Questions 101-150

Question 1

101. A 55-year-old female presents with lateral hip pain over the outer thigh. She has no history of injury, although she has just begun a walking program to lose weight. She has increased pain when she lies on that side at night. Her examination is unremarkable except that she is overweight and has tenderness over the greater trochanter. There is no pain with internal and external rotation of the hip. A radiograph reveals minimal osteoarthritic changes.

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

A) Serum protein electrophoresis
B) A bone scan
C) A bone density study
D) MRI
E) A corticosteroid injection

Answer 1

ANSWER: E

Trochanteric bursitis develops insidiously after repetitive use, and the patient may report morning stiffness and pain when lying on the affected side. Palpation of the greater trochanter elicits tenderness, and occasionally swelling may be noted as well. Early injection with a corticosteroid usually produces a satisfactory response.

Question 2

102. A 70-year-old male who recently moved to your area sees you for the first time. He has a previous history of myocardial infarction, has a pacemaker, and has hypertension that had been well controlled on hydrochlorothiazide and atenolol (Tenormin) for several years. About 6 months ago his previous physician had to add amlodipine (Norvasc) to his regimen. On examination he has mild arteriolar narrowing in his fundi and there is a systolic bruit just to the right of his umbilicus. He has a log of home blood pressure readings that average 138/88 mm Hg for the past 2 months. His serum creatinine level has gone from 1.2 mg/dL to 1.4 mg/dL (N 0.6–1.2) in the past 2 months.

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

A) Referral for stent placement
B) Scheduling an arteriogram
C) A captopril renal scan
D) Adding losartan (Cozaar) to his regimen
E) Continued monitoring of serum creatinine

Answer 2

ANSWER: E

Renal artery stenosis may be present in as many as 5% of patients with hypertension. It is often seen in those who have coronary artery disease and/or peripheral vascular disease. Hypertension requiring four or five drugs to control, abdominal bruits, and development of hyperkalemia or renal insufficiency after initiating therapy with an ACE inhibitor can all point toward renal artery stenosis as a diagnosis.

For patients with renal artery stenosis who have good control, no testing is necessary other than monitoring renal function, particularly if an ACE inhibitor or ARB is part of the regimen. Screening tests recommended by clinical guidelines include duplex ultrasonography, CT angiography, or MR cystography (SOR B). Captopril renography was used in the past but is no longer recommended.

In the 1990s uncontrolled studies were done that suggested that either stenting or angioplasty resulted in significant blood pressure reduction and reduced renal failure. However, a clinical trial has shown that stenting did not benefit patients when added to comprehensive multifactorial medical therapy.

Question 3

103. A 25-year-old male presents with a 3-day history of cough, chills, and fever. The patient was previously healthy and has no chronic medical problems. He has no known drug allergies. On examination he is alert and oriented, and has a temperature of 38.4°C (101.1°F), a pulse rate of 88 beats/min, a blood pressure of 120/70 mm Hg, a respiratory rate of 16/min, and an oxygen saturation of 98%.

Auscultation of the lungs reveals no wheezing and the presence of right basilar crackles. A chest radiograph shows a right lower lobe infiltrate.

There is a low rate of macrolide-resistant pneumococcus in the community. Which one of the following is the most appropriate initial management of this patient?

A) Outpatient treatment with azithromycin (Zithromax)
B) Outpatient treatment with cefuroxime (Ceftin)
C) Inpatient treatment on the medical floor with ceftriaxone (Rocephin) and azithromycin
D) Inpatient treatment on the medical floor with piperacillin/tazobactam (Zosyn) and levofloxacin
E) Inpatient treatment in the intensive-care unit with ceftriaxone, levofloxacin, and vancomycin (Vancocin)

Answer 3

ANSWER: A

In patients with community-acquired pneumonia it is necessary to decide on both the antibiotic regimen and the treatment setting. The decision regarding site of care is based on the severity of illness, which can be assessed with tools such as the CURB-65 score, which take into account factors such as respiratory rate, blood pressure, uremia, confusion, and age.

Patients who have only mild symptoms can be treated with azithromycin on an outpatient basis if there is a low level of macrolide resistance in the community. If there is a high level of resistance in the community, if the patient has comorbidities such as diabetes mellitus or COPD, or if there is a history of use of an immunosuppressing drug or recent use of an antibiotic, the patient can still be treated as an outpatient but should be treated with levofloxacin. Patients with more severe symptoms, such as an elevated pulse rate or respiratory rate, should be treated on an inpatient basis with ceftriaxone or azithromycin. Patients who have more severe symptoms along with bronchiectasis should be treated with piperacillin/tazobactam plus levofloxacin.

Patients with the most severe symptoms, including hypotension, a more elevated pulse rate, low oxygen saturation, and confusion, should be treated in the intensive-care unit with levofloxacin and vancomycin.

Question 4

104. A mother brings in her 10-year-old son because of a swollen area in his neck that she first noticed yesterday. He has also had symptoms of an upper respiratory infection. On examination the child has a runny nose but otherwise appears well. Palpation reveals a soft, 1.5-cm, slightly tender mass, inferior to the angle of the mandible and anterior to the sternocleidomastoid muscle.

The most likely diagnosis is

A) thyroglossal duct cyst
B) dermoid cyst
C) branchial cleft cyst
D) thyroid tumor

Answer 4

ANSWER: C

In children, neck masses usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic. The history and physical examination can help narrow the diagnosis, with location of the mass being particularly helpful.

Branchial cleft cysts make up approximately 20% of neck masses in children. They commonly present in late childhood or adulthood, when a previously unrecognized cyst becomes infected. They are most frequently found anterior to the sternocleidomastoid muscle, but can also be preauricular.

Thyroglossal duct cysts are located in the midline over the hyoid bone. Frequently, they elevate when the patient swallows. Dermoid cysts are usually mobile, moving with the overlying skin. They can be located in the submental or midline region. Thyroid tumors are also usually located in the midline. Malignant masses are usually hard, irregular, nontender, and fixed.

Question 5

105. Treatment of rhabdomyolysis should routinely include which one of the following?

A) Bicarbonate-containing fluids
B) Loop diuretics
C) Mannitol
D) Parenteral corticosteroids
E) Isotonic saline

Answer 5

ANSWER: E

The treatment of rhabdomyolysis includes rapid large infusions of isotonic saline to prevent and treat acute kidney injury, which occurs in 10%–60% of patients. Sodium bicarbonate administration is unnecessary and is not better than normal saline diuresis and increasing urine pH. Loop diuretics and mannitol have little human evidence to support their use. Corticosteroid use is not recommended.

Question 6

106. A 26-year-old pet groomer sustained a dog bite to her left hand 2 hours ago. On examination a 4-cm × 2.5-cm laceration is noted on the thenar eminence of her palm. Although the wound shows some gaping there is minimal active bleeding. No neurovascular injury is noted.

Which one of the following is an indication for antibiotics in this patient?

A) A wound size greater than 2 cm
B) The presence of wound gaping
C) A bite involving the hand
D) The patient’s occupation

Answer 6

ANSWER: C

Antibiotic prophylaxis should be used for high-risk bite wounds. Factors associated with a high risk include a bite on an extremity with underlying venous and/or lymphatic compromise, a bite involving the hand, a bite near or in a prosthetic joint, cat bites, crush injuries, delayed presentation, puncture wounds, underlying diabetes mellitus, and immunosuppression. A Cochrane review of nine trials showed no statistical difference in infection rates between prophylaxis and no treatment, except when the bite wound was on the hand. The role of tetanus and rabies prophylaxis should be considered on a case-by-case basis. The other factors listed do not influence whether or not an antibiotic should be prescribed (SOR B).

Question 7

107. You see a 27-year-old male with autosomal dominant polycystic kidney disease. He has no other medical problems and his renal function has always been normal on annual testing. Today the patient reports his blood pressure at home has been 142–150/84–90 mm Hg. His blood pressure at this visit is 145/88 mm Hg.

Which one of the following medications is preferred for the initial management of hypertension
in this patient?

A) Amlodipine (Norvasc)
B) Chlorthalidone
C) Furosemide (Lasix)
D) Lisinopril (Prinivil, Zestril)

Answer 7

ANSWER: D

Hypertension is the most common manifestation of autosomal dominant polycystic kidney disease and it also contributes to worsening renal function and an increased risk for cardiovascular disease and death. ACE inhibitors such as lisinopril are first-line agents because they have renal protective benefits in addition to their effects on blood pressure. Some studies have suggested they help slow the decline in renal function and help to prevent left ventricular hypertrophy (more so than diuretics or calcium channel blockers). Angiotensin receptor blockers should be reserved for those who cannot tolerate ACE inhibitors.

Question 8

108. A 30-year-old female is being evaluated for chronic pain, fatigue, muscle aches, and sleep disturbance. Which one of the following would be best for making a diagnosis of fibromyalgia?

A) A structured symptom history
B) Examination for tender points
C) Laboratory testing
D) A muscle biopsy
E) Electromyography

Answer 8

ANSWER: A

The American College of Rheumatology has defined diagnostic criteria for fibromyalgia based on the patient’s symptoms (SOR A). Previously, tender points on examination were the diagnostic criterion. Laboratory testing, muscle biopsies, and electromyography can be used to rule out other conditions.

Question 9

109. Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be problematic in elderly patients because they can

A) decrease blood pressure
B) cause bradycardia
C) worsen existing urinary obstruction
D) enhance the anticholinergic effects of other medications
E) enhance the sedative effects of other medications

Answer 9

ANSWER: C

Sympathomimetic agents can elevate blood pressure and intraocular pressure, may worsen existing urinary obstruction, and adversely interact with B-blockers, methyldopa, tricyclic antidepressants, oral hypoglycemic agents, and MAOIs. They also speed up the heart rate. First-generation nonprescription antihistamines can enhance the anticholinergic and sedative effects of other medications.

Question 10

110. You have prescribed oral iron replacement for a 46-year-old female with iron deficiency anemia related to heavy menses. She wants to be sure that the iron she takes will be absorbed well.

Which one of the following would you suggest for improving iron absorption?

A) Calcium
B) Vitamin C
C) Coffee
D) Tea

Answer 10

ANSWER: B

Taking oral iron with vitamin C or a meal high in meat protein increases iron absorption. Calcium and coffee both decrease iron absorption, but not as much as tea, which can reduce absorption of oral iron by as much as 90%.

Question 11

111. Which one of the following conditions can affect hemoglobin A1c levels?

A) Heart failure
B) Chronic hemolytic anemia
C) COPD
D) Hypothyroidism

Answer 11

ANSWER: B

The hemoglobin A1c (HbA1c) blood test provides information regarding average glucose levels over the past 3 months. Any condition that shortens erythrocyte survival or decreases mean erythrocyte age, such as recent acute blood loss or hemolytic anemia, will falsely lower HbA1c levels. Hemoglobin variants and iron deficiency, kidney failure, and liver disease can also affect HbA1c results. Heart failure, COPD, and hypothyroidism do not influence HbA1c values.

Question 12

112. Many of the changes that occur as part of aging affect pharmacokinetics. Which one of the following is INCREASED in geriatric patients?

A) Drug absorption
B) The glomerular filtration rate
C) Lean body mass
D) The volume of distribution of water-soluble compounds such as digoxin
E) The percentage of body fat

Answer 12

ANSWER: E

The physiologic changes that accompany aging result in altered pharmacokinetics. In older persons there is a relative increase in body fat and a relative decrease in lean body mass, which causes increased distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such medications. The volume of distribution of water-soluble compounds such as digoxin is decreased in older patients, which means a smaller dose is required to reach a given target plasma concentration. There is also a predictable reduction in glomerular filtration rate and tubular secretion with aging, which causes decreased clearance of medications in the geriatric population. The absorption of drugs changes little with advancing age. All of these changes are important to consider when choosing dosages of medications for the older patient.

Question 13

113. A 60-year-old male with a long-standing history of hypertension seeks your advice about pain relief from his osteoarthritis. He has tried acetaminophen and topical capsaicin cream without much benefit. He is concerned about media reports of NSAIDs causing heart problems and is unsure which ones would be safest for him to use.

Based on current evidence, which one of the following NSAIDs would you recommend as being LEAST likely to be associated with an increased risk of myocardial infarction?

A) Celecoxib (Celebrex)
B) Diclofenac (Zorvolex)
C) Ibuprofen
D) Meloxicam (Mobic)
E) Naproxen (Naprosyn)

Answer 13

ANSWER: E

NSAIDs cause an elevation of blood pressure due to their salt and water retention properties. This effect can also lead to edema and worsen underlying heart failure. In addition, all NSAIDs can have a deleterious effect on kidney function and can worsen underlying chronic kidney disease, in addition to precipitating acute kidney injury. Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk of cardiovascular adverse effects and myocardial infarction, compared with placebo. However, naproxen has not been associated with an increased risk of myocardial infarction and is therefore preferred over other NSAIDs in patients with underlying coronary artery disease risk factors (SOR B).

Question 14

114. A 26-year-old male presents with a sore throat and a temperature of 38.3°C (101.0°F). On examination you note muffling of the voice and unilateral tonsillar swelling with a shift of the uvula away from the affected tonsil. A rapid test for Streptococcus pyogenes is negative.

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

A) Laboratory testing for infectious mononucleosis
B) Immediate tonsillectomy
C) Initiation of antibiotics with close clinical follow-up
D) Culture of the throat and delayed initiation of antibiotics pending results

Answer 14

ANSWER: B

This patient has examination findings that strongly suggest a peritonsillar abscess, which is the most common deep infection of the head and neck in young adults. Although antibiotics are indicated in this case, the cornerstone of management is drainage of the abscess either by needle drainage or by incision and drainage. Immediate tonsillectomy is less favored, as it is a less cost-effective option.

Question 15

115. A 7-year-old male is brought to your office with a 2-day history of rash. He developed two itchy spots on his legs yesterday and today he has multiple purple, slightly painful lesions on his legs. A few days ago he was ill with cold-like symptoms, stomach pain, and a fever up to 101.2°F. He complained of leg pain at the time and his left ankle is now swollen. His fever resolved 2 days ago and he now feels fine but limps when he walks.

On examination he is afebrile with a normal blood pressure and pulse rate. He is active in the examination room. His physical examination is normal except for purpuric lesions on his legs and buttocks and edema and mild pain of the left ankle. A urinalysis is negative.

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

A) Acetaminophen
B) Amlodipine (Norvasc)
C) Amoxicillin
D) Cyclophosphamide
E) Prednisone

Answer 15

ANSWER: A

This patient meets the clinical criteria for Henoch-Schönlein purpura (HSP), an immune-mediated vasculitis found commonly in children under the age of 10. The clinical triad of purpura, abdominal pain, and arthritis is classic.

Almost 95% of children with HSP spontaneously improve, so supportive therapy is the main intervention. Acetaminophen or ibuprofen can be used for the arthritic pain. However, ibuprofen should be avoided in those with abdominal pain or known renal involvement. Prednisone has been found to help in those with renal involvement or other complications of the disease such as significant abdominal pain, scrotal swelling, or severe joint pains (SOR B). However, it is not effective for preventing renal disease or reducing the severity of renal involvement, as was once thought (SOR A).

Immunosuppressants such as cyclophosphamide and cyclosporine have been suggested for treating patients with severe renal involvement, but there is insufficient evidence to support their use. Amoxicillin is appropriate for patients with a bacterial infection, such as streptococcal pharyngitis, which has led to HSP. In this patient, however, there is no indication of pharyngitis or another bacterial focus. Patients with renal involvement and resultant hypertension with HSP should be treated with calcium channel blockers such as amlodipine. This patient exhibits neither renal involvement nor hypertension.

Question 16

116. A 32-year-old male smoker presents with a 4-day history of progressive hoarseness. He is almost unable to speak, and associated symptoms include a cough slightly productive of yellow sputum, as well as tenderness over the ethmoid sinuses. He is afebrile and has normal ear and lung examinations. His oropharynx is slightly red with no exudate, and examination of his nasal passages reveals mucosal congestion.

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

A) Amoxicillin for 10 days
B) Omeprazole (Prilosec), 40 mg daily
C) Azithromycin (Zithromax) for 5 days
D) Symptomatic treatment only

Answer 16

ANSWER: D

Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate. A Cochrane review concluded that antibiotics appear to have no benefit in treating acute laryngitis. Proton pump inhibitors such as omeprazole can be of benefit in treating chronic laryngitis caused by acid reflux, but not for an acute problem such as the one described.

Question 17

117. A 26-year-old female presents with acute low back pain. She says it started a week ago after she lifted a sofa when helping a friend move. The patient’s medical history is otherwise negative. The patient says the pain is limited to the lower back. The physical examination is normal, including the neurologic examination.

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

A) No imaging
B) A plain film of the lumbar spine
C) MRI of the lumbar spine
D) A DXA scan
E) A PET scan

Answer 17

ANSWER: A

Low back pain is one of the most common reasons for visits to physicians. The workup should start with a thorough history and physical examination to determine whether the patient has nonspecific back pain, back pain possibly related to radiculopathy or spinal stenosis, or back pain due to some other specific cause. Nonspecific back pain does not require imaging (SOR B). An initial plain film would be appropriate if there were a history of recent significant trauma, or even a history of minor trauma in an elderly patient. Immediate MRI would be appropriate in the presence of other red flags such as bladder dysfunction, areflexia, saddle anesthesia, progressive motor weakness, a history of cancer, or the presence of fever, unexplained weight loss, or night sweats.

Question 18

118. A 50-year-old female sees you for follow-up of uncontrolled hypertension. Her recent blood pressure measurements average greater than 175/105 mm Hg. The patient has diabetes mellitus and a BMI of 32.3 kg/m2. Physical findings are otherwise noncontributory. Recent laboratory studies include three different potassium levels less than 3.5 mEq/L (N 3.5–5.0) despite increasing dosages of oral potassium supplements, with the dosage now at 100 mEq daily.

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

A) Measurement of peripheral aldosterone concentration and peripheral renin activity
B) CT of the abdomen
C) Renal CT angiography
D) An aldosterone suppression test

Answer 18

ANSWER: A

Hyperaldosteronism, usually caused by a hyperaldosterone-secreting adrenal mass, has to be considered in a middle-aged patient with resistant hypertension and hypokalemia. Peripheral aldosterone concentration (PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred screening tests for hyperaldosteronism. A PAC greater than 15 ng/dL and a PAC/PRA ratio greater than 20 suggest an adrenal cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma. Renal CT angiography is useful for detecting renal artery stenosis. If the PAC/PRA is abnormal, an aldosterone suppression test should be ordered.

Question 19

119. You are asked to medically manage a 66-year-old patient who is scheduled for an elective cholecystectomy. He is also being treated for panhypopituitarism secondary to a pituitary macroadenoma resection many years ago. His medications include levothyroxine (Synthroid), 125 ug/day; prednisone, 10 mg in the morning and 5 mg in the evening; and fludrocortisone, 10 mg/day.

Preoperative orders for this patient should include which one of the following?

A) Normal saline intravenously as a bolus
B) ACTH daily while on intravenous fluids
C) Hydrocortisone, 25 mg intravenously every 8 hr
D) Levothyroxine, 250 ug intravenously daily

Answer 19

ANSWER: C

A patient with known adrenal insufficiency secondary to hypopituitarism who is undergoing a period of stress such as illness or surgery should be given intravenous corticosteroids. For moderate-risk procedures such as vascular or orthopedic operations, 50 mg of hydrocortisone is recommended. For major surgery, such as open heart surgery or an esophagectomy, 100 mg of hydrocortisone would be needed. These doses can be repeated every 8 hours until the patient is stable and is able to take his usual oral maintenance dose.

Thyroid replacement is not required for short-term situations, and ACTH is not recommended. If the patient becomes hypotensive a bolus of normal saline may be indicated. However, in a stable patient undergoing elective surgery, only routine hydration is indicated.

Question 20

120. In which one of the following patients should a creatine kinase level be obtained to detect
     Duchenne muscular dystrophy?

A) A 2-month-old male who is unable to roll over from prone to supine
B) A 7-month-old male who is unable to get into a sitting position unassisted
C) A 15-month-old male who is walking but is unable to stand up from a supine position
without support
D) A 16-month-old male who is not walking unassisted
E) A 6-month-old with high neuromuscular tone on physical examination

Answer 20

ANSWER: C

Periodic developmental screening is essential for the early recognition of neuromuscular disorders and motor delays in children. Multiple developmental screening tools are available for primary care physicians to use. Motor development should progress throughout infancy and childhood. Either failure to adequately progress or signs of regression should be cause for concern and raise the suspicion for a neuromuscular disorder such as muscular dystrophy.

Infants should roll from prone to supine by 4 months of age and supine to prone by 6 months of age. They should be able to get themselves into a sitting position by 9 months of age. While low muscular tone in an infant suggests muscular dystrophy, high muscle tone is concerning for an upper motor neuron condition and should be evaluated with MRI.

A 15-month-old who is unable to rise to a standing position without using his hands should have a creatine kinase (CK) level obtained—this is the classic Gower’s sign. Although many children walk unassisted by 12 months, CK levels should not be obtained (unless indicated for other reasons) unless a male child is not walking by 18 months of age.

Question 21

121. You see a 4-year-old male in your office for evaluation of persisting fever, rash, and red eyes. In a discussion with his father you learn that the child has had temperatures in the 99°F–102°F range for 6 days, along with what the father describes as “pink eye.” Today the child broke out in a rash on his chest and back and also has cracked red lips. On examination you confirm that he has bilateral nonpurulent conjunctival injection and a generalized maculopapular rash, as well as erythema of his hands and feet.

Which one of the following is recommended at this time to evaluate for cardiac complications?

A) An EKG
B) Transthoracic echocardiography
C) Cardiac CT
D) Magnetic resonance (MR) coronary angiography
E) A radionuclide myocardial perfusion scan

Answer 21

ANSWER: B
This patient meets the criteria for Kawasaki disease, also known as mucocutaneous lymph node syndrome. It is an acute type of vasculitis that predominantly affects small and medium-size vessels and is the most common cause of acquired coronary artery disease in childhood.

Diagnostic criteria include fever for at least 5 days and at least 4 of the 5 principal clinical features:
• changes of the oral cavity and lips
• polymorphous rash
• bilateral nonpurulent conjunctivitis
• changes in the extremities (erythema followed by desquamation)
• cervical lymphadenopathy

Coronary abnormalities, including coronary aneurysms, are the most concerning sequelae of Kawasaki disease and may occur in the first week. For this reason early cardiac evaluation is recommended, with transthoracic echocardiography being the preferred initial imaging. Radionuclide imaging can be useful in assessing cardiac perfusion in patients found to have persisting echocardiographic findings. MR coronary angiography can be used to assess response to treatment over time. Intravenous immunoglobulin and corticosteroids reduce the risk of coronary abnormalities and should be administered as soon as the disease is suspected.

Question 22

122. Which one of the following is true regarding electronic cigarettes?

A) They release lower concentrations of particulate matter than tobacco cigarettes
B) They are a nicotine-free alternative to tobacco
C) They are not regulated by the FDA
D) They have been proven to be effective for smoking cessation
E) They have been shown to be safe in pregnancy

Answer 22

ANSWER: C

Electronic cigarettes (e-cigarettes) are not currently regulated by the FDA. The amount of particulate matter released into the air by low-nicotine e-cigarettes is comparable to that released by tobacco cigarettes, while higher-nicotine e-cigarettes release more particulate matter. E-cigarettes have various concentrations of nicotine in solution. While the number of tobacco cigarettes smoked per day is decreased in e-cigarette users, this has not yet been shown to lead to smoking cessation. There are no studies of e-cigarettes in pregnant women, and nicotine is contraindicated during pregnancy.

Question 23

123. Which one of the following is the leading cause of human death in the world as a whole?

A) Ischemic heart disease
B) Premature birth
C) Diarrheal diseases
D) HIV/AIDS
E) Cancers of the lungs, bronchi, and trachea

Answer 23

ANSWER: A

Cardiovascular disease, in particular ischemic heart disease, has now become the leading cause of human deaths worldwide. It was once considered a disease of the wealthy, but now more than 80% of deaths from noncommunicable diseases occur in low- to middle-income countries. The other conditions listed remain among the top 10 causes of human deaths worldwide, along with stroke, lower respiratory infections, COPD, diabetes mellitus, and road deaths.

Question 24

124. A 25-year-old female who is 3 months post partum presents with multiple complaints, including increasing weakness and fatigue, intolerance to warm environments, a weight loss of 30 lb despite an increased appetite, difficulty sleeping, awareness that her heart is beating faster and “pounding” in her chest, increasing restlessness and difficulty concentrating, increased tremulousness, and a significant swelling in her neck. She takes no medication, has experienced no recent trauma, and has not ingested large amounts of iodine.

When you examine her you find no exophthalmos or lid lag and no pretibial edema, but her skin is warm, smooth, and moist. You also find a smooth, non-nodular, nontender, enlarged thyroid gland, clear lungs, a resting tremor, and hyperactive reflexes.

Laboratory testing reveals a low TSH level, elevated free T3 and free T4, and high uptake on a radioactive iodine uptake scan.

Which one of the following is the most likely diagnosis?

A) Postpartum thyroiditis
B) Silent thyroiditis
C) Subacute thyroiditis
D) Graves disease
E) Exogenous thyroid ingestion

Answer 24

ANSWER: D

This patient has symptoms consistent with hyperthyroidism, which could be caused by any of the options listed. TSH is suppressed and free T4 and free T3 are elevated in all of these conditions. Only Graves disease, however, will cause high radioactive iodine uptake on a thyroid scan. Uptake will be low in the other conditions.

Question 25

125. A previously healthy 59-year-old male is brought to the emergency department by his wife, who describes symptoms of confusion and ataxia. She also says that he has had a fever and cough for the past 2 weeks. On examination he has a temperature of 39.0°C (102.2°F), a heart rate of 125 beats/min, a respiratory rate of 25/min, a blood pressure of 85/46 mm Hg, and an O2 saturation of 88%. Laboratory findings include a WBC count of 15,500/mm3 (N 4300–10,800), a glomerular filtration rate of 45%, and a hemoglobin level of 9.1 g/dL (N 13.0–18.0). A chest radiograph reveals a large left lower lobe infiltrate.

You start the patient on an appropriate antibiotic regimen. Which one of the following is the most appropriate initial treatment of this patient’s hypotension?

A) Dobutamine
B) Dopamine
C) Norepinephrine
D) Aggressive fluid resuscitation
E) Packed red blood cell transfusion

Answer 25

ANSWER: D

This patient meets the criteria for severe inflammatory response syndrome (SIRS) (fever greater than 38.5°C, heart rate greater than 90 beats/min, respiratory rate greater than 20/min, WBC count greater than 12,000/mm3). He also meets the criteria for severe sepsis, with a positive chest radiograph and evidence of organ hypoperfusion (mental status changes), as well as septic shock (mean arterial pressure less than 60 mm Hg). The most appropriate initial treatment for patients with hypotension in septic shock is fluid resuscitation (SOR A). While vasopressor therapy is certainly appropriate in septic shock, it should be initiated only after fluid resuscitation fails to restore mean arterial pressure (greater than 65 mm Hg) or when there is evidence of continued organ hypoperfusion. Appropriate antibiotics to cover community-acquired pneumonia are recommended during the first hour of presentation in sepsis (SOR B) but will likely have little effect on acute hypotension. Packed red blood cell transfusion is not indicated in this scenario, as the patient’s hemoglobin is above 7 g/dL.

Question 26

126. A 17-year-old male high school football running back is hit on the lower leg by an opposing player’s helmet when the other player dives for a fumble. The running back presents to the emergency department after the game with significant swelling and bruising of the lower leg. Symptoms include exceptionally severe pain that is worse with stretching the calf muscles. There is no weakness of the extremity and sensation is intact. You examine the leg and can palpate pulses. Plain radiographs do not show a fracture.

Which one of the following should be ordered next?

A) Noninvasive arterial ultrasonography of the leg
B) Noninvasive venous ultrasonography of the leg
C) CT of the calf region
D) MRI of the calf region
E) Tissue pressure studies

Answer 26

ANSWER: E

This patient has symptoms and findings consistent with acute compartment syndrome, which is an emergency. The diagnostic test is tissue pressure studies. This condition can occur after a severe injury to the extremity, although it can also develop after a relatively minor injury. Associated problems include fractures, a badly bruised muscle, crush injuries, constricting bandages, and bites with swelling.

Question 27

127. A 23-year-old healthy male is sexually active with other men and does not use condoms. He is interested in reducing his risk of contracting HIV by using a daily oral antiretroviral medication.

Which one of the following laboratory tests should be done no more than 7 days before initially prescribing pre-exposure prophylaxis with emtricitabine/tenofovir disoproxil (Truvada)?

A) A CD4 cell count
B) Antibody testing for HIV
C) Hemoglobin concentration
D) A platelet count
E) An ALT level

Answer 27

ANSWER: B

It is of critical importance that patients have a documented negative HIV antibody test (from serum or point-of-care fingerstick) prior to starting pre-exposure prophylaxis (PrEP) to avoid inadvertent treatment of HIV infection with emtricitabine/tenofovir. This is the only medication currently approved in the United States for PrEP, but it is inadequate for HIV treatment. Using this treatment by itself in HIV-positive patients increases the risk of HIV strains developing resistance to these antiviral agents.

Other recommended testing prior to PrEP use includes creatinine clearance calculation, hepatitis B antibody testing, screening for sexually transmitted diseases, and pregnancy testing in females capable of pregnancy. The CDC does not recommend testing liver function, hemoglobin, or platelet levels prior to PrEP use in otherwise healthy individuals.

Question 28

128. A patient is admitted to the hospital for acute deep vein thrombosis of the lower extremity and started on anticoagulation therapy. The nursing staff asks for an activity order.

Which one of the following should be ordered?

A) Activity as tolerated
B) Bed rest until the patient has been hospitalized for 24 hours
C) Bed rest with bathroom privileges until the patient has been hospitalized for 24 hours
D) Bed rest until discharged
E) Bed rest with bathroom privileges until discharged

Answer 28

ANSWER: A

The 2012 American College of Chest Physicians evidenced-based clinical practice guidelines recommend early ambulation over initial bed rest in patients with acute DVT of the leg (SOR C). If edema and pain are severe, ambulation may need to be deferred. Several studies and meta-analyses have shown there is no statistically significant difference between ambulation and bed rest for development of a pulmonary embolus, a new thrombus, or progression of a thrombus. Therefore, based on the evidence and the well-recognized benefits of mobility, the current recommendation is to consider early ambulation as soon as effective anticoagulation has been achieved.

Question 29

129. Which one of the following potential bioterrorism agents requires treatment with 60 days of continuous antibiotics?

A) Anthrax
B) Botulism
C) Pneumonic plague
D) Smallpox
E) Tularemia

Answer 29

ANSWER: A

Of the bioterrorism agents listed, only anthrax requires 60 days of antibiotic treatment (SOR B). If used in an intentional attack, anthrax spores would be released into the air to be inhaled by the target population. The full incubation period of the bacterium is 60 days and treatment should cover the entire period. Appropriate antibiotics include oral fluoroquinolones and doxycycline.

Smallpox is a result of infection with the variola virus. Potential treatments include postexposure treatment with the smallpox vaccine and two compounds currently in development. Pneumonic plague, caused by Yersinia pestis, can be provoked by inhalation of the released bacterium or by contact with an infected individual. Treatment consists of a 10-day course of an aminoglycoside or doxycycline.

Inhalational botulism is treated with an antitoxin (equine-derived heptavalent antitoxin). Tularemia could be caused by an intentional release of the bacterium Francisella tularensis, which would cause a pneumonia. Treatment is a 10-day course of an aminoglycoside, ciprofloxacin, or doxycycline.

Question 30

130. Which one of the following is recommended in all patients with croup, including those with mild disease?

A) Humidification therapy
B) Oral dexamethasone as a single dose
C) Oral diphenhydramine (Benadryl) every 6 hours until improvement
D) Subcutaneous epinephrine as a single dose
E) Intramuscular ceftriaxone (Rocephin) as a single dose

Answer 30

ANSWER: B

A single dose of dexamethasone (0.15–0.60 mg/kg, usually given orally) is recommended in all patients with croup, including those with mild disease. Humidification therapy has not been proven beneficial. Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup. Subcutaneous epinephrine, diphenhydramine, and ceftriaxone are not recommended treatments.

Question 31

131. A 17-year-old male presents to the urgent care clinic 15 minutes after being stung by a wasp. He feels weak, his voice is hoarse, and he is beginning to have trouble breathing.

Which one of the following should be administered first?

A) Intramuscular epinephrine
B) Intravenous diphenhydramine (Benadryl)
C) Intravenous famotidine (Pepcid)
D) Intravenous methylprednisolone sodium succinate (Solu-Medrol)
E) An intravenous bolus of normal saline

Answer 31

ANSWER: A

H1 and H2 histamine blockers and corticosteroids may be useful, but they are not first-line treatments for an anaphylactic reaction to a Hymenoptera sting. Intravenous normal saline may also be necessary for fluid resuscitation, but the first treatment should be immediate administration of intramuscular epinephrine.

Question 32

132. A pet reptile is most likely to transmit which one of the following to human contacts?

A) Hantavirus
B) Psittacosis (Chlamydophila psittaci)
C) Plague (Yersinia pestis)
D) Pasteurella multocida
E) Salmonella

Answer 32

ANSWER: E

Reptiles, including snakes, lizards, and turtles, cause both isolated cases of Salmonella infection and local and widespread outbreaks. While the sale of small pet turtles was outlawed in 1975, the law is not widely enforced and pet turtles are often a source of Salmonella infection in small children. The infection can also be spread by other reptiles and amphibians, including snakes and frogs. At a Colorado zoo in 1996, a total of 65 children were infected by touching a wooden barrier around a Komodo dragon exhibit. Pasteurella multocida is a common cause of infection as a result of dog or cat bites. Yersinia pestis, the organism of plague, is transmitted to humans from rodents or their fleas. Hantavirus is also transmitted by rodents, and psittacosis by certain bird species.

Question 33

133. A mother brings in her 2-month-old infant for a routine checkup. The baby is exclusively breastfed, and the mother has no concerns or questions.

In addition to continued breastfeeding, which one of the following would you recommend continuing or adding at this time?

A) Iron supplementation
B) Vitamin D supplementation
C) A multivitamin
D) 8 oz of water daily
E) 4 oz of cereal daily

Answer 33

ANSWER: B

Although breast milk is the ideal source of nutrition for healthy term infants, supplementation with 400 IU/day of vitamin D is recommended beginning in the first few days of life and continuing until the child is consuming at least 500 mL/day of formula or milk containing vitamin D (SOR B). The purpose of supplementation is to prevent rickets. Unless the baby is anemic or has other deficiencies, neither iron nor a multivitamin is necessary at this age. For exclusively breastfed infants, iron supplementation should begin at 4 months of age. Parents often mistakenly think babies need additional water, which can be harmful because it decreases milk intake and can cause electrolyte disturbances. The introduction of cereal is recommended at 6 months of age.

Question 34

134. A 78-year-old white male presents to your office with his daughter for a follow-up visit for his diabetes. He has a history of peripheral neuropathy and mild Alzheimer’s dementia. He continues to be socially active in his community. He is on several medications, including insulin glargine (Lantus), amitriptyline, donepezil (Aricept), and clonazepam (Klonopin). His daughter asks whether he should continue to drive his car.

Which one of the following would be most appropriate in the context of this office visit with regard to evaluating his driving safety?

A) A thorough history focused on the patient’s driving, from both him and his daughter
B) A written driving test
C) A road test to observe his driving
D) A letter to the local agency in charge of drivers’ licenses advising license removal

Answer 34

ANSWER: A

Many older drivers have physiologic or cognitive impairment that may affect mobility and driving safety, and older drivers have an increased crash rate per mile driven. However, older individuals who stop driving are at higher risk for isolation and depression and there is also an increased cost to the family and society in general for transportation assistance.

A comprehensive assessment of the ability to drive begins with a driving history from both the patient and a passenger. Any mention of close calls, mishaps, disorientation, or becoming lost in familiar locations is an important hint at unsafe driving. It is important to ask the passenger, “Do you feel safe riding with this individual?”

In this patient a medication review would also be appropriate. His tricyclic antidepressant, benzodiazepine, and insulin could all contribute to unsafe driving. Medical illnesses should also be considered in this history. Dementia, peripheral neuropathy, and retinopathy can all increase the risk for unsafe driving.

Further testing such as a Snellen eye test, audiometry, timed gait, range of motion, muscle strength, clock drawing, and a Mini-Mental State Examination may also be indicated, but a thorough driving history should be obtained first. If a concern arises about unsafe driving, referral to a rehabilitative driving center or the appropriate government agency for further written/road testing may be warranted.

Question 35

135. Which one of the following is more typical of a keloid rather than a hypertrophic scar?

A) Location on an extensor surface
B) Expansion beyond the margins of the inciting injury
C) Development soon after the inciting trauma
D) Regression over time

Answer 35

ANSWER: B

Keloids may arise from scars that result from any cause of skin trauma or infection. Keloids, unlike hypertrophic scars, are not confined to the margins of the primary injury. Hypertrophic scars are more likely on extensor surfaces of the body, typically develop soon after the inciting injury, and are more likely to regress with time.

Question 36

136. Which one of the following should be monitored during testosterone replacement therapy?

A) Patient Health Questionnaire 9 (PHQ-9) scores
B) Fasting glucose levels
C) Fasting lipid profiles
D) Hematocrit
E) Overnight polysomnography

Answer 36

ANSWER: D

Testosterone replacement therapy can cause erythrocytosis, so monitoring hematocrit at regular intervals is recommended. Testosterone replacement therapy does not significantly affect lipid levels, and additional monitoring of these levels is not recommended. Although there have been anecdotal reports of testosterone replacement therapy being associated with sleep apnea, current recommendations do not advise routine testing with overnight polysomnography for patients on testosterone replacement. There is inconsistent evidence of the effects of testosterone replacement therapy on depression, and thus no recommendation for monitoring of mood symptoms related to testosterone therapy. Low testosterone levels have been associated with insulin resistance, but testosterone replacement therapy is not recommended as treatment for hyperglycemia. Monitoring of serum glucose while on testosterone therapy is not routinely recommended.

Question 37

137. A 67-year-old male presents with thoracic spine pain and is found to have two thoracic vertebral compression fractures. He has no history of recent trauma. His general health has been satisfactory except for a seizure disorder controlled with levetiracetam (Keppra). He does not smoke and uses alcohol rarely. A CBC, comprehensive metabolic panel, and erythrocyte sedimentation rate are within normal limits. A DXA scan shows a T-score of –2.8.

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

A) Protein electrophoresis
B) HIV screening
C) A testosterone level
D) A parathyroid hormone level

Answer 37

ANSWER: C

Osteoporosis in males can be caused by multiple conditions, including multiple myeloma, AIDS, hyperparathyroidism, and hypotestosteronism. In this patient, multiple myeloma is unlikely because of the normal erythrocyte sedimentation rate, AIDS is unlikely given his past history, and a parathyroid abnormality is unlikely since his blood chemistry results were normal. Hypotestosteronism is not an infrequent cause of osteoporosis in men.

Question 38

138. A 45-year-old male was admitted to the hospital for nausea resulting from chemotherapy for colon cancer. He has no other chronic diseases and takes no routine medications. He was mildly dehydrated on admission and has been receiving intravenous fluids (D5 1⁄2-normal saline with potassium chloride) at slightly higher than maintenance rates through an indwelling port for the last 24 hours. The nausea is being controlled by antiemetics, and his condition is improving. Results of routine blood work at the time of admission and from the following morning are shown below.

Test Admission Following Morning

Glucose 109 mg/dL (N 65–110) 371 mg/dL
BUN 13 mg/dL (N 7–21) 9 mg/dL
Creatinine 0.9 mg/dL (N 0.6–1.6) 0.9 mg/dL
Sodium 143 mEq/L (N 136–144) 129 mEq/L
Potassium 3.7 mEq/L (N 3.6–5.1) 6.6 mEq/L
Chloride 110 mEq/L (N 101–111) 108 mEq/L
Total CO2 20 mEq/L (N 22–32) 22 mEq/L

Which one of the following would be the most appropriate next step?

A) Start an intravenous insulin drip
B) Order blood work taken from a peripheral vein
C) Restrict the patient’s free water intake
D) Switch from normal saline to hypertonic saline
E) Treat with diuretics

Answer 38

ANSWER: B

Physicians should avoid reacting to laboratory values without considering the clinical scenario. This patient presented with mild dehydration and normal laboratory values. Although he is improving clinically, his laboratory values show multiple unexpected results. The most noticeable is the severely elevated glucose, because he has no history of diabetes mellitus or use of medications that could cause this effect. Similarly, the elevated potassium and decreased sodium suggest profound electrolyte abnormalities. Most likely, the laboratory technician drew blood from the patient’s indwelling port without discarding the first several milliliters. Thus, the blood was contaminated with intravenous fluids, leading to erroneous results. A repeat blood test from a peripheral vein should give more accurate results.

Question 39

139. Which one of the following is most likely to be associated with resistant hypertension in adults?

A) Obstructive sleep apnea
B) Primary aldosteronism
C) Renal artery stenosis
D) Renal parenchymal disease
E) Thyroid disease

Answer 39

ANSWER: A

Obstructive sleep apnea is found in 30%–40% of hypertensive patients and 60%–70% of patients with resistant hypertension, whereas primary aldosteronism is present in only 7%–20% of patients with resistant hypertension. Renal artery stenosis is seen in 2%–24% of cases of resistant hypertension in various studies, renal parenchymal disease in 2%–4%, and thyroid disease in less than 1%.

Question 40

140. A 78-year-old female presents with a red eye. She reports drainage and pain in her left eye since she woke up today, but no photophobia. Examination of the eye shows conjunctival erythema and a mucopurulent discharge. The pupil is normal in size and reactive to light.

Which one of the following should prompt immediate referral to an ophthalmologist?

A) Bilateral eye redness
B) A corneal abrasion noted on fluorescein staining
C) Copious mucopurulent drainage from the eye
D) Bright red blood noted under the conjunctiva
E) Reduction of visual acuity

Answer 40

ANSWER: E

Reduced visual acuity may be a symptom of acute angle-closure glaucoma and requires immediate referral to an ophthalmologist. Copious mucopurulent drainage from the eye is a sign of infectious conjunctivitis, most likely bacterial, and bilateral eye redness is typically seen with allergic conjunctivitis. Allergic or infectious conjunctivitis and small corneal abrasions can be managed by the family physician. Bright red blood under the conjunctiva is consistent with a subconjunctival hemorrhage that will typically resolve without intervention.

Question 41

141. A long-term care resident is admitted to the hospital. The patient has a living will which specifies that “treatment be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain.” The patient has appointed his wife as his health care surrogate. He has mild Alzheimer’s disease and scored 26 out of 30 on a Mini-Mental State Examination performed within the last month. He is alert and pleasant and responds appropriately to questions but cannot remember the current date. His wife is with him.

Which one of the following would be most appropriate with regard to decision making and ordering related to the patient’s code status?

A) Determine the patient’s competence
B) Assess the patient’s decision-making capacity
C) Confirm the code status with the patient’s wife
D) Write a Do Not Resuscitate (DNR) order
E) Order comfort measures only

Answer 41

ANSWER: B

Advance directives, including a living will and durable power of attorney for health care, are used so that the desires of the individual will be followed in the event he or she lacks the capacity to participate in health care decisions. This ability refers to decision making capacity. The standards for decision making capacity vary from state to state but generally include four abilities: patients must (1) have the ability to understand the relevant information about proposed diagnostic tests or treatment, (2) appreciate their situation (including their values and current medical situation), (3) use reason to make a decision, and (4) communicate their choice.

A patient’s capacity is both temporal and situational and capacity evaluations should occur in the context of the specific health care decision that needs to be made. Some patients lack capacity for specific periods of time, such as when critically ill, but not permanently. Although some people are completely incapacitated, many have limited capacity. Those with limited capacity may be able to make some diagnostic and treatment decisions (generally less risky decisions) but not others. Physicians commonly hold patients to higher standards when judging capacity for more serious medical decisions.

There is a relationship between capacity and cognition but a patient with dementia can still have decision-making capacity. With Mini-Mental State Examination scores less than 20 (maximum score = 30) there is an increased likelihood of incapacity, but this varies from case to case and is situation dependent.

Competence is a legal term and is a judicial decision made by a court. Any licensed physician can make a determination of capacity, and a psychiatrist is not required.

Question 42

142. A 42-year-old female presents with a 2-month history of right-sided shoulder pain. A history reveals that her job requires repetitive motion, including abduction of the shoulder. Ibuprofen has not been helpful and the pain interferes with her sleep. The physical examination suggests rotator cuff tendinitis. A radiograph of the shoulder is normal.

You discuss treatment options and the patient decides to proceed with a corticosteroid injection. Which one of the following is the appropriate anatomic location for the injection?

A) The acromioclavicular joint
B) The subacromial space
C) The intra-articular shoulder joint under fluoroscopy
D) The area of insertion of the deltoid muscle
E) The area of insertion of the long head of the biceps

Answer 42

ANSWER: B

Injection of glucocorticoids (usually mixed with a local anesthetic) into the subacromial space may be considered in patients with rotator cuff tendinitis if the pain is significant enough to interfere with sleep and/or function despite adequate analgesia.

An intra-articular injection is appropriate for a patient with severe shoulder osteoarthritis. A corticosteroid injection into the biceps or deltoid insertions is not appropriate. An acromioclavicular injection is appropriate for acromioclavicular arthritis but not for rotator cuff tendinitis.

Question 43

143. A 35-year-old female asks you about options for weight loss. She weighs 104 kg (229 lb) and has a BMI of 34 kg/m2. Her health problems include hypertension and depression.

According to the U.S. Preventive Services Task Force, which one of the following is the most appropriate initial recommendation for weight-loss management in this patient?

A) A high-protein diet
B) A low-carbohydrate diet
C) Behavioral counseling
D) Bariatric surgery

Answer 43

ANSWER: C

The U.S. Preventive Services Task Force found that the most effective behavioral counseling interventions for obesity management were comprehensive and of high intensity (12–26 sessions in a year), and involved multiple behavioral management activities, such as group and individual sessions, setting weight-loss goals, addressing barriers to change, and active use of self-monitoring. Low-carbohydrate diets are minimally effective over the long term without behavioral interventions.

Question 44

144. A 7-year-old male is brought to your office with a 10-day history of cough and fever. A chest radiograph shows no acute air-space process but four posterior healing rib fractures. The child’s past medical history is unremarkable.

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

A) A skeletal survey
B) Studies to evaluate for osteogenesis imperfecta
C) Studies to evaluate for rickets
D) An immediate referral to initiate a child abuse investigation

Answer 44

ANSWER: D

Posterior or posteromedial rib fractures are secondary to child abuse until proven otherwise, justifying notification of Child Protective Services or referral to an emergency department familiar with the appropriate workup. Osteogenesis imperfecta can cause continuous beading of the ribs and crumpled long bones such as accordina femora, and is often associated with blue sclerae, skin fragility, or brittle teeth. A skeletal survey is appropriate in a child 2 years of age or younger suspected of being physically abused. It is not thought to be necessary in children 4 years of age or older, especially in a case where suspicious fractures have already been discovered. Rickets usually is associated with long bone bowing deformities. In the chest it can cause prominence of the costochondral junctions (rachitic rosary) and indentation of the lower ribs where the diaphragm attaches (Harrison’s grooves).

Question 45

145. A 50-year-old male sees you for a health maintenance visit. He has not been to a physician for 5 years because he feels very healthy and believed he was up-to-date on all preventive screenings. You review his medical record and notice he has never had an HIV screening test. On further questioning you confirm that he is at very low risk for contracting HIV.

Based on recommendations from the U.S. Preventive Services Task Force, you tell him that you routinely conduct opt-out HIV screening for

A) all patients age 5 to 75
B) all patients age 15 to 65
C) all patients younger than 50, and patients 50 or older who are at high risk
D) only patients at high risk for HIV, regardless of age

Answer 45

ANSWER: B

The U.S. Preventive Services Task Force recommends opt-out HIV screening for all adolescents and adults 15–65 years of age (SOR A). The Centers for Disease Control recommends routine HIV screening in patients age 13–64 (SOR A). Opt-out screening is preferred to opt-in screening, as opt-in screening based on demographic, behavioral, or clinical subpopulations only identifies approximately 75% of patients with HIV. Rapid screening tests are highly accurate; however, subsequent conventional testing is necessary to confirm an HIV diagnosis.

Question 46

146. A 28-year-old gravida 1 para 0 at 39 weeks gestation presents for routine outpatient obstetric care and is found to have a blood pressure of 145/95 mm Hg. A complete review of systems is notable only for chronic low back pain causing poor sleep. The physical examination is normal, including a nontender, gravid uterus and a fetal heart rate of 150 beats/min. The cervical examination reveals firm consistency, 1 cm dilation, 50% effacement, and –3 station. The patient’s blood pressure is checked 5 hours later and is 142/94 mm Hg.

Based on the 2013 ACOG guidelines for management of hypertension in pregnancy, which one of the following should be the next step in management?

A) Admit the patient for induction of labor
B) Measure 24-hour urine protein, with induction of labor if the level exceeds 300 mg
C) Begin oral nifedipine (Procardia) and recheck her blood pressure in 24–48 hours
D) Place the patient on strict bed rest and check her blood pressure twice weekly
E) Begin twice-weekly office visits with assessment for preeclampsia

Answer 46

ANSWER: A

The 2013 ACOG guideline recommends induction of labor for gestational hypertension after 37 weeks. Identifying elevated urine protein is not required for this decision, as gestational hypertension and preeclampsia without severe features are managed in the same way at 39 weeks gestation. Twice-weekly office visits with assessment of blood pressure and the other tests mentioned may be appropriate for patients at less than 37 weeks gestation. Bed rest is no longer recommended for control of hypertension in pregnancy. Oral antihypertensives are used only at higher blood pressure readings in the setting of chronic hypertension.

Question 47

147. A 40-year-old obese African-American male presents with a history of excessive daytime drowsiness. At home he falls asleep shortly after starting to read or watch television. He admits to nearly crashing his car twice in the past month because he briefly fell asleep behind the wheel. Most frightening to the patient have been episodes characterized by sudden loss of muscle tone, lasting about 1 minute, associated with laughing. An overnight sleep study shows decreased sleep latency and no evidence of obstructive sleep apnea.

Appropriate treatment includes which one of the following?

A) Methylphenidate (Ritalin)
B) Zolpidem (Ambien) at bedtime
C) Carbidopa/levodopa (Sinemet)
D) Weight reduction
E) Avoidance of daytime napping

Answer 47

ANSWER: A

The clinical history and laboratory findings presented are consistent with a diagnosis of narcolepsy. In addition to the sleepiness, the patient also has cataplexy, which is manifested in this case by episodes of sudden weakness when laughing and is almost pathognomonic for narcolepsy. Some patients may also have vivid hallucinations when falling asleep or waking up. Treatment involves improving both the quantity and quality of sleep during the night, which can be accomplished with sodium oxybate. This improves daytime alertness and cataplexy. Scheduling naps is the second important aspect of managing narcolepsy. The third important step is the use of stimulants such as methylphenidate to improve function during the day. Periodic daytime naps may also help to reduce symptoms. Since there is no evidence of obstructive sleep apnea in this patient, weight reduction would not be expected to address his sleep problem. In general, sedatives, hypnotics, and alcohol should be avoided.

Question 48

148. A 68-year-old female presents with a 2-month history of painful, swollen wrists and knees. The pain is always present and is accompanied by stiffness in these joints for 2–3 hours every morning. Her past medical history, family history, and social history are unremarkable. She takes a daily multivitamin.

A complete physical examination is notable only for symmetric, moderately swollen, slightly erythematous, and very tender wrists and knees. Range of motion is intact but increases her pain. Plain radiographs of these joints show erosions at the ulnar styloids. Lyme disease serologies are negative. Anti–cyclic citrullinated peptide (CCP) antibody testing is positive.

Which one of the following would be appropriate for this patient as a sole therapy for her joint condition?

A) Aspirin
B) Doxycycline 
C) Methotrexate
D) Naproxen
E) Prednisone

Answer 48

ANSWER: C

This patient meets the American College of Rheumatology’s criteria for rheumatoid arthritis. The criteria use an algorithm giving a weighted score to joints involved, rheumatoid serology, acute phase reactants and duration of symptoms. Of the medications listed, oral methotrexate is the only disease-modifying antirheumatic drug, which should be part of the treatment for rheumatoid arthritis. Prednisone, aspirin, and NSAIDs are not disease-modifying and should not be used as sole agents, although they can be used for symptom relief. Doxycycline could be considered in the treatment of Lyme disease but this patient meets the criteria for rheumatoid arthritis and has negative Lyme serologies.

Question 49

149. A 50-year-old female presents to your office for evaluation of a 2-month history of dyspnea on exertion and a nonproductive cough. She has a previous history of hypertension, overactive bladder, gastroesophageal reflux disease, and recurrent urinary tract infections. Vital signs are unremarkable and she has an oxygen saturation of 94%. She has inspiratory crackles in the posterior lung bases that do not clear with coughing. Office spirometry shows that the FVC is only 80% of normal, but the FEV1/FVC ratio is 0.85.

Which one of the patient’s current medications is most likely to be the cause of her problem?

A) Lisinopril (Prinivil, Zestril)
B) Conjugated estrogens (Premarin)
C) Omeprazole (Prilosec)
D) Solifenacin (Vesicare)
E) Nitrofurantoin (Macrodantin)

Answer 49

ANSWER: E

Interstitial lung disease is a consideration in patients with chronic dyspnea. It is often accompanied by a chronic nonproductive cough. Office spirometry is useful in detecting whether the problem is restrictive or obstructive. If the FVC is normal or decreased and the FEV1 is decreased, an FEV1/FVC ratio less than 0.7 means there is an obstructive ventilatory impairment. If the FVC is decreased and the FEV1 is normal or decreased the ratio would be greater than 0.7, indicating a restrictive impairment.

Diffuse parenchymal lung disease may be idiopathic, but there are a number of identified causes such as environmental or occupational exposures. Many collagen vascular diseases and medications used to treat them can induce interstitial lung disease. Common offenders also include amiodarone and nitrofurantoin, which can induce a pneumonitis. In this patient, lisinopril might explain the cough but not the dyspnea, crackles, or abnormal spirometry.

Question 50

150. A 25-year-old gravida 1 para 0 sees you for a routine prenatal visit. This is a planned pregnancy and you calculate her to be at approximately 14 weeks gestation based on the dates of her last menstrual period. She is healthy without any medical problems, takes no medication, and does not use tobacco products. She is adopted and does not know her family history. She feels well today and has no specific concerns. Her vital signs are stable, her weight is normal, and fetal heart tones are auscultated with a Doppler stethoscope at approximately 140 beats/min.

Which one of the following should be completed today?

A) A 1-hour glucose tolerance test
B) A group B Streptococcus screen
C) A TSH level
D) A urinalysis and urine culture
E) Evaluation for bacterial vaginosis

Answer 50

ANSWER: D

All pregnant women should be screened for asymptomatic bacteriuria between 11 and 16 weeks gestation and should be appropriately treated if the urine culture is positive. Asymptomatic bacteriuria is a known contributor to recurrent urinary tract infections, pyelonephritis, and preterm labor. TSH levels should be checked in patients with a history of thyroid disease or symptoms of disease, but universal testing is not recommended. Although treatment of bacterial vaginosis decreases the risk of low birth weight and premature rupture of membranes, universal screening is not recommended. This patient should be screened for both group B Streptococcus (GBS) and diabetes mellitus, but not at this point in her pregnancy. GBS screening should be done between 35 and 37 weeks gestation, and diabetes screening should be performed with a 50-g glucose load between 24 and 28 weeks gestation.