Family Med AAFP

American Urological Association guidelines define asymptomatic microscopic hematuria as what in the absence of an obvious benign cause?

>3 RBC's p/hpf Note a positive dipstick could clue you in to do a UA micro but is not diagnostic

Which one of the following is the only medication that has consistent evidence for decreasing depressive symptoms in children and adolescents? (check one) A. Fluoxetine (Prozac) B. Venlafaxine (Effexor XR) C. Nortriptyline (Pamelor) D. Aripiprazole (Abilify) E. Paroxetine (Paxil)

A

A 24-year-old asymptomatic female has a chest radiograph that incidentally shows bilateral hilar adenopathy. Additional evaluation supports a diagnosis of sarcoidosis. Which one of the following would be most appropriate at this point? (check one) A. Monitoring only B. Treatment with corticosteroids C. Treatment with methotrexate D. A transbronchial lung biopsy

A According to an international consensus statement, there are three criteria for diagnosing sarcoidosis: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings. The main exceptions to the need for histologic confirmation are the presence of bilateral hilar adenopathy in an asymptomatic patient (stage I) and the presentation of sarcoid-specific Lofgren syndrome—with fever, erythema nodosum, and bilateral hilar adenopathy that can be diagnosed based on clinical presentation alone. An asymptomatic patient with stage I sarcoidosis (bilateral hilar lymphadenopathy on chest radiography) without suspected infection or malignancy does not require an invasive tissue biopsy because the results would not affect the recommended management, which is monitoring only. Treatment is not indicated because spontaneous resolution of stage I sarcoidosis is common.

A long-term care resident is admitted to the hospital. The patient has a living will which specifies that "treatment be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain." The patient has appointed his wife as his health care surrogate. He has mild Alzheimer's disease and scored 26 out of 30 on a Mini-Mental State Examination performed within the last month. He is alert and pleasant and responds appropriately to questions but cannot remember the current date. His wife is with him. Which one of the following would be most appropriate with regard to decision making and ordering related to the patient's code status? (check one) A. Determine the patient's competence B. Assess the patient's decision-making capacity C. Confirm the code status with the patient's wife D. Write a Do Not Resuscitate (DNR) order E. Order comfort measures only

A Advance directives, including a living will and durable power of attorney for health care, are used so that the desires of the individual will be followed in the event he or she lacks the capacity to participate in health care decisions. This ability refers to decision making capacity. The standards for decision making capacity vary from state to state but generally include four abilities: patients must (1) have the ability to understand the relevant information about proposed diagnostic tests or treatment, (2) appreciate their situation (including their values and current medical situation), (3) use reason to make a decision, and (4) communicate their choice.

A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The remainder of the examination is within normal limits. Which one of the following would be the most appropriate management for this patient? (check one) A. Admit to the hospital and obtain urine, blood, and CSF cultures, then start intravenous antibiotics B. Admit to the hospital and treat for herpes simplex virus infection C. Follow up in the office in 24 hours and admit to the hospital if not improved D. Order a CBC and a urinalysis with culture, and send the patient home if the results are normal

A Any child younger than 29 days old with a fever and any child who appears toxic, regardless of age, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated (SOR C). Observation only, with close follow-up, is recommended for nontoxic infants 3-36 months of age with a temperature <39.0°C (102.2°F) (SOR C). Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and urinalysis, can be sent home with precautions and with follow-up in 24 hours (SOR B). Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics (SOR C).

According to the guidelines developed by the JNC 8 panel, which medications should be used as a first-line treatment for hypertension?

ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics all yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes. They are all recommended for initial treatment of high blood pressure in the nonblack population, including patients with diabetes mellitus. $-Blockers were not recommended for the initial treatment of hypertension because one study found there was a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke with use of these drugs compared to the use of an ARB.

A 72-year-old male sees you for an annual follow-up visit. He has well controlled type 2 diabetes mellitus, hypertension, and chronic kidney disease. His hemoglobin A1c is 6.2% today and his blood pressure is 122/76 mm Hg. Historically, his serum creatinine level has been rising by 0.1-0.2 mg/dL per year. Last year his creatinine level was 1.9 mg/dL (N 0.6-1.2), which translated to an estimated glomerular filtration rate (eGFR) of 39.8 mL/min/1.73 m2 (N 90-120). Which one of the following findings on this year's laboratory testing should prompt a referral to a nephrologist for management? (check one) A. A phosphorus level of 5.0 mg/dL (N 2.5-4.5) B. A hemoglobin level of 9.2 g/dL (N 13.5-17.5) with normal iron studies C. A serum creatinine level of 2.1 mg/dL (eGFR 36.0 mL/min/1.73 m2) D. A urine microalbumin to creatinine ratio of 160 μg/mg (N <30) E. A serum vitamin D level of 10 ng/mL (N 20-100)

A Chronic kidney disease is defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 for at least 3 months, or other evidence of kidney damage such as albuminuria, abnormal imaging, or an abnormal biopsy. Current guidelines recommend referral to a nephrologist if a patient's renal disease is either of unknown etiology, is deteriorating quickly (eGFR decreasing by >5 mL/min/1.73 m2 per year), or is severe. Thresholds used to define severe chronic kidney disease include an eGFR <30 mL/min/1.73 m2, a urine albumin to creatinine ratio >300 μg/mg, persistent acidosis or potassium imbalance, non-iron deficiency anemia with a hemoglobin level <10 g/dL, and evidence of secondary hyperparathyroidism. The elevated phosphorus in this patient most likely indicates metabolically significant renal disease and warrants consultation.

A 50-year-old female sees you for follow-up of uncontrolled hypertension. Her recent blood pressure measurements average >175/105 mm Hg. The patient has diabetes mellitus and a BMI of 32.3 kg/m2. Physical findings are otherwise noncontributory. Recent laboratory studies include three different potassium levels <3.5 mEq/L (N 3.5-5.0) despite increasing dosages of oral potassium supplements, with the dosage now at 100 mEq daily. Which one of the following would be most appropriate at this point? (check one) A. Measurement of peripheral aldosterone concentration and peripheral renin activity B. CT of the abdomen C. Renal CT angiography D. An aldosterone suppression test

A Hyperaldosteronism, usually caused by a hyperaldosterone-secreting adrenal mass, has to be considered in a middle-aged patient with resistant hypertension and hypokalemia. Peripheral aldosterone concentration (PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred screening tests for hyperaldosteronism. A PAC >15 ng/dL and a PAC/PRA ratio >20 suggest an adrenal cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma. Renal CT angiography is useful for detecting renal artery stenosis. If the PAC/PRA is abnormal, an aldosterone suppression test should be ordered.

Which one of the following is most likely to be associated with resistant hypertension in adults? (check one) A. Obstructive sleep apnea B. Primary aldosteronism C. Renal artery stenosis D. Renal parenchymal disease E. Thyroid disease

A Obstructive sleep apnea is found in 30%-40% of hypertensive patients and 60%-70% of patients with resistant hypertension, whereas primary aldosteronism is present in only 7%-20% of patients with resistant hypertension. Renal artery stenosis is seen in 2%-24% of cases of resistant hypertension in various studies, renal parenchymal disease in 2%-4%, and thyroid disease in less than 1%.

A patient is admitted to the hospital for acute deep vein thrombosis of the lower extremity and started on anticoagulation therapy. The nursing staff asks for an activity order. Which one of the following should be ordered? (check one) A. Activity as tolerated B. Bed rest until the patient has been hospitalized for 24 hours C. Bed rest with bathroom privileges until the patient has been hospitalized for 24 hours D. Bed rest until discharged E. Bed rest with bathroom privileges until discharged

A The 2012 American College of Chest Physicians evidenced-based clinical practice guidelines recommend early ambulation over initial bed rest in patients with acute DVT of the leg (SOR C). If edema and pain are severe, ambulation may need to be deferred. Several studies and meta-analyses have shown there is no statistically significant difference between ambulation and bed rest for development of a pulmonary embolus, a new thrombus, or progression of a thrombus. Therefore, based on the evidence and the well-recognized benefits of mobility, the current recommendation is to consider early ambulation as soon as effective anticoagulation has been achieved.

A 28-year-old gravida 1 para 0 at 39 weeks gestation presents for routine outpatient obstetric care and is found to have a blood pressure of 145/95 mm Hg. A complete review of systems is notable only for chronic low back pain causing poor sleep. The physical examination is normal, including a nontender, gravid uterus and a fetal heart rate of 150 beats/min. The cervical examination reveals firm consistency, 1 cm dilation, 50% effacement, and -3 station. The patient's blood pressure is checked 5 hours later and is 142/94 mm Hg. Based on the 2013 ACOG guidelines for management of hypertension in pregnancy, which one of the following should be the next step in management? (check one) A. Admit the patient for induction of labor B. Measure 24-hour urine protein, with induction of labor if the level exceeds 300 mg C. Begin oral nifedipine (Procardia) and recheck her blood pressure in 24-48 hours D. Place the patient on strict bed rest and check her blood pressure twice weekly E. Begin twice-weekly office visits with assessment for preeclampsia

A The 2013 ACOG guideline recommends induction of labor for gestational hypertension after 37 weeks. Identifying elevated urine protein is not required for this decision, as gestational hypertension and preeclampsia without severe features are managed in the same way at 39 weeks gestation. Twice-weekly office visits with assessment of blood pressure and the other tests mentioned may be appropriate for patients at less than 37 weeks gestation. Bed rest is no longer recommended for control of hypertension in pregnancy. Oral antihypertensives are used only at higher blood pressure readings in the setting of chronic hypertension.

A 30-year-old female is being evaluated for chronic pain, fatigue, muscle aches, and sleep disturbance. Which one of the following would be best for making a diagnosis of fibromyalgia? (check one) A. A structured symptom history B. Examination for tender points C. Laboratory testing D. A muscle biopsy E. Electromyography

A The American College of Rheumatology has defined diagnostic criteria for fibromyalgia based on the patient's symptoms (SOR A). Previously, tender points on examination were the diagnostic criterion. Laboratory testing, muscle biopsies, and electromyography can be used to rule out other conditions.

A 25-year-old gravida 1 para 1 presents for insertion of a levonorgestrel-releasing intrauterine device (Mirena). She is on the last day of her menses, which began 5 days ago. A urine pregnancy test in the office is negative. You insert the device without complications and she asks how long she needs to use backup contraception. Which one of the following would be the most appropriate advice? (check one) A. Backup contraception is not necessary B. She should use backup contraception for the next 48 hours C. She should use backup contraception for the next 7 days D. She should use backup contraception for the next 14 days E. She should use backup contraception for the next month

A The Centers for Disease Control and Prevention (CDC) provides specific recommendations for backup contraception after IUD insertion. According to the CDC guidelines, this patient does not need to use backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts, the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

A 42-year-old male has symptoms of hypogonadism. Which one of the following should be ordered first? (check one) A. Early morning total serum testosterone B. Early morning total and free serum testosterone C. Early morning total and late afternoon total serum testosterone D. Early morning and late afternoon free serum testosterone E. Early morning and late afternoon total and free serum testosterone

A The best initial test for the diagnosis of male hypogonadism is measurement of total testosterone in serum in a morning sample. Low concentrations of testosterone in serum should be confirmed by repeat measurement. If abnormalities in concentrations of sex hormone-binding globulin are suspected, measurement of free or bioavailable testosterone is indicated. Examples of conditions associated with altered sex hormone-binding globulin include liver disease, obesity, and diabetes mellitus.

A 40-year-old obese African-American male presents with a history of excessive daytime drowsiness. At home he falls asleep shortly after starting to read or watch television. He admits to nearly crashing his car twice in the past month because he briefly fell asleep behind the wheel. Most frightening to the patient have been episodes characterized by sudden loss of muscle tone, lasting about 1 minute, associated with laughing. An overnight sleep study shows decreased sleep latency and no evidence of obstructive sleep apnea. Appropriate treatment includes which one of the following? (check one) A. Methylphenidate (Ritalin) B. Zolpidem (Ambien) at bedtime C. Carbidopa/levodopa (Sinemet) D. Weight reduction E. Avoidance of daytime napping

A The clinical history and laboratory findings presented are consistent with a diagnosis of narcolepsy. In addition to the sleepiness, the patient also has cataplexy, which is manifested in this case by episodes of sudden weakness when laughing and is almost pathognomonic for narcolepsy. Some patients may also have vivid hallucinations when falling asleep or waking up. Treatment involves improving both the quantity and quality of sleep during the night, which can be accomplished with sodium oxybate. This improves daytime alertness and cataplexy. Scheduling naps is the second important aspect of managing narcolepsy. The third important step is the use of stimulants such as methylphenidate to improve function during the day. Periodic daytime naps may also help to reduce symptoms. Since there is no evidence of obstructive sleep apnea in this patient, weight reduction would not be expected to address his sleep problem. In general, sedatives, hypnotics, and alcohol should be avoided.

An 85-year-old female is admitted to the hospital for surgery and develops confusion postoperatively. The patient is a widow and lived independently prior to admission. Her daughter says the confusion is atypical for her mother. She does not have a history of memory loss, forgetfulness, or confusion prior to admission. Which one of the following cognitive assessment tests should be used to assess her acute change in mental status? (check one) A. Confusion Assessment Method (CAM) B. Mini-Cog C. Mini-Mental State Examination (MMSE) D. Montreal Cognitive Assessment test (MoCA) E. Saint Louis University Mental Status exam (SLUMS)

A The patient is experiencing an acute cognitive change from baseline, indicating possible delirium. The Confusion Assessment Method (CAM) is a delirium diagnosis tool useful for evaluating acute cognitive changes. The other tests listed, including the Mini-Mental State Examination, Mini-Cog, Montreal Cognitive Assessment, and Saint Louis Mental Status exam, test chronic baseline cognitive function and are not designed to test for acute changes.

An 85-year-old male nursing home resident with a past history of a stroke has developed a pressure ulcer over his right greater trochanter. The ulcer is 2 cm in size and is noted to be shallow with a reddish-pink wound base. There is no evidence of secondary infection. Which one of the following would be best for cleansing the wound? (check one) A. Tap water B. Aluminum acetate (Burow's solution) C. Hydrogen peroxide D. Povidone/iodine solution (Betadine) E. Sodium hypochlorite (Dakin's solution)

A This patient has a stage 2 pressure ulcer. It is recommended that pressure ulcers not be cleaned with povidone/iodine, Dakin's solution, hydrogen peroxide, wet-to-dry dressings, or any solutions that may impede granulation tissue formation. These sites should be cleaned with either saline or tap water and covered with hydrocolloid, foam, or another nonadherent dressing that promotes a moist environment.

A 7-year-old male is brought to your office with a 2-day history of rash. He developed two itchy spots on his legs yesterday and today he has multiple purple, slightly painful lesions on his legs. A few days ago he was ill with cold-like symptoms, stomach pain, and a fever up to 101.2°F. He complained of leg pain at the time and his left ankle is now swollen. His fever resolved 2 days ago and he now feels fine but limps when he walks. On examination he is afebrile with a normal blood pressure and pulse rate. He is active in the examination room. His physical examination is normal except for purpuric lesions on his legs and buttocks and edema and mild pain of the left ankle. A urinalysis is negative. Which one of the following would be most appropriate in the management of this patient? (check one) A. Acetaminophen B. Amlodipine (Norvasc) C. Amoxicillin D. Cyclophosphamide E. Prednisone

A This patient meets the clinical criteria for Henoch-Schönlein purpura (HSP), an immune-mediated vasculitis found commonly in children under the age of 10. The clinical triad of purpura, abdominal pain, and arthritis is classic. Almost 95% of children with HSP spontaneously improve, so supportive therapy is the main intervention. Acetaminophen or ibuprofen can be used for the arthritic pain. However, ibuprofen should be avoided in those with abdominal pain or known renal involvement. Prednisone has been found to help in those with renal involvement or other complications of the disease such as significant abdominal pain, scrotal swelling, or severe joint pains (SOR B). However, it is not effective for preventing renal disease or reducing the severity of renal involvement, as was once thought (SOR A).

A 34-year-old female with newly diagnosed diarrhea-predominant irritable bowel syndrome (IBS) presents with worsening abdominal discomfort. Her abdominal discomfort is not severe but it is constant. She has tried dicyclomine (Bentyl) without relief and is interested in trying a different approach. The patient has had negative testing for inflammatory bowel disease and celiac disease, along with normal blood tests. She asks about specific dietary modifications or medications that may be helpful for her abdominal discomfort. Which one of the following interventions would you recommend? (check one) A. Amitriptyline B. Clarithromycin (Biaxin) C. Loperamide (Imodium) D. Increased intake of insoluble dietary fiber

A Tricyclic antidepressants (TCAs) such as amitriptyline have shown benefit in patients with irritable bowel syndrome (IBS), as have SSRIs. Because of the anticholinergic properties of TCAs it is thought that TCAs may be more beneficial than SSRIs in patients with diarrhea-predominant IBS, such as this patient. Unfortunately, studies have not shown a significant benefit from increasing either insoluble or soluble fiber to the diet of patients with IBS. Although increasing fiber may help improve constipation in patients with constipation-predominant IBS, this does not improve abdominal pain. In some studies adding insoluble fiber resulted in either worsening of symptoms or no change in symptoms.

A 62-year-old male comes to your office as a new patient. He has a past history of a myocardial infarction and is currently in stage C heart failure according to the American Heart Association classification. His ejection fraction is 30%. Which one of the following medications that the patient is currently taking is potentially harmful and should be discontinued if possible? (check one) A. Diltiazem (Cardizem) B. Lisinopril (Prinivil, Zestril) C. Carvedilol (Coreg) D. Atorvastatin (Lipitor)

A. ACE inhibitors or angiotensin receptor blockers should be used in all patients with a history of myocardial infarction and reduced ejection fraction. Aldosterone receptor antagonists are indicated in patients who have a left ventricular ejection fraction 35%. Nondihydropyridine calcium channel blockers with negative inotropic effects (verapamil and diltiazem) may be harmful in patients with low left ventricular ejection fractions. Statin therapy is recommended in all patients with a history of myocardial infarction. Evidence-based $-blockers (carvedilol or metoprolol succinate) should be used in all patients with a history of myocardial infarction.

A 43-year-old female smoker has type 2 diabetes mellitus, morbid obesity, and a recent diagnosis of symptomatic peripheral arterial disease. You have started her on atorvastatin (Lipitor), offered a supervised exercise program, and discussed smoking cessation and interventions. Which one of the following should be recommended to prevent cardiovascular events in this patient? (check one) A. Aspirin B. Cilostazol (Pletal) C. Enoxaparin (Lovenox) D. Pentoxifylline E. Warfarin (Coumadin)

A. ASA is recommended in PAD to prevent a coronary artery event. Clopidegrol is also effective. Cilostazol and pentoxyfylline are second and third line but not very effective. Neither warfarin or enoxaparin is indicated in PAD..

A 3-year-old female is brought to your office with coughing and a tactile fever. Her only other symptom is mild rhinorrhea. She has a temperature of 38.2°C (100.8°F) and is mildly tachypneic. Her vital signs are otherwise normal and she appears to be well and in no respiratory distress. Her examination is unremarkable except for decreased breath sounds and crackles in the right lower lung field. She has no allergies to medications. Which one of the following would be the most appropriate treatment? (check one) A. Amoxicillin B. Azithromycin (Zithromax) C. Cefdinir D. Moxifloxacin (Avelox) E. Ceftriaxone (Rocephin)

A. Amoxicillin is the recommended first-line treatment for previously healthy infants and school-age children with mild to moderate community-acquired pneumonia (CAP) (strong recommendation; moderate-quality evidence). The most prominent bacterial pathogen in CAP in this age group is Streptococcus pneumoniae, and amoxicillin provides coverage against this organism. Azithromycin would be an appropriate choice in an older child because Mycoplasma pneumoniae would be more common. Moxifloxacin should not be used in children. Ceftriaxone and cefdinir can both be used to treat CAP, but they are broader spectrum antibiotics and would not be a first-line choice in this age group.

A local dentist contacts you for a prescription for the appropriate antibiotic dosage for one of your patients who has an appointment for dental cleaning to eliminate a significant plaque buildup. The patient is a 55-year-old male who has controlled hypertension and mitral valve prolapse with mitral regurgitation. He is allergic to sulfonamides. Which one of the following would be the most appropriate prophylaxis for this patient? (check one) A. Amoxicillin, 2 g orally 1 hour prior to the procedure B. Amoxicillin, 3 g orally 1 hour prior to the procedure and 1.5 g orally 6 hours after the procedure C. Ceftriaxone (Rocephin), 1 g intramuscularly 1 hour prior to the procedure D. Clindamycin (Cleocin), 600 mg orally 1 hour prior to the procedure E. No antibiotic prophylaxis

According to the American Heart Association's 2007 guidelines, prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease. Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are associated with mitral regurgitation. The American Dental Association has endorsed this guideline.

A 70-year-old male with widespread metastatic prostate cancer is being cared for through a local hospice. Surgery, radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. Over the past few days he has been experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min. What is the best next step in his care?

Administer Morphine. Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment and other measures may be appropriate in specific circumstances. For example, inhaled bronchodilators or glucocorticoids may be helpful in patients with COPD, and diuresis may be helpful in patients with heart failure. The evidence for oxygen in patients with hypoxemia is not clear, but there is no benefit from oxygen for nonhypoxemic patients.

A mother brings in her 2-month-old infant for a routine checkup. The baby is exclusively breastfed, and the mother has no concerns or questions. In addition to continued breastfeeding, which one of the following would you recommend continuing or adding at this time? (check one) A. Iron supplementation B. Vitamin D supplementation C. A multivitamin D. 8 oz of water daily E. 4 oz of cereal daily

Although breast milk is the ideal source of nutrition for healthy term infants, supplementation with 400 IU/day of vitamin D is recommended beginning in the first few days of life and continuing until the child is consuming at least 500 mL/day of formula or milk containing vitamin D (SOR B). The purpose of supplementation is to prevent rickets. Unless the baby is anemic or has other deficiencies, neither iron nor a multivitamin is necessary at this age. For exclusively breastfed infants, iron supplementation should begin at 4 months of age. Parents often mistakenly think babies need additional water, which can be harmful because it decreases milk intake and can cause electrolyte disturbances. The introduction of cereal is recommended at 6 months of age.

Terminally ill cancer patients who receive palliative chemotherapy (check one) A. survive longer B. are less likely to die at home C. are less likely to undergo CPR D. are less likely to undergo mechanical ventilation E. are referred to hospice earlier in their disease

Although family physicians do not prescribe chemotherapy, they are often called upon by families to help navigate the choices specialists offer. Patients who receive palliative chemotherapy for end-stage cancers are less likely to die at home, more likely to undergo CPR, and more likely to undergo mechanical ventilation. In addition, these patients are referred to hospice later and there is no survival benefit.

A resting ankle-brachial index of 1.50 indicates which one of the following? (check one) A. Normal circulation to a lower extremity B. Borderline normal circulation which may not be problematic in an asymptomatic patient C. Mild peripheral artery disease in a lower extremity D. Severe peripheral artery disease in a lower extremity E. Incompressible vessels in a lower extremity

An ankle-brachial index (ABI) is considered normal between 1.00 and 1.40, borderline from 0.91 to 0.99, and abnormal if £0.90. The lower the ABI, the more severe peripheral artery disease is likely to be. Values greater than 1.40 indicate incompressible vessels and are not reliable. Incompressible vessels may be found in patients with long-standing diabetes mellitus, or in older persons. A toe-brachial index measurement may be used in persons with incompressible arteries of the more proximal lower extremity.

Which one of the following is most appropriate for patients with asplenia? (check one) A. Lifelong daily antibiotic prophylaxis B. Antibiotics for any episode of fever C. An additional dose of Hib vaccine D. Avoiding live attenuated influenza vaccine E. Withholding pneumococcal vaccine

Asplenic patients who develop a fever should be given antibiotics immediately. Due to the increased risk of pneumococcal sepsis in asplenic patients, vaccinations against these particular bacteria are specifically recommended. Since pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) can interact with each other they should be given at least 8 weeks apart. Prophylactic penicillin given orally twice a day is particularly important in children under 5 years of age who are asplenic, and may be considered for 1-2 years post splenectomy in older patients. Lifelong daily antibiotics may be considered following post-splenectomy sepsis. The risk for Haemophilus influenzae type b infection is not increased in asplenic patients, so additional vaccine is not needed for those who have already been vaccinated. Live attenuated influenza vaccine may be used in asplenic patients, unless they have sickle cell disease.

A 12-month-old male is brought to your office for a routine well child visit. His father has epilepsy and takes seizure medication. Which one of the following vaccines will slightly increase the child's risk of a febrile seizure for up to 2 weeks after administration? (check one) A. Hepatitis B B. MMR C. HiB D. Pneumococcal E. Polio

B Fever and febrile seizures may occur after administration of several vaccines. Postimmunization seizures, especially febrile seizures, occur at a higher rate in children who have a past history of seizures or a first-degree relative with a history of seizures. The benefits of the vaccines outweigh the risks, so they are not contraindicated in this situation, although the parents need to be cautioned about the increased risk of seizure. Of the vaccines listed, the only one likely to put the child at risk for a seizure up to 2 weeks after administration is the MMR vaccine. Specifically, it is the measles component of the vaccine that is the potential culprit. A temperature of 39.4°C (103°F) or higher develops in approximately 5%-15% of susceptible vaccine recipients, usually 6-12 days after receipt of MMR vaccine. The fever generally lasts 1-2 days but may last up to 5 days.

A 43-year-old female complains of easy bruising. She is otherwise asymptomatic. A CBC reveals a platelet count of 23,000/mm3 (N 150,000-450,000). A peripheral smear reveals giant platelets. A workup is negative for autoimmune causes, including Graves disease, HIV, Epstein-Barr virus, cytomegalovirus, varicella zoster, hepatitis C, and Helicobacter pylori. She is on no prescription or over-the-counter medications and denies alcohol or drug use. Which one of the following would be the most appropriate initial management? (check one) A. Platelet transfusion B. Corticosteroids C. Thrombopoietin-receptor agonists D. A bone marrow biopsy E. Splenectomy

B Immune (idiopathic) thrombocytopenic purpura is an acquired immune-mediated disorder defined as isolated thrombocytopenia not found to have another cause. Treatment is usually restricted to severe thrombocytopenic cases (platelet count <50,000/mm3) unless there is evidence of acute bleeding. Corticosteroids are considered the first-line therapy (SOR C). Intravenous immunoglobulin and rituximab have also been used as first-line agents. Second-line therapies include thrombopoietin-receptor agonists and splenectomy. Further evaluation, including a bone marrow biopsy, to rule out myelodysplastic syndrome and lymphoproliferative disorders is indicated in patients over the age of 60 (SOR C). Platelet transfusion is not indicated in the absence of hemorrhage or a need for surgery.

A 34-year-old white female sees you for a routine follow-up visit. She takes haloperidol, 2 mg after each meal, for schizophrenia, and you notice that she seems unable to sit still and is extremely anxious. The most likely cause of her restlessness is (check one) A. drug-induced parkinsonism B. akathisia C. tardive dyskinesia D. hysteria E. dystonia

B Motor side effects of the antipsychotic drugs can be separated into five general categories: dystonias, parkinsonism, akathisia, withdrawal dyskinesias, and tardive dyskinesia. Akathisia is a syndrome marked by motor restlessness. Affected patients commonly complain of being inexplicably anxious, of being unable to sit still or concentrate, and of feeling comfortable only when moving. Hysteria is no longer considered a useful term.

Which one of the following community health programs best fits the definition of secondary prevention? (check one) A. An antismoking education program at a local middle school B. Blood pressure screening at a local church C. A condom distribution program D. Screening patients with diabetes mellitus for microalbuminuria

B Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition. Examples include childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex. Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications. Examples include routine Papanicolaou tests and screening for hypertension, diabetes mellitus, or hyperlipidemia. Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. Examples include screening patients with diabetes for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with β-blockers and aspirin.

A 16-year-old female presents for follow-up after a tibial stress fracture. The fracture was diagnosed 5 weeks ago by characteristic physical examination findings and radiographs showing a transverse fracture of the tibial diaphysis. She was placed on non-weight-bearing status for 2 weeks and after that was advised to limit activities that caused discomfort. In addition, she was placed on appropriate calcium and vitamin D supplementation based on results of her laboratory workup. The patient is a basketball player and would like to begin practicing with the team in 1 week. She says she is now able to walk without discomfort but has not tried running or jumping. Which one of the following is necessary for this patient to be able to return to basketball participation next week? (check one) A. Consultation with a sports medicine physician B. A normal physical examination of the affected area C. Normal radiographs of the tibia D. A normal hydroxyvitamin D level

B Stress fractures are common in teenage athletes. Because this patient has a normal physical examination and can walk without pain, she can return to basketball as long as her symptoms do not return. Most stress fractures heal in 6-10 weeks with conservative management such as non-weight bearing and activity limitation. Athletes can return to play once they are pain free and have a normal physical examination, even if the time since diagnosis is less than 6 weeks. However, they should refrain from all high-impact activities such as running and jumping until they can walk without pain. Repeat radiographs are rarely indicated. Calcium and vitamin D supplementation are recommended as part of the management of stress fractures, but checking blood levels of vitamin D is not necessary either at the time of the injury or prior to return to play. Most stress fractures in low-risk locations such as the tibia can be managed in a primary care office without consulting a sports medicine or orthopedic physician. Fractures in high-risk locations are at increased risk for malunion and thus are often managed by specialists. This patient has a low-risk stress fracture.

A 62-year-old female presents with numbness and tingling in her feet. She first noticed tingling in the toes of her right foot several months ago; it is now present in both feet and is causing numbness. She has not experienced any weakness, or any changes in vision, speech, or memory. Her medical history includes hypertension controlled by lisinopril (Prinivil, Zestril), 20 mg daily, and she also takes aspirin, 81 mg daily. She drinks a glass of wine nightly and does not smoke. She does not have a family history of neurologic disorders. On examination she has symmetric decreased sensation to light touch and vibration in her feet. Reflexes and strength are intact bilaterally. Laboratory findings include a normal CBC and normal TSH and vitamin B12 levels. Her erythrocyte sedimentation rate is 32 mm/hr (N 0-20). A comprehensive metabolic panel is normal except for a total protein level of 8.5 g/dL (N 6.0-8.3). Which one of the following tests would be most useful for making a diagnosis? (check one) A. An angiotensin converting enzyme level B. Serum protein electrophoresis C. A chest radiograph D. A lumbar puncture with cerebrospinal fluid analysis E. MRI of the lumbar spine

B This patient has a peripheral neuropathy. A review of the patient's history and specific laboratory testing was performed to evaluate for the most common treatable causes of peripheral neuropathy, which include diabetes mellitus, hypothyroidism, and nutritional deficiencies. Additional causes of peripheral neuropathy include chronic liver disease and renal disease. It is important to consider medications as a possible cause, including amiodarone, digoxin, nitrofurantoin, and statins. Excessive alcohol use is another important consideration. In this patient, the mildly elevated total protein and erythrocyte sedimentation rate, which suggest a monoclonal gammopathy such as MGUS (monoclonal gammopathy of unknown significance) or multiple myeloma, should direct her workup. Serum protein electrophoresis is indicated to assess for this. Other less common causes of peripheral neuropathy include carcinoma causing a paraneoplastic syndrome, lymphoma, sarcoidosis, AIDS, and genetic disorders such as Charcot-Marie-Tooth disease. Approximately 25% of patients with peripheral neuropathy have no clearly defined cause after a thorough evaluation and are diagnosed with idiopathic polyneuropathy. MRI of the lumbar spine can identify central lesions causing spinal cord or nerve root compression but is not indicated in the evaluation of peripheral neuropathy. Serum angiotensin converting enzyme levels and a chest radiograph can assist in the diagnosis of sarcoidosis, which can cause peripheral neuropathy but is less likely in this patient. Cerebrospinal fluid analysis is important in assessing for chronic inflammatory demyelinating polyradiculoneuropathy, a more rare cause of peripheral neuropathy.

You see a 4-year-old male in your office for evaluation of persisting fever, rash, and red eyes. In a discussion with his father you learn that the child has had temperatures in the 99°F-102°F range for 6 days, along with what the father describes as "pink eye." Today the child broke out in a rash on his chest and back and also has cracked red lips. On examination you confirm that he has bilateral nonpurulent conjunctival injection and a generalized maculopapular rash, as well as erythema of his hands and feet. Which one of the following is recommended at this time to evaluate for cardiac complications? (check one) A. An EKG B. Transthoracic echocardiography C. Cardiac CT D. Magnetic resonance (MR) coronary angiography E. A radionuclide myocardial perfusion scan

B This patient meets the criteria for Kawasaki disease, also known as mucocutaneous lymph node syndrome. It is an acute type of vasculitis that predominantly affects small and medium-size vessels and is the most common cause of acquired coronary artery disease in childhood. Diagnostic criteria include fever for at least 5 days and at least 4 of the 5 principal clinical features: • changes of the oral cavity and lips • polymorphous rash • bilateral nonpurulent conjunctivitis • changes in the extremities (erythema followed by desquamation) • cervical lymphadenopathy Coronary abnormalities, including coronary aneurysms, are the most concerning sequelae of Kawasaki disease and may occur in the first week. For this reason early cardiac evaluation is recommended, with transthoracic echocardiography being the preferred initial imaging. Radionuclide imaging can be useful in assessing cardiac perfusion in patients found to have persisting echocardiographic findings. MR coronary angiography can be used to assess response to treatment over time. Intravenous immunoglobulin and corticosteroids reduce the risk of coronary abnormalities and should be administered as soon as the disease is suspected.

You evaluate an 18-month-old male with fecal impaction and determine that disimpaction is indicated. Which one of the following would be most appropriate initially? (check one) A. An oral stimulant such as sennosides (Senokot) B. An oral osmotic agent such as polyethylene glycol 3350 (MiraLax) C. An enema using saline, mineral oil, or phosphate soda D. A bisacodyl (Dulcolax) rectal suppository E. Manual disimpaction

B. Oral osmotics such as polyethylene glycol-based solutions are recommended as an appropriate initial approach to constipation in children because they are effective, easy to administer, noninvasive, and well tolerated (SOR C). Rectal therapies are similar in terms of effectiveness but are more invasive and less commonly used as first-line treatment (SOR A). Oral stimulants and bisacodyl rectal suppositories are not recommended for children under 2 years of age. Enemas are sometimes used as second-line therapy, but the addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation (SOR B). Manual disimpaction is a more invasive option and is not recommended as first-line treatment in young children.

A 37-year-old graphic designer presents to your office with a history of several months of radial wrist pain. She does not recall any specific trauma but notes that it hurts to hold a coffee cup. Finkelstein's test is positive and a grind test is negative, and there is tenderness to palpation over the radial tubercle. Which one of the following would be most appropriate at this point? (check one) A. Plain radiography focusing on the scaphoid B. Rest and a thumb spica wrist splint C. MRI of the wrist D. A short arm cast

B. This patient has de Quervain's tenosynovitis. Finkelstein's test has good sensitivity and specificity (SOR C) in patients with a negative grind test. A positive grind test would be more consistent with scaphoid fracture. A hand radiograph with secondary thumb spica splinting would be appropriate for a suspected scaphoid fracture, but the insidious onset as opposed to overt trauma makes this diagnosis unlikely in this case. A short arm cast is not indicated in de Quervain's tenosynovitis but may be appropriate for forearm/wrist fractures.

A 68-year-old male with end-stage lung cancer is being treated for pain secondary to multiple visceral and skeletal metastases. He has been on oral ibuprofen and parenteral morphine. However, over the past few weeks he reports progressive worsening of his pain. In order to achieve better pain control his morphine dosage has been continuously titrated up. In spite of this increase he continues to report severe pain that is now diffuse and occurs even when his caregivers touch him. Which one of the following would be most appropriate at this time? (check one) A. Increase the morphine dosage until continuous sedation is obtained B. Attempt a reduction in the morphine dosage C. Add an anxiolytic to help relieve anxiety D. Advise the family that nothing more can be done for his pain

B. Opioid-induced hyperalgesia is characterized by a paradoxical increase in sensitivity to pain despite an increase in the opioid dosage. It is seen in patients who are receiving high doses of parenteral opioids such as morphine. Patients report the development of diffuse pain away from the site of the original pain. Allodynia, a perception of pain in the absence of a painful stimulus, is also typical in opioid-induced hyperalgesia. Strategies to manage this condition include reducing the current opioid dosage, and occasionally eliminating the current opioid and starting another opioid. The addition of non-opioid pain medications should also be considered. The addition of an anxiolytic is not likely to improve this patient's pain

A 45-year-old male presents to the emergency department with a complaint of acute, sharp chest pain relieved only by leaning forward. On examination you hear a pericardial friction rub. An EKG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion. What is the most appropriate initial treatment?

Colchicine or NSAIDS. Steroids are reserved for severe or refractory cases.

A U.S. Preventive Services Task Force "D" recommendation indicates (check one) A. high certainty that the net benefit is substantial B. high certainty that the net benefit is moderate C. moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits D. that the decision to provide the service should be based on professional judgment and patient preferences E. that current evidence is insufficient to assess the balance of benefits and harms of the service

C

Which one of the following coexisting conditions could require the use of a much higher than expected dose of levothyroxine (Synthroid) to adequately treat hypothyroidism? (check one) A. Chronic kidney disease B. Diabetes mellitus C. Helicobacter pylori gastritis D. Hepatitis C infection E. Hyperparathyroidism

C Absorption of levothyroxine is impaired by several gastrointestinal conditions, including atrophic gastritis, chronic proton pump inhibitor use, and Helicobacter pylori infection. Treatment of H. pylori infection reverses this effect, and following eradication of the infection a reduction of the levothyroxine dosage by 30% or more will often be required.

An 11-year-old female is brought to your office for a routine well child examination. The American Academy of Pediatrics recommends screening this patient for which one of the following? (check one) A. Anemia B. Diabetes mellitus C. Dyslipidemia D. HIV

C Because of concerns about the growing epidemic of obesity in this population, the American Academy of Pediatrics now recommends screening for elevated serum cholesterol levels in children 9-11 years of age (SOR C). This patient should also be screened annually for depression beginning at 11 years of age and continuing through 21 years of age. Universal screening for iron deficiency anemia is recommended at 12 months of age and again at 15-30 months of age if the patient is determined to be high risk. HIV screening is recommended in adolescents 16-18 years of age, and age 21 is now the recommended starting age for screening for cervical dysplasia. Universal screening for diabetes mellitus is not recommended for children or adolescents.

Which one of the following should be the next step in the evaluation and management of her aortic stenosis? (check one) A. Exercise treadmill testing B. Right heart catheterization C. Repeat echocardiography in 3 years D. Cardiothoracic surgery consultation E. Initiation of statin therapy

C Family physicians see many patients with aortic stenosis (AS) and it is important to know when and if further workup is indicated for asymptomatic patients. Although aortic stenosis can result in adverse cardiac events, most of these events occur in patients who are symptomatic. Thus, the American Heart Association and the American College of Cardiology recommend that asymptomatic patients with mild aortic stenosis undergo repeat echocardiography every 3-5 years. Further workup or treatment is not indicated for patients who have mild AS and are asymptomatic. Exercise treadmill testing may be indicated in patients with severe AS based on echocardiography even if they are asymptomatic.

A 51-year-old female comes to your office for follow-up of fibromyalgia. She is currently taking amitriptyline, 10 mg at bedtime, and naproxen (Naprosyn), 500 mg twice daily, for her symptoms. A member of her fibromyalgia support group recommended fluoxetine (Prozac) to her and she asks you if it would be helpful. It would be appropriate to tell her that SSRIs for the treatment of fibromyalgia (check one) A. do not affect depression scores B. reduce fatigue C. provide some pain reduction D. help with sleep problems E. are superior to tricyclics for pain control

C Fibromyalgia is a chronic complex condition characterized by muscle pain, fatigue, muscle tenderness, and sleep disorders, often accompanied by mood disorders. SSRIs have been studied in the treatment of these symptoms, and while they have been shown to produce up to a 30% reduction in pain scores in patients with fibromyalgia, they have not been shown to affect fatigue or sleeping problems. They also have not been shown to be superior to tricyclics when treating pain. As with other patient populations, SSRIs have been shown to improve depression in those with fibromyalgia.

A 65-year-old female is admitted to the hospital for a carotid endarterectomy and you are asked to make preoperative recommendations in advance of her surgery scheduled for tomorrow. She takes only low-dose aspirin. The physical examination is normal, including her blood pressure, as is an EKG. She has good exercise capacity and denies any symptoms of angina. You judge her to be stable for surgery. Which one of the following should you recommend that the patient start today? (check one) A. An ACE inhibitor B. A β-blocker C. A statin D. A diuretic

C If recommended prior to surgery, β-blockers should be started several weeks beforehand and carefully titrated. They may be harmful if initiated in the immediate perioperative period. Statins are recommended in the perioperative period for vascular surgery regardless of other cardiac risk factors; a statin would ideally have been initiated previously in this case, but may still be started in the immediate preprocedural period. There is no specific indication in this case for an ACE inhibitor.

A 28-year-old male has had bright red blood in his semen with his last three ejaculations. He is sexually active. He considers himself in good health, takes no medications, has no other symptoms to suggest a coagulopathy, and has no other genitourinary symptoms. Examination of the testes shows no masses or tenderness. Findings on a digital rectal examination are normal. Which one of the following would be appropriate at this time? (check one) A. Coagulation studies including a platelet count and a prothrombin time B. A serum PSA level C. A urine probe for Neisseria gonorrhoeae and Chlamydia trachomatis D. CT of the pelvis E. Referral to a urologist

C In males younger than 40, hematospermia is usually benign and self-limited. Examination of the testes and prostate is warranted but findings are usually normal. If the patient is sexually active a screen for STDs is reasonable. Imaging of the genitourinary tract, a serum PSA level, and urology referral are unnecessary in this age group unless the history or physical examination suggests an unusual cause.

Which one of the following is true regarding direct observational therapy (DOT) in the treatment of active tuberculosis? (check one) A. It guarantees patient compliance with the prescribed regimen B. It is recommended only in the office or clinic setting C. It decreases drug-resistant tuberculosis D. Patients require less monitoring for signs of treatment failure

C In the treatment of active tuberculosis, direct observational therapy (DOT) involves providing the antituberculosis drugs directly to patients and watching them swallow the medication. It is the preferred care management strategy for all patients with tuberculosis. The use of DOT does not guarantee the ingestion of all doses of every medication, as patients may miss appointments, may not actually swallow the pills, or may regurgitate the medication, sometimes deliberately. Due to these limitations, the use of DOT does not remove the need to monitor patients for signs of treatment failure. DOT is effective in a wide variety of settings, including in the community with health nurses. It even shows benefit when the observation makes use of telehealth settings or mobile phones. Among the important benefits of DOT are that it has been shown to decrease both the acquisition and transmission of drug-resistant tuberculosis and to increase treatment success in HIV-positive patients.

A 35-year-old female asks you about options for weight loss. She weighs 104 kg (229 lb) and has a BMI of 34 kg/m2. Her health problems include hypertension and depression. According to the U.S. Preventive Services Task Force, which one of the following is the most appropriate initial recommendation for weight-loss management in this patient? (check one) A. A high-protein diet B. A low-carbohydrate diet C. Behavioral counseling D. Bariatric surgery E. Polypeptides

C Indication for bariatric surgery if BMI is >40 or if BMI is >35 and pt has at least one obesity related comorbidity such as DM II

A 43-year-old female presents with an 8-month history of posttraumatic stress disorder following a motor vehicle accident that severely injured her and a friend. She has had a positive response to counseling and SSRI treatment but continues to have sleep disturbances and nightmares. Which one of the following medications is most likely to decrease the frequency of her nightmares? (check one) A. Clonazepam (Klonopin) B. Divalproex (Depakote) C. Prazosin (Minipress) D. Propranolol

C Prazosin is an α-adrenergic receptor antagonist and is recommended for the treatment of nightmares in posttraumatic stress disorder (SOR A). It is thought to reduce sympathetic outflow in the brain. Although clonidine may be tried, evidence of its effectiveness is sparse (SOR C). Clonazepam, propranolol, and divalproex have not been recommended.

Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be problematic in elderly patients because they can (check one) A. decrease blood pressure B. cause bradycardia C. worsen existing urinary obstruction D. enhance the anticholinergic effects of other medications E. enhance the sedative effects of other medications

C Sympathomimetic agents can elevate blood pressure and intraocular pressure, may worsen existing urinary obstruction, and adversely interact with β-blockers, methyldopa, tricyclic antidepressants, oral hypoglycemic agents, and MAOIs. They also speed up the heart rate. First-generation nonprescription antihistamines can enhance the anticholinergic and sedative effects of other medications.

A 20-year-old female presents to your office with questions about her contraceptive method. She has been using a combined oral contraceptive pill for the past 2 years without any complications. She has learned that several of her friends recently switched to an IUD. She is concerned about the efficacy of her current method and asks about the failure rate. You tell her that with typical use, the annual failure rate of a combined oral contraceptive pill is (check one) A. 0.2% B. 2% C. 9% D. 18% E. 22%

C The annual failure rate of combined oral contraceptive pills with typical use is 9%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 6% for injectable progestin, 18% for male condoms, and 22% for the withdrawal method.

A 33-year-old female comes to your office for follow-up of irritable bowel syndrome. You ruled out other causes of her abdominal bloating, abdominal pain, and diarrhea at earlier visits. She has no change in symptoms, such as constipation or blood in her stool. She has resisted treatment in the past, but her symptoms are becoming more frequent and she would now like to consider treatment. Evidence shows that which one of the following would most likely be beneficial for this patient? (check one) A. Acupuncture B. Increased insoluble fiber in her diet C. Fluoxetine (Prozac), 20 mg daily D. Neomycin, 1000 mg every 6 hours for 7 days E. Polyethylene glycol (MiraLAX), 17 g daily

C This patient has diarrhea-predominant irritable bowel syndrome (IBS). There are many treatments available, with varying degrees of evidence. SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS. Polyethylene glycol is a treatment for constipation and would not help this patient. Acupuncture has not been shown to be superior to sham acupuncture in improving IBS symptoms. Neomycin has been shown to improve symptoms in constipation-predominant IBS but would not be helpful in diarrhea-predominant IBS. Soluble fiber such as psyllium improves symptoms and decreases abdominal pain scores in patients with IBS. Insoluble fiber has not been shown to improve any IBS outcomes.

A 79-year-old female had a total knee replacement yesterday. She has mild dementia as a result of a stroke 10 years ago, but her dementia has been stable since then. Last night she became confused and agitated, striking out at nurses, and could not be consoled. Which one of the following would be most appropriate at this time? (check one) A. Soft restraints B. CT of the head C. Adequate pain control D. A sedating SSRI such as paroxetine (Paxil) E. Lorazepam (Ativan) intravenously as needed

C This patient has postoperative delirium, which is associated with an increased mortality rate. Reorientation and pain management are important management strategies. Benzodiazepines, antipsychotics, antidepressants, and restraints are not helpful and may make the situation worse. Imaging modalities are not helpful in the absence of localizing signs.

Slipped capital femoral epiphysis is most likely in which one of the following patients with no history of trauma? (check one) A. A 3-day-old male with a subluxable hip B. A 7-year-old male with groin pain and a limp C. A 13-year-old male with knee pain D. A 16-year-old female with lateral thigh numbness

C. Slipped capital femoral epiphysis (SCFE) occurs most commonly during the adolescent growth spurt (11-13 years of age for girls, 13-15 years of age for boys). While the cause is unknown, associated factors include anatomic variables such as femoral retroversion or steeper inclination of the proximal femoral physis, in addition to being overweight. African-Americans are affected more commonly as well. The patient may present with pain in the groin or anterior thigh, but also may present with pain referred to the knee. That is also the case for Legg-Calvé-Perthes disease, also known as avCascular or aseptic necrosis of the femoral head. This condition most commonly occurs in boys 4-8 years of age. In addition to hip (or knee) pain, limping is a prominent feature. Upper thigh numbness in an adolescent female is a classic symptom of meralgia paresthetica, which is attributed to impingement of the lateral femoral cutaneous nerve in the groin, often associated with obesity or wearing clothing that is too tight in the waist or groin. Developmental dysplasia of the hip is identified by a click during a provocative hip examination of the newborn, using both the Barlow and Ortolani maneuvers to detect subluxation or dislocation.

You are the medical director of a long-term-care facility that has 60 residents. Several patients experience fever, cough, and upper respiratory symptoms. Two of these patients test positive for influenza A (H1N1) virus. What is the most appropriate managment based off guidelines by the CDC?

Chemoprophylaxis for all residents in a long term care facility if 2 or more have had confirmed influenza A. This is considered an outbreak in a long term care facility.

A female pt with symptomatic signs of acute pyelonephritis and culture pending should be started on what abx?

Cipro. Nitro and amoxicillin are good options for UTI's but cipro is started as a broad spectrum until results come back.

A 32-year-old male smoker presents with a 4-day history of progressive hoarseness. He is almost unable to speak, and associated symptoms include a cough slightly productive of yellow sputum, as well as tenderness over the ethmoid sinuses. He is afebrile and has normal ear and lung examinations. His oropharynx is slightly red with no exudate, and examination of his nasal passages reveals mucosal congestion. Which one of the following would be the most appropriate treatment? (check one) A. Amoxicillin for 10 days B. Omeprazole (Prilosec), 40 mg daily C. Azithromycin (Zithromax) for 5 days D. Symptomatic treatment only

D Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate. A Cochrane review concluded that antibiotics appear to have no benefit in treating acute laryngitis. Proton pump inhibitors such as omeprazole can be of benefit in treating chronic laryngitis caused by acid reflux, but not for an acute problem such as the one described.

A 57-year-old female with a past medical history significant for well-controlled type 2 diabetes mellitus, hypertension, and hyperthyroidism presents to your office with a chief complaint of a sore throat and a fever to 101.5°F at home. She has had chills and night sweats but has not had a cough, chest pain, or abdominal pain. Physical Findings General.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ill appearing HEENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . diffuse tender anterior cervical adenopathy; thyroid nontender; oropharynx erythematous with some purulence on her tonsils Cardiovascular.. . . . . . . . . . . . . . . . . . . . . . . . tachycardia without murmur Lungs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . clear to auscultation bilaterally Skin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . mild jaundice Laboratory Findings Rapid strep test. . . . . . . . . . . . . . . . . . . . . . . . negative Total WBC count. . . . . . . . . . . . . . . . . . . . . . . 3000/mm3 (N 4500-11,000) and absolute neutrophil count 0 Total bilirubin. . . . . . . . . . . . . . . . . . . . . . . . . 5 mg/dL (N 0-1.0) Alkaline phosphatase. . . . . . . . . . . . . . . . . . . . 151 U/L (N 38-126) Which one of the following medications is most likely to cause these laboratory abnormalities? (check one) A. Amlodipine (Norvasc) B. Aspirin C. Metformin (Glucophage) D. Methimazole (Tapazole)

D Approximately 0.3% of patients taking methimazole develop agranulocytosis, usually within the first 60 days of starting therapy. Other rare complications of methimazole include serum sickness, cholestatic jaundice, alopecia, nephrotic syndrome, hypoglycemia, and loss of taste. It is associated with an increased risk of fetal anomalies, so propylthiouracil (PTU) is preferred in pregnancy. The other medications listed are not known to cause the combination of agranulocytosis and cholestatic jaundice that this patient has.

A 35-year-old male with a 4-month history of pain in the medial aspect of his right knee sees you for follow-up. He has been doing physical therapy for the past month with minimal benefit. A plain radiograph is negative and MRI shows a tear in the medial meniscus. Which one of the following is most likely to yield the best long-term result? (check one) A. Referral for meniscectomy B. Corticosteroid injection C. Hylan GF 20 (Synvisc) injection D. Continued physical therapy E. A knee brace

D Arthroscopic partial meniscectomy is the most common orthopedic procedure performed in the United States. For patients without osteoarthritis of the knee, studies show meniscectomy for a tear of the meniscus is no more beneficial than conservative therapy in terms of functional status at 6 months. In a high-quality randomized, controlled trial involving patients with a medial meniscus tear but no osteoarthritis, meniscectomy and sham surgery were equally effective (SOR B). The optimal approach in patients with a degenerative tear of the meniscus is a physical therapy and exercise regimen.

A 7-month-old infant is hospitalized for the third time with lower-lobe bronchopneumonia. Findings include a weight and height below the 10th percentile. A sibling died of sudden infant death syndrome. Laboratory testing reveals a hemoglobin level of 9.0 g/dL (N 10.5-14.0), a mean corpuscular volume of 85 μm3 (N 72-88), and a serum calcium level of 9.0 mg/dL (N 9.0-10.5). A sweat chloride level is 20 mEq/L (N <60). Which one of the following is the most likely cause of this infant's failure to thrive? (check one) A. Cystic fibrosis B. DiGeorge's syndrome C. Battered child syndrome D. Gastroesophageal reflux E. β-Thalassemia

D Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. A sweat chloride level of 20 mEq/L rules out cystic fibrosis. Normal serum calcium excludes DiGeorge's syndrome. The battered child generally presents with more than just a single recurring medical problem. β-Thalassemia would be indicated by a microcytic anemia.

A 53-year-old female without risk factors for colorectal cancer undergoes a screening colonoscopy. A high-quality examination reveals five 3- to 7-mm sessile polyps in the sigmoid and rectal areas. Biopsy results show that they are hyperplastic polyps. No other abnormalities are noted. When should this patient have her next colonoscopy? (check one) A. 1 year B. 3 years C. 5 years D. 10 years E. No further colonoscopies needed

D Hyperplastic polyps <10 mm in size in the rectum and sigmoid colon carry a low risk for developing into colon cancer. If they are the only finding, colonoscopy may be repeated in 10 years.

You see a 27-year-old male with autosomal dominant polycystic kidney disease. He has no other medical problems and his renal function has always been normal on annual testing. Today the patient reports his blood pressure at home has been 142-150/84-90 mm Hg. His blood pressure at this visit is 145/88 mm Hg. Which one of the following medications is preferred for the initial management of hypertension in this patient? (check one) A. Amlodipine (Norvasc) B. Chlorthalidone C. Furosemide (Lasix) D. Lisinopril (Prinivil, Zestril)

D Hypertension is the most common manifestation of autosomal dominant polycystic kidney disease and it also contributes to worsening renal function and an increased risk for cardiovascular disease and death. ACE inhibitors such as lisinopril are first-line agents because they have renal protective benefits in addition to their effects on blood pressure. Some studies have suggested they help slow the decline in renal function and help to prevent left ventricular hypertrophy (more so than diuretics or calcium channel blockers). Angiotensin receptor blockers should be reserved for those who cannot tolerate ACE inhibitors.

A 22-year-old female with polycystic ovary syndrome comes in to discuss contraception. She has no other health conditions and takes no medications. Her menses are somewhat irregular, occurring every 28-42 days. She also asks about treatment for her mild hirsutism. Which one of the following medications would be most likely to address her need for contraception and also improve her hirsutism? (check one) A. Spironolactone (Aldactone) B. Cyclic progesterone C. Progesterone-only contraceptive pills D. Oral combined hormonal contraceptives E. A levonorgestrel-releasing IUD (Mirena)

D Management of polycystic ovary syndrome is typically aimed at addressing patient symptoms, as well as irregular menses and the risk of endometrial hyperplasia. Infertility may become a therapeutic target for women who desire pregnancy at some point in their lives. In this patient, who needs contraception and hopes to address her hirsutism, combined oral contraceptives are most likely to address both concerns. In addition to suppressing ovulation they also suppress gonadotropin and ovarian androgen production. The estrogen component increases hepatic production of sex hormone binding globulin, thus decreasing androgen bioavailability. Progestin-only pills and the levonorgestrel IUD protect against pregnancy but will not improve hirsutism. Cyclic progesterone every 1-3 months can be used to prevent endometrial hyperplasia but will not provide contraception or address hirsutism. Spironolactone is an androgen receptor antagonist that can decrease hair growth, but it will not provide contraception.

Which one of the following should be monitored during testosterone replacement therapy? (check one) A. Patient Health Questionnaire 9 (PHQ-9) scores B. Fasting glucose levels C. Fasting lipid profiles D. Hematocrit E. Overnight polysomnography

D Testosterone replacement therapy can cause erythrocytosis, so monitoring hematocrit at regular intervals is recommended. Testosterone replacement therapy does not significantly affect lipid levels, and additional monitoring of these levels is not recommended. Although there have been anecdotal reports of testosterone replacement therapy being associated with sleep apnea, current recommendations do not advise routine testing with overnight polysomnography for patients on testosterone replacement. There is inconsistent evidence of the effects of testosterone replacement therapy on depression, and thus no recommendation for monitoring of mood symptoms related to testosterone therapy. Low testosterone levels have been associated with insulin resistance, but testosterone replacement therapy is not recommended as treatment for hyperglycemia. Monitoring of serum glucose while on testosterone therapy is not routinely recommended.

A 78-year-old male presents for a routine health maintenance examination and is concerned about a gradual loss in his vision during the past year. He has smoked 1 pack of cigarettes per day for the past 60 years. He has no other medical problems. On Amsler grid testing he notes distorted grid lines. Which one of the following would you recommend for this patient? (check one) A. Watchful waiting B. Avoiding all vitamin supplements C. Treatment to reverse his visual changes D. Smoking cessation to prevent further vision loss

D This patient presents with signs and symptoms that suggest age-related macular degeneration. Smoking is a modifiable risk factor and smokers should be counseled to quit (SOR C). The patient should be referred to an ophthalmologist for further evaluation and management. Watchful waiting would not be appropriate. Vitamin supplements with Age-Related Eye Disease (AREDS) and AREDS2 formulations have been shown to delay visual loss in patients with age-related macular degeneration (SOR A). Age-related macular degeneration is not reversible but treatment can delay progression or stabilize the changes (SOR A).

A 57-year-old male presents to the emergency department complaining of dyspnea, cough, and pleuritic chest pain. A chest radiograph shows a large left-sided pleural effusion. Thoracentesis shows a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. Which one of the following causes of pleural effusion would be most consistent with these findings? (check one) A. Cirrhosis B. Heart Failure C. Nephrotic syndrome D. Pulmonary embolism E. Superior vena cava obstruction

D. The protein and lactate dehydrogenase (LDH) levels in pleural fluid can help differentiate between transudative and exudative effusions. Light's criteria (pleural fluid protein to serum protein ratio >0.5, pleural fluid LDH to serum LDH ratio >0.6, and/or pleural LDH >0.67 times the upper limit of normal for serum LDH) are 99.5% sensitive for diagnosing exudative effusions and differentiate exudative from transudative effusions in 93%-96% of cases. Of the listed pleural effusion etiologies, only pulmonary embolism is exudative. The remainder are all transudative.

A 56-year-old female comes in for evaluation of gradually worsening right hip pain. She describes her pain as located in the groin and dull in nature, and with activity often notes a clicking sensation associated with sharp pain. On examination her hip range of motion is intact but pain is elicited with extremes of internal and external rotation and her groin pain is exacerbated with the FABER test (knee flexion, abduction and external rotation of the leg until the ankle rests proximal to the contralateral knee) and FADIR test (knee flexion, adduction, and internal rotation of the leg). Which one of the following is the most likely diagnosis? (check one) A. Femoral neck fracture B. Femoral hernia C. Trochanteric bursitis D. Hip labral tear

D. This patient has signs and symptoms of a hip labral tear. This causes dull or sharp groin pain, which in some patients radiates to the lateral hip, anterior thigh, or buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. Half of patients also have mechanical symptoms, such as catching or painful clicking with activity. The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 75%-96% for the FADIR test and 88% for the FABER test), although neither test has high specificity. Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears, as it has a sensitivity of 90% and an accuracy of 91%. However, if a labral tear is not suspected, less invasive imaging modalities such as plain radiography and conventional MRI should be used first to assess for other causes of hip and groin pain. This patient has no history of trauma or risk factors to suggest a fracture. A femoral hernia would typically present as pain that is worse with straining or lifting, associated with a palpable bulge in the upper thigh. Trochanteric bursitis typically causes lateral hip pain with point tenderness over the greater trochanter of the femur.

In the United States, cow's milk is not recommended for children until the age of (check one) A. 4 months B. 6 months C. 9 months D. 12 months E. 15 months

D. It is because it doesn't supply them with enough nutrients

Which one of the following is true regarding respiratory syncytial virus (RSV) infection? A. Most infections in the United States occur between August and December B. Corticosteroids should be a routine part of treatment C. The diagnosis is usually based on positive serology D. It is rarely associated with bacterial co-infection

D. Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young infants, prematurely born infants, or those with pre-existing heart/lung conditions, the infection can be severe. In North America, RSV season is November to April. Treatment is primarily supportive, including a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and antibiotics are not routinely indicated (SOR B). Routine laboratory and radiologic studies should not be used in making the diagnosis, as it is based on the history and physical examination

A 50-year-old male presents to your office with a 1-hour history of an intense retro-orbital headache. This started while he was jogging and eased somewhat when he stopped, but has persisted along with some pain in his neck. Other than a blood pressure of 165/100 mm Hg, his examination is unremarkable. Noncontrast CT of the head is also unremarkable. His pain has persisted after 2 hours in the emergency department. Which one of the following would be most appropriate at this time? (check one) A. MRI of the head B. Angiography C. Nifedipine (Procardia) sublingually D. Sumatriptan (Imitrex) subcutaneously E. A lumbar puncture

E Early diagnosis of a nontraumatic subarachnoid hemorrhage is paramount for achieving a good outcome when a patient presents with a headache that is unusually severe and feels different than other headaches. Risk factors include smoking, hypertension, heavy alcohol use, and a family history of aneurysm or hemorrhagic stroke. The initial evaluation should consist of noncontrast CT of the head (SOR C). If it is negative or equivocal the next step would be to perform a lumbar puncture to determine whether or not the cerebrospinal fluid is xanthochromic. The absence of xanthochromia rules out subarachnoid hemorrhage

A 50-year-old female presents to your office for evaluation of a 2-month history of dyspnea on exertion and a nonproductive cough. She has a previous history of hypertension, overactive bladder, gastroesophageal reflux disease, and recurrent urinary tract infections. Vital signs are unremarkable and she has an oxygen saturation of 94%. She has inspiratory crackles in the posterior lung bases that do not clear with coughing. Office spirometry shows that the FVC is only 80% of normal, but the FEV1/FVC ratio is 0.85. Which one of the patient's current medications is most likely to be the cause of her problem? (check one) A. Lisinopril (Prinivil, Zestril) B. Conjugated estrogens (Premarin) C. Omeprazole (Prilosec) D. Solifenacin (Vesicare) E. Nitrofurantoin (Macrodantin)

E Interstitial lung disease is a consideration in patients with chronic dyspnea. It is often accompanied by a chronic nonproductive cough. Office spirometry is useful in detecting whether the problem is restrictive or obstructive. If the FVC is normal or decreased and the FEV1 is decreased, an FEV1/FVC ratio <0.7 means there is an obstructive ventilatory impairment. If the FVC is decreased and the FEV1 is normal or decreased the ratio would be >0.7, indicating a restrictive impairment. Diffuse parenchymal lung disease may be idiopathic, but there are a number of identified causes such as environmental or occupational exposures. Many collagen vascular diseases and medications used to treat them can induce interstitial lung disease. Common offenders also include amiodarone and nitrofurantoin, which can induce a pneumonitis. In this patient, lisinopril might explain the cough but not the dyspnea, crackles, or abnormal spirometry.

Which one of the following medications used for anxiety has also been shown to reduce the symptoms of irritable bowel syndrome? (check one) A. Buspirone B. Clonazepam (Klonopin) C. Divalproex sodium (Depakote) D. Risperidone (Risperdal) E. Citalopram (Celexa)

E Irritable bowel syndrome (IBS) symptoms improve with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

A 60-year-old male with a long-standing history of hypertension seeks your advice about pain relief from his osteoarthritis. He has tried acetaminophen and topical capsaicin cream without much benefit. He is concerned about media reports of NSAIDs causing heart problems and is unsure which ones would be safest for him to use. Based on current evidence, which one of the following NSAIDs would you recommend as being LEAST likely to be associated with an increased risk of myocardial infarction? (check one) A. Celecoxib (Celebrex) B. Diclofenac (Zorvolex) C. Ibuprofen D. Meloxicam (Mobic) E. Naproxen (Naprosyn)

E NSAIDs cause an elevation of blood pressure due to their salt and water retention properties. This effect can also lead to edema and worsen underlying heart failure. In addition, all NSAIDs can have a deleterious effect on kidney function and can worsen underlying chronic kidney disease, in addition to precipitating acute kidney injury. Celecoxib, ibuprofen, meloxicam, and diclofenac are associated with an increased risk of cardiovascular adverse effects and myocardial infarction, compared with placebo. However, naproxen has not been associated with an increased risk of myocardial infarction and is therefore preferred over other NSAIDs in patients with underlying coronary artery disease risk factors (SOR B).

A 70-year-old male who recently moved to your area sees you for the first time. He has a previous history of myocardial infarction, has a pacemaker, and has hypertension that had been well controlled on hydrochlorothiazide and atenolol (Tenormin) for several years. About 6 months ago his previous physician had to add amlodipine (Norvasc) to his regimen. On examination he has mild arteriolar narrowing in his fundi and there is a systolic bruit just to the right of his umbilicus. He has a log of home blood pressure readings that average 138/88 mm Hg for the past 2 months. His serum creatinine level has gone from 1.2 mg/dL to 1.4 mg/dL (N 0.6-1.2) in the past 2 months. Which one of the following would be most appropriate at this time? (check one) A. Referral for stent placement B. Scheduling an arteriogram C. A captopril renal scan D. Adding losartan (Cozaar) to his regimen E. Continued monitoring of serum creatinine

E Renal artery stenosis may be present in as many as 5% of patients with hypertension. It is often seen in those who have coronary artery disease and/or peripheral vascular disease. Hypertension requiring four or five drugs to control, abdominal bruits, and development of hyperkalemia or renal insufficiency after initiating therapy with an ACE inhibitor can all point toward renal artery stenosis as a diagnosis. For patients with renal artery stenosis who have good control, no testing is necessary other than monitoring renal function, particularly if an ACE inhibitor or ARB is part of the regimen. Screening tests recommended by clinical guidelines include duplex ultrasonography, CT angiography, or MR cystography (SOR B). Captopril renography was used in the past but is no longer recommended. In the 1990s uncontrolled studies were done that suggested that either stenting or angioplasty resulted in significant blood pressure reduction and reduced renal failure. However, a clinical trial has shown that stenting did not benefit patients when added to comprehensive multifactorial medical therapy.

Beyond short-term pain relief, local corticosteroid injection provides the best long-term improvement for which one of the following? (check one) A. Greater trochanteric bursitis B. Knee osteoarthritis C. Lateral epicondylitis D. Subacromial impingement syndrome E. Trigger finger

E Reported cure rates for trigger finger after corticosteroid injection range from 54% to 86%. Corticosteroid injection for the other conditions listed results in temporary pain relief, but the underlying conditions are not improved by the injection.

A pet reptile is most likely to transmit which one of the following to human contacts? (check one) A. Hantavirus B. Psittacosis (Chlamydophila psittaci) C. Plague (Yersinia pestis) D. Pasteurella multocida E. Salmonella

E Reptiles, including snakes, lizards, and turtles, cause both isolated cases of Salmonella infection and local and widespread outbreaks. While the sale of small pet turtles was outlawed in 1975, the law is not widely enforced and pet turtles are often a source of Salmonella infection in small children. The infection can also be spread by other reptiles and amphibians, including snakes and frogs. At a Colorado zoo in 1996, a total of 65 children were infected by touching a wooden barrier around a Komodo dragon exhibit. Pasteurella multocida is a common cause of infection as a result of dog or cat bites. Yersinia pestis, the organism of plague, is transmitted to humans from rodents or their fleas. Hantavirus is also transmitted by rodents, and psittacosis by certain bird species.

A 24-year-old female presents to the emergency department because she thinks she is having an allergic reaction to her medication for depression. About 3 hours after taking her first dose of citalopram (Celexa) she noted extreme anxiety, agitation, palpitations, and a dry mouth. On examination she has a blood pressure of 180/110 mm Hg, a pulse rate of 120 beats/min, a respiratory rate of 24/min, and a temperature of 37.2°C (99.0°F). Her pupils are dilated and she has slow, continuous horizontal eye movements. Marked hyperreflexia is noted in the lower extremities. In addition to supportive care, the patient should be given intravenous (check one) A. propranolol B. diphenhydramine C. haloperidol lactate (Haldol Lactate) D. flumazenil (Romazicon) E. diazepam

E Serotonin syndrome is a result of increased serotonergic activity in the central nervous system and may be life-threatening. It is usually a combination of autonomic hyperactivity, neuromuscular abnormality, and mental status changes. The most common group of medications that may cause this is the SSRIs. Serotonin syndrome most commonly occurs in the first 24 hours of treatment. Patients often present with agitation and confusion, tachycardia, and elevated blood pressure, as well as a dry mouth. While there are usually no focal neurologic findings, hyperreflexia and even spontaneous clonus may be seen. The finding of slow, horizontal movement of the eyes is also helpful in making the diagnosis. The initial management is to discontinue the offending agent, begin supportive care, and attempt to calm the patient verbally. Many times medication is needed, and the drug of choice is an intravenous benzodiazepine such as lorazepam or diazepam.

A patient is admitted to the hospital with severe acute pancreatitis, based on diagnostic criteria for severity. After appropriate intravenous hydration, which one of the following is associated with shorter hospital stays and lower mortality? (check one) A. Parenteral nutrition B. Nothing by mouth until the pain has resolved C. Clear liquids by mouth after 48 hours D. Bolus nasogastric enteral nutrition E. Continuous nasogastric enteral nutrition

E The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay. Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.

Many of the changes that occur as part of aging affect pharmacokinetics. Which one of the following is INCREASED in geriatric patients? (check one) A. Drug absorption B. The glomerular filtration rate C. Lean body mass D. The volume of distribution of water-soluble compounds such as digoxin E. The percentage of body fat

E The physiologic changes that accompany aging result in altered pharmacokinetics. In older persons there is a relative increase in body fat and a relative decrease in lean body mass, which causes increased distribution of fat-soluble drugs such as diazepam. This also increases the elimination half-life of such medications. The volume of distribution of water-soluble compounds such as digoxin is decreased in older patients, which means a smaller dose is required to reach a given target plasma concentration. There is also a predictable reduction in glomerular filtration rate and tubular secretion with aging, which causes decreased clearance of medications in the geriatric population. The absorption of drugs changes little with advancing age. All of these changes are important to consider when choosing dosages of medications for the older patient.

A mother brings her 5-year-old daughter to see you because she found a mass in the child's neck. The mass appeared over the past week and was preceded by a sore throat. Her pharyngitis is now resolved but she still has a fever, although it is not as high. The mother is most concerned because the mass developed over a short span of time, and it is warm, red, and tender. When asked, she says that her daughter has had no recent exposure to cats. When you examine the child you note that her temperature is 38.0°C (100.4°F). You also find shotty adenopathy in both anterior cervical lymph node chains, and a 2.5-cm warm, firm, moderately tender lymph node in the right anterior cervical chain. The overlying skin is also erythematous. Which one of the following would be the most appropriate management at this time? (check one) A. Ultrasonography of the neck mass B. CT with intravenous contrast of the neck mass C. Ultrasound-guided fine-needle aspiration of the mass D. Immediate referral to a head and neck surgeon E. Empiric antibiotic therapy with observation for 4 weeks

E This child has cervical lymphadenitis, characterized by systemic symptoms, unilateral lymphadenopathy, skin erythema, node tenderness, and a node that is 2-3 cm in size. The most common organisms associated with lymphadenitis are Staphylococcus aureus and group A Streptococcus. Empiric antibiotic therapy with observation for 4 weeks is acceptable for children with presumed reactive lymphadenopathy (SOR C). If symptoms do not resolve, or if the mass increases in size during antibiotic treatment, further evaluation is appropriate.

You see a 38-year-old male 11 days after his cat bit him on the thumb. He went to an urgent care clinic and was given a ceftriaxone (Rocephin) injection and 10 days of oral amoxicillin/clavulanate (Augmentin). He says the redness and pain in his thumb and hand have improved some, but the thumb remains very painful. He received a tetanus booster recently. His cat is well. His vital signs are normal and examination of the thumb reveals a swollen, erythematous, tender, warm interphalangeal joint with decreased range of motion. There are healing 2-mm dorsal skin wounds over the joint. Which one of the following would you recommend at this point? (check one) A. Continued amoxicillin/clavulanate B. Azithromycin (Zithromax) C. Clindamycin (Cleocin) D. Rabies vaccine and continued amoxicillin/clavulanate E. Consultation for surgery

E This patient's cat is well more than 10 days after the bite, so rabies vaccine is not necessary. Azithromycin is indicated for cat scratch disease, but the presentation does not suggest this. Severe infections may require incision, drainage, and intravenous antibiotics. A surgery consultation is recommended to evaluate for tendon sheath or joint infection.

Screening for chronic hepatitis B infection is NOT recommended for which one of the following? (check one) A. Patients on chronic immunosuppressive therapy B. Patients with end-stage renal disease who are on hemodialysis C. Household contacts of individuals with chronic hepatitis B D. Pregnant women with no risk factors for hepatitis B E. All newborns

E Worldwide, hepatitis B is a common cause of liver failure, cirrhosis, and hepatocellular carcinoma. The disease characteristically is asymptomatic before such complications develop. Although routine infant vaccination against hepatitis B has greatly decreased the incidence of this infection in the United States, it remains a significant cause of morbidity and mortality both in the United States and globally. Identifying persons infected with hepatitis B allows vaccination of their household contacts and sexual partners, thereby preventing further transmission. It also allows for medical treatment of infected individuals, including antiviral therapy and monitoring for the development of cirrhosis or hepatocellular carcinoma.

A 4-year-old male has a BMI of 17.5 kg/m2, which places him between the 90th and 95thpercentiles for BMI. According to the CDC should he be classified as being obese?

He should be classified as being overweight. Children under the age of 2 years are identified as being overweight when their weight-for-length ratio exceeds the 95th percentile for their sex. The term obese is not used for children under the age of 2 years. Children age 2-18 years are appropriately classified as underweight when their BMI falls below the 5th percentile, healthy weight when their BMI is between the 5th and 85th percentile, overweight when their BMI is between the 85th and 94th percentile, and obese when their BMI is in the 95th or greater percentile. There is currently no standard definition of childhood morbid obesity, but obesity is sometimes classified as severe or extreme when a child's BMI is at the 99th percentile or greater.

Which one of the following medications is associated with a higher risk of death due to stroke or sudden cardiac death in patients with dementia? (check one) A. Diazepam (Valium) B. Fluoxetine (Prozac) C. Paroxetine (Paxil) D. Quetiapine (Seroquel) E. Venlafaxine

In April 2005 the FDA issued a boxed warning for second-generation antipsychotics, including quetiapine, after a meta-analysis demonstrated a 1.6- to 1.7-fold increase in the risk of death associated with their use in elderly patients with dementia, related in part to sudden cardiac death and also to stroke. In June 2008, after two large cohort studies showed a similar risk with first-generation antipsychotics, boxed warnings were added to this class as well. The other medications listed do not have this association or warning.

A school nurse discovers head lice on a fourth-grade student. When should the student be permitted to return to class? (check one) A. Immediately B. When there are no visible nits C. After a single treatment with a topical agent D. After two treatments with a topical agent, 7 days apart

Head lice are a common and easily treated inconvenience in school-aged children that, unlike body lice, are not associated with significant illnesses. Transmission generally requires head-to-head contact, as lice cannot survive when separated from their host for more than 24 hours and do not fly or hop. Visible nits are generally present at the time of diagnosis, confirming that the infestation has been present for some time, so immediate isolation from other children would not be expected to change the natural course of events. The American Academy of Pediatrics (AAP) recommends that children found to be infested with lice remain in class but be discouraged from close contact with others until treated appropriately with a pediculicide. The AAP position also recommends abandonment of "no nits" school policies, which prohibit attendance until no visible nits are identified. Nits can be found long after their deposition at the scalp level and generally have already hatched by the time they are easily noted at some distance from the scalp.

23-year-old healthy male is sexually active with other men and does not use condoms. He is interested in reducing his risk of contracting HIV by using a daily oral antiretroviral medication. Which one of the following laboratory tests should be done no more than 7 days before initially prescribing pre-exposure prophylaxis with emtricitabine/tenofovir disoproxil (Truvada)? (check one) A. A CD4 cell count B. Antibody testing for HIV C. Hemoglobin concentration D. A platelet count E. An ALT level

It is of critical importance that patients have a documented negative HIV antibody test (from serum or point-of-care fingerstick) prior to starting pre-exposure prophylaxis (PrEP) to avoid inadvertent treatment of HIV infection with emtricitabine/tenofovir. This is the only medication currently approved in the United States for PrEP, but it is inadequate for HIV treatment. Using this treatment by itself in HIV-positive patients increases the risk of HIV strains developing resistance to these antiviral agents.

A 15-year-old male presents to the emergency department after suffering a lateral dislocation of his patella. Which one of the following would be the best method for reducing this dislocation? (check one) A. Medially directed pressure on the patella while extending the leg B. Medially directed pressure on the patella while flexing the leg C. Rapid leg extension D. Lateral retinacular release

It is usually simple to reduce a lateral patellar dislocation, and these injuries rarely require acute surgical management. The proper technique is to have the patient sit or lie with the leg in a flexed position and then apply gentle medial pressure to the patella until the most lateral edge is over the femoral condyle. The leg should then be gently extended and the knee brought into full extension. This should cause the patella to slip back into place, and the knee should then be immobilized.

Which one of the following can help to minimize the pain of lidocaine (Xylocaine) injection? (check one) A. Slowly inserting the needle through the skin B. Avoiding injectionnn into the subcutaneous tissue C. Injection of the solution only after fully inserting the needle at the target site D. Cooling the solution to refrigerator temperature prior to injecting it E. Buffering the solution with sodium bicarbonate

Lidocaine buffered with sodium bicarbonate decreases the pain associated with the injection. This effect is enhanced when the solution is warmed to room temperature (SOR B). Rapidly inserting the needle through the skin, injecting the solution slowly and steadily while withdrawing the needle, and injecting into the subcutaneous tissue also minimize the pain of injection.

Examination of a 2-day-old infant reveals flesh-colored papules with an erythematous base located on the face and trunk, containing eosinophils. Which one of the following would be most appropriate at this time?

Observation only. This infant has findings consistent with erythema toxicum neonatorum, which usually resolves in the first week or two of life (SOR A). No testing is usually necessary because of the distinct appearance of the lesions. The cause is unknown.

You have prescribed oral iron replacement for a 46-year-old female with iron deficiency anemia related to heavy menses. She wants to be sure that the iron she takes will be absorbed well. Which one of the following would you suggest for improving iron absorption? (check one) A. Calcium B. Vitamin C C. Coffee D. Tea

Taking oral iron with vitamin C or a meal high in meat protein increases iron absorption. Calcium and coffee both decrease iron absorption, but not as much as tea, which can reduce absorption of oral iron by as much as 90%.

Which one of the following screening practices is recommended for the adolescent population by the U.S. Preventive Services Task Force? (check one) A. Lipid screening for 3 months B. Scoliosis screening C. Testicular examination D. Papanicolaou tests starting 3 years after first sexual intercourse E. Chlamydia screening in sexually active females

The U.S. Preventive Services Task Force recommends screening for Chlamydia infection in all sexually active, nonpregnant young women under the age of 25 (grade B recommendation). Papanicolaou testing is recommended starting at 21 years of age. Testicular cancer screening, whether by self-examination or as part of the physical examination, is not recommended. Scoliosis screening for asymptomatic adolescents is also not recommended. There is insufficient evidence to recommend for or against lipid screening.

Complications of hypoparathyroidism include (check one) A. somnolence B. low vitamin D C. muscle flaccidity D. hyperkalemia E. refractory heart failure

The classic symptoms of hypoparathyroidism are those of insufficient calcium. Typically these include refractory heart failure, tetany, seizures, altered mental status, and stridor. Refractory heart failure is related to the low calcium interfering with the normal contractility of myocytes. Low vitamin D can cause hypocalcemia but is not caused by it. Patients are not at risk for hyperkalemia if they have hypoparathyroidism. Seizures, not somnolence, and muscle twitching, not flaccidity, are symptoms of low calcium.

61-year-old female tells you that her brother was recently diagnosed with hereditary hemochromatosis and his physician suggested that she get tested. She feels well and has no significant health problems. Which one of the following would be most appropriate for initial screening? (check one) A. Serum transaminases B. A CBC and a serum iron level C. Testing for the HFE gene D. Ferritin and transferrin saturation E. Total iron building capacity

The diagnosis of hereditary hemochromatosis requires a random measurement of serum ferritin and calculation of transferrin saturation. The transferrin saturation is calculated by dividing the serum iron level by the total iron binding capacity. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is ³45% the HFE gene should be checked. Measurement of liver transaminases plays a role in determining liver disease but is not helpful in the diagnosis.

A 61-year-old female tells you that her brother was recently diagnosed with hereditary hemochromatosis and his physician suggested that she get tested. She feels well and has no significant health problems. Which one of the following would be most appropriate for initial screening? (check one) A. Serum transaminases B. A CBC and a serum iron level C. Testing for the HFE gene D. Ferritin and transferrin saturation E. Total iron binding capacity

The diagnosis of hereditary hemochromatosis requires a random measurement of serum ferritin and calculation of transferrin saturation. The transferrin saturation is calculated by dividing the serum iron level by the total iron binding capacity. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is ≥45% the HFE gene should be checked. Measurement of liver transaminases plays a role in determining liver disease but is not helpful in the diagnosis.

A 52-year-old healthy male presents with a 2½-week history of diarrhea, consisting of 4-6 watery stools daily. He is afebrile and his examination is normal. You recommend symptomatic care. Two days later the laboratory notifies you that Salmonella is growing in his stool culture. You call the patient and he remains free of fever but with ongoing diarrhea. Which one of the following would you recommend? (check one) A. Azithromycin (Zithromax) B. Ciprofloxacin (Cipro) C. Clindamycin (Cleocin) D. Doxycycline E. No treatment

The recommended management for patients who have non-severe Salmonella infection and are otherwise healthy is no treatment. Patients with high-risk conditions that predispose to bacteremia, and those with severe diarrhea, fever, and systemic toxicity or positive blood cultures should be treated with levofloxacin, 500 mg once daily for 7-10 days (or another fluoroquinolone in an equivalent dosage), or with a slow intravenous infusion of ceftriaxone, 1-2 g once daily for 7-10 days (14 days in patients with immunosuppression).

Treatment of rhabdomyolysis should routinely include which one of the following? (check one) A. Bicarbonate-containing fluids B. Loop diuretics C. Mannitol D. Parenteral corticosteroids E. Isotonic saline

The treatment of rhabdomyolysis includes rapid large infusions of isotonic saline to prevent and treat acute kidney injury, which occurs in 10%-60% of patients. Sodium bicarbonate administration is unnecessary and is not better than normal saline diuresis and increasing urine pH. Loop diuretics and mannitol have little human evidence to support their use. Corticosteroid use is not recommended.

A right-hand-dominant 38-year-old male comes to your office because of right elbow pain. He recently began participating in a highly competitive adult volleyball league, and 2 weeks after he first began playing he developed mild pain in the medial elbow of his right arm. While completing an overhead serve last night he felt an acute worsening of the elbow pain. After the match he noted bruising over his medial elbow. When you examine him you find bruising and pain to palpation around the medial elbow. With his shoulder in 90° of abduction and external rotation you rapidly flex and extend the elbow while maintaining valgus torque on the elbow (the moving valgus stress test). The patient reports pain between 70° and 120° of flexion. This clinical presentation is most consistent with which one of the following causes of elbow pain? (check one) A. Medial epicondylitis B. Biceps tendinopathy C. Cubital tunnel syndrome D. Ulnar collateral ligament injury E. Triceps tendinopathy

This patient has injured his ulnar collateral ligament (UCL). The UCL is the primary restraint to valgus stress on the elbow during overhead throwing. These injuries often occur in athletes participating in sports that require overhead throwing, such as baseball, javelin, and volleyball. Patients often report a pop followed by immediate pain and bruising around the medial elbow. The moving valgus stress test has 100% sensitivity and 75% specificity for diagnosing UCL injuries. Medial epicondylitis usually presents with an insidious onset of pain related to a recent increase in occupational or recreational activities. Patients also often report weakened grip strength. The point of maximal tenderness is 5-10 mm distal to and anterior to the medial epicondyle. It is most often a tendinopathy of the flexor carpi radialis and the pronator teres.

A 24-year-old male complains of feeling on edge all of the time. For the past 2 years he has had difficulty controlling his worrying about work, school, and relationships. He has had more difficulty concentrating at work and school, is more irritable, and has difficulty staying asleep all night. He drinks alcohol moderately and does not use drugs. You recommend regular exercise and refer him to a therapist for cognitive-behavioral therapy to help manage his symptoms. Which one of the following would be first-line medical therapy for this patient? (check one) A. Bupropion (Wellbutrin) B. Fluoxetine (Prozac) C. Lorazepam (Ativan) D. Methylphenidate (Ritalin, Concerta) E. Quetiapine (Seroquel)

Though symptoms of generalized anxiety disorder (GAD) overlap with other psychiatric and medical conditions, the case presented is most consistent with GAD. SSRIs are first-line therapy for GAD (SOR B). Benzodiazepines such as lorazepam can improve anxiety-related symptoms, but due to the side effects and addiction potential they are recommended for short-term use (SOR B). Bupropion is approved for the treatment of depression but is not used to treat GAD. Quetiapine may be considered as second-line therapy for GAD (SOR B). Methylphenidate is first-line therapy for attention-deficit/hyperactivity disorder but is not indicated to treat GAD. Psychotherapy, especially cognitive-behavioral therapy, is also first-line treatment for GAD (SOR A), and exercise can also improve symptoms (SOR B).

A 40-year-old female sees you for a health maintenance visit. She has no complaints and other than being overweight she has an unremarkable examination. Laboratory results are also unremarkable except for her lipid profile. She has a total cholesterol level of 251 mg/dL, an HDL-cholesterol level of 31 mg/dL, and a triglyceride level of 1250 mg/dL. The LDL-cholesterol level could not be calculated and measured 145 mg/dL. In addition to lifestyle changes, this patient would most likely benefit from (check one) A. niacin B. omega-3 fatty acid supplementation C. atorvastatin (Lipitor) D. ezetimibe (Zetia) E. fenofibrate (Tricor)

Treatment of hypertriglyceridemia depends on its severity. Contributing factors include a sedentary lifestyle, being overweight, excessive alcohol intake, type 2 diabetes mellitus, and genetic disorders. Triglyceride levels of 150-199 mg/dL are considered mild hypertriglyceridemia, levels of 200-999 mg/dL are moderate, 1000-1999 mg/dL are severe, and levels >2000 mg/dL are considered very severe. Patients with hypertriglyceridemia in the mild to moderate range may be at risk for cardiovascular disease, but those who have severe or very severe hypertriglyceridemia have a significant risk of pancreatitis. In addition to having the patient exercise, reduce intake of fat and carbohydrates, and lose weight, she should also be counseled to avoid alcohol. For patients at risk for pancreatitis, fibrates are recommended as the initial treatment for pancreatitis. It should be noted that statins may have a modest triglyceride-lowering effect and may be helpful in decreasing cardiovascular risk in those who have moderately elevated triglycerides. However, they should not be used alone in patients who have severe hypertriglyceridemia. Studies have also shown that while omega-3 fatty acids decrease triglycerides and very low density lipoprotein cholesterol levels, they may increase LDL-cholesterol levels. Treatment with omega-3 fatty acids does not decrease total mortality or cardiovascular events, and therefore is not recommended