Aquifer FM Qs at end of case 1-40

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

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

Ms. Anderson is a 60-year-old woman who comes in to clinic as a walk in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn't know why but she has been very sad of late. She reports trouble falling asleep and staying asleep. She used to be the head of her Bridge club, but quit two weeks ago and doesn't feel like going out anymore. She also says she has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. She also says she feels weak and fatigued and no longer has the energy to do her gardening or shopping. She spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. She denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A and CT of the head were all within normal limits. *How long do the above symptoms need to be present in order to make the diagnosis of Major Depressive Disorder?* A. One week B. Two weeks C. Four weeks D. Five weeks E. Eight weeks

*The correct answer is B.* Depressed mood or anhedonia and at least five of the following eight criteria must have been present for two weeks or longer. (Mneumonic = SIG E CAPS) *Sleep: Insomnia* *Guilt*: *Energy* (decreased): Fatigue or loss of energy nearly every day *Concentration* (decreased): *Appetite* (increased or decreased) *Psychomotor agitation* or retardation nearly every day (observable by others, not merely subjective feelings) *Suicidal ideation*: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

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

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

*Case 13: Question 3* An 18-year-old non-smoking male comes to the clinic with cough, chest tightness, and difficulty breathing. His past medical history is positive only for allergic rhinitis as well as an undiagnosed chronic cough primarily at night since he was 4 years old. He has no past surgical history and no recent travel. On physical exam, you notice the patient appears in mild distress, has hunched shoulders, is using accessory muscles during respiration, and is only able to talk in two to three word sentences. His vitals are: Pulse 125/min, O2 sat 88%, BP 100/70 mmHg. On auscultation, you hear wheezing on inspiration and expiration throughout both lungs. You also notice a prolonged expiratory phase. What is the most likely diagnosis? A. Cystic Fibrosis B. CHF exacerbation C. Foreign body aspiration D. Severe asthma exacerbation E. Pulmonary embolism

The correct answer is * D. Severe asthma exacerbation* Based on the clinical presentation including the patient's age and uncomplicated past medical history, the most likely diagnosis is an asthma exacerbation. The presence of hypoxemia places this in the "severe" category. While pulmonary embolism and foreign body aspiration are still on your differential, they are both much further down again based on the patient's age and reported past medical history. Neither cystic fibrosis nor heart failure are likely given the past medical history.

*Case 15: Question 4* A 24-year-old male presents to clinic with history of upper abdominal pain, nausea and vomiting. He has previously had his gallbladder removed due to symptomatic gallstones. In reviewing his history, you want to screen for alcohol abuse due to the possibility of pancreatitis. Which one of the following is a sign of alcohol use disorder (AUD)? Choose the single best answer. A. Failure to fulfill work, school or social obligations due to the effects of drinking B. Denial of a drinking problem C. A score of 2 on the AUDIT-C test D. Consumption of 10 drinks per week E. Three drinks per social occasion

The correct answer is *A. Failure to fulfill work, school or social obligations due to the effects of drinking* Alcohol Use Disorder is characterized by a maladaptive pattern of alcohol use in which patients report two or more signs of the negative effects of alcohol on their health and lives. Such negative effects include finding that drinking interferes with taking care of one's family and/or home; or has caused job troubles or school problems. Denying the presence of a drinking problem does not distinguish a patient with AUD from one without. The AUDIT-C test is a good screening test for AUD, though it is not one of the diagnostic criteria for AUD. For a male patient, a score of 4 or more is considered positive. The number of drinks a person consumes are not part of the DSM 5 definition of AUD.

*Case 13: Question 4* Which of the following is a comorbid condition that needs to be controlled in order to improve asthma symptoms? A. High BMI B. Insomnia C. Atopic dermatitis D. Anxiety E. Anemia

The correct answer is *A. High BMI* When a patient experiences difficulty with asthma control, the physician must consider and address comorbid conditions known to effect asthma control. These comorbid conditions include: gastroesophageal reflux (GERD), chronic sinusitis/uncontrolled allergic rhinitis, stress/depression, obstructive sleep apnea, and being overweight or obese. Successful treatment of these conditions often results in improved control of the patient's asthma symptoms.

*Case 16: Question 4* A 64-year-old African American man with a history of frontotemporal dementia is brought to the doctor for multiple dark spots found on the palms of his hands. The lesions are asymmetric and some have more than one color. Based on the information provided, which is the most likely finding on the biopsy? A. Nodular melanoma B. Acral lentiginous melanoma C. Squamous cell carcinoma D. Superficial spreading melanoma E. Benign nevus

The correct answer is *B. Acral lentiginous melanoma* Acral lentiginous melanoma is seen more often in dark-skinned people, and typically appears on the palms and soles of feet, including under the nails. *Nodular melanoma* presents as a single dark brown or black nevus on a sun-exposed area that grows deep into the skin. *Superficial spreading melanoma* presents as a nevus that has been growing and spreading along the skin surface. *Benign nevi* appear as small, symmetric, uniform colored moles. *Squamous cell carcinoma* tends to have a scaly, erythematous appearance more typical of a patch, plaque or nodule.

*Case 14: Question 1* A 24-year-old female presents to the clinic complaining of nausea and headache for the last week. She denies any fever, changes in bowel movements, or sinus symptoms. She is sexually active with one partner, and admits to not being consistent with her birth control pills. She does not remember the date of her last menstrual period, and reports a history of irregular menstrual cycles. She has not taken a home pregnancy test. Her vital signs reveal a blood pressure of 124/76 mmHg, a pulse of 78/min, respirations of 20/min, temperature of 98.1o F (taken orally), and an oxygen saturation of 98% on room air. The first most appropriate step in management is to: A. Obtain a urine hCG. B. Admit the patient to the hospital for monitoring. C. Obtain a serial serum hCG. D. Perform a pelvic exam to test for sexually transmitted infections. E. Ask the patient to return to the clinic after she has taken a home pregnancy test, and prescribe Zofran 8mg to control her nausea.

The correct answer is *A. Obtain a urine hCG.* Obtaining a urine hCG is the most appropriate first step in the case of a female of childbearing age, whose history includes the patient unable to remember her LMP date and is inconsistent with her contraception method. Admission to the hospital is unnecessary, as her vital signs are normal and her symptoms not life-threatening. Serial serum hCG tests are used when monitoring fetal viability, not to make the diagnosis of pregnancy. The patient does not complain of symptoms that would indicate a sexually transmitted infection, and if pregnancy can be confirmed in the office, it would make no sense to send her home to take a home pregnancy test.

*Case 16: Question 1* A 47-year-old caucasian female presents to the clinic complaining of an "itchy patch" on her skin. On further examination, you note a solid, elevated 1.5cm lesion on the extensor surface of the right forearm. How would you best describe the lesion? A. Plaque B. Papule C. Patch D. Nodule E. Macule F. Bulla G. Pustule

The correct answer is *A. Plaque* A *plaque* is a palpable flat lesion that is greater than 1cm in size. *Papules* are small raised palpable lesions that are less than 1cm in size. *Nodules* are solid raised palpable lesions which are larger in height and dimension than papules, occurring in the epidermis, subcutaneous tissue, or dermis. *A macule* is an area of skin discoloration that is 0.5-1cm in diameter, and a patch is a larger area of differently colored skin which is smooth to touch. *A pustule* is a small pus-filled raised lesion, while a bulla is a larger (greater than 1cm) fluid-filled raised lesion.

*Case 13: Question 2* A 15-year-old female with a history of allergic rhinitis presents to the clinic with a five day history of productive cough and wheezing that is worse at night. She denies any shortness of breath, chest pain, or fever. The patient states that she has had similar symptoms in the past, especially when seasons change. The only reported past medical history is atopic dermatitis which is well-controlled with an over-the-counter steroid cream. What is the best next step? A. Prescribe a short acting beta agonist inhaler with a short course of oral steroids B. Prescribe a long acting beta agonist inhaler C. Prescribe a daily corticosteroid inhaler D. Prescribe a daily corticosteroid and long acting beta agonist inhaler E. Prescribe antibiotic therapy

The correct answer is *A. Prescribe a short acting beta agonist inhaler with a short course of oral steroids* Because the patient is symptomatic and wheezing, she needs to be treated with a medication to control her symptoms and treat her exacerbation. A short acting beta-agonist and short course of oral steroids do just that. After controlling her symptoms and treating her exacerbation, a more in-depth interview needs to be performed around the asthma symptoms and other ancillary tests need to be ordered and interpreted including a chest x-ray and pulmonary function test. Then, a decision can be made regarding daily controller inhalers (inhaled corticosteroids, chromolyn, etc). Finally, antibiotic therapy is not indicated in the treatment of an asthma exacerbation.

*Case 19: Question 5* Ms. Jones is a 35-year-old female with a significant past medical history of SLE who had been on NSAID therapy for the previous three months presented four weeks ago with heartburn. At that time, she reported episodic, mealtime epigastric burning radiating to the throat for the past few months. She has had no surgeries. Serologic testing for H. pylori IgG was reported to be positive a few days after her visit and she was begun on triple therapy. She now returns to the office for follow up. Today she denies any epigastric burning or tenderness. Physical exam is not significant. Which of the following is an accepted indication for performing repeat testing at this visit for H. pylori eradication? Choose the single best answer. A. Restarting of chronic NSAID therapy for SLE B. Documentation is required for all patients with confirmed H. pylori infection C. Treatment with triple rather than quadruple therapy D. Positive serologic test prior to therapy E. Age below 40 years

The correct answer is *A. Restarting of chronic NSAID therapy for SLE* Indications for testing for proof of H. pylori eradication include: patients with an H. pylori-associated ulcer, persistent symptoms despite appropriate therapy for H. pylori, patients with H. pylori-associated MALT lymphoma, history of resection for early gastric cancer, and patients planning to resume chronic NSAID therapy. Documentation of eradication is NOT required for all patients who have tested positive.

*Case 14: Question 5* A 20-year-old female G1P0 at 37 weeks gestation presents to the emergency department with the complaint of a headache that has not gone away, despite taking acetaminophen 3 hours ago. She reports no visual changes, but admits to feeling nauseous and having stomach pain that she attributed to having a "bad case of heartburn." She states she went to her primary care physician that morning, and her blood pressure was elevated. She states she was asked to do a 24-hour urine collection when she left the clinic, but has not been able to use the restroom. Her vitals reveal a blood pressure of 182/106, a pulse of 92, a temperature of 98.2o F, a respiration rate of 20, and a pulse oximetry of 97%. What is the diagnosis and the best course of management? A. Severe gestational hypertension - admitting the patient to the hospital, with administration of magnesium-sulfate, workup for preeclampsia, followed by possible induction or cesarean section B. Pharmacological management with 1 tablet metoprolol 50mg bid C. Admitting the patient to the hospital, and giving IV fluids and IV labetalol 20 mg, followed by close monitoring until a urinalysis is obtained D. Pharmacological management with Macrobid 100mg q12 hours x7 days E. Admitting the patient to the hospital, followed by pharmacologic management of Lopressor HCT 50/20 bid, and obtaining a urinalysis

The correct answer is *A. Severe gestational hypertension - admitting the patient to the hospital, with administration of magnesium-sulfate, workup for preeclampsia, followed by possible induction or cesarean section* This patient is exhibiting symptoms that are associated with severe gestational hypertension and possible preeclampsia. Admission to the hospital for monitoring and evaluation of the fetus, work up for preeclampsia (i.e. CBC, CMP, 24-hour urine collection), and administration of magnesium-sulfate (prophylactic therapy for preeclampsia) are appropriate. A diagnosis of preeclampsia involves a systolic blood pressure of > 140 mmHg, and/or a diastolic blood pressure of > 90 mmHg, and proteinuria of 0.3 g or more in a 24-hour urine collection. If necessary, the patient with severe preeclampsia may undergo induction for delivery or cesarean section due to the possible risks involved to both the mother and fetus.

*Case 12: Question 2* A 32-year-old female presents at your office for a preconception health visit. She is a G2P2, both deliveries were vaginal. Her first child was born with a neural tube defect. According to the USPSTF, what doseage of folate should this patient take daily before she gets pregnant? A. 1 mg B. 4 mg C. 400 mcg D. 800 mcg

The correct answer is *B. 4 mg* US Preventative Services Task Force (USPSTF) recommends that all women planning or capable of becoming pregnant take a 400-800 mcg daily supplement of folate to prevent neural tube defects. The recommendation increases to 1 mg daily in patients with diabetes and epilepsy. In patients who have previously had a child with a neural tube defect, the recommendation increases to 4 mg daily.

*Case 15: Question 3* A 42-year-old woman presents with nausea, vomiting and RUQ pain radiating to her back for one day. She reports a history of similar episodes but none have ever lasted for this long of a time period. Her vital signs are HR of 108, BP of 145/90, RR of 20, O2 saturation of 98% and temperature of 100.8F. Her labs reveal the following: WBC = 14.0 x 103/mL AST = 55 U/L ALT = 60 U/L Amylase = 70 U/L Lipase = 7 U/L What is the most likely diagnosis? A. Biliary colic B. Acute cholecystitis C. Acute pancreatitis D. Duodenal ulcer E. Hepatitis

The correct answer is *B. Acute cholecystitis* Acute cholecystitis has similar pathophysiology to biliary colic and often results from a bile stone that is lodged in the biliary tree. However, there are additional pathophysiologic reasons for acute cholecystitis. The symptoms are similar to biliary colic but typically last longer than 4-6 hours and may be more severe. Symptoms may include fever and elevated WBC. Biliary colic typically lasts 4-6 hours or less, radiates under right shoulder blade, often is accompanied by nausea, vomiting and can often follow a heavy, fatty meal. The hallmark of biliary colic is the stone is still mobile and gallbladder function resumes with relief of symptoms. Acute pancreatitis is often difficult to distinguish from biliary colic but will have an increased lipase and amylase. A patient with duodenal ulcer typically has epigastric pain that is relieved by food or antacids. Hepatitis is usually distinguished by malaise, anorexia, itching and icterus or jaundice. Signs of hepatitis would include hepatomegaly and elevated transaminases.

*Case 11: Question 4* A 51-year-old woman comes to you with acute pain and swelling of the knee. Joint fluid analysis confirms the diagnosis of acute gout. Which of the following information from her history would dissuade you from initiating NSAID therapy? A. Her age B. Currently on warfarin C. Previous H. pylori infection D. Current UTI E. Hypothyroidism

The correct answer is *B. Currently on warfarin* NSAIDs can increase the effect of anticoagulants, and should be avoided in patients taking warfarin. NSAIDs do increase the risk of GI bleeding and peptic ulcer disease in the elderly (older than 75), but this patient is only 51-years-old. The other answers would not contraindicate NSAID use.

*Case 17: Question 3* A 52 year-old female with no past medical history presents to your office with amenorrhea. The patient states that her menstrual cycles previously occurred approximately every 28-34 days. However, she has not had a menstrual cycle for the last 10 months. She also endorses insomnia and intermittent dysuria. She denies any headaches, abdominal pain, constipation or diarrhea, changes in hair distribution, or easy bruising. She has lost 15 pounds since her last visit eight months ago, which she attributes to improving her diet and beginning regular exercise. Which one of the following tests can be used to confirm your diagnosis? A. Thyroid Stimulating Hormone (TSH) and Free T4 B. Luteinizing Hormone (LH) and Follicular Stimulating Hormone (FSH) C. Prothrombin Time (PT) and International Normalized Ratio (INR) D. Morning Cortisol and Prolactin E. Testosterone and Dehydroepiandrosterone sulfate (DHEA-S)

The correct answer is *B. Luteinizing Hormone (LH) and Follicular Stimulating Hormone (FSH)* Elevated FSH and LH levels can be used to confirm menopause. During menopause, ovarian granulosa cells produce less inhibin, thereby affecting the negative feedback loop of FSH and LH secretion from the pituitary gland. TSH and free T4 are used in testing thyroid function. One might be concerned about thyroid function if there was unexplained weight loss along with other positive symptoms in the ROS, but those are not present in this case. PT and INR are used to test bleeding time and can be an indicator of liver function, while morning cortisol tests adrenal function - and neither are of concern in this patient. Prolactin is produced by the pituitary but is not affected during menopause.

*Case 18: Question 5* A 68-year-old male with a past medical history significant for hypertension and diabetes presents to your office with a three month history of headaches. He describes a pain that has occasionally awoken him from sleep and is often worse in the morning. He denies any weakness or changes in vision. His exam shows 4+ reflexes in the right upper and lower extremities but is otherwise normal. What is the best next step in management for this patient? A. Reassurance B. Neuroimaging C. Initiate treatment with sumatriptan D. Sleep Study

The correct answer is *B. Neuroimaging* This patient exhibits several red flags that are of concern for intracranial pathology: age over 50, headaches awakening him from sleep and abnormal reflexes. Because of these concerning features, it is important to perform neuroimaging without delay (thus reassurance is inappropriate). Symptoms described do not raise concerns for sleep apnea, so a sleep study would not be indicated. The symptoms are not typical of migraine, so initiating sumatriptan would not be ideal.

*Case 17: Question 1* A 53-year-old woman with a past medical history of diet-controlled hypertension presents to the office with a two-month history of worsening hot flashes. Her menstrual cycles are regular, occurring every 30-32 days, but they have gradually lessened in duration, now lasting 4-5 days instead of the previous 6-7 days. Vital signs and physical exam are normal. Which one of the following treatments is most likely to improve the patient's symptoms? A. Black cohosh B. Oral estrogen C. Venlafaxine D. Gabapentin E. Yoga

The correct answer is *B. Oral estrogen* While all of the listed items have been touted for treatment of hot flashes, estrogen is clearly the most effective, but should be used with progesterone if a woman still has a uterus. There is evidence that venlafaxine and gabapentin help some. There is no convincing evidence that black cohosh or other herbal medications help, as there is no evidence that yoga, mindfulness or exercise help.

*Case 11: Question 1* You are seeing one of your regular patients, a 65-year-old female for a follow-up appointment for intractable knee pain from osteoarthritis. The knee pain has not responded to ibuprofen or acetaminophen. She has a past medical history that also includes obesity, diabetes, hypertension and depression. Her current medications include aspirin, HCTZ, metformin, and duloxetine. You are considering prescribing tramadol. She has never taken any kind of opioid medication in the past. Which of the following potential problems should you counsel the patient about when adding tramadol? A. Hypotension B. Seizures C. Rash D. Agitation E. Hypercoagulability

The correct answer is *B. Seizures* Tramadol is a centrally-acting synthetic opioid analgesic that works by binding to mu-opioid receptors and weakly inhibiting norepinephrine and serotonin reuptake. Significant side effects can include seizures, serotonin syndrome, respiratory depression, angioedema, bronchospasm and dependency. Other common side effects include constipation, nausea, dizziness, and pruritis.

*Case 18: Question 3* Which of the following is most typical of tension headaches? A. They are associated with certain food triggers B. They are associated with occipital tenderness C. Patients with them often complain of a pulsating quality of pain D. They are aggravated by physical activity

The correct answer is *B. They are associated with occipital tenderness* Tension headaches generally cause pain in a hatband distribution, which would include the occipital area of the head. The quality of pain is a tightness or squeezing type of pain. Tension headaches are not associated with food triggers (migraines are more typically associated with these). Physical activity does not necessarily aggravate the headache.

*Case 18: Question 1* Which of the following characteristics is most typical of cluster headaches? A. They are associated with photophobia and phonophobia B. They are associated with rhinorrhea, lacrimation, miosis, and ptosis C. Patients with them often complain of a pulsating quality of pain D. They typically last less than a week

The correct answer is *B. They are associated with rhinorrhea, lacrimation, miosis, and ptosis* Cluster headaches are generally associated with rhinorrhea, lacrimation, miosis and ptosis. The pain is usually a very severe stabbing type of pain. Typically headaches occur every day for a period of one week to many months or a year. Migraine headaches are commonly associated with photophobia and phonophobia, and are throbbing (pulsating) in nature.

*Case 15: Question 1* A 35-year-old man presents to clinic with acute onset of constant right upper quadrant abdominal pain. Additionally, he complains of ongoing nausea and vomiting. He denies any past abdominal surgeries or chronic diseases and his only medication is a multivitamin. His AUDIT-10 was positive. What lab(s) would you most likely expect to be abnormal to confirm your diagnosis of acute alcoholic hepatitis? A. GFR and INR B. CRP and alkaline phosphatase C. AST, ALT and total bilirubin D. AST, ALT, INR and WBC E. Lipase and amylase

The correct answer is *C. AST, ALT and total bilirubin* It is expected that someone with acute alcoholic hepatitis would have an elevated AST, ALT and total bilirubin. GFR (glomerular filtration rate) is a marker of kidney function and is often not abnormal in early hepatitis. INR is a marker of synthetic functioning of the liver and would be elevated in end-stage liver disease. WBC is often elevated in cholecystitis and infectious processes. Elevation of lipase and amylase is associated with pancreatitis.

*Case 12: Question 5* A 23-year-old heterosexual Caucasian G0P0 female presents to your office with abdominal pain, fever and vaginal discharge. The discharge has an abnormal odor. She denies new or multiple sex partners. On pelvic exam, there is cervical motion tenderness and adnexal pain during the bimanual exam. A cervical culture is positive for chlamydia trachomatis. What risk factor for chlamyida infection is present in this patient? A. Sexual orientation B. Ethnicity C. Age D. Nulliparity

The correct answer is *C. Age* Chlamydia is the most common sexually transmitted bacterial infection in the U.S. Chlamydial infection is often asymptomatic and can result in serious complications-particularly for females. Risk factors for chlamydial infection include: age (women and men less than 24 years old and younger are at greatest risk), history of chlamydial or other sexually transmitted infection, new or multiple sex partners, inconsistent condom use, exchanging sex for drugs or money.

*Case 11: Question 5* On the prior patient you determine NSAIDs are not an appropriate option. In considering how to treat this woman, what is the next question you should ask? A. Who in her family also has gout? B. Has she recently traveled outside the country? C. Are there any other joints involved besides her knee? D. Has she ever received steroid injections in the past?

The correct answer is *C. Are there any other joints involved besides her knee?* In patients with contraindications to NSAIDs or colchicine, the choice of treatment can be guided by the number of joints involved. If one or two joints are involved, arthrocentesis with intra-articular glucocorticoid injection is appropriate. For polyarticular disease, oral glucocorticoids would be a more appropriate option.

*Case 18: Question 4* A 35-year-old female with a history of headaches presents to your office with a headache that is not responsive to 400 mg Ibuprofen TID or 500 mg Tylenol TID. Upon gathering further history you find that in the past her headaches were controlled with these medications but recently have been worse with this same treatment. She complains of 4-5 headaches weekly that are often present on awakening. Which of the following is the best treatment for her disorder? A. Prescribe a different NSAID to take for acute headaches B. Prescribe an opioid medication to take for acute headaches C. Discontinue use of Ibuprofen and Tylenol D. Prescribe a calcium-channel blocker for headache prevention

The correct answer is *C. Discontinue use of Ibuprofen and Tylenol* The patient in this case is likely experiencing rebound headaches, due to a dependence on the ibuprofen and Tylenol. The appropriate treatment for this type of headache is discontinuation of the agents. ** Counseling must be provided that headaches may worsen before resolving over time. Adding an opioid would not resolve symptoms but might also lead to dependence. A calcium channel blocker would not help the patient overcome the rebound headaches.

*Case 15: Question 2* A 35-year-old man presents to clinic with acute onset of abdominal pain. On abdominal exam, you flex the patient's right hip to 90 degrees and take his right ankle in your right hand and with your left hand externally then internally rotate his hip by moving the knee back and forth. The patient denies any abdominal pain with this movement. What physical exam sign did you just perform and what disease is it ruling out? A. Psoas sign to rule out appendicitis B. Psoas sign to rule out cholecystitis C. Obturator sign to rule out appendicitis D. Murphy's sign to rule out appendicitis E. Obturator sign to rule out cholecystitis

The correct answer is *C. Obturator sign to rule out appendicitis* During an abdominal exam, it is important to rule out other causes of abdominal pain. Appendicitis is another cause of acute abdominal pain and can be ruled out with a number of signs. One of these signs is the Obturator sign and the technique is discussed in the question stem. Another sign to rule out appendicitis is the psoas sign. This sign includes passive extension of patient's thigh as they lie on their side with their knees extend, or asking the patient to actively flex their thigh and hip. Pain with movement is often indicative of appendicitis due to inflammation and irritation of the psoas muscle. Murphy's sign is to identify cholecystitis. The technique involves having the patent breathe out slowly and completely, then gently placing your hands under the right costal margin. The patient is then instructed to take a deep breath in while you palpate for a hardened mass and determine if you elicit any significant tenderness.

*Case 19: Question 4* Mr. Rodriguez is a 32-year-old male who presents with three months of post-prandial epigastric burning. He reports no relief with antacid therapy. He has no allergies and no significant past medical history. He denies any hematemesis, odynophagia, dysphagia, hoarseness, or sore throat. Physical exam is unremarkable other than epigastric tenderness. H. pylori IgG serology is positive. Which of the following treatment regimens will most likely be successful in treating Mr. Rodriquez? Choose the single best answer. A. Omeprazole daily for 8 weeks B. Omeprazole twice daily for 4 weeks C. Omeprazole twice daily, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily D. Omeprazole daily, clarithromycin 500mg twice daily, and tetracycline 500mg three times daily E. Omeprazole twice daily, tetracycline 500mg three times daily, and metronidazole 500mg twice daily

The correct answer is *C. Omeprazole twice daily, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily* The eradication of H. pylori required triple or quadruple therapy. Options include: twice daily dosing of a proton pump inhibitor (PPI) plus amoxicillin plus clarithromycin; a PPI once or twice daily (OR ranitidine twice daily) plus metronidazole, tetracycline and bismuth salicylate four times daily; or, for penicillin-allergic patients, twice daily dosing of a PPI plus clarithromycin plus metronidazole.

*Case 16: Question 3* A 26-year-old professional football player comes to the clinic with the complaint of hair loss. On examination, the scalp is scaly, erythematous, and certain regions are purulent. There are several circular spots where the hair follicles are no longer present. KOH of skin shows hyphae. What is the most appropriate treatment for this patient? A. Punch biopsy of lesion B. Topical griseofulvin C. Oral griseofulvin D. Oral prednisone E. Topical prednisone

The correct answer is *C. Oral griseofulvin* The description given in this scenario is suggestive of tinea capitis. Tinea capitis requires oral antifungals, rather than topical treatments. Topical therapies do not penetrate the infected hair shaft. Prednisone is not the treatment of choice for this condition. Biopsy is not necessary due to the typical appearance of this condition.

*Case 18: Question 2* Which of the following characteristics is most typical of migraine headaches? A. They are associated with an aversion to certain colors B. They are associated with rhinorrhea, lacrimation, miosis, and ptosis C. Patients with them often complain of a pulsating quality of pain D. They usually last more than a week

The correct answer is *C. Patients with them often complain of a pulsating quality of pain* Migraine headaches are commonly associated with photophobia and phonophobia, and are throbbing (pulsating) in nature. Migraines can be triggered by foods, but not by exposure to certain colors. Migraines can last from a few hours to a few days, but do not typically last more than a week. Cluster headaches are generally associated with rhinorrhea, lacrimation, miosis and ptosis. The pain is usually a very severe stabbing type of pain. Typically cluster headaches occur every day for a period of one week to many months or a year.

*Case 14: Question 4* A 36-year-old female, G3P2 at 21 weeks gestation, returns to clinic for an ultrasound. She currently smokes a half pack of cigarettes per day. Her last two children were delivered by cesarean section. She reports no vaginal bleeding, no urinary symptoms, and no fluid leaking. She states her baby moves "all the time." Her vitals reveal a blood pressure of 130/74 mmHg, a temperature of 98.3o F, a pulse of 82, a respiration rate of 18, and a pulse oximetry of 98%. The ultrasound reveals no fetal abnormalities, but the location of the placenta is partially covering the cervical os. The diagnosis and treatment plan is: A. Placenta previa with immediate cesaerean section B. Placenta previa with admittance to the hospital for fetal and maternal monitoring C. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution D. Placenta previa with no additional education or counseling given to mom on risk of bleeding during pregnancy

The correct answer is *C. Placenta previa with subsequent ultrasound surveillance to monitor for any progression or resolution* Answer 'C' is the best answer, given the patient's history, symptoms, and ultrasound findings. Placenta previa is a condition in which the placenta is attached at a position that gives it the potential to cover the cervical os. A pregnant woman with placenta previa will usually present after 24 weeks gestation with painless vaginal bleeding. If detected early in gestation, the condition has a higher chance of resolving without intervention. Without resolution, there is a risk for excessive bleeding at or just before delivery, and cesarean section is usually warranted. Prior to term, if a woman is diagnosed with placenta previa and is asymptomatic, she can return home with instructions to seek immediate medical care if she experiences any bleeding. When found on routine ultrasound screening, these women may require more frequent ultrasound surveillance to see of the previa resolves on its own or not which will affect delivery planning as the due date approaches.

*Case 16: Question 2* A 12-year-old boy is brought to the clinic with a linear maculopapular rash extending down both of his arms. He has just returned from a summer camp program in Wisconsin. Excoriation marks are visible. Which of the following is the most appropriate course of action? A. Biopsy the skin lesion B. Ask the patient to return to the clinic after 3 days C. Prescribe topical corticosteroids D. Prescribe oral antibiotics E. Prescribe oral corticosteroids

The correct answer is *C. Prescribe topical corticosteroids* This child appears to have poison ivy. People affected by poison ivy tend to have linear lesions, due to contact with a branch or leaf or due to self-inoculation by scratching. The lesion are often fluid-filled, or vesicular, but over time can have less vesicular appearance. Treatment of choice is corticosteroids. For milder conditions, such as the case here, topical steroids are effective. For more severe cases in which a larger portion of the body is affected, oral steroids may be indicated. Antibiotics are not necessary, since this is not due to an infection. Biopsy is not necessary due to typical appearance and history. Treatment is important in order to reduce symptoms, so waiting 3 days would not be indicated.

*Case 17: Question 5* An otherwise healthy 57 year-old G2P2 female presents to your office with vaginal bleeding that began one week ago. She began her menses at age 13 and had regular menstrual cycles until the age of 49. She denies any tobacco or alcohol use. Further review of systems is negative. You perform a physical exam, including a vaginal exam, pap smear, and bimanual exam. Which of the following is the most appropriate next step? A. Reassurance B. Trial of oral contraceptives C. Transvaginal ultrasound D. Endometrial ablation E. Referral for hysterectomy

The correct answer is *C. Transvaginal ultrasound* Any postmenopausal bleeding needs to be investigated; reassurance alone is inappropriate in this case. A transvaginal ultrasound is the most cost-effective initial test in women with abnormal uterine bleeding at low-risk for endometrial cancer. It is highly sensitive (96%) for the detection of endometrial cancer. Endometrial biopsy is considered the gold standard for evaluation of post-menopausal bleeding and is up to 99% sensitive. Oral contraceptives, endometrial ablation, and hysterectomy are treatment modalities that would not be appropriate until an actual diagnosis is made.

*Case 12: Question 4* A 25-year-old caucasian female presents with vaginal bleeding and cramping. Her last normal menstrual period was six weeks ago. The patient's vital signs are stable. On speculum exam of the vagina, there is no bleeding from the cervix. A quantitative beta-human chorionic gonadotropin (beta-hCG) level is 1492 mIU/ml. The patient is sent home and told to return to in 48 hours. Her beta-hCG on the return visit is 3000 mIU/ml. What is the appropriate next step in the management of this patient? A. Surgery for ectopic pregnancy B. Methotrexate for ectopic pregnancy C. Ultrasound to confirm intrauterine pregnancy D. Dilation and currettage

The correct answer is *C. Ultrasound to confirm intrauterine pregnancy* Quantitative serum beta-hCG levels rise at a predictable rate, making it a useful tool to help distinguish between an intrauterine pregnancy and an ectopic pregnancy. During the first 6-7 weeks of gestation, beta-hCG levels double every 48 hours. With a beta-hCG level of 1500-1800 mIU/ml, a transvaginal ultrasound will be able to detect an intrauterine pregnancy. A transabdominal ultrasound will be able to detect pregnancy when beta-hCG levels > 5000 mIU/ml. An ectopic pregnancy will have beta-hCG levels lower than normal and levels aren't expected to double during early gestation. In the above case, the beta-hCG levels are doubling every 48 hours and a transvaginal ultrasound would be used to confirm intrauterine pregnancy.

*Case 14: Question 3* A 27-year old female, G2P1, returns to the clinic for her second prenatal visit. Her labs reveal that her blood type is A Rh-. She states she has done research online, and is concerned that this pregnancy will result in her baby dying if it has a different blood type than her own. To reassure the patient, you explain that her team of health care providers will: A. perform a cesarean section to prevent fetal demise B. treat the baby with Rhogam within the first 72 hours after delivery to prevent hemolytic anemia of the newborn C. treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum. D. treat the mother with penicillin during labor to prevent transmission of gram-positive bacteria E. treat the mother with Rhogam when she is at 28-weeks gestation to prevent thalassemia in the newborn, and if it is determined the neonate is Rh+ the mother will receive a second dose of Rhogam postpartum

The correct answer is *C. treat the mother with Rhogam when she is at 28-weeks gestation to prevent development of antibodies against Rh+ antigens, and if it is determined the neonate is Rh+, the mother will receive a second dose of Rhogam postpartum.* If a pregnant woman is Rh-, she is given Rhogam (anti-Rh antibodies) in order to prevent sensitization of her immune system to the fetus' Rh+ antigens. Rhogam is given at 28 weeks gestation, within 72 hours post delivery, or with any episode of vaginal or intrauterine bleeding. If untreated, the antibody containing blood of a sensitized Rh- mother may cross the placenta and cause hemolytic anemia in her Rh+ fetus.

*Case 19: Question 3* Sally is a generally healthy 27-year-old female graduate student who presented to your office twelve weeks ago with episodic post-prandial epigastric burning. This had been bothering her for nearly six months but she had been busy with her thesis and was unable to find the time necessary for an appointment. She reported this year has been particularly stressful, with limited time resulting in increased consumption of coffee and take-out fast food. At that time, she began an eight-week trial of omeprazole. She returns now with no improvement of her symptoms. She discontinued the omeprazole one month ago because she ran out of the medication. She has no additional symptoms and physical exam is unremarkable. Which of the following is the most appropriate next step in her management? Choose the single best answer. A. Refer her for an upper gastrointestinal endoscopy B. Begin treatment with triple therapy of pantoprazole, clarithromycin, and azithromycin for 14 days C. Continue omeprazole for another 4 weeks with close follow up D. Administer a urea breath test E. Switch PPI from omeprazole to pantoprazole

The correct answer is *D. Administer a urea breath test* This patient exhibits no alarm symptoms, but does have persistent symptoms despite adequate empiric therapy. This case warrants testing for H. pylori as a cause of symptoms. One test which is sensitive and specific for H. pylori infection is the urea breath test. The antibiotic regimen listed in choice B is for treatment of H. pylori, but a diagnosis must be made before instituting such a treatment regimen. Switching PPI's or doing a longer treatment of the same medication would not be optimal choices, since the patient hasn't found any relief thus far with the medication. While an upper endoscopy might assist with diagnosis, it is more invasive and in the absence of alarm symptoms, a less invasive test for H. pylori (urea breath test) is acceptable.

*Case 13: Question 1* A 40-year-old male presents to the clinic with dry cough and wheezing for the past two days. He states that his symptoms began two days ago with a headache for which he took aspirin. He denies fever, but does report some continued shortness of breath. He is a smoker but only smokes 1-2 cigarettes a day for about six months. Physical exam is negative except for bilateral wheezing and erythema on the face. What is the most likely diagnosis? A. COPD B. Foreign body aspiration C. Pneumonia D. Asthma E. Pulmonary embolism

The correct answer is *D. Asthma* 21% of adults who have asthma have aspirin-induced asthma and should avoid aspirin and NSAIDS. Even though the patient is a smoker, he is less likely to have a COPD exacerbation because he has only smoked for six months. The patient's duration of symptoms (two days) and reporting no fever lead away from the diagnosis of pneumonia. Also, the clinical history gives you very little reason to suspect foreign body aspiration or pulmonary embolism. The diagnosis of asthma could be confirmed with pulmonary function testing.

*Case 12: Question 1* A 33-year-old G0P0 female presents to your clinic for her first prenatal visit. Her home pregnancy test was positive, she has been experiencing mild nausea for two weeks. Her last normal menstrual period was six weeks ago. Her initial prenatal visit should include: A. Quad screen B. Abdominal ultrasound C. Complete metabolic panel D. Complete blood count

The correct answer is *D. Complete blood count* An initial pregnancy evaluation should include CBC, RPR, HIV, Rubella, Blood type and Hepatitis B. A CBC is included to test for nutritional and congenital anemias as well as platelet disorders. The quad screen typically occurs later in the pregnancy (15-20 weeks) and transvaginal ultrasound (not abdominal ultrasound) is more reliable for dating a pregnancy at six weeks gestation. A complete metabolic profile is not a routine part of an initial pregnancy evaluation, and should be ordered only when indicated.

*Case 12: Question 3* A 24-year-old African American G1P0 at 14 weeks presents with vaginal bleeding and abdominal cramping. On examination her vital signs are: blood pressure 120/75 mmHg, pulse rate 74/minute, temperature 98.4 degrees F taken orally, respiratory rate 18/minute, and oxygen saturation 99% on room air. On pelvic examination, there is a small amount of blood in the vagina, the cervical os is open, and there is no cervical or adnexal tenderness noted. On pelvic ultrasound, an intrauterine gestational sac with a yolk sac is seen. What is her diagnosis? A. Complete abortion B. Threatened abortion C. Missed abortion D. Inevitable abortion

The correct answer is *D. Inevitable abortion* When the cervical os is open or dilated bleeding in early pregnancy is classified as an inevitable abortion. When the cervical os is closed with bleeding before 20 weeks, the correct diagnosis is a threatened abortion. A missed abortion is fetal demise without cervical dilation. Complete abortion occurs when products of conception have been completely expelled from the uterus.

*Case 13: Question 5* A 28-year-old male comes to the Emergency Department with shortness of breath, cough and wheezing for the last 4 hours. He states that he was diagnosed with asthma recently, and is currently using inhaled corticosteroid with a long acting B2-agonist daily to control his symptoms. His RR is 34/min; Temp: 98.8 degrees F; O2sat: 88%; BP: 130/85 mmHg. What treatment should be given to this patient first? A. Albuterol breathing treatment using a nebulizer B. Intravenous corticosteroids C. Ipratropium breathing treatment using a nebulizer D. Oxygen E. Intravenous third generation cephalosporin

The correct answer is *D. Oxygen* This patient is in acute respiratory distress with a decreased oxygen saturation and increased respiratory rate. The first treatment this patient should receive is oxygen supplementation. After giving the patient oxygen, you can then continue treatment for his acute asthma exacerbation with albuterol and ipratropium breathing treatments and intravenous or oral corticosteroids. Antibiotics are not indicated for treatment of asthma exacerbations.

*Case 19: Question 1* Ms Smith is a 38-year-old female with a significant past medical history of hypercholesterolemia who presents to her primary care physician after 4 weeks of episodic epigastric discomfort. She reports a recurrent ache-like sensation in the epigastric region occurring about 10 minutes after eating and lasting for several hours. The pain does not appear to be associated with any particular food. She denies any odynophagia or dysphagia. Ms Smith is a smoker, with a 30-pack year history. You are concerned about peptic ulcer disease. Which additional history finding would increase your level of concern? Choose the single best answer. A. Report of hoarseness B. Epigastic discomfort associated with recumbency or bending C. Bouts of recurrent laryngitis D. Return symptoms despite consistent use of antacids E. Sour or bitter taste in mouth

The correct answer is *D. Return symptoms despite consistent use of antacids* Symptoms that would increase the likelihood of PUD include pain that improves with meals (although some people experience the opposite), history of NSAID use, a pain described as "gnawing" or "hunger-like" and persistent symptoms despite adequate acid-blocking therapy. Hoarseness, epigastric discomfort with lying down, laryngitis, discomfort after large meals, and bitter taste are all typical symptoms of GERD.

*Case 11: Question 2* A 59-year-old patient comes to the local ER with a swollen, tender knee that started yesterday. He returned home two days ago from a 5-day hike on the Appalachian Trail. He denies any recent or previous injury to the knee and any history of previous inflammatory joint disease. Vital signs: temperature is 97.7, pulse is 80, BP is 139/75, and RR is 22. He holds the knee in full extension. The knee is swollen, reddened, tender, and it feels warm. Synovial joint fluid aspiration is done. Which of the following bedside observations of the aspirate would be inconsistent with the presentation? A. Yellow-green fluid B. Cloudy fluid C. Pink or red fluid D. Straw-colored fluid

The correct answer is *D. Straw-colored fluid* *Straw-colored* fluid is the color of normal synovial fluid, and would not be an expected finding in this patient with probable septic arthritis. *Yellow-green* fluid indicates an increased number of plasma/nucleated cells, seen in inflammatory and septic arthritis. *Cloudy* fluid has an increased opacity due to an increased number of WBC's or crystals. *Pink* or red fluid indicates blood, and can be present if there was a traumatic tap done when collecting the sample.

*Case 17: Question 2* A 56-year-old woman with a past medical history significant for hypothyroidism and recurrent urinary tract infections presents to a local health fair to discuss dyspareunia and hot flashes that began approximately one year ago. Her last menstrual cycle was 14 months ago, and her family history is significant for breast cancer in her sister, diagnosed at the age of 47. She has become increasingly bothered by the frequency of her hot flashes and has stopped attending social events with her friends due to these symptoms. Which one of the following is true regarding the risks and benefits of hormone-replacement therapy (HRT)? A. Use of combined estrogen and progesterone therapy decreases the risk of breast cancer. B. Use of unopposed estrogen in patients with an intact uterus decreases the risk of endometrial cancer. C. Use of hormone therapy for less than five years will not affect a patients risk of coronary artery disease. D. Use of hormone therapy decreases the risk of osteoporotic fractures. E. Both systemic and topical estrogens are equally effective for the treatment of vasomotor symptoms.

The correct answer is *D. Use of hormone therapy decreases the risk of osteoporotic fractures.* Use of combined estrogen and progesterone beyond three years increases the risk of breast cancer. Use of unopposed systemic estrogen in women with an intact uterus increases endometrial cancer risk. Beginning HRT after age 60 increases the risk of coronary artery disease. Systemic estrogen is most effective for treatment of vasomotor symptoms. HRT has been shown to decrease the risk of osteoporotic fractures.

*Case 19: Question 2* Mr Gill is a 27-year-old male who presents to his primary care physician with post-prandial epigastric burning. The burning is episodic, without associated hematemesis, dysphagia, or odynophagia. In the past, he has episodically used an OTC chewable calcium carbonate to provide relief. Over the past month, he has had to increase the frequency of its use to four times daily. His blood pressure is 120/71 mm Hg, heart rate at 75/min and regular. Physical exam reveals only minimal epigastric tenderness on palpation but is otherwise normal. Which of the following is the most appropriate next step in management? Choose the single best answer. A. Upper endiscopy B. H. pylori IgG serologic testing C. Fecal immunochemical testing (FIT) D. Fecal occult blood testing (FOBT) E. 8 week trial of pantoprazole

The correct answer is *E. 8 week trial of pantoprazole* This patient displays no red flag symptoms at this time. The most widely accepted initial intervention in a patient like this is empiric treatment with a histamine-2 receptor blocker or a proton pump inhibitor such as pantoprazole. Upper endoscopy would be indicated if there were alarm symptoms or if empiric therapy did not resolve symptoms. H. pylori testing might be indicated if symptoms persisted after empiric therapy. There is not a specific concern for rectal bleeding at this time, so fecal testing for blood is not indicated.

*Case 15: Question 5* A 58-year-old man presents to clinic with right upper quadrant pain. The patient has a history of hypertension and GERD, but denies any past surgeries. His abdominal exam reveals a positive Murphy's sign. What would be the next best step to confirm your working diagnosis? A. Complete blood count B. Liver function tests C. CT abdomen without contrast D. CT abdomen with contrast E. Abdominal ultrasound

The correct answer is *E. Abdominal ultrasound* Real-time ultrasonography is the preferred study to evaluate right upper abdominal quadrant because it is inexpensive, noninvasive and widely available. US provides good evaluation of gallbladder and is accurate in detection of gallstones as well as dilation of biliary tree. A CT with contrast may give you some evidence of gallbladder disease but is not the preferred test when suspecting biliary colic or cholecystits. A CT without contrast is used primarily when there is a suspicion for kidney stones. The other tests would help with your diagnosis, but US is preferred method for biliary colic/gallstones.

*Case 17: Question 4* A 61 year-old G4P4 female presents to a local emergency room with vaginal bleeding. The bleeding began two days ago and is described as spotting. She began her menses at age 16 and had regular menstrual cycles until the age of 59. She endorses smoking ½ pack per day for the last 23 years and drinks 1-2 glasses of wine with dinner every evening. She denies any abdominal pain or dysuria. She is 5'7" and weighs 112 lbs. You perform a physical exam, including a vaginal exam, pap smear, and bimanual exam. Which one of the following characteristics of this particular patient increases her risk of endometrial cancer? A. Smoking B. Multiparity C. Body habitus D. Age of menarche E. Age of menopause

The correct answer is *E. Age of menopause* Any characteristic that increases exposure to unopposed estrogen increases the risk of endometrial cancer. This includes Tamoxifen therapy, obesity, anovulatory cycles no prior history of pregnancy, early menarche (before age 12), and late menopause (after age 52). Smoking decreases estrogen exposure, thereby decreasing risk. Oral contraceptives increase progestin levels, thus providing protection against endometrial cancer.

*Case 16: Question 5* A 57-year-old Caucasian woman comes in, concerned about a 1.5 cm dark multicolored mole on her chin that has been increasing in size over the past 6 months. An excisional biopsy shows pathology indicative of squamous cell carcinoma with clear margin. What is a preventative measure that the patient could implement to prevent further recurrences? A. Use of sunscreen with an SPF of at least 15 B. Avoid artificial sources of UV light, such as indoor tanning C. Visit the doctor every six months for a whole body skin examination D. Wear a wide brimmed hat when in direct sunlight E. All of the above

The correct answer is *E. All of the above* All of the above are important measures to take for skin cancer prevention in someone who has already been diagnosed with one cancerous lesion. All of these measures are appropriate preventative measures for those who have no skin cancer as well, except the frequency of screening exams would be annually instead.

*Case 14: Question 2* A 31-year-old female, G1P0 at 26 weeks gestation, presents to the clinic for her gestational diabetes screening. Her pregnancy has been uncomplicated. Vital signs are stable. Which of the following would require a follow up three-hour glucose tolerance test? A. Fasting serum glucose concentration of 91 mg/dL B. Fasting serum glucose concentration of 112 mg/dL, and a one-hour serum glucose concentration of 128 mg/dL C. Two-hour serum glucose concentration of 146 mg/dL D. Fasting serum glucose concentration of 113 mg/dL, and a two-hour serum glucose concentration of 134 mg/dL E. Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 158 mg/dL

The correct answer is *E. Fasting serum glucose concentration of 130 mg/dL, and a one-hour serum glucose concentration of 158 mg/dL* Screening for gestational diabetes is usually performed between 24 and 28 weeks gestation, using a fasting glucose and a one-hour glucose following a 50g glucose load. If the fasting glucose is greater than 126 mg/dL, OR the one-hour glucose is greater than 130mg/dL or 140mg/dL Then the patient is considered to have a positive result. In the case of a positive one-hour glucose, the patient should undergo a three-hour GTT with a 100g glucose load.

*Case 11: Question 3* Preliminary results from the joint aspirate for the prior patient above show the following: Cell count: >100,000/mm3 Gram stain: positive Crystals: negative Which of the following would be the next appropriate step in diagnosis? A. ESR and CRP B. Blood culture C. Immediate surgical exploration D. Urinalysis E. Synovial fluid PCR F. Synovial fluid culture G. Steroid injections into joint space

The correct answer is *E. Synovial fluid PCR* Synovial fluid PCR can aid in the diagnosis of arthritis caused by Yersina, Chlamydia, Ureoplasma urealyticum, N. gonorrhoeae, and in this case, Borrelia burgdorferi. PCR has a > 90% sensitivity for Lyme disease, and helps confirm the diagnosis. Synovial fluid culture is insensitive in extracutaneous manifestations of Lyme. ESR and CRP are elevated in inflammatory processes, but are not reliably elevated in septic arthritis. This patient does not appear septic based upon his physical exam, making blood cultures less urgent. Immediate surgical exploration is overly aggressive as the next step, urinalysis would not help in the diagnosis of this patient, and septic arthritis can complicate joint space injections and should not be the next step for this patient's work-up.

A 61-year-old female has recently been diagnosed with Type 2 diabetes. Her fasting glucose was 240 mg/dL and her A1c was 8.9%. Her BP has been 148/90 and 146/86 at two separate office visits. Her home BP measurements have been in a similar range. Her creatinine is 0.9 and she has no known heart disease. She currently takes losartan 100 mg daily for a diagnosis of hypertension. Which of the following would be the most appropriate step in managing this patient's blood pressure? A. Make no changes to her medications as her blood pressure is at goal. B. Start lisinopril daily. C. Start amlodipine daily. D. Start metoprolol daily. E. Start furosemide daily.

The correct answer is (C). According to the 2017 AHA/ACC blood pressure guidelines, this patient's blood pressure goal should be 130/80 mmHg. She is clearly above that, and she should have a blood pressure medication added (or in a highly motivated patient, dramatic behavioral changes with close follow up). There is no preference for a first line treatment for blood pressure in diabetic patients, although many providers start with and ACE inhibitor or ARB because diabetes is a risk factor for chronic kidney disease. Furosemide and metoprolol are not among the four major classes of medications for blood pressure management (ACEIs, ARBS, calcium channel blockers, and thiazides), so D and E are not acceptable choices. Lisinopril is an acceptable first-line choice, but it should not be combined with an ARB. Since this patient is taking losartan (an ARB), adding an ACEI is contraindicated. Amlodipine is a good choice for this patient.

A 24-year-old previously healthy female has been exhibiting some new concerning symptoms over the past four months. From her history, you gather that she's been having increased diarrhea, tremors, palpitations, and fatigue over this time. Your physical exam reveals a fine tremor in the bilateral upper extremities, sweaty palms, and a smooth, mildly enlarged thyroid gland. You determine that serum testing is warranted. *Of the following lab results, which would best support the diagnosis of Graves disease?* A. Low TSH, normal free T4, high free T3 B. Low TSH, normal free T4, normal free T3 C. Low TSH, low free T4, low radioactive iodine uptake, low thyroglobulin D. Low TSH, high free T4; high, diffuse radioactive iodine uptake E. Low TSH, high free T4; high, nodular radioactive iodine uptake F. High TSH, high free T4

The correct answer is (D). The diagnostic algorithm of the AAFP for hyperthyroidism can be found by clicking on the following weblink: http://www.aafp.org/afp/2005/0815/p623.html. As can be intuited from the answer choices, the first step is to check if serum TSH is low or high and if serum T4 is low or high. If TSH is low and T4 is high, primary hyperthyroidism is diagnosed, and a radioactive iodine uptake scan is next.

A 45-year-old female presents to your office complaining of left calf pain and swelling. She reports first noticing the pain after her yoga class earlier in the week. She denies having any chest pain or shortness of breath. She has no significant PMH. Her physical exam is significant for tenderness to palpation over the left calf. No edema or redness is present. The circumference of her left calf is 10 cm and the circumference of her right calf is 9 cm. What is the most appropriate next step in diagnosis? A. D-dimer B. MRI C. Lower extremity Doppler D. CT angiography

The correct answer is A. This is the case where the pretest probability of a DVT is low, so that a negative D-dimer would save further testing. If the D-dimer is positive then the next step would be the lower extremity Doppler. CT and MRI are expensive and do not add anything to diagnostic accuracy in the majority of cases.

A 55-year-old man with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35-pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" *Which stage of change best describes this patient at this time?* A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance

The correct answer is A. Based on this man's response, it appears he has not actively considered quitting smoking despite his family's concern. All options refer to different stages in the Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses.

A 60-year-old woman presents to the office complaining of increased frequency of urination and fatigue for the past several months. She denies fevers, dysuria, back pain, diarrhea and abdominal pain. She has noted some weight loss without working on diet or exercise. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril. She is a non-smoker and consumes one to two glasses of wine per week. Her vitals are: - Heart rate: 70 beats/minute - Blood pressure: 130/70 mmHg - Body Mass Index: 30 kg/m2 - Physical examination reveals increased pigmentation in her axilla bilaterally. Her labs are as follows: - Random plasma blood glucose: 205 mg/dL - Creatinine: 0.8 mg/dL - TSH: 2.1 U/L. What test is needed to diagnose diabetes mellitus? A. The random blood glucose is sufficient B. Fasting blood glucose C. An oral glucose tolerance test D. HgbA1c E. Urine microalbumin

The correct answer is A. Diabetes can be diagnosed with either an HbA1c > 6.5%, a fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l), a plasma glucose ≥ 200 mg/dL (11/1 mmol/l) two hours after a 75 g glucose load, or symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dL (11.1 mmol/l). Answers (B), (C), (D) and (E) are incorrect, as the diagnosis of diabetes can be made based on random blood glucose with symptoms.

A 27-year-old woman comes into your office because she heard from her friend about a vaccination against cervical cancer and would like one. She has no medical problems and has had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having sex at the age of 18 and is currently sexually active with one partner. She occasionally uses condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer several years ago and had a total hysterectomy. *Why is the patient not an ideal candidate for the Gardasil vaccination?* A. Age B. Sexual activity C. Mirena IUD D. Allergy to penicillin E. Tobacco use

The correct answer is A. Gardasil9 is a vaccination against 9 HPV types and is approved for females ages 9 to 26. While the recommendation is to end at age 26, that does not mean it is dangerous; it just hasn't been studied and will not likely be covered by insurance. Activity (B) is not a contraindication to Gardasil vaccination. The other choices are not contraindications to vaccinations.

Ms. Marcos is a 65-year old woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5' 2" and weighs 250 lbs. *When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly?* A. Sleep Apnea B. Pneumonia C. Chronic sinusitis D. Asymptomatic coronary artery disease E. Hypoparathyroidism

The correct answer is A. Sleep apnea occurs in 20% to 70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep. Some of the other most common causes of insomnia in the elderly are: Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep.

Mr. Giovanni is a 37-year-old male who drives a delivery truck. He presents to your clinic after acute onset of severe lower back pain, which began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which of additional physical exam finding would be consistent with this man's level of disc herniation? A. Hypoactive ankle tendon reflex B. Decreased range of motion on lumbar extension C. 2/5 strength on hip flexion D. Decreased rectal tone E. Positive Stoop test

The correct answer is A. The clinical signs presented by this patient - difficulty with heel walk and the abnormal strength of ankle plantar flexion - is consistent with nerve root impingement at the level of L5-S1. Of the answers listed, a hypoactive ankle tendon reflex is also consistent with a nerve root impingement at this level. Pain with lumbar extension suggests degenerative disease or spinal stenosis, and spinal stenosis is similarly suggested by a positive stoop test. Diminished hip flexor strength suggests a lesion at the L2, L3, or L4 level and decreased rectal tone suggests a cauda equina lesion.

Case 29: Question 3* A 68-year-old male becomes confused and agitated on post-operative day three after open cholecystectomy. He does not recall his surgery or where he is and wants to leave the hospital. Physical exam shows temperature of 99.9 Fahrenheit, blood pressure of 143/89 mmHg, heart rate of 90 beats/minute, respiratory rate of 13 breaths/minute, and O2 sat of 98% on room air. He appears agitated and uncomfortable. He has a Foley catheter. His physical exam is unremarkable. Labs: WBC-11,000, Urinalysis: 2+ nitrites and 2+ leukocyte esterase, 10 WBC/hpf. Glucose finger stick: 80, EKG: normal sinus rhythm at 88 beats per minute. Which of the following is the best initial step in the management of this patient? A. Remove urine catheter B. Give IV ceftriaxone C. Order urine gram stain D. Order urine culture E. Give oral ceftriaxone

The correct answer is A. Remove the urine catheter This patient has an UTI which is the most common cause of delirium in the elderly. Catheters increase the incidence of UTIs and removal would be the appropriate first step. The other options would be appropriate to consider once the catheter is removed.

A 48-year-old man with a past medical history that includes hypertension, Chronic Obstructive Pulmonary Disease (COPD), and hyperlipidemia presents to clinic as a new patient for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently noncompliant with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. *Which of the following vaccine combinations would be most appropriate for this patient?* A. Influenza, Meningococcal, and Zoster B. Influenza, Pneumococcal, and Tdap C. Influenza, Zoster, and Tdap D. Meningococcal, Pneumococcal, and Tdap E. Meningococcal, Pneumococcal, and Zoster

The correct answer is B. Because this man has a diagnosis of COPD and smokes cigarettes, both annual Influenza and Pneumococcal vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time Tdap is recommended. At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. Zoster vaccine is recommended to all adults at age 50 or older.

Ms. Burton is a 45-year-old woman presents today to establish care and get her health in order. Her concerns today are: fatigue, weakness, numbness, insomnia, feeling sad at times, anhedonia, increased appetite, weight gain, dry skin, and increasing hair loss within the past month. Her vital signs are: - Heart rate: 78 beats/minute - Respiratory rate: 18 breaths/minute - Oxygen saturation: 95% - Blood pressure: 152/84 mmHg - Weight: 325 lbs - Body Mass Index: 41 kg/m2 Today, her physical exam is significant for thinning hair, poor dentition, a systolic murmur heard at the left upper sternal border, an obese abdomen, and bilateral knee stiffness and pain on range of motion exam. *Remainder of the physical exam is within normal limits. Which laboratory tests or studies can be done to rule out medical causes of insomnia, fatigue, and depression?* A. Chest-X Ray B. CBC, CMP, and TSH C. HgbA1c, lipid panel, urine microalbumin D. CT head without contrast E. MRI brain with contrast

The correct answer is B. CMP can be used to detect electrolyte, renal and hepatic problems. TSH can be used to rule out hypo- or hyperthyroidism. CBC can be helpful to detect anemia and vitamin deficiencies. In addition, ESR can be used to test for rheumatologic disease. An ECG should be done if the patient is using drugs that might alter cardiac conductivity, such as TCAs.

A 35 year old overweight woman in good health comes to the clinic for a routine physical. Which of the following screenings are recommended by the U.S. Preventative Services Task Force (USPSTF)? A. Complete blood count B. Thyroid stimulating hormone levels C. Cholesterol panel D. Blood pressure screening E. HbA1C

The correct answer is D. The only one of these that the USPSTF recommends in this age group is blood pressure screening. It is recommended to screen women with a cholesterol if there are risk factors for CHD.

A 60-year-old male with a past medical history of chronic gout, depression, and Stage 1 hypertension presents to your office for a follow-up visit. He has been attempting to reduce his blood pressure with behavioral changes, but has had difficulty maintaining the changes. Today, his vitals are blood pressure 144/90 mmHg, pulse 78 beats/min, respirations 12/min, temperature 98.7 F. His recent basic metabolic panel was completely normal. Based on cholesterol levels he had done in the prior week, you calculate his 10-year ASCVD risk at 11%. As you consider starting a medication for his hypertension, which of the following medications is most likely to cause an adverse event in this patient? A. Lisinopril B. Hydrochlorothiazide C. Amlodipine D. Losartan E. Metoprolol

The correct answer is B. Hydrochlorothiazide (HCTZ) can cause hyperuricemia and therefore should be used with caution in patients with gout. Metoprolol is not a first-line choice for the management of blood pressure, but there is no particular reason to expect this patient to experience an adverse drug event due to a beta-blocker. While all of the other medications listed are appropriate first-line anti-hypertensives, many clinicians would select one of the other options over HCTZ for this patient given his history of gout.

A 20-year-old female who is a long-standing patient at this clinic with no significant past medical history presents with first-time onset of dysuria accompanied by frequency and urgency for the past day. She thinks that there is a strange odor to her urine but denies any hematuria. In addition, she feels mild lower abdominal discomfort but denies fevers, chills, nausea, vomiting, constipation, diarrhea, or costo-vertebral angle (CVA) pain. She reports no known allergies She has never been sexually active and has no vaginal discharge nor irritation. LMP was one week ago and was typical. She wonders if using a perfumed bubble bath for the first time a few days ago might have triggered her symptoms. On exam, her vital signs are stable; she has no CVA tenderness and mild suprapubic discomfort. Urinalysis of a mid-stream catch is within normal limits, and a pregnancy test on the same sample, performed despite her history, is negative. *Which of the following reflects best management in this situation?* A. Insist that a pelvic exam and cervical DNA probe be performed today. B. Await urine culture results before any treatment. C. Reassure that this is not a urinary tract infection. D. Trimethoprim/sulfamethoxazole (one tab twice daily for three days). E. Urine DNA probe

The correct answer is D. There is very good evidence that common typical symptoms of urinary tract infection (UTI) (e.g. dysuria and frequency) with the absence of vaginal symptoms are highly predictive of UTI in young women who have no systemic symptoms. The constellation of typical symptoms outweighs a normal urinalysis. Therefore, based on the symptoms presented, the most reasonable treatment option is to treat empirically with a standard antibiotic for a short course. It is not unreasonable to send urine for culture but management does not need to wait till that result is available. While it is always prudent to consider the possibility of sexually transmitted infection in this age group, based on the information presented about an established patient, it would be inappropriate to insist on a pelvic exam or await results of a urine DNA probe in the face of such strong UTI symptoms.

A 72-year-old woman with a 30-year history of Type 2 diabetes returns to your office for routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. The patient notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is true regarding diabetic retinopathy? A. The majority of people with diabetes only develop retinopathy after 10 years with the diagnosis. B. 40% of people with severe diabetes requiring insulin have retinopathy five years after diagnosis. C. Vision changes are an early sign of retinopathy. D. Primary care physicians should examine the retina on every visit for ongoing diabetes care.

The correct answer is B. The patient's symptoms describe diabetic retinopathy. Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Early changes of retinopathy are asymptomatic. Patients need to see an ophthalmologist regularly for a dilated retina exam, not rely on a view of the retina from primary care physicians. Abnormalities seen include macular edema ( a common cause of blurry vision) and new blood vessel formation which can leak and cause dark spots in the vision. Diabetic eye disease often can be treated before vision loss occurs. Glaucoma (causing increased intraocular pressure) is 40% more likely in people with diabetes, but usually causes nausea, headaches, and narrowing of vision or halos around lights.

A 68-year-old male was diagnosed with Stage 1 essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28, mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94 mmHg. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. which of the following is the most appropriate medication to begin in this patient? A. Beta blocker B. Thiazide diuretic C. Nitrate D. Loop diuretic E. Clonidine

The correct answer is B. This patient now meets criteria for Stage 2 hypertension as indicated by a systolic BP 140 to 159 mmHg and diastolic BP 90 to 99 mmHg. The ACC/AHA guidelines recommend thiazide diuretics, ACE inhibitors, angiotensin II receptor blockers, or calcium channel blockers as first-line treatment for most patients with newly diagnosed hypertension, with a slight preference for chlorthalidone in the diuretic class. The other options are not first-line treatments for hypertension.

A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96 mmHg. You repeat the blood pressure in her other arm and get 148/92 mmHg. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76 mmHg. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. At this time, the most appropriate diagnosis is... A. White coat hypertension B. Elevated blood pressure reading C. Stage 1 hypertension D. Stage 2 hypertension E. Secondary hypertension

The correct answer is B. To diagnose hypertension, two separate readings greater than 130/80 mmHg each time - taken a week or more apart - are needed. Furthermore, ideally home blood pressure readings in the hypertensive range would be needed to confirm that she does not have white coat hypertension. Because this patient has had elevated blood pressure documented on only one occasion (today), the most appropriate current diagnosis is elevated blood pressure. If she has a second similarly elevated reading, Stage 2 hypertension may be diagnosed. Stage 1 hypertension refers to blood pressures between 130-139/80-89 mmHg. This patient has not yet been diagnosed with hypertension, so neither A, C nor D is appropriate.

A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has an aunt who had breast cancer that was BRCA positive, though her mother is BRCA negative. Her periods have been regular since they started at the age of 13 and occur every 32 days. She is currently menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32, up from 28 three years ago and her other vital signs are stable. On breast exam, you note a mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. *Of the information provided, which of the following places this patient at increased risk for breast cancer?* A. Age B. Weight C. Parity history D. Family history of cancer E. Age of menarche

The correct answer is B. With a BMI of 32, obesity is the one risk factor for this patient based on the information given. Other risk factors for breast cancer include family history of breast cancer in a first degree relative (mother or sister - not aunt), prolonged estrogen exposure (menarche before age 12, menopause after 45, advanced age at first pregnancy), genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age, and this patient is relatively young), female sex, increased breast density and certain exposures (diethylstilbestrol, hormone or radiation therapy, heavy smoking).

A 21-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing soccer a day prior to presentation. She remembers immediate pain and swelling but was able to weight bear and limp off the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical exam reveals that the lateral right ankle is edematous with purplish bruising, bilateral pulses are good and the patient had good sensation and motor function in both feet about equally. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. What is the next best step in the management of this patient? A. Reassurance B. Immobilize with cast or splint C. X-ray imaging of right ankle D. Emergent fasciotomy E. Rest, ice, Ibuprofen, compression and elevation and re-evaluate in one week

The correct answer is C. Based on the Ottawa Ankle Rules, tenderness of the lower 6 cm of the posterior lateral malleolus may predict fracture and justifies X-ray imaging of the ankle. Tenderness of the lower anterior lateral malleolus, on the other hand, is very common in ligamentous injury such that x-rays are not warranted. Because of the possibility that a fracture exists, the other treatment options are not correct in this scenario.

A 56-year-old Spanish-speaking male presents to your office for a six-month follow-up visit for DM Type 2 diagnosed at his previous visit with a HbA1C of 7.0%. At that visit, you discussed dietary modification including eliminating carbohydrates like rice from his diet. You also emphasized the importance of exercise and recommended he join a gym. On repeat testing of HbA1C today, you find that his HbA1C has increased to 7.5%. What might you do differently when counseling the patient at this visit? A. Suggest he get a personal trainer. B. Recommend he follow a more strict dietary protocol including elimination of meat from his diet. C. Find out from the patient whether barriers exist to his adherence to your previous suggestions. D. Tell him you are disappointed that he was not able to adhere to your previous recommendations.

The correct answer is C. Before counseling a patient it is critical to assess barriers to adhering to the plan developed together. It is important to ask patients for understanding of the plan and whether they feel confident that they can follow the plan. Suggesting a personal trainer may be unrealistic for financial or time reasons. Eliminating meat may not appeal to him and telling him about your disappointment could make him less likely to tell you what is going on, or even making a follow-up visit.

A 65-year-old truck driver presents to your office complaining of right calf redness and swelling. He reports that he has had these symptoms off and on for some time but noticed that the redness and swelling on the right has worsened over the past few days and he also noticed fevers and chills. His PMH is significant for DM Type 2, COPD, and heart failure. He has a 25-pack-year smoking history. His physical exam shows a temperature of 101.1, 2+ pitting edema of his calves bilaterally, and dry, flaking skin over both calves. His right foot shows interdigital maceration and he has redness, warmth, and tenderness just inferior to the knee. When measuring the circumference of his right leg, you note that it is 12 cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in this patient's care? A. Initiate treatment with Low molecular weight heparin. B. Order a lower extremity Doppler. C. Initiate treatment with antibiotics. D. Check a D-dimer.

The correct answer is C. In light of the fever with redness and tenderness of the exam, the extra swelling is most likely due to cellulitis. There is no added benefit of treating with heparin and no particular reason to rule out a DVT with the Doppler or D-dimer.

A 55-year-old man presents to your office complaining of pain and stiffness in his knees. He used to play basketball three times a week with his friends but stopped about seven months ago because he was finding it difficult to keep up. His PMH is significant for hypertension, hyperlipidemia, and obesity. His BMI is 32. On exam, he is afebrile. There is no erythema or effusion of his knee joints but there is crepitus on movement of each joint. His range of motion of the knees is full. His x-rays show narrowed joint spaces and subchondral calcification. What is the most appropriate initial counseling for this patient? A. Instruct him to see an orthopedist for steroid injections. B. Refer him for knee replacement surgery. C. Develop a weight loss plan with the patient. D. Prescribe opioids for pain relief.

The correct answer is C. Obesity is an important cause of mortality and morbidity. Knee pain is common in obese patients and losing weight can be helpful. Steroid injections generally help in osteoarthritis when there is joint inflammation, and this patient does not have signs of an effusion. There is no indication at this point for knee replacement surgery or opioids. Opioid pain medications are generally only indicated for severe acute pain and in this case his pain is likely to be chronic.

A 42-year-old woman presents for a visit after recently being diagnosed with Type 2 diabetes. She has made a plan to work on diet and exercise. Her A1c is found to be 8.0%. What is the best medicine to start at this time? A. A sulfonylurea B. Basal insulin C. Metformin D. GLP-1 receptor agonist E. An SGLT2 inhibitor

The correct answer is C. Sulfanylureas, GLP-1 receptor agonists, and SGLT2 inhibitors may be used as second-line agents. Insulin is generally not used until two other oral medications are insufficient to control the blood sugar, but most people with Type 2 diabetes become insulinopenic over time and require insulin treatment.

A 62-year-old man with hypertension and diabetes is discharged home from the hospital, following a viral upper respiratory tract infection. He is prescribed several medications, including low dose aspirin. The patient asks you why he is taking aspirin along with the other medications. What is the reasoning behind your response? A. Aspirin helps decrease the risk of ischemic stroke in men. B. Aspirin helps decrease the risk of developing a hypercoagulable state. C. Aspirin helps decrease the risk of myocardial infarction in men. D. Aspirin decreases the risk of gastrointestinal hemorrhage.

The correct answer is C. The USPSTF recommends initiating aspirin therapy in men age 45 to 79 years to reduce the risk of myocardial infarction. In women age 55 to 79, the USPSTF advises taking aspirin to reduce the risk of ischemic stroke. For both men and women, the benefit of decreased risk from those outcomes must be weighed against an increased threat of gastrointestinal hemorrhage. Other groups disagree that all men be treated, and only use aspirin for high risk patients, where the benefits outweigh the risk of GI hemorrhage, which is increased in patients taking aspirin.

A 30-year-old male with PMH significant for one month of progressive hoarseness and fever presents with a painful neck mass. He reports increased sweating, racing heart, diarrhea, and fatigue. His vital signs are: - Temperature: 39.5 Celsius - Heart rate: 85 beats/minute - Respiratory rate: 19 breaths/minute - Blood pressure: 130/70 mmHg On physical exam, you palpate a hard, fixed, painless nodule on the left side of the thyroid gland. Bloodwork results show: - TSH: decreased - Free T4: increased *Which of the following is correct about thyroid nodules?* A. 25% of patients with hyperthyroidism are caused by thyroid nodules B. The majority of thyroid nodules symptomatic C. 4% to 5% of thyroid nodules are cancerous D. Older patients with thyroid nodules usually have solitary nodules E. Thyroid radioactive iodine uptake and scan is the best initial test to evaluate a new thyroid nodule

The correct answer is C. The correct answer is (C). Four percent to 5% of thyroid nodules are cancerous. Only 5% cases of hyperthyroidism are due to nodules (A). Most thyroid nodules are asymptomatic and are found by physical exam or imaging done for another purpose (B). Older patients are more likely to have multinodular disease, and younger patients solitary nodules (D). The best initial imaging for a thyroid nodule is thyroid ultrasound (E). The patient in this case could either have an ultrasound or fine needle biopsy as this case is consistent with thyroid cancer, probably papillary.

Mr. Jones is an 82-year-old man who presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; reports decreased enjoyment of his activities, such as playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He denies any suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife's voice while going to bed. He says he goes to church to pray. You are trying to determine if your patient's symptoms are normal grief or if you should diagnose and treat him for Major Depressive Disorder (MDD). *Which feature of Mr. Jones' case would suggest MDD rather than a normal grief reaction?* A. Insomnia B. Change in appetite C. Inability to experience any joy D. Hearing wife's voice E. Fatigue

The correct answer is C. The loss of a loved one can be a traumatic event and it is normal to experience a period of grief. DSM-5 states that MDD can be diagnosed during a period of grief as long as the criteria are met. Grief can be difficult to distinguish from major depression with symptoms of sadness, fatigue, changes in appetite, sleep disruption, and decreased concentration. Since your patient is also exhibiting *diminished pleasure with normally enjoyable activities*, this may indicate the patient has MDD, as pervasive unhappiness and misery are rarely a part of the normal grieving process. Other features that differentiate MDD from grief include: - Guilt about things other than actions taken or not taken at the time of death - Thoughts of death other than feeling that he or she would be better off dead or should have died with the deceased person - Morbid preoccupation with worthlessness - Marked psychomotor retardation - Prolonged and marked functional impairment - Hallucinatory experiences other than hearing the voice of, or transiently seeing the image of, the deceased person

A 63-year old woman comes into your office for her annual preventive exam. She has hypertension and type 2 diabetes. She is not sexually active. Her blood pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year ago was normal. She has never had an abnormal Pap smear. *At the age of 45 she had a total hysterectomy for fibroids. You tell her she does not require a Pap smear today because:* A. She has never had an abnormal Pap smear B. She is not sexually active C. She had a total hysterectomy for fibroids D. She is 63 years old E. She experienced menopause more than 10 years ago

The correct answer is C. The patient described above underwent a total hysterectomy (total removal of the uterus and cervix with or without oophorectomy) for benign reasons (fibroids). USPSTF guidelines recommend against continued cervical cancer screening in patients whose uterus has been removed for benign disease and evidence showed cytologic screening to be very low yield and poor evidence that screening to detect vaginal cancers improves health outcomes in women after hysterectomy for benign disease. Cervical cancer screening should begin at the age of 21 and women between the ages of 65 and 70 who have had three or more normal Pap tests in the past ten years may choose to stop cervical cancer screening. Not being sexually active; age 63; only having had normal PAP smears and years since menopause are not reasons to stop screening for cervical cancer.

A 41-year-old male with no significant past medical history is brought to the Emergency Department after falling to the ground in the middle of a pick-up basketball game with friends. He did not lose consciousness nor hit his head when he fell. As he landed on the ball of his foot after having taken a shot, he recalls hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and palpation is tender. He is unable to plantarflex his right foot. *What is the most likely diagnosis of his current condition?* A. Ankle ligament sprain B. Calcaneal fracture C. Achilles tendon rupture D. Ankle tendonitis E. Ankle arthritis

The correct answer is C. This is a classical description of an acute rupture of the achilles tendon. Middle-aged males are more commonly affected than other groups. The mechanism does not describe inversion injury making an ankle ligament sprain less likely and there is no direct trauma making fracture less likely. There is no history of overuse or chronicity making arthritis and tendonitis less likely.

A 65-year-old truck driver presents to your office complaining of right calf pain and swelling. He has recently returned from a four-day cross-country trip after which he had onset of his current symptoms. The patient reports that the week prior to his four-day trip, he was mostly in bed recovering from a bout of the flu. His PMH is significant for DM type 2 and COPD. He has a 25-pack-year smoking history. He denies having any chest pain or SOB. His physical exam shows 2+ pitting edema of his right leg. When measuring the circumference of his right leg, you note that it is 14 cm compared to the left, which has a circumference of 10 cm. What is the most appropriate next step in diagnosis? A. D-dimer B. MRI C. Lower extremity Doppler D. CT angiography

The correct answer is C. Venous Doppler has the best sensitivity and specificity for diagnosing a DVT. D-dimer is best used when there is a low pre-test probability of a DVT. If it is negative then it is fairly certain that there is not a DVT. A positive test does not diagnose a DVT (poor specificity) but indicates the need for further testing. MRI and CT angiography are very expensive, carry risks with contrast, and do not add to the care unless an invasive intervention is being contemplated.

Which of the following patients is an appropriate candidate for a exercise stress test? A. A 58-year-old male who presents to the emergency room with constant substernal chest pressure, diaphoresis and shortness of breath B. A 44-year-old female with a BMI of 40 kg/m2 and history of asthma C. A 48-year-old female with a history of intermittent anginal episodes that have been controlled on medications. D. A 52-year-old female with new atypical chest pain with a history of elevated cholesterol, smoking and family history of coronary artery disease

The correct answer is D. An exercise stress test is useful if the pretest probability of the disease is high as in D with 3 significant risk factors. False positives increase if the pretest probability is low so the usefulness of a stress test is low in B. Likewise if the diagnosis is certain as in A then there is not as much use in getting a stress, especially in an unstable patient. Since the purpose of invasive treatment is symptom control, the patient in C has controlled symptoms and hence no need for stress testing.

A 55-year-old man comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. *Which of the following categories most accurately describes the patient based on his BMI?* A. Underweight B. Ideal C. Overweight D. Obese E. Morbidly (very severely) obese

The correct answer is D. Based on BMI measurements, Underweight is considered < 18.5; Ideal: 18.5 to 25; Overweight 25 to 30; Obese 30 to 40; Morbidly (very severely) obese > 40.

Case 29: Question 1* Ms. Martinez, 74-years-old, is brought to your family practice by her husband. He is concerned because his wife, who used to take pride in keeping the house in good shape, has stopped cleaning and caring for her appearance. She recently went shopping and left the stove on. She frequently misplaces her car keys and checkbook. Ms. Martinez reports trouble concentrating and does not have much energy. She has a poor appetite and no longer enjoys knitting. Her mini-mental status exam is 28/30. Physical Exam: General Appearance: well-nourished, appears stated age, HEENT[LW1]: pupils equally round and reactive to light, moist mucus membranes, Chest: normal S1 and S2, no murmurs, Lungs: clear to auscultation bilaterally, Abdomen: soft, non-tender, non-distended, Extremities: no cyanosis, no clubbing. Neurologic: no focal deficits Psychiatric: flat affect. Labs: TSH: 2, WBC: 6.0, HgbA1c: 4.5. Which of the following is the most likely diagnosis? A. Normal bereavement B. Dementia C. Depression D. Pseudo dementia E. Delirium

The correct answer is C. Depression Ms. Martinez has a normal mini mental status exam, her exam findings are normal with the exception of her affect. This suggests a mood disorder. ** As there is nothing in the history to suggest a recent loss, bereavement is not likely. History is not suggestive of delirium which would present with more fluctuations in symptoms and alteration in cognition

Case 29: Question 4* Ms. Michaels is an 80-year-old female with a past medical history of shingles. She comes to your office accompanied by her daughter Jennifer who reports that her mother is forgetting things. Jennifer explains that her mother will ask the same question several times throughout the day although it was answered. Ms. Michaels also gets confused easily and is more passive than usual. Her memory problem was noticed two years ago after she forgot to pay her bills on multiple occasions. Jennifer now pays her mothers' bills and cleans and cooks for her. Ms. Michaels' vital signs are temperature of 99.2 Fahrenheit, blood pressure of 118/70 mmHg, heart rate of 80 beats/minute, and respiratory rate of 12 breaths/minute. Her physical exam is significant for bilateral osteoarthritis hand deformities. CT head shows mild atrophy of the hippocampus. Her MMSE is 20. The patient's diagnosis is most likely associated with? A. Lewy bodies B. Caudate nucleus atrophy C. Plaque formation D. Prion protein E. Vascular disease

The correct answer is C. Plaque formation Ms. Michaels symptoms and CT results are consistent with Alzheimer's Disease as are plaque formations. Lewy bodies are abnormal aggregates of protein that develop inside nerve cells in Parkinson's disease. Huntington's disease presents with caudate nucleus atrophy. Prion proteins are seen in transmissible spongiform encephalopathies

A 65-year-old male with known Type 2 diabetes mellitus presents to the Emergency Department with altered mental status. The patient experienced no known head trauma. His vitals are: Temperature: 38.1 Celsius Heart rate: 102 beats/minute Respiratory rate: 16 breaths/minute Blood pressure: 90/74 mmHg His mucous membranes appear very dry and he is started on IV fluids. Neurological exam reveals no focal deficits. His plasma glucose is found to be 700 mg/dL. Urinalysis reveals no ketone bodies. What is the most likely diagnosis? A. Thiamine deficiency B. Diabetic ketoacidosis (DKA) C. Cerebrovascular accident D. Hyperosmolar hyperglycemic state (HHS) E. Cardiac arrhythmia

The correct answer is D. HHS is seen typically in patients with Type 2 diabetes. It includes very high sugars > 600; ph > 6.4; dehydration; and lack of ketones in the urine and blood. Diabetic ketoacidosis is more common in Type 1 diabetes, and the patient will have ketone bodies in the urine. Thiamine deficiency can cause Korsakoff syndrome, and is typically seen in alcoholics with severe malnutrition, however, this patient is not a known alcoholic and doesn't appear malnourished. Despite the confusion in this patient, stroke is an unlikely diagnosis in this case given the lack of focal deficits on exam. Cardiac arrhythmia can cause dizziness, but is less likely to cause prolonged altered mental status.

A 47-year-old woman comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34 and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date, she has a PAP smear today and will have labs drawn. *According to USPSTF, which of the following is the best recommendation to give her concerning mammography?* A. Should have started at age 40 and every year thereafter B. Should have started at age 40 and every 2 years thereafter C. Start at age 50 and every year thereafter D. Start at age 50 and every 2 years thereafter E. Should have started at age 45 and every year thereafter

The correct answer is D. Mammography has a sensitivity of 60% to 90% for detecting breast cancer and decreases breast cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not indicated for women younger than 50 years old except as based on patient context (history) and beliefs about risks/benefits. The USPSTF recommends biennial testing for women between the ages of 50 and 74. There is insufficient evidence to assess the benefits versus risk of screenings in women after the age of 75. Other groups such as the American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly mammograms starting at age 40, continuing as long as the woman is in good health.

Which of the following symptoms are most likely to be due to acute coronary syndrome? A. 23-year-old male with acute onset of difficulty breathing and hyperresonance upon lung auscultation B. 42-year-old woman with a pulsating pain in the center of her chest at night C. 35-year-old man with chest pain radiating down his left arm after falling off a ladder at work one week ago D. 59-year-old woman with palpitations that increase with exercise and are associated with nausea and vomiting E. 55-year-old woman with diffuse central chest pain that is worse when lying down

The correct answer is D. Palpitations, nausea, and vomiting are seen as prodromal symptoms of ACS in women more than men. Young men with difficulty breathing and hyperresonance are likely to have a pneumothorax. Pulsating pain is one of the types of pain, along with pleuritic and positional pain, that is less likely to be related to heart disease. Chest pain in a young man associated with trauma is less likely to be ACS.

Ms. Vasquez is a 38-year-old female with a past medical history of sarcoidosis and recently completed a six-month steroid taper. She presents to her primary care physician after two weeks of lower lumbar back pain. She does not recall any trauma but began to feel a sharp pain after bending over to pick up laundry. The pain radiates bilaterally into her anterior abdomen. She has found no relief with over the counter NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2 region. There are no neurologic deficits and reflexes are intact. Which of the following is the most appropriate next step in management? A. Reassess in four weeks B. Refer to spine specialist C. Order complete blood count D. Order a plain x-ray E. Recommend conservative management

The correct answer is D. The "red flag" in this history is that of chronic steroid use, and the concomitant risk of osteoporotic vertebral fracture. A vertebral fracture is best diagnosed with a plain x-ray. A CBC will not help with the diagnosis, and referral to a spine specialist is unnecessary. Conservative management and/or reassessment in four weeks demonstrate a failure to recognize the "red flag."

A 35-year-old woman has been diagnosed with Graves disease and has decided to go for treatment with radioactive iodine (RAI). She has had good relief from taking propranolol for her palpitations. What is the best way to counsel this patient about what to do after her treatment? A. Tell her to stop her propranolol a week after she gets the RAI. B. Check her TSH level two weeks after her treatment with RAI. C. Describe the symptoms of hypothyroidism to her and tell her to expect to become symptomatic within one month. D. Check her TSH levels two to three months after her treatment and treat as necessary.

The correct answer is D. The RAI takes several months to destroy the overactive thyroid cells. There is no point in checking the TSH after only two weeks and since she may still be symptomatic from her hyperthyroidism for several months there is no reason to stop her propranolol until she becomes euthyroid. It generally takes a number of months to notice symptoms of hypothyroidism, so while it is important to let her know what to expect in the future you do not want her to have unrealistic expectations.

Ms. Rogers is a 75-year-old woman who was found unresponsive in her house by her neighbor who had come over to help clean her house. An empty unlabeled pill container was found next to her on the bathroom floor. She was rushed to the ER, stabilized and is now in ICU on a mechanical ventilator. *Which of the following are true regarding suicide in the elderly?* A. Elderly persons attempting suicide are more likely to be married and living with their spouse. B. Elderly persons attempting suicide usually report good sleeping habits. C. Suicidal behaviors increase with age, but rates of completed suicides don't. D. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized. E. Firearms are the most common means of suicide in the elderly.

The correct answer is D. The USPSTF recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks. The purpose of the PHQ -2 is not to establish a final diagnosis, but rather to screen for depression as a "first-step" approach. Patients who screen positive should be evaluated by the PHQ-9 to determine whether they meet the criteria for depression. Another screening tool which can be used is the Geriatric Depression Scale - Short Form (GDS-SF) which includes a series of 15 questions. Specifically related to suicide in the geriatric population: Elderly persons attempting suicide are more likely to be WIDOW(ER)S, AND LIVE ALONE; Elderly persons attempting suicide have REDUCED sleep quality; Suicidal behaviors DO NOT increase with age, but rates of completed suicides DO. Drug overdose is the most common means of suicide in the elderly.

A 53-year-old man has been experiencing three months of weight loss and palpitations. Work-up for hyperthyroidism, which is high on your differential, is pending. *Which of the following symptoms is inconsistent with a diagnosis of hyperthyroidism?* A. Tremor B. Insomnia C. Gynecomastia D. Constipation E. Fatigue

The correct answer is D. The correct answer is (D) constipation. The other answer choices are typically associated with hyperthyroidism, while constipation is usually seen with hypothyroidism. Gynecomastia seen in 10% to 40% of patients with Graves disease and is thought to be because of sex hormone binding globulins being increased in Graves disease. Fatigue is common in both hyper- and hypothyroidism.

A 62-year-old woman presents for follow-up of her hypertension and diabetes. In general, her chronic diseases are well controlled and she has suffered no target organ damage. She has worked hard to begin exercising, and is walking vigorously five times a week. She has also worked hard on dietary changes, and has been following the DASH eating plan very seriously. She quit smoking three months ago. Her blood pressure today is 148/88 mmHg, pulse is 72 and BMI is 32. She is taking metformin 500 mg twice daily, simvastatin 20 mg daily and hydrochlorothiazide (HCTZ) 25 mg daily, and she is compliant with her daily medications. Her labs today include an A1C of 6.6, an LDL of 88 and a basic metabolic panel within normal limits. Which of the following management steps today do you consider the most appropriate? A. Increase HCTZ to 50 mg daily B. Make no changes as she is at her treatment goals C. Impress upon her the importance of making more lifestyle modifications D. Add amlodipine 5 mg daily E. Change her simvastatin to atorvastatin 20 mg

The correct answer is D. The goal blood pressure for patients with hypertension is 130/80 mmHg, and this patient has not met this goal with HCTZ and major lifestyle changes. Increasing the dose of HCTZ from 25 to 50 does not improve blood pressure further, so adding a second medication would be more beneficial. While commending her on her lifestyle changes is important, counseling about intensifying them is not likely to be realistic nor helpful given all that she has already done. There is no need to change her statin, however calculating her ASCVD risk to determine whether she is on the appropriate dose would be helpful. The current cholesterol guidelines recommend a moderate intensity statin for patients with diabetes. For simvastatin, a dose of 10 mg represents a low-intensity dose. Increasing this to 20 mg would put her management more in line with these guidelines, though it would not address her elevated blood pressure.

A 22-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing volleyball. The ankle quickly became edematous, but she used ice and was able bear weight on the foot. When she comes to clinic two days later, there is mininmal edema, she has good motor function, and has normal sensation. She has tenderness at the anterior lower lateral malleolus but not inferiorly nor posteriorly. X-rays are not indicated. You recommend continued relative rest and also tell the patient to keep it elevated and ice it several times during the day to help with the pain and swelling. You inform the patient that immobilization and compression is good for the conservative management of her condition. What is the best compression device to use in this situation? A. Tape B. Compression stockings C. Elastic wrap D. Semi-rigid ankle support E. Solid cast

The correct answer is D. This patient apparently has a ligamentous injury to her anterior talo-fibular ligament. In recommending the RICE mnemonic, a semi-rigid ankle support (like an Air Stirrup) provides protection from repeat inversion injury while allowing the patient to actively dorsi- and plantar-flex her foot, which aids recovery. Compression stockings and elastic wrap do not provide adequate support. A solid cast completely immobilizes the ankle and delays recovery, while the evidence supporting taping of the ankle is lacking.

A 55-year-old man with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. *Which of the following characteristics would most justify it being biopsied today?* A. Symmetry B. Borders C. Color D. Diameter E. Location

The correct answer is D. Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is > 6 mm, which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma.

A 54-year-old male with a history of chronic gout and GERD presents to your office for his health maintenance exam. Vitals today are blood pressure 138/88 mmHg, pulse 65 beats/min, respirations 10/min, afebrile, BMI 29 kg/m2. He smokes 10 cigarettes per day, does not regularly exercise, and drinks one to two beers daily, four or five times a week. He has no current concerns, review of systems is negative, and his physical exam is unremarkable. You recommend lifestyle changes. Which of the following changes is least likely to improve his blood pressure? A. Smoking cessation B. DASH eating plan C. Weight loss D. Alcohol cessation E. Increased exercise

The correct answer is D. While all of these options are reasonable lifestyle modifications to recommend for patients, this particular patient's blood pressure is least likely to be reduced by alcohol cessation. Moderate alcohol consumption actually improves blood pressure by 2 to 4 mmHg; therefore, stopping his moderate alcohol consumption could increase his blood pressure. However, it is not recommended to encourage alcohol use in patients who do not drink, because of the risk of encouraging problem drinking. Initiation of the NIH-sponsored Dietary Approaches to Stop Hypertension (DASH) eating plan has been shown to lower systolic pressure as have smoking cessation, weight loss, and increased exercise.

Working at your clinic, you receive a call from a patient of yours, Mr Smith, a 45-year-old male who was seen three days ago complaining of lower back pain. At that time he had no history of trauma, pain that improved while lying down and no neurologic deficits. He works as a truck driver. He was treated conservatively along with pharmacologic intervention with NSAIDs and muscle relaxants. He calls your office now due to only minimal improvement. And although his symptoms have not changed, he is frustrated with the slow progress, needs to get back to work as soon as possible, and is concerned this might be "something serious." Which of the following is the most appropriate next step in management? A. Obtain a plain film x-ray B. Order an MRI C. Ask him to double the dosage of his muscle relaxants D. Schedule him for an appointment immediately E. Reassure him and schedule a follow-up appointment in a few days

The correct answer is E. Given this clinical presentation, the likelihood of this being an episode of lumbar sprain/strain is high, and the odds of this being "something serious" (nerve root compression, malignancy, infection) is still low. The original plan is a good one, and should continue. No new meds or imaging studies would help, and an urgent appointment will not change the anticipated course. Some physicians might choose to involve a physical therapist at this time, but this option is not available for this question.

Mr. Brown is a 42-year-old male accountant with a significant past medical history of obesity who presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He denies any recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely? A. Increased pain with coughing B. Abnormal gait C. Point tenderness on spinous processes D. Loss of ankle jerk E. Spasm of paraspinous muscles

The correct answer is E. Spasm of the paraspinous muscles suggests lumbosacral sprain/strain. Increased pain with coughing, abnormal gait and loss of ankle jerk point to conditions that compress a regional nerve root, while point tenderness on the spinous processes often indicates an origin in the vertebra (osteoporotic fracture, malignancy, etc.).

A 55-year-old man with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. He is a lifelong non-smoker, and he doesn't drink alcohol or use recreational drugs. *Which of the following screening tests is given either an A or B recommendation in favor of its routine use for patients such as this one?* A. Prostate Specific Antigen (PSA) testing B. Lung cancer screening C. Pancreatic cancer screening D. ECG screening for coronary artery disease E. Colon cancer screening

The correct answer is E. The USPSTF gives colon cancer screening an A recommendation for people age 50 to 75 years due to clear evidence of benefit. Lung cancer screening is given a B recommendation for 55-year-old men with a 30 pack-year tobacco history and who have smoked in the past 15 years. This patient is a non-smoker. Pancreatic cancer screening and ECG screening are both given D recommendations (against their use). PSA screening is given a C recommendation, indicating that doctors and patients should make individualized decisions about the use of this test.

A 45-year-old woman presents to the ED with two weeks of abdominal pain, progressive weakness and palpitations. She notes an unexplained 3-lb weight loss as well as black, sticky diarrhea. Her vital signs are: Temperature: 99.1 Fahrenheit Heart rate: 117 beats/minute Respiratory rate: 22 breaths/minute Blood pressure: 92/67 mmHg She appears pale and diaphoretic. Her neck is supple and non-tender. Lungs are clear to auscultation bilaterally. Cardiac exam reveals elevated heart rate and a diastolic murmur. Her abdominal exam is notable for diffuse epigastric pain and hyperactive bowel sounds. Which of the following additional lab values might you expect? A. PaO2 of 60 B. Elevated LDH C. Free T4 of 15 mcg/dL (nml range 4.5-11.2 mcg/dL) D. TSH of 0.3 uU/mL (nml range 0.5-5.0 uU/mL E. Hgb of 8.4 g/dL (nml range 12.0-16.0 g/dL) F. Platelet count of 530,000 /mm3 (nml range 150,000-400,000/mm3)

The correct answer is E. The correct answer is (E). This woman appears to be suffering from anemia due to GI losses, as evidenced by her abdominal pain, weakness, tachycardia, diastolic murmur, and tar-like stools. There is some evidence of exam of hyperthyroidism (C), like tachycardia and diarrhea, but the other aspects of her presentation point to loss of blood. PaO2 is not impacted in blood loss (A), nor is platelet count (F). LDH is elevated in hemolytic anemia.

A 64-year-old woman who is overweight with well-controlled hypertension comes to your office complaining of a lump in her breast that she noticed while showering. She denies any pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 31 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. *Which of the information provided thus far puts the patient at decreased risk for breast cancer?* A. Age B. Weight C. Age at first birth D. Age at menarche E. Age at menopause

The correct answer is E. The patient experienced menopause at the age of 44, which shortens her time of estrogen exposure, a known risk factor for the development of breast cancer. Factors associated with decreased breast cancer risk include pregnancy at an early age, late menarche, early menopause, high parity and medications such as selective estrogen receptor modulators along with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in a first degree relative (mother or sister), prolonged estrogen exposure (menarche before age 12, menopause after 55, advanced age at pregnancy, obesity after menopause), female sex, genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk increases with age), increased breast density and exposures (diethylstilbestrol, hormone or radiation therapy, smoking).

A 19-year-old female with no significant past medical history is involved as the driver in a motor vehicle accident and brought to the Emergency Department by EMS. She is complaining of severe pain in her right lower extremity that has been worsening since the accident. In addition, she has started to notice what she describes as "burning and tingling" in her right foot. On physical exam, her right calf is edematous and tender with tense overlying skin. There is no swelling or tenderness of the right foot or ankle but the right dorsalis pedis and posterior tibial artery pulses are barely palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. *What is the next best step in the management of this patient?* A. Reassurance and icepacks q 2 hours B. Immobilize leg and ankle with a cast C. Urgent EMG of the right lower extremity D. Diagnostic imaging of right foot and ankle E. Emergent fasciotomy

The correct answer is E. This clinical scenario describes acute compartment syndrome which is a vascular emergency. Emergent fasciotomy is the treatment of choice to relieve pressure in the calf and, if not performed, the limb could be lost due to acute ischemia. While emergent radiographs of the tibia and fibula are appropriate to evaluate for co-existent fracture, x-rays of the foot and ankle are not indicated. Reassurance, ice packs, urgent EMG and immobilization are all incorrect treatments and place the patient at risk of serious permanent adverse outcome.

A 52-year-old woman with a history of diabetes and rheumatoid arthritis presents for her annual examination. She works in an office 10 hours a day, and rarely gets exercise. Her BMI is 23 and her blood pressure is 152/85. Her previous visit two months ago showed blood pressure of 148/82. Her father had a history of diabetes and her maternal grandmother died of rheumatic heart disease at the age of 42. She admits to marijuana drug use in the past and is a nonsmoker. Which of the following is a risk factor for coronary heart disease (CHD) that this patient has? A. Age B. Family history C. Rheumatoid arthritis D. Obesity E. Lifestyle

The correct answer is E. This patient's lack of exercise and sedentary job are risk factors. Age becomes a risk factor over age 55 for women and 45 for men. The family history becomes a risk factor if a first degree relative has CHD male <55 and female <65. Rheumatoid arthritis is not a risk factor, and the patient is not obese.

Case 29: Question 5* Dr. Rodriquez, your family medicine preceptor, is giving a talk about ways to prevent delirium in patients during their hospital stay. What did she most likely suggest? A. Only allow the patients visitors to come at night B. Give diazepam every six hours C. Keep the patient in restraints D. Keep the patients room quiet E. Keep the patients room well lit

The correct answer is E. Keep the patients room well lit Stimulation such as a well lit room with activity has been shown to decrease delirium in hospitals. Limiting visitors and keeping the room quiet could increase the risk of delirium. Benzodiazepines such as diazepam can bring on delirium.

Case 29: Question 2* Ms. Brady, a 78-year-old female prevents to your office after six months for follow-up. Her interval history is significant for a TIA three months ago. Today her MMSE is 19. You note that six months ago her MMSE was 22 and nine months ago it was 26. Physical exam shows temperature of 98.8 Fahrenheit, blood pressure of 167/95 mmHg, heart rate of 76 beats/minute, and respiratory rate of 14 breaths/minute. Chest: regular rate and rhythm, no murmurs. Lungs: clear to auscultation. Neuro: weakness in the right upper extremity. Abdomen: soft, non-tender. She takes atorvastatin and aspirin. Lab studies show Hgb A1c: 5, TSH: 3, B12: 500 pg/mL. Which of the following is the most important recommendation to prevent further disability in this patient? A. Nothing can be done B. Start metformin C. Start vegetarian diet D. Weight loss E. Start hydrochlorothiazide

The correct answer is E. Start Hydrochlorothiazide To prevent additional TIAs and stroke, her blood pressure needs to be controlled. Hydrochlorothiazide is a reasonable first line medication.

Mr. Roberts is a 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension who presents lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of symptoms he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. Vital signs are temperature 100.2 F, blood pressure 135/75, pulse 76/min, and respiratory rate 15/min. Given this history, which of the following physical exam maneuvers are most helpful in making the diagnosis? Select all that apply. A. Abdominal palpation B. Costovertebral angle percussion C. Straight leg test D. Digital rectal exam E. Pinprick sensation of the legs

The correct answers are B and D. In an older male patient, prostatitis may present with low back pain. This patient's symptoms-general malaise, chills, hesitancy and pain on urination-and signs (fever) suggest acute bacterial prostatitis. Patients with acute bacterial prostatitis will often have exquisite tenderness over the prostate on rectal exam. This patient could also have pyelonephritis, which often goes along with costovertebral angle tenderness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The correct answer is: E. Age-appropriate development

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

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

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

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

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

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

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

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

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

The correct answer is: A. Primary hypertension

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

The correct answer is: A. Wilms' tumor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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