CME Study II (b)

Correct This patient has lichen simplex chronicus, consisting of lichenified plaques and excoriations that result from excessive scratching. Treatment focuses on stopping the itch-scratch cycle. Topical corticosteroids under an occlusive dressing or intralesional corticosteroids can be helpful. Scabies lesions are small, erythematous papules that are frequently excoriated. Contact dermatitis is usually associated with direct skin exposure to an allergen or irritant and is typically localized to the area of exposure. Chronic urticaria causes a typical circumscribed, raised, erythematous lesion with central pallor.

A 56-year-old male with diabetes mellitus and hypertension presents with a 6-month history of generalized pruritus. He reports that he scratches frequently. On examination his skin is dry and scaly. He has multiple linear excoriations and thickened skin on his forearms, legs, and neck. Which one of the following is the most likely cause of his pruritus? (check one) A. Contact dermatitis B. Chronic urticaria C. Lichen simplex chronicus D. Scabies

Correct The presence of a solitary enlarged left supraclavicular lymph node (Virchow's node) is associated with a gastrointestinal system malignancy. When combined with painless jaundice and a palpable nontender gallbladder (Courvoisier's sign), pancreatic cancer is the most likely diagnosis. A pancreatic pseudocyst develops after repeated bouts of pancreatitis and is not directly associated with jaundice. Biliary cirrhosis and hepatocellular carcinoma typically present with pain, fatigue, malaise, hepatomegaly, jaundice, and eventually ascites. The jaundice of biliary cirrhosis is generally accompanied by severe pruritus. In neither condition is a palpably enlarged gallbladder present. Ascending cholangitis presents with a high fever, right upper quadrant pain, and an overall toxic, septic picture, often accompanied by delirium and rigors.

A 72-year-old white female presents to your office with a 6-week history of "tanned skin." She initially attributed it to having gone on a cruise 2 months ago, but noticed her skin continued to darken as time passed. She is slender and has lost 5 kg (11 lb) since her last checkup 6 months ago. She denies fever, malaise, or abdominal pain. Her only medications are hydrochlorothiazide and a baby aspirin daily. On examination your suspicion of jaundice is confirmed by the presence of scleral icterus. You also note a single enlarged left supraclavicular lymph node which is nontender. The abdomen is soft and nontender; on deep palpation of the right upper quadrant you feel a smooth, nontender mass. Which one of the following is the most likely diagnosis? (check one) A. Biliary cirrhosis B. Ascending cholangitis C. Obstructing pancreatic pseudocyst D. Carcinoma of the head of the pancreas E. Hepatocellular carcinoma

Which one of the following is associated with bisphosphonate use for the treatment of osteoporosis? (check one) A. Hypercalcemia B. Hyperphosphatemia C. Vitamin D deficiency D. Atypical femoral shaft fractures E. Renal failure

Correct The use of bisphosphonates is associated with a small increase in the risk of atypical femoral shaft fractures. The risk increases with the duration of use (SOR B). These drugs are also associated with an increased risk of osteonecrosis of the jaw, esophagitis, and esophageal ulceration, as well as hypocalcemia. In fact, bisphosphonates are used as a treatment for hypercalcemia. They do not affect phosphorus or vitamin D levels.

A 4-year-old male sees you for pre-kindergarten screening. On corneal light reflex testing, the light reflex in the patient's right eye is in the center of the pupil. In the left eye it is located below the pupil, over the inferior-lateral portion of the iris. This clinical finding is associated with a congenital palsy of which one of the following cranial nerves? (check one) A. Third B. Fourth C. Fifth D. Sixth E. Seventh

Correct In a corneal light reflex test, the patient's attention is attracted to a target while a light is directed at the eyes. In normally aligned eyes the light reflex will be located in the center of each pupil. In patients with esotropia the reflex will be over the lateral portion of the iris in the affected eye. In exotropia the light reflex is over the medial iris, in hypertropia it is over the inferior iris, and in hypotropia it is over the superior iris. The finding observed in this child, hypertropia, will occur with a congenital palsy involving the superior oblique muscle, which is innervated by the fourth cranial nerve.

A 55-year-old male has a 3-month history of chronic shortness of breath and dyspnea on exertion. His physical examination is unremarkable except for 1+ ankle edema bilaterally and a soft systolic murmur. A stress echocardiogram is normal. Pulmonary function tests are normal except for a low diffusing capacity of the lung for carbon monoxide (DLCO). Which one of the following conditions should be considered in this patient? (check one) A. Chronic pulmonary thromboembolism B. Emphysema C. Interstitial lung disease D. Asthma E. Hypersensitivity pneumonitis

Correct A diffusion capacity test assesses how well a tracer gas in inspired air can cross from the air into the blood. The diffusion capacity provides a general assessment of the air-blood interface. Reduced values are seen with severe interstitial fibrosis, or when the capillary surface has been compromised by vascular obstruction (pulmonary embolism) or is destroyed by emphysema. Chronic pulmonary embolism causes a low diffusing capacity of the lung for carbon monoxide (DLCO) with normal pulmonary function tests. Emphysema causes a low DLCO and an obstructive pattern on pulmonary function testing (PFT). Interstitial lung disease and hypersensitivity pneumonitis both cause a low DLCO with a restrictive pattern of PFTs. Patients with asthma may have an increased DLCO with an obstructive pattern, with reversibility after bronchodilator administration.

Which one of the following therapeutic interventions improves outcomes in adults with acute respiratory distress syndrome (ARDS)? (check one) A. Early initiation of antibiotics B. Surfactant therapy C. Pulmonary artery catheterization D. Aggressive intravenous fluid resuscitation E. Starting mechanical ventilation with lower tidal volumes

Correct In patients with acute respiratory distress syndrome (ARDS), starting mechanical ventilation with lower tidal volumes of 6 mL/kg is superior to starting with traditional tidal volumes of 10-14 mL/kg (SOR A). Conservative fluid therapy is recommended in patients with ARDS, as this is associated with a decrease in the number of days on the ventilator and in the intensive-care unit (SOR B). Pulmonary artery catheters are not recommended for routine management of ARDS (SOR A). Surfactant therapy does not improve mortality in adults with ARDS (SOR A), and antibiotics are not an effective treatment.

Which one of the following findings on pulmonary function testing is most consistent with restrictive lung disease? (check one) A. Reduced FEV1 and a decreased FEV1/FVC ratio B. Reduced FEV1 and a normal FEV1/FVC ratio C. Reduced FEV1 and an increased FEV1/FVC ratio D. Reduced FVC and an increased FEV1/FVC ratio E. Decreased diffusing capacity of the lung for carbon monoxide (DLCO)

Correct A full set of pulmonary function tests consists of spirometry, helium lung volume measurements, and the measurement of diffusing capacity of the lung for carbon monoxide (DLCO). A bronchodilator challenge will allow assessment of reversible airway obstruction. A methacholine challenge test can also be used to look for airway hyperreactivity. A reduced FVC with either a normal or increased FEV1/FVC ratio is consistent with restrictive lung disease. There are three basic categories of restrictive lung disease: intrinsic lung disease, chest wall deformities, and neuromuscular disorders. A reduced FEV1 and decreased FEV1/FVC ratio is seen in obstructive lung disease (asthma, COPD). The DLCO is the measure of the diffusion of carbon monoxide across the alveolar-capillary membrane. Reduced values are obtained when interstitial fibrosis is extensive, or when the capillary surface is compromised by vascular obstruction or nonperfusion, or is destroyed (as in emphysema).

The parents of a 4-year-old male bring him in for evaluation because of behavioral problems in his preschool. They report that he is inattentive, hyperactive, and impulsive, has difficulty remaining seated, always seems to be moving, frequently interrupts others, and talks incessantly. His teacher also told them that he never plays quietly, has difficulty taking turns, and intrudes often in other children's play. Which one of the following is recommended by the American Academy of Pediatrics for initial management in this child's case? (check one) A. Behavioral treatment alone B. Methylphenidate (Ritalin) alone C. Atomoxetine (Strattera) alone D. Methylphenidate combined with behavioral treatment E. Methylphenidate combined with atomoxetine

Correct According to the American Academy of Pediatrics, preschool-age children with ADHD should receive behavioral therapy alone, administered by a parent and/or teacher. Initially prescribing behavioral therapy alone is supported by strong overall evidence and also by a study finding that many preschool-age children with moderate to severe dysfunction had improved symptoms with behavioral therapy alone. If significant improvement is not observed, then methylphenidate can be added. Medications combined with behavioral therapy should be prescribed in elementary school-age children. Evidence for the use of stimulants is strong, and evidence for the use of atomoxetine is sufficient, but not as strong as for the stimulants.

A 45-year-old female has been admitted to the hospital for an episode of acute diverticulitis. Which one of the following features would most strongly suggest a need for surgical intervention? (check one) A. A previous admission for diverticulitis in the last 12 months B. Pain uncontrolled by oral analgesics C. A microperforation seen on CT at the site of the diverticulitis D. A 4-cm simple abscess at the site of the diverticulitis E. The presence of generalized peritonitis

Correct Acute diverticulitis can be treated using oral antibiotics on an outpatient basis in 90% of cases. In fact, there is good evidence that those with uncomplicated diverticulitis (no signs of abscess, fistula, phlegmon, obstruction, bleeding, or perforation) can be treated without the use of antibiotics, using only bowel rest and close follow-up. Among patients who require hospitalization, it is estimated that <10% of cases will require surgical intervention. Thus, the majority of patients hospitalized with this condition, even those with complicated diverticulitis, will respond well to bowel rest and intravenous antibiotics. Indications for surgery include generalized peritonitis, unconfined perforation, uncontrolled sepsis, an undrainable abscess, and failure of conservative management. CT-guided percutaneous drainage of an accessible abscess is a well-proven treatment to avoid the use of open surgery. Prevention of future episodes of diverticulitis increasingly revolves around the use of daily oral medications. Some experts recommend considering surgery to remove a section of bowel after a patient's third admission for diverticulitis.

A 23-year-old male presents to your office with a 2-day history of dull, achy, right testicular pain. He reports that the pain began gradually, reaching a peak last night. He does not recall any trauma and denies any urethral complaints. Your examination reveals an extremely tender right testis with some tenderness extending to the epididymis. A preliminary report from a stat ultrasound examination shows an enlarged, heterogeneous right testis with increased color flow. Which one of the following is the preferred management? (check one) A. Watchful waiting B. Repeat ultrasonography in 24 hours C. Antibiotic treatment D. Emergent urology referral

Correct Acute epididymitis is often the result of descending infection caused by urinary tract pathogens. When the infection involves the epididymis and testis (epididymo-orchitis), sonography will frequently show an enlarged heterogeneous testis with increased color flow. In sexually active men under age 35, acute epididymitis is caused most frequently by Chlamydia trachomatis and less commonly by Neisseria gonorrhoeae. Clinical features suggestive of urethritis maybe absent (subclinical urethritis). Epididymitis in men who have practiced unprotected insertive rectal intercourse is often caused by Enterobacteriaceae. These men usually do not have urethritis but do have bacteriuria. Treatment of acute epididymo-orchitis consists of administering appropriate antibiotics for the treatment of both gonorrhea and Chlamydia infections. Additional antibiotic coverage may be indicated based on the patient's sexual history. Unilateral absent flow on color and spectral Doppler sonography is a highly sensitive and specific finding in acute testicular torsion and emergent urology referral is indicated. Heterogeneous echotexture of the testis is a common finding in sonograms performed to evaluate acute scrotal pain, regardless of the cause. There is no role for repeat ultrasonography or watchful waiting in patients with acute epididymo-orchitis(SOR C).

A 75-year-old male reports that his handwriting seems more "cramped," he has started shuffling more as he walks, and he has been experiencing some difficulty turning over in bed, rising from a chair, and opening jars. He also reports increasing body stiffness and a resting tremor in his hand. Given the stage of his disease, which one of the following options for initial medical management is supported by the best evidence? (check one) A. Amantadine B. Bromocriptine (Parlodel) C. Benztropine D. Carbidopa/levodopa (Sinemet) E. Entacapone (Comtan)

Correct All of the drugs listed are used to treat motor symptoms in patients with Parkinson's disease. However, the best evidence supports the use of carbidopa/levodopa, non-ergot dopamine agonists such as pramipexole or ropinirole, or monoamine oxidase-B inhibitors such as selegiline or rasagiline for initial management of patients with early disease (SOR A).

An 85-year-old male is brought to your office by his family because they are concerned that he may be depressed. Which one of the following is most likely in a depressed patient in this age group? (check one) A. Suicidal ideation B. Somatic symptoms C. Depressed mood D. Preoccupation with guilt

Correct Somatic complaints are seen in up to two-thirds of primary care patients with depression, and are more likely in certain groups, including pregnant women, children, the elderly, and low-income groups.

An 18-month-old male is brought to your office by his mother. The patient is tugging at both ears and has a temperature of 39.0°C (102.2°F). You diagnose bilateral acute otitis media for the third time in the last 6 months. The most recent infection was 3 weeks ago and resolution of the infection was documented after 10 days of treatment with amoxicillin. Which one of the following antibiotic regimens would be most appropriate at this time? (check one) A. Amoxicillin, 45 mg/kg/day for 10 days B. Amoxicillin, 90 mg/kg/day for 10 days C. Amoxicillin, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months D. Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days E. Amoxicillin/clavulanate, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months

Correct Although high-dose amoxicillin (90 mg/kg/day) is recommended as the antibiotic of choice for acute otitis media (AOM) in the nonallergic patient, amoxicillin/clavulanate is recommended if a child has received antibiotic therapy in the previous 30 days. Prophylactic antibiotics are not recommended, as harms outweigh benefits. Tympanostomy tubes are an option if a child has had three episodes of AOM in the past 6 months or four episodes in the past year with at least one episode in the past 6 months.

A 50-year-old female with a history of refractory hypertension presents with abdominal pain. Her laboratory results are significant for a positive Helicobacter pylori antibody. You decide to initiate treatment for her H. pylori infection with sequential therapy using the following drug regimen: rabeprazole (Aciphex) plus amoxicillin, followed by clarithromycin (Biaxin) plus tinidazole (Tindamax). She is currently on multiple medications for her hypertension. Which one of her antihypertensive agents would be most affected by the treatment regimen described? (check one) A. Amlodipine (Norvasc) B. Clonidine transdermal (Catapres-TTS C. Hydrochlorothiazide D. Metoprolol tartrate (L

Correct Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of calcium channel blockers metabolized by this enzyme, thus increasing their levels. This can lead to hypotension, edema, and acute kidney injury due to decreased renal perfusion. It is preferable to choose a different antibiotic regimen for patients on a dihydropyridine calcium channel blocker such as amlodipine, but if another antibiotic cannot be used, either temporarily stopping the calcium channel blocker or empirically lowering the dosage should be considered.

A 53-year-old male complains of fatigue, dyspnea, and orthopnea. Which one of the following would have the highest specificity for heart failure? (check one) A. Ankle edema B. A third heart sound (S3 gallop) C. Crackles D. Cardiomegaly on a chest radiograph E. Elevated BNP

Correct Among the constellation of history and physical findings that can be found in patients with heart failure, none provides a proof-positive diagnosis alone, as most are found in other disease states as well. Each of the options listed raises the possibility of heart failure but the only one that has a specificity >90% is the third heart sound, which is 99% specific for the diagnosis of heart failure. Other findings with >90% sensitivity include a displaced point of maximal impulse, interstitial edema or venous congestion on a chest radiograph, jugular vein distention, and hepatojugular reflux. The other options listed here have specificities for heart failure that fall within the range of 65%-80%.

A 3-week-old male is brought to your office because of a fever and increasing fussiness. He had a rectal temperature at home earlier today of 101.5°F (38.6°C). The mother reports that he is not breastfeeding as often as usual and has had fewer wet diapers. He has no nasal congestion and no cough. There are no recent sick contacts or known exposures. On examination you note a fever of 39.2°C (102.5°F) and a pulse rate of 200 beats/min. The remainder of his examination is normal. You order a full sepsis workup and admit him to the hospital. Which one of the following is the best intravenous antibiotic regimen for empiric coverage at this point? (check one) A. Ampicillin and cefotaxime (Claforan) B. Ampicillin and clindamycin (Cleocin) C. Ciprofloxacin (Cipro) D. Gentamicin E. Vancomycin

Correct Any child younger than 29 days with a fever should undergo a complete sepsis workup and be admitted for observation until culture results are obtained or the source of the fever is found and treated (SOR A).The most common bacterial organisms in this age group are group B Streptococcus and Escherichia coli. However, many other pathogens have been known to cause sepsis; therefore, broad empiric coverage with ampicillin and cefotaxime is recommended (SOR B). Gentamicin is commonly used, but should be used in combination with ampicillin. Vancomycin is not recommended as first-line treatment unless the child has evidence of a soft-tissue infection suspected to be methicillin resistant (SOR C). Ciprofloxacin and clindamycin are not indicated treatments in this case.

Blood pressure classification in children is based on (check one) A. sex, weight, and height B. sex, weight, and age C. sex, height, and age D. weight, height, and age

Correct Blood pressure in children should be measured with an appropriate size cuff. Blood pressure standards are based on age, sex, and height, and provide a precise classification of blood pressure according to body size. Blood pressure tables for children now include the 50th, 90th, 95th, and 99th percentiles by age, sex, and height (SOR A).

A 20-year-old male college student comes to the emergency department in January acutely shortof breath and looking very ill, with tachypnea, tachycardia, nausea, and a headache. Pulseoximetry shows an oxygen saturation of 100% on room air, and arterial blood gas measurementshows a PaO2 of 95 mm Hg. Of the following, which one is the most likely diagnosis? (check one) A. Carbon monoxide poisoning B. Adult respiratory distress syndrome C. Methemoglobinemia D. Lobar pneumonia E. Viral pneumonia

Correct Carbon monoxide (CO) exposure most commonly results from fuel combustion in heaters, stoves, or automobiles, so it is most often seen during cold periods when people are in closed quarters. Symptoms include headache, nausea, vomiting, and weakness, and patients have a flushed complexion, so symptoms are commonly attributed to viral flu-like illnesses. CO poisoning results in the formation of carboxyhemoglobin, which does not carry oxygen. All oxygen-carrying sites are occupied by CO, which has such a high affinity for hemoglobin that oxygen cannot displace it. If a patient has a carboxyhemoglobin level of 25%, and their hemoglobin level is 12 mg/dL, their effective hemoglobin level is only 9 mg/dL since 25% of their hemoglobin is not carrying oxygen. If the carboxyhemoglobin level is 25%, then the maximum oxygen saturation that can be attained is 75%. However, a pulse oximeter will show an oxygen saturation of 100% because the color of carboxyhemoglobin is bright red, which is what the pulse oximeter is detecting. Thus, pulse oximetry is not reliable in patients with CO poisoning. Similarly, arterial blood gas measurements are based on oxygen gas tension (pO2) and not oxygen content or true oxygen saturation. The only arterial blood gas abnormality in CO poisoning may be metabolic acidosis, which is a consequence of inadequate oxygen delivery to the peripheral tissues. This causes an anaerobic metabolism and lactic acid production, but is not seen early in CO poisoning. Serious cases of pneumonia, ARDS, or methemoglobinemia would produce abnormalities on pulse oximetry or arterial blood gas measurements. To detect CO poisoning it would be necessary to order either a CO level or a co-oximetry test.

A 58-year-old female presents with a 6-month history of persistent intermittent unilateral rhinorrhea. The drainage is clear, and seems to be worse in the early morning when she first gets up. Her past medical history includes hypertension and controlled migraines. Her surgical history includes a total hysterectomy 5 years ago and septal deviation surgery 7 months ago. She has tried oral antihistamines and intranasal corticosteroids without relief. The patient should undergo further evaluation for: (check one) A. vasomotor rhinitis B. allergic rhinitis C. cerebrospinal fluid rhinorrhea D. an intranasal tumor

Correct Cerebrospinal fluid (CSF) rhinorrhea is not that rare, and has both surgical and nonsurgical causes. It results from a direct communication between the subarachnoid space and the paranasal sinuses. Accidental trauma causes 70%-80% of CSF rhinorrhea cases, with 2%-4% of acute head injuries resulting in CSF rhinorrhea. Nontraumatic CSF rhinorrhea includes high-pressure and normopressure leaks from causes including tumors, processes including boney erosion, empty sella syndrome, and congenital defects including meningoceles. The rhinorrhea is clear and often has a sweet or salty taste. The drainage can be continuous or intermittent, and is often associated with a gush when changing from a recumbent to an upright position. CSF rhinorrhea can lead to meningitis or other infections by serving as a pathway for bacteria.

Which one of the following strategies for preventing the spread of Clostridium difficile infection has been shown to be most effective? (check one) A. Use of alcohol-based hand sanitizer B. Handwashing with soap and water C. Screening health care providers for the carrier state D. Administration of probiotics to at-risk patients E. Use of N95 masks and negative-pressure rooms

Correct Clostridium difficile infection (CDI) may be transmitted by direct contact with an infected patient, by contact with a contaminated environment, or by contact with a health care worker with transient hand colonization. Effective prevention efforts are essential to limit the spread from one patient to another in the hospital and other health care settings. Although alcohol-based hand antiseptics have been shown to increase compliance with hand hygiene and reduce the incidence of MRSA and VRE infections, alcohol does not kill the spore form of C. difficile and the use of these antiseptics does not reduce the incidence of CDI. There is insufficient data to support the widespread use of probiotics for prevention of CDI, and there is a potential risk of bloodstream infection with their use. Health care workers rarely become colonized with C. difficile, and screening them has not been shown to affect nosocomial transmission rates. Handwashing with soap and water removes C. difficile from the hands of health care workers and remains the cornerstone of prevention efforts. Additional contact precautions such as the use of gloves and gowns may also be helpful. CDI is not transmitted by the respiratory route, so the use of respiratory isolation techniques is not helpful

A 75-year-old male with a history of hypertension, TIA, and atrial fibrillation sees you for follow-up. Ten days ago he was on vacation in another state when he developed chest pain. He went to a local hospital where he was diagnosed with an ST-elevation myocardial infarction (STEMI) and was taken immediately for cardiac catheterization. He had a drug-eluting stent placed in his left anterior descending artery. He brings some discharge paperwork with him, including a medication list, but has not yet seen a local cardiologist. He is concerned that he is taking too many blood thinners. He feels well and does not have any chest pain, shortness of breath, or excessive bleeding or bruising. Prior to his STEMI the patient was taking lisinopril (Prinivil, Zestril), 10 mg daily; warfarin (Coumadin), 2.5 mg daily; and metoprolol succinate (Toprol-XL), 25 mg daily. Upon discharge he was instructed to continue all of those medications and to add clopidogrel (Plavix), 75 mg daily, and aspirin, 81 mg daily. The patient's vital signs and physical examination are normal except for an irregularly irregular rhythm on the cardiovascular examination. His INR is 2.5.Which one of the following would be most appropriate at this time? (check one) A. Continue the current regimen B. Discontinue aspirin C. Discontinue clopidogrel D. Discontinue warfarin E. Decrease warfarin with a goal INR of 1.5-2.0

Correct Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0-3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1-3 months. However, this patient's STEMI occurred less than 2 weeks ago and he should continue triple therapy.

A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which one of the following would be the most appropriate next step? (check one) A. Referral for orthopedic consultation B. Reassurance only, and follow-up in 2 weeks C. Triple diapering and follow-up in 2 weeks D. A radiograph of the pelvis

Correct Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts are divided as to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech females, breech males (optional), and females with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of overtreating.

A 24-year-old gravida 2 para 1 presents to your office for her first prenatal visit at 7 weeks gestation. You review her vaccine records and note that she received Tdap 1 year ago. When should you recommend that she get her next Tdap? (check one) A. Post partum B. At this visit C. Anytime after the first trimester D. Between 27 and 36 weeks gestation E. 10 years after the last dos

Correct Due to the increasing incidence of pertussis, the Centers for Disease Control and Prevention recommends that all pregnant women receive Tdap vaccine during every pregnancy regardless of when their last dose was. It is ideally administered between 27 and 36 weeks gestation to maximize the maternal antibody response and passive antibody transfer to the infant.

A 57-year-old female on dialysis for end-stage renal disease develops chronic, severe generalized pain. Which one of the following opioids is preferred for management of her pain? (check one) A. Codeine B. Fentanyl C. Hydrocodone D. Morphine

Correct Fentanyl is metabolized in the liver and has no active metabolites. All of the other listed opioid medications have active metabolites that can accumulate in patients with renal failure, leading to serious side effects. These agents should be avoided in patients on dialysis.

A 36-year-old male is diagnosed with midsubstance Achilles tendinopathy. He has had symptoms for approximately 8 weeks. For this patient, which one of the following would be the first-line treatment? (check one) A. Tendon massage B. Eccentric exercise C. Iontophoresis D. Therapeutic ultrasound E. Electrical stimulation therapy

Correct For chronic midsubstance Achilles tendinopathy (symptoms lasting longer than 6 weeks), the preferred first-line treatment is an intense eccentric strengthening program of the gastrocnemius/soleus complex (SOR A). In randomized, controlled trials, eccentric strengthening programs have provided 60%-90% improvement in pain and function. Therapeutic modalities such as ultrasonography, electrical stimulation, iontophoresis, and massage and stretching have shown inconsistent results for helping patients achieve a long-term return to function. Surgical techniques are a last resort for severe or recalcitrant cases, but these techniques have not been consistently successful and carry additional risk. To perform eccentric strengthening for Achilles tendinopathy the patient should stand on the ball of the injured foot with the calcaneal area of the foot over the edge of a stair step. The patient begins with a straight leg and the ankle in flexion. The ankle is then lowered to full dorsiflexion with the heel below the level of the step and then returned to flexion with the assistance of the uninjured leg.

A 52-year-old female with a history of well-controlled diabetes mellitus presents with right shoulder pain for 2 months. She cannot recall any injury. The pain is fairly constant, has a burning quality, and disturbs her sleep. On examination the patient has no redness or swelling. Passive and active abduction are limited to 45°. There is some limitation of shoulder flexion and internal rotation, but it is less pronounced. No focal tenderness is found. Plain films are negative. Which one of the following is the most likely diagnosis for this patient? (check one) A. Calcific tendinitis B. Diabetic neuropathy C. Partial rotator cuff tear D. Locked posterior dislocation E. Frozen shoulder

Correct Frozen shoulder is an inflammatory contracture of the shoulder capsule and mostly affects the anterosuperior and anteroinferior capsular ligaments, limiting glenohumeral movement. Diabetic patients have a 10%-20% lifetime risk of frozen shoulder. Only two other common conditions selectively limit passive external rotation: locked posterior dislocation and osteoarthritis. Plain films of the shoulder should reveal both conditions. Rotator cuff tears do not limit passive range of motion, and calcific tendinitis has a characteristic radiographic appearance.

A 48-year-old female sees you for routine follow-up. She was diagnosed with type 2 diabetes mellitus 2 years ago and has been treated with metformin (Glucophage), 850 mg orally 3 times daily, and glipizide (Glucotrol XL), 20 mg orally daily, along with diet and exercise. Her other medical problems include hypertension and obesity. She has no known cardiovascular disease or microvascular complications. She came in for laboratory testing yesterday, and her hemoglobin A1c is 8.0% (N <5.7%). Which one of the following medications would help with both glycemic control and weight loss for this patient? (check one) A. Exenatide (Byetta) B. Pioglitazone (Actos) C. Sitagliptin (Januvia) D. Insulin

Correct Given the information about this patient, such as her relatively recent diagnosis, her age, and her lack of macro-or microvascular complications, a more strict hemoglobin A1c goal is indicated. There are several oral and injectable medicines that are reasonable choices in this case. Exenatide is an injectable GLP-1 agonist that is associated with weight loss. Pioglitazone is also effective but is associated with fluid retention rather than weight loss. Sitagliptin is a dipeptidyl peptidase IV (DPP-IV) inhibitor that may be a reasonable option in this case, but is not associated with weight loss. Insulin, either basal only, mixed, or basal-bolus regimens, may also be the best option for the patient described, but it does cause weight gain. Cost is another major consideration in treatment decisions, but more information would be needed to address this issue.

Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved? (check one) A. Waiting until lipase has normalized before beginning oral intake B. Early initiation of a clear liquid diet C. Early initiation of a low-fat diet D. Early initiation of tube feeding E. Early initiation of total parenteral nutrition

Correct Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays. Total parenteral nutrition should be avoided in patients with mild or severe acute pancreatitis. There have been multiple randomized trials showing that total parenteral nutrition is associated with infectious and other line-related complications.

In patients who die from an opioid overdose, a second medication is often present that contributes to the patient's death. Which one of the following additional medications is most likely to be found in conjunction with a fatal opioid overdose? (check one) A. Acetaminophen B. Antidepressants C. Antipsychotics D. Benzodiazepines E. Muscle relaxants

Correct In 2010, opioid analgesics were implicated in 75% of pharmaceutical-related overdose deaths. Benzodiazepines were involved in 30% of these opioid analgesic-related deaths. Conversely, opioids were a factor in 77% of pharmaceutical overdose deaths that involved benzodiazepines. Antidepressants are involved in less than half as many opioid deaths as benzodiazepines. Antipsychotics, acetaminophen, and muscle relaxants are implicated in opioid overdose deaths with far less frequency than benzodiazepines.

Azithromycin (Zithromax) is prescribed for a 65-year-old male with coronary artery disease. This drug should be used with caution in this patient due to an increased risk for (check one) A. an adverse effect on left ventricular function B. peripheral edema C. elevation of systolic blood pressure D. fatal arrhythmia

Correct In March of 2013 the FDA issued a safety warning regarding azithromycin and its potential to lead to serious and even fatal arrhythmias, particularly in at-risk patients. Risk factors include hypokalemia, hypomagnesemia, a prolonged QT interval, and the use of certain medications to treat abnormal heart rhythms. The mechanism of action is prolongation of the QT interval, leading to torsades de pointes (level of evidence 2, SOR A).The FDA recommends that physicians consider the risk of torsades de pointes and fatal heart rhythms associated with azithromycin when considering antibiotic treatment options, particularly in patients who are already at risk for cardiovascular events.

A 22-year-old male college student presents with 1-2 weeks of worsening tenesmus associated with frequent stools that are mixed with blood and mucus. He is afebrile and has no other signs of systemic illness. Initial blood and stool testing is normal. Which one of the following would be most appropriate at this point to evaluate this patient for the presence of inflammatory bowel disease? (check one) A. Serum markers B. Ultrasonography C. CT of the abdomen and pelvis D. Colonoscopy with biopsies E. A barium enema

Correct Inflammatory bowel disease is an autoimmune disorder that affects the gastrointestinal tract, usually beginning in early adulthood. Ulcerative colitis and Crohn's disease are the most common of these conditions. Ulcerative colitis involves just the mucosa of the colon, starting at the anus and extending proximally to a variable distance. Crohn's disease, on the other hand, may involve all layers of gastrointestinal tissue and can occur anywhere between the mouth and the anus. The diagnosis of either of these conditions is made by endoscopy with biopsies in order to best assess the extent and depth of inflammation.

A 39-year-old female presents with a 4-month history of gradually worsening left elbow pain. She does not recall an injury but frequently lifts and holds her 10-month-old son in her left arm. She has tenderness over the lateral epicondyle. Her elbow range of motion is normal but she has pain with supination and pronation. The remainder of the examination is normal. For long-term pain relief, the best evidence supports which one of the following? (check one) A. Expectant/conservative management B. Physical therapy C. Oral anti-inflammatory agents D. A corticosteroid injection

Correct Lateral epicondylitis is a common condition characterized by degeneration of the extensor carpi radialis muscle tendon originating in the lateral epicondyle. It is a self-limited condition and usually resolves within 12-18 months without treatment. It is not an inflammatory condition and anti-inflammatory agents have not been found to be beneficial. Corticosteroid injections have been found to be associated with poor long-term outcomes, as well as high recurrence rates. Neither physical therapy, bracing, nor splinting is proven to provide long-term pain relief. Approximately 90%-95% of all patients with lateral epicondylitis show improvement at 1 year despite the type of therapy utilized (SOR A).

A 72-year-old previously healthy male presents with a 3-week history of mild, intermittent chest pressure that occurs when he walks up a steep hill. Which one of the following EKG abnormalities would dictate the use of a pharmacologic stress test as opposed to an exercise stress test? (check one) A. First degree atrioventricular block B. Left bundle branch block C. Poor R-wave progression in leads V1 through V3 D. Q-waves in the inferior leads E. Ventricular trigeminy

Correct Left bundle branch block makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test. It is associated with transient positive defects in the anteroseptal and septal regions in the absence of a lesion within the left anterior descending coronary artery. This leads to a high rate of false-positive tests and low specificity. Pharmacologic stress tests using vasodilators such as adenosine with nuclear imaging have a much higher specificity and positive predictive value for LAD lesions, and the same is true for dobutamine stress echocardiography, which is why these are the preferred methods for evaluating patients with left bundle branch block. Pharmacologic stress testing would not be preferred for evaluating the other EKG abnormalities listed.

A 7-year-old female is brought to your office with a complaint of right hip pain and a limp with an insidious onset. There is no history of injury or repetitive use. Her vital signs are within normal limits and she has no history of fever or chills or other systemic symptoms. On examination you note that she cannot fully abduct her hip and she winces with pain on internal rotation. A FABER test is normal. Her right leg is 2 cm (¾ in) shorter than the left. Plain films reveal flattening and sclerosis of the proximal femur with joint space widening. What is the most likely diagnosis in this patient? (check one) A. Iliopsoas bursitis B. Labral tear C. Legg-Calvé-Perthes disease D. Septic arthritis E. Stress fracture

Correct Legg-Calvé-Perthes disease results from interruption of the blood supply to the still-growing femoral head. It occurs in children 2-12 years of age and presents with hip pain and an atraumatic limp. Common physical findings include leg-length discrepancies, and limited abduction and internal rotation. Radiographs reveal sclerosis of the proximal femur with joint space widening. MRI confirms osteonecrosis. Septic arthritis also causes atraumatic anterior hip pain but occurs in the acutely ill, febrile patient. A CBC, erythrocyte sedimentation rate, C-reactive protein level, and guided hip aspiration are recommended if septic arthritis is suspected. A diagnosis of stress fracture should be considered in patients with a history of overuse and weight-bearing exercise. These patients have pain that is worse with activity, and pain on active leg raising. MRI can detect fractures not seen on plain films. Iliopsoas bursitis presents with snapping or popping of the hip on extension from a flexed position. Labral tears present with sharp anterior hip pain at times, with radiation to the thigh or buttock. Usually patients will have mechanical symptoms such as clicking with activity. The FABER (flexion, abduction, external rotation) and FADIR (flexion, adduction, internal rotation) impingement tests are sensitive for labral tears.

A 53-year-old white female with chronic hepatitis C is concerned about ulcers in her mouth. She is not currently receiving therapy. Your examination reveals several ulcers involving the buccal mucosa. The patient also points out a number of pruritic, reddish-purple plaques on her wrists, ankles, and back. Laboratory studies are within normal limits except for mildly elevated transaminases. Which one of the following is the most likely diagnosis? (check one) A. Behçet's syndrome B. Lichen planus C. Aphthous stomatitis D. Herpetic stomatitis E. HIV infection

Correct Lichen planus is an idiopathic inflammatory disease affecting the skin and oral mucosa. The characteristic violaceous, polygonal papules may be intensely itchy. There is a significant association between lichen planus and hepatitis C virus infection.

A 70-year-old white female with hypertension and atrial fibrillation has been chronically anticoagulated. A higher dosage of warfarin (Coumadin) would be required to achieve a therapeutic INR if the patient were found to have (check one) A. malnutrition B. hypothyroidism C. heart failure D. acute kidney injury E. progressive nonalcoholic cirrhosis

Correct Medical conditions that decrease responsiveness to warfarin and reduce the INR include hypothyroidism, visceral carcinoma, increased vitamin K intake, diabetes mellitus, and hyperlipidemia. Conditions that increase responsiveness to warfarin, the INR, and the risk of bleeding include vitamin K deficiency caused by decreased dietary intake, malabsorption, scurvy, malnutrition, cachexia, small body size, hepatic dysfunction, moderate to severe renal impairment, hypermetabolic states, fever, hyperthyroidism, infectious disease, heart failure, and biliary obstruction (SOR B, SOR C).

Hyperbaric oxygen treatment has been shown to be beneficial for which one of the following conditions? (check one) A. Tinnitus B. Malignant otitis externa C. Crush injury wounds D. Nonunion of bone fractures E. Vascular dementia

Correct Medical hyperbaric oxygen is considered a reimbursable treatment option by many insurers for a long list of diagnoses. The list of conditions shown to benefit from hyperbaric oxygen is a much shorter one, however, and includes decompression sickness and wounds caused by crush injuries. Hyperbaric oxygen treatment has been shown to improve diabetic foot ulcers in the short term but studies have so far failed to prove long-term benefit.

An 85-year-old male smoker presents with a 6-day history of subacute abdominal pain. He reports nausea without vomiting, and no change in stool. His past medical history includes coronary artery disease, peripheral vascular disease, and a cholecystectomy. The physical examination reveals moderate periumbilical tenderness without guarding or rebound. Laboratory Findings WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20,000/mm3 (N 4500-10,800) Segmented neutrophils.. . . . . . . . . . . . . . . . 82% Bands. ............................. 7% Chemistry panel.. . . . . . . . . . . . . . . . . . . . . . . normal Urinalysis.. . . . . . . . . . . . . . . . . . . . . . . . . . . . normal Amylase.............................. 180 U/L (N <140) Lactic acid............................ 3.8 mmol/L (N 0.5-2.2) Abdominal CT reveals air within the wall of dilated loops of small bowel. Which one of the following is the most likely diagnosis? (check one) A. Acute cholangitis secondary to a common duct stone B. Acute diverticulitis C. Acute mesenteric ischemia D. Acute pancreatitis E. Acute appendicitis

Correct Mesenteric ischemia presents with pain disproportionate to the findings on examination, often with nausea, vomiting, or diarrhea. Air within the wall of dilated loops of small bowel (pneumatosis intestinalis) and evidence of acidosis also suggest bowel ischemia. Cholangitis most likely would be associated with a more substantial elevation of the amylase and/or lipase levels, as well as elevated bilirubin and/or alkaline phosphatase levels. Pancreatitis would also be associated with higher amylase and/or lipase levels. Acute appendicitis often has a vague presentation in older patients, presenting without fever and not localizing to the right lower quadrant as it does in younger patients. However, the leukocytosis is usually not as dramatic as in this case, there is usually no elevation of the amylase or lipase levels, and imaging does not show air within the small bowel.

A 34-year-old male who recently immigrated to the United States from Mexico comes to your clinic to complete a comprehensive health evaluation for a custodial job at a hospital, and he must be screened for tuberculosis. He recalls getting many vaccines as a child, including one for tuberculosis. Which one of the following screening tests for tuberculosis is preferred for this patient? (check one) A. A stained sputum culture for acid-fast bacilli B. Skin testing C. Serology D. Nucleic acid amplification testing E. Interferon-gamma release assays

Correct Most Hispanic immigrants have received the bacille Calmette-Guérin (BCG) vaccine. Although past practice has been to interpret skin test results without regard to BCG status, false-positive tests in this population are common. Interferon-y release assays are preferred to tuberculin skin testing in immigrants who have been vaccinated with BCG.

You test a patient's muscle strength and find that his maximum performance consists of the ability to move with gravity neutralized. This qualifies as which grade of muscle strength, on a scale of 0 to 5? (check one) A. 0 B. 1 C. 2 D. 3 E. 4

Correct Muscle strength is scored on a scale of 0 to 5. The inability to contract a muscle is scored as 0. Contraction without movement constitutes grade 1 strength. Movement with the effect of gravity neutralized is grade 2 strength, while movement against gravity only is grade 3 strength. Movement against gravity plus some additional resistance indicates grade 4 strength. Normal, or grade 5, strength is demonstrated by movement against substantial resistance.

A 77-year-old female is admitted to the critical care unit for acute respiratory failure and is on a ventilator for more than 48 hours. Stress ulcer prophylaxis is ordered. This prophylaxis should be continued until (check one) A. venous thromboembolism prophylaxis is stopped B. the patient is transferred out of the critical care unit C. the patient is discharged from the hospital D. the patient is discharged from a skilled care or rehabilitation care facility E. 30 days after discharge from the hospital

Correct Not all hospitalized patients need stress ulcer prophylaxis. Routine acid-suppression therapy to prevent stress ulcers has no benefit in hospitalized patients outside of the critical care setting. Only critically ill patients who meet specific criteria should receive this therapy. One indication for stress ulcer prophylaxis is prolonged mechanical ventilation for more than 48 hours. Hemodynamically stable patients admitted to general care floors should not receive stress ulcer prophylaxis, as it only decreases the rate of gastrointestinal bleeding from 0.33% to 0.22%. Furthermore, long-term proton pump inhibitor therapy has been associated with complications such as Clostridium difficile diarrhea and community-acquired pneumonia. Discontinuation of stress ulcer prophylaxis should be considered for this patient when she moves out of the critical care unit. It could also be considered when the patient is removed from the ventilator.

In a woman whose group B Streptococcus status is unknown, which one of the following is a risk factor requiring empiric intrapartum antibiotic prophylaxis against early-onset group B streptococcal infection in her newborn? (check one) A. Fetal tachycardia B. Delivery at less than 35 weeks gestation C. Rupture of the membranes 12 hours before delivery D. Gestational diabetes during the pregnancy E. Use of vacuum extraction during delivery

Correct Of the choices listed, prematurity is the greatest risk factor for group B streptococcal infection. The most important risk would be signs or symptoms of sepsis in a neonate. The other conditions listed are not risk factors for early-onset GBS in neonates. Ref: Verani JR, McGee L, Schrag SJ: Prevention of perinatal group B streptococcal disease—Revised guidelines from CDC, 2010. MMWR Recomm Rep 2010;59(RR-10):1-36.

A 21-year-old male comes to your office for a follow-up visit to discuss pharmacologic treatment for his acne. He has moderate inflammatory acne lesions with comedones and several papules and pustules, but few nodules. Multiple topical antibiotic therapies, in combination with benzoyl peroxide, have been minimally effective. He is currently using just topical benzoyl peroxide. You would like to prescribe an oral agent to add to his regimen. Which one of the following would be the most effective oral medication to start at this time? (check one) A. Amoxicillin B. Ciprofloxacin (Cipro) C. Minocycline (Minocin) D. Prednisone

Correct Oral antibiotics are effective for the treatment of moderate to severe acne (SOR A). Combined treatment with benzoyl peroxide is recommended to reduce the risk of bacterial resistance (SOR C). Amoxicillin and ciprofloxacin are not recommended for acne treatment. Intralesional corticosteroid therapies have been tried for acne treatment, but long-term use of oral corticosteroids is not recommended.

A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running. An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated. Which one of the following is the most likely diagnosis? (check one) A. Sesamoid fracture B. Gout C. Morton's neuroma D. Cellulitis

Correct Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury. Gout often involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton's neuroma typically causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized.

A 25-year-old male presents to your office after recently being diagnosed with HIV infection at the health department. You obtain blood work and note that his CD4+ count is 180 cells/mm3.This patient should receive prophylaxis against which one of the following opportunistic infections? (check one) A. Histoplasma capsulatum B. Microsporidiosis C. Mycobacterium avium-intracellulare complex D. Pneumocystis E. Toxoplasma g

Correct Patients with HIV infection and severe immunodeficiency are at risk for certain opportunistic infections. Susceptibility to opportunistic infections can be measured by CD4+ T lymphocyte counts. Patients with a CD4+ count <200 cells/mm3 should receive trimethoprim/sulfamethoxazole for prevention of Pneumocystis pneumonia, and prophylaxis against Toxoplasma gondii should also be given if the CD4+ level is <100 cells/mm3. Azithromycin is used to prevent infection with Mycobacterium avium-intracellulare complex when CD4+ counts are <50 cells/mm3. Itraconazole is used to prevent Histoplasma capsulatum infection when the CD4+ count is :150 cells/mm3 if the patient is at risk due to occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases per 100 patient years). There is no recommendation for prophylaxis against microsporidiosis.

A 55-year-old male with diabetes mellitus is found to have asymptomatic microscopic hematuria. The rest of his urinalysis is negative. He has no other medical problems and quit smoking 10 years ago. His only medication is metformin (Glucophage). A urine culture is negative and his renal function is normal. CT urography is also negative. Which one of the following should be the next step in the evaluation of his microscopic hematuria? (check one) A. Urine cytology B. Cystoscopy C. Nephrology referral D. Stopping metformin and performing a repeat urinalysis E. Antibiotic therapy

Correct Patients with microscopic hematuria should initially be assessed for benign causes such as urinary tract infection, vigorous exercise, menstruation, and recent urologic procedures. If none of these is found, the next step would be assessing for renal disease using urine microscopy to look for casts or dysmorphic blood cells, and checking renal function. If the results are negative, CT urography and cystoscopy should be performed. CT evaluates the upper urinary tract for nephrolithiasis and renal cancer, while cystoscopy evaluates the bladder for bladder cancer, urethral strictures, and prostatic problems. Urine cytology is less sensitive than cystoscopy for bladder cancer. This patient has normal renal function and no signs of renal disease on the urinalysis other than hematuria, so a nephrology consultation is not necessary at this time. Metformin use is not associated with microscopic hematuria. There is no role for antibiotics, given the negative urine culture.

A 25-year-old female with asthma uses her albuterol (Proventil, Ventolin) inhaler only before running, but reports waking up short of breath four times per month. She went to the emergency department recently for increased dyspnea during peak ragweed season and remained overnight until her symptoms improved. Which one of the following is the best treatment option now? (check one) A. Oral prednisone as needed B. Inhaled albuterol daily C. Inhaled cromolyn sodium daily D. Inhaled salmeterol (Serevent Diskus) daily E. Inhaled fluticasone (Flovent) daily

Correct Patients with mild asthma are often undertreated. Constant inhaled corticosteroids improve both asthma control and quality of life. Inhaled albuterol is useful as a quick treatment for acute symptoms in patients with mild asthma. Oral prednisone causes many side effects and is best for chronic use in patients whose symptoms are not controlled by other means. Cromolyn sodium has a good side-effect profile, but is not as effective as inhaled corticosteroids. Inhaled salmeterol, when used chronically, increases the risk of asthma-related death.

A 20-year-old college student who has been working in the woods on a forestry project presents with a 3-to 4-day history of a severely pruritic rash on his arms, hands, and face. There is erythema with multiple bullae and vesicles, some of which are in a streaked linear distribution on the arms. There are patches of erythema on his face with some vesicles. The itching is intense and he sleeps fitfully. In addition to cool compresses and antihistamines for the itching, which one of the following is the best treatment option for this patient? (check one) A. Triamcinolone, 20 mg intramuscularly as a single dose B. A 6-day oral methylprednisolone (Medrol) dose pack, starting at 24 mg C. A 7- to 10-day course of topical halobetasol propionate (Ultravate), 0.05% ointment D. A 7-to 10-day course of topical mupirocin (Bactroban) 2%, after decompression of vesicles and bullae E. A 10- to 14-day tapering course of oral prednisone, starting at 60 mg

Correct Poison ivy dermatitis is caused by urushiol, a resin found in poison ivy, poison oak, and poison sumac plants. Direct contact with the leaves or vines will result in an acute dermatitis manifested initially by erythema, and later in more severe cases by vesicles and bullae. This is a type IV T cell-mediated allergic reaction, so it typically takes at least 12 hours and often 2-3 days before the reaction is fully manifested. Depending on the degree of contact (i.e., the amount of resin on the skin), the rash often progresses over a couple of days, giving the impression that it is spreading. Also, delayed contact with resin from contaminated clothing, gloves, or pets may result in new lesions appearing over several days. Brushing against the leaves of the plant causes the linear streaking pattern characteristic of poison ivy dermatitis. It has been demonstrated that the resin can be inactivated with any type of soap, thereby preventing the reaction, but the sooner the better. Approximately 50% of the resin can be removed by soap and water within 10 minutes of contact, but after 30 minutes only about 10% can still be removed. Therapy depends on the severity of the reaction. Group I-V topical corticosteroids are effective for limited eruptions (less than 3%-5% body surface area) but are ineffective in areas with vesicles or bullae. Group I-II fluorinated agents are at the strongest end of the spectrum and are not recommended for use on the face or intertriginous areas. Short bursts of low-potency oral corticosteroids such as a methylprednisolone dose pack have a high rate of relapse as the taper finishes, so the expert consensus is to use a higher dosage tapered over a longer period, generally 10-14 days, in order to prevent a relapse. Most experts recommend oral corticosteroids over intramuscular corticosteroid suspensions, which may not provide high enough concentrations in the skin (SOR C). However, 40-80 mg of intramuscular triamcinolone (or an equivalent) is an alternative to oral treatment, especially if adherence is an issue. Pruritus can be treated.

A 45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now has anterior neck tenderness and swelling, with pain radiating up to her ears. Your examination reveals a tender goiter. Which one of the following would support a diagnosis of subacute granulomatous thyroiditis? (check one) A. Pretibial myxedema B. Exophthalmos C. Multiple nodules on ultrasonography D. Low radioactive iodine uptake (<5%)

Correct Subacute granulomatous thyroiditis is the most common cause of thyroid pain. Free T4 is elevated early in the disease, as it is in Graves disease; however, later in the disease T4 becomes depressed and then returns to normal as the disease resolves. Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be found in Graves disease, but are not associated with subacute granulomatous thyroiditis. Multiple nodules on ultrasonography suggests multinodular goiter rather than subacute granulomatous thyroiditis. Patients with subacute granulomatous thyroiditis will have a low radioactive iodine uptake (RAIU) at 24 hours, but patients with Graves disease will have an elevated RAIU (SOR C).

A 24-year-old female complains of irritability, anxiety, and feeling restless. These symptoms began 3 months ago after she was in a car accident in which two people died. She has become very socially withdrawn and when she tries to sleep she has flashbacks to the accident. In addition to recommending trauma-focused psychotherapy, which one of the following medications would be most appropriate? (check one) A. Buspirone B. Clonazepam (Klonopin) C. Quetiapine (Seroquel) D. Topiramate (Topamax) E. Sertraline (Zoloft)

Correct Posttraumatic stress disorder (PTSD) occurs in approximately 20% of women and 8% of men exposed to traumatic events. Symptoms of PTSD include reexperiencing the event, depression, anxiety, changes in behavior, restlessness, social withdrawal, hypervigilance, poor attention, irritability, and fear. Many people with PTSD suffer from anxiety, depression, and substance abuse, and as many as one in five attempt suicide. Treatment with a combination of trauma-focused therapy and medications is recommended. SSRIs and SNRIs are considered first-line treatment. While paroxetine and sertraline are the only ones FDA-approved for PTSD, any of these drugs may be used. Other antidepressant medications can be used but are considered second-line treatment. Benzodiazepines have been used to treat the symptoms of hyperarousal but can worsen other PTSD symptoms and should be avoided. Studies of mood stabilizers in the treatment of PTSD have been mixed and many guidelines discourage their use. Antipsychotic medications are also not recommended. A large multi-site trial of risperidone reported no benefit over placebo.

A 25-year-old female reports the absence of menses for the past 6 months. She is currently not taking any medications. You confirm that she is not pregnant and order additional laboratory testing. TSH, LH, and FSH levels are normal but she has an elevated prolactin level. Which one of the following would be most appropriate at this point to further evaluate her pituitary gland? (check one) A. A follow-up serum prolactin level in 4 weeks B. A prolactin-stimulating hormone level C. MRI of the pituitary D. Head CT with intravenous contrast

Correct Prolactin levels can be elevated because of a pituitary adenoma, medication side effects, hypothyroidism, or a mass lesion compromising normal hypothalamic inhibition. Elevated prolactin levels inhibit the secretion and effect of gonadotropins. In almost all patients with an elevated prolactin level, MRI of the pituitary is recommended to exclude the possibility of a pituitary adenoma (SOR C). This patient is not on any medications, essentially ruling out a pharmacologic trigger for her elevated prolactin.

A 6-year-old male is diagnosed with acute bacterial sinusitis. He has a previous history of a rash 5 days after beginning penicillin treatment. Which one of the following medications is most appropriate for this patient? (check one) A. Amoxicillin/clavulanate (Augmentin) B. Trimethoprim/sulfamethoxazole (Bactrim) C. Cefuroxime (Ceftin) D. Doxycycline E. Azithromycin (Zithromax)

Correct Recent reports indicate that the risk of a serious allergic reaction to second-and third-generation cephalosporins in patients with penicillin or amoxicillin allergy appears to be almost nil, and no greater than the risk among patients without such allergies. While patients with a history of a serious type I immediate or accelerated (anaphylactoid) reaction to amoxicillin can be safely treated with cefdinir, cefuroxime, or cefpodoxime, some physicians may wish to recommend an allergy referral to determine tolerance before initiation of therapy. Pneumococcus and Haemophilus influenzae are often resistant to trimethoprim/sulfamethoxazole and azithromycin, and these agents are therefore not recommended for the treatment of acute bacterial sinusitis in the penicillin-allergic patient. Doxycycline should not be used in children younger than 8 years of age except for anthrax and some tickborne infections. Amoxicillin/clavulanate is contraindicated in a penicillin-allergic patient.

An 18-month-old previously healthy infant is admitted to the hospital with bronchiolitis. Pulse oximetry on admission is 92% on room air. Which one of the following should be included in the management of this patient? (check one) A. Tracheal suction to clear the lower airways B. Nasal suction to clear the upper airway C. Chest physiotherapy D. Corticosteroids E. Azithromycin (Zithromax)

Correct Recommendations for the treatment of hospitalized infants with bronchiolitis include nasal suctioning via bulb or neosucker to clear the upper airway. Deep suction (beyond the nasopharynx) is not recommended. Oxygen is recommended for infants with a persistent oxygen saturation <90%. Bronchodilators should not be used routinely in the management of bronchiolitis, and corticosteroids, antibiotics, nasal decongestants, and chest physiotherapy are not recommended. A single trial of inhaled epinephrine or albuterol for respiratory distress may be considered, but only if there is a history of asthma, atopy, or allergy.

An 18-month-old male with a history of prematurity at 36 weeks gestation but no baseline lung disease is brought to the emergency department with a fever of 38.3°C (100.9°F), rhinorrhea, cough, wheezing, mild tachypnea, and an oxygen saturation of 88%. A chest radiograph reveals perihilar infiltrates, and a nasal swab is positive for respiratory syncytial virus (RSV) antigen. Which one of the following management options has evidence of benefit for this patient? (check one) A. Aerosolized ribavirin B. Supplemental oxygen C. Intravenous corticosteroids D. Macrolide antibiotics

Correct Respiratory syncytial virus (RSV) bronchiolitis is responsible for approximately 2.1 million health care encounters annually in the United States. The child in this case has a typical presentation of RSV bronchiolitis. The diagnosis can be made clinically, although specific testing for RSV is often used in the hospital setting to segregate RSV-infected patients from others. Management is primarily supportive, especially including maintenance of hydration and oxygenation. Bronchodilators, corticosteroids, and antiviral agents do not have a significant impact on symptoms or the disease course. Ribavirin is not recommended for routine use due to its expense, conflicting data on effectiveness, and potential toxicity to exposed health care workers. Antibiotics are of no benefit in the absence of bacterial superinfection.

A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation causes pain over the lateral fifth metatarsal. The pain is also reproduced when he jumps on the affected leg. When you ask about his shoes he tells you he bought them several years ago. Which one of the following is the most likely diagnosis? (check one) A. Ligamentous sprain of the arch B. Stress fracture C. Plantar fasciitis D. Osteoarthritis of the metatarsal joint

Correct Running injuries are primarily caused by overuse due to training errors. Runners should be instructed to increase their mileage gradually. A stress fracture causes localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg. Plantar fasciitis causes burning pain in the heel and there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.

A 75-year-old otherwise healthy white female states that she has passed out three times in the last month during her daily brisk walk. Which one of the following is the most likely cause of her syncope? (check one) A. Vasovagal syncope B. Transient ischemic attack C. Orthostatic hypotension D. Atrial myxoma E. Aortic stenosis

Correct Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise (or even fall) with exertion. Syncope, commonly occurring with exertion, is reported in up to 42% of patients with severe aortic stenosis. Vasovagal syncope is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained upright posture, heat, hunger, and acute blood loss. Transient ischemic attacks are not related to exertion. Orthostatic hypotension is associated with changing from a sitting or lying position to an upright position. Atrial myxoma is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.

A 30-year-old male is treated with topical medications for his papulopustular rosacea with only partial improvement. The preferred antibiotic is (check one) A. amoxicillin B. cephalexin (Keflex) C. doxycycline D. erythromycin E. trimethoprim/sulfamethoxazole (Bactrim)

Correct Tetracycline and its derivatives have historically been used for the treatment of papulopustular rosacea and there is data to support their use. A modified-release doxycycline is FDA-approved for this indication. Amoxicillin, cephalexin, erythromycin, and trimethoprim/sulfamethoxazole lack evidence to support their use in the treatment of papulopustular rosacea.

An 80-year-old male presents with a 10-day history of intermittent colicky abdominal pain. The pain is low and central and seems to be worse after eating. He has no associated fever or vomiting but does feel nauseated when the pain is present. He says that prior to this episode he had hard stools once or twice a week that were difficult to pass. For the past several days he has had only watery stools, several times a day. On examination there is fullness in his left lower quadrant with nonspecific tenderness diffusely and no guarding or rebound. A urine dipstick is normal. Which one of the following is the most likely diagnosis? (check one) A. Viral gastroenteritis B. Acute colitis C. Constipation D. Urinary tract infection E. Nephrolithiasis

Correct The Rome criteria define constipation as the presence of two or more of the following: straining on defecation, hard stools, incomplete evacuation, or less than three bowel movements per week. This patient has multiple symptoms on this list. The presence of watery bowel movements does not rule out the diagnosis of constipation, as it is common for liquid stool to pass an obstructive source.

A 4-year-old female is treated at a local urgent care center with amoxicillin for acute pharyngitis. Several days after starting treatment her initial symptoms resolve. When she is 8 days into the 10-day course of her antibiotic treatment she returns to your office because she has developed a diffuse erythematous maculopapular rash starting on her torso and extending to her proximal extremities. Which one of the following is the best course of action at this time? (check one) A. Continue the amoxicillin and begin prednisone and diphenhydramine (Benadryl) B. Continue the amoxicillin and change the diagnosis to scarlet fever C. Discontinue the amoxicillin and change the diagnosis to viral exanthem D. Discontinue the amoxicillin and note amoxicillin as a potential allergy in her record

Correct The cause of this patient's rash is difficult to determine. There are many infections that could result in a cutaneous reaction similar to what she is experiencing. Scarlet fever is caused by a systemic reaction to Streptococcus. In this case, however, the patient is already taking an antibiotic for streptococcal disease so the emergence of new symptoms over a week after starting therapy is highly unlikely. A viral exanthem could also cause a skin rash similar to the one described here. Unfortunately, differentiating between a drug-induced rash and a viral exanthem is not clinically possible. If this differentiation is necessary, the patient should undergo a skin biopsy and allergy testing to determine the offending agent. However, since this approach is impractical in the ambulatory setting, it is most straightforward to discontinue the agent she is on and list it as a potential allergy. An alternative antibiotic such as erythromycin could be used to complete the course of treatment at the discretion of the physician.

A 36-year-old male who participates in his neighborhood basketball league visits your office with a 3-week history of heel pain. On examination he has pain over the medial plantar region of the right heel and the pain is aggravated by passive ankle dorsiflexion. Which one of the following should you order to confirm the diagnosis? (check one) A. Plain films of the foot B. Ultrasonography of the foot C. CT of the foot D. MRI of the foot E. No diagnostic imaging

Correct The diagnosis of plantar fasciitis is based primarily on the history and physical examination. Patients may present with heel pain, and palpation of the medial plantar calcaneal region may elicit a sharp pain. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. In recalcitrant plantar fasciitis plain films may be helpful for detecting bony lesions of the foot. Ultrasonography is inexpensive and may be useful for ruling out soft-tissue pathology of the heel in some patients. While MRI is expensive, it is a valuable tool for assessing causes of recalcitrant heel pain.

A new serum marker has been developed for the diagnosis of pulmonary embolism. The test has a likelihood ratio of 1.Which one of the following conclusions can be made from this information? (check one) A. The test can confirm pulmonary embolism B. The test rules out pulmonary embolism C. The test can neither confirm nor rule out pulmonary embolism D. The likelihood ratio does not determine how well a test performs

Correct The likelihood ratio (LR) is the ratio of the probability of a specific test result in people who have a particular disease to the probability in people who do not. LRs correspond to the clinical impression of how well a test rules in or rules out a given disease. A test with an LR of 1.0 indicates that it does not change the probability of disease. The higher above 1 the LR is, the more likely it is that the disease is present (an LR >10 is considered good). Conversely, the lower the LR is below 1, the more likely it is that the disease is not present (an LR <0.1 is considered good). Likelihood ratios are alternative statistics for summarizing diagnostic accuracy, and have several particularly powerful properties that make them more useful clinically than other statistics.

Which one of the following is a risk factor for prolonged recovery from a sports-associated concussion? (check one) A. Blurred vision B. Headache lasting longer than 60 hours C. Amnesia for the injury D. Loss of consciousness at the time of injury E. Convulsions following the injury

Correct The majority of symptoms associated with sports-related concussions resolve within 72 hours of injury. However, some concussions result in prolonged recovery periods. Risk factors associated with a prolonged recovery include headaches lasting 60 hours or more, self-reported fatigue or fogginess, and four or more symptoms at the onset of injury (SOR B). Loss of consciousness and amnesia have not been found to be related to recovery time. Convulsions associated with the injury are benign and do not affect prognosis. Nausea is one of the symptoms of concussion, but by itself is not a risk factor for prolonged recovery.

A 4-month-old female is brought to your office by her parents for a 3-day history of fever up to 101.7°F (38.7°C). She is fussy and her oral intake is down. She has no rash, no emesis, and no diarrhea. Her urine output is normal. She is in day care 3 days a week. On examination she is alert but fussy. Her rectal temperature is 38.4°C (101.1°F). The examination is otherwise normal and there are no focal findings of infection. The parents are reliable and you choose to manage the baby as an outpatient. Which one of the following tests is most likely to be helpful in this situation? (check one) A. A CBC with manual differential B. A urinalysis and urine culture C. A chest radiograph D. C-reactive protein E. A lumbar puncture

Correct The most common causes of serious bacterial infection in children 3-36 months of age are pneumonia and urinary tract infection. In children without an obvious source of infection, the urinalysis and culture are key tests in the evaluation. A valid urine sample should be obtained in all children under the age of 2 with a fever of unknown source. The sample should be obtained through catheterization or suprapubic aspiration. If the patient is toilet trained a clean-catch urine sample is acceptable (SOR C). C-reactive protein is currently under investigation for its utility in detecting serious infection in young children. It is thought to have a greater predictive value than WBC counts but is not yet standardized for common use. A CBC with differential is most useful in neonates but is not as helpful in older infants for detecting serious infection. It is recommended for hospitalized patients but not for those managed as outpatients (SOR C).A chest radiograph is indicated for children with an abnormal respiratory examination or respiratory symptoms. It is also recommended for children older than 1 month of age with a fever >39°C (102°F) and a WBC count >20,000/mm3. A lumbar puncture is indicated for infants with meningeal signs such as focal neurologic findings, petechiae, or nuchal rigidity.

Antiphospholipid antibody syndrome

Correct The most common inhibitor discovered during the evaluation of an elevated aPTT is an antiphospholipid antibody. Antiphospholipid antibody syndrome is characterized by venous or arterial thromboembolism and recurrent spontaneous abortion, often in the second trimester, due to placental infarction. Protein C deficiency is associated with recurrent deep vein thrombophlebitis, but does not cause elevation of aPTT. Hemophilia A is associated with an elevated aPTT which corrects with the addition of normal plasma. In chronic liver disease one would expect an elevation of the prothrombin time also. Von Willebrand disease is not associated with thrombophlebitis or recurrent abortion.

While making rounds on the rehabilitation floor of your hospital, you see a 62-year-old female who was recently transferred from the acute-care section of the hospital where she was admitted for urosepsis. She is a liver-transplant recipient and her specialist has been tapering her immunosuppressive drug regimen for the last 2 months. According to the nursing staff the patient became hypoxic suddenly and had a low-grade fever and cough. You note that she looks ill and uncomfortable, and has an increased respiratory rate. A chest radiograph reveals diffuse bilateral interstitial infiltrates. Which one of the following is the most likely diagnosis? (check one) A. Pneumococcal pneumonia B. Staphylococcal pneumonia C. Pneumocystis pneumonia D. Pulmonary tuberculosis E. Pneumothorax

Correct The most likely diagnosis is Pneumocystis pneumonia. Initially named Pneumocystis carinii, the causative organism has been reclassified and renamed Pneumocystis jiroveci. It causes disease in immunocompromised patients. In non-HIV-infected patients, the most significant risk factors are defects in cell-mediated immunity, glucocorticoid therapy, use of immunosuppressive agents (especially when dosages are being lowered), hematopoietic stem cell or solid organ transplant, cancer, primary immunodeficiencies, and severe malnutrition. The clinical presentation in patients without HIV/AIDS is typically an acute onset of hypoxia and respiratory failure, associated with a dry cough and fever. Characteristic radiographic findings include diffuse bilateral interstitial infiltrates. Pneumococcal pneumonia typically presents with fever, chills, cough, and pleuritic chest pain. A sudden onset of severe hypoxia is less common. Radiologic findings typically include lobar infiltrates or bronchopneumonia (with a segmental pattern of infiltrate), whereas diffuse bilateral infiltrates are much less common. Staphylococcal pneumonia usually has radiologic findings of focal, multiple infiltrates or cavitary lesions. Pulmonary tuberculosis presents most commonly with pleuritic or retrosternal chest pain. Fever is present in about 25% of patients. Cough is actually less common, and a sudden onset of acute hypoxia would be a very rare presentation. Radiographs typically reveal hilar adenopathy and pleural effusion. Diffuse bilateral interstitial infiltrates would be a very rare finding. Spontaneous pneumothorax does present with an acute onset of hypoxia, tachypnea, and respiratory distress. However, fever would be unlikely and the radiologic findings in this patient are not consistent with pneumothorax. Ref: Wilkin A, Feinberg J: Pneumocystis carinii pneumonia: A clinical review. Am Fam Physician 1999;60(6):1699-1708, 1713-1714. 2) Gilroy SA, Bennett NJ: Pneumocystis pneumonia. Semin Respir Crit Care Med 2011;32(6):775-782.

Which one of the following is the most likely cause of acute kidney injury in a patient with eosinophiluria? (check one) A. Rhabdomyolysis B. Poststreptococcal glomerulonephritis C. Acute interstitial nephritis D. Ethylene glycol poisoning E. Tumor lysis syndrome

Correct The presence of eosinophiluria in a patient with acute kidney injury (AKI) suggests acute interstitial nephritis, which is typically an allergic reaction to medications such as penicillins, sulfa-containing antibiotics and diuretics, NSAIDs, proton pump inhibitors, etc. Patients with acute interstitial nephritis may also present with a rash, fever, eosinophilia, and other constitutional symptoms. The combination of elevated levels of creatine kinase or myoglobin, a dipstick positive for blood but negative for RBCs, and a history of muscle trauma would suggest rhabdomyolysis. An elevated uric acid level along with a history of rapidly proliferating tumors or recent chemotherapy suggests tumor lysis syndrome and malignancy. Poisoning with ethylene glycol or methanol should be suspected in a patient with AKI and altered mental status with an increased anion gap and osmolar gap. An elevated antistreptolysin O titer suggests poststreptococcal glomerulonephritis when combined with a history of recent pharyngitis.

A 29-year-old female presents with a 1-week history of a rash on her legs. A full review of systems is significant only for regular borderline-heavy periods that lasted for 7 days during her last two menstrual cycles. She has not had any recent illness or hospitalization, and takes no medications. Her examination shows nonblanching purple macules on her upper legs. A comprehensive metabolic panel reveals normal renal function and liver enzyme tests, and a urine pregnancy test is negative. A CBC reveals a platelet count of 27,000/mm3 (N 150,000-400,000) but is otherwise normal. Which one of the following is the most likely cause of the rash? (check one) A. Acute leukemia B. Congenital thrombocytopenia C. Immune thrombocytopenic purpura D. Thrombotic thrombocytopenic purpura E. Henoch-Schönlein purpura

Correct The rash described in this patient with significant thrombocytopenia is consistent with purpura. Purpura from vasculitic causes such as meningococcal infection, disseminated intravascular coagulation, or Henoch-Schönlein purpura (also known as IgA nephropathy) is typically palpable rather than macular as in this case. Immune thrombocytopenic purpura is a relatively common cause of isolated thrombocytopenia. The lack of systemic symptoms or other abnormal laboratory findings make acute lymphoproliferative disorders such as leukemia unlikely. Likewise anemia, neurologic changes, fever, and renal failure are seen with thrombotic thrombocytopenic purpura. The acute onset of purpura and heavy periods makes congenital thrombocytopenia unlikely.

Which one of the following is most likely to cause hypoglycemia in elderly patients? (check one) A. Metformin (Glucophage) B. Pioglitazone (Actos) C. Glipizide (Glucotrol) D. Sitagliptin (Januvia) E. Glyburide (DiaBeta)

Correct The sulfonylureas are the oral hypoglycemic agents most likely to cause hypoglycemia, with glyburide more likely to cause low glucose levels than glipizide, due to its longer half-life. The use of these agents should be rare in elderly patients with diabetes mellitus.

Which one of the following is recommended with regard to the use of osteoporosis medications in elderly patients? (check one) A. Substitution of denosumab (Prolia) for bisphosphonates in patients planning extensive dental work B. Use of denosumab in patients at increased risk for infection C. Use of denosumab rather than bisphosphonates in patients with class III or IV renal dysfunction D. Continuous use of bisphosphonates for 10 years or more

Correct The use of medications for osteoporosis is associated with various side effects, some of which have only recently been recognized. Denosumab and bisphosphonates have similar, albeit low, risks for jaw osteonecrosis. Bisphosphonates should not be used in patients with a creatinine clearance <35 mL/min/1.73 m2, but denosumab is not cleared by the kidneys and is safe in patients with chronic kidney disease. The use of bisphosphonates for more than 5 years can increase the risk of atypical fractures and a holiday from the drug is recommended after either 3 or 5 years, depending on the drug used.

A 49-year-old white female is concerned because she has painful, cold fingertips that sometimes turn white when she is hanging out her laundry. Which one of the following medications has been shown to be useful for this patient's condition? (check one) A. Propranolol B. Nifedipine (Procardia) C. Ergotamine/caffeine (Cafergot) D. Cilostazol (Pletal)

Correct There is no currently approved treatment for Raynaud's disease. However, patients with this disorder reportedly experience subjective symptomatic improvement with dihydropyridine calcium channel antagonists, with nifedipine being the calcium channel blocker of choice. (1-Antagonists such as prazosin or terazosin are also effective. p-Blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol are contraindicated. Drugs such as ergotamine preparations can produce cold sensitivity, and should therefore be avoided in patients with Raynaud's disease. Cilostazol is indicated for intermittent claudication but not for Raynaud's disease.

One week after a complete and adequate baseline screening colonoscopy, a 51-year-old female with no history of previous health problems visits you to review the pathology report on the biopsy specimen obtained from the solitary 8-mm polyp discovered in her sigmoid colon. The report confirms that this was a hyperplastic polyp. Her family history is negative for colon cancer. Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient? (check one) A. 1 year B. 2 years C. 5 years D. 10 years

Correct There is substantial evidence that small (<10 mm) hyperplastic polyps found in the rectum or sigmoid colon are not neoplastic. Data obtained from numerous studies provides considerable evidence of moderate quality that individuals with no significant findings other than rectal or sigmoid hyperplastic polyps of this size should be included in the same low-risk cohort as those who have an unremarkable colonoscopy. For patients at low risk the recommended interval between screening colonoscopies is 10 years. Reductions in this interval are recommended for patients with one or two small tubular adenomas (5-10 years) or those with three or more tubular adenomas (3 years); the interval for more extensive disease is best individualized but can be as often as annually in unusual cases.

A 4-year-old male is brought to your office by his parents who are concerned that he is increasingly "knock-kneed." His uncle required leg braces as a child, and the parents are worried about long-term gait abnormalities. On examination, the patient's knees touch when he stands and there is a 15° valgus angle at the knee. He walks with a stable gait. Which one of the following should you do now? (check one) A. Refer to orthopedics for therapeutic osteotomy B. Refer to physical therapy for customized bracing C. Prescribe quadriceps-strengthening exercises D. Provide reassurance to the patient and his family

Correct This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers under 2 years of age typically have a varus angle at the knee (bowlegs). This transitions to physiologic genu valgus, which gradually normalizes by around 6 years of age. As this condition is physiologic, therapies such as surgical intervention, special bracing, and exercise programs are not indicated.

A 62-year-old female with type 2 diabetes mellitus routinely has fasting blood glucose levels in the 80-100 mg/dL range and her hemoglobin A1c level is 7.8%. She has been diligently monitoring her blood glucose levels and all are acceptable with the exception of elevated bedtime readings. She currently is on insulin glargine (Lantus), 18 U at night. Which one of the following changes would be most appropriate for this patient? (check one) A. Adding rapid-acting insulin at breakfast B. Adding rapid-acting insulin at lunch C. Adding rapid-acting insulin at dinner D. Increasing the nightly insulin glargine dose E. Increasing the insulin glargine dosage and giving two-thirds in the morning and one-third at night

Correct This patient continues to have an elevated hemoglobin A1c and bedtime hyperglycemia. The addition of a rapid-acting insulin at dinner would be the next step in management. For patients exhibiting blood glucose elevations before dinner, the addition of rapid-acting insulin at lunch is preferred. For patients with elevations before lunch, rapid-acting insulin with breakfast would most likely improve glucose control. Increasing or splitting the insulin glargine would be unlikely to improve management.

A 56-year-old male is brought to the emergency department by his wife because of a 3-day history of fever up to 102.1°F (38.9°C). He complains of headache, body aches, and a cough. His wife notes that he seems to be confused at times, and mentions that he has type 2 diabetes mellitus. On examination the patient's temperature is 38.7°C (101.7°F), heart rate 113 beats/min, blood pressure 96/64 mm Hg, respiratory rate 24/min, and oxygen saturation 93% on room air. You administer 2 L of oxygen via nasal cannula and his oxygen saturation rises to 98%. A CBC, blood cultures, and a basic metabolic panel are ordered, as well as a chest radiograph and urinalysis. In addition to starting antibiotics, which one of the following would be most appropriate at this point? (check one) A. A bolus of normal saline B. Bicarbonate therapy C. Vasopressin (Pitressin) D. Hydrocortisone intravenously E. Norepinephrine

Correct This patient exhibits signs of possible sepsis, including fever, altered mental status, tachycardia, and tachypnea. Confirmation of a documented infection would establish the diagnosis, but treatment should be started before the infection is confirmed. Initial management includes respiratory stabilization. This patient responded to oxygen supplementation, but if he had not, mechanical ventilation would be indicated. The next appropriate step is fluid resuscitation. A bolus of intravenous fluids at 20 mL/kg over 30 minutes or less is recommended (SOR A). Vasopressors should be started if a patient does not respond to intravenous fluids as evidenced by an adequate increase in mean arterial pressure and organ perfusion (SOR B). First-line agents include dopamine and norepinephrine. Vasopressin may be added but has not been shown to improve mortality. Bicarbonate therapy is not usually recommended to improve hemodynamic status. Hydrocortisone may be used in patients who do not respond to fluids and vasopressors.

A 55-year-old male presents with severe pain, swelling, and erythema in his left first metatarsophalangeal joint. His symptoms started yesterday and he has never had this problem in the past. He has a history of hypertension, but normal renal function and no diabetes mellitus. There is no overlying skin lesion or obvious source of infection.Which one of the following would be the most appropriate treatment for this patient? (check one) A. Allopurinol (Zyloprim) B. Cephalexin (Keflex) C. Colchicine (Colcrys) D. Febuxostat (Uloric)

Correct This patient has a classic presentation of podagra (acute metatarsophalangeal joint gout). Without an overlying skin lesion as an indicator of infection, this patient can be assumed to have gout in this classic presentation. Low-dose colchicine, 1.2 mg initially, followed by 0.6 mg in 1 hour, is recommended over high-dose colchicine, 1.2 mg initially, followed by 0.6 mg hourly for 6 hours. The high-dose regimen increases side effects but the effectiveness is not improved. This case should not be assumed to represent a septic joint and treated with cephalexin, given the typical podagra presentation. Febuxostat and allopurinol are urate-lowering drugs used as treatment for intercritical gout and not for acute treatment. Generally, treatment with urate-lowering therapy is not necessary in patients having fewer than two attacks per year.

A disheveled 89-year-old male with dementia who relies on a caregiver for bathing, dressing, shopping, and meal preparation is brought in for continued evaluation of weight loss. No medical cause has been found at this point. On examination a large purplish bruise is noted over his posterior leg and a more faded greenish-yellow bruise is noted over his abdomen, which his caregiver explains by saying that he has fallen several times recently. The patient is also noted to have a large sacral decubitus ulcer. Which one of the following should you suspect as the cause of bruising in this patient? (check one) A. Senile purpura B. Thrombocytopenia C. Leukemia D. Elder abuse E. Cushing syndrome

Correct This patient has numerous red flags for elder abuse, including unexplained weight loss, reliance on a caregiver, a disheveled appearance, a pressure ulcer, and bruising in locations that are not typically associated with unintentional trauma from falls. Although the other listed causes of bruising are possible, in this scenario the index of suspicion should be highest for elder abuse.

A 38-year-old female presents to the emergency department with an acute onset of fever, chills, and rapidly progressive right lower extremity redness. She reports being in her usual state of health until a few hours ago when she developed shaking chills and noted a fever of 103.0°F (39.4°C). Shortly after she arrives she complains of right lower extremity pain and a bright red skin discoloration from her ankle to her right knee. She is also noted to have a heart rate of 123 beats/min and a WBC count of 22,000/mm3 (N 4300-10,800). Her past medical history is significant for congenital arthritis, a recent bilateral hip replacement, and recurrent lower extremity cellulitis. You admit the patient to the hospital. When selecting an empiric treatment for this patient, which one of the following organisms should you be most concerned about? (check one) A. Candida albicans B. Chlamydia trachomatis C. Mycoplasma hominis D. Group A Streptococcus E. Trichophyton rubrum

Correct This patient has rapidly progressive erythema and pain in her right lower extremity, along with fever, tachycardia, and leukocytosis. Group A Streptococcus (GAS) is a common monomicrobial cause of type II necrotizing skin infections, which are often referred to as necrotizing fasciitis and warrant immediate attention (SOR C). Type I infections are often polymicrobial due to combinations of staphylococci (especially Staphylococcus epidermidis in combination with p-hemolytic streptococci), enterococci, Enterobacteriaceae species (commonly Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and Pseudomonas aeruginosa), streptococci, Bacteroides/Prevotella species, anaerobic gram-positive cocci, and Clostridium species. For this patient with a suspected necrotizing skin infection, aggressive treatment with a broad-spectrum empiric antibiotic is recommended along with hemodynamic support and consideration of surgical exploration and debridement of necrotic tissue (SOR C). Empiric antibiotic treatment of a potential necrotizing infection should consist of broad-spectrum antimicrobial therapy with activity against gram-positive, gram-negative, and anaerobic organisms; special consideration should be given to group A Streptococcus, Clostridium species, and methicillin-resistant Staphylococcus aureus (MRSA).

An 85-year-old male admitted to the hospital for shortness of breath is diagnosed with terminal lung cancer. He decides he would like to receive home hospice care. Over the course of his hospitalization he becomes increasingly confused and forgets where he is and why he is there. He appears depressed with a flat affect. He repeatedly tries to get out of bed and pulls at his IV line and catheter. Which one of the following medications would be most appropriate for treating these symptoms? (check one) A. Haloperidol B. Nortriptyline (Pamelor) C. Pentobarbital (Nembutal) D. Lorazepam (Ativan) E. Mirtazapine (Remeron)

Correct This patient is showing signs of delirium, which is common in hospice patients. Delirium should be considered in anyone with disturbances of cognitive function, altered attention, fluctuating consciousness, or acute agitation. The mainstay of management is the diagnosis and treatment of any conditions that may cause delirium. Medications that may cause delirium should be discontinued or reduced if possible. Antipsychotic medications are the drug of choice to improve delirium. Central nervous system depressants such as benzodiazepines and barbiturates should be avoided because they can make delirium worse. Nortriptyline has anticholinergic side effects and can also cause delirium. Mirtazapine would not be helpful for treating delirium.

A 32-year-old primigravida at 36 weeks gestation complains of headaches. She denies vaginal bleeding, leakage of fluid, and contractions, and the fetus is moving normally. Her blood pressure is 155/100 mm Hg and a urinalysis shows 4+ protein. The rest of her examination is normal and a cervical examination shows 1 cm of dilation, 50% effacement, a soft consistency, anterior position, and -2 vertex station. Results of a preeclampsia panel are all in the normal range. Which one of the following is the most appropriate management for this patient? (check one) A. Start labetalol (Trandate) and discharge home on bed rest with close follow-up B. Start magnesium sulfate and induce labor now C. Start magnesium sulfate, administer corticosteroids, and induce labor in 48 hours D. Start magnesium sulfate, lower blood pressure to 140/90 mm Hg, and induce labor at 37 weeks gestation E. Arrange for urgent cesarean section

Correct This patient likely has severe preeclampsia based on her elevated blood pressure with 4+ protein on her urinalysis. Patients with severe preeclampsia near term should be placed on magnesium sulfate to prevent seizures, and labor should be induced immediately. An urgent cesarean section is not necessary. Corticosteroids have not been shown to improve neonatal outcomes when given after 34 weeks gestation. Elevated blood pressures can be managed with hydralazine and labetalol. Normalizing blood pressure is not recommended, but these drugs should be used when blood pressure is over 160/105 mm Hg.

A 36-year-old male laborer presents to an urgent care center 5 hours after falling off a ladder. He was 7-8 feet off the ground, and he fell directly on his anterolateral leg as he landed. Weight bearing is painful. Foot pulses are normal, as is a sensorineural examination of the foot and leg. The anterolateral lower leg is quite tender but only slightly swollen, and there is exquisite pain in that area with passive plantar flexion of the great toe. Radiographs of the lower leg and ankle are negative. In addition to ice, elevation, and analgesia, which one of the following would be most appropriate? (check one) A. Scheduled oral muscle relaxants B. A 6-day oral corticosteroid taper C. Physical therapy referral for early mobilization and ultrasound therapy D. A short leg splint and non-weight bearing for 5-7 days E. Urgent orthopedic referral for possible fasciotomy

Correct This patient most likely has acute compartment syndrome and must be urgently evaluated by an orthopedic surgeon. Typically, compartment pressure can be measured using a needle attached to a manometer, and if the pressure is elevated (usually >40 mm Hg) urgent fasciotomy is necessary to prevent muscle necrosis. If the classic "Five Ps" (pain, paresthesia, pallor, pulselessness, and paralysis) are all present, the outcome will most certainly be bad, even limb-threatening. Early identification with a high index of suspicion and urgent referral for fasciotomy is necessary to prevent tragic results. Before the classic findings develop, patients will have tenderness out of proportion to the physical appearance of the injury and, most importantly, severe pain in the involved compartment with passive stretching of the involved muscles. While rest, immobilization, non-weight bearing, and analgesia are all appropriate measures, none of these is sufficient treatment for this urgent problem.

A 23-year-old gravida 1 para 0 at 35 weeks gestation presents with a 2-day history of ankle swelling and headache. She denies any abdominal pain or visual disturbances. On examination you note a fundal height of 35 cm, a fetal heart rate of 140 beats/min, 2+ lower extremity edema, and a blood pressure of 144/92 mm Hg. A urine dipstick shows 1+ proteinuria. A cervical examination reveals 2 cm dilation, 90% effacement, -1 station, and vertex presentation. You send her to labor and delivery triage for further evaluation. Over the next 4 hours she has a reactive nonstress test and her blood pressure ranges from 142/90 mm Hg to 148/96 mm Hg. Laboratory results show a urine protein to creatinine ratio of 0.4 (N <0.3), normal BUN and creatinine levels, normal liver enzyme and LDH levels, normal hemoglobin and hematocrit levels, and a platelet count of 95,000/mm3 (N 150,000-350,000).Which one of the following would be the most appropriate next step in the management of this patient? (check one) A. A biophysical profile B. Ultrasonography to check for fetal intrauterine growth restriction C. Initiation of antihypertensive treatment D. Immediate induction of labor E. Immediate cesarean delivery

Correct This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein or a spot urine protein to creatinine ratio, blood pressure monitoring, and laboratory evaluation that includes hemoglobin, hematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid. A peripheral smear and coagulation profiles also may be obtained. Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate. Ultrasonography should be performed to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation. Delivery is the definitive treatment for preeclampsia. The timing of delivery is determined by the gestational age of the fetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over cesarean delivery, if possible, in patients with preeclampsia. It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.

A 2-year-old female is brought to the urgent care center with a fever and cough. Her symptoms started suddenly a few hours ago with a runny nose and fever to 101°F. On examination the child is crying and has a persistent barking cough but has no stridor or significant respiratory distress. Her lungs are clear to auscultation. Her skin is warm, pink, and well perfused, and her oxygen saturation is 99% on room air. A chest radiograph is normal. Which one of the following treatments has been shown to improve outcomes for this problem? (check one) A. Humidified air B. Nebulized albuterol (Proventil, Ventolin) C. Oral azithromycin (Zithromax) D. Oral dexamethasone E. Oxygen therapy

Correct This patient presents with a typical case of mild to moderate croup. This is a viral infection that results in swelling in the larynx. It rarely is severe enough to cause respiratory collapse or require intubation and must be differentiated from more severe conditions such as epiglottitis, retropharyngeal abscess, or pneumonia. There is no reason to treat this viral infection with an antibiotic. The condition is usually benign and self-limiting, with the worst symptoms occurring at night. Cool and/or humidified air has traditionally been recommended, but studies have not confirmed any significant benefit from these interventions. Since this child is not in respiratory distress and oxygenation is normal, supplemental oxygen therapy is not indicated. Studies have confirmed the benefits of treating croup with a single dose of either an oral or intramuscular corticosteroid. Specifically, dexamethasone is recommended due to its 72-hour length of effect. Inhaled racemic epinephrine has been shown to reduce the need for intubation in cases of moderate to severe croup. Albuterol, however, is not indicated.

A 37-year-old male complains of severe headaches that typically involve his right eye, and often cause the eye to tear. The headaches occur at about the same time each day and recur for several days in a row before remitting. He reports that he is currently experiencing a third episode of these headaches. Which one of the following therapies will help prevent future recurrences of this patient's headaches? (check one) A. Oxygen B. Sumatriptan (Imitrex) C. Lithium D. Verapamil (Calan, Verelan)

Correct This patient suffers from cluster headaches. Both verapamil and lithium are the mainstays of treatment for chronic cluster headaches, but of the options listed, only verapamil is indicated for the prevention of cluster headaches, and it is actually the first-line prophylactic agent (SOR A). Oxygen and sumatriptan are first-line abortive therapies for cluster headaches (SOR A).

A 34-year-old male presents with low back pain and stiffness that has been slowly worsening over the past 6 months. It is especially bothersome at night and in the morning when he gets out of bed. It improves with physical activity. He has taken ibuprofen, 400 mg several times a day, which provides moderate pain relief but is not working as well as it used to. He does not have any other joint pain, there is no history of trauma, and he is otherwise well. His BMI is 24 kg/m2. Radiographs of the lumbar spine show mild degenerative changes of the lumbar vertebrae without other abnormalities. Which one of the following additional tests would most likely lead to a specific diagnosis? (check one) A. An erythrocyte sedimentation rate B. C-reactive protein C. Antinuclear antibody D. HLA-B27 E. Rheumatoid factor

Correct This patient's back pain is most consistent with an inflammatory cause rather than a mechanical cause. Morning stiffness and improvement with physical activity are key features of inflammatory back pain. Ankylosing spondylitis (AS), one subset of the broader diagnostic category of axial spondyloarthritis, is the likely diagnosis in this patient. Delays in diagnosis are common due to the widespread presence of mechanical low back pain. The identification of patients with inflammatory back pain is important, because early intervention with disease-modifying agents can preserve long-term joint function. HLA-B27 is found in 74%-89% of patients with AS and it can be diagnostic in a patient with typical inflammatory back pain symptoms. Inflammatory markers such as the erythrocyte sedimentation rate and C-reactive protein are often elevated in patients with AS but are not specific to this diagnosis. Rheumatoid arthritis is not a likely cause of back pain in this patient without any other joint findings. Antinuclear antibody testing can assist in the diagnosis of systemic lupus erythematosus, which can cause an inflammatory arthritis, but it is similarly nonspecific and lupus typically has other findings in addition to back pain.

A 20-year-old offensive lineman who plays football for the small college in your town presents to your office at midseason with pain in his right groin. He describes it as a burning, aching sensation that gets worse when he coughs or strains during a bowel movement, and when he is required to block opponents or push against the blocking sled in practice. As part of the physical examination, you have the patient stand, and you insert your finger into the inguinal canal and follow the spermatic cord to the internal inguinal ring. When you reach the internal ring the patient reports discomfort. When you ask him to cough and strain the pain increases and you feel an impulse or bulge at the tip of your finger. The remainder of his physical examination is normal. This patient's history and examination findings are most consistent with which one of the following diagnoses? (check one) A. Athletic pubalgia (sports hernia) B. Osteitis pubis C. Adductor muscle tendinopathy D. Ilioinguinal nerve entrapment E. Inguinal hernia

Correct This patient's history, along with the bulge/impulse detected on physical examination when he strained or coughed, is most consistent with the diagnosis of inguinal hernia. A "sports hernia" is not a true hernia, but rather a tearing of tissue fibers. The patient often presents with symptoms consistent with a hernia, but without evidence on physical examination. Pain along the symphysis pubis would suggest osteitis pubis, and pain along the adductor tendons would suggest adductor tendinopathy. Ilioinguinal nerve entrapment syndrome is an abdominal muscular pain syndrome characterized by the clinical triad of muscle-type iliac fossa pain with a characteristic radiation pattern, altered sensory perception in the ilioinguinal nerve cutaneous innervation area, and a well-circumscribed trigger point medial to and below the anterosuperior iliac spine.

You are treating an 18-year-old college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following intranasal medications is considered optimal treatment for this condition? (check one) A. Glucocorticoids B. Cromolyn sodium C. Decongestants D. Antihistamines

Correct Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety. Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms. Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis. Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause somnolence and a bitter taste. Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea. Overall, they are not as effective as topical glucocorticoids.

A 35-year-old female with a history of chronic abdominal pain and diarrhea develops tender red nodules on her shins. These findings are most consistent with which one of the following? (check one) A. Celiac disease B. Crohn's disease C. Diverticular disease D. Irritable bowel syndrome E. Clostridium difficile colitis

Correct Unlike the other conditions listed, Crohn's disease is associated with many extra gastrointestinal conditions: erythema nodosum (as with this patient), anemia, inflammatory arthropathies, uveitis, and venous thromboembolism (level of evidence 3).

. In a patient presenting with unstable angina, which one of the following findings would denote the highest risk for death or myocardial infarction? (check one) A. New-onset angina beginning 2 weeks to 2 months before presentation B. Angina with hypotension C. Angina provoked at a lower threshold than in the past D. Increased anginal frequency

Correct Unstable angina patients at high risk include those with at least one of the following: • Angina at rest with dynamic ST-segment changes 1 mm • Angina with hypotension • Angina with a new or worsening mitral regurgitation murmur • Angina with an S3 or new or worsening crackles • Prolonged (>20 min) anginal pain at rest • Pulmonary edema most likely related to ischemia

A 24-year-old male presents with a 1-week history of right eye redness. He says his eye hurts, especially with light exposure. He reports no history of trauma, but recalls his 2-year-old daughter having "pink eye" about a month ago. He has a previous history of ankylosing spondylitis. On examination his conjunctiva appears injected and he has a sluggishly reacting pupil. No discharge is noted. Reduced anterior spine flexion is noted on examination of the back. Fluoroscein staining of the cornea is negative. Which one of the following is the most appropriate next step to manage this patient's eye condition? (check one) A. Artificial tears B. Ocular antibiotics C. Ocular corticosteroids D. Oral acetazolamide E. Ophthalmic olopatadine (Patanol)

Correct Uveitis is inflammation of the uveal tract and can affect any or all of its components, including the iris. It is the most common extra-articular manifestation of ankylosing spondylitis (AS), seen in up to 60% of patients with AS. Iritis presents with a painful red eye with conjunctival injection, photophobia, and a sluggishly reacting pupil. A hazy-appearing anterior chamber results from the iris producing an inflammatory exudate. Treatment includes topical corticosteroids, but oral or parenteral corticosteroids and NSAIDs are also effective. Reduced anterior spine flexion (a positive modified Schober test) results from the skeletal manifestations of AS. A "bamboo spine" is classically seen on lumbar radiographs. Oral or ocular antibiotics, artificial tears, ophthalmic olopatadine, and oral acetazolamide are ineffective. Ophthalmology referral is recommended (SOR B).

In a patient with symptoms of thyrotoxicosis and elevated free T4, the presence of thyroid TSH receptor site antibodies would indicate which one of the following as the cause of thyroid gland enlargement? (check one) A. Toxic multinodular goiter B. Toxic adenoma C. Hashimoto's (lymphadenoid) thyroiditi D. Subacute (giant cell) thyroiditis E. Graves disease

Correct When there is a question about the cause of goiter and thyrotoxicosis, the presence of TSH receptor immunoglobulins indicates Graves disease. The prevalence of specific forms of TSH receptor site antibodies can distinguish Graves disease from Hashimoto's disease. Both are autoimmune diseases, but in Graves disease there is a predominance of TSH receptor antibodies. In Hashimoto's disease TSH receptor-blocking antibodies are more predominant. These immunoglobulins tend to disappear with therapy.

A 50-year-old female with significant findings of rheumatoid arthritis presents for a preoperative evaluation for planned replacement of the metacarpophalangeal joints of her right hand under general anesthesia. She generally enjoys good health and has had ongoing medical care for her illness. Of the following, which one would be most important for preoperative assessment of this patient's surgical risk? (check one) A. Resting pulse rate B. Resting oxygen saturation C. Erythrocyte sedimentation rate D. Rheumatoid factor titer E. Cervical spine imaging

Correct While all of the options listed may have some value in evaluating the preoperative status of a patient with long-standing rheumatoid arthritis, imaging of the patient's cervical spine to detect atlantoaxial subluxation would be most important for preventing a catastrophic spinal cord injury during intubation. In many cases cervical fusion must be performed before other elective procedures can be contemplated. Although rheumatoid arthritis may influence oxygen saturation and the erythrocyte sedimentation rate, these tests would not alert the surgical team to the possibility of significant operative morbidity and mortality. Resting pulse rate and a rheumatoid factor titer are unlikely to be significant factors in this preoperative scenario.

A decrease in which one of the following could be expected from long-term use of postmenopausal estrogen plus progesterone? (check one) A. Ischemic heart disease B. Dementia C. All-cause mortality D. Breast cancer E. Hip fracture

Correct While hormonal therapy was initially used to treat postmenopausal vasomotor symptoms, it was also believed to prevent disease. Based on retrospective studies, a decrease in ischemic heart disease and dementia was suspected. The Women's Health Initiative trials, first undertaken in the 1990s, showed that this was unfortunately not the case, and that hormone therapy actually increases the risk for coronary heart disease, stroke, breast cancer, gallbladder disease, dementia, and venous thrombosis, particularly in older women. A decrease in fractures was demonstrated, however, along with some other health benefits, such as a reduced risk of endometrial cancer.

A 25-year-old female kindergarten teacher comes to your office for evaluation of a cough she has had for 2 weeks. The preceding week she had symptoms of rhinorrhea, mild malaise, low-grade fever, and lacrimation. She reports that episodes of coughing are so severe that vomiting is induced. She was evaluated at a walk-in clinic 1 week ago and was diagnosed with bronchitis. Treatment with hydrocodone cough syrup and amoxicillin has not helped. On examination she has mild rhinorrhea and injected conjunctivae, but her lungs are clear. A chest radiograph is normal and her laboratory results reveal a mild lymphocytosis. Which one of the following is the most appropriate next step in the management of this patient? (check one) A. Corticosteroid therapy B. A sputum culture C. A nasopharyngeal culture and polymerase chain reaction testing D. Direct fluorescent antibody testing E. Serologic testing

Correct Whooping cough has reemerged over the past few years. The initial catarrhal stage is manifested by nonspecific symptoms similar to those of a viral upper respiratory illness. This stage is usually 1-2 weeks in duration, and the patient is highly contagious. The paroxysmal stage is manifested by severe coughing spells that occur in paroxysms and may be followed by the inspiratory whoop (much more likely in children). Post-tussive emesis is another classic sign. There are no characteristic findings on examination other than signs induced by extreme coughing. The CDC recommends both a nasopharyngeal culture and polymerase chain reaction testing to confirm the diagnosis. Serologic testing is useful only in research settings, and direct fluorescent antibody testing is not recommended. Azithromycin should be used as initial therapy, but this is to decrease transmission of the illness and does not improve symptoms.

A 36-year-old male with a history of complex regional pain syndrome has been on oxycodone (OxyContin) for the past 5 years. His pain is well controlled. Which one of the following side effects is most likely to occur with long-term chronic use of opioids? (check one) A. Diarrhea B. Sedation C. Hypoalgesia D. Respiratory depression E. Hypogonadism

Hypogonadism is an often underrecognized and undertreated side effect of long-term opioid therapy. It is more often seen in men and in patients receiving larger doses of opioids, including intrathecally. Typical symptoms include decreased libido, erectile dysfunction, amenorrhea, or fatigue. Constipation is not uncommon in patients on chronic opioid therapy, especially if they are elderly, have limited mobility, or are concurrently using other constipating medications. Sedation can occur in the first few weeks after starting therapy but usually tapers off. Hyperalgesia (not hypoalgesia) and allodynia are other side effects resulting from chronic opioid therapy. Respiratory depression is infrequent (SOR C).

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

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 next7 days.

Based on U.S. Preventive Services Task Force guidelines, screening for lung cancer with low-dose CT of the chest is indicated for which one of the following patients with a 30-pack-year smoking history? (check one) A. A 50-year-old current smoke B. An 85-year-old current smoker C. A 60-year-old who quit smoking 10 years ago D. A 75-year-old who quit smoking 20 years ago

The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults 55-80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have lung surgery (B recommendation). The risk of lung cancer increases with age and cumulative exposure to tobacco smoke and decreases with time since quitting smoking. The best evidence comes from the National Lung Screening Trial, which enrolled adults age 55-74 who had at least a 30-pack-year smoking history and were current smokers or had quit in the past 15 years. Screening with LDCT resulted in a 20% reduction in lung-cancer mortality among participants. Stratification of participants according to lung cancer risk showed that screening with LDCT prevented the greatest number of deaths from lung cancer among participants with the highest risk and prevented few deaths in the lowest-risk groups. Smoking cessation remains the most effective way to decrease the mortality and morbidity associated with lung cancer, however.

An obese 70-year-old male with chronic pain due to osteoarthritis complains of fatigue, anhedonia, hypersomnolence, and increased appetite. Which one of the following would be the best pharmacologic agent for this patient? (check one) A. Duloxetine (Cymbalta) B. Mirtazapine (Remeron) C. Citalopram (Celexa) D D. Paroxetine (Paxil) E. Nortriptyline (Pamelor)

The best pharmacologic agent for this patient is duloxetine, as it is indicated for both depression and chronic pain and is unlikely to cause weight gain. The other agents listed can cause weight gain to varying degrees, and the tricyclic antidepressant nortriptyline is on the Beers list of drugs not recommended for elderly patients (SOR A). Ref: Drugs associated with weight gain. Pharmacist's Letter/Prescriber's Letter 2007;23(3):220312. 2) Gelenberg AJ, FreemanMP, Markowitz JC, et al: Guideline for the Treatment of Patients With Major Depressive Disorder, ed 3. AmericanPsychiatric Association, 2010, p 74.

A 24-year-old male who just moved to town for a new job presents to your office with a 2-week history of a rash. His previous medical records are not available. The physical examination reveals pink, scaling papules and plaques on the trunk and proximal aspect of the arms and legs. You suspect pityriasis rosea. To complete the diagnostic evaluation you should order (check one) A. a fungal culture B. heterophile antibody testing C. a platelet count D. a rapid plasma reagin (RPR) test E. a TSH level

The differential diagnosis of multiple small scaling plaques includes drug eruptions, secondary syphilis, guttate psoriasis, and erythema migrans. If the diagnosis cannot be made conclusively by clinical examination, a test for syphilis should be ordered. The rash of secondary syphilis may be indistinguishable from pityriasis rosea on initial examination, particularly when no herald patch is noted. The rashes associated with hyperthyroidism, infectious mononucleosis, idiopathic thrombocytopenic purpura, and fungal infections are not in the differential diagnosis for this patient. Ref: Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and Therapy, ed 5. Mosby Elsevier, 2010, pp 316-318.

Correct Many types of exercise programs are beneficial for older adults, including simply walking for 30 minutes three times a week. However, a meta-analysis of progressive resistance training programs in nursing homes showed that there were significant improvements in muscle strength, chair-to-stand time, stair climbing, gait speed, and balance. This is seen even in those with advanced age, disabilities, chronic diseases, or extremely sedentary lifestyles.

Which one of the following is the best exercise to improve function in older adults living in nursing homes? (check one) A. Swimming B. Walking C. Stretching D. Stationary bicycling E. Resistance training

Correct A helpful guideline for assessing normal growth of a full-term healthy infant is that birth weight should be regained within 14 days. Other useful guidelines for healthy term infants include an average weight gain of 30 grams (1 oz) per day for the first month of life and doubling of birth weight between 4 and 5 months of age.

When assessing the nutritional status and growth of a full-term infant, it is useful to know that birth weight is expected to be regained within (check one) A. 5 days B. 14 days C. 21 days D. 28 days