ABFM ITE 2018

22. An otherwise healthy 3-year-old child with no allergies is found to have otitis media with effusion in the right ear. Which one of the following would you recommend? A) No treatment, and follow-up in 3 months B) Amoxicillin C) Oral antihistamines D) Nasal corticosteroids E) Tympanostomy tube placement

ANSWER: A This child has otitis media with effusion, and the recommended course of action is to follow up in 3 months. Medications, including decongestants, antihistamines, antibiotics, and corticosteroids, are not recommended.

6. An otherwise healthy 57-year-old female presents with a sudden onset of hearing loss. She awoke this morning unable to hear out of her left ear. There was no preceding illness and she currently feels well otherwise. She does not have ear pain, headache, runny nose, congestion, or fever, and she does not take any daily medications. On examination you note normal vital signs and find a normal ear, with no obstructing cerumen and with normal tympanic membrane motion on pneumatic otoscopy. You perform a Weber test by placing a tuning fork over her central forehead. She finds that the sound lateralizes to her right ear. The Rinne test shows sounds are heard better with bone conduction on the left and with air conduction on the right. You refer her to an otolaryngologist for further evaluation including audiometry. You should also consider initiating which one of the following medications at this visit in order to optimize the likelihood of recovery? A) Acyclovir (Zovirax) B) Amoxicillin/clavulanate (Augmentin) C) Aspirin D) Nifedipine (Procardia) E) Prednisone

ANSWER: E This patient has sudden sensorineural hearing loss (SSNHL) of the left ear without any accompanying features to suggest a clear underlying cause. An appropriate evaluation will fail to identify a cause in 85%-90% of cases. Idiopathic SSNHL can be diagnosed if a patient is found to have a 30-dB hearing loss at three consecutive frequencies and an underlying condition is not identified by the history and physical examination. The most recent guideline from the American Academy of Otolaryngology-Head and Neck Surgery recommends that oral corticosteroids be considered as first-line therapy for patients who do not have a contraindication. While there is equivocal evidence of benefit, for most patients the risk of a short-term course of corticosteroids is thought to be outweighed by the potential benefit, especially when considering the serious consequences of long-term profound hearing loss. Because the greatest improvement in hearing tends to occur in the first 2 weeks, corticosteroid treatment should be started immediately. The recommended dosage is 1 mg/kg/day with a maximum dosage of 60 mg daily for 10-14 days. Antiviral medications, antiplatelet agents, and vasodilators such as nifedipine have no evidence of benefit. Antibiotics also have no evidence of benefit in the absence of signs of infection.

89. A 20-year-old football player presents with pain in the proximal fifth metatarsal. The pain was initially present only after practices, but now it causes push-off pain during practice. There is tenderness to palpation. Plain films show no signs of fracture. Which one of the following would be most appropriate at this point? A) Start NSAIDs and allow him to continue practicing as tolerated B) Place him at non-weight bearing for 2 weeks and repeat the plain films C) Place him in a hard shoe for 3 weeks and then reexamine D) Order MRI of the foot E) Order a bone scan of the foot

Item 89 ANSWER: D A stress fracture in the proximal fifth metatarsal is particularly prone to nonunion and completion of the fracture. Because complete non-weight bearing or surgical intervention may be necessary with this high-risk fracture, MRI is indicated as the most sensitive test. Bone scans are sensitive but nonspecific. Most stress fractures of the metatarsals occur distally and can be managed with a hard shoe initially, with progressive activity as tolerated. NSAIDs are discouraged because of possible effects on fracture healing.

12. A 62-year-old female with diabetes mellitus presents to your office with left lower quadrant pain and guarding. She has a previous history of a shellfish allergy that caused hives and swelling. Further evaluation of this patient should include which one of the following? A) Ultrasonography of the abdomen B) CT of the abdomen and pelvis with oral and intravenous (IV) contrast C) Oral corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral and IV contrast D) Intravenous corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral and IV contrast E) Laparotomy

ANSWER: B Evaluation of this patient should include CT of the abdomen and pelvis with oral and intravenous (IV) contrast. There is no reason to inquire about shellfish allergies prior to CT with IV contrast, because premedication is not needed. There is no correlation between shellfish allergies and allergic reactions to contrast. Patients with moderately severe to severe reactions to IV contrast in the past would need pretreatment with corticosteroids.

74. A 61-year-old white male with type 2 diabetes mellitus sees you for a follow-up visit. His blood pressure is 156/94 mm Hg. At a visit 1 week ago his blood pressure was 150/92 mm Hg. Laboratory studies obtained prior to this visit show a BUN of 16 mg/dL (N 6-20), a serum creatinine level of 0.9 mg/dL (N 0.7-1.3), and microalbuminuria on a urinalysis. His diabetes is well controlled with metformin (Glucophage) and he is taking aspirin. Which one of the following would you recommend? A) Observation only B) An ACE inhibitor C) A -blocker D) A calcium channel blocker E) A diuretic

ANSWER: B The panel members of the Eighth Joint National Committee for the management of blood pressure recommended that ACE inhibitors should be initiated for renal protection in adults with diabetes mellitus, hypertension, and microalbuminuria. This patient appears to be in an early stage of nephropathy, and ACE inhibitors will reduce the decline in renal function. -Blockers are no longer recommended for first-line treatment. In white patients who do not have diabetes, therapy may be started with ACE inhibitors, thiazide diuretics, or calcium channel blockers.

26. A 28-year-old female presents with a 3-month history of fatigue and postural lightheadedness. On examination she is diffusely hyperpigmented, especially her skin creases and areolae. A CBC and basic metabolic panel are normal except for an elevated potassium level. You order a corticotropin stimulation test. Prior to the corticotropin injection, you should order which one of the following tests to confirm that this patient has a primary insufficiency and not a secondary (pituitary) disorder? A) ACTH B) Aldosterone C) Melanocyte-stimulating hormone D) Renin E) TSH

ANSWER: A A plasma ACTH level is recommended to establish primary adrenal insufficiency. The sample can be obtained at the same time as the baseline sample in the corticotropin test. A plasma ACTH greater than twice the upper limit of the reference range is consistent with primary adrenal insufficiency. Aldosterone and renin levels should be obtained to establish the presence of adrenocortical insufficiency, but these do not differentiate primary from secondary adrenal insufficiency. The hyperpigmentation of Addison's disease is caused by the melanocyte-stimulating hormone (MSH)-like effect of the elevated plasma levels of ACTH. ACTH shares some amino acids with MSH and also produces an increase in MSH in the blood. TSH is not part of the feedback loop of adrenal insufficiency.

51. A 34-year-old female presents with a 3-month history of a minimally productive cough. She has never smoked. She does not have any fever, weight loss, rhinorrhea, congestion, or heartburn. She does not have a known history of allergies or asthma and has tried over-the-counter cold remedies, cough syrups, and cough drops without significant relief. She is otherwise healthy and takes no medications. On examination her vital signs are normal. An ear, nose, and throat examination is remarkable for swollen nasal turbinates. A lung examination is normal. Given the duration of the cough, you order a chest radiograph, which is normal as well. Which one of the following would be most appropriate at this point? A) A trial of an intranasal corticosteroid B) A trial of an inhaled bronchodilator C) A trial of a proton pump inhibitor D) A sinus radiograph E) Referral for allergy testing

ANSWER: A According to the CDC, cough is the most common symptom resulting in primary care visits. Chronic cough in adults is defined as one that lasts 8 weeks or more. The workup should include a history focusing on potential triggers, as well as the identification of any red flags. If the physical examination is normal and the patient's history does not indicate the cause of the cough, a chest radiograph is appropriate. The most common cause of chronic cough in adults is upper airway cough syndrome. Patients might have nasal symptoms such as rhinorrhea or congestion. Physical findings can include swollen turbinates and posterior pharyngeal cobblestoning, or they can be unremarkable. Initial treatment may include the use of decongestants, oral or intranasal antihistamines, intranasal corticosteroids, or saline nasal rinses (SOR C). Symptoms should resolve within a few weeks, and referral for allergy testing can be considered if they are not resolved within 2 months. CT of the sinuses can be considered as well, but sinus radiographs are more specific. Other common causes of chronic cough include asthma, nonasthmatic eosinophilic bronchitis, and GERD. If asthma is suspected, spirometry is indicated. If spirometry is positive for asthma, a trial of an inhaled bronchodilator is indicated. If there are other indications of GERD such as heartburn, globus sensation, or hoarseness, an antacid or a trial of a proton pump inhibitor is indicated.

8. A 65-year-old male with type 2 diabetes mellitus, hypertension, and obstructive sleep apnea sees you for follow-up. He does not use tobacco or other drugs, and his alcohol consumption consists of two drinks per day. His BMI is 31.0 kg/m2, and he just started a fitness program. The patient tells you that his brother was recently diagnosed with atrial fibrillation and he asks you if this increases his own risk. Which one of the following factors would increase the risk of atrial fibrillation in this patient? A) Alcohol use B) Treatment with lisinopril (Prinivil, Zestril) C) Treatment with pioglitazone (Actos) D) Use of a continuous positive airway pressure (CPAP) device E) Physical stress

ANSWER: A Alcohol consumption greater than one drink/day has been associated with atrial fibrillation. While not recommended to prevent atrial fibrillation, pioglitazone and lisinopril have both been associated with lower rates of atrial fibrillation compared to alternative therapies. Treatment of obstructive sleep apnea, along with a regular fitness regimen, has been associated with a decrease in the recurrence of atrial fibrillation.

36. A 58-year-old male with a 30-pack-year smoking history comes to your office to discuss screening for COPD. His older brother and sister have both recently been diagnosed with COPD and he wants to be screened for this soon. He continues to smoke and does not express a desire to quit. He does not have shortness of breath, cough, orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion. His only medication is aspirin, 81 mg daily. He has never used inhaled medications such as albuterol (Proventil, Ventolin). His family history is otherwise negative. You counsel him on tobacco cessation today. Which one of the following is recommended with regard to COPD screening for this patient? A) No screening B) Spirometry with pre- and postbronchodilator testing C) Posteroanterior and lateral chest radiographs D) Noncontrast CT of the chest E) 1-Antitrypsin deficiency gene testing

ANSWER: A All patients with a smoking history and symptoms of COPD such as a chronic cough with sputum production and/or chronic and progressive dyspnea should be screened for COPD with spirometry. However, asymptomatic individuals such as this patient should not be screened with spirometry regardless of risk factors. Neither chest radiography nor chest CT has a role in screening for COPD. Screening for alpha 1-antitrypsin deficiency in the absence of a family history is not recommended.

66. A 24-year-old female with a history of bulimia nervosa sees you for treatment of depression. She is currently receiving cognitive-behavioral therapy. You decide that she requires medication to treat her depression. Which one of the following medications has been associated with an increased risk of seizures in patients with bulimia nervosa? A) Bupropion (Wellbutrin) B) Fluoxetine (Prozac) C) Nortriptyline (Pamelor) D) Sertraline (Zoloft) E) Venlafaxine (Effexor XR)

ANSWER: A Antidepressants in every class (SSRIs, SNRIs, tricyclic antidepressants, and monoamine oxidase inhibitors) have been shown to reduce bulimic symptoms and can be used safely to treat depression, with the exception of bupropion. Bupropion use has been associated with an increased risk of seizures in patients with bulimia and an FDA warning limits its use.

34. A 43-year-old male who works in a warehouse sees you because of dizziness. He first noticed mild dizziness when he rolled over and got out of bed this morning. He had several more severe episodes that were accompanied by nausea, and on one occasion vomiting occurred after he tilted his head upward to look for items on the higher shelves at work. You suspect benign paroxysmal positional vertigo, so you perform the Dix-Hallpike maneuver as part of the examination. Which one of the following findings during the examination would confirm the diagnosis? A) Nystagmus when vertigo is elicited B) Vertigo that occurs immediately following the test-related head movement C) Persistence of vertigo for 5 minutes following the test-related head movement D) A drop in systolic blood pressure of >10 mm Hg when supine

ANSWER: A Benign paroxysmal positional vertigo (BPPV) originates in the posterior semicircular canal in the majority of patients (85%-95% range reported). The Dix-Hallpike maneuver, which involves moving the patient from an upright to a supine position with the head turned 45° to one side and the neck extended 20° with the affected ear down, will elicit a specific series of responses in these patients. Following a latency period that typically lasts 5-20 seconds but sometimes as long as 60 seconds, the patient will experience the onset of rotational vertigo. The objective finding of a torsional, upbeating nystagmus will be associated with the vertigo. The vertigo and nystagmus typically increase in intensity and then resolve within 1 minute from onset.

61. A 68-year-old male presents with chronic right knee pain from osteoarthritis that inhibits his activity and is associated with stiffness throughout the day. He has tried acetaminophen and NSAIDs with limited effect. He has consulted an integrative medicine specialist who recommended multiple modalities to reduce pain and increase function, and he asks whether you think they would be helpful. Which one of the following measures recommended by the other physician has the STRONGEST evidence of benefit? A) A low-impact aerobic exercise program B) Lateral wedge insoles C) Oral glucosamine and chondroitin D) A platelet-rich plasma injection E) Needle lavage of the knee

ANSWER: A Despite the prevalence of osteoarthritis of the knee and a myriad of treatment modalities available for those with symptomatic disease, there is very limited evidence to suggest that many of these treatments are effective. There is strong evidence to suggest that self-management programs, strengthening exercises, low-impact aerobic exercises, and neuromuscular education have some benefit. Moderate evidence recommends against the use of needle lavage of the knee; the two main studies of this modality showed little or no benefit. In 15 studies, 14 outcomes were not statistically significant, including three pain and three functional outcomes. There is also moderate evidence to recommend against the use of lateral wedge insoles. Four studies of lateral wedge insoles showed no significant change in pain or function of the knee when compared to neutral insoles. The evidence is inconclusive for platelet-rich plasma injections. A few studies have shown decreased pain in patients after injection, but there was no placebo control, so the effectiveness cannot be adequately assessed. Glucosamine and chondroitin have been shown with strong evidence to be ineffective when compared to placebo.

98. A 68-year-old female sees you for a routine health maintenance visit. She feels well and says she has been eating more carefully and exercising for 45 minutes 4 days a week for the past 6 months. Her past medical history includes controlled hypertension and osteoarthritis of the knee. Her family history is notable for a myocardial infarction in her mother at 48 years of age. Her only medication is lisinopril (Prinivil, Zestril). The physical examination is notable only for a BMI of 36.0 kg/m2. Laboratory findings are notable for significant hyperlipidemia and you recommend starting a statin. She reports that she will undergo an elective total knee replacement next month and asks about the safety of starting a new medication before this surgery. You recommend that she A) start a statin immediately to decrease her risk of cardiovascular disease and perioperative mortality B) start a statin immediately to decrease her risk of cardiovascular disease, although her risk of perioperative mortality will not be affected C) start a statin immediately to decrease her risk of cardiovascular disease, stop the statin 1 week before surgery, and resume taking it after the surgery, to decrease her risk of perioperative mortality D) start a statin immediately after the surgery to decrease her risk of cardiovascular disease and perioperative mortality E) start a statin after she is released postoperatively by her surgeon to decrease her risk of cardiovascular disease and perioperative mortality

ANSWER: A Family physicians are often consulted for perioperative medical management. Studies have shown decreased perioperative mortality in patients who continue statins and in patients with clinical indications for statin therapy who start statins prior to undergoing vascular or high-risk surgeries such as joint replacement. A meta-analysis of 223,000 patients showed a significant reduction in perioperative mortality in patients receiving statin therapy versus placebo who underwent noncardiac surgical procedures. This patient has a clinical indication (multiple risk factors) to start statin therapy now.

82. A 42-year-old male with alcohol use disorder tells you that his last drink was 7 days ago and asks if there are any medications available to help him maintain abstinence from alcohol. He has no other medical or psychological problems. Which one of the following pharmacologic agents could help reduce this patient's alcohol consumption and increase abstinence? A) Acamprosate B) Amitriptyline C) Paroxetine (Paxil) D) Promethazine E) Venlafaxine (Effexor XR)

ANSWER: A For this patient, acamprosate is the most effective medication to help maintain alcohol abstinence. Antidepressants may be beneficial in patients with coexisting depression. The antiemetic ondansetron may also help decrease alcohol consumption in patients with alcohol use disorder.

21. You perform the initial newborn examination on a male on his first day of life, following an uncomplicated vaginal delivery at an estimated gestational age of 37 weeks and 6 days. The prenatal course was significant for the initial presentation for prenatal care at 22 weeks gestation. You note that the infant's upper lip is thin and the philtrum is somewhat flat. Which additional finding would increase your concern for fetal alcohol syndrome? A) Curvature of the fifth digit of the hand (clinodactyly) B) A supernumerary digit of the hand C) Flattening of the head (plagiocephaly) D) Metatarsus adductus in one foot E) Syndactyly of the toes (webbed feet)

ANSWER: A In addition to clinodactyly, fetal alcohol syndrome is associated with camptodactyly (flexion deformity of the fingers), other flexion contractures, radioulnar synostosis, scoliosis, and spinal malformations. It is also associated with many neurologic, behavioral, and cardiovascular abnormalities, as well as other types of abnormalities. Plagiocephaly, supernumerary digits, syndactyly, and metatarsus adductus are common in newborns but are not related to fetal alcohol spectrum disorders.

67. At a routine well child visit the mother of a 3-year-old male expresses concern that his toes turn in, causing a clumsy gait when he walks. You diagnose internal tibial torsion, because his feet point inward when his patellae face forward. The examination is otherwise normal. Which one of the following is recommended at this time? A) No intervention B) Shoe modification with wedges to externally rotate the feet while walking C) Night splinting with the feet externally rotated D) Serial casting to gradually externally rotate the feet E) Surgery to correct the deformity

ANSWER: A Internal tibial torsion usually resolves spontaneously by age 5. Surgery may be considered in patients older than 8 years of age who have a severe residual deformity, especially if it is symptomatic or cosmetically unacceptable. Night splints, shoe modifications, other orthotics, casting, and braces are not recommended for this condition.

54. A 72-year-old male with type 2 diabetes mellitus sees you for routine follow-up. He takes metformin (Glucophage), 1000 mg twice daily. He is sedentary and does not adhere to his diet. His BMI is 32.0 kg/m2. The examination is otherwise within normal limits. His hemoglobin A1c is 9.5%. Which one of the following is recommended by the American Diabetes Association to better control his blood glucose? A) Start an intensive diet and exercise program for weight loss B) Start home monitoring of blood glucose with close follow-up C) Start basal insulin at 10 units/day D) Stop metformin and start a sulfonylurea E) Stop metformin and start a basal and bolus insulin regimen

ANSWER: C According to the American Diabetes Association's 2018 guidelines for the management of diabetes, a healthy person with a reasonable life expectancy should have a hemoglobin A1c goal of <7%. Metformin is recommended as first-line therapy as long as there are no contraindications. If the hemoglobin A1c is not at the goal or is 9%, then adding another agent to metformin is recommended. Basal insulin at 10 units/day is an acceptable choice for additional therapy to improve blood glucose control. Diet, exercise, and home monitoring of blood glucose are recommended in addition to starting another agent for blood glucose control.

16. A 45-year-old African-American male returns to your clinic to evaluate his progress after 6 months of dedicated adherence to a diet and exercise plan you prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg. He is not overweight and he does not have other known medical conditions or drug allergies. Which one of the following would be the most appropriate initial antihypertensive treatment option for this patient? A) Chlorthalidone B) Hydralazine C) Lisinopril (Prinivil, Zestril) D) Losartan (Cozaar) E) Metoprolol

ANSWER: A Lifestyle modifications addressing diet, physical activity, and weight are important in the treatment of hypertension, particularly for African-American and Hispanic patients. When antihypertensive drugs are also required, the best options may vary according to the racial and ethnic background of the patient. The presence or absence of comorbid conditions is also important to consider. For African-Americans, thiazide diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or -blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs. Racial or ethnic background should not be the basis for the exclusion of any drug class when multidrug regimens are required to reach treatment goals.

41. A 55-year-old female presents with the new onset of palpitations. An underlying cardiac cause should be suspected if the patient's palpitations A) affect her sleep B) are associated with dry mouth C) are worse in public places D) last less than 5 minutes

ANSWER: A Palpitations are a common symptom in ambulatory care. Cardiac causes are the most worrisome so it is important to distinguish cardiac from noncardiac causes. Patients with a history of cardiovascular disease, palpitations that affect their sleep, or palpitations that occur at work have an increased risk of an underlying cardiac cause (positive likelihood ratio 2.0-2.3) (SOR C). Psychiatric illness, adverse effects of medications, and substance abuse are other common causes. Palpitations that are worse in public places and those of very short duration (<5 minutes), especially if there is a history of anxiety, are often related to panic disorder. However, even a known behavioral issue should not be presumed to be the cause of palpitations, as nonpsychiatric causes are found in up to 13% of such cases. The use of illicit substances such as cocaine and methamphetamine can cause palpitations that are associated with dry mouth, pupillary dilation, sweating, and aberrant behavior. Excessive caffeine can also cause palpitations.

4. A 50-year-old male carpet layer presents with swelling of his right knee proximal to the patella. He does not have any history of direct trauma, fever, chills, or changes in the overlying skin. On examination the site is swollen but minimally tender, with no warmth or erythema. Which one of the following would be most appropriate at this point? A) Rest, ice, and compression B) Aspiration of fluid for analysis C) Injection of a corticosteroid D) An oral corticosteroid taper E) Referral to an orthopedic surgeon for resection

ANSWER: A Prepatellar bursitis is a common superficial bursitis caused by microtrauma from repeated kneeling and crawling. Other terms for this include housemaid's knee, coal miner's knee, and carpet layer's knee. It is usually associated with minimal to no pain. This differs from inflammatory processes such as acute gouty superficial bursitis, which presents as an acutely swollen, red, inflamed bursa and, in rare cases, progresses to chronic tophaceous gout with minimal or no pain. The proper management of prepatellar bursitis is conservative and includes ice, compression wraps, padding, elevation, analgesics, and modification of activity. There is little evidence that a corticosteroid injection is beneficial, even though it is often done. If inflammatory bursitis is suspected, a corticosteroid injection may be helpful. Fluid aspiration is indicated if septic bursitis is suspected. Surgery can be considered for significant enlargement of a bursa if it interferes with function.

87. You suspect a 45-year-old female may have irritable bowel syndrome. She has a 6-month history of crampy, diffuse abdominal pain associated with defecation. Her symptoms occur several days per week. According to the Rome IV criteria, an associated symptom that would help in making this diagnosis is A) a change in stool frequency B) increased gas and bloating C) pain brought on by eating D) waking up at night to defecate E) weight loss of 5 lb (2 kg)

ANSWER: A The Rome IV criteria are widely used as guidelines to diagnose suspected irritable bowel syndrome. These criteria specify that there should be recurrent abdominal pain associated with two or more additional symptoms at least 1 day per week in the last 3 months. These symptoms include pain related to defecation, a change in stool frequency, or a change in stool form. Pain brought on by eating and increased gas and bloating are observed in irritable bowel syndrome but are not included in the Rome IV criteria. Weight loss and waking at night to defecate are not typically seen in this disorder.

18. A 15-year-old female presents with a 3-month history of intermittent abdominal pain and headaches. She does not have any associated weight loss, fever, nausea, change in bowel habits, or other worrisome features. An examination is unremarkable. She does report being stressed at school and has a PHQ-2 score of 4. Which one of the following would be most appropriate at this point? A) Further evaluation for depression B) Laboratory studies C) Abdominal imaging D) Citalopram (Celexa) E) Fluoxetine (Prozac)

ANSWER: A The U.S. Preventive Services Task Force recommends depression screening for all adolescents 12-18 years of age. Although this patient has abdominal pain, the history and physical examination suggest that depression may be playing a role in her somatic complaints. She had a positive initial depression screen on her PHQ-2. This is a brief screening tool, and a positive result merits further evaluation. The evaluation should include a full PHQ-A or a discussion with a qualified clinician. If the patient meets the criteria for major depressive disorder then she should receive treatment for her depression, which could include medication. Both fluoxetine and citalopram have been approved by the FDA to treat depression in this age group. She could also be referred for psychotherapy. Further laboratory studies and imaging may be appropriate at some point, but the most urgent need is to evaluate her positive depression screen.

44. A 42-year-old male with hypertension and hyperlipidemia sees you for a routine health maintenance examination. His blood pressure is 185/105 mm Hg. He does not have any current symptoms, including headache, chest pain, edema, or shortness of breath. He is adherent to his current medication regimen, which includes lisinopril (Prinivil, Zestril), 10 mg daily, and simvastatin (Zocor), 20 mg at night. A thorough history and physical examination are both unremarkable. Which one of the following would be the most appropriate next step? A) A 30-minute rest period followed by a repeat blood pressure reading B) Clonidine (Catapres), 0.2 mg given in the office C) A comprehensive metabolic panel, fasting lipid profile, and TSH level D) A stress test E) Hospital admission for blood pressure reduction

ANSWER: A The first step in the management of severe hypertension is determining whether a hypertensive emergency is present. A thorough history and physical examination are crucial (SOR C). Severe hypertension (blood pressure >180 mm Hg systolic or >110 mm Hg diastolic) with end-organ damage constitutes a hypertensive emergency. A physical examination should center on evaluating for papilledema, neurologic deficits, respiratory compromise, and chest pain. If end-organ damage is present the patient should be hospitalized for monitored blood pressure reduction and further diagnostic workup. If end-organ damage is not present and the physical examination is otherwise normal, a 30-minute rest with reevaluation is indicated. Approximately 30% of patients will improve to an acceptable blood pressure without treatment (SOR C). Home medications should then be adjusted with outpatient follow-up and home blood pressure monitoring (SOR A). Short-acting antihypertensives are indicated if mild symptoms are noted such as headache, lightheadedness, nausea, shortness of breath, palpitations, anxiety, or epistaxis. Diagnostic testing is not immediately indicated for asymptomatic patients (SOR C). A basic metabolic panel or other testing should be considered if mild symptoms are present. Aggressive lowering of blood pressure can be detrimental and a gradual reduction over days to weeks is preferred (SOR C).

59. The U.S. Preventive Services Task Force recommends screening all adults for obesity and offering intensive, multicomponent behavioral interventions to patients with a BMI 30 kg/m2. This recommendation is based on trials that show that behavioral weight-loss interventions for overweight and obese patients with elevated plasma glucose levels reduce the incidence of diabetes mellitus by 30%-50% over 2-3 years and the number needed to treat is 7. What is the absolute risk reduction for developing diabetes, based on these trials? A) 1/7 B) 1/5 C) 1/0.7 D) 1/0.2 E) 1/0.02

ANSWER: A The number needed to treat (NNT) is defined as the number of people who would need to receive an intervention in order for one person to benefit. It is the inverse of the absolute risk reduction (ARR). The ARR is the difference in risk for a disease without and with an intervention. The correct formula for calculating NNT is 1/ARR.

57. A 62-year-old female has a history of COPD graded as moderate on pulmonary function testing, with an FEV1 of 65% of predicted and a PaO2 of 57 mm Hg. Because her symptoms of dyspnea on exertion and fatigue seem out of proportion to her pulmonary function tests, you order echocardiography, which shows a pulmonary artery systolic pressure of 50 mm Hg, indicating pulmonary hypertension. Which one of the following would be most effective for decreasing mortality in this situation? A) Supplemental oxygen B) An endothelin receptor antagonist such as bosentan (Tracleer) C) A calcium channel blocker such as nifedipine (Procardia) D) A phosphodiesterase 5 inhibitor such as sildenafil (Revatio) E) Referral for pulmonary artery endarterectomy

ANSWER: A The only proven therapy for pulmonary hypertension related to COPD is supplemental oxygen. Supplemental oxygen should be recommended when the PaO2 is <60 mm Hg, because it has been shown to improve mortality by lowering pulmonary arterial pressures. Treatments effective for pulmonary artery hypertension should not be used. Pulmonary vasodilators such as nifedipine, sildenafil, and bosentan may cause a ventilation-perfusion mismatch. Pulmonary endarterectomy may be indicated for pulmonary hypertension caused by chronic thromboembolic disease.

49. A patient asks which shingles vaccine he should receive. Which one of the following is an advantage of the recombinant zoster vaccine (Shingrix) compared to the live zoster vaccine (Zostavax)? A) Improved efficacy B) Lower cost C) Subcutaneous administration D) Proven safety for immunocompromised patients E) Administration as a single dose

ANSWER: A The recombinant zoster vaccine is preferred over the live zoster vaccine due to its increased efficacy. The recombinant vaccine is estimated to be about 97% effective for preventing shingles, compared to 51% with the live vaccine. It requires two intramuscular doses separated by 2-6 months, compared to only one subcutaneous dose with the live vaccine. It is also slightly more expensive than the live vaccine. Although the recombinant vaccine is not a live vaccine, studies are still ongoing as to whether it is safe to give to immunocompromised patients.

9. You have diagnosed a 32-year-old female with moderate iron deficiency anemia, presumed to be due to chronic menstrual blood loss. She has no gastrointestinal or genitourinary symptoms, and no bruising or bleeding other than menstrual bleeding. Her vital signs are normal and a physical examination is unremarkable. You initiate a trial of oral iron therapy. Which one of the following would be the best way to assess the patient's response to oral iron? A) A reticulocyte count in 1-2 weeks B) A repeat hematocrit in 2 weeks C) A peripheral smear to look for new RBCs in 4 weeks D) A serum total iron binding capacity and ferritin level in 6 weeks

ANSWER: A The reticulocyte count is the first and best indicator of iron absorption and bone marrow response to oral iron therapy in the treatment of iron deficiency anemia. An increase in reticulocytes is seen as early as 4 days, peaking at 7-10 days. The rate of production of new RBCs slows thereafter due to a compensatory decrease in erythropoietin as more iron becomes available. It typically takes 4-6 weeks before seeing recovery in the hematocrit, and for the RBC count and indices to normalize. However it is usually 4-6 months before iron stores are fully restored to normal levels, so treatment should continue for at least that long.

80. A 55-year-old female sees you for a preoperative evaluation prior to having cataract surgery. The patient has a previous history of type 1 diabetes mellitus. She reports that she takes a brisk daily walk and has no angina or other cardiac symptoms. The cardiovascular and pulmonary examinations are unremarkable. Which one of the following would be most appropriate for the preoperative cardiac evaluation of this patient? A) No further evaluation B) An EKG C) A treadmill stress test D) Pharmacologic stress testing E) A chest radiograph

ANSWER: A This 55-year-old patient is undergoing a low-risk procedure. While her diabetes mellitus is a cardiovascular risk factor, she is asymptomatic, her age lowers her risk, and her functional status is good. She should be allowed to undergo cataract surgery with no further evaluation. Guidelines from the American College of Cardiology and the American Heart Association recommend that the patient be allowed to undergo surgery with no further testing.

78. A 47-year-old male who lives at sea level attempts to climb Mt. Rainier. On the first day he ascends to 3400 m (11,000 ft). The next morning he has a headache, nausea, dizziness, and fatigue, but as he continues the climb to the summit he becomes ataxic and confused. Which one of the following is the treatment of choice? A) Administration of oxygen and immediate descent B) Dexamethasone, 8 mg intramuscularly C) Acetazolamide, 250 mg twice a day D) Nifedipine (Procardia), 10 mg immediately, followed by 30 mg in 12 hours E) Helicopter delivery of a portable hyperbaric chamber

ANSWER: A This patient initially showed signs of acute mountain sickness. These include headache in an unacclimated person who recently arrived at an elevation >2500 m (8200 ft), plus one or more of the following: anorexia, nausea, vomiting, insomnia, dizziness, or fatigue. The patient's condition then deteriorated to high-altitude cerebral edema, defined as the onset of ataxia and/or altered consciousness in someone with acute mountain sickness. The management of choice is a combination of descent and supplemental oxygen. Often, a descent of only 500-1000 m (1600-3300 ft) will lead to resolution of acute mountain sickness. Simulated descent with a portable hyperbaric chamber also is effective, but descent should not be delayed while awaiting helicopter delivery. If descent and/or administration of oxygen is not possible, medical therapy with dexamethasone and/or acetazolamide may reduce the severity of symptoms. Nifedipine has also been shown to be helpful in cases of high-altitude pulmonary edema where descent and/or supplemental oxygen is unavailable.

93. A 14-year-old male is brought to your office with a 2-month history of a lump in his left chest. An examination reveals a slightly tender 2-cm area of concentric firm mobile tissue under the left areola. He has no skin changes, nipple discharge, or associated adenopathy. The right side is unremarkable. A genital examination reveals Tanner 3 development but is otherwise unremarkable. Growth curves are appropriate for the patient's age, with a BMI of 19.1 kg/m2. Which one of the following would be most appropriate at this point? A) Follow-up in 6-12 months B) A prolactin level C) Ultrasonography of the left breast D) Tamoxifen (Soltamox), 10 mg/day for 3 months E) A biopsy

ANSWER: A This patient's history and the examination support the diagnosis of adolescent physiologic gynecomastia. The most appropriate next step is follow-up with this patient in 6-12 months. One-half of all adolescent males will experience some form of gynecomastia. This condition is often bilateral, but it is more common on the left side if it is unilateral. It will typically resolve 6-24 months after onset. Patients should be asked about medications and supplements, because these may be a cause of nonphysiologic breast enlargement. Concerning factors include persistence for longer than 2 years; hard, immobile, nontender masses; masses >5 cm; nipple discharge; testicular masses; and systemic symptoms such as weight loss. Evaluation for persistent gynecomastia can include laboratory studies to exclude hepatic, renal, and thyroid disorders, and can progress to include tests to detect gonadotropin and hormone-related tumors and disorders. Imaging and/or a biopsy would be indicated if signs of a carcinoma were noted. The additional options listed are not indicated at this point, although they are a part of the recommended algorithm for further evaluation and treatment considerations.

42. A 69-year-old female presents with scaling, redness, and irritation under her breasts for the past several months. She has tried several over-the-counter antifungal creams without any improvement. On examination you note erythematous, well demarcated patches with some scale under both breasts. You examine the rash with a Wood's lamp to confirm your suspected diagnosis. This rash is most likely to fluoresce A) bright yellow B) coral pink C) lime green D) pale blue E) totally white

ANSWER: B A Wood's lamp may assist with the diagnosis of certain skin conditions. This patient's presentation is consistent with erythrasma caused by a Corynebacterium minutissimum infection, and use of an ultraviolet light would reveal a coral pink color. Pale blue fluorescence occurs with Pseudomonas infections, yellow with tinea infections, and totally white with vitiligo. A lime green fluorescence is not characteristic of a particular skin condition.

75. A 66-year-old female with a previous history of hypertension, stable angina, and carotid endarterectomy presents with acute upper abdominal pain, which has developed over the past 3 hours. A physical examination reveals epigastric tenderness without guarding or rebound, but does not reveal a cause for the level of pain reported by the patient. Initial laboratory findings are within normal limits, including a CBC, glucose, lactic acid, amylase, lipase, liver enzymes, and kidney function tests. You suspect acute mesenteric ischemia. Which one of the following diagnostic imaging tests is the preferred initial evaluation for this problem? A) Duplex ultrasonography B) CT angiography C) Catheter angiography D) Magnetic resonance angiography (MRA) E) Upper and lower GI endoscopy

ANSWER: B CT angiography (CTA) is the recommended imaging procedure for the diagnosis of acute mesenteric vascular disease. The procedure can also identify other possible intra-abdominal causes of pain. Duplex ultrasonography is also accurate, especially for proximal lesions, but can be difficult to perform in patients with obesity, bowel gas, and marked calcification of the vessels, and may be problematic in patients presenting acutely, due to the length of the study and the abdominal pressure required. It is more useful in cases of suspected chronic mesenteric ischemia. Endoscopy is often normal in acute ischemia and may not reach the ischemic section of bowel. MR angiography may be useful, but it takes longer to perform than CTA and lacks the necessary resolution. Catheter angiography is required for endovascular therapies such as thrombolysis or angioplasty with or without stenting, but is usually not performed for making the initial diagnosis in the acute setting.

35. You are initiating pharmacologic therapy for a 75-year-old patient with depression. Which one of the following would be most appropriate for this patient? A) Amitriptyline B) Escitalopram (Lexapro) C) Imipramine (Tofranil) D) Paroxetine (Paxil)

ANSWER: B Escitalopram is a preferred antidepressant for older patients (SOR C). Paroxetine should generally be avoided in older patients due to a higher likelihood of adverse effects (SOR C). Amitriptyline, imipramine, and paroxetine are highly anticholinergic and sedating, and according to the Beers Criteria, they can cause orthostatic hypotension. They have an "avoid" recommendation (SOR A).

27. You see a 3-year-old female with a 2-day history of intermittent abdominal cramps, two episodes of emesis yesterday, and about five watery, nonbloody stools each day. She does not have a fever, her other vital signs are normal, and she has not traveled recently. Today she has tolerated sips of fluid but still has mild fatigue and thirst. An examination is normal except for mildly dry lips. A friend at preschool had a similar illness recently. Which one of the following would be the most appropriate initial management of this patient? A) A sports drink and food on demand B) Half-strength apple juice and food on demand C) Ginger ale and no food yet D) Water and no food yet E) A bolus of intravenous normal saline and no food yet

ANSWER: B Family physicians often see patients with diarrheal illnesses and most of these are viral. Patients sometimes have misconceptions about preferred fluid and feeding recommendations during these illnesses. The World Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution) and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks. Water increases the risk of hyponatremia in children. This patient is not ill enough to need intravenous fluids. Early refeeding has been shown to decrease the duration of illness.

30. A 30-year-old female with anovulatory uterine bleeding asks about treatment options. An examination is normal and blood testing is negative. She is unmarried and is undecided about having children. Which one of the following would be the most appropriate treatment for this patient? A) Oral progestin during the luteal phase B) A levonorgestrel-releasing IUD C) Endometrial ablation D) Hysterectomy

ANSWER: B Few treatments for dysfunctional uterine bleeding have been studied. NSAIDs, oral contraceptive pills, and danazol have not been shown to have sufficient evidence of effect for the treatment of dysfunctional uterine bleeding. Progestin is effective when used on a 21-day cycle, but not if used only during the luteal phase. Hysterectomy and ablation are very effective, but both eliminate fertility. In a young woman unsure about having children, the levonorgestrel-releasing IUD is the most effective treatment that preserves fertility (SOR A).

39. A 67-year-old female presents with a swollen wrist after falling on her outstretched hand. A radiograph of the affected wrist is shown below. Prior to surgical intervention, you recommend application of a A) radial gutter splint B) sugar tong splint C) thumb spica splint D) forearm circumferential cast

ANSWER: B Fractures involving the distal end of the radius are the most common upper extremity fractures and are most common in elderly women. The mechanism of injury is usually from falling on an outstretched hand (FOOSH). Prompt surgical intervention is recommended in patients with neurovascular compromise, open fractures, or evidence of compartment syndrome. In general, circumferential casts should be avoided, as the underlying swelling can compromise distal circulation. The splint of choice in patients with these fractures is a sugar tong splint. Radial gutter splints are indicated for uncomplicated fractures of the second and third metacarpals. Thumb spica splints are often used in patients with suspected scaphoid fractures (SOR B).

47. An 11-year-old female is referred to you after a sports physical examination because 2+ protein was found on a random dipstick urinalysis. She feels well and does not have any health concerns. She plays soccer an average of 5 days a week. The patient's medical history is unremarkable and she takes no medications. Menarche has not occurred. She does not report any urinary or back symptoms, recent illness, edema, or weight change. A physical examination is normal. A dipstick urinalysis in your office shows 1+ protein but is otherwise normal. Which one of the following would you recommend next? A) Withdrawing from all physical activity for 24 hours and a 24-hour urine for protein B) A spot protein/creatinine ratio performed on first morning urine C) Serum BUN, creatinine, electrolyte, and albumin levels D) Ultrasonography of the kidneys and bladder E) Referral to a pediatric nephrologist

ANSWER: B It is important to distinguish serious illness from benign causes of proteinuria, which are the most common etiology in children. Confirming the presence of proteinuria is the next step in this case because functional (exercise/stress-induced) and orthostatic proteinuria are common types of proteinuria and are transient. A 24-hour urine for protein is a possible option, but would be impractical and burdensome for a healthy-acting 11-year-old. The pediatric nephrology panel of the National Kidney Foundation reported that a spot protein/creatinine ratio is a reliable test for ruling out proteinuria. A specialist referral, blood analysis, and ultrasonography are unnecessary unless persistent proteinuria is identified.

56. You are notified by the nurse that a 66-year-old female who was admitted for pain control for her bone metastases is still having breakthrough pain. You gave her 10 mg of immediate-release oxycodone (Roxicodone) 15 minutes ago. You are hoping to optimize pain control and minimize sedation, so you advise the nurse that the last dose will have its peak effect A) now B) 1 hour after it was given C) 2 hours after it was given D) 4 hours after it was given

ANSWER: B Most orally administered immediate-release opioids such as morphine, oxycodone, and hydromorphone reach their peak effect at about 1 hour, at which time additional medication can be given if the patient is still in pain. Intravenous opioids reach their peak effect at about 10 minutes and intramuscular and subcutaneous opioids at about 20-30 minutes. Additional medication may therefore be given at those intervals if additional pain relief is required.

10. You see an adult patient who has chronic urticaria and no other known chronic conditions. He continues to experience hives after a 3-month course of daily loratadine (Claritin). Which one of the following would be the most appropriate addition to his treatment regimen at this time? A) A short course of oral corticosteroids B) Cyclosporine C) Ranitidine (Zantac) D) Narrow-band UV light treatment

ANSWER: C First- and second-generation H1 antihistamine receptor antagonists are generally considered first-line treatment for chronic urticaria, and approximately 60% of patients experience a satisfactory result. Second-generation options such as loratadine have the added benefit of a lower likelihood of side effects such as drowsiness. For those who fail to achieve the desired result with monotherapy using an H1 antihistamine receptor antagonist, the addition of an H2 antihistamine receptor antagonist such as cimetidine or ranitidine is often beneficial. The tricyclic antidepressant doxepin has strong H1 and H2 antihistamine receptor antagonist effects and has been used as an off-label treatment option in some studies. A short course of oral corticosteroids, narrow-band UV light treatment, or cyclosporine can be used in the management of recalcitrant chronic urticaria, but these are considered second- or third-line adjunctive options.

29. An 85-year-old female with advanced Alzheimer's disease is brought to your office for treatment of agitation, aggressive behavior, and delusions. Behavioral and psychological interventions have had little success and the family is willing to try medications because they prefer to keep the patient at home. Which one of the following would most likely help control this patient's symptoms? A) Alprazolam (Xanax) B) Aripiprazole (Abilify) C) Clozapine (Clozaril) D) Donepezil (Aricept) E) Haloperidol

ANSWER: B Nonpharmacologic interventions are the first-line treatment for patients with behavioral and psychological symptoms of dementia. Antipsychotic medications can be prescribed for refractory cases but this is an off-label use. Both the patient and family should be aware that the use of atypical antipsychotics for behavioral symptoms of dementia is associated with increased mortality. Patients should be monitored for side effects and the medication should be discontinued if there is no evidence of symptom improvement after a month. Typical antipsychotics such as haloperidol have significant side effects and would not be a good choice. Donepezil is initiated early in the course of Alzheimer's disease to delay progression of the disease. Benzodiazepines are likely to cause significant side effects including sedation, increased confusion, and falls. Several of the antipsychotics, such as ziprasidone and clozapine, are ineffective. Results with olanzapine, quetiapine, and risperidone are inconsistent. Aripiprazole produces small reductions in behavioral and psychological symptoms of dementia, and it has the least adverse effects of the atypical antipsychotics.

63. A 13-year-old male sees you because of pain in his throwing arm. He is a very dedicated football quarterback and has been practicing throws and playing games every day for 2 months. The pain started gradually over the season, and there is no history of acute injury. The patient is right-hand dominant, and on examination he has pain when he raises his right arm above his shoulder. There is also tenderness to palpation of the proximal and lateral humerus. Which one of the following would be most appropriate at this point? A) Injection of 10 mL of lidocaine into the subacromial space B) Plain radiographs of the shoulder C) Ultrasonography of the supraspinatus muscle D) MRI of the shoulder E) A bone scan of the shoulder

ANSWER: B Pain in the shoulder of a young athlete can be caused by many problems, including acromioclavicular strain, biceps tendinitis, glenohumeral instability, and rotator cuff pathology. Although rotator cuff pathologies are the most frequent cause of shoulder pain in adults, they are uncommon in children. Unique to children, however, is a repetitive use injury causing disruption at the proximal growth plate of the humerus. This condition is referred to as Little League shoulder and can be seen on plain radiographs as widening, demineralization, or sclerosis at the growth plate. If the radiograph is normal but suspicion for this condition is high, a bone scan or MRI can be ordered.

77. A 45-year-old male sees you for follow-up of several chronic medical problems including hypertension, diabetes mellitus, and obesity. He is a truck driver, smokes one pack of cigarettes per day, and does not exercise. His blood pressure is 166/94 mm Hg and his hemoglobin A1c is 9.7%. His medical conditions have been difficult to control with medications and he has been resistant to making lifestyle changes. Which one of the following strategies would be most effective for inducing significant behavioral change? A) Counsel the patient on the complications of smoking and uncontrolled diabetes B) Utilize motivational interviewing to explore the patient's level of desire to change C) Treat the patient with an SSRI and refer him to a counselor D) Transfer the patient to another family physician in your community

ANSWER: B Patients who are resistant to change require skillful management. Motivational interviewing is a technique that has been shown to improve the therapeutic physician-patient alliance and help to engage patients in their own care. The other options listed are not helpful and may damage the therapeutic relationship.

94. A 52-year-old male presents for evaluation of a long-standing facial rash. He reports that the rash is itchy, with flaking and scaling around his mustache and nasolabial folds. Which one of the following is most likely to be beneficial? A) Topical antibacterial agents B) Topical antifungal agents C) Topical vitamin D analogues D) Oral zinc supplementation

ANSWER: B Seborrheic dermatitis is commonly seen in the office setting and affects the scalp, eyebrows, nasolabial folds, and anterior chest. The affected skin appears as erythematous patches with white to yellow greasy scales. The etiology is not exactly known, but it is likely that the yeast Malassezia plays a role. Topical antifungals are effective and recommended as first-line agents. Topical low-potency corticosteroids are also effective alone or when used in combination with topical antifungals, but they should be used sparingly due to their adverse effects. The other agents listed have no role in the management of seborrheic dermatitis (SOR A).

91. Which one of the following diabetes mellitus medications is MOST likely to cause weight gain? A) Empagliflozin (Jardiance) B) Glimepiride (Amaryl) C) Liraglutide (Victoza) D) Metformin (Glucophage) E) Sitagliptin (Januvia)

ANSWER: B Since many patients with diabetes mellitus are obese, the impact of medications on the patient's weight is important to consider. Treatment with sulfonylureas, including glimepiride, is associated with weight gain. Empagliflozin, liraglutide, metformin, and sitagliptin are not associated with weight gain. In particular, the SGLT2 inhibitors such as empagliflozin and the GLP1 agonists such as liraglutide are associated with clinically significant weight loss.

48. Intensive behavioral intervention has more benefit than other treatment modalities in treating children who have been diagnosed with A) attention-deficit/hyperactivity disorder B) autism C) depression D) obsessive-compulsive disorder E) posttraumatic stress disorder

ANSWER: B The only evidence-based treatment that confers significant benefits to children with autism is intensive behavioral interventions, which should be initiated before 3 years of age. Attention-deficit/hyperactivity disorder can be treated with cognitive-behavioral therapy (CBT) but medication is often required. CBT is as effective, if not more effective, than medication for treating anxiety, depression, and trauma-related disorders.

46. A patient has a past medical history that includes a sleeve gastrectomy for weight loss. Which one of the following medications should be AVOIDED in this patient? A) Acetaminophen B) Gabapentin (Neurontin) C) Hydrocodone D) Ibuprofen E) Tramadol (Ultram)

ANSWER: D NSAIDs such as ibuprofen are thought to increase the risk of anastomotic ulcerations or perforations in patients who have had bariatric surgery and should be completely avoided after such surgery if possible (C Recommendation, Level of evidence 3). It is also recommended that alternative pain medications that can be used are identified prior to the surgery (D Recommendation). Options such as acetaminophen, gabapentin, hydrocodone, and tramadol can be considered in patients who have had bariatric surgery if the medications are clinically appropriate otherwise.

15. You see a patient with a serum sodium level of 122 mEq/L (N 135-145) and a serum osmolality of 255 mOsm/kg H2O (N 280-295). Which one of the following would best correlate with a diagnosis of syndrome of inappropriate antidiuresis? A) A fractional excretion of sodium below 1% B) Elevated urine osmolality C) Elevated serum glucose D) Elevated BUN E) Low plasma arginine vasopressin

ANSWER: B The syndrome of inappropriate antidiuresis (SIAD, formerly SIADH) is related to a variety of pulmonary and central nervous system disorders in which hyponatremia and hypo-osmolality are paradoxically associated with an inappropriately concentrated urine. Most cases are associated with increased levels of the antidiuretic hormone arginine vasopressin (AVP). Making a diagnosis of SIAD requires that the patient be euvolemic and has not taken diuretics within the past 24-48 hours, and the urine osmolality must be high in conjunction with both low serum sodium and low osmolality. The BUN should be normal or low and the fractional excretion of sodium >1%. Fluid restriction (<800 cc/24 hrs) over several days will correct the hyponatremia/hypo-osmolality, but definitive treatment requires eliminating the underlying cause, if possible. In the case of severe, acute hyponatremia with symptoms such as confusion, obtundation, or seizures, hypertonic (3%) saline can be slowly infused intravenously but might have dangerous neurologic side effects. Elevated serum glucose levels may cause a factitious hyponatremia, but not SIAD.

33. A 62-year-old female who is a new patient requests a thyroid evaluation because she has a history of abnormal thyroid test results. You obtain a copy of her records, which include a TSH level of 0.2 U/mL (N 0.4-4.2) and a free T4 level of 2.0 ng/dL (N 0.8-2.7) from 3 years ago. She reports feeling well and has no other health conditions. She does not take any medications. A physical examination reveals normal vital signs, a BMI of 23.0 kg/m2, no neck masses, a normal thyroid size, and normal heart sounds. Laboratory studies reveal a TSH level of 0.1 U/mL, a free T4 level of 2.5 ng/dL, and a free T3 level of 3.1 pg/mL (N 2.3-4.2). Treatment for this condition would be indicated if the patient has an abnormal A) calcium level B) DXA scan C) glucose level D) lipid level E) thyroid ultrasonography study

ANSWER: B This patient has subclinical hyperthyroidism as evidenced by her low TSH level with normal free T4 and free T3 levels. Common causes of subclinical hyperthyroidism include Graves disease, autonomous functioning thyroid adenoma, and multinodular toxic goiter. Subclinical hyperthyroidism may progress to overt hyperthyroidism; this is more likely in patients with TSH levels <0.1 U/mL. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including atrial fibrillation, heart failure, and osteoporosis. For this reason it is important to assess for these conditions and consider treating the underlying thyroid condition, as well as the complication. The American Thyroid Association recommends treating patients with complications who are either over age 65 or have a TSH level <0.1 U/mL. Lipid and glucose abnormalities are not known to be related to subclinical hyperthyroidism. Calcium levels may be abnormal in hyperparathyroidism but not hyperthyroidism. Thyroid ultrasonography may be helpful to determine the cause of hyperthyroidism but is not used to help decide when to treat subclinical hyperthyroidism.

45. You see a 53-year-old female with diabetes mellitus, hypertension, mixed hyperlipidemia, and GERD. Recent laboratory studies include an incidental finding of thrombocytopenia. The patient has no other significant past medical history, and she does not use tobacco or drink alcohol. Her current medications include metformin (Glucophage), lisinopril (Prinivil, Zestril), omeprazole (Prilosec), calcium citrate, and pravastatin (Pravachol). A physical examination is notable for a BMI of 31.3 kg/m2. Her skin, heart, lungs, abdomen, and extremities are normal. Results of a CBC and a comprehensive metabolic panel are normal with the following exceptions: Platelets 70,000 (N 150,000-379,000) Glucose 108mg/dL Bilirubin 0.4mg/dL(N0.0-0.4) Alkaline phosphatase 175U/L(N38-126) ALT(SGPT) 52 U/L (N 10-28) A peripheral smear is normal except for reduced platelets. Tests for hepatitis B, hepatitis C, and HIV are negative. The most likely etiology of this patient's thrombocytopenia is A) a hematologic malignancy B) chronic liver disease C) drug-induced thrombocytopenia D) immune thrombocytopenic purpura (ITP) E) primary bone marrow failure

ANSWER: B This patient presents with a typical example of nonalcoholic steatohepatitis (NASH) progressing toward cirrhosis, with multiple risk factors including diabetes mellitus, hyperlipidemia, obesity, and mildly elevated hepatic transaminases. Abnormalities of other cell lines would likely occur if a hematologic malignancy or bone marrow failure were present. While immune thrombocytopenic purpura is a diagnostic consideration, it is much less common than NASH and requires other causes to be ruled out. This patient is not taking any medications that have been frequently reported to cause drug-induced thrombocytopenia.

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

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

85. A 46-year-old male with a 30-pack-year smoking history has had multiple episodes of coughing up blood that he describes as a "quarter size" amount. This has happened over the last couple of days. He has not had any chronic cough and has not been ill. A chest radiograph is negative. Which one of the following would be the most appropriate management at this point? A) Observation with no further workup unless the cough persists for >1 month or the quantity of hemoptysis increases B) CT of the chest C) Referral for bronchoscopy D) Referral for nasolaryngoscopy

ANSWER: B While a plain chest radiograph should come first in the workup for hemoptysis, patients with normal radiographs who have a higher risk of malignancy (age 40 and a smoking history of 30 years) should undergo CT, usually with contrast. If CT is negative, pulmonary consultation and possible bronchoscopy should be pursued. Nasolaryngoscopy is not indicated if the initial history and examination do not indicate an upper airway source. Observation alone is not appropriate in patients with risk factors for malignancy.

62. A 52-year-old female nurse sees you for the first time. She was previously a patient of a recently retired physician in your practice. Her history is significant for a Roux-en-Y gastric bypass, degenerative joint disease of both knees and shoulders, and chronic low back pain. She takes oxycodone (Roxicodone), 5-10 mg every 4 hours. She tells you that she has been taking this for almost 10 years as treatment for various pains. She says that acetaminophen just "does not touch the pain" and that physical therapy has not worked. She asks you to continue this medication. Which one of the following would be the most appropriate management of this patient? A) Add an NSAID to the current regimen B) Initiate weekly urine drug screens C) Taper oxycodone by 5%-10% every 1-4 weeks D) Discontinue oxycodone

ANSWER: C According to the Choosing Wisely recommendations from the American Society of Anesthesiologists, opioids should not be used as first-line therapy for chronic noncancer pain. However, more than one-half of patients who receive continuous opioids for 90 days are still receiving them after 4 years. Chronic opioids should not be abruptly discontinued. When discontinuing chronic opioid therapy, the best practice is to reduce the dosage by 5%-10% every 1-4 weeks, but even this may be too fast for some patients. While controlled substance prescribing plans are considered good practice for long-term opioid use, continuing opioids for this patient would not be good practice given the indication of chronic noncancer pain and the need for safety in her work. Because her use of opioids should be tapered, weekly urine drug screens would continue to be positive and therefore would not be an appropriate management strategy for this patient. NSAIDs are not indicated for this patient due to her history of gastric bypass.

99. A 40-year-old male presents to your office for follow-up of an abnormal clean-catch urine test performed at his employee health clinic during a preemployment screening examination. He had a positive urine dipstick for hemoglobin and 5 RBCs/hpf on microscopy. The urine was negative for protein, WBCs, and casts. A basic metabolic panel was notable for a creatinine level of 0.8 mg/dL (N 0.6-1.2) and a BUN of 15 mg/dL (N 8-23). He reports that he has been healthy and has not sought medical care in the last 5 years. He quit smoking 6 months ago and walks the dog daily for 30 minutes. A physical examination today is normal. According to the guidelines of the American Urological Association, which one of the following would be the most appropriate next step in the workup? A) Repeat urine microscopy B) Urine cytology C) Cystoscopy D) Renal ultrasonography E) Retrograde pyelography

ANSWER: C Asymptomatic microhematuria is defined as 3 or more RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause. Vigorous exercise, viral illness, trauma, and infection have been ruled out as a cause of hematuria in this patient. His renal function is normal. The most appropriate next step in evaluating a patient 35 years of age is to perform a urologic evaluation with cystoscopy. Cystoscopy is also recommended for patients of any age who have risk factors for urinary tract malignancy. The initial examination should also include CT urography with and without contrast. When CT with contrast is contraindicated, an alternative is retrograde pyelography in conjunction with noncontrast CT, MR urography, or ultrasonography. Obtaining urine cytology and urine markers is not recommended as part of the routine evaluation of asymptomatic microhematuria. A repeat urinalysis with microscopy is not needed to confirm asymptomatic microhematuria. According to the American Urological Association, one positive urine sample is sufficient to prompt an evaluation.

53. A 48-year-old male presents with pain in the right antecubital fossa after lifting a trailer in his garage. On examination you note ecchymosis and tenderness in the antecubital fossa. You suspect a possible distal biceps tendon rupture. Which one of the following would be most appropriate at this point? A) A Speed's test B) Plain radiographs of the elbow C) MRI of the elbow D) A local corticosteroid injection E) Referral for physical therapy

ANSWER: C Distal biceps tendon ruptures are relatively uncommon, accounting for about 3% of tendon ruptures. In a patient with a suspected distal biceps tendon rupture, clinical signs can be unreliable and MRI imaging is the test of choice. Bony abnormalities do not contribute to the evaluation of this tendon. A Speed's test is used to evaluate pain related to the long head of the biceps tendon. Surgical repair is the treatment of choice when the tendon is ruptured. Physical therapy and local corticosteroid injections are not beneficial.

3. A healthy 2-month-old female is brought to your office for a routine well baby examination by both of her parents, who have no concerns. The parents refuse routine recommended vaccines for their daughter because of their personal beliefs. You want to incorporate patient-centeredness and are also concerned about improving the health of the population. You decide to follow the CDC recommendations by A) accepting their decision without further action B) not offering vaccines at future visits to preserve a positive doctor-patient relationship C) having the parents sign a refusal to vaccinate form D) dismissing the family from the practice E) pursuing a court order for vaccine administration since the child has no medical exemptions

ANSWER: C Experts recommend that a refusal to vaccinate form be signed by patients or parents who refuse a recommended vaccine. This form should document that the patient/parents were provided the vaccine information statement (SOR C). The CDC recommends against dismissing a patient or family from a practice if they refuse vaccination. Physicians should continue to discuss the benefits of immunizations at subsequent visits, because some patients/parents may reconsider their decision not to vaccinate.

76. A 38-year-old patient wishes to start contraception. She currently takes lisinopril (Prinivil, Zestril) for hypertension and also takes sumatriptan (Imitrex) occasionally for migraines at the first sign of flashing lights or zigzagging lines in her vision. Her medical, family, and social histories are otherwise unremarkable. An examination is notable only for a blood pressure of 130/80 mm Hg and a BMI of 36.0 kg/m2. The patient is interested in using either the vaginal ring or the contraceptive patch. Which one of the following would you recommend? A) Transdermal norelgestromin/ethinyl estradiol (Ortho Evra) B) The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) C) Neither method due to her migraines D) Neither method due to her age E) Losing weight before starting either method

ANSWER: C Family physicians are often asked to provide contraception and need to be familiar with the current methods and contraindications. Estrogen-containing products, including the contraceptive patch and the vaginal ring, are contraindicated in smokers >35 years of age and in patients with migraine with aura.

25. A 60-year-old male presents with a several-month history of a dry cough and progressive shortness of breath with exertion. On examination he has tachypnea and bibasilar end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities. Which one of the following patient occupations would most likely support a diagnosis of silicosis? A) Baker B) Firefighter C) Stone cutter D) Goat dairy farmer E) High-tech electronics fabricator

ANSWER: C Family physicians should be aware of the environmental exposures associated with pulmonary disease. Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens) can result in "farmer's lung," a hypersensitivity pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.

69. Which one of the following malignancies is associated with hereditary hemochromatosis? A) Biliary carcinoma B) Chronic myeloid leukemia C) Hepatocellular carcinoma D) Multiple myeloma E) Pancreatic cancer

ANSWER: C Hereditary hemochromatosis is a genetic disorder of iron regulation and subsequent iron overload. Possible end-organ damage includes cardiomyopathy, cirrhosis of the liver, and hepatocellular carcinoma. Symptoms are often nonspecific early on, but manifestations of iron overload eventually occur. The diagnosis should be suspected in patients with liver disease or abnormal iron studies indicative of iron overload. A liver biopsy can confirm the diagnosis and the degree of fibrosis. Identification of such patients and proper ongoing treatment with phlebotomy may prevent the development of hepatocellular carcinoma and other complications of this disease. There is some data that suggests an association of breast cancer with hereditary hemochromatosis but not with any of the other malignancies listed.

19. A 69-year-old male with type 2 diabetes mellitus, obesity, and a history of coronary artery disease sees you for follow-up of his diabetes. His hemoglobin A1c has increased to 8.7% despite therapy with metformin (Glucophage), 1000 mg twice daily, and insulin glargine (Lantus). Which one of the following additional medications would be most effective for reducing his blood glucose level and lowering his risk of cardiovascular events? A) Exenatide (Byetta) B) Glipizide (Glucotrol) C) Liraglutide (Victoza) D) Rosiglitazone (Avandia) E) Sitagliptin (Januvia)

ANSWER: C Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication. Glipizide (a sulfonylurea), rosiglitazone, and sitagliptin have not been associated with improved cardiovascular outcomes. Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary prevention of cardiovascular disease.

40. A 7-year-old female with asthma is brought to your office because of her fourth episode of wheezing in the last 3 months. She has also had to use her short-acting -agonist rescue inhaler more frequently. Which one of the following should be added to reduce the frequency of asthma exacerbations? A) A leukotriene receptor antagonist B) A long-acting -agonist C) An inhaled corticosteroid D) Inhaled cromolyn via nebulizer

ANSWER: C Pediatric asthma is the most commonly encountered chronic illness, occurring in nearly one out of seven individuals. Short-acting -agonists in the form of metered-dose inhalers are clearly favored for acute exacerbations, as well as for intermittent asthma. Treatment for persistent asthma requires the use of inhaled corticosteroids, with short-acting -agonists used for exacerbations. For patients not well controlled with those options, either a long-acting -agonist or a leukotriene receptor antagonist may be added. While both cromolyn and nedocromil are fairly devoid of adverse effects, their use is limited because of a lack of efficacy in the prevention of acute asthma exacerbations.

2. Which one of the following factors related to pregnancy and delivery increases the risk of developmental dysplasia of the hip in infants? A) A large-for-gestational age infant B) Twin birth C) Breech presentation D) Cesarean delivery E) Premature birth

ANSWER: C Risk factors for developmental dysplasia of the hip in infants include a breech presentation in the third trimester, regardless of whether the delivery was cesarean or vaginal. Other indications to evaluate an infant for this condition include a positive family history, a history of previous clinical instability, parental concern, a history of improper swaddling, and a suspicious or inconclusive physical examination. Twin birth, a large-for-gestational age infant, and prematurity are not considered risk factors.

38. A 32-year-old female sees you for a health maintenance visit. She reports that she experiences severe anxiety when involved in social situations. She lives with her mother and dreads meeting unfamiliar people. At work she remains in her cubicle throughout the day and avoids staff parties. She has a history of alcoholism in remission. She has otherwise been in good health and a physical examination is normal. Which one of the following would be first-line treatment for this patient? A) Amitriptyline B) Bupropion (Wellbutrin) C) Escitalopram (Lexapro) D) Lorazepam (Ativan) E) Pregabalin (Lyrica)

ANSWER: C Social anxiety disorder can be treated with psychotherapy, pharmacotherapy, or both. Several medications have been used for the treatment of social anxiety disorder. SSRIs are considered to be the first-line pharmacologic treatment. Response rates reported for the SNRI venlafaxine have been similar to those reported for SSRIs. Randomized trials have also supported the efficacy of benzodiazepines for social anxiety disorder, but they carry a risk of physiologic dependence and withdrawal symptoms and are not recommended for patients with coexisting depression or a history of substance abuse. Response rates to pregabalin have been lower than with SSRIs. Tricyclic antidepressants and bupropion are not considered to be useful in the treatment of social anxiety disorder.

37. The dietary herbal supplement with the highest risk for drug interactions is A) black cohosh B) ginseng C) St. John's wort (Hypericum perforatum) D) saw palmetto E) valerian

ANSWER: C St. John's wort can reduce the effectiveness of multiple medications because it is an inducer of CYP3A4 and P-glycoprotein synthesis. Concurrent use of St. John's wort with drugs that are metabolized with these systems should be avoided. These include cyclosporine, warfarin, theophylline, and oral contraceptives. St. John's wort should be avoided in patients taking either over-the-counter or prescription medications.

60. A 25-year-old female sees you because of irregular menses, hirsutism, and moderate acne. She is sexually active in a monogamous relationship with a male, has never been pregnant, and prefers not to become pregnant at this time. Which one of the following is considered first-line therapy? A) Clomiphene (Clomid) B) Letrozole (Femara) C) Levonorgestrel/ethinyl estradiol D) Metformin (Glucophage) E) Spironolactone (Aldactone)

ANSWER: C The Endocrine Society recommends hormonal contraception as the first-line medication for women diagnosed with polycystic ovary syndrome (PCOS) who are experiencing irregular menses, acne, and hirsutism and do not desire pregnancy (SOR A). Metformin may help regulate menses but has not been shown to be as effective as oral hormone therapy. In a 2015 Cochrane review, oral contraceptives were recommended as the most effective treatment for hirsutism. Either letrozole or clomiphene is appropriate for women diagnosed with PCOS who want to become pregnant.

95. A 58-year-old male sees you for a routine health maintenance visit. He has a 20-pack-year smoking history and proudly tells you that he quit "for good" 1 year ago. You congratulate him on this accomplishment and encourage him to continue to abstain from tobacco. He has not seen a physician for 20 years. U.S. Preventive Services Task Force recommendations for this patient include which one of the following? A) Abdominal aortic aneurysm screening B) Fall prevention screening C) Hepatitis C screening D) Lung cancer screening with low-dose CT

ANSWER: C The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for hepatitis C virus infection for adults born between 1945 and 1965. Abdominal aortic aneurysm screening with ultrasonography is recommended for men 65-75 years of age who have any history of smoking. The USPSTF recommends annual screening for lung cancer with low-dose CT in adults 55-80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Fall risk screening is recommended in community-dwelling adults 65 years of age or older.

88. The U.S. Preventive Services Task Force recommends routine screening for gestational diabetes mellitus no sooner than A) 16 weeks gestation B) 20 weeks gestation C) 24 weeks gestation D) 32 weeks gestation

ANSWER: C The U.S. Preventive Services Task Force recommends screening for gestational diabetes mellitus after 24 weeks gestation with a fasting blood glucose level, a 50-g oral glucose challenge, or an assessment of risk factors (A recommendation). Screening at an earlier date receives a rating of insufficient evidence, and screening at later dates is not recommended (SOR C).

79. A 60-year-old male presents with the lesion shown below. It has grown over the last few months. His past medical history includes well controlled hypertension. He takes lisinopril (Prinivil, Zestril), 10 mg daily, and aspirin, 81 mg daily. After the diagnosis is established with a biopsy, which one of the following has the highest cure rate for this problem? A) Standard wide excision B) Electrodesiccation and curettage C) Mohs surgery D) Photodynamic therapy E) Radiation therapy

ANSWER: C This patient most likely has a basal cell carcinoma, which can be proven by a shave biopsy. Given its size and location, Mohs surgery would be the preferred treatment. It also has the highest cure rate of any of the options listed, including a standard wide excision, electrodesiccation and curettage, photodynamic therapy, and radiation therapy. It has a 99% cure rate for primary basal cell cancers, compared with just over 91% for other methods. Photodynamic therapy and radiation therapy should be used for lesions such as this only if surgery is not an option due to medical comorbidities and/or patient preference.

13. A 45-year-old female who works as a house cleaner presents with left shoulder pain. On examination she has pain and relative weakness when pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back. This presentation is most consistent with an injury of which one of the following tendons? A) Deltoid B) Infraspinatus C) Subscapularis D) Supraspinatus E) Teres minor

ANSWER: C This patient's pain and weakness while pushing against resistance reveals weakness on internal rotation of the shoulder, which suggests a possible tear of the subscapularis tendon. The inability to keep her hand away from her body when it is placed behind her back describes a positive internal lag test, also suggesting involvement of the subscapularis tendon. The infraspinatus and teres minor are involved in external rotation rather than internal rotation. The supraspinatus and deltoid are involved in abduction of the shoulder.

100. A 68-year-old female presents with a 3-month history of low back pain and fatigue. She has unintentionally lost 15 lb. A physical examination is positive for vertebral point tenderness over the third and fourth lumbar vertebrae. Initial laboratory testing reveals a normocytic anemia, elevated total protein, and a mild decrease in renal function. You order a lumbar spine radiograph and additional diagnostic testing. Which one of the following would be most appropriate at this point? A) A serum ferritin level and iron studies B) TSH and vitamin B12 levels C) Serum protein electrophoresis D) MRI of the lumbar spine E) A bone marrow biopsy

ANSWER: C This patient's presentation is concerning for hematologic malignancy, in particular multiple myeloma. Along with radiography, the next appropriate step is serum protein electrophoresis. If laboratory work shows a monoclonal spike or if a skeletal survey indicates lytic lesions, referral to an oncologist is indicated for a bone marrow biopsy. MRI of the lumbar spine would be premature and obtaining iron studies, a TSH level, or a vitamin B12 level would not adequately address the initial abnormal laboratory studies or facilitate making the diagnosis of multiple myeloma.

17. An 85-year-old female with metastatic breast cancer requests hospice care. She has type 2 diabetes mellitus, stage 3 renal failure, and heart disease. The patient's eligibility for hospice care will be based on her A) age B) cancer diagnosis C) comorbid conditions D) life expectancy E) Medicare Part B plan

ANSWER: D Eligibility for hospice care is based on a life expectancy of 6 months or less in the natural course of an illness. A majority of hospice patients have cancer but it is not a requirement to qualify for hospice care. Age is not relevant. Comorbid conditions may affect longevity but are not required. For those insured by Medicare, Medicare Part A provides hospice care but Medicare Part B does not.

52. A 68-year-old female presents with a history of episodic severe lower abdominal pain relieved by defecation. She has had a long history of constipation with normal to very firm stools. Her history and a physical examination are otherwise normal. A colonoscopy 3 years ago was normal. You diagnose constipation-predominant irritable bowel syndrome. Which one of the following agents would be the most appropriate treatment for this patient? A) Lactulose B) Magnesium citrate C) Milk of magnesia D) Polyethylene glycol E) Sodium phosphate

ANSWER: D Hypertonic osmotic laxatives such as milk of magnesia, magnesium citrate, and sodium phosphate draw water into the bowel and should be used with caution in older adults and those with renal impairment because of the risk of electrolyte abnormalities and dehydration in patients with irritable bowel syndrome (IBS). Lactulose, also an osmotic laxative, should be avoided in patients with IBS because it is broken down by colonic flora and produces excessive gas. Polyethylene glycol, a long-chain polymer of ethylene oxide, is a large molecule that causes water to be retained in the colon, which softens the stool and increases the number of bowel movements. It is approved by the FDA for short-term treatment in adults and children with occasional constipation and is commonly prescribed for patients with IBS. It is considered safe and effective for moderate to severe constipation when used either daily or as needed.

55. A 47-year-old male presents with bilateral lower extremity edema of undetermined etiology extending to the proximal lower extremities, associated with fatigue. His lipid levels were also very high on recent testing. He does not take any daily medications and his thyroid function is normal. The only significant findings on examination are lower extremity edema and some periorbital edema. Which one of the following urine tests could help confirm the most likely diagnosis? A) Crystals B) Ketones C) pH D) Protein E) Specific gravity

ANSWER: D Nephrotic syndrome includes peripheral edema, heavy proteinuria, and hypoalbuminemia. Hyperlipidemia also occurs frequently and can be significant. Nephrotic-range proteinuria is a spot urine showing a protein/creatinine ratio >3.0-3.5 mg protein/mg creatinine or a 24-hour urine collection showing >3.0-3.5 g of protein. Testing urine for ketones, pH, specific gravity, or crystals does not help to diagnose nephrotic syndrome.

32. A 66-year-old male recently underwent percutaneous angioplasty for persistent angina with exertion. He does not have any symptoms now. His LDL-cholesterol level is 90 mg/dL. Which one of the following would be most appropriate for secondary prevention of this patient's coronary artery disease? A) No drug treatment B) Evolocumab (Repatha), 140 mg subcutaneously every 2 weeks C) Ezetimibe (Zetia), 10 mg daily D) Rosuvastatin (Crestor), 20 mg daily E) Simvastatin (Zocor), 40 mg daily

ANSWER: D Patients <75 years of age with established coronary artery disease should be on high-intensity statin regimens if tolerated. These regimens include atorvastatin, 40-80 mg/day, and rosuvastatin, 20-40 mg/day. Moderate-intensity regimens include simvastatin, 40 mg/day. Monotherapy with non-statin medications (bile acid sequestrants, niacin, ezetimibe, and fibrates) does not reduce cardiovascular morbidity or mortality. The PCSK9 inhibitors evolocumab and alirocumab are second-line or add-on therapies at this time.

31. A 73-year-old male with advanced degenerative arthritis of the knees asks what you would recommend for relief. He does not wish to have a total knee replacement. He says that NSAIDs have not been effective. Which one of the following would be the best recommendation? A) Acetaminophen B) Intra-articular corticosteroids C) Intra-articular hylan GF 20 (Synvisc) D) Physical therapy for quadriceps strengthening E) Tramadol (Ultram)

ANSWER: D Quadriceps-strengthening exercises have been shown in good studies to stabilize the knee and reduce pain for patients with degenerative arthritis. Acetaminophen has not been shown to produce clinically significant improvement from baseline pain. Intra-articular corticosteroids can acutely relieve pain and effusions but do not affect moderate-term outcomes. Hylan GF 20 products are minimally effective. Opiates and other similar drugs are addictive and should be avoided.

97. Which one of the following is the preferred first-line agent in the treatment of rheumatoid arthritis? A) Adalimumab (Humira) B) Etanercept (Enbrel) C) Hydroxychloroquine (Plaquenil) D) Methotrexate (Trexall) E) Prednisone

ANSWER: D The American College of Rheumatology recommends methotrexate, a nonbiologic disease-modifying antirheumatic drug (DMARD), as a first-line agent in the treatment of rheumatoid arthritis in the absence of contraindications, such as underlying liver disease. Starting DMARDs within 3 months of the onset of rheumatoid arthritis symptoms is more likely to result in sustained remissions. The addition of short-term prednisone is indicated in select cases when disease activity is high. The use of biological agents such as adalimumab, etanercept, and others is indicated only in refractory cases and in patients who cannot tolerate nonbiologic DMARDs.

7. You are the team physician for the local high school track team. During a meet one of the athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She is able to bear weight but with significant pain. She reports pain across her right midfoot. An examination reveals edema over the lateral malleolus and diffuse tenderness, but she does not have any pain with palpation of the navicular, the base of the fifth metatarsal, or the posterior distal lateral and medial malleoli. Which one of the following would be most appropriate at this time? A) Radiographs of the right ankle only B) Radiographs of the right foot only C) Radiographs of the right foot and ankle D) Lace-up ankle support, ice, compression, and clinical follow-up E) Crutches and no weight bearing for 2 weeks, followed by a slow return to weight bearing

ANSWER: D The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot and ankle injuries. A radiograph of the ankle is recommended if there is pain in the malleolar zone along with the inability to bear weight for at least four steps immediately after the injury and in the physician's office or emergency department (ED), or tenderness at the tip of the posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain in the midfoot zone along with the inability to bear weight for four steps immediately after the injury and in the physician's office or ED, or tenderness at the base of the fifth metatarsal or over the navicular bone. The Ottawa foot and ankle rules are up to 99% sensitive for detecting fractures, although they are not highly specific. In this case there are no findings that would require radiographs, so treatment for the ankle sprain would be recommended. Compression combined with lace-up ankle support or an air cast, along with cryotherapy, is recommended and can increase mobility. Early mobilization, including weight bearing as tolerated for daily activities, is associated with better long-term outcomes than prolonged rest.

50. A 45-year-old female sees you because of an increase in fibromyalgia pain. On examination she has a BMI of 35.6 kg/m2 and normal vital signs except for a blood pressure of 156/91 mm Hg. Her other medical problems include obstructive sleep apnea, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder. She smokes one pack of cigarettes daily and does not drink alcohol. She is currently taking metformin (Glucophage), 500 mg twice daily; lisinopril (Prinivil, Zestril), 10 mg daily; gabapentin (Neurontin), 300 mg 3 times daily; oxycodone (OxyContin), 10 mg every 6 hours; and lorazepam (Ativan), 1 mg 3 times daily. Which one of the following findings in this patient's history greatly increases her risk of an accidental overdose? A) Tobacco use B) Morbid obesity C) Use of oxycodone D) Use of oxycodone and lorazepam E) Use of lorazepam and gabapentin

ANSWER: D The increase in opiate-related accidental overdoses has become a significant concern in recent years, prompting the CDC to release updated guidelines for the use of narcotic medications for chronic noncancer pain. There are several concerning issues in this patient's care. Her obstructive sleep apnea, psychiatric ailments, and concurrent use of opiates and benzodiazepines all increase the risk of an accidental overdose. The CDC also warns against using opiates in patients with heart failure, chronic pulmonary diseases, and a personal history of drug or alcohol abuse. These risks are so great that the CDC recommends that chronic noncancer pain be primarily treated with nonpharmacologic and nonopiate medications. The use of opioids should be reserved for recalcitrant cases under close supervision at the lowest effective dose for the shortest time possible. The CDC also recommends against using opiates in fibromyalgia and neuropathy due to limited efficacy and side-effect profiles (SOR B). The concurrent use of opiates and benzodiazepines should be avoided in nearly all situations (SOR C). Safety should never be compromised for reduced pain and increased functionality.

84. A 16-year-old white male sees you for a sports preparticipation examination. His height is 193 cm (76 in), his weight is 69 kg (152 lb), and he appears to have long arms. A physical examination reveals a high arched palate, kyphosis, myopia, and pectus excavatum. Which one of the following valvular abnormalities is most likely in this patient? A) Mitral stenosis B) Pulmonic stenosis C) Aortic stenosis D) Aortic insufficiency E) Bicuspid aortic valve

ANSWER: D This adolescent has findings of Marfan syndrome. It is associated with arachnodactyly, an arm span greater than height, a high arched palate, kyphosis, lenticular dislocation, mitral valve prolapse, myopia, and pectus excavatum. The cardiac examination may reveal an aortic insufficiency murmur, or a murmur associated with mitral valve prolapse. Cardiovascular defects are progressive, and aortic root dilation occurs in 80%-100% of affected individuals. Aortic regurgitation becomes more common with increasing age.

23. A 32-year-old male presents with a 4-week history of persistent low back pain. He started feeling tightness in his low back after helping a friend move into a new apartment. The pain does not radiate, there is no associated paresthesia or numbness, and he has not had any bowel or bladder incontinence. The pain is constant and worsens with prolonged sitting. He rates the pain as 6 on a scale of 10. Ibuprofen has provided minimal relief. Examination of the lumbar area over the paraspinous muscles reveals minimal tenderness. A neurovascular examination and a straight leg raise are normal in both lower extremities. Which one of the following would be most appropriate at this point? A) Imaging studies of the lumbar spine B) A short course of an oral corticosteroid C) Gabapentin (Neurontin) started at a low dose and titrated to effect D) A skeletal muscle relaxant and an NSAID E) A short-acting opioid and an NSAID

ANSWER: D This patient has acute to subacute nonspecific low back pain. Combination treatment with an NSAID and a skeletal muscle relaxant is recommended as second-line therapy when an NSAID is ineffective as monotherapy. Opioids have not been shown to have significant benefit when added to an NSAID and would not be recommended as a second-line treatment. Systemic corticosteroids do not have evidence to support their use in the treatment of acute nonspecific back pain. Gabapentin does not have evidence to support its use in treating acute back pain and has been shown to produce only minimal improvement in chronic back pain. This patient has no red-flag symptoms so imaging studies are not recommended at this time.

11. A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There are no other historical or physical examination findings to suggest active tuberculosis infection and a chest radiograph is normal. Which one of the following would be most appropriate at this point? A) Monitoring with annual tuberculin skin testing B) Observation and repeat tuberculin skin testing in 3 weeks C) Rifampin (Rifadin) daily for 4 months D) Isoniazid daily for 9 months E) Once-weekly isoniazid and rifampin for 3 months

ANSWER: D This patient's close contact with a person known to be infected with tuberculosis (TB) places him at risk for infection, so screening for TB is indicated. For this patient, testing with either a tuberculin skin test or an interferon-gamma release assay is appropriate. Based on CDC guidelines an induration 5 mm at 48-72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been in recent contact with a person with infectious TB, those with radiographic evidence of prior TB, HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the threshold for a positive test is an induration 10 mm at 48-72 hours. For those with no known risks for TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is no indication for additional skin tests. A positive screening test along with a review of systems, a physical examination, and a chest radiograph that do not show evidence of active infection confirms the diagnosis of latent TB. For children age 2-11 years, treatment with isoniazid, 10-20 mg/kg daily or 20-40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment regimen. The shorter 6-month treatment course is considered an acceptable option for adults, but it is not recommended for children. The use of rifampin alone or in combination with isoniazid is also an acceptable option for adults but not for children under the age of 12.

68. A 24-year-old female seeks your advice regarding the recent onset of a cough when running. She moved to the United States from Mexico last year and her symptoms first became apparent during her first winter in the Midwest. The cough starts after she has been running approximately 1 mile but no sputum is produced and no other symptoms occur. She has no other health concerns. A physical examination and office spirometry are consistent with a healthy young adult. You ask her to run around the outside of the clinic several times and then you reexamine her. The only change noted is an increase in her pulse rate and a 10% drop in her FEV1. Which one of the following would be the most appropriate initial treatment for this patient? A) An endurance conditioning program B) An over-the-counter antihistamine as needed C) An inhaled corticosteroid 2 hours before running D) An inhaled short-acting 2-agonist 15 minutes before running E) Daily use of an inhaled long-acting 2-agonist

ANSWER: D This patient's history and examination findings are typical for exercise-induced asthma. The most appropriate initial treatment for this condition is an inhaled short-acting 2-agonist (SABA) 15 minutes before exercise (SOR A). Daily use of an inhaled long-acting 2-agonist as a single agent is not recommended even for those who continue to experience symptoms when using an inhaled SABA (SOR B). The addition of a daily inhaled corticosteroid is an appropriate consideration for patients who require more than a SABA to control symptoms but these should not be used on an as-needed basis before exercise (SOR B). Use of an antihistamine in an individual with exercise-induced asthma but no known allergies is not recommended (SOR B). Other treatment considerations with weak recommendations include a low-sodium diet, air humidification, and supplemental dietary fish oils.

5. An 85-year-old female with a previous history of diabetes mellitus, hypertension, dementia, and peptic ulcer disease has been in a skilled nursing facility for 4 weeks for rehabilitation after a hip fracture repair secondary to a fall during an ischemic stroke. She is transported to the emergency department today when she develops confusion, shortness of breath, and diaphoresis. Her blood pressure is 172/98 mm Hg, her heart rate is 122 beats/min with an irregular rhythm, and her respiratory rate is 22/min. An EKG demonstrates atrial fibrillation and 0.2 mV ST-segment elevation compared to previous EKGs. Her first troponin level is elevated. Which one of the following conditions in this patient is considered an ABSOLUTE contraindication to fibrinolytic therapy? A) Poorly controlled hypertension B) Peptic ulcer disease C) Alzheimer's dementia D) Hip fracture repair E) Ischemic stroke

ANSWER: E A history of an ischemic stroke within the past 3 months is an absolute contraindication to fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI), unless the stroke is diagnosed within 41⁄2 hours. Poorly controlled hypertension, dementia, peptic ulcer disease, and major surgery less than 3 weeks before the STEMI are relative contraindications that should be considered on an individual basis.

92. A previously healthy 34-year-old female presents with a 1-hour history of palpitations. She does not have a cough, shortness of breath, wheezing, or chest pain. An EKG is shown below. Which one of the following laboratory tests is most likely to demonstrate the cause of the patient's underlying problem? A) BNP B) D-dimer C) Lactic acid D) Troponin E) TSH

ANSWER: E This patient's EKG shows atrial fibrillation with a rapid ventricular response. A TSH level should be obtained in all patients presenting with acute atrial fibrillation, because patients with subclinical hyperthyroidism have a threefold increased risk of developing atrial fibrillation. D-dimer has a negative predictive value in the diagnosis of pulmonary embolism. Elevated troponin is a diagnostic marker of acute myocardial infarction and a troponin level should be obtained when acute coronary syndrome is being considered as a cause of acute atrial fibrillation. Elevated lactic acid is associated with sepsis. BNP levels should be ordered if heart failure is suspected (SOR C).

1. A 68-year-old male presents to your office with a 2-day history of headache, muscle aches, and chills. His wife adds that his temperature has been up to 104.1°F and he seems confused sometimes. His symptoms have not improved with usual care, including ibuprofen and increased fluid intake. He and his wife returned from a cruise 10 days ago but don't recall anyone having a similar illness on the ship. This morning he started to cough and his wife was concerned because she saw some blood in his sputum. He also states that he experiences intermittent shortness of breath and feels nauseated. His blood pressure is 100/70 mm Hg, heart rate 98/min, temperature 39.4°C (102.9°F), and oxygen saturation 95% on room air. Which one of the following would be the preferred method to confirm your suspected diagnosis of Legionnaires' disease? A) Initiating azithromycin (Zithromax) to see if symptoms improve B) A chest radiograph C) Legionella polymerase chain reaction (PCR) testing D) A sputum culture for Legionella E) Urine testing for Legionella pneumophila antigen

ANSWER: E A urine test for Legionella pneumophila antigen is the preferred method to confirm Legionnaires' disease. This test is rapid and will only detect Legionella pneumophila antigen. A sputum culture is the gold standard for the diagnosis of Legionnaires' disease but it requires 48-72 hours. A chest radiograph does not confirm the diagnosis but may show the extent of disease. Responding to antibiotic treatment does not confirm a specific diagnosis.

43. A 25-year-old female who recently moved to the area comes in for a well woman visit. She reports that she has had yearly Papanicolaou (Pap) tests and sexually transmitted infection (STI) screening since age 21 with no abnormal results. She has had a total of six sexual partners. She is asymptomatic and does not have any history of STIs or new partners in the past year. Your nurse informs her that STI screening can be done, but a Pap test is not necessary at this time. The patient is concerned about not having a Pap test this year and asks you why it is not recommended. You explain that the most important reason is that A) she has no history of STIs B) she has had several normal Pap tests in a row C) she is in a low-risk group for HPV infection D) Pap test abnormalities would require no further evaluation in a patient her age E) the risk of harm from unnecessary procedures and treatment exceeds the potential benefit at her age

ANSWER: E Annual HPV screening in patients age 21-29 years has very little effect on cancer prevention and leads to an increase in procedures and treatments without significant benefit. In this age group there is a high prevalence of high-risk HPV infections but a low incidence of cervical cancer. If this patient were due for a Papanicolaou (Pap) test and results were ASC-US with a positive high-risk HPV or a higher grade abnormality, colposcopy would be recommended. Current recommendations are for a Pap test with cytology every 3 years for women age 21-29 years with normal results, and the frequency does not change with an increased number of normal screens. HPV is the most common sexually transmitted infection (STI) and up to 79% of sexually active women contract HPV infection in their lifetime, so the lack of other STIs does not preclude the possibility of an HPV infection.

72. Of the following, which one is the greatest risk factor for developing knee osteoarthritis as an older adult? A) A sedentary lifestyle B) Cigarette smoking C) Low socioeconomic status D) Male sex E) Obesity

ANSWER: E Because debilitating knee osteoarthritis is a frequent health concern in older adults, physicians should try to identify and possibly modify factors that increase the risk for this condition. Pooled data from many large studies has been sufficient to clearly identify several major risk factors for the development and progression of osteoarthritis of the knees. Overweight and obesity have consistently been found to approximately double the risk for developing knee osteoarthritis. Other factors that have been identified as risk factors include female sex, advancing age (50-75 years of age), and previous trauma. Smoking, inactivity, moderate physical activity, and socioeconomic status have not been shown to affect one's risk for developing knee osteoarthritis. However, any of these factors in the extreme may be detrimental to joint health in general.

90. An 84-year-old female with severe dementia due to Alzheimer's disease is a resident of a long-term care facility. She has been hitting the staff while receiving personal care and recently had an altercation with another resident. Behavioral interventions have been unsuccessful in managing her symptoms and you suggest to the patient's family that she be started on low-dose risperidone (Risperdal). They ask about appropriate use of the drug and the potential for side effects. Which one of the following would be appropriate advice? A) Extrapyramidal side effects are more common compared to typical antipsychotics B) Dementia-related psychosis is an FDA-approved indication C) No monitoring will be necessary D) The risk of diabetes mellitus is decreased E) The risk of mortality is increased

ANSWER: E Both typical and atypical antipsychotics increase the risk of mortality in patients with dementia. The FDA has a black box warning on these medications, including risperidone, about the increased risk of mortality in patients with dementia. Risperidone is not approved by the FDA for dementia-related psychosis. The typical antipsychotics are more commonly associated with extrapyramidal side effects. Diabetes mellitus and agranulocytosis are associated with the atypical antipsychotics, including risperidone. Periodic monitoring of serum glucose levels and CBCs is recommended.

58. Which one of the following antihypertensive drugs may reduce the severity of sleep apnea? A) Amlodipine (Norvasc) B) Hydralazine C) Lisinopril (Prinivil, Zestril) D) Metoprolol E) Spironolactone (Aldactone)

ANSWER: E Diuretics lessen the severity of obstructive sleep apnea and reduce blood pressure. Aldosterone antagonists offer further benefit beyond that of traditional diuretics. Resistant hypertension is common in patients with obstructive sleep apnea. Resistant hypertension is also associated with higher levels of aldosterone, which can lead to secondary pharyngeal edema, increasing upper airway obstruction.

28. A 32-year-old female requests a physical examination prior to participating in an adult soccer league. Her blood pressure is 118/70 mm Hg and her pulse rate is 68 beats/min. The examination is otherwise normal except for a systolic murmur that intensifies with Valsalva maneuvers. She says that she has recently been experiencing mild exertional dyspnea and moderate chest pain. The chest pain has been atypical and is not necessarily related to exertion. Echocardiography reveals hypertrophic cardiomyopathy. In addition to referring the patient to a cardiologist, you recommended initiating therapy with A) amiodarone (Cordarone) B) amlodipine (Norvasc) C) furosemide (Lasix) D) lisinopril (Prinivil, Zestril) E) metoprolol

ANSWER: E Hypertrophic cardiomyopathy is the most common primary cardiomyopathy, with a prevalence of 1:500 persons. Many patients with hypertrophic cardiomyopathy are asymptomatic and are diagnosed during family screening, by auscultation of a heart murmur, or incidentally after an abnormal result on electrocardiography. On examination physicians may hear a systolic murmur that increases in intensity during Valsalva maneuvers. The main goals of therapy are to decrease exertional dyspnea and chest pain and prevent sudden cardiac death. -Blockers are the initial therapy for patients with symptomatic hypertrophic cardiomyopathy. Nondihydropyridine calcium channel blockers such as verapamil can be used if -blockers are not well tolerated.

71. A 21-year-old female is being evaluated for secondary causes of refractory hypertension. Which one of the following would be most specific for fibromuscular dysplasia? A) A serum creatinine level B) An aldosterone:renin ratio C) 24-hour urine for metanephrines D) Renal ultrasonography E) Magnetic resonance angiography of the renal arteries

ANSWER: E In young adults diagnosed with secondary hypertension, evaluation for fibromuscular dysplasia of the renal arteries with MR angiography or CT angiography is indicated (SOR C). The aldosterone/renin ratio is the most sensitive test to diagnose primary hyperaldosteronism. Renal ultrasonography is an indirect test that is not as sensitive or specific for fibromuscular dysplasia. Serum creatinine elevation shows renal involvement but does not identify the cause. Testing for metanephrines is indicated only if a pheochromocytoma is suspected.

20. A 2-year-old African-American male with a history of sickle cell disease is brought to your office for a well child check. Which one of the following would be most appropriate for screening at this time? A) A chest radiograph B) A DXA scan C) Abdominal ultrasonography D) Renal Doppler ultrasonography E) Transcranial Doppler ultrasonography

ANSWER: E Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle cell patients 2-16 years of age should be screened with transcranial Doppler ultrasonography (SOR A). A chest radiograph, abdominal ultrasonography, a DXA scan, and renal Doppler ultrasonography are not recommended for screening patients with sickle cell disease.

81. The novel anticoagulants (NOACs) include apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto). Which one of the following should be considered when starting or adjusting the dosage of a NOAC? A) Serum albumin B) INR C) Liver enzymes D) Partial thromboplastin time E) Renal function

ANSWER: E The novel anticoagulants (NOACs) require dosage adjustments based on renal function. There are no dosing recommendations for NOACs based on liver function or albumin level. The INR is used to adjust warfarin dosing and the partial thromboplastin time is used to adjust heparin dosing.

64. A 30-year-old female presents with an episode of recurrent, painful vesicular lesions on the labia. She noted a tingling, burning sensation a few days before the lesions appeared. A few years ago she had a similar outbreak just before the birth of her second child. Which one of the following is indicated for this patient? A) Doxycycline B) Fluconazole (Diflucan) C) Metronidazole D) Penicillin G benzathine (Bicillin L-A) E) Valacyclovir (Valtrex)

ANSWER: E This patient has a recurrent outbreak of genital herpes, and valacyclovir is the preferred treatment. Penicillin G benzathine is a treatment for syphilis, which usually begins as a painless papule that transforms into the classic chancre. Fluconazole and metronidazole are treatments for yeast vaginitis and bacterial vaginitis; these conditions present with itching and a vaginal discharge but not vesicular lesions. Doxycycline is a treatment for Chlamydia infection, which is often completely asymptomatic and detected only with screening.

73. A staff member at a local assisted living facility calls you about an 88-year-old female who has chronic urinary incontinence and well controlled hypertension. A urinalysis was obtained after the patient reported some dizziness and malaise. She does not have dysuria and has had no change to her incontinence. The patient is afebrile and other vital signs are normal. The urine culture reveals >100,000 colony-forming units of Escherichia coli, with sensitivities pending. In addition to supportive care and hydration, which one of the following would be indicated at this time? A) Ciprofloxacin (Cipro) B) Fosfomycin (Monurol) C) Nitrofurantoin (Macrodantin) D) Trimethoprim/sulfamethoxazole

ANSWER: E This patient has asymptomatic bacteriuria and does not require antibiotic therapy at this time. In women age 70 and older the incidence of asymptomatic bacteriuria is 16%-18%, and in chronically incontinent and disabled older adults rates may reach 43%. Symptoms that raise concern for a urinary tract infection (UTI) include acute dysuria, new or worsening urinary urgency or frequency, new incontinence, gross hematuria, and suprapubic or costovertebral angle tenderness. General malaise in the absence of these symptoms is unlikely to represent a UTI and unlikely to improve with antibiotic therapy. When antibiotic therapy is indicated for a UTI, trimethoprim/sulfamethoxazole remains the first-line agent. Nitrofurantoin may be used for those with a creatinine clearance >40 mL/min/1.73 m2. Ciprofloxacin is recommended as a first-line agent only in communities with trimethoprim/sulfamethoxazole resistance rates above 10%-20%. Fosfomycin may be used for more highly resistant organisms. The choice of antibiotic should be guided by bacterial pathogens if they are known.

96. A 30-year-old female who gave birth to a healthy infant 3 months ago has had mildlydepressed moods almost daily for the last 7 weeks. She takes very little joy in daily activities and interacting with her baby. She is exclusively breastfeeding and has difficulty sleeping. She says that she felt fine during the first month after the delivery, and has not experienced any homicidal or suicidal ideations. You rule out postpartum psychosis and bipolar disorder. Which one of the following would be most appropriate at this point? A) Reassurance only B) A home health visit C) Oral contraceptives D) Trazodone (Oleptro) E) Referral for psychotherapy

ANSWER: E This patient has peripartum depression. All women should be screened for depression during pregnancy and the postpartum period (SOR B). Reassurance may be appropriate for the baby blues, which usually start 2-3 days after birth and last less than 10 days. First-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery may benefit from home health visits or peer support to prevent but not treat peripartum depression. Mild to moderate peripartum depression can be treated with psychotherapy or SSRIs, with consideration of medications with the lowest serum medication levels in breastfed infants. Tricyclic antidepressants such as trazodone are not considered first-line treatment for peripartum depression.

24. A 48-year-old female with GERD treated with a proton pump inhibitor for the past 2 years sees you for a routine visit. She reports that she has paresthesia and numbness in both feet. Her hemoglobin A1c is 5.8%, her hemoglobin level is 10.4 g/dL (N 12.0-16.0), and her mean corpuscular volume is 102 m3 (N 81-99). Microfilament testing shows decreased sensation in both feet. Which one of the following is the most likely cause of her peripheral neuropathy? A) Charcot-Marie-Tooth disease B) Diabetic peripheral neuropathy C) Hyperthyroidism D) Tarsal tunnel syndrome E) Vitamin B12 deficiency

ANSWER: E This patient has polyneuropathy, macrocytic anemia, and a history of chronic proton pump inhibitor use. The most likely cause is vitamin B12 deficiency and a serum level is indicated. Her hemoglobin A1c is 5.8%, which puts her at risk of developing diabetes mellitus but is not indicative of diabetes. Charcot-Marie-Tooth disease is a rare cause of polyneuropathy and unlikely in this case. Hypothyroidism, and not hyperthyroidism,

83. A 68-year-old male with a 40-pack-year history of smoking presents with a 2-month history of dyspepsia and difficulty swallowing. He also reports a 20-lb unintentional weight loss. He takes omeprazole (Prilosec), 20 mg daily. Which one of the following would be most appropriate at this point? A) Increasing omeprazole to 40 mg twice daily B) Abdominal CT C) Barium esophagography D) Esophageal manometry E) Upper endoscopy

ANSWER: E This patient has risk factors and symptoms that suggest esophageal cancer. According to the Society of Thoracic Surgeons and the National Comprehensive Cancer Network, upper endoscopy with a biopsy of suspicious lesions is the recommended initial evaluation for symptoms of esophageal cancer (SOR C). Esophagography would be appropriate in patients unable to undergo endoscopy but would not be the preferred test. CT of the abdomen is not indicated in the initial evaluation for esophageal cancer but can be integrated with a PET scan for staging. Esophageal manometry is reserved for patients with dysphagia if upper endoscopy does not establish a diagnosis and a motility disorder is suspected. Increasing the dosage of the proton pump inhibitor would not be an appropriate treatment for this patient's condition and may delay the diagnosis and treatment of suspected cancer if the patient is not referred promptly for upper endoscopy.

86. A 68-year-old female presents for evaluation of shortness of breath with activity for the past several weeks. She used to walk 2 miles daily for exercise but can no longer do so because of dyspnea and chest tightness. She also reports mild lower extremity edema. She has a history of a bicuspid aortic valve and aortic stenosis. Echocardiography 1 year ago showed moderately severe aortic stenosis with a mean valve area of 1.1 cm2. Echocardiography today shows aortic stenosis with an aortic valve area of 0.9 cm2, a mean pressure gradient of 42 mm Hg, and a transaortic velocity of 4.3 m/sec. The ejection fraction is estimated to be 50%. Which one of the following is indicated at this time? A) Atorvastatin (Lipitor) B) Furosemide (Lasix) C) Lisinopril (Prinivil, Zestril) D) Metoprolol succinate (Toprol-XL) E) Referral for aortic valve replacement

ANSWER: E This patient has severe symptomatic aortic stenosis. The only therapy shown to improve symptoms and mortality in such patients is an aortic valve replacement. In patients with asymptomatic disease, watchful waiting is usually the recommended course of action. No medications or other therapies have been shown to prevent disease progression or alleviate symptoms. Patients with coexisting hypertension should be managed medically according to accepted guidelines. Diuretics should be used with caution due to their potential to reduce left ventricular filling and cardiac output, which leads to an increase in symptoms.

65. A 62-year-old Asian female presents to your office with pain and redness in her left eye that started last night. She does not wear contact lenses. The pain has become more severe and she now has a headache, light sensitivity, and mild nausea. Examination of the eyes reveals diffuse conjunctival injection on the left. Her pupils are 4 mm bilaterally but the left one reacts poorly to light. Her visual acuity is 20/30 on the right and 20/100 on the left. Which one of the following would be most appropriate at this time? A) Polymyxin B/trimethoprim ophthalmic drops (Polytrim) B) Prednisolone ophthalmic drops (Omnipred) C) An erythrocyte sedimentation rate and C-reactive protein level D) MRI of the brain with contrast E) Emergent evaluation by an ophthalmologist

ANSWER: E This patient has symptoms and examination findings that are concerning for acute angle-closure glaucoma. Her risk factors include her age, sex, and Asian ancestry. The examination findings include conjunctival redness, corneal edema, a poorly reactive mid-dilated pupil, decreased vision, severe eye pain, headache, and nausea. This condition needs to be evaluated and treated emergently to preserve vision. The examination is not consistent with infectious conjunctivitis, which generally does not cause severe pain, headache, or decreased pupillary response. Conditions such as scleritis or episcleritis may present with similar features, but the pupillary response may help differentiate them from glaucoma. Referral to an ophthalmologist would still be most prudent. This patient's presentation is not consistent with a vasculitis or multiple sclerosis.

70. You admit a previously healthy 62-year-old female to the hospital for intractable nausea and vomiting with intravascular volume depletion and hypotension. She lives in rural northern New Mexico. Prior to the onset of her symptoms she had been gardening and cleaning out a chicken coop, where she encountered several rodents. She is febrile and you obtain blood and urine cultures. Two out of four blood culture bottles are positive for gram-negative rods. Which one of the following is the most likely pathogen? A) Brucella melitensis B) Coxiella burnetii C) Escherichia coli D) Listeria monocytogenes E) Yersinia pestis

ANSWER: E Yersinia pestis is an aerobic fermentative gram-negative rod. It causes a zoonotic infection with humans as the accidental host. The disease is spread by a bite from a flea vector, direct contact with infected tissue, or inhalation of infectious aerosols from a person with pulmonary plague. Plague occurs in two regions in the western United States. One region includes northern New Mexico, northern Arizona, and southern Colorado, and the other region includes California, southern Oregon, and far western Nevada. Escherichia coli is also an aerobic fermentative gram-negative rod but it generally causes symptoms of gastroenteritis, hemolytic-uremic syndrome, urinary tract infection, intra-abdominal infection, and meningitis. E. coli infection does not have a specific regional distribution. Listeria monocytogenes is a gram-positive rod and causes an influenza-like illness with or without gastroenteritis in adults. Infection occurs through ingestion of contaminated food products such as milk, cheese, processed meats, and raw vegetables. Outbreaks can occur in any geographic distribution. 25 Coxiella burnetii is a gram-negative intracellular bacterium that causes Q fever. Human infections are associated with contact with infected cattle, sheep, goats, dogs, and cats. Brucella melitensis is a gram-negative coccobacilli that causes brucellosis. Humans are accidental hosts who can develop the disease from contact with tissues rich in erythritol, and from shedding of organisms in milk, urine, and birth products from goats and sheep.