Stats/Ambulatory

Question 1

When a percentage of subjects from two group are lost to follow-up and not included in final analysis, it is this type of bias.

Answer 1

Selection bias (inappropriate selection or poor retention)

Question 2

This bias is common in retrospective studies where subjects with negative outcomes are more likely to report exposures than controls

Answer 2

recall bias

Question 3

This bias has subjects over or underreporting exposure history due to perceived social stigma

Answer 3

reporting bias

Question 4

exposures that happen long before disease assessment can cause study to miss dx pts that die early or recover

Answer 4

prevalence bias

Question 5

Incidence represents this.

Answer 5

measure of appearance of new cases.

Question 6

Prevalence represents this.

Answer 6

measure of those with the disease in the population at a particular point in time (P = Incidence x Time)

Question 7

A 62-year-old Caucasian woman complains of a several month history of pain and stiffness in the
shoulder and pelvic girdle that is worse in the morning and lasts at least 30 minutes. She has
occasional fevers, night sweats, fatigue and weight loss. Her erythrocyte sedimentation rate is
elevated, but the rest of her labs are normal. She is given oral prednisone 10 mg daily and her
symptoms completely resolve within 48 hours. What is the likely diagnosis?

Answer 7

Polymyalgia rheumatica (due to over age 50, bilateral, proximal morning stiffness more than 30 minutes, and rapid improvement in symptoms with oral steroids)

Question 8

A 9-year-old boy is brought to the clinic because of complaints of fatigue. Though he sleeps 10 hours
per night he continues to complain of sleepiness during the day. While sleeping the patient does snore
consistently. On examination he has tonsillar hypertrophy and polysomnography shows moderate
obstructive sleep apnea. What is the next best step in the treatment of this patient if adenotonsillectomy isn’t applicable?

Answer 8

can use CPAP like in adults

Question 9

A 52-year-old post-menopausal woman is being placed on long-term (> 3 months) prednisone
treatment for severe rheumatoid arthritis. In regards to bone health, what is the next best step for this
patient?

Answer 9

For men over 50 and any postmenop. woman, its recommended that use Ca 1200 mg, Vit D 800 IU, and biphos

Question 10

A 78-year-old man with a history of type 2 diabetes and hypertension presents with progressively
worsening shortness of breath, lower extremity edema and paroxysmal nocturnal dyspnea. His
medications include lisinopril, pioglitazone, glipizide and saxagliptin. His creatinine is 1.0 mg/dL. An
echocardiogram shows an ejection fraction of 30%. Which of his medications is likely contributing to
his symptoms?

Answer 10

pioglitazone (cause fluid retention)

Question 11

A 6-month-old male infant is brought to the clinic for diarrhea and vomiting for the past 24 hours. He
has had low grade fever and has been acting fussy. He is primarily breastfed but has been tolerating
solids. He has a 3-year-old brother with similar symptoms. On examination he has moist mucus
membranes, good skin turgor and is active. What is the treatment for this patient?

Answer 11

Continue age appropriate diet and continue breastfeeding (virus most likely)

Question 12

A 76-year-old man complains of pruritic lower extremities. Though no rash seems to be present the
pruritic areas become dry and scaly. This occurs only during the winter months and tends to be worse
after bathing. He has no history of eczema and takes no medications. On examination he has normal
extremity pulses, no lower extremity edema and the affected area has no obvious rash but does
appear dry. What is the most likely diagnosis and treatment?

Answer 12

xerosis (seen in older pts in winter); skin hydration with topical emollients

Question 13

A 62-year-old man with a history of lung cancer has a serum calcium of 15.1 mg/dL with a normal
serum albumin. The patient complains of polyuria and weakness. What is the next best step in the
management of this patient?

Answer 13

saline hydration (help excrete Ca and keep hydration) and calcitonin

Question 14

An 8-month-old male infant is brought to the clinic for a rash that has been present for several weeks.
The infant has been eating well and has had no ill-like symptoms. On examination the rash appears dry
and located bilaterally over the antecubital and popliteal fossae. The affected skin is mildly thickened
but no scaling is present. No tenderness or surrounding erythema is present. The parents report a
family history of eczema and are asking if they can use the pimecrolimus that they were given for their
other older child. What do you tell the parents?

Answer 14

No; Pimecrolimus can’t be used in kids under 2 years so have to use topical emollients then if not effective, low topical steroid

Question 15

A 42-year-old woman is diagnosed with rheumatoid arthritis. Her rheumatologist wants to start her on
infliximab. What tests need to be performed prior to starting this medication?

Answer 15

Hep B surface Ag and TBD

Question 16

A 65-year-old man has progressive memory loss over the past several months. He has waxing and
waning alertness and even has audio and visual hallucinations. He has had several falls over this time
period. On examination he has a resting tremor and moderate rigidity of his trunk and face. He has
normal labs and a normal CT of the head. What is the most likely diagnosis?

Answer 16

Dementia with Lewy bodies (dementia, fluctuating cognition, visual hallucinations, and parkinsonism)

Question 17

A 22-year-old sexually active woman complains of gradually worsening dysuria and urinary frequency
for one week. She denies fever, flank pain or gross hematuria. A urinalysis reveals pyuria but the
culture did not grow any bacteria. After 3 days of nitrofurantoin the patient reports no improvement in
symptoms. What is the likely cause of these symptoms?

Answer 17

chlamydia or gonorrhea

Question 18

A 52-year old homeless man is hospitalized for community acquired pneumonia. The patient had been
improving quickly but then on day-of-admission three the patient becomes agitated, starts to
hallucinate and become very tremulous. The patient is afebrile, is not hypoxemic and his chest x-ray is
slightly improved from admission. A D-dimer is negative. His white blood cell count is normal. What is
the most appropriate treatment for this patient?

Answer 18

Benzos (EtOH withdrawal becuz DTs happen 3-4 days where get shaky and hemodynamic issues)

Question 19

A 23-year-old man has asthma. He admits to needing to use his short-acting β-agonist 3 times per week during the day. What is the most appropriate initial treatment for this patient?

Answer 19

Low dose inhaled corticosteroid daily plus short-acting beta agonist PRN (if patient uses beta agonist more than 2x a day, then it is at least mild persistent asthma)

Question 20

What are the U.S. Preventative Services Task Force recommendations for abdominal aortic aneurysm screening?

Answer 20

All men 65-75 who have ever smoked

Question 21

A 42-year-old woman complains of gnawing mid-epigastric pain for the past 3 weeks. The pain improves with eating and radiates to her back. She reports darkly colored stools for the past 4 days. She has a long history of alcohol abuse and occasionally uses ibuprofen for headaches. What is the most likely cause of these symptoms?

Answer 21

H.pylori (peptic ulcer

Question 22

A 42-year-old woman complains of sore areas on the proximal nail folds of several fingers over the past several months. She works as a dish-washer at a local restaurant. She has no other complaints or medical problems. What is the most appropriate treatment for this condition?

Answer 22

wear gloves or topical medium to high potent corticosteroid (for chronic paronychia)

Question 23

A 21-year-old pregnant woman at 26 weeks gestation complains of frequent migraine headaches. What migraine medications should be avoided in pregnant patients?

Answer 23

ergotamines and triptans (cause vasoconstriction of the placenta and uterine vessels)

Question 24

A 22-year-old man is diagnosed with meningococcal meningitis. His only close contact is his roommate. What measures should be taken with the roommate?

Answer 24

rifampin, cipro, or IM ceftriaxone

Question 25

A 66-year-old woman has yearly labs performed that showed a TSH of 11.0 uU/mL (normal 0.45-4.5). A follow-up free T4 was normal. She is asymptomatic. What is the diagnosis?

Answer 25

subclinical hypothyroidism (likely to convert to overt; shud treat TSH with greater than 10)

Question 26

A 37-year-old obese man has a fasting serum glucose of 170 mg/dL. 2 weeks later another fasting glucose is 181 mg/dL and a hemoglobin A1C of 8.9%. What are the criteria used to diagnose type 2 diabetes? In addition to lifestyle changes, what other treatments would be appropriate at this time?

Answer 26

• fasting gluc over 126
• random gluc over 200 + hyperglycemia symptoms
• gluc over 200 after 2-hour oral GTT
• A1C over 6.5
• tx: metformin (first line)

Question 27

A 27-year-old man complains of acute right ankle pain located on the lateral side. This started after an inversion injury while playing basketball. He has tenderness over the posterior edge of the lateral malleolus. What is the next best step?

Answer 27

Ottawa ankle rules:

• malleolar zone pain
• unable to bear weight
• tenderness at base of 5th metatarsal or navicular

Question 28

A 68-year-old woman is currently taking omeprazole for gastroesophageal reflux disease. She asks about the potential side-effects associated with omeprazole. What do you tell her?

Answer 28

• decreased Ca absorption
• inc risk of hip fracture
• inc risk of CAPneum
• inc risk of C diff
• dec B12 absorption

Question 29

A 49-year-old woman complains of abnormal periods which are lasting 4-6 days longer than her usual periods. Overall the bleeding is heavier with clotting and she is having bleeding between periods as well. Otherwise, she is asymptomatic. On examination she has dark blood at the cervical os. Her pregnancy test is negative and her hemoglobin is normal. What is the best next step in the management of this patient?

Answer 29

Endometrial bx (any woman over 45 yo with uterine bleeding)

Question 30

A 12-year-old boy complains of bilateral heel pain for the past several months. He plays soccer several times per week and his heel pain worsens several minutes into practice. In general, his pain is much less during walking or at rest. On examination he has no swelling or tenderness over the Achilles tendon. He has bilateral posterior heel pain during dorsiflexion of the ankles. What is the most likely diagnosis?

Answer 30

Sever disease (calceneal apophysitis)

Question 31

A 22-year-old G1P0 pregnant woman at 38 weeks gestation is seen in the clinic for a routine visit. She has no past medical history and has tested negative for gestational diabetes. On examination her uterine fundus measures 40 cm from the pubic symphysis. An ultrasound estimates the fetal weight at 4200 g. What is the next best step in the management of this patient?

Answer 31

Await spontaneous labor (only do C-sx if 4500g in diabetic mom,, 5000g w/o)

Question 32

An 86-year-old complains of slow, progressive, symmetric hearing loss. At this age what it the most common type of hearing loss?

Answer 32

high frequency hearing loss

Question 33

A 42-year-old woman complains of a cough for over 3 weeks. It started with fatigue, scratchy throat and nasal congestion. She has had low grade fever, but no chest pain or shortness of breath. Her coughing comes in dramatic fits that sometimes causes her to vomit. She has no smoking history. She has had no immunizations since childhood. On examination her lungs are clear. She has excessive lacrimation and conjunctival injection. A chest x-ray is normal. What is the likely diagnosis?

Answer 33

pertussis (coughing fits with emesis)

Question 34

A 2-year-old girl is brought to the clinic by her parents. The parents complain that the patient walks with mild intoeing. The patient denies any pain and she is able to walk and run without difficulty. On examination her patellae faces forward while she is standing but her feet do show mild intoeing. What is the next best step?

Answer 34

Reassurance

Question 35

A 48-year-old man complains of a 2 cm darkly pigmented macule on his right forearm. The macule is irregularly shaped and variations in color from black to blue. He believes that it has been enlarging in size over the past few months. What is the next best step?

Answer 35

excisional bx with 1-2 mm rim of normal skin

Question 36

A 25-year-old woman complains of acute pelvic pain that began 5 days ago. She is sexually active but denies any vaginal discharge or previous sexually transmitted infections. On pelvic examination she has tenderness and fullness on the right side. What imaging study would be most appropriate in this setting?

Answer 36

Transvag US

Question 37

A 38-year-old man presents for a routine physical. He reports that his father had colon cancer at age 52. According to the American College of Gastroenterology, when should this patient begin colon cancer screening?

Answer 37

40 y.o. (earlier screen if have 1 first degree relative with colon cancer or advanced adenoma before 60 or 2 first degree relatives dx at any age, then screen at 40 or 10 year younger which ever comes first)

Question 38

A 41-year-old man with a history of hypertension and hyperlipidemia complains of severe pain, swelling and tenderness in his right 1st toe. This began spontaneously 3 days ago and has not improved. His medications include losartan, metoprolol, simvastatin and hydrochlorothiazide. His uric acid level is found to be elevated. What is the appropriate management of this patient?

Answer 38

NSAIDs or naproxen or indomethacin or colcochine if cant do NSAIDs. Plus, have to stop HCTZ