Questions 51-100

Question 1

51. A 40-year-old male is brought to the emergency department with seizures and a change in his mental status. He is found to be severely hyponatremic with a serum sodium level of 112 mEq/L (N 135–145).

Initial management while evaluating this patient further should include which one of the following?

A) Infusion of 0.45% saline

B) Infusion of 3% saline

C) Infusion of normal saline

D) Fluid restriction

E) Hemodialysis

Answer 1

ANSWER: B

Severe hyponatremia with symptoms of confusion and seizures requires raising the serum sodium level until symptoms improve. Symptomatic hyponatremia occurs when sodium levels decrease over less than 24 hours. Once symptoms resolve, the cause should be determined. The rate of sodium correction should be 6–12 mEq/L in the first 24 hours and 18 mEq/L or less in the first 48 hours. An increase of 4–6 mEq/L is usually sufficient to reduce symptoms of acute hyponatremia. Rapid correction of sodium levels can result in osmotic demyelination (previously called central pontine myelinolysis).

Infusion of normal saline or 0.45% saline will not correct the sodium as rapidly as 3% saline in acute, severe hyponatremia. Desmopressin, 1–2 Mug every 4–6 hours, can be used concurrently with 3% saline.

Question 2

52. An 82-year-old bedridden male develops a partial thickness skin loss ulcer (stage 2) over his right heel. He is noted to have a dry, intact eschar without erythema or fluctuance.

After gentle cleansing with saline, which one of the following is the most appropriate management of this wound?

A) Additional cleansing with a chlorine-based (Dakin’s) solution

B) Additional cleansing with a povidone-iodine solution (Betadine)

C) Application of a moist, nonadhesive bandage

D) Application of a wet-to-dry dressing

E) Sharp debridement of the dry eschar

Answer 2

ANSWER: C

After cleansing with saline or tap water, application of a moist, nonadhesive bandage is the preferred way to manage a pressure ulcer. A moist wound environment assists in healing and aids in autolytic debridement. Wet-to-dry dressings may impede healing by causing pain and unnecessary debridement when a fully dry dressing is removed. Chlorine-based and povidone-iodine solutions should be avoided because they may impede granulation tissue formation. While it is important to debride necrotic tissue and slough, a dry, intact eschar over the heels without any sign of infection should be left in place as a natural biologic cover.

Question 3

53. Which one of the following has been consistently identified as the most common cause of medication-related adverse events across health care settings in the United States?

A) Antibiotics

B) Anticoagulants

C) Chemotherapeutic agents

D) Diabetic agents

E) Opioids

Answer 3

ANSWER: B

Anticoagulant medications have been consistently identified as the most common cause of adverse drug events across health care settings in the United States. The top three categories responsible for adverse drug events are anticoagulants, opioids, and diabetic agents.

Question 4

54. A 63-year-old female complains of left shoulder pain and stiffness that have been increasing in severity for the last year. She works as a hotel housekeeper. On examination you note decreased passive and active range of motion of her left shoulder compared to the right. Both active and passive motion produce pain.

Which one of the following is the most likely diagnosis?

A) Glenohumeral osteoarthritis

B) Subdeltoid bursitis

C) Adhesive capsulitis

D) Partial rotator cuff tear

E) Teres minor myositis

Answer 4

ANSWER: C

Shoulder pain is the third most common musculoskeletal reason patients consult primary care physicians, and rotator cuff disease is the most common cause of shoulder pain. Pain and restricted active and passive range of motion, accompanied by pain and joint stiffness, are diagnostic of adhesive capsulitis. Range of motion would not likely be affected with a partial rotator cuff tear, subdeltoid bursitis, active myositis, or osteoarthritis. Limitations that occur only with active motion suggest impairment of rotator cuff muscles.

Question 5

55. A 34-year-old female with no significant past medical history is being evaluated for acute abdominal pain. CT of the abdomen reveals a 3-cm right adrenal mass.

This lesion is most likely to be which one of the following?

A) A benign adenoma

B) An adrenocortical carcinoma

C) A pheochromocytoma

D) A neuroblastoma

E) A metastatic lesion

Answer 5

ANSWER: A

An incidentally discovered adrenal mass is a common finding on abdominal CT and MRI, occurring in approximately 3%–4% of scans. However, only about 1% of these are malignant, and malignancies rarely occur in lesions <5 cm in size. Metastatic lesions are rare in patients without a history of cancer. An incidentally discovered adrenal mass 1–4 cm in size is most likely to be a benign adenoma, although follow-up is often indicated to ensure stability of the lesion.

Question 6

56. Which one of the following is a risk factor for uncomplicated cystitis?

A) Obesity

B) Low fluid intake

C) Frequent sexual intercourse

D) Use of hot tubs

E) Wearing synthetic underwear

Answer 6

ANSWER: C

There are multiple risk factors for uncomplicated cases of cystitis. Sexual intercourse is the most common. Others include spermicide use, previous urinary tract infection, a new sex partner, and a family history of urinary tract infections in a first degree female relative.

Various studies have shown no relationship between cystitis and water consumption, urinating after intercourse, patterns of wiping after urination, use of hot tubs, type of underwear, or obesity.

Question 7

57. A 65-year-old female sees you for a routine health maintenance visit. She has a newborn granddaughter that she is planning to watch a few days a week and asks if there are any vaccines that she can get that will help protect the health of her granddaughter. She has not received any vaccines other than yearly influenza vaccine in the past 20 years.

According to the Centers for Disease Control and Prevention, which one of the following would be recommended for her to protect her infant grandchild from illness?

A) Meningococcal vaccine (Menactra)

B) 13-valent pneumococcal conjugate vaccine (Prevnar 13)

C) 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23)

D) Tdap

E) Varicella vaccine

Answer 7

ANSWER: D

Infants less than 12 months of age have higher rates of pertussis infection and have the largest proportion of pertussis-related deaths. The majority of pertussis cases, admissions, and deaths occur in children under 2 months of age before they receive their first vaccines. The Advisory Committee on Immunization Practices recommends that all unvaccinated family members get a dose of Tdap to help protect infants from pertussis. Both 13-valent and 23-valent pneumococcal vaccine are indicated for someone over 65 years of age, but there is not a demonstrated benefit for the health of the infant in this case. Meningococcal and varicella vaccines are not routinely given to adults over age 65 and have not been shown to help protect the infants they have contact with.

Question 8

58. A 64-year-old female with a history of controlled hypertension reports that her older sister was recently hospitalized for a stroke. The patient feels well and has never had stroke symptoms. She requests your advice regarding carotid artery screening for stroke risk reduction.

Which one of the following would you recommend?

A) Carotid artery ultrasonography only if she has two or more cardiovascular risk factors

B) Carotid artery ultrasonography once between the ages of 65 and 75 if she is a former smoker

C) Carotid artery ultrasonography once at age 65

D) Carotid artery auscultation annually after age 65

E) No screening for carotid artery disease

Answer 8

ANSWER: E

The U.S. Preventive Services Task Force recommends against screening for asymptomatic carotid artery stenosis (grade D recommendation), citing with moderate certainty that risks outweigh benefits. Although carotid artery stenosis is a risk factor for stroke, which is a major cause of death and disability, screening tests were not found to improve patient outcomes.

Asymptomatic carotid artery stenosis has a low prevalence (0.5%–1%) and carotid ultrasonography has a high rate of false-positives, exposing patients to harm from unnecessary treatment. Surgical treatments for carotid artery stenosis have a 30-day risk of stroke and mortality of 2.2%–3.8%. Carotid auscultation has not been found to be accurate or beneficial, and screening has not been shown to help optimize medical therapy.

Question 9

59. A 52-year-old female presents with a 5-day history of nasal congestion, facial pressure, heavy nasal discharge, and decreased sense of smell. She has not had a fever and says her symptoms have not started to improve. She is mildly tender over both maxillary sinuses. Even though you have reassured her that this is most likely a viral illness, she would like antibiotics because she is going on vacation in 2 days and she wants to be better for her trip.

Which one of the following strategies has been shown to improve the acceptance of symptomatic care only and reduce the use of antibiotics in this situation?

A) Using medical terminology for the condition, such as acute bronchitis or acute tracheitis

B) Providing a “pocket” prescription with advice to fill it after a defined period without improvement

C) Ordering sinus radiographs

D) Referral to a specialist

Answer 9

ANSWER: B

In spite of good evidence that antibiotics are ineffective for the treatment of acute bronchitis, and that 90% of cases are caused by viruses, rates of antibiotic prescription for acute bronchitis remain in the 60%–80% range. Several strategies have been shown to reduce the rate of antibiotic prescribing for this condition. These include careful use of nonmedical terminology such as referring to the problem as a “chest cold,” providing “pocket” prescriptions with advice to fill the prescription only if the patient does not improve in a defined period of time, and educating patients about the natural history of bronchitis, informing them that symptoms may persist for 3 weeks. Specialists are not less likely than primary care physicians to prescribe antibiotics. Sinus films would not provide evidence to confirm that the infection is viral.

Question 10

60. A 19-year-old female sees you for evaluation of severe dysmenorrhea. She tells you she is not sexually active and has never had intercourse. A physical examination is unremarkable and you determine that a pelvic examination is not necessary.

Which one of the following is the treatment of choice for this patient?

A) Acetaminophen

B) Hydrocodone

C) Medroxyprogesterone acetate (Depo-Provera)

D) An NSAID

E) An oral contraceptive

Answer 10

ANSWER: D

NSAIDs should be used as first-line treatment for primary dysmenorrhea (SOR A). A Cochrane review that included 73 randomized, controlled trials demonstrated strong evidence to support NSAIDs as the first-line treatment for primary dysmenorrhea. Since no NSAID has been proven more effective than others, the choice of NSAID should be based on effectiveness and tolerability for each patient. The medication should be taken 1–2 days before the expected onset of the menstrual period and continued on a fixed schedule for 2–3 days. Oral contraceptives may be effective for relieving symptoms of primary dysmenorrhea but the evidence is limited. Hydrocodone, acetaminophen, and medroxyprogesterone acetate are not appropriate choices.

Question 11

61. A 44-year-old male presents to the emergency department in the evening with facial, lip, and tongue edema that has been gradually progressing over the last few hours. He was started on lisinopril (Prinivil, Zestril) earlier today for mild hypertension. He does not have a rash or pruritus. He reports tightness in his throat and, although he is moving air well at this time, you do note some mild stridor.

Which one of the following is most likely to prevent the need for intubation?

A) Epinephrine

B) An antihistamine such as diphenhydramine (Benadryl)

C) An angiotensin receptor blocker such as losartan (Cozaar)

D) A bradykinin receptor antagonist such as icatibant (Firazyr)

E) A corticosteroid such as methylprednisolone (Medrol)

Answer 11

ANSWER: D

Less than 1% of patients started on an ACE inhibitor develop angioedema, but some studies have reported that up to 10% of these patients require intubation. This type of angioedema is due to increased bradykinin rather than histamine, and antihistamines, anticholinergics, corticosteroids, and epinephrine would not be effective. Icatibant is a bradykinin receptor type 2 blocker and is recommended in patients with laryngeal angioedema compromising airway function (level 2 evidence). Angiotensin receptor blockers, although probably not harmful, would not be helpful.

Question 12

62. A 62-year-old male is admitted to the hospital for urosepsis. His past medical history is significant only for hypertension. On examination he has a temperature of 36.5°C (97.7°F), a TSH level of 0.2 MuU/mL (N 0.4–5.0), and a free T4 level of 0.4 ng/dL (N 0.6–1.5).

Which one of the following is the most likely explanation for these findings?

A) Pituitary adenoma

B) Graves disease

C) Subacute thyroiditis

D) Subclinical hypothyroidism

E) Euthyroid sick syndrome

Answer 12

ANSWER: E

The euthyroid sick syndrome refers to alterations in thyroid function tests seen frequently in hospitalized patients, and abnormal thyroid function tests may be seen early in sepsis. These changes are statistically much more likely to be secondary to the euthyroid sick syndrome than to unrecognized pituitary or hypothalamic disease (SOR C). Graves disease generally is a hyperthyroid condition associated with low TSH and elevated free T4. Subclinical hypothyroidism is diagnosed by high TSH and normal free T4 levels. Subacute thyroiditis most often is a hyperthyroid condition.

Question 13

63. A 56-year-old male with daily heartburn symptoms is found to have Barrett’s esophagus on endoscopy. Biopsies do not show any evidence of dysplasia.

Which one of the following should be recommended for surveillance of this condition?

A) Endoscopy every year

B) Endoscopy every 3 years

C) Endoscopy every 10 years

D) A PET scan every 2 years

E) No routine surveillance, with endoscopy only if symptoms worsen

Answer 13

ANSWER: B

Endoscopic screening results in the detection of Barrett’s esophagus in 6%–12% of patients with prolonged gastroesophageal reflux disease symptoms. Barrett’s esophagus, in which specialized intestinal columnar epithelium replaces the normal esophageal lining in response to chronic inflammation, is a precursor of esophageal adenocarcinoma. The annual cancer risk for patients with nondysplastic Barrett’s esophagus is 0.12%–0.4%, with a significant increase in risk if dysplasia is present. Surveillance with endoscopy every 3 years is recommended for patients with Barrett’s esophagus without dysplasia. Patients with adenocarcinoma of the esophagus found during surveillance endoscopy are more likely to have early-stage, curable cancer than those whose cancer is found during a diagnostic endoscopy for evaluation of symptoms.

Question 14

64. A healthy 65-year-old female is noted to have a 1.5-cm thyroid nodule during a routine health maintenance visit. She has no history of radiation exposure or cancer, and no family history of endocrine cancers.

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

A) A TSH level

B) Antithyroid antibody

C) A fine-needle aspiration biopsy

D) Thyroid ultrasonography

E) A thyroid radionuclide scan

Answer 14

ANSWER: A

If TSH is suppressed in this patient it indicates that the nodule is producing thyroid hormone and further evaluation with a radionuclide scan is indicated. If the TSH is normal or elevated the next step is to determine whether the nodule needs to be biopsied. Thyroid ultrasonography can determine the size and characteristics of the nodule to help determine whether to refer the patient for a fine-needle aspiration biopsy. With a large, firm lesion that is highly suspicious for malignancy, it may be appropriate to refer directly for a fine-needle aspiration biopsy. However, for this patient the lesion did not appear suspicious. If the patient were hyperthyroid it might be appropriate to check antithyroid antibodies to look for Graves disease.

Question 15

65. A 40-year-old male develops a keloid 6 months after a laceration repair. Which one of the following is the most appropriate initial treatment to decrease the size of the keloid?

A) Topical retinoids

B) Topical corticosteroids

C) Intralesional corticosteroid injections

D) Surgical excision

E) Mohs surgery

Answer 15

ANSWER: C

Keloids are overgrowths of scar tissue seen more commonly in individuals with dark skin. The best initial treatment is intralesional corticosteroid injections. If this does not produce acceptable results, other treatment modalities include surgery, laser therapy, and bleomycin injection.

Question 16

66. A 45-year-old male reports being held up at gunpoint while on vacation 3 months ago. Since that time he has had intrusive memories of the event, as well as nightmares. Further questioning reveals that he has been having dissociative reaction flashbacks and meets the criteria for posttraumatic stress disorder.

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

A) Clonazepam (Klonopin)

B) Clonidine (Catapres)

C) Mirtazapine (Remeron)

D) Sertraline (Zoloft)

E) Risperidone (Risperdal)

Answer 16

ANSWER: D

The dissociative reactions (flashbacks) in this patient are consistent with the diagnosis of posttraumatic stress disorder (PTSD). The first-line medications for this disorder are SSRIs and SNRIs. Paroxetine and sertraline have FDA approval for PTSD. Other antidepressants such as mirtazapine would be second-line therapy. The effectiveness of central A2-agonists such as clonidine are unknown, and even though benzodiazepines might help with hyperarousal symptoms, they can worsen other symptoms. Atypical antipsychotics such as risperidone are not recommended.

Question 17

67. Which one of the following is more characteristic of Crohn’s disease, as opposed to ulcerative colitis?

A) Bloody diarrhea

B) Perianal manifestations

C) Involvement of the rectum

D) Proximal progression

E) Associated inflammatory arthropathies

Answer 17

ANSWER: B

Crohn’s disease typically spares the rectum. Ulcerative colitis usually has rectal involvement, progresses proximally, and rarely has perianal or systemic manifestations (SOR A). Both conditions may cause bloody diarrhea as well as inflammatory arthropathies, eye inflammation such as uveitis, and skin findings such as erythema nodosum.

Question 18

68. A 75-year-old male has a past medical history significant for atrial fibrillation, ischemic cardiomyopathy, diabetes mellitus, and hyperlipidemia. He is admitted to the hospital with bronchiolitis obliterans organizing pneumonia (cryptogenic organizing pneumonia).

Which one of the medications he takes is the most likely cause of this problem?

A) Amiodarone (Cordarone)

B) Carvedilol (Coreg)

C) Digoxin (Lanoxin)

D) Lisinopril (Prinivil, Zestril)

E) Pioglitazone (Actos)

Answer 18

ANSWER: A

Many drugs can cause lung disease. Amiodarone has been known to cause both bronchiolitis obliterans organizing pneumonia (BOOP) and interstitial pneumonitis. BOOP, also known as cryptogenic organizing pneumonia, is characterized by interstitial inflammation superimposed on the dominant background of alveolar and ductal fibrosis. This is a very distinctive pattern of lung response to exposure to several drugs, including amiodarone, bleomycin, gold, penicillamine, sulfasalazine, radiation, interferons, methotrexate, mitomycin C, cyclophosphamide, and cocaine.

Interstitial pneumonitis is the most common manifestation of drug-induced lung disease. Drugs that can cause this include amiodarone, azathioprine, bleomycin, chlorambucil, methotrexate, phenytoin, statins, and sulfasalazine.

Question 19

69. A 4-year-old female is brought to your office with a limp that was first noted 2 days ago. There has been no known injury or recent illness. Her vital signs are normal. Observation of her gait reveals shortening of the stance phase to take weight off her left leg. The physical examination reveals an otherwise healthy female with no focal tenderness or pathology of her lower legs or abdomen.

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

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

B) Plain radiographs of both lower extremities

C) Ultrasonography of both hips

D) MRI of the left lower extremity, including the hip

E) A bone scan

Answer 19

ANSWER: B

This patient demonstrates an antalgic gait without a clear etiology. The evaluation of a limping child begins with a thorough history, observation of the child’s gait, and a physical examination. If the history is not contributory and the physical examination demonstrates no focal source of pain, radiographs of both lower extremities should be the first step in the workup (SOR C). If there is a focal source of pain, radiographs of the affected joint would be appropriate (SOR C). If the patient demonstrates systemic signs of illness such as fever or anorexia, a laboratory evaluation (CBC, erythrocyte sedimentation rate, and C-reactive protein) should be performed in addition to radiographs. Ultrasonography is useful subsequently if there is concern about joint effusion. If no source of the problem is found, additional testing should include a bone scan (SOR C) and MRI.

Question 20

70. A 26-year-old male who is in a monogamous sexual relationship with another male sees you for a routine health maintenance visit. He is employed in a grocery store, is in good health, and reports having the usual immunizations as a child.

Based on expert consensus, which one of the following would be most appropriate at this visit?

A) Pre-exposure HIV prophylaxis

B) Screening for STIs now and every 3 months

C) Meningococcal vaccine

D) Hepatitis B surface antigen (HBsAG) testing

Answer 20

ANSWER: D

Men who have sex with men but are in a monogamous relationship need not be offered preexposure or postexposure HIV prophylaxis, unlike men with multiple or anonymous sexual partners. Meningococcal vaccine is not indicated unless there are other risk factors. Since this patient is in a monogamous relationship, screening for sexually transmitted infections once a year is considered adequate. Screening for hepatitis C at this visit is recommended, as well as testing for hepatitis B infection.

Question 21

71. A 65-year-old white female requests bone density screening because her mother had premenopausal osteoporosis. The patient has no previous history of fracture, and her past medical and family histories are otherwise unremarkable. She has not had a hysterectomy and is not taking any medications or supplements. Her dietary calcium intake is low. DXA shows T-scores of –1.8 at the hip and –2.1 at the spine. Her estimated 10-year risk of hip fracture is 1.3%. Serum TSH, calcium, and 25-hydroxyvitamin D levels are normal.

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

A) An increase in dietary calcium to 1200 mg daily and starting vitamin D3 (cholecalciferol) supplementation, 800 IU daily

B) Alendronate (Fosamax), 70 mg orally once weekly for 5 years

C) Conjugated estrogen/medroxyprogesterone (Prempro), 0.625 mg/5 mg orally, once

daily

D) Calcitonin-salmon (Miacalcin) in alternating nostrils daily

E) A repeat DXA scan in 2 years and initiation of osteoporosis treatment if her FRAX score shows her 10-year risk of major osteoporotic fracture is >10%

Answer 21

ANSWER: A

Based on the patient’s age it is appropriate for her to be screened. Her bone density is consistent with osteopenia and she has no identified secondary causes of osteopenia. Because her estimated 10-year risk of hip fracture is <3% and she has not had any fractures to date, prescription medications such as bisphosphonates or calcitonin are not indicated. Estrogen does increase bone density but it is not indicated for osteoporosis prevention or treatment, due to associated cardiovascular risks. Professional organizations vary on the daily calcium and vitamin D intake recommended for postmenopausal women, but 1200 mg of dietary calcium and supplementation with 800 IU of vitamin D3 are reasonable recommendations. The National Osteoporosis Foundation suggests treatment of osteoporosis if the 10-year risk of major osteoporotic fracture is >20%.

Question 22

72. A 32-year-old male presents to your office with a right knee injury that occurred while he was playing tennis. His description of the injury indicates that he twisted the knee while his foot was planted. Given the mechanism of injury, you suspect a meniscal tear.

Which one of the following is the most useful single maneuver to evaluate for a meniscal tear?

A) The anterior drawer test

B) The pivot-shift test

C) The valgus stress test

D) Lachman’s maneuver

E) Thessaly’s maneuver

Answer 22

ANSWER: E

Meniscal tears are a common source of knee pain in acute knee injuries, occurring in approximately 10% of cases presenting with acute pain after an injury. Although the McMurray test (passive extension of the knee while applying valgus and varus stresses to the knee) has historically been used to detect meniscus injuries, the Thessaly test has superior positive and negative predictive value for meniscus injuries compared with the McMurray test. The Thessaly test is performed by having the patient stand on the affected leg while it is flexed 20° and internally and externally rotate the knee three times while holding the examiner’s hands for support. Locking, catching, or joint-line pain constitutes a positive test. The pivot-shift, Lachman, and anterior drawer tests are used to detect injuries to the anterior cruciate ligament, not meniscal injuries. The valgus stress test detects injuries to the medial collateral ligament.

Question 23

73. An 18-year-old female is seen for a preparticipation physical examination for soccer. She exercises 2–3 hours/day but states that she has low energy levels. Her past medical history includes a stress fracture of the third metatarsal that healed properly. She has intermittent amenorrhea. A physical examination is normal except for a BMI of 18.0 kg/m2.

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

A) No further evaluation

B) An exercise stress test

C) Echocardiography

D) Radiographs of both feet

E) A bone mineral density test

Answer 23

ANSWER: E

This patient has low energy, menstrual irregularities, and a history of stress fractures, which is consistent with the female athlete triad. She is at risk for altered bone density and needs a bone mineral density test. This condition is also associated with disordered eating and low body mass. Echocardiography may be indicated if there is a personal or family history of cardiac problems. Radiographs of the feet are not sensitive for osteoporosis evaluation. A stress test is not indicated.

Question 24

74. A 27-year-old male presents to the emergency department with a 1-week history of fatigue, dyspnea, chest pain, and fever. He is a heroin addict but has no other significant previous history. On examination his lungs are clear but he has a systolic heart murmur. A chest radiograph shows multiple lesions consistent with emboli.

Pending blood culture results, initial antibiotic coverage should include which one of the following?

A) Clindamycin (Cleocin)

B) Levofloxacin (Levaquin)

C) Rifampin (Rifadin)

D) Trimethoprim/sulfamethoxazole (Bactrim)

E) Vancomycin (Vancocin)

Answer 24

ANSWER: E

Over 85% of cases of infectious endocarditis are caused by gram-positive cocci. In patients suspected of having acute infectious endocarditis, empiric antibiotic treatment should be started immediately after obtaining initial blood cultures and should include coverage against gram-positive cocci with vancomycin. For patients with prosthetic heart valves, initial coverage should include vancomycin plus rifampin. Clindamycin, levofloxacin, and trimethoprim/sulfamethoxazole have no role in the initial treatment of infectious endocarditis.

Question 25

75. You see a 12-year-old male in October for a preparticipation physical examination for basketball. He has no complaints. You are able to document that he was up-to-date with immunizations at 6 years of age, but has not been vaccinated since. His vital signs and examination are normal.

In addition to Tdap, which one of the following sets of vaccines should be given at this visit?

A) HPV and varicella

B) HPV and influenza

C) HPV, meningococcal, and influenza

D) Meningococcal, varicella, and influenza

Answer 25

ANSWER: C

Vaccination rates for younger children (4–6 years of age) generally surpass 90%, but rates are much lower in older children. Only 34% of boys receive HPV vaccine at age 11 or 12, and only 40% receive Tdap. Family physicians need to be familiar with routine immunizations in this age group so they can be recommended at the appropriate time.

This patient was up to date with immunizations at age 6 years, so the only catch-up vaccines needed are those in the routine 11- to 12-year-old set, which includes influenza, meningococcal, HPV, and Tdap vaccines. DTap and varicella vaccine are not routinely recommended after the age of 6 years.

Question 26

76. A 52-year-old healthy female nonsmoker who has a family history of coronary artery disease presents with episodes of left-sided chest pain that last 10–15 minutes but are unrelated to activity. A resting EKG is normal. She is on medication for hypertension and is in good physical condition.

Which one of the following is the best study to order at this time?

A) Exercise treadmill testing

B) Stress echocardiography

C) Coronary CT angiography

D) Stress myocardial perfusion imaging

E) Dobutamine echocardiography

Answer 26

ANSWER: A

Early studies of ischemic heart disease included mostly male subjects. More recently there has been a determined effort to understand the special considerations associated with this problem and its management in women. In 2014 the American Heart Association published a consensus statement summarizing the research on how to best evaluate women with suspected ischemic heart disease. Its recommendations focused on the level of pretest risk for ischemic heart disease (low, intermediate, and high), a normal or abnormal resting EKG, the ability of the subject to exercise, and potential risks of radiation exposure. The patient in this scenario would be considered low to intermediate risk for ischemia due to her age and risk factors, along with a history of atypical chest pain. Since her resting EKG is normal and she is physically fit, she should undergo an exercise treadmill test without imaging.

Question 27

77. A 4-month-old female is brought to your office by her parents because she spits up after most feedings. She is their first child and was born at term with no prenatal or postnatal complications. She is formula fed. A review of her growth chart shows normal growth. Her physical examination and vital signs are normal as well.

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

A) Reassurance only

B) Advising the parents to place the infant in a prone position for sleeping

C) An upper GI series

D) Omeprazole (Prilosec)

E) Ranitidine (Zantac)

Answer 27

ANSWER: A

Gastroesophageal reflux is very common in infants. Reflux in infants peaks at 4 months of age, and two-thirds of infants regurgitate at least once a day at this age. The incidence declines dramatically in the next few months, and by 1 year of age less than 5% of infants regurgitate on a daily basis. If the infant is healthy and growing normally, reassurance is appropriate (SOR C). Conservative measures are recommended if the reflux causes distress (SOR C). Such measures include placing the infant on her side or prone while awake to reduce reflux. However, infants should not be placed prone while sleeping, to prevent SIDS. Appropriate conservative measures also include smaller, more frequent feedings, the addition of thickening agents such as rice cereal to formula, and changing to amino acid formulas if infants are allergic to cow’s milk protein.

If conservative measures and time do not alleviate the symptoms, a 4-week trial of H2-blockers or proton pump inhibitors can be tried. The American Academy of Pediatrics and the Society of Hospital Medicine (Pediatric) recommend not routinely treating reflux with medication. Imaging, such as esophagogastroduodenoscopy, is not routinely used in the initial workup of reflux in infants. It is reserved for recalcitrant cases, atypical symptoms, or complications (SOR C).

Question 28

78. A 50-year-old male presents to your office with a 4-day history of the rash shown on the page at right. It spread from the lower trunk to the lower extremities, including the genital area. He also complains of pain and swelling of the testes. He considers himself to be in good health and takes no medications. He is afebrile with a normal examination except for the pink-purple maculopapular eruption and bilateral swollen testes. A CBC, urinalysis, and comprehensive metabolic panel are normal.

Which one of the following is the most likely diagnosis?

A) Henoch-Schönlein purpura

B) Kawasaki disease

C) Polyarteritis nodosa

D) Rocky Mountain spotted fever

E) Thrombocytopenic purpura

Answer 28

ANSWER: A

Henoch-Schönlein purpura (HSP) presents most often in children but not infrequently in adults. The purpuric rash is classically seen on the waist and extends to the legs, sparing the proximal trunk and arms. Orchitis with testicular swelling occurs in 35% of men with HSP and is often complicated by abdominal pain, arthritis, and renal insufficiency.

Kawasaki disease is a pediatric disease presenting with fever, conjunctivitis, and lesions of the lips. Polyarteritis nodosa often presents with fever and multisystem symptoms and findings. There are most often abnormalities on the CBC and chemistry profile. Rocky Mountain spotted fever is associated with a petechial rash that involves the proximal trunk and extremities, including the palms and soles. Thrombocytopenic purpura, by definition, is associated with a low platelet count.

Question 29

79. A 90-year-old male with a history of metastatic lung cancer is admitted to hospice. You agree to follow the patient. The following week the hospice nurse calls you because the patient is complaining of significant dyspnea. His oxygen saturation is 91% on room air. A physical examination reveals diminished but otherwise clear breath sounds.

Which one of the following is the treatment of choice for this patient’s dyspnea?

A) Oxygen

B) Albuterol in normal saline by nebulizer

C) Prednisone orally

D) Morphine sulfate sublingually

E) Lorazepam (Ativan) orally

Answer 29

ANSWER: D

Opioids, given either orally or intravenously, are the treatment of choice for dyspnea and have been studied thoroughly in patients with COPD and patients with cancer. They have been found to be effective in alleviating dyspnea and, when used carefully, do not have serious side effects such as respiratory depression. When the patient is experiencing anxiety, which regularly occurs in association with breathlessness, benzodiazepines can be added, although there is no evidence that they improve the dyspnea. Patients are regularly given supplemental oxygen for dyspnea, but systematic reviews have found no benefit for patients with cancer or heart failure who do not have hypoxemia. However, oxygen may provide some relief for patients with COPD who do not have hypoxemia. Prednisone and albuterol are not indicated for this patient.

Question 30

80. A 58-year-old minister comes to your office accompanied by his wife for a follow-up evaluation of personality changes. His wife says he has been making inappropriate comments to females in the church and has been more withdrawn at social gatherings. He has also not been preparing his sermons or balancing their checking account. These behaviors are uncharacteristic for him and his symptoms have been progressively worsening over the past 6–12 months. He is quiet during this discussion. He has been on an SSRI for 3 months with minimal to no improvement. The history is otherwise normal, as is a physical examination, including a focused neurologic examination. Short-term memory is intact.

This presentation is most consistent with which one of the following diagnoses?

A) Alzheimer’s disease

B) Frontotemporal dementia

C) Lewy body dementia

D) Mixed dementia

E) Vascular dementia

Answer 30

ANSWER: B

Core features of the behavioral variant frontotemporal dementia (FTD) include an insidious onset and gradual progression, an early decline in social and interpersonal conduct, early impairment in regulation of personal conduct, early emotional blunting, and early loss of insight. Common initial symptoms include apathy, lack of initiation, diminished interest, and inactivity. Common features also include disinhibition and impulsivity. Examples include socially inappropriate remarks, including sexual comments.

These types of symptoms are less common in early phases of other types of dementia. FTD is frequently misdiagnosed as a primary psychiatric disorder such as depression. Alzheimer’s disease presents with memory and visuospatial loss. Lewy body dementia tends to cause memory loss, fluctuating cognition, visual hallucinations, and spontaneous parkinsonian motor features. Vascular dementia patients usually have a history of cerebrovascular events. Mixed dementias generally are a combination of Alzheimer’s and other types of dementias.

Question 31

81. A 54-year-old male returns to your office for follow-up of chronic right knee pain that has worsened over the past month. On examination, range of motion of the knee is normal with no catching in the joint. There is a subtle effusion of the right knee and tenderness along the medial joint line. A radiograph shows medial joint space narrowing and subchondral sclerosis of the medial tibiofemoral joint.

Which one of the following should you recommend at this point?

A) Stretching and strengthening with physical therapy

B) Taping and therapeutic ultrasound with physical therapy

C) Lateral wedge insoles

D) Oral glucosamine and chondroitin

Answer 31

ANSWER: A

The mainstay of treatment for osteoarthritis of the knee is active rehabilitation and exercise (SOR A). Active rehabilitation, such as stretching and strengthening, is more effective than passive rehabilitation, such as taping, heat, electrostimulation, or therapeutic ultrasound (SOR B). Lateral wedge insoles and glucosamine and chondroitin supplements are unlikely to significantly improve pain in patients with knee arthritis (SOR B).

Question 32

82. A 5-year-old male has a 10-day history of respiratory symptoms, including nasal congestion. He seemed to improve around day 5 but acutely worsened on day 7 with a new onset of fever, daytime cough, and persistent nasal drainage. On examination his oral temperature is 38.1°C (100.6°F), heart rate 100 beats/min, respiratory rate 24/min, and blood pressure 90/68 mm Hg. He has no sinus tenderness or cervical lymphadenopathy, and normal tympanic membranes bilaterally. You note nasal mucosal swelling and erythema, and mild pharyngeal erythema. Cardiac and lung examinations are normal.

Which one of the following would you recommend?

A) Saline nasal rinses, decongestants, fluids, and rest

B) A laboratory workup including a CBC, an erythrocyte sedimentation rate, and a

C-reactive protein level

C) Sinus CT

D) Amoxicillin

E) Azithromycin (Zithromax)

Answer 32

ANSWER: D

This child meets the criteria for acute bacterial sinusitis (ABS) and should be treated with antibiotics. He exemplifies the concept of “double sickening,” in which a child initially has typical symptoms of a viral upper respiratory infection and improves initially only to worsen later, with daytime cough, persistent nasal discharge, and/or new fever. Other criteria for ABS include persistence of URI symptoms without improvement after 7–10 days and “severe onset” ABS with a high fever and purulent nasal discharge for at least 3 days. Evidence shows that treatment with antibiotics in these situations improves outcomes (SOR B). The first-line antibiotic is amoxicillin with or without clavulanate. The length of treatment can range from 10 to 28 days. Depending on risks, patients may be treated with either high-dose amoxicillin or amoxicillin/clavulanate, with an amoxicillin dosage of 90 mg/kg/day. Many of the bacteria causing ABS have been shown to be resistant to azithromycin and trimethoprim/sulfamethoxazole and these antibiotics should be avoided. For patients allergic to penicillins, cephalosporins should be used.

The diagnosis of ABS is based on the history (SOR C). The physical examination is not particularly helpful and findings such as sinus tenderness, mucosal swelling, and transillumination of the sinuses do not help differentiate ABS from a viral URI. Laboratory studies are not indicated in the diagnosis. Imaging studies are likewise not indicated for the initial diagnosis, as they are often abnormal in both viral URIs and ABS. If complications such as orbital cellulitis or neurologic compromise are a concern, then CT may be indicated.

There is no good evidence to support adjuvant care for ABS. Saline nasal irrigation, decongestants, or intranasal corticosteroids may be helpful but cannot replace antibiotic therapy in children who meet the criteria for ABS.

Question 33

83. According to the JNC 8 panel guidelines, which one of the following would be first-line drug therapy for hypertension in an African-American male who has no other medical problems?

A) An ACE inhibitor

B) An aldosterone antagonist

C) An A-blocker

D) Hydralazine

E) A thiazide-type diuretic

Answer 33

ANSWER: E

The 2014 evidence-based guideline from the JNC 8 panel recommends that in the general African-American population, including those with diabetes mellitus, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (for general African-American population: SOR B; for African-American patients with diabetes: SOR C).

Question 34

84. A 13-year-old female has been having difficulty breathing while playing soccer for the last few weeks. She has no personal or family history of asthma and has never needed medical treatments for breathing problems before. Her symptoms include coughing and wheezing only when running intensely for long periods of time. These symptoms persist for up to an hour after she stops exercising. She has no symptoms at other times during the day or at night. A pulmonary function test shows better than average lung function with no change after albuterol (Proventil, Ventolin) inhalation.

Which one of the following treatments would be a good first choice to help with this patient’s symptoms?

A) A 5-day burst of oral prednisone

B) Daily use of a cromolyn inhaler

C) Daily inhaled corticosteroids during soccer season

D) An albuterol inhaler 10–15 minutes prior to exercise

E) Inhaled salmeterol (Serevent Diskus) every morning during soccer season

Answer 34

ANSWER: D

Asthmatic symptoms during exercise are common. These can occur as exacerbations of underlying airway inflammation or as bronchospasm in otherwise normal airways. This patient seems to have bronchospasm that would be best managed by albuterol prior to exercise. If she finds that she needs her inhaler frequently, the addition of an anti-inflammatory agent such as inhaled corticosteroids or oral montelukast would be reasonable.

Question 35

85. A 23-year-old male presents with moderate pain and stiffness of the low back and buttock area that began 3–4 months ago. There was no known precipitating event and the symptoms are worsening.

Which one of the following characteristics of his pain and stiffness would make ankylosing spondylitis more likely?

A) An acute onset over days

B) Improvement with exercise and activity

C) Stiffness in the late afternoon and evening

D) Symptom relief at night

Answer 35

ANSWER: B

Ankylosing spondylitis is an inflammatory condition that affects the axial skeleton primarily, but other joints may be involved. The pain begins insidiously in the lower back and gluteal region. The symptoms improve with exercise and activity but they worsen at night. The stiffness is most prominent in the morning and may last up to a few hours.

Question 36

86. In an adult, the radiation exposure from a typical abdominal CT examination is approximately the same as how many posteroanterior chest radiographs?

A) 4

B) 40

C) 400

D) 4000

Answer 36

ANSWER: C

Radiation exposure in humans is quantified by the sievert (Sv), which equals 1 joule of radiation energy/kg of human tissue. Most clinical diagnostic test exposures measure in the millisievert (mSv) range. Natural background exposure in the United States averages 3 mSv/year. Although exact exposures will vary according to patient size, type of equipment used, and operator expertise, typical radiation doses for common radiographic studies include the following:

Posteroanterior chest—0.02 mSv

Skull—0.1 mSv

Lumbar spine—1.5 mSv

CT head—2 mSv

CT abdomen—8 mSv

This list shows that CT of the abdomen provides a radiation dose 400 times that of the typical posteroanterior chest radiograph. A small increased relative risk of cancer mortality was demonstrated in Japanese survivors of atomic bombs receiving doses in the range of 5–20 mSv, suggesting that consideration of the risk/benefit ratio of some radiographic studies is warranted.

Question 37

87. A 41-year-old male presents to your office for follow-up of recurrent nephrolithiasis. He currently follows a normal diet and does not drink soft drinks very often.

Which one of the following would help prevent recurrent kidney stones?

A) A loop diuretic

B) A thiazide diuretic

C) A high-protein diet

D) Two 12-oz cola-flavored soft drinks per day

Answer 37

ANSWER: B

Patients with recurrent nephrolithiasis should first try to increase fluid intake to achieve a daily urine output greater than or equal to 2 L. Increasing fluid intake decreases the recurrence of stones by at least 50%. Reducing soft drink intake may also help but this seems to be limited to those who drink colas, which are acidified by phosphoric acid. Soft drinks acidified with citric acid, such as fruit-flavored drinks, do not appear to have the same effect. There is little evidence that dietary changes help significantly. If a patient’s fluid increase is not sufficient, treatment with a thiazide diuretic, citrate, or allopurinol is recommended (SOR C).

Question 38

88. You see a 45-year-old white male smoker for follow-up of his hypertension. His past medical history is otherwise unremarkable. At this visit he has a blood pressure of 136/84 mm Hg. A lipid panel reveals the following:

Triglycerides . . . . . . . . . 226 mg/dL

Total cholesterol . . . . . . 228 mg/dL

LDL-cholesterol . . . . . . . 159 mg/dL

HDL-cholesterol . . . . . . . 31 mg/dL

The ASCVD Risk Estimator yields a 10-year atherosclerotic cardiovascular disease risk of 15.4%.

Based on the 2013 American College of Cardiology/American Heart Association guideline for reducing atherosclerotic cardiovascular disease risk in adults, which one of the following is the most appropriate medication regimen for this patient?

A) Moderate- or high-intensity statin therapy

B) Statin therapy titrated to reduce LDL-cholesterol by 20%–30%

C) Combined statin and fibrate therapy to reduce both LDL-cholesterol and triglycerides

D) Combined statin and niacin therapy to reduce LDL-cholesterol and raise HDL-cholesterol

E) Combined statin and PCSK9 inhibitor therapy to reduce the LDL-cholesterol level to <70 mg/dL

Answer 38

ANSWER: A

The 2013 American College of Cardiology/American Heart Association guideline for reducing atherosclerotic cardiovascular disease (ASCVD) risk in adults recommended several significant changes in the management of hyperlipidemia. This guideline recommends looking at overall risk as estimated by a tool, the ASCVD Risk Estimator, which considers not only lipid parameters but also age, sex, ethnicity, systolic blood pressure, and the presence or absence of diabetes mellitus, treated hypertension, and smoking. Four major risk groups were identified for treatment, one of which was adults greater than or equal to 40 years of age with an estimated 10-year risk of ASCVD greater than or equal to 7.5%.

Therapy is graded by intensity (low-, moderate-, or high-intensity statin therapy), and therapeutic targets for LDL-cholesterol were abandoned since there is no demonstrable benefit from achieving a certain level of LDL-cholesterol in treated patients. This patient has an estimated 10-year ASCVD risk well above 7.5% and is a candidate for moderate- or high-intensity statin therapy under the guideline. Niacin and fibrate therapy do not have a demonstrable impact on cardiovascular outcomes and are not recommended in the guideline. PCSK9 inhibitors are also not yet recommended in any guideline.

Question 39

89. Acute altitude sickness consists of headache, nausea, dizziness, and sleep disturbance. Risk factors include which one of the following?

A) Below-average physical fitness

B) Fast ascent

C) Age greater than or equal to 65 years

D) Male sex

Answer 39

ANSWER: B

Major risk factors for acute mountain sickness include a history of previous mountain sickness, fast ascent, and lack of acclimatization. Slow ascent with frequent stops at various levels is the safest way to prevent altitude sickness. Females are at increased risk and good physical fitness is not protective. Persons <46 years of age are at increased risk.

Question 40

90. A 45-year-old Hispanic female presents to your office for follow-up of a blood pressure measurement of 155/95 mm Hg at a health fair screening. She has no significant past medical history. She reports that she exercises daily for 30 minutes, follows a low-salt diet, and rarely drinks alcohol. Her blood pressure in the office today is 154/95 mm Hg.

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

A) Chlorthalidone

B) Clonidine (Catapres)

C) Doxazosin (Cardura)

D) Metoprolol succinate (Toprol-XL)

E) Spironolactone (Aldactone)

Answer 40

ANSWER: A

Thiazide diuretics such as chlorthalidone are considered a first-line therapy for hypertension. B-Blockers, aldosterone antagonists, and other antihypertensive medications may be used as add-on therapy to reach blood pressure goals.

Question 41

91. A 70-year-old male presents to the emergency department with confusion and a fever of 38.9°C (102.0°F). He has a history of decreased mental status, feeling weak and confused, and low urinary output. On examination he has a blood pressure of 80/50 mm Hg, a pulse rate of 100 beats/min, a respiratory rate of 24/min, and a temperature of 38.9°C (102.0°F). He has mottling of the skin, and his capillary refill time is 5 seconds. A CBC reveals a WBC count of 24,000/mm3 (N 4500–11,000) with 90% neutrophils. His urinalysis is remarkable for WBCs too numerous to count, with 4+ bacteria. Aggressive intravenous fluid resuscitation and intravenous antibiotics are initiated but the patient remains hypotensive.

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

A) High-dose intravenous corticosteroids

B) Hydroxyethyl starch (Hespan)

C) Low-dose dopamine

D) Norepinephrine (Levophed)

E) Dobutamine

Answer 41

ANSWER: D

Prompt recognition and treatment of sepsis increases the chances of survival. Aggressive fluid resuscitation is the initial treatment for hypotension in patients in septic shock. Antibiotic therapy should be administered within 1 hour of suspecting sepsis. If fluid resuscitation is not successful in restoring blood pressure, norepinephrine is the currently recommended first-line vasopressor. The use of hydroxyethyl starch is not recommended because the mortality rate is higher in sepsis patients. Previously, dopamine was recommended, but low-dose dopamine for renal perfusion has now been shown to be ineffective. For patients who are vasopressor dependent, low-dose corticosteroids can be considered.

Question 42

92. A healthy 65-year-old female presents for a health maintenance visit. She has no record of having received pneumococcal vaccine.

Which one of the following does the CDC recommend for this patient?

A) Both 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) now

B) PCV13 now and PPSV23 in 1 year

C) PPSV23 now and PCV13 in 1 year

D) Both PCV13 and PPSV23 now, and PPSV23 every 5 years

E) PCV13 only, now and every 5 years

Answer 42

ANSWER: B

In spite of an estimated 50%–80% reduction in cases of invasive pneumococcal disease (IPD) as a result of vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), IPD remains a significant problem in the United States, with approximately 40,000 cases in 2010 resulting in about 4000 deaths. The introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) has been shown to further reduce vaccine-type cases of IPD by as much as 75%, leading to the 2014 recommendation from the Advisory Committee on Immunization Practices to administer PCV13 to adults age 65 and older. In immunocompetent adults age 65 and older who are pneumococcal vaccine–naive, administering PPSV23 1 year or more after PCV13 results in a better immune response than giving PPSV23 first, and reduces local reactions to the vaccines compared to simultaneous administration or administering PPSV23 first. For some immunocompromised patients the recommendation is to wait a minimum of 8 weeks after giving PCV13 before administering PPSV23.

Question 43

93. A 30-year-old male asks about colon cancer screening. He is healthy, but his father was diagnosed with colon cancer at the age of 45.

At what age would you recommend that this patient have his first screening colonoscopy?

A) 30

B) 35

C) 40

D) 45

E) 50

Answer 43

ANSWER: B

Average-risk adults should be screened for colorectal cancer starting at age 50. People who are at higher risk for developing colon cancer should be screened at either age 40 or 10 years earlier than the age at which the youngest affected family member was diagnosed, whichever is earliest. Risk factors for colon cancer include age, ethnicity, and family history. There is good evidence that screening identifies premalignant lesions, which allows for early treatment and reduced mortality.

Question 44

94. Which one of the following is the most common cause of hearing loss in the newborn?

A) Aminoglycosides

B) Genetic inheritance

C) Head trauma

D) Prematurity

E) Rubella

Answer 44

ANSWER: B

In the past, rubella was a common cause for reduced hearing. With the advent of vaccination, genetic inheritance has become the most frequent cause for deafness. Aminoglycosides are rarely a reason for hearing loss. The well-known association of aminoglycosides with hearing loss has reduced the exposure risk from these drugs. Head trauma and prematurity remain important causes for deafness but are still very small risk factors compared to simple inheritance. Prematurity risk has diminished with improvements in the care of premature infants.

Question 45

95. A 32-year-old female at 12 weeks gestation presents with an itchy vulvar lesion, which you diagnose as external genital warts. Which one of the following would be accurate advice regarding treatment?

A) The recurrence rate is low with treatment

B) Cryotherapy is the most effective treatment

C) Treatment should be based on patient preference

D) Treatment is effective in preventing congenital transmission

Answer 45

ANSWER: C

Treatment of genital warts should be based on patient preference and cost (SOR C). There is no treatment that is more effective than others, and the recurrence rate for any treatment is relatively high. Cryotherapy is not more effective than other treatments. Treatment in pregnancy has not been found to decrease the risk of transmission.

Question 46

96. An agitated 35-year-old male is brought to the urgent-care clinic by his wife. She reports that her husband has been restless and tremulous since early this morning. Further history reveals that he was seen 2 days ago for a work-related back injury and was given a prescription for cyclobenzaprine, 10 mg 3 times daily as needed. He reports improvement in his back pain but admits that last night he took an extra dose of a sleeping pill prescribed by his psychiatrist. His chronic medical conditions include controlled essential hypertension and depression.

On examination the patient’s vital signs include a temperature of 38.1°C (100.6°F), a blood pressure of 124/82 mm Hg, a heart rate of 98 beats/min, and a respiratory rate of 12/min. The patient appears diaphoretic with a resting symmetrical tremor. He has a regular heart rate and rhythm and his lungs are clear. His abdomen is soft with normal bowel sounds. His strength is 5/5 bilaterally in the upper and lower extremities, and he has 4+ patellar and biceps reflexes bilaterally.

Which one of the following is the most likely explanation for these findings?

A) Anticholinergic syndrome

B) Central cord syndrome

C) Malignant hyperthermia

D) Neuroleptic malignant syndrome

E) Serotonin syndrome

Answer 46

ANSWER: E

Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonergic activity, and certain medications are more likely to precipitate it. Early recognition of symptoms is important, as most cases can be managed on an outpatient basis with discontinuation of the precipitating medication/agent and supportive care. The Hunter Serotonin Toxicity Criteria can be used to diagnose serotonin syndrome (SOR C).

The differential diagnosis includes anticholinergic syndrome, malignant hyperthermia, and neuroleptic malignant syndrome. Anticholinergic syndrome is associated with tachycardia, tachypnea, and hyperthermia. Malignant hyperthermia and neuroleptic malignant syndrome are associated with hypertension, tachycardia, tachypnea, and hyperthermia. These conditions are precipitated by other classes of medications. Central cord syndrome is a spinal cord disease caused by spinal trauma, syringomyelia, and intrinsic cord tumors, and presents with arm weakness greater than leg weakness.

Question 47

97. A 30-year-old female is 3 months post partum. She had a recent upper respiratory infection and now has anterior neck pain, anxiety, and palpitations. On examination her thyroid is palpable and extremely tender. Laboratory testing reveals that free T4 is elevated and TSH is suppressed.

Which one of the following is the most likely diagnosis?

A) Hashimoto thyroiditis

B) Postpartum thyroiditis

C) Subacute thyroiditis

D) Postpartum depression

Answer 47

ANSWER: C

Only subacute thyroiditis is associated with a painful and tender thyroid. It often follows an upper respiratory viral illness that triggers inflammatory destruction of thyroid tissue. Thyroid hormone is increased and TSH is suppressed. Treatment consists of corticosteroids or NSAIDs. The condition is usually self-limited.

Question 48

98. An 82-year-old female with a history of diastolic heart failure, stage 3 chronic kidney disease, and essential hypertension presents to your office with shortness of breath. She does not have chest pain. The physical examination reveals an elderly female in mild distress. Her blood pressure is 138/82 mm Hg, pulse rate 92 beats/min, respiratory rate 24/min, and oxygen saturation 88% on room air, increased to 92% on 2 L/min of oxygen via nasal cannula. Her lungs are clear to auscultation bilaterally. Her heart rate is regular and no murmurs are detected. She has 1+ bilateral lower extremity edema that is slightly worse on the right. A chest radiograph is normal and her D-dimer level is elevated.

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

A) A serum BNP level

B) A serum troponin I level

C) Echocardiography

D) A bilateral venous duplex study of the lower extremities

E) CT angiography of the chest

Answer 48

ANSWER: E

This patient has a high risk of pulmonary embolism based on her presentation and the elevated D-dimer assay. CT angiography (CTA) of the chest would be the next step in the evaluation of this patient (SOR A). The other tests may be helpful but should not delay chest CTA. If chest CTA is negative a venous duplex study would be helpful in ruling out a DVT.

Question 49

99. A 68-year-old female sees you because she developed increased floaters followed by flashes of lights after a sneezing attack. She then noted a dark spot in the periphery of her right eye. Three weeks ago she underwent cataract removal with intraocular lens implantation in this eye. Her examination is notable for decreased visual acuity and a loss of peripheral field in the right eye.

Which one of the following is the most likely diagnosis?

A) Posterior vitreous detachment

B) Central retinal artery occlusion

C) Retinal detachment

D) Intraocular lens dislocation

E) Acute angle-closure glaucoma

Answer 49

ANSWER: C

Retinal detachments can be caused by a break in the retina, exudate or leakage from beneath the retina, or traction on the retina. Retinal detachments are often preceded by a posterior vitreous detachment, which can lead to a break in the retina, and patients may experience an increase in floaters but not light flashes or loss of vision. With a retinal detachment, patients typically experience floaters followed within 1 week by flashes of light as the retina tears. If the retinal tear becomes large enough vision is impaired. Any patient with the typical history and loss of visual acuity or peripheral field should be urgently referred to an ophthalmologist, as urgent surgery may be required.

Risk factors for retinal detachment include age 50–75, ocular trauma, previous cataract surgery, family history, and a past history of retinal detachment. A patient with a previous retinal detachment has a 25% risk of developing a retinal detachment in the other eye. Myopia is the other significant risk factor, associated with a tenfold increased risk in patients with >3 diopters of refractive error.

Central retinal artery occlusion is manifested by painless complete loss of vision in the affected eye. Acute angle-closure glaucoma is associated with eye pain, photophobia, headache, nausea and vomiting, and cloudy loss of vision, and the onset is not typically associated with coughing or sneezing.

Question 50

100. Which one of the following does the 2014 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommend for the treatment of exacerbations of COPD?

A) Prednisone, 40 mg daily for 5 days

B) Prednisone, 40 mg daily for 10 days

C) A methylprednisolone (Medrol) dose pack

D) Methylprednisolone sodium succinate (Solu-Medrol), 100 mg intravenously, followed by prednisone, 40 mg for 7 days

Answer 50

ANSWER: A

The 2014 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommends administration of prednisone, 40 mg daily for 5 days, for COPD exacerbations. The 2011 GOLD guideline had recommended the same dosage of prednisone for 10–14 days. The guideline does not recommend a methylprednisolone dose pack or intravenous methylprednisolone sodium succinate. A recent multicenter study showed that the shorter duration of low-dose prednisone was equivalent to the longer treatment. Corticosteroids are associated with elevated blood glucose; the development of cataracts, diabetes mellitus, and osteopenia; and thromboembolic complications.