin levels. The other antibiotics listed do not have this effect.

Question 18

18. Which one of the following is associated with treatment of COPD with inhaled corticosteroids?

A) An increased risk of monilial vaginitis
B) An increased risk of bruising
C) Consistent improvement in FEV1
D) A decreased risk of pneumonia
E) Decreased mortality

Answer 18

ANSWER: B

Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia. They also have the potential for increasing bone loss and fractures. They decrease the risk of COPD exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.

Question 19

19. A 56-year-old male complains of daily early awakening and low energy for the past 3 weeks. Six weeks ago he had a myocardial infarction treated with a coronary artery stent. During that hospitalization his CBC, fasting glucose level, and thyroid function were normal. A recent phone note from the cardiac rehabilitation nurse indicates that he became apathetic and stopped attending his rehabilitation sessions. He admits to a feeling of hopelessness. He denies chest pain, dyspnea, orthopnea, and palpitations. His vital signs and physical examination are remarkable for a healing radial artery catheterization wound.

In addition to resumption of cardiac rehabilitation, which one of the following would be most appropriate at this point?

A) Reassurance and a follow-up appointment in 6 weeks
B) A Patient Health Questionnaire 9 (PHQ-9)
C) Polysomnography
D) A BNP level
E) An exercise thallium stress test

Answer 19

ANSWER: B

Depression affects up to 9% of U.S. patients and can cause significant disability. The U.S. Preventive Services Task Force recommends screening for depression in adults in practices that have systems in place to ensure accurate diagnosis and treatment with follow–up. Brief validated depression screening tools are readily available to assist in the diagnosis of depressed patients.

In his history, this patient gave the equivalent of positive answers to the two-question Patient Health Questionnaire (PHQ-2), a screening instrument that is specific for depression. In other words, depression can be ruled out when the responses are negative. Because the PHQ-2 questions are positive in this patient, the next step is confirmation with the PHQ-9, a questionnaire that includes the two questions in the PHQ-2 plus seven additional questions.

Cardiovascular testing may be indicated in the future for this patient, but not for these symptoms. The patient’s sleep disturbance, viewed in the context of his other depressive symptoms and positive PHQ-2, is not likely to be due to a sleep disorder, so polysomnography is not indicated at this point. Untreated depression is associated with worse outcomes in coronary artery disease, so postponing further evaluation would be inappropriate for this patient.

Question 20

20. A 5-year-old white male is brought to your office with a chief complaint of chronic nocturnal limb pain. His mother states that his pain is often severe enough that it awakens him at night and she often gives him ibuprofen to help alleviate his calf pain, but she has never seen him limp or heard him complain of pain during the day. She also has not noticed any grossly swollen joints, fever, rash, or weight change. She is concerned because of a family history of juvenile rheumatoid arthritis in a distant cousin. The physical examination is within normal limits, as are a CBC and an erythrocyte sedimentation rate.

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

A) Bilateral plain radiographs of the lower extremities
B) Testing for antinuclear antibody
C) Testing for rheumatoid factor
D) Referral to orthopedic surgery
E) No further workup

Answer 20

ANSWER: E

This patient has benign nocturnal limb pains of childhood (previously known as “growing pains”). These crampy pains often occur in the thigh, calf, or shin, occur in up to 35% of children 4–6 years of age, and may continue up to age 19. The pathology of these pains is unknown. The pain is nocturnal, without limping or other signs of inflammatory processes. The erythrocyte sedimentation rate and CBC are normal in this condition but testing is indicated in patients with chronic joint pain to rule out malignancy or infection (SOR C). Rheumatoid factor and ANA have a low predictive value in primary care settings and are not indicated in the pediatric population without evidence of an inflammatory process (SOR C). Plain radiographs are more useful for excluding certain conditions such as cancer than for making a diagnosis of arthritis in children (SOR C). Reassurance of the parents is indicated in this situation, along with instruction on supportive care and over-the-counter analgesics as necessary.

Question 21

21. According to the guidelines developed by the JNC 8 panel, which one of the following should NOT be used as a first-line treatment for hypertension?

A) ACE inhibitors
B) Angiotensin receptor blockers
C) Calcium channel blockers
D) B-Blockers
E) Thiazide-type diuretics

Answer 21

ANSWER: D

In 2014 new evidence-based guidelines for blood pressure management were published by the panel members of the Eighth Joint National Committee (JNC 8). They looked only at randomized, controlled trials that compared one class of antihypertensive agent to another to develop the treatment recommendations. ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood pressure in the nonblack population, including patients with diabetes mellitus. B-Blockers were not recommended for the initial treatment of hypertension because one study found there was a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these drugs compared to the use of an ARB.

Question 22

22. A 67-year-old male presents with a 10-day history of bilateral shoulder pain and stiffness accompanied by upper arm tenderness. On examination there is soreness about both shoulders and the patient has great difficulty raising his arms above his shoulders. There is no visual disturbance, and no tenderness over the temporal arteries. C-reactive protein is elevated and the erythrocyte sedimentation rate is 65 mm/hr (N 0–17).

Which one of the following would help to confirm the most likely diagnosis?

A) The use of published validated diagnostic criteria
B) Synovitis of the glenohumeral joint on ultrasonography
C) A response to treatment with prednisone
D) A response to NSAIDs
E) A lack of systemic symptoms

Answer 22

ANSWER: C

This patient has characteristic features of polymyalgia rheumatica, a disease whose prevalence increases with age in older adults but is almost never seen before age 50. Most people will have accompanying systemic symptoms including fatigue, weight loss, low-grade fever, a decline in appetite, and depression. There are no validated diagnostic criteria available to assist in the diagnosis. The treatment response to 15 mg of prednisone daily is dramatic, often within 24–48 hours, and if this response is not seen, alternative diagnoses must be considered. NSAIDs are not useful in the management of polymyalgia rheumatica and, in fact, are associated with high drug morbidity. Ultrasonography may be useful in making the diagnosis, with typical findings of subdeltoid bursitis and tendon synovitis of the shoulders, but synovitis of the glenohumeral joint is less common.

Question 23

23. A 70-year-old male with hypertension, benign prostatic hyperplasia, depression, and well-controlled diabetes mellitus sees you because of increasing fatigue. His medical history also includes stent placement for coronary artery disease. A physical examination is unremarkable except for decreased peripheral pulses. A CBC, basic metabolic profile, hemoglobin A1c level, free T4 level, and TSH level are all normal, except for a serum sodium level of 125 mEq/L (N 135–145). His serum osmolality is 268 mOsm/kg (N 275–290). His urine sodium level is 50 mEq/L (N less than 20) and his urine osmolality is 300 mOsm/kg.

Which one of the patient’s medications is most likely to cause this problem?

A) Losartan (Cozaar)
B) Tamsulosin (Flomax)
C) Metformin (Glucophage)
D) Atorvastatin (Lipitor)
E) Sertraline (Zoloft)

Answer 23

ANSWER: E

In patients who are euvolemic but have hyponatremia, decreased serum osmolality, and elevated urine osmolality, the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is likely. Other causes to rule out include thyroid disorders, adrenal insufficiency, and diuretic use. Renal function has to be normal as well. Common drugs that cause SIADH include SSRIs (particularly in patients over 65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, and NSAIDs. Treatment of the problem consists of discontinuing the offending drug. Temporary fluid restriction may also be required.

Question 24

24. A 21-year old female comes to her family physician’s office with an unintended pregnancy and states that she wishes to have a medical abortion. Elective abortion is against the physician’s personally held moral principles.

According to the American Academy of Family Physicians, which one of the following would
be the most appropriate course of action for the physician in this situation?

A) Explaining the rationale for morally opposing medical abortions
B) Providing no further assistance at this visit
C) Offering to match the patient with prospective adoptive parents
D) Advising the patient that it would be safer for her to continue the pregnancy
E) Providing resources that explain how to access a safe and legal medical abortion

Answer 24

ANSWER: E

Although the American Academy of Family Physicians (AAFP) states that physicians are not compelled to perform any act that violates their moral principles, the AAFP also states that physicians do have a responsibility to provide resources on how to access a safe and legal abortion for women who are considering that option. Induced abortion is safer than live childbirth. Between 1998 and 2005 in the United States, mortality was 8.8 per 100,000 live births among women who delivered live neonates and 0.6 per 100,000 abortions among women who had legal abortions. Physicians should not broker adoptions, either by matching pregnant women with prospective parents or by offering to adopt children from their patients. Physicians should also not advocate or argue their personal moral position to patients. Conscientious refusal does not excuse a physician from providing appropriate medical care, including providing unbiased, medically accurate information regarding options and either having a referral process for transfer of care or identifying resources where such information can be obtained.

Question 25

25. A 65-year-old male presents to an urgent care center with a foot ulcer. His past medical history is significant for hypertension, COPD, and diabetes mellitus. He has been hospitalized several times in the past year for COPD exacerbations and a hip fracture. He does not have any other current problems.

On examination he has a temperature of 37.3°C (99.1°F), a pulse rate of 105 beats/min, a respiratory rate of 16/min, and a blood pressure of 142/83 mm Hg. His examination is unremarkable except for a 2-cm ulcer on the ball of his left foot that has 3 cm of surrounding erythema and some purulent drainage. His CBC is normal except for a WBC count of 14,300/mm3 (N 4300–10,800).

Which one of the following would be the most appropriate choice for initial treatment?

A) Amoxicillin/clavulanate (Augmentin)
B) Linezolid (Zyvox)
C) Ciprofloxacin (Cipro)
D) Ceftriaxone (Rocephin) and levofloxacin (Levaquin)
E) Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)

Answer 25

ANSWER: E

This patient has a severe diabetic foot ulcer. It appears to be infected and there are signs of a systemic inflammatory response. This is an indication for intravenous antibiotics. Piperacillin/tazobactam and vancomycin would be the most appropriate choice of antibiotics because together they cover the most common pathogens in diabetic foot ulcers, as well as MRSA, which is present in 10%–32% of diabetic foot ulcers. This patient has recently been hospitalized and would thus be at high risk for a MRSA infection. Moderate to severe diabetic foot ulcers are often polymicrobial and can include gram-positive cocci, gram-negative bacilli, and anaerobic pathogens.

Question 26

26. Which one of the following is the most common cause of unintentional deaths in children?

A) Motor vehicle accidents
B) Drowning
C) Poisoning
D) Fires
E) Falls

Answer 26

ANSWER: A

Unintentional injuries account for 40% of childhood deaths. Motor vehicle accidents are the most frequent cause of these deaths (58.2% of unintentional deaths). The proper use of child restraints is the most effective way to prevent injury or death, and the American Academy of Family Physicians and the American Academy of Pediatrics strongly recommend that physicians actively promote the proper use of motor vehicle restraints for all patients. Drowning accounts for 10.9% of all unintentional deaths in children, poisoning for 7.7%, fires 5.7%, and falls 1.4%.

Question 27

27. A 45-year-old male presents with shortness of breath and a cough. On pulmonary function testing his FVC is less than 80% of predicted, his FEV1/FVC is 90% of predicted, and there is no improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide (DLCO) is also low.

Based on these results, which one of the following is most likely to be the cause of this patient’s problem?

A) Asthma
B) Bronchiectasis
C) COPD
D) Cystic fibrosis
E) Idiopathic pulmonary fibrosis

Answer 27

ANSWER: E

Based on the results of pulmonary function testing, this patient has a pure restrictive pattern with a low diffusing capacity for carbon monoxide. Pulmonary fibrosis is compatible with this pattern. A patient with any of the other listed diagnoses would be expected to have an obstructive pattern on testing.

Question 28

28. A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion.

Which one of the following is the most appropriate initial treatment?

A) B-Blockers
B) Nitrates
C) Glucocorticoids
D) NSAIDs

Answer 28

ANSWER: D

Patients with acute pericarditis should be treated empirically with colchicine and/or NSAIDs for the first episode of mild to moderate pericarditis. B-Blockers would only be appropriate if the cause of the patient’s chest pain were an infarction or ischemia. Nitrates do not relieve the pain of pericarditis. Glucocorticoids are typically reserved for use in patients with severe or refractory cases or in cases where the likely cause of the pericarditis is connective tissue disease, autoreactivity, or uremia (SOR C).

Question 29

29. A 4-year-old male has a BMI of 17.5 kg/m2, which places him between the 90th and 95th percentiles for BMI. According to the CDC, he should be classified as being

A) at a healthy weight
B) overweight
C) obese
D) morbidly obese

Answer 29

ANSWER: B

The recommended terminology for weight classification in children is based on age and either BMI (for children ages 2–18 years) or weight-for-length ratio (for children ages 0–2 years). Children under the age of 2 years are identified as being overweight when their weight-for-length ratio exceeds the 95th percentile for their sex. The term obese is not used for children under the age of 2 years. Children age 2–18 years are appropriately classified as underweight when their BMI falls below the 5th percentile, healthy weight when their BMI is between the 5th and 85th percentile, overweight when their BMI is between the 85th and 94th percentile, and obese when their BMI is in the 95th or greater percentile. There is currently no standard definition of childhood morbid obesity, but obesity is sometimes classified as severe or extreme when a child’s BMI is at the 99th percentile or greater.

Question 30

30. A 13-year-old female is being evaluated for primary amenorrhea. On examination she has short stature, a webbed neck, and a low hairline. A physical examination reveals no signs of pubertal development.

Which one of the following is most likely to provide a diagnosis?

A) MRI of the pituitary
B) FSH and LH levels
C) A prolactin level
D) Pelvic ultrasonography
E) Karyotyping

Answer 30

ANSWER: E

Primary amenorrhea is defined as a history of no menses in a female 13 years of age or older with no pubertal development, or 5 years after initial breast development, or in a patient older than 15 years. Primary amenorrhea is typically due to chromosomal problems that lead to primary ovarian insufficiency or anatomic abnormalities. If the patient has dysmorphic features such as short stature, a low hairline, or a webbed neck, the suspicion for Turner’s syndrome should be high. While FSH and LH levels may be elevated, the definitive diagnosis would be made from a karyotype.

Question 31

31. A 71-year-old female comes in for follow-up of hypertension. She is worried about her heart and says that some of her friends have had stress tests and she would like to get one as well just to be on the safe side. She has no chest pain, shortness of breath, or exercise intolerance, and a complete review of systems is negative.

The patient’s current medications include lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 25 mg daily; and omeprazole (Prilosec), 20 mg daily. Her past medical history includes hypertension, obesity, and gastroesophageal reflux disease. A physical examination reveals a blood pressure of 130/70 mm Hg, a heart rate of 90/min, and a BMI of 31.2 kg/m2. An EKG 2 years ago was normal.

Which one of the following should be ordered to assess this patient’s cardiovascular risk?

A) A lipid profile
B) A coronary artery calcification score
C) A C-reactive protein level
D) An EKG
E) An exercise stress test

Answer 31

ANSWER: A

There is no indication for cardiac testing in a low-risk asymptomatic person, and testing may lead to harm resulting from false positives. The U.S. Preventive Services Task Force does not recommend resting or stress EKG testing for asymptomatic low-risk patients (D recommendation). Asymptomatic patients should be risk stratified to assess the risk of chronic heart disease, and this patient should have a lipid profile for risk stratification. Low-risk patients do not benefit from nontraditional risk assessments, including high-sensitivity C-reactive protein or coronary artery calcium assessment.

Question 32

32. Which one of the following is true regarding respiratory syncytial virus (RSV) infection?

A) Most infections in the United States occur between August and December
B) Corticosteroids should be a routine part of treatment
C) The diagnosis is usually based on positive serology
D) It is rarely associated with bacterial co-infection

Answer 32

ANSWER: D

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young infants, prematurely born infants, or those with pre-existing heart/lung conditions, the infection can be severe. In North America, RSV season is November to April. Treatment is primarily supportive, including a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and antibiotics are not routinely indicated (SOR B). Routine laboratory and radiologic studies should not be used in making the diagnosis, as it is based on the history and physical examination (SOR C).

Question 33

33. An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now has difficulty with normal activities such as getting out of a chair and brushing her teeth. Her medical problems include hypertension, diabetes mellitus, and hyperlipidemia. Her medications include glipizide (Glucotrol), simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on examination are within normal limits except for diffuse proximal muscle weakness and normal deep tendon reflexes. A CBC, urinalysis, erythrocyte sedimentation rate, TSH level, and serum electrolyte levels are normal. Her blood glucose level is 155 mg/dL and her creatine kinase level is 1200 U/L (N 40–150).

Which one of the following is the most likely diagnosis?

A) Statin-induced myopathy
B) Polymyalgia rheumatica
C) Guillain-Barré syndrome
D) Diabetic ketoacidosis

Answer 33

ANSWER: A

This patient is most likely suffering from a drug-induced myopathy caused by simvastatin, which is associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated erythrocyte sedimentation rate. Guillain-Barré syndrome is associated with depressed deep tendon reflexes. This case has no clinical features or laboratory findings that suggest ketoacidosis.

Question 34

34. A 3-year-old female is brought to your office with coughing and a tactile fever. Her only other symptom is mild rhinorrhea. She has a temperature of 38.2°C (100.8°F) and is mildly tachypneic. Her vital signs are otherwise normal and she appears to be well and in no respiratory distress. Her examination is unremarkable except for decreased breath sounds and crackles in the right lower lung field. She has no allergies to medications.

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

A) Amoxicillin
B) Azithromycin (Zithromax)
C) Cefdinir
D) Moxifloxacin (Avelox) 
E) Ceftriaxone (Rocephin)

Answer 34

ANSWER: A

Amoxicillin is the recommended first-line treatment for previously healthy infants and school-age children with mild to moderate community-acquired pneumonia (CAP) (strong recommendation; moderate-quality evidence). The most prominent bacterial pathogen in CAP in this age group is Streptococcus pneumoniae, and amoxicillin provides coverage against this organism. Azithromycin would be an appropriate choice in an older child because Mycoplasma pneumoniae would be more common. Moxifloxacin should not be used in children. Ceftriaxone and cefdinir can both be used to treat CAP, but they are broader spectrum antibiotics and would not be a first-line choice in this age group.

Question 35

35. When compared to a figure-of-eight dressing, which one of the following modalities of treatment has been shown to have similar fracture-healing outcomes and increased patient satisfaction for nondisplaced mid-shaft clavicular fractures?

A) A shoulder sling
B) A short arm cast
C) A long arm cast
D) Operative fixation

Answer 35

ANSWER: A

When compared to a figure-of-eight dressing, a sling has been shown to have similar fracture healing rates in patients with a nondisplaced midshaft clavicular fracture. In addition, a figure-of-eight dressing is uncomfortable and difficult to adjust, and patients have reported increased satisfaction when treated with a sling. Long and short arm casts are not appropriate options to manage a patient with a clavicular fracture. Operative treatment is an option to treat displaced midshaft fractures (SOR B).

It should be noted that a Cochrane review of interventions for clavicle fracture pointed out that the studies of this problem were done in the 1980s and did not meet current standards. One of the conclusions of this review was that further research should be done.

Question 36

36. The mother of a 6-year-old male is concerned about his snoring, and she recently observed him stop breathing for a few seconds while he was sleeping. He has also been more sleepy during the day recently. His height and weight are normal. Polysomnography confirms obstructive sleep apnea.

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

A) Methylphenidate (Ritalin)
B) Lorazepam (Ativan)
C) Fluoxetine (Prozac) on a daily basis
D) A mouthguard
E) Adenotonsillectomy

Answer 36

ANSWER: E

In children, obstructive sleep apnea (OSA) is most often due to enlarged tonsils and adenoids. OSA onset is usually between 2 and 8 years of age, coinciding with peak tonsil growth. Adenotonsillectomy is the primary treatment for most non-obese children with OSA (SOR B). SSRIs are sometimes effective in treating nightmares because these medications can suppress rapid eye movement sleep. Benzodiazepines are an option for treating sleep terrors. Methylphenidate is a stimulant used to treat attention-deficit/hyperactivity disorder and has no benefit for OSA. The use of a mouthguard at night is recommended for management of temporomandibular joint syndrome to reduce excessive teeth grinding during sleep. It is not a treatment for OSA.

Question 37

37. A 70-year-old male sees you for a routine annual evaluation. He complains of fatigue but has no other symptoms. He has a history of hypertension but has not fully adhered to his drug regimen, which includes hydrochlorothiazide, amlodipine (Norvasc), and lisinopril (Prinivil, Zestril).

Laboratory Findings

Hemoglobin. . . . . . . . . . . 9.0 g/dL (N 13.5–17.2)
Serum creatinine. . . . . . . 2.2 mg/dL (N 0.6–1.2)
Glomerular filtration rate. . 26 mL/min/1.73 m2
Serum iron. . . . . . . . . . . . . .30 ug/dL (N 60–170)
Total iron
binding capacity. . . . . .300 ug/dL (N 240–450)
Ferritin. . . . . . . . . . . . . . . . . . 55ng/mL(N46–100)
Mean corpuscular volume. .77 um3 (N 80–100)

One year ago the patient had a serum creatinine level of 2.0 mg/dL. A colonoscopy 6 months ago was unremarkable and a stool test for occult blood is negative.

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

A) An erythropoietin level
B) Transfusion of packed RBCs
C) Epoetin alfa (Procrit)
D) Ferrous sulfate orally
E) Intravenous iron therapy

Answer 37

ANSWER: D

Chronic kidney disease (CKD) is now divided into five stages of progressively worsening function based on the glomerular filtration rate (GFR). Stage 1 is defined as a GFR >90 mL/min/1.73 m2, while the fifth stage, kidney failure, is defined as a GFR less than 15 mL/min/1.73 m2. Anemia is associated with not only stage 5 disease, where it is universal, but also with earlier stages. The National Kidney Foundation Guidelines define anemia as a hemoglobin level less than or equal to 13.5 g/dL in men or less than or equal to 12.0 g/dL in women.

Anemia due to CKD is diagnosed by excluding other etiologies. Anemia in CKD is due to decreased production of erythropoietin, but testing for levels is not needed, nor is a bone marrow biopsy. The indicated tests include a CBC, reticulocyte count, ferritin level, vitamin B12 level, folate level, and transferrin saturation (serum iron to total iron binding capacity ratio). Usually the CBC will demonstrate a normochromic, normocytic anemia, but can show microcytosis (mean corpuscular volume less than 80). A serum ferritin level less than 25 ng/mL is indicative of low iron stores. Some patients have a combination of iron deficiency and anemia of chronic disease due to the kidney disease.

Patients with depleted iron stores will benefit from replenishment, which serves to correct an isolated iron deficiency or improve the response to erythropoiesis-stimulating agents. Iron therapy is generally initiated orally with ferrous sulfate, 325 mg 3 times a day. The effectiveness of this therapy can be monitored by checking hemoglobin, transferrin saturation, and ferritin levels at 1 and 3 months after beginning treatment. If the goals have not been achieved by 3 months, intravenous iron therapy should be considered.

For patients who do not respond to iron replacement, erythropoiesis-stimulating agents such as epoetin alfa or darbepoetin alfa should be used. The goal should be to relieve symptoms such as fatigue and to achieve a hemoglobin level of 11–12 g/dL. Levels >13 g/dL increase the mortality rate, particularly from cardiovascular disease.

Question 38

38. Which one of the following is most likely to be seen with diastolic dysfunction?

A) A dilated left ventricle
B) A preserved ejection fraction
C) Aortic insufficiency
D) Pericardial effusion

Answer 38

ANSWER: B

Heart failure due to diastolic dysfunction occurs in the older population. The criteria for diastolic heart failure include symptoms and signs consistent with heart failure (including dyspnea), a nondilated left ventricle with a preserved ejection fraction (greater than or equal to 50%), and evidence of structural heart disease such as diastolic dysfunction on echocardiography (SOR C).

Question 39

39. Slipped capital femoral epiphysis is most likely in which one of the following patients with no history of trauma?

A) A 3-day-old male with a subluxable hip
B) A 7-year-old male with groin pain and a limp
C) A 13-year-old male with knee pain
D) A 16-year-old female with lateral thigh numbness

Answer 39

ANSWER: C

Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt (11–13 years of age for girls, 13–15 years of age for boys). While the cause is unknown, associated factors include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral physis, in addition to being overweight. African-Americans are affected more commonly as well.

The patient may present with pain in the groin or anterior thigh, but also may present with pain referred to the knee. That is also the case for Legg-Calvé-Perthes disease, also known as avascular or aseptic necrosis of the femoral head. This condition most commonly occurs in boys 4–8 years of age. In addition to hip (or knee) pain, limping is a prominent feature.

Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity or wearing clothing that is too tight in the waist or groin. Developmental dysplasia of the hip is identified by a click during a provocative hip examination of the newborn, using both the Barlow and Ortolani maneuvers to detect subluxation or dislocation.

Question 40

40. A 43-year-old female smoker has type 2 diabetes mellitus, morbid obesity, and a recent diagnosis of symptomatic peripheral arterial disease. You have started her on atorvastatin (Lipitor), offered a supervised exercise program, and discussed smoking cessation and interventions.

Which one of the following should be recommended to prevent cardiovascular events in this patient?

A) Aspirin
B) Cilostazol (Pletal)
C) Enoxaparin (Lovenox)
D) Pentoxifylline
E) Warfarin (Coumadin)

Answer 40

ANSWER: A

Patients with symptomatic peripheral arterial disease should be started on a daily dose of either aspirin or clopidogrel to prevent cardiovascular events such as acute myocardial infarction or stroke (SOR B). Cilostazol is a phosphodiesterase inhibitor with both antiplatelet and arterial vasodilatory activity. It has been shown to improve claudication symptoms by 50% compared to placebo. Likewise, pentoxifylline is also used in the treatment of claudication symptoms but is less effective than cilostazol and is reserved as a second-line agent. Neither agent has been shown to decrease cardiovascular events in patients with symptomatic peripheral artery disease. Neither enoxaparin nor warfarin is indicated for symptomatic peripheral artery disease.

Question 41

41. A 56-year-old female comes in for evaluation of gradually worsening right hip pain. She describes her pain as located in the groin and dull in nature, and with activity often notes a clicking sensation associated with sharp pain. On examination her hip range of motion is intact but pain is elicited with extremes of internal and external rotation and her groin pain is exacerbated with the FABER test (knee flexion, abduction and external rotation of the leg until the ankle rests proximal to the contralateral knee) and FADIR test (knee flexion, adduction, and internal rotation of the leg).

Which one of the following is the most likely diagnosis?

A) Femoral neck fracture
B) Femoral hernia
C) Trochanteric bursitis
D) Hip labral tear

Answer 41

ANSWER: D

This patient has signs and symptoms of a hip labral tear. This causes dull or sharp groin pain, which in some patients radiates to the lateral hip, anterior thigh, or buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. Half of patients also have mechanical symptoms, such as catching or painful clicking with activity. The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 75%–96% for the FADIR test and 88% for the FABER test), although neither test has high specificity. Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears, as it has a sensitivity of 90% and an accuracy of 91%. However, if a labral tear is not suspected, less invasive imaging modalities such as plain radiography and conventional MRI should be used first to assess for other causes of hip and groin pain.

This patient has no history of trauma or risk factors to suggest a fracture. A femoral hernia would typically present as pain that is worse with straining or lifting, associated with a palpable bulge in the upper thigh. Trochanteric bursitis typically causes lateral hip pain with point tenderness over the greater trochanter of the femur.

Question 42

42. A doctor and patient are discussing using a particular drug to treat the patient’s uncontrolled hypertension. Which one of the following potential effects of the drug is a patient-oriented outcome that should be discussed during shared decision-making?

A) A decrease in diastolic blood pressure
B) A decrease in hemoglobin A1c
C) A decrease in carotid intimal thickness
D) A decrease in all-cause mortality
E) Improvement in the Framingham cardiac risk score

Answer 42

ANSWER: D

Shared decision-making should include a discussion of risks and benefits that are meaningful to the individual patient. It is an important component of patient-centered care, but published studies often report intermediate endpoints. Patient-oriented outcomes typically include data on mortality (especially all-cause mortality because changes in disease-specific mortality may be offset by changes in other causes of mortality), morbidity, symptoms, and quality of life. Intermediate endpoints typically involve disease-oriented data, including histologic, physiologic, or clinical measurements such as blood pressure, carotid intimal thickness, hemoglobin A1c, and risk scores such as the Framingham score.

Question 43

43. A 12-month-old male is brought to your office for a routine well child visit. His father has epilepsy and takes seizure medication.

Which one of the following vaccines will slightly increase the child’s risk of a febrile seizure for up to 2 weeks after administration?

A) Hepatitis B
B) MMR
C) HiB
D) Pneumococcal
E) Polio

Answer 43

ANSWER: B

Fever and febrile seizures may occur after administration of several vaccines. Postimmunization seizures, especially febrile seizures, occur at a higher rate in children who have a past history of seizures or a first-degree relative with a history of seizures. The benefits of the vaccines outweigh the risks, so they are not contraindicated in this situation, although the parents need to be cautioned about the increased risk of seizure.

Of the vaccines listed, the only one likely to put the child at risk for a seizure up to 2 weeks after administration is the MMR vaccine. Specifically, it is the measles component of the vaccine that is the potential culprit. A temperature of 39.4°C (103°F) or higher develops in approximately 5%–15% of susceptible vaccine recipients, usually 6–12 days after receipt of MMR vaccine. The fever generally lasts 1–2 days but may last up to 5 days.

Question 44

44. A right-hand–dominant 38-year-old male comes to your office because of right elbow pain. He recently began participating in a highly competitive adult volleyball league, and 2 weeks after he first began playing he developed mild pain in the medial elbow of his right arm. While completing an overhead serve last night he felt an acute worsening of the elbow pain. After the match he noted bruising over his medial elbow.

When you examine him you find bruising and pain to palpation around the medial elbow. With his shoulder in 90° of abduction and external rotation you rapidly flex and extend the elbow while maintaining valgus torque on the elbow (the moving valgus stress test). The patient reports pain between 70° and 120° of flexion.

This clinical presentation is most consistent with which one of the following causes of elbow pain?

A) Medial epicondylitis
B) Biceps tendinopathy
C) Cubital tunnel syndrome
D) Ulnar collateral ligament injury
E) Triceps tendinopathy

Answer 44

ANSWER: D

This patient has injured his ulnar collateral ligament (UCL). The UCL is the primary restraint to valgus stress on the elbow during overhead throwing. These injuries often occur in athletes participating in sports that require overhead throwing, such as baseball, javelin, and volleyball. Patients often report a pop followed by immediate pain and bruising around the medial elbow. The moving valgus stress test has 100% sensitivity and 75% specificity for diagnosing UCL injuries.

Medial epicondylitis usually presents with an insidious onset of pain related to a recent increase in occupational or recreational activities. Patients also often report weakened grip strength. The point of maximal tenderness is 5–10 mm distal to and anterior to the medial epicondyle. It is most often a tendinopathy of the flexor carpi radialis and the pronator teres.

Biceps tendinopathy usually presents with a history of vague anterior elbow pain and a history of repeated elbow flexion with forearm supination and pronation, such as dumbbell curls. Resisted supination produces pain deep in the antecubital fossa.

Cubital tunnel syndrome is a neuropathy of the ulnar nerve caused by compression or traction as it passes through the cubital tunnel of the medial elbow. The onset of pain is more insidious than UCL injury, occurring with repetitive activity, and is usually accompanied by numbness and tingling in the ulnar border of the forearm and hand. If it has existed for some time, the intrinsic hand muscle may become weak.

Tendinopathy of the triceps insertion is more common in weight lifters or athletes who repetitively extend their elbows against resistance. Pain occurs at the posterior elbow with resisted extension, and tenderness is located over the triceps insertion.

Question 45

45. Which one of the following is true regarding the live attenuated intranasal influenza vaccine?

A) It is preferred in all children >6 months of age
B) It is more effective in children age 2–6 years than the inactivated vaccine
C) It is more effective in children >6 years of age than in younger children
D) It is the vaccine of choice for pregnant women
E) It is less effective in adults age 18–49 than the inactivated vaccine

Answer 45

ANSWER: B

The live attenuated intranasal influenza vaccine is recommended for healthy nonpregnant persons 2–49 years of age. It is more effective than the inactivated vaccine in children 2–6 years of age; for patients 6–49 years of age either the live attenuated intranasal or the inactivated vaccine is recommended. The live intranasal vaccine is contraindicated in pregnancy and in patients with asthma or COPD. Patients older than 49 years should receive the inactivated vaccine.

Question 46

46. A 63-year-old female with corticosteroid-dependent COPD has developed pneumonia. Which one of the following pathogens should the antibiotic regimen cover in this patient that would be unlikely in someone with pneumonia and otherwise healthy lungs?

A) Streptococcus pneumoniae
B) Mycoplasma pneumoniae
C) Haemophilus influenzae
D) Staphylococcus aureus
E) Pseudomonas aeruginosa

Answer 46

ANSWER: E

All of the pathogens listed can cause pneumonia in any patient. However, in patients with chronic lung disease who are taking corticosteroids, Pseudomonas is more common than in those with otherwise healthy lungs. The antibiotics chosen empirically should cover this pathogen.

Question 47

47. A 30-year-old male presents to your office because he thinks he may be suffering from alcohol withdrawal. He was dependent on alcohol for at least 10 years and has completed treatment programs twice. He had been abstinent for over a year until he began drinking heavily after his wife filed for divorce 2 weeks ago. A friend found him in a bar last night and has kept him from consuming alcohol for the past 12 hours.

The patient is now nauseated, miserable, restless, shaky, and sweating, and says he can feel his heart pounding. He has not had any seizures or episodes of delirium tremens. His temperature is 37.5°C (99.6°F), pulse rate 100 beats/min, and blood pressure 150/92 mm Hg. His palms are moist and he has a mild tremor on arm extension. He is oriented but cannot perform serial additions. A CBC, basic metabolic panel, and urine drug screen are normal.

You decide that outpatient treatment would be appropriate. Which one of the following alcohol withdrawal management options is supported by the best evidence?

A) Thiamine and magnesium 
B) Carbamazepine (Tegretol) 
C) Phenytoin (Dilantin) 
D) Chlordiazepoxide 
E) Clonidine (Catapres)

Answer 47

ANSWER: D

This patient scores in the moderate range for withdrawal severity and is a candidate for pharmacotherapy, based on the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale. He also has no known contraindications to outpatient treatment, such as abnormal laboratory results, absence of a support network, acute illness, high risk for delirium tremens, history of alcohol withdrawal seizure, recent long-term intake of large amounts of alcohol, poorly controlled chronic medical conditions, a serious psychiatric condition, severe withdrawal symptoms, or a positive urine drug screen.

Benzodiazepines are the preferred medication for treating alcohol withdrawal (SOR A) and preventing alcohol withdrawal seizures. There is no evidence that indicates that any particular medication is superior, but long-acting benzodiazepines are preferred. Neither fixed nor symptom-triggered dosing of benzodiazepines has been shown to be superior to the other. Although anticonvulsants have less abuse potential than benzodiazepines, they do not prevent seizures or delirium tremens. Clonidine and 6-blockers can help reduce adrenergic symptoms but do not prevent alcohol withdrawal seizures. Thiamine or magnesium may be appropriate to address nutritional deficiencies resulting from alcoholism but would not reduce withdrawal symptoms.

Question 48

48. In the United States, cow’s milk is not recommended for children until the age of

A) 4 months 
B) 6 months 
C) 9 months 
D) 12 months 
E) 15 months

Answer 48

ANSWER: D

Whole cow’s milk does not supply infants with enough vitamin E, iron, and essential fatty acids, and overburdens them with too much protein, sodium, and potassium. Skim and low-fat milk lead to the same problems as whole milk, and also fail to provide adequate calories for growth. For these reasons cow’s milk is not recommended for children under 12 months of age. Human breast milk or iron-fortified formula, with introduction of certain solid foods and juices after 4–6 months of age if desired, is appropriate for the first year of life.

Question 49

49. A 15-year-old male presents to the emergency department after suffering a lateral dislocation of his patella. Which one of the following would be the best method for reducing this dislocation?

A) Medially directed pressure on the patella while extending the leg
B) Medially directed pressure on the patella while flexing the leg
C) Rapid leg extension
D) Lateral retinacular release

Answer 49

ANSWER: A

It is usually simple to reduce a lateral patellar dislocation, and these injuries rarely require acute surgical management. The proper technique is to have the patient sit or lie with the leg in a flexed position and then apply gentle medial pressure to the patella until the most lateral edge is over the femoral condyle. The leg should then be gently extended and the knee brought into full extension. This should cause the patella to slip back into place, and the knee should then be immobilized.

Question 50

50. In a 15-year-old female with no known chronic medical conditions, which one of the following is essential before initiating oral combined hormonal contraception?

A) Bimanual pelvic examination
B) Clinical breast examination
C) Cervical cytology and HPV screening
D) Blood pressure measurement
E) Weight measurement

Answer 50

ANSWER: D

The U.S. Selected Practice Recommendations for Contraceptive Use, 2013, focuses on optimizing the use of contraceptive methods. Perceived obstacles to obtaining guidance and prescription contraceptives are identified, and are addressed by recommendations that facilitate the ease of obtaining both. In the absence of coexisting medical conditions that may require additional evaluation or limit contraceptive options, the only medical evaluation identified as essential before prescription of combined hormonal contraception is measurement of blood pressure, as severe hypertension is a contraindication to oral contraception. Ascertaining the likelihood of pregnancy based on the sexual history and/or phase of the menstrual cycle is also necessary before determining a start date. Each of the listed examination options is ideal, but none has been found to contribute substantially to the safe and effective use of combined hormonal contraceptives. A baseline weight is useful in determining excessive weight gain on reevaluation following the initiation of oral contraception, but it is not a prerequisite.