Questions 201-240

Question 1

240. Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved?

A) Waiting until lipase has normalized before beginning oral intake
B) Early initiation of a clear liquid diet
C) Early initiation of a low-fat diet
D) Early initiation of tube feeding
E) Early initiation of total parenteral nutrition

Answer 1

Item 240
ANSWER: C
Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.
Total parenteral nutrition should be avoided in patients with mild or severe acute pancreatitis. There have been multiple randomized trials showing that total parenteral nutrition is associated with infectious and other line-related complications.

Question 2

239. A 45-year-old male with diabetes mellitus sees you for the first time. If the patient has not previously received it, which one of the following vaccines is recommended for him by the Advisory Committee on Immunization Practices?

A) Hepatitis A
B) Hepatitis B
C) Meningococcal
D) Varicella zoster

Answer 2

Item 239
ANSWER: B
Late in 2012, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended hepatitis B vaccine for all previously unvaccinated adults between the ages of 19 and 59 with diabetes mellitus, as soon as possible after the diagnosis of diabetes is made. Vaccination should be considered for patients ≥ age 60, after assessing their risk and the likelihood of an adequate immune response.

Question 3

238. A 34-year-old female with a history of type 2 diabetes mellitus requests your advice regarding influenza vaccine. She is concerned because 6 months ago she developed hives after ingesting eggs and another physician suggested that she avoid influenza vaccine. She has not experienced wheezing, vomiting, or swelling in her throat after ingesting eggs.

Which one of the following would be the best strategy for this patient?

A) Avoid giving influenza vaccine
B) Administer the live-attenuated influenza vaccine and observe for 30 minutes
C) Administer trivalent inactivated vaccine and observe for 30 minutes
D) Have the patient take prednisone, 20 mg for 3 days, then administer the live-attenuated influenza vaccine and observe for 30 minutes
E) Have the patient take prednisone, 20 mg for 3 days, and then administer the trivalent inactivated vaccine and observe for 30 minutes

Answer 3

Item 238
ANSWER: C
For patients with a history of egg allergy who have experienced only hives, the Advisory Committee on Immunization Practices recommends influenza vaccination with inactivated vaccine rather than live-attenuated vaccine. The vaccine should be administered by a health care professional proficient in potential manifestations of egg allergy, and the patient observed for at least 30 minutes afterward. Persons who have had allergic reactions to egg proteins that include angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who required epinephrine or other emergency medical interventions, are more likely to have a systemic or anaphylactic reaction to the vaccine. A previous severe reaction to influenza vaccine is a contraindication to future vaccination. Prednisone is not appropriate as a preventive measure.

Question 4

237. As part of routine care for a 31-year-old female you obtain a Papanicolaou (Pap) test for cervical cancer screening. The cytology results are normal, and the sample is positive for the presence of HPV but negative for serotypes 16 and 18.

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

A) Immediate colposcopy
B) Repeat Pap and HPV testing in 3 months
C) Repeat Pap and HPV testing in 6 months
D) Repeat Pap and HPV testing in 1 year
E) Repeat Pap and HPV testing in 3 years

Answer 4

Item 237
ANSWER: D
According to the American Society for Colposcopy and Cervical Pathology, a Papanicolaou test with co- testing for HPV is the preferred cervical cancer screening strategy for women age 30–64. This is because despite negative cytology, women with oncogenic HPV are at higher risk for later CIN 3+ than women with negative HPV tests. The risk of CIN 3+ in HPV-positive but cytology-negative women is sufficient to justify an earlier return for retesting. However, most HPV infections are cleared spontaneously, which reduces the risk of CIN 3+, so observing patients to allow time for this to happen is an attractive option.

Guidelines must balance the risks arising from interventions for HPV that may clear spontaneously against the risks of disease. Women with HPV 16 are at particular risk for CIN 3+. HPV 18 merits special consideration because of its association with cervical adenocarcinomas, which are less efficiently detected by cytology than squamous cell cancers. The patient described here should be advised to return for co- testing in 1 year. If her cytology remains negative but her HPV test remains positive, she should be advised to have colposcopy at that time regardless of the serotype of the HPV. If her current test had shown evidence of either strain 16 or 18 immediate colposcopy would be indicated.

Question 5

236. A 51-year-old female has resistant hypertension, and you decide to test her for primary hyperaldosteronism.

Which one of the following is the preferred initial test for this condition?

A) A morning serum cortisol level
B) A morning serum renin to aldosterone ratio
C) A morning urinary potassium level
D) A salt suppression test
E) Abdominal MRI

Answer 5

Item 236
ANSWER: B
Primary hyperaldosteronism is a relatively common cause of resistant hypertension. Because there are effective treatments, it is reasonable to consider testing for hyperaldosteronism in patients with resistant hypertension. This is true even for patients with a normal potassium level. The preferred initial test is a morning renin to aldosterone ratio. A ratio less than 20 (when plasma aldosterone is reported in ng/dL and plasma renin activity is in ng/mL/hr) effectively rules out primary hyperaldosteronism. A ratio greater than or equal to 20 with a serum aldosterone level greater than 15 ng/dL suggests aldosteronism, but a salt suppression test must be done for confirmation. Although abdominal MRI may detect an adrenal mass, it is not recommended as a test for hyperaldosteronism. Urinary potassium levels do not play a role in the diagnosis of primary hyperaldosteronism.

Question 6

235. A 52-year-old male with diabetes mellitus reports that he ran out of insulin a week ago. He is drowsy but responds to your verbal commands, and the remainder of his examination is unremarkable.

Laboratory Findings
Bloodglucose. …………….625mg/dL
Serum sodium……………..128 mEq/L (N 135–145) Serum potassium…………………… 5.9 mEq/L (N 3.5–5.0) Serum bicarbonate …………………12 mEq/L (N 22–26)
BUN…………………………….. 52mg/dL(N8–25)

Which one of the laboratory abnormalities is an indication that he has severe diabetic ketoacidosis?

A) Glucose 
B) Sodium 
C) Potassium
D) Bicarbonate
E) BUN

Answer 6

Item 235
ANSWER: D
The diagnosis of diabetic ketoacidosis (DKA) is based on an elevated serum glucose level (greater than 250 mg/dL), an elevated serum ketone level, a pH less than 7.3, and a serum bicarbonate level less than 18 mEq/L. The severity of DKA is determined by the arterial pH, bicarbonate level, anion gap, and mental status of the patient. Elevation of BUN and serum creatinine levels reflects intravascular volume loss. The measured serum sodium is reduced as a result of the hyperglycemia, as serum sodium is reduced by 1.6 mEq/L for each 100 mg/dL rise in serum glucose. The degree of hyperglycemia does not necessarily correlate closely with the degree of DKA since a variety of factors determine the level of hyperglycemia, such as oral intake and urinary glucose loss (SOR C).

Question 7

234. A previously healthy 50-year-old male presents with a heart rate of 156 beats/min and a blood pressure of 126/84 mm Hg. An EKG shows a regular, narrow-complex tachycardia. Vagal maneuvers have no effect, and the patient appears anxious.

Administration of which one of the following medications is the best initial treatment?

A) Vasopressin (Pitressin)
B) Verapamil (Calan)
C) Diltiazem
D) Adenosine (Adenocard)
E) Digoxin

Answer 7

Item 234
ANSWER: D
Patients with persistent supraventricular tachycardias require immediate medical attention. A patient who has no underlying heart disease and a regular, narrow complex tachycardia should be treated with adenosine. If the patient does not respond to this treatment, cardioversion should be considered. Vasopressin would be useful if the patient were unstable with a ventricular tachycardia.

Question 8

233. A 54-year-old male presents to your office with a 10-day history of increasing cough. A physical examination reveals coarse crackles in the left lower lobe. You make a diagnosis of pneumonia. The patient’s only current medication is simvastatin (Zocor).

Which one of the following is CONTRAINDICATED in this patient?

A) Amoxicillin/clavulanate (Augmentin)
B) Azithromycin (Zithromax)
C) Clarithromycin (Biaxin)
D) Doxycycline
E) Levofloxacin (Levaquin)

Answer 8

Item 233
ANSWER: C
In older adults, coprescription of clarithromycin or erythromycin with a statin that is metabolized by CYP 3A4 (atorvastatin, simvastatin, lovastatin) increases the risk of statin toxicity. The other antibiotics listed do not interact with statins.

Question 9

232. A 65-year-old male comes to your office with symptoms consistent with intermittent claudication in both lower extremities. These symptoms are making it difficult for him to walk any significant distance and to manage his daily activities. He has smoked one pack of cigarettes per day for the past 40 years and has moderate hypertension, an elevated LDL-cholesterol level, and a low HDL-cholesterol level.

On examination you note that the skin on the patient’s lower legs is cool and shiny, with sparse hair. Distal pulses are not palpable and capillary refill is prolonged. His ankle-brachial index is 0.85 (N 1.0–1.4). His cardiac examination is normal, with no evidence of heart failure.

Which one of the following pharmacologic options for improving this patient’s claudication symptoms is supported by the best available evidence?

A) Aspirin
B) Warfarin (Coumadin)
C) Clopidogrel (Plavix)
D) Pentoxifylline
E) Cilostazol (Pletal)

Answer 9

Item 232
ANSWER: E
A trial of cilostazol is recommended by the American College of Cardiology and the American Heart Association as initial treatment for peripheral arterial disease (PAD) that limits the lifestyle of patients without heart failure (SOR A). Cilostazol has been shown to increase walking distance and improve health-related quality of life (level of evidence 2). Although neither aspirin nor clopidogrel improves claudication symptoms, antiplatelet therapy is recommended to reduce the risk of myocardial infarction, stroke, or vascular death in patients with symptomatic PAD. Warfarin has not been shown to improve cardiovascular outcomes in patients with PAD, but may increase bleeding without clinical benefit. The available evidence indicates that the benefit of pentoxifylline is marginal, and it is, at best, a second-line alternative to cilostazol.

Question 10

231. A 54-year-old male presents with hearing loss associated with tinnitus. Which one of the following additional characteristics would be an indication for MRI of the brain to assess for an intracranial tumor?

A) A rapid onset of symptoms
B) Unilateral symptoms
C) Association with pain and otorrhea in the affected ear
D) Exposure to loud noise shortly before the symptoms began

Answer 10

Item 231
ANSWER: B
Hearing loss and tinnitus are both common and typically benign complaints in primary care. If both are present in only one ear, the diagnosis of acoustic neuroma, also known as vestibular schwannoma, should be considered. Acoustic neuroma is a slow-growing benign tumor of the Schwann cells surrounding the vestibular cochlear (8th cranial) nerve. Hearing loss associated with acoustic neuroma is typically slow in onset. The presence of vertigo on the affected side is another symptom of abnormal function of the vestibular cochlear nerve and should further raise suspicion of acoustic neuroma or another process affecting that nerve. MRI is the preferred imaging study for diagnosing acoustic neuroma (SOR A). Bilateral hearing loss is more common and is less likely to be caused by an intracranial mass. Exposure to loud sounds can cause hearing loss unrelated to an intracranial mass. Pain and otorrhea suggest infection rather than an intracranial tumor.

Question 11

230. A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There is no history of a specific injury, and his past medical history is negative. He has had no fevers, night sweats, or weight loss, and the pain does not awaken him at night. He tried out for his school’s basketball team but had to quit because of the pain, which was worse when he tried to run.

Which one of the following physical examination findings would be pathognomonic for slipped capital femoral epiphysis?

A) Excessive forward passive motion of the tibia with the knee flexed
B) Lateral displacement of the patella with active knee flexion
C) Limited internal rotation of the flexed hip
D) Reduced hip abduction with the hip flexed
E) An inability to extend the hip past the neutral position

Answer 11

Item 230
ANSWER: C
Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt, when the femoral head is displaced posteriorly through the growth plate. Physical activity, obesity, and male sex are predisposing factors for the development of this condition. There is pain with physical activity, most commonly in the upper thigh anteriorly, but one-third of patients present with referred lower thigh or knee pain, which can make accurate and timely diagnosis more difficult.

The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected.

Hip extension and abduction are also limited in SCFE, but these findings are nonspecific. Displacement of the patella is not associated with SCFE.

Question 12

229. A 72-year-old female who remains very active and engaged in the community comes to your office concerned by urinary symptoms that disrupt her life. She reports that she often has a strong, abrupt desire to void that frequently causes her to leak urine involuntarily. She also reports occasional episodes of urinary frequency and nocturia.

Which one of the following is the first-line treatment for her condition?

A) Anticholinergic drugs such as oxybutynin or solifenacin (Vesicare)
B) B-Adrenergic agonists such as mirabegron (Myrbetriq)
C) Duloxetine (Cymbalta)
D) Bladder training
E) A pessary

Answer 12

Item 229
ANSWER: D
This patient suffers from urge urinary incontinence, defined as the loss of urine accompanied or preceded by a strong impulse to void. It may be accompanied by frequency and nocturia, and is common in older adults. Conservative therapies such as behavioral therapy, including bladder training and lifestyle modification, should be the first-line treatment for both stress and urge urinary incontinence (SOR C). Pharmacologic interventions should be used as an adjunct to behavioral therapies for refractory urge incontinence (SOR C). Vaginal inserts, such as pessaries, can be used for treating stress incontinence but not urge incontinence.

Question 13

228. Which one of the following is NOT a risk factor for stillbirth?

A) Smoking
B) Advanced maternal age
C) Congenital anomalies
D) Vigorous exercise
E) BMI >30 kg/m2

Answer 13

Item 228
ANSWER: D
Risk factors for stillbirth include advanced maternal age, smoking >1/2 pack of cigarettes a day, congenital anomalies, and a BMI >30 kg/m2. Excessive exercise has not been shown to increase the risk for stillbirth.

Question 14

227. A 62-year-old female presents to your office with diarrhea and signs and symptoms of dehydration. She has a temperature of 38.6°C (101.5°F) and a WBC count of 17,000/mm3 (N 5300–10,800). You admit her to the hospital, and a Clostridium difficile toxin assay is positive. Because of the severity of her infection, you initiate oral vancomycin (Vancocin), 125 mg 4 times daily. She has a poor clinical response and you decide to alter the antibiotic regimen to include intravenous coverage.

Which one of the following intravenous antibiotics would be most appropriate?

A) Ciprofloxacin (Cipro)
B) Imipenem/cilastatin (Primaxin)
C) Meropenem (Merrem)
D) Metronidazole
E) Vancomycin

Answer 14

Item 227
ANSWER: D
Metronidazole, vancomycin, and fidaxomicin are the three medications recommended for treatment of Clostridium difficile colitis infections. Only metronidazole is effective intravenously, because its biliary excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the bloodstream. Treatment for this condition with vancomycin and fidaxomicin is oral. Imipenem/cilastatin, ciprofloxacin, and meropenem have not been shown to be effective for C. difficile infection.

Question 15

226. A 45-year-old male who has been complaining of dyspnea undergoes pulmonary function testing. The results show an FEV1/FVC ratio of 85% and an FVC below the lower limits of normal.

Based on these results, which one of the following possible causes of dyspnea is most likely?

A) Asthma
B) Bronchiectasis
C) A1-Antitrypsin deficiency
D) COPD
E) Idiopathic pulmonary fibrosis

Answer 15

Item 226
ANSWER: E
This patient has a restrictive pattern on pulmonary function testing as evidenced by an FEV1/FVC ratio >70% and an FVC below the lower limits of normal. Of the diagnostic options listed, idiopathic pulmonary fibrosis is the only restrictive cause of lung disease. All of the other conditions listed are obstructive causes of lung disease.

Question 16

225. Staff members in your practice often complain about one of your patients. He exhibits odd behaviors and beliefs, and is always very anxious about his visit and about when he will be seen, despite long familiarity with your practice.

Which one of the following personality disorders best fits the description of this patient?

A) Antisocial 
B) Borderline 
C) Dependent
D) Narcissistic 
E) Schizotypal

Answer 16

Item 225
ANSWER: E
This patient most likely has schizotypal personality disorder. These patients have problems with social and interpersonal relationships, which are marked by significant anxiety and discomfort, and they also exhibit odd thinking, speech, and perceptions. This disorder is classified as being in the cluster A personality disorder group. Patients with disorders in this group exhibit odd or eccentric personalities, and the group includes paranoid, schizoid, and schizotypal personality disorders.

Cluster B disorders are characterized by dramatic, emotional, or erratic personalities, and include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C disorders include avoidant, obsessive-compulsive, and dependent personality disorders. Patients with disorders in this group exhibit mainly anxious or fearful behaviors.

Question 17

224. In which one of the following cardiac emergency cases should atropine be used?

A) Symptomatic Mobitz type II atrioventricular block
B) Cardiac arrest with pulseless electrical activity
C) Asystolic cardiac arrest
D) Acute cardiac ischemia and a heart rate less than 60 beats/min
E) Sinus bradycardia with hypotension

Answer 17

Item 224
ANSWER: E
The main use of atropine in cases of cardiac arrest is for symptomatic bradycardia. It has little effect with complete heart block and Mobitz type II atrioventricular block. It is not recommended or effective for cardiac arrest with pulseless electrical activity or in cases of asystole. It has been removed from these algorithms by the ACLS committee. During an acute myocardial infarction or acute cardiac ischemia, an increase in heart rate may increase the amount of ischemia.

Question 18

223. In a patient with chronic, severe, noncancer pain, which one of the following would be most appropriate for initial opioid therapy?

A) Buprenorphine (Buprenex)
B) Transdermal fentanyl (Duragesic)
C) Hydromorphone (Dilaudid)
D) Methadone (Dolophine)
E) Morphine

Answer 18

Item 223
ANSWER: E
Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive, and equivalent doses can be easily calculated if the patient must later be switched to another medication. Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not recommended as first-line therapy because they are expensive and can produce tolerance relatively quickly (SOR B). Methadone is another second-line option and tolerance is usually less of a problem. It is inexpensive and long-acting but also has unique pharmacokinetics. It has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Methadone can prolong the QT interval, especially in patients who are taking other QT-prolonging medications (SOR B). Buprenorphine is a partial opioid agonist that is usually used for treatment of patients with opioid addictions. Although it can be effective for treatment of pain, it is expensive and requires special prescriber training, so it is currently not recommended as a first-line agent for treatment of chronic pain (SOR C).

Question 19

222. A 54-year-old female concert pianist presents to your office with a 9-month history of searing pain and bilateral paresthesias in the distribution of her median nerve. She says that the pain frequently radiates as far as her shoulder, and that her fingers feel swollen even though they look normal. She states that she has worsening paresthesias at night and often finds herself flicking her wrist in an attempt to alleviate her symptoms.

The patient’s symptoms are reproducible with wrist flexion and she exhibits mild weakness of the abductor pollicis brevis on examination. She has been wearing neutral wrist splints at night for the last 8 weeks and has also been taking oral NSAIDs, resulting in only minimal relief. She is in the middle of her concert season and is unable to take time off for a surgical procedure.

Which one of the following therapies will provide this patient with the longest symptom relief?

A) Full rest for 8 weeks
B) Full-time cock-up splinting for 8 weeks
C) Physical therapy
D) Oral corticosteroids
E) Local corticosteroid injection

Answer 19

Item 222
ANSWER: E
This patient has carpal tunnel syndrome. Initial conservative approaches for mild to moderate symptom relief include full-time splinting for 8 weeks (SOR B) and oral corticosteroids. However, studies suggest that local corticosteroid injections offer symptom relief for 1 month longer than oral corticosteroid therapy and some individuals experience relief for up to 1 year. Severe or chronic symptoms usually require surgical intervention for nerve decompression. Physical therapy is not recommended, and full rest is unlikely in a person in a high-risk occupation for overuse syndromes.

Question 20

221. A 72-year-old white female is admitted to the hospital with her first episode of acute heart failure. She has a history of hypertension treated with a thiazide diuretic. An echocardiogram reveals no evidence of valvular disease and no segmental wall motion abnormalities. Left ventricular hypertrophy is noted, and her ejection fraction is 55%. Her pulse rate is 72 beats/min.

The most likely cause of her heart failure is

A) systolic dysfunction
B) diastolic dysfunction
C) hypertrophic cardiomyopathy
D) high-output failure

Answer 20

Item 221
ANSWER: B
Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic hypertension, left ventricular hypertrophy, and a normal ejection fraction (50%–55%).

Question 21

220. A 46-year-old perimenopausal female complains of hot flashes, which are very troubling to her. She would like treatment for these symptoms, but has a history of deep vein thrombosis while taking oral contraceptives.

Which one of the following treatments has evidence of benefit for her symptoms with the least potential for causing deep vein thrombosis?

A) Vaginal estradiol
B) Oral estradiol combined with progestin
C) Oral phytoestrogens such as soy protein
D) Oral venlafaxine (Effexor XR)
E) Topical bio-identical hormones

Answer 21

Item 220
ANSWER: D
Vasomotor symptoms associated with menopause are best controlled with oral or topical estrogens. However, one of the known risks of systemic estrogen treatment is an increased rate of developing deep vein thrombosis (DVT). This risk is not lessened by the addition of progestin. Bio-identical hormones are not FDA-regulated and are highly variable in their hormonal potency. For this reason their efficacy and safety cannot be determined. Vaginal estrogen treatment results in very little circulating estrogen. Its use has not been associated with venous thrombosis, but it does not provide relief from vasomotor symptoms. A Cochrane meta-analysis reviewed multiple small studies using phytoestrogens and found no benefit for control of menopausal symptoms.

Oral SSRIs and SNRIs, including venlafaxine, are effective for menopausal vasomotor symptoms, and paroxetine is FDA-approved for this purpose without an associated risk for developing a DVT. Other nonhormonal treatments that have evidence of benefit include gabapentin and clonidine.

Question 22

219. CT imaging for which one of the following conditions is best done without contrast?

A) Acute appendicitis
B) Diverticulitis
C) Pulmonary embolism
D) Nephrolithiasis

Answer 22

Item 219
ANSWER: D
Common indications for CT without contrast include suspected stroke within the first 3 hours of symptom onset; closed head injury; diffuse lung disease; chronic dyspnea; soft-tissue swelling, infection, or trauma of the extremities; suspected kidney stone; and suspected spinal trauma. Evaluation using contrast-enhanced CT is indicated in the following common scenarios: acute appendicitis, cancer staging, diverticulitis, suspected complications of inflammatory bowel disease, pancreatitis, and suspected pulmonary embolism.

Question 23

218. Which one of the following tests is recommended for the detection and diagnosis of gestational diabetes mellitus?

A) Hemoglobin A1c
B) Fasting blood glucose
C) 2-hour postprandial glucose
D) An oral glucose tolerance test
E) A fasting insulin/glucagon ratio

Answer 23

Item 218
ANSWER: D
In pregnant women not known to have diabetes mellitus, screening for gestational diabetes mellitus should be done at 24–28 weeks gestation. There are two acceptable screening strategies. The one-step 2-hour 75-g oral glucose tolerance test should be performed in the morning after a minimum 8-hour fast. The diagnosis of gestational diabetes mellitus is made if the fasting plasma glucose level is ≥92 mg/dL, if the level at 1 hour is ≥180 mg/dL, or if the level at 2 hours is ≥153 mg/dL.

A two-step approach may also be used, consisting of a nonfasting 1-hour 50-g oral glucose tolerance test. If the 1-hour glucose level is ≥140 mg/dL, a 3-hour 100-mg glucose tolerance test should be performed. (ACOG recommends 135 mg/dL in ethnic minorities with a higher risk of diabetes mellitus, and some experts recommend 130 mg/dL.) The 3-hour test should be performed when the patient is fasting. A diagnosis of gestational diabetes is made when at least two of the following four plasma glucose levels are met or exceeded:

              Carpenter/Coustan       National Diabetes Group Fasting      95 mg/dL                       105 mg/dL 1h               180 mg/dL                      190 mg/dL 2h              155 mg/dL                      165 mg/dL 3h              140 mg/dL                      145 mg/dL

Women with risk factors for diabetes mellitus should also be screened for undiagnosed diabetes at their first prenatal visit.

Question 24

217. A 45-year-old male with Down syndrome is brought to your office because of complaints of increased aggression toward the staff and peers at his group home. He is usually pleasant and compliant but he has been acting out for the last 2 1/2 weeks. He is not considered to be a danger to himself or others at this point. He is minimally verbal and unable to give a history for himself. Staff members report no change in appetite or urination, and no signs of outward illness. His vital signs in your office are within normal limits.

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

A) A complete history, physical examination, and basic laboratory tests
B) CT of the head
C) Risperidone (Risperdal)
D) Sertraline (Zoloft)
E) Valproic acid (Depakene)

Answer 24

Item 217
ANSWER: A
In mentally handicapped patients it is important to avoid the use of psychotropic medications for managing new behaviors until an attempt has been made to rule out potential medical and environmental causes, except in patients with a high potential for harm to themselves or others. The underlying cause of behaviors may be an undiagnosed medical condition, such as tooth pain, a urinary tract infection, or an electrolyte disturbance. It is also important to consider environmental factors such as loss of a regular staff member, a change in living environment, or family dynamics. If pharmacologic intervention is deemed necessary the treatment should be aimed at minimizing emotional trauma and maximizing community integration. Medication to restrict behaviors should not be used on a long-term basis. The history in this patient does not suggest that imaging is needed.

Question 25

216. A 2-month-old female is brought to your office with tachypnea and a staccato cough. She is afebrile. A chest radiograph shows hyperinflation and bilateral infiltrates, and a CBC reveals eosinophilia.

Which one of the following is the most likely etiologic agent?

A) Chlamydia trachomatis
B) Listeria pneumoniae
C) Streptococcus pneumoniae
D) A gram-negative bacteria
E) Respiratory syncytial virus

Answer 25

Item 216
ANSWER: A
This infant has the typical findings of chlamydial pneumonia, which usually develops 1–3 months after birth and should be suspected in a young infant who has tachypnea, a staccato cough, and no fever (SOR A). Radiographs often show hyperinflation and infiltrates, and a CBC will reveal eosinophilia.

Question 26

215. Which one of the following is a common cause of prerenal acute kidney injury?

A) Acute tubular necrosis
B) Diuretic overuse
C) Glomerulonephritis
D) Neurogenic bladder
E) Prostate hypertrophy

Answer 26

Item 215
ANSWER: B
The diagnosis of acute kidney injury (AKI) is based on elevated serum creatinine levels and is often associated with a reduction in urine output (SOR C). The causes of AKI are commonly divided into three categories: prerenal, intrinsic renal, and postrenal (SOR C). Prerenal AKI is most commonly due to decreased renal perfusion, often because of volume depletion. In addition to vomiting and diarrhea, overuse of diuretics can lead to prerenal AKI. Intrinsic renal AKI is caused by a process within the kidneys. Glomerulonephritis and acute tubular necrosis are types of intrinsic AKI. Postrenal AKI refers to a process distal to the kidneys and is most often caused by inadequate drainage of urine. Neurogenic bladder and prostate hypertrophy contribute to extrarenal obstruction.

Question 27

214. You are caring for a 60-year-old female with Crohn’s disease that is well controlled by infliximab (Remicade). As your staff updates her immunization status, which one of the following should be kept in mind?

A) Hepatitis A vaccine is contraindicated
B) Pneumococcal vaccine is contraindicated
C) Tetanus toxoid is contraindicated
D) Zoster vaccine is contraindicated
E) All routine immunizations are considered safe

Answer 27

Item 214
ANSWER: D
Zoster vaccine, a live attenuated virus vaccine, is contraindicated in this patient due to her immunocompromised state. The other vaccines listed are safe and particularly recommended for patients with inflammatory bowel disease, given their increased susceptibility to infections.

Immunosuppression is defined as:

• Treatment with glucocorticoids (treatment with the equivalent of 20 mg/day of prednisone for 2 weeks or more, and discontinuation within the previous 3 months)
• Ongoing treatment with effective doses of 6-MP/azathioprine or discontinuation within the previous 3 months
• Treatment with methotrexate or discontinuation within the previous 3 months
• Treatment with infliximab or discontinuation within the previous 3 months
• Significant protein-calorie malnutrition

Question 28

213. A 76-year-old female presents with a history of bilateral shoulder pain for the past month. She reports stiffness in the morning for about 1 hour and also reports difficulty getting up when seated in a chair. Acetaminophen is ineffective for her pain. Her erythrocyte sedimentation rate is 65 mm/hr (N 1–25).

Which one of the following is the best initial treatment for this condition?

A) Oral dexamethasone, 8 mg twice a day
B) Oral methylprednisolone (Medrol Dosepak), taper 24 mg to 0 mg over 7 days
C) Oral prednisolone (Orapred), 60 mg daily
D) Oral prednisone, 15 mg/day
E) Intravenous methylprednisolone, 120 mg every 6 hours

Answer 28

Item 213
ANSWER: D
This patient has polymyalgia rheumatica, based on her history and elevated erythrocyte sedimentation rate. The initial treatment is prednisone, 15 mg per day with a slow taper over 1–2 years (SOR C). Alternative treatment includes intramuscular methylprednisolone, 120 mg every 3 weeks.

Question 29

212. A 72-year-old male with dyslipidemia and coronary artery disease sees you for a routine evaluation. He asks if he should take fish oil supplements.

You advise the patient that good evidence shows that supplementation with omega-3 fatty acids decreases

A) triglycerides
B) LDL-cholesterol
C) cardiovascular events
D) total mortality

Answer 29

Item 212
ANSWER: A
Level A evidence shows that supplementation with fish oil (omega-3 fatty acids) decreases triglycerides and very low–density lipoprotein (VLDL cholesterol) but can increase LDL-cholesterol. Treatment with fish oil has not been shown to decrease cardiovascular events, total mortality, or cancer incidence.

Question 30

211. A 40-year-old male is admitted to the hospital with a generalized rash consistent with Stevens-Johnson syndrome. His previous medical problems include obesity, gout, hypertension, type 2 diabetes mellitus, and depression. His medications include lisinopril (Prinivil, Zestril), allopurinol (Zyloprim), colchicine (Colcrys), metoprolol succinate (Toprol-XL), metformin (Glucophage), and venlafaxine (Effexor XR).

Which one of these medications is most likely to be the cause of his Stevens-Johnson syndrome?

A) Allopurinol 
B) Colchicine 
C) Lisinopril
D) Metformin 
E) Venlafaxine

Answer 30

Item 211
ANSWER: A
Stevens-Johnson syndrome is a rare, potentially life-threatening condition. There are many potential causes, including infection, vaccines, systemic disease, physical agents, food, and drugs. Allopurinol is the only drug listed that is a potential causative agent. Other drugs commonly cited as causes include antibiotics, antiepileptics, and NSAIDs. Of these, antibiotics are the most common alleged cause of Stevens-Johnson syndrome.

Question 31

210. A 6-year-old male is brought to your office for a well child check. His vital signs are normal; he is 117 cm (46 in) tall and weighs 19 kg (42 lb). The patient has grown out of his car seat, and his mother recently was told by a friend that he can now sit in the front seat of a car. She asks you if this is true.

According to recommendations from the American Academy of Pediatrics, which one of the following is true for this patient?

A) He should be using a rear-facing child safety seat in the back seat of the car
B) He should be using a belt-positioning booster seat in the back seat of the car
C) He should be using a belt-positioning booster seat and can ride in the front or back seat
of the car
D) He no longer needs a safety seat but should always ride in the back seat of the car
E) He no longer needs a safety seat and can ride in the front or back seat of the car

Answer 31

Item 210
ANSWER: B
Children who reach the weight or height limit of their forward-facing child safety seat should use a belt-positioning booster seat until the seat belt fits properly, typically when the child is 145 cm (57 in) tall and between 8 and 12 years of age (SOR C). All children younger than 13 years should ride in the rear seats of vehicles for optimal protection (SOR C). All infants and toddlers should ride in a rear-facing child safety seat until they are 2 years of age or until they reach the weight or height limit recommended by the seat’s manufacturer (SOR C).

Question 32

209. A 32-year-old female comes to your office because she has had increasing difficulty performing her daily tasks for the past 6 months. She says she worries excessively about routine events every day and constantly feels tense, restless, jittery, “on edge,” irritable, and unable to relax. She also reports that sometimes her heart pounds and races, her hands feel sweaty and clammy, and her mouth feels like it is “full of cotton.” She reports difficulty concentrating and falling asleep at night. A recent TSH level was normal. During your examination you note frequent sighing, a fine tremor in her hands, bitten nails, and clammy hands.

Based on her symptoms and examination, which one of the following pharmacologic agents for managing her condition is supported by the best available evidence?

A) Alprazolam (Xanax)
B) Buspirone
C) Hydroxyzine
D) Escitalopram (Lexapro)
E) Quetiapine (Seroquel)

Answer 32

Item 209
ANSWER: D
This patient’s symptoms and examination meet the diagnostic criteria for generalized anxiety disorder. Based on the best evidence, pharmacologic agents that are beneficial for treating generalized anxiety disorder in adults include antidepressants such as imipramine, duloxetine, paroxetine, sertraline, escitalopram, and venlafaxine. Buspirone and hydroxyzine are likely to be beneficial but are supported by less convincing evidence and can have unpleasant adverse effects. The antipsychotics and benzodiazepines must be evaluated in terms of trade-offs between benefits and harms. Quetiapine is approved for use in adults as add-on treatment in major depressive disorder for patients who do not have an adequate response to antidepressant therapy alone, for acute depressive episodes in bipolar disorder, for acute manic or mixed episodes in bipolar disorder either alone or with lithium or divalproex, for long-term treatment of bipolar disorder with lithium or divalproex, and for schizophrenia.

Question 33

208. Which one of the following is most appropriate in the management of frostbite?

A) Complete surgical debridement of hemorrhagic blisters
B) Rapid rewarming with dry heat and warm blankets
C) Withholding analgesics to ensure accurate assessment
D) Vigorously rubbing affected tissues to restore circulation
E) Leaving simple, non-tense areas of clear blistering intact

Answer 33

Item 208
ANSWER: E
Because of an increased risk of infection, simple non-tense areas of clear blistering in a frostbitten patient are best left intact. Tense or hemorrhagic blisters may be carefully aspirated, but only under sterile conditions. Rapid rewarming of affected areas is best done in a whirlpool bath containing a mild antiseptic at 40°C–41°C. Freezing injuries are extremely painful and analgesics are indicated. Vigorous rubbing of affected tissue is contraindicated, as it may lead to further tissue loss.

Question 34

207. A 3-week-old male is brought to your office because of a fever and increasing fussiness. He had a rectal temperature at home earlier today of 101.5°F (38.6°C). The mother reports that he is not breastfeeding as often as usual and has had fewer wet diapers. He has no nasal congestion and no cough. There are no recent sick contacts or known exposures.

On examination you note a fever of 39.2°C (102.5°F) and a pulse rate of 200 beats/min. The remainder of his examination is normal. You order a full sepsis workup and admit him to the hospital.

Which one of the following is the best intravenous antibiotic regimen for empiric coverage at this point?

A) Ampicillin and cefotaxime (Claforan)
B) Ampicillin and clindamycin (Cleocin)
C) Ciprofloxacin (Cipro)
D) Gentamicin
E) Vancomycin

Answer 34

Item 207
ANSWER: A
Any child younger than 29 days with a fever should undergo a complete sepsis workup and be admitted for observation until culture results are obtained or the source of the fever is found and treated (SOR A). The most common bacterial organisms in this age group are group B Streptococcus and Escherichia coli. However, many other pathogens have been known to cause sepsis; therefore, broad empiric coverage with ampicillin and cefotaxime is recommended (SOR B). Gentamicin is commonly used, but should be used in combination with ampicillin. Vancomycin is not recommended as first-line treatment unless the child has evidence of a soft-tissue infection suspected to be methicillin resistant (SOR C). Ciprofloxacin and clindamycin are not indicated treatments in this case.

Question 35

206. Stretching has NO demonstrable benefit for which one of the following?

A) Hamstring strain
B) Chronic neck pain
C) Joint contracture
D) Osteoarthritis
E) Rehabilitation post knee replacement

Answer 35

Item 206
ANSWER: C
Stretching is often included in comprehensive treatment programs for musculoskeletal injuries and chronic conditions, making the determination of how much of the benefit is derived specifically from the stretching component difficult. Trials using different stretching techniques have demonstrated measurable benefit from a tailored stretching program for each of the options listed, with the exception of joint contracture. This mobility-impairing condition results from post-healing shortness of noncontractile tissues that are not easily released with stretching.

When applied to healing tissues, stretching is thought to increase muscle length and align collagen fibers, thereby increasing range of motion and flexibility post healing. A program that includes static, dynamic, and proprioceptive neuromuscular facilitation (PNF) stretching increases range of motion post knee replacement. Static and PNF stretching increases range of motion in osteoarthritis of the knee. A program of precontraction and static stretching increases hamstring flexibility following a strain. A yearlong stretching program for relief of chronic neck pain has been shown to have a benefit equal to that of strengthening exercises or manual therapy.

Question 36

205. A 25-year-old female with asthma uses her albuterol (Proventil, Ventolin) inhaler only before running, but reports waking up short of breath four times per month. She went to the emergency department recently for increased dyspnea during peak ragweed season and remained overnight until her symptoms improved.

Which one of the following is the best treatment option now?

A) Oral prednisone as needed
B) Inhaled albuterol daily
C) Inhaled cromolyn sodium daily
D) Inhaled salmeterol (Serevent Diskus) daily
E) Inhaled fluticasone (Flovent) daily

Answer 36

Item 205
ANSWER: E
Patients with mild asthma are often undertreated. Constant inhaled corticosteroids improve both asthma control and quality of life. Inhaled albuterol is useful as a quick treatment for acute symptoms in patients with mild asthma. Oral prednisone causes many side effects and is best for chronic use in patients whose symptoms are not controlled by other means. Cromolyn sodium has a good side-effect profile, but is not as effective as inhaled corticosteroids. Inhaled salmeterol, when used chronically, increases the risk of asthma-related death.

Question 37

204. A 21-year-old male college student presents to the emergency department with a 2-day history of fever, severe muscle and joint pain, nausea, and vomiting. He spent his winter break traveling in South America and returned 4 days ago. On examination he has a temperature of 39.4°C (103.0°F), gingival bleeding, lower extremity non-pitting edema, right upper quadrant tenderness, a diffuse maculopapular rash, muscle tenderness, and petechiae on his extremities.

WBCs …………………………………… 3100/mm3 (N4300–10,800)
Neutrophils ………………………. 40% (N 45–75)
Lymphocytes. ……………………. 50% (N 16–46)
Bands ……………………………….. 1% (N 0–5)
Hematocrit……………………………… 50.0% (N 37.0–49.0)
Platelets…………………………….. 75,000/mm3 (N150,000–350,000)
Thick and thin blood smear…….negative
AST(SGOT)……………………………… 100U/L(N10–40)
ALT(SGPT)……………………………….. 120U/L(N7–30)
Total bilirubin…………………………… 1.0 mg/dL (N 0.0–1.0)
Albumin……………………………… 3.5 g/dL (N 3.1–4.3)
Creatinephosphokinase………….500U/L(N60–400)

Which one of the following is the most likely diagnosis?
A) Hepatitis A
B) Yellow fever
C) Dengue fever
D) Typhoid fever
E) Influenza

Answer 37

Item 204
ANSWER: C
This patient has symptoms consistent with dengue fever, which is endemic in more than 100 tropical countries. Dengue fever should always be suspected in patients returning from an endemic area with spiking fevers and leukopenia. The dengue virus is an arbovirus that is transmitted by the Aedes mosquito. The incubation period is typically 4–8 days (range 3–14). Some patients with dengue fever may be asymptomatic or have a mild febrile illness, but it can also be very severe and manifest as dengue hemorrhagic fever or dengue shock syndrome. Dengue hemorrhagic fever is defined by thrombocytopenia, hemorrhagic manifestations, and plasma leakage.

Patients with dengue fever may have leukopenia, thrombocytopenia, hemoconcentration, elevated CPK, and elevated liver enzymes. Treatment consists of supportive care and avoidance of NSAIDs and aspirin due to their anticoagulant properties. There is no vaccine. The best way to prevent dengue is to wear protective clothing, use bed nets, and apply repellents containing 30%–50% DEET.

The presentation of yellow fever is very similar to dengue, but it is usually associated with elevated bilirubin levels and jaundice. Typhoid fever has a presentation similar to that of a number of diseases. It has a gradual onset of fever that rises in a stepwise fashion. Other symptoms include headache, arthralgias, pharyngitis, constipation, anorexia, and abdominal pain. As the disease progresses a number of other symptoms may develop, including skin lesions. Influenza can have a clinical presentation similar to dengue fever but does not cause thrombocytopenia and hemorrhagic manifestations. Hepatitis A presents with anorexia, nausea and vomiting, fatigue, malaise, myalgias, and a low-grade fever. It then usually progresses to an icteric phase characterized by dark urine, pale stools, and jaundice.

Question 38

203. A 23-year-old male presents to your office with a 2-day history of dull, achy, right testicular pain. He reports that the pain began gradually, reaching a peak last night. He does not recall any trauma and denies any urethral complaints.

Your examination reveals an extremely tender right testis with some tenderness extending to the epididymis. A preliminary report from a stat ultrasound examination shows an enlarged, heterogeneous right testis with increased color flow.

Which one of the following is the preferred management?

A) Watchful waiting
B) Repeat ultrasonography in 24 hours
C) Antibiotic treatment
D) Emergent urology referral

Answer 38

Item 203
ANSWER: C
Acute epididymitis is often the result of descending infection caused by urinary tract pathogens. When the infection involves the epididymis and testis (epididymo-orchitis), sonography will frequently show an enlarged heterogeneous testis with increased color flow.

In sexually active men under age 35, acute epididymitis is caused most frequently by Chlamydia trachomatis and less commonly by Neisseria gonorrhoeae. Clinical features suggestive of urethritis may be absent (subclinical urethritis). Epididymitis in men who have practiced unprotected insertive rectal intercourse is often caused by Enterobacteriaceae. These men usually do not have urethritis but do have bacteriuria. Treatment of acute epididymo-orchitis consists of administering appropriate antibiotics for the treatment of both gonorrhea and Chlamydia infections. Additional antibiotic coverage may be indicated based on the patient’s sexual history.

Unilateral absent flow on color and spectral Doppler sonography is a highly sensitive and specific finding in acute testicular torsion and emergent urology referral is indicated. Heterogeneous echotexture of the testis is a common finding in sonograms performed to evaluate acute scrotal pain, regardless of the cause. There is no role for repeat ultrasonography or watchful waiting in patients with acute epididymo-orchitis (SOR C).

Question 39

202. A 66-year-old male sees you for follow-up after a recent hospitalization for his second episode of diverticulitis in the past 3 years. He is currently in excellent health and takes no daily medications except for occasional acetaminophen for arthritis pain. His physical examination is unremarkable except for a BMI of 19.0 kg/m2. He asks you about preventing further recurrences of his diverticulitis.

You suggest that he do which one of the following?

A) Lose weight
B) Increase his dietary fiber intake
C) Stop acetaminophen use
D) Avoid eating nuts, corn, or popcorn
E) Avoid high-impact aerobic exercise

Answer 39

Item 202
ANSWER: B
Increased intake of dietary fiber and increased exercise have been shown to prevent recurrences of diverticulitis (SOR B). Weight loss has been shown to be effective in persons with a body mass index of 30 kg/m2 or higher but this patient is underweight and should not be counseled to lose weight (SOR B). There is no evidence that avoiding nuts, corn, or popcorn decreases the risk of diverticulitis (SOR B). Risk factors for diverticulitis include the use of NSAIDs, but not acetaminophen.

Question 40

201. A 38-year-old female presents with an itchy rash she says has been present for the past several months. She has been using over-the-counter hydrocortisone cream with no improvement. On examination she has an oval 12-cm erythematous plaque on her buttocks. The plaque is covered with silvery scales.

Which one of the following would be the best initial treatment for her rash?

A) Clobetasol 0.05% cream (Temovate) applied twice daily
B) Clotrimazole 1% cream applied twice daily
C) Diclofenac 3% gel applied twice daily
D) Mupirocin 2% ointment (Bactroban) applied twice daily
E) Salicylic acid 2% gel applied twice daily

Answer 40

Item 201
ANSWER: A
This patient has mild plaque psoriasis. Topical corticosteroids, vitamin D analogs, and tazarotene are effective treatments for mild psoriasis (SOR A). Antimicrobials, anitfungals, diclofenac, and salicylic acid are not effective treatments.