Questions 101-150

Question 1

101. When evaluating a patient with menorrhagia, which one of the following laboratory findings would be most consistent with von Willebrand disease?

A) An isolated prolonged prothrombin time

B) An isolated prolonged partial thromboplastin time

C) A low serum iron level

D) A low platelet count

E) A low fibrinogen level

Answer 1

ANSWER: B

Von Willebrand disease (vWD) is a common coagulation disorder generally due to a hereditary reduction in the quality or quantity of a protein complex required for platelet adhesion, known as von Willebrand factor (vWF). The extent of deficiency varies greatly, resulting in vWD subtypes ranging from asymptomatic to serious. A common problem associated with vWD is menorrhagia, and the diagnosis should always be entertained in women who experience excessive menstrual blood loss. Although tests measuring vWF are easily obtained, interpretation of the results can be challenging since vWF levels can be affected by blood type, inflammation, infection, trauma, and emotional stress. Confirmation of vWD often requires the expertise of a hematologist. Although the results for all laboratory tests listed can fall within their reference ranges in a patient with vWD, the finding most suggestive of this diagnosis is an isolated prolonged partial thromboplastin time.

Question 2

102. A 68-year-old female with well-controlled hypertension presents for a routine evaluation. The physical examination is significant for a BMI of 35.4 kg/m2. A comprehensive metabolic panel prior to the visit revealed the following:

Serum calcium . . . . . . . 9.2 mg/dL (N 8.5–10.2)

Albumin . . . . . . . . . . . . 4.0 g/dL (N 3.5–5.4)

Creatinine . . . . . . . . . . 0.6 mg/dL (N 0.6–1.1)

25-hydroxyvitamin D . . . . . 9 ng/mL (N >20)

Alkaline phosphatase . . . . 151 U/L (N 47–147)

Which one of the following is true, based on these findings?

A) She has primary hyperparathyroidism

B) She should take 1,25-dihydroxyvitamin D (calcitriol)

C) She should take vitamin D supplements

D) She should take calcium supplements

E) She has rickets

Answer 2

ANSWER: C

This patient has slight elevations of her alkaline phosphatase along with a deficiency of vitamin D and normal calcium levels. This constellation of findings is most consistent with secondary hyperparathyroidism related to vitamin D deficiency. Vitamin D storage is best reflected by the serum 25-hydroxyvitamin D level. While there is some disagreement regarding normal levels, a level <10 ng/mL is clearly deficient. This would put the patient at risk for osteomalacia but not rickets, which is a clinical diagnosis based on the effects of insufficient bone mineralization secondary to low vitamin D activity before the closure of growth plates. Supplementation with activated vitamin D (calcitriol) is generally only necessary in patients with renal failure or other conditions associated with inadequate activation of the storage forms of vitamin D. Supplementation with vitamin D should decrease PTH activity and thus bone turnover in this patient, which would likely normalize the alkaline phosphatase.

Question 3

103. A 16-year-old male presents with acute testicular pain that has been constant for the last 2 hours. He has nausea and vomiting that started about the same time. On examination you note that the left testis is situated higher in the scrotum than the right testis. The left hemiscrotum is erythematous, slightly warm, and indurated. The patient is currently afebrile.

Which one of the following is the most appropriate management at this time?

A) NSAIDs and scrotal support

B) Doxycycline plus intravenous ceftriaxone (Rocephin)

C) Rotating the testicle from lateral to medial (like closing a book)

D) Immediate urologic consultation for surgical exploration

Answer 3

ANSWER: D

This patient presents with a classic description of torsion of the left testicle, and not an infectious process requiring antibiotics. Surgical exploration is the immediate priority, with ischemic damage starting between 4 and 8 hours after onset. Attempts at manual detorsion should not delay surgical exploration and often require analgesia or sedation. If surgery is not an immediate option, manual detorsion is performed by rotating the testicle from medial to lateral, like opening a book. Doppler ultrasonography is the imaging modality of choice, but it delays surgical exploration and should be used only when the history and physical examination make the diagnosis questionable.

Question 4

104. U.S. federal labor law requires companies with >50 employees to provide which one of the following benefits for employees who are nursing mothers?

A) Extended Family and Medical Leave Act protection for a total of 6 months

B) Reasonable unpaid break time to express milk

C) Extended bathroom access time to express milk

D) A refrigerator dedicated to storage of expressed milk

Answer 4

ANSWER: B

The Patient Protection and Affordable Care Act amended the Federal Labor Standards Act of 1938 to require employers of >50 employees to provide nursing mothers reasonable break time to express milk for up to 1 year following the birth of their children. The employer is not required to compensate nursing mothers during the breaks and is not required to provide refrigerated storage for the expressed milk. The law also requires that the employer provide a place to express milk, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public.

Question 5

105. A 30-year-old ICU nurse has been caring for several patients infected with Clostridium difficile. She is asymptomatic but is worried that she may also be infected.

Which one of the following is the most appropriate recommendation for this nurse?

A) No testing and no treatment

B) Testing for C. difficile toxin

C) Testing for C. difficile antigen

D) Empiric treatment with metronidazole

E) Probiotics

Answer 5

ANSWER: A

Laboratory testing for Clostridium difficile should be done only on symptomatic patients. A diagnosis of C. difficile infection requires the presence of diarrhea (greater than or equal to 3 unformed stools in a 24-hour period) or radiographic evidence of ileus and toxic megacolon. In addition, the diagnosis requires a positive stool test for toxigenic C. difficile or its toxins, or colonoscopic or histopathologic findings showing pseudomembranous colitis. Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection. Test of cure is not recommended after C. difficile treatment. Probiotics may prevent antibiotic-associated diarrhea and may also reduce C. difficile diarrhea in children and adults younger than 65, but are not specifically recommended for preventing or treating C. difficile infection.

Question 6

106. A 36-year-old white male complains of episodic pain in the rectum over the past several years. The pain occurs every 3–6 weeks and is sharp, cramp-like, and severe. It lasts from 1 to 15 minutes. He has no other gastrointestinal complaints. A physical examination, including a digital rectal examination and anoscopy, is normal.

The most likely diagnosis is

A) fecal impaction

B) coccygodynia

C) anal fissure

D) proctalgia fugax

E) sacral nerve neuralgia

Answer 6

ANSWER: D

Symptoms consistent with proctalgia fugax occur in 13%–19% of the general population. These consist of episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination. All the other diagnoses listed would be evident from the physical examination, except for sacral nerve neuralgia, which would not be intermittent for years and the pain would not be transitory.

Question 7

107. A patient presents with a lesion on her forearm that first appeared 6 months ago. The lesion is shown on the page at left.

Which one of the following is the most likely diagnosis?

A) A cutaneous horn

B) Keratoacanthoma

C) Pyogenic granuloma

D) Seborrheic keratosis

E) Verruca vulgaris

Answer 7

ANSWER: A

This is a cutaneous horn, sometimes referred to as a hypertrophic actinic keratosis. It is a horn-like projection of keratin on a slightly raised base. These usually arise in areas subject to photoaging, including the forearms. The differential diagnosis often includes keratoacanthoma, which occurs most commonly on the face, grows very rapidly, and often is more nodular with a central pit. Pyogenic granulomas are fleshy appearing, and a wart or seborrheic keratosis would both look slightly different but would rarely become so large in just months. Cutaneous horns should be removed due to the possible development of in situ or invasive squamous cell carcinoma (SOR A).

Question 8

108. An 82-year-old female sees you for follow-up 6 weeks after fracturing her hip when she tripped on a hose and fell in her garden. She underwent surgical repair and acute inpatient rehabilitation. She has successfully recovered, is participating in an outpatient physical therapy program, and is now walking with a cane. She reports gastroesophageal reflux controlled with over-the-counter ranitidine (Zantac) as her only chronic medical condition. She recalls having been told that she had only mild bone loss on a bone density test last year. She has been taking a calcium and vitamin D supplement since then. She is concerned about sustaining another fracture.

Which one of the following should you do now to reduce her risk of recurrent fracture?

A) Prescribe alendronate, 70 mg weekly

B) Prescribe raloxifene (Evista), 60 mg daily

C) Prescribe teriparatide (Forteo), 20 :g daily

D) Discontinue ranitidine

Answer 8

ANSWER: A

Undertreatment of osteoporosis occurs frequently after a hip fracture. Unless a contraindication exists, patients should be treated with a bisphosphonate after a hip fracture, regardless of bone mineral density (SOR C). Controlled gastroesophageal reflux is not a contraindication to bisphosphonate therapy. Proton pump inhibitor use, but not H2-blocker use, is also a modifiable risk factor for osteoporosis. Raloxifene and teriparatide are not bisphosphonates or first-line therapy for prevention of recurrent hip fracture. Raloxifene has not been shown to reduce the rate of nonvertebral fractures.

Question 9

109. A 28-year-old male hospital employee sees you for a mandatory workplace influenza vaccination. He has never received influenza vaccine and is apprehensive about it because of a history of egg allergy. He says he developed hives on his trunk after eating scrambled eggs on several occasions when he was in high school and since then has avoided eating cooked eggs, but not all egg-containing food items. He has had no cases of hives since making this change in his diet.

According to the Advisory Committee on Immunization Practices, which one of the following would be the most appropriate action?

A) Administer live attenuated influenza vaccine

B) Administer an intradermal test dose of inactivated influenza vaccine and if the patient

does not develop hives administer a full dose of inactivated influenza vaccine 2 or

more hours later

C) Administer inactivated influenza vaccine

D) Administer oral diphenhydramine (Benadryl) 1 hour before inactivated influenza

vaccine

E) Do not vaccinate for influenza

Answer 9

ANSWER: C

All currently available influenza vaccines, with the exceptions of recombinant and cell-culture–based inactivated influenza vaccines, are prepared using embryonated egg culture and can potentially provoke allergic and anaphylactic reactions. Large studies of influenza vaccine administration to egg-allergic patients have resulted in a few mild reactions but no documented occurrences of anaphylaxis, although there are reports of serious reactions. The data collected from these studies provided sufficient confidence for the Advisory Committee on Immunization Practices to develop guidelines for administration of influenza vaccine in individuals with egg allergy.

For those who report that they can eat lightly cooked scrambled eggs, vaccination can proceed without precaution or observation. Those who have experienced only hives can also receive any influenza vaccine appropriate for their age and health status. In the past the CDC recommended observing these patients for 30 minutes afterward, but this recommendation was changed in 2016. People who have experienced symptoms such as hypotension, wheezing, nausea, or vomiting, or reactions requiring emergency attention or epinephrine after eating eggs or egg-containing foods can also receive any influenza vaccine appropriate for their age and health status and also do not need to be observed. However, the vaccine should be administered by a provider who can recognize and manage severe allergic reactions. Withholding vaccination because of egg-induced hives is not recommended.

Question 10

110. A 65-year-old female presents to your office with a 1-day history of severe low back pain that began acutely after she moved some furniture. She is in good health otherwise, has no previous history of back problems, and has not had a fever. She is having pain in the bilateral low back region, bilateral buttock region, and upper thigh. She has not been able to void since the pain started.

Which one of the following diagnoses should be considered in this patient?

A) Acute lumbar strain

B) Lumbar muscle spasm

C) Mechanical low back pain

D) Large midline disc herniation

E) Sciatica

Answer 10

ANSWER: D

Patients with low back pain should be evaluated for the presence of neurologic deficits. Urinary retention is the most frequent finding in cauda equina syndrome (90% sensitivity), caused by compression of nerve roots from the lower cord segments. This is usually due to a massive, centrally herniated disc, which can result in urinary retention or incontinence from loss of sphincter function, bilateral motor weakness of the lower extremities, and saddle anesthesia. This problem should be addressed urgently. In patients without urinary retention, the probability of the cauda equina syndrome is approximately 1 in 10,000.

Question 11

111. A 35-year-old male has a 5-day history of cough and has had one episode of blood-streaked sputum. He is otherwise healthy and has never smoked. He is afebrile and has normal findings on examination. A chest radiograph is normal.

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

A) Observation

B) CT of the chest

C) Pulmonary function studies

D) Bronchoscopy

E) A trial of antibiotics

Answer 11

ANSWER: A

This patient has a low risk of cancer, based upon his age and medical history, and no suggestion of a lower respiratory infection. With this presentation, a chest radiograph is recommended as the first step in the workup, and if findings are normal he should be observed for 2–6 weeks (SOR A). If there is a recurrence of hemoptysis further evaluation is indicated, which should include an interval history, a repeat examination, and CT of the chest.

Question 12

112. The Timed Up and Go test is used to evaluate geriatric patients for which one of the following?

A) Risk of falling

B) Effects of peripheral neuropathy

C) Kinetic tremor

D) Neurocardiogenic syncope

E) Central causes of vertigo

Answer 12

ANSWER: A

The Timed Up and Go test is the most frequently recommended screening test for mobility. It takes less than a minute to perform and involves asking the patient to rise from a chair, walk 10 feet, turn, return to the chair, and sit down. Any unsafe or ineffective movement with this test suggests balance or gait impairment and an increased risk of falling. If the test is abnormal, referral to physical therapy for complete evaluation and assessment should be considered. Other interventions should also be considered, such as a medication review for factors related to the risk of falling.

Question 13

113. Which one of the following can falsely elevate hemoglobin A1c?

A) Antiretroviral treatment for HIV infection

B) Chronic liver disease

C) Hemolytic anemia

D) Iron deficiency anemia

E) Pregnancy

Answer 13

ANSWER: D

Hemoglobin A1c (HbA1c) testing measures the percentage of glycosylation of the HbA1c chain, and correlates to average blood glucose levels over the previous 2–3 months. However, hypertriglyceridemia, hyperbilirubinemia, iron deficiency anemia, splenectomy, renal failure, and aplastic anemia can all falsely elevate HbA1c levels. The other factors listed can all falsely lower HbA1c levels, as can vitamins C and E, and acute blood loss.

Question 14

114. A 62-year-old male presents for a routine health maintenance visit. He has osteoarthritis and controlled hypertension, but is otherwise healthy. He does not smoke and his alcohol consumption consists of 2–3 drinks a week. His medications include lisinopril (Prinivil, Zestril) and acetaminophen. His wife just had a DXA scan and he asks if he should also be screened for osteoporosis.

For this patient, the U.S. Preventive Services Task Force

A) makes no recommendation for or against DXA

B) recommends DXA at this visit

C) recommends DXA at age 65

D) recommends DXA at age 70

Answer 14

ANSWER: A

The U.S. Preventive Services Task Force has a grade I recommendation for routine screening for osteoporosis in men, meaning there is insufficient evidence to recommend for or against routine screening. Men older than 50 with a minimal-trauma fracture and men with conditions associated with bone loss could be considered for screening. The National Osteoporosis Foundation recommends screening all men age 70 and above for osteoporosis.

Question 15

115. A healthy 45-year-old female presents to your office to establish care. She has no significant past medical history and is up to date on her immunizations. She has no chest pain, shortness of breath, or exercise intolerance. She does not take any prescribed medications but does take a low-dose aspirin daily for prevention of coronary artery disease. She does not smoke and she exercises by walking for 45 minutes 4–5 times a week. She is concerned because her mother had a fatal cardiac arrest at age 63 and her father was recently diagnosed with end-stage renal disease at age 75.

On examination the patient’s blood pressure is 120/75 mm Hg and her BMI is 22.1 kg/m2. Her cardiovascular and pulmonary examinations are unremarkable.

Which one of the following would you recommend to this patient?

A) A resting EKG

B) An exercise EKG

C) Discontinuing aspirin therapy

D) Increasing aspirin to 325 mg daily

E) A basic metabolic panel to screen for chronic kidney disease

Answer 15

ANSWER: C

Although this patient has a family history of coronary artery disease, she is under the age of 50 and thus aspirin therapy as primary prevention is not recommended and may increase the risk for gastrointestinal bleeding, regardless of the dosage. The U.S. Preventive Services Task Force found insufficient evidence for screening for chronic kidney disease even in individuals with a positive family history. Neither a resting nor exercise EKG is recommended for asymptomatic individuals to detect or prevent coronary artery disease.

Question 16

116. A 19-year-old female comes to your office with lower abdominal pain that has increased over the past 2 days. Her last menstrual period was 4 days ago. She has been nauseated and has been vomiting. The physical examination reveals a temperature of 38.0°C (100.4°F) and lower abdominal tenderness with mild rebound. She has a mucopurulent cervical discharge, tenderness with cervical motion, a normal-size uterus, and left adnexal fullness. A serum hCG is negative.

Which one of the following is the most appropriate management?

A) Ceftriaxone (Rocephin), 250 mg intramuscularly

B) Hospitalization for intravenous antibiotics

C) Surgical consultation for immediate appendectomy

D) Laparoscopy

Answer 16

ANSWER: B

This patient has signs and symptoms of acute salpingitis. This condition is commonly confused with appendicitis, ectopic pregnancy, and other pelvic pathology. In this case the findings are clearly pelvic in origin. Endocervical inflammation with a mucopurulent discharge is noted in almost every case of acute salpingitis. The acute nature of this presentation and the adnexal fullness suggest gonorrhea rather than chlamydial infection, although the antibiotic regimen should probably cover Chlamydia as well. Admission to the hospital and treatment with parenteral antibiotics is most appropriate in this case because of the severity of the illness, the desire to maintain reproductive function, and the adnexal fullness.

Routine laparoscopy for every case of salpingitis is considered too costly and dangerous. The choice of intravenous antibiotic may vary, but usually consists of a $-lactam antibiotic (cefoxitin or ceftriaxone) plus doxycycline, or gentamicin and clindamycin. Ceftriaxone, 250 mg intramuscularly, is appropriate for uncomplicated gonococcal infection.

Question 17

117. An 18-year-old female presents with an intensely pruritic papular eruption in the vicinity of her waist that began shortly after she spent a day walking in the woods with her boyfriend. Her rash consists of multiple small excoriated papules and welts along her beltline. She says she was wearing jeans and sandals.

Which one of the following is the most likely cause of her rash?

A) Bedbugs

B) Chiggers

C) Fleas

D) Deer ticks

E) Mosquitoes

Answer 17

ANSWER: B

Mite larvae called chiggers cause itchy bites. The chiggers crawl on skin until they reach constrictive clothing like belts or socks and then bite there. Flea bites are usually at ankle height because fleas jump. Mosquito bites would be diffuse on exposed areas. Bedbugs tend to bite on the upper body and neck. This is not a typical presentation for Lyme disease, which has an initial rash that is localized and not pruritic (SOR C).

Question 18

118. A homeless 47-year-old male visits the local health department and asks to be screened for tuberculosis. He is not aware of any definite exposure to tuberculosis and is asymptomatic. The nurse asks whether the patient should be screened with a tuberculin skin test or an interferon-gamma release assay (IGRA, QuantiFERON-TB Gold).

Which one of the following would be an advantage of IGRA in this patient?

A) It helps to distinguish latent tuberculosis from active tuberculosis

B) The patient’s blood can be stored for up to 36 hours if needed, to allow transport to

a qualified laboratory to run the test

C) A follow-up visit is not required to obtain results

D) The IGRA will be positive within 2 weeks of exposure to an individual with active

tuberculosis

E) The IGRA can simultaneously detect resistance to rifampin (Rifadin)

Answer 18

ANSWER: C

It is important for health care professionals to be familiar with the various options for screening and testing for latent or active tuberculosis. In the United States the tuberculin skin test (TST) is the traditional screening test for tuberculosis. The interferon-gamma release assay (IGRA) is a blood test that can also aid in the diagnosis of latent tuberculosis. Advantages of IGRA include the ability to get results without follow-up and the fact that prior bacille Calmette-Guérin (BCG) vaccination does not cause a false-positive test. With TST testing, prior BCG vaccination, especially if given within the last 10 years, can result in a false-positive test.

As with the TST, conversion (i.e., a positive test) of IGRA may not occur within the first 8–12 weeks following exposure to an individual with active tuberculosis. In addition, neither the TST nor the IGRA can distinguish between latent and active tuberculosis.

There are two IGRA tests available for use in the United States and both tests need to be processed within 8–30 hours, depending on the specific test used. Although there is now a test available that can detect Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin, it is a separate test called the Xpert MTB/RIF assay.

Question 19

119. During a routine health maintenance visit, a 24-year-old female admits that she is not feeling well due to being overwhelmed with stress. She feels she has always worried more than most people, but recent troubles at home and at work have made things much worse. She says she is irritable with people around her, has trouble focusing at work, and feels fatigued late in the day. Despite her fatigue, she has difficulty falling asleep at night. The patient denies anhedonia, suicidal thoughts, or a persistently depressed mood. She limits her caffeine intake, does not smoke or drink alcohol, and is not using any illicit drugs.

In addition to psychotherapy, which one of the following medications is recommended for this patient?

A) Alprazolam extended release (Xanax XR)

B) Clonazepam (Klonopin)

C) Gabapentin (Neurontin)

D) Quetiapine (Seroquel)

E) Sertraline (Zoloft)

Answer 19

ANSWER: E

This patient’s symptoms are consistent with the DSM-5 criteria for generalized anxiety disorder. First-line treatments for this condition are SSRIs, SNRIs, and tricyclic antidepressants. Quetiapine and gabapentin are considered second-line medications for anxiety if control cannot be obtained with more traditional agents. Benzodiazepines such as alprazolam and clonazepam are sometimes necessary for short-term control of anxiety symptoms but are generally discouraged due to sedating side effects, the potential for abuse or diversion, and gradual tolerance.

Question 20

120. A 35-year-old female who is approximately 90 kg (200 lb) above her ideal body weight comes to you for weight loss recommendations. Her mother, who had a BMI of 37.0 kg/m2, recently suffered a fatal heart attack and the patient would like to avoid this. She has no other medical problems except for well-controlled hypertension. Her medication list includes lisinopril (Prinivil, Zestril), 20 mg daily, and an etonogestrel subdermal (Nexplanon) implant for contraception.

Which one of the following strategies would be most effective for reducing her cardiac risk?

A) A low-fat diet

B) A high-protein diet

C) Orlistat (Xenical), 120 mg 3 times daily with meals

D) Phentermine (Suprenza), 30 mg daily

E) Referral for bariatric surgery

Answer 20

ANSWER: E

Bariatric surgery has been shown to reduce all-cause mortality in patients with morbid obesity, mostly from reduced myocardial infarctions. Although orlistat and phentermine, along with other weight loss drugs, have been shown to be associated with moderate weight loss, there is no evidence that any of these agents reduce morbidity or mortality. A low-carbohydrate diet has been associated with increased HDL-cholesterol levels and decreased triglyceride levels when compared to a low-fat diet, which may indicate a reduction in cardiac risk. No particular diet strategy has been shown to be more effective for weight loss than any other strategy.

Question 21

121. Which one of the following is most likely to improve outcomes in schizophrenia?

A) Combining antipsychotic medication with psychosocial treatment
B) Prescribing two second-generation antipsychotic medications together in small dosages
C) Initial treatment in the outpatient rather than inpatient setting
D) Using only one first-generation, or typical, antipsychotic medication combined with

an antidepressant medication

Answer 21

ANSWER: A

The combination of antipsychotic medication and psychosocial treatments, including cognitive-behavioral therapy, family therapy, and social skills training, is associated with the best outcomes in patients with schizophrenia (SOR B). Antipsychotic medications should not be combined. Hospitalization, especially for the first episode of schizophrenia, is also recommended for the best outcome (SOR C). Antidepressant medication will treat depression associated with schizophrenia but will not necessarily improve the symptoms of schizophrenia.

Question 22

122. The preferred method for diagnosing psychogenic nonepileptic seizures (pseudoseizures) is

A) inducing seizures by suggestion

B) postictal prolactin levels

C) EEG monitoring

D) video-electroencephalography (vEEG) monitoring

E) MRI of the brain

Answer 22

ANSWER: D

Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.

Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2, and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.

MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.

Question 23

123. A 27-year-old male calls and reports that he has an elevated temperature of 101.5°F (38.6°C). He underwent a surgical splenectomy following an automobile accident 5 months ago. He has no allergies and is otherwise healthy.

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

A) Temperature monitoring with follow-up if it exceeds 39.0°C (102.2°F)

B) Antipyretics to maintain a temperature <39.0°C (102.2°F)

C) Oral antibiotics, with follow-up if the elevated temperature persists

D) Urgent parenteral antibiotic therapy

Answer 23

ANSWER: D

In an asplenic patient, fever might be an initial manifestation of a catastrophic infection and must be treated immediately with a parenteral antibiotic agent. Quick administration of antibiotics might prevent sepsis. Mortality can be as high as 50% among patients with postsplenectomy sepsis. Intravenous or intramuscular ceftriaxone is recommended for patients who have normal laboratory test results and who do not appear ill. If the patient lives more than 2 hours from a medical facility that can administer parenteral antibiotic therapy, oral antibiotics should be given.

Question 24

124. A 4-year-old female is brought to your office with a 6-day history of fever to a maximum temperature of 103.2°F. She was seen 2 days ago and treated empirically for streptococcal pharyngitis because she has a close contact who had a streptococcal infection. She has a mild cough, rhinorrhea, and a sore throat. On examination she is febrile and fussy. She has a maculopapular rash over her trunk, bilateral eye injection, shotty bilateral lymphadenopathy, erythematous lips, a strawberry tongue, and pharyngeal erythema. Her examination is otherwise unremarkable.

Laboratory Studies

WBCs . . . . . . . . . . 16,200/mm3 (N 4500–11,000)

Hemoglobin . . . . . 10.9 g/dL (N 14.0–17.5)

Hamatocrit . . . . . . . 32.3% (N 41.0–50.0)

Platelets . . . . . . . . . 495,000/mm3 (N 150,000–350,000)

AST (SGOT) . . . . . . . 78 U/L (N 10–30)

ALT (SGPT) . . . . . . . . 66 U/L (N 10–40)

Alkaline phosphate . . . 165 U/L (N 30–120)

Albumin . . . . . . . . . . . . . 2.8 g/dL (N 3.5–5.5)

C-reactive protein . . . . . 12.9 mg/L (N 0.08–3.1)

Urine dipstick . . . . . . . . normal

A full urinalysis with a microscopic examination reveals 20–25 WBCs/hpf, 0–4 RBCs/hpf, 0–4 bacteria/hpf, and 0–10 epithelial cells/hpf. Additional laboratory tests are ordered, with the following results:

Sodium . . . . . . . . . 132mEq/L(N136–142)

Potassium . . . . . . . 4.0 mEq/L (N 3.5–5.0)

Chloride . . . . . . . . . 104 mEq/L (N 96–106)

Bicarbonate . . . . . . 22 mEq/L (N 21–28)

BUN . . . . . . . . . . . . . 9 mg/dL (N 8–23)

Creatinine . . . . . . . . 0.6 mg/dL (N 0.6–1.2)

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

A) Supportive measures only

B) Ceftriaxone (Rocephin)

C) Intramuscular penicillin

D) Aspirin and intravenous immunoglobulin

E) Prednisone

Answer 24

ANSWER: D

This child has atypical Kawasaki disease. The diagnostic criteria for classic Kawasaki disease is fever for at least 5 days and at least four of five principal clinical features. The clinical features include:

• Changes of the oral cavity and lips: cracked erythematous lips, strawberry tongue
• Polymorphous rash: maculopapular, erythema multiforme–like or scarlitiniform rash, involving the extremities, trunk, and perineal regions
• Bilateral nonpurulent conjunctivitis
• Changes in the extremities (erythema of the hands and feet, desquamation of the hands and toes in weeks 2 and 3)
• Cervical lymphadenopathy (>1.5 cm in diameter and generally unilateral)

Some patients do not meet the classic criteria but are labeled as having incomplete or atypical disease. While Kawasaki disease is generally a clinical diagnosis and there are no specific diagnostic tests, supplemental laboratory testing can help in the diagnosis of these atypical cases. The supplemental laboratory criteria include:

• Anemia
• Cerebrospinal fluid pleocytosis
• Elevated C-reactive protein and erythrocyte sedimentation rate
• Elevated liver enzymes
• Hypoalbuminemia
• Hyponatremia
• Platelets >450,000/mm3 after 5 weeks
• Sterile pyuria
• WBCs greater than or equal to 15,000/mm3

Patients who have a fever for 5 days or more and two or three of the classic criteria should be treated for atypical Kawasaki’s disease if the C-reactive protein level is elevated and they have three or more associated laboratory abnormalities. The treatment of choice is IVIG and high-dose aspirin to reduce the risk of coronary abnormalities. Corticosteroids have been used as an adjunct in refractory cases or with IVIG, but not alone.

Question 25

125. A 22-year-old male presents to the emergency department with a debilitating headache that occurs 3–4 times per month. Over the past 6 hours he has developed a throbbing, sharp pain over the right side of his head, with significant nausea and vomiting. Previous headaches have not lasted more than 1 day. He did not get any relief with ibuprofen, 600 mg taken 2 hours ago.

Which one of the following is the most appropriate next step in the management of this patient’s headache?

A) Oral acetaminophen

B) Oral butalbital/aspirin/caffeine (Fiorinal)

C) Intravenous hydromorphone (Dilaudid)

D) Intravenous metoclopramide

E) Supplemental oxygen

Answer 25

ANSWER: D

This patient has an acute migraine headache that did not respond to NSAIDs. Metoclopramide is an effective treatment for migraine beyond its antiemetic benefit (SOR B) and intravenous administration may be helpful for the patient unable to tolerate oral medications. Acetaminophen has not been proven to be effective for migraine. Opiates and barbiturate-containing medications should only be used for patients who have failed multiple other treatments (SOR C). Supplemental oxygen has shown efficacy in the treatment of cluster headaches. Triptan medications would be another evidence-based choice for abortive therapy of migraine.

Question 26

126. A 25-year-old female presents to your office to discuss abnormal menstrual periods. She says that her cycles have always been irregular but she has not had any bleeding in 3 months. She also says she has gained 20 lb over the past 6 months. She is not taking any medications. You perform an examination and order laboratory tests. Her blood pressure is 110/72 mm Hg, heart rate 84 beats/min, respiratory rate 12/min, and weight 78.0 kg (172 lb) with a BMI of 29.5 kg/m2. She is noted to have moderate cystic acne. Her examination is otherwise unremarkable. A serum hCG measurement is negative and TSH, FSH, and LH levels are normal. Follow-up laboratory evaluation is significant for a total testosterone level 3 times the upper limit of normal and a normal 17-hydroxyprogesterone level.

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

A) An estradiol level

B) A dexamethasone suppression test

C) Karyotyping

D) CT of the abdomen and pelvis

E) MRI of the brain

Answer 26

ANSWER: D

This patient presents with mild symptoms of hyperandrogenism. Her initial laboratory results rule out pregnancy, thyroid disorders, and primary ovarian failure. The follow-up laboratory evaluation indicates significant hyperandrogenism. The rapid onset and high testosterone level suggest an ovarian or adrenal tumor that should be evaluated by abdominal/pelvic imaging.

MRI of the brain is not helpful in evaluating hyperandrogenism. It would be appropriate in evaluating hypothalamic and pituitary causes of secondary amenorrhea such as the female athlete triad or other causes of stress and malnutrition that are associated with weight loss. A karyotype would be helpful in identifying the cause of primary amenorrhea. An estradiol level is not helpful in evaluating hyperandrogenism. A dexamethasone suppression test aids in the diagnosis of Cushing syndrome, which generally does not cause amenorrhea and is usually associated with stigmata of hypercortisolism, which this patient does not have.

Question 27

127. Which one of the following is the most prevalent form of elder abuse?

A) Financial exploitation

B) Verbal abuse

C) Physical abuse

D) Sexual abuse

Answer 27

ANSWER: A

Recent studies suggest that financial exploitation is emerging as the most prevalent form of elder abuse. By the time cases are detected the older adult’s financial resources have often been drastically reduced, so early detection and intervention are critical. Financial exploitation of older adults, which was explored only minimally in previous studies, has recently been identified as a virtual epidemic and is a problem that may be detected or suspected by an alert physician.

Question 28

128. A 45-year-old female complains of debilitating fatigue that seemed to start suddenly 8 months ago, associated with symptoms of a viral infection. She denies symptoms of depression or substance abuse.

Which one of the following, if present, would indicate a diagnosis other than chronic fatigue syndrome (myalgic encephalomyelitis)?

A) Impairment of focus and concentration

B) Joint erythema

C) Orthostatic intolerance

D) Post-exertional malaise

E) Tender lymph nodes

Answer 28

ANSWER: B

The diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is made by determining that a patient’s symptoms are consistent with a standard definition of this disorder and by ruling out the presence of other systemic diseases that can result in similar symptoms. Currently suggested criteria for ME/CFS require at least 6 months of pathologic fatigue, along with a combination of other symptoms including post-exertional fatigue, impaired focus/concentration, orthostatic intolerance, and unrefreshing sleep. Other symptoms frequently encountered in patients with this condition include headache, diffuse myalgias, tender lymph nodes, and gastrointestinal or genitourinary impairments. The diagnosis of ME/CFS should not be considered in patients with red flag symptoms of a potentially more severe condition, such as chest pain, focal neurologic deficits, joint erythema/swelling, enlarged lymph nodes, or shortness of breath.

Question 29

129. A previously healthy 6-month-old female is admitted to the hospital with bronchiolitis. Which one of the following would be an appropriate treatment for this patient?

A) Albuterol (Proventil, Ventolin)

B) Epinephrine

C) Nebulized hypertonic saline

D) Systemic corticosteroids

Answer 29

ANSWER: C

The American Academy of Pediatrics (AAP) recommends nebulized hypertonic saline for infants and children hospitalized with bronchiolitis (SOR B). They do not recommend nebulized hypertonic saline for infants in the emergency department with a diagnosis of bronchiolitis.

The AAP guideline also recommends that clinicians do not administer albuterol or epinephrine to infants and children with a diagnosis of bronchiolitis (SOR B). In addition, clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting (SOR A).

Question 30

130. A 41-year-old premenopausal female presents to your office with amenorrhea, headache, and abnormal vision. Visual field testing reveals bitemporal hemianopsia. You order laboratory tests and MRI of the brain. The MRI reveals a 15-mm mass in the pituitary gland.

Which one of the following laboratory results would suggest an ACTH-secreting adenoma?

A) Elevated LH and FSH

B) Elevated serum prolactin

C) Elevated serum insulin-like growth factor 1

D) Low free T4 with a normal TSH level

E) Elevated 24-hour urine free cortisol

Answer 30

ANSWER: E

Pituitary adenomas are the most common disorder of the pituitary gland and are responsible for 10%–15% of all intracranial masses. They present with symptoms of hormone secretion or a neurologic mass effect, or as an incidental finding on CT/MRI. Premenopausal women often experience amenorrhea, while the most common neurologic symptoms are headache and vision changes (classically bitemporal hemianopsia) due to compression of the optic chiasm.

Tumors secreting prolactin (lactotrophs) are the most common, comprising 40%–57% of all pituitary adenomas. Nonsecreting tumors make up 28%–37%, growth hormone–secreting adenomas (somatotrophs) 11%–13%, and ACTH-secreting adenomas (corticotrophs) 1%–2%. FSH-, LH-, and TSH-secreting tumors are rare. ACTH-secreting tumors result in an increase in circulating cortisol, and the diagnosis is confirmed by 24-hour urine cortisol, late-night salivary cortisol, or overnight dexamethasone suppression testing.

Gonadotrophs cause a resulting elevation of FSH and LH. Lactotrophs increase serum prolactin, and somatotrophs increase serum insulin-like growth factor. Thyrotrophs result in normal TSH with low free T4.

Question 31

131. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics support the advance provision of emergency contraception to sexually active women. Evidence shows that this practice

A) decreases pregnancy rates on a population level

B) decreases the time from unprotected sex to use of emergency contraception

C) decreases contraception use by the patient prior to sexual activity

D) increases rates of sexually transmitted infection

E) increases rates of unprotected intercourse

Answer 31

ANSWER: B

Multiple studies, including randomized, controlled trials, have compared standard access to emergency contraception (EC) with advance provision in which the patient is given a prescription for the EC and encouraged to have it filled in order to have it immediately available in case of unprotected intercourse. In multiple populations in the United States and Europe advance provision compared to standard access has been shown to increase the rate of use of EC and to reduce the interval between intercourse and use of EC.

However, no change has been shown for several outcomes when advance provision was compared to standard access to EC. These include rates of sexually transmitted infections, unprotected intercourse, use of routine contraceptives prior to sexual activity, and pregnancy within the population studied.

Question 32

132. You see a 90-year-old patient with elevated blood pressure. Which one of the following is an expected physiologic change in elderly patients?

A) Increased renal blood flow

B) Increased diastolic blood pressure

C) Decreased systolic blood pressure

D) Decreased peripheral resistance

E) Wider pulse pressure

Answer 32

ANSWER: E

Age-related physiologic differences such as wider pulse pressure should be a consideration when treating hypertension in the elderly. These patients also have lower cardiac output, higher peripheral resistance, lower intravascular volume, and lower renal blood flow compared with younger patients. Pulse pressure (the difference between systolic blood pressure and diastolic blood pressure) is a measure of the degree of age-related vascular stiffness and is a risk factor for coronary artery disease events.

With increasing age the strongest predictor of coronary artery disease gradually shifts from diastolic blood pressure to systolic blood pressure, and then to pulse pressure. Systolic blood pressure rises gradually throughout adult life, whereas diastolic blood pressure peaks and plateaus in late middle age, and declines slightly thereafter. Diastolic hypertension occurs in <10% of all patients with hypertension after age 70.

Question 33

133. At a routine health maintenance visit a 60-year-old male complains of urinary frequency. A review of systems reveals nocturia but no dysuria. He is otherwise healthy. He has smoked 1 pack of cigarettes per day since age 18 and has a history of benign prostatic hyperplasia (BPH). On examination his prostate is smooth and enlarged without nodules. A dipstick urinalysis shows 1+ blood but is otherwise negative. Urine microscopy reveals 7 RBCs/hpf and 2 WBCs/hpf.

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

A) Reassuring the patient that his BPH is causing microscopic hematuria

B) A repeat urinalysis with microscopy in 6 months

C) Urine cytology

D) BUN and creatinine levels, CT urography, and referral for cystoscopy

E) Empiric antibiotic treatment and a repeat urinalysis after completion of treatment

Answer 33

ANSWER: D

Asymptomatic microscopic hematuria is defined by the American Urological Association (AUA) as 3 RBCs/hpf in the absence of an obvious cause such as menstruation, infection, vigorous exercise, renal disease, trauma, a recent urologic procedure, or a viral illness. Urine microscopy is required to confirm hematuria found on a dipstick examination.

This patient has risk factors for urothelial cancer, including smoking, his age, and his sex. In a patient with no obvious cause for hematuria, the AUA does NOT recommend repeating the urinalysis or treating empirically with antibiotics, as this may delay the diagnosis of cancer. In addition, assuming that benign prostatic hyperplasia (BPH) is the cause for his hematuria is inadvisable; patients with BPH usually also have risk factors for malignancy. The recommended initial workup includes renal function testing, CT urography, and cystoscopy.

Question 34

134. A 32-year-old primigravida at 20 weeks gestation presents with a 5-day history of gradually worsening left calf pain and swelling. She was placed in a walking boot 3 weeks ago to immobilize a left foot fracture. She feels well otherwise, and she specifically denies any chest pain, cough, palpitations, dyspnea, fever, chills, easy bruising, or bleeding. Her examination is notable only for posterior tenderness and swelling of the left calf. A CBC, prothrombin time, and partial thromboplastin time are all normal. Duplex Doppler ultrasonography of the left leg is consistent with deep vein thrombosis.

Which one of the following do you recommend at this point?

A) Low molecular weight heparin (Lovenox)

B) Unfractionated heparin

C) Aspirin and clopidogrel (Plavix)

D) Rivaroxaban (Xarelto)

Answer 34

ANSWER: A

Moderate evidence of lower risk from randomized, controlled trials supports the use of low molecular weight heparin over unfractionated heparin for treatment of venous thromboembolism (VTE) in pregnancy. Aspirin is not a first-line treatment for VTE, as it crosses the placenta and has a weak association with miscarriage. Clopidogrel is not indicated for treatment of VTE. Rivaroxaban and other new non–vitamin K oral anticoagulants are not recommended because of the lack of data regarding their use in pregnancy. Warfarin crosses the placenta and is associated with fetal hemorrhage and loss.

Question 35

135. A 60-year-old male sees you for a follow-up visit for degenerative disc disease that has been causing mild to moderate pain for 6 months. He has had an extensive workup with no reversible or worrisome findings. He has been taking acetaminophen for the past 3 months but remains symptomatic. He asks about herbal supplements that may be beneficial, as he is reluctant to start NSAIDs or opioid therapy at the present time.

Which one of the following supplements has the most evidence of benefit for this problem?

A) S-adenosyl-L-methionine

B) “-Lipoic acid

C) B-vitamin supplementation

D) Gamma-linolenic acid (evening primrose oil)

E) Glucosamine/chondroitin

Answer 35

ANSWER: A

S-adenosyl-L-methionine is found in all human cells and assists in producing a wide range of compounds such as cartilage and neurotransmitters. It has been shown to be as effective as celecoxib in relieving joint pain, but may take up to 2 months to take effect. Glucosamine and chondroitin have not been shown to be effective. B-complex vitamins may have some benefit in diabetic and alcoholic neuropathy. a-Lipoic acid and gamma-linolenic acid have also been shown to improve symptoms of neuropathy.

Question 36

136. An 86-year-old female is in the emergency department with community-acquired pneumonia confirmed on a chest radiograph. Physical findings include a temperature of 38.4°C (101.1°F), a pulse rate of 101 beats/min, a blood pressure of 101/50 mm Hg, an oxygen saturation of 90% on room air, and a respiratory rate of 32/min. The patient is awake, alert, and oriented times three. The physical examination is otherwise unremarkable except for coarse breath sounds in the left lung base. Laboratory findings include a BUN level of 14 mg/dL (N 8–25), a serum creatinine level of 0.7 mg/dL (N 0.6–1.5), a blood glucose level of 144 mg/dL, and a WBC count of 15,000/mm3 (N 4300–10,800).

Which one of the following would be most appropriate?

A) Discharge to home and treatment with azithromycin (Zithromax)

B) Discharge to home and treatment with amoxicillin/clavulanate (Augmentin)

C) Discharge to home and treatment with amoxicillin/clavulanate plus azithromycin

D) Hospital admission and treatment with amoxicillin/clavulanate

E) Hospital admission and treatment with ceftriaxone (Rocephin) plus azithromycin

Answer 36

ANSWER: E

This patient requires hospitalization based on her CURB-65 score of 3 (age >65, diastolic blood pressure <60 mm Hg, respiratory rate >30/min, BUN <19 mg/dL, no confusion), which places her mortality risk at 14%. Although azithromycin has been associated with an increased risk of myocardial infarction in elderly patients hospitalized with community-acquired pneumonia, the combination of azithromycin with a B-lactam has been associated with decreased mortality in this population. Azithromycin alone is acceptable treatment in the outpatient setting, but not when the patient requires hospitalization. A macrolide plus a B-lactam antibiotic has been shown to have a lower 30-day mortality rate than a B-lactam alone. This combination also results in a greater proportion of hospitalized patients achieving clinical stability at 7 days (defined as stable vital signs and oxygen saturation >90% on room air) when compared with B-lactam therapy alone.

Question 37

137. A 55-year-old female who works at a local day care center presents with a severe cough. Her illness began 10 days ago with malaise, a low-grade fever, rhinorrhea, tearing, and a mild cough. Over the past 3 days the cough has become much more severe and she coughs to the point that vomiting is induced.

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

A) A Gram stain and culture of sputum

B) Serologic studies

C) Polymerase chain reaction testing

D) A chest radiograph

E) Office pre- and post-bronchodilator spirometry

Answer 37

ANSWER: C

Pertussis has been increasing in incidence. The initial presentation usually involves nonspecific symptoms including malaise, lacrimation, and rhinorrhea, which is referred to as the catarrhal stage. The following stage, known as the paroxysmal stage, is manifested by severe coughing that may lead to the characteristic high-pitched whooping sound when the patient tries to catch his or her breath. Coughing to the point of emesis is also characteristic of pertussis, and the cough can be severe enough to actually result in rib fractures. The cough may last several weeks before it begins to wane during the convalescent phase, which usually lasts 2–3 weeks.

Pertussis can be diagnosed clinically if there is a coughing illness of 2 weeks’ duration with one of the classic signs of pertussis (post-tussive emesis, respiratory whoop, or paroxysmal cough) and there is no other apparent cause. The CDC also recommends the use of both cultures and polymerase chain reaction testing to confirm the diagnosis. Culture is not the best choice, however, as it is often done improperly, and culture results may not be available for several days. Polymerase chain reaction has the advantage of providing results in 1–2 days. It has good specificity and the sensitivity is much higher than that of a culture; its sensitivity is highest during the first 2 weeks of symptoms.

Treatment with antibiotics usually does not improve clinical symptoms, although it does decrease transmission. The CDC continues to recommend antibiotics for pertussis. Either azithromycin or clarithromycin is currently recommended.

Question 38

138. A mother presents to your office with her newborn son for a well child examination. She states that he is healthy and she has no current concerns.

Which one of the following is appropriate in the evaluation of this child for developmental dysplasia of the hip?

A) Limited hip abduction assessment

B) Barlow and Ortolani maneuvers

C) Measurement of leg length

D) Hip ultrasonography

Answer 38

ANSWER: B

Screening all infants for developmental dysplasia of the hip (DDH) has been a mainstay of care for many years. DDH is an abnormality of the acetabulum or femoral head and their congruence, presenting in infancy. The prevalence of instability on examination ranges from 1.6–28.5 per 1000 births. While many screening measures may be helpful in identifying DDH, none has been found to improve long-term clinical outcomes (SOR C). The U.S. Preventive Services Task Force found insufficient evidence to recommend routine screening to prevent poor outcomes. However, the American Academy of Pediatrics and the Pediatric Orthopedic Society of North America both recommend that the physical examination of all newborns include screening for DDH. There are no studies recommending the abandonment of this screening.

Ortolani (reducing a dislocated hip) and Barlow (dislocating an unstable hip) maneuvers are commonly performed early in infancy. By 2–3 months of age these are less useful and limited hip abduction assessment is more acceptable (SOR C). A clunk denotes a positive finding. Leg length measurement is useful in the evaluation of a child presenting with a limp but is not indicated in DDH.

More than 50% of patients with positive physical findings have been found to have normal hips within 1 month on follow-up ultrasonography. Universal ultrasonography resulted in a higher rate of detected DDH with subsequent treatment but did not reduce the need for surgery. Most of these abnormalities resolve spontaneously, and ultrasonography should not be used as a universal screening measure (SOR C). Plain films are inappropriate in infancy because the hip is primarily cartilaginous and the associated radiation exposure is unacceptable. It may be useful in older children to track progress after treatment.

Question 39

139. A 6-month-old male is brought to your office for a well child check. He has been healthy except for mild eczema that resolved with about 7 days of a medium-potency corticosteroid when he was 4 months old. He is the only child of a single mother. The mother has introduced some solid foods including eggs, cheese, and bananas, and her son has tolerated these without any trouble. However, she is concerned about introducing peanuts into her son’s diet. The mother’s brother suffers from a severe peanut allergy and was recently hospitalized after an accidental peanut ingestion. The mother herself does not eat nuts regularly because of her brother’s allergy but has had peanuts in small amounts without any trouble.

Which one of the following would you recommend regarding the introduction of foods containing peanuts and other nuts into this child’s diet?

A) Begin introducing these foods before 12 months of age

B) Start introducing these foods once he has reached 12 months of age

C) Wait until at least 5 years of age to introduce these foods

D) Introduce these foods only after allergy testing of the child is performed

E) Introduce these foods only after allergy testing of the mother is performed

Answer 39

ANSWER: A

The American Academy of Pediatrics now recommends early introduction of peanut-containing products for most children to reduce the incidence of peanut allergy. For children at high risk for an allergic reaction (e.g., those with severe eczema or a first degree relative with peanut allergy) allergy testing can be considered first. For this child, it should be recommended that the mother introduce peanut-containing products soon. There is no evidence that testing a parent prior to introducing the child to peanut-containing products is beneficial.

Question 40

140. Which one of the following is the strongest modifiable risk factor for abdominal aortic aneurysm?

A) Cigarette smoking

B) Excessive alcohol consumption

C) Hyperlipidemia

D) Hypertension

E) Type 2 diabetes mellitus

Answer 40

ANSWER: A

Smoking is the strongest modifiable risk factor for the development of an abdominal aortic aneurysm. Nonmodifiable risk factors include older age, male sex, and a family history of the problem. Other less prominent risk factors include hypertension, an elevated cholesterol level, obesity, and preexisting atherosclerotic occlusive disease.

Question 41

141. Which one of the following antidepressants can prolong the QT interval and should be avoided with concomitant QT-prolonging agents such as atypical antipsychotics?

A) Bupropion (Wellbutrin)

B) Citalopram (Celexa)

C) Mirtazapine (Remeron)

D) Sertraline (Zoloft)

E) Venlafaxine

Answer 41

ANSWER: B

Prolongation of the QT interval is an important medication adverse effect to consider. This is particularly true in patients taking multiple medications, because this effect can be additive and increases the risk of life-threatening arrhythmias such as torsades de pointes. Among commonly used antidepressants, citalopram and escitalopram may prolong the QT interval. Other SSRIs, as well as bupropion, venlafaxine, and mirtazapine, do not have this effect. Both tricyclic antidepressants and antipsychotics, commonly used in patients also taking SSRIs, can cause QT prolongation, making their combined use problematic.

Question 42

142. A healthy 50-year-old male consults you about preparations for a business trip to India. He will be traveling in rural areas at times and has read that he should have antibiotics with him in case of traveler’s diarrhea.

Which one of the following would be best for you to prescribe?

A) Trimethoprim/sulfamethoxazole (Bactrim)

B) Azithromycin (Zithromax)

C) Ciprofloxacin (Cipro)

D) Rifampin (Rifadin)

E) Doxycycline

Answer 42

ANSWER: B

Antibiotics shorten the course of moderate to severe traveler’s diarrhea. Azithromycin is recommended as self-treatment for moderate to severe traveler’s diarrhea in South and Southeast Asia, where Campylobacter species are a more common cause of the illness than anywhere else. Campylobacter species are resistant to fluoroquinolones. Ciprofloxacin is recommended for travel to South and Central America and to Africa. When symptoms are mild (1–3 loose bowel movements per 24 hours without limiting activities), traveler’s diarrhea can be treated with loperamide or bismuth subsalicylate. Rifampin and doxycycline are not commonly prescribed for presumptive treatment of traveler’s diarrhea.

Question 43

143. A 49-year-old female presents for recheck of an elevated serum calcium level. She complains of constipation and reports that her brother has hypercalcemia. The remainder of her review of systems, physical examination, and past medical, surgical, family, and social histories is unremarkable. She takes no medications.

Six months ago the patient’s calcium level was 10.4 mg/dL (N 8.5–10.2) and a serum parathyroid hormone (PTH) level was 58 pg/mL (N 9–77).

Repeat laboratory studies today reveal the following:

Calcium . . . . . . . 10.6 mg/dL

Serum PTH . . . . 66 pg/mL

24-hour urine calcium . . . 205 mg/24 hour (N 100–300)

Creatinine . . . . . 0.8 mg/dL (N 0.4–1.1), estimated GFR 62 mL/min/1.73 m2

Serum albumin . . . . . . . 4.7 g/dL (N 3.2–5.2)

25-hyroxyvitamin D . . . . 32 ng/mL (N 30–80)

Which one of the following is the most likely diagnosis?

A) Familial hypocalciuric hypercalcemia

B) Primary hyperparathyroidism

C) Secondary hyperparathyroidism

D) Secondary vitamin D deficiency

E) Renal insufficiency

Answer 43

ANSWER: B

Secondary hyperparathyroidism is most likely due to low vitamin D intake or low serum vitamin D, often in the setting of renal disease. However, the serum vitamin D level and estimated glomerular filtration rates are normal in this patient. This rules out secondary hyperparathyroidism, as well as vitamin D deficiency and renal insufficiency. Primary hyperparathyroidism is more likely in the presence of hypercalcemia and inappropriately normal or high parathyroid hormone levels. Familial hypocalciuric hypercalcemia is ruled out by a normal 24-hour urine calcium level.

Question 44

144. You are seated directly across from a patient who has very limited English proficiency. The interpreter you have arranged for enters the examination room and waits next to the door.

In order to best facilitate the interview, you request that the interpreter

A) maintain her current position by the door

B) sit next to or slightly behind your patient

C) sit next to you

D) stand directly behind you

E) switch places with you

Answer 44

ANSWER: B

In order to facilitate the most effective interview, the interpreter should be as inconspicuous as possible. This is best achieved by having the interpreter seated next to or slightly behind the patient.

Question 45

145. A 6-month-old uncircumcised male is brought to your clinic by his parents, who are concerned because his foreskin remains “tight” and cannot be retracted when they bathe him. He has never been treated for a urinary tract infection or balanitis and his parents report he has a good urine stream. On examination the skin at the preputial outlet appears healthy with no scarring.

Which one of the following is the most appropriate intervention?

A) Reassurance and continued routine foreskin hygiene

B) A short course of a topical corticosteroid twice daily to the foreskin

C) Prophylactic topical antibacterial ointment twice daily

D) Forceful retraction of the foreskin twice daily to reduce adhesions

E) Referral to a pediatric urologist for circumcision

Answer 45

ANSWER: A

Phimosis is the inability of the foreskin (prepuce) to retract over the glans and it can be physiologic or pathologic. Nonretractile foreskin is very common in young boys, and is seen in up to 10% of uncircumcised 3-year-old boys. This physiologic phimosis is part of normal development and over time the foreskin will become retractile due to intermittent erections and keratinization of the inner foreskin. Pathologic phimosis is due to distal scarring and on examination typically appears as a white, contracted fibrotic ring around the preputial outlet. Pathologic phimosis, painful erections with a tight foreskin, recurrent bouts of balanitis, and recurrent urinary tract infections in conjunction with phimosis are indications for urologic consultation and consideration of circumcision. This child’s examination is consistent with physiologic phimosis.

A short course of a topical corticosteroid (2–8 weeks of 0.05% betamethasone twice daily) applied to the preputial outlet may result in accelerated resolution of physiologic phimosis. However, given this child’s age and the absence of complications, reassurance and continued good foreskin hygiene are recommended. The foreskin should not be forcibly retracted, as this may lead to microtears and resultant scarring. In the absence of infection, neither antibacterial nor antifungal ointment is indicated.

Question 46

146. A 35-year-old female presents to your office with a 3-month history of dyspnea. She does not smoke and has not had a productive cough. She has no other significant past medical history and takes no medications. A chest radiograph reveals significant hilar adenopathy with bilateral infiltrates.

Which one of the following physical examination findings would be consistent with the most likely diagnosis in this patient?

A) Bilateral conjunctivitis

B) Alopecia

C) Erythema nodosum

D) A malar rash

E) Xerostomia

Answer 46

ANSWER: C

This patient has sarcoidosis. Extrapulmonary manifestations are common in patients with sarcoidosis and erythema nodosum is a common cutaneous sign. Ocular symptoms usually include uveitis, not conjunctivitis. Xerostomia is associated with Sjögren’s syndrome. A malar rash and alopecia are dermatologic findings associated with lupus erythematosus.

Question 47

147. An 83-year-old male with moderate Alzheimer’s disease and a BMI of 32.6 kg/m2 is admitted to the nursing home. He has significant osteoarthritis and has difficulty with ambulation. In recent years he has become increasingly frail and has frequently fallen in his home. He has no history of coronary artery disease or stroke, but has had type 2 diabetes mellitus for the past 15 years.

Which one of the following goals would be most appropriate for managing this patient’s diabetes?

A) A hemoglobin A1c of approximately 8%–9%

B) Limiting caloric intake to 1600 kcal/day

C) An LDL-cholesterol level <100 mg/dL

D) A systolic blood pressure <130 mm Hg

Answer 47

ANSWER: A

The treatment of diabetes mellitus in frail elderly patients, especially nursing home residents, can be less stringent than with other patients. Sliding-scale insulin and diabetic diets should both be avoided in nursing home residents. Lowering LDL-cholesterol levels and aggressive blood pressure control are not indicated for frail elderly patients. The acceptable levels of hemoglobin A1c can also be liberalized, with levels of 8%–9% being acceptable.

Question 48

148. A 66-year-old male is diagnosed with monoclonal gammopathy of undetermined significance. This patient will require regular follow-up visits because of the risk his condition will progress to

A) aplastic anemia

B) multiple myeloma

C) chronic lymphocytic leukemia

D) acute myelogenous leukemia

E) idiopathic thrombocytopenic purpura

Answer 48

ANSWER: B

Monoclonal gammopathy of undetermined significance (MGUS) is present in approximately 2%–3% of the white population older than 50. It is associated with a risk of progression to multiple myeloma at a rate of 1% per year. Most patients diagnosed with MGUS should be reevaluated in 6 months with a medical history, physical examination, CBC, calcium and creatinine levels, and serum electrophoresis, and then annually thereafter.

Question 49

149. A 59-year-old female with hypertension takes hydrochlorothiazide and amlodipine (Norvasc). A routine basic metabolic panel is normal except for a mildly elevated calcium level. Upon further questioning, she admits to a history of kidney stones in the past.

After stopping her hydrochlorothiazide, which one of the following laboratory evaluations would be most appropriate?

A) Parathyroid hormone (PTH) and PTH–related peptide

B) 25-hydroxyvitamin D, magnesium, and creatinine

C) 24-hour urine calcium and creatinine

D) A repeat basic metabolic panel with ionized calcium

E) Sestamibi scintigraphy

Answer 49

ANSWER: D

Isolated elevated calcium levels should be confirmed before pursuing further testing. After calcium elevation is confirmed, immediate treatment should be undertaken if hypercalcemia is severe. Otherwise, a history and physical examination would be appropriate, as well as 25-hydroxyvitamin D, magnesium, creatinine, and PTH levels. In patients with a normal or elevated PTH level, 24-hour urine calcium and creatinine levels can help to differentiate between primary hyperparathyroidism and familial hypocalciuric hypercalcemia. If the PTH level is low, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and parathyroid hormone–related peptide levels should be checked to evaluate possible causes of hypercalcemia independent of the parathyroid. Sestamibi scintigraphy is indicated only after confirmation of hyperparathyroidism, and typically in anticipation of surgical treatment.

Question 50

150. A 10-year-old female is brought to your clinic complaining of toe pain after a playground injury. A radiograph reveals a displaced fracture involving half the joint surface of the first proximal phalanx.

Which one of the following is the most appropriate management of this fracture?

A) Buddy taping to the second phalanx for 6 weeks

B) A rigid-sole shoe for 6 weeks

C) A short leg walking cast with a toe plate for 6 weeks

D) A posterior splint with orthopedic referral at 1 week

E) Prompt orthopedic referral for surgical fixation

Answer 50

ANSWER: E

Phalangeal fractures of the second to fifth toes can usually be managed with buddy taping and a rigid-sole shoe for 3 weeks followed by buddy taping for another 3 weeks. If the fracture is significantly displaced, closed reduction in the office using local anesthesia may be appropriate.

However, because of its importance in weight bearing and balance, fractures of the first toe (hallux) have a higher potential for negative outcomes. Specifically, fractures of the hallux can be managed nonsurgically if they are not displaced and involve less than 25% of the articular surface of the joint. Nonsurgical management involves use of a short leg walking cast with a toe plate (extending past the end of the great toe) for 3 weeks and then progression to a rigid-sole shoe with buddy taping after that.

Since this patient’s fracture involves more than 25% of the articular surface of the joint of the first toe, early referral for surgical pinning by an orthopedic surgeon would lead to the best outcome.