ABFM 2022

Which one of the following cardiovascular medications may lead to hyperthyroidism? A) Amiodarone B) Digoxin C) Flecainide D) Metoprolol E) Valsartan

ANSWER: A Amiodarone-induced thyrotoxicosis (AIT) is a less common cause of hyperthyroidism and can be particularly difficult to accurately diagnose and treat. AIT type 1 is a form of iodine-induced thyrotoxicosis caused by the high iodine content in amiodarone. AIT type 2 is a form of amiodarone-induced thyroiditis. Digoxin, flecainide, metoprolol, and valsartan do not cause hyperthyroidism.

A 22-year-old female presents to your clinic after awakening to find a rash on her hands (shown below). She does not have any other medical issues today. Which one of the following is the most likely cause of this rash?

A) Addison's disease B) An allergic reaction C) Cellulitis D) A chemical burn E) Phytophotodermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . ANSWER: E Phytophotodermatitis is an inflammation and/or discoloration of the skin caused by contact with specific plants followed by exposure to sunlight. Limes are commonly associated with this phenomenon. Addison's disease causes generalized hyperpigmentation and has an insidious onset along with other constitutional symptoms such as anorexia, nausea, and weakness. An allergic reaction would likely be pruritic and a chemical burn would be expected to be painful. Cellulitis would also be uncomfortable and would likely be associated with erythema.

A 72-year-old female presents with progressive hand pain and stiffness. She is a seamstress and is concerned because sewing has been more difficult over the past 6 months. She recalls that her mother's hands were misshapen, but her mother never received a diagnosis. You examine her hands, which are shown below. Which one of the following would be the most appropriate pharmacotherapy?

A) Colchicine (Colcrys) B) Diclofenac (Zorvolex) C) Hydroxychloroquine (Plaquenil) D) Infliximab (Remicade) injections E) Methotrexate (Trexall) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ANSWER: B This patient presents with erosive osteoarthritis that involves the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints with sparing of the metacarpophalangeal (MCP) joints. The primary goals for treating osteoarthritis are to control symptoms such as pain and stiffness and optimize function in order to preserve quality of life. Topical or oral NSAIDs are the most appropriate pharmacotherapy for osteoarthritis of the hand. Colchicine and methotrexate have not been studied for the treatment of osteoarthritis and their use for this condition is not recommended. Colchicine is indicated for the treatment of gout, which is usually pauciarticular and asymmetrical, and methotrexate is effective for rheumatoid arthritis. Conventional synthetic and biologic disease-modifying medications such as hydroxychloroquine and infliximab have not been shown to be effective in the treatment of osteoarthritis. These medications are appropriate for the treatment of systemic lupus erythematosus and rheumatoid arthritis, which have examination findings that involve the MCP and PIP joints but spare the DIP joints.

A 45-year-old male presents for follow-up of migraine headaches, which had previously responded well to occasional as-needed use of ibuprofen but have recently worsened in severity and frequency. He is interested in trying an abortive therapy. Triptan use would be CONTRAINDICATED with a history of which one of the following in this patient? A) Coronary artery stent placement B) Depression with psychotic features C) Diabetes mellitus with a hemoglobin A1c >7.5% D) Hypertension requiring two medications to achieve control E) Stage 4 chronic kidney diseas

ANSWER: A Because of their vasoconstricting properties, triptan medications are contraindicated in patients with established coronary artery disease, cerebrovascular disease, or peripheral vascular disease; patients with uncontrolled or multiple cardiovascular risk factors; and patients with certain high-risk migraine syndromes, including basilar and hemiplegic migraines. Triptan use for the treatment of migraine headaches would not be contraindicated with a history of depression with psychotic features, poorly controlled diabetes mellitus, hypertension requiring two medications, or stage 4 chronic kidney disease.

Based on the current CDC treatment guidelines, which one of the following is recommended as first-line treatment of urethritis in a 24-year-old male who weighs 152 kg (335 lb), when nucleic acid amplification testing (NAAT) for gonorrhea is positive and Chlamydia testing is negative? A) One dose of ceftriaxone, 1 g intramuscularly B) One dose of ceftriaxone, 500 mg intramuscularly, plus one dose of azithromycin (Zithromax), 1 g orally C) One dose of ceftriaxone, 500 mg intramuscularly, plus doxycycline, 100 mg orally twice daily for 7 days D) One dose of gentamicin, 240 mg intramuscularly, plus one dose of azithromycin, 2 g orally

ANSWER: A In 2020, the CDC updated its treatment guidelines for gonococcal infections. The recommended first-line therapy for patients weighing >150 kg (330 lb) with gonococcal urethritis is one dose of ceftriaxone, 1 g intramuscularly. One dose of ceftriaxone, 500 mg intramuscularly, is recommended for those weighing <150 kg. Patients presenting with an unknown cause of urethritis, such as before urine or urethral nucleic acid amplification test results are known, should be prescribed a combination of one dose of ceftriaxone, 500 mg intramuscularly (1 g if >150 kg), and doxycycline, 100 mg orally for 7 days. Azithromycin, 1 g orally as a single dose, may be used as an alternative to doxycycline for treatment of chlamydial infection, but it is no longer the preferred agent in nonpregnant adults and adolescents. Intramuscular gentamicin is inferior to intramuscular ceftriaxone for the treatment of gonorrhea, even when used in combination with oral azithromycin (SOR B).

Cardiac stress testing would be most appropriate for which one of the following patients? A) A 57-year-old female who is scheduled for a knee replacement and has dyspnea when walking up a few stairs B) A 60-year-old male with diabetes mellitus who was admitted to the hospital for chest pain and acute stroke and has a normal EKG and troponin levels C) A 66-year-old male with diabetes and hypertension without cardiac symptoms who would like to stratify his risk for heart disease D) A 68-year-old female with coronary artery disease who is scheduled for a knee replacement and does not have cardiac symptoms when walking up a flight of stairs E) A 79-year-old male who is scheduled for a transcatheter aortic valve replacement for severe aortic stenosis and has dyspnea when walking up a few stairs?

ANSWER: A In the setting of acute symptoms, cardiac stress testing is indicated when there is an intermediate probability of acute coronary syndrome. Cardiac stress testing is also indicated in a preoperative assessment when surgery is at least a moderate risk and the patient cannot reach 4 METs of exertion (climbing a single flight of stairs) without cardiac symptoms. Cardiac stress testing is contraindicated after a recent stroke or TIA and in patients with severe symptomatic aortic stenosis. It is not indicated in asymptomatic patients with no history of revascularization.

A 12-year-old female presents with a sore throat and tonsillar exudate, and a rapid antigen test is positive for streptococcal pharyngitis. She returns to your office after completing a 10-day course of penicillin this morning. She says that although she saw some initial improvement, she now has a sore throat again, accompanied by a runny nose and cough. Her mother asks if another antibiotic would be appropriate. A physical examination reveals nonexudative pharyngitis, but a rapid antigen test for group A Streptococcus is again positive. Which one of the following would be the most appropriate treatment at this point? A) No further antibiotic therapy B) Oral azithromycin (Zithromax) for 5 days C) Oral ciprofloxacin (Cipro) for 10 days D) A single dose of intramuscular benzathine penicillin E) A single dose of intramuscular ceftriaxone

ANSWER: A Most bacteriologic treatment failures for group A Streptococcus (GAS) represent a GAS carrier state. This patient had clinical improvement followed by a second illness with typical features of a viral infection. Oral azithromycin, oral ciprofloxacin, intramuscular benzathine penicillin, and intramuscular ceftriaxone are not appropriate for the treatment of viral infections in a patient who is a pharyngeal GAS carrier.

A 45-year-old male sees you for a routine visit. His medical history includes hypertension treated with hydrochlorothiazide, amlodipine (Norvasc), and losartan (Cozaar). He also has type 2 diabetes treated with metformin and empagliflozin (Jardiance). Laboratory findings are significant for an LDL-cholesterol level of 167 mg/dL and you prescribe simvastatin (Zocor), 80 mg daily. At a follow-up visit 3 months later he tells you that he stopped taking the simvastatin after a week due to muscle pain and weakness. Which one of the following medications in this patient's current regimen most likely contributed to his risk for developing statin-induced myopathy? A) Amlodipine B) Empagliflozin C) Hydrochlorothiazide D) Losartan E) Metformin

ANSWER: A Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. In patients on statin therapy, concurrent use of other medications that are also metabolized by this system, including amiodarone, calcium channel blockers such as amlodipine, certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy. In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9), and this patient's other medications are metabolized by different mechanisms (empagliflozin) or not significantly metabolized (hydrochlorothiazide and metformin).

A 62-year-old female underwent a total knee replacement 3 months ago. She has no other surgical history and is in good health. Her dental office calls you to discuss antibiotic prophylaxis prior to a dental cleaning. Based on current guidelines, which one of the following would be most appropriate regarding antibiotic prophylaxis prior to routine dental procedures in this patient? A) No prophylaxis B) Prophylaxis for 6 months post knee replacement C) Prophylaxis for 1 year post knee replacement D) Prophylaxis for 5 years post knee replacement E) Prophylaxis for the patient's lifetime

ANSWER: A One of the most potentially devastating late complications of joint replacement surgery is infection of the prosthetic joint. Because dental procedures are known to induce transient bacteremia, the use of prophylactic antibiotics prior to dental procedures for patients with prosthetic joints was considered orthopedic dogma for many years. However, current evidence to support this practice is limited and antibiotic use is known to increase cost, bacterial resistance, and the risk of adverse drug reactions. In most cases the risks of antibiotic prophylaxis outweigh the likelihood of benefit. Recent guidelines from the American Dental Association and the American Academy of Orthopaedic Surgeons recommend against the routine use of prophylactic antibiotics for dental procedures in patients with a history of joint replacement, except for situations in which infectious risk is increased, such as immunocompromise or a history of a previous joint infection.

A 62-year-old male is found to have an alkaline phosphatase (ALP) level of 152 U/L (N 32-91). Laboratory studies performed last year showed an ALP level of 134 U/L. The review of systems today is negative, including for pain, nausea, and dyspnea. You note that his AST and ALT levels are in the normal range, and a gamma-glutamyl transaminase level is also normal. Which one of the following would be the most appropriate next step in the evaluation? A) Plain radiography of the skull, pelvis, and tibia B) Right upper quadrant ultrasonography C) A full-body CT scan D) A HIDA scan E) A radionuclide bone scan

ANSWER: A Paget disease of bone is the second most common metabolic bone disorder after osteoporosis and has a lifetime prevalence of 1%-2% in the United States. Only 30%-40% of patients have symptoms such as bone pain at diagnosis. Most patients are diagnosed after an incidental finding of elevated alkaline phosphatase (ALP) on routine laboratory studies or by plain films performed for another reason. When an elevated ALP level is found in an asymptomatic patient, other liver function tests such as a gamma-glutamyl transaminase level should be performed to evaluate for hepatobiliary pathology. If negative, this should be followed by plain radiography of the skull and tibia, and an enlarged view of the pelvis to assess for lytic lesions and cortical thickening. If plain radiography is consistent with Paget disease of bone, a radionuclide bone scan is performed to assess the full extent of the disease. Bisphosphonates are the first-line treatment in active disease, which is signified by bone pain, hearing loss, and lytic lesions. Right upper quadrant ultrasonography, a full-body CT scan, and a HIDA scan would not be the most appropriate next step in the evaluation.

Which one of the following is the most common radiologic finding in early pulmonary sarcoidosis? A) Bilateral hilar adenopathy B) Caseating granulomas C) Pleural granulomas D) Peribronchiolar thickening

ANSWER: A Sarcoidosis is an inflammatory disease that can affect many organ systems, but 90% of patients have pulmonary involvement. While many patients diagnosed with sarcoidosis are asymptomatic, pulmonary symptoms including dry cough, the gradual onset of dyspnea, and fatigue are nonspecific, and the condition is often not suspected until chest radiography is performed. The most common finding is bilateral hilar adenopathy alone (stage 1). Other findings, which usually develop over time, include infiltrates and, in some patients, ultimately fibrosis. The classic pathologic findings from biopsies are noncaseating granulomas. Caseating granulomas are indicative of tuberculosis. Pleural involvement is not typical in sarcoidosis. Peribronchiolar or peritracheal thickening and interstitial infiltrates may be seen on CT scans, but bilateral hilar adenopathy is the most characteristic finding in earlier pulmonary sarcoidosis and is readily seen on plain chest radiographs.

You see a 45-year-old male with fatigue, arthralgias, and mildly elevated liver function tests. You are considering hereditary hemochromatosis as a possible diagnosis. Which one of the following should you order first? A) A serum ferritin level and transferrin saturation B) Genetic testing for HFE mutations C) T2-weighted MRI for hepatic iron concentration D) A liver biopsy

ANSWER: A The initial tests used in the workup for suspected hemochromatosis are a serum ferritin level and transferrin saturation. A transferrin saturation >45% and a serum ferritin level >300 ng/mL in men or >200 ng/mL in women are indicative of iron overload and highly suggestive of hereditary hemochromatosis. A serum iron level is ordered as part of transferrin saturation testing, but an elevated iron level by itself is not as sensitive or specific as the other tests. Other etiologies of iron overload should be ruled out, including liver disease, alcohol abuse, and metabolic syndrome. If no secondary etiologies are found, genetic testing would be appropriate to identify HFE mutations indicating hereditary hemochromatosis. Genetic testing should not be performed in a patient without iron overload or a family history of hereditary hemochromatosis. MRI may help determine the risk of developing cirrhosis, and a liver biopsy is used to determine the amount of liver damage.

A 15-year-old female presents for a well adolescent examination and reports painful, heavy periods. Menarche occurred at age 11, and by age 12 her menses were regular but quite painful. She misses at least 1 day of school each month due to the discomfort. She has tried acetaminophen/caffeine/pyrilamine (Midol Complete) and ibuprofen, 200 mg, without much relief. She is not sexually active. Her past medical history and surgical history are unremarkable. A urine pregnancy test is negative. Which one of the following would be the most appropriate next step for this patient? A) Empiric treatment with maximum-dose naproxen B) Screening for sexually transmitted infections C) A pelvic examination D) Pelvic ultrasonography E) Referral to a gynecologist

ANSWER: A Dysmenorrhea affects 50%-90% of females and the great majority of cases are primary dysmenorrhea, or pain that occurs in the absence of pelvic pathology. After a complete history confirming cyclic cramping pelvic pain beginning around the start of menses and a negative urine pregnancy test, empiric treatment should be offered (SOR C). First-line treatment is an NSAID at moderate to maximum dosing, such as naproxen, 500 mg every 12 hours. Any NSAID can be used and should be started 1-2 days before the onset of menses and continued through the first several days of bleeding. A secondary benefit to NSAID use is a reduction in heavy menstrual bleeding. Combined estrogen/progestin oral contraceptives may also be used as first-line therapy or in conjunction with NSAIDs. While screening for sexually transmitted infections is important for sexually active adolescents, it is not indicated in the evaluation of dysmenorrhea. Neither pelvic examination nor imaging is indicated when the history is consistent with primary dysmenorrhea. If there is evidence of secondary dysmenorrhea (due to pelvic pathology or a recognized medical condition), then an examination and imaging are indicated. Family physicians are able to manage the majority of cases of primary dysmenorrhea. If there is no improvement in treatment after 3 months, referral to a gynecologist may be indicated.

A 37-year-old female presents to your clinic with a long-standing history of abnormal menstrual cycles, often occurring irregularly more than 40 days apart. She has ongoing struggles with weight gain, acne, and facial hair growth. She states that she is not currently sexually active. Her last Papanicolaou smear 2 years ago was normal. Her vital signs and a physical examination are unremarkable other than a BMI of 36 kg/m2. An office urine pregnancy test is negative. Laboratory evaluation reveals a hemoglobin A1c of 6.2%, and normal TSH, prolactin, and 17-hydroxyprogesterone levels. Which one of the following is required to confirm the most likely diagnosis? A) No additional evaluation B) A serum C-peptide test C) A dexamethasone suppression test D) Ultrasonography of the pelvis E) CT of the abdomen and pelvis

ANSWER: A This patient has signs and symptoms consistent with polycystic ovary syndrome (PCOS). The Rotterdam 2003 criteria are the most widely used diagnostic criteria for PCOS, endorsed by multiple national and international professional societies. These criteria require the presence of two out of the following three features: oligomenorrhea, hyperandrogenism, and the presence of polycystic ovaries on ultrasonography. When the first two of these criteria are clearly met, ultrasonography to establish the presence of polycystic ovaries is not required. Therefore, a diagnosis is already warranted for this patient and additional evaluation is not needed. When patients require imaging, pelvic ultrasonography is the preferred modality rather than CT. While this patient has evidence of insulin resistance, as is common for patients with PCOS, a C-peptide test is not indicated. Dexamethasone suppression testing is not indicated because this patient does not have any other clinical signs and symptoms that would be consistent with Cushing syndrome.

An 83-year-old female with a history of Alzheimer's dementia presents with concerns about worsening agitation in the evenings. She is accompanied by her daughter who has power of attorney. The patient is dependent on her daughter for all instrumental activities of daily living and requires assistance with certain core activities of daily living such as dressing and bathing. She has no other chronic medical problems. Her daughter states that starting around 4:00 p.m., the patient becomes increasingly disoriented and agitated. There has been no physical aggression, but the daughter asks for medical intervention to "help calm her down." Which one of the following should you recommend initiating first for the management of this patient's symptoms? A) Sensory stimulation including touch and music B) Cognitive training C) Haloperidol D) Quetiapine (Seroquel) E) Valproic acid.

ANSWER: A This patient is experiencing behavioral and psychological symptoms of dementia (BPSD) as her cognitive and functional status decline. Evening agitation is a common form of BPSD, often referred to as sundowning. As with most BPSD, a nonpharmacologic approach to improve agitation has much stronger evidence for efficacy compared to a pharmacologic approach. A recent network meta-analysis showed that sensory stimulation, including massage, touch, and music therapy, significantly outperforms pharmacologic intervention (level of evidence 1a). Cognitive training, especially for BPSD in the context of advanced dementia, does not have strong evidence to support its use. Pharmacologic intervention should be initiated with caution given the potential for side effects, and should be a last resort in situations where there is a risk of self-harm or harm to others.

A 35-year-old female presents to your office with a feeling of vague fullness in her neck for the last month. She has noticed a gradual onset of fatigue, constipation, and cold intolerance over that time. A few weeks ago the patient took a selfie and was surprised by how puffy her face appeared in the photo. On examination her thyroid is diffusely enlarged and nontender and feels pebbly on palpation. An HEENT examination, including an eye examination, is otherwise normal. Which one of the following is the most likely diagnosis? A) Chronic autoimmune (Hashimoto) thyroiditis B) Graves disease C) Lymphadenitis D) Lymphoma E) Thyroid cáncer

ANSWER: A This patient's clinical picture is most consistent with chronic autoimmune thyroiditis, traditionally known as Hashimoto thyroiditis. This diagnosis is suggested by her neck fullness and symptoms of hypothyroidism. Additionally, a nontender goiter that feels like pebbles on examination is classically reported with chronic autoimmune thyroiditis. Graves disease typically presents with symptoms of hyperthyroidism and, in many patients, orbitopathy (eye bulging). A patient with lymphadenitis typically shows symptoms of a causative infection. Lymphadenitis tends to rapidly enlarge the lymph nodes, which are also typically painful and tender. Lymphoma more commonly presents with fevers, night sweats, unintentional weight loss, itchy skin, and dyspnea. This patient lacks a discrete thyroid nodule, which makes thyroid cancer less likely. Thyroid nodules are more frequently painful, while the neck fullness in chronic autoimmune thyroiditis is usually painless and nontender.

Patients with autosomal dominant polycystic kidney disease are most likely to develop extrarenal cysts in which one of the following locations? A) Liver B) Pancreas C) Spleen D) Central nervous system E) Reproductive system

ANSWER: A Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary cause of kidney disease and is a frequent cause of end-stage renal disease. The most common extrarenal cystic complication is the formation of liver cysts, which are found in >90% of patients with ADPKD who are older than 35 years of age. Other locations for ADPKD-related cyst formation include the pancreas, spleen, and reproductive system, although these are not as common as hepatic cysts. The most severe complication of ADPKD is intracranial aneurysms, which are 2-4 times more prevalent in patients with ADPKD than in the general population but are not as common as liver cysts.

40-year-old female presents with several pruritic, thickened, scaly areas on her lower back, knees, and elbows. She says that when she tries to remove the scales they often bleed. Which one of the following would be the most appropriate pharmacologic therapy for this patient? A) Clobetasol propionate 0.05% lotion (Clobex) B) Selenium sulfide 2.5% lotion C) Permethrin cream (Nix) D) Terbinafine cream 1% E) Loratadine (Claritin), 10 mg daily

ANSWER: A This patient has psoriasis that is characterized by plaques on her extensor extremities and limited bleeding with removal of the scales (Auspitz sign). First-line treatment for localized plaques is topical corticosteroid therapy, such as clobetasol propionate lotion. Antifungals such as selenium sulfide lotion and terbinafine cream are used to treat dermatophytosis infections including tinea pedis and tinea versicolor. Permethrin cream is indicated for treatment of scabies and lice. Loratadine, an oral antihistamine, is used to treat urticaria

You receive a call from a hospitalist reporting that a 77-year-old male who is a patient of yours has been admitted to the hospital. You note that this is his third hospital admission over the last 4 months, due to a variety of acute medical concerns. His medical history includes heart failure, mild dementia, chronic kidney disease, and type 2 diabetes. You consider transitions of care planning for this patient upon discharge. Which one of the following interventions would offer the best efficacy for this patient? A) Rapid medication reconciliation, a home visit, and follow-up with you within 7 days of discharge B) Rapid medication reconciliation, a home visit, and follow-up with his endocrinologist within 7 days of discharge C) Rapid post-discharge laboratory studies, and follow-up with his cardiologist within 7 days of discharge D) Rapid post-discharge laboratory studies, and follow-up with both you and his cardiologist within 7 days of discharge E) Rapid medication reconciliation, rapid post-discharge laboratory studies, and follow-up with his endocrinologist within 7 days of discharge

ANSWER: A Given this patient's substantial burden of multimorbidity as well as ongoing patterns of high acute care utilization, he is at very high risk for readmission upon discharge. Although there has been significant heterogeneity across interventions over the last decade in optimizing transitions of care for high-risk patients, many analyses, including systematic reviews, have identified medication reconciliation and close follow-up with a primary care physician to be among the components critical to success, along with a home visit from either a nursing team member or a licensed independent practitioner. There is no clear evidence that rapid post-discharge laboratory studies improve outcomes. While there may be a tendency to focus on disease-specific interventions via specialty care, the preponderance of evidence supports a holistic focus through comprehensive primary care follow-up. Primary care continuity and accountability for care after discharge are also key components valued by patients and caregivers.

Which one of the following is necessary to make the diagnosis of a functional gastrointestinal disorder? A) Symptom-based clinical criteria B) Noninvasive testing for Helicobacter pylori infection C) Celiac serology D) Gastric emptying studies E) Esophagogastroduodenoscopy

ANSWER: A In the absence of red-flag symptoms such as nocturnal defecation, weight loss, or gastrointestinal bleeding, functional gastrointestinal disorders can be diagnosed using symptom-based clinical criteria. Symptoms such as recurrent abdominal pain related to defecation, pain related to a change in the frequency of defecation, abdominal bloating and distension, and loose and watery or lumpy and hard stools are used to diagnose functional bowel disorders. Noninvasive testing for Helicobacter pylori, celiac serology, gastric emptying studies, and esophagogastroduodenoscopy are not required in order to make a diagnosis.

Which one of the following disorders is caused by an underlying mechanism of osteochondrosis rather than apophysitis? A) Legg-Calvé-Perthes disease B) Osgood-Schlatter disease C) Sever's disease D) Sinding-Larsen-Johansson syndrome

ANSWER: A Osteochondrosis refers to degenerative changes in the epiphyseal ossification areas of growing bones. Legg-Calvé-Perthes disease is a type of osteochondrosis that affects the femoral head. Patients with Legg-Calvé-Perthes disease should be referred to an orthopedist and instructed to avoid all weight-bearing activities until reossification occurs. Osteochondrosis should be differentiated from apophysitis because the etiologies and management strategies differ. Apophysitis is a traction injury to the cartilage and bony attachments of tendons in growing children. Osgood-Schlatter disease, Sever's disease, and Sinding-Larsen-Johansson syndrome are apophysitis disorders that affect the anterior tibial tubercle, posterior heel, and inferior patellar pole, respectively. Treatment of apophysitis involves stretching, activity modification, icing, and limited use of NSAIDs

Which one of the following medications for the treatment of type 2 diabetes has been associated with ketoacidosis? A) Dapagliflozin (Farxiga) B) Liraglutide (Victoza) C) Metformin D) Pioglitazone (Actos) E) Sitagliptin (Januvia)

ANSWER: A SGLT2 inhibitors such as dapagliflozin have increasingly been shown to be associated with diabetic ketoacidosis under certain circumstances. Liraglutide, metformin, pioglitazone, and sitagliptin are not associated with diabetic ketoacidosis.

A 55-year-old male comes to your clinic for follow-up of his recent diagnosis of New York Heart Association class II heart failure with an ejection fraction of 40%. His past medical history is notable only for coronary artery disease. His current medications include the following: Aspirin, 81 mg daily Atorvastatin (Lipitor), 80 mg daily Furosemide (Lasix), 40 mg daily Lisinopril (Zestril), 40 mg daily Metoprolol succinate (Toprol-XL), 100 mg daily Spironolactone (Aldactone), 25 mg daily Today he is asymptomatic. His vital signs include a temperature of 37.0°C (98.6°F), a blood pressure of 118/75 mm Hg, and a heart rate of 60 beats/min. A physical examination is unremarkable. Which one of the following additional medications would be most appropriate to reduce his risk for worsening heart failure? A) Dapagliflozin (Farxiga) B) Digoxin C) Isosorbide dinitrate/hydralazine (BiDil) D) Ivabradine (Corlanor) E) Liraglutide (Victoza)

ANSWER: A The prevalence of heart failure has continued to increase due to the aging population in the United States. Dapagliflozin is approved by the FDA for the treatment of New York Heart Association class II-IV heart failure with reduced ejection fraction regardless of the presence of diabetes mellitus. Notably, recent studies showed a reduction in the worsening of heart failure and death from cardiovascular causes. Digoxin may be initiated in patients who remain symptomatic despite optimal therapy with other agents, but it does not affect morbidity or mortality. Isosorbide dinitrate/hydralazine provides a mortality benefit in patients who are unable to tolerate an ACE inhibitor or angiotensin receptor blocker. Ivabradine is a sinus node modulator and may reduce hospitalization or cardiovascular death in patients with a resting heart rate >70 beats/min who are taking a beta-blocker at maximal dosage. Liraglutide reduces cardiovascular events in patients with diabetes but has no role in the treatment of heart failure.

A 75-year-old male sees you for evaluation of a unilateral resting tremor of his right hand. The tremor resolves if he is touched on the hand by someone. His wife notes that he seems to drag his feet now, but he has no history of falls. Which one of the following has been shown to delay progression of his disease? A) No currently available pharmacologic agents B) Amantadine C) Carbidopa/levodopa (Sinemet) D) Rasagiline (Azilect) E) Ropinirole

ANSWER: A There are no currently available medications that have been shown to delay progression of Parkinson's disease. However, guidelines recommend initiating the treatment of motor symptoms when they begin to affect the functions of daily life or decrease the quality of life. The first-line treatment for motor symptoms is carbidopa/levodopa due to its effectiveness for tremors, rigidity, and bradykinesia. It is a myth that delaying the use of levodopa will prevent a lack of efficacy later in the course of the illness, as what appears to be a lack of efficacy actually represents progression of the disease. Amantadine can be used for patients under 65 years of age who are only experiencing tremors. Monoamine oxidase inhibitors such as rasagiline and non-ergot dopamine agonists such as ropinirole are not as effective as carbidopa/levodopa for motor symptoms, but they do not cause the dyskinesias and motor fluctuations seen with levodopa. Monoamine oxidase inhibitors are considered first-line therapy for patients under age 65 with mild motor symptoms.

The most effective therapy to improve quality of life in patients with tinnitus is A) a benzodiazepine B) an SSRI C) transcutaneous electrical nerve stimulation (TENS) D) acupuncture E) cognitive behavioral therapy

ANSWER: E Tinnitus is the sensation of hearing an abnormal sound, such as a ringing, buzzing, or clicking, that is perceived in the ear or head in the absence of an internal or external source. Cognitive behavioral therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Treatments that should be avoided include benzodiazepines, transcutaneous electrical nerve stimulation (TENS), and acupuncture. An SSRI could be considered for the management of tinnitus-associated anxiety, but is not considered the most effective therapy for tinnitus.

A 62-year-old male was recently diagnosed with adhesive capsulitis. Which one of the following is associated with a higher risk of developing adhesive capsulitis compared with the general population? A) Addison's disease B) Diabetes mellitus C) Hyperparathyroidism D) Hypertension E) Rheumatoid arthritis

ANSWER: B According to a 2016 meta-analysis, patients with diabetes mellitus were five times more likely than the control group to have adhesive capsulitis. The same study also found the prevalence of diabetes in patients with adhesive capsulitis to be about 30%. Because of this high prevalence, screening for diabetes with a fasting glucose level or hemoglobin A1c is recommended in patients with adhesive capsulitis who have not previously been diagnosed with diabetes. There is no evidence to support screening for Addison's disease or rheumatoid arthritis in patients with adhesive capsulitis (SOR C). Hyperparathyroidism and hypertension are not associated with adhesive capsulitis.

Which one of the following statements regarding hormone therapy for transgender patients is true? A) Hormone therapy to facilitate development of secondary sex characteristics is generally reversible B) Patients who receive hormone therapy generally report improved quality of life, higher self-esteem, and decreased anxiety C) Masculinizing hormone therapy is associated with reduced muscle mass and fat redistribution D) Patients receiving feminizing hormone therapy are at increased risk for erythrocytosis

ANSWER: B Hormone therapy is not required for all transgender patients, but those who receive treatment generally report improved quality of life, higher self-esteem, and decreased anxiety. Feminizing and masculinizing hormone therapies, including the use of estrogen and/or androgen therapies such as testosterone, are partially irreversible. Thus, it is important to make a reasonable, educated decision and use informed consent prior to treatment. Patients who receive masculinizing therapy are at increased risk for erythrocytosis and those who receive feminizing hormone therapy often experience reduced muscle mass and fat redistribution.

A 36-year-old female presents for evaluation of elevated blood pressure. She is asymptomatic and does not take any medications. On examination her blood pressure is 160/96 mm Hg and her BMI is 26 kg/m2. Fasting laboratory studies include the following: Sodium 142. Potassium 3.0. Creatinine 0.76. Glucose 97. Which one of the following additional laboratory evaluations should be performed to assess her blood pressure? A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA) B) A serum aldosterone/renin ratio C) A serum cortisol level D) A serum cystatin C level

ANSWER: B Primary hyperaldosteronism should be suspected as a cause for hypertension if a patient has a spontaneously low potassium level or persistent hypertension despite the use of three or more antihypertensive medications, including a diuretic. This can be evaluated by checking a serum renin activity level and a serum aldosterone concentration and determining the aldosterone/renin ratio. Primary hyperaldosteronism typically presents with a very low serum renin activity level and an elevated serum aldosterone concentration. A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA) would be used to evaluate for a neuroendocrine tumor, which can present as chronic flushing and diarrhea. Cortisol levels can be checked if Cushing syndrome is suspected. Hypertension can be present in Cushing syndrome, but it is typically associated with other signs such as obesity and an elevated blood glucose level due to insulin resistance. Cystatin C is a marker of renal function and measurement would not be indicated given this patient's normal creatinine level.

A 12-year-old female is brought to your office for a routine well child examination. The U.S. Preventive Services Task Force recommends screening this patient for which one of the following? A) Anemia B) Depression C) Diabetes mellitus D) Dyslipidemia E) HIV

ANSWER: B The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents and adults starting at age 12. The USPSTF states that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children 6-24 months of age (I recommendation) and does not offer recommendations regarding other age groups. There are no USPSTF recommendations regarding universal screening for diabetes mellitus in children or adolescents. The American Academy of Pediatrics now recommends screening for dyslipidemia in children once between 9 and 11 years of age, but the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents <20 years of age (I recommendation). HIV screening is recommended in adolescents and adults 15-65 years of age (A recommendation).

A 67-year-old male with a history of hypertension comes to your clinic for a follow-up visit. He has had two myocardial infarctions in the past 5 years and has undergone stent placement. He is currently asymptomatic. His vital signs are stable and his blood pressure is well controlled. Laboratory studies reveal a normal hemoglobin A1c and lipid profile. In addition to high-dose statin therapy, his current medication regimen includes the following: Aspirin Carvedilol (Coreg) Chlorthalidone Clopidogrel (Plavix) Lisinopril (Zestril) Adding which one of the following would help to provide secondary prevention of cardiovascular events in this patient? A) Azithromycin (Zithromax) B) Colchicine (Colcrys) C) DHA D) Niacin E) Omega-3 supplements

ANSWER: B The central role of inflammation in the progression of coronary disease is well recognized and the use of an anti-inflammatory medication may improve outcomes in these patients. The low-dose colchicine (LoDoCo2) trial evaluated colchicine, 0.5 mg daily, versus placebo in patients with chronic coronary artery disease and found a 30% risk reduction in cardiovascular deaths, spontaneous myocardial infarctions, ischemic stroke, and ischemia-driven revascularization. It did not find any observable difference with regard to new-onset atrial fibrillation, deep vein thrombosis, diabetes mellitus, or pulmonary embolism. Of note, the trial excluded individuals with heart failure or renal impairment. At one time, azithromycin had shown some evidence in the secondary prevention of cardiovascular disease, but subsequent trials did not show the same benefit. Studies of fish oil capsules that contain marine omega-3 fatty acid supplements mixed with EPA/DHA formulations have failed to show cardiovascular benefit in patients with known cardiovascular disease. Similarly, niacin does not reduce overall mortality, cardiovascular mortality, or noncardiovascular mortality. The benefits of niacin therapy in the prevention of cardiovascular disease events are not well proven.

A 56-year-old male presents to your office with a new onset of nonvalvular atrial fibrillation. His CHA2DS2-VASc score is 3 based on his previous history of hypertension, diabetes mellitus, and heart failure. He has no major risk factors for bleeding. Which one of the following would be recommended for the prevention of ischemic stroke secondary to atrial fibrillation in this patient? A) No antithrombotic therapy B) Apixaban (Eliquis), 5 mg twice daily C) Aspirin only, 81 mg daily D) Aspirin only, 325 mg daily E) Aspirin, 81 mg daily, plus full-dose warfarin, with a target INR of 2..0-3.0

ANSWER: B The decision regarding antithrombotic therapy in atrial fibrillation is a careful risk assessment balancing the reduction in the risk of ischemic stroke against the risk of major bleeding associated with anticoagulants and antiplatelets. The CHA2DS2-VASc tool is widely used to help weigh these benefits versus potential harms. Due to the overall benefit of stroke reduction, anticoagulation with either a direct oral anticoagulant (DOAC) such as apixaban or a vitamin K antagonist such as warfarin is recommended in patients with atrial fibrillation who have a CHA2DS2-VASc score >2. Aspirin monotherapy is considered an ineffective antithrombotic strategy and inferior to a DOAC or warfarin for preventing thromboembolic events in patients with atrial fibrillation. Adding aspirin therapy to warfarin does not confer extra benefit and increases the risk of major bleeding.

An obese 40-year-old female with diabetes mellitus sees you for evaluation of painful, deep-seated nodules in both axillae. On examination you note nodules in the axillae with purulent drainage and associated scarring. This condition is associated with which one of the following? A) Amyotrophic lateral sclerosis B) Crohn's disease C) Dermatitis herpetiformis D) Systemic lupus erythematosus E) Trauma

ANSWER: B The patient has hidradenitis suppurativa, a chronic folliculitis affecting intertriginous areas in the axillae and the groin that may also occur around the anus and nipples. Treatment depends on severity and ranges from topical to systemic antibiotics. Hidradenitis suppurativa is associated with obesity, diabetes mellitus, Crohn's disease, arthritis and spondyloarthropathy, metabolic syndrome, polycystic ovary syndrome, pyoderma gangrenosum, and trisomy 21. There are three stages: stage I is single or multiple abscesses without sinus tracts or scarring, stage II is abscess recurrence with sinus tracts and scarring and widely separated lesions, and stage III is diffuse abscesses with interconnecting sinus tracts. Amyotrophic lateral sclerosis has no typical skin manifestation. Dermatitis herpetiformis is associated with celiac disease and has clusters of pruritic lesions. Systemic lupus erythematosus has cutaneous manifestations of a malar rash and may involve subcutaneous lesions without scarring. Hidradenitis suppurativa is not associated with trauma.

An ill-appearing 50-year-old male presents with malaise, nausea, anorexia, and lethargy. He has a recent diagnosis of a high-grade lymphoma and is undergoing aggressive chemotherapy. His last chemotherapy session was 2 days ago. An examination is nonspecific. Initial laboratory studies reveal a creatinine level of 2.1 mg/dL (N 0.6-1.2). His baseline creatinine level is 1.0 mg/dL. Which one of the following laboratory findings would be expected in this patient? A) Hypercalcemia B) Hyperuricemia C) Hypokalemia D) Hypophosphatemia E) Low LDH

ANSWER: B Tumor lysis syndrome is considered the most common oncologic emergency. It is caused by the rapid release of intracellular material from lysis of the malignant cells. The breakdown of nucleic acids releases large amounts of uric acid and leads to acute kidney failure, which limits clearance of potassium, phosphorus, and uric acid. This leads to hyperuricemia, secondary hypocalcemia, hyperkalemia, and hyperphosphatemia. It can result in acute renal failure, arrhythmia, seizure, and sudden death. While tumor lysis syndrome has been reported with many cancer types, it is more common with acute leukemia and high-grade lymphomas. Patients with this condition generally present within 7 days of cancer treatment, including chemotherapy, radiation, or biologic therapies. It can also occur spontaneously. An LDH elevation related to a high cell turnover rate prior to cancer treatment may indicate an increased risk of tumor lysis syndrome. Hypercalcemia, hypokalemia, hypophosphatemia, and low LDH would not be expected laboratory findings in patients with tumor lysis syndrome.

A 44-year-old female presents to your office reporting that she hurts all over. After performing a thorough history and physical examination and appropriate laboratory studies you diagnose fibromyalgia. You explain to the patient that the initial treatment recommendation with the most proven efficacy is: A) acupuncture B) aerobic exercise C) amitriptyline D) duloxetine (Cymbalta) E) tramadol

ANSWER: B Aerobic exercise, a balanced diet, good sleep hygiene, and weight reduction are appropriate strategies for the management of fibromyalgia, and treatment goals should be focused on improving function and quality of life, along with managing symptoms. According to the 2017 European League Against Rheumatism, exercise is the strongest and most critical treatment for fibromyalgia. Not only does it lessen fibromyalgia symptoms, but it can also help with coexisting conditions including sleep disorders, depression, and anxiety. While some studies show improvement in symptoms with acupuncture, most evidence is low to moderate in quality. A Cochrane review found that acupuncture was superior to no treatment at all, but not superior to sham acupuncture. Pharmacologic treatments have shown only modest benefits and are often accompanied by adverse effects, so they are best used in conjunction with nonpharmacologic therapies.

A 65-year-old male is discharged following placement of a drug-eluting stent in the left anterior descending artery. Which one of the following is NOT appropriate first-line therapy in this patient? A) Aspirin plus clopidogrel (Plavix) B) Diltiazem (Cardizem) C) Metoprolol D) Rosuvastatin (Crestor)

ANSWER: B Beta-Blockers are first-line therapy for antihypertensive therapy and antianginal therapy, whereas calcium channel blockers are second-line agents in patients who are unable to tolerate beta-blockers. Calcium channel blockers may also be added as additional therapy when hypertension and angina symptoms are not controlled with beta-blockers alone. Patients who have been treated with a drug-eluting stent require dual antiplatelet therapy for 6-12 months. All patients with coronary artery disease should be on high-dose statin therapy.

Increasing greenhouse gas concentrations are resulting in multiple climate changes that can adversely affect the health of patients. Which one of the following examples describes a direct effect of climate change? A) Weather-related disasters have lessened, leading to an improvement in overall mental health B) Shorter and warmer winters allow insect vectors to spread into new areas, increasing the rate of multiple infectious diseases C) Increasing global temperatures have decreased the production of highly allergenic pollens such as ragweed D) Increasing consumption of plant-based foods has resulted in increased air pollution, further exacerbating many cardiopulmonary conditions

ANSWER: B Climate change is responsible for multiple negative impacts on patient health, including furthering the spread of multiple infectious diseases, a decline in mental health due to weather-related natural disasters, an increased risk of allergies, and increased exacerbation of cardiopulmonary conditions. Following a plant-based diet, transitioning to more active modes of transportation, and working within the health care system to help decrease greenhouse emissions can positively impact climate change.

A 64-year-old male is hospitalized with anorexia, intractable abdominal pain, and dehydration due to locally advanced pancreatic cancer. He is started on intravenous fluids and morphine, along with a prophylactic dose of subcutaneous heparin. Shortly after admission he develops right-sided chest pain and shortness of breath. His vital signs are normal, except for a respiratory rate of 24/min. An abdominal examination reveals tenderness in the epigastric area. An examination of the heart and lungs is normal. There is no calf tenderness or leg edema. An EKG shows new right bundle branch block. Which one of the following tests should you order next? A) A D-dimer level B) A troponin level C) Doppler ultrasonography of the lower extremities D) A ventilation-perfusion (V/Q) scan E) Computed tomography pulmonary angiography (CTPA)

ANSWER: E This patient's pretest probability for pulmonary embolism is high given his multiple risk factors, signs, and symptoms. The presence of a new onset of right bundle branch block in a patient presenting with a sudden onset of shortness of breath and chest pain, especially in the setting of active cancer, should raise suspicion of pulmonary embolism. Other EKG abnormalities include tachycardia or bradycardia, an S1Q3T3 pattern, atrial fibrillation, and T-wave inversions in the anterior leads. Patients with cancers of the pancreas and stomach have the highest risk of developing venous thromboembolism (VTE) and should receive pharmacologic VTE prophylaxis during hospitalizations. In the absence of renal failure, a computed tomography pulmonary angiogram (CTPA) is the most appropriate diagnostic study and would be preferred over a ventilation-perfusion (V/Q) scan. A D-dimer level has a high negative predictive value in the diagnosis of pulmonary embolism; however, it has low specificity, and therefore a high rate of false positives, in patients with active cancer. An elevated troponin level can occur in the setting of pulmonary embolism and is nondiagnostic. Their principal value is in the diagnosis of acute myocardial infarction (SOR A). Doppler ultrasonography of the lower extremities helps identify and locate peripheral deep vein thrombosis and helps support but not confirm the diagnosis of pulmonary embolism. A V/Q scan is a reasonable option when CTPA is contraindicated.

The front office staff reports that a patient has been difficult to deal with. Which one of the following is an effective strategy for managing a difficult patient encounter? A) Avoiding any mention of the patient's anger B) Listening with empathy and a nonjudgmental attitude C) Ignoring one's own internal emotional responses D) Limiting the encounter to discussion of a single problem E) Using a directive approach to the patient's care with a predetermined agenda

ANSWER: B Difficult patient encounters may arise from a wide variety of patient, situational, and even physician factors. The triggering of an emotional response from the staff or the physician is the common factor that defines a difficult encounter. Empathetic listening skills and a nonjudgmental attitude are helpful to facilitate effective communication. Acknowledging anger and ascertaining the patient's concerns can help to validate the patient's feelings and defuse the situation. Physicians should be aware of their own emotional response in order to navigate the situation successfully. While boundaries can be helpful, arbitrarily limiting the visit to a single problem is unlikely to meet the patient's needs effectively. A patient-centered approach to interviewing, rather than a directive approach, is also more likely to be successful.

A 51-year-old patient asks about recommended lung cancer screenings. The U.S. Preventive Services Task Force recommends annual lung cancer screening with low-dose CT for individuals starting at what age and how many pack year smoking history? A) 45 with a 15-pack-year smoking history B) 50 with a 20-pack-year smoking history C) 55 with a 30-pack-year smoking history D) 60 with a 35-pack-year smoking history E) 65 with a 40-pack-year smoking history

ANSWER: B Lung cancer is the second most common cancer in both women and men, after breast cancer for women and prostate cancer for men. It is the leading cause of cancer deaths in the United States, making it important for primary care providers to screen for this disease process. The primary risk factor for lung cancer is tobacco smoking, which accounts for 90% of all lung cancer cases. Lung cancer has a relatively poor prognosis, but early-stage lung cancer is more amenable to treatment and has a better prognosis. Low-dose CT has a reasonable specificity and high sensitivity for lung cancer in patients at high risk. The eligibility criteria were recently updated by the U.S. Preventive Services Task Force (March 2021) due to evidence of mortality benefit, with a recommendation for screening to begin at age 50 for patients with a 20-pack-year smoking history who are current smokers or have quit within the past 15 years.

A 70-year-old female tells you she is confused about recommendations regarding aspirin. She has heard through friends and news articles that new guidelines seem to be discouraging people from taking a daily aspirin due to the risk of bleeding, especially severe gastrointestinal bleeding. She has no history of bleeding but has decided to stop taking her aspirin, 81 mg daily. Her blood pressure is well controlled on her current antihypertensive regimen, and she also takes a daily statin. Her medical history includes a stroke a few years ago. Which one of the following would you recommend? A) No antithrombotic therapy B) Resuming aspirin, 81 mg daily C) Starting aspirin, 500 mg daily D) Starting apixaban (Eliquis), 2.5 mg daily E) Starting warfarin, with a target INR >3.0

ANSWER: B Most studies of aspirin for secondary prevention of cardiovascular disease involved prevention of recurrent strokes, and showed a reduction in recurrent strokes in patients taking 75-325 mg of aspirin daily. For this patient with a history of stroke, resuming aspirin at 81 mg daily would be clearly indicated. Multiple organizations have advised on the role of aspirin in the primary prevention of cardiovascular disease. In 2022 the U.S. Preventive Services Task Force released an update recommending against the initiation of low-dose aspirin for primary prevention of cardiovascular disease in adults >60 years of age as there is no net benefit. The American College of Cardiology/American Heart Association (ACC/AHA) came to a similar conclusion regarding primary prevention. Specifically, the ACC states that low-dose aspirin, 75-100 mg daily, should not be administered on a routine basis for the primary prevention of atherosclerotic cardiovascular disease in adults >70 years of age. There is no benefit in taking an aspirin dosage >325 mg daily. The apixaban dosage for stroke prophylaxis is 5 mg twice daily. When taking warfarin for stroke prophylaxis, the INR target is 2-3, not >3.

A 30-year-old gravida 3 para 2 sees you for prenatal care at 13 weeks gestation. During her previous pregnancies she became hypertensive and had bilateral leg edema and proteinuria. These conditions resolved after delivery. Her only current medication is a prenatal vitamin. In order to prevent this condition, which one of the following should be started today? A) No new medications B) Aspirin C) Fish oil D) Magnesium E) Vitamin C

ANSWER: B Preeclampsia is diagnosed when the blood pressure is >140/90 mm Hg on two separate occasions after 20 weeks gestation, accompanied by proteinuria (>300 mg protein in a 24-hour urine collection or 2+ protein on a dipstick). If there is no protein in the urine, new-onset hypertension and the presence of any of the following would meet the criteria for preeclampsia: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. This patient had preeclampsia during her previous pregnancies, which puts her at high risk for preeclampsia during her current pregnancy. Aspirin, 81 mg daily, is recommended for high-risk pregnant patients to prevent preeclampsia. Prophylaxis should begin after 12 weeks gestation and continue until delivery. Fish oil, magnesium, and vitamin C are not beneficial in the prevention of preeclampsia.

A 27-year-old female with hypothyroidism presents to your clinic at 5 weeks gestation. Her current medications include levothyroxine (Synthroid), 100 μg daily, and a prenatal vitamin. She had a normal TSH level 3 months ago. She is very concerned about the negative effects of medication during pregnancy and asks if she should continue taking levothyroxine. Which one of the following would be most appropriate for this patient at this time? A) Continuing the current levothyroxine dosage and referring her to an endocrinologist B) Increasing the levothyroxine dosage by 30% by taking an extra dose twice weekly C) Checking her TSH level today and increasing the levothyroxine dosage by 12.5 μg daily if it is >2.5 μU/mL D) Discontinuing levothyroxine and checking her TSH and free T4 levels in 6 weeks

ANSWER: B Pregnant patients with hypothyroidism require increased dosages of levothyroxine as early as the first 4 weeks of pregnancy. General recommendations advise taking an extra dose 2 days per week for a total of 9 weekly doses, which is roughly a 30% increase. The TSH level should be monitored every 4 weeks during pregnancy, and the levothyroxine dosage should be titrated to the pregnancy-specific reference range, which is generally lower than the normal reference range. Referral to an endocrinologist to manage fluctuating levels should be considered. Untreated hypothyroidism can lead to adverse pregnancy outcomes including spontaneous abortion, preterm birth, preeclampsia, and placental abruption.

An 11-year-old female is brought to your office by her parent who is concerned that the child's spine might be curved. The most appropriate evaluation for scoliosis at this point is A) comparing the length from the pelvic brim to the pelvic floor on the left and the right B) scoliometer measurement with the patient bent over to 90° C) scoliometer measurement with the patient upright and arms to her side D) determination of the Cobb angle with the patient bent over to 90° E) determination of the Cobb angle with the patient upright and arms to her side

ANSWER: B The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient's spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°-7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis. The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°

An 8-year-old male is brought to your office because of acute lower abdominal pain. He does not have constipation and has never had abdominal surgery. You suspect acute appendicitis. Which one of the following imaging modalities would be most appropriate to consider first? A) Plain radiography B) Ultrasonography C) CT without contrast D) CT with contrast E) MRI

ANSWER: B Ultrasonography is recommended as the initial imaging modality to evaluate acute abdominal pain in children. It avoids radiation exposure and is useful for detecting many causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis. Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history of previous abdominal surgery. The American Academy of Pediatrics Choosing Wisely recommendation on the evaluation of abdominal pain states that CT is not always necessary. Similarly, the American College of Surgeons Choosing Wisely recommendation on the evaluation of suspected appendicitis in children says that CT should be avoided until after ultrasonography has been considered as an option

A 27-year-old male presents to establish care after relocating to the community. He was diagnosed with β-thalassemia major at birth and has been transfusion-dependent since early childhood. His microcytic anemia is stable with blood transfusions every 4 weeks, but his most recent DEXA scan indicates an advancement from osteopenia to osteoporosis. In addition to bisphosphonates, calcium, and vitamin D, which one of the following medications may improve his bone density? A) Hydroxyurea (Hydrea) B) Vitamin C C) Zinc D) Deferoxamine (Desferal) E) Luspatercept (Reblozyl)

ANSWER: C In addition to bisphosphonates, calcium, and vitamin D, zinc supplementation is recommended to improve bone density in patients with thalassemia and osteoporosis (SOR C). Though hydroxyurea is an indicated therapy to minimize the frequency of blood transfusions needed in transfusion-dependent thalassemia, it does not improve bone density (SOR C). Vitamin C supplementation does not improve bone health in patients with thalassemia and osteoporosis. Deferoxamine infusions are indicated when ferritin levels are >1000 ng/mL in patients with transfusion-dependent thalassemia to reduce iron overload (SOR C). Luspatercept reduced transfusion burden by 33% in a phase 3, randomized study but is not indicated to improve bone density.

A 42-year-old Asian male presents for follow-up of elevated blood pressure. He has no additional chronic medical problems and is otherwise asymptomatic. An examination is significant for a blood pressure of 162/95 mm Hg but is otherwise unremarkable. Laboratory work shows that his BMP is within normal limits. According to the American College of Cardiology/American Heart Association 2017 guidelines, which one of the following would be the most appropriate medication to initiate at this time? A) Clonidine (Catapres), 0.1 mg twice daily B) Hydralazine, 25 mg three times daily C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily D) Metoprolol tartrate (Lopressor), 25 mg twice daily E) Triamterene (Dyrenium), 50 mg daily

ANSWER: C This patient has hypertension and according to both JNC 8 and American College of Cardiology/American Heart Association 2017 guidelines, antihypertensive treatment should be initiated. For the general non-African-American population, monotherapy with an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a thiazide diuretic would be appropriate for initial management. It is also appropriate to initiate combination antihypertensive therapy as an initial management strategy, although patients should not take an ACE inhibitor and an angiotensin receptor blocker simultaneously. Studies have shown that blood pressure control is achieved faster with the initiation of combination therapy compared to monotherapy, without an increase in morbidity. Lisinopril/hydrochlorothiazide would be an appropriate choice in this patient. Alpha blockers, vasodilators, beta-blockers, and potassium-sparing diuretics are not recommended as initial choices for the treatment of hypertension.

A recently divorced 47-year-old male comes to your office appearing disheveled, with the smell of alcohol on his breath. His Patient Health Questionnaire-9 (PHQ-9) score today is 20, and his last PHQ-9 score was 7. He has a history of depression and is currently taking citalopram (Celexa). The patient is tearful during the encounter and admits to thinking the world would be better without him in it. He does not have a weapon with him but keeps a gun in an unlocked drawer in his nightstand. Which one of the following would be most appropriate at this point? A) Avoiding direct inquiry about suicide B) Calling 911 C) Crisis planning D) Creating a suicide prevention contract E) Withholding psychogenic medications

ANSWER: C Crisis planning is recommended for patients presenting with suicidal ideation (SOR B). By identifying social support, local resources, and counseling services, suicidal ideation and days spent in the hospital can be reduced. Direct inquiry about suicide is recommended to better evaluate and treat suicidal patients with more favorable outcomes (SOR B). Though calling 911 may be appropriate for transportation for inpatient therapy if involuntary treatment is recommended, further assessment is needed in this case. Suicide prevention contracts do not effectively prevent suicide (SOR B). Psychogenic medications should not be withheld when treating a patient with suicidal ideation. Evidence has shown that the combination of pharmacotherapy and psychotherapy is most effective (SOR C).

A 32-year-old female presents to your office 3 months after surviving a serious rollover car accident. Since the accident she has had flashbacks, nightmares, and difficulty sleeping. She has been unable to resume work or care for her young children due to difficulty concentrating and feeling like she is in a daze. She has not been able to drive, and riding in a vehicle triggers anxiety and fear. She tells you that she cannot stop feeling responsible for the accident. She does not take any medications and has no history of substance use. After performing a structured diagnostic interview and review of DSM-5 criteria to confirm your diagnosis, you discuss treatment options. She is not willing to consider psychotherapy at this time. Which one of the following would be the most appropriate pharmacotherapy? A) Clonazepam (Klonopin) B) Divalproex (Depakote) C) Fluoxetine (Prozac) D) Quetiapine (Seroquel) E) Risperidone (Risperdal)

ANSWER: C This patient has posttraumatic stress disorder (PTSD). She was exposed to threatened death and injury (DSM-5 criterion A) and exhibits multiple symptoms from several clusters of the DSM-5 criteria for PTSD (reliving of the traumatic event [criterion B], avoidance of trauma-related stimuli [criterion C], negative thoughts or feelings that began or worsened after the trauma [criterion D], and trauma-related arousal and reactivity that began or worsened after the trauma [criterion E]). She has symptoms that have caused distress and functional impairment for more than 1 month and are not triggered by medication or substance use (criteria F-H). Individual, trauma-focused psychotherapy has strong evidence for benefit in the treatment of PTSD and is recommended as the first-line treatment. If psychotherapy is not available or preferred by the patient, pharmacotherapy is then recommended. Among the options listed, fluoxetine has the strongest evidence of efficacy as monotherapy for PTSD. There is a lack of evidence for the efficacy of benzodiazepines such as clonazepam, antiepileptics such as divalproex, and atypical antipsychotics such as quetiapine and risperidone. Furthermore, risks outweigh any potential benefits from these medications.

A 24-year-old female presents to your office in Maine in November because for the past few weeks she has been sleeping much more than usual and craving sweets. She says she has gained 8 lb since her symptoms started. She enjoys her job and is in a stable relationship. She feels somewhat depressed but does not have any suicidal or homicidal thoughts. She has had similar episodes in the fall and winter for the past 4 years, and her symptoms usually resolve in the spring. The symptoms are starting to affect her quality of life and she asks for your advice. Which one of the following would be the most appropriate treatment at this time? A) Vitamin D supplementation B) Trazodone C) Light therapy D) A high-protein diet

ANSWER: C This patient presents with symptoms consistent with seasonal affective disorder (SAD). According to the DSM-5, this condition is not defined as a separate diagnosis, but instead a variant of major depressive or bipolar disorder. SAD is a mood disorder with depressive symptoms occurring at a specific time of year with full remission in between episodes, which usually occur during fall and winter months. A less common form can present during summer or spring. Criteria specify that full remission must occur when the specific season ends and there must be at least two consecutive years of mood episodes. The pathology is unclear but risk factors include family history, living at a more northern latitude, female sex, and age 18-30. First-line therapy for the treatment of SAD includes light therapy (SOR A), with a response rate of about 50%; cognitive therapy (SOR A); and antidepressants such as SSRIs (SOR B). Vitamin D supplementation is not a first-line treatment for SAD, and trazodone would not be used for someone who is already having issues with excessive sleeping. There is no convincing evidence that a high-protein diet is an effective treatment for SAD. For this patient with regular recurrences, long-term preventive intervention each year with light therapy starting in the early fall is indicated.

A 37-year-old male presents for a physical evaluation prior to starting a new job in a hospital. He recently immigrated from Uganda. An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) is positive. He is otherwise healthy. He has not had any cough, fever, unintended weight loss, or night sweats. Which one of the following is the most appropriate next step? A) Tuberculin skin testing B) Inducing sputum for mycobacterial culture C) Chest radiography D) Proceeding with treatment for latent tuberculosis E) Proceeding with treatment for active tuberculosis

ANSWER: C This patient's tuberculosis (TB) screening test is positive, and the next step in the evaluation involves determining whether he has a latent infection or active disease. Diagnosis of latent TB requires ruling out active disease by assessing the patient clinically with a history, physical examination, and chest radiograph. If this evaluation does not suggest active disease, sputum studies are not needed. Interferon-gamma release assays (IGRA), which are blood tests used to screen for TB infection, are more accurate than tuberculin skin testing, so a tuberculin skin test is not needed. Treatment should not be started until a determination of latent versus active TB is made.

A 73-year-old female with diabetic neuropathy and osteoarthritis of the knees sees you to request a prescription for an assistive mobility device. The neuropathy has caused poor balance and the knee pain has made walking more painful. As a result her physical endurance has declined over the last several months. Which one of the following assistive devices would be most appropriate for this patient? A) A cane B) Crutches C) A walker D) A wheelchair

ANSWER: C A walker would be the most appropriate assistive device for this patient given her balance limitations and bilateral extremity pain. Canes are most effective for unilateral lower extremity limitations and should be held in the hand opposite the affected leg and advanced simultaneously with the affected leg. Using a cane also requires good balance and dexterity, which are limited in this patient. Crutches require significant upper body strength, balance, and increased energy expenditure, which makes their use impractical in many older adults. Wheelchairs are generally the last option, as patients who can walk should do so to maintain function and avoid deconditioning. Referral to a physical therapist can be helpful to determine the most appropriate assistive device.

Which one of the following regimens is recommended for the treatment of hypertension in a patient with stage 3 chronic kidney disease and proteinuria? A) A loop diuretic and a β-blocker B) An ACE inhibitor and an angiotensin receptor blocker C) An ACE inhibitor and a thiazide diuretic D) A calcium channel blocker and a thiazide diuretic E) A potassium-sparing diuretic and a thiazide diuretic

ANSWER: C Based on a reduction in all-cause mortality, JNC 8 advises more intensive blood pressure control in patients with chronic kidney disease (CKD) and proteinuria. This is most often achieved with combination therapy, with either an ACE inhibitor or an angiotensin receptor blocker (ARB), plus either a thiazide diuretic or a calcium channel blocker. ACE inhibitors and ARBs both slow the progression of CKD to end-stage renal disease and reduce morbidity and mortality in patients with CKD (SOR A). However, combining an ACE inhibitor and an ARB actually increases the risk of end-stage renal disease, so these drugs should not be used simultaneously. The other combinations listed may be effective in improving blood pressure control, but in patients with CKD and proteinuria the combination of an ACE inhibitor or an ARB with a diuretic or calcium channel blocker is most effective for lowering morbidity and mortality.

Montelukast (Singulair) has an FDA boxed warning related to an increased risk of: A) delirium B) myocardial infarction C) suicidality D) venous thromboembolism

ANSWER: C In March 2020, the FDA upgraded its warning label for montelukast to a boxed warning (black box warning) based on the trends for all neuropsychiatric adverse events, including suicidality, associated with montelukast use reported in the FDA Adverse Event Reporting System database from the date of FDA approval in February 1998 through May 2019 (SOR B). The boxed warning does not indicate an increased risk of delirium, myocardial infarction, or venous thromboembolism

A 35-year-old female presents to discuss her recent diagnosis of metastatic breast cancer. She has many questions about potential treatments and outcomes. You discuss palliative care with her. Which one of the following is true regarding patients who receive palliative care? A) Patients must have a life expectancy of 6 months or less to qualify B) Care must be offered in person (outpatient or inpatient) C) Patients may simultaneously undergo aggressive chemotherapy D) Costs for palliative care are higher than for usual chronic disease care E) Medicare and most commercial insurances provide bundled payments for palliative care

ANSWER: C Palliative care can be offered to patients of any age with serious illness. It can be provided at any stage of the illness and there are no life-expectancy criteria. Unlike hospice, patients receiving palliative care may simultaneously undergo aggressive therapy. Palliative care can be offered in any setting, including via telehealth. It has been shown that patients receiving palliative care incur fewer health care costs than patients receiving usual care. The Choosing Wisely campaign recommends early referral to palliative care, as it improves patient care, increases patient satisfaction, and reduces costs. While Medicare covers hospice care through bundled payments, there is no similar coverage for palliative care, which can limit access. Commercial coverage for palliative care is inconsistent.

A 32-year-old female comes to your office because of chronic diarrhea, abdominal cramping, and bloating. She has had these symptoms for many years but has never discussed them in depth with a physician. A thorough history and physical examination are most consistent with irritable bowel syndrome (IBS). You order IgA tissue transglutaminase (tTG) antibody and fecal calprotectin testing to rule out other conditions and both are negative. She has expressed an interest in nonpharmacologic measures as initial management of her IBS. Which one of the following should you recommend initially, given that it has the best evidence of benefit for her condition? A) A gluten-free diet B) A low-FODMAP diet C) Soluble fiber D) Prebiotics E) Probiotics

ANSWER: C This patient has diarrhea-predominant irritable bowel syndrome (IBS-D) and may benefit from validation of her symptoms and a clear diagnosis that has several substantiated treatment options. A 2021 clinical guideline from the American College of Gastroenterology (ACG) is based on a systematic review performed by a committee of experts in this field. Based on this review, soluble fiber (but not insoluble fiber) has good evidence for the alleviation of global IBS symptoms and is recommended strongly as a first-line intervention. In contrast, a gluten-free diet has not been shown to be beneficial for IBS. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has low-quality evidence supporting its benefit but merits a trial in patients who do not have an adequate response to fiber supplementation. The ACG has not commented on prebiotics as a treatment for IBS. A 2018 systematic review concluded that while there are small individual studies suggesting benefit for prebiotics (and probiotics) there is inadequate long-term consistent evidence to support their routine use. Probiotics have mixed and low-quality evidence for benefit in IBS. Because of the inconsistent data the ACG recommends against their use.

A previously healthy 44-year-old female presents to the emergency department (ED) with severe, sharp, right upper quadrant abdominal pain and nausea that began shortly after eating dinner. On examination she is noted to have a low-grade fever with a positive Murphy sign. A laboratory analysis is notable for leukocytosis with a left shift and a mildly elevated total bilirubin level. A lipase level and liver transaminases are normal. Ultrasonography reveals several small gallstones, gallbladder wall thickening, and pericholecystic fluid. After receiving intravenous fluids, pain management, and antiemetic treatment in the ED, her symptoms improve. In addition to intravenous antibiotics, the most appropriate next step in management would be to offer: A) expectant management B) endoscopic retrograde cholangiopancreatography (ERCP) C) laparoscopic cholecystectomy D) outpatient general surgery consultation

ANSWER: C This patient presents with signs and symptoms of acute cholecystitis, and ultrasonography confirms the presence of gallstones and gallbladder inflammation. While most patients with acute cholecystitis will have symptoms that improve with supportive care over 2-7 days, the risk of recurrent symptoms and complications increases with delayed surgical intervention. The Choosing Wisely initiative recommends that surgical treatment be offered to the patient during the initial hospitalization. The Society of American Gastrointestinal and Endoscopic Surgeons has found that laparoscopic cholecystectomy is safe and cost-effective in the immediate hospital setting. This stable, uncomplicated patient should be offered laparoscopic cholecystectomy during the current visit. Offering outpatient options such as expectant management and surgical consultation at a later date may increase this patient's risk of recurrent symptoms and complications as well as costs. Since she does not have signs of obstructive cholangitis such as elevated liver enzymes and jaundice, endoscopic retrograde cholangiopancreatography (ERCP) is not indicated.

A 4-year-old female is brought to your office by her father for a well child check. The father reports that the child is having difficulty using her albuterol (Proventil, Ventolin) metered-dose inhaler for asthma exacerbations and he is not sure whether it is improving her symptoms. On demonstration in the office, the child is unable to time her breathing with inhaler actuation. Which one of the following would you recommend? A) Montelukast (Singulair) B) Albuterol via oral liquid C) Albuterol metered-dose inhaler via a spacer device D) Albuterol via nebulizer E) Salmeterol inhaled (Serevent Diskus)

ANSWER: C Young children often have difficulty coordinating inhaler use, which can reduce the effectiveness of asthma medications. The use of spacer devices eliminates the need for coordination and increases medication delivery to the lungs. Oral albuterol is no longer recommended. Montelukast, nebulized albuterol, and inhaled salmeterol are not indicated as first-line treatment for asthma exacerbations.

Despite limited evidence, systemic corticosteroids are frequently prescribed for multiple conditions in primary care. Which one of the following conditions has grade A evidence for treatment with systemic corticosteroids? A) Acute bronchitis B) Acute pharyngitis C) Acute sinusitis D) Bell's palsy E) Lumbar radiculopathy

ANSWER: D Although many providers assume short-term systemic corticosteroids are safe, evidence shows multiple negative effects including elevated blood glucose and blood pressure, mood and sleep disturbance, and an increased risk of sepsis and venous thromboembolism. There are adequate trials to support the use of systemic corticosteroids within 3 days of the onset of Bell's palsy (SOR A). Adequate studies recommend against prescribing systemic corticosteroids for acute bronchitis in the absence of underlying asthma or COPD, or acute sinusitis (SOR B). There is insufficient evidence (SOR B) to support the routine use of systemic corticosteroids for patients with acute pharyngitis or lumbar radiculopathy.

A 47-year-old female sees you for a health maintenance visit. During the course of your discussion she discloses a long history of significant alcohol intake that has impaired her work and personal life, meeting criteria for moderate to severe alcohol use disorder. She began working with a therapist to address this issue several months ago and reports that her last drink was 26 days ago. Her health is otherwise good and laboratory studies reveal normal liver and renal function. Which one of the following medications would help reduce the risk of relapse? A) Buspirone B) Duloxetine (Cymbalta) C) Fluoxetine (Prozac) D) Naltrexone E) Quetiapine (Seroquel)

ANSWER: D Alcohol use disorder (AUD) is common in the United States but remains undertreated, especially with pharmacotherapy. FDA-approved therapies include naltrexone, acamprosate, and disulfiram. Non-FDA-approved therapies with evidence of benefit include baclofen and topiramate. AUD commonly coexists with other psychiatric conditions and in these situations treating those comorbid conditions is critical. For patients with coexisting depression or anxiety, buspirone, duloxetine, or fluoxetine could be considered in addition to one of the other medications listed to address AUD. Quetiapine, which is an antipsychotic, has no role in the treatment of AUD.

A 43-year-old female with lifelong asthma asks if she would be a candidate for treatment with a biologic agent such as omalizumab (Xolair). A CBC reveals mild eosinophilia, indicating type 2 inflammatory asthma. In which one of the following patient scenarios should biologic treatment for asthma be considered? A) Any patient with poorly controlled, severe asthma B) A patient with severe non-type 2 asthma that is poorly controlled despite adherence to optimal therapy with long-term controller medication C) A patient with type 2 inflammatory asthma that is poorly controlled despite therapy with as-needed inhaled albuterol (Proventil, Ventolin) and low-dose inhaled corticosteroids D) A patient with severe type 2 inflammatory asthma that is poorly controlled despite adherence to optimal therapy with long-term controller medication

ANSWER: D Biologic therapy for asthma targets type 2 inflammation pathways. According to the 2019 Global Initiative for Asthma (GINA) guidelines, diagnosis and management of severe asthma includes determination of the asthma phenotype to assess for type 2 inflammation. Type 2 asthma includes allergic and eosinophilic asthma. Non-type 2 asthma is driven by neutrophils and is associated with smoking and obesity. Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy. Biologic therapy may be considered in patients with severe type 2 inflammatory asthma who continue to have significant symptoms despite adherence to optimal therapy, including high-dose inhaled corticosteroids and a long-acting -agonist.

A 35-year-old female presents with very pruritic, recurrent, grouped papules, vesicles, and erosions on her knees and elbows. She does not have any known connective tissue diseases, gastrointestinal disturbances, sexually transmitted infections, or recurrent exposures. A skin biopsy is consistent with dermatitis herpetiformis. A positive test for which one of the following is most consistent with this diagnosis? A) Anti-thyroid antibodies B) Herpes simplex virus antibody titers C) Intrinsic factor antibodies D) IgA tissue transglutaminase (tTG) antibodies E) Varicella zoster virus antibody titers

ANSWER: D Dermatitis herpetiformis is a very pruritic, papulovesicular reaction that is secondary to cutaneous IgA and immune complex deposition related to gluten sensitivity, as in celiac disease. The majority of patients do not have the gastrointestinal disturbances of celiac disease but do have the changes of gluten enteropathy on small bowel biopsies. The diagnosis is supported by elevated IgA tissue transglutaminase (tTG) antibodies, which is the serology of choice for diagnosing celiac disease. The rash frequently responds well to a gluten-free diet and is classically treated with dapsone. The disease is not related to thyroid disease, herpesviruses, or pernicious anemia.

A 39-year-old female presents to the urgent care clinic on a Saturday evening with fever, cough, diarrhea, and malaise. She is undergoing treatment for breast cancer and her last chemotherapy treatment was 2 weeks ago. On examination her temperature is 38.6°C (101.5°F), her heart rate is 120 beats/min, her blood pressure is 124/68 mm Hg, her respiratory rate is 24/min, and her oxygen saturation is 95% on room air. You order stat laboratory studies, a chest radiograph, a urinalysis, and blood cultures. A CBC reveals a WBC count of 1200/mm3 (N 4800-10,800), 34% neutrophils, 4% bands, and 48% lymphocytes. A COVID-19 rapid antigen test is negative. Which one of the following would be most appropriate at this point? A) No treatment until results are available for the remainder of the laboratory studies, chest radiograph, and urinalysis B) Oral acetaminophen, 1000 mg C) Empiric oral high-dose amoxicillin/clavulanate (Augmentin) D) Empiric intravenous piperacillin/tazobactam (Zosyn)

ANSWER: D Febrile neutropenia is a relatively common complication of chemotherapy. It usually occurs within 6 weeks of a chemotherapy treatment. It is defined as a single oral temperature of 38.5°C (101.3°F) or a sustained temperature of 38°C (100.4°F) for at least 1 hour in patients with an absolute neutrophil count (ANC) <500 cells/mm. This patient's ANC is 456 cells/mm. Such patients should be presumed to have a bacterial infection. For patients who meet the criteria for febrile neutropenia, guidelines recommend administration of empiric intravenous antibiotics within an hour of presentation. Early administration of intravenous antibiotics has been shown to reduce the potential 11% mortality rate of febrile neutropenia (SOR B). Once the remainder of the laboratory results are available, a decision can be made about inpatient versus outpatient treatment in consultation with the patient's oncologist, but initial treatment should not be delayed. The patient may benefit symptomatically from acetaminophen but it is not an urgent consideration. Oral antibiotics have not been shown to be as effective as initial empiric treatment with an intravenous broad-spectrum antibiotic.

A 35-year-old female at 36 weeks gestation presents to your office. She reports that for the past few days she has had itching of her palms and soles that has been quite bothersome. She has tried moisturizer with no improvement. A physical examination is unremarkable with no rashes, erythema, or warmth of the palm and soles. The patient otherwise feels well. Which one of the following would be most appropriate at this time? A) A low-potency corticosteroid cream B) Tacrolimus topical (Protopic) C) Cetirizine (Zyrtec Allergy) D) Bile acid levels E) A BUN/creatinine ratio

ANSWER: D Intrahepatic cholestasis of pregnancy (ICP) presents with pruritus of the palms and soles with or without jaundice along with an elevation in serum bile acid concentrations. ICP, which is most common in the late second and/or third trimester, can cause significant risk to the fetus, including fetal death, and is therefore treated aggressively with ursodeoxycholic acid and often early delivery. Corticosteroid creams, tacrolimus, and cetirizine are not appropriate treatments for ICP. Kidney function tests such as a BUN/creatinine ratio would not be initially appropriate in this case.

Which one of the following interventions has been shown to increase retinal screening rates in patients with diabetes mellitus? A) One minute of counseling about the importance of retinal screening at each primary care visit B) Digital reminders sent monthly to patients' cell phones until they complete their retinal screenings C) Conducting an office-wide prize drawing for patients who complete retinal screenings D) Asynchronous teleretinal screening performed at the primary care provider's office E) Sharing office/clinic space with an ophthalmologist

ANSWER: D Telemedicine can be helpful in the management of many chronic conditions, including diabetes mellitus. Medicare and most private insurers pay for telemedicine visits at the same rate as in-person visits. Teleretinal screening performed at the primary care provider's office should be considered in patients with diabetes as a cost-effective option for improving retinopathy screening rates (SOR B). Eyecare specialists can remotely evaluate the retinal photos for timely completion of annual retinopathy screening. Counseling about the importance of retinal screening, digital reminders, office-wide prize drawings, and sharing office space with an ophthalmologist have not been proven to be effective in increasing retinal screening rates in patients with diabetes.

A 33-year-old male presents to your office with a 4-week history of a runny and itchy nose, nasal congestion, watery eyes, sneezing, and cough. He reports that he always has similar symptoms this time of year. He has tried taking over-the-counter diphenhydramine (Benadryl Allergy) for the past week but finds it too sedating. He reports that his symptoms are interfering with his quality of life. On examination he has pale, boggy nasal mucosa with clear rhinorrhea. Lung auscultation is normal. Which one of the following is the most appropriate treatment? A) Butterbur herbal supplement B) Oral amoxicillin C) Oral montelukast (Singulair) D) Intranasal fluticasone (Flonase Allergy Relief) E) Intramuscular methylprednisolone

ANSWER: D This patient has signs and symptoms of seasonal allergic rhinitis. He has a history of seasonal symptoms with a predominance of itchy nose, clear rhinorrhea, and watery eyes. The American Academy of Allergy, Asthma & Immunology (AAAA&I) Rhinitis 2020 practice parameter update recommends an intranasal corticosteroid such as fluticasone as initial treatment for seasonal allergic rhinitis (SOR strong, certainty of evidence [COE] high). Due to the lack of available evidence, the AAAA&I cannot make a recommendation for or against the use of herbal treatments such as butterbur or Yu ping feng san. An oral antibiotic such as amoxicillin would be used for suspected bacterial infectious rhinitis, which this patient does not have. The AAAA&I suggests not using the leukotriene receptor antagonist montelukast as initial treatment due to its decreased efficacy when compared to other treatments (SOR conditional, COE very low). Furthermore, the FDA has advised that, due to the risk of serious neuropsychiatric events, montelukast should only be used for treatment of allergic rhinitis when other options are not tolerated or effective. The AAAA&I also advises against the use of depot parenteral corticosteroids such as intramuscular methylprednisolone due to the risks of systemic and local side effects (SOR conditional, COE low).

An otherwise healthy 29-year-old gravida 2 para 1 at 28 weeks gestation presents to your office with a laceration sustained while doing yard work. After thoroughly cleaning the wound, you decide not to suture it because of the risk of infection. The patient received Tdap during her previous pregnancy 6 years ago and you confirm in her medical records that she completed her primary immunizations as a child. Which one of the following would be most appropriate regarding tetanus prophylaxis? A) No tetanus prophylaxis B) Tetanus immune globulin now C) Td now D) Tdap now E) Tdap at 38 weeks gestation

ANSWER: D This patient needs a tetanus toxoid-containing vaccine for the management of her wound. Since pregnant people should receive a dose of Tdap between 27 and 36 weeks gestation to protect against pertussis, Tdap is the best choice for this patient. Tetanus immune globulin would be appropriate if this patient had not previously completed the primary series or were showing signs of clinical tetanus. Td would be an appropriate option for tetanus prophylaxis in nonpregnant patients who have previously received Tdap. Because this patient requires some form of tetanus prophylaxis at this time, waiting until 38 weeks to administer Tdap is not appropriate.

Once hemolysis is excluded, the most common cause of unconjugated hyperbilirubinemia is A) alcoholic liver disease B) biliary tract disease C) fatty liver disease D) Gilbert syndrome E) Wilson disease

ANSWER: D Unconjugated hyperbilirubinemia can be defined as an elevated indirect bilirubin level. While unconjugated hyperbilirubinemia is most commonly seen in hemolysis, another common cause is Gilbert syndrome, which stems from a genetic defect that affects how the liver processes bilirubin. Alcoholic liver disease, biliary tract disease, fatty liver disease, and Wilson disease do not lead to unconjugated hyperbilirubinemia.

A 34-year-old gravida 2 para 2 presents for a postpartum examination 6 weeks after an uncomplicated vaginal delivery. Both the mother and infant are doing well. Her only complication during the pregnancy was an abnormal 3-hour glucose tolerance test. She managed her blood glucose with a combination of diet and exercise and delivered at 39 weeks gestation. The patient's vital signs and a physical examination are normal today. Which one of the following should you recommend for this patient based on her history of gestational diabetes? A) No glucose testing today, and initiation of metformin to prevent diabetes B) No glucose testing today, and annual screening with a fasting plasma glucose level starting 1 year after delivery C) No further glucose testing unless she becomes pregnant again D) A 2-hour plasma glucose level using a 75-g oral glucose load

ANSWER: D A 2-hour, 75-g glucose tolerance test should be performed at 4-12 weeks post partum following a pregnancy in which gestational diabetes was diagnosed. This will identify patients who have developed diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance. Women who have a history of gestational diabetes have a sevenfold increased risk of developing type 2 diabetes compared to women without a history of gestational diabetes. This patient should not begin taking metformin because she may not be a candidate for treatment. Testing is required to make the diagnosis of diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance. If a patient who was diagnosed with gestational diabetes tests negative for diabetes mellitus on postpartum screening, fasting glucose levels should still be assessed every 1-3 years regardless of pregnancy status. With the next pregnancy the patient should have early screening with a 1-hour glucose tolerance test at the time the pregnancy is confirmed

Your patient, who is overweight and says she has struggled with bulimia in the past, asks for your advice on strategies to help prevent obesity and eating disorders in her 12-year-old daughter. Which one of the following strategies should be incorporated? A) Implementing a diet of moderate calorie restriction for healthy adolescents and adults 1 week per month B) Having more frequent discussions regarding weight control and healthy eating C) Limiting home-prepared dinners to 1-2 times per week D) Eating meals together as a family at least 7 times per week E) Watching television during mealtimes

ANSWER: D A higher frequency of family meals is associated with improved dietary quality, as evidenced by increased consumption of fruits, vegetables, and grains. Eating meals together as a family on most days or every day is protective against purging and binge eating, as well as frequent dieting, which is a risk factor for both obesity and eating disorders. Parental talk about weight revolving around their children or their own dieting is linked to becoming overweight. Meals that are home-prepared and undistracted are also beneficial to maintaining healthy weight and attitudes toward food.

Which one of the following is an individual risk factor for committing intimate partner violence? A) A belief in flexible gender roles B) Having many friends C) High income D) Planned pregnancy E) Young age

ANSWER: E Understanding individual, relational, societal, and community risk and protective factors associated with intimate partner violence (IPV) perpetration can help prevent it. Among the options listed, young age is an individual risk factor for committing IPV. IPV is most prevalent in adolescence and young adulthood and declines with age. A belief in strict gender roles, having few friends, low income, and unplanned pregnancy are also risk factors.

A 48-year-old male with schizophrenia presents for a new patient visit after recently relocating to your area. He has been stable on clozapine (Clozaril) for the past 15 years and asks you to refill his prescription. He has been told the earliest available appointment with a local psychiatric provider is in 3 months. Under the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program, which one of the following is required to prescribe clozapine to this patient? A) A signed patient consent form B) Serum clozapine levels C) Creatinine levels D) Neutrophil counts E) Specialty training in psychiatry

ANSWER: D Clozapine is a highly effective antipsychotic medication, but its use is limited due to its association with severe drug-induced neutropenia, also referred to as agranulocytosis. Patients must be enrolled in the national Clozapine Risk Evaluation and Mitigation Strategy (REMS) program to receive treatment, and all prescribers and pharmacies must be certified by this program in order to dispense clozapine. The patient's absolute neutrophil count must be submitted at least every 30 days, or more frequently as determined by stability in treatment. A signed patient consent form should be obtained but is not a part of the Clozapine REMS monitoring system. Monitoring serum clozapine levels and creatinine levels may be appropriate but is not part of the Clozapine REMS program. Family physicians can prescribe clozapine if registered and certified in the Clozapine REMS program, which includes passing a brief knowledge assessment, but specialty training in psychiatry is not required.

A 69-year-old male with a history of diabetes mellitus presents to your clinic with concerns of mild vision problems. His brother lost his vision due to glaucoma and encouraged the patient to seek care. Which one of the following is most consistent with the typical vision changes of glaucoma? A) Central vision loss with peripheral sparing B) Halos and decreased night vision C) Intermittent complete blackening of the visual field D) Patchy peripheral vision blurring E) Sudden scattered floaters

ANSWER: D Glaucoma and other common eye conditions cause a range of visual disturbances. Glaucoma is typically associated with blurring of peripheral vision as elevated pressure in the eye pushes on the periphery of the ophthalmic nerve. Central vision loss with peripheral sparing is classically seen with macular degeneration. Halos and decreased night vision are classic problems for patients with cataracts. Intermittent complete blackening of the visual field may be seen with ischemia associated with stroke or temporal arteritis. Sudden scattered floaters should raise concern for retinal detachment.

A 31-year-old nulligravida presents to your office with an inability to conceive for the past 12 months. She reports irregular menses for the past 2 years. Her medical history is significant for Hashimoto thyroiditis that is currently controlled. A urine pregnancy test is negative. On examination you note vaginal dryness and labial atrophy. You suspect primary ovarian insufficiency. Which one of the following combinations of FSH and LH levels is consistent with this diagnosis? A) Normal FSH and normal LH B) Low FSH and low LH C) Low FSH and elevated LH D) Elevated FSH and elevated LH

ANSWER: D In a female younger than 40 years of age, elevated FSH and LH levels indicate primary ovarian insufficiency. Ovarian insufficiency leads to low estrogen levels, which stimulate increased production of FSH in the pituitary in a feedback loop. In this scenario, LH levels are high but do not rise as much as FSH levels. Normal FSH and LH levels may indicate an outflow tract obstruction. Low FSH and LH levels indicate that the hypothalamic-pituitary axis is suppressed, as in the female athlete triad when there is an excess of energy expenditure compared to intake. Low FSH and elevated LH levels may be detected immediately prior to ovulation as part of a normal cyclical pattern.

A 62-year-old male presents with a 2-day history of a painful abscess in his perianal area. He has a history of well controlled type 2 diabetes and hypertension and he currently takes metformin and lisinopril (Zestril). He also has a history of recurrent skin abscesses, which have responded well to oral sulfamethoxazole/trimethoprim (Bactrim). He has occasional chills but has not had a fever. On examination his vital signs are normal and you note the presence of a 2.5×2.5-cm perianal abscess. A point-of-care glucose level is 172 mg/dL and the results of a CBC are pending. Which one of the following would be the most appropriate next step? A) Continue current management and follow up in 48 hours B) Perform incision and drainage, obtain a culture, and start sulfamethoxazole/trimethoprim only C) Perform incision and drainage, obtain a culture, and start oral linezolid (Zyvox) D) Perform incision and drainage, obtain a culture, and start sulfamethoxazole/trimethoprim plus amoxicillin/clavulanate (Augmentin)

ANSWER: D Incision and drainage of an abscess along with MRSA antibiotic coverage is recommended for all abscesses greater than 2×2 cm. Incision and drainage of an abscess is almost always indicated and is a cornerstone of treatment. A wound culture with antibiotic sensitivity must be obtained in all cases to guide therapy. MRSA is the most common causative pathogen, so an antibiotic that provides coverage against MRSA, such as sulfamethoxazole/trimethoprim, doxycycline, or clindamycin, should be used as an empiric first-line agent for treatment of a skin abscess, pending culture results. Additional anaerobic coverage is recommended when an abscess is located in the perirectal area or when an abscess occurs in an area where tissue ischemia is likely. Continuing current management with follow-up in 48 hours is not recommended due to the potential for expansion of the abscess in patients with diabetes mellitus (SOR A). When an abscess is less than 2×2 cm, incision and drainage is often the only recommended intervention, and treatment with antibiotics is typically not indicated in such cases. Most patients with uncomplicated skin abscesses can be managed in the outpatient setting. The presence of certain host factors such as poorly controlled type 2 diabetes, surrounding cellulitis, rapid progression, signs and symptoms of systemic illness, associated comorbidities or immunosuppression, extremes of age, an abscess in an area difficult to drain, and underlying tissue ischemia/gangrene are indications for hospitalization and parenteral antibiotics. Linezolid is reserved for patients who are allergic or intolerant to commonly used anti-MRSA antibiotics. Because linezolid has limited anaerobic coverage, it is not recommended when anaerobic infection is likely.

Your patient lives in an unincorporated community located about 30 miles from the nearest town and does not have access to municipal water. She reports her family gets their water from a well and that all the members of her family have had intermittent diarrheal illnesses for the past few months. Currently everyone is feeling better. There is no relevant travel history. Which one of the following would you advise? A) Discontinuing use of the well water for any purpose until it is tested B) Routinely testing the well water every 2 years C) Pouring a gallon of bleach into the well D) Drinking, cooking, and bathing with boiled or bottled water until the well is uncontaminated E) A stool culture and testing for ova and parasites for all family members

ANSWER: D Many homes rely on well water, particularly in rural areas. Unlike water from municipal supplies, well water is not tested routinely by government agencies, and it is generally the responsibility of the property owner to ensure the safety of the water. If there is cause for concern in regard to the well, appropriate testing should be performed, in this case for fecal coliforms. In most locations, the county health department or other government agency will test well water on request. The water should be retested following treatment, and not used for drinking, cooking, or bathing until it is known to be safe. Water can still be used for laundry, yard maintenance, or any purpose where ingestion is unlikely. Wells should be tested yearly, generally in the spring, and following flooding or other environmental concerns such as nearby excavation or dumping. While the treatment of bacterial contamination does require bleach in most cases, the dose is calculated by characteristics of the individual well, and most experts advise that treatment be done by a well drilling and maintenance company. Since all of this patient's family members are currently asymptomatic, there is no need to obtain stool samples.

Which one of the following classes of diabetes medications is most associated with hypoglycemia? A) Biguanides B) DPP-4 inhibitors C) SGLT2 inhibitors D) Sulfonylureas E) Thiazolidinediones

ANSWER: D Multiple classes of diabetes medications are used to address the pathways that lead to hyperglycemia, and it is important to select medication classes that reduce the risk of hypoglycemia while improving long-term outcomes. Hypoglycemia is associated with cardiovascular disease and all-cause mortality. Sulfonylureas, such as glipizide, glyburide, and glimepiride, commonly cause hypoglycemia as an adverse effect and require glucose monitoring when used. Biguanides most commonly cause diarrhea, vomiting, and other gastrointestinal symptoms. In high-risk patients such as those with heart failure, sepsis, or impaired kidney function, biguanides can also result in lactic acidosis. The only biguanide currently available is metformin. The most common adverse effects of DPP-4 inhibitors, which include saxagliptin, sitagliptin, linagliptin, alogliptin, are headache, nasopharyngitis, infections of the urinary tract or upper respiratory tract, and elevated liver enzymes. SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, can cause adverse effects such as urinary tract infections, candidiasis, dehydration, and hypovolemia. Only two thiazolidinediones, pioglitazone and rosiglitazone, are available in the United States. Their adverse effects include weight gain, salt retention, edema, and, for some patients, cardiovascular complications. Pioglitazone in particular is contraindicated in patients with heart failure, hemodynamic instability, and hepatic dysfunction. Thiazolidinediones may also increase the risk of bone fractures with long-term use.

A patient is brought to the emergency department by his wife due to acute anxiety, jittery movements, confusion, vomiting, and fever, all of which started without warning a few hours ago. The wife reports that he has had a cough and upper respiratory symptoms recently, and he took an over-the-counter medication with dextromethorphan this morning. His usual medications include fluoxetine (Prozac), 30 mg daily for depression, and methylphenidate (Metadate CD), 50 mg daily for attention-deficit/hyperactivity disorder. She checked his medication bottles and does not think he has taken extra doses. His vital signs include a blood pressure of 160/95 mm Hg, a heart rate of 116 beats/min, a respiratory rate of 25/min, a temperature of 38.5°C (101.3°F), and an oxygen saturation of 98% on room air. A physical examination is remarkable for restlessness, anxiety, diaphoresis, and inducible clonus most prominent in the lower extremities. His lungs are clear and his neck is supple. He is alert and oriented to self only. Laboratory studies reveal a WBC count of 14,000/mm3 (N 4500-11,000) and a serum bicarbonate level of 20 mEq/L (N 23-30), and a urine drug screen is positive for amphetamines only. A COVID-19 polymerase chain reaction test is negative. The most likely cause of his symptoms is: A) an overdose of methylphenidate B) an infectious process C) malignant hyperthermia D) serotonin syndrome

ANSWER: D Symptoms of serotonin syndrome range from mild to life-threatening and typically appear minutes to hours after ingestion of serotonergic medications. SSRIs are the most commonly associated class of medication due to their widespread use. The Hunter Serotonin Toxicity Criteria are the most commonly used diagnostic tool. This patient has a history of serotonergic medication use, signs of inducible clonus, agitation, and diaphoresis, as well as hyperthermia. It is likely that the addition of dextromethorphan precipitated this episode. This patient's history does not suggest an overdose of methylphenidate, and there is little evidence in this scenario for a serious infectious process. Malignant hyperthermia generally appears over a longer period of time and does not typically induce clonus. There are few, if any, choices for medication therapy of concomitant attention-deficit/hyperactivity disorder and depression that do not increase the risk of serotonin syndrome, so patients on these regimens should be educated about the symptoms of serotonin syndrome and common causative agents.

A 39-year-old gravida 3 para 3 comes to your office for a routine health maintenance visit. She reports gradual leaking of urine over the past year. It mostly occurs when she does strength training at the gym and has become so bothersome that she has limited her exercise. She also notices leaking when coughing, sneezing, and picking up her young children. Her BMI is 27 kg/m2 . A pelvic examination is notable for a normal urethral body and thick, pink vulvar tissue. The vaginal vault is without prolapse. You ask her to cough with a full bladder and note leakage of urine. A urinalysis is normal. You counsel her on appropriate fluid intake, timed voiding, the reduction of caffeinated and carbonated beverages, regular moderate physical activity, and weight loss. In addition to these behavioral modifications, which one of the following is the most appropriate intervention at this time? A) An oral antimuscarinic agent B) Intravaginal estrogen C) OnabotulinumtoxinA (Botox) D) Pelvic floor muscle training E) Urethropexy

ANSWER: D The cough stress test confirms that this patient is experiencing chronic stress urinary incontinence. In addition to other behavioral modifications such as appropriate fluid intake, timed voiding, the reduction of caffeinated and carbonated beverages, regular moderate physical activity, and weight loss, pelvic floor muscle training is a first-line treatment for stress urinary incontinence. Surgical intervention with urethropexy or sling procedures can be considered if conservative treatment with behavioral modification and pelvic floor muscle training fails. There are no FDA-approved oral medications for the treatment of stress incontinence. Oral antimuscarinic agents and onabotulinumtoxinA are approved for use in urge incontinence. Intravaginal estrogen can be used to treat underlying vaginal and vulvar atrophy that can contribute to urinary incontinence, but it has not been approved by the FDA for the treatment of urinary incontinence. This patient does not have concurrent atrophic vaginitis so she would not be an appropriate candidate for intravaginal estrogen.

A 70-year-old female who is an established patient at your practice calls you late on a Saturday afternoon. Earlier in the day she misjudged the location of a bench at a neighbor's house and sat down hard on the porch floor. She felt immediate pain in her back. She went home and took naproxen, 440 mg, and sustained-release acetaminophen, 1300 mg, 3 hours ago. She still describes her pain as unbearable, rating it as 10 on a scale of 10. You agree to meet her in the emergency department, where you confirm an acute T12 vertebral compression fracture. Of the following, the most appropriate treatment option for this patient's acute pain is a short course of: A) prescription-strength NSAIDs B) methadone C) transdermal fentanyl D) immediate-release oxycodone (Roxicodone)

ANSWER: D The most appropriate treatment for this patient's acute pain following a T12 vertebral compression fracture is round-the-clock class II narcotics. Subcutaneous calcitonin can also be useful for relieving pain from vertebral fractures. NSAIDs and acetaminophen are usually insufficient during the acute phase of a vertebral compression fracture, and this patient has already tried these. Methadone or transdermal fentanyl can be used, but plasma levels of methadone may take 5-7 days to stabilize and fentanyl takes 24-48 hours to take effect.

Which one of the following is the most common cause of prerenal acute kidney injury in the intensive-care setting? A) ACE inhibitor use B) NSAID use C) Membranoproliferative glomerulonephritis D) Polyarteritis nodosa E) Sepsis

ANSWER: E Acute kidney injury (AKI) is defined by a rapid decline in glomerular filtration rate (GFR) and an increase in metabolic waste products. It is associated with an increased risk of cardiovascular events, progression to chronic kidney disease, and mortality. AKI is categorized as prerenal, intrinsic renal, and postrenal. Diagnosing the underlying cause is vital to successful management. Management includes determining volume status, treating acute volume changes with diuretics and fluid resuscitation, adjusting medications according to renal function, and discontinuing nephrotoxic medications. Prerenal AKI is caused by a depletion of intravascular volume, which leads to decreased renal perfusion and GFR. In the intensive-care setting, sepsis is the most common cause of prerenal AKI. Angiotensin receptor blockers, ACE inhibitors, and NSAIDs lower renal perfusion, causing the kidneys to activate compensatory mechanisms to maintain the GFR. For those with chronic kidney disease, this increases the risk for AKI. Membranoproliferative glomerulonephritis and polyarteritis nodosa are intrinsic renal causes for AKI. Postrenal causes include lower and upper urinary tract disorders such as infections, carcinoma, and nephrolithiasis. Systemic postrenal causes include diabetes mellitus, stroke, and multiple sclerosis.

A 77-year-old female presents to your office as a new patient. She recently moved from New York to Florida to live with her daughter, after her partner died 2 years ago. Her past medical history is significant for hypertension, hypothyroidism, osteoarthritis, and cachexia. Her current medications, which were prescribed by her previous primary care physician, include the following: Acetaminophen Hydrochlorothiazide Levothyroxine (Synthroid) Losartan (Cozaar) Megestrol (Megace) A multivitamin Her vital signs are unremarkable except for a 7% weight loss in the past year. A recent TSH level was within the normal range. Which one of the following medications should be discontinued? A) Acetaminophen B) Hydrochlorothiazide C) Levothyroxine D) Losartan E) Megestrol

ANSWER: E Although it is considered an appetite stimulant, megestrol is not recommended in older adults due to potential harmful side effects and a lack of evidence supporting improved outcomes for the treatment of cachexia in the geriatric population, according to the American Geriatrics Society's Choosing Wisely recommendation. Acetaminophen is not considered a contributor to weight loss. Though loop diuretics, spironolactone, ACE inhibitors, calcium channel blockers, and propranolol may contribute to weight loss due to their adverse effects, hydrochlorothiazide and angiotensin receptor blockers such as losartan are less likely to contribute to weight loss and the patient's hypertension is currently controlled on this regimen. The patient's hypothyroidism is currently stable, so changes to the levothyroxine dosage are unnecessary.

A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a rash on the extensor surfaces of his lower legs consisting of painful, subcutaneous, nonulcerated, erythematous nodules. This rash is consistent with which one of the following? A) Erythema ab igne B) Erythema infectiosum C) Erythema migrans D) Erythema multiforme E) Erythema nodosum

ANSWER: E Erythema nodosum, a panniculitis that typically affects the subcutaneous fat on the anterior surface of the lower legs, is associated with coccidioidomycosis (valley fever) and can suggest the diagnosis. It is a manifestation of the patient's immune response and often indicates a good prognosis. In addition to coccidioidomycosis, it can also be associated with streptococcal infections as well as tuberculosis. Erythema ab igne is a cutaneous rash caused by prolonged heat exposure (such as a heating pad) presenting as an otherwise asymptomatic, red, reticulated pattern on the skin. Erythema infectiosum is associated with parvovirus B19 infection and is usually seen in young children. It manifests as an erythematous rash of the face (slapped cheek appearance), arms, and legs. Erythema migrans is an expanding, erythematous, annular rash with or without central clearing and is often associated with tick exposure (Lyme disease). Erythema multiforme consists of raised, annular, target-like lesions with central erythema and is usually associated with herpes simplex virus type 1.

While reviewing laboratory studies for a patient who was recently started on antihypertensive medication, you note new hyperkalemia. Which one of the following medications is most likely to cause this finding? A) Amlodipine (Norvasc) B) Chlorthalidone C) Hydrochlorothiazide D) Metoprolol E) Olmesartan (Benicar)

ANSWER: E Hyperkalemia is a known side effect of ACE inhibitors and angiotensin receptor blockers such as olmesartan. The risk of hyperkalemia is increased with chronic kidney disease, diabetes mellitus, moderately severe to severe heart failure, NSAID use, and older adults. Chlorthalidone and hydrochlorothiazide can cause hypokalemia, while amlodipine and metoprolol have no significant effect on potassium levels.

Which one of the following interventions has the best evidence for effectiveness in the treatment of frailty syndrome in geriatric patients? A) Protein supplements B) Vitamin D supplements C) Hormonal treatment with anabolic steroids D) Aerobic conditioning training E) Progressive resistance training

ANSWER: E In geriatric patients with frailty syndrome, the intervention with the best evidence for effectiveness is progressive resistance training as a part of a physical activity program. The routine use of protein supplements, vitamin D supplements, or hormonal treatments, including anabolic steroids, is not recommended. Aerobic conditioning training may be helpful but the strongest evidence for efficacy is for activities that include progressive resistance training.

A 50-year-old male presents with chronic abdominal pain. A workup leads you to suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small duodenal ulcer. The endoscopist also notes some small esophageal varices without red wale signs. Further evaluation confirms that the patient has compensated cirrhosis in the setting of alcohol use disorder. He readily accepts this diagnosis and enters an Alcoholics Anonymous program. His ulcer symptoms resolve with antibiotic therapy for Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would like to further reduce his risks from cirrhosis. The most appropriate next step in the management of his esophageal varices would be: A) octreotide (Sandostatin) B) omeprazole (Prilosec) C) propranolol D) endoscopic variceal ligation E) repeat endoscopy in 1-2 years

ANSWER: E Primary prevention of variceal hemorrhage is an important consideration in the management of patients with cirrhosis. Although this patient's varices were diagnosed incidentally, patients with cirrhosis and clinically significant portal hypertension should be screened for varices every 2-3 years with esophagogastroduodenoscopy (EGD). EGD can be deferred in patients with platelet counts <150,000/mm3 and transient elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of bleeding. Findings associated with a high risk of bleeding include small varices in patients with decompensated cirrhosis, small varices with red wale signs (thinning of the variceal wall), and medium to large varices. Patients with small varices not meeting these criteria have a low risk of hemorrhage and do not require prophylaxis. They should be rescreened with EGD every 1-2 years. For patients requiring treatment due to high-risk features, options for primary prophylaxis of hemorrhage include nonselective -blockers such as propranolol or endoscopic variceal ligation. Treatment decisions are based on patient preference, other potential contraindications, and local resources. The need for repeat endoscopy in these cases will depend on the clinical circumstances. If nonselective -blockers are used, they should be continued indefinitely. Octreotide is only given intravenously for acute hemorrhage. There is no evidence that omeprazole slows the progression of esophageal varices.

An 18-year-old football player collapses on the field at the beginning of summer conditioning workouts. There was no obvious contact or injury. Upon assessment, he is awake but somnolent and diaphoretic. He reports a headache and is unable to identify where he is or the day of the week. His core temperature is 40.2°C (104.4°F). Which one of the following is the most likely diagnosis? A) Exercise-associated collapse B) Heat edema C) Heat exhaustion D) Heat injury E) Heat stroke

ANSWER: E The prompt recognition of heatstroke is critical to effective treatment. Heatstroke is characterized by a core temperature >40°C (104°F) in association with neurologic abnormalities such as headache, confusion, altered mental status, irritability, and seizure. Exercise-associated collapse, previously called heat syncope, generally occurs immediately after strenuous exercise and is more associated with hydration status. Heat edema is a benign condition manifested by mild swelling in the extremities and facial flushing in a patient with a normal temperature. Heat exhaustion may involve neurologic symptoms but is associated with a lower temperature (38.3°C-40.0°C [101°F-104°F]) and thus a better outcome. Like heatstroke, heat injury can be associated with a temperature >40°C, but does not involve neurologic symptoms. Instead, kidney, muscle, or liver injury may be present.

A 70-year-old female presents to your office to discuss osteoporosis that was noted on a recent bone density test. Initial laboratory studies reveal an abnormal TSH level of 0.27 μU/mL (N 0.36-3.74). Additional studies reveal the following: Repeat TSH -- 0.04μU/mL FreeT3 -- 3.4pg/mL(N1.7-5.2) FreeT4 -- 1.4ng/dL(N0.7-1.6) A radioactive iodine uptake scan is notable for multiple areas of increased and suppressed uptake Which one of the following is the most likely explanation for these findings? A) Exogenous thyroid hormone use B) Graves disease C) Painless thyroiditis D) Recent excess iodine intake E) Toxic multinodular goiter

ANSWER: E This patient has a low serum TSH level in the presence of normal free T4 and total or free T3 levels, which is consistent with subclinical hyperthyroidism. The etiology of overt and subclinical hyperthyroidism should be determined by clinical symptoms, biochemical markers, and, if indicated, diagnostic studies such as a radioactive iodine uptake (RAIU) scan. A scan that shows multiple areas of increased and suppressed uptake is consistent with toxic multinodular goiter. There is no RAIU with exogenous ingestion of thyroid hormone, painless thyroiditis, and recent excess iodine intake. Graves disease causes diffuse RAIU. It is important to determine the etiology of subclinical hyperthyroidism in order to treat it appropriately. In patients who have TSH levels that are persistently <0.1 U/mL, the American Thyroid Association has a strong recommendation with moderate-quality evidence for treating patients 65 years of age and older; persons with cardiac risk factors, heart disease, or osteoporosis; postmenopausal women not on estrogens or bisphosphonates; and those with hyperthyroid symptoms.

A 22-year-old female sees you to establish care. She describes firing her previous primary care physician because he was not adequately treating her. She states that she was diagnosed with borderline personality disorder 1 year ago and is seeking better treatment. Which one of the following would be the most appropriate first-line therapy? A) Lamotrigine (Lamictal), 25 mg daily B) Lithium, 300 mg twice daily C) Omega-3 fish oil (Lovaza), 4 g daily D) Quetiapine (Seroquel), 50 mg at bedtime E) Cognitive behavioral therapy

ANSWER: E Borderline personality disorder is characterized by emotional dysregulation, unstable self-image, and instability in interpersonal relationships. Patients with borderline personality disorder frequently overvalue and then rapidly devalue relationships, depending on perceived rejection. Cognitive behavioral therapy, specifically dialectical behavioral therapy and mentalization-based therapy, has shown the best efficacy in treating borderline personality disorder (SOR B). Pharmacologic treatments, including mood stabilizers, fatty acids, antipsychotics, and antidepressants, have been utilized in the treatment of borderline personality disorder despite limited or low-quality evidence, and would not be considered first-line therapy.

Chronic cough in an adult is defined as a cough that has been present for longer than 8 weeks. Which one of the following is the most common cause of chronic cough in an adult? A) Asthma B) Laryngopharyngeal reflux disease C) Nonasthmatic eosinophilic bronchitis D) Protracted bacterial bronchitis E) Upper airway cough syndrome

ANSWER: E Chronic cough in adults is a common presenting symptom for primary care visits. The four most common causes of chronic cough in adults include upper airway cough syndrome (UACS), asthma, nonasthmatic eosinophilic bronchitis, and reflux-related disorders. UACS, previously referred to as postnasal drip syndrome, is the most common cause of chronic cough in adults. This syndrome can have multiple etiologies, including chronic rhinosinusitis, allergic rhinitis, and nonallergic rhinitis. The diagnosis may be suggested by symptoms of rhinorrhea such as nasal stuffiness, sneezing, and postnasal drainage, but the absence of these symptoms does not rule out the diagnosis. The most common causes of chronic cough in children 6-14 years of age are asthma, protracted bacterial bronchitis, and UACS.

A 53-year-old female sees you for a routine health maintenance visit. The patient reports that she is newly menopausal and asks you about osteoporosis screening. Her past medical history includes morbid obesity, and her family history includes type 2 diabetes in her mother and hypertension in her father. The patient is a nonsmoker and rarely consumes alcohol. Her only medication is loratadine (Claritin), 10 mg daily. Which one of the following would you recommend regarding osteoporosis screening for this patient? A) No screening now or in the future, and calcium supplementation only B) No screening now or in the future, and calcium and vitamin D supplementation C) Radiography of her hip and lumbar spine now D) A DEXA scan now E) A DEXA scan at age 65

ANSWER: E For women with no risk factors, the U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women 65 years and older with bone measurement testing such as DEXA to prevent osteoporotic fractures (grade B recommendation). The USPSTF recommends screening for osteoporosis with DEXA in postmenopausal women younger than age 65 who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (B recommendation). Factors associated with an increased risk of osteoporosis include smoking, excessive alcohol consumption, low body weight, and a parental history of hip fracture. This patient is not at increased risk for osteoporosis, so a DEXA scan at age 65 would be most appropriate. Calcium and vitamin D supplementation to prevent osteoporosis are no longer routinely recommended. Plain radiography would not be recommended as screening for osteoporosis.

A 55-year-old female with a BMI of 50 kg/m2 and recently diagnosed severe obstructive sleep apnea (OSA) presents for follow-up after a sleep study. She was unable to tolerate positive pressure therapy. Her OSA could be most effectively addressed by which one of the following interventions? A) Use of a nasal dilator device B) A positional sleep alarm to avoid the supine position C) Clonidine, 0.1 mg orally before bedtime D) Uvulopalatopharyngoplasty E) Bariatric surgery

ANSWER: E Obstructive sleep apnea (OSA) is a common disorder that, if left untreated, can be associated with other serious health conditions such as atrial fibrillation, depression, heart failure, and stroke. Positive pressure therapy is effective and considered the first-line treatment for OSA, although some patients are unable to tolerate this therapy. In obese patients with OSA, bariatric surgery has been shown to reliably result in improvement in >75% of patients and result in remission in 40% of patients after 2 years. Nasal dilator devices and pharmacologic interventions such as clonidine have not been shown to improve symptoms or to be effective for treatment. Positional therapy is not recommended as a long-term solution for severe OSA due to poor long-term compliance. Currently there is insufficient evidence to support oral procedures such as uvulopalatopharyngoplasty as primary interventions for OSA.

55-year-old female comes to your clinic for follow-up of her poorly controlled hypertension. Her medical history also includes type 2 diabetes and worsening obstructive sleep apnea (OSA). Her BMI is 52 kg/m2 . Her heart rate is 62 beats/min and regular. Her blood pressure in the clinic today is 160/96 mm Hg, and she reports similar average readings at home. She is asymptomatic and says she has been following lifestyle modifications including a low-salt diet. She also reports that she has been adherent with her current antihypertensive regimen, which includes the following: Amlodipine (Norvasc), 10 mg daily Carvedilol (Coreg), 25 mg twice daily Chlorthalidone, 25 mg daily Losartan (Cozaar), 100 mg daily Which one of the following antihypertensive medication changes would benefit both her blood pressure and her OSA? A) Switching chlorthalidone to hydrochlorothiazide, 25 mg daily B) Switching carvedilol to an equivalent dosage of metoprolol tartrate (Lopressor) C) Switching losartan to an equivalent dosage of an ACE inhibitor D) Increasing the current dosage of losartan to 100 mg twice daily E) Adding a low dosage of spironolactone (Aldactone) to her current regimen

ANSWER: E Secondary forms of hypertension are common in patients with resistant hypertension, and sleep-disordered breathing is an important cause of resistant hypertension. Multiple studies have shown that excess aldosterone plays a key role in the association between the two. As rates of obesity and obstructive sleep apnea (OSA) have increased, the prevalence of resistant hypertension has also increased. It is estimated that almost 17%-22% of patients with resistant hypertension may have undiagnosed primary hyperaldosteronism. The increased expression of mineralocorticoid receptors in patients with a high BMI contributes to hyperaldosteronism, and blockage of these receptors with medications such as spironolactone has been shown to provide benefit in reducing the severity of OSA as well as hypertension in these patients. Substituting one thiazide for another does not have a beneficial effect in patients with resistant hypertension. Switching beta-blockers in this case is unlikely to have a significant impact on blood pressure and might have an adverse impact, as carvedilol has been shown to have more favorable effects on glycemic control and other components of metabolic syndrome relative to metoprolol tartrate in patients with diabetes. Increasing the angiotensin receptor blocker dosage or substituting an ACE inhibitor will not be as beneficial in controlling this patient's blood pressure.

A healthy 40-year-old male is concerned about his risk for myocardial infarction (MI) because his father had an MI at age 45. The patient is a nonsmoker and does not take any medications. He states that he plans to start a regular exercise program, and asks for your advice regarding the best dietary approach for him. His vital signs are normal, including his BMI. Which one of the following would be most likely to reduce this patient's cardiovascular risk? A) Intermittent fasting (fasting for up to 16 hours each day, or eating only one meal on certain days) B) A low-fat, low-cholesterol diet C) A low-carbohydrate diet (Atkins diet) D) A very-low-carbohydrate, high-fat diet (ketogenic diet) E) A Mediterranean diet

ANSWER: E The Mediterranean diet has moderate to strong evidence for reducing the incidence of cardiovascular disease and associated mortality, preventing type 2 diabetes, decreasing overall mortality, and treating obesity. Intermittent fasting has been shown to be effective in weight loss, although not clearly more effective than overall calorie restriction, but a decrease in cardiovascular risk has not been shown. Low-fat, low-cholesterol diets may lead to substituting foods with increased sugar and overall calories. A low-carbohydrate diet has been shown to have more beneficial effects on lipid profiles than a low-fat diet. Additionally, mono- and polyunsaturated fats are actually beneficial in cardiovascular health, so focusing on a low-fat diet may be counterproductive. Low-carbohydrate diets can be useful to promote weight loss and decrease the incidence of type 2 diabetes, but their impact on cardiovascular disease is less clear. It is recommended that less than 5%-10% of total calories should come from added sugars, but a diet very low in carbohydrates may excessively limit healthy carbohydrates such as those found in whole grains, fruits, and vegetables.

A 69-year-old male is found to have an infrarenal abdominal aortic aneurysm (AAA) on screening ultrasonography. Which one of the following is most important when determining the risk of his AAA rupturing? A) His age B) His sex C) His history of hypertension D) His history of smoking E) The diameter of his aneurysm

ANSWER: E The single most important determinant of the risk that an abdominal aortic aneurysm (AAA) will rupture is the diameter of the aneurysm. In men, aneurysm repair is recommended when the aneurysm reaches 5.5 cm in diameter. In women, whose aortas tend to be smaller, the recommended maximum diameter is 5.0 cm. Age, sex, a history of hypertension, and a history of smoking all increase the risk of developing an AAA, but do not increase the risk of rupture.

Which one of the following vaccines is CONTRAINDICATED during pregnancy? A) Hepatitis A B) Hepatitis B C) Rabies D) Tdap E) Varicella

ANSWER: E The varicella vaccine is a live virus vaccine that is contraindicated during pregnancy because of the potential for fetal infection. The indications for hepatitis A, hepatitis B, rabies, and Tdap vaccines are the same for pregnant patients and nonpregnant patients.

A 28-year-old female presents with a 2.5-cm pruritic, erythematous, oval macule on her left thigh. She was seen at an urgent care facility 2 days ago for a urinary tract infection (UTI) and was treated with sulfamethoxazole/trimethoprim (Bactrim). Her UTI symptoms have improved. She reports that she was called earlier this morning and told that her infection was caused by Escherichia coli. The patient reports a similar lesion in the same area about a year ago at the time of her last UTI. You explain this is most likely secondary to: A) an immunologic reaction to E. coli B) erythema multiforme C) nummular eczema D) the Shiga toxin sometimes produced by E. coli E) the sulfamethoxazole/trimethoprim used to treat the infection

ANSWER: E This is a typical history for a fixed drug eruption (FDE), which is an immunologic reaction that recurs upon re-exposure to the offending drug. It is most likely related to T-lymphocytes at the dermal-epidermal junction. Sulfonamides and anticonvulsants are the most frequently cited medications, but tetracycline and penicillins have also been reported to cause FDE. FDE is not caused by bacteria. Erythema multiforme does not present as an isolated, recurrent macule and generally has central clearing. Nummular eczema is a coin-shaped, very pruritic patch but does not fit this clinical scenario. Shiga toxin-producing Escherichia coli are rarely found in extra-intestinal sites.

A 17-year-old cross country runner sees you to discuss the results of pulmonary function tests to evaluate his episodic shortness of breath and chest tightness. He had previously been diagnosed with exercise-induced asthma and prescribed albuterol (Proventil, Ventolin), which provided minimal relief. You tell him that the pulmonary function tests revealed normal expiratory findings including normal FEV1 and FVC and a flattened inspiratory flow loop. The test most likely to confirm a diagnosis for this patient's shortness of breath is: A) a sleep study B) chest radiography C) chest CT D) esophagogastroduodenoscopy E) nasolaryngoscopy

ANSWER: E This patient has vocal cord dysfunction, sometimes called paradoxical vocal fold motion, a condition in which the vocal cords close during inspiration when they should be open. It is not entirely understood why this occurs but it is associated with other conditions including asthma, GERD, and anxiety disorders. It typically causes sudden, severe shortness of breath and often has a trigger such as exercise, gastroesophageal reflux, inhalation of an irritant, or stress. Symptoms may include chest or throat tightness, inspiratory stridor, and wheezing predominantly over the upper airway. In less severe situations the voice may be impacted, and patients sometimes also describe a chronic cough that occurs separately from more acute symptoms. Vocal cord dysfunction is confirmed by direct visualization of the vocal cords during inspiration via nasolaryngoscopy. Pulmonary function tests are often performed as part of the assessment for shortness of breath and, if performed while the patient is experiencing symptoms, will show a flattened inspiratory flow loop. Treatment is primarily focused on therapeutic breathing maneuvers and vocal cord relaxation techniques. A speech therapist may assist in instructing patients in these techniques. Associated conditions should also be treated to help prevent vocal cord dysfunction. A sleep study, chest radiography, chest CT, and esophagogastroduodenoscopy would not confirm a diagnosis of vocal cord dysfunction.

A 67-year-old male presents for follow-up of ongoing chest pain that he experiences when walking up hills. His medical history is significant for hypertension and coronary artery disease. Four months ago he had a positive exercise stress test and underwent coronary angiography, which showed diffuse atherosclerotic disease but no lesions suitable for percutaneous intervention. His current medications include aspirin, 81 mg; atorvastatin (Lipitor), 80 mg; and metoprolol succinate (Toprol-XL), 100 mg. His vital signs include a blood pressure of 120/66 mm Hg and a pulse rate of 68 beats/min. Recent laboratory studies are significant for an LDL-cholesterol level of 58 mg/dL, a triglyceride level of 120 mg/dL, and a troponin level of 0.05 ng/mL (N <0.04). The addition of which one of the following agents would decrease this patient's all-cause mortality risk? A) Clopidogrel (Plavix), 75 mg daily B) Colchicine (Colcrys), 0.6 mg daily C) Icosapent ethyl (Vascepa), 2 g twice daily D) Isosorbide mononitrate, 30 mg daily E) Rivaroxaban (Xarelto), 2.5 mg twice daily

ANSWER: E This patient presents with stable angina and documented coronary atherosclerosis. His slight troponin elevation is a marker of elevated risk. The addition of low-dose rivaroxaban to aspirin has been shown to decrease cardiac and all-cause mortality in patients with coronary artery disease (CAD) and may be offered to this patient (SOR A). Dual antiplatelet therapy with clopidogrel and aspirin is recommended for 1 year after stenting but is not recommended in patients with stable angina who do not have stents. Colchicine has been associated with decreased cardiac events in patients with CAD but may increase all-cause mortality. Icosapent ethyl has been shown to decrease cardiac events but not mortality in patients with hypertriglyceridemia >150 mg/dL. Isosorbide mononitrate may be indicated to improve angina symptoms but does not improve mortality risk.

The American Academy of Pediatrics recommends obtaining a blood pressure reading at well child checks beginning at what age?

The American Academy of Pediatrics recommends annual blood pressure screening at well child checks beginning at 3 years of age. This recommendation does not differ for children who have a strong family history of hypertension.

The diagnosis of type 2 diabetes can be confirmed by two hemoglobin A1c values at or above a threshold of ____ %

The diagnostic cutoff point for type 2 diabetes is a fasting plasma glucose level >126 mg/dL or a hemoglobin A1c >6.5%. The diagnosis requires confirmation by repeat testing or by obtaining both a fasting glucose level and hemoglobin A1c.