Questions 151-200

Question 1

151. Static stretching before running has been shown to

A) increase strength
B) increase endurance
C) decrease the frequency of lower limb muscle injury
D) reduce delayed-onset muscle soreness
E) have no benefit

Answer 1

ANSWER: E
Once considered generally beneficial to the running athlete, preparticipation static stretching has been found lacking in terms of benefit and even detrimental when subjected to scientific study. There is strong evidence that static stretching significantly slows performance in sprints up to 100 meters. Studies have failed to demonstrate that static stretching before running significantly decreases the likelihood of muscular injury of the lower limbs or results in a measurable reduction of delayed-onset muscle soreness. Limited evidence suggests that preparticipation static stretching, when performed alone, adversely affects both strength and endurance in elite athletes but has little measurable effect on amateur and casual athletes. Based on current understanding of sports performance, static stretching is of most benefit when performed during the cool-down period following exercise, which has been found to increase flexibility, and is best avoided immediately before athletic endeavors. A preparatory aerobic warm-up combined with dynamic range-of-motion exercises may be of some benefit for runners.

Question 2

152. A 17-year-old football player presents to your office on a Monday with a right knee injury. He injured the knee in Friday night’s game when an opposing player fell against the knee from the front while the patient had his right foot planted. He was unable to bear weight after the injury, and noted immediate swelling of the knee.

A positive result with which one of the following would indicate an anterior cruciate ligament tear?

A) Ballottement test
B) Lachman test
C) McMurray test
D) Posterior drawer test
E) Thessaly test

Answer 2

ANSWER: B
A positive Lachman test indicates that the anterior cruciate ligament may be torn. The posterior drawer test evaluates posterior cruciate ligament stability. The McMurray and Thessaly assessments test for meniscal tears. The ballottement test is for detecting intra-articular knee effusion.

Question 3

153. A 14-year-old female sees you for a well child visit. She is healthy and has no complaints or concerns today. A review of her past immunizations shows that she was up to date on all required immunizations at her 8-year-old well child visit. She also received HPV vaccine at age 11 and 12, and quadrivalent meningococcal vaccine (MCV4) and TdaP at age 12.

Which one of the following vaccines should she receive at this visit?

A) Hepatitis C
B) HPV
C) Inactivated poliovirus
D) Measles
E) Rubella

Answer 3

ANSWER: B
HPV vaccine is given as a three-dose series, so this patient is due for her third dose. The recommended interval between the first and third doses is 6 months, with approximately 4 months recommended between the second and third doses; however, the series can safely be completed at longer intervals (SOR C). The patient received her second dose at age 12 and she is now 14 years of age, so it has been over 4 months. She was up to date on all immunizations at age 8, so it can be assumed that she has received her rubella, measles, and polio vaccinations. There is currently not a vaccine approved for hepatitis C.

Question 4

154. A 79-year-old male with low libido has been found to have a low testosterone level. Which one of the following studies is important to obtain prior to treatment with testosterone replacement?

A) Hematocrit/hemoglobin
B) An FSH level
C) Hemoglobin A1c
D) A basic metabolic profile

Answer 4

ANSWER: A
Testosterone replacement can induce polycythemia, so baseline hematocrit/hemoglobin levels should be obtained prior to treatment and repeated approximately every 6 months. FSH is not relevant in the workup or treatment of hypogonadism. Testosterone treatment does not directly affect glucose tolerance or electrolytes, so baseline studies and follow-up are not necessary.

Question 5

155. You are counseling a 45-year-old obese male regarding weight loss. The patient has elevated triglycerides, low HDL-cholesterol, and stage 1 hypertension. He does not currently take medications and would like to avoid taking medications in the future. The patient has heard good things about low-carbohydrate diets and asks your opinion.

A low-carbohydrate diet in a patient such as this is most likely to result in

A) increased LDL-cholesterol
B) increased triglycerides
C) increased blood pressure
D) development of metabolic syndrome
E) better short-term weight loss than with a low-fat diet

Answer 5

ANSWER: E
Emerging data on low-carbohydrate diets is mostly encouraging, in that these diets do not seem to cause the expected increases in blood pressure, LDL-cholesterol levels, or triglyceride levels that the medical community had first assumed. Although low-carbohydrate diets have been shown to result in clinically meaningful weight loss, reduced-calorie diets appear to result in similar weight loss regardless of which macronutrients they emphasize. This patient has symptoms of metabolic syndrome and has a higher risk of glucose intolerance or diabetes mellitus. Low-carbohydrate diets have been shown to reduce insulin resistance at least as well as, if not better than, traditional diet plans.

Question 6

156. A 24-year-old nulligravida comes to your office for contraception counseling. She has a seizure disorder that is well controlled on carbamazepine (Tegretol). She is a nonsmoker and has no other medical problems or complaints. She is currently in a relationship and does not want to get pregnant in the next several years.

Which one of the following contraceptive options would be the most appropriate?

A) Progestin-only pills
B) Combined oral contraceptives
C) The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing)
D) The norelgestromin/ethinyl estradiol contraceptive patch (Ortho Evra)
E) A levonorgestrel intrauterine device (Mirena)

Answer 6

ANSWER: E
Certain antiepileptic drugs induce hepatic metabolism of estrogen and progestin (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate). This can potentially lead to failure of any contraceptive that contains estrogen and progestin. Progestin-only pills are most effective in women who are exclusively breastfeeding. They are not as effective in pregnancy prevention in other circumstances. Another effective option for women taking antiepileptic medications would be an intrauterine device. The levonorgestrel (progestin only) IUD and copper IUD are acceptable choices even for a nulligravida. The single-rod implantable progestin system also would be an acceptable choice for this patient.

Question 7

157. A 78-year-old male is on dual antiplatelet therapy (aspirin and clopidogrel) as a result of a stroke 6 months ago. He recently underwent coronary angiography, and his cardiologist has scheduled coronary artery bypass surgery for a week from today.

Which one of the following is recommended with regard to his antiplatelet therapy?

A) Stopping only aspirin 5 days before surgery
B) Stopping only clopidogrel 5 days before surgery
C) Stopping both aspirin and clopidogrel 5 days before surgery
D) Continuing both aspirin and clopidogrel

Answer 7

ANSWER: B
Patients receiving dual antiplatelet therapy who require bypass surgery should continue taking aspirin. Clopidogrel or prasugrel should be stopped 5 days before the surgery due to the increased risk of major bleeding during surgery.

Question 8

158. A 72-year-old female presents to the emergency department complaining of dizziness. She also reports palpitations since yesterday, with dyspnea on exertion. She does not have chest pain. On examination her blood pressure is 102/60 mm Hg, pulse rate 140 beats/min, respirations 16/min, and O2 saturation 94% on room air. She has tachycardia with no murmurs and her lungs are clear. The remainder of her examination is normal, including the absence of lower-extremity edema. Her EKG is shown below.

Which one of the following is the best initial step in the management of her tachycardia?

A) Amiodarone (Cordarone)
B) Intravenous adenosine (Adenocard)
C) Intravenous metoprolol tartrate (Lopressor)
D) Immediate synchronized cardioversion
E) Unsynchronized cardioversion under conscious sedation

Answer 8

ANSWER: C
The EKG shows atrial fibrillation with a rapid ventricular rate. The patient is stable, so initial treatment should focus on rate control. Intravenous B-blockers or nondihydropyridine calcium channel antagonists are preferred for initial therapy to control the rate. Amiodarone may be used for rhythm control but would not be the initial treatment of choice in this case. Cardioversion is not indicated unless the patient becomes unstable. Adenosine is not a recommended treatment for atrial fibrillation.

Question 9

159. Misleadingly low serum sodium can be caused by

A) hyperglycemia
B) diuretic use
C) heart failure
D) renal disease

Answer 9

ANSWER: A
A decrease in serum sodium concentration does not always indicate a decrease in osmolality of body fluids. In cases of hyperglycemia, the main cause of the hyponatremia is the glucose-related increase in osmolality of extracellular fluid, followed by the movement of water from intracellular to extracellular fluid compartments and a subsequent loss of excessive extracellular fluid and electrolytes. The serum sodium concentration is also diminished in patients with hyperlipidemia or hyperproteinuria because of the volume occupied by the lipids or proteins. If the lipids or proteins are removed, the sodium concentration in the remaining plasma is found to be normal. No treatment is needed for these conditions.

Question 10

160. The parents of a 5-year-old male ask you about treating him for attention-deficit/hyperactivity disorder (ADHD) because of his hyperactivity at home and preschool. According to the newest guidelines, the most appropriate next step is to

A) prescribe a very low dose of stimulant medication
B) explain to the parents that drug therapy for ADHD is not appropriate at this age
C) perform a dietary history focusing on the child’s sugar intake
D) explore the nature of his hyperactivity and whether there are coexisting behavioral problems

Answer 10

ANSWER: D
Guidelines from the American Academy of Pediatrics state that stimulant medication can be prescribed for preschool children, but only after a thorough trial of behavior modification. Foods and additives have never been shown to cause or aggravate ADHD. Children with ADHD often have other behavioral problems such as depression or oppositional-defiant disorder.

Question 11

161. A 17-year-old female presents to your office with anterior knee pain. She tells you she recently started a running program. She says the pain is worse running down hills, and is vaguely localized just medial to the patella. Examination of the knee shows no effusion or instability, and there is no joint-line pain or patellar tenderness. McMurray’s maneuver is negative. Plain radiographs of the knee appear normal.

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

A) MRI of the knee
B) Modification of her running program and a quadriceps and hip strengthening program
C) Static stretching of the quadriceps and hamstrings prior to running
D) A corticosteroid injection in the area of the pes anserine bursa

Answer 11

ANSWER: B
This patient is suffering from patellofemoral pain syndrome, which causes anterior knee pain that is worse with running downhill. The examination is often normal, although there may be apprehension when the knee is extended with pressure over the patella and the patella will sometimes track laterally. Patellofemoral pain syndrome can be treated with exercises to strengthen the quadriceps and hips, and by using a knee sleeve with a doughnut-type cushion that the patella fits into. Static stretching would not address the problem. MRI would be indicated if there were joint-line pain or an unstable knee. Pes anserine bursitis usually causes pain and tenderness medially, below the joint line.

Question 12

162. A 50-year-old female reports a 1-month history of pain in her wrists. She does not recall any injury. On examination both wrists are warm but not red, feel boggy on palpation, and lack 30° of both flexion and extension. No other joints are affected. She feels fatigued and unwell, but attributes this to her busy schedule.

Radiographs of the wrists are normal. Laboratory findings are unremarkable except for a mildly elevated erythrocyte sedimentation rate and a negative rheumatoid factor.

Which one of the following is the most likely diagnosis?

A) Rheumatoid arthritis
B) Osteoarthritis
C) Inapparent injury
D) Fibromyalgia
E) Lyme disease

Answer 12

ANSWER: A
Rheumatoid arthritis is most often symmetric at presentation and particularly affects the wrists and other extremity joints that have a high ratio of synovium to articular cartilage. Rheumatoid factor is often negative in the early months of the disease, although it may be positive later. Radiographs and laboratory tests are helpful, but the diagnosis is primarily clinical. Osteoarthritis of the wrists usually involves the carpal-metacarpal joint of the thumb primarily, and the joint would be red if there were an injury. Fibromyalgia usually involves the soft tissue of the trunk, and there is no evidence of inflammation. Lyme disease can cause a variety of joint diseases, but not chronic symmetric arthritis.

Question 13

163. During a well child examination, you notice that a 2-month-old male has a flattened left occiput. His records show that his skull was normally shaped at birth. Further evaluation shows that the left frontal region is more prominent than the right, and the left ear is slightly forward of its expected position. The infant seems comfortable rotating his head to either side while being held in his mother’s arms.

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

A) Recommend that the infant sleep in a prone position, and follow up in 1 month
B) Educate the parents about positioning and follow up in 2 months
C) Order physical therapy
D) Order CT of the head
E) Refer for surgical evaluation

Answer 13

ANSWER: B
The parallelogram shape of this infant’s head is typical of positional skull deformity, also known as benign positional molding or occipital plagiocephaly. This condition has been estimated to be present in at least 1 in 300 infants, with some studies showing milder variants in up to 48% of healthy infants. The incidence of positional skull deformity is increased in children who sleep in the supine position, but switching to prone sleeping is not recommended because this would increase the risk of sudden infant death syndrome. The deformity can be prevented by routine switching of the dependent side of the infant’s head. Supervised “tummy time” for 30–60 minutes each day can also decrease the amount of flattening and can increase the child’s motor development. Children who have positional skull deformity should also be screened for torticollis. This condition can prevent correct positioning and is remedied with physical therapy techniques.

Positional skull deformity should be differentiated from cranial synostosis, which is the result of abnormal fusion of one or more of the sutures between the skull bones. Ipsilateral frontal bossing and ear advancement are not seen, resulting in a trapezoid-shaped head.

Most infants with positional skull deformity improve within 2–3 months with the institution of positional changes and tummy time. If the condition does not significantly improve after this amount of time, referral to a pediatric neurosurgeon with expertise in craniofacial malformations would be appropriate.

Question 14

164. A 25-year-old white female comes to your office complaining of abdominal pain. She requests that you hospitalize her and do whatever is necessary to get rid of the pain that has been present for a number of years. She has difficulty describing the pain. She is a divorced single parent, and becomes defensive when asked about her former marriage, stating only that her ex-husband is an alcoholic, “just like my father.”

Her previous medical history includes an appendectomy, a cholecystectomy, and a hysterectomy. On physical examination she appears healthy, and a CBC, erythrocyte sedimentation rate, serum amylase level, and comprehensive metabolic panel are all normal.

Management of this patient should include which one of the following?

A) Reassurance that her symptoms are simply psychogenic
B) Long-term use of antidepressants
C) Scheduling frequent, regular office visits
D) Hospitalization, then consultation with a psychiatrist
E) Referral to a surgeon for exploratory laparotomy

Answer 14

ANSWER: C
Somatoform disorders are often encountered in family medicine. Studies have documented that 5% of patients meet the criteria for somatization disorder, while another 4% have borderline somatization disorder. Most of these patients are female and have a low socioeconomic status. They have a high utilization of medical services, usually reflected by a thick medical chart, and are often single parents. Physicians tend to be less satisfied with the care rendered to these patients compared to those without the disorder. Patients with multiple unexplained physical complaints have been described as functionally disabled, spending an average of one week per month in bed. Many of these patients seek and ultimately undergo surgical procedures, and it is not uncommon for them to have multiple procedures, especially involving the pelvic area. Often there are associated psychiatric symptoms such as anxiety, depression, suicide threats, alcohol or drug abuse, interpersonal or occupational difficulties, and antisocial behavior. A history of a dysfunctional family unit in which one or both parents abused alcohol or drugs or were somatically preoccupied is also quite common. These individuals often enter relationships with alcohol abusers.

Somatization disorder should be managed by one primary physician so that an established relationship and regular visits can help curtail the dramatic symptoms that otherwise may lead to hospitalization. The family physician is in a position to monitor family dynamics and provide direction on such issues as alcoholism and child abuse. Each office visit should include a physical examination, and the temptation to tell the patient that the problem is not physical should be avoided. Knowing the patient well helps to avoid unnecessary hospitalizations, diagnostic procedures, surgery, and laboratory tests. These measures should be carried out only if clearly indicated. Psychotropic medications should be avoided except when clearly indicated, as medications reinforce the sick role, may be abused, and may be used for suicide gestures. Following these recommendations significantly decreases the cost of care for the patient.

Question 15

165. A 25-year-old clinically healthy African-American female is involved in a minor motor vehicle collision. Chest radiographs obtained after the accident reveal bilateral hilar lymphadenopathy. She has no history of environmental exposures and has no symptoms. A physical examination is completely normal. Your initial workup includes a normal comprehensive metabolic panel, CBC, and urinalysis; a negative tuberculin skin test; a normal EKG; and normal pulmonary function tests. A transbronchial lung biopsy specimen reveals a noncaseating epithelioid granuloma.

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

A) Long-term high-dose systemic corticosteroids
B) Pulsed doses of systemic corticosteroids
C) Inhaled corticosteroids
D) Oral methotrexate (Trexall) weekly
E) Observation only

Answer 15

ANSWER: E
Sarcoidosis is a disease of unknown cause characterized by the presence of noncaseating epithelioid granulomas; it involves many different organ systems. The lungs are commonly involved; bilateral hilar lymphadenopathy is often present and pulmonary infiltrates and fibrosis somewhat typical. Sarcoidosis may also affect the skin, central nervous system, eyes, liver, heart, salivary glands, kidneys, muscles, or bones. When the disease is limited to asymptomatic hilar adenopathy, it is termed stage I and no treatment has been shown to be beneficial. The most appropriate management of stage I patients is routine follow-up.

Question 16

166. A 68-year-old white male with severe COPD has diminished symmetric breath sounds, +1 ankle edema, a regular heart rhythm, a loud pulmonic component of the second heart sound, and a right parasternal heave. Which one of the following interventions is most likely to be therapeutic?

A) 4-Blocker therapy
B) ACE inhibitor therapy
C) Calcium channel blocker therapy
D) Digoxin therapy
E) Long-term oxygen therapy

Answer 16

ANSWER: E
This patient has cor pulmonale. Patients should be assessed for chronic oxygen therapy, which has been shown to reduce hospitalization rates and mortality (SOR A). O2 saturation is less than 88% in most cases. Oxygen therapy may be justified with a slightly higher O2 saturation if cor pulmonale is well documented in a patient with COPD. Cautious diuretic therapy may be useful for symptomatic edema.

Digoxin is not thought to be beneficial in the absence of atrial fibrillation and is more likely to cause an arrhythmia in a hypoxic patient. 4-Blockers, calcium channel blockers, and ACE inhibitors are not recommended for cor pulmonale. Calcium channel blockers and vasodilators may have some benefit in primary pulmonary hypertension, but they have not proven beneficial in COPD-related cor pulmonale.

Question 17

167. A 23-year-old female nonsmoker has a history of an unusually high number of sinus infections and episodes of bronchitis. She has not required hospitalization, and the infections have not been due to a fungus or methicillin-resistant Staphylococcus aureus. Her growth as a child was normal, and she has a BMI of 24 kg/m2.

Which one of the following laboratory findings would be most likely?

A) An abnormal nitroblue tetrazolium test
B) Severe lymphopenia
C) Thrombocytopenia
D) Decreased serum levels of IgG, IgM, and IgA

Answer 17

ANSWER: D
Common variable immunodeficiency is the most commonly diagnosed disorder among the primary immunodeficiencies. It is a disorder of humoral immunity associated with reduced serum levels of IgG, IgM, and IgA, and frequently presents as late as the third or fourth decade of life. The disorder is associated with recurrent sinus infections, otitis media, bronchiectasis, and chronic gastrointestinal problems. Recognition of the disorder is important, as infections may be reduced when patients are treated with intravenous immune globulin.

Abnormalities in the other test results are compatible with less common primary immunodeficiencies. Lymphopenia suggests a disorder of cellular immunity such as severe combined immunodeficiency, thrombocytopenia suggests the Wiskott-Aldrich syndrome, and an abnormal nitroblue tetrazolium test suggests a phagocytic disorder.

Question 18

168. Which one of the following effects of vitamin D is supported by the best evidence?

A) It prevents cardiovascular disease
B) It prevents colon cancer
C) It prevents dementia
D) It reduces falls in community-dwelling older adults

Answer 18

ANSWER: D
The U.S. Preventive Services Task Force recommends vitamin D supplementation to prevent falls in community-dwelling adults 65 and older who are at increased risk for falls (grade B recommendation). Some studies suggest that low vitamin D levels are associated with an increased risk of cardiovascular disease, multiple sclerosis, colon cancer, dementia, and even diabetes mellitus, but these studies are epidemiologic and thus are not based on high-quality evidence (SOR C).

Question 19

169. The Timed Up and Go test consists of a patient rising from a chair, walking 3 meters (or about 10 feet), turning around, walking back, and sitting back down. The average healthy adult over the age of 60 can perform this in how many seconds?

A) 5
B) 10
C) 20
D) 30
E) 45

Answer 19

ANSWER: B
For the average adult over the age of 60, the normal time required for the Timed Up and Go test is 10 seconds. A time longer than 10 seconds may indicate weakness, a balance or gait problem, and/or an increased fall risk.

Question 20

170. What is the specific antidote used to treat methanol poisoning?

A) Ethanol
B) Haloperidol
C) Lorazepam (Ativan)
D) Naloxone
E) Thiamine

Answer 20

ANSWER: A
The current management of methanol intoxication, depending on its severity, includes ethanol administration to inhibit the metabolism of methanol, hemodialysis to remove alcohol and its toxins, and vigorous management of metabolic acidosis with bicarbonate therapy. Ethanol is a competitive inhibitor of toxin metabolism and slows the formation of toxic metabolites, formaldehyde, and formic acid from methanol, permitting these products to be disposed of by ordinary metabolic or excretory pathways. It has a similar effect in ethylene glycol poisoning, slowing the formation of glycoaldehyde and glycolic, glyoxylic, and oxalic acids.

Question 21

171. A 6-month-old male is brought in for a routine checkup. Only one testicle is palpable. The genital examination is otherwise within normal limits.

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

A) Observation only, until 18 months of age
B) Abdominal ultrasonography
C) Urologic referral for surgical exploration
D) HCG treatment for 3 months

Answer 21

ANSWER: C
Treatment for a unilateral undescended testis should be started at 6–12 months of age to avoid testicular damage. It was once thought that delaying descent lowered the incidence of testicular cancer, but it is now believed that orchiopexy allows for early cancer detection. HCG treatment may promote descent into the distal canal, but the testicle often ascends again. Ultrasonography will not show an undescended testis in many cases and is therefore not recommended. Hormonal treatments have been used in Europe but randomized, controlled trials have not shown them to be effective.

Question 22

172. A 72-year-old male is admitted to the hospital after a syncopal episode that led to a skull fracture. All of his blood tests are in the normal range. The following morning his sodium level is 132 mEq/L (N 135–145) and further testing confirms that he is suffering from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). He is placed on a free-water restriction of less than 1 L/day. Later that evening he complains of a headache and vomits repeatedly. A recheck of his electrolytes shows that his sodium level has dropped to 121 mEq/L.

What would be the most appropriate way to address his hyponatremia at this time?

A) Start oral tolvaptan (Samsca)
B) Start oral sodium tablets
C) Start an intravenous infusion of hypertonic saline
D) Further restrict fluid intake

Answer 22

ANSWER: C
Head trauma is a known cause of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This patient’s course has been very acute, with hyponatremia developing within 48 hours. Such a precipitous drop in serum sodium may lead to cerebral and pulmonary edema. If left untreated the patient can have seizures, become obtunded, and die from brain herniation. These dangers require immediate treatment with hypertonic saline to correct the falling levels of sodium. This must be done cautiously so as to not overcorrect the sodium level too quickly, which could lead to osmotic demyelination syndrome. An increase in serum sodium levels of about 6 mEq/L should be enough to reduce symptoms and prevent progressive cerebral edema.

Question 23

173. Human parvovirus B19 is associated with which one of the following?

A) Erythema marginatum
B) Erythema multiforme
C) Erythema toxicum
D) Erythema infectiosum
E) Erythema chronicum

Answer 23

ANSWER: D
Parvovirus B19 is associated with erythema infectiosum, or fifth disease. It is also associated with nonspecific fever, arthropathy, chronic anemia, and transient aplastic crisis.

Question 24

174. Which one of the following is the basis for the most effective method of natural family planning?

A) Calendar calculation
B) Basal body temperature charting
C) Cervical mucus monitoring
D) Monitoring for urine estrogen metabolites
E) Coitus interruptus (withdrawal)

Answer 24

ANSWER: C
Natural family planning (NFP) is a potentially effective method for contraception and for determining the time of ovulation for purposes of conception. While the contraceptive effectiveness of the different NFP methods varies significantly, the success rates for typical use are as high as 92%–98% (SOR B). Monitoring the presence and consistency of cervical mucus production allows for the determination of both the beginning and end of a woman’s most fertile period. Some NFP methods use cervical mucus secretion as the sole basis for determining fertility. The symptothermal method also incorporates calendar calculations, basal body temperature measurement, and ovulation-related symptoms as a complement to the cervical mucus component. The Marquette Model incorporates cervical mucus and basal body temperature charting with electronic monitoring of urine estrogen and LH metabolites to provide additional information to determine when ovulation has occurred.

Question 25

175. A 32-year-old white primigravida has a stillbirth at 33 weeks gestation. Which one of the following is the most likely cause?

A) Infection
B) Placental disease
C) A fetal structural disorder
D) A hypertensive disorder

Answer 25

ANSWER: B
Stillbirth is defined as fetal death occurring at or after 20 weeks gestation, and affects approximately 1 in 160 pregnancies in the United States. A large study of stillbirths from 2006 to 2008 tried to establish a cause in 663 cases, and a probable or possible cause was identified in approximately 75% of these. While there were some significant ethnic differences, placental abnormalities and obstetric complications were the largest category of causes in white women, and this was even more true after 32 weeks gestation. Other important causes included infection and fetal defects. More than one cause was found in one-third of cases.

Question 26

176. A 55-year-old female has a 2-year history of a slowly progressive bilateral tremor. The tremor interferes with her writing and eating. She has recently noted head bobbing and a change in her voice.

Which one of the following would be an appropriate first-line medication for this problem?

A) Levetiracetam (Keppra)
B) Olanzapine (Zyprexa)
C) Alprazolam (Xanax)
D) Carbidopa/levodopa (Sinemet)
E) Propranolol

Answer 26

ANSWER: E
Primidone and propranolol are the first-line drugs for essential tremor. Alprazolam is considered to be possibly effective. The tremor described is not due to Parkinson’s disease and would not respond to carbidopa/levodopa. Levetiracetam is not effective. There is not enough evidence to recommend for or against the use of olanzapine.

Question 27

177. A 70-year-old male without underlying lung disease presents with a 36-hour history of fever, body aches, cough, and dyspnea. He did not receive influenza vaccine this year, and was recently exposed to his grandson who had influenza.

On examination the patient has a temperature of 38.8°C (101.8°F), a blood pressure of 90/50 mm Hg, a heart rate of 110 beats/min, and an O2 saturation of 87% on room air. A nasal swab rapid antigen test is negative, and his WBC count is 15,000/mm3 (N 4300–10,800). A viral culture is sent to the laboratory. A chest radiograph shows a large lobar pneumonia.

You hospitalize the patient and initiate

A) ceftriaxone (Rocephin) and azithromycin (Zithromax)
B) levofloxacin (Levaquin)
C) oseltamivir (Tamiflu)
D) oseltamivir, ceftriaxone, and azithromycin
E) oseltamivir, ceftriaxone, azithromycin, and vancomycin (Vancocin)

Answer 27

ANSWER: E
This patient has pneumonia, sepsis, and suspected coinfection with influenza. Although the rapid antigen-based nasal swab was negative, false-negative rates may be as high as 70% and this test should not be relied upon to rule out influenza. Treatment should include both antiviral and antibacterial agents that include coverage against methicillin-resistant Staphylococcus aureus (MRSA), the most common bacterial pathogen isolated from critically ill patients with coinfection. Oseltamivir, ceftriaxone, azithromycin, and vancomycin should be initiated empirically for the pneumonia and sepsis. The criteria for sepsis are satisfied by a temperature >38.3°C, a WBC count >12,000/mm3, a respiratory rate >20/min, and a source of probable infection.

Question 28

178. A mother brings her 10-year-old son to your office because he has recently experienced a flare-up of atopic dermatitis, including increased pruritus. Physical findings include increased erythema of the involved skin on the flexural surfaces of his arms and legs, with weeping eruptions located within areas of lichenification.

Which one of the following topical treatments for managing this episode is supported by the best available evidence?

A) Emollients
B) Pimecrolimus (Elidel)
C) Mupirocin (Bactroban)
D) Corticosteroids
E) Antihistamines

Answer 28

ANSWER: D
Emollients are a mainstay of chronic therapy for atopic dermatitis (SOR C), but topical corticosteroids are the first-line treatment for flare-ups (SOR A). Calcineurin inhibitors such as pimecrolimus are a second-line treatment for moderate to severe atopic dermatitis (SOR A). Antibiotics are not useful in reducing flare-ups of atopic dermatitis unless there is clear evidence of a secondary infection (SOR A). Neither topical nor oral antihistamines are recommended for routine treatment of atopic dermatitis because they are not effective in treating the associated pruritus.

Question 29

179. A 34-year-old white female presents with complaints of polydipsia, polyuria, and fatigue. Her family history is positive for diabetes mellitus. On examination she has a BMI of 38 kg/m2. Her fasting blood glucose level is 152 mg/dL and her hemoglobin A1c is 8.5%. Her fasting blood glucose level was 89 mg/dL 6 months ago. She says her vision has been somewhat blurry lately, but she has not noticed any tingling in her feet.

Which one of the following initial management options would be most appropriate?

A) Lifestyle modification
B) Pioglitazone (Actos)
C) Sitagliptin (Januvia)
D) Insulin
E) Bariatric surgery

Answer 29

ANSWER: A
The most cost-effective intervention for type 2 diabetes mellitus is lifestyle modification. The difficulty with this intervention, however, lies in keeping the patient motivated. Metformin is also cost-effective.

Bariatric surgery shows immediate benefits in lowering glucose levels in patients who have undergone this treatment. Unfortunately, studies on its long-term effects are lacking. Sitagliptin, pioglitazone, and insulin are effective secondary agents but are expensive and not as cost-effective as metformin or dietary changes and exercise.

Question 30

180. Which one of the following is a preferred first-line agent for managing hypertension in patients with stable coronary artery disease?

A) A thiazide diuretic
B) An angiotensin receptor blocker
C) A B-blocker
D) A long-acting calcium channel blocker
E) A long-acting nitrate

Answer 30

ANSWER: C
American Heart Association guidelines recommend treating hypertension in patients with stable heart failure with ACE inhibitors and/or B-blockers. Other agents, such as thiazide diuretics or calcium channel blockers, can be added if needed to achieve blood pressure goals (SOR B). B-Blockers with intrinsic sympathomimetic activity should be avoided, as they increase myocardial oxygen demand.

While thiazide diuretics are often a first choice for uncomplicated hypertension, this is not the case for patients with coronary artery disease. Long-acting calcium channel blockers may be used in patients who do not tolerate B-blockers, but short-acting calcium channel blockers should be avoided because they increase mortality. ACE inhibitors are recommended as antihypertensive agents in patients already on B-blocker therapy (especially following myocardial infarction), in diabetics, and in patients with left ventricular dysfunction. Although angiotensin receptor blockers have indications similar to those of ACE inhibitors, the American Heart Association recommends using them only in patients who do not tolerate ACE inhibitors. Long-acting nitrates are used for their anti-anginal properties and have no role in the management of hypertension.

Question 31

181. A 54-year-old female presents with a complaint of dizziness. Two days ago, while riding in a friend’s car and trying to read a book, she experienced sudden extreme nausea and a “spinning” feeling that lasted for 20 minutes. She also had a headache that mainly felt like a fullness in the area around her left ear. Since then she has had only mild dizziness when she moves her head too quickly. She recalls experiencing these symptoms on two other occasions but cannot remember the circumstances, although she thinks one episode may have been related to having had too much caffeine.

A review of systems is positive for a humming in her ears over the last few years. On examination both ears appear normal. Mild horizontal nystagmus can be seen on movement of the head to the left. Audiograms are normal in the right ear, with a low-frequency hearing loss on the left.

Which one of the following is the most likely diagnosis?

A) Motion sickness
B) Meniere’s disease
C) Vestibular migraine
D) Benign positional vertigo

Answer 31

ANSWER: B
This patient’s symptoms are compatible with Meniere’s disease, which is characterized by multiple episodes of vertigo lasting for 20–120 minutes, accompanied by a fluctuating hearing loss, tinnitus, and a sense of aural fullness. Audiograms will reveal a low-frequency hearing loss with an upsloping curve, which can become flattened over the years. Most patients develop unilateral symptoms, and many patients will develop bilateral disease many years after the onset of the unilateral symptoms. Multiple studies have reported the rate of bilateral Meniere’s disease to be as high as 50% many years after the initial diagnosis.

Motion sickness is a common cause of nausea, but the nausea usually does not come on suddenly and is not as pronounced as with Meniere’s disease. A vestibular migraine can present like a sudden Meniere’s disease attack but in this patient the audiograms, tinnitus, and aural fullness suggest Meniere’s disease. Benign positional vertigo is very common, and hearing loss could be an incidental finding. However, the most common form of age-related hearing loss is seen at the higher frequencies. Positional vertigo like this patient has is common between attacks of Meniere’s disease.

There is often a family history of Meniere’s disease, and there is frequently an association with allergies. The condition can also get worse with caffeine use. Even though the diagnosis is clinical, MRI and blood tests are recommended to rule out other conditions that may be putting pressure on the endolymphatic system and thus causing the symptoms.

Question 32

182. A 32-year-old female has a 3-week history of depressed mood. She reports markedly diminished interest or pleasure in most activities, fatigue, a diminished ability to concentrate, and insomnia. She has had recurrent suicidal thoughts, but has no specific plan. Further investigation reveals a past history of several hypomanic episodes lasting 4–5 days, characterized by a persistently elevated, expansive mood. During these episodes she needed little sleep, was talkative, met multiple goals, and had trouble keeping up with the thoughts that were running through her head. She was treated with lithium in her early twenties but she stopped taking it because it stifled her artistic creativity. She currently takes no medication.

Her physical examination is unremarkable. Results from comprehensive laboratory studies, including a urine toxicology screen, are also normal.

Which one of the following is most appropriate for her current depressive symptoms?

A) Aripiprazole (Abilify)
B) Venlafaxine
C) Divalproex (Depakote)
D) Divalproex and bupropion (Wellbutrin)
E) Lithium and paroxetine (Paxil)

Answer 32

ANSWER: C
This patient has bipolar II disorder. She has a history of hypomanic episodes as well as major depression, with no history of a manic or mixed episode. Among the pharmacologic options listed, only divalproex and lithium are indicated for treating bipolar depression or acute mania, and for maintenance. They should be given as single agents, however, not in combination with other drugs. No evidence supports combination therapy or the addition of an antidepressant in the acute phase of depression.

In a study of patients with bipolar II disorder, initially adding paroxetine or bupropion to the mood stabilizer was no more effective than using lithium or valproate. An SSRI or bupropion can be added if a therapeutic dosage of a mood stabilizer does not resolve symptoms and the patient is not in a mixed state. Tricyclic antidepressants and antidepressants with dual properties, such as venlafaxine, should be avoided because they may induce mania. Aripiprazole is indicated for acute mania but not for bipolar depression.

Question 33

183. A 65-year-old male with type 2 diabetes mellitus is having increasing symptoms of angina pectoris. His cardiologist has recommended that he undergo heart catheterization and possible intervention if coronary artery disease is found. He comes to your office prior to the procedure and asks for your thoughts regarding treatment options presented by the cardiologist.

In addition to optimal medical treatment, if this patient is found to have multivessel coronary disease at the time of heart catheterization, you would recommend which one of the following?

A) Angioplasty without stenting
B) Angioplasty with bare-metal stents
C) Angioplasty with drug-eluting stents
D) Angioplasty of the most significantly blocked artery, followed by coronary artery bypass graft surgery
E) Coronary artery bypass graft surgery

Answer 33

ANSWER: E
The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial funded by the National Heart, Lung, and Blood Institute concluded that in patients with diabetes mellitus and advanced coronary artery disease, coronary artery bypass graft surgery was superior to percutaneous coronary intervention (PCI) in that it significantly reduced rates of death and myocardial infarction, although stroke rates were higher in the 30-day perioperative period. The FREEDOM trial suggested that these outcomes are similar whether PCI is performed without stents, with bare-metal stents, or with drug-eluting stents. These results were consistent with reports from other smaller or retrospective studies of revascularization in patients with diabetes mellitus.

Question 34

184. A 2 1⁄2-year-old male is brought to the emergency department with the acute onset of diffuse abdominal pain that began approximately 6 hours ago. He has also had 3 episodes of bilious emesis in the last 2 hours. A review of systems is positive for anorexia today but negative for fever, weight loss, diarrhea, and bloody stools.

On examination the patient’s height and weight are in the 50th percentile for age, his blood pressure is normal, his heart rate is 110 beats/min, and his temperature is 36.9°C (98.4°F). Cardiovascular and pulmonary examinations are unremarkable. The abdominal examination is significant for slightly hypoactive bowel sounds and diffuse tenderness to palpation without rebound, guarding, or rigidity. A genitourinary examination is normal.

Which one of the following studies is the most appropriate next step to diagnose the cause of abdominal pain in this patient?

A) Scrotal ultrasonography
B) Abdominal ultrasonography
C) Abdominal and pelvic CT
D) An upper gastrointestinal series

Answer 34

ANSWER: D
In young children with bilious emesis, anorexia, and lack of fever, the most likely diagnosis is intestinal malrotation with volvulus. Abdominal ultrasonography is less sensitive and specific for malrotation than an upper gastrointestinal series, so an upper GI series should be ordered initially if volvulus is suspected. If appendicitis were suspected, ultrasonography would be preferred. CT is not a good choice because of the amount of radiation it delivers, especially given efforts to decrease the use of CT in children unless absolutely necessary. This patient’s presentation is not typical for testicular torsion, therefore scrotal ultrasonography should not be the initial test of choice.

Question 35

185. Which one of the following juices can greatly increase the blood level of a statin?

A) Apple
B) Grapefruit 
C) Orange
D) Pineapple 
E) Tomato

Answer 35

ANSWER: B
Ingestion of grapefruit juice can increase absorption and serum levels of statins, leading to an increased risk of muscle injury. The mechanism for this is believed to be the cytochrome p-450 pathway. Starfruit juice and pomegranate juice can have a similar effect. These juices contain an irreversible inhibitor of intestinal CYP3A4, and increase the bioavailability of atorvastatin, lovastatin, and simvastatin. Rosuvastatin and fluvastatin utilize the CYP2C9 system for metabolism, so the effect on these drugs is minimal.

Grapefruit juice reduces CYP3A4 activity by 50% within 4 hours of ingestion, and activity is reduced by 30% for as long as 24 hours after ingestion. Several studies document that consuming 600 mL of double-strength juice for 3 days produces a more than tenfold increase in the area under the curve for simvastatin and lovastatin, but only a 250% increase in atorvastatin.

Question 36

186. A 53-year-old male with hypertension, hyperlipidemia, and nonalcoholic fatty liver disease began taking atorvastatin (Lipitor) 3 months ago. His LDL-cholesterol level is now at goal, but he has developed an asymptomatic elevation of his hepatic transaminases to twice-normal levels.

Which one of the following is the most appropriate course of action?

A) Continue the atorvastatin at the current dosage
B) Reduce the dosage of atorvastatin by half
C) Discontinue atorvastatin and switch to another statin
D) Discontinue atorvastatin and switch to an antihyperlipidemic agent from a different class
E) Order hepatic ultrasonography

Answer 36

ANSWER: A
HMG-CoA reductase inhibitors, or statins, play an important role in the management of patients with cardiovascular disease and have an excellent safety and tolerability record. The incidence of significant liver injury from statin drugs is about 1%, and nonalcoholic fatty liver disease or stable hepatitis B or C infection is not a contraindication to treatment with statins. Although many patients taking statins experience elevation of hepatic transaminases, these elevations are generally mild and asymptomatic, and often resolve spontaneously even with no changes in treatment. Transaminase elevations up to three times the upper limit of normal are not a contraindication to continued use of the drug at the same dosage.

Question 37

187. A 95% confidence interval means

A) at least 95% of patients with a disease have a positive test for that disease
B) at least 95% of patients without a disease have a negative test for that disease
C) there is a 95% difference in risk between the treatment and control groups
D) it is 95% certain that the true value lies within the given range
E) at least 95% of the patients need to receive an intervention instead of the alternative in
order for one additional patient to benefit

Answer 37

ANSWER: D
A 95% confidence interval is an estimate of certainty. It means there is 95% certainty that the true value lies within the given interval range. When a confidence interval crosses 1.00, the validity of the resulting statistical estimate is questionable. Sensitivity is the percentage of patients with a disease who have a positive test for the disease. Specificity is the percentage of patients without a disease who have a negative test for the disease. Relative risk reduction is the percentage difference in risk between the treatment and control groups. The number needed to treat is the number of patients who need to receive an intervention instead of the alternative in order for one additional patient to benefit.

Question 38

188. An 11-year-old male is brought to your clinic for follow-up after a recent well child visit revealed elevated blood pressure. The parents have restricted his intake of sodium and fatty foods during the last several weeks. His blood pressure today is 140/92 mm Hg, which is similar to the reading at his last visit. The parents checked the child’s blood pressure with a home unit several times and found it consistently to be in the 130s systolic and low 80s diastolic. The child had a normal birth history and has no known chronic medical conditions. Both of his parents and his two younger siblings are healthy. He is at the 75th percentile for both height and weight with a BMI in the normal range. He eats a balanced diet and is active.

What should be the next step for this patient?

A) Reassurance that this is likely white-coat hypertension
B) A goal weight loss of at least 5 lb
C) Evaluation for causes of secondary hypertension
D) Hydrochlorothiazide
E) Lisinopril (Prinivil, Zestril)

Answer 38

ANSWER: C
The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents defines hypertension in children as a systolic or diastolic blood pressure above the 95th percentile for the patient’s sex, age, and height on several different readings. Although it is appropriate to have this finding confirmed in the outpatient setting, 130 mm Hg is still at the 99th percentile for systolic blood pressures in this patient. Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography.

Question 39

189. A 52-year-old white male presents for a health maintenance visit. The patient has mild osteoarthritis but is otherwise healthy. He lives at home with his wife. He drinks approximately 2 beers a week and does not smoke. He takes a multivitamin, but no other medications.

What is the recommendation for immunizing this patient with pneumococcal polyvalent-23 vaccine (Pneumovax)?

A) One dose now
B) One dose after age 65
C) One dose now, and again after age 65
D) One dose now, in 5 years, and again after age 65
E) No vaccination unless he develops an immunocompromising disease

Answer 39

ANSWER: B
For a healthy nonsmoker with no chronic disease who is not in a high-risk group, pneumococcal vaccine is recommended once at age 65, or as soon afterward as possible. Persons that should be immunized before age 65 include patients with chronic lung disease, cardiovascular disease, diabetes mellitus, chronic liver disease, cerebrospinal fluid leaks, cochlear implants, immunocompromising conditions, or asplenia, and residents of nursing homes and long-term care facilities. The Advisory Committee on Immunization Practices of the CDC updated the recommendations for pneumococcal vaccination in 2011 to include immunization for persons age 50–64 in the following categories: Alaska Natives, Native Americans living in areas of increased risk, persons with asthma, and smokers.

Question 40

190. Long-term alleviation of carpal tunnel syndrome in patients with persistent symptoms is best accomplished by which one of the following?

A) Splinting
B) Physical therapy
C) Ibuprofen
D) Corticosteroid injection
E) Surgery

Answer 40

ANSWER: E
NSAIDs, pyridoxine, and diuretics have been shown to be no more effective than placebo in the treatment of patients with carpal tunnel syndrome. Splinting, physical therapy, and corticosteroid injections have all been shown to result in short-term improvement. Patients with persistent symptoms achieve the best long-term relief with surgery.

Question 41

191. A 32-year-old male presents to an urgent care center with a 2-day history of left calf pain and swelling, which started gradually a few hours after he played tennis. He remembers that he “tweaked” his calf on a serve late in the match but was able to continue playing. He has no history of prior medical problems, and no recent surgery or immobilization.

On examination his left calf appears slightly erythematous and swollen from the mid-calf to the ankle, with 1+ pitting over the lower leg. There is no venous distention. The left calf is 3 cm greater in circumference than the right calf. He has pain with dorsiflexion, and there is an area of tenderness in the medial calf.

Which one of the following is the most appropriate next step in ruling out deep vein thrombosis
in this patient?

A) D-dimer
B) Ultrasonography
C) Venography
D) Impedance plethysmography

Answer 41

ANSWER: A
A number of pretest probability scoring systems are available for assessing venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism. Although the Wells clinical prediction rule is widely used, other tools such as the Hamilton score and the AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) score are also available. The Wells rule divides patients suspected of having a DVT into low, intermediate, and high-risk categories, with a 5%, 17%, and 53% prevalence of DVT, respectively. This patient has a Wells score of 0 (+1 for calf circumference increase >3 cm, +1 for pitting edema, –2 for a likely alternative diagnosis of gastrocnemius strain) and is therefore at low risk. A negative D-dimer assay has a high negative predictive value for DVT, so the diagnosis can be ruled out in a patient who has a low pretest probability and a negative D-dimer result. A negative D-dimer assay does not rule out DVT in a patient with a moderate to high pretest probability (SOR C).

Question 42

192. A 39-year-old male presents to the emergency department with a 2-hour history of chest discomfort, dyspnea, dizziness, and palpitations. He has no history of coronary artery disease. He states that he has had several similar episodes in the last year. On examination he has a temperature of 36.8°C (98.2°F), a respiratory rate of 25/min, a heart rate of 193 beats/min, a blood pressure of 134/82 mm Hg, and an O2 saturation of 96% on room air. The physical examination is otherwise normal. An EKG reveals a regular narrow QRS complex tachycardia with no visible P waves.

He converts to normal sinus rhythm with intravenous adenosine (Adenocard). Which one of the following would be most useful in the long-term management of this patient’s condition?

A) Adenosine
B) Digoxin
C) Vagal maneuvers
D) Pacemaker placement
E) Radiofrequency ablation

Answer 42

ANSWER: E
This patient presents with a classic description of supraventricular tachycardia (SVT). The initial management of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient initial measures should include vagal maneuvers (SOR C), intravenous adenosine or verapamil (SOR B), intravenous diltiazem or B-blockade, intravenous antiarrhythmics, or cardioversion in refractory cases. While digoxin is occasionally useful in atrial fibrillation with a rapid ventricular rate, it is not recommended for SVT. Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT, not just those refractory to suppressive drug therapies. Observational studies have shown that this therapy results in improved quality of life and lower cost as compared to drug therapy (SOR B).

Question 43

193. A 44-year-old male in the intensive-care unit develops acute respiratory distress syndrome (ARDS). Which one of the following has been shown to improve outcomes in this situation?

A) Surfactant
B) Lower positive end-expiratory pressure (PEEP) settings
C) Lower tidal volumes
D) Aggressive fluid therapy
E) Pulmonary artery catheters

Answer 43

ANSWER: C
Acute respiratory distress syndrome (ARDS) may be caused by pulmonary sepsis or sepsis from another source, or it may be due to acute pulmonary injury, including inhalation of smoke or other toxins. Inflammatory mediators are released in response to the pulmonary infection or injury. The syndrome has an acute onset and is manifested by rapidly developing profound hypoxia with bilateral pulmonary infiltrates. The mortality rate in patients with ARDS may be as high as 55%.

Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival. Patients with ARDS should be started at lower tidal volumes (6 mL/kg) instead of the traditional volumes (10–15 mL/kg) (SOR A). These patients also often require higher positive end-expiratory pressure settings (SOR B).

Fluid management should be conservative to allow for optimal cardiorespiratory and renal function and to avoid fluid overload. However, the routine use of central venous or pulmonary artery pressure catheters is not recommended due to the potential complications associated with their use (SOR A). While surfactant is commonly used in children with ARDS, it does not improve mortality in adults (SOR A).

Question 44

194. A 49-year-old uninsured female with diabetes mellitus presents with painful burning of her feet, particularly at night. She has tried ibuprofen and acetaminophen without relief. Her last hemoglobin A1c was 7.1%. Her medications include metformin (Glucophage), glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and lovastatin (Mevacor).

Which one of the following would be the best choice to treat her foot pain?

A) Amitriptyline
B) Topiramate (Topamax)
C) Fluoxetine (Prozac)
D) Lamotrigine (Lamictal)

Answer 44

ANSWER: A
First-line treatment for diabetic peripheral neuropathy, according to the American Diabetes Association, is tricyclic antidepressants. Anticonvulsants are second line and opioids are third line. Many medications have been found to be effective, including the tricyclics, duloxetine, pregabalin, oxycodone, and tramadol (SOR A).

Among the tricyclics, amitriptyline, imipramine, and nortriptyline have been found to be the most effective (SOR A). For an uninsured patient, the tricyclics are also the most affordable.

Question 45

195. A 2-year-old male is brought in for an initial office visit. He just moved to your community to live with foster parents. On examination, you note a thin upper lip, a smooth philtrum, a flat nasal bridge, small palpebral fissures, a curved fifth finger (clinodactyly), and a widened upper palmar crease that ends between the second and third fingers.

These findings suggest which one of the following?

A) Trisomy 21 (Down syndrome)
B) Marfan syndrome
C) Oligohydramnios sequence (Potter syndrome)
D) Fetal alcohol syndrome
E) Prader-Willi syndrome

Answer 45

ANSWER: D
The child described has facial features characteristic of fetal alcohol syndrome. Fetal alcohol spectrum disorders (FASD) are caused by the effects of maternal alcohol consumption during pregnancy. Fetal alcohol syndrome is the most clinically recognized form of FASD and is characterized by a pattern of minor facial anomalies, including a thin upper lip, a smooth philtrum, and a flat nasal bridge; other physical anomalies, such as clinodactyly; prenatal and postnatal growth retardation; and functional or structural central nervous system abnormalities.

Children with Down syndrome have hypotonia, a flat face, upward and slanted palpebral fissures and epicanthic folds, and speckled irises (Brushfield spots); varying degrees of mental and growth retardation; dysplasia of the pelvis; cardiac malformations; a simian crease; short, broad hands; hypoplasia of the middle phalanx of the 5th finger; and a high, arched palate.

Marfan syndrome is characterized by pectus carinatum or pectus excavatum, an arm span to height ratio >1.05, a positive wrist and thumb sign, limited elbow extension, pes planus, and aortic ascendens dilatation with or without aortic regurgitation.

The bilateral renal agenesis seen with Potter syndrome leads to death shortly after birth. Other anomalies include widely separated eyes with epicanthic folds, low-set ears, a broad and flat nose, a receding chin, and limb anomalies.
Finally, Prader-Willi syndrome is characterized by severe hypotonia at birth, obesity, short stature (responsive to growth hormone), small hands and feet, hypogonadism, and mental retardation.

Question 46

196. Which one of the following is most characteristic of the pain associated with acute pericarditis?

A) Improvement when sitting up and leaning forward
B) Improvement when lying supine
C) Worsening with the Valsalva maneuver
D) Radiation to the right scapula
E) Radiation to both arms

Answer 46

ANSWER: A
While there is substantial overlap in the signs, symptoms, and physical findings for the various etiologies of chest pain, a good history and physical examination can help determine which patients require immediate further evaluation for a potentially serious cause. The chest pain associated with pericarditis is typically pleuritic, and is worse with inspiration or in positions that put traction on the pleuropericardial tissues, such as lying supine. Patients with acute pericarditis typically get relief or improvement when there is less tension on the pericardium, such as when sitting and leaning forward. This position brings the heart closer to the anterior chest wall, which incidentally is the best position for hearing the pericardial friction rub associated with acute pericarditis.

Radiation of chest pain to both arms should raise concerns about myocardial ischemia or infarction. Radiation to the right scapula is sometimes seen with cholelithiasis. Worsening pain with the Valsalva maneuver is nonspecific and is of no particular diagnostic value.

Question 47

197. According to the American Diabetes Association, screening should be considered for which one
     of the following conditions in children with type 1 diabetes mellitus?

A) Hypothyroidism
B) Cystic fibrosis
C) Cushing syndrome
D) Systemic lupus erythematosus 
E) Pancreatic pseudocysts

Answer 47

ANSWER: A
Children with diabetes mellitus are at increased risk for retinopathy, nephropathy, and hypertension. They are also more likely to have immune-mediated disorders such as celiac disease and hypothyroidism. For all children and adolescents with type 1 diabetes mellitus, the American Diabetes Association recommends screening for hypothyroidism, nephropathy, hypertension, celiac disease, and retinopathy. Screening for dyslipidemia should be considered if there is a family history of hypercholesterolemia or cardiac events before age 55.

Question 48

198. A 9-year-old male is brought to your office because he has developed a limp and refuses to bear weight on his right leg. On examination he has a temperature of 38.6°C (101.5°F) and pain with range of motion of the right hip. His WBC count and erythrocyte sedimentation rate are both elevated. A radiograph of the right hip is normal.

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

A) A repeat radiograph in 48 hours
B) Ultrasonography of the right hip
C) CT of the right hip
D) MRI of the right hip
E) A bone scan of the lumbar spine, right hip, and right femur

Answer 48

ANSWER: B
The most likely diagnosis is septic arthritis of the hip. Ultrasonography is highly sensitive for the effusion seen in septic arthritis, which can be aspirated to confirm the diagnosis (SOR A). It is important to diagnose this problem as soon as possible. Clinical features of septic arthritis include an oral temperature >38.5°C (101.3°F), refusal to bear weight on the affected leg, an erythrocyte sedimentation rate >40 mm/hr, a peripheral WBC count >12,000/mm3, and a C-reactive protein level >20 mg/L. If ultrasonography is negative, a bone scan should be done. CT of the hip is indicated to visualize cortical bone. MRI is especially valuable for osteomyelitis.

Question 49

199. Prophylactic cholecystectomy for asymptomatic gallstones is indicated for patients with which one of the following?

A) Sickle cell disease
B) A renal transplant
C) Diabetes mellitus
D) Cirrhosis

Answer 49

ANSWER: A
Asymptomatic gallstones are not usually an indication for prophylactic cholecystectomy, as most patients remain asymptomatic throughout their lives, and only 1%–4% develop symptoms or complications from gallstones each year. Only 10% of patients found to have asymptomatic gallstones develop symptoms within the first 5 years after diagnosis, and only 20% within 20 years.
In the past, cholecystectomy was recommended for diabetic patients with asymptomatic gallstones, based on the assumption that autonomic neuropathy masked the pain and signs associated with acute cholecystitis, and that patients would therefore develop advanced disease and more complications. More recent evidence has shown that these patients have a lower risk of major complications than previously thought.

Prophylactic cholecystectomy is not recommended in renal transplant patients with asymptomatic gallstones. One study found that 87% of these patients remained asymptomatic after 4 years, with only 7% developing acute cholecystitis and requiring subsequent uncomplicated laparoscopic cholecystectomy. Other studies have shown that the presence of gallstone disease does not negatively affect graft survival.

Patients with hemoglobinopathies are at a significantly increased risk for developing pigmented stones. Gallstones have been reported in up to 70% of sickle cell patients, up to 85% of hereditary spherocytosis patients, and up to 24% of thalassemia patients. In sickle cell patients, complications from asymptomatic gallstones have been reported to be as high as 50% within 3–5 years of diagnosis. This has been attributed largely to the diagnostic challenge associated with symptomatic cholelithiasis versus abdominal sickling crisis. In the past these patients were managed expectantly because of the significant morbidity and mortality associated with open operations. The operative risk for these patients (especially sickle cell patients) has been lowered by laparoscopic cholecystectomy, along with improved understanding of preoperative hydration and transfusion, improved anesthetic technique, and better postoperative care. Prophylactic laparoscopic cholecystectomy in these patients prevents future diagnostic confusion, as well as the mortality and morbidity risk associated with emergency surgery. Furthermore, cholecystectomy can and should be performed at the time of splenectomy, whether open or laparoscopic.
Studies have shown no significant differences in progression to symptoms from silent gallstones in cirrhotic patients compared with noncirrhotic patients. Expectant management is therefore recommended in patients with cirrhosis.

Question 50

200. You have diagnosed chronic fatigue syndrome in a 32-year-old female. Her PHQ-9 is negative for depression. An evaluation for sleep disturbance and other comorbid disorders is also negative.

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

A) Cognitive-behavioral therapy
B) Interpersonal therapy
C) Citalopram (Celexa)
D) Methylphenidate (Ritalin)

Answer 50

ANSWER: A
The criteria for chronic fatigue syndrome include fatigue for 6 months and a minimum of four of the following physical symptoms: impaired memory, postexertional malaise, muscle pain, polyarthralgia, tender lymph nodes, sore throat, new headaches, and unrefreshing sleep. Both cognitive-behavioral therapy and graded exercise therapy have been shown to improve fatigue levels, anxiety, work/social adjustment, and postexertional malaise (SOR A). Treatments that have not been shown to be effective include methylphenidate, melatonin, and galantamine. Citalopram has not been shown to be effective in the absence of a comorbid diagnosis of depression.