Questions 201-240

Question 1

201. A 22-year-old female has a 4-month history of suprapubic pain, urinary frequency, urinary urgency, dysuria, and dyspareunia. She has been empirically treated with antibiotics for a urinary tract infection despite the fact that multiple urine tests have been negative for infection or other abnormalities. You suspect the patient has interstitial cystitis.

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

A) Fluoxetine (Prozac)
B) Ibuprofen
C) Nitrofurantoin (Macrobid)
D) Pentosan polysulfate sodium (Elmiron)
E) Trimethoprim/sulfamethoxazole (Bactrim, Septra)

Answer 1

ANSWER: D

The only FDA-approved oral medication for the treatment of interstitial cystitis is pentosan polysulfate sodium, which is thought to repair the urothelium (SOR B). Trimethoprim/sulfamethoxazole and nitrofurantoin are indicated for urinary tract infections (UTIs), but usually not in cases of cystitis with no infection. In addition, this patient has already received empiric treatment for a UTI despite having multiple negative urine cultures. Ibuprofen is an anti-inflammatory medication commonly used to treat pain but is not specifically indicated for interstitial cystitis. While tricyclic antidepressants such as amitriptyline have been used to treat interstitial cystitis, fluoxetine is not generally recommended.

Question 2

202. Which one of the following is a risk factor for depression during pregnancy?

A) High socioeconomic status
B) Nonsmoking
C) Age over 25
D) A family history of hyperthyroidism
E) Childhood abuse

Answer 2

ANSWER: E

A previous history of depression is the strongest risk factor for depression during pregnancy. Other risk factors include childhood abuse, smoking, age under 20, and low socioeconomic status, especially without social support. A family history of hyperthyroidism is not a risk factor.

Question 3

203. A 62-year-old female presents with painful lesions at both corners of her mouth characterized by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth. She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it has not helped.

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

A) A biopsy of the lesions
B) An anticandidal medication
C) Bacitracin
D) Vitamin B12

Answer 3

ANSWER: B

This patient has perlèche, or angular cheilitis. Most cases are secondary to moisture from patients licking their lips, promoting a monilial or staphylococcal infection. Other causes include contact and irritant dermatitis. Underlying HIV infection, celiac disease, or vitamin B12 and iron deficiencies have also been reported. Treatment may include appropriate topical creams such as mupirocin or antifungal agents, or low-potency nonfluorinated corticosteroid creams for irritant or contact causes.

Question 4

204. A 40-year-old male presents with right eye pain and redness. There is no history of trauma or injury.

Which one of the following should be done initially?

A) Irrigation
B) Funduscopic examination
C) Visual acuity testing
D) Fluorescein staining
E) Application of a local anesthetic

Answer 4

ANSWER: C

Almost all patients with ocular problems should have visual acuity testing before anything else is done (level of evidence 3, SOR A). If this is difficult, a local anesthetic may be applied. The main exception to this rule is a chemical burn of the eye, which should be irrigated for 30 minutes before further evaluation or treatment is undertaken.

Question 5

205. While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He began treating himself with an over-the-counter topical hydrocortisone cream, and when the eruption did not improve after 24 hours of treatment he sought help from the local emergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face.

The most appropriate management at this time would be to

A) prescribe a superpotent topical corticosteroid
B) repeat the oral methylprednisolone treatment
C) begin diphenhydramine (Benadryl), 4 times a day
D) begin high-dose oral prednisone and taper over 2 weeks
E) discontinue all medications and recommend cool compresses

Answer 5

ANSWER: D

Systemic corticosteroids are recognized for their dramatic impact on both the subjective and objective course of poison ivy dermatitis. Oral prednisone at an initial dosage of 1 mg/kg/day tapered over 14–21 days is the standard regimen. Complications can result from the use of shorter prepackaged courses of corticosteroid therapy, resulting in significant rebound flares. These products usually begin with an initial dosage approximately half that of the recommended dosage, with the course tapering too rapidly. Over-the-counter topical hydrocortisone is ineffective for all but the mildest cases, and once the disease is established, superpotent topical corticosteroids do little to alter the overall course and natural history. Antihistamines and compresses provide some symptomatic relief, but do little to alter the course of established disease.

Question 6

206. A 56-year-old male sees you for a health maintenance visit. He inquires about the options for colon cancer screening. He has not had any screening tests performed in the past and has no personal or family history of colon cancer. You tell him that there are several alternatives, but according to the U.S. Preventive Services Task Force, recommendations regarding the optimal screening intervals vary by test. He opts for fecal occult blood testing.

You recommend he repeat this test at which one of the following intervals?

A) Yearly
B) Every 5 years
C) Every 7 years
D) Every 10 years
E) Never, if the results are negative

Answer 6

ANSWER: A

The U.S. Preventive Services Task Force recommends that all adults be screened for colon cancer beginning at age 50 and continue regular screening until age 75 (SOR A). They recommend against continued routine screening in previously screened adults 75–85 years of age and against any screening in adults over 85 (SOR A). Most organizations do not recommend a particular screening method, but instead list screening options, including fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy. The recommended interval for fecal occult blood testing is every year. There is new evidence based on randomized, controlled trials that participation and detection rates for advanced adenomas and cancer are higher for immunochemical fecal testing than for stool guaiac testing (SOR A). As long as results are normal, screening colonoscopy is recommended at 10-year intervals and screening sigmoidoscopy at 5-year intervals.

Question 7

207. Which one of the following is the leading cause of death among adolescents age 12–19 in the United States?

A) Accidents
B) Suicide
C) Homicide
D) Cancer
E) Heart disease

Answer 7

ANSWER: A

Teenage mortality is an important public health issue because the majority of deaths among teenagers are caused by external causes of injury such as accidents, homicide, and suicide. The leading causes of death for the teenage population remained constant throughout the period 1999–2006: accidents (48% of deaths), homicide (13%), suicide (11%), cancer (6%), and heart disease (3%). Motor vehicle accidents accounted for 73% of all deaths from unintentional injury.

Question 8

208. An 80-year-old female who lives independently at home is admitted to the hospital with acute pyelonephritis. When she is taken to her hospital room she is incontinent, unsteady when walking, and somewhat disoriented. Her past medical history includes hypertension with evidence of diastolic dysfunction on echocardiography and asymptomatic glucose intolerance.

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

A) Telemetry
B) Continuous pulse oximetry
C) Foley catheter placement
D) A regular diet
E) Bed rest

Answer 8

ANSWER: D

Interventions recommended for hospitalized older patients to reduce the risk of hospital-induced disability include minimizing restricted diets. Bed rest orders should be avoided, with recommendations that the patient ambulate 3–4 times/day and be out of bed and in a chair for all meals. This patient is disoriented and probably has delirium. Restraints should be avoided if possible, and should be limited if they become necessary. This would also apply to functional restraints, such as indwelling urinary catheters, IV poles, nasal cannulas, continuous pulse oximetry, and telemetry, which all increase the risk of delirium.

Question 9

209. A 70-year-old male sees you because his left leg feels tender and swollen. Questioning reveals that a few days ago he returned from a long road trip with his wife, and that they had spent several days driving to visit relatives. On examination there is marked asymmetry between his left calf and his right calf; there is also a slight discoloration around the area of his left calf where it is most tender.

You suspect the edema may be due to a deep-vein thrombosis (DVT). The patient has no personal or family history of blood clots. Further investigation reveals a high pretest probability score on the Wells Clinical Prediction Rule test for DVT.

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

A) D-dimer
B) Contrast venography
C) Compression ultrasonography
D) Helical CT
E) MRI

Answer 9

ANSWER: C

The first step in diagnosing deep-vein thrombosis (DVT) is to complete a validated clinical prediction inquiry such as the Wells Clinical Prediction Rule in order to estimate the pretest probability of DVT. The Wells criteria include such factors as active cancer, calf swelling, pitting edema, prolonged inactivity, or major surgery within the previous 12 weeks.

The next step for patients with a low pretest probability of DVT is a high-sensitivity D-dimer assay, with a negative result indicating a low likelihood of DVT (SOR A). D-dimer is a degradation product of cross-linked fibrin blood clots and is usually elevated in patients with DVT, although it can also be elevated with other conditions such as recent surgery, hemorrhage, trauma, pregnancy, or cancer. If the assay is negative, the likelihood of DVT is very small.

In this case, the patient has several factors listed in the Wells criteria, indicating a high pretest probability of DVT. D-dimer testing would not be useful, as the next step in this patient’s evaluation should be imaging. Ultrasonography is the best test for symptomatic proximal-vein thrombosis, with a sensitivity ranging between 89% and 96% (SOR A). Although ultrasonography is the most appropriate first imaging test, contrast venography is considered the definitive test to rule out the diagnosis of DVT if there is still a high degree of suspicion after negative ultrasonography.

Helical CT is commonly used to detect pulmonary embolism but is not routinely recommended to diagnose DVT. Similarly, MRI is not routinely recommended for detecting DVT.

Question 10

210. A 45-year-old female with type 1 diabetes mellitus currently takes NPH insulin (Humulin, Novolin) twice a day. She expresses a desire to change to insulin glargine (Lantus). Her diabetes has always been well controlled, and her current hemoglobin A1c of 7.4% is typical for her.

Which one of the following is most likely to be reduced if this change is made?

A) Quality of life
B) Hemoglobin A1c
C) Morbidity from all causes
D) Treatment costs
E) Her risk for hypoglycemia

Answer 10

ANSWER: E

The extended flat pharmacokinetic curve of long-acting insulin analogues makes once-daily administration of larger doses of insulin possible. Such treatment should, in theory, provide increased flexibility with regard to the timing of injections and improve compliance. This should improve control of the patient’s diabetes, reduce the risk of hypoglycemia, and improve overall patient satisfaction. To date, however, the only proven benefit of treatment with insulin analogues is a reduction in the low rate of symptomatic, nocturnal, and overt hypoglycemia experienced by patients treated with isophane insulin. Although the total cost of treatment with insulin analogues is higher, a Cochrane review of the limited number of studies comparing insulin treatments showed no statistically significant differences in the hemoglobin A1c levels measured at the end of the studies in any treatment group (SOR C). Significant changes in morbidity, mortality, or quality of life have not been demonstrated (SOR C).

Question 11

211. A 52-year-old female sees you for the first time to establish care for her stable COPD. Since losing her insurance 4 months ago she has been off all medications except for a short-acting bronchodilator. She stopped smoking 2 years ago. She has a frequent, chronic cough and is dyspneic when climbing stairs. Pulmonary function testing reveals an FEV1 of 55%. Her O2 saturation is 90% on room air.

In addition to the short-acting inhaled bronchodilator, recommended maintenance monotherapy for this patient would be either an inhaled long-acting anticholinergic agent or an inhaled

A) corticosteroid
B) long-acting B-agonist
C) mast-cell stabilizer
D) antihistamine

Answer 11

ANSWER: B

In 2011, the American College of Physicians published new guidelines on COPD management. For patients with COPD who are symptomatic and have an FEV1 less than 60% of predicted, the recommendation is monotherapy with either a long-acting inhaled anticholinergic (tiotropium) or a long-acting inhaled B-agonist such as salmeterol or formoterol. This is in addition to rescue therapy with a short-acting inhaled bronchodilator such as albuterol. Long-acting inhaled anticholinergics and long-acting inhaled B-agonists reduce exacerbations and improve quality of life. The evidence is inconclusive with regard to their effect on mortality, hospitalizations, and dyspnea.

Inhaled corticosteroids have been found to be better than placebo for decreasing COPD exacerbations, but their side-effect profile keeps them from being preferred as monotherapy. Neither inhaled mast-cell stabilizers nor inhaled antihistamines are recommended as first-line agents for the treatment of COPD.

Question 12

212. A 62-year-old female presents to your office because of painless rectal bleeding. Over the past several months she has occasionally noted blood on the toilet tissue and in her stool after bowel movements. She also reports periodic anal itching and discharge, and protrusion of rectal tissue during bowel movements that resolves spontaneously. She had a normal colonoscopy at age 50.

An abdominal examination is normal and a digital rectal examination is not painful and no mass is palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilated purplish-blue veins above the dentate line.

Which one of the following has the best evidence for reducing symptoms in this situation?

A) Sitz baths
B) Fiber supplementation
C) Topical 1% hydrocortisone
D) Topical diltiazem (Cardizem)
E) Topical lidocaine cream (LidaMantle)

Answer 12

ANSWER: B

This patient has grade 2 internal hemorrhoids. These protrude with defecation but reduce spontaneously. Sitz baths are commonly recommended, but a review of studies found no benefit from sitz baths for various anorectal disorders, including hemorrhoids. A meta-analysis of seven randomized trials of patients with symptomatic hemorrhoids showed that fiber supplementation with psyllium, sterculia, or unprocessed bran decreased bleeding, pain, prolapse, and itching. No randomized, controlled trials support the use of corticosteroid creams for treating hemorrhoidal disease. Topical diltiazem and topical lidocaine have been shown to provide pain relief postoperatively following excision of external hemorrhoids.

Question 13

213. Which one of the following reflects the percentage of patients with a disease who have a positive test for the disease in question?

A) Likelihood ratio
B) Sensitivity
C) Specificity
D) Positive predictive value
E) Negative predictive value

Answer 13

ANSWER: B

Sensitivity is defined as the percentage of patients with a disease who have a positive test for the disease in question. Specificity is the percentage of patients without the disease who have a negative test. The positive predictive value is the percentage of patients with a positive or abnormal test who have the disease in question. The negative predictive value is the percentage of patients with a negative or normal test who do not have the disease in question. Likelihood ratios correspond to the clinical impression of how well a test rules in or rules out a given disease.

Question 14

214. Patients with which one of the following platelet disorders should be hospitalized and treated emergently?

A) Drug-induced thrombocytopenia
B) Congenital thrombocytopenia
C) Gestational thrombocytopenia
D) Thrombotic thrombocytopenic purpura
E) Thrombocytopenia associated with Lyme disease

Answer 14

ANSWER: D

Thrombotic thrombocytopenic purpura (TTP) is an emergent condition that can result in up to 30% mortality. Prompt hospitalization with plasma exchange is the preferred treatment. Patients with TTP present with nonspecific symptoms such as fever, abdominal pain, nausea, and weakness. Patients may also exhibit neurologic deficits. Microangiopathic anemia is also likely to be present, as evidenced by schistocytes on a peripheral smear and elevated levels of LDH and nucleated RBCs.

Congenital thrombocytopenia is a benign condition in which patients have long-standing low platelet counts and/or a family history of thrombocytopenia. It is usually asymptomatic but a concomitant bleeding diathesis may occur.

Gestational thrombocytopenia is also benign and asymptomatic. It is often confused with mild immune thrombocytopenic purpura. Platelet counts rarely drop below 70,000/mm3. There is no associated fetal thrombocytopenia. Preeclampsia and HELLP syndrome should also be ruled out. Platelet counts return to normal after delivery (SOR C).

Drug-induced thrombocytopenia can be severe, but platelet counts do not usually drop below 20,000/mm3. It is characterized by an abrupt drop in the platelet count within a week of starting the offending medication and resolves within 2 weeks after the medication is stopped.

Lyme disease can be associated with a transient thrombocytopenia. Patients present with common symptoms of Lyme disease, such as fever, myalgias, and rash. The thrombocytopenia resolves with treatment of the underlying infection.

Question 15

215. A 12-year-old male presents to the office with a 2-day history of fever, myalgias, and rhinorrhea. He is otherwise healthy, and you suspect influenza.

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

A) Symptomatic treatment only
B) Diagnostic testing to confirm influenza infection
C) Oseltamivir (Tamiflu)
D) Amantadine (Symmetrel)
E) Antibiotics to prevent bacterial coinfection

Answer 15

ANSWER: A

Influenza should be diagnosed on the basis of clinical signs and symptoms rather than diagnostic testing. Antiviral treatment is not recommended in otherwise healthy adults and children. Symptomatic treatment should be initiated with over-the-counter antipyretics and anti-inflammatory medications, and aspirin should be avoided due to the risk of Reye’s syndrome. Antibiotics are indicated only when a bacterial coinfection is diagnosed and not for prophylaxis.

Question 16

216. A 40-year-old male with diabetes mellitus has the following fasting lipid profile:

Totalcholesterol . . . . . . . . . . . . . . . . 204mg/dL
Triglycerides . . . . . . . . . . . . . . . . . . 223mg/dL
Low-density lipoprotein (LDL). . . . . 112 mg/dL
High-density lipoprotein (HDL). . . . .42 mg/dL

The patient is currently on simvastatin (Zocor), 40 mg, for management of his dyslipidemia. Which one of the following would be most appropriate?

A) Continuing the current medication regimen
B) Increasing the dosage of simvastatin
C) Switching to atorvastatin (Lipitor)
D) Adding gemfibrozil (Lopid)

Answer 16

ANSWER: C

This patient does not meet the LDL-cholesterol goals for a diabetic patient and therefore needs adjustment of his antihyperlipidemic regimen. In June 2011, the Food and Drug Administration recommended limiting the use of the highest dosage of simvastatin (80 mg/day) because of concerns about an increased risk of muscle damage. This dosage should only be used in patients who have already been taking 80 mg/day for 12 months or more without evidence of muscle injury, and it should not be started in new patients. This patient should be switched to an alternative medication that provides a greater reduction of LDL-cholesterol, such as atorvastatin. Gemfibrozil is contraindicated for use with simvastatin because it can raise simvastatin drug levels and increase the risk of myopathy.

Question 17

217. An obese 32-year-old female has not conceived after more than 4 years of unprotected intercourse. You perform an appropriate workup and diagnose polycystic ovary syndrome.

Of the following, the most effective management for her infertility would be

A) spironolactone (Aldactone) 
B) luteinizing hormone
C) basal body temperature monitoring 
D) clomiphene (Clomid) 
E) bromocriptine (Parlodel)

Answer 17

ANSWER: D

Polycystic ovary syndrome may be the most common cause of female infertility, affecting 6%–8% of women. Some patients with polycystic ovary syndrome have hyperandrogenism, elevated levels of luteinizing hormone, and hyperinsulinemia. While early studies supported the use of metformin to increase fertility, a more recent study has shown that only 7% of women treated with metformin were able to conceive, whereas 22% of women treated with clomiphene citrate had a live birth. Spironolactone is useful for treating hirsutism, but not infertility. Since levels of other hormones are already elevated, the other measures listed would not be of benefit.

Question 18

218. A patient has fatigue and joint pain and is concerned about the possibility of systemic lupus erythematosus (SLE) after reading about this condition on the Internet. After taking a brief history you decide that further evaluation is appropriate.

In addition to the history and physical findings, which one of the following laboratory findings would most support the diagnosis of SLE?

A) An abnormal C-reactive protein level
B) An erythrocyte sedimentation rate of 48 mm/hr
C) A positive antimicrosomal antibody test
D) A positive test for antiphospholipid antibodies
E) A positive test for rheumatoid factor

Answer 18

ANSWER: D

The American College of Rheumatology criteria for the diagnosis of systemic lupus erythematosus (SLE) includes the presence of 4 of 11 criteria. One criterion is evidence of the presence of an immunologic disorder. Evidence of an immunologic disorder includes a positive finding of antiphospholipid antibodies, based upon one of the following: an abnormal serum level of immunoglobulin G or M anticardiolipin antibodies, a positive lupus anticoagulant test, or a false-positive serologic test for syphilis. The other test results listed are not criteria for the diagnosis of SLE.

Question 19

219. A 54-year-old female presents with a new onset of headaches. She rates her pain as severe and reports that the headaches frequently awaken her in the early morning. The patient has a history of hypertension and stage 4 chronic kidney disease. Her glomerular filtration rate is 24 mL/min.

You suspect the patient has a brain tumor and order gadolinium-enhanced MRI of the head. Which one of the following is the patient at high risk for developing with the use of gadolinium contrast?

A) Nephrogenic systemic fibrosis
B) Anaphylaxis to contrast dye
C) Dermatomyositis
D) Focal seizures
E) Hypertensive crisis

Answer 19

ANSWER: A

This patient has stage 4 chronic kidney disease with a glomerular filtration rate (GFR) less than 30 mL/min. This puts her at high risk for developing nephrogenic systemic fibrosis. The FDA recommends against using gadolinium-based contrast agents in patients with acute or chronic kidney disease and a GFR less than 30 mL/min.

While anaphylaxis is possible, this patient would not be at a high risk for this. Dermatomyositis, focal seizures, and hypertensive crisis are not associated with gadolinium-based contrast agents.

Question 20

220. You suspect mild Pneumocystis jiroveci pneumonia in a patient whose past medical history is significant for HIV infection. He has not been compliant with his disease management and is not on any medications.

What is the recommended treatment for this patient’s pneumonia?

A) Azithromycin (Zithromax)
B) Clindamycin (Cleocin)
C) Rifampin (Rifadin)
D) Trimethoprim/sulfamethoxazole (Bactrim, Septra)

Answer 20

ANSWER: D

Trimethoprim/sulfamethoxazole is the drug of choice for treating Pneumocystis jiroveci pneumonia. Atovaquone has been shown to be very effective for treating mild to moderate Pneumocystis jiroveci pneumonia and is also very well tolerated, and would be the first choice for a patient with a sulfa allergy. Clindamycin plus primaquine is also effective therapy, but clindamycin is not effective as monotherapy. Azithromycin and rifampin are not effective against this organism. Other treatment options include pentamidine, dapsone plus trimethoprim, and clindamycin plus primaquine.

Question 21

221. A 66-year-old white female presents to your office for a routine physical examination. Her medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and gastroesophageal reflux, all controlled with medications. A bone density study is consistent with osteopenia. She is taking a multivitamin and calcium carbonate, 1200 mg daily.

Which one of her medications would reduce her calcium carbonate absorption?

A) Atorvastatin (Lipitor)
B) Hydrochlorothiazide
C) Lisinopril (Prinivil, Zestril)
D) Metformin (Glucophage)
E) Omeprazole (Prilosec)

Answer 21

ANSWER: E

Because of the high prevalence of reduced gastric acidity related to either endogenous causes or medications such as proton pump inhibitors, calcium carbonate is best taken with meals to optimize absorption. Calcium citrate, which is well absorbed regardless of gastric acidity, may be taken with or without food. The other medications listed do not impair calcium absorption.

Question 22

222. A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee pain and fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain and fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.

On examination the child appears well and is afebrile. He had a dose of acetaminophen about 2 hours ago. There are no signs of upper respiratory infection. Examination of the knee reveals no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion of both the knee and hip without pain. You note tenderness to firm palpation of the proximal tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his knee. Plain films of the knee are normal.

The next step in the evaluation of this patient should include which one of the following?

A) Close monitoring at home

B) A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate

C) Ultrasonography of the hip

D) Knee joint aspiration

E) MRI of the knee

Answer 22

ANSWER: B

Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.

Question 23

223. A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which is worse with activity. There has been no trauma. She tells you one of her friends had a similar problem and was treated successfully with “some sort of shock wave treatments.”

Which one of the following diagnoses is most likely to be successfully treated with extracorporeal shock wave therapy?

A) Calcific tendinitis
B) Gout
C) Partial rotator cuff tear
D) Frozen shoulder
E) Hooked acromion

Answer 23

ANSWER: A

Extracorporeal shock wave therapy is effective for calcific tendinitis of the rotator cuff. Side effects include bruising and pain. Needling and irrigation, physical therapy, and cortisone injections are sometimes used in patients with acute symptoms. Endoscopic and open surgical treatments are alternatives to extracorporeal shock wave therapy in refractory cases. Extracorporeal shock wave therapy does not have an established role in gout, rotator cuff tear, frozen shoulder, or hooked acromion.

Question 24

224. A 24-year-old female presents with a 10-day history of cough productive of green sputum. Her past medical history is unremarkable and she is up to date on all immunizations. The patient’s temperature is 37.2°C (98.9°F), blood pressure 127/76 mm Hg, pulse rate 89 beats/min, respiratory rate 24/min, and O2 saturation 95% on room air. Her physical examination is unremarkable except for a loose cough.

Which one of the following is best supported by evidence for management of this patient’s condition?

A) A macrolide antibiotic such as azithromycin (Zithromax)

B) An oral corticosteroid such as prednisone

C) An inhaled B-agonist such as albuterol (Proventil, Ventolin)

D) An expectorant such as guaifenesin

E) Reassurance that symptoms will likely resolve on their own within 3 weeks

Answer 24

ANSWER: E

This patient has acute bronchitis. The most appropriate management option is to provide reassurance that symptoms will likely resolve on their own within 3 weeks. Approximately 90% of cases are caused by viruses, and antibiotics do not significantly change the course of the condition. For this reason, and because of concerns about antibiotic resistance and side effects from antibiotic use, antibiotics should not be used routinely for the treatment of acute bronchitis (SOR B). Despite this, approximately two-thirds of patients in the United States diagnosed with bronchitis are still treated with antibiotics. Corticosteroids and B-agonists are not indicated in the absence of asthma or wheezing on examination. Expectorants have not been shown to be effective in the treatment of bronchitis (SOR B).

Question 25

225. You are managing a patient who is critically ill and is being placed on a ventilator. Management should include which one of the following to reduce the occurrence of ventilator-associated pneumonia?

A) Continuous sedation
B) Nasotracheal intubation
C) Metoclopramide (Reglan) prophylaxis
D) Elevation of the head of the bed
E) Initiation of tube feedings within 24 hours

Answer 25

ANSWER: D

Recommendations for reducing ventilator-associated pneumonia (VAP) include elevation of the head to an angle of at least 30°, noninvasive mechanical ventilation rather than intubation when appropriate, oral intubation when an endotracheal tube is necessary, orogastric rather than nasogastric tubes, minimization of sedation, administration of a proton pump inhibitor when prophylaxis is indicated, changing ventilator tubing every 7 days or when it becomes soiled, avoidance or elimination of endotracheal tube leaks, good technique in removal of condensate, and excellent hand hygiene. One study favored waiting more than 5 days before initiating tube feedings, as this reduced the incidence of VAP, although further data is needed to confirm this.

Question 26

226. Which one of the following has good evidence of effectively improving borderline personality disorder?

A) SSRIs
B) Second-generation antipsychotics
C) Omega-3 fatty acids
D) No currently available pharmacotherapy

Answer 26

ANSWER: D

There are no proven therapies to reduce the severity of borderline personality disorder (SOR A). The most promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program specifically designed to treat borderline personality disorder. The few, small studies of DBT found improvement in many symptoms of borderline personality disorder, but long-term data is lacking. Another promising therapy is psychoanalytic-oriented day hospital therapy. Again, study sizes have been small and data cannot be extrapolated to the population as a whole.

Omega-3 fatty acids, second-generation antipsychotics, and mood stabilizers have been shown to be helpful for some symptoms of borderline personality disorder but not for overall severity. Their benefits are based on single-study results and side effects were not addressed in the studies. SSRIs are not recommended for borderline personality disorder unless there is a concomitant mood disorder.

Question 27

227. A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks gestation for prenatal care. Her physical examination is normal except for a blood pressure of 156/114 mm Hg.

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

A) Labetalol (Trandate)
B) Lisinopril (Prinivil, Zestril)
C) Losartan (Cozaar)
D) Metoprolol (Lopressor, Toprol-XL)
E) Nifedipine, immediate release (Procardia)

Answer 27

ANSWER: A

The drug most often recommended as first-line therapy for hypertension in pregnancy is labetalol. Reports of an association of metoprolol with fetal growth restriction have given rise to the recommendation to avoid its use in pregnancy. Both ACE inhibitors and angiotensin-receptor blockers are contraindicated in pregnancy because of the risk of birth defects and fetal or neonatal renal failure. Immediate-release nifedipine is not recommended due to the risk of hypotension.

Question 28

228. A 26-year-old male presents to the emergency department with a fever, and he appears acutely ill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracic echocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.

Which one of the following is the most likely causative organism?

A) Cardiobacterium hominis
B) Enterococcus faecalis
C) Pseudomonas aeruginosa
D) Staphylococcus aureus
E) Streptococcus viridans

Answer 28

ANSWER: D

Staphylococcus aureus is the most common cause of acute infectious endocarditis worldwide. Additionally, the most common cause of tricuspid valve endocarditis is intravenous drug abuse, and Staphylococcus aureus is the infecting organism in 80% of tricuspid valve infections. Streptococcus viridans is also a frequent cause of infectious endocarditis, with Enterococcus, Pseudomonas, and Cardiobacterium being less likely causes.

Question 29

229. A neurologically intact 77-year-old female presents with severe low back pain following a fall 2 days ago that caused her to land on her buttocks. A radiograph of her lower spine shows a compression fracture of L3 with a loss of about 50% of the vertebral body height.

Which one of the following is most appropriate at this point?

A) Referral for kyphoplasty
B) Referral for vertebroplasty
C) Back bracing
D) Bed rest
E) Calcitonin-salmon (Miacalcin)

Answer 29

ANSWER: E

A number of measures for managing spinal compression fractures have been evaluated. The evidence for recommending kyphoplasty is weak, and the evidence for recommending against vertebroplasty is strong. The data on bracing is inconclusive, as is the recommendation for bed rest. Calcitonin has been shown to reduce the incidence of recurrent fractures and may be useful in the relief of pain.

Question 30

230. Which one of the following is the most common cause of death for African-American males in the United States?

A) Heart disease
B) Stroke
C) Cancer
D) Accidental injuries
E) Homicide

Answer 30

ANSWER: A

Heart disease is the leading cause of death in the U.S., and this holds true for both men and women. Among men the only ethnicity for which heart disease is not the most common cause of death is Asian/Pacific Islander.

Question 31

231. A 45-year-old female has an alkaline phosphatase level that is twice the normal level on a chemistry panel ordered for evaluation of pruritus. Other tests of liver function are within normal limits, including bilirubin and ALT (SGPT) levels, and repeat testing 2 months later shows no change. A y-glutamyltransferase level is also significantly elevated, as is an antimitochondrial antibody titer. Hepatic ultrasonography is unremarkable.

Which one of the following diagnoses is most likely?

A) Primary biliary cirrhosis
B) Paget’s disease of the bone
C) Sarcoidosis
D) Choledocholithiasis
E) Drug-induced cholestasis

Answer 31

ANSWER: A

A middle-aged woman with pruritus and elevated levels of alkaline phosphatase, y-glutamyltransferase (GGT), and antimitochondrial antibody titers is likely to have primary biliary cirrhosis. Levels of 5’-nucleotidase or GGT are usually elevated in parallel with those of alkaline phosphatase in patients with liver disease, but not in patients with bone disorders. Infiltrative liver disease, as seen with sarcoidosis, drug-induced cholestasis, and choledocholithiasis, is not associated with elevated antimitochondrial antibody levels. Patients with choledocholithiasis will also usually have dilated hepatic ducts on ultrasonography. This patient should next have a liver biopsy to confirm her diagnosis.

Question 32

232. A 19-year-old sexually active female comes to your office for a routine checkup. She is generally healthy with no chronic conditions and does not smoke.

For this patient, screening for which one of the following is supported by the best evidence?

A) Hypercholesterolemia
B) Cervical cancer
C) Chlamydia infection
D) HPV infection
E) Intimate partner violence

Answer 32

ANSWER: C

According to the U.S. Preventive Services Task Force (USPSTF), there is good evidence that screening for Chlamydia infection in women who are at increased risk can reduce the incidence of pelvic inflammatory disease, while the harms are minimal. The evidence regarding screening for cervical cancer with Papanicolaou testing or human papillomavirus (HPV) testing, however, shows that the harms outweigh any possible benefits. Harms include overdiagnosis and overtreatment, including invasive cervical procedures that can affect future pregnancy outcomes. In addition, there is adequate evidence that screening women younger than 21 years of age (regardless of sexual history) does not reduce the incidence of cervical cancer or mortality compared with beginning screening at age 21. The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders or intimate partner violence in women this age.

Question 33

233. You see a 72-year-old male for follow-up after his third hospital admission for heart failure within the past 4 months. He is a widower and lives alone, but he wants to talk about options for in-home nursing care. He is accompanied today by his sister and his neighbor. This is the first time you have seen the patient.

Which one of the following is the best choice regarding your interactions with the three of them?

A) Construct a family genogram to determine how to proceed with the patient’s care

B) Speak privately with the sister and neighbor to determine possible ulterior motives

C) Determine the reason each person is present today

D) Discuss the patient’s health information freely, as he willingly brought the neighbor and sister along

Answer 33

ANSWER: C

Interactions between the physician and patient involve the patient’s family and friends, as well as others who may be part of the patient’s social support system. These interactions, as well as the physician-patient relationship itself, are also strongly influenced by ethnic, cultural, and spiritual values and by beliefs about illness and approaches to treatment and ongoing care. Involvement of family members in a patient’s care is advantageous to good communication and helpful for both accurate diagnosis and appropriate treatment (SOR C).

Patient confidentiality should be protected, and the mere presence of other people accompanying the patient does not automatically constitute permission to discuss private health information with them. The physician should determine not only who is present with a patient, but also each person’s reason for being present (SOR C). Speaking to relatives or friends without the patient present may be appropriate under certain circumstances but would not be the best option in this scenario. Constructing a genogram can also be helpful, but that would not be the first priority in this case.

Question 34

234. An 80-year-old male presents with a 4-hour history of generalized abdominal pain, vomiting, and fever to 101°F. On examination you note normal cardiovascular findings, generalized moderate abdominal tenderness, absent bowel sounds, and a normal rectal examination.

Figure 1 shows a diagnostic abdominal film, which suggests

A) a leaking abdominal aortic aneurysm
B) toxic megacolon
C) small bowel obstruction
D) diverticulitis
E) a perforated viscus

Answer 34

ANSWER: C

Radiographs confirm the clinical diagnosis of small-bowel obstruction in most patients and more accurately define the site of obstruction. Small-bowel obstruction typically occupies the more central portions of the abdomen. Patients with mechanical small-bowel obstruction usually have minimal or no colonic gas. Films taken in the upright or lateral decubitus position in patients with small-bowel obstruction usually show multiple gas-filled levels, with the distended bowel resembling an inverted U.

Patients with small-bowel obstruction are likely to be depleted of fluids and electrolytes, and will require intravenous fluids, electrolyte management, and surgical evaluation.

Question 35

235. The EKG shown in Figure 2 reveals

A) sinus tachycardia
B) paroxysmal atrial tachycardia
C) multifocal atrial tachycardia
D) atrial fibrillation
E) atrial flutter

Answer 35

ANSWER: D

The salient feature of atrial fibrillation is the absence of P waves, along with normal QRS complexes that are irregular in time (irregularly irregular) and sometimes vary in amplitude. Sinus tachycardia, paroxysmal tachycardia, multifocal atrial tachycardia, and atrial flutter are all associated with P waves that are constantly related to QRS complexes, although they may sometimes be abnormal and difficult to discern.

Question 36

236. A 37-year-old previously healthy male presents with a 1-week history of a painful swollen area on his left eye, associated with redness (see Figure 3). He complains of dull aching in the eye that radiates to his ipsilateral temple. He denies any ocular discharge or vision changes. His visual acuity is normal.

Which one of the following is the most appropriate first step in managing this patient’s condition?

A) A topical mydriatic agent
B) A topical cycloplegic agent
C) A topical antibiotic
D) An oral NSAID
E) An oral antibiotic

Answer 36

ANSWER: D

Scleritis is an inflammatory disorder affecting the sclera, often associated with a connective tissue disorder such as rheumatoid arthritis, systemic lupus erythematosus, Wegener’s granulomatosis, polyarteritis nodosa, or relapsing polychondritis. In the anterior form of scleritis, inflammation results in local or diffuse erythema and thickening of the sclera. Patients present with either diffuse or focal ocular erythema, tenderness, and pain. When the inflammation is focal, a tender nodule may be present. The initial treatment of scleritis is an oral NSAID to help reduce ocular inflammation. Topical or systemic corticosteroids may be used when NSAIDs fail or are contraindicated (SOR B).

Question 37

237. The most likely diagnosis of the condition shown in the radiographs in Figure 4 is

A) dislocation of the trapezium
B) dislocation of the scaphoid
C) dislocation of the lunate
D) fracture of the distal radius
E) fracture of the distal ulna

Answer 37

ANSWER: C

The condition shown is representative of a simple anterior dislocation of the lunate. The semilunar shape of the lunate bone is displaced anterior to the distal radial articular surface. Occasionally, a transnavicular fracture may occur along with this injury and is termed a trans-scaphoid perilunate fracture-dislocation. There is no evidence in the radiograph shown, however, of dislocations of the other areas mentioned.

Question 38

238. A 28-year-old white male alcoholic presents with a 4-week history of fever, malaise, cough, sputum production, and weight loss. Twelve hours ago his cough increased and he noted frank blood in his sputum, along with a foul taste. Sputum is obtained for routine culture. A chest radiograph is shown in Figure 5.

Which one of the following diagnostic procedures should be performed prior to the initiation of therapy?

A) A culture of expectorated sputum
B) An open lung biopsy
C) Immediate bronchoscopy
D) Transtracheal aspiration

Answer 38

ANSWER: A

The findings in this patient are consistent with a lung abscess caused by anaerobic organisms, which is usually related to aspiration. Most patients have a history of compromised consciousness, such as a seizure disorder or drug and alcohol abuse, and many have dental or gingival disease.

Routine bacteriologic studies of expectorated sputum are hampered by mouth contamination, but are useful for detecting mycobacteria and other potential etiologic agents. An open lung biopsy, immediate bronchoscopy, and transtracheal aspiration are useful when the patient has not responded to initial therapy.

Since this is a typical clinical picture for anaerobic lung abscess, the treatment of choice would be large doses of intravenous clindamycin.

Question 39

239. A 58-year-old African-American male presents to the emergency department with a 6-hour history of substernal pain. He has a previous history of hypertension. His blood pressure drops to 60 mm Hg systolic after three sublingual nitroglycerin tablets. His EKG is shown in Figure 6.

In addition to nitrate side effects, which one of the following should be the first diagnostic consideration?

A) Right ventricular infarction
B) Pericarditis with tamponade
C) Papillary muscle rupture
D) Ventricular free wall rupture
E) Ventricular septal rupture

Answer 39

ANSWER: A

Right ventricular infarction is most frequently an extension of an inferior myocardial infarction (MI). Right-sided precordial leads may need to be evaluated to document this on the EKG. Hypotension during the acute event, especially after nitrate administration, is characteristic. Frequently, 1–2 liters of normal saline must be administered.

Acute pericarditis most frequently develops 2–4 days after the infarction. Free wall rupture, septal rupture, and papillary muscle rupture typically do not occur until 1–5 days after the acute MI. Septal rupture is more common with anterior MI.

Question 40

240. During a follow-up visit for a 72-year-old white female with type 2 diabetes mellitus, her daughter asks you to treat the lesions shown in Figure 7. These lesions bother the patient and she complains of itching, especially at night.

The most likely diagnosis is

A) chronic, reactive scabies infestation
B) eczema craquelé (xerotic eczema)
C) neurodermatitis
D) necrobiosis lipoidica
E) lichen sclerosus

Answer 40

ANSWER: B

Eczema craquelé, a common complication of aging, is due to dryness of the skin. It is best treated with wet compresses and antibiotics to remove crusts and suppress infection, followed by topical corticosteroids and lubricants. The primary lesions do not suggest scabies or necrobiosis lipoidica, and neurodermatitis and lichen sclerosis are secondary responses to itching.