Questions 51-100

Question 1

51. A 14-year-old male has open and closed comedones without evidence of surrounding inflammation on his face and upper back. Which one of the following is the most appropriate initial treatment?

A) Topical antibiotics
B) Topical retinoids
C) Oral antibiotics
D) Oral isotretinoin

Answer 1

ANSWER: B
Comedones are noninflammatory acne lesions. Inflammatory lesions include papules, pustules, and nodules. Grading acne based on the type of lesion and severity helps guide therapy. Topical retinoids prevent the formation of comedones and reduce their number, and are indicated as monotherapy for noninflammatory acne. Topical antibiotics are used primarily for the treatment of mild to moderate inflammatory or mixed acne. Oral antibiotics are effective for the treatment of moderate to severe acne. Oral isotretinoin is reserved for treatment of severe, recalcitrant acne.

Question 2

52. A 13-year-old African-American male is brought to your office by his mother for a limp that she has noticed for about 1 week. The patient admits to vague right-sided hip and knee pain present only with activity. He says the pain has never awakened him from sleep and is never present at rest. Neither the mother nor the patient has noticed any systemic symptoms such as fever, night sweats, weight loss, or appetite changes. There is no recent history of trauma.

On examination the patient’s weight is in the 90th percentile and his height is in the 50th percentile. He has an antalgic gait. Examination of the left hip is normal. Examination of the right hip is significant for decreased internal rotation. The right hip externally rotates involuntarily with passive flexion. There is no external deformity and no skin changes are noted. He has a negative FABER test. Palpation of the bursa and bone does not elicit pain. Examination of both knees is normal. Plain radiographs confirm your clinical impression.

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

A) Reassurance with close follow-up
B) Physical therapy
C) Injection of the sacroiliac joint
D) Hospital admission for intravenous antibiotics
E) Surgery

Answer 2

ANSWER: E
The most likely diagnosis for this patient is stable slipped capital femoral epiphysis (SCFE). This is more frequent in males than in females, and is more common in African-Americans and Pacific Islanders than in whites. Although some patients present with pain, many present with a painless limp or vague pain. The average age of onset is 13.5 years for males and 12 years for females. Obesity is strongly associated with SCFE.

The lack of systemic symptoms makes osteomyelitis, abscess, or a septic joint much less likely. Malignancy is a possibility, but night pain would be more likely. Sacroiliitis is much less likely given a negative FABER test. The patient’s age makes transient synovitis or Legg-Calvé-Perthes disease less likely. Although muscle strain is a possibility, the physical examination findings of external rotation deformity and limited internal rotation are more specific for SCFE.

Once the diagnosis of SCFE is made, the patient should not bear weight and should be referred promptly for surgery to prevent complications.

Question 3

53. A 57-year-old previously healthy menopausal female presents to your office with a 1-year history of palpitations and an unintentional 10-lb weight loss. A review of systems is negative for tremors or visual changes. Vital signs include a blood pressure of 129/85 mm Hg and a heart rate of 110 beats/min. A physical examination is otherwise unremarkable except for a nontender, diffusely enlarged thyroid with no distinct nodules, and mild proptosis.

Laboratory studies are significant for a TSH level less than 0.01 mU/mL (N 0.60–3.30), a free T3 level of 14.51 pg/mL (N 2.0–3.5), and a free T4 level of 4.52 ng/dL (N 0.71–1.40). A thyroid- stimulating immunoglobulin test is positive.

In addition to a B-blocker, which one of the following is the most appropriate initial management?

A) Radioactive iodine ablation
B) Thyroidectomy
C) Methimazole (Tapazole)
D) Propylthiouracil (PTU)

Answer 3

ANSWER: C
Methimazole and propylthiouracil (PTU) are the two oral antithyroid medications available. However, because of reports of severe hepatocellular damage, methimazole should be used instead of PTU unless it is contraindicated. Radioactive iodine treatment (131I) is an option, especially for patients who do not achieve remission with antithyroid medications. However, worsening of preexisting orbitopathy is a well-recognized potential complication of 131I treatment, as well as a transient increase in thyroid hormone levels that can precipitate thyroid storm. Thus, patients with elevated free T3 or free T4 levels should be treated with methimazole prior to 131I administration. Thyroidectomy is most often recommended for patients with thyroid nodules and those who are suspected of having cancer or who do not tolerate or refuse alternative forms of therapy. However, antithyroid medication should be given to achieve a euthyroid state prior to surgery in most patients.

Question 4

54. A 39-year-old male with a BMI of 41 kg/m2 is interested in weight loss. His medical history includes adequately controlled type 2 diabetes mellitus, well-controlled hypertension, hyperlipidemia, and obstructive sleep apnea. He has no history of coronary artery disease or COPD.

Which one of the following is likely to be most effective for long-term weight loss in this patient?

A) A very low calorie diet
B) Increased physical activity
C) Frequent, long-term weight-loss counseling
D) Pharmacotherapy
E) Bariatric surgery

Answer 4

ANSWER: E
Obesity increases the risk of a variety of medical conditions, including type 2 diabetes mellitus, hypertension, hyperlipidemia, pulmonary disease, coronary artery disease, gallstones, fatty liver disease, obstructive sleep apnea, GERD, osteoarthritis, and a variety of forms of cancer. A weight loss of at least 10% for greater than 1 year leads to statistically significant improvement in lipid ratios, blood glucose homeostasis, and coronary artery disease risk reduction.

The AAFP recommends screening for obesity and intensive counseling (more than 1 session per month for more than 3 months) with behavior modification for obese patients. Counseling is ineffective by itself and must be combined with lifestyle modification.

Dietary modification, increased physical activity, and behavior modification are effective for maintaining modest weight loss for greater than 1 year (SOR B). However, there are few large, randomized, controlled trials with subjects maintaining weight reductions of 10% for over 1 year, even when combining therapy, exercise, and dietary restriction. Long-term pharmacotherapy can lead to weight loss, but regaining some weight is typical.

Bariatric surgery leads to the most effective weight reduction and long-term maintenance in patients who are morbidly obese (SOR A). Gastric bypass is effective, with a mean weight loss of 71.2% at 3 years; with laparoscopic gastric banding the mean weight loss is 55.2% at 3 years. In one study, 94% of gastric bypass patients maintained at least a 20% weight loss at 6 years. Bariatric surgery has also been shown to significantly reduce fasting blood glucose, with resolution of diabetes mellitus in 31%–77% of lap band patients and 72%–100% of gastric bypass patients. Bariatric surgery is a safe and effective means for long-term weight loss and should be considered in adults with a BMI >40, or >35 with obesity-related comorbidities.

Question 5

55. A 45-year-old female with no significant past medical history presents to your office with 2 weeks of worsening pain in her right arm. For the past 2 months she has worked on a plastics manufacturing assembly line. A physical examination reveals no swelling and a normal range of motion. She has normal strength in the upper extremity but she experiences increased pain with extension of her right wrist against resistance. Palpation reveals marked tenderness over the lateral epicondyle of the right arm.

Which one of the following is most likely to improve the patient’s long-term outcome?

A) Physical therapy
B) Regular physical activity using her hands and arms
C) Use of an inelastic, nonarticular proximal forearm strap
D) Modifying her work routines

Answer 5

ANSWER: D
This patient has signs and symptoms of lateral epicondylitis, also known as tennis elbow, or alternatively as lateral epicondylalgia to reflect the noninflammatory nature of the condition. This is an overuse tendinopathy of the common extensor tendon origin of the lateral elbow. Conservative care that includes offloading the involved tendons is the key to improving outcomes at 1 year, which would mean modifying this patient’s work. Physical therapy can improve pain and function in the short term, but has not been shown to improve long-term outcomes at 1 year in randomized trials (SOR A). The evidence is weaker for bracing, with some studies showing improved pain and function at 3–6 weeks (SOR B). Recent randomized, controlled trials have made it clear that while corticosteroid injections reduce acute pain for up to 6 weeks, their use increases rates of poor long-term outcomes (SOR A).

Question 6

56. A 76-year-old white male with heart failure is admitted to the hospital for the third time in a year. He responds to treatment with intravenous furosemide (Lasix), oxygen, and morphine. When he is discharged, his medications include carvedilol (Coreg), 25 mg twice daily; furosemide, 40 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He is also placed on a low-salt diet.

Which one of the following is most likely to help prevent future admissions and decrease overall medical costs for this patient during the next year?

A) Case management by a heart failure specialist nurse
B) Nursing home admission
C) Adding amiodarone (Cordarone)
D) Increasing the dosage of lisinopril

Answer 6

ANSWER: A
Many elderly patients with heart failure are hospitalized repeatedly at short intervals. As described in a 2012 Cochrane review of 25 randomized, controlled trials, there is now good evidence that case management interventions led by a heart failure specialist nurse reduce heart failure readmissions, all-cause readmissions, and all-cause mortality. Case management interventions include home care, telephone calls, patient education, self-management, and face-to-face visits. It is not possible to say which specific interventions were optimal, but telephone follow-up was a common component in most of these trials. Multidisciplinary interventions may also be effective. For patients treated with lisinopril, 40 mg/day is the maximum amount recommended for heart failure. While B-adrenergic blockers and aldosterone antagonists are used in the treatment of heart failure, prophylactic amiodarone would not be expected to help and may be harmful. Admission to a nursing home may reduce hospitalization, but it would also increase overall costs of care.

Question 7

57. A 56-year-old African-American male with long-standing hypertension and a 30-pack-year smoking history has a 2-day history of dyspnea on exertion. A physical examination is unremarkable except for rare crackles at the bases of the lungs.

Which one of the following serologic tests would be most helpful for detecting left ventricular dysfunction?

A) B-type natriuretic peptide (BNP)
B) Troponin T
C) C-reactive protein (CRP)
D) D-dimer
E) Cardiac interleukin-2

Answer 7

ANSWER: A
B-type natriuretic peptide (BNP) is a 32–amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of the minimal presence of BNP in storage granules, its release is directly proportional to ventricular dysfunction. A BNP test is simple and time efficient, and reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram.

Question 8

58. A 35-year-old male presents with acute low back pain after he spent a weekend building a storage shed in his backyard. He has no neurologic symptoms, and the pain does not radiate into either leg.

Which one of the following has been shown to be a useful treatment in this situation?

A) Bed rest
B) Acupuncture
C) Lumbar traction
D) Cyclobenzaprine (Flexeril)
E) Methylprednisolone (Medrol)

Answer 8

ANSWER: D
Nonbenzodiazepine muscle relaxants such as cyclobenzaprine are beneficial for the relief of acute low back pain for the first 7–14 days after the onset of symptoms. Patient education, physical therapy, and the application of ice or heat may also help. Unsupported treatment options for acute low back pain include oral corticosteroids, acupuncture, lumbar support, massage, chiropractic spinal manipulation, and traction. Bed rest for acute low back pain is inadvisable.

Question 9

59. For which one of the following respiratory infections should antibiotic therapy be initiated immediately upon diagnosis?

A) Bronchitis 
B) Epiglottitis 
C) Laryngitis
D) Rhinosinusitis 
E) Tracheitis

Answer 9

ANSWER: B
Many infections of the respiratory tract have a viral etiology, and when this is the case early antibiotic treatment offers little to no benefit. Once the clinical course of a respiratory illness exceeds the expected length for a viral illness, it may be proper to initiate antibiotic treatment for a suspected atypical or secondary bacterial infection. Epiglottitis is one exception to this approach because of the possibility of a bacterial infection, particularly with Haemophilus influenzae type b, that can produce a rapidly worsening, potentially fatal airway compromise. When epiglottitis is suspected based on findings such as hoarseness, dysphagia, stridor, drooling, fever, chills, and respiratory distress, intravenous antibiotic treatment should be instituted immediately, ideally with a B-lactam drug that exhibits activity against methicillin-resistant Staphylococcus aureus.

Question 10

60. A mother meets you in the emergency department with her 3-week-old infant. The infant was delivered at term, with an uneventful prenatal and postnatal course to this point. The mother reports that the infant stopped breathing for 20–25 seconds, and that his lips and tongue appeared bluish. There was no coughing, choking, or congestion, but the child seemed “limp.” The episode ended when the mother vigorously stimulated her child and he started crying. On examination, the child appears normal.

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

A) Reassurance and no further evaluation
B) Discharge with a home apnea monitor
C) Hospital admission for observation
D) Mandatory referral to child protective services
E) Direct laryngoscopy to rule out a foreign body

Answer 10

ANSWER: C
Some experts recommend inpatient observation for all children with apparent life-threatening events such as this. Hospital admission is not always necessary, however, for a short, self-correcting episode associated with feeding. Given the history of not breathing for 20–25 seconds, having a blue tongue and lips, and being limp, admitting the child for observation is appropriate.

Although child abuse is a concern, referral to child protective services is not mandatory. Laryngoscopy would not be routine, but might be appropriate in some cases depending on the history and physical findings. Many groups recommend home apnea monitoring after discharge for patients with more severe or undiagnosed cases.

Question 11

61. A 30-year-old female at 36 weeks gestation has a positive culture for group B Streptococcus. Her past medical history is significant for the development of a nonurticarial rash in response to penicillin.

Which one of the following is most appropriate for intrapartum antibiotic prophylaxis in this patient?

A) Azithromycin (Zithromax) 
B) Clindamycin (Cleocin) 
C) Vancomycin (Vancocin) 
D) Ampicillin
E) Cefazolin

Answer 11

ANSWER: E
Cefazolin is appropriate for intrapartum prophylaxis against group B Streptococcus (GBS) in penicillin-allergic patients who do not have a history of anaphylaxis, urticaria, angioedema, or respiratory distress. Depending on the antibiotic sensitivity of the GBS organism, either vancomycin or clindamycin is recommended for patients at higher risk for anaphylaxis.

Question 12

62. For the prevention of ischemic stroke in patients at low risk for gastrointestinal bleeding, the U.S. Preventive Services Task Force recommends aspirin for

A) men age 45–79
B) men age 55–79
C) women age 45–79
D) women age 55–79
E) no one, regardless of sex or age

Answer 12

ANSWER: D
The U.S. Preventive Services Task Force has concluded that the net benefit of daily aspirin is substantial in women 55–79 years of age for whom the benefit of ischemic stroke prevention exceeds the harm of an increased risk for gastrointestinal bleeding (SOR A). Aspirin use is recommended in men 45–79 years of age for prevention of myocardial infarction when the potential benefit outweighs the potential harm of gastrointestinal hemorrhage (SOR A).

Question 13

63. Pretibial myxedema is a cutaneous manifestation of

A) subclinical diabetes mellitus
B) collagen vascular disease
C) hyperlipidemia, type III
D) ischemia
E) Graves disease

Answer 13

ANSWER: E
Pretibial myxedema is a complication of Graves disease, whether it presents as hypo- or hyperthyroidism. It is a dermopathy that most often occurs in the lower legs and results from increased deposition of mucin due to the endocrine abnormality. Diabetes mellitus can cause necrobiosis lipoidica, a lesion on the lower extremities; hyperlipidemia can cause waxy papules; and collagen vascular and ischemic disease can cause urticaria and/or ulceration.

Question 14

64. A 45-year-old male presents with a 3-month history of hoarseness. He denies any other complaints and has not been ill recently. He is not on any medication, has no history of chronic medical problems, and does not smoke cigarettes or drink alcohol.

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

A) Voice rest for 1 month
B) Laryngoscopy
C) A trial of a proton pump inhibitor
D) A trial of inhaled corticosteroids
E) Oral corticosteroids

Answer 14

ANSWER: B
Laryngoscopy should be performed to visualize the larynx and evaluate for vocal cord pathology in a patient whose hoarseness does not resolve within 3 months (SOR C). If a serious condition is suspected for some other reason, laryngoscopy should be performed regardless of the duration of symptoms. If there is a recent history of upper respiratory infection or vocal abuse, then it would be appropriate to recommend voice rest for 2 weeks. Laryngoscopy would then be indicated if the hoarseness did not improve or recurred after voice rest. For patients with symptoms of gastroesophageal reflux, a trial of a proton pump inhibitor is recommended (SOR B). Inhaled corticosteroids, especially fluticasone, may cause hoarseness. Oral corticosteroids do not have a role in the management of hoarseness.

Question 15

65. In which one of the following populations does the U.S. Preventive Services Task Force support ultrasound screening for abdominal aortic aneurysm?

A) All men age 55–75
B) Males age 55–75 who currently smoke
C) Patients of both sexes age 55–75 who currently smoke
D) Men age 65–75 who have ever smoked
E) No population group

Answer 15

ANSWER: D
The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men age 65–75 who have ever smoked (Grade B recommendation). The USPSTF recommends against routine screening for AAA in women (Grade D recommendation).

Question 16

66. A previously healthy 74-year-old male presents to the emergency department with a fever and altered mental status. His illness began 2 days ago with symptoms of fever, malaise, body aches, reduced appetite, nausea, and diarrhea. His temperature is 39.6°C (103.3°F) in the emergency department and his examination is nonfocal. Initial laboratory studies include a sodium level of 131 mEq/L (N 135–145) and a WBC count of 14,200/mm3 (N 4500–11,000) with a neutrophilic predominance. Blood and urine cultures are obtained and he is admitted to the hospital for observation.

The next morning he develops a productive cough and shortness of breath. You order a chest radiograph, which shows patchy consolidation of the bilateral bases.

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

A) Chlamydophila pneumoniae
B) Legionella pneumophila
C) Mycoplasma pneumoniae
D) Streptococcus pneumoniae

Answer 16

ANSWER: B
Pneumonia caused by Legionella pneumophila is commonly preceded by nonspecific systemic symptoms that may lead a clinician to consider other diagnoses. Symptoms may include high-grade fever, malaise, myalgias, anorexia, and headache. Gastrointestinal and neurologic symptoms are also common and include nausea, vomiting, abdominal pain, diarrhea, and confusion. Focal neurologic signs are less common, but have been reported. Localizing respiratory symptoms will typically develop later, most often a dry cough and dyspnea. From this point on the illness resembles a typical pneumonia with fever, productive cough, pleuritic pain, and breathlessness.

Question 17

67. A 62-year-old male underwent percutaneous coronary intervention and placement of two stents for a myocardial infarction yesterday. He is currently taking simvastatin (Zocor), aspirin, lisinopril (Prinivil, Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was 70 mg/dL and his blood pressure is 130/80 mm Hg.

Which one of the following additions to his current regimen would be most appropriate at this time?

A) Amlodipine (Norvasc)
B) Diltiazem (Cardizem)
C) Verapamil (Calan, Verelan)
D) Metoprolol (Lopressor, Toprol-XL)
E) No changes

Answer 17

ANSWER: D
B-Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD) and have been shown to reduce the risk of death by 23% at 2 years. They should also be given to normotensive patients with CAD if tolerated. Cardioselective (B1) B-blockers such as metoprolol and atenolol are preferred, as they cause fewer adverse effects.

Question 18

68. You see a 55-year-old female for the first time. She has a 2-year history of chronic daily cough; thick, malodorous sputum; and occasional hemoptysis. She has been treated with antibiotics for recurrent respiratory infections, but is frustrated with her continued symptoms. She has never smoked. Her FEV1/FVC ratio is 60% and CT shows bronchial wall thickening and luminal dilation.

The most likely diagnosis is

A) emphysema
B) bronchiectasis
C) chronic bronchitis
D) bronchiolitis
E) asthma

Answer 18

ANSWER: B
Bronchiectasis is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation. In addition to daily viscid, often purulent sputum production with occasional hemoptysis, wheezing and dyspnea occur in 75% of patients. Emphysema and chronic bronchitis, forms of COPD, also cause a decreased FEV1/FVC ratio, but the sputum is generally mucoid and luminal dilation of bronchi is not characteristically present. Bronchiolitis is usually secondary to respiratory syncytial virus infection in young children. Asthma is not characterized by the sputum and CT findings seen in this patient.

Question 19

69. Which one of the following is a classic finding in multiple myeloma?

A) Hypokalemia
B) Bone pain
C) Polycythemia
D) Hepatic failure
E) Insomnia

Answer 19

ANSWER: B
Multiple myeloma can be asymptomatic, but it becomes symptomatic when there is organ damage or other abnormalities, including renal insufficiency, elevated calcium, anemia, and bone disease.

The majority of patients have bone pain, but hypocalcemia is not common. Hypokalemia almost never occurs, and both hepatic failure and insomnia are not usual signs of multiple myeloma. Anemia typically occurs either because of renal failure or infiltration of the bone marrow by myeloma cells. Polycythemia does not occur.

Question 20

70. Which one of the following is the recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis?

A) 7 days
B) 14 days
C) 35 days
D) 60 days
E) 90 days

Answer 20

ANSWER: C
For patients undergoing major orthopedic surgery, the American College of Chest Physicians recommends outpatient thromboprophylaxis for a duration of up to 35 days. Older recommendations for 10–14 days of prophylaxis were based on studies performed when this was the usual hospital stay. This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.

Question 21

71. A 52-year-old male with hypertension complains of increased dyspnea for the past 6 months. He reports that he has increased fatigue and dyspnea with normal activities. There is no cough or chest pain. He has a 30-pack-year history of smoking.

On examination his blood pressure is 130/85 mm Hg, pulse rate 90 beats/min, respiratory rate 18/min, and O2 saturation 95% on room air. Heart sounds are normal with no murmurs. Auscultation of the lungs reveals bilateral rhonchi.

In addition to ordering a chest radiograph, which one of the following should be performed next in the evaluation of this patient’s dyspnea?

A) A B-type natriuretic peptide (BNP) level 
B) A D-dimer level
C) Arterial blood gas measurement 
D) Spirometry
E) High-resolution CT of the chest

Answer 21

ANSWER: D
Based on this patient’s history and physical examination, COPD is the most likely cause of his dyspnea. Initial testing should include spirometry to diagnose airflow obstruction (SOR C). CT, a BNP level, a D-dimer level, and arterial blood gas measurements would not be the best initial tests in the evaluation of this patient’s dyspnea.

Question 22

72. You respond to a code blue in the obstetrics department. The patient is a 19-year-old primigravida at 35 weeks gestation, hospitalized with severe preeclampsia. A nurse anesthetist has placed an oral airway and is administering 100% oxygen to the apneic patient. She reports no difficulty ventilating the patient with a bag and valve, and no gagging with oral airway insertion. The patient’s blood pressure is 100/60 mm Hg and her pulse rate is 70 beats/min and regular. Her pupils are equal and sluggishly reactive, and she is flaccid and areflexic. The patient had been treated with a magnesium sulfate infusion and a recent bolus of labetalol.

Which one of the following medications should you administer initially?

A) Calcium gluconate
B) Fosphenytoin
C) Labetalol
D) Lorazepam (Ativan)
E) Dopamine

Answer 22

ANSWER: A
During the treatment of severe preeclampsia with intravenous magnesium, the occurrence of apnea and areflexia is most consistent with magnesium toxicity. In addition to hemodynamic support, calcium infusion is recommended as an antidote. Calcium chloride can be used if a central line has been established. Calcium gluconate would be safer with a peripheral intravenous site.

Lorazepam, phenytoin, and fosphenytoin are less useful in preventing eclamptic seizures than magnesium. Labetalol is not indicated given the patient’s current blood pressure level. Dopamine, a pressor agent, is not indicated in this scenario, and could aggravate the patient’s preeclampsia.

Question 23

73. A 21-year-old male presents with a complaint of headaches for the past 6 months. He has severe, sharp, right-sided periorbital pain 3–4 days each week. When these headaches occur his right eye gets watery, his right nostril feels clogged, and his forehead feels sweaty. When he gets the headaches he takes four 200-mg ibuprofen tablets and goes into a dark, quiet room. The headaches usually resolve in about 90 minutes. Currently he is feeling well and his examination is completely normal.

What type of headache does he most likely have?

A) Medication overuse headache
B) Migraine
C) Paroxysmal hemicrania
D) Temporal arteritis
E) Cluster headache

Answer 23

ANSWER: E
This patient has cluster headaches. Most people with cluster headaches are male. These headaches typically present with severe unilateral pain that lasts from 15 minutes to 3 hours. The pain is generally extremely sharp, continuous, and incapacitating. In addition to the pain, the headaches are associated with at least one of the following ipsilateral signs: conjunctival injection, lacrimation, nasal congestion, miosis or ptosis, eye edema, and forehead and facial sweating. Patients may also have a sense of restlessness or agitation. The headaches occur anywhere from every other day up to 8 times a day, often in cycles for 4–12 weeks. Cluster headaches respond to most of the same medications as migraine headaches (DHE, ergotamines, triptans). They also respond well to 100% oxygen therapy.

Paroxysmal hemicranias are very unusual and present with a similar type of pain, but the attacks are usually short and they are more common in women. Medication rebound headaches tend to be diffuse, bilateral, almost daily headaches. These occur in people who are overusing medications, and they tend to get worse with physical or mental exertion. Temporal arteritis usually occurs in older adults. Migraines are also often unilateral but they are usually pulsatile, and are associated with nausea and vomiting or photophobia and phonophobia.

Question 24

74. An 82-year-old white male has a cardiopulmonary arrest while mowing his lawn and his heart rhythm is restored after 8 minutes of CPR by a neighbor. He is now your patient in the coronary care unit. He is on a ventilator and has severe hypoxic encephalopathy. Echocardiography shows an ejection fraction of 12% as a result of the massive anterior myocardial infarction he sustained. Your neurology consultant confirms that the patient will never again be able to meaningfully communicate, and will be ventilator-dependent.

Prior to this, the patient had been living independently and had no health problems. He has no living relatives, and his attorney confirms that he has no written advance directives. The neighbor, who is a close friend, tells you that on several occasions recently he and the patient had discussed such a scenario, and that the patient had said that if he had little chance of a meaningful recovery he would not want to remain on life support.

In consultation with the hospital ethics committee, which one of the following would be most appropriate in this case?

A) Transfer care of the patient to another physician
B) Ask a court to appoint a guardian to make medical decisions
C) Withdraw life support
D) Defer the decision regarding life support to the hospital attorney
E) Ask the patient’s attorney to decide whether to terminate life support

Answer 24

ANSWER: C
The most common form of advance directive is a patient’s conversations with relatives and friends, and these carry the same ethical and legal weight as written directives. Neither the hospital attorney nor the patient’s personal attorney, in the absence of a previous discussion with the patient, has the ethical or legal authority to make the decision. Since the patient has previously expressed his wishes, it is unnecessary to have the court appoint a surrogate decision maker. Care should be transferred to another physician only if the original physician has a philosophical or religious objection to carrying out the patient’s wishes.

Question 25

75. According to national and international guidelines, which one of the following is the next step for adults with asthma who require therapy with inhaled B-agonists more than three times a week?

A) Inhaled glucocorticoids
B) Inhaled salmeterol (Serevent)
C) Sustained-release oral B-agonists
D) Sustained-release oral theophylline

Answer 25

ANSWER: A
Patients who require inhalation therapy with B2-adrenergic-receptor agonists more than twice weekly but not daily have mild persistent asthma. Long-term control with inhaled corticosteroids is recommended for adults with persistent asthma.

Question 26

76. A 30-year-old male presents to your office with a 3-week history of nausea, weight loss, diarrhea, and hematochezia. He states that he has had similar episodes twice in the past and was treated at the local urgent care clinic for infectious diarrhea, with resolution of his symptoms. Your initial laboratory workup is negative for enteric pathogens and you refer the patient for colonoscopy and esophagogastroduodenoscopy with small bowel follow-through. The patient is found to have multiple noncontiguous transmural ulcerations throughout both the small and large intestines.

Which one of the following initial management strategies is most likely to induce remission in this patient?

A) Laparotomy with colectomy
B) Metronidazole (Flagyl)
C) Prednisone
D) Infliximab (Remicade)

Answer 26

ANSWER: C
Inflammatory bowel disease is divided into two categories: Crohn’s disease and ulcerative colitis. Noncontiguous or “skip” lesions that are transmural in nature and are found throughout the gastrointestinal tract make a diagnosis of Crohn’s disease likely in this patient. Corticosteroids are more effective in inducing remission than placebo and 5-ASA products (SOR A). A Cochrane review revealed no difference between elemental and nonelemental diets with regard to symptom remission (SOR A). Anti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy, but these are not recommended for initial treatment. While antibiotics such as metronidazole are widely used for both their anti-inflammatory and anti-infectious properties, controlled trials have not demonstrated their effectiveness. Surgical intervention should be considered in patients with ulcerative colitis, but surgery is not indicated for Crohn’s disease.

Question 27

77. A 7-year-old male presents with a 3-day history of sore throat, hoarseness, fever to 100°F (38°C), and cough. Your examination reveals injection of his tonsils, no exudates, shotty lymphadenopathy, and normal breath sounds.

Which one of the following would be most appropriate?

A) Symptomatic treatment only
B) Empiric treatment for streptococcal pharyngitis
C) A rapid antigen test for streptococcal pharyngitis
D) A throat culture for streptococcal pharyngitis
E) An office test for mononucleosis

Answer 27

ANSWER: A
Pharyngitis is a common complaint, and usually has a viral cause. The key factors in diagnosing streptococcal pharyngitis are a fever over 100.4°F, tonsillar exudates, anterior cervical lymphadenopathy, and absence of cough. The scenario described is consistent with a viral infection, with no risk factors to make streptococcal infection likely; therefore, this patient should be offered symptomatic treatment only. Testing for other infections is not indicated unless the patient worsens or does not improve.

Question 28

78. Which one of the following is more common in non-Hispanic whites than in the Hispanic population?

A) Obesity
B) Osteoporosis
C) Diabetes mellitus
D) Hypertension
E) Neurocysticercosis

Answer 28

ANSWER: B
Many minority populations in the United States, including Hispanics, suffer health care disparities. Some medical problems are also more common in certain populations. In 2009, Hispanics made up approximately 16% of the U.S. population and were the largest minority. This group is projected to make up 30% of the U.S. population by 2050. The rates of obesity and diabetes mellitus in Hispanics are disproportionately higher than those of non-Hispanic whites. Hypertension is closely linked to obesity, and Hispanics have higher rates of hypertension as well. Neurocysticercosis is the most common cause of seizures in Hispanic immigrants. Risk factors for osteoporosis include female gender, non-Hispanic white ethnicity, smoking, and low BMI.

Question 29

79. A 60-year-old male smoker has lung cancer, and a life expectancy of 4–6 months. His wife is concerned about his state of mind and requests medication for him. His cancer-related pain is generally controlled.

When evaluating the patient, which one of the following features would be more characteristic of depression as opposed to a grief reaction?

A) Insomnia
B) Loss of interest or pleasure in all activities
C) Feelings of guilt
D) Thoughts of wanting to die
E) Psychomotor agitation

Answer 29

ANSWER: B
While there is significant overlap in the symptoms of each condition, there are some signs and symptoms that help the family physician determine whether a terminally ill patient is experiencing grief or has major depression. This distinction is important because the terminally ill patient with depression would likely benefit from antidepressant medication, whereas a patient with end-of-life grief is generally best managed without psychotherapeutic medications.

The key clinical feature in distinguishing the two conditions is in the pervasiveness of symptoms in depression, particularly the loss of pleasure or interest in all activities. Episodic feelings of guilt, anxiety, and helplessness, and even thoughts of wanting to die can and do occur with grief reactions, but these feelings are not constant and over time the symptoms gradually wane. Terminally ill patients with major depression feel helplessly hopeless all the time, but they often respond to and significantly benefit from antidepressant medication (SOR A).

Question 30

80. A 70-year-old male with long-standing poorly controlled hypertension presents with a 6-month history of fatigue and dyspnea on exertion. He lives in a rural area and continues to be active outdoors but has less stamina. He denies edema, orthopnea, chest pain, and palpitations. His only medication is hydrochlorothiazide.

On examination the patient’s pulse rate is 80 beats/min, his blood pressure is 160/90 mm Hg, and his O2 saturation is 97% on room air. You hear a grade 2/6 midsystolic ejection murmur, which is loudest at the right upper sternal border but is also heard at the lower left sternal border. An S4 is heard at the apex, with the point of maximal intensity at the anterior axillary line of the 5th intercostal space. The S2 is not split but is a single sound. There is no S3. His lungs are clear and there is no peripheral edema.

Which one of the following conditions is the most likely cause of the auscultatory findings?

A) Aortic regurgitation
B) Aortic stenosis
C) Mitral regurgitation
D) Mitral stenosis
E) Mitral valve prolapse

Answer 30

ANSWER: B
This patient has aortic stenosis, which is most likely of the degenerative, age-related type. An echocardiogram should be included in this patient’s evaluation, but the diagnosis can still be made on the basis of the auscultatory findings. The second heart sound (closure of the aortic valve then the pulmonic valve) is normally split, consisting of two distinct components during inspiration. As the aortic valve becomes more rigid with the progression of aortic stenosis, the valve closures occur simultaneously or even become paradoxically split during expiration.

The murmur of aortic stenosis is a midsystolic ejection-type murmur, heard loudest at the right second intercostal space parasternally. It may radiate to the right carotid, and to a lesser degree may also be heard in the fourth intercostal space at the left lower sternal border. An S3 gallop is heard only late in the progression of aortic stenosis and is associated with left ventricular dilatation and heart failure.

The murmur of aortic regurgitation is a diastolic descrescendo blowing-type murmur best heard at the left fourth intercostal space at the lower left sternal border, with the patient sitting and leaning forward. Mitral valve murmurs are typically located at the heart apex or even in the left infra-axillary area. Mitral valve prolapse is characterized by a prominent systolic click, often with a brief mitral regurgitation murmur.

Question 31

81. A 63-year-old male with a history of alcoholism and compensated hepatic cirrhosis asks if there are pain medications he can use to treat his chronic low back pain and knee and hand osteoarthritis. He also has occasional headaches. He has not used alcohol for several years.

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

A) Acetaminophen
B) Gabapentin (Neurontin)
C) Naproxen
D) Pregabalin (Lyrica)
E) Tramadol (Ultram)

Answer 31

ANSWER: C
Although patients with chronic mild liver disease may take NSAIDs, they should be avoided in all patients with cirrhosis, due to the risk of precipitating hepatorenal syndrome. Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful. Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day. Tramadol is also safe in patients with cirrhosis.

Question 32

82. A 64-year-old male comes to your office for evaluation of a persistent rash affecting his groin. It is itchy but not painful and does not affect his daily activities. He has tried over-the-counter antifungal creams without relief. On examination you find well-demarcated, dark red patches in the inguinal region bilaterally. When examined with a Wood’s light the area fluoresces coral-red.

The most effective treatment for this condition is topical

A) ketoconazole (Nizoral)
B) erythromycin
C) hydrocortisone
D) mupirocin (Bactroban)
E) terbinafine (Lamisil)

Answer 32

ANSWER: B
Coral-red fluorescence on Wood’s light examination is typical of infection with Corynebacterium minutissimum, a condition known as erythrasma. This organism commonly complicates intertrigo, often in the groin or interdigital spaces. Erythromycin is the most effective treatment for this bacterial infection.

Question 33

83. A 58-year-old healthy white female sees you for a routine visit. She is monogamous with her husband, is a nonsmoker, has two alcoholic drinks a week, and has mild GERD. Her BMI is normal. She takes an over-the-counter H2-blocker and a multivitamin with calcium. She had a normal mammogram 1 month ago and a negative colonoscopy at age 53. She has never had a DXA scan or screening for ovarian cancer. Her family history is noncontributory.

According to the U.S. Preventive Services Task Force, you should recommend

A) HIV screening
B) CA-125 testing for ovarian cancer screening
C) DXA for osteoporosis screening
D) colonoscopy for colorectal cancer screening

Answer 33

ANSWER: A
The U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) recommend that all adults age 65 years and under be screened for HIV regardless of risk factors. The USPSTF does not recommend routine screening for ovarian cancer with a bimanual examination, transvaginal ultrasonography, or CA-125 testing. The USPSTF recommends that women age 65 and older be screened for osteoporosis with a DXA scan. Women younger than age 65 should be screened only if their risk of fracture is equal to or greater than a 65-year-old white female with no additional risk factors. The USPSTF recommends that women age 50–75 be screened for colorectal cancer with colonoscopy every 10 years OR with flexible sigmoidoscopy every 5 years plus fecal occult blood testing (FOBT) every 3 years OR with FOBT annually.

Question 34

84. A 27-year-old male complains of difficulty sleeping, forgetfulness, numbness, and feeling detached from life. These symptoms started 2 weeks ago after he was in a motor vehicle accident in which his younger brother was killed. He admits to troubling flashbacks to the accident and would like help with these problems.

Which one of the following is likely to be most effective for this patient?

A) Cognitive-behavioral therapy
B) Critical incident stress debriefing
C) Supportive counseling
D) Fluoxetine (Prozac)
E) Propranolol

Answer 34

ANSWER: A
Acute stress disorder (ASD) is a condition that develops within 4 weeks of a traumatic experience. The individual with ASD suffers dissociative symptoms including amnesia, a reduction in awareness of his or her surroundings, numbness, and detachment. Patients who suffer from ASD are at higher risk for developing PTSD, but appropriate treatment can reduce this risk. Cognitive-behavioral management (muscle relaxation techniques, gradual introduction to avoided situations, restructuring beliefs about the trauma) aids in the treatment of ASD (SOR A). Cognitive-behavioral therapy has been found to be more effective than supportive counseling.

Although pharmacologic management can be helpful, the evidence does not show it to be broadly beneficial. Imipramine, fluoxetine, risperidone, and propranolol have all been used for ASD, but are not recommended for routine use (SOR C).

Critical incident stress debriefing is a group activity usually provided shortly after a traumatic event. During the sessions, patients are invited to share their feelings and education is provided on coping with the trauma. There has been no evidence of a positive effect of stress debriefing and it may actually be harmful by interfering with the natural course of recovery (SOR C).

Question 35

85. A 24-year-old gravida 2 para 1 at 10 weeks gestation presents with fever, myalgias, headache, and malaise. There have been multiple cases of influenza in the community and her influenza swab is positive.

Which one of the following is recommended by the Centers for Disease Control and Prevention in this situation?

A) Rimantadine (Flumadine)
B) Oseltamivir (Tamiflu)
C) Acyclovir (Zovirax)
D) Supportive therapy only

Answer 35

ANSWER: B
The Centers for Disease Control and Prevention (CDC) recommends treatment for persons at higher risk for complications from influenza. Pregnant women and postpartum women within 2 weeks of delivery are considered to be at higher risk. Some data has shown that early antiviral treatment may shorten the duration of symptoms and reduce the risk of complications, especially in these higher risk populations.

The CDC recommends against using adamantines due to increased resistance of influenza viruses. Other antivirals such as acyclovir and famciclovir are not active against influenza A and B. The recommended treatment of influenza in pregnancy is one of the neuraminidase inhibitors.

Question 36

86. A 54-year-old male presents with progressively worsening pain just below his right knee. He describes the pain as deep and aching, and says it is always present throughout the day, even while he is at rest, and worsens at night. Weight bearing intensifies the pain, as does heat. The patient does not recall any injury or other reason for the leg to hurt. He has not had any fever. His family history is positive for osteoarthritis in both parents when they were older, and an uncle has had a knee replacement.

A physical examination is negative except for some varus deformity of the right lower extremity just below the knee. There is no redness. Radiographs demonstrate mild to moderate bowing of the proximal tibia. His alkaline phosphatase level is elevated but his y-glutamyl transaminase level is normal. The remainder of a comprehensive metabolic panel is also normal. A CBC is normal, including the WBC count and differential.

You should suspect which one of the following conditions?

A) Osteoarthritis
B) Osteoporosis
C) Osteomyelitis
D) Paget’s disease of bone
E) Seronegative spondyloarthritis

Answer 36

ANSWER: D
Patients with bone pain caused by Paget’s disease usually describe the pain as continuous. Unlike osteoarthritis, the bone pain of Paget’s disease usually increases with rest, when the limbs are warmed, and at night. A variety of deformities may occur, including bowing of the tibia, and alkaline phosphatase is elevated. The case presented is not typical for osteoarthritis or osteoporosis, and the patient does not have a fever, elevated WBC count, or other findings suggestive of osteomyelitis.

Seronegative spondyloarthritis (or spondyloarthropathy) is a family of inflammatory rheumatic diseases that cause arthritis. The most common is ankylosing spondylitis, which affects mainly the spine. Others include axial spondyloarthritis, which affects mainly the spine and pelvic joints; peripheral spondyloarthritis, affecting mostly the arms and legs; reactive arthritis (formerly known as Reiter’s syndrome); psoriatic arthritis; and enteropathic arthritis/spondylitis associated with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease). The main symptom in most patients with spondyloarthritis is low back pain, which is most common in axial spondyloarthritis. In a minority of patients, the major symptom is pain and swelling in the arms and legs. This type is known as peripheral spondyloarthritis.

Question 37

87. A 62-year-old male with a 20-year history of diabetes mellitus presents with bilateral calf and buttock pain that occurs after he walks 2 blocks. The symptoms are relieved with rest. On examination his pedal pulses are not palpable and his ankle-brachial index is 1.45.

Which one of the following would be most appropriate?

A) Reassuring the patient that his ankle-brachial index is normal
B) MRI of the lumbar spine
C) A repeat evaluation in 6 months if the symptoms persist
D) MR or CT angiography of the lower extremities

Answer 37

ANSWER: D
The National Health and Nutrition Examination Survey (NHANES) found that 1.4% of adults over 40 have an ankle-brachial index (ABI) >1.4; this group accounts for approximately 20% of all adults with peripheral artery disease. An ABI >1.4 indicates noncompressible arteries (calcified vessels). In patients with arterial calcification, such as diabetic patients, more reliable information is often obtained by using toe pressures to calculate a toe-brachial index and from pulse volume recordings.

Vascular imaging should be used to confirm peripheral vascular disease. MR or CT arteriography, duplex scanning, and hemodynamic localization are noninvasive methods for lesion localization and may be helpful when symptoms or findings do not correlate with the ABI. Contrast arteriography is used for definitive localization before intervention.

Question 38

88. An 85-year-old navy veteran presents to your office with a complaint of cough and dyspnea with exertion. He spent his entire career in ship maintenance and repair, and retired from the navy at the age of 45. His chest radiograph shows pleural plaques. He has a 20-pack-year smoking history, but quit at the age of 39.

You suspect his problem is due to occupational exposure to which one of the following?

A) Asbestos
B) Beryllium
C) Iron oxide
D) Silica
E) Uranium

Answer 38

ANSWER: A
The inhalation of asbestos fibers may lead to a number of respiratory diseases, including lung cancer, asbestosis, pleural plaques, benign pleural effusion, and malignant mesothelioma. High-risk populations for asbestos exposure include individuals who worked in construction trades or as boilermakers, shipyard workers, or railroad workers, as well as U.S. Navy veterans. The occupational history helps to guide clinical suspicion in these high-risk populations. This patient is a retired U.S. Navy veteran who spent his entire career in ship maintenance and repair.

The patient history is not consistent with berylliosis, silicosis, or uranium exposure. Berylliosis is an occupational disease related to mining and manufacturing. Silicosis is seen in sandblasters, miners, persons who have worked with abrasives, and several other occupations. Uranium exposure occurs after nuclear reactor leaks or blasts. Uranium compounds are also used in photography and as dyes or fixatures. The chemical toxicity involves nonmalignant damage to alveolar cells. Iron oxide exposure is not known to be related to lung disease.

Question 39

89. A 15-year-old male is seen in the office for ankle pain. While playing basketball he jumped and landed on the lateral edge of his foot. He had immediate pain and did not continue playing, but was able to walk after the injury. On examination his right ankle has tenderness, swelling, and bruising over the anterior talofibular and calcaneofibular ligaments. There is no bony tenderness.

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

A) Taping the ankle for future sports participation
B) An elastic compression wrap
C) A lace-up ankle support
D) A radiograph of the ankle
E) A below the knee cast

Answer 39

ANSWER: C
A lace-up ankle support reduces pain and recovery time after an ankle sprain (SOR B). The Ottawa Rules state that radiography is required only if there is pain in the malleolar or midfoot zone and either bony tenderness over an area of potential fracture (i.e., distal fibula or tibia, lateral or medial malleolus, base of the fifth metatarsal, or navicular bone) or an inability to bear weight immediately after the injury and when evaluated by a physician. This patient did not have those findings, and therefore would not need a radiograph (SOR A). A cast is not necessary for an ankle sprain. An elastic compression wrap alone is not as effective as a lace-up support. Taping of the ankle for future sports participation can reduce the risk of ankle sprains during sports, but would not be appropriate for an acute injury.

Question 40

90. Which one of the following is best for preventing acute mountain sickness?

A) Acetazolamide (Diamox Sequels) started the day before arriving at altitude
B) Prednisone started the day before arriving at altitude
C) Moderate alcohol consumption on the first day at altitude
D) Ascending quickly, then resting to acclimatize before beginning planned activities

Answer 40

ANSWER: A
Acute mountain sickness is common in people traveling to altitudes higher than 8200 ft. Symptoms include headache and at least one of the following: nausea or vomiting, anorexia, dizziness or lightheadedness, fatigue or weakness, and difficulty sleeping. Slow ascent is the most effective way to prevent acute mountain sickness. Acetazolamide or dexamethasone can be used for both prevention and treatment. Ataxia and altered mental status are signs of cerebral edema and occur with end-stage acute mountain sickness. This can progress to coma and death and requires prompt treatment and descent. High-altitude pulmonary edema can occur without acute mountain sickness. Alcohol consumption on the first day at altitude can exacerbate acute mountain sickness.

Question 41

91. A 70-year-old alcoholic male is recovering from a myocardial infarction. On the fourth hospital day he complains of a sudden onset of excruciating abdominal pain that is not significantly reduced by large doses of morphine. He becomes nauseated, begins to vomit, and has diarrhea.

The patient appears agitated and confused, and his heart rate increases. He also becomes hypotensive. Physical examination of his abdomen reveals minimal tenderness, decreased bowel sounds, and a moderately enlarged liver.

Laboratory Findings

WBCs . . . . . . . .17,600/mm3 with a left shift (N 4300–10,800)
BUN . . . . . . . . . 40 mg/dL (N 8–25)
Creatinine . . . . 1.0 mg/dL (N 0.6–1.5)
Serum lipase . . 150 U/L (N 0–160)
ArterialpH . . . . . 7.14 (N 7.35–7.45)

The most likely diagnosis is

A) alcohol withdrawal syndrome
B) pulmonary embolus
C) pancreatitis
D) acute mesenteric artery embolism
E) perforated gastric ulcer

Answer 41

ANSWER: D
The hallmark of acute mesenteric artery ischemia is severe abdominal pain that is out of proportion to physical findings. This is a life-threatening event, which often follows a myocardial infarction when a mural thrombus occludes a superior mesenteric artery. Patients rapidly become acidotic and hypotensive, and experience a high mortality rate.

Alcoholic withdrawal syndrome has a much more insidious onset, with tremors, agitation, and anxiety being the prominent features. Abdominal pain is not a common prominent symptom or finding. Although pulmonary embolism is possible in the patient described, the major symptoms are dyspnea and chest pain, and abdominal pain and tenderness would not be a typical finding. A normal serum lipase level should point to a nonpancreatic origin for this patient’s problem. A perforated gastric ulcer would typically have a more insidious onset and the abdominal examination would usually demonstrate marked focal tenderness.

Question 42

92. Which one of the following cardiovascular changes is a recognized age-related effect?

A) Decreased maximal heart rate with exercise
B) Decreased myocardial collagen
C) Decreased myocardial mass
D) Increased left ventricular compliance
E) Increased heart rate at rest

Answer 42

ANSWER: A
Maximal heart rate with exercise generally decreases with age. A frequently used formula for predicting maximal heart rate is 220 minus age, with a correction factor of 0.85 often applied for females, who have a lower peak heart rate and a more gradual decline.

Myocardial collagen and mass both increase with age. The increase in collagen may play a role in decreasing left ventricular compliance. The resting heart rate, like the maximal exercising heart rate, decreases with normal aging. Tachycardia at rest may suggest a pathologic state.

Question 43

93. A 55-year-old male has New York Heart Association class III chronic systolic heart failure due to hypertensive cardiomyopathy. Which one of the following is CONTRAINDICATED in this patient?

A) Carvedilol (Coreg)
B) Digoxin
C) Ramipril (Altace)
D) Spironolactone (Aldactone)
E) Verapamil (Calan)

Answer 43

ANSWER: E
ACE inhibitors and B-blockers improve mortality in heart failure (HF). Digoxin and furosemide improve symptoms and reduce hospitalizations in systolic HF, and furosemide may decrease mortality. Spironolactone, an aldosterone antagonist, reduces all-cause mortality and improves ejection fractions in systolic HF. Verapamil, due to its negative inotropic effect, is associated with worsening heart failure and an increased risk of adverse cardiovascular events.

Question 44

94. A 13-year-old female is brought to your office for evaluation of school difficulties and depressed mood. Her mother and older sister have both been diagnosed with depression. After a thorough history and physical examination, you diagnose major depressive disorder. You arrange for the patient to receive cognitive-behavioral therapy, but after 6 weeks her condition is only minimally improved.

Which one of the following medications would be appropriate to add to this patient’s treatment plan at this point?

A) Fluoxetine (Prozac)
B) Imipramine (Tofranil)
C) Lithium
D) Venlafaxine

Answer 44

ANSWER: A
The diagnostic criteria for depression are the same for children and adults, although the manner in which these symptoms present may be different. Adolescents with depression are more likely to experience anhedonia, boredom, hopelessness, hypersomnia, weight change, alcohol or drug use, and suicide attempts. Psychotherapy should always be included as part of a treatment plan for depression in adolescents.

Cognitive-behavioral therapy and interpersonal therapy are two modalities that have been proven effective in the treatment of adolescent depression. Medications should be considered for more severe depression or depression failing to respond to psychotherapy. A Cochrane review found that fluoxetine was the only agent with consistent evidence of effectiveness in decreasing depressive symptoms in adolescents. Consensus guidelines recommend fluoxetine, citalopram, or sertraline as first-line treatments for moderate to severe depression in children and adolescents. Escitalopram is also licensed for the treatment of depression in adolescents age 12 or older. All antidepressants have a boxed warning regarding an increased risk of suicide; therefore, close monitoring is recommended to assess for suicidality and other adverse effects, such as gastrointestinal effects, nervousness, headache, and restlessness. Tricyclic antidepressants were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children.

Question 45

95. Which one of the following medications used in the treatment of osteoporosis can also be used to treat the pain associated with acute and chronic vertebral compression fractures?

A) Calcitonin-salmon (Miacalcin)
B) Raloxifene (Evista)
C) Risedronate (Actonel)
D) Teriparatide (Forteo)
E) Zoledronic acid (Reclast)

Answer 45

ANSWER: A
While all of the medications listed can be used to treat osteoporosis, only calcitonin-salmon is useful in the management of pain associated with acute or chronic vertebral fractures. Calcitonin is an antiresorptive agent that has been shown to decrease the risk of vertebral fractures, but it is not considered a first-line treatment for osteoporosis because there are more effective agents. However, it does have modest analgesic properties that make it useful in the treatment of the pain associated with vertebral fractures.

Question 46

96. A morbidly obese 68-year-old male complains of breast enlargement. He has not noticed any pain or discomfort from this problem. His past medical history is negative except for type 2 diabetes mellitus and hypertension. His medications include metformin (Glucophage), 1000 mg twice daily; lisinopril (Prinivil, Zestril), 20 mg daily; and aspirin, 81 mg daily. His family history is negative for breast cancer. A physical examination is negative except for a BMI of 45 kg/m2 and symmetric bilateral adipose tissue in the breast region on inspection and palpation. There is no glandular tissue on careful palpation of the area beneath the areolae and nipples. No nodules or axillary nodes are detected. There is no nipple retraction or discharge, and no skin changes.

Which one of the following is the most likely cause of this problem?

A) Fat necrosis
B) Gynecomastia
C) Pseudogynecomastia
D) Breast cancer
E) Mastitis

Answer 46

ANSWER: C
This patient most likely has pseudogynecomastia due to increases in subareolar fat secondary to his obesity. This is based upon clinical findings of symmetric adipose tissue in the breast region bilaterally and a lack of firm, palpable glandular tissue in the nipple and areolar region. In gynecomastia, there is palpable, firm glandular tissue in a concentric mass around the nipple-areola complex. Hard, immobile masses, masses associated with skin changes, nipple retraction, nipple discharge, or enlarged lymph nodes would suggest possible malignancy. Fat necrosis would involve a history of breast region trauma and would generally be asymmetric. Mastitis would cause clinical signs of infection.

Question 47

97. Which one of the following is most likely to cause hypoglycemia in elderly patients?

A) Metformin (Glucophage)
B) Pioglitazone (Actos)
C) Glipizide (Glucotrol)
D) Sitagliptin (Januvia)
E) Glyburide (DiaBeta)

Answer 47

ANSWER: E
Among the oral antiglycemic drugs, the sulfonylurea agents are the most likely to cause hypoglycemia, and glyburide is more likely to cause hypoglycemia than glipizide. Glyburide should rarely be used in the elderly.

Question 48

98. A 42-year-old female is troubled by her lack of interest in sex. She is generally healthy, takes no medications, and has regular menstrual periods. She is content with the emotional intimacy of her marriage and has had satisfying sexual interactions in the past. She does not have any religious or cultural barriers regarding her sexuality, and asks for ideas on how to improve her situation.

Which one of the following has consistent evidence of benefit in cases such as this?

A) Cognitive-behavioral therapy
B) Viewing pornography
C) Oral estrogen
D) Oral sildenafil (Viagra)
E) Topical testosterone

Answer 48

ANSWER: E
This patient meets the criteria for hypoactive sexual desire disorder (HSDD). The incidence of this condition is variable based on the age, life stage, and culture of the patient, but is estimated to be present in about 5%–15% of the adult female population. This diagnosis includes two components: (1) recurrent deficiency or absence of sexual desire or receptivity to sexual activity, and (2) distress about such a deficiency. In menstruating women, oral estrogen and oral sildenafil have not been shown to be superior to placebo. Cognitive-behavioral therapy has been shown to be helpful for other sexual dysfunctions, but not with HSDD. Topical testosterone, in either patch or gel form, has shown consistent improvements in arousal, desire, fantasy, orgasm, and overall satisfaction in cases of HSDD.

Question 49

99. A 25-year-old white male truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid.

Which one of the following is the preferred initial treatment for this patient?

A) Infrared coagulation
B) Rubber band ligation of the hemorrhoid
C) Elliptical excision of the thrombosed hemorrhoid
D) Stool softeners and a topical analgesic/hydrocortisone cream

Answer 49

ANSWER: C
The appropriate management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms is elliptical excision of the hemorrhoid and overlying skin under local anesthesia, such as 0.5% bupivacaine hydrochloride in 1:200,000 epinephrine, infiltrated slowly with a 27-gauge needle.

Incision and clot removal may provide inadequate drainage, resulting in rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots that may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids, and infrared coagulation is also used for this purpose. Banding an external hemorrhoid would cause exquisite pain.

If the pain is already subsiding or more time has elapsed, and if there is no necrosis or ulceration, measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may be helpful. Some local anesthetics carry the risk of sensitization. Counseling to avoid precipitating factors such as prolonged standing/sitting, constipation, and delay of defecation is also appropriate.

Question 50

100. A 20-year-old male presents with complaints of abdominal pain and diarrhea. He says he often has abdominal cramping that is relieved with defecation. The pain is accompanied by frequent loose, mucous stools, and his symptoms tend to get worse with stress. He says he has tried antidiarrheal medications and antispasmodics, but did not get satisfactory results.

Your evaluation leads to a diagnosis of diarrhea-predominant irritable bowel syndrome. Which one of the following would be the most appropriate treatment?

A) Fiber supplements
B) Neomycin
C) Citalopram (Celexa)
D) Alosetron (Lotronex)
E) Lubiprostone (Amitiza)

Answer 50

ANSWER: C
A Cochrane review of 15 studies involving 922 patients showed that antidepressants had a beneficial effect on the symptoms of irritable bowel syndrome (IBS). Both SSRIs and tricyclic antidepressants have shown benefit. Another Cochrane review of 12 randomized, controlled trials did not show any benefit from the use of fiber in any type of IBS. Antibiotics have been shown to have some beneficial effects, but neomycin is used only in constipation-predominant IBS. Lubiprostone is a selective C-2 chloride channel activator and can be used for patients with chronic constipation. Alosetron is a 5-hydroxytryptamine 3 antagonist and is FDA approved to treat severe diarrhea-predominant IBS only in women who have not improved with conventional therapy. Alosetron is associated with uncommon but serious adverse events (ischemic colitis, constipation, death) and its use is restricted in the United States. Other potentially beneficial therapies for IBS include peppermint oil, psychological treatments, exercise, and probiotics.