Questions 151-200

Question 1

151. An 85-year-old female with hypertension and chronic kidney disease was admitted to the hospital for a total knee replacement. The next evening she becomes agitated and disoriented to place and time.

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

A) Haloperidol

B) Zolpidem (Ambien)

C) Avoiding opioids

D) Removing hearing aids

E) Early mobilization

Answer 1

ANSWER: E

Sedative hypnotics such as zolpidem are associated with increased delirium symptoms and should not be used as first-line therapy (SOR C). Behavioral interventions such as early and recurrent mobilization, continuous observation, improving sensory perception (such as with hearing aids), initial reorientation, and removal of unnecessary irritations such as intravenous lines and catheters have been shown to decrease symptoms of delirium (SOR B). While opioids can affect mental status, untreated pain is also associated with delirium, and opioids are likely indicated in this postoperative patient. Antipsychotic medications such as haloperidol, as well as physical restraints, should be used as last resorts and only after an appropriate medical evaluation (SOR A).

Question 2

152. You are evaluating a 7-year-old male for long-standing nighttime bed wetting. He has no daytime symptoms and no other health problems. A thorough physical examination is normal.

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

A) Urinalysis alone

B) Urinalysis and a serum metabolic panel

C) Urinalysis and a lumbosacral radiograph

D) Urinalysis and renal ultrasonography

Answer 2

ANSWER: A

This child has monosymptomatic enuresis, meaning there are no other symptoms except nighttime bed wetting. His physical examination is normal. In this setting, the recommended initial workup is a urinalysis alone. If the results are normal and there are no other symptoms suggestive of underlying behavioral or medical conditions, reassurance and instruction on possible behavioral interventions is appropriate without further evaluation.

Question 3

153. Which one of the following is the only intervention shown to be effective in the prevention and treatment of pressure ulcers?

A) Vitamin C supplements

B) Protein supplements

C) Topical collagen dressings

D) Dextranomer paste applied to wounds

E) Negative-pressure wound therapy

Answer 3

ANSWER: B

The American College of Physicians recently published clinical practice guidelines for the treatment of pressure ulcers. Many modalities were evaluated, but good studies and evidence were available only for a few treatments. Several good-quality studies indicate that protein supplementation improves wound healing and also appears to have some benefit in prevention as well. Vitamin C supplementation made no difference in wound healing. Dextranomer paste applied to wounds actually worsened wound healing compared to standard wound dressings. Topical collagen dressings and negative-pressure wound therapy yielded no improvement in wound healing compared to usual care.

Question 4

154. A healthy 30-year-old male presents to your office with a 2-cm abscess on his leg. There is no surrounding erythema and he is afebrile. You incise and drain the abscess.

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

A) Observation only

B) Amoxicillin/clavulanate (Augmentin)

C) Cephalexin (Keflex)

D) Clindamycin (Cleocin)

E) Trimethoprim/sulfamethoxazole (Bactrim)

Answer 4

ANSWER: A

A simple abscess with no overlying cellulitis that is treated with incision and drainage does not require antibiotics. If there were overlying cellulitis, antibiotic use would be appropriate. Purulent infections have a higher likelihood of being caused by MRSA, so coverage with trimethoprim/sulfamethoxazole or clindamycin would be appropriate. In nonpurulent skin infections, amoxicillin/clavulanate or cephalexin would be appropriate choices.

Question 5

155. Which one of the following is most effective for treating fibromyalgia?

A) Tricyclic antidepressants

B) SSRIs

C) NSAIDs

D) Opioid analgesics

E) Corticosteroids

Answer 5

ANSWER: A

Pain in fibromyalgia is thought to be due to a centralized pain state. Medications that reduce the activity of neurotransmitters or increase the activity of inhibitory neurotransmitters such as norepinephrine and serotonin work best, and tricyclic antidepressants appear to be most effective (SOR A). Older SSRIs have limited benefit. Oral analgesics only work in about one-third of patients, and opioids may increase hyperalgesia. Corticosteroids are ineffective.

Question 6

156. An 84-year-old female sees you for a follow-up visit for cardiovascular issues, including a previous myocardial infarction. Her current medication regimen consists of lisinopril (Prinivil, Zestril) and carvedilol (Coreg). While she is not dyspneic at rest, she now becomes short of breath after walking half a block. On examination her blood pressure is 122/74 mm Hg, pulse rate 72 beats/min, respirations 18/min, and oxygen saturation 97% on room air. She has no jugular venous distention and her lungs are clear. No edema is noted. A recent echocardiogram showed a left ventricular ejection fraction of 30%.

Adding which one of the following would help to decrease both mortality and the risk of hospitalization?

A) Digoxin

B) Furosemide

C) Isosorbide dinitrate/hydralazine (BiDil)

D) Losartan (Cozaar)

E) Spironolactone (Aldactone)

Answer 6

ANSWER: E

Systolic heart failure, or heart failure with a reduced left ventricular ejection fraction (<40%), should be managed with an ACE inhibitor and a B-blocker. If there is volume overload, a diuretic should be added. For those who cannot tolerate an ACE inhibitor, an angiotensin receptor blocker can be used. However, an ACE inhibitor should not be given with an angiotensin receptor blocker, as this combination increases mortality.

Digoxin will decrease symptoms and lessen the chance of hospitalization, but mortality is not reduced. Mortality and hospitalization can be reduced by the addition of an aldosterone antagonist such as spironolactone. In African-American patients, using a combination of hydralazine and isosorbide dinitrate improves both symptoms and mortality for those with New York Heart Association class III or IV heart failure with a reduced ejection fraction.

Question 7

157. In a healthy full-term infant who is exclusively breastfed, iron supplementation should begin at what age in order to prevent iron deficiency anemia?

A) 1 month

B) 4 months

C) 6 months

D) 9 months

E) 12 months

Answer 7

ANSWER: B

Healthy full-term infants receive 60%–80% of their iron stores from their mothers during the third trimester of pregnancy. Thus, even an exclusively breastfed infant will not typically be at risk of developing iron deficiency anemia until the age of 4 months. Iron supplementation should then be started and continued until the child is eating foods containing sufficient dietary iron. Preterm babies who are exclusively breastfed should begin iron supplementation at 1 month of age due to a foreshortened third trimester.

Question 8

158. A previously healthy 46-year-old female presents with a 1-month history of leg swelling and weight gain. She denies chest pain and shortness of breath. She takes no medications, has never smoked, and drinks only an occasional glass of wine.

The physical examination is notable for 2+ pitting edema to the mid-thigh on both legs, and mild ascites. The remainder of her examination is normal. A dipstick urinalysis shows 3+ protein. You suspect primary nephrotic syndrome.

In addition to proteinuria and low albumin, which one of the following is the most common finding in patients with primary nephrotic syndrome?

A) Coagulopathy B) Hypercalcemia C) Hyperglycemia

D) Hyperlipidemia E) Infection

Answer 8

ANSWER: D

Nephrotic syndrome is the triad of edema, proteinuria, and hypoalbuminemia, and it usually is also associated with hyperlipidemia. The initial evaluation of this patient should include testing for hyperlipidemia. Nephrotic syndrome is associated with an increased risk of deep vein thrombosis but does not cause a coagulopathy. Diabetes mellitus can be a secondary cause of nephrotic syndrome but is not a finding in primary nephrotic syndrome. Relative hypocalcemia may be found in patients with nephrotic syndrome due to low protein, but hypercalcemia is not associated with nephrotic syndrome. Children and patients with relapses of nephrotic syndrome have an increased risk of infection.

Question 9

159. A 62-year-old male with type 2 diabetes mellitus, hypertension, and hypercholesterolemia is found to have a low serum vitamin B12 level. Which one of his current medications is most likely to cause this?

A) Aspirin

B) Enalapril (Vasotec)

C) Metformin (Glucophage)

D) Simvastatin (Zocor)

E) Hydrochlorothiazide

Answer 9

ANSWER: C

Low vitamin B12 is seen with prolonged use of metformin, H2-blockers, and proton pump inhibitors. The mechanism is unclear, and it is not known whether prophylactic supplementation prevents deficiency. Metformin reduces absorption of vitamin B12 in 30% of patients and reduces vitamin B12 concentrations in 5%–10% of those taking it. The dosage and duration of metformin therapy is correlated with the risk of vitamin B12 deficiency. Given this risk, it seems prudent to monitor vitamin B12 levels periodically in patients taking metformin.

Question 10

160. A 25-year-old gravida 1 para 0 presents for follow-up of gestational diabetes mellitus. She had a positive screening test at her 24-week visit last week and has been checking her blood glucose at home twice daily since that time. She is not currently on any diabetes medications and has a nutrition visit scheduled for later today. She is currently unclear on what her glucose level should be at various times throughout the day.

Which one of the following is the goal fasting blood glucose in this patient? Less than or equal to…

A) 75 mg/dL

B) 95 mg/dL

C) 120 mg/dL

D) 140 mg/dL

E) 180 mg/dL

Answer 10

ANSWER: B

Clinicians who care for pregnant women need to be familiar with the diagnosis and monitoring parameters for gestational diabetes mellitus, as these help to determine the need for management strategies outside of diet and exercise. The goal is less than or equal to 95 mg/dL for fasting blood glucose, less than or equal to 140 mg/dL for 1-hour postprandial glucose, and less than or equal to 120 mg/dL for 2-hour postprandial glucose.

Question 11

161. Which one of the following is the strongest risk factor for primary hypertension in children and adolescents?

A) A family history of hypertension

B) Elevated BMI

C) Male sex

D) African-American ethnicity

Answer 11

ANSWER: B

There is an increasing prevalence of hypertension in children and adolescents. BMI is the strongest risk factor for hypertension in this age group. Other risk factors include a family history of hypertension, low birth weight, male sex, and certain ethnic backgrounds. The prevalence of hypertension in obese children is 11%, which is more than double that of the general pediatric population (reported at 1%–5%).

Question 12

162. A 75-year-old female presents with a 6-week history of the gradual onset of pain behind her right knee. She has a previous history of osteoarthritis and mild hypertension, but no other significant problems. Examination of the knee reveals a soft mass in the medial popliteal fossa that is present when the knee is extended, but is much smaller when the knee is flexed to 45°, which also causes the pain to subside.

Which one of the following would be most appropriate to diagnose this problem?

A) A plain radiograph

B) MRI

C) Ultrasonography

D) Arteriography

E) No imaging

Answer 12

ANSWER: E

Popliteal cysts cause posterior knee pain, and are thought to be a result of increased intra-articular pressure forcing fluid into the bursa and causing expansion and subsequent pain. Risk factors include rheumatoid arthritis or osteoarthritis and advanced age. With the patient lying down, a mass can be palpated in the medial popliteal fossa while the knee is extended. When the knee is flexed to 45° the pain subsides and the mass is reduced in size or disappears.

Imaging is generally not needed for the diagnosis. Plain radiographs are obtained if there is a possible fracture. Ultrasonography can be used if deep vein thrombosis is a consideration. If significant internal derangement of the knee is suspected, MRI may be useful. An arteriogram would be an option if aneurysm of the popliteal artery were suspected.

Treatment is generally conservative, although addressing the underlying knee pathology will prevent the cyst from recurring. Pain is often decreased by keeping the knee in flexion and the use of ice and NSAIDs. If this is not successful, intra-articular corticosteroids or cyst aspiration is often effective.

Question 13

163. Which one of the following screening measures does the U.S. Preventive Services Task Force recommend against (USPSTF D recommendation)?

A) Abdominal ultrasonography to evaluate for an abdominal aortic aneurysm in a 65-year-old male smoker

B) BRCA testing in a high-risk 40-year-old female

C) A Papanicolaou test in a 58-year-old female who previously had an abdominal

hysterectomy for fibroids

D) Colonoscopy for a 70-year-old male with no history of rectal bleeding

Answer 13

ANSWER: C

Overscreening has become increasingly common. This inappropriate care costs the health care system while providing no benefit and possibly causing harm to patients. All of the listed screenings are appropriate with the exception of cervical cancer screening for a patient who has had a hysterectomy. The U.S. Preventive Services Task Force recommends against screening for cervical cancer in women over 65 who have had adequate recent screening, and in women who have had a hysterectomy for benign disease (SOR A).

Question 14

164. A 52-year-old male was admitted to the hospital with evidence of an acute myocardial infarction. He underwent cardiac catheterization and percutaneous coronary intervention with placement of two drug-eluting stents. Echocardiography revealed a left ventricular ejection fraction of 30%. By the time of his discharge the patient had been started on several new medications, including aspirin.

Which one of the following medications is more useful for symptom control than for improving mortality in this situation?

A) Atorvastatin (Lipitor)

B) Clopidogrel (Plavix)

C) Lisinopril (Prinivil, Zestril)

D) Metoprolol tartrate (Lopressor)

E) Nitroglycerin

Answer 14

ANSWER: E

Evidence-based guidelines for the treatment of patients with acute coronary syndrome support several medications in the subacute period. Dual antiplatelet therapy, such as clopidogrel combined with aspirin, has been shown to reduce cardiovascular mortality (SOR B). ACE inhibitors and statins should be initiated immediately after a myocardial infarction and continued indefinitely to reduce mortality and the risk of repeat infarction (SOR A). B-Blockers have been shown to improve mortality in patients with a left ventricular ejection fraction <40% (SOR A). Nitroglycerin is often used to manage angina but has no demonstrated mortality benefit.

Question 15

165. A 24-year-old female sees you for follow-up of her chronic abdominal pain. You have diagnosed her with somatization disorder. You have scheduled regular, frequent visits and she has been in counseling for a few months. She still has significant anxiety about her symptoms and you would like to start her on a medication.

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

A) Amitriptyline

B) Aripiprazole (Abilify)

C) Bupropion (Wellbutrin)

D) Carbamazepine (Tegretol)

E) Lamotrigine (Lamictal)

Answer 15

ANSWER: A

Somatic disorders usually require a multifaceted approach to treatment. It is important to schedule regular visits at short intervals to establish a collaborative relationship with the patient. It is also important to limit diagnostic testing and reassure the patient that serious diseases have already been ruled out, and to screen for other mental illnesses. Referral for counseling using cognitive-behavioral therapy and mindfulness-based therapies is also effective. SSRIs and tricyclic antidepressants have been found to be the most effective pharmacotherapy (SOR B) for somatic symptom disorders. Amitripityline is the most studied tricyclic antidepressant, and trials have shown that it has a greater likelihood of success compared to SSRIs. Other antidepressants, anticonvulsants, and antipsychotic medications are ineffective and should be avoided (SOR B).

Question 16

166. A 27-year-old male complains of severe back and left leg pain that started yesterday afternoon. He states that just before the pain began he was moving some patio furniture around his back porch when he felt a sudden “pop” in his left lumbar region. Over the subsequent few hours he developed gradually increasing pain in his low back that radiates down the posterolateral side of his left leg and onto the top of his left foot. He describes the pain as lancinating and knife-like, rating it as 10/10 on a pain scale. He is unable to stand up straight or sit down comfortably for an examination. He denies any bowel or bladder dysfunction and appears to have otherwise intact strength and sensation. Prior to this event he was in good health and took no routine medications.

Which one of the following is recommended at this time?

A) No imaging

B) Radiographs of the lumbar spine only

C) CT of the lumbar spine without contrast

D) MRI of the lumbar spine without contrast

E) MRI of the lumbar spine with contrast

Answer 16

ANSWER: A

This case can be best described as acute lumbar pain with radiculopathy. There are no red flags that would suggest the presence of a time-sensitive condition such as cauda equina syndrome, cancer, infection, or fracture. In cases like this, consensus agreements recommend against any imaging studies. Instead, a 6-week course of pain medication, manipulation, physical therapy, and self-care should be undertaken.

Question 17

167. The son of a 76-year-old female with metastatic cancer calls you stating that the patient is having uncontrollable nausea. She takes long-acting morphine for pain and he has already tried giving her promethazine and ondansetron (Zofran) without significant benefit. She has been able to drink fluids, but feels “full” and has not eaten more than a few bites of food each day. She has not been vomiting and her urine output has been normal. However, the son reports that she has not had a bowel movement in about 5 days, which he assumes is due to her low intake of food.

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

A) Increasing the dosage of oral morphine

B) Initiating subcutaneous hydration

C) Assessing for possible fecal impaction

D) Inserting a nasogastric tube

E) Suggesting oral or inhaled marijuana

Answer 17

ANSWER: C

Nausea is a common symptom near the end of life and can have many causes. One of the first objectives in the palliative care of nausea is to identify and address the underlying cause. This patient is taking a long-acting opiate that predisposes her to constipation. Furthermore, the family seems to accept the fact that she is not having any bowel movements because she is not eating very much, which is an incorrect understanding. There are no signs of dehydration to warrant subcutaneous hydration, nor are there signs of bowel obstruction that would warrant a nasogastric tube.

Question 18

168. A 90-year-old female is being considered for transcatheter aortic valve replacement due to severely symptomatic critical aortic stenosis. In addition to a medication review, which one of the following tests would be best to assess for frailty as a component of the preoperative assessment?

A) Gait speed

B) The Geriatric Depression Scale

C) The Confusion Assessment Method (CAM)

D) The Mini-Cognitive Assessment Instrument (Mini-Cog)

Answer 18

ANSWER: A

Frailty is an age-related, multidimensional state of decreased physiologic reserves. Frail patients are at increased risk of decline as a result of illness or stressors such as surgery. The definition and assessment of frailty are still not uniformly agreed upon, but gait speed is recognized as a highly reliable single measurement tool. The other options listed are useful components of a geriatric assessment but are not used as a single test for the evaluation of frailty.

Question 19

169. Which one of the following topical antibiotics used in the treatment of acne vulgaris is not known to increase bacterial resistance?

A) Benzoyl peroxide

B) Clindamycin (Cleocin)

C) Dapsone (Aczone)

D) Erythromycin

E) Metronidazole

Answer 19

ANSWER: A

Benzoyl peroxide is the only topical antibiotic without evidence to suggest that its use contributes to bacterial antimicrobial resistance. For this reason it is recommended as first-line therapy in mild to moderate inflammatory acne and as an adjunctive agent with other topical antibiotics that can induce bacterial resistance, such as clindamycin and erythromycin. Dapsone is an antibiotic but is thought to primarily improve acne via its anti-inflammatory effect. Metronidazole is used chiefly in acne rosacea rather than acne vulgaris and it may contribute to antimicrobial resistance.

Question 20

170. Which one of the following therapies is most likely to reduce abdominal cramping in a patient with irritable bowel syndrome?

A) Peppermint oil

B) Polyethylene glycol (MiraLAX)

C) Probiotics

D) Wheat bran

Answer 20

ANSWER: A

Peppermint oil is an antispasmodic that has moderate evidence of benefit in the relief of abdominal cramping in patients with irritable bowel syndrome (IBS). Probiotics as a group have some evidence of benefit in improving global IBS symptoms, but the studies have used different probiotic preparations so it is difficult to draw definite conclusions about their effectiveness or to recommend a specific preparation. Polyethylene glycol is an osmotic laxative that has evidence of benefit for bowel symptoms, including improvement in stool frequency and consistency, but it does not improve abdominal pain. Wheat bran is an insoluble fiber that contains fructans that can exacerbate IBS symptoms and should be avoided in patients with IBS.

Question 21

171. A 4-year-old male is brought to your office by his neighbor with a 1-day history of fever, lethargy, stiff neck, and rash. You suspect meningitis. The neighbor reports that the patient’s father is on his way to the office and should arrive within 30 minutes.

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

A) Initiate treatment now

B) Obtain informed consent to treat from the neighbor

C) Call the father to obtain informed consent to treat

D) Wait until the father arrives to obtain informed consent to treat

Answer 21

ANSWER: A

The American Academy of Pediatrics recommends that medical care for children with an urgent or emergent condition never be withheld or delayed because of problems obtaining consent. All efforts to obtain consent should be documented. In the case of a 4-year-old male who is suspected to have meningitis, even a brief delay in treatment could result in a bad outcome for the patient.

Question 22

172. A 35-year-old female is concerned about a persistent rash on her face. It waxes and wanes in severity but she has persistent redness over her forehead, nose, cheeks, and chin. She also reports an occasional flush that usually lasts less than 5 minutes, sometimes spreads to her neck and chest, and is accompanied by a sensation of warmth. In addition to redness and flushing, the affected areas often contain papules, pustules, and small red streaks. Your examination confirms erythema over her centrofacial features with accompanying papulopustular lesions on her nose and telangiectasia on her chin and nose.

Which one of the following agents is an FDA-approved first-line topical therapy for this patient’s condition?

A) Benzoyl peroxide

B) Clindamycin (Cleocin)

C) Metronidazole

D) Selenium sulfide

E) Tretinoin

Answer 22

ANSWER: C

This patient presents with the classic symptoms and signs of rosacea. FDA-approved first-line agents for treating rosacea include metronidazole 0.75% lotion, 0.75% cream, and 1% gel; azelaic acid 15% gel; sulfacetamide 10%/sulfur 5% cream, foam, lotion, and suspension; brimonidine 0.33% gel; and ivermectin 1% cream (SOR A).

Question 23

173. A 19-year-old female college student is referred to you by her dentist for a medical evaluation related to dental problems. The patient states that she feels well and exercises at least 2–3 hours every day. On examination her teeth are stained and there are enamel erosions. She has nontender enlargement of both parotid glands. The remainder of the examination is normal.

Which one of the following is associated with these findings?

A) Bacterial parotitis

B) Bulimia nervosa

C) Cat scratch disease

D) Mononucleosis

E) Mumps

Answer 23

ANSWER: B

Bulimia nervosa is an eating disorder associated with recurrent binge eating and induced vomiting. There is also a history of excessive physical activity in many cases. Because of vomiting, the teeth are stained and there is destruction of the enamel from stomach acid. Parotid swelling is also noted frequently. With mumps and bacterial parotitis the patient feels sick and parotid glands are tender. Cat scratch disease and mononucleosis affect lymph glands.

Question 24

174. A drug available for over 20 years has been noted to have beneficial effects for a common disease. Because it is a cheap, generically available drug, no pharmaceutical firm is willing to fund a clinical trial.

What type of study would be best suited to evaluate this treatment?

A) A double-blind crossover study

B) A meta-analysis

C) A non-inferiority trial

D) A case-control study

E) A single-blind trial

Answer 24

ANSWER: C

A new treatment may not be more effective than available treatments but it may have lower costs, fewer adverse effects, or greater convenience compared to standard treatment. A treatment with other advantages might be preferred to standard treatment for some patients. A non-inferiority trial rigorously evaluates a treatment against accepted and effective treatments, with the goal of demonstrating that it is at least almost as good. Single- and double-blind studies (with or without crossover of the control and experimental groups) can be done to demonstrate the drug is effective, but showing that a new treatment is not inferior to standard treatments can be rigorously demonstrated by a non-inferiority trial. A non-inferiority trial does not distinguish between a new treatment that is not inferior and one that is truly superior, and cannot demonstrate equivalence. A case-control trial is not appropriate to compare one medication to another; its retrospective design is better for evaluating risk factors or exposures as possible causes or contributors to a disease or illness, as it involves no intervention in either the control or the experimental group.

Question 25

175. While working yesterday, a 53-year-old roofer stepped on a nail that went through his shoe and penetrated the sole of his foot. He irrigated his foot thoroughly with water when he got home. He comes to your office today because he has developed some erythema and pain in his foot, with a small amount of drainage.

While Staphylococcus aureus and Streptococcus species are the most common causes of skin and soft-tissue infection, which organism should also be considered in this situation?

A) Corynebacterium

B) Klebsiella

C) Pasteurella multocida

D) Pseudomonas aeruginosa

E) Vibrio vulnificus

Answer 25

ANSWER: D

Streptococcus species and Staphylococcus aureus are the most common causes of skin and soft-tissue infections. With a puncture wound caused by an object penetrating the sole of the shoe, another organism that should be considered as a possible cause of the infection is Pseudomonas aeruginosa. Klebsiella is not a common cause of these infections. Pasteurella multocida is a common cause of infection from a cat bite, and can also be seen in dog bites. Corynebacterium is also associated with infections from animal bites. Vibrio vulnificus should be considered when there is a skin infection after exposure to salt water.

Question 26

176. A newborn female is found to have constricted ear deformity (cup ears). Her mother had gestational diabetes mellitus.

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

A) A single-view chest radiograph

B) Long bone radiographs

C) Echocardiography

D) Renal ultrasonography

E) Unenhanced head CT

Answer 26

ANSWER: D

If isolated ear anomalies such as cup ears, preauricular skin tags, or ear pits are associated with maternal gestational diabetes mellitus, ultrasonography is warranted to screen for renal abnormalities. Ear malformations are also associated with renal abnormalities in children with other malformations, dysmorphic features, a family history of deafness, or teratogenic exposures (SOR C).

Question 27

177. The U.S. Preventive Services Task Force recommends routine screening for which one of the following in adolescents?

A) Alcohol use

B) Cervical cancer

C) Chlamydia infection

D) Depression

E) Scoliosis

Answer 27

ANSWER: D

According to the U.S. Preventive Services Task Force, screening for major depression is recommended if adequate treatment and follow-up can be provided. Sexually active females should be screened for Chlamydia infection. Cervical cancer screening begins at age 21. Because of undue harm from unnecessary treatment, scoliosis screening is not recommended. There is insufficient evidence to recommend for or against routine screening for alcohol use (SOR A, B).

Question 28

178. In an adult patient with significant depression and no other health problems, which one of the following is the best initial choice for pharmacotherapy?

A) Amitriptyline

B) Duloxetine (Cymbalta)

C) Fluoxetine (Prozac)

D) Mirtazapine (Remeron)

E) Trazodone (Oleptro)

Answer 28

ANSWER: C

Depression can be treated with counseling and/or medication. The choice of medication depends on many factors including side effects, dosing schedule, cost, patient preference, and comorbidities. In a patient with significant depression and no comorbidities, a second-generation SSRI should be the initial medication choice. Fluoxetine is the only SSRI choice listed.

Duloxetine is an SNRI that may lead to sweating, tachycardia, urinary retention, and elevation of blood pressure. It is indicated if the patient has fibromyalgia. Trazodone is associated with somnolence, orthostatic hypotension, and priapism. It may be used in low doses as an adjuvant in patients with insomnia. Mirtazapine can cause sedation, weight gain, increased appetite, dry mouth, dizziness, and constipation. It is helpful for patients with significant insomnia and loss of appetite. Amitriptyline is a tricyclic antidepressant and has significant anticholinergic side effects. It is also associated with conduction abnormalities that can lead to arrhythmias.

Question 29

179. A 29-year-old male presents with a 3-week history of multiple small, brownish-red macules in his left inguinal fold that are now coalescing into larger macules. The rash does not itch, and he has not used any new bath or laundry products. Wood’s lamp illumination of the area reveals a reddish fluorescence.

Which one of the following topical treatments would be most appropriate for this patient’s rash?

A) Erythromycin

B) Hydrocortisone

C) Nystatin

D) Selenium sulfide

E) Zinc oxide

Answer 29

ANSWER: A

An intertriginous rash of brownish-red macules that often coalesce is characteristic of a bacterial infection caused by Corynebacterium minutissimum known as cutaneous erythrasma. Coral-red fluorescence under a Wood’s lamp confirms the diagnosis. The best treatment for erythrasma is oral or topical erythromycin, with the oral form being most effective. Topical clindamycin and antibacterial soaps may also be of some benefit.

Question 30

180. Which one of the following is routinely required to establish a diagnosis of chronic lymphocytic leukemia?

A) A lymph node biopsy

B) A bone marrow biopsy and aspirate

C) CT of the chest, abdomen, and pelvis

D) Flow cytometry and immunophenotyping of peripheral blood

E) Weight loss of more than 10%, unexplained fever, and night sweats

Answer 30

ANSWER: D

Flow cytometry and immunophenotyping of peripheral blood demonstrate clonality of the circulating lymphocytes in chronic lymphocytic leukemia (CLL). Absolute lymphocytosis is defined as >5000 cells/mm3.

Ninety percent of CLL patients are asymptomatic at the time of diagnosis. Imaging procedures are not necessary for establishing the diagnosis. While a bone marrow biopsy or aspiration and/or a lymph node biopsy may be necessary as the disease progresses, they are not routinely needed to establish a CLL diagnosis.

Question 31

181. A 43-year-old male presents to your office for an urgent visit because he has a feeling that he is being followed and is fearful for his life. He tells you someone is listening to his cell phone conversations and has stolen files from his laptop, and he has observed “shadowy figures” watching him. He reports that the police have done nothing to protect him, and he has considered hiring a private investigator. He reports that he has been living out of his car for the past month. Upon further questioning the patient admits that he lost his job as an accountant a year ago and is estranged from his family. His overall appearance is unkempt and his speech is pressured and rapid. His heart rate is 88 beats/min, blood pressure 138/80 mm Hg, and temperature 37.0°C (98.6°F).

In ruling out medical causes for his psychosis, which one of the following would be most useful?

A) The PHQ-9 questionnaire

B) Urine toxicology

C) MRI of the brain

D) HIV antibody testing

E) A serum calcium level

Answer 31

ANSWER: B

Illicit substance use is the most common medical cause or secondary cause of acute psychosis. Conditions diagnosed by brain imaging, blood chemistry, and HIV tests (intracranial mass, paraneoplastic syndrome, and HIV infection, respectively) are less common medical causes of acute psychosis. Major depression with psychosis would be considered a psychiatric or primary cause of psychosis.

Question 32

182. A 62-year-old male with a history of smoking comes to your office for evaluation of a solitary 2-cm right upper lobe pulmonary nodule noted on CT. Which one of the following radiologic features is most predictive of malignancy?

A) Smooth borders

B) A ground-glass appearance

C) Central calcification of the nodule

D) A solid density

Answer 32

ANSWER: B

In the evaluation of a solitary pulmonary nodule, a risk assessment is used to determine the diagnostic evaluation of the nodule. Clinical risk factors for malignancy include older age, a history of smoking, and a previous history of cancer. Radiologic features indicative of malignancy include a nodule diameter >10 mm, an upper lung location, irregular or spiculated borders, no calcifications, a ground-glass appearance, and increasing size over time. Radiologic characteristics suggesting benign disease include a size <5 mm, central calcifications, smooth borders, a solid appearance, and a stable size over 1 year.

Question 33

183. A 13-year-old male is brought to the emergency department because of acute worsening of his asthma. His routine medications are inhaled fluticasone (Flovent) and an albuterol metered-dose inhaler (Proventil, Ventolin), which he has used every hour for the past 3 hours without significant improvement. He is unable to talk in complete sentences and his peak expiratory flow is 200 L/min, down from a baseline of 480 L/min. He has no previous history of intubations and only one short hospital admission.

Which one of the following should be given to reduce the likelihood of hospitalization?

A) Cromolyn

B) Epinephrine via nebulizer

C) Inhaled fluticasone

D) Montelukast (Singulair)

E) Oral prednisone

Answer 33

ANSWER: E

Rapid administration of systemic corticosteroids can reduce the frequency of hospitalization in patients with severe asthma who present with an exacerbation (SOR A). There is no clear benefit from parenteral versus oral administration (SOR B). The same benefit is not seen with inhaled corticosteroids during an exacerbation. Montelukast and cromolyn are not appropriate treatments for an asthma exacerbation. Nebulized epinephrine is used in the treatment of croup.

Question 34

184. A 52-year-old gravida 3 para 3 comes to your office with concerns about symptoms related to menopause. Her last menstrual period was 18 months ago. Her main concern is a 1-year history of chronic vaginal dryness, irritation, and painful intercourse. She has occasional mild hot flashes that are minimally bothersome to her. Her obstetric and gynecologic history is unremarkable. On examination you note thin, pale tissue around the introitus, and dry vaginal mucosa.

Which one of the following treatments is safest and most effective for managing her condition?

A) Oral estradiol (Estrace)

B) Oral raloxifene (Evista)

C) Oral conjugated estrogens/medroxyprogesterone (Prempro)

D) Vaginal estradiol (Estring)

E) Vaginal etonogestrel/ethinyl estradiol (NuvaRing)

Answer 34

ANSWER: D

The safest and most effective treatment for postmenopausal atrophic vaginitis is local estrogen such as the estradiol vaginal ring, estradiol vaginal tablets, or estrogen cream. All of these therapies are effective, and while there is a theoretical risk of small amounts of systemic absorption, there is no evidence to suggest that there is an increased risk of endometrial cancer or thromboembolic disease related to this type of estrogen use. These therapies are therefore preferred over systemic estrogens such as estradiol or a combination of conjugated estrogens and medroxyprogesterone. Raloxifene, a synthetic estrogen agonist/antagonist, has not been found to be effective for the treatment of atrophic vaginitis. The vaginal ring is approved for use as a contraceptive and is not intended for use in postmenopausal patients.

Question 35

185. A newborn male is brought to your office for his first examination after hospital discharge. He has been diagnosed with Down syndrome.

Which one of the following is indicated for all newborns with Down syndrome?

A) A cervical spine film

B) An echocardiogram

C) Polysomnography

D) Ultrasonography of both hips

Answer 35

ANSWER: B

Down syndrome is the most common chromosomal abnormality. The 5-year survival rate is >90%, with most individuals living past 60 years of age, and there has been significant progress in improving quality of life for these patients. Infants with Down syndrome present with a wide variety of symptoms and signs, however, and there are certain health complications that can increase the risk of hospitalization.

All infants with Down syndrome should be screened for cardiac, feeding, vision, hearing, thyroid, and hematologic abnormalities. Up to 50% manifest congenital cardiac defects, and a cardiology consultation and echocardiography are warranted. Hypotonia may affect feeding and should be noted for assessment. Congenital cataracts are common, so a red reflex examination is imperative. Cervical spine films, hip ultrasonography, and polysomnography are not recommended in a newborn with Down syndrome. However, all children with Down syndrome should have polysomnography between the ages of 1 and 4 years. Due to concerns about atlantoaxial instability parents should be advised to monitor for any signs of spinal cord impingement.

Screening for subclinical thyroid disease should also be performed, as well as a CBC to evaluate for transient myeloproliferative disorder, leukemoid reaction, and polycythemia, which all occur more frequently in Down syndrome patients.

It is important to congratulate the parents on their newborn and carefully explain the rationale for each recommended test and discuss results and their meaning clearly. An Individual Family Service Plan is also recommended, with a review every 6 months to evaluate specific measures indicated for each age group.

Question 36

186. One of your patients is admitted to the hospital with an acute myocardial infarction and requires a drug-eluting stent in his left circumflex artery. Which one of the following antiplatelet regimens would be most appropriate for at least the next 6–12 months?

A) Clopidogrel (Plavix) alone

B) Clopidogrel plus aspirin, 81 mg daily

C) Aspirin alone, 325 mg daily

D) Aspirin/dipyridamole (Aggrenox)

E) Prasugrel (Effient) plus aspirin, 325 mg daily

Answer 36

ANSWER: B

Evidence strongly supports the use of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel for a minimum of 6–12 months in patients with a drug-eluting stent. Aspirin at a dosage of 81 mg is as effective as 325 mg, if not more effective. It is also associated with a lower bleeding risk. Prasugrel is a second-line antiplatelet agent and can be used when there is a contraindication to clopidogrel or if the patient is resistant to clopidogrel. When it is used, it should be used with an aspirin dosage of 81 mg daily. Aspirin/dipyridamole is effective for secondary stroke prevention but does not have a role in the treatment of ischemic cardiovascular disease.

Question 37

187. In hypothyroid patients, which one of the following makes TSH levels alone unreliable for assessing the response to thyroid replacement?

A) A history of total surgical thyroidectomy

B) Treatment with desiccated thyroid USP

C) Treatment with liothyronine (T3)

D) Hypothyroidism due to pituitary disease

E) Graves disease

Answer 37

ANSWER: D

Secondary centrally mediated hypothyroidism is caused by hypothalamic or pituitary disease in which TSH is not being produced, resulting in failure to stimulate the thyroid gland to make thyroid hormone. Standard treatment for this type of hypothyroidism is levothyroxine, but determining the response to therapy requires measuring free T4 rather than TSH. Desiccated thyroid USP is a combination of T3 and T4 and response to treatment is usually assessed with TSH levels. T3 levels can fluctuate in patients treated with desiccated thyroid, as well as those who are on liothyronine (T3), and are therefore generally not used. TSH is also used to monitor treatment in patients with surgical hypothyroidism. Graves disease is an autoimmune disorder commonly causing hyperthyroidism, but patients usually become hypothyroid after treatment. TSH is used to monitor these patients as well.

Question 38

188. A 65-year-old male is admitted to the hospital with diastolic heart failure and stage 3 chronic kidney disease. He is noted to have a confirmed serum potassium level of 6.8 mEq/L (N 3.6–5.0).

Which one of the following is the best initial management to reduce his potassium level?

A) Intravenous calcium gluconate solution

B) Intravenous furosemide

C) Intravenous insulin and glucose

D) A rectal sodium polystyrene sulfonate (Kayexalate) retention enema

E) Hemodialysis

Answer 38

ANSWER: C

This patient has severe hyperkalemia and needs urgent treatment. Intravenous insulin followed by glucose will shift potassium intracellularly and is an effective treatment for severe hyperkalemia (SOR B). Sodium polystyrene sulfonate is not recommended as an urgent treatment and would not be an initial treatment for severe hyperkalemia. Intravenous calcium gluconate solution does not lower serum potassium but is indicated to prevent arrhythmias in patients with hyperkalemia and EKG changes. Intravenous furosemide is not a treatment for hyperkalemia, although hypokalemia is a common side effect. Hemodialysis is a treatment for severe hyperkalemia but is not considered a first-line treatment.

Question 39

189. A 2-year-old male is brought to the emergency department by his frightened mother following the sudden onset of nasal stuffiness and a harsh, barking, nonproductive cough. The child does not appear significantly distressed. His temperature is 37.9°C (100.2°F) orally. Mild nasal flaring is present. The nasopharyngeal mucus appears mildly edematous and injected, and upper airway noises are heard, but good air movement is evident on auscultation of his chest.

Which one of the following is the most appropriate treatment for this patient?

A) A bedside humidifier

B) A single dose of oral dexamethasone

C) Amoxicillin for 7 days

D) Nebulizer treatment with racemic epinephrine

E) Tracheal intubation and oxygen administration

Answer 39

ANSWER: B

Croup is a common, self-limited illness caused by viral infection of the upper respiratory tract. The diagnosis is based primarily on the clinical history and examination findings. A history of the abrupt onset of a barking cough, inspiratory stridor, and hoarseness in a 2-year-old child is typical of croup, although it can present at any age between 6 months and 12 years. Low-grade fever, a barking cough, and varying degrees of respiratory distress (nasal flaring, retractions, or stridor) are typically present on examination. Findings such as a toxic appearance, wheezing, drooling, and difficulty swallowing are not consistent with the diagnosis.

Treatment of mild disease with a corticosteroid has proven benefit (SOR A) even when administered as a single oral dose (SOR B). Nebulized epinephrine has been shown to improve outcomes in children with moderate to severe croup (SOR A). Humidification therapy in the emergency department setting provides no benefit (SOR A). This child has mild croup and a single dose of dexamethasone (0.15–0.60 mg/kg, usually given orally) followed by close observation is the most appropriate treatment.

Question 40

190. Which one of the following outcomes is seen with intensive glycemic control in patients with type 2 diabetes mellitus?

A) Fewer hypoglycemic events

B) Improved blood pressure control

C) A delay in the development of macroalbuminuria

D) A reduced need for dialysis

E) Lower all-cause mortality rates

Answer 40

ANSWER: C

Intensive glycemic control in type 2 diabetes mellitus results in a reduced rate of progression to macroalbuminuria, which is an indicator of the development of diabetic nephropathy. Intensive glycemic control does not reduce the likelihood of dialysis, nor does it improve blood pressure control. Intensive control does increase the incidence of hypoglycemic events, which is particularly hazardous in the elderly. As was demonstrated in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, intensive glycemic control actually increases all-cause mortality.

Question 41

191. A 61-year-old truck driver is admitted to your service through the emergency department in the evening because of possible cellulitis. When you examine him in the morning he has blistering along his left forearm and dorsal hand that has not receded from the lines drawn in the emergency department. It is not erythematous or tender. He does not recall any injuries, insect bites, infections, or fever, and has been afebrile since admission. He denies pain in his arm, but does complain of itching.

Laboratory studies reveal a normal CBC and comprehensive metabolic panel, with the exception of an ALT (SGPT) level of 100 U/L (N 7–35) and an AST (SGOT) level of 75 U/L (N 10–34). The patient reports no significant past medical problems but has had similar blistering intermittently on the back of both hands that is worse in the summer. He admits to drinking alcohol heavily on the weekends when he is not driving and has smoked a pack of cigarettes per day for the last 45 years.

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

A) Intravenous antibiotics until clinical improvement is noted

B) Discharge on oral antibiotics

C) Total serum, plasma, or spot urine porphyrins

D) Ultrasonography of the arm to rule out an underlying abscess

E) Surgical consultation for possible debridement

Answer 41

ANSWER: C

Porphyria cutanea tarda (PCT) should be suspected in patients who present with blistering lesions on sun-exposed skin. Factors associated with increased susceptibility to PCT include those that cause liver damage, such as alcohol use and hepatitis C, as well as smoking, estrogen use, HIV infection, and HFE mutations. The initial test in suspected PCT should be total serum, plasma, or spot urine porphyrins. The clinical presentation of this patient is less consistent with cellulitis, which usually presents with erythema, pain, and warmth, and when severe may lead to fever and leukocytosis.

Question 42

192. An 8-year-old male is diagnosed with attention-deficit/hyperactivity disorder. Which one of the following is the most effective treatment?

A) Behavioral therapy

B) Atomoxetine (Strattera)

C) Bupropion (Wellbutrin)

D) Psychostimulants such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine)

E) a2-Receptor agonists such as guanfacine (Tenex)

Answer 42

ANSWER: D

Psychostimulants are the most effective medication option for treating attention-deficit/hyperactivity disorder (ADHD) and are widely accepted as first-line therapy. Behavioral therapy is recommended before considering medications for children under the age of 6, and may be considered for older children but may not add much benefit in this age group, particularly when there is a good response to medication. Atomoxetine and the a2-receptor agonist guanfacine are considered second-line agents because of lower effectiveness against core ADHD symptoms and a greater frequency of side effects. Bupropion has been used off-label for ADHD but is not FDA approved for this indication.

Question 43

193. A 17-year-old high school football player presents to your office with right fourth finger pain that began suddenly after he made a tackle during last night’s game. Pain and tenderness are greatest at the flexor crease of the distal interphalangeal (DIP) joint. He can fully flex the fourth metacarpophalangeal and proximal interphalangeal (PIP) joints. Flexion of the DIP is weak and cannot be held against applied resistance.

Which one of the following is most likely?

A) Rupture of the extensor tendon at the DIP

B) Rupture of the extensor tendon’s central slip at the PIP

C) Flexor digitorum profundus rupture

D) Rupture of both flexor tendons

Answer 43

ANSWER: C

This patient has ruptured the flexor digitorum profundus (FDP) tendon as a result of a sudden force applied to the distal phalanx while in flexion. This happens when catching the finger in an opponent’s jersey or belt loop while making a tackle, hence the name jersey finger. This injury is also seen in wrestlers.

The FDP attaches at the base of the distal phalanx while the flexor digitorum sublimis (FDS) attaches at the base of the middle phalanx. Thus, it can be determined by physical examination which tendon is injured, providing for early and accurate diagnosis and proper treatment. With the noninvolved fingers held in full extension, if the patient can flex the proximal interphalangeal (PIP) joint the FDS is intact. With rupture of the FDP, distal interphalangeal (DIP) joint flexion may still be weakly present, but the patient is unable to hold flexion against resistance and this maneuver elicits pain. With rupture of both flexor tendons, the patient is unable to flex either the PIP or the DIP joint. In the scenario presented, rupture of both flexor tendons is unlikely. Rupture of the extensor digitorum tendons may cause mallet finger at the DIP joint, or a boutonnière deformity of the PIP joint. Since many of these flexor tendon injuries require surgical exploration and repair, early orthopedic consultation is recommended.

Question 44

194. A 50-year-old female with no other significant past medical history undergoes a total vaginal hysterectomy because of uterine fibroids. She has a pulmonary embolism 2 weeks after the surgery.

How long should she remain on anticoagulant therapy?

A) 1 month

B) 3 months

C) 6 months

D) 9 months

E) Indefinitely

Answer 44

ANSWER: B

Anticoagulant therapy is the treatment for pulmonary embolism and should be started immediately. A rapid-acting parenteral anticoagulant (heparin, enoxaparin) or a direct orally active factor Xa inhibitor (rivaroxaban) should be started initially. After the initial treatment, the factor Xa inhibitor should be continued or the parenteral anticoagulant should be transitioned to an oral anticoagulant. Patients who develop a pulmonary embolism as a complication of a reversible factor have a low risk of recurrence when the anticoagulant therapy is stopped. A 3-month course of anticoagulant is adequate treatment.

Question 45

195. Risk factors for sudden infant death syndrome include which one of the following?

A) Side sleeping

B) Being large for gestational age at birth

C) A history of an apparent life-threatening event

D) Pacifier use

E) Asian or Pacific Islander ethnicity

Answer 45

ANSWER: A

Proper sleep position is highly important in reducing the risk of sudden infant death syndrome (SIDS). Side sleeping and prone sleeping increase the risk for SIDS (SOR A). Bed sharing also increases the risk. The “Back to Sleep” campaign of the American Academy of Pediatrics (AAP) was associated with a 53% decrease in the incidence of SIDS in the United States in the 1990s.

The use of pacifiers during sleep decreases the risk for SIDS, as does exclusive breastfeeding. The AAP recommends offering a pacifier for use during sleep for infants in whom breastfeeding is well established.

There are also multiple invariable risk factors for SIDS. These include male sex, Native American ethnicity, birth weight <2500 g, and birth before 37 weeks gestation. Large for gestational age infants are not at increased risk for SIDS, and infants of Asian or Pacific Islander ethnicity actually have a lower than average risk of SIDS. Apparent life-threatening events are not a risk factor for SIDS and are not related to SIDS (SOR B).

Question 46

196. An 86-year-old female presents to the emergency department with shortness of breath and a nonproductive cough. On examination she is slightly tachypneic and tachycardic but her temperature and blood pressure are normal. Bilateral crackles are noted on the pulmonary examination, but the cardiac examination is unremarkable. A chest radiograph shows bilateral fluffy infiltrates compatible with heart failure or pneumonia. A CBC, comprehensive metabolic panel, and troponin level are normal. Her EKG shows sinus tachycardia.

Which one of the following laboratory studies would be best to help determine whether the patient should be treated for pneumonia, heart failure, or both?

A) A serum D-dimer level

B) BNP and procalcitonin levels

C) Serial troponin and creatine phosphokinase levels

D) An erythrocyte sedimentation rate and C-reactive protein level

E) A serum lactic acid level

Answer 46

ANSWER: B

BNP is a sensitive marker for heart failure and procalcitonin is a reasonable marker for acute infection. Serum lactate is used to help assess the severity of hypoperfusion, or shock. The erythrocyte sedimentation rate and C-reactive protein level are not specific and would not be good discriminators in this case. Serial troponin and creatine phosphokinase can help rule out acute myocardial ischemia but would not help discriminate between heart failure and pneumonia. D-dimer is a marker for thromboembolism and is not relevant in this situation.

Question 47

197. A 52-year-old male runner with a long-standing history of essential hypertension presents for a follow-up visit. A review of his medical record shows blood pressure readings that are consistently 10–15 mm Hg above his goal. He is currently on hydrochlorothiazide, 25 mg/day, and is compliant with a low-sodium diet. An EKG is shown on the page at left.

Based on the EKG, which one of the following would be most appropriate?

A) A coronary calcium score

B) An exercise stress test

C) 24-hour Holter monitoring

D) Echocardiography

E) Coronary angiography

Answer 47

ANSWER: D

The diagnosis and treatment of left ventricular hypertrophy (LVH) in patients with hypertension is important, as it is associated with increased morbidity and mortality from heart failure, arrhythmias, and sudden cardiac death. LVH is often seen in patients with long-standing uncontrolled hypertension. If the sum of the S wave in lead V1 and the R wave in lead V5 or V6 is 35 mm or the R wave in aVL is 11 mm, it suggests the presence of LVH (Sokolow-Lyon indices). The sensitivity of an EKG for LVH ranges from 7% to 50%, however, so echocardiography is the test of choice to make the diagnosis. Echocardiography helps to directly visualize and quantify left ventricle wall size, in addition to providing other valuable information such as cardiac wall motion abnormalities, ejection fraction, and cardiac chamber dimensions. There is no primary role for the other tests listed in this setting (SOR B).

Question 48

198. A 28-year-old gravida 2 para 1 visits your office for routine prenatal care at 36 weeks gestation. Today she reports some mildly increased lower extremity edema without associated headache, visual changes, or right upper quadrant pain. She has not noticed any leaking amniotic fluid and has only had occasional mild uterine contractions. Her blood pressure has been normal at past visits, but on examination today it is 144/92 mm Hg. Repeat measurement confirms the blood pressure reading, and a urine dipstick shows trace protein. Her fundal height measures 36 cm, fetal heart tones have a rate of 134 beats/min, and Leopold’s maneuvers indicate that her fetus is in a cephalic position. Laboratory tests reveal a normal platelet count, normal transaminase and creatinine levels, and a normal urine protein/creatinine ratio.

Your plan at this time should include which one of the following?

A) Immediate induction of labor

B) Home blood pressure and symptom monitoring, and induction of labor at 37 weeks

gestation

C) Home blood pressure and symptom monitoring, weekly office visits and laboratory

evaluation, and induction of labor at 39 weeks gestation

D) Home blood pressure and symptom monitoring, weekly office visits and laboratory

evaluation, and induction of labor at 40 weeks gestation

E) Home blood pressure and symptom monitoring, weekly office visits and laboratory

evaluation, and induction of labor at 41 weeks gestation

Answer 48

ANSWER: B

This patient has gestational hypertension. She has no findings consistent with a diagnosis of preeclampsia, although she is now at risk for this condition. Current evidence suggests that, in the absence of preeclampsia with severe features (blood pressure >160/110 mm Hg, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, cerebral edema, or visual disturbance), pregnancy can safely be continued until 37 weeks gestation. At that point delivery is recommended in order to avoid the risks associated with gestational hypertension, which include abruption, intrauterine growth restriction, and progression to preeclampsia and eclampsia.

Question 49

199. A 35-year-old production worker has developed intermittent numbness and paresthesias in the first three fingers of her right hand since being moved to a new workstation 6 weeks ago. These symptoms usually occur mostly while she is working, but sometimes while she is driving or sleeping. She is asymptomatic when you see her in your office. Your examination reveals normal skin color, normal musculature, and no pain to palpation around the hand, wrist, and forearm. Holding the affected wrist in flexion for 30 seconds reproduces her symptoms.

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

A) Nerve conduction studies of the hand, wrist, and forearm

B) Arterial Doppler studies of the hand, wrist, and forearm

C) A Velcro compression strap to wear just below her right elbow while working

D) A cock-up wrist splint to wear during times that she is symptomatic

E) Referral for carpal tunnel release surgery

Answer 49

ANSWER: D

This patient has signs and symptoms of carpal tunnel syndrome. Her new task is likely causing inflammation and/or hypertrophy of the flexor tendons of the wrist and hand, which in turn are placing pressure on the median nerve within the closed space of the carpal tunnel. The use of a wrist splint and NSAIDs has been shown to reduce pain and should be tried along with exercises of the wrist and hand, and activity modification if possible. Nerve conduction studies are not recommended unless conservative management fails and carpal tunnel release is being considered.

Question 50

200. Which one of the following is the preferred first-line treatment for chronic midsubstance Achilles tendinopathy?

A) Oral NSAIDs

B) Oral corticosteroids

C) Local corticosteroid injection of the retrocalcaneal bursa

D) Eccentric strengthening of the gastrocnemius and soleus muscles

E) Tendinoplasty

Answer 50

ANSWER: D

The term Achilles tendinopathy reflects the chronic, noninflammatory, degenerative nature of this disorder as opposed to the traditional term tendinitis. Eccentric strengthening programs of the gastrocnemius and soleus muscles have demonstrated 60%–90% improvement in pain and function and are considered the first-line treatment for chronic midsubstance Achilles tendinopathy. Oral NSAIDs and oral corticosteroids are ineffective, and local corticosteroid injection in or near a load-bearing tendon such as the Achilles tendon increases the risk of tendon rupture. Surgical tendinoplasty is inconsistently beneficial and carries added risk, and is not a first-line treatment.