Aquifer FM Qs at end of case 1-40

*Case 36: Question 2* A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy? A. Heroin B. Alcohol C. Marijuana D. Cocaine E. Tobacco

A. Heroin Heroin is the correct choice. Opiate use during pregnancy may result in several different symptoms, including *CNS findings* (irritability, hyperactivity, *hypertonicity, incessant high-pitched cry, tremors*, seizures), *GI symptoms* (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation), and *respiratory findings* (including nasal stuffiness, sneezing, and yawning).

Case 28: Question 1* A 68-year-old male with GOLD Stage 3, Group D, COPD requiring 2L of oxygen at nighttime presents to clinic complaining of increasing lower extremity edema over the past few weeks. He also thinks his nighttime cough might be worse. His physical exam reveals distant breath sound with scattered rhonchi, a normal cardiac exam, and 2+ bilateral pitting edema in his legs up to his mid shins. What is the most likely mechanism of disease underlying his lower extremity edema? A. Decreased blood flow to the lower extremities due to thromboembolism B. Hepatomegaly from infiltration of the liver with granulomas C. Irregular heart rate due to atrial fibrillation D. Overexpansion of lower extremity veins due to incompetent venous valves E. Pulmonary hypertension causing right heart failure

Correct answer is E E. Pulmonary hypertension causing right heart failure Chronic hypoxia causes pulmonary vasoconstriction that increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention. Given this patient's history of advanced COPD, E is the most likely cause.

Case 26: Question 3* You are seeing a 55-year-old female patient for follow-up who you met two weeks ago at her physical exam. Her review of systems and physical exam were only significant for fatigue. Her blood work shows iron deficiency anemia. She is post-menopausal x 2 years with no significant past medical history or family history but a 10 pack per year smoking history. Prior to establishing with you she hadn't seen a doctor since she was 18 years old. Which of the following would be the most appropriate next step in diagnosis? A. Chest x-ray B. Colonoscopy C. Hemoglobin electrophoresis D. Pelvic ultrasound

The correct answer is B. B. Colonoscopy Colonoscopy is recommended at age 50 and blood loss in a non-menstruating female is commonly GI related.

*Case 30: Question 4* A 32-year-old female at 33 weeks and 5 days gestation (G2P1) presents to the clinic with headache and RUQ abdominal pain. Blood pressure is 172/121 mmHg on examination while seated. No visual changes noted. Edema is present in the hands, bilaterally. Urine dipstick demonstrated 4+ protein. FHT are 117. Which of the following is the most appropriate next step in the management of this patient? A. Twice-weekly non-stress testing B. Daily aspirin C. Expedited delivery of the premature fetus D. Lisinopril E. Strict bed rest until 37 weeks

The correct answer is C. C. Expedited delivery of the premature fetus Expedited delivery of the fetus is the best treatment for severe pre-eclampsia. (Note: severe pre-eclampsia is not necessarily an indication for a C-section, however.)

*Case 30: Question 1* A 21-year-old G1P0 female present to clinic as a new patient to establish prenatal care. Which statement represents something that would not be expected to be a benefit of group prenatal care for this patient? A. Decreases the likelihood of preterm delivery B. Increases physician contact C. Increases support network D. Shared education between patients E. Increases adherence to techniques for pain management during labor

The correct Answer is E. E. Increases adherence to techniques for pain management during labor Clear, health literate communication about options for pain management are a benefit of group prenatal care, not adherence to a particular pain management plan. Answer choices A, B, C and D are benefits of group prenatal care. Advantages of group prenatal visits: increase prenatal knowledge, labor preparedness, support network, shared education between patients, and patient satisfaction provide more time for prenatal education and anticipatory guidance improve provider efficiency preterm delivery less likely (more significant for African-American women) -preterm birth is the number one cause for neonatal death in African-American infants increased birth weight of preterm infants (a significant survival determinant) combat racial disparities used for a variety of medical conditions, including diabetes and chronic pain.

Case 28: Question 3* A 61-year-old male with a history significant for COPD presents to the emergency department for shortness of breath. Upon exam you see a thin male with perspiration on his forehead. He is having a difficult time answering questions because "he just can't catch his breath." You order an arterial blood gas on the patient. The results are pH 7.22 (7.34-7.44) PaCO2 81 mmHg (35-45 mmHg) PaO2 55 mmHg (75-100 mmHg) . What is the next best step in diagnosis or management? A. Administer Rocephin B. Begin noninvasive mechanical ventilation C. Immunize against influenza D. Provide nicotine replacement patches E. Repeat the test in two hours

The correct answer is B. Begin noninvasive mechanical ventilation This patient is in respiratory distress as evidenced by his dyspnea, physical exam, and ABG. He has a respiratory acidosis as his pH is low and he is retaining CO2. His PaO2 is also low. Initially you would want to improve his respiratory status with some type of mechanical ventilation such as nasal cannula, facemask, bipap, or even intubation if indicated by worsening of respiratory status such as decreasing oxygen saturation, confusion and drowsiness.

Case 28: Question 5* A 52-year-old female presents for her third visit this year for productive cough. She has a 34-pack year history but has weaned down to only five cigarettes per day since she began to notice a cough. With her smoking history, you are concerned about the possibility of COPD. Which of the following criteria is included in the GOLD classification for diagnosis of COPD? A. Brain natriuretic peptide >500 B. Post-bronchodilator FEV1/FVC ratio of < 70% of predicted C. Flattened diaphragm on lateral chest film D. Left ventricular function <40% E. Oxygen saturation level of < 89%

The correct answer is B. Post-bronchodilator FEV1/FVC ratio of < 70% of predicted Spirometry (pulmonary function tests) is the gold standard for diagnosing COPD. If the FEV1 to FVC ratio is less than 70% of predicted (or less than the 5th percentile), then the patient has COPD.

Case 28: Question 4* A 63-year-old male with a past medical history significant for hypertension, COPD, and long-term tobacco use is accompanied by his wife to a hospital follow-up clinic appointment. She is very concerned about her husband's recent hospitalization for a COPD exacerbation and asks what can be done to improve her husband's health. Which of the following holds the greatest long-term health benefit for this patient? A. Cessation of tobacco products B. Immunization against pneumococcus C. Prednisone taken daily D. Pulmonary rehabilitation program E. Tiotropium (Spiriva) inhaled daily

The correct answer is A. Cessation of tobacco products This is a key intervention in all patients with COPD who continue to smoke and can reduce the rate of FEV1 decline.

*Case 34 Internal Medicine 02: Question 1* A 58-year-old woman presents to the clinic complaining of chest pain over the past three months. She describes the pain as sharp and stabbing, in the mid-sternal region, lasting for one to two minutes, occurring a few times a day. The pain can come on at rest or with exertion and resolves on its own. It has not become worse since it began. There is no associated diaphoresis, shortness of breath, nausea, jaw pain, or pain with movement, eating, or laying supine. She has a 10-year history of obesity and hypertension for which she takes chlorthalidone. She was recently diagnosed with diabetes, but does not require medication for treatment. Physical examination shows her pulse is 86 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 135/85 mmHg. Her lungs are clear, heart sounds are normal, and there is no chest wall tenderness to palpation or abdominal tenderness. There is no peripheral edema. How would you best characterize her chest pain? A. Atypical angina B. Gastroesophageal reflux C. Musculoskeletal D. Stable angina E. Unstable angina

The correct answer is A A. Atypical angina This woman is experiencing atypical angina. She does not meet the criteria for angina which includes substernal chest discomfort with characteristic duration and features, is exertional in nature and relieved with rest or nitroglycerin. This is considered atypical angina because the pain does not follow the classic pattern of angina; however, it is still possible that the pain is cardiac in origin, especially since atypical features are more common in women and patients with diabetes. Gastroesophageal reflux typically occurs after meals or while laying flat and is often described as having a burning quality. Musculoskeletal pain is typically worse with certain movements and associated with chest wall tenderness. Stable angina would meet the criteria and follow a predictable pattern with exertion. Unstable angina is characterized by chest pain at rest or with progressively less exertion. Angina with worsening features or new within the past four to six weeks is also considered unstable.

Case 27: Question 2* A 16-year-old male patient presents with dull, aching pain in his left scrotum. He says that the dull aching pain is more prominent upon standing. Which of the following the most likely diagnosis? A. Varicocele B. Epididymitis C. Hydrocele D. Testicular torsion E. Anatomical variant

The correct answer is A. *Varicocele* is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum. Patients may be asymptomatic in some cases. As much as 15% of cases are seen in adolescents.

*Case 22: Question 1* Which of the following statement is true regarding TIAs when compared to infarction? A. A brief episode, lasting < 24 hour, of neurologic dysfunction caused by focal brain ischemia with no evidence of acute brain infarction B. A brief episode, lasting <48 hours, of neurologic dysfunction caused by focal brain ischemia with no evidence of brain infarction C. A neurologic episode lasting >24 hours of presumed vascular origin leading to a sudden onset of neurologic impairment D. A sudden onset of neurologic impairment lasting > 48 hours associated with sudden onset of facial weakness

The correct answer is A. A brief episode, lasting < 24 hour, of neurologic dysfunction caused by focal brain ischemia with no evidence of acute brain infarction Transient ischemic attacks are defined as episodes of neurologic dysfunction caused by focal brain or retinal ischemia with clinical symptoms lasting less than 24 hours and no evidence of acute infarction on imaging. Stroke is defined as sudden onset of focal (or global) of neurologic impairment with symptoms lasting more than 24 hours.

*Case 25: Question 3* A 72-year-old female presents to the clinic one year after having suffered a stroke that left her with some residual left sided weakness/paralysis. On exam, the left shoulder demonstrates a severe decrease in both active and passive ROM and significant pain. The patient has a history of hypertension, hyperlipidemia, and diabetes. What is the most likely diagnosis? A. Adhesive capsulitis B. Osteoarthritis C. Rotator cuff tear D. Biceps tendonitis E. Subacromial bursitis

The correct answer is A. A. Adhesive capsulitis Also known as frozen shoulder, is characterized by pain and stiffness in the shoulder joint. Symptoms usually appear gradually and the majority will resolve in 1-3 years. The risk of developing adhesive capsulitis increases with conditions that limit the mobility of the arm, such as recovery from injury, stroke or mastectomy and also in diabetics. Adhesive capsulitis demonstrates a decrease in both active and passive ROM. Loss of active and passive ROM is more likely due to joint disease, whereas loss of only active ROM is more likely due to muscle tissue pathology. While osteoarthritis can present with decrease in both passive and active ROM, it is less common in the shoulder than in the hip and knee and the history is classic for adhesive capsulitis.

*Case 22: Question 4* Which of the following therapies are recommended as first-line therapy for secondary prevention of noncardioembolic TIA or noncardioembolic stroke? A. Aspirin B. Coumadin C. Atorvastatin D. Recombinant tissue plasminogen activator (t-PA)

The correct answer is A. A. Aspirin For noncardioembolic (or atherthrombotic, lacunar) strokes, possible first-line therapies for secondary prevention include aspirin, aspirin in combination with extended-release dipyridamole (aggrenox), and plavix. For cardioembolic strokes, aspirin may potentially be desirable in patients with a contraindication for anticoagulation, but most people will need to be on coumadin for secondary prevention of stroke. Statins are used to help treat high cholesterol in patients who have had a stroke or have risk factors for stroke. T-PA is used in the acute management of a stroke and not as secondary prevention of noncardioembolic stoke.

*Case 22: Question 5* Why is it important to distinguish between cardioembolic etiologies of stroke versus atherothrombotic? A. Cardioembolic etiologies require treatment with oral anticoagulant therapy B. Distinguishing between these two etiologies is not particularly important because treatment for either is the same; anti-platelet C. Distinguishing between these two etiologies is not particularly important because treatment for either is the same; anticoagulant D. Atherothrombotic etiologies require treatment with oral anticoagulant therapy

The correct answer is A. A. Cardioembolic etiologies require treatment with oral anticoagulant therapy Finding the cause of a stroke is important because the source of the stroke can help determine the treatment. For patients with a cardioembolic cause, they should be placed on coumadin therapy. For patients with an atherothrombotic stroke, they need to be placed on an anti-platelet agent. Both of these treatment options are intended to reduce the risk of stroke

*Case 24: Question 3* Ms. Kovacs is a first time mother you are seeing on postpartum day two in the hospital, with her newborn son Christopher. Her pregnancy was uncomplicated and Christopher was born full-term via spontaneous vaginal delivery with no complications and a birth weight 7 lbs (3178 grams). Ms. Kovacs is getting ready to be discharged home today but is concerned because the baby now weighs 6.8 lbs (3087 grams) and she hasn't been able to produce milk every time Christopher wants to feed. Upon receiving your recommendations, she has been attempting to breastfeed with good technique every two to three hours with strong latching and vigorous suckling. Mom is still concerned her baby isn't getting enough to eat. Which of the following would be the most appropriate advice for mom? A. Continue to attempt breastfeeding B. Stop attempting to breastfeed and begin formula C. Switch from breast milk to formula for a few days to allow moms body to produce more milk, and then attempt breastfeeding again D. Remain in the hospital until Christopher is having full and consistent feeds with breast milk E. Request a lactation consultation to ensure the baby gains weight

The correct answer is A. A. Continue to attempt breastfeeding Given the history, the correct approach is for the mother to continue breastfeeding as it can take up to 72 hours after delivery for significant milk production to begin. It would be inappropriate to supplement with or switch to formula. There is no rationale for continued hospitalization as the baby is suckling well on a regular basis that will stimulate appropriate milk production in the mother. A lactation consultation is unnecessary as the baby's weight loss is normal (down only 3% since birth) and as the mother has appropriate technique and the baby is latching and suckling well.

*Case 24: Question 1* Ms. Jones is a first time mother who brings in her 5-day-old son Tommy for his first scheduled newborn visit. Upon reviewing Tommy's hospital records you note that mom's pregnancy was uncomplicated and that Tommy was born full term via spontaneous vaginal delivery and his birth weight was average for gestational age at 3000 grams. Per your discussion with mom, she has been breastfeeding successfully with good technique every two to three hours on demand since delivery. Tommy's physical exam is normal and largely unchanged from the hospital; he is at the 70th percentile for height and head circumference, but his weight has decreased to 2750 grams. Mom is very concerned by this weight loss and wants to know what she should do. You should recommend: A. Continuing breast feeding with same frequency and return to clinic in 5-7 days B. Hospitalizing Tommy until he shows adequate weight gain for his age C. Increasing the frequency of breast feeding until Tommy starts gaining weight D. Supplementing breast milk with 1-2 ounces of baby formula until Tommy starts

The correct answer is A. A. Continuing breast feeding with same frequency and return to clinic in 5-7 days It is normal for newborns to lose up to 10% of their birth weight in the first week. Their weight should be back to their birth weight by two weeks of age.

Case 26: Question 4* Ms. Wicket is a 30-year-old woman establishing with you as a new patient. Her past medical history is significant for hypothyroidism for which she has been without treatment for five years. She currently takes no medication and has no surgical or family history. She is single, with no children, drinks alcohol socially, and does not use tobacco or other recreational drugs. The only records she has are from blood work that she had done last month significant for a very elevated thyroid stimulating hormone (TSH). What constellation of symptoms would you expect to find on your review of systems? A. Dry skin, sensitivity to cold, constipation, and fatigue B. Palpitations, sweating,lightheadedness, and fatigue C. Anxiety, frequent bowel movements, sweating and increased appetite D. Tremor, hair changes, difficulty sleeping and irregular menses

The correct answer is A. A. Dry skin, sensitivity to cold, constipation, and fatigue Goiter and weight gain are also common symptoms. Answers B, C, and D would be more consistent with hyperthyroidism.

*Case 31: Question 2* A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral rales at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What is the most likely diagnosis? A. New onset heart failure B. Pneumonia C. Sleep apnea D. Anxiety

The correct answer is A. A. New onset heart failure The patient's description of the cough (worse at night, unable to lie flat, wakes from sleep), physical exam findings (obesity, rales in the lung bases, pitting edema), and history (started after a fish fry/BBQ) point to CHF as the most likely diagnosis. A lack of fever points away from pneumonia and a lack of description of snoring or pauses during sleep points away from sleep apnea. Anxiety would not cause the symptoms or physical exam findings described here.

*Case 32: Question 3* A 23-year-old female patient comes to your office complaining of bothersome symptoms the week before her period each month. She reports that she has significant breast tenderness, is very irritable, and eats significantly more than she does at any other time during the month. Her coworkers notice the difference in her mood and it is beginning to affect her interactions with them. The symptoms resolve after her period. She has no other medical problems or significant past medical history. Physical exam is normal. What is this patient's most likely diagnosis? A. Premenstrual syndrome B. Primary dysmenorrhea C. Premenstrual dysphoric disorder D. Secondary dysmenorrhea

The correct answer is A. A. Premenstrual syndrome Premenstrual syndrome occurs in the second half of a woman's cycle. It has physical symptoms like bloating, fatigue, and breast tenderness. The patient also may have behavioral symptoms like irritability, easy crying, and eating more than the rest of the month. There has to be an effect on the woman's life to count as premenstrual syndrome. Premenstrual dysphoric disorder is more severe and those criteria are listed in the DSM-IV for psychiatry. These symptoms have to significantly impair a woman's life. Primary dysmenorrhea is defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea implies painful menses secondary to some pelvic pathology, by definition. Neither of these situations is implicated as the etiology of this patient's problems.

*Case 24: Question 5* Mr. and Mrs. Thomas are first time parents who have brought their 5-day-old newborn son into your office for his first visit. Mom's pregnancy, baby birth, and today's physical exam are all normal. Both parents are sharing the duties of feeding, cleaning, holding, and watching their son without any problems. When Mrs. Thomas steps out of the room to use the restroom, Mr. Thomas asks to speak with you privately. He wants to know if you can prescribe some antidepressant medication for his wife because since giving birth she hasn't been the same. She has been having mood swings multiple times a day, he has found her crying in bed at night after putting their son in his crib, and she gets very irritated and yells at her parents any time they try to help with the baby. What would be the most appropriate advice to give Mr. Thomas? A. This behavior is very common and normal within the first two weeks postpartum and should resolve B. This behavior is very common and a mild antidepressant can help most women get through it C. The behavior is uncommon at five days postpartum and mental health counseling should be considered D. This behavior sounds dangerous and hospitalization is in order

The correct answer is A. A. This behavior is very common and normal within the first two weeks postpartum and should resolve Mood swings, crying spells, and irritability are common (~50%) in the first week after giving birth. Symptoms that persist after two weeks are more serious and may represent postpartum depression.

*Case 20: Question 5* A 23-year-old female comes to the clinic to discuss infertility. She states she was treated for an STD two years ago, and remembers receiving a Rocephin shot and taking a course of doxycycline. She admits to being hospitalized last year due to a severe infection with gonorrhea. She states that she and her fiance have attempted to have a baby for the past year, without success. She reports no dysmennorhea and has regular menses, but has pain during intercourse. Her last menstrual period was 4 weeks ago. Urine hCG is negative. Vital signs stable. Physical exam is unremarkable. The most likely cause of the patient's inability to conceive is: A. Pelvic inflammatory disease B. Uterine leiomyoma C. Endometriosis D. Candidiasis E. Ovarian cyst

The correct answer is A. Pelvic inflammatory disease The patient most likely was treated for pelvic inflammatory disease twice in the past. The most common cause of PID is Neisseria gonorrhoeae and/or Chlamydia trachomatis. It is treated with ceftriaxone and doxycycline to cover both bacteria. Pelvic inflammatory disease can cause infertility due to scarring of the fallopian tubes/ tubal adhesions.

Case 27: Question 3* Your 28-year-old male patient who presented with severe testicular pain has an exam consistent with a testicular torsion. Which of the following imaging studies is best for confirmation? A. X-ray B. Color Doppler US C. CT scan without contrast D. MRI E. Angiography

The correct answer is B. *Color Doppler* is the best imaging test among the choices above to evaluate for a possible testicular torsion. If a testicular torsion is present, intratesticular flow is either decreased or absent in comparison to a non-torsed testicle.

*Case 30: Question 5* A 28-year-old, G2P1 female delivers a 6lb 7oz baby boy at 39 weeks gestation. At one minute, baby has blue extremities and a pink body, his arms and legs are flexed. HR is 118 bpm and he is coughing and crying vigorously. What would his APGAR score be at one minute? A. 6 B. 8 C. 7 D. 9 E. 10

The correct answer is B. B. 8 The APGAR scoring is done at one minute and 5 minutes of life. It is a tool that helps to predict early infant mortality. The scoring criteria is shown here.

*Case 31: Question 4* Mr. Turner is a 60-year-old male with a past medical history of hypertension and diabetes who presents with fatigue. Upon further questioning, you realize that Mr. Turner does not have trouble falling asleep but has difficulty staying asleep because he often wakes up short of breath. He also notes that he has swelling in his ankles and feet. He denies having any chest pain or palpitations. On exam, you find that his heart has a regular rate and rhythm. You observe hepatojugular reflux and notice 2+ pitting edema in his legs bilaterally. A recent echocardiogram revealed an ejection fraction of 50 percent. What is the pathophysiology of his condition? A. Death of the myocardial cells due to lack of oxygen leading to dysfunction of the heart B. Decreased compliance of the ventricles leading to dysfunctional filling of the heart C. Decreased forward flow of blood from the heart due to dysfunction of the ventricles D. Dysfunction of the pacemaker cells of the atrium

The correct answer is B. B. Decreased compliance of the ventricles leading to dysfunctional filling of the heart In CHF, decreased compliance of the ventricles leads to increased filling pressures, which leads to congestion. Answer A is describing the pathophysiology of a myocardial infarction, which may lead to CHF, but is not always the cause. Answer C is describing a situation (perhaps an arrhythmia) in which ventricular dysfunction causes abnormal flow of blood from the heart. Answer D is also describing a situation that would lead to an arrhythmia.

*Case 31: Question 1* Which of the following is not a risk factor for CAD? A. Hypertension B. Female sex C. Smoking D. Diabetes

The correct answer is B. B. Female sex Hypertension, smoking, and diabetes (along with elevated lipid levels, obesity, and sedentary lifestyle) are modifiable risk factors for CAD. Non-modifiable risk factors include older age (men>45 and women >55), family history of CAD in a first-degree relative at a young age, and male sex.

*Case 30: Question 3* The NST tracing attached is most consistent with: A. Cord compression B. Head compression C. Uteroplacental insufficiency D. Fetal bradycardia E. Fetal tachycardia

The correct answer is B. B. Head compression The NST tracing shows early decelerations which indicate head compression. Early decelerations coincide with the beginning and end of a contraction. It is the characteristic "mirror image" of a contraction. Cord compression is indicated by variable decelerations which are a decrease in fetal heart rate that vary in timing, duration, and intensity. It often looks like the letter "V" and does not necessarily correspond to contractions.

*Case 32: Question 5* A 29-year-old female presents to your office complaining of very heavy periods. These started about six months ago. She reports that her periods were always normal until six months ago when she started passing a significant number of clots each day. Her periods occur in a regular pattern but usually last more than eight days. She reports having to change a super absorbent pad every two to three hours. On pelvic exam, the uterus is small, non-tender, and has uniform, smooth contour. On physical exam, you note a moderately enlarged thyroid and dry skin. What is her most likely diagnosis? A. Metrorrhagia B. Menorrhagia C. Uterine leiomyoma D. Cervical polyp

The correct answer is B. B. Menorrhagia Menorrhagia is a descriptive diagnosis that has at the core of its definition, an increased length (usually ≥ 7 days) and quantify of menses. Quantity of menses is very difficult to define precisely and is only one of the terms that can mean abnormal uterine bleeding. The absolute criterion for menorrhagia is blood loss of more than 80 milliliters. Some providers try to use pad or tampon count. However there is variability in the absorption of different pads and how much blood a woman has on the pad prior to changing. Asking about clots may help, but again not easy to quantify. In fact, many women either over- or under-estimate the blood loss. A uterine leiomyoma can present as menorrhagia, but when uterine fibraoids do present with menorrhagia, they are much more likely present with an enlarged uterus. Cervical polyps more commonly present with irregular bleeding, often after intercourse. Metrorrhagia is irregular bleeding.

*Case 32: Question 1* A 13-year-old female patient comes to your office for a physical. Her mother is concerned because she complains of menstrual cramps during her period each month. You determine that menarche was earlier that year and her periods have been mostly regular since that time. The pain is in her lower abdomen and is relieved with Ibuprofen and a heat pack. She has no other medical problems and her physical exam is normal. What best describes this patient's condition? A. Premenstrual dysphoric disorder B. Primary dysmenorrhea C. Premenstrual syndrome D. Secondary dysmenorrhea

The correct answer is B. B. Primary dysmenorrhea Primary dysmenorrhea is defined as the onset of painful menses without pelvic pathology, and is the most likely diagnosis in this case, given the normal history and physical. Secondary dysmenorrhea implies painful menses secondary to some pelvic pathology, by definition. Finally, this patient's symptoms are during menses, as opposed to during the other phases of the menstrual cycle.

*Case 25: Question 1* A 55-year-old female with exercise induced asthma, but no other chronic health problems, presents to the office with left shoulder pain. She is a tennis player, left handed and notices pain serving the ball. When you suggest that it might be her rotator cuff your preceptor asks, "what muscles make up the rotator cuff?" A. Supraspinatus, infraspinatus, teres major, subscapularis B. Supraspinatus, infraspinatus, teres minor, subscapularis C. Supraspinatus, infraspinatus, teres minor, deltoid D. Supraspinatus, infraspinatus, teres major, teres minor E. Supraspinatus, infraspinatus, teres minor, rhomboid minor

The correct answer is B. B. Supraspinatus, infraspinatus, teres minor, subscapularis The muscles that make up the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis muscles. The teres major, deltoid and rhomboid minor are not part of the rotator cuff.

*Case 25: Question 4* A 23-year-old epileptic male presents to the emergency department after a generalized tonic-clonic seizure. You notice that the patient is holding his right shoulder and that his arm is adducted and internally rotated. What is the best imaging modality for this type of injury? A. MRI B. X-ray C. Ultrasound D. CT scan E. PET scan

The correct answer is B. B. X-ray X-ray is the indicated imaging in the setting of acute injury and suspected fracture or dislocation. MRI is used to evaluate possible rotator cuff tears and other soft tissue etiology. Ultrasound can be used to evaluate soft tissue structures. It's desirable due to its low-cost and because it exposes the patient to no radiation. CT can be used in the setting of complicated fracture, suspected tumor, or when MRI is contraindicated. PET scans indicate functional activity of organs such as the brain, heart and lung and are mostly used in the oncologic setting.

*Case 26: Question 1* You are working in a free clinic for patients who are uninsured and mostly from a very low socioeconomic class. You're seeing a 45-year-old patient whose only complaint is intermittent headaches and a family history significant for a brother who recently died at the age of 47 due to colon cancer. The patient states that he is concerned about developing colon cancer like his brother and wants to know if he should be screened; however, he cannot afford a colonoscopy. Your county has a government-funded colonoscopy screening program for patients who are asymptomatic and 50 years old. For the time being, what testing could you recommend to your patient based on his means as a secondary screening method for colon cancer? A. Yearly abdominal x-rays B. Yearly fecal occult blood testing C. Yearly hemoglobin checks D. Yearly sigmoidoscopy

The correct answer is B. B. Yearly fecal occult blood testing While colonoscopy is still the recommended screening test for colon cancer and screening in first degree relatives is recommended to start 10 years before age of diagnosis and you will advocate for your patient to have this covered because of his family history, annual home based sensitive FOBT (fecal occult blood testing) has the same life years gained as colonoscopy every 10 years and is more affordable for those uninsured. Abdominal x-rays are not effective in screening for colon cancer. Yearly hemoglobin tests would identify if the patient is losing a significant amount of blood due to colorectal cancer, but anemia can be a later stage sign. Sigmoidoscopy is a reasonable alternative, but is recommended every 5 years in conjunction with FOBT.

Case 28: Question 2* A 67-year-old female with an 80 pack year smoking history presents to an urgent care for worsening shortness of breath. She also reports her chronic cough is more frequent and is producing greenish mucous throughout the day. She is using her inhaler every two hours and has been taking an antibiotic left over from a previous sinus infection. On exam there is a whistling noise when she exhales. What other treatment should you consider at this time? A. Digoxin B. Furosemide C. Prednisone D. Propranolol E. Theophylline

The correct answer is C Prednisone This patient meets the criteria for a COPD exacerbation as she has increased dyspnea, increased sputum volume and increased sputum purulence. Inhaled bronchodilators (albuterol) and oral glucocorticosteriods such as prednisone are effective treatments with or without an antibiotic. Digoxin is commonly used for patients with congestive heart failure or atrial fibrillation. Furosemide is a diuretic used for a number of things including volume overload. Propranolol is a beta-blocker used for hypertension and coronary artery disease. Theophylline is an oral methylxanthine that antagonizes adenosine receptors and increases cAMP. It can be used in asthma and COPD but would not be the initial choice of drug in this case.

*Case 20: Question 2* A 24-year-old female presents to the clinic complaining of a headache and arm pain. She is accompanied by her boyfriend, who insists on staying in the room with her during the visit. When asked to describe when she noticed the pain and how it occurred, the boyfriend states that the patient hit her head on the bathroom cabinet two days ago, and fell on her side afterwards, hitting her arm. The patient nods in agreement, while looking down at the floor. The next best step in obtaining an accurate history and physical exam is to: A. Direct all questions to the boyfriend, since it appears the patient does not want to discuss her situation with you B. Accuse the boyfriend of domestic abuse and call the police to report him C. Ask the boyfriend to leave the room so you can perform the physical exam, and explain that you always do that part of the exam with just the patient, and that he may join you after that part is completed D. Give the patient referrals to neurology and orthopedics to evaluate the patients headache and arm pain E. Prescribe Tylenol 650mg po BID to manage the pain, and tell the patient to return in a week if symptoms have not disappeared

The correct answer is C. Ask the boyfriend to leave the room so you can perform the physical exam, and explain that you always do that part of the exam with just the patient, and that he may join you after that part is completed When domestic violence is suspected and the partner is present for the visit, the best step in obtaining an accurate history and physical from the patient is to politely but firmly ask the partner to leave the room. To aid you in asking the partner to leave, it is suitable to tell them that the next part of the exam is done with the patient independently, and the partner may rejoin you and the patient after the exam is performed. ** If the partner still insists on staying, use other tactics, such as a test performed outside of the exam room or by taking the patient to get a urine sample.

Case 26: Question 2* You are seeing a 55-year-old established male patient of yours in the office for his yearly physical. He has a past medical history significant for hypertension and hyperlipidemia with no significant family history. He has no complaints and your review of systems and physical exam are all within normal limits. However, he would like you to write him an order for a PSA test because a friend of his recently passed away from prostate cancer. What would be the best response to this patient's request concerning checking PSA and prostate cancer? A. Many men are understandably concerned about prostate cancer. A negative test can be very reassuring. B. Studies have shown significant survival advantages to checking PSA levels in men with proper follow-up testing. C. I can see that you are concerned about having prostate cancer. PSA screening in asymptomatic men is not recommended, but I would be happy to discuss this with you. D. PSA is best used to track the progression of prostate cancer and getting a baseline now when you dont have symptoms can be advantageous.

The correct answer is C. The United States Preventative Services Task Force recommends against PSA screening. It is still recommended that you discuss their concerns and the risks and benefits of PSA testing with patients. A is wrong because while a negative test can be reassuring, the anxiety and testing caused by a positive test in most cases is worse and unnecessary. B is not the best choice because early detection does not result in improved outcomes. C is incorrect because while it is true that PSA is helpful in tracking progression of disease, getting a baseline is not felt to have significant benefit.

Case 27: Question 1* A 22-year-old male comes to the office for a physical before he graduates from college. He wants to know which cancer is most common in males in his age range. A. Pancreatic cancer B. Skin cancer C. Testicular cancer D. Gastric cancer E. Follicle cancer

The correct answer is C. The median age of diagnosis is 33 years of age.

*Case 23: Question 1* James is brought in by his mother and father today for a well-child visit. His mother had a normal term pregnancy and uncomplicated spontaneous vaginal delivery. Thus far James has been meeting all his developmental milestones. Today James can feed himself, pedal a tricycle, uses three-five word sentences, can be understood by strangers 75% of the time, can copy a square, and engages in fantasy play with his siblings. At what developmental age is James? A. 2 years B. 18 months C. 1 year D. 3 years E. 6 years

The correct answer is C. The milestones are consistent with a developmental age of 3 years.

*Case 20: Question 4* A 32-year-old female comes to the ER complaining of abdominal pain. She states the pain has been bothering her for the last week, and has progressively become worse. She denies nausea, vomiting, any episodes of diarrhea, or chest pain. She states she was diagnosed with high blood pressure six months ago, and is currently taking medication for it. She is sexually active with her boyfriend, and admits to having some pain during sex. She states she does not feel comfortable telling her boyfriend that she does not want to have sex. Her last menstrual period was two weeks ago. She denies a history of sexually transmitted infections, but says that she has not questioned her significant other because "he would be upset." Vital signs reveal a temperature of 98.7, blood pressure of 142/90 mmHg, heart rate of 82, and respirations of 18. The patient is visibly uncomfortable during the physical exam, which shows a few bruises on her abdomen and lower back, which are at different stages of healing. Which of the following is an appropriate technique for screening for domestic violence? A. Request an appointment with the patients significant other, and asking him about abusing the patient B. Ask if she had ever been sexually abused as a child C. Ask the patient, "all couples disagree at some point in time. What happens when you and your partner argue or disagree?" D. Stand above the the patient while asking them questions E. Avoid direct questions about guns in the house or about drug/alcohol use by them or their partner

The correct answer is C. Ask the patient, "all couples disagree at some point in time. What happens when you and your partner argue or disagree?" To screen for domestic violence in a patient should involve asking indirect questions that include the opportunity to directly assess the safety of the the patient and their environment.

*Case 33: Question 3* You are seeing a 60-year-old man brought into your office because of "dizzy spells where he almost passes out" for a week. Your records indicate a history of back pain and diabetes. Upon further questioning, he says he sometimes feels like he's going to pass out and gets short of breath after walking about half a block. He's never felt this way before. He denies having a spinning sensation when he is dizzy. His back has also been really bothering him for the past several weeks so he has been taking ibuprofen "all the time." His temperature is 98.6 Fahrenheit; blood pressure is 105/65 mmHg; heart rate is 100 beats/minute; and respiratory rate is 18 breaths/minute. On physical exam, you note no nystagmus, but he does have conjunctival pallor. His lungs are clear to auscultation, and his cardiac exam reveals mild tachycardia with a regular rate and no murmurs. His abdomen is mildly tender and non-distended. As you think through your differential diagnosis and tests to order, which of the following best describes the likely etiology of his symptoms? A. Myocardial infarction B. Thyroid storm C. Anemia D. Acute labrynthitis E. Aortic stenosis

The correct answer is C. C. Anemia This patient is likely bleeding from his stomach from taking too many NSAIDs for his back pain resulting in a gastritis or ulcer. The resulting blood loss and anemia leads to decreased preload and episodes of presyncope when his cardiac output is unable to keep pace with the increase in metabolic needs. As a result, his brain is inadequately perfused. Though his age and diabetes put him at risk for a myocardial infarction, it is unlikely to present in such a subacute way and his physical exam findings do not point in that direction. Choices B, D and E would likely be present with different physical exam findings. *Thyroid storm*, a life-threatening condition in someone with hyperthyroidism, typically presents with elevated blood pressure, tachycardia and fever. Conjunctival pallor would not be expected in this condition. *Acute labrynthitis* is a cause of peripheral vertigo. Patients typically report acute disequilibrium with a prominent sensation of the room spinning (vertigo), exacerbated by head movement. Nystagmus with eye movement that improves with fixed gaze is typical for a peripheral source of vertigo such as this. *Aortic stenosis* can be appreciated on physical exam as a systolic ejection murmur, which this patient does not have.

*Case 32: Question 2* A 13-year-old female patient comes to your office for a physical. Her mother is concerned because she complains of menstrual cramps during her period each month. You determine that menarche was earlier that year and her periods have been mostly regular since that time. The pain is in her lower abdomen and is relieved with Ibuprofen and a heat pack. She has no other medical problems and her physical exam is normal. What is the most appropriate treatment for this patient? A. Start OCPs B. Start an SSRI C. Continue Ibuprofen and heat packs, return if worsening D. Start Danazol

The correct answer is C. C. Continue Ibuprofen and heat packs, return if worsening Primary dysmenorrhea is associated with increasing amounts of prostaglandins. Therefore, NSAIDs are often the first line of treatment, rather than the other therapies mentioned, of which OCPs would be the most common first/second-line treatment in the appropriate candidate. SSRIs may help with comorbidities, but is not a primary treatment for primary dysmenorrhea. Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. It is primarily used for conditions like endometriosis or premenstrual syndrome, which this patient doesn't have, and its multiple androgenic side effects, including weight gain, suppressing high-density lipids, and hirsutism, limit its desirability among patients.

*Case 32: Question 4* A 23-year-old female patient comes to your office complaining of bothersome symptoms the week before her period each month. She reports that she has significant breast tenderness, is very irritable, and eats significantly more than she does at any other time during the month. Her coworkers notice the difference in her mood and it is beginning to affect her interactions with them. The symptoms resolve after her period. She has no other medical problems or significant past medical history. Physical exam is normal. What is the most effective treatment for this patient's condition? A. Danazol B. OCPs C. Continuous SSRI treatment D. Regular exercise

The correct answer is C. C. Continuous SSRI treatment Selective serotonin reuptake inhibitors during menses are an effective treatment of premenstrual syndrome, especially if severe or mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as daily treatment for decreasing both psychologic and physical symptoms. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a woman has symptoms and continue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine can be used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior to considering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost.

*Case 30: Question 2* A 24-year-old G1P0 female at 38 weeks gestation presents to ED complaining of strong lower abdominal contractions that are 10 minutes apart for the last hour. Subsequent cervical examination demonstrates that she is 2cm dilated. FHT are 140 and NST is non-reactive with early decelerations. What is the most appropriate management of this patient? A. Augment labor with Pitocin B. C-section C. Expectant management D. Immediate vacuum delivery E. Rupture membranes to increase labor

The correct answer is C. C. Expectant management Expectant management is the most appropriate management at this time. ** Patient is currently not in active labor. Active labor is defined as cervical dilation > 6 cm in the presence of contractions. Contractions are normally 3-5 minutes apart. Fetus is not in distress at this time. Early decelerations are indicative of head compression and are not especially concerning. It is not generally advised to induce patients prior to 39 weeks if there are no complications and fetus is not in distress. C-section would not be indicated in this case because neither mother and baby are stable and not in distress. Immediate vacuum delivery is not indicated in this case. Vacuum delivery is indicated only during the second stage of labor, which is the beginning of pushing to the delivery of the baby.

*Case 21: Question 1* A 13-year-old girl comes to your clinic stating she has been having fever and chills for three days, and aching muscles for the last two days. She states she has also had a mild cough, but is not having any difficulty with breathing. She is up to date on vaccines and her only other medical history is having her tonsils and adenoids removed last year. On physical exam, you find her temperature to be 102.6 degrees F, pulse 96, and her BP to be 108/62 mmHg. She has clear rhinorrhea and her oropharynx is mildly erythematous. The rest of her physical exam is normal, and a rapid strep test in the office is negative. What is the next best step in management? A. Zanamavir B. Aspirin C. Ibuprofen D. Amantadine E. Albuterol

The correct answer is C. C. Ibuprofen While this patient's presentation is strongly suspicious for Influenza infection, antivirals such as zanamivir, oseltamivir, amantadine, and rimantadine only decrease the duration of the infection by 24 hours, and are generally not efficacious outside of 48 hours from the beginning of symptoms. Since this patient is presenting outside of the 48-hour window, she should be treated supportively with rest, hydration, and ibuprofen or Tylenol for pain/fever.

*Case 22: Question 3* When evaluating a person with a possible stroke, when is it acceptable to administer t-PA? A. If onset of neurologic symptoms was <6 hrs prior to presentation B. if emergent CT head shows a hemorrhagic stroke C. If onset of neurologic symptoms was <3 hours prior to presentation D. If emergent CT head shows early infarction

The correct answer is C. C. If onset of neurologic symptoms was <3 hours prior to presentation When assessing a patient who presents acutely with symptoms suggestive of a stroke, one possible treatment option is using recombinant tissue plasminogen activator. When used in the appropriate patient, this medication can help minimize the damage done related to suffering an acute ischemic injury to the brain. However, it is only acceptable to administer t-PA in select situations. These include when onset of neurologic symptoms has been within three hours of the onset of symptoms, emergent CT head does not show an intracranial bleed, an early acute infarct, or a brain mass.

*Case 21: Question 5* A 9-year-old boy who moved to the United States from Canada one year ago presents to your clinic with a three day history of fever, sore throat, and muscle aches. He lives at home with his parents who practice strict vegetarianism, and he does not eat meat of any kind. He is up to date on all vaccinations, and review of his medical records indicates that he has had several episodes of otitis media in the last five years. He was hospitalized twice in the past, once for a splenic rupture sustained in a MVA, and the second time was two months ago when he was diagnosed with Kawasaki's disease for which he was put on daily aspirin. You suspect a viral infection and order the appropriate tests. Which of the following is the greatest risk factor for complications of your suspected diagnosis in this patient? A. Recent immigrant B. Splenectomy C. Long-term aspirin therapy D. Age < 10 E. Decreased Vitamin B-12

The correct answer is C. C. Long-term aspirin therapy Risk factors for complications of Influenza are children < 5 years, increased in children less than 2 years of age, COPD, conditions that affect the ability to handle respiratory secretions/increased risk of aspiration, CHD, metabolic conditions, Chronic Renal Disease, Immunosuppression, and Long term aspirin therapy. A splenectomy increases his risk of infection by encapsulated bacteria (strep, h. flu etc.), but in this case he probably has influenza so it is not a risk to him now.

*Case 33: Question 2* You are seeing a 54-year-old female with a past medical history of kidney stones who presents with a chief complaint of "I have a terrible summer cold." She reports three days of low grade fevers (peak of 100.0 Fahrenheit), cough, sore throat, headaches, and nasal congestion. She denies myalgias. Her temperature today is 99.2 Fahrenheit, respirations 14/minute, pulse 78 beats/minute, and blood pressure of 128/74 mmHg. Her head and neck exam reveals normal tympanic membranes, mildly congested nasal turbinates with thin mucous, erythema of the tonsillar pillars and soft palate without tonsillar enlargement or exudate, and mild anterior cervical lymphadenopathy. Her lungs are clear to auscultation. Which of the following options would be the most appropriate therapeutic option for this patient? A. Vitamin C supplementation B. Oseltamivir (Tamiflu) 75 mg twice daily for five days C. Pseudoephedrine (Sudafed) as needed for nasal congestion D. Zinc supplementation E. Echinacea supplementation

The correct answer is C. C. Pseudoephedrine (Sudafed) as needed for nasal congestion This patient has the symptoms and physical exam consistent with the acute infectious rhinosinusitis (ie. the common cold). Treatments that have been demonstrated to help symptoms of the common cold include decongestants such as pseudoephedrine, nasal ipratropium spray, and (with weaker evidence supporting it) vitamin C. Vitamin C would be inappropriate in this patient because it can cause kidney stones, which she has had in the past. Zinc and echinacea have not been demonstrated to consistently improve symptoms of the common cold. Oseltamivir is a treatment for influenza, which typically has outbreaks in the winter and typically causes higher fevers and prominent myalgias.

*Case 25: Question 5* A 41 year old male presents to clinic with left shoulder pain after a fall where he caught himself with his left arm. To assess the injury the patient's arms were placed in thirty degrees of horizontal adduction and shoulders were abducted to ninety degrees. The patient attempted to resist downward pressure and was unable. This test assesses the integrity of the: A. infraspinatus muscle B. Teres minor muscle C. Supraspinatus muscle D. Biceps tendon E. Deltoid muscle

The correct answer is C. C. Supraspinatus muscle The Empty Can Test assesses for pathology of the supraspinatus muscle. For the Empty Can Test, the patient's arms are placed in approximately 30-degrees of horizontal adduction with the shoulders abducted to 90-degrees. The patient attempts to resist downward overpressure applied by the person performing the test. If the patient cannot resist the pressure, that is a positive result and can indicate pathology of the supraspinatus muscle.

*Case 33: Question 4* You are seeing is a 35-year-old female with no past medical history who presents with dizziness for the past week. She says these episodes of dizziness in which the room feels as though it is spinning last for a minute or two at most but she cannot seem to identify what is causing them. She denies any change in diet, headaches or recent illness. Her father passed away from a stroke at the age of 60 but she denies any other significant family medical history. Her vital signs are all normal, as is her head and neck exam. Her lungs are clear to auscultation bilaterally, and her cardiac exam reveals a regular rate and rhythm with no murmurs. You are unable to elicit saccades with a head thrust maneuver. You perform a Dix-Hallpike maneuver, which elicits her symptoms and causes rotary nystagmus when she looks to the right. What is the most appropriate next step? A. Emergency CT scan B. Emergency MRI scan C. EKG D. Cardiac enzymes E. Epley maneuver

The correct answer is E. E. Epley maneuver This patient likely has benign paroxysmal positional vertigo (BPPV) caused by calcium carbonate debris in the semicircular canals. BPPV is the most common cause of vertigo. Her presentation is classic: episodic vertigo triggered by position changes lasting seconds or minutes. Patients may not always be able to identify triggers unless specifically questioned. Despite a negative head thrust, which would suggest a central lesion in the vestibular system, the Dix-Hallpike maneuver is diagnostic for BPPV. While always good to consider in your differential given the severity of a cerebrovascular event, Head CT or MRI to evaluate for central lesions is not indicated in a young patient with no other risk factors. While dizziness may be related to cardiac causes, she clearly describes symptoms of vertigo. Hence, an EKG and cardiac enzymes are also unnecessary. Therefore, the Epley maneuver used to reposition the canalith in the vestibular canals would treat her BPPV.

*Case 23: Question 3* Samantha and Joe bring in their newly adopted 5-year-old son, Matthew to your office with the chief complaint of sore throat. He was born in the United States and was neglected by his biological parents. Samantha and Joe believe Matthew lived in an old building and ate mostly non-nutritious meals. They are unsure if his immunizations are up to date. His immunization record is attached. Upon physical exam his T= 101, HR=80, RR=19, BP= 95/63. He has anterior cervical lymphadenopathy, tonsillar exudates and palatal petechiae. What is the most appropriate next step in the management of this patient? A. give immunizations at todays visit and vitamins B. give immunizations at todays visit and screen for anemia C. give immunizations at well child visit and screen for lead toxicity D. do not give any vaccines until he starts school E. give immunizations at today's visit and screen for child abuse.

The correct answer is C. C. give immunizations at well child visit and screen for lead toxicity Immunizations that are due (or overdue) should be given unless there is a contraindication. Having an minor acute illness with or without a fever is not a contraindication. As the history includes having lived in an old building with potential exposure to lead, screening for lead toxicity is appropriate. There is no indication there is ongoing child abuse by the adoptive parents.

*Case 23: Question 2* Timmy, a five-year-old boy with a past medical history of eczema is brought to your office today for a well-child visit. His caregiver reports no concerns since his last visit and that he is adjusting well to kindergarten. You instruct Timmy to look straight ahead at the clock on the wall and you then cover his left eye. You notice that his right eye moves inward upon this request. When you cover his right eye, you notice that his left eye remains in a forward position. Which of the following is the most likely diagnosis? A. myopia of the left eye B. playfulness during physical exam C. strabismus of the right eye D. myopia of the right eye E. strabismus of the left eye

The correct answer is C. C. strabismus of the right eye The right eye moving inward as the L eye is covered indicates that the L eye is aligned and focused on the clock until it is covered. Once covered, the clock can only be seen by bringing the R eye into direct (normal) alignment. Myopia or near-sightedness of either eye is not associated with alignment problems.

*Case 20: Question 1* A 34-year-old male comes to the clinic complaining of abdominal pain. He says the pain has been bothering him for the past two weeks. He reports episodes of diarrhea and constipation, with more episodes of constipation. He states he has noticed an increase in flatulence. He denies any nausea or vomiting. He has noticed mucus in his stools, but no blood. He states that he cannot recall if anything aggravates the pain, but admits to being under more stress than usual, due to his mother-in-law moving in with him and his wife. Vital signs show a blood pressure of 124/76 mmHg, pulse of 74, respirations of 16, a temperature of 97.9, and oxygen saturation of 98% on room air. Physical exam is unremarkable. The most appropriate initial step in management is: A. Scheduling the patient for a colonoscopy to look for colon cancer B. Discussing the patients diet, and educating him about avoiding dairy products C. Performing a CBC, TSH, complete metabolic panel, and stool studies D. Prescribing an antispasmodic E. Scheduling the patient for a CT scan of the abdomen to rule out small bowel obstruction

The correct answer is C. Performing a CBC, TSH, complete metabolic panel, and stool studies The patient most likely has a diagnosis of irritable bowel syndrome. When a patient presents with abdominal pain, mucus in stool, episodes of diarrhea and/or constipation, it is appropriate to perform lab studies to rule out other etiologies, such as infection, autoimmune disease, or an obstruction. Since IBS is a diagnosis of exclusion, the diagnosis can be made once other sources of abdominal pain have been ruled out by appropriate studies.

Case 27: Question 5* A 21-year-old female comes into your family medicine office complaining of an abnormal discharge with a foul odor. She has been sexually active with four to five partners over the past year, uses condoms inconsistently. Which of the following can be seen on a wet prep? A. Chlamydia B. Gonorrhea C. Syphilis D. Trichomonas E. Herpes

The correct answer is D. * Trichomonas* While WBC's may be evident on the wet prep in chlamydia and gonorrhea, for diagnosis these require nucleic acid amplification tests done on urine, endocervical or urethral samples to be detected. RPR and FTS-ABS are the ways to detect syphilis. Herpes is usually diagnosed clinically or through a PCR blood test; herpes is not visible on a wet prep.

Case 27: Question 4* Your 28-year-old male patient with testicular pain has been experiencing pain at a level of 8/10 x 2 hours. Within how many hours should surgery be performed on a patient with a diagnosed testicular torsion? A. 24 hours B. 12 hours C. 8 hours D. 6 hours E. 4 hours

The correct answer is D. 6 hours In order to increase the chances of saving the testis in a testicular torsion, one must seek medical attention and have the testicle detorsed within 6 hours of onset of pain. If the individual waits longer than 6 hours, he increases his chances of losing the testicle and/or impaired fertility.

*Case 25: Question 2* A 17-year-old male football player presents to the emergency department with acute onset of rightshoulder pain. The pain started approximately two hours ago when he was tackled during a game while carrying the football. Shoulder swelling and pain were present after injury. He is holding ice to a swollen shoulder, and on exam you notice severe bruising, pain on palpation over the lateral edge of the shoulder and raised bump over that same area. There is also severe tenderness over the coracoclavicular ligaments. What is most likely diagnosis? A. Rotator cuff tear B. Subacromial impingement C. Subacromial bursitis D. AC joint sprain E. Rotator cuff tendonitis

The correct answer is D. D. AC joint sprain AC joint sprain presents with swelling, bruising and point tenderness of the AC joint after a fall directly on the acromion with arm adducted. AC joint injuries are classified Type I- Type VI depending on the number of ligaments involved. Type I injuries involve injury of AC ligaments with no injury to the coracoclavicular (CC) ligaments. This causes a tender AC joint that often has mild swelling. This type usually heals within a few weeks.Type II injuries involve a complete tear of the AC ligaments and a sprain or partial tear of the coracoclavicular (CC) ligaments. This causes a tender AC joint, often with significant swelling.Type III injuries involve a complete tear of both the AC and CC ligaments. Significant swelling and tenderness of CC ligaments is present along with visible abnormality of the AC joint. Type III injuries can take several weeks to months to heal.Type IV, V, VI injuries are the most severe. Treatment often requires surgery. With rotator cuff tears, there is limited ROM with significant pain. In a complete tear, the patient will not be able to raise their arm above the head. In patients with subacromial impingement or subacromial bursitis, there will be pain with overhead ROM and patients will have positive Neer and Hawkins-Kennedy tests. Patients with Rotator cuff tendonitis, when mild, will have preserved ROM and minimal pain but can have a positive Apley's scratch tests.

*Case 31: Question 3* A 56-year-old male presents for care at the ED complaining of dry cough for the past three days. He notes that this problem started a few days after his family's annual fish fry and barbecue and has been worsening since. He has no known past medical history but mentions that he has not seen a doctor in years. He notes that the cough is worse at night often waking him from sleep. He is unable to lie flat on his back and has started using three to four pillows to sleep comfortably. He also reports increased swelling in his legs that worsens throughout the day. He denies having any chest pain or palpitations and also does not believe he has had any sick contacts. He does not know his family history since he was adopted as a child. He has not had any fevers, sweats, or chills. On exam, you observe a tachypneic, obese man in mild distress. On chest auscultation, he has an S3, bilateral rales at the lung bases, and 2+ pitting edema in the lower legs bilaterally. What diagnostic test would you perform first? A. Exercise stress test B. Pharmacologic stress test C. Echocardiogram D. EKG

The correct answer is D. D. EKG An EKG can quickly help determine whether the patient is in sinus rhythm, whether there is ischemia or infarction, or whether there is Left Ventricular Hypertrophy. These findings may help you determine the etiology of this patient's CHF. Other tests (especially an echocardiogram) may be indicated at some point during the patient's work-up, but may not be appropriate first tests to order. Specifically, cardiac stress testing is more useful in ascertaining the diagnosis and prognosis of coronary artery disease than in congestive heart failure, although they are often a concurrent part of an extensive workup.

*Case 22: Question 2* In the secondary prevention of ischemic stroke, when using Aspirin alone as anti-platelet therapy, which of the following doses is recommended; and on what basis? A. Higher dose; more anti-platelet activity B. Lower dose; less bleeding risk C. Either high or low dose aspirin; they confer equivalent benefit and similar risk D. Low dose aspirin; confers equivalent benefit to high dose, and less bleeding risk

The correct answer is D. D. Low dose aspirin; confers equivalent benefit to high dose, and less bleeding risk Although in the past it was believed that patients on a 325 mg dose of aspirin compared to those on an 81 mg dose where conferred more protection from ischemic stroke, studies now show that increasing the dose of aspirin, while increasing the risk of hemorrhage, does not confer more benefit than the 81 mg dose. For that reason, the 81 mg dose of aspirin, is sufficient to help prevent a stroke in a patient with a TIA or other risk factors for stroke.

*Case 31: Question 5* Mr. Jones is a 63-year-old male with no significant past medical history who presents with increased swelling in his legs and shortness of breath. He reports that he has smoked two packs per day for the past 20 years. He does not exercise regularly and notes that he has always been overweight. Mr. Jones notes that his maternal uncle died of a heart attack at age 43. He denies having any chest pain or palpitations and his exam is notable only for 2+ pitting edema in the lower extremities. His most recent labs show HDL of 50, LDL 101, and a blood glucose of 112. Which of the following risk factors has most likely contributed to Mr. Jones' problem? A. Diabetes B. Elevated HDL C. Heart attack in uncle D. Male sex

The correct answer is D. D. Male sex With a blood glucose of 112, he is in the pre-diabetic range, but does not have a formal diagnosis of diabetes. His HDL is on the high side, but this is a protective factor. His uncle, though he did have a heart attack at a young age, is not a first-degree relative.

*Case 24: Question 2* Ms. Smith is a first time mother who brings in her 3-day-old Caucasian daughter Michelle for her scheduled newborn visit. Upon reviewing Michelle's hospital records you note that mom's pregnancy was uncomplicated and that Michelle was born full-term via spontaneous vaginal delivery with no complications and her birth weight was average for gestational age. Per your discussion with mom, she initially tried breastfeeding immediately postpartum but has since been feeding Michelle an adequate amount of regular baby formula with good technique. On today's exam she is at the 80th percentile for height, weight, and head circumference. Her physical exam is largely unchanged from the hospital except for prominent bilateral scleral icterus and a hint of yellow skin to the head and upper chest with no change in skin over the abdomen or distal extremities. The baby is active and suckles well. What is the most likely diagnosis based upon the presentation and course of Michelle's jaundice? A. Breast milk jaundice B. Gilberts disease C. Crigler-Najjar Syndrome (Type I) D. Physiologic Jaundice of the Newborn E. Biliary tract atresia

The correct answer is D. D. Physiologic Jaundice of the Newborn Physiologic jaundice is very common and is consistent with its appearance at 3 days postpartum. It likely will need no treatment unless the baby's jaundice becomes much deeper and extensive (involving the whole body). As the baby is not breast feeding, breast feeding is not causal. Crigler-Najjar is a rare enzymatic disorder of the liver that can present with severe features during the newborn period. Gilbert is a mild genetic disorder that is often overlooked until adolescence. Biliary tract atresia is also less common and generally presents with acholic stools over the first few weeks of life.

*Case 21: Question 2* It is November and you are working in a small, rural, emergency department serving a community who is currently going through a flu epidemic. Your next patient is a 4-year-old boy who was brought in by his mother for a sore throat and fever that started two nights ago. She says he has a mild cough, and is complaining of headaches as well. Since last night, he has had a decreased appetite and hasn't been his normal, active self. She also wants you to know that he is allergic to eggs and latex, and uses an inhaler once a month for asthma like symptoms. On physical exam you note an erythematous throat, clear rhinorrhea, and rhonchi on auscultation. A rapid strep test was performed in the office and is negative. His last well child check was 14 months ago, and his mother says she knows he is due for another but her schedule has been too busy. What is the next best step in management? A. Flu Shot B. Amoxicillin therapy C. FluMist (influenza vaccine, live intranasal) D. Tamiflu (oseltamivir phosphate) E. Influenza test.

The correct answer is D. D. Tamiflu (oseltamivir phosphate) Tamiflu can be prescribed in patients who show signs of flu like symptoms without further testing in communities with known flu outbreaks. Tamiflu can reduce symptoms of the flu, and is recommended only in patients who are still within a 48 hour window since symptoms began.

*Case 24: Question 4* You are on call over the weekend for the pediatric clinic and a concerned mother calls in. She has three children at home, her youngest being 5-weeks-old. She's very busy and about to leave town on Monday to visit relatives out of state. She tells you that for the last week her two oldest children have had a cough, runny nose, and one or two fevers as high as 101.2 F, but these symptoms have improved in both children with Tylenol. Her youngest child is now having the same symptoms and has a temperature of 100.5 F. Because they're about to go out of town, mom wants to know if you can call in something stronger like an antibiotic so her youngest can feel better sooner. What do you recommend mom should do for her youngest child: A. Call in a prescription for amoxicillin as this will cover the likely causative organisms for this infection B. Continue to use Tylenol as needed for fevers and supportive care C. Educate mom that this is likely a viral infection and it will have to run its course D. Urge mom to bring her child to the nearest Emergency Department

The correct answer is D. D. Urge mom to bring her child to the nearest Emergency Department While the baby may well have the same viral URI given the likely exposure to her older siblings with similar symptoms, a 5-week-old with a fever should be evaluated for possible sepsis. It would be inappropriate to reassure the mother that the cause is a virus with only symptomatic care and Tylenol or treat with antibiotics empirically before a full evaluation.

Case 26: Question 5* You are seeing a 42-year-old established female patient of yours in the office for her yearly physical. She has a past medical history of hypertension only, with no significant family history. She is a tenured professor at the local university. She has no complaints and your review of systems and physical exam are all within normal limits. However, she would like you to write her an order for a colonoscopy because a friend of hers was just diagnosed with colon cancer and passed away. You explain that based on USPSTF recommendation she doesn't need to start colon cancer screening until she is 50 years old. What would not be an appropriate statement to help support these guidelines and educate your patient? A. All colonoscopy procedures have risks that we try to minimize by screening only when necessary. B. Early screening is usually only recommended in patients with a first-degree relative or personal history of colon cancer. C. Most cancerous colonic polyps don't start growing until patients are about 50 years old and usually take about 10 years to mature. D. While a screening colonoscopy is not indicated here, a sigmoidoscopy is recommended.

The correct answer is D. D. While a screening colonoscopy is not indicated here, a sigmoidoscopy is recommended. In asymptomatic patients with a negative family history, no colon cancer screening is recommended before the age of 50.

*Case 23: Question 5* 12-year-old Jennifer is brought to the emergency room by her mother with a fever of 104.1 and difficulty breathing. She was seen by her family medicine doctor this morning who advised them to report to the emergency room immediately. Jennifer also has dysphagia and neck pain. Physical exam shows T=104.0, HR=85, RR=15, BP: 110/70. She speaks in a muffled voice and appears in severe distress. She has asymmetric tonsillar enlargement and deviation of the uvula to the right side. Laboratory studies: WBC: 14, Hgb: 12. Which of the following is the most likely diagnosis? A. viral pharyngitis B. group A B-hemolytic streptococcal pharyngitis C. croup D. peri-tonsillar abscess E. epiglottis

The correct answer is D. D. peri-tonsillar abscess The presentation is consistent with peri-tonsillar abscess with asymmetric tonsillar enlargement and uvular deviation, fever and difficulty breathing (likely related to tonsillar enlargement.

*Case 20: Question 3* A 22-year-old female comes to the clinic complaining of frequent urination. She states she has noticed some increased frequency for the past week. She denies itching or pain in the vaginal area, but reports a burning sensation during urination that began a week ago. When asked if she has noticed blood in her urine, she admits to not paying attention to its color. She states that she has some abdominal pain in her pelvic area. She admits to being inconsistent with her birth control pills, and states she is sexually active. She does not recall the date of her last menstrual period. Urine hCG test is negative. Physical exam reveals suprapubic tenderness. She exhibits no costovertebral angle tenderness. Vital signs show a blood pressure of 126/78 mmHg, temperature of 98.2, respirations of 18, heart rate of 82, and oxygen saturation of 97%. The most likely diagnosis is: A. Pyelonephritis B. Urosepsis C. Pregnancy D. Uncomplicated urinary tract infection E. Vaginitis

The correct answer is D. Uncomplicated UTI A urinary tract infection presents with increased urinary frequency, dysuria, urinary urgency, and suprapubic pain. It can be associated with burning upon urination. Risk factors for UTIs include sexual intercourse, female gender, pregnancy, the presence of an indwelling urinary catheter, structural abnormalities (BPH, neurogenic bladder,etc.), immunocompromised states, diabetes, spinal cord injuries, and a history of recurrent UTIs. **

*Case 33: Question 5* An otherwise healthy 58-year-old woman presents in your office with a cough, sore throat and fevers for the past five days. Which of the following clinical details would lead you to treat with antibiotics? A. Non-erythematous tympanic membrane with clear effusion B. Myalgias consistent with influenza C. Wheezing and productive cough consistent with acute bronchitis D. Purulent discharge and sinus tenderness consistent with acute sinusitis E. Dullness to percussion and crackles on lung exam consistent with community-acquired pneumonia

The correct answer is E. E. Dullness to percussion and crackles on lung exam consistent with community-acquired pneumonia The differential diagnosis for a patient presenting with cough, sore throat and fevers includes the common cold, influenza, acute sinusitis, acute bronchitis, and community acquired pneumonia. Option A describes otitis media with effusion (OME), a common and painless finding in adults and children in the setting of a cold or its aftermath. Unlike some cases of acute otitis media (which features a bulging, red, and painful tympanic membrane) OME is not treated with antibiotics. Influenza (B) is treated with antiviral medications, such as oseltamivir. 90% of cases of acute bronchitis (C) are viral, and Choosing Wisely recommends against the use of antibiotics for this diagnosis. The latter is true also for most episodes of acute sinusitis. In this patient with only five days of symptoms, antibiotics would not be appropriate for the diagnosis of sinusitis. Community-acquired pneumonia is always treated with antibiotics.

*Case 21: Question 3* 7-year-old boy is brought to your clinic with a fever of 102-103° F (38.9-39.4° C) for the last three days. He is up-to-date on all vaccinations and has no significant medical history. His mother notes that he has not had a cough but is eating and drinking less because "it hurts to swallow." On examination of his neck you notice tender cervical lymphadenopathy bilaterally, and auscultation of his back shows clear lung sounds on both sides. His oropharyngeal exam shows erythematous throat, but no tonsillar exudates. What would be the most appropriate next step? A. Empiric Amoxicillin therapy B. Empiric Levofloxacin therapy C. Empiric Tamiflu therapy D. Chest x-Ray E. Rapid Strep Test

The correct answer is E. E. Rapid Strep Test In addressing this child presenting with fever, symptoms of pharyngitis (sore throat), and the absence of cough, the physician needs to consider the possibility of strep throat. Predictive scoring tools such as the Modified Centor criteria are useful in determining which patients need testing for strep, but should not be used to make a positive diagnosis of strep throat. This child would have a score of 4 (one each for fever, absence of cough, high-risk age group, and tender cervical lymphadenopathy) and should be tested for strep using a rapid strep test. Empiric antibiotics are not appropriate here. In the case of a positive strep test, amoxicillin would be an appropriate choice, but levofloxacin would not. Influenza often presents with fever and sore throat, but typically involves cough as a prominent symptom. This patient has no lung findings, so a chest x-ray is unlikely to be of benefit.

*Case 21: Question 4* A 48-year-old female with no smoking history comes to the emergency department with complaints of sore throat for the last two days. She does not have a thermometer at home, but states she has been feeling hot and her children have also been out from school for a fever and sore throat. Her children are now staying with their father who she is separated from, and he notified her yesterday that they were on antibiotics for their symptoms. She was holding off coming to the doctor because she wasn't coughing or having any problems with swallowing until breakfast this morning. You note that she has a fever of 38.6 degrees Celsius measured by the nurse, and on physical exam you observe an erythematous throat with exudate, and bilateral cervical lymphadenopathy. What is the next best step? A. Amoxicillin therapy B. Levofloxacin (Levaquin) therapy C. Tamiflu therapy D. CXR E. Rapid Strep Test

The correct answer is E. E. Rapid Strep Test McIsaac Decision rule allows you to calculate the need for various interventions in a patient who presents with signs/symptoms of strep throat. One point is assigned each for fever greater than 38.0 degrees Celsius, absence of cough, tonsillar exudates, cervical lymphadenopathy, and age less than 15 years old. One point is removed for age older than 45 years old. Her total points is 4 for temp, cervical lymphadenopathy, no cough, and tonsillar exudates, minus 1 point for age < 45. This gives you a total score of 3, indicating the need for rapid strep test to guide further treatment (see chart below). *Score Treatment* <1 Symptomatic treatment 2 or 3 Rapid strep. Abx tx dependent result. >4 Culture or start empiric antibiotics.

*Case 33: Question 1* Mr. Jones is a 67-year-old man brought into your office because he's been having "dizzy spells and room spinning" for the past two days that are intermittent. Your records indicate a history of back pain, diabetes and hypertension. Upon further questioning, Mr. Jones cannot identify when these spells come on and nothing seems to relieve them. His temperature is 98.6 Fahrenheit; blood pressure is 165/95 mmHg; heart rate is 78 beats/minute; and respiratory rate is 18 breaths/minute. On physical exam, you notice a slight nystagmus. You ask him to focus on your nose but the nystagmus continues. What is the most likely cause of his "dizzy spells"? A. Hyperthyroidism with thyroid storm B. Bleeding gastric ulcer C. Vestibular neuritis D. Anemia E. Stroke

The correct answer is E. E. Stroke This patient displays symptoms of vertigo and findings of nystagmus suggesting a neurologic problem with balance. Thus thyroid storm (A), bleeding ulcer (B), and anemia (D), all of which may present with presyncope (but should not cause vertigo), are not likely diagnoses. He is likely suffering from a central lesion (ie: TIA/stroke) causing vertigo. The acute onset of symptoms, nystagmus that changes direction and nystagmus that does not resolve with gaze fixation are consistent with a central lesion as opposed to a peripheral lesion.

*Case 23: Question 4* Samantha and Joe bring in their newly adopted 5-year-old son, Matthew, to your office with the chief complaint of sore throat. He was born in the United States and was neglected by his biological parents. Samantha and Joe believe Matthew lived in an old building and ate mostly non-nutritious meals. They are unsure if his immunizations are up to date. His immunization record is attached. Upon physical exam his T= 101, HR=80, RR=19, BP= 95/63. He has anterior cervical lymphadenopathy, tonsillar exudates and palatal petechiae. In addition to MMR and influenza, and Hep B, which other immunizations does Matthew need? A. Varicella, meningococcal B. Varicella, HPV, DTAP C. Hib, DTap, PCV, IPV D. RV, IPV, Hep A, varicella E. Varicella, IPV, DTAP,\,Hep A

The correct answer is E. E. Varicella, IPV, DTAP,\,Hep A Varicella, IPV, DTAP, and Hep A vaccines are appropriate. RV vaccine is only given up to 6 months. Hib series has been completed. HPV is not given until a child is at least 9 years of age. The first dose of Meningococcal vaccine is given at age 11-12.

*Case 38: Question 1* A 3-year-old boy is brought to the clinic by his parents for follow-up of iron deficiency anemia. His diet consists mostly of sweet, bland, low-texture foods. He drinks 32 ounces daily of milk from a bottle. In addition to prescribing oral iron supplementation, what is the best advice to give the parents concerning this patient's diet? A. Continue bottle-feeding B. Encourage eating small amounts of food throughout the day C. Gradually introduce new foods and slowly decrease his old favorites D. Bribe the patient to eat healthy food E. No change is needed since he is on the optimal diet for his age

The correct answer is: C. Gradually introduce new foods and slowly decrease his old favorites

*Case 38: Question 2* A 2-year-old girl is brought to the clinic by her mother for a health maintenance visit. While waiting for the pediatrician, her mother reads her a short book. When you enter the room, her mother asks her to take the book and return it to a bookshelf. Developmental history reveals that the patient can scribble with a pencil but cannot write her name. She can kick and throw a ball, but cannot jump in place. Which of the following best describes this child's development? A. Delayed language B. Delayed social skills C. Advanced fine motor skills D. Advanced gross motor skills E. Age-appropriate development

The correct answer is: E. Age-appropriate development

*Case 39: Question 1* An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management? A. Prescribe a stimulant medication for ADHD B. Suggest behavior modification for the child and parenting classes C. Group therapy for the child D. Do nothing, as this child's behavior is normal E. Contact the teacher to find out more about his behavior. Find out more about the child's behavior at home

The correct answer is: E. Contact the teacher to find out more about his behavior. Find out more about the child's behavior at home

*Case 34 Internal Medicine 02: Question 3* A 66-year-old man presents to his primary care provider complaining of intermittent chest pain. He describes several episodes a week of pressure under his sternum that comes on with exertion, lasts for about 5 to 10 minutes and is improved with rest, over the last two weeks. He notes some shortness of breath with the pain, but denies any associated diaphoresis, nausea, or jaw pain. He has a history of hypertension and hyperlipidemia treated with lisinopril, simvastatin, and aspirin. He exercises at a gym for 30 minutes, two to three times per week. Physical examination shows his pulse is 78 beats/minute, respiratory rate is 16 breaths/minute, and blood pressure is 145/80 mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity edema. His electrocardiogram (ECG) is normal. Which of the following is the most-appropriate next step in his workup? A. Cardiac catheterization B. Computed tomography (CT) scan C. Echocardiogram D. Pharmacologic stress test with imaging E. Treadmill stress test without imaging

The correct answer is: A. Cardiac catheterization The man should proceed directly for a cardiac catheterization. His symptoms meet the criteria for angina (substernal chest discomfort with a characteristic duration and features, exertional in nature and relieved with rest or nitroglycerin) and since it is relatively new and started within the month, it should be considered unstable angina. In addition, he has considerable risk factors, thus his pretest probability is high for cardiac disease and cardiac catheterization is recommended. A CT scan is not the first line for diagnosing angina. An echo alone would not be sufficient to diagnose coronary artery disease, or determine its severity and the need for treatment. Pharmacologic stress tests with imaging should be reserved for patients who are not able to exert themselves. If he had been experiencing symptoms for more than six weeks, he would be considered intermediate probability and a treadmill stress test without imaging would be indicated given his normal ECG and ability to exercise.

*Case 40: Question 1* A 4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests? A. Chest x-ray and tuberculin skin test B. CT of nasal sinuses C. Spirometry, before and after bronchodilator therapy D. Chest x-ray and methacholine challenge E. None needed, patient likely has habitual cough

The correct answer is: A. Chest x-ray and tuberculin skin test

*Case 36: Question 4* A mother brings her 20-day-old male infant to your clinic for the child's first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends' infants. On exam, you note an eczematous rash and a musty odor to the infant's skin and urine. Which enzyme deficiency would you expect the infant to display? A. Phenylalanine hydroxylase B. Cystathionine synthase C. Sphingomyelinase D. Alpha-L-iduronidase E. Glucose-6-phosphatase

The correct answer is: A. Phenylalanine hydroxylase This infant likely has phenylketonuria (PKU), an autosomal recessive disorder of amino acid metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Affected infants are normally detected by newborn screening, but can present with vomiting, hypotonia, musty odor, developmental delay, and decreased pigmentation of the hair and eyes. The best developmental outcomes occur if a phenylalanine-restricted diet is initiated in infancy.

*Case 39: Question 2* An 8-year-old healthy obese African American male with no past medical history is found to have a blood pressure of 125/90 mmHg on all four extremities on routine evaluation during an office visit for well-child care. Review of symptoms is negative. A physical exam and screening bloodwork are performed. Both are normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis? A. Primary hypertension B. Renal artery stenosis C. Coarctation of the aorta D. Pheochromocytoma E. Hyperthyroidism

The correct answer is: A. Primary hypertension

*Case 37: Question 3* Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass? A. Wilms' tumor B. Teratoma C. Renal cell carcinoma D. Hepatoblastoma

The correct answer is: A. Wilms' tumor

*Case 36: Question 3* A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby? A. Tobacco exposure B. Alcohol exposure C. Congenital rubella D. Vertically transmitted HIV E. Congenital CMV infection

The correct answer is: B. Alcohol exposure Fetal alcohol syndrome has very characteristic facial features, including a smooth philtrum, thinning of the upper lip, and small palpebral fissures.

*Case 36: Question 1* A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn? A. Hepatosplenomegaly B. Cardiac defects C. Absent red reflex D. Chorioretinitis E. Tremors

The correct answer is: B. Cardiac defects B. The mother was on an anticonvulsant for her seizures. Taking anticonvulsants during pregnancy may lead to cardiac defects, dysmorphic craniofacial features, hypoplastic nails and distal phalanges, IUGR, and microcephaly. Mental retardation may be seen. A rare neonatal side effect is methemoglobinuria.

*Case 34 Internal Medicine 02: Question 2* A 42-year-old woman presents to the emergency department complaining of mild chest pain lasting three to four minutes with vigorous exercise, three times over the past week. She has no past medical history and is not taking any medications or supplements. She has no family history of cardiac disease. She follows a vegetarian diet, exercises regularly, and is training for a half-marathon. Physical examination shows her pulse is 66 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 110/70 mmHg. Her lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Which of the following is the most likely laboratory study in the acute setting to assist with the diagnosis? A. Brain natriuretic peptide (BNP) B. Complete blood count (CBC) C. Hemoglobin A1c D. Low-density lipoprotein (LDL) E. Triglycerides

The correct answer is: B. Complete blood count (CBC) Although cardiac causes of chest pain should be considered, it is important to consider other sources of pain. Anemia may cause chest pain by decreasing oxygen carrying capacity. BNP should be ordered when congestive heart failure is suspected; however heart failure is unlikely in this case, given her clear lungs, lack of edema, and lack of risk factors. Hemoglobin A1c would be helpful for the diagnosis of insulin resistance and diabetes, which are significant risk factors for cardiac disease, but do not cause chest pain on their own. LDL and triglycerides would be helpful to characterize her cardiac risk, but would not help determine the source of her symptoms.

*Case 35 - Internal Medicine 16: Question 2* A 52-year-old woman comes to the clinic to discuss weight loss. Her medical history is significant for obesity; her body mass index (BMI) is 41; hypertension; hyperlipidemia; and obstructive sleep apnea. She knows that losing weight will help her hypertension and hyperlipidemia, but she doesn't feel like these things bother her. Her only other concern is fatigue; she doesn't use her continuous positive airway pressure (CPAP) machine, because she doesn't like the mask. What additional information can you provide her to help motivate her weight loss? A. Her risk of cardiovascular disease is similar to that of a woman with a normal BMI. B. Her obstructive sleep apnea may improve with weight loss. C. Obesity is mainly a cosmetic issue. D. Surgery should be considered before diet and exercise.

The correct answer is: B. Her obstructive sleep apnea may improve with weight loss. Obesity is associated with a number of medical co-morbidities affecting multiple organ systems, including the cardiovascular (atherosclerotic cardiovascular disease, atrial fibrillation, heart failure, venous thromboembolism), pulmonary (obstructive sleep apnea, obesity hypoventilation syndrome), gastrointestinal (gastroesophageal reflux disease, cholelithiasis, hepatic steatosis), endocrine (diabetes), and renal (chronic kidney disease). In patients with medical co-morbidities related to obesity, weight loss is a cornerstone of therapy. In this woman, improvement in hypertension, hyperlipidemia, and sleep apnea can be expected with weight loss. Therefore, counseling regarding lifestyle interventions, weight loss medications, and possibly surgery if non-surgical interventions are unsuccessful, is warranted to manage obesity-related co-morbidities.

*Case 38: Question 3* A 4-year-old boy is brought to the clinic by his mother for developmental evaluation. She is concerned that he is delayed when compared to the children of her friends. Although he can throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. Which of the following are the expected milestones in this patient? A. Throw a ball overhand, ride tricycle, build tower of 6-8 cubes B. Hop on 1 foot, copy a cross, brush teeth C. Tie a knot, copy squares D. Mature pencil grasp, print some letters and numbers E. Skip, draw a person with 6 or more body parts

The correct answer is: B. Hop on 1 foot, copy a cross, brush teeth B. This choice is correct. A a normally developing 4-year-old should be able to hop on 1 foot, copy a cross, pour/cut/mash their own food, and brush teeth. *Incorrect answers:* A. Throwing a ball overhand, riding a tricycle, building a tower of 6-8 cubes, and copying a circle are developmental milestones for 3-year-olds. C. These are milestones for 5-year-olds. D. These are milestones for 5-year-olds. E. These are milestones for 5-year-olds.

*Case 35 - Internal Medicine 16: Question 5* Ms. H is a 68-year-old woman with a medical history significant for obesity, type II diabetes, hypothyroidism, hypertension, and recently diagnosed hyperlipidemia. Her most-recent lipoprotein (LDL), three months ago, was 197 mg/dL. At that time, atorvastatin was initiated. Other medications include metformin, insulin glargine, amlodipine, hydrochlorthiazide, and levothyroxine. Which of the following may be contributing to her elevated LDL? A. Amlodipine B. Hydrochlorthiazide C. Insulin glargine D. Levothyroxine E. Metformin

The correct answer is: B. Hydrochlorthiazide Dyslipidemia is typically familial, although there are secondary causes of hyperlipidemia that clinicians should be aware of. These include type II diabetes, cholestatic or obstrutive liver disease, nephrotic syndrome, acute hepatitis, alcohol, and medications including hydrochlorthiazide, beta blockers, oral contraceptives, and protease inhibitors. In addition to a possible familial cause of hyperlipidemia, this woman's type II diabetes, hypothyroidsm, and hydrochlorthiazide all may be contributing to dyslipidemia.

*Case 40: Question 2* An 11-year old boy presents to clinic with wheezing. Mom states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. On further history you find out that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy? A. Only rescue inhaler PRN B. Low dose inhaled corticosteroids C. Medium dose inhaled corticosteroids and course of oral corticosteroids D. Medium dose inhaled corticosteroids, LABA, and course of oral corticosteroids E. Course of oral corticosteroids

The correct answer is: B. Low dose inhaled corticosteroids Low dose inhaled corticosteroid is correct because this patient has mild persistent asthma. His symptoms occur 3-6 days/week and 3-4 nights/month.

*Case 35 - Internal Medicine 16: Question 4* Mr. York is a 44-year-old man presenting for evaluation of an eyelid lesion. He noticed the lesion about one year ago. There is no associated itching, discharge, or other bothersome symptoms. Which of the following is the next-best step in the management of the eyelid lesion? A. Low potency topical corticosteroid B. Measurement of serum cholesterol levels C. Measurement of serum uric acid levels D. No further management E. Skin biopsy

The correct answer is: B. Measurement of serum cholesterol levels The correct answer is B. The eyelid lesion is most likely a xanthelasma associated with hyperlipidemia. Xanthelasma are cholesterol-filled, soft, yellow plaques which may appear on the medial aspect of the eyelid or on extensor surfaces. They are benign findings, and removal is typically only pursued for cosmetic reasons. Despite the benign nature of the lesion itself, measurement of serum cholesterol levels should be pursued to identify hyperlipidemia in patients with xanthelasma.

*Case 37: Question 6* A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis? A. Sheets of lymphocytes with interspersed macrophages B. Small round blue cells with dense nuclei forming small rosettes C. Hypersegmented neutrophils D. Stacks of RBCs E. Enlarged cells with intranuclear inclusion bodies

The correct answer is: B. Small round blue cells with dense nuclei forming small rosettes In addition to neuroblastoma, other tumors associated with small blue cells include Ewing's sarcoma and medulloblastoma, both of which tumors are seen in children.

*Case 37: Question 2* Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy's age to be based upon his developmental milestones? A. 12 months B. 15 months C. 18 months D. 30 months E. 36 months

The correct answer is: C. 18 months At 18 months, a child should be able to walk backward, and 50-90% of children can run at this stage. An 18-month-old should be able to scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments.

*Case 40: Question 5* A 10-year-old boy comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup? A. Response to inhaled beta-agonist B. Hyperinflation in one lung field C. Alevolar consolidation in the RLL D. Positive PCR for pertussis E. Fluffy bilateral infiltrates and a large heart on chest x-ray

The correct answer is: C. Alevolar consolidation in the RLL C. Pneumonia is the most likely cause for his symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely.

*Case 34 Internal Medicine 02: Question 5* A 68-year-old man presents complaining of substernal chest pressure with exertion lasting five minutes, alleviated with rest. He has a remote history of a myocardial infarction (MI). He recently presented with angina symptoms and had a cardiac catheterization which did not reveal any concerning areas of stenosis. He has not been taking his medications. Physical examination shows his pulse is 88 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 130/80 mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Which of the following is the best treatment to manage the chest pain? A. Angiotensin-converting-enzyme (ACE) inhibitor B. Baby aspirin C. Beta blocker D. Calcium channel blocker E. Statin

The correct answer is: C. Beta blocker This man has stable angina and should be treated with a beta blocker. The beta blocker will reduce angina by slowing his heart rate and decreasing his blood pressure, thus decreasing myocardial oxygen consumption. Although studies have shown that calcium channel blockers may reduce angina, beta blockers are the first line since data suggests an improved survival rate. Aspirin and statins are indicated for secondary prevention of cardiovascular disease (CVD), but will not treat angina. There is conflicting data as to whether or not ACE inhibitors reduce angina symptoms.

*Case 37: Question 5* A 9-month old baby boy comes to the clinic for a well-child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today's visit? A. Influenza, Hep B, IPV, DTaP B. Influenza, IPV C. Influenza, Hep B, IPV D. Hep B, DTaP, IPV E. Hep B, IPV, and MMR

The correct answer is: C. Influenza, Hep B, IPV Influenza, Hep B, IPV is correct. The patient needs a third Hep B, a third IPV, and a yearly flu shot starting at 6 months of age.

*Case 39: Question 4* Jane is an 8-year-old girl who presents to your clinic for follow-up after being hospitalized for status asthmaticus. She has just completed a 10-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes Advair, a combined steroid and bronchodilator. She was also diagnosed with ADHD one year ago and was started on Concerta, 18 gm PO once a day. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension? A. Obesity B. The blood pressure cuff is too big C. Medications D. Renal insufficiency E. Neurofibromatosis 1

The correct answer is: C. Medications C. Both steroids and CNS stimulants can cause increases in blood pressure, especially when used in combination. Steroids increase blood pressure by mimicking endogenous cortisol and the sympathetic fight or flight response. Stimulants mimic norepinephrine, stimulating alpha and beta adrenergic receptors, causing an overall increase in blood pressure.

*Case 37: Question 1* You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient? A. Perform a brain-stem auditory evoked potential hearing screen B. Perform a screening exam for autism C. Reassure the parents that the boy's development appears normal D. Refer the child to a developmental specialist for comprehensive evaluation E. Refer the child to a specialist for evaluation of his delayed motor development

The correct answer is: C. Reassure the parents that the boy's development appears normal The developmental milestones mentioned in the vignette are within the range of normal for a 36-month-old child. In the absence of any other evidence of significant impairment, there is no indication for referral at this point.

*Case 38: Question 4* A 3-year-old boy described by his mother as a picky eater comes in for a regularly scheduled well-child visit. His mother complains that he has had less energy than usual for the past few months. There is a high clinical suspicion he is anemic. Which of the following is most correct? A. Complete blood count B. Serum lead C. Serum iron D. Serum folate E. Albumin

The correct answer is: C. Serum iron C. The most likely cause of anemia in the question is picky eating, which can result in insufficient iron intake. Low iron intake causes a microcytic anemia *Incorrect Answers:* A. This child is at risk of iron deficiency anemia. Although a CBC may show microcytic anemia, a serum iron level is more specific. B. Most 3-year-old children no longer mouthing objects. Although they may have been exposed to lead in the past one would explore other options of fatigue first. Lead levels are usually checked at 1 and 2 years of age. D. Iron deficiency is the most common cause of anemia in this scenario. Note that folate deficiency may be associated with a goat's milk diet. E. Protein malnutrition is uncommon in children in developed countries.

*Case 40: Question 4* A 9-year-old boy presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. He has struggled with these complaints over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him? A. Oral antibiotics B. Short-acting beta agonist PRN C. Short-acting beta agonist PRN with low-dose inhaled corticosteroid D. Short-acting beta agonist PRN with medium-dose inhaled corticosteroid E. Long-acting beta agonist

The correct answer is: C. Short-acting beta agonist PRN with low-dose inhaled corticosteroid Persistent cough and wheezing that affect the patient every other day (3-4 days with symptoms/week) are consistent with mild persistent asthma, which is appropriately treated with short-acting beta agonist PRN and low dose inhaled corticosteroid. The swelling under the eyes (allergic "shiners") and skin rash are other signs of atopy, as mentioned above.

*Case 39: Question 5* George is a 7-year-old boy frequently in trouble at school for being disruptive and inappropriately talkative in class, not following directions set by his teacher, and not working well with classmates during group activities. His mother relates that at home George is always on the go, sleeping only 6 to 7 hours a night. He does not follow her rules all the time either, including not doing his homework, and sometimes putting himself in danger by doing things she tells him not to do, such as running away unaccompanied. Which of the following is the most likely diagnosis? A. Bipolar mood disorder B. Anti-social personality disorder C. Conversion disorder D. ADHD E. Rett syndrome

The correct answer is: D. ADHD D. ADHD is characterized by the triad of impulsivity, hyperactivity, and inattention. Other symptoms include motor impairment and emotional labiality. ADHD is typically diagnosed before the age of 7 but persists into adulthood. Intelligence is usually normal, but individuals with ADHD commonly perform more poorly academically than would be expected for their IQ.

*Case 39: Question 3* Billy, a 7-year-old boy, presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. Billy was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is a likely cause of Billy's hypertension? A. Coarctation of the aorta B. Renal vascular disease C. Renal insufficiency due to renal scarring D. Catecholamine excess E. Primary hypertension

The correct answer is: D. Catecholamine excess D. Catecholamine excess (pheochromocytoma or neuroblastoma) should be suspected in a child who is hypertensive and has episodes of sudden sweating, flushing, or feels that his heart is racing. Billy is exhibiting these signs and a urine catecholamine testing would be appropriate in this case.

*Case 38: Question 5* A 5-year-old girl is brought by her mother to the clinic for a well-child visit. Medical history is significant for 3 upper respiratory infections in the past year. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. She lives with her mother and father in a home built in 1985. Her height is at the 50%, weight is at the 50% and BMI is at the 60%. Vital signs are normal. Physical examination is normal. Lab studies today show a hemoglobin of 10.0 g/dL. Her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia? A. Chronic blood loss B. Lead poisoning C. Chronic illness D. Iron deficiency E. Hemoglobinopathy

The correct answer is: D. Iron deficiency D. This choice is correct. Given the patient's age and preference for pasta and milk, the most likely cause of anemia would be iron deficiency. Treatment would include oral iron supplementation and increased dietary iron intake. *Incorrect Answers:* A. No complaint of melena, and the child is overall healthy. Chronic blood loss would therefore be unlikely. B. Risk of lead poisoning in homes built before the 1950s. No complaint of other symptoms suggestive of lead poisoning: weight loss, lethargy, vomiting, and learning difficulties. C. The patient has no significant past medical history, and the review of systems is unremarkable. Chronic illness is unlikely. E. If she had a hemoglobinopathy, she would have been expected to have been anemic at her previous visit as well.

*Case 35 - Internal Medicine 16: Question 3* Ms. Tsvetanova is a 42-year-old woman with no significant past medical history presenting to establish care with her primary care physician. On review, she notes a weight gain of 14 kg (30 lbs) over the last three years. She attributes this mostly to her sedentary lifestyle, snacking, and difficulty with portion control. She works as a receptionist for a local physician's office and spends most of her day sitting. She denies constipation, low energy, cold intolerance, muscle weakness, depressed mood, easy bruisability, or other skin changes. On physical exam, vital signs reveal temperature is 36.8C (98.2F), pulse is 82 beats/minute, respiratory rate is 12 breaths/minute, blood pressure is 130/82 mmHg, weight is 81.6 kg (180 lbs), and height is 163 cm (64 in). The remainder of her physical exam is normal. Which of the following laboratory tests is most appropriate for the evaluation of this patient? A. 24-hour urine catecholamine levels B. 24-hour urine cortisol level C. Basic metabolic profile D. Lipid profile E. Thyroid stimulating hormone (TSH)

The correct answer is: D. Lipid profile In the absence of symptoms and signs associated with secondary causes of obesity such as hypothyroidism and Cushing's disease, the initial laboratory evaluation in patients with obesity should be limited to assessment of co-existing risk factors for atherosclerotic cardiovascular disease (ASCVD), including dyslipidemia and diabetes. Screening guidelines vary regarding lipid screening in adults. The American Heart Association (AHA) recommends screening all adults aged 20 to 79 years old every four to six years in those without ASCVD. The U.S. Preventive Services Task Force (USPSTF) strongly recommends (grade A recommendation) screening in all men >35 years old and women >45 years old who are at increased risk for heart disease. The USPSTF also recommends (grade B recommendation) screening for men 20 to 35 years old and women 20 to 45 years old if they are at increased risk for heart disease.

*Case 34 Internal Medicine 02: Question 4* A 46-year-old woman presents to her primary care provider to discuss her risk of cardiovascular disease. She notes that her mother had a heart attack at age 66. She denies any recent symptoms of chest pain or shortness of breath. She has a history of hypertension, hyperlipidemia, and obesity. She drinks a glass of wine daily. Current medications are 10mg amlodipine daily, and 40mg atorvastatin daily. Her pulse is 78 beats/minute, respiration rate is 16 breaths/minute, and blood pressure is 154/80 mmHg. Her lungs are clear, heart sounds are normal, and there is no lower-extremity edema. Her electrocardiogram (ECG) is normal. Which of the following is the most appropriate management to lower her risk of cardiovascular disease? A. Limit alcohol intake B. Limit polyunsaturated fats C. Start a beta blocker D. Start a thiazide diuretic E. Take an aspirin daily

The correct answer is: D. Start a thiazide diuretic This woman should have her blood pressure medication titrated upward to optimize her risk reduction. Thiazide diuretics are first-line antihypertensive agents and should be added to her regimen. One serving of alcohol daily in women has been shown to lower the risk of cardiovascular disease (CVD). In addition, she should be counseled on lifestyle modification to reduce her risk of developing coronary heart disease. Polyunsaturated fats have been shown to reduce the risk of CVD and should not be limited. Beta blockers have been shown to lower mortality for secondary prevention of CVD, but not for primary prevention. An aspirin daily is recommended by the United States Preventive Services Task Force (USPSTF) for individuals over 50 years old who have a 10% or greater risk of CVD, have no bleeding risk, and at least a 10-year life expectancy.

*Case 40: Question 3* A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would be characteristic of the cough that this patient would present with? A. Does not awaken patient from sleep B. Paroxysmal C. Barking cough D. Worse at night E. Associated with crackles on exam

The correct answer is: D. Worse at night Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough.

*Case 37: Question 4* An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child? A. Lymph node involvement is a poor prognostic factor B. Prognosis of neuroblastoma is predictable C. Children who are older than 12 months have a better prognosis than younger children D. Favorable histology does not play a role in prognosis E. Non-amplification of the n-myc gene is a favorable prognostic factor.

The correct answer is: E. Non-amplification of the n-myc gene is a favorable prognostic factor.

*Case 35 - Internal Medicine 16: Question 1* A 67-year-old man comes to the clinic for a health maintenance visit. His past medical history is significant for chronic allergic rhinitis, severe chronic obstructive pulmonary disease (COPD), osteoporosis, psoriasis, atrial fibrillation, and benign prostatic hypertrophy. Vital signs show his temperature is 36.8C (98.2F), pulse is 76 beats/minute, respiratory rate is 12 breaths/minute, and blood pressure is 118/70 mmHg. His weight is 129.2 kg (285 lbs) and his body mass index (BMI) is 41. Which of his co-morbidities is most likely to be associated with his BMI? A. Atrial fibrillation B. Benign prostatic hypertrophy C. Chronic allergic rhinitis D. Osteoporosis E. Psoriasis

The correct answer is: A. Atrial fibrillation Obese patients are at a significantly increased risk for developing atrial fibrillation. This is thought to be related to increased left-atrial volume. Weight loss may reduce the burden of atrial fibrillation in obese patients. Also, obesity has been associated with COPD and asthma, although the nature of the association has not been fully elucidated. Additional related health risks include atherosclerotic cardiovascular disease (including stroke, coronary artery disease, and peripheral vascular disease) and heart failure. Psoriasis, chronic allergic rhinitis, and benign prostatic hypertrophy are less likely to be associated with obesity. Osteoporosis is associated with low BMI, not obesity.