Questions 201-240

Question 1

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

A) NSAIDs

B) Bracing

C) Eccentric strengthening exercises

D) Corticosteroid injection

E) Therapeutic ultrasonography

Answer 1

ANSWER: C

Eccentric exercise should be the first-line treatment for chronic midsubstance Achilles tendinopathy. Corticosteroid injections, bracing, and NSAIDs are not effective for providing long-term relief for chronic degenerative tendon injuries. Therapeutic ultrasonography is a reasonable second-line alternative.

Question 2

202. A 69-year-old female presents with her first episode of Clostridium difficile colitis, which is characterized as severe. Which one of the following is the most appropriate initial therapy?

A) Oral metronidazole (Flagyl)

B) Intravenous metronidazole

C) Oral vancomycin (Vancocin)

D) Intravenous vancomycin

E) Rifaximin (Xifaxan)

Answer 2

ANSWER: C

Vancomycin, 125 mg orally 4 times daily for 10–14 days, is recommended for the first severe episode of Clostridium difficile colitis (SOR B). If the first episode is mild to moderate, oral metronidazole, 500 mg 3 times daily for 10–14 days, would be preferred. Intravenous vancomycin is not effective in the treatment of colitis. Rifaximin is not well studied and is not recommended in any current guidelines.

Question 3

203. Which one of the following is the most common cause of sudden cardiac death in young athletes?

A) Coronary artery abnormalities

B) Myocarditis

C) Hypertrophic cardiomyopathy

D) Brugada syndrome

E) Idiopathic left ventricular hypertrophy

Answer 3

ANSWER: C

Structural non-atherosclerotic heart disease is the predominant cause of sudden death in young athletes. Hypertrophic cardiomyopathy, an autosomal dominant condition with variable expression, accounts for more than one-third of these cases. Coronary artery abnormalities are second in frequency as a cause of sudden cardiac death in this population, with idiopathic ventricular hypertrophy third.

Question 4

204. A 44-year-old male is being evaluated for a 3-month history of cough. His chest radiograph is shown below.

Which one of the following abnormalities is seen on the radiograph?

A) Bronchiectasis

B) A pulmonary cavitary lesion

C) A hiatal hernia

D) A thoracic aortic aneurysm

E) Pericardial effusion

Answer 4

ANSWER: D

Most thoracic aortic aneurysms are asymptomatic, but symptoms can be produced by distortion, compression, or erosion of adjacent structures by the aneurysm. Resulting symptoms include cough, hemoptysis, chest pain, hoarseness, and dysphagia. A chest radiograph showing widening of the mediastinum and prominence of the aortic arch and thoracic aorta suggests a thoracic aortic aneurysm. Contrast-enhanced CT, MRI, and aortography are sensitive and specific tests for assessment of thoracic aneurysms and involvement of branch vessels. Echocardiography (especially transesophageal) helps in further evaluating the proximal ascending and descending thoracic aorta.

A pulmonary cavitary lesion, seen in pulmonary tuberculosis, is typically located in the upper lung lobe and is often associated with mediastinal lymphadenopathy. The presence of a retrocardiac gas-filled structure suggests the presence of a hiatal hernia. The chest radiograph may show a “water bottle” configuration of the cardiac silhouette in a patient with pericardial effusion (SOR C).

Question 5

205. A 15-year-old male presents to the emergency department at 10 p.m. with a 2-hour history of severe, acute scrotal pain associated with vomiting. On examination the right testicle is swollen. Ultrasonography is inconclusive.

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

A) Repeat ultrasonography in the morning

B) Antibiotics

C) Corticosteroids

D) Scrotal support

E) Immediate surgical consultation

Answer 5

ANSWER: E

The patient has typical signs and symptoms of testicular torsion despite inconclusive ultrasonography. Surgical exploration is necessary because the testicle can be salvaged if the torsion is repaired within 6 hours of symptom development (SOR C).

Question 6

206. A 66-year-old female sees you for the first time. She has a history of iron deficiency anemia and chronic diarrhea associated with a diagnosis of celiac disease.

This history increases her risk for which one of the following?

A) Diverticulitis

B) Ulcerative colitis

C) Crohn’s disease

D) Colon cancer

E) Osteoporosis

Answer 6

ANSWER: E

Patients who are diagnosed with celiac disease are at increased risk of osteoporosis due to bone loss from decreased calcium and vitamin D absorption. These patients are at higher risk for fractures. Patients with celiac disease are not at increased risk for inflammatory bowel disease, diverticulitis, or colon cancer.

Question 7

207. A 44-year-old female is brought to your office by her mother. The patient was in a severe car accident 2 weeks ago. Her husband was killed instantly and she was extracted by emergency responders almost an hour later. She received a full examination at a local emergency department and was discharged home with only minor contusions and abrasions and no evidence of a closed head injury.

The patient has been panicked and unable to sleep. She has recurrent flashbacks of the event and dreams repeatedly about her husband’s death. She says that sometimes, even while awake, she can almost sense her husband’s lifeless body near her. She has refused to get into a car since the accident, which is the reason she has not sought care sooner. She has not been able to focus on daily tasks but has been able to eat and drink adequate amounts.

Which one of the following diagnoses best describes her condition?

A) Acute stress disorder

B) Major depressive disorder

C) Obsessive-compulsive disorder

D) Panic disorder

E) Generalized anxiety disorder

Answer 7

ANSWER: A

Acute stress disorder (ASD) lies on a spectrum of trauma-related disorders between adjustment disorder and posttraumatic stress disorder (PTSD). ASD is differentiated from PTSD primarily by duration, with PTSD requiring the presence of similar symptoms (intrusion, negative mood, dissociation, avoidance, and arousal) for longer than 1 month. Conversely, adjustment disorder is a less severe condition than ASD that involves either a less traumatic or threatening inciting event and/or less severe symptoms that do not meet DSM-5 criteria for acute stress disorder.

Question 8

208. You are covering the inpatient service and following up on a 67-year-old female admitted 3 days ago for severe pancreatitis. CT on admission showed edema and mild inflammation. Currently the patient is receiving intravenous fluids, daily laboratory evaluations, and pain medications. She is NPO and afebrile, with a blood pressure of 130/78 mm Hg and a pulse rate of 88 beats/min.

Which one of the following therapies should be initiated to lower complication rates and shorten the patient’s hospital stay?

A) Enteral nutrition

B) Parenteral nutrition

C) Surgical debridement

D) Prophylactic antibiotics

Answer 8

ANSWER: A

Enteral nutrition is preferred over parenteral nutrition for patients with severe pancreatitis who have been on prolonged bowel rest, and it is associated with lower complication rates and shorter hospitalizations (SOR A). Prophylactic antibiotics should only be used when there is significant necrosis (SOR C). Similarly, surgical debridement is indicated only if there is infected necrosis or persistent fluid collections (SOR C).

Question 9

209. A 30-year-old female complains of dysmenorrhea, pelvic pain, and dyspareunia. Which one of the following would be appropriate to detect endometriosis?

A) A CA-125 assay

B) Transvaginal ultrasonography

C) CT of the pelvis

D) MRI of the pelvis

E) Colonoscopy

Answer 9

ANSWER: B

Endometriosis is caused by menstrual tissue in the pelvic peritoneal cavity. Infertility, dysmenorrhea, and dyspareunia with postcoital bleeding are common. Although laparoscopy with histology is the definitive test, transvaginal ultrasonography is the noninvasive test of choice. CA-125 will often be elevated but is nonspecific. CT and MRI also have low specificity, and colonoscopy is of no value in the evaluation of endometriosis.

Question 10

210. The CDC has designated several diseases as neglected parasitic infections in the United States. Which one of these, if untreated, has potential consequences that include cardiomyopathy, heart failure, and fatal cardiac arrhythmias?

A) Trichomoniasis

B) American trypanosomiasis (Chagas disease)

C) Toxoplasmosis

D) Cysticercosis

E) Toxocariasis

Answer 10

ANSWER: B

Chagas disease is caused by Trypanosoma cruzi, and is estimated to infect some 300,000 persons in the United States. Potential consequences include cardiomyopathy, heart failure, and fatal cardiac arrhythmias. The CDC has designated Chagas disease as a neglected parasitic infection, based on the number of people estimated to be infected in the United States, the potential severity of the illness, and the ability to prevent and treat this disease. This infection is considered neglected because relatively little attention has been devoted to its surveillance, prevention, and/or treatment. It is most common in those who live in rural, impoverished areas in Mexico or central America, where the vector of the disease, the kissing bug, is found.

Trichomoniasis can lead to infertility and poor birth outcomes. Toxocariasis and toxoplasmosis cause developmental defects in children. Cysticercosis can lead to epilepsy in young adults. Some of these sequelae develop years after an initial mild infection.

Question 11

211. A 30-year-old female stepped off a curb earlier today and twisted her left ankle. She was able to bear weight immediately following the injury and tried to continue her normal routine, but the pain in her ankle and foot increased over the next few hours.

She comes to your office and your examination reveals swelling of the ankle and bruising of the lateral foot. Tenderness to palpation is present over the distal aspect of the fibula and lateral malleolus and to a lesser degree over the proximal fifth metatarsal. No bony tenderness is present along the medial aspect of the ankle or foot.

According to the Ottawa Ankle Rules, which one of the following would be most appropriate at this point?

A) Radiographs of the ankle and foot

B) Radiographs of the foot only

C) Radiographs of the ankle only

D) No radiographs

Answer 11

ANSWER: A

The Ottawa Ankle Rules are widely accepted guidelines for appropriate evaluation of ankle and midfoot injuries occurring in adults age 19 or older presenting for the first time in a clinical setting. The guidelines utilize the historical and physical findings to determine which radiographic studies, if any, are indicated. Patients who were able to bear weight immediately following their injury and who can take 4 steps independently in a clinical setting require radiographic study only when the following criteria are met: pain is present in the malleolar zone and bony tenderness of the posterior edge or tip of either malleolus is elicited (ankle radiograph), or pain is present in the midfoot zone and bony tenderness of either the base of the fifth metatarsal or the navicular region is present.

Question 12

212. A U.S. Preventive Services Task Force “D” recommendation indicates

A) high certainty that the net benefit is substantial

B) high certainty that the net benefit is moderate

C) moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits

D) that the decision to provide the service should be based on professional judgment and patient preferences

E) that current evidence is insufficient to assess the balance of benefits and harms of the service

Answer 12

ANSWER: C

A “D” recommendation means the U.S. Preventive Services Task Force (USPSTF) recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. An “I” recommendation means the USPSTF concludes that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. A “C” recommendation means the USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. A “B” recommendation means the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. An “A” recommendation means the USPSTF recommends the service and there is high certainty that the net benefit is substantial. The highest levels of evidence and most recent evidence available are used by the USPSTF in making all of its recommendations.

Question 13

213. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the severity of anorexia nervosa is based on which one of the following?

A) Refusal to eat

B) The frequency of episodes of binge eating or purging behavior

C) Body mass index (BMI)

D) The presence or absence of amenorrhea

E) Orthostatic changes in pulse or blood pressure

Answer 13

ANSWER: C

According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass index (BMI). Mild is a BMI greater than 17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of 15.0–15.9 kg/m2, and extreme is a BMI less than 15.0 kg/m2. Recurrent episodes of binge eating or purging behavior help differentiate restricting type from binge-eating/purging type, but do not indicate severity. Orthostatic changes in pulse or blood pressure and refusal to eat are criteria for inpatient hospitalization, but are not part of the classification of severity according to the DSM-5. Amenorrhea can be a clinical sign of anorexia nervosa but is not part of the classification of severity.

Question 14

214. A 29-year-old previously healthy male presents with a 1-hour history of the sudden onset of progressively worsening shortness of breath. On examination he has a blood pressure of 126/96 mm Hg, a heart rate of 110 beats/min, an oxygen saturation of 90%, and a respiratory rate of 24/min. A chest radiograph is shown below.

Which one of the following is the recommended treatment?

A) Observation

B) The Valsalva maneuver

C) Needle aspiration

D) Intravenous heparin

E) Intravenous methylprednisolone sodium succinate (Solu-Medrol)

Answer 14

ANSWER: C

The radiograph shown depicts a right-sided spontaneous pneumothorax. Primary spontaneous pneumothorax, which results from the rupture of subpleural apical blebs, typically affects young men who are smokers with no underlying history of lung disease. The recommended treatment is needle aspiration of air from the pleural space (SOR B). In a reliable patient with a small (less than 15% of a hemithorax), stable spontaneous primary pneumothorax, observation alone may be appropriate. There is no role for intravenous heparin or corticosteroids in the management of pneumothorax. The Valsalva maneuver could potentially expand an underlying tension pneumothorax.

Question 15

215. Which one of the following comorbid conditions increases the risk that latent tuberculosis infection will progress to active disease?

A) Hypertension

B) Lung cancer

C) Obesity

D) Coronary artery disease

E) Hyperlipidemia

Answer 15

ANSWER: B

Risk factors for progression from latent to active tuberculosis include lung cancer, diabetes mellitus, alcoholism, recent contact with a person who has an active tuberculosis infection, any condition treated with immunosuppressive therapy, and lung parenchymal diseases such as COPD, silicosis, or lung cancer. The medically underserved and those in low-income groups are also more at risk of progression, as well as children under age 5 and individuals weighing less than 90% of their ideal minimum body weight.

Question 16

216. Which one of the following immunizations is indicated for all pregnant women at any stage of pregnancy?

A) MMR

B) Varicella

C) Influenza

D) HPV

Answer 16

ANSWER: C

Influenza vaccine is indicated for all pregnant women, and there are no known deleterious effects on the course of pregnancy or the fetus. Women are advised to avoid pregnancy for 28 days after receiving MMR or varicella vaccines. HPV vaccine is not recommended during pregnancy.

Question 17

217. A 24-year-old gravida 2 para 1 at 9 weeks gestation sees you for a routine prenatal check. She complains of significant nausea, and recommended dietary modifications have not helped. She drives a school bus so she would like to avoid sedating medications. She appears well-hydrated and her examination is otherwise normal.

Which one of the following would be best for relieving this patient’s nausea?

A) Auricular acupressure

B) A scopolamine patch (Transderm Scop)

C) Vitamin B6 (pyridoxine)

D) Methylprednisolone (Medrol)

Answer 17

ANSWER: C

Nearly 75% of pregnant women are affected by nausea and vomiting of pregnancy. Though dietary modifications are often recommended, there is little evidence to support their use. Vitamin B6 is recommended as first-line therapy. It is safe to use in the first trimester and is associated with less drowsiness compared with other medications.

Scopolamine is effective for nausea and vomiting of pregnancy but should be avoided in the first trimester due to the possibility of causing trunk and limb deformities. Likewise, methylprednisolone is also effective but should be avoided in the first trimester as it is associated with an increased risk of cleft palate if used before 10 weeks of gestation. Auricular acupressure has been found to be ineffective.

Question 18

218. A local dentist contacts you for a prescription for the appropriate antibiotic dosage for one of your patients who has an appointment for dental cleaning to eliminate a significant plaque buildup. The patient is a 55-year-old male who has controlled hypertension and mitral valve prolapse with mitral regurgitation. He is allergic to sulfonamides.

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

A) Amoxicillin, 2 g orally 1 hour prior to the procedure

B) Amoxicillin, 3 g orally 1 hour prior to the procedure and 1.5 g orally 6 hours after the procedure

C) Ceftriaxone (Rocephin), 1 g intramuscularly 1 hour prior to the procedure

D) Clindamycin (Cleocin), 600 mg orally 1 hour prior to the procedure

E) No antibiotic prophylaxis

Answer 18

ANSWER: E

According to the American Heart Association’s 2007 guidelines, prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease.

Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are associated with mitral regurgitation. The American Dental Association has endorsed this guideline.

Question 19

219. A 40-year-old female sees you for a health maintenance visit. She has no complaints and other than being overweight she has an unremarkable examination. Laboratory results are also unremarkable except for her lipid profile. She has a total cholesterol level of 251 mg/dL, an HDL-cholesterol level of 31 mg/dL, and a triglyceride level of 1250 mg/dL. The LDL-cholesterol level could not be calculated and measured 145 mg/dL.

In addition to lifestyle changes, this patient would most likely benefit from

A) niacin

B) omega-3 fatty acid supplementation

C) atorvastatin (Lipitor)

D) ezetimibe (Zetia)

E) fenofibrate (Tricor)

Answer 19

ANSWER: E

Treatment of hypertriglyceridemia depends on its severity. Contributing factors include a sedentary lifestyle, being overweight, excessive alcohol intake, type 2 diabetes mellitus, and genetic disorders. Triglyceride levels of 150–199 mg/dL are considered mild hypertriglyceridemia, levels of 200–999 mg/dL are moderate, 1000–1999 mg/dL are severe, and levels greater than 2000 mg/dL are considered very severe. Patients with hypertriglyceridemia in the mild to moderate range may be at risk for cardiovascular disease, but those who have severe or very severe hypertriglyceridemia have a significant risk of pancreatitis.

In addition to having the patient exercise, reduce intake of fat and carbohydrates, and lose weight, she should also be counseled to avoid alcohol. For patients at risk for pancreatitis, fibrates are recommended as the initial treatment for pancreatitis. It should be noted that statins may have a modest triglyceride-lowering effect and may be helpful in decreasing cardiovascular risk in those who have moderately elevated triglycerides. However, they should not be used alone in patients who have severe hypertriglyceridemia. Studies have also shown that while omega-3 fatty acids decrease triglycerides and very low density lipoprotein cholesterol levels, they may increase LDL-cholesterol levels. Treatment with omega-3 fatty acids does not decrease total mortality or cardiovascular events, and therefore is not recommended.

Niacin does seem to have the advantage of raising HDL cholesterol and lowering LDL cholesterol, but it has never been proven in clinical trials to have benefit with regard to the primary outcome of cardiovascular disease, and some trials have shown significant increases in adverse events.

Question 20

220. A 57-year-old female with a past medical history significant for well-controlled type 2 diabetes mellitus, hypertension, and hyperthyroidism presents to your office with a chief complaint of a sore throat and a fever to 101.5°F at home. She has had chills and night sweats but has not had a cough, chest pain, or abdominal pain.

Physical Findings

General…………………… ill appearing

HEENT…………………….. diffuse tender anterior cervical adenopathy; thyroid nontender; oropharynx erythematous with some purulence on her tonsils

Cardiovascular……….. tachycardia without murmur

Lungs………………………. clear to auscultation bilaterally

Skin. ……………………….. mild jaundice

Laboratory Findings

Rapidstreptest. …………… negative

TotalWBCcount……………. 3000/mm3 (N 4500–11,000) and absolute neutrophil count 0

Total bilirubin……………….. 5 mg/dL (N 0–1.0)

Alkalinephosphatase…… 151U/L(N38–126)

Which one of the following medications is most likely to cause these laboratory abnormalities?

A) Amlodipine (Norvasc)

B) Aspirin

C) Metformin (Glucophage)

D) Methimazole (Tapazole)

Answer 20

ANSWER: D

Approximately 0.3% of patients taking methimazole develop agranulocytosis, usually within the first 60 days of starting therapy. Other rare complications of methimazole include serum sickness, cholestatic jaundice, alopecia, nephrotic syndrome, hypoglycemia, and loss of taste. It is associated with an increased risk of fetal anomalies, so propylthiouracil (PTU) is preferred in pregnancy. The other medications listed are not known to cause the combination of agranulocytosis and cholestatic jaundice that this patient has.

Question 21

221. A 31-year-old gravida 1 para 0 presents for a routine visit at 32 weeks gestation. She has gestational diabetes mellitus (GDM) and has been following the dietary guidelines from her dietitian. However, her blood glucose is still elevated and you discuss starting medications for management of her GDM. She is adamant about not starting insulin but is willing to consider taking metformin (Glucophage). Before making a decision she would like to know the specific benefits to her and her baby.

You would tell her that one benefit of treatment of GDM is a decreased risk for

A) maternal type 2 diabetes mellitus after delivery

B) maternal preeclampsia

C) perinatal death

D) a small-for-gestational-age infant

Answer 21

ANSWER: B

Although there is no specific recommendation about when to initiate pharmacotherapy for the treatment of gestational diabetes mellitus (GDM), many women do require specific treatment beyond diet and exercise. Insulin has traditionally been used but oral medications are becoming increasingly common despite the lack of long-term safety data. Many outcomes for both the mother and infant are improved with pharmacologic management of GDM. These include a decreased risk for operative delivery, large-for-gestational-age infants, shoulder dystocia, and maternal preeclampsia. Although a significant percentage of women with GDM subsequently develop type 2 diabetes mellitus after delivery, pharmacologic treatment of GDM has not been shown to decrease that risk. In addition, neither perinatal death nor the likelihood of small-for-gestational-age infants is significantly affected. The risk of neonatal hypoglycemia has also not consistently been shown to be affected by treatment.

Question 22

222. A 34-year-old white female sees you for a routine follow-up visit. She takes haloperidol, 2 mg after each meal, for schizophrenia, and you notice that she seems unable to sit still and is extremely anxious.

The most likely cause of her restlessness is

A) drug-induced parkinsonism

B) akathisia

C) tardive dyskinesia

D) hysteria

E) dystonia

Answer 22

ANSWER: B

Motor side effects of the antipsychotic drugs can be separated into five general categories: dystonias, parkinsonism, akathisia, withdrawal dyskinesias, and tardive dyskinesia. Akathisia is a syndrome marked by motor restlessness. Affected patients commonly complain of being inexplicably anxious, of being unable to sit still or concentrate, and of feeling comfortable only when moving. Hysteria is no longer considered a useful term.

Question 23

223. A 45-year-old male is seen for a well-demarcated, nonpruritic rash in the right axilla. It is fine-scaled with a cigarette-paper appearance. The rash has a coral-red fluorescence under a Wood’s light.

Which one of the following is the most likely diagnosis?

A) Candidiasis

B) Tinea cruris

C) Erythrasma

D) Inverse psoriasis

Answer 23

ANSWER: C

All of the diagnoses listed are intertriginous rashes but only erythrasma fluoresces with Wood’s light. Erythrasma is a superficial gram-positive bacterial infection caused by Corynebacterium minutissimum. The fluorescence is caused by porphyrins. Erythrasma is most often seen between the toe web spaces, followed by the groin and axillae. There are multiple treatments, including topical and oral erythromycins and clindamycins (level of evidence 3, strength of evidence 1).

Question 24

224. A 28-year-old female just delivered a male infant over an intact perineum. She has had polyhydramnios during this pregnancy, but her prenatal course has otherwise been normal. Her only significant chronic medical problem is asthma, treated with a long-acting B-agonist/corticosteroid combination inhaler. Vital signs were stable throughout her labor. After delivery of the placenta, bleeding becomes brisk and you note a soft, boggy, uterus.

Which one of the following medications is contraindicated in this patient?

A) Carboprost (Hemabate)

B) Methylergonovine

C) Misoprostol (Cytotec)

D) Oxytocin (Pitocin)

Answer 24

ANSWER: A

All of the drugs listed are appropriate for uterine atony and postpartum hemorrhage. Carboprost should not be used in this patient, however, as it is contraindicated in patients with asthma. Methylergonovine is contraindicated in hypertensive patients but may be used in patients with asthma.

Question 25

225. A 52-year-old male presents with a swollen and tender area anterior to the left ear and extending to below the left angle of the mandible. One week ago he had a Nissen fundoplication for intractable GERD. This was complicated by difficulty swallowing and drinking. On examination his tympanic temperature is 37.7°C (99.9°F), his blood pressure is 110/70 mm Hg, and his pulse rate is 95 beats/min and regular. His left parotid gland is diffusely enlarged and tender. Purulent material is noted coming from the left parotid duct orifice.

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

A) Amoxicillin/clavulanate (Augmentin)

B) Penicillin

C) CT of the parotid gland

D) Incision and drainage of the parotid gland

E) Excision of the parotid gland

Answer 25

ANSWER: A

This case is typical for acute parotitis, which is commonly caused by dehydration and can be diagnosed from the history and examination. Empiric treatment is directed toward gram-positive and anaerobic organisms, with the most common pathogen being Staphylococcus. These are often penicillin resistant so a B-lactamase inhibitor is the agent of choice. Treatment should be followed up with cultures. Administration of sialagogues such as lemon drops may be helpful, as well as parotid gland massage.

CT or MRI may help confirm the diagnosis but imaging is usually not necessary. The history and clinical examination are most important for making the diagnosis. Incision and drainage would be appropriate only for an abscess, and surgical removal of the parotid gland is not indicated.

Question 26

226. A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The remainder of the examination is within normal limits.

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

A) Admit to the hospital and obtain urine, blood, and CSF cultures, then start intravenous antibiotics

B) Admit to the hospital and treat for herpes simplex virus infection

C) Follow up in the office in 24 hours and admit to the hospital if not improved

D) Order a CBC and a urinalysis with culture, and send the patient home if the results are normal

Answer 26

ANSWER: A

Any child younger than 29 days old with a fever and any child who appears toxic, regardless of age, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated (SOR C).

Observation only, with close follow-up, is recommended for nontoxic infants 3–36 months of age with a temperature less than 39.0°C (102.2°F) (SOR C). Children 29–90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and urinalysis, can be sent home with precautions and with follow-up in 24 hours (SOR B). Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics (SOR C).

Question 27

227. A 70-year-old female presents to your office as a new patient. She is healthy and has no complaints. She walks for exercise 30–45 minutes daily and takes no prescription medications. Her blood pressure is 125/75 mm Hg, heart rate 72 beats/min, and respiratory rate 14/min.

On examination she has a systolic crescendo-decrescendo murmur heard loudest at the right upper sternal border. An EKG in the office is within normal limits. Echocardiography shows mild aortic stenosis based on peak aortic jet velocity, aortic valve area, and mean pressure gradient. Her ejection fraction is 55%. At a follow-up visit she states that she continues to be symptom free.

Which one of the following should be the next step in the evaluation and management of her aortic stenosis?

A) Exercise treadmill testing

B) Right heart catheterization

C) Repeat echocardiography in 3 years

D) Cardiothoracic surgery consultation

E) Initiation of statin therapy

Answer 27

ANSWER: C

Family physicians see many patients with aortic stenosis (AS) and it is important to know when and if further workup is indicated for asymptomatic patients. Although aortic stenosis can result in adverse cardiac events, most of these events occur in patients who are symptomatic. Thus, the American Heart Association and the American College of Cardiology recommend that asymptomatic patients with mild aortic stenosis undergo repeat echocardiography every 3–5 years. Further workup or treatment is not indicated for patients who have mild AS and are asymptomatic. Exercise treadmill testing may be indicated in patients with severe AS based on echocardiography even if they are asymptomatic.

Use of statin drugs has not been shown to slow or stop progression of AS. Right and left heart catheterization can be used in an attempt to resolve discrepancies between symptoms and echocardiographic findings. Because this patient is asymptomatic and her echocardiogram shows only mild AS, left and/or right heart catheterization is not indicated. An ACE inhibitor would be indicated in patients who have a reduced ejection fraction.

Question 28

228. A 79-year-old female had a total knee replacement yesterday. She has mild dementia as a result of a stroke 10 years ago, but her dementia has been stable since then. Last night she became confused and agitated, striking out at nurses, and could not be consoled.

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

A) Soft restraints

B) CT of the head

C) Adequate pain control

D) A sedating SSRI such as paroxetine (Paxil)

E) Lorazepam (Ativan) intravenously as needed

Answer 28

ANSWER: C

This patient has postoperative delirium, which is associated with an increased mortality rate. Reorientation and pain management are important management strategies. Benzodiazepines, antipsychotics, antidepressants, and restraints are not helpful and may make the situation worse. Imaging modalities are not helpful in the absence of localizing signs.

Question 29

229. A 58-year-old male sees you for a physical examination so he can receive a commercial driver’s license. On examination you note a 2-cm hard, nodular protuberance on his hard palate, shown below. He believes that this has been there for some time, but says it seems to be enlarging.

The most likely diagnosis is

A) osteoid osteoma

B) torus palatinus

C) mucocele

D) osteosarcoma

E) calcinosis cutis

Answer 29

ANSWER: B

Torus palatinus is an exostosis, or benign bony overgrowth. It is usually located on the midline of the hard palate, and occurs in 12%–27% of the population. Since these are usually not symptomatic many people are not even aware of their presence.

Torus palatinus is easily diagnosed from the history and physical examination. Imaging studies are usually unnecessary. These growths typically enlarge gradually throughout life but have no potential for malignant transformation.

Question 30

230. Which one of the following is the best diagnostic test for vitamin D deficiency?

A) Ionized calcium

B) Serum phosphorus

C) 24-hour urine for calcium

D) 1,25-hydroxyvitamin D

E) 25-hydroxyvitamin D

Answer 30

ANSWER: E

Undiagnosed vitamin D deficiency is not uncommon, and 25-hydroxyvitamin D is the barometer for vitamin D status. Although there is no consensus on optimal levels of 25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most experts as a 25-hydroxyvitamin D level less than 20 ng/mL (50 nmol/L).

Question 31

231. A 31-year-old male has experienced multiple outbreaks of the rash shown below. He was initially told that the rash was due to an allergy to an antibiotic prescribed for a suspected dental abscess, but avoiding all medications has not prevented the recurrences.

Which one of the following oral medications has been shown to reduce the severity, duration, and recurrences of this type of rash?

A) Acyclovir

B) Cetirizine (Zyrtec)

C) Prednisone

D) Ranitidine (Zantac)

E) Terbinafine (Lamisil)

Answer 31

ANSWER: A

Sharply demarcated lesions with raised borders surrounding a paler region containing a darker center (target or iris lesions) are characteristic of erythema multiforme. The lesions of erythema multiforme usually appear on the distal extremities, are often accompanied by burning and pruritus, and may progress centrally. Usually the rash resolves spontaneously within 4–6 weeks but some patients experience frequent recurrences. Erythema multiforme results from a hypersensitivity reaction to any number of medications, vaccine preparations, or infections, the most commonly identified being herpes simplex virus (HSV) infection. In a minority of those harboring HSV infection, recurrent outbreaks of erythema multiforme are often associated with HSV reactivations, even those that may occur unnoticed. Continuous antiviral treatment using acyclovir, valacyclovir, or famciclovir has been shown to be effective in reducing or eliminating the frequency of recurrent outbreaks in these patients (SOR A). In patients not helped by daily antiviral suppressive therapy, treatment with dapsone, azathioprine, cyclosporine, and thalidomide have been used with some success, but evidence-based data supporting the use of these drugs is limited.

Question 32

232. Which one of the following is the only medication that has consistent evidence for decreasing depressive symptoms in children and adolescents?

A) Fluoxetine (Prozac)

B) Venlafaxine (Effexor XR)

C) Nortriptyline (Pamelor)

D) Aripiprazole (Abilify)

E) Paroxetine (Paxil)

Answer 32

ANSWER: A

Fluoxetine is the only medication with consistent evidence showing that it improves depression symptoms in children and adolescents, including a Cochrane review of three randomized trials. Escitalopram is licensed for treatment of depression in children 12 and over, and consensus guidelines also recommend the use of citalopram and sertraline as first-line treatment in children and adolescents. However, these drugs do not have the same level of evidence for their effectiveness as fluoxetine.

Tricyclic antidepressants have not been shown to be more effective than placebo and should not be used (SOR A). All antidepressants carry a black box warning about an increased risk of suicide with their use in younger patients. It is recommended that children and adolescents be monitored closely, including weekly contact. Psychotherapy should be used in conjunction with pharmacologic treatment.

Aripiprazole, a second-generation antipsychotic medication, would not be indicated. Paroxetine should not be used in young people because of its association with increased suicide risk.

Question 33

233. Which one of the following, especially in homeless people, is a vector for Bartonella quintana, which causes trench fever, an influenza-like syndrome with relapsing fever?

A) Fleas

B) Maggots

C) Bedbugs

D) Scabies

E) Lice

Answer 33

ANSWER: E

Lice, scabies, and secondary bacterial infections are endemic in the homeless. Body lice transmit Bartonella quintana, which causes trench fever. This disease got its name in World War I, when soldiers in the trenches were often infested with body lice. This is a serious disease that can be treated with antibiotics.

Question 34

234. A 72-year-old previously healthy female comes in for evaluation of recent headaches. She describes the pain as generalized all over her head and persisting over the past several months. She reports feeling more achy and fatigued in the past several weeks, with a decreased appetite and unintentional weight loss of 4 lb in the past 2 months. She denies any other symptoms including sinus congestion, nausea, vomiting, numbness, tingling, weakness, or vision changes. Acetaminophen has been minimally helpful for the pain.

On examination you note a temperature of 37.9°C (100.2°F), normal cranial nerves, a normal eye examination, and no tenderness to palpation of the head. She is mildly tender to palpation of the shoulders and upper arms. Laboratory testing reveals an erythrocyte sedimentation rate of 88 mm/hr (N 1–25).

Which one of the following is necessary to confirm the most likely diagnosis?

A) EEG

B) CT of the head

C) MRI of the head

D) A temporal artery biopsy

E) A lumbar puncture

Answer 34

ANSWER: D

This patient’s clinical picture is most concerning for giant cell arteritis (also known as temporal arteritis). This condition is a type of vasculitis and in its most serious form can lead to blindness. It is most common in the elderly and is twice as common in women as in men. Because of its inflammatory nature, patients commonly have systemic symptoms, including fever. The temporal artery may be thickened, tender, or lacking pulsation, although a normal artery does not rule out the diagnosis. Jaw claudication is a fairly specific but nonsensitive finding.

The laboratory finding most classically associated with giant cell arteritis is an elevated erythrocyte sedimentation rate (ESR). Only 4% of patients with biopsy-proven giant cell arteritis have a normal ESR. However, a high ESR is nonspecific and may be caused by other conditions. Because the treatment for giant cell arteritis involves high-dose corticosteroids, which may cause significant morbidity, most clinicians favor confirmation of the diagnosis with a temporal artery biopsy prior to committing a patient to full treatment. MRI and CT would be used in the evaluation of other causes of headaches, including a cerebral hemorrhage or mass. A lumbar puncture would identify benign intracranial hypertension or meningitis, and an EEG would be helpful for evaluating seizures.

Question 35

235. A 3-year-old male is brought to the urgent-care clinic on a Monday morning by his mother with a 1-day history of complaining of ear pain. The child’s mother says she has not noticed any fever during this time. He is up to date on all immunizations and has no previous history of ear infections or history of recent illness. The history is negative for medication allergies.

On examination the child has a temperature of 38.2°C (100.8°F) and seems to be uncomfortable. When you examine his ears you note moderate bulging of the tympanic membrane in both ears. All other findings are normal.

According to the guidelines published by the American Academy of Pediatrics, which one of the following would be the most appropriate initial management?

A) Amoxicillin, 40–50 mg/kg, for 10 days

B) Amoxicillin, 80–90 mg/kg, for 10 days

C) Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day of amoxicillin and 6.4 mg/kg/day of clavulanate, divided into two doses, for 7 days

D) Cefdinir, 14 mg/kg/day for 10 days

E) Ciprofloxacin (Cipro), 10–20 mg/kg for 7 days

Answer 35

ANSWER: B

The American Academy of Pediatrics (AAP) recommends antibiotic therapy for children 6 months of age or older with severe signs and symptoms of acute otitis media (AOM), including moderate or severe otalgia or otalgia for more than 48 hours, or a temperature greater than or equal to 39°C (102°F), whether the AOM is unilateral or bilateral (SOR B). Children younger than 24 months without severe symptoms should receive antibiotic therapy for bilateral AOM, whereas older children or those with unilateral AOM can be offered the option of observation and follow-up.

The usual treatment for AOM is amoxicillin, but an antibiotic with additional 6-lactamase coverage, such as amoxicillin/clavulanate, should be given if the child has received amoxicillin within the past 30 days, has concurrent purulent conjunctivitis, or has a history of AOM unresponsive to amoxicillin (SOR C). Penicillin-allergic patients should be treated with an alternative antibiotic such as cefdinir, cefuroxime, cefpodoxime, or ceftriaxone.

Question 36

236. A 20-year-old male with a history of exercise-induced bronchoconstriction presents to your office with a complaint of cough and decreasing performance when he runs. He is training for a marathon and is currently running 30 miles/week, but has noted that his times have been worsening and that he is using his albuterol inhaler (Proventil, Ventolin) as needed for symptom relief 5 days a week.

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

A) Inhaled albuterol before he runs

B) A daily low-dose inhaled corticosteroid

C) A daily inhaled long-acting B2-agonist

D) A daily low-dose oral corticosteroid

E) Immunotherapy

Answer 36

ANSWER: B

An inhaled daily low-dose corticosteroid plus occasional use of as-needed inhaled albuterol is the best regimen for the treatment of exercised-induced bronchospasm. Daily use of short-acting B2-agonists can lead to overuse and tolerance. Long-acting B2-agonists should not be used without the concomitant use of an inhaled corticosteroid. Chronic oral corticosteroids are not indicated in this situation, and may require a therapeutic use exemption by the sports authority overseeing athletic competitions. Immunotherapy has limited benefit for the treatment of asthma.

Question 37

237. A 44-year-old obese female complains of intermittent right upper quadrant pain that is worse after fatty meals. Which one of the following is the preferred initial imaging modality for evaluating her complaint and confirming the diagnosis?

A) A plain radiograph

B) Ultrasonography

C) Cholescintigraphy

D) Contrast-enhanced CT

E) Contrast-enhanced MRI

Answer 37

ANSWER: B

Ultrasonography is the preferred initial imaging modality for suspected acute cholecystitis or cholelithiasis (SOR C). If ultrasound findings are equivocal, contrast CT, cholescintigraphy, or contrast MRI can be used as second-line imaging modalities (SOR C). While useful in evaluating abdominal pain in some cases, a plain radiograph would not be an appropriate first-line evaluation when cholecystitis or cholelithiasis is suspected.

Question 38

238. A 52-year-old healthy male presents with a 21⁄2-week history of diarrhea, consisting of 4–6 watery stools daily. He is afebrile and his examination is normal. You recommend symptomatic care. Two days later the laboratory notifies you that Salmonella is growing in his stool culture. You call the patient and he remains free of fever but with ongoing diarrhea.

Which one of the following would you recommend?

A) Azithromycin (Zithromax)

B) Ciprofloxacin (Cipro)

C) Clindamycin (Cleocin)

D) Doxycycline

E) No treatment

Answer 38

ANSWER: E

The recommended management for patients who have non-severe Salmonella infection and are otherwise healthy is no treatment. Patients with high-risk conditions that predispose to bacteremia, and those with severe diarrhea, fever, and systemic toxicity or positive blood cultures should be treated with levofloxacin, 500 mg once daily for 7–10 days (or another fluoroquinolone in an equivalent dosage), or with a slow intravenous infusion of ceftriaxone, 1–2 g once daily for 7–10 days (14 days in patients with immunosuppression).

Question 39

239. A mother brings her 5-year-old daughter to see you because she found a mass in the child’s neck. The mass appeared over the past week and was preceded by a sore throat. Her pharyngitis is now resolved but she still has a fever, although it is not as high. The mother is most concerned because the mass developed over a short span of time, and it is warm, red, and tender. When asked, she says that her daughter has had no recent exposure to cats.

When you examine the child you note that her temperature is 38.0°C (100.4°F). You also find shotty adenopathy in both anterior cervical lymph node chains, and a 2.5-cm warm, firm, moderately tender lymph node in the right anterior cervical chain. The overlying skin is also erythematous.

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

A) Ultrasonography of the neck mass

B) CT with intravenous contrast of the neck mass

C) Ultrasound-guided fine-needle aspiration of the mass

D) Immediate referral to a head and neck surgeon

E) Empiric antibiotic therapy with observation for 4 weeks

Answer 39

ANSWER: E

This child has cervical lymphadenitis, characterized by systemic symptoms, unilateral lymphadenopathy, skin erythema, node tenderness, and a node that is 2–3 cm in size. The most common organisms associated with lymphadenitis are Staphylococcus aureus and group A Streptococcus. Empiric antibiotic therapy with observation for 4 weeks is acceptable for children with presumed reactive lymphadenopathy (SOR C). If symptoms do not resolve, or if the mass increases in size during antibiotic treatment, further evaluation is appropriate.

When imaging is indicated, ultrasonography is the preferred initial study for most children with a neck mass. CT with intravenous contrast media is the preferred study for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess that may require surgical drainage. If the initial mass is suspicious for malignancy (greater than 3.0 cm in size, hard, firm, immobile, and accompanied by type B symptoms such as fever, malaise, weight loss, or night sweats) immediate referral to a surgeon for evaluation and possible biopsy is appropriate.

Question 40

240. A 45-year-old male with diabetes mellitus returns to your office for follow-up. He is on metformin (Glucophage), 1000 mg/day, as well as atorvastatin (Lipitor), 40 mg daily for hyperlipidemia. There is no diagnosis of hypertension, and his blood pressure at today’s visit is 120/70 mm Hg. Laboratory results include a hemoglobin A1c of 6.4% and an LDL-cholesterol level of 105 mg/dL. His urine albumin/creatinine ratio is in the microalbuminuric range for the first time.

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

A) Renal ultrasonography

B) A repeat urine albumin/creatinine ratio

C) 24-hour urine for microalbumin

D) Increasing the atorvastatin dosage

E) Stopping metformin

Answer 40

ANSWER: B

This normotensive diabetic patient, appropriately screened for microalbuminuria, should have this finding confirmed on at least one of two additional spot tests, since temporary factors other than nephropathy can also result in microalbuminuria. Once a diagnosis of chronic kidney disease is confirmed, renal ultrasonography should be ordered to detect potentially reversible causes.

A 24-hour urine is not necessary since the urine microalbumin/creatinine ratio correlates well with a 24-hour urine for albumin. Metformin is not contraindicated in the presence of microalbuminuria alone without a decline in the glomerular filtration rate. The patient is already on high-intensity statin therapy and there is no specific indication to increase the statin dosage based on his current LDL-cholesterol level since treatment to the target LDL-cholesterol goal has fallen out of favor.