Questions 201-240

Question 1

201. A 45-year-old male with hyperlipidemia presents to your office for follow-up. Because of his cardiovascular risk level he has been on moderate-intensity statin therapy with atorvastatin (Lipitor) for the past 6 months. His HDL-cholesterol level at this visit is 29 mg/dL.

Which one of the following steps is most appropriate?

A) Continue the statin

B) Add fibrates

C) Add niacin

D) Supplement with fish oil

Answer 1

ANSWER: A

Drug therapy aimed at increasing HDL-cholesterol levels when added to a statin treatment does not decrease a patient’s cardiovascular risk. Such agents have no effect on all-cause mortality, cardiovascular mortality, or the risk of stroke (SOR B). Current guidelines for treatment of hyperlipidemia are based on individual cardiovascular risk stratification rather than LDL-cholesterol levels, and recommend low-, medium-, or high-intensity therapy with statins, based on an individual patient’s risk.

Question 2

202. A 65-year-old asymptomatic female is found to have extensive sigmoid diverticulosis on screening colonoscopy. She asks whether there are any dietary changes she should make.

In addition to increasing fiber intake, which one of the following would you recommend?

A) Limiting intake of dairy products

B) Limiting intake of spicy foods

C) Limiting intake of wheat flour

D) Limiting intake of nuts

E) No dietary limitations

Answer 2

ANSWER: E

Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to slow progression of the diverticular disease. Avoiding nuts, corn, popcorn, and small seeds has not been shown to prevent complications of diverticular disease. Limiting intake of dairy products, spicy foods, and wheat flour would be appropriate for other gastrointestinal problems such as lactose intolerance, gastroesophageal reflux disease (GERD), and celiac disease.

Question 3

203. A 32-year-old male with type 1 diabetes mellitus presents to your office with a tender, scaly lesion on his anterior left shin. It is a 5-cm reddish-brown plaque with well-defined borders and what appears to be yellowish deposits in the center.

You perform a punch biopsy of the lesion to confirm your diagnosis of

A) granuloma annulare

B) necrobiosis

C) sarcoidosis

D) xanthoma

Answer 3

ANSWER: B

Necrobiosis lipoidica diabeticorum is seen in 0.3% of patients with diabetes mellitus or impaired glucose tolerance. The lesions may precede the diagnosis of diabetes mellitus by several years. The sharply demarcated reddish-brown plaque with central yellow deposits in the pretibial area is characteristic and a biopsy is not always necessary. Topical corticosteroids are sometimes helpful.

Granuloma annulare and sarcoidosis are unlikely on the leg. Early lesions of necrobiosis lipoidica diabeticorum can be confused with granuloma annulare or sarcoidosis, however, and a biopsy may be helpful. While xanthomas can be flat plaques up to several centimeters in size, they usually occur on flexor surfaces of the limbs along with the trunk and face. They lack the reddish-brown outer portion of the lesions described here.

Question 4

204. Pioglitazone (Actos) has been found to be associated with which one of the following adverse effects?

A) Steatohepatitis

B) Fluid retention

C) Cognitive dysfunction

D) Increased stroke risk

E) Increased all-cause mortality

Answer 4

ANSWER: B

Thiazolidinediones (TZDs) improve hyperglycemia by improving insulin resistance and by maintaining or improving B-cell secretory function. One of the side effects of TZDs is that they can cause fluid retention, especially in patients with cardiac and renal disease. This may lead to weight gain and peripheral edema. Because of this effect, TZDs are contraindicated in patients with New York Heart Association class III or IV heart failure. They can also reduce bone mineral density and are associated with a higher risk of non-osteoporotic bone fractures. In addition to their ability to decrease glucose levels, however, there have been some other favorable effects noted with their use. Clinical trials have shown that treatment with pioglitazone resulted in a significant reduction in the composite outcome of nonfatal acute myocardial infarction, stroke, and all-cause mortality. They may also help prevent central nervous system insulin resistance–related cognitive dysfunction. TZDs are also useful in patients with nonalcoholic steatohepatitis.

Question 5

205. A 52-year-old male with a history of severe esophageal reflux and dysphagia undergoes upper GI endoscopy that reveals a mid-esophageal stricture and severe erosive esophagitis. The stricture is dilated by the gastroenterologist and he recommends long-term proton pump inhibitor therapy.

While long-term proton pump inhibitor therapy should alleviate symptoms of reflux, it may be associated with an increased risk of which one of the following?

A) Clostridium difficile infection

B) Helicobacter pylori infection

C) Type 2 diabetes mellitus

D) Iron deficiency anemia

E) Hypothyroidism

Answer 5

ANSWER: A

Proton pump inhibitor use has been shown to increase the risk for Clostridium difficile and other enteric infections, and elderly patients and those with significant comorbid conditions may already be at increased risk. Studies have not shown an increased risk for iron deficiency. There is no increased risk for hypothyroidism, Helicobacter pylori infection, or type 2 diabetes mellitus.

Question 6

206. A 4-year-old female is brought to your office after a recent camping excursion and presents with a large number of mosquito bites. She has developed a number of areas of honey-colored crusting lesions you diagnose as nonbullous impetigo.

Which one of the following oral medications is preferred for this patient?

A) Cephalexin (Keflex)

B) Doxycycline

C) Erythromycin

D) Penicillin VK

E) Trimethoprim/sulfamethoxazole (Bactrim)

Answer 6

ANSWER: A

Nonbullous impetigo is most often caused by Streptococcus pyogenes and methicillin-sensitive Staphylococcus aureus. Cephalexin is the most appropriate option, with good coverage for both of these bacteria. Penicillin VK has been found to be no more effective than placebo in the treatment of impetigo. Macrolide resistance limits the use of erythromycin. Tetracycline should not be used in children <8 years old as it may cause staining of permanent teeth. Trimethoprim/sulfamethoxazole has coverage against both methicillin-sensitive and methicillin-resistant Staphylococcus aureus, but may have inadequate coverage for Streptococcus.

Question 7

207. Which one of the following medications blocks dopamine stimulation in the chemoreceptor trigger zone, making it an effective antiemetic for patients with gastroenteritis?

A) Diphenhydramine (Benadryl)

B) Meclizine (Antivert)

C) Metoclopramide (Reglan)

D) Ondansetron (Zofran)

E) Scopolamine (Transderm Scop)

Answer 7

ANSWER: C

Dopamine antagonists, such as metoclopramide, block dopamine stimulation in the chemoreceptor trigger zone, thereby limiting emetic input to the medullary vomiting center (SOR C). SSRIs, such as ondansetron, also work in the chemoreceptor trigger zone. They inhibit serotonin at the 5-HT3 receptor in the small bowel, vagus nerve, and chemoreceptor trigger zone. Antihistamines and anticholinergics limit stimulation of the vomiting center through inhibition of the H1 receptor and acetylcholine, respectively. These medications are particularly beneficial in vestibular-mediated nausea, such as motion sickness.

Question 8

208. An asymptomatic 46-year-old male with autosomal dominant polycystic kidney disease sees you for a routine visit. His vital signs in the office include a blood pressure of 152/93 mm Hg, a heart rate of 82 beats/min, a respiratory rate of 17/min, a temperature of 37.0°C (98.6°F), and an oxygen saturation of 99% on room air. His glomerular filtration rate is 49 mL/min/1.73 m2.

Which one of the following is the preferred initial therapy for controlling this patient’s blood pressure?

A) Amlodipine (Norvasc)

B) Furosemide

C) Lisinopril (Prinivil, Zestril)

D) Metoprolol

E) Spironolactone (Aldactone)

Answer 8

ANSWER: C

Autosomal dominant polycystic kidney disease (ADPCKD) is the most common genetic kidney disease and accounts for 4.7% of end-stage kidney disease cases in America. Many patients with ADPCKD are asymptomatic, but early symptoms can include flank pain, gross hematuria, or recurrent urinary tract infections. The most common extrarenal manifestation of ADPCKD is hypertension, which can precipitate cardiovascular dysfunction, including left ventricular hypertrophy. Thus, early diagnosis and management of hypertension is crucial.

The goal blood pressure should be <140/90 mm Hg in patients under the age of 60. All ADPCKD patients eventually develop a loss of renal function, and approximately 80% develop end-stage renal disease by age 70. An ACE inhibitor is the recommended first-line therapy (SOR C), so lisinopril is the best choice for this patient. Angiotensin receptor blockers are acceptable in patients who cannot tolerate ACE inhibitors.

Question 9

209. A 70-year-old female presents to your office with a 1-month history of generalized aching of both shoulders. She denies a specific injury but believes that her dog has been pulling too much on the leash. She has also noticed joint stiffness in her hips and trouble getting moving in the mornings. She denies headaches and visual disturbance. A physical examination is normal except for mild pitting edema of the ankles. The patient has lost 5 kg (11 lb) since her health maintenance visit 8 months ago. Laboratory studies reveal an erythrocyte sedimentation rate of 66 mm/hr (N 1–25) and a platelet count of 450,000/mm3 (N 150,000–350,000). Her creatine kinase level is 50 U/L (N 40–150).

Which one of the following should you prescribe now?

A) Aspirin, 81 mg daily

B) Colchicine (Colcrys), 1.2 mg initially, 0.6 mg an hour later, then 0.6 mg daily

C) Hydroxychloroquine (Plaquenil), 200 mg twice a day for a month then 100 mg twice

daily

D) Methotrexate, 7.5 mg weekly increased by 2.5 mg/week as needed to obtain

symptom control

E) Prednisone, 15 mg daily with a slow taper

Answer 9

ANSWER: E

Polymyalgia rheumatica (PMR) without concurrent giant cell arteritis is treated with a slow taper of low-dose corticosteroids (SOR C). Disease-modifying antirheumatic drugs and antimalarial medications have no role in the treatment of PMR. Aspirin therapy is recommended as adjuvant therapy for giant cell arteritis to decrease stroke risk (SOR C). Colchicine may alleviate acute symptoms of gout and pseudogout.

Question 10

210. An active 76-year-old male presents to your office as a new patient. He recently fell while hiking and was diagnosed with rib fractures in the emergency department. He says he has always been healthy except he was told his blood pressure was mildly elevated 10 years ago. He has not followed up with a doctor since that visit. Today his examination is normal other than bruising and mild tenderness over his left 7th to 9th ribs laterally and a blood pressure of 144/88 mm Hg.

You review his transition of care document from the emergency department and his problem list states that he has chronic kidney failure stage 3A based on an estimated glomerular filtration rate of 55 mL/min/1.73 m2. A urinalysis in your office is normal, with no hematuria or proteinuria.

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

A) Reassurance and observation

B) Renal ultrasonography

C) CT of the abdomen

D) Magnetic resonance angiography of the renal artery

Answer 10

ANSWER: A

Chronic kidney disease appears to be overdiagnosed in the older population. Stage 3A kidney disease is defined as an estimated glomerular filtration rate (GFR) of 45–59 mL/min/1.73 m2 and is predominantly seen in older patients. It is seldom progressive in the absence of significant proteinuria. Older patients with chronic kidney disease are less likely to develop end-stage renal disease than to die of complications related to aging and cardiovascular disease. There is a decline in estimated GFR with normal aging, and the likelihood of patients progressing to end-stage renal disease and dialysis is minimal if they have a GFR of 45–59 mL/min/1.73 m2.

Question 11

211. A 13-year-old baseball pitcher develops pain in the upper arm at the shoulder when throwing and is diagnosed with Little League shoulder. This entity is actually a

A) coracoclavicular ligament sprain

B) sprain or tear of the acromioclavicular ligament

C) deltoid muscle strain

D) proximal humeral epiphysitis

E) labral tear on the acromion

Answer 11

ANSWER: D

In contrast to Little League elbow, which is a complex of possible injuries, Little League shoulder refers to one entity, proximal humeral epiphysitis, most often developing as an overuse injury in baseball pitchers age 11–16.

Question 12

212. A 35-year-old white male who has had type 1 diabetes mellitus for 20 years begins having episodes of hypoglycemia. His glucose levels had previously been stable and well controlled, and he has not recently changed his diet or insulin regimen.

Which one of the following is the most likely cause of the hypoglycemia?

A) Spontaneous improvement of $-cell function

B) Renal disease

C) Reduced physical activity

D) Insulin antibodies

Answer 12

ANSWER: B

The most common cause of hypoglycemia in previously stable, well-controlled diabetic patients who have not changed their diet or insulin dosage is diabetic renal disease. A reduction in physical activity or the appearance of insulin antibodies (unlikely after 20 years of therapy) would increase insulin requirements and produce hyperglycemia. Spontaneous improvement of B-cell function after 20 years would be very rare.

Question 13

213. A 63-year-old female presents with a complaint of a painful, red right eye. She says that her vision has also been blurry. She has also noted a discharge. The patient wears contact lenses.

When you examine the patient you note photophobia. The pupils are equal, round, and reactive to light. You also note unilateral diffuse injection. Fluorescein staining reveals focal corneal uptake.

Which one of the following is the most likely diagnosis?

A) Corneal abrasion

B) Subconjunctival hemorrhage

C) Uveitis

D) Acute angle-closure glaucoma

E) Herpes zoster ophthalmicus

Answer 13

ANSWER: A

Common causes of red eye include infectious conjunctivitis, allergies, corneal abrasion, keratoconjunctivitis, subconjunctival hemorrhage, uveitis, blepharitis, iritis, acute angle-closure glaucoma, and herpes zoster ophthalmicus.

Viral infections typically cause conjunctivitis with mild pain and no loss of vision. The problem is usually unilateral in the beginning and a watery to serous discharge may be noted. Adenovirus is the most common cause. Acute bacterial conjunctivitis has a similar presentation and may include eyelid edema and a purulent discharge. Allergic conjunctivitis is usually bilateral and painless, with intense itching, and a stringy or ropy watery discharge.

Herpes zoster ophthalmicus is associated with a vesicular rash, keratitis, and uveitis. The rash is preceded by pain and a tingling sensation. Findings include conjunctivitis and dermatomal involvement, which are usually unilateral.

With corneal abrasion there is usually a history of an injury involving a foreign object. Signs and symptoms include severe eye pain; red, watery eyes; photophobia; and a foreign body sensation. Vision is usually normal and pupils are equal and reactive to light.

Symptoms of uveitis include a red eye, loss of vision, and photophobia. It is associated with many autoimmune diseases, including reactive arthritis, ankylosing spondylitis, and inflammatory bowel disease.

Acute angle-closure glaucoma causes a significant loss of vision, with dilated pupils that don’t react normally to light. Symptoms include severe pain and watery eyes, with halos around lights. Patients may have nausea and vomiting. This form of glaucoma often has an acute onset.

Question 14

214. A 54-year-old male smoker with a family history of coronary artery disease tells you that he takes B-carotene and vitamin E regularly to help prevent cancer and heart disease. In counseling this patient, you discuss smoking cessation and advise him that

A) he should continue both supplements

B) he should continue B-carotene and discontinue vitamin E

C) he should discontinue B-carotene and continue vitamin E

D) he should discontinue both supplements

E) evidence is insufficient to assess the risk and benefit of these supplements

Answer 14

ANSWER: D

The U.S. Preventive Services Task Force recommends against the use of B-carotene or vitamin E supplementation for the prevention of cardiovascular disease or cancer. This is a class D recommendation (do not recommend). Overall there is no beneficial effect on cancer or heart disease from these vitamin supplements. In one study vitamin E appeared to increase the risk of hemorrhagic stroke, and B-carotene has been found to increase the risk of lung cancer in persons already at higher risk for lung cancer.

Question 15

215. In its dental recommendations from birth to 5 years of age, the U.S. Preventive Services Task Force recommends fluoride supplementation for which one of the following when the primary water supply is deficient in fluoride?

A) All children starting at birth

B) All children starting at 6 months of age

C) All children starting at 2 years of age

D) All children with erupted primary teeth

E) Children with erupted primary teeth who have no access to fluoride varnish

Answer 15

ANSWER: B

The U.S. Preventive Services Task Force recommends that primary care clinicians prescribe oral fluoride supplementation starting at 6 months of age for children whose water supply is deficient in fluoride (<0.6 ppm) (B recommendation). The task force found evidence of moderate benefit of oral fluoride supplementation for the prevention of dental caries in this group.

Question 16

216. You see a 5-week-old female for a well child visit in December. She was delivered at 28 weeks gestation because of severe preeclampsia in the mother. Her parents state that she is doing well, feeding well, and growing. The physical examination is normal.

At this time, you recommend immunoprophylaxis with

A) influenza vaccine

B) palivizumab (Synagis)

C) pertussis vaccine

D) rotavirus vaccine

E) intravenous immunoglobulin

Answer 16

ANSWER: B

For all infants born before 29 weeks gestation, palivizumab is recommended for the first year of life during respiratory syncytial virus season to reduce the likelihood of hospitalization. Immunization against pertussis and rotavirus is not recommended until the 2-month visit. Influenza vaccine is not recommended for any infant until 6 months of age. There is no indication for immunoglobulin in this infant.

Question 17

217. A 25-year-old male presents to the emergency department with a complaint of his heart racing for the past 45 minutes. He has no known medical problems. He does have occasional episodes of palpitations, but they usually only last a short period. An EKG shows a narrow QRS complex tachycardia at a rate of 180 beats/min. His condition is not improved by vagal maneuvers and adenosine (Adenocard). He remains hemodynamically stable.

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

A) Amiodarone (Cordarone)

B) Procainamide

C) Sotalol (Betapace)

D) Verapamil (Calan, Verelan)

E) DC cardioversion

Answer 17

ANSWER: D

The treatment goal of narrow QRS complex tachycardia is to slow down the heart rate and to convert to normal sinus rhythm by blocking, or increasing the refractoriness of, the atrioventricular node. In a hemodynamically stable patient vagal maneuvers are a good first-line treatment, followed by adenosine. If those do not work verapamil or diltiazem can be used. DC cardioversion is used in narrow QRS complex tachycardia if the patient becomes hemodynamically unstable. Amiodarone, procainamide, and sotalol are all used for the treatment of wide QRS complex tachycardia but not for narrow-complex tachycardia.

Question 18

218. A 19-year-old female high school student is brought to your office by a friend who is concerned about the patient cutting herself on the wrists. The patient denies that she was trying to kill herself, and states that she did this because she “just got so angry” at her boyfriend when she caught him sending a text message to another woman. She denies having a depressed mood or anhedonia, and blames her fluctuating mood on everyone who “keeps deserting her,” making her feel like she’s “nothing.” She admits that she has difficulty controlling her anger. Her sleep quality and pattern appear normal, as does her appetite. She denies hallucinations or delusions. The wounds on her wrists appear superficial and there is evidence of previous cutting behavior on her forearms. Her vital signs are stable.

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

A) Clonazepam (Klonopin)

B) Fluoxetine (Prozac)

C) Quetiapine (Seroquel)

D) Inpatient psychiatric admission

E) Psychotherapy

Answer 18

ANSWER: E

This patient displays most of the criteria for borderline personality disorder. This is a maladaptive personality type that is present from a young age, with a strong genetic predisposition. It is estimated to be present in 1% of the general population and involves equal numbers of men and women; women seek care more often, however, leading to a disproportionate number of women being identified by medical providers.

Borderline personality disorder is defined by high emotional lability, intense anger, unstable relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness. Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak when patients are in their early 20s, but completed suicide is most common after age 30 and usually occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a high short-term risk, and serve to communicate distress.

Inpatient hospitalization may be an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning, and pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in certain patients, psychotherapy is considered the mainstay of therapy, especially in a relatively stable patient such as the one described.

Question 19

219. Long-term treatment with which one of the following is known to reduce serum vitamin D levels?

A) Estrogen replacement

B) Isoniazid

C) Phenytoin

D) Statins

E) Thiazide diuretics

Answer 19

ANSWER: C

Absorption and metabolism of vitamin D is known to be affected by interaction with other medications. Isoniazid and thiazide diuretics can lead to increased blood levels or activity of vitamin D. Estrogen replacement therapy can also increase levels of vitamin D in the blood, although this potential benefit seems to diminish when progesterone is added. Vitamin D absorption through the gut can be reduced by mineral oil, cholestyramine, and certain antacid preparations, leading to lower blood levels. The metabolism of vitamin D is accelerated by anticonvulsant drugs such as phenobarbital and phenytoin, which can also result in lower than desired levels of vitamin D. Statins are not reported to have any known effect on vitamin D levels.

Question 20

220. A 6-year-old male is brought to your office by his parents. He describes pain in the right hip for the past month or two, and the parents report that for the past few weeks they have noticed intermittent limping. The history is negative for trauma, injury, and fever. On examination the patient indicates that the pain is over the anterior hip joint, with increased pain on internal rotation, which is limited to 90°.

Of the options listed below, which one of the following is the most likely diagnosis in this case?

A) Septic arthritis of the hip

B) Transient synovitis of the hip

C) Osteoarthritis of the hip

D) Osteonecrosis of the femoral head (Legg-Calvé-Perthes disease)

E) Slipped capital femoral epiphysis

Answer 20

ANSWER: D

This case presents a child with an insidious onset of pain and mild limitation of range of motion of one hip joint. The case suggests involvement of the femoroacetabular joint, and all of the listed options can affect this joint. Idiopathic osteonecrosis of the hip (Legg-Calvé-Perthes disease) occurs most commonly in children at 2–12 years of age and has a male predominance. Symptom onset is insidious, as in this case, with symptom severity and functional limitations dependent on the level of disease progression. Slipped capital femoral epiphysis occurs much more commonly in adolescents. Transient synovitis and septic arthritis have a more acute onset, and typically cause fever. Osteoarthritis typically occurs in older adults.

Question 21

221. Which one of the following is considered first-line therapy for nausea and vomiting of pregnancy?

A) Ginger

B) Blue cohosh

C) Cranberry juice

D) Vitamin B6

E) Fenugreek

Answer 21

ANSWER: D

A number of alternative therapies have been used for problems related to pregnancy, although vigorous studies are not always possible. For nausea and vomiting, however, vitamin B6 is considered first-line therapy, sometimes combined with doxylamine. Other measures that have been found to be somewhat useful include ginger and acupressure.

Cranberry products can be useful for preventing urinary tract infections, and could be recommended for patients if this is a concern. Blue cohosh has been used as a partus preparator, but there are concerns about its safety. Fenugreek has been used to increase milk production in breastfeeding mothers, but no rigorous trials have been performed.

Question 22

222. A 38-year-old female calls your office and reports nausea, vomiting, abdominal cramps, and diarrhea that developed 1 hour after she ate some chicken salad that had been sitting outside at a picnic. Prior to that she was asymptomatic.

Which one of the following is the most likely cause of this patient’s foodborne illness?

A) Campylobacter jejuni

B) Escherichia coli O157:H7

C) Shigella species

D) Staphylococcus aureus

E) Hepatitis A

Answer 22

ANSWER: D

Most of the symptoms of foodborne illness are not specific to the causative organism. However, the onset of vomiting and diarrhea within hours of consumption of contaminated food results from the ingestion of preformed toxins, most often from Staphylococcus aureus or Bacillus cereus in the United States. Campylobacter jejuni, Escherichia coli O157:H7, Shigella species, and hepatitis A typically produce symptoms more than a day after ingestion.

Question 23

223. A 76-year-old nursing home resident complains of constipation. He has had minimal improvement with trials of scheduled toileting and increased fiber and fluids. A physical examination is normal.

Which one of the following is the best intervention at this point?

A) Bisacodyl (Dulcolax)

B) Lactulose solution

C) Magnesium citrate solution

D) Polyethylene glycol (MiraLAX)

Answer 23

ANSWER: D

For functional constipation in older adults, behavioral changes should be first-line management. These include scheduled toileting with proper positioning, increased intake of fiber and fluids, and avoiding bedpan use. If there is not an adequate response to behavioral interventions, osmotic laxatives should be initiated. Polyethylene glycol is more effective and has fewer side effects compared to lactulose. Magnesium salts, including magnesium citrate, do not have strong evidence for safety or efficacy, and magnesium toxicity is a concern with long-term use. Due to possible adverse effects of stimulant laxatives in the long term, particularly with older adults, these drugs should be used only if fiber and osmotic laxatives are unsuccessful.

Question 24

224. A 44-year-old male complains of feeling tired and sad for the last few months. He has a past medical history of obesity, diabetes mellitus with painful peripheral neuropathy, and seizure disorder. He has also noticed that he is not as interested in his usual hobbies and is eating more than usual. You diagnose depression.

Which one of the following would be the most appropriate agent for this patient, considering his comorbidities and symptoms?

A) Bupropion (Wellbutrin)

B) Citalopram (Celexa)

C) Duloxetine (Cymbalta)

D) Nortriptyline (Pamelor)

Answer 24

ANSWER: C

SSRIs and SNRIs are both effective in reducing depressive symptoms, but SNRIs have been shown to be superior to SSRIs for management of neuropathic pain (SOR A). Bupropion would effectively treat the patient’s depression and could cause weight loss, but it is contraindicated in patients with seizure disorders (SOR A). Tricyclic antidepressants such as nortriptyline could also help with the pain but might also worsen the patient’s obesity and fatigue (SOR A).

Question 25

225. A 16-year-old male presents to your office with a 1-month history of paresthesias in the ring finger and little finger of his left hand. He is the catcher on his high school baseball team. The physical examination reveals no abnormalities of his neck, shoulder, or elbow. His hand grip is normal, but maximal flexion of the wrist elicits paresthesias in the fourth and fifth digits.

Which one of the following is the most likely diagnosis?

A) Carpal tunnel syndrome

B) Ulnar entrapment

C) Flexor carpi ulnaris tendinitis

D) De Quervain’s tenosynovitis

E) Stress fracture of the scaphoid

Answer 25

ANSWER: B

An ulnar neuropathy most commonly presents with sensory changes in the fourth and fifth digits and usually does not involve weakness in hand grip. There is usually no specific injury, but any activity that results in repetitive or prolonged wrist extension, as with cycling or playing catcher, may increase the risk of this problem. It is important to examine the neck for cervical disc disease and to examine the shoulder to see if motion elicits the pain, which would indicate a brachial plexus problem. If symptoms are reproduced by compressing the ulnar nerve at the elbow this could be the site of entrapment. Clinical tests may include a positive Tinel sign on percussion of the ulnar nerve over Guyon’s canal. Also, there may be a positive Phalen sign, with maximum passive flexion of the wrist for 1 minute inducing paresthesias in the fourth and fifth fingers.

With ulnar neuropathy, plain radiographs are usually normal. Ultrasonography of the peripheral nerves may be helpful in identifying compression etiologies. However, electromyelography and nerve conduction velocities may be required to identify the area of entrapment.

Question 26

226. A 52-year-old male was recently diagnosed with mild essential hypertension. His average blood pressure over several repeated weekly readings is 142/92 mm Hg. He now comes to your office to discuss a management plan. He is particularly interested in trying to manage his hypertension nonpharmacologically if possible.

Which one of the following nonpharmacologic interventions should you recommend for this patient?

A) Limit table salt consumption to 500 mg/day

B) Consume 3 glasses of red wine daily

C) Consume a high-protein diet

D) Monitor home blood pressure readings

E) Start a yoga program

Answer 26

ANSWER: D

Self-measured blood pressure monitoring, with or without additional support (e.g., education, counseling, telemedicine, home visits, Web-based logging), lowers blood pressure when compared with usual care, although the benefits beyond 12 months are not clear (SOR A). Limiting sodium intake to 2400 mg/day (approximately 1 teaspoon of table salt) is recommended to lower blood pressure. Additional benefit occurs with a limit of 1500 mg/day (SOR B). A diet that emphasizes vegetables, fruits, and whole grains is also recommended to lower blood pressure (SOR A), as well as limiting alcohol consumption to no more than 2 drinks/day for men, and 1 drink/day for women (SOR C). Because of mixed results from therapeutic trials and many limitations to the trials, the American Heart Association does not recommend either yoga or acupuncture to lower blood pressure.

Question 27

227. A 52-year-old male sees you at the request of his wife because of his snoring and her concerns that he has obstructive sleep apnea. Further evaluation with a sleep study is recommended if the patient reports which one of the following?

A) Insomnia

B) A history of hypertension

C) Snoring that awakens his wife

D) Unexplained daytime sleepiness

Answer 27

ANSWER: D

Daytime sleepiness is the clinically relevant symptom of obstructive sleep apnea (OSA) that is most responsive to treatment. Other associated symptoms such as snoring, insomnia, and fatigue are either less clinically relevant or less responsive to treatment. Hypertension, diabetes mellitus, and coronary artery disease are associated with OSA, but evidence is insufficient that continuous positive airway pressure (CPAP) improves outcomes for these conditions, especially if they are not associated with daytime sleepiness.

Question 28

228. A healthy 18-year-old male plans to play soccer and basketball and presents for a preparticipation sports evaluation. The American Academy of Family Physicians recommends AGAINST which one of the following measures to screen for cardiac disease for this patient?

A) A detailed past medical history

B) A detailed family history

C) A detailed cardiovascular physical examination

D) An EKG

Answer 28

ANSWER: D

A baseline EKG is currently not recommended in an asymptomatic patient to screen for cardiovascular disease. The American Academy of Family Physicians (AAFP) specifically advises against performing a baseline EKG.

The AAFP does endorse performing a detailed past medical history to exclude a history of hypertension, chest pain, prior heart murmur, or syncope. It also recommends obtaining a family history that includes questions about any family members with prolonged QT syndrome, Marfan syndrome, or sudden death before the age of 50. A physical examination is recommended, including palpation of the femoral pulses simultaneously to detect coarctation of the aorta, as well as heart auscultation performed with the patient both supine and standing, and with the Valsalva maneuver, to detect a heart murmur suggestive of cardiac disease.

Question 29

229. A full-term newborn female develops respiratory distress 1 hour after an uncomplicated caesarean delivery. She has a respiratory rate of 70/min, and mild grunting and intercostal retractions are noted on examination. The remainder of the examination is within normal limits. A chest radiograph shows some hyperexpansion and fluid in the fissures.

Which one of the following is the most likely cause of her symptoms?

A) Respiratory distress syndrome of the newborn

B) Transient tachypnea of the newborn

C) Pneumothorax

D) Meconium aspiration syndrome

Answer 29

ANSWER: B

This patient has transient tachypnea of the newborn, which typically occurs within 2 hours of birth. The chest radiograph usually shows hyperexpansion with perihilar densities and fluid within the fissures. Respiratory distress syndrome of the newborn is most often seen in premature infants, and the chest radiograph shows a classic diffuse ground-glass appearance. With pneumothorax a chest radiograph would typically show a partial or complete lung collapse. Meconium aspiration syndrome occurs in the setting of meconium-stained fluid and is usually apparent immediately after delivery. The chest radiograph typically shows fluffy densities with hyperinflation.

Question 30

230. In a critically ill adult, which one of the following options for deep vein thrombosis prophylaxis is associated with the greatest reduction in mortality risk?

A) Anticoagulation therapy

B) Antiplatelet therapy

C) Mechanical device use (pneumatic compression)

D) Inferior vena cava filter use

Answer 30

ANSWER: A

In critically ill adult patients, the only deep vein thrombosis prophylaxis that decreases mortality risk is anticoagulation therapy. Mechanical device prophylaxis does not lower the mortality risk compared to no prophylaxis. Data suggests that patients managed with both prophylactic anticoagulation and mechanical device prophylaxis have a higher mortality risk than those managed by prophylactic anticoagulation alone.

Question 31

231. An 18-year-old male comes to your office because of the recent onset of recurrent, unpredictable episodes of palpitations, sweating, dyspnea, gastrointestinal distress, dizziness, and paresthesias. He says he is always concerned about when the next attack will occur. His physical examination is unremarkable except for moderate obesity. Laboratory findings, including a CBC, blood chemistry profile, and TSH level, reveal no abnormalities.

The most likely diagnosis is

A) mitral valve prolapse

B) paroxysmal supraventricular tachycardia

C) pheochromocytoma

D) generalized anxiety disorder

E) panic disorder

Answer 31

ANSWER: E

Panic disorder typically presents in late adolescence or early adulthood with unpredictable episodes of palpitations, sweating, gastrointestinal distress, dizziness, and paresthesias. The attacks are sporadic and last 10–60 minutes. Generalized anxiety disorder is more common, and common symptoms include restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance. Pheochromocytoma is associated with headache and hypertension, and usually occurs in thin patients. Paroxysmal supraventricular tachycardia is usually not associated with gastrointestinal distress or paresthesias. While mitral valve prolapse can be associated with anxiety and panic disorder, the physical examination would not be normal.

Question 32

232. A 70-year-old male comes to your office for a wellness evaluation. He smoked for many years, but quit 10 years ago. While searching through several health-related websites he read that because of his smoking history he should undergo screening for an abdominal aortic aneurysm.

Which by the one of the following screening tests for abdominal aortic aneurysm is recommended U.S. Preventive Services Task Force for this patient?

A) One-time low-dose abdominal CT

B) One-time diffusion-weighted MRI

C) One-time conventional abdominal duplex ultrasonography

D) Annual conventional abdominal duplex ultrasonography

E) No screening tests

Answer 32

ANSWER: C

The U.S. Preventive Services Task Force recommends one-time conventional abdominal duplex ultrasonography for screening patients who are at risk of abdominal aortic aneurysm (males 65–75 years of age who have smoked a total of 100 cigarettes or more during their lifetime). This imaging modality has high sensitivity and specificity, and it is noninvasive, easy to use, and low cost. None of the other imaging modalities have been formally evaluated in clinical trials.

Question 33

233. A 35-year-old female presents to your office with a 2-week history of pain, mild swelling, and point tenderness in the midportion of her anterior tibia. She has recently increased her jogging from 6 miles per week to 30 miles per week. She is unable to hop on the involved leg, as this induces significant pain at the site. A plain radiograph reveals a faint lucency at the same location.

This patient would most likely benefit from which one of the following?

A) NSAIDs

B) Bisphosphonate therapy

C) Vitamin E supplementation

D) A bone stimulator

E) A walker boot

Answer 33

ANSWER: E

Repetitive high-intensity training places an individual at risk for developing a stress fracture. A plain radiograph is the best initial test for a suspected stress fracture. If this is negative, then the study should be repeated in 2–3 weeks. MRI is now considered the procedure of choice if there is an urgent need for a diagnosis, although triple-phase bone scintigraphy has a similar sensitivity.

Treatment of stress fractures usually consists of decreasing activity or, in some instances, such as involvement of the anterior tibial cortex (where there is a risk of a complete fracture), non–weight bearing with immobilization. Using a walker boot for tibial stress fractures reduces the time to resumption of full activity. Most stress fractures should not be treated with a bone stimulator. Supplementation with vitamin D and calcium has shown some benefit in prevention, whereas bisphosphonates have not. NSAIDs are relatively contraindicated, as limited studies have shown that they may actually inhibit healing of traumatic fractures.

Question 34

234. A 42-year-old female continues to have elevated blood pressure while on three antihypertensive agents. You are concerned that she may have idiopathic adrenal hyperplasia or an aldosterone-producing adenoma.

Which one of the following would be the most appropriate laboratory test?

A) Serum cortisol

B) An aldosterone:renin ratio

C) 17-Hydroxyprogesterone

D) A dexamethasone suppression test

E) Renal ultrasonography

Answer 34

ANSWER: B

Up to 28% of patients may be defined as having resistant hypertension (not controlled on three drugs or controlled on four or more drugs). Primary aldosteronism is present in up to 5%–10% of all hypertensive patients and 7%–20% of those with resistant hypertension. This may be due to bilateral adrenal hyperplasia or a unilateral aldosterone-secreting adenoma, which can be diagnosed if there is elevated serum aldosterone in the presence of suppressed renin levels.

A cortisol level and a dexamethasone suppression test are appropriate tests for Cushing syndrome. A 17-hydroxyprogesterone level tests for congenital adrenal hyperplasia. Renal ultrasonography will not adequately screen for any of these conditions.

Question 35

235. For the past 2 weeks a 16-year-old female has had an eruption on one breast, shown below. She reports being troubled by the appearance of the lesions.

Of the following, the most appropriate management of this condition is to

A) curette each lesion to remove the top

B) apply a corticosteroid ointment locally twice daily for 10 days

C) advise the patient that the lesions will disappear in 2 weeks without treatment

D) prescribe penicillin, once daily for 10 days

E) order a serologic test for syphilis and treat if positive

Answer 35

ANSWER: A

This patient has molluscum contagiosum, which can be easily treated by curetting the lesions and inducing an inflammatory reaction. The lesions may disappear spontaneously in a few months; however, the best management of this condition in a patient who is bothered by it is to induce resolution.

Question 36

236. A 45-year-old male presents with what he suspects is a dislocated finger. He was playing football with some friends 2 days ago and when he was trying to catch the ball it struck his finger. On examination the distal interphalangeal (DIP) joint of the left fifth finger has full passive range of motion, but he cannot actively extend the joint. A radiograph confirms an avulsion fracture from the dorsum of the proximal fifth distal phalanx, with a mallet deformity.

Which one of the following is the most appropriate treatment of this fracture?

A) Immobilization of the DIP joint in 30° flexion for 6–8 weeks

B) Immobilization of the DIP joint in extension for 6–8 weeks

C) Immobilization of both the DIP and proximal interphalangeal (PIP) joints in

extension for 6–8 weeks

D) Referral for surgical pinning

Answer 36

ANSWER: B

The patient has a mallet fracture, an avulsion fracture of the distal phalanx with a bone fragment on the terminal extensor tendon, resulting in unopposed flexion and the inability to actively extend the distal interphalangeal (DIP) joint. Conservative treatment consists of immobilization of the DIP joint in extension for 8 weeks and is recommended for most cases of mallet fracture. If the joint is allowed to flex at any time during that period, then the treatment period must be extended. Immobilization of the proximal interphalangeal (PIP) joint is not required. Surgical pinning may be indicated in more complicated fractures or with failure of conservative therapy.

Question 37

237. A 62-year-old male with severe COPD without hypoxia (based on spirometry within the last year) comes to your office because of continued breathlessness. He has a 41-pack-year smoking history but stopped 1 year ago and reports he is using his inhalers as prescribed, which include albuterol (Proventil, Ventolin) as needed, budesonide/formoterol (Symbicort) twice daily, and tiotropium (Spiriva) daily. He has previously demonstrated that he is able to use the metered-dose inhalers appropriately. He is discouraged about his continued difficulty breathing and asks if there is anything else that can be done to improve this problem. His oxygen saturation on room air in the office is 92%.

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

A) Replace his inhaled medications with nebulized alternatives

B) Replace his tiotropium with ipratropium (Atrovent)

C) Order home oxygen

D) Refer for outpatient pulmonary rehabilitation

Answer 37

ANSWER: D

Pulmonary rehabilitation should be considered in patients with COPD who are optimally medically managed and continue to have symptoms, particularly dyspnea. Pulmonary rehabilitation improves exercise capacity, dyspnea, and health-related quality of life outcomes in patients with COPD. Supplemental oxygen use has been shown to decrease mortality in patients with COPD who have severe hypoxemia. Short-acting anticholinergics such as ipratropium should be used for patients with mild disease requiring only as-needed medications. The long-acting anticholinergic tiotropium has been shown to improve quality-of-life scores.

Question 38

238. A 68-year-old female who is a recent immigrant from Mexico is brought to your office by her son with a complaint of headaches. The patient speaks English adequately, but diverts her eyes to look at her son when answering your questions.

Which one of the following is the most likely reason for this patient not making eye contact?

A) Her son is overly controlling

B) She is a victim of abuse

C) She is being untruthful

D) She is showing respect to you

E) She is depressed

Answer 38

ANSWER: D

Nonverbal communication is important for identifying issues that a patient may be hiding or be unwilling to divulge. Some nonverbal clues, however, are culturally based. Many older or less-educated Mexican-Americans consider direct eye contact to be disrespectful. Because a physician is held in high regard, these patients will often either look down or look at another, more “equal” person in the room while being interviewed. Many Americans, on the other hand, may consider a lack of eye contact to be negative, and that it indicates that a patient is unsure of the information they are providing, has poor self-esteem, or is hiding something.

Question 39

239. Which one of the following is an absolute contraindication to combined oral contraceptives in a 42-year-old female?

A) Varicose veins

B) Obesity (BMI >30.0 kg/m2)

C) Sickle cell disease

D) A history of ovarian cancer

E) Smoking 1 pack of cigarettes/day

Answer 39

ANSWER: E

In a female greater than or equal to 35 years old, smoking 15 or more cigarettes per day poses an unacceptable health risk with the use of combined oral contraceptives. Patients with varicose veins are not at increased risk for deep vein thrombosis (DVT)/pulmonary embolism, which would be an unacceptable health risk with the use of combined oral contraceptives. Combined oral contraceptives actually lower the risk of ovarian cancer, and women may continue to use them while awaiting treatment for ovarian cancer. Women with a BMI 30.0 kg/m2 who take oral contraceptives are more likely to develop DVTs than those who do not use them, but the advantages of oral contraceptives are considered to be greater than the disadvantages in these patients, and obesity is not an absolute contraindication. A patient with sickle cell disease is at a higher risk of adverse events from an unintended pregnancy than from the use of combined oral contraceptives.

Question 40

240. Which one of the following descriptions of an injury by an athlete is most consistent with an isolated posterior cruciate ligament tear?

A) Hearing a pop in the knee during a pivoting motion

B) An immediate onset of pain after cutting on the knee

C) A direct blow to the anterior tibia while the knee is in flexion

D) Forceful twisting of the knee

E) An onset of pain after a running jump

Answer 40

ANSWER: C

An understanding of the anatomy and function of the components of the knee, coupled with a clear description of the traumatic event, is essential for making an accurate initial clinical assessment of sports-related knee injuries. The posterior cruciate ligament (PCL) connects the medial femoral condyle to the posterior intercondylar area of the tibia and is affixed in such a way that the anterolateral section is taut in flexion and the posteromedial section is taut in extension, helping to maintain the correct anatomic relationship between the femur and tibia. The PCL alone provides almost all of the resistance to posterior displacement of the tibia and so is appropriately the strongest of the cruciate ligaments. Tearing or rupture of the PCL can occur with hyperextension, hyperflexion, or rotation applied with a force that is so great that other knee components are also generally injured.

The most common mechanism leading to an isolated injury of the PCL is a direct blow to the anterior tibia with the knee in flexion, like that experienced when the proximal tibia impacts the dashboard in an automobile crash or when an athlete is hit or kicked in the proximal tibia while the knee is in flexion. Athletes with a PCL injury frequently complain of posterior knee pain and pain when kneeling. The presence of painful limitation of flexion and a posterior sag sign (posterior drawer sign) on examination strongly supports a diagnosis of isolated PCL injury.