CME qstns Set 3

In patients with COPD, which one of the following inhaled medications has been shown to reduce exacerbations and exacerbation-related hospitalizations? (check one) A. Albuterol (Proventil, Ventolin) B. Fluticasone (Flovent) C. Ipratropium (Atrovent) D. Salmeterol (Serevent) E. Tiotropium (Spiriva)

A Cochrane review found that the long-acting antimuscarinic agent tiotropium improved quality of life and reduced exacerbations and exacerbation-related hospitalizations in patients with underlying COPD. Tiotropium was noted to be superior to long-acting β-agonists such as salmeterol. Albuterol, fluticasone, and ipratropium have not been shown to have these effects (SOR A). Ref: Chong J, Karner C, Poole P: Tiotropium versus long-acting β-agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012;(9):CD009157. 2) Karner C, Chong J, Poole P: Tiotropium versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014;(7):CD009285.

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

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

A 32-year-old Yazidi female from Iraq is brought to your office to establish care. She is a refugee who was relocated 2 weeks ago. Which one of the following would be appropriate at this visit? (check one) A. Having a family member who speaks English serve as an interpreter B. Screening for posttraumatic stress disorder C. Hepatitis B vaccine D. Varicella vaccine

A full history and physical examination are indicated for all refugees within 30 days of arrival in the United States, with a professional medical interpreter if needed (SOR C). In addition to addressing medical needs, the focus should be on emotional support and barriers to health care access (SOR C). All refugees should be screened for depression, anxiety, and posttraumatic stress disorder (SOR C). They should also be screened for anemia, hypertension, impaired fasting glucose, nutritional deficiencies, tuberculosis, and COPD (SOR C). If there is no vaccination documentation, routine vaccines should be provided except for varicella and hepatitis B. Serology should be performed before these vaccines are administered (SOR C).

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

A history of an ischemic stroke within the past 3 months is an absolute contraindication to fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI), unless the stroke is diagnosed within 4½ hours. Poorly controlled hypertension, dementia, peptic ulcer disease, and major surgery less than 3 weeks before the STEMI are relative contraindications that should be considered on an individual basis.

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

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

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

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

Laboratory FindingsFasting glucose 92 mg/dLTotal cholesterol 190 mg/dLLDL-cholesterol 98 mg/dLHDL-cholesterol 50 mg/dLTriglycerides 145 mg/dLHis calculated 10-year risk for cardiovascular disease is 5.4%. Which one of the following has the best evidence to prevent cardiovascular disease in a patient such as this? (check one) A. Moderate-intensity exercise, 150 minutes weekly B. A low-dose statin C. Aspirin, 81 mg daily D. Fish oil supplements E. Niacin supplements

A systematic evidence review released by the U.S. Preventive Services Task Force (USPSTF) noted that the most active people had median cardiovascular risk reductions of about 30%-35% when compared with the least active. Statins are beneficial for both primary and secondary prevention of cardiovascular disease, but the benefit is greater when the baseline risk is greater. Current guidelines would not support statin therapy for a patient with a 10-year risk of atherosclerotic cardiovascular disease (ASCVD) <5%. Fish oil supplements have not proven to be useful for primary prevention of ASCVD. Aspirin is recommended for the prevention of cardiovascular disease in adults 50-59 years of age with a >10% 10-year ASCVD risk who are not at increased risk of bleeding, are expected to live at least 10 years, and are willing to take low-dose daily aspirin for 10 years (USPSTF B recommendation). Niacin is no longer recommended for cardiovascular risk reduction due to a lack of evidence for benefit.

A 72-year-old male with type 2 diabetes mellitus sees you for routine follow-up. He takes metformin (Glucophage), 1000 mg twice daily. He is sedentary and does not adhere to his diet. His BMI is 32 kg/m2. The examination is otherwise within normal limits. His hemoglobin A1c is 9.5%. Which one of the following is recommended by the American Diabetes Association to better control his blood glucose? (check one) A. Start an intensive diet and exercise program for weight loss B. Start home monitoring of blood glucose with close follow-up C. Start basal insulin at 10 units/day D. Stop metformin and start a sulfonylurea E. Stop metformin and start a basal and bolus insulin regimen

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

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

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

Which one of the following is the most reliable measure to protect children from lead toxicity in the United States? (check one) A. Anticipatory guidance for parents and caregivers during well child visits B. Checking the serum lead level after a known exposure C. Eliminating the sources of lead in the community D. Iron and calcium supplementation to reduce lead absorption E. Providing appropriate cleaning equipment to families with known lead in the home

Although lead poisoning in children has decreased over the past few decades it is still a problem in the pediatric population. The most reliable and cost-effective way to protect U.S. children from lead toxicity is primary prevention, which includes reducing or eliminating the sources of lead in the community. Checking serum lead levels after exposures, anticipatory guidance regarding hand washing or dust control, iron and calcium supplementation, and providing cleaning equipment have been shown to have either little or no effect, or they address high lead levels only after the lead poisoning has occurred.

At what age should a patient at average risk be switched from a universal screening strategy for colon cancer to a more individualized strategy? (check one) A. 45 B. 55 C. 65 D. 75 E. 85

Although national guidelines vary, it is generally advised to start routine colon cancer screening between ages 45 and 50, and to screen with a more individualized approach between ages 75 and 85. Factors to consider include life expectancy, the patient's overall health, whether the patient has been screened previously, and patient preference. Most guidelines recommend stopping colon cancer screening in patients older than 85 years or when their life expectancy falls below 10 years (SOR B).

An otherwise healthy 64-year-old male comes to your office accompanied by his wife because of tinnitus that has affected both ears for the last 3 years. It has been most troublesome at bedtime. His wife says that he is becoming irritable and depressed because he is bothered by the buzzing in his ears many times during the day. His only medication is allopurinol (Zyloprim) for the prevention of gout. The most likely identifiable cause of this patient's tinnitus is (check one) A. medication B. Meniere's disease C. temporomandibular joint dysfunction D. sensorineural hearing loss E. impacted cerumen

Although tinnitus is idiopathic, sensorineural hearing loss is the most common identified cause. It can also be caused by other otologic, vascular, neoplastic, neurologic, pharmacologic, dental, and psychological factors. Almost all patients with tinnitus should undergo audiometry with tympanometry, and some patients require neuroimaging or assessment of vestibular function with electronystagmography. Counseling may also improve the chances of successful subsequent treatment. Several medications can cause tinnitus, but allopurinol is not one of them.

A 36-year-old female presents with a 10-year history of daily headaches. The headaches are bilateral, have a pressure and tightening quality, and are not aggravated by activity. They tend to worsen as the day progresses. There is no associated prodrome, nausea, or sensitivity to light or noise. A neurologic examination is normal.Which one of the following has been shown to reduce the severity and duration of this type of headache? (check one) A. Amitriptyline B. OnabotulinumtoxinA (Botox) C. Propranolol D. Sertraline (Zoloft) E. Topiramate (Topamax)

Amitriptyline may reduce headache duration and severity compared with placebo for chronic tension-type headaches (SOR B). SSRIs have no proven benefit for headache prophylaxis over placebo or tricyclic antidepressants in patients with chronic daily headaches. Propranolol reduces the frequency of migraine headaches, although its effectiveness for chronic migraine is unclear. Propranolol is not effective for tension headaches. Topiramate can reduce the frequency of chronic migraine headaches by 50% but is not effective for tension-type headaches. OnabotulinumtoxinA has been shown to reduce headache frequency in chronic migraine, but evidence of its effectiveness is lacking for chronic tension-type headaches.

Which one of the following is most commonly associated with oligohydramnios? (check one) A. Anencephaly B. Esophageal atresia C. Hydrops D. Maternal α-thalassemia E. Posterior urethral valves

Amniotic fluid volume is regulated in part by fetal swallowing, inspiration, and urination. Some malformations of the urinary tract, including renal agenesis and persistent obstruction from posterior urethral valves, lead to oliguria or anuria, and are associated with marked oligohydramnios. Anencephaly, esophageal atresia, heart failure, and maternal α-thalassemia are associated with polyhydramnios. Anencephaly is probably the most common cause of polyhydramnios, via transudation from the exposed meninges; swallowing difficulties and excessive urination may also be contributing factors. Esophageal atresia is almost always associated with polyhydramnios due to an inability to swallow. Intrauterine heart failure, whether due to dysrhythmias, structural defects, or severe anemia, often leads to fetal hydrops, which is associated with polyhydramnios. α-Thalassemia, relatively common in Asians, can also cause fetal hydrops and polyhydramnios.

A 35-year-old male has a negative past medical history and a normal physical examination. He reports that he smokes half a pack of cigarettes per day and has 3-4 beers per week. A comprehensive metabolic panel reveals an ALT (SGPT) of 30 U/L (N 10-40) and an AST (SGOT) of 84 U/L (N 10-30). The remaining laboratory studies are negative. There is no family history of liver disease. The laboratory findings suggest which one of the following? (check one) A. Hepatitis C B. Hemochromatosis C. Gilbert syndrome D. Alcoholic liver disease E. Nonalcoholic liver disease

An AST (SGOT) to ALT (SGPT) ratio greater than 2:1 suggests alcoholic liver disease, and a ratio of 3:1 or higher is highly suggestive of alcoholic liver disease. With most hepatocellular disorders, including nonalcoholic fatty liver disease, viral hepatitis, and iron overload disorder, the patient will have an AST to ALT ratio <1.

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

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

Acne appearing at which one of the following ages should prompt detailed endocrine laboratory testing for possible underlying systemic disease? (check one) A. 3 weeks B. 7 months C. 5 years D. 9 years E. 13 years

As many as 20% of newborns will be affected by neonatal acne, usually in the form of pustules confined to the cheeks, chin, eyelids, and forehead. This is typically mild, self-limited, and best managed by reassuring the parents. Acne can also appear in infants, typically males 6-12 months of age, and is also usually self-limited and not associated with underlying endocrine pathology in the absence of any other findings suggesting hormonal abnormalities such as clitoromegaly, breast or testicular development, pubic hair growth, hirsutism, or a growth abnormality consistent with increased muscle development. Acne appearing during mid-childhood is rare and, if present, warrants referral for extensive laboratory testing to identify an underlying endocrine abnormality. Preadolescents and adolescents are very likely to develop acne as a result of normal ovarian/testicular development. In the absence of other findings to suggest an endocrine problem, developing an effective treatment regimen is most appropriate for these individuals.

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

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

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

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

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

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

In a 60-year-old patient who has not previously received pneumococcal vaccine, which one of the following would be an indication for both 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23)? (check one) A. Alcoholism B. Chronic renal failure C. Cigarette smoking D. COPD E. Diabetes mellitus

Both 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) are recommended for patients with chronic renal failure. Indications for PPSV23 alone in immunocompetent persons younger than 65 include chronic lung disease, diabetes mellitus, chronic heart disease, smoking, and alcoholism.

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

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

A 30-year-old female presents for follow-up after an emergency department visit for an episode of symptomatic supraventricular tachycardia that was diagnosed as Wolff-Parkinson-White syndrome. Which one of the following would be most appropriate for the initial long-term management of this patient? (check one) A. Adenosine (Adenocard) B. Amiodarone (Cordarone) C. Diltiazem (Cardizem) D. Metoprolol E. Catheter ablation

Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White syndrome (WPW). Catheter ablation has a very high immediate success rate (96%-98%). The most significant risk associated with the procedure is permanent atrioventricular block, which occurs in approximately 0.4% of procedures. Adenosine and amiodarone are used for the acute management of supraventricular tachycardia, but not for long-term management. Node-blocking medications such as diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk of ventricular fibrillation.

A 62-year-old female with stage 3 chronic kidney disease and an estimated glomerular filtration rate of 37 mL/min/1.73 m2 is found to have a mildly low ionized calcium level. Which one of the following would you expect to see if her hypocalcemia is secondary to her chronic kidney disease? (check one) A. Elevated parathyroid hormone (PTH) and elevated phosphorus B. Elevated PTH and low phosphorus C. Low PTH and elevated phosphorus D. Low PTH and low phosphorus

Chronic kidney disease-mineral and bone disorder (CKD-MBD) is found in many patients with CKD andis associated with an increased risk of bone fractures and cardiovascular events due to vascular calcification. In patients with CKD, phosphate is not appropriately excreted and the subsequent hyperphosphatemia leads to secondary hyperparathyroidism and binding of calcium. Decreased production of calcitriol in patients with CKD also leads to hypocalcemic hyperparathyroidism. Patients with CKD stages 3a-5 should have phosphorus, calcium, parathyroid hormone, and 25-hydroxyvitamin D levels checked regularly, and consultation with a nephrologist or endocrinologist should be obtained if CKD-MBD is suspected.

You see a 47-year-old female for follow-up of a rash. She is a carpenter and was seen 4 days ago for increasing redness and tenderness of her anterior shin after hitting the area with a board 3 days earlier. She was afebrile during that visit and the area was red but not fluctuant. She chose observation rather than treatment at that time. The patient smokes 10 cigarettes daily. Past medical, surgical, and family histories are otherwise negative. Screening for diabetes mellitus was normal last year. Today the patient's anterior shin is still tender. She is afebrile and other vital signs are unremarkable. The extent of the infection was drawn 4 days ago with an indelible marker by your partner. Currently the area of redness extends beyond this border. There is no fluctuance or drainage of the wound. The skin appears mildly indurated. Which one of the following would be best to provide coverage against Streptococcus pyogenes or methicillin-resistant Staphylococcus aureus (MRSA) in this patient? (check one) A. Amoxicillin/clavulanate (Augmentin) and ciprofloxacin (Cipro) B. Cephalexin and dicloxacillin C. Dicloxacillin and fosfomycin (Monurol) D. Doxycycline and trimethoprim/sulfamethoxazole (Bactrim) E. Trimethoprim/sulfamethoxazole and cephalexin

Clindamycin or a combination of trimethoprim/sulfamethoxazole (or doxycycline or minocycline) plus cephalexin (or dicloxacillin or amoxicillin/clavulanate) should provide adequate coverage for Streptococcus and methicillin-resistant Staphylococcus aureus (MRSA) for mild to moderate cellulitis. Doxycycline plus trimethoprim/sulfamethoxazole would provide inadequate coverage for streptococcal bacteria. Cephalexin plus dicloxacillin would provide inadequate coverage for MRSA. The primary indication for ciprofloxacin is treatment of infections with gram-negative rods. Fosfomycin is indicated only for urinary tract infections. Neither is typically used in the treatment of cellulitis.

Which one of the following is the most appropriate psychotherapy for patients with obsessive-compulsive disorder? (check one) A. Traditional psychotherapy B. Cognitive-behavioral therapy C. Psychoanalysis D. Psychodynamic therapy

Cognitive-behavioral therapy, specifically exposure and response prevention, is considered the most effective psychotherapy method (SOR A). There is no evidence for psychodynamic or "talk" therapy. Traditional psychotherapy and psychoanalysis are less effective than cognitive-behavioral therapy.

A 36-year-old female singer presents with a 10-day history of hoarseness. She has never smoked and does not take any medications. Her vital signs are normal. An oropharyngeal examination is normal, her chest is clear to auscultation, and there is no cervical adenopathy and no masses. She is anxious to be able to sing again as soon as possible. Which one of the following would you advise at this time? (check one) A. No talking, whispering, or throat clearing for 48 hours B. No singing or loud talking for 5-7 days C. Nebulized hypertonic saline treatments 3 times daily for 2-3 days D. Nebulized ribavirin twice daily for 3 days E. Inhaled corticosteroids twice daily for 5 days

Complete vocal rest, including no whispering or throat clearing, is the most effective and quickest initial remedy for short-duration laryngitis, whether viral or due to vocal overuse or abuse. Limiting voice use or whispering, as opposed to complete vocal rest, will likely prolong and possibly worsen hoarseness. Clearing the throat of mucus should also be avoided for the same reason. Inhaled corticosteroids and antibiotics are not effective treatments for laryngitis. Hypertonic saline nebulization treatments would likely cause violent coughing fits that would worsen the condition. Nebulized ribavirin is never indicated for use in adults.

You see a 58-year-old female who received a drug-eluting stent 10 days ago during a hospitalization for acute coronary syndrome and coronary artery disease. She asks for recommendations about anticoagulation. You determine that she is not at high risk for bleeding. Which one of the following would you recommend? (check one) A. Long-term aspirin use B. Clopidogrel (Plavix) and aspirin for 30 days and then aspirin alone C. Clopidogrel alone for 1 year and then aspirin alone D. Clopidogrel and aspirin for 1 year and then aspirin alone E. Prasugrel (Effient) for 1 year with no anticoagulation after that

Coronary artery stenting is a common procedure, and stent restenosis carries a high mortality rate. Current American College of Cardiology guidelines recommend dual antiplatelet therapy (aspirin with a second agent such as clopidogrel) for at least 12 months following the placement of a drug-eluting stent. Dual antiplatelet therapy with aspirin plus clopidogrel for more than 1 year gives no additional benefit and carries an additional risk of bleeding. Aspirin has been shown to be effective for the secondary prevention of heart disease and should be continued after 1 year.

A 52-year-old pianist is concerned that she may have carpal tunnel syndrome. Which one of the following would be consistent with this problem? (check one) A. Weakness of thumb adduction B. Decreased sensation over the thenar eminence C. Decreased sensation over the dorsal aspect of the fourth finger D. Decreased sensation over the dorsal aspect of the fifth finger E. Decreased sensation over the palmar aspect of the thumb, index, and middle finger

Correct Carpal tunnel syndrome is the most common entrapment neuropathy of the upper extremity. It is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with this condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index, and middle fingers, and the radial half of the ring finger. In more severe cases motor fibers are affected, leading to weakness of thumb abduction and opposition. Sensation over the thenar eminence should be normal in patients with carpal tunnel syndrome because it is in the distribution of the palmar cutaneous branch of the median nerve, which branches off proximal to the carpal tunnel.

A 67-year-old female who was recently diagnosed with colon cancer presented to the emergency department 2 days ago with acute shortness of breath and was diagnosed with a pulmonary embolism. She was started on enoxaparin (Lovenox) and was hemodynamically stable during her stay in the hospital. Her shortness of breath has improved and her oxygen saturation is currently 95% on room air. Which one of the following would be most appropriate for this patient? (check one) A. Continue enoxaparin upon discharge B. Discontinue enoxaparin and start rivaroxaban (Xarelto) C. Discontinue enoxaparin and start warfarin (Coumadin) D. Start warfarin and continue enoxaparin until the INR is 2.0

Correct Enoxaparin and other low molecular weight heparins are effective and are the preferred agents for acute and long-term anticoagulation in patients with an active malignancy (SOR B). Warfarin has been shown to be less effective in cancer patients and is not recommended to treat venous thromboembolic disease in this setting (SOR B). The novel oral anticoagulants including rivaroxaban have not been studied in the setting of malignancy and are not recommended.

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

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

A 67-year-old female with hypertension and atrial fibrillation has been taking warfarin (Coumadin) for the past 10 years. She has been hemodynamically stable for many years with no complications from her atrial fibrillation. She is scheduled to undergo elective bladder sling surgery for urinary incontinence. She does not have any other significant past medical history. Which one of the following would be the most appropriate perioperative management of her warfarin? (check one) A. Continue warfarin without interruption B. Discontinue warfarin the day prior to surgery and provide bridge therapy with low molecular weight heparin C. Discontinue warfarin 2 days prior to surgery and restart it 2 days postoperatively unless there is a bleeding complication D. Discontinue warfarin 2 days prior to surgery and restart it 5 days postoperatively unless there is a bleeding complication E. Discontinue warfarin 5 days prior to surgery and restart it 12-24 hours postoperatively unless there is a bleeding complication

Correct Perioperative management of chronic anticoagulation requires an assessment of the patient's risk for thromboembolism and the risk of bleeding from the surgical procedure. High-risk patients include those with mechanical heart valves, a stroke or TIA within the past 3 months, venous thromboembolism within the past 3 months, or coronary stenting within the previous 12 months. High-risk patients require bridging therapy with low molecular weight heparin, while patients at low risk do not require bridging anticoagulation. For low-risk patients, it is recommended that warfarin be discontinued 5 days prior to surgery and restarted 12-24 hours postoperatively. This patient is at low risk for thromboembolism because her CHA2DS2-VASc score is 3. A patient with atrial fibrillation should receive bridging therapy with a CHA2DS2-VASc score 6. This patient's surgery is associated with a high risk for bleeding, so it is preferable to stop her warfarin 5 days before the operation.

A 48-year-old female smoker presents with solid, but not liquid, dysphagia that causes her to feel as if food is "getting stuck." She sometimes regurgitates this food. When you ask her where it feels like the food is sticking she points to a location below the suprasternal notch. The most appropriate next step is (check one) A. a fluoroscopic swallowing study B. barium radiography C. CT of the chest D. endoscopy E. esophageal manometry

Correct Solid but not liquid dysphagia suggests a structural lesion. A location in the chest indicates esophageal dysphagia. Endoscopy is the single most useful test for esophageal dysphagia and can visualize mucosal lesions better than barium radiography. Therapy can also be performed during the procedure. A fluoroscopic swallowing study would be indicated if the patient's history pointed to oral or pharyngeal dysphagia. Even if it is thought that the dysphagia is caused by a motility disorder, endoscopy is still preferred, because neoplastic and inflammatory conditions can produce spasm and motility symptoms. Manometry can be performed if endoscopy does not adequately explain the symptoms.

A 25-year-old gravida 1 para 0 at 24 weeks gestation comes to your office with right lower extremity swelling and pain. Her pregnancy has been uncomplicated so far and her only medication is a prenatal vitamin. She does not have chest pain, shortness of breath, or fever. She recently started feeling the baby move, and an anatomy scan at 20 weeks gestation was normal. Lower extremity Doppler ultrasonography confirms a right lower extremity deep vein thrombosis (DVT). Laboratory studies including a CBC, coagulation studies, and renal function are normal. Which one of the following would be the most appropriate initial treatment of her DVT? (check one) A. Oral apixaban (Eliquis) B. Oral aspirin C. Oral warfarin (Coumadin) D. Subcutaneous enoxaparin (Lovenox) E. Subcutaneous heparin

D. Subcutaneous enoxaparin (Lovenox)

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

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

A 62-year-old female comes to your office for evaluation of pain in her right thumb and wrist associated with sewing. She does not have any injury, numbness, tingling, or weakness. An examination reveals an otherwise healthy-appearing female with normal vital signs and no deformity or swelling in her wrists or hands. She has tenderness to palpation at the first dorsal compartment over the radial styloid and has pain with active and passive stretching of the thumb tendons over the radial styloid. She is very worried that she will have to stop sewing and asks if there is anything she could try to alleviate her symptoms. Which one of the following would be most appropriate at this point? (check one) A. Reassurance that it will likely improve on its own within about a year B. A corticosteroid injection into the first extensor compartment C. Immobilization in a thumb spica splint and an NSAID for 1-4 weeks D. Radiographs of the thumb and wrist E. Referral to an orthopedic surgeon

De Quervain's tenosynovitis usually occurs with repeated use of the thumb and is characterized by pain in the radial wrist. The course is typically self-limited but can last for up to a year, so waiting would not be a good option for this patient who wants to continue her usual activities as soon as possible. Conservative therapy with immobilization and NSAIDs is recommended if there are no contraindications to NSAIDs. A corticosteroid injection is helpful but is typically reserved for severe cases or if conservative therapy fails. Surgery may be beneficial but is generally not recommended unless the course is severe, given the natural history of resolution.

A 58-year-old male sees you for follow-up of diabetic gastroparesis. He has tried managing his symptoms with more frequent meals and taking in more calories in semisolid or liquid form. These approaches have been unsuccessful in controlling his symptoms and he would like to try a medication. Which one of the following would be considered first-line pharmacotherapy for this patient? (check one) A. Metoclopramide (Reglan) B. Nortriptyline (Pamelor) C. Omeprazole (Prilosec) D. Ondansetron (Zofran) E. Ranitidine (Zantac)

Diabetic gastroparesis is a delay in the emptying of food from the upper gastrointestinal tract in the absence of a mechanical obstruction of the stomach or duodenum. Metoclopramide is the only prokinetic agent that has been studied specifically for long-term use in gastroparesis and is considered first-line therapy (SORB). It is among the only FDA-approved medications for gastroparesis. Nortriptyline is a prokinetic agent but has not been shown to be more effective than placebo for decreasing gastroparesis symptoms. Proton pump inhibitors such as omeprazole, histamine H2-receptor antagonists such as ranitidine, and ondansetron delay gastric emptying and should be withheld in patients with gastroparesis whenever possible.

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

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

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

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

A 36-year-old male presents with a 2-day history of painless right-sided facial droop. There are no associated symptoms and his medical history is otherwise unremarkable. An examination is remarkable for an unfurrowed right brow, mouth droop, a sagging right lower eyelid, and a complete inability to move the muscles of the right face and forehead. No other weakness is elicited and no rash is seen. Which one of the following would be the most appropriate management at this point? (check one) A. Reassurance only B. Valacyclovir (Valtrex) alone C. A tapering dose of prednisone alone D. Valacyclovir and a tapering dose of prednisone E. Immediate transfer to the emergency department

Early recognition and effective treatment of acute Bell's palsy (idiopathic facial paralysis) has been shown to decrease the risk of chronic partial paralysis and pain. Corticosteroids have been shown in a meta-analysis to decrease chronic symptoms, but a Cochrane meta-analysis of 10 studies concluded that antiviral medication along with corticosteroids is significantly more effective than corticosteroids alone. The medications are most effective if started within 72 hours of symptom onset. The same analysis showed that antiviral medications alone were less effective than corticosteroids alone. This patient's presentation is not consistent with stroke or another emergency. Because supranuclear input to the facial nerves comes from both cerebral hemispheres, strokes and other central pathologies affecting the facial nerves typically spare the forehead, which is not the case in this patient.

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

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

The mother of a newborn infant is concerned because her baby's eyes are sometimes crossed. Assuming the intermittent eye crossing persists, which one of the following is the most appropriate age for ophthalmologic referral? (check one) A. 10-14 days B. 6 months C. 12 months D. 24 months

In many normally developing infants there may be imperfect coordination of eye movements and alignment during the early days and weeks of life, but proper coordination should be achieved by age 4-6 months. Persistent deviation of an eye in an infant requires evaluation.

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

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

A 38-year-old patient wishes to start contraception. She currently takes lisinopril (Prinivil, Zestril) for hypertension and also takes sumatriptan (Imitrex) occasionally for migraines at the first sign of flashing lights or zigzagging lines in her vision. Her medical, family, and social histories are otherwise unremarkable. An examination is notable only for a blood pressure of 130/80 mm Hg and a BMI of 36 kg/m2.The patient is interested in using either the vaginal ring or the contraceptive patch. Which one of the following would you recommend? (check one) A. Transdermal norelgestromin/ethinyl estradiol (Ortho Evra) B. The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) C. Neither method due to her migraines D. Neither method due to her age E. Losing weight before starting either method

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

A 68-year-old female sees you for a routine health maintenance visit. She feels well and says she has been eating more carefully and exercising for 45 minutes 4 days a week for the past 6 months. Her past medical history includes controlled hypertension and osteoarthritis of the knee. Her family history is notable for a myocardial infarction in her mother at 48 years of age. Her only medication is lisinopril (Prinivil, Zestril). The physical examination is notable only for a BMI of 36 kg/m2. Laboratory findings are notable for significant hyperlipidemia and you recommend starting a statin. She reports that she will undergo an elective total knee replacement next month and asks about the safety of starting a new medication before this surgery. You recommend that she (check one) A. start a statin immediately to decrease her risk of cardiovascular disease and perioperative mortality B. start a statin immediately to decrease her risk of cardiovascular disease, although her risk of perioperative mortality will not be affected C. start a statin immediately to decrease her risk of cardiovascular disease, stop the statin 1 week before surgery, and resume taking it after the surgery, to decrease her risk of perioperative mortality D. start a statin immediately after the surgery to decrease her risk of cardiovascular disease and perioperative mortality E. start a statin after she is released postoperatively by her surgeon to decrease her risk of cardiovascular disease and perioperative mortality

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

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

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

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

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

A 67-year-old female sees you because of a cough she has had for the past few days anda fever that started today. She is short of breath and generally does not feel well. She has no history of lung disease and is a nonsmoker. Her medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus, all of which are well managed with medications and diet. A physical examination reveals a mildly ill-appearing female with a temperature of 38.2°C (100.8°F), a pulse rate of 90 beats/min, a respiratory rate of 21/min, a blood pressure of 110/60 mm Hg, and an oxygen saturation of 98% on room air. Her heart has a regular rhythm and her respirations appear unlabored. She has rhonchi in the left lower lung field but has good air movement overall. A chest radiograph reveals a left lower lobe infiltrate. Which one of the following is the most appropriate setting for the management of this patient's pneumonia? (check one) A. Home with close monitoring B. An inpatient medical bed without telemetry monitoring C. An inpatient medical bed with telemetry monitoring D. An inpatient intensive care bed

For community-acquired pneumonia, an important decision point is the severity of illness that indicates the need for inpatient care. There are multiple tools for evaluation of pneumonia severity, including SMART-COP (predicts the likelihood of the need for invasive ventilation or vasopressor support), the Pneumonia Severity Index (predicts the risk of 30-day mortality and the need for admission to the intensive-care unit), and CURB-65 or CRB-65. In an outpatient setting, CURB-65 and CRB-65 are easy to use, although they have weaker predictive values for 30-day mortality. In addition, clinical judgment should always be used. In this scenario, the patient does not clinically appear markedly ill, and her vital signs and physical examination do not fit any criteria for increased risk in any of the scoring systems. Her only risk factor is age 65 years, and those with zero or one criteria for CURB-65 or CRB-65 can be managed as outpatients.

A 67-year-old female sees you because of a cough she has had for the past few days anda fever that started today. She is short of breath and generally does not feel well. She has no history of lung disease and is a nonsmoker. Her medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus, all of which are well managed with medications and diet. A physical examination reveals a mildly ill-appearing female with a temperature of 38.2°C (100.8°F), a pulse rate of 90 beats/min, a respiratory rate of 21/min, a blood pressure of 110/60 mm Hg, and an oxygen saturation of 98% on room air. Her heart has a regular rhythm and her respirations appear unlabored. She has rhonchi in the left lower lung field but has good air movement overall. A chest radiograph reveals a left lower lobe infiltrate. Which one of the following is the most appropriate setting for the management of this patient's pneumonia? (check one) A. Home with close monitoring B. An inpatient medical bed without telemetry monitoring C. An inpatient medical bed with telemetry monitoring D. An inpatient intensive care bed

For community-acquired pneumonia, an important decision point is the severity of illness that indicates the need for inpatient care. There are multiple tools for evaluation of pneumonia severity, including SMART-COP (predicts the likelihood of the need for invasive ventilation or vasopressor support), the Pneumonia Severity Index (predicts the risk of 30-day mortality and the need for admission to the intensive-care unit), and CURB-65 or CRB-65. In an outpatient setting, CURB-65 and CRB-65 are easy to use, although they have weaker predictive values for 30-day mortality. In addition, clinical judgment should always be used. In this scenario, the patient does not clinically appear markedly ill, and her vital signs and physical examination do not fit any criteria for increased risk in any of the scoring systems. Her only risk factor is age 65 years, and those with zero or one criteria for CURB-65 or CRB-65 can be managed as outpatients.

A 75-year-old white male presents to your office following hospitalization for an episode of heart failure. His edema has resolved but he still becomes symptomatic with minor exertion such as walking less than a block. A recent chest radiograph shows cardiomegaly, and echocardiography reveals an ejection fraction of 25%. He is currently taking furosemide (Lasix), 20 mg daily; carvedilol (Coreg), 25 mg twice daily; and lisinopril (Prinivil, Zestril), 20 mg daily. His vital signs include a pulse rate of 60 beats/min, a blood pressure of 110/70 mm Hg, a respiratory rate of 18/min, and a temperature of 37.0°C (98.6°F). No crackles or hepatojugular reflux are noted on auscultation. Which one of the following would improve this patient's symptoms and decrease his mortality risk? (check one) A. Digoxin B. Hydralazine and isosorbide dinitrate (BiDil) C. Hydrochlorothiazide D. Spironolactone (Aldactone)

For patients with left ventricular systolic dysfunction, clinical trials have demonstrated that ACE inhibitors, β-blockers, angiotensin receptor blockers, and aldosterone antagonists decrease hospitalizations and all-cause mortality. In African-American patients, all-cause mortality and hospitalizations have been reduced by hydralazine and isosorbide dinitrate. Aldosterone antagonists such as spironolactone, as well as β-blockers, decrease mortality in patients with symptomatic heart failure (SOR A). Digoxin improves symptoms of heart failure but does not improve mortality.

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

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

A 30-year-old male presents with intermittent right upper quadrant pain after meals. He has been in moderate pain for the past 3 hours. On examination the patient's vital signs are normal except for a temperature of 39.2°C (102.6°F). He appears toxic. Examination of the abdomen reveals a positive Murphy's sign. Laboratory Findings WBCs 3000/mm3 (N 4300-10,800) ALT (SGPT) 132 U/L (N 10-55) AST (SGOT) 123 U/L (N 9-25) Alkaline phosphatase 200 U/L (N 45-115) Bilirubin 2.6 mg/dL (N 0.0-1.0) Lipase 15 U/dL (N 3-19) Ultrasonography reveals cholelithiasis. Other findings include an enlarged gallbladder, thickening of the gallbladder wall, and a common bile duct diameter of 11 mm. Which one of the following is the most likely cause of this patient's symptoms? (check one) A. Acute cholangitis B. Acute viral hepatitis C. Cholangiocarcinoma D. Gallstone pancreatitis

Gallstones are often asymptomatic and found incidentally on imaging. However, they may become symptomatic, which usually causes pain in the right upper quadrant or epigastrium. Most patients with symptomatic gallstones present with chronic cholecystitis, which causes recurrent attacks of pain. The pain is constant, increases in severity at the beginning, and lasts from 1 to 5 hours. It often starts during the night after a fatty meal and may be associated with nausea and vomiting. Abdominal ultrasonography is the initial imaging method. The two main complications of choledochal stones are cholangitis and pancreatitis. Acute cholangitis is a bacterial infection. Bacterial growth is enhanced by obstruction of the duct. It may present as a mild self-limited disease but can also lead to sepsis. Cases typically present with fever, pain, and jaundice. Laboratory findings include an elevated WBC count and elevated bilirubin, transaminases, and alkaline phosphatase. Ultrasonography will show a dilated bile duct in many cases, although it might not be dilated in acute obstruction. Patients with pancreatitis present with pain, nausea, and vomiting. The pain is usually epigastric and radiates to the back. It reaches its maximum intensity within 1 hour and may last for days. The physical examination may reveal tachycardia, hypotension, tachypnea, and fever. The abdomen may be distended and is typically tender to palpation. The diagnosis requires two of three primary features: abdominal pain, elevation of serum amylase or lipase, and findings on imaging studies that are consistent with the diagnosis. Ultrasonography can show pancreatic enlargement or edema, and visualization of gallstones will suggest choledocholithiasis as the cause of the pancreatitis.

A 25-year-old female was involved in a motor vehicle accident 2 weeks ago. A chest radiograph to assess for rib fractures revealed bilateral hilar lymphadenopathy. She thinks that her mother had a similar finding when she was younger. Records from the emergency department reveal that a CBC, comprehensive metabolic panel, and urinalysis were all normal. The patient has never been sexually active, does not take any medications, and does not smoke or use any illicit drugs. Her rib pain has since resolved and she has no other symptoms. She does not have a cough, dyspnea, weight loss, or skin lesions. Spirometry in the office today is normal. Which one of the following would be the most appropriate next step? (check one) A. A follow-up visit and a repeat chest radiograph in 6 months B. Oral prednisone, 40 mg daily for 4 weeks C. CT of the chest, abdomen, and pelvis D. Formal pulmonary function tests E. Referral for bronchoscopy with a biopsy

Given this patient's age, lack of symptoms, and possible family history, the presence of asymptomatic bilateral hilar lymphadenopathy most likely represents stage 1 pulmonary sarcoidosis. Because the patient does not have any symptoms and stage 1 sarcoidosis resolves in most cases, the most prudent course is to reevaluate her in 6 months with a careful history, a physical examination, and a chest radiograph. Given the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a lung biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but would be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.

Referral for bariatric surgical evaluation is indicated for patients with a BMI of (check one) A. 35 kg/m2 and mild cognitive impairment B. 36 kg/m2 and type 2 diabetes mellitus C. 37 kg/m2 and no other medical problems D. 40 kg/m2 and active alcohol abuse E. 42 kg/m2 and uncontrolled schizophrenia

Inclusion criteria for bariatric surgery include a BMI 40 kg/m2 without coexisting medical problems or a BMI 35 kg/m2 with one or more severe obesity-related comorbidities such as diabetes mellitus. Exclusion criteria include active substance abuse, uncontrolled severe psychiatric illness, severe cardiopulmonary disease that makes the surgical risk prohibitive, and lack of cognitive function to comprehend the associated risks, benefits, and required lifestyle changes.

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

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

You are reviewing the home health care progress report of a 68-year-old female who was hospitalized with pneumonia 2 months ago. The patient moved to the area to live with her daughter following treatment for breast cancer 5 years earlier. Before the hospitalization her only medical needs had been for preventive services, treatment for hypertension, and surveillance for problems related to her chemotherapy and for return of her cancer. During the recent hospitalization oxygen supplementation was required to maintain healthy oxygen saturation levels, and after failing several attempts at weaning, home oxygen service was arranged. You ask the home health nurse to test the patient's oxygen saturation after 1 hour on room air and the nurse reports that the patient's oxygen saturation is now consistently above 90% on room air. The care plan provided by the home health service includes a recommendation for the continuation of supplemental oxygen. Which one of the following would be most appropriate for this patient? (check one) A. Order arterial blood gas studies to confirm her oxygenation status B. Discontinue oxygen supplementation C. Discontinue daytime use of oxygen and continue nighttime oxygen D. Continue oxygen use, but only as needed when short of breath E. Continue oxygen use to obtain a saturation >92% on room air

Hypoxemia following an acute illness is often short-lived and as many as half the patients prescribed home oxygen on discharge from the hospital will not meet criteria supporting continuation after 3 months. For this group of patients there is no apparent benefit derived from supplemental oxygen once their oxygen saturation is 88% or greater on room air. Potential harmful effects of continuing unnecessary home oxygen include decreased mobility, falls, house fires, and mucosal irritation, and oxygen toxicity must be considered as well. Continuing home oxygen beyond what is needed also results in a misallocation of resources. According to the American Thoracic Society and the American College of Chest Physicians, prescriptions for supplemental home oxygen should not be renewed for patients who have recently been hospitalized for acute illnesses without assessing them for ongoing hypoxemia.

A 27-year-old female with a past medical history of polycystic ovary syndrome (PCOS) would like to become pregnant. Which one of the following treatments for PCOS is associated with greater live-birth and ovulation rates? (check one) A. Finasteride (Proscar) B. Letrozole (Femara) C. Metformin (Glucophage) D. Spironolactone (Aldactone)

In a double-blind randomized trial, letrozole was associated with greater live-birth and ovulation rates compared to clomiphene (SOR A). A Cochrane review indicated that metformin does not increase fertility in patients diagnosed with polycystic ovary syndrome (PCOS). Spironolactone and finasteride are both used to treat PCOS in women who do not desire pregnancy.

In a patient presenting with truncal obesity, hypertension, type 2 diabetes mellitus, hirsutism, osteopenia, and skin fragility, which one of the following tests is needed to confirm the diagnosis of Cushing syndrome? (check one) A. A dexamethasone suppression test B. Inferior petrosal sinus sampling C. Plasma corticotropin D. Plasma free cortisol E. Urinary free cortisol

In a patient presenting with obesity, hypertension, type 2 diabetes mellitus, and hirsutism, who also has thin skin and osteopenia, an elevated 24-hour collection showing high urinary free cortisol confirms the presence of Cushing syndrome. The dexamethasone suppression test, though still commonly used, no longer has a place in the diagnosis and treatment of patients with Cushing syndrome. Corticotropin-dependent and corticotropin-independent causes of Cushing syndrome can be separated by measuring plasma corticotropin. Plasma free cortisol measurements should be obtained only to determine the success or failure of transsphenoidal microadenomectomy or adrenalectomy. Inferior petrosal sinus sampling is used to confirm the source of corticotropin secretion before surgical intervention.

The preferred antibiotic treatment for community-acquired pneumonia in a young adult in the ambulatory setting is: (check one) A. trimethoprim/sulfamethoxazole (Bactrim, Septra) B. cephalexin (Keflex) C. azithromycin (Zithromax) D. penicillin V E. ciprofloxacin (Cipro)

In a young adult with community-acquired pneumonia who is not sick enough to be hospitalized, the current recommendation is to empirically treat with a macrolide antibiotic such as azithromycin. This covers the atypical organism Mycoplasma pneumoniae, which is one of the most common causes of community-acquired pneumonia. Certain fluoroquinolones such as levofloxacin also cover atypical causes, but ciprofloxacin does not. The other antibiotics listed are also ineffective against Mycoplasma.

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

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

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

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

A 57-year-old female is admitted to the hospital with lower lobe pneumonia. She has no history of diabetes mellitus. She has not met sepsis criteria but had a blood glucose level of 172 mg/dL in the emergency department. Insulin should be started if this patient has a persistent blood glucose level greater than or equal to (check one) A. 120 mg/dL B. 140 mg/dL C. 160 mg/dL D. 180 mg/dL

Insulin therapy should be initiated in hospitalized patients with persistent hyperglycemia, starting at a threshold of 180 mg/dL. Once insulin therapy is started, a target glucose range of 140-180 mg/dL is recommended for the majority of hospitalized patients, regardless of whether they have a critical illness.

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

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

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

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

A 50-year-old male with hypertension who is not at increased risk for gastrointestinal bleeding should begin low-dose aspirin at what 10-year risk level for cardiovascular disease? (check one) A. 1% B. 7.5% C. 10% D. 15% E. 20%

Low-dose aspirin therapy is recommended by the U.S. Preventive Services Task Force for the primary prevention of cardiovascular disease (CVD) in patients 50-59 years of age who have a risk of CVD 10% (USPSTF B recommendation). The recommendation statement adds that the patient should have a life expectancy of at least 10 years, should be willing to take daily aspirin for at least 10 years, and should not be at increased risk for gastrointestinal bleeding. The decision to start aspirin therapy for patients 60-69 years of age should be based on individual considerations (USPSTF C recommendation). For adults younger than 50 or age 70 or older, the evidence is insufficient to assess the balance of benefits and harms (C recommendation). The recent Aspirin in Reducing Events in the Elderly (ASPREE) trial indicated that daily aspirin use in those over age 70 did not significantly lower the risk of cardiovascular disease, and did not increase disability-free survival.

A 54-year-old female sees you for a wellness examination. Her last screening mammography 10 years ago revealed dense breasts but was otherwise normal. A past history of which one of the following would indicate the need for MRI of the breasts? (check one) A. Very dense breasts B. Morbid obesity C. Combination estrogen/progesterone therapy for the last 3 years D. Chest radiation for Hodgkin's disease E. Radioiodine treatment for Graves disease

MRI of the breasts should be reserved for women at very high risk for breast cancer such as those with genetic mutations, a history of breast irradiation, or a very high-risk family history. Women who had chest radiation therapy during childhood or adolescence, generally for Hodgkin's disease, are at an extremely high risk for breast cancer.

A 75-year-old patient is admitted to the hospital. The Joint Commission National Patient Safety Goals program requires medication reconciliation for this patient both on admission and at the time of discharge. The primary intent of this reconciliation is to detect (check one) A. potentially inappropriate medication use in the elderly B. high-risk medication use C. medication discrepancies D. polypharmacy E. adverse drug effects

Maintaining and communicating accurate patient medication information is one of the goals of the Joint Commission National Patient Safety Goals program. This includes medication reconciliation, which is intended to identify and resolve discrepancies. In this process, a clinician compares the medications a patient should be using and is actually using with the new medications that are ordered. While adverse drug effects, potentially inappropriate medication use in the elderly, high-risk medication use, or polypharmacy might also occur and might be beneficial to address, these are not the primary focus of medication reconciliation.

A 15-year-old male sees you after injuring his right index finger while playing volleyball. He has pain and a flexion deformity at the distal interphalangeal (DIP) joint. Which one of the following would be an indication for further evaluation before splinting? (check one) A. The patient wants to continue athletic activities B. The patient first presented for treatment 3 weeks after the injury C. The patient is unable to passively fully extend the joint D. an oral syringe E. A radiograph shows a bony avulsion of 10% of the joint space

Mallet finger, an injury to the distal extensor tendon of the finger at the distal interphalangeal (DIP) joint, is usually caused by forceful flexion of an extended DIP joint. This is frequently the result of being struck by an object such as a ball. The inability to actively extend the DIP joint is a hallmark of mallet finger. The inability to passively extend the DIP joint completely may be an indication of trapped soft tissue or bone that may require surgery. Up to one-third of distal extensor tendon injuries are associated with an avulsion fracture, and if the avulsion is greater than 30% of the joint space, referral to an orthopedist is recommended. Splinting with strict use of the splint and avoidance of any flexion of the DIP joint is the recommended treatment, and is beneficial even with a delayed presentation. Athletic activities may be continued with the splint in place.

A 46-year-old female with a past medical history of polycystic ovary syndrome and migraine headaches presents with bilateral, hyperpigmented patches along her mandible. The patches are asymptomatic but bother her cosmetically and seem to be darkening. Which one of her medications would be most likely to contribute to her melasma? (check one) A. B-complex vitamins B. Metformin (Glucophage) C. Oral contraceptives D. Spironolactone (Aldactone) E. Sumatriptan (Imitrex)

Melasma is a progressive, macular, nonscaling hypermelanosis of skin exposed to the sun, typically involving the face and dorsal forearms. It is often associated with pregnancy and the use of oral contraceptives or anticonvulsants (SOR C). Some melasma is idiopathic. Women are nine times more likely to be affected than men, and darker-skinned individuals are also at greater risk. There are three common patterns of melasma: centrofacial, malar, and mandibular.

A 38-year-old female presents for ongoing management of type 2 diabetes mellitus, obesity, and chronic abdominal pain related to her history of recurrent pancreatitis. She says that her self-monitored blood glucose has been running in the range of 200-300 mg/dL on most occasions. She is not currently taking any medications but has tried metformin (Glucophage) and extended-release metformin (Glucophage XR) unsuccessfully in the past. On both occasions she experienced worsening abdominal pain and diarrhea. She does not feel she can manage insulin and requests an oral medication. Her hemoglobin A1c in your office today is 9.0%. In addition to lifestyle and nutrition counseling, which one of the following would be the best treatment at this time? (check one) A. Restart metformin B. Start empagliflozin (Jardiance) C. Start liraglutide (Victoza) D. Start sitagliptin (Januvia)

Metformin should be used as first-line therapy in type 2 diabetes to reduce microvascular complications, assist in weight management, reduce the risk of cardiovascular events, and reduce the risk of mortality in patients (SOR A). Patients who are intolerant of metformin are unlikely to be successful with a third trial of that agent. Empagliflozin, an SGLT2 inhibitor, is considered a second-line choice for patients who are intolerant of metformin. Both sitagliptin, a DPP-4 inhibitor, and liraglutide, a GLP-1 receptor agonist, should be avoided or used with caution in patients with a history of pancreatitis.

A 52-year-old male sees you for a routine health maintenance examination. He does not take any medications, does not drink alcohol, and is feeling well. A physical examination is normal with the exception of a BMI of 33 kg/m2. Routine laboratory studies reveal mild elevations of ALT (SGPT) and AST (SGOT), which remain elevated on repeat testing 2 months later. Hepatitis B and hepatitis C testing are negative. In addition to ultrasonography of the liver, which one of the following laboratory studies should be ordered to further evaluate this patient? (check one) A. Serum ferritin B. Serum phosphorus C. α-Fetoprotein D. Carcinoembryonic antigen (CEA) E. Serum protein electrophoresis

Mild asymptomatic elevations (<5 times the upper limit of normal) of ALT and AST are common in primary care. It is estimated that approximately 10% of the U.S. population has elevated transaminase levels. The most common causes of elevated transaminase levels are nonalcoholic fatty liver disease and alcoholic liver disease. The initial evaluation should include assessment for metabolic syndrome and insulin resistance. Waist circumference, blood pressure, a fasting lipid level, and a fasting glucose level or hemoglobin A1c should be obtained. A CBC with platelets and measurement of serum albumin, iron, total iron-binding capacity, and ferritin levels would also be indicated. Iron studies should be ordered to rule out hereditary hemochromatosis, which is an autosomal recessive disease that causes increased iron absorption in the intestines and release by tissue macrophages.

An 18-month-old male is brought to your office for a well child check. He is walking only with assistance. You and the parents are concerned about gross motor delay. Which one of the following findings would be most suggestive of muscular dystrophy in this patient? (check one) A. A cross-legged "scissoring" posturing B. Head lag when sitting up C. Hyperreflexia in the legs D. Partial hemiparesis of the lower extremities E. Toe walking

Some abnormal gross motor developmental findings suggest muscular dystrophy. Signs of increased muscular tone, such as cross-legged posturing, neck stiffness, and hyperreflexia, suggest a central cause of motor delay such as cerebral palsy. Head lag due to neck muscle weakness in infants is a classic early finding of muscular dystrophies. Hemiparesis similarly suggests a central nervous system abnormality. Toe walking can be seen with both central and peripheral neuromuscular abnormalities, including muscular dystrophy, but is less specific, and therefore less helpful, in differentiating the cause of motor delay. In muscular dystrophies it is a sign of quadriceps weakness.

A 4-year-old male is brought to your office for a well child examination. The patient has no significant medical history. The mother has noted new skin lesions first appearing on the back, with a new lesion behind the right knee. She has not used any new detergents or skin or hair care products. She has not made any changes in the patient's diet. The child does not have pruritus. The examination reveals a temperature of 37.2°C (99.0°F), a pulse rate of 80 beats/min, and a blood pressure within normal limits. The examination is unremarkable except for nonerythematous flesh-colored, dome-shaped papules with a central indentation, on the lower back and popliteal fossa. Which one of the following would be most appropriate for the initial management of this condition? (check one) A. Observation only B. Consistent use of emollients and avoiding frequent hot baths C. Use of a topical low-dose corticosteroid cream once daily until resolved D. Use of a topical antifungal cream until resolved E. Paring, followed by topical salicylic acid or cryotherapy

Molluscum contagiosum is a common disease during childhood, but can also occur in adolescents and adults. It is caused by a poxvirus and is characterized by flesh-colored, dome-shaped papules with central umbilication, most commonly on the trunk, axilla, popliteal or antecubital fossae, and crural folds. If lesions are asymptomatic and not inflamed, the initial treatment is observation, with most lesions resolving spontaneously within 2-12 months. If the lesions are inflamed or pruritic, then topical corticosteroid treatment, chemical treatment with cantharidin, podofilox 0.5% solution, curettage, or cryotherapy may be indicated. Atopic dermatitis (eczema) is initially treated with emollients and by avoiding frequent hot baths. Verruca (warts) are commonly treated with paring, followed by topical salicylic acid or cryotherapy. Antifungal cream would not be appropriate.

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

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

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

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

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

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

In addition to group B Streptococcus (GBS), which one of the following is the most common cause of neonatal sepsis? (check one) A. Escherichia coli B. Group A Streptococcus C. Listeria monocytogenes D. Staphylococcus aureus E. Streptococcus pneumoniae

Newborns with sepsis may have focal signs of infection such as pneumonia or respiratory distress syndrome, but they also may have nonfocal signs and symptoms. In the newborn period the two most common causes of neonatal sepsis are group B Streptococcus and Escherichia coli. Listeria monocytogenes was once a more common cause but it is now uncommon. Streptococcal pneumonia is an uncommon cause of sepsis in neonates. Staphylococcus aureus and group A Streptococcus are not as common but should be considered in newborns with cellulitis.

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

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

A 43-year-old male presents with a 6-week history of right ankle pain. The pain worsens with walking or running for a moderate distance and fails to improve with heat application or reduction of activity. He has been following a moderate cardiovascular exercise program for several years without problems and did not increase his physical activity before the onset of the pain. He does not recall any injury to the ankle. On examination the area of pain is localized in the right Achilles tendon proximal to its insertion. No swelling, redness, or deformity is apparent but tenderness is elicited with application of moderate fingertip pressure to the tendon. Which one of the following would be the most appropriate initial treatment? (check one) A. Use of a heel cup in the right shoe B. A 1-month course of daily NSAIDs at a prescription dosage C. An eccentric gastrocnemius-strengthening program D. A corticosteroid injection into the right Achilles tendon sheath E. Immobilization of the right ankle for 3 weeks with a boot

Pain located between the myotendinous junction and the insertion of the Achilles tendon that occurs during prolonged walking or running is typical for midsubstance Achilles tendinopathy. The mechanisms resulting in pain are complex and not fully understood but inflammation is believed to contribute little to the process. This is evidenced in part by the ineffectiveness of treatments typically used to reduce inflammation such as NSAIDs and corticosteroids, which are not recommended in the treatment of this condition (SOR A). Other commonly used musculoskeletal therapeutic modalities such as immobilization, ultrasonography, orthotics, massage, and stretching exercises have not been shown to consistently offer significant benefits and are not considered to be first-line therapy for Achilles tendinopathy. A gastrocnemius-strengthening eccentric exercise program performed in sets of controlled, slow, active release from weight-bearing full extension to full flexion of the foot at the ankle has been shown to reduce pain and improve function in the 60%-90% range, making this the logical first-line treatment for Achilles tendinopathy (SOR A). The less common insertional Achilles tendinopathy localized to the enthesis is typically more recalcitrant, and immobilization in a walking boot for a period of time may be necessary before eccentric exercise can be tolerated.

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

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

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

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

A 55-year-old male sees you for an annual health maintenance visit. He is a former smoker and has a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia. He had a normal colonoscopy at age 50, and had an ST-elevation myocardial infarction 2 years ago treated with a drug-eluting stent. He is currently asymptomatic and does not have any chest pain, hypoglycemia, dyspepsia, melena, or rectal bleeding. His medications include metformin (Glucophage), 2000 mg daily; glimepiride (Amaryl), 2 mg daily; bisoprolol (Zebeta), 5 mg daily; losartan/hydrochlorothiazide (Hyzaar), 50 mg/12.5 mg daily; rosuvastatin (Crestor), 20 mg daily; clopidogrel (Plavix), 75 mg daily; and aspirin, 81 mg daily. His blood pressure is 128/76 mm Hg and his heart rate is 63 beats/min. A physical examination is unremarkable. His hemoglobin A1c is 6.4%. You recommend that the patient stop taking (check one) A. aspirin B. clopidogrel C. aspirin and clopidogrel D. metformin

Patients with drug-eluting stents should be on dual antiplatelet therapy with aspirin plus a thienopyridine such as clopidogrel for a minimum of 1 year. At the time of this patient's visit, 2 years after the stent placement, there is no indication to continue clopidogrel, but aspirin therapy should be continued indefinitely. All of the patient's other medications have current active indications and should be continued, although if the patient experiences hypoglycemia, the sulfonylurea could be decreased or discontinued.

A 49-year-old male is concerned about lesions on his penis that he has noticed over the past 6 months. He was circumcised as a child and has had the same female sexual partner for 5 years. He does not have any pain, itching, or dysuria. On examination you note multiple reddish-blue papules on the scrotum and a few similar lesions on the shaft of the penis.The most likely diagnosis is (check one) A. pearly penile papules B. lichen nitidus C. lichen sclerosus D. angiokeratomas E. squamous cell carcinoma in situ (Bowen's disease)

Penile lesions are usually easily diagnosed from clinical findings. Pearly penile papules are common and benign, and present as small, skin-colored, dome-shaped papules in a circular pattern around the coronal sulcus. Lichen nitidus is benign but uncommon. It presents as discrete, pinhead-sized hypopigmented papules that are asymptomatic. Papules are often found scattered all over the penis, as well as on the abdomen and upper extremities. Lichen sclerosus is more common and appears as hypopigmented lesions with the texture of cellophane. The lesions are usually located on the glans or prepuce. Atrophy, erosions, and bullae are common, and patients often present with itching, pain, bleeding, and possibly phimosis or obstructed voiding. Lichen sclerosus is associated with squamous cell cancer in a small percentage of cases. Carcinoma in situ is a premalignant condition that is more common in uncircumcised males over age 60. Lesions are typically beefy red, raised, irregular plaques and can be found on the glans, meatus, frenulum, coronal sulcus, and prepuce. Lesions can be ulcerated or crusted. Pruritus and pain are common. A biopsy is important for making the diagnosis. Angiokeratomas are lesions that are usually asymptomatic, circumscribed, red or bluish papules. They may appear solely on the glans of the penis, but are also found on the scrotum, abdomen, thighs, groin, and extremities. They may be misdiagnosed as pearly papules or carcinoma. Treatment is not necessary unless the lesions are bleeding or extensive. It is important to realize that angiokeratomas on the shaft of the penis, the suprapubic region, or the sacral region can be associated with Fabry disease. Patients with this finding should be promptly referred.

A 45-year-old female presents with throbbing right-sided heel pain that started a few weeks ago. She says the pain is worst in the morning and seems to improve during the day but will return after a long day on her feet. She does not have a history of trauma, change in exercise, unexplained fever, or unintended weight loss. On examination the patient's vital signs are normal. You note pain on palpation of the right medial calcaneal tuberosity and along the plantar fascia, and pain with passive dorsiflexion of the right foot. The skin over the foot reveals no sign of trauma, lesions, or masses. Which one of the following is the most likely cause of this patient's heel pain? (check one) A. The heel spur B. A calcaneal stress fracture C. Heel pad syndrome D. Plantar fasciitis E. Sever's disease

Plantar fasciitis is the most common cause of heel pain, with a prevalence of 10% in the general population. It often presents with throbbing heel pain that is worst in the morning with the first step after rest. Palpation of the medial calcaneal tuberosity and dorsiflexion of the affected foot will elicit sharp pain. Diagnostic imaging is not required. Heel spurs are present in approximately 50% of patients with plantar fasciitis, but can also be found in patients without plantar fasciitis. Calcaneal stress fractures are caused by repetitive overuse and the pain usually begins after an increase in weight-bearing activities or a change in activities. It usually occurs only with activity, but may eventually also occur at rest. Heel pad syndrome causes pain with deep palpation of the middle of the heel or walking barefoot on harder surfaces. Sever's disease is the most common cause of heel pain in children and adolescents 8-12 years of age.

A 29-year-old gravida 2 para 1 comes to the hospital for scheduled induction of labor. Her last delivery was a spontaneous vaginal delivery without complications. Her pregnancy has been uneventful. Oxytocin (Pitocin) is used during induction according to the hospital protocol and her labor progresses without difficulty. Which one of the following should be AVOIDED to minimize the risk of postpartum hemorrhage in this patient? (check one) A. Administration of oxytocin with delivery of the anterior shoulder B. Controlled cord traction C. Active management of the third stage of labor D. Routine episiotomy E. Manual removal of a retained placenta

Postpartum hemorrhage (PPH) is the cause of one-fourth of maternal deaths worldwide and 12% in the United States. It is defined as the loss of 1000 mL of blood or the loss of blood with coinciding signs and symptoms of hypovolemia within 24 hours after delivery. Twenty percent of PPH occurs in patients without risk factors, so methods to prevent this common problem should be in place with every delivery. Active management of the third stage of labor (AMTSL) is crucial in the prevention of PPH. Administering oxytocin with or soon after the delivery of the anterior shoulder is the most important step of this process (SOR A). Even if oxytocin is used for induction, or as a part of AMTSL, it is still the most effective treatment for PPH (SOR A). Controlled cord traction is part of AMTSL and is necessary for the delivery of the placenta. If a retained placenta occurs it may be necessary to manually remove the placenta with necessary anesthesia. Trauma such as lacerations and episiotomies increases the risk of postpartum hemorrhage, so routine episiotomy should be avoided (SOR A).

A 38-year-old female with a 5-year history of diabetes mellitus has developed a "pins and needles" sensation in her feet. Which one of the following is considered first-line therapy for her condition? (check one) A. Acupuncture B. Lidocaine 5% spray C. Oxycodone (Roxicodone) D. Pregabalin (Lyrica) E. Venlafaxine (Effexor XR)

Pregabalin is considered first-line therapy for painful diabetic peripheral neuropathy (SOR A). Based on a meta-analysis, the American Academy of Neurology recommends pregabalin as first-line medication and gabapentin as a first-line alternative. While opioids such as oxycodone may provide a possible benefit in the treatment of neuropathy, the risk of dependency and adverse effects limits their use to patients with pain not relieved by first-line therapies. Acupuncture is not recommended as a first-line therapy due to the lack of high-quality, randomized, controlled trials. Venlafaxine and lidocaine 5% spray are considered second-line therapies.

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

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

A 63-year-old female is concerned about her long-term use of medication. She has been taking omeprazole (Prilosec), 20 mg daily for the past 4 months, and tells you that it works well to relieve her symptoms of heartburn and regurgitation. She notes, however, that if she misses a dose her symptoms return. You tell her that long-term proton pump inhibitor use is associated with which one of the following complications? (check one) A. Gastrointestinal malignancy B. Hip fracture C. Myocardial infarction D. Nephrotic syndrome E. Vitamin D deficiency

Proton pump inhibitors (PPIs) are safe and well tolerated for short-term use. It is recommended that the lowest dosage and shortest duration of therapy be used to control symptoms of GERD. Long-term PPI use is associated with fractures, hypomagnesemia, vitamin B12 deficiency, iron deficiency, and acute interstitial nephritis with progression to chronic kidney disease. Use of PPIs has also been associated with community-acquired pneumonia and Clostridium difficile infection, although studies have been conflicting. Vitamin D deficiency, nephrotic syndrome, gastrointestinal malignancy, and myocardial infarction are not proven complications of long-term PPI use.

A 40-year-old white female sees you for the first time. When providing a history she describes several problems, including anxiety, insomnia, fatigue, persistent depressed mood, and low libido. These symptoms have been present for several years and are worse prior to menses, although they also occur to some degree during menses and throughout the month. Her menstrual periods are regular for the most part. Based on this history, the most likely diagnosis is (check one) A. premenstrual dysphoric disorder B. menopause C. dysthymia D. anorexia nervosa E. dementia

Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with premenstrual dysphoric disorder, and must be ruled out before initiating therapy. Symptoms are cyclic in true premenstrual dysphoric disorder. The most accurate way to make the diagnosis is to have the patient carefully record daily symptoms on a menstrual calendar for at least two cycles. Dysthymia consists of a pattern of ongoing, mild depressive symptoms that have been present for at least 2 years and are less severe than those of major depression, which is consistent with the findings in this case.

A 64-year-old male with midsternal chest pain is brought to the emergency department by ambulance. He is on oxygen and an intravenous line is in place. Shortly after arrival he loses consciousness and becomes pulseless and apneic, and CPR is begun. Cardiac monitoring shows ventricular tachycardia with a rate of 160 beats/min. Which one of the following would be most appropriate at this point? (check one) A. Amiodarone, intravenous infusion, followed by synchronized cardioversion B. Adenosine (Adenocard), rapid intravenous push, repeated in 1-2 minutes if needed C. Epinephrine, intravenous push, followed by synchronized cardioversion D. Lidocaine (Xylocaine), intravenous push, repeated in 5 minutes if needed E. Defibrillation

Pulseless ventricular tachycardia (VT) should be treated the same as ventricular fibrillation. The first step is defibrillation. If that is unsuccessful, epinephrine is administered and defibrillation is reattempted. Lidocaine, adenosine, and procainamide may be used for the initial treatment of a wide-complex tachycardia of uncertain type, but should not be used for the initial treatment of pulseless VT. Synchronized cardioversion alone would be indicated for the initial treatment of rapid unstable tachycardia with a pulse.

A 1-day-old newborn is brought to your office for a routine examination. His parents report that he is well. The prenatal course and delivery were unremarkable. An examination is normal except for a 1-cm wide dimple on the sacrum, 1 cm superior to the anus. The dimple has a tuft of dark hair. At this point you would recommend: (check one) A. a follow-up examination in 1 month B. ultrasonography C. MRI D. a fistulogram/sinogram E. a dermatology consultation

Recognizing clinically significant abnormalities on the newborn examination is important. Newborns with small sacral dimples located far from the anal verge, without other skin findings such as hair, do not need imaging to rule out spinal dysraphism (tethered cord). While the exact parameters of what is considered large (>0.5 cm diameter) and close (within 2.5 cm of the anal verge) can easily be found in reference materials, the dimple described here is clearly concerning and needs imaging. Ultrasonography can accurately and safely detect spinal dysraphism in these cases.

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

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

A 17-year-old female comes to your office with an 8-month history of amenorrhea. Menarche occurred at age 12 and her menses were regular until the past year. On examination the patient's vital signs are in the normal range for her age but she has a BMI of 16 kg/m2, which is below the third percentile for her age. She is a high school senior who dances with the local ballet company. She practices dance several hours a day and works out regularly. She tells you that she follows a strict 800-calorie/day diet to keep in shape for ballet. You order a CBC, a comprehensive metabolic panel, a urine β-hCG level, FSH and LH levels, and a TSH level. Which one of the following is also recommended as part of the workup? (check one) A. An EKG B. Pelvic ultrasonography C. Abdominal/pelvic CT D. A DXA scan E. A nuclear bone scan

Relative energy deficiency in sport (RED-S), formerly known as the female athlete triad, is a relatively common condition in female athletes, and is characterized by amenorrhea, disordered eating, and osteoporosis. It is more common in sports that promote lean body mass. Female athletes should be screened for the disorder during their preparticipation evaluations. Individuals who present with one or more components of RED-S should be evaluated for the other components. This patient has a low BMI for her age, which indicates an eating disorder, and secondary amenorrhea, and should be screened for osteoporosis using a DXA scan. The International Society for Clinical Densitometry recommends using the Z-score, rather than the T-score, when screening children or premenopausal women. The T-score is based on a comparison to a young adult at peak bone density, whereas the Z-score uses a comparison to persons of the same age as the patient. A Z-score less than -2.0 indicates osteoporosis. The American College of Sports Medicine defines low bone density as a Z score of -1.0 to -2.0. An EKG is not required in this patient since she has normal vital signs. Pelvic ultrasonography is not necessary unless an abnormal finding is identified on a pelvic examination. Abdominopelvic CT would be inappropriate given the patient's age and lack of abdominopelvic symptoms such as pain or a mass. A nuclear bone scan likewise is not recommended, as it is not used to diagnose osteoporosis (SOR C).

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

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

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

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

Which one of the following comorbidities would falsely lower the hemoglobin A1c level in a patient with type 2 diabetes mellitus? (check one) A. Vitamin B12 deficiency B. Iron deficiency anemia C. Hemolytic anemia D. Chronic kidney disease E. A history of splenectomy

Several factors can alter the hemoglobin A1c value, including variability and erythrocyte lifespan. When the mean erythrocyte lifespan is increased by a condition such as asplenia, hemoglobin A1c increases because of increased RBC exposure time for glycation. Conversely, when the mean erythrocyte lifespan is decreased by conditions such as hemolytic anemia, hemoglobin A1c is decreased because of reduced RBC exposure time for glycation. Conditions that decrease erythropoiesis, such as iron deficiency anemia, increase the mean age of the RBC, thereby increasing hemoglobin A1c. Severe chronic kidney disease may increase RBC glycation through lipid peroxidase of hemoglobin and by extending the erythrocyte lifespan due to decreased erythropoietin levels, causing a false elevation of hemoglobin A1c. Vitamin B12 deficiency also decreases erythropoiesis and leads to falsely elevated hemoglobin A1c.

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

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

A 33-year-old gravida 3 para 2 presents for prenatal care 8 weeks after her last menstrual period. She asks if she will need any immunizations during this pregnancy. Which one of the following vaccines is recommended for all women with each pregnancy? (check one) A. 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13) B. Hepatitis B C. MMR D. Tdap E. Varicella

Tdap is recommended for all women with each pregnancy, preferably between 27 and 36 weeks gestation. Live vaccines such as varicella and MMR are contraindicated during pregnancy. There is inadequate data to recommend vaccination against pneumococcal disease during pregnancy. Hepatitis B vaccine is recommended during pregnancy only for women at high risk for infection.

A 54-year-old male is concerned about testosterone deficiency. He has erectile dysfunction with impaired erections and decreased libido. He has also noted hair loss on his legs, breast tenderness, and fatigue. He has chronic renal disease and compensated heart failure, and he takes opioids for chronic pain. Five years ago he had a non-ST-elevation myocardial infarction and has done well with medical management. The patient's morning testosterone level is low on two separate readings and you want to initiate testosterone replacement. Laboratory Findings: Estimated glomerular filtration rate 58 mL/min/1.73 m2 Creatinine 2.0 mg/dL (N 0.7-1.3) Hematocrit 55% (N 42-52) Prostate-specific antigen 3.9 ng/dL (N 0.0-4.0) Which one of the following is an ABSOLUTE contraindication to starting treatment with testosterone in this patient? (check one) A. The history of coronary artery disease B. Benign prostatic hyperplasia C. Chronic renal disease D. Compensated heart failure E. Polycythemia

Testosterone replacement has significant risks and contraindications. Absolute contraindications include breast cancer, prostate cancer, a prostate-specific antigen (PSA) level >4 ng/dL, an abnormal rectal examination with nodules, and polycythemia with a hematocrit >54%. Relative contraindications include a baseline hematocrit >50%, a desire for fertility, uncontrolled heart failure, untreated sleep apnea, and severe lower tract symptoms. This patient has polycythemia with a hematocrit >54% and should not be started on testosterone. Testosterone stimulates erythropoiesis and increases the risk of thrombosis. Although there may be an association between testosterone deficiency and coronary artery disease, a history of coronary artery disease is not a contraindication to testosterone replacement. Patients with chronic renal disease who are on chronic opioid therapy are at higher risk of developing secondary testosterone deficiency. Testosterone replacement may increase PSA levels and should not be used in patients with known or suspected prostate cancer.

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

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

According to the recommendations of the American Heart Association, which one of the following patients requires endocarditis prophylaxis? (check one) A. A 10-year-old female with a previous history of Kawasaki disease without valvular dysfunction B. A 22-year-old female who underwent surgical repair of a ventricular septal defect 1 year ago C. A 28-year-old female with mitral valve prolapse without regurgitation D. A 35-year-old female with a history of infectious endocarditis in her 20s that was related to intravenous drug use E. A 42-year-old female with a history of rheumatic fever with chorea who has normal cardiovascular findings

The American Heart Association and the American College of Cardiology have decreased the number of indications for antibiotic prophylaxis prior to dental procedures. Currently antibiotics are indicated for prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease or a repaired congenital defect with a residual shunt, and a cardiac transplant with valve regurgitation due to a structurally abnormal valve. Amoxicillin, 2 g, is the antibiotic prophylaxis of choice.

A U.S. hospital or birthing center seeking to be certified as "Baby-Friendly" by the Baby-Friendly Hospital Initiative must satisfy which one of the following criteria in addition to meeting other requirements? (check one) A. Demonstrating proper use of an infant car seat to parents prior to discharge B. Providing no other food or fluids to breastfeeding infants without a medical indication C. Providing a pacifier to each baby prior to discharge D. Providing easy access to a variety of infant formulas E. Providing on-site daycare facilities for staff

The Baby-Friendly Hospital Initiative is a global program established by UNICEF and WHO to promote healthy infant feeding and mother-baby bonding. The primary objective is to educate the public on the benefits of breastfeeding and encourage, promote, and facilitate breastfeeding as outlined in the UNICEF/WHO Ten Steps to Successful Breastfeeding chart. These steps promote breastfeeding to the public and provide guidelines for hospitals and birthing centers for the successful initiation and continuation of breastfeeding. Baby-friendly facilities must have a written breastfeeding policy that is routinely communicated to all health care staff, and all health care staff must be trained in the skills necessary to implement this policy. All pregnant women should be informed about the benefits and management of breastfeeding. Mothers should be helped to initiate breastfeeding within an hour after birth and shown how to breastfeed and to maintain lactation, even if they are separated from their infants. Breastfeeding infants should not be given food other than breast milk, unless medically indicated. If mothers choose to give formula after appropriate education, they should be instructed in proper preparation and use. Rooming in should be practiced, allowing mothers and infants to remain together 24 hours a day. Mothers should be encouraged to breastfeed on demand. Breastfeeding infants should not be given pacifiers or artificial nipples. Mothers should be referred to breastfeeding support groups on discharge from the hospital. In addition, the hospital must comply with the International Code of Marketing of Breast Milk Substitutes, which requires that formula companies cannot give free gifts to staff or mothers, that breast milk substitutes are not marketed in the maternity unit, and that breast milk supplements and infant feeding supplies are purchased at fair market price.

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

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

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

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

You are evaluating a 64-year-old female in the emergency department for pyelonephritis. Her past medical history is negative and she has previously been in good health. The patient appears acutely ill but is oriented. On examination her weight is 100 kg (220 lb), her temperature is 38.9°C (102.0°F), her pulse rate is 110 beats/min, her respiratory rate is 24/min, her blood pressure is 136/72 mm Hg, and her oxygen saturation is 94% on room air. Initial laboratory findings include a venous lactate level of 4.0 mmol/L (N 0.6-1.7).You decide to start normal saline intravenously. Which one of the following would be the most appropriate initial rate? (check one) A. 100 mL/hr B. 150 mL/hr C. 200 mL/hr D. 3000 mL over 30 minutes E. 3000 mL over 3 hours

The Surviving Sepsis Campaign recommends that patients with elevated serum lactate or hypotension receive isotonic intravenous fluids such as normal saline or lactated Ringer's solution at an initial rate of 30 mL/kg in the first 3 hours using small boluses of approximately 500 mL. A serum lactate value >36 g/dL (4 mmol/L) is correlated with increased severity of illness and poorer outcomes even if hypotension is not yet present. Patients who are hypotensive or whose serum lactate level is >36 g/dL require intravenous fluids or colloid to expand their circulating volume and effectively restore perfusion pressure. The administration of 30 mL/kg of fluid is recommended as a fluid challenge, which should be started as early as possible in the course of septic shock.

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

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

A 29-year-old male smoker presents with a 10-day history of a cough. He also had a low-grade fever for 2 days that has resolved. He has had some mild rhinorrhea and has noted that the cough has become productive of greenish sputum over the past 3-4 days. He has not tried any medication. An examination reveals some mild rhinorrhea but his lungs are clear. Which one of the following would be most appropriate at this point? (check one) A. Supportive care only B. A chest radiograph C. Albuterol (Proventil, Ventolin) D. Antibiotic therapy E. An inhaled corticosteroid

The defining symptom of acute bronchitis is cough. Even in smokers the etiologic agent is viral at least 90% of the time, so antibiotics are not indicated. Unless wheezing is noted, albuterol is not helpful. Inhaled corticosteroids are used in maintenance therapy for asthma. Indications for an adult patient with acute bronchitis to have a chest radiograph include: bloody sputum, rusty-colored sputum, or dyspnea; a pulse rate >100 beats/min; a respiratory rate >24/min; or a temperature >37.8°C (100.0°F). A chest radiograph is also indicated if there are abnormal findings on a chest examination such as fremitus, egophony, or focal consolidation. Supportive care is made easier by informing the patient that symptoms are likely to last 2-3 weeks. Symptoms may be managed with measures such as dextromethorphan, guaifenesin, or honey.

A 4-year-old male presents with a 3-day history of sores on his right leg. The sores began as small red papules but have progressed in size and now are crusting and weeping. Otherwise he is in good health and is up to date with immunizations. On examination he has three lesions on the right anterior lower leg that are 0.5-1.5 cm in diameter, with red bases and honey-colored crusts. There is no regional lymphangitis or lymphadenitis. Which one of the following is the preferred first-line therapy? (check one) A. Oral erythromycin (Erythrocin) B. Oral penicillin V C. Topical hexachlorophene (pHisoHex) D. Topical mupirocin (Bactroban)

The lesions described are nonbullous impetigo, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area. Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs. Penicillin V and hexachlorophene have both been shown to be no more effective than placebo. Topical antibiotics have been shown to be as effective as erythromycin, which has a common adverse effect of nausea.

A 7-month-old male is admitted to the hospital for respiratory syncytial virus bronchiolitis. His temperature is 37.9°C (100.2°F), pulse rate 160 beats/min, respiratory rate 70/min, and oxygen saturation 92% on room air. Auscultation of the lungs reveals diffuse wheezing and crackles accompanied by nasal flaring and retractions. Which one of the following interventions would most likely be beneficial? (check one) A. Bronchodilators B. Corticosteroids C. Epinephrine D. Nasogastric fluids E. Oxygen supplementation to maintain O2 saturation above 95%

The mainstay of therapy for acute respiratory syncytial virus bronchiolitis is supportive care, and maintaining hydration is important. Infants with respiratory rates >60/min may have poor feeding secondary to difficulty breathing and oral rehydration may increase the risk of aspiration. In these cases, nasogastric or intravenous fluids should be administered. Oxygen saturation of 90% or more on room air is sufficient for infants with bronchiolitis, and using supplemental oxygen to maintain higher oxygen saturations only prolongs hospitalization because of an assumed need for oxygen. Bronchodilators should not be administered to infants with bronchiolitis, because they have not been shown to have any effect on the need for hospitalization, oxygen saturation, or disease resolution. In addition, there is no evidence to support the use of epinephrine or corticosteroids in the inpatient setting.

A 69-year-old male presents for follow-up of hypertension treated with spironolactone (Aldactone) and amlodipine (Norvasc). His past medical history is remarkable only for a kidney stone several years ago. A physical examination is unremarkable. A comprehensive metabolic panel is unremarkable except for a calcium level of 12.0 mg/dL (N 8.0-10.0). Which one of the following is the most likely cause of his elevated calcium level? (check one) A. Excessive ingestion of calcium supplements B. His current medication regimen C. Occult malignancy D. Primary hyperparathyroidism E. Vitamin D deficiency

The most common cause of hypercalcemia is hyperparathyroidism. This is seldom symptomatic and is often discovered through routine blood testing. Hypercalcemia due to cancer can be caused by secretion of the parathyroid hormone-related protein and by osteoclastic bone resorption. Other causes of hypercalcemia include thiazide diuretics, lithium, vitamin D intoxication, hyperthyroidism, milk alkali syndrome from excessive calcium antacid ingestion, adrenal insufficiency, and lymphoma.

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

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

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

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

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

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

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

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

A 25-year-old female at 31 weeks gestation presents to the labor wing with painful uterine contractions every 3 minutes. On examination her cervix is 3 cm dilated and 50% effaced. Her membranes are intact and fetal heart monitoring is reassuring. She is treated with tocolysis, betamethasone, antibiotics, and intravenous hydration, and cultured for group B Streptococcus. The neonatal intensive care unit is notified, but the contractions ease and eventually stop. After 2 days of observation, her cervix is unchanged and she is discharged home. One week later, the patient presents with contractions for the last 8 hours. Her cervical findings are unchanged. Her group B Streptococcus culture was negative. Which one of the following would be the most appropriate next step in the management of this patient? (check one) A. Repeat tocolysis, betamethasone, antibiotics, and intravenous hydration B. Betamethasone, antibiotics, and intravenous hydration only C. Antibiotics and intravenous hydration only D. Tocolysis only E. Expectant management

The purpose of obstetric management of preterm labor before 34 weeks gestation is to allow time to administer corticosteroids. Treatment does not substantially delay delivery beyond 1 week. Repeated administration of corticosteroids does not confer more benefit than a single course. Antibiotics are administered for prophylaxis of group B Streptococcus and are useful for delaying delivery if membranes are ruptured. They do not add any benefit otherwise, even though subclinical amnionitis may be a causative factor in many cases of preterm labor. Prolonged and repeated tocolysis is believed to be harmful. Tocolysis would not be indicated in this patient because she has had no cervical change and is therefore having preterm contractions, not preterm labor. Careful monitoring for fetal compromise, consultation with obstetric colleagues, and neonatal intensive-care unit involvement should be part of expectant management of preterm labor cases.

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

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

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

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

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

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

Fibromyalgia is characterized by tender trigger points (check one) A. along the medial border of each scapula B. bilaterally at the anatomic snuffbox C. at the insertion of the Achilles tendon into the posterior heel D. at the second and third web spaces on the plantar surface of the foot

The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees. Tenderness of the anatomic snuffbox, Achilles tendons, or web spaces of the toes would most likely be related to another diagnosis.

A 64-year-old female with hypertension, diabetes mellitus, hyperlipidemia, and chronic kidney disease has had headaches that have been escalating over the past 6 months and are associated with double vision and ataxia. Her medications include lisinopril (Prinivil, Zestril) and atorvastatin (Lipitor). She weighs 61 kg (135 lb) and her blood pressure is 144/64 mm Hg. A basic metabolic panel is normal except for a creatinine level of 2.1 mg/dL (N 0.6-1.1) and an estimated glomerular filtration rate of 26 mL/min/1.73 m2.You decide to order MRI of the brain. Which one of the following would be most appropriate with regard to the use of gadolinium contrast in this patient? (check one) A. Use of gadolinium if the patient's blood pressure is controlled to a goal systolic pressure of <130 mm Hg B. Use of gadolinium if the patient is pretreated with n-acetylcysteine and intravenous normal saline C. Use of gadolinium if lisinopril is stopped 48 hours before the MRI D. Avoiding the use of gadolinium contrast

The use of gadolinium contrast has been associated with acute kidney injury and also with the development of nephrogenic systemic sclerosis in patients with stage 4 or 5 chronic kidney disease. Because of these risks, the FDA recommends avoiding gadolinium contrast in patients with a glomerular filtration rate <30 mL/min/1.73 m2, as well as in patients with acute renal failure. The risk of nephrogenic systemic sclerosis is not affected by blood pressure, medications, intravenous hydration, or pretreatment with n-acetylcysteine.

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

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

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

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

A 52-year-old male presents with a swollen and tender area anterior to the left ear and extending to below the left angle of the mandible. One week ago he had a Nissen fundoplication for intractable GERD. This was complicated by difficulty swallowing and drinking. On examination his tympanic temperature is 37.7°C (99.9°F), his blood pressure is 110/70 mm Hg, and his pulse rate is 95 beats/min and regular. His left parotid gland is diffusely enlarged and tender. Purulent material is noted coming from the left parotid duct orifice. Which one of the following would be most appropriate at this point? (check one) A. Amoxicillin/clavulanate (Augmentin) B. Penicillin C. CT of the parotid gland D. Incision and drainage of the parotid gland E. Excision of the parotid gland

This case is typical for acute parotitis, which is commonly caused by dehydration and can be diagnosed from the history and examination. Empiric treatment is directed toward gram-positive and anaerobic organisms, with the most common pathogen being Staphylococcus. These are often penicillin resistant so a β-lactamase inhibitor is the agent of choice. Treatment should be followed up with cultures. Administration of sialagogues such as lemon drops may be helpful, as well as parotid gland massage. CT or MRI may help confirm the diagnosis but imaging is usually not necessary. The history and clinical examination are most important for making the diagnosis. Incision and drainage would be appropriate only for an abscess, and surgical removal of the parotid gland is not indicated.

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

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

A 69-year-old male presents with acute right hip pain, which has been worsening over the past week and is now causing difficulty walking. He has had occasional hip pain in the past but this is more severe than previous episodes. He has no history of trauma and he feels well otherwise. His medical history includes hypertension, hyperlipidemia, osteoarthritis, and psoriasis. His current medications include lisinopril/hydrochlorothiazide (Zestoretic), aspirin, and adalimumab (Humira). An examination reveals normal vital signs and a BMI of 29 kg/m2. The joint is not red or swollen. There is no tenderness over the greater trochanter, groin, or buttock. Active and passive range of motion of the hip is limited in all directions due to pain. A radiograph shows mild degenerative changes of the hip joint. A C-reactive protein level is mildly elevated. Which one of the following would be indicated at this point to rule out a serious cause of joint pain? (check one) A. A radionuclide bone scan B. Arthrocentesis C. CT D. MR arthrography E. MRI

This patient has a history and physical examination concerning for septic arthritis, which is a rheumatologic emergency due to the potential for joint destruction. Joint swelling, redness, and warmth may accompany the pain but these are more difficult to detect at the hip than the knee. Systemic symptoms such as fever may occur but are absent in more than 40% of patients, particularly elderly patients and those who are immunocompromised. Risk factors for septic arthritis include underlying joint disease such as rheumatoid arthritis or osteoarthritis, and immunosuppressive states such as HIV infection, diabetes mellitus, and taking immunosuppressive medications. This patient has a history of osteoarthritis and is taking adalimumab, an immunosuppressive agent. Although there may be clues to the diagnosis of septic arthritis on imaging and laboratory assessment, the diagnostic test of choice is analysis of synovial fluid obtained through arthrocentesis. A radionuclide bone scan, CT, MR arthrography, and MRI are not sensitive enough to rule out septic arthritis.

A 50-year-old gravida 2 para 2 who is 3 years post menopausal presents with fatigue, headache, galactorrhea, and loss of libido. Your evaluation reveals elevated serum prolactin and a pituitary adenoma of 5-6 mm.You recommend (check one) A. bromocriptine (Parlodel) B. estrogens C. haloperidol D. testosterone E. neurosurgical consultation

This patient has a pituitary microadenoma. Microadenomas <10 mm in size that are secreting prolactin may be treated with a dopaminergic agent such as bromocriptine. This will lower the prolactin level and shrink the adenoma. Nonprolactin-secreting adenomas, especially those >10 mm in size (macroadenomas), require neurosurgical evaluation.

A 63-year-old female sees you for evaluation of recurrent right foot swelling and redness. She has a history of obesity and type 2 diabetes with retinopathy, nephropathy, and peripheral neuropathy. She presented with similar symptoms 2 weeks ago and was diagnosed with cellulitis and treated with a 10-day course of amoxicillin/clavulanate (Augmentin). Her symptoms seemed to initially improve with this therapy along with elevation of the foot but then worsened. She does not have any pain in the foot, fever, or chills. She does not recall any trauma or other inciting event. The patient's vital signs include a temperature of 37.1°C (98.8°F), a pulse rate of 72 beats/min, and a blood pressure of 124/82 mm Hg. Her right foot appears swollen, red, and warm to the touch, and is not tender to palpation. There are no open sores or calluses. Her dorsalis pedis pulse is 2+. Monofilament testing confirms a diagnosis of peripheral neuropathy. A WBC count is normal. Radiographs reveal soft-tissue edema with no other abnormalities. The most appropriate treatment at this point would be: (check one) A. immobilization B. antibiotics C. biphosphonates D. corticosteroids E. surgical repair

This patient has acute Charcot neuroarthropathy, an inflammatory condition that occurs in obese patients with peripheral neuropathy and ultimately leads to foot deformities (the classic rocker-bottom foot) and resultant ulcerations and infections. Its clinical appearance can easily be initially mistaken for cellulitis. However, the absence of tenderness and other signs of infection such as fever, an elevated WBC count, and inflammatory markers is not consistent with cellulitis. Radiography is an appropriate initial imaging modality but the results are often interpreted as normal early in the disease process. MRI is the modality of choice for a definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent soft-tissue edema, joint effusion, and microtrabecular or stress fractures. The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which increases the total surface area of contact to the entire lower extremity, distributing pressure away from the foot. Immobilization is typically required for at least 3-4 months but in some cases may be needed for up to 12 months. Bisphosphonates were found to be ineffective as adjunctive therapy in acute Charcot neuroarthropathy. Corticosteroids and antibiotics have no role in the treatment of Charcot foot but would be appropriate therapy for cellulitis or gout, which are important alternative diagnoses to consider. The role of surgery is more controversial but may be indicated in the acute phase of Charcot neuroarthropathy in patients with severe dislocation or instability.

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

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

A 32-year-old female sees you for evaluation of hair loss. On examination she has a smooth, circular area of complete hair loss on her scalp with no other skin changes. Which one of the following would you recommend? (check one) A. An oral antifungal agent B. Topical minoxidil (Rogaine) C. Topical immunotherapy D. Topical corticosteroids E. Intralesional corticosteroids

This patient has alopecia areata, which is a chronic, relapsing, immune-mediated inflammatory disorder affecting hair follicles that results in patchy hair loss. The treatment of choice is intralesional corticosteroid injections. Topical immunotherapy is reserved for patients with extensive disease, such as >50% scalp involvement. Topical corticosteroids are less effective and are usually reserved for children and adults who cannot tolerate intralesional injections. Minoxidil is used for androgenetic alopecia and is less effective for alopecia areata. Oral antifungal drugs are used to treat tinea capitis.

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

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

A 47-year-old male presents with a 3-day history of fever, chills, low back pain, and urinary frequency. He does not have any nausea, vomiting, or abdominal pain. There is no significant past medical history. The patient's vital signs include a temperature of 38.1°C (100.6°F), a pulse rate of 88 beats/min, and a respiratory rate of 14/min. The examination reveals a mildly tender lower abdomen with no guarding or rebound tenderness; no costovertebral angle tenderness; and an enlarged, homogeneous, exquisitely tender prostate. Which one of the following is indicated to help guide this patient's treatment? (check one) A. A serum prostate-specific antigen level B. A culture of prostate secretions after massage of the prostate C. A culture of midstream voided urine D. CT of the abdomen and pelvis with intravenous and oral contrast E. An ultrasound-guided prostate biopsy

This patient has clinically diagnosable acute bacterial prostatitis, and no further testing, including imaging, is required to establish the diagnosis. Culture of a midstream voided urine may aid in identifying the pathogen, but prostate massage should be avoided because it may increase the risk of bacteremia. A prostate biopsy is not indicated in the presence of acute infection, and a prostate-specific antigen level is not indicated because it is likely to be elevated in the presence of infection.

A 50-year-old female sees you for follow-up of her hypertension. At her last visit 4 weeks ago you started her on lisinopril (Prinivil, Zestril), 10 mg daily, because of a blood pressure of 158/92 mm Hg and confirmed hypertension on ambulatory blood pressure monitoring. She is tolerating the medication well and has no side effects. She does not take any other medications. Today her blood pressure is 149/90 mm Hg, which you confirm on repeat measurement. This is also consistent with her home measurements. At her last visit a basic metabolic panel was normal. You repeat a basic metabolic panel today and the results are normal except for a BUN of 25 mg/dL (N 8-23) and a creatinine level of 1.5 mg/dL (N 0.6-1.1). At her last visit her BUN was 12 mg/dL and her creatinine level was 0.7 mg/dL. Which one of the following would be most appropriate at this time? (check one) A. Continue her current treatment regimen B. Increase lisinopril to 20 mg daily C. Continue lisinopril at the current dosage and add amlodipine (Norvasc), 5 mg daily D. Discontinue lisinopril and begin amlodipine, 5 mg daily E. Discontinue lisinopril and begin losartan (Cozaar), 25 mg daily

This patient has essential hypertension and her goal blood pressure is <140/90 mm Hg based on JNC 8 guidelines, or 130/80 mm Hg based on the more recent recommendations of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Until recently, it was recommended that physicians should tolerate a rise of <30% in serum creatinine after ACE inhibitor or angiotensin receptor blocker (ARB) initiation. Rises in serum creatinine of >30% from baseline increase the risk of renal failure, adverse cardiac outcomes, and death. A recent study suggests that rises in serum creatinine of <30% also put patients at risk for these outcomes, with a dose-response relationship between the magnitude of creatinine change and the risk of adverse outcomes. This patient has more than a 30% rise in creatinine and has no other factors, such as diabetes mellitus, heart failure, or chronic kidney disease, that would indicate a need for ACE or ARB therapy for her hypertension. Discontinuing her ACE inhibitor and starting a medication from a different class is the most appropriate treatment at this time. Based on JNC 8 guidelines, additional options for blood pressure medications include thiazide diuretics and calcium channel blockers.

A 52-year-old male smoker presents to your office in January with worsening respiratory symptoms over the past 24 hours, along with a rapid onset of fever and chills, nausea, myalgias, and sore throat. He has a history of mild chronic bronchitis and hypertension, and his medications include tiotropium (Spiriva) inhaled daily; lisinopril/hydrochlorothiazide (Zestoretic), 20/12.5 mg daily; and albuterol (Proventil, Ventolin) as needed. On examination the patient has a temperature of 38.8°C (101.8°F), a heart rate of 102 beats/min, a respiratory rate of 24/min, and an oxygen saturation of 94% on room air. He is ill-appearing and pale. Examination of his throat reveals mild erythema, and chest auscultation reveals bilateral bronchovesicular breath sounds with no crackles or wheezing. The examination is otherwise unremarkable. Laboratory and radiology services are not available. Which one of the following would be most appropriate at this point? (check one) A. Observation only, with follow-up in a few days B. Azithromycin (Zithromax) C. Oseltamivir (Tamiflu) D. Penicillin VK E. Prednisone

This patient has findings consistent with influenza, including a rapid onset of fever, nausea, and sore throat, and negative pulmonary findings. Influenza is considered a clinical diagnosis and confirmation of the diagnosis with laboratory testing is not required. Treatment of influenza is recommended for individuals at a high risk of influenza-related complications. High-risk individuals include those with chronic lung disease; cardiovascular (excluding hypertension), renal, hepatic, hematologic, or neurologic disease; or age >65. Children on long-term aspirin therapy, and pregnant and postpartum women are also considered high risk. This patient should be treated with antiviral medication because of his chronic pulmonary disease. While pneumonia and streptococcal pharyngitis should be considered in the differential diagnosis, these are less likely given the examination findings, and antibiotics are not recommended. Prednisone is not indicated for influenza-like illness and may cause harm.

A 45-year-old female has a history of intermittent asthma and her only medication is an albuterol (Proventil, Ventolin) inhaler. Over the past 2 months her asthma has limited her activities. She is using her inhaler daily and waking up at night once or twice a week with a cough. Which one of the following would be the preferred medication to control her asthma? (check one) A. Fluticasone (Flovent) B. Salmeterol (Serevent Diskus) C. Fluticasone/salmeterol (Advair) D. Montelukast (Singulair)

This patient has intermittent asthma that has become at least moderate persistent as defined by the frequency of her symptoms. The National Asthma Education and Prevention guidelines recommend a moderate-dose inhaled corticosteroid (ICS) with a long-acting bronchodilator as the preferred treatment in moderate persistent asthma. Fluticasone/salmeterol at a dosage of 250/50 μg is the only option that fits this category. Montelukast alone is an alternative treatment for mild persistent asthma (SOR A).

A 42-year-old female presents with shortness of breath that has slowly worsened over the past 6 months. She can now walk only 10 feet without becoming short of breath. She does not have a cough or chest pain. Her history is significant only for obesity. She smoked one pack of cigarettes per day for 20 years and quit smoking 6 years ago. Her blood pressure is 138/88 mm Hg, pulse rate 92 beats/min, respiratory rate 18/min, and oxygen saturation 92% on room air. Her BMI is 42 kg/m2. Her heart has a regular rate and rhythm with no murmurs and her lungs are clear to auscultation. Her lower extremities have bilateral 1+ edema. A chest radiograph is normal. Spirometry reveals a decreased FVC with a normal FEV1/FVC ratio. A CBC, a TSH level, and a basic metabolic panel are all normal except for a serum bicarbonate level of 35 mEq/L (N 22-29). These findings are most consistent with (check one) A. asthma B. COPD C. obstructive sleep apnea D. obesity hypoventilation syndrome E. pulmonary fibrosis

This patient has obesity hypoventilation syndrome (OHS), a disorder in which central obesity leads to chronic hypoventilation due at least in part to restricted diaphragm excursion. Current criteria for this condition include hypoventilation leading to carbon dioxide retention (PaCO2 >45 mm Hg) in an individual with a BMI > 30 kg/m2 when other causes of chronic alveolar hypoventilation have been ruled out. These patients retain bicarbonate to compensate for the respiratory acidosis. It has been suggested that an increased serum bicarbonate level (>29 mEq/L) in the absence of another cause for metabolic alkalosis should be included in the definition of OHS.OHS leads to a restrictive pattern on spirometry, which this patient has. Asthma and COPD are obstructive lung diseases and can therefore be ruled out in this patient who has no signs of airway obstruction on spirometry. Obstructive sleep apnea is often present in patients with OHS, but sleep apnea alone does not lead to daytime hypoventilation and carbon dioxide retention. Pulmonary fibrosis is a cause of restrictive lung disease and has not yet been completely ruled out in this patient, but a normal chest radiograph makes this less likely. Comprehensive pulmonary function testing, including the diffusion capacity of the lung for carbon monoxide (DLCO), would help rule this out. Pulmonary fibrosis leads to a decreased DLCO while OHS does not.

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

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

A 26-year-old male presents with a rash on his anterior neck in the area of his beard that has been present for over a year. On examination he has dark, curly facial hair, and you find slightly tender, red, hyperpigmented papules on the superior anterior neck. Which one of the following would you recommend to improve this patient's rash? (check one) A. Shaving with a multi-blade razor B. Shaving with electric clippers C. Pulling the skin taut while shaving D. Plucking hairs rather than shaving E. Oral cephalexin (Keflex)

This patient has pseudofolliculitis barbae, which is a common condition affecting the face and neck in people with tightly curled hair. The condition occurs when hairs are cut at an angle and curl in on themselves, creating a foreign body reaction. The condition may progress to scarring and keloid formation. Cessation of hair removal improves the condition. If this is not desired, less aggressive hair trimming is recommended. Clippers generally result in a less close shave and contribute less to pseudofolliculitis barbae. Multi-blade razors, pulling the skin taut, and plucking hairs all result in shorter hair and are likely to exacerbate the problem. The description of the rash is not consistent with secondary infection, so oral cephalexin would not be indicated at this time. Treatment is similar to the treatment of acne, with benzoyl peroxide, topical retinoids, and topical antibiotics having a role, along with topical corticosteroids.

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

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

A 45-year-old male presents to your office with a 2-month history of a nonproductive cough, mild shortness of breath, fatigue, and a 5-lb weight loss. On examination his lungs are clear. A PPD skin test is negative. A chest radiograph shows bilateral hilar adenopathy and his angiotensin converting enzyme level is elevated. A biopsy of the lymph node shows a noncaseating granuloma. Which one of the following would be the most appropriate initial treatment? (check one) A. Azathioprine (Imuran) B. Fluconazole (Diflucan) C. Isoniazid D. Levofloxacin (Levaquin) E. Prednisone

This patient has sarcoidosis that has been confirmed by a biopsy. He is symptomatic so treatment would be indicated. The recommended initial treatment for sarcoidosis is oral corticosteroids. Anti-infective agents are not appropriate treatment for sarcoidosis. Immunosuppressants are second- and third-line therapy for sarcoidosis and would not be recommended as first-line treatment.

A 60-year-old Chinese female asks you about being tested for osteoporosis. She is postmenopausal and has never used hormone therapy. She does not consume dairy products because she has lactose intolerance. She is on no medications, is otherwise healthy, and has no history of falls or fractures. Her mother had osteoporosis and vertebral compression fractures. Her BMI is 20 kg/m2 . Which one of the following tests would be best to determine whether this patient has osteoporosis? (check one) A. A central DXA scan of the lumbar spine and hips B. A forearm DXA scan C. Quantitative CT of the lumbar spine D. Quantitative calcaneal ultrasonography E. Measurement of biochemical markers of bone turnover in the urine

This patient has several risk factors for osteoporosis: Asian ethnicity, low body weight, positive family history, postmenopausal status with no history of hormone replacement, and low calcium intake. The best diagnostic test for osteoporosis is a central DXA scan of the hip, femoral neck, and lumbar spine. Quantitative CT is accurate, but cost and radiation exposure are issues. Peripheral DXA and calcaneal sonography results do not correlate well with central DXA. Measurement of biochemical markers is not recommended for the diagnosis of osteoporosis.

A 54-year-old male comes to your office to establish care. He has a past history of hypertension treated with lisinopril (Prinivil, Zestril) and hydrochlorothiazide but has not taken his medications for over a year. He does not have any symptoms, including chest pain, shortness of breath, or headache. On examination his blood pressure is 200/115 mm Hg on two separate readings taken 5 minutes apart. The remainder of the physical examination is normal. Which one of the following management options would be most appropriate? (check one) A. Institute out-of-office monitoring with an ambulatory device and follow up in 2 weeks B. Restart the patient's previous antihypertensive medications and follow up within 1 week C. Administer a short-acting antihypertensive medication in the office to lower his blood pressure to <160/100 mm Hg D. Hospitalize for hypertensive emergency

This patient has severe asymptomatic hypertension (systolic blood pressure 180 mm Hg or diastolic blood pressure 110 mm Hg). If there were signs or symptoms of acute target organ injury, such as neurologic deficits, altered mental status, chest pain, shortness of breath, or oliguria, hospitalization for a hypertensive emergency would be indicated. Because this patient was asymptomatic and has a known history of hypertension, restarting his prior antihypertensive regimen and following up in 2 weeks would be the most appropriate management option. If he had no past history of hypertension it would be reasonable to consider out-of-office monitoring with an ambulatory device for 2 weeks before initiating treatment. In the absence of acute target organ injury, blood pressure should be gradually lowered to less than 160/100 mm Hg over several days to weeks. Aggressively lowering blood pressure can lead to adverse events such as myocardial infarction, cerebrovascular accident, or syncope, so administering a short-acting antihypertensive medication in the office should be reserved for the management of hypertensive emergencies.

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

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

A 62-year-old female who is a new patient requests a thyroid evaluation because she has a history of abnormal thyroid test results. You obtain a copy of her records, which include a TSH level of 0.2 μU/mL (N 0.4-4.2) and a free T4 level of 2.0 ng/dL (N 0.8-2.7) from 3 years ago. She reports feeling well and has no other health conditions. She does not take any medications. A physical examination reveals normal vital signs, a BMI of 23 kg/m2, no neck masses, a normal thyroid size, and normal heart sounds. Laboratory studies reveal a TSH level of 0.1 μU/mL, a free T4 level of 2.5 ng/dL, and a free T3 level of 3.1 pg/mL (N 2.3-4.2).Treatment for this condition would be indicated if the patient has an abnormal (check one) A. calcium level B. DXA scan C. glucose level D. lipid level E. thyroid ultrasonography study

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

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

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

A 22-year-old female presents to your office for evaluation of nasal and sinus congestion, frequent sneezing, and itchy red eyes. These symptoms have been present 5-7 days per week for the past 6 months. She has had similar symptoms in the past but they have never lasted this long. She moved into a new home 2 months ago. There are no animals in the house. She has tried over-the-counter fexofenadine (Allegra) with only partial relief of symptoms. Which one of the following would be the most appropriate recommendation at this time? (check one) A. Use of a mite-proof impermeable pillow cover B. Intranasal saline irrigation C. Intranasal azelastine (Astepro) D. Intranasal budesonide (Rhinocort) E. CT of the sinuses

This patient has symptoms consistent with allergic rhinitis, and the presence of symptoms more than 4 days per week and for more than 4 weeks places her into the persistent symptoms category. In addition to allergen avoidance and patient education, an intranasal corticosteroid should be the first-line treatment for allergic rhinitis with persistent symptoms (SOR A). The Choosing Wisely recommendations from the American Academy of Otolaryngology-Head and Neck Surgery Foundations include avoiding sinonasal imaging in patients with symptoms limited to a primary diagnosis of allergic rhinitis. Impermeable pillow or mattress covers are often recommended but there is no evidence of any benefit (SOR A). Intranasal saline irrigation is beneficial and can be used as monotherapy for mild intermittent symptoms, but intranasal corticosteroids are likely to provide more benefit for more persistent symptoms. Intranasal antihistamines such as azelastine are more expensive, less effective, and more likely to produce adverse effects than intranasal corticosteroids, so they are not recommended as first-line therapy (SOR B).

An 18-month-old female is brought to your office in January for evaluation of a cough and fever. She has no chronic medical conditions. She abruptly developed a barking cough and hoarseness with a low-grade fever 2 days ago. The cough is worse at night. She has been drinking normally but is not interested in eating. On examination she is alert and resists the examination. Her respiratory rate and effort are normal. She has no stridor or wheezing. Which one of the following would be most appropriate at this point? (check one) A. A nasal swab for influenza testing B. A chest radiograph C. A single dose of oral dexamethasone D. Azithromycin (Zithromax) E. Oseltamivir (Tamiflu)

This patient has symptoms consistent with croup, a lower respiratory infection that is common in the winter months in children ages 6 months to 3 years. The diagnosis is clinical and should be suspected in children with a history of a sudden onset of a deep cough, hoarseness, and a low-grade fever. Randomized studies have shown that even with mild croup (an occasional barking cough with no stridor at rest), oral corticosteroids provide some benefit. A Cochrane review of two randomized trials with a total of 2024 patients found that chest radiographs did not change the outcome of ambulatory children with lower respiratory tract infections. A patient such as this would not need antiviral treatment for influenza.

While sitting in the waiting room a patient develops the acute onset of diffuse hives, itching, and flushing; swelling of the lips, tongue, and uvula; and bilateral wheezing. He becomes weak and almost passes out. Which one of the following would be the most appropriate immediate treatment? (check one) A. Corticosteroids B. Diphenhydramine (Benadryl) C. Epinephrine D. Glucagon E. Normal saline

This patient has symptoms of anaphylaxis. Symptoms include an acute onset (minutes to several hours); involvement of the skin, mucosal tissue, or both; plus one of the following: respiratory compromise (dyspnea, wheezing, bronchospasm, stridor, reduced peak expiratory flow, hypoxemia), reduced blood pressure, or associated symptoms of end-organ dysfunction (hypotonia, collapse, syncope, incontinence). The first and most important treatment in anaphylaxis is intramuscular epinephrine, 1:1000 dilution dosed at 0.01 mg/kg (maximal dose of 0.3 mg in children and 0.5 mg in adults) (SOR B). Management of the airway, breathing, and circulation is also essential (SOR B). Other essential treatments include volume replacement with normal saline for the treatment of hypotension that does not respond to epinephrine (SOR B). Histamine H1-receptor antagonists such as diphenhydramine and corticosteroids may be considered as second-line treatments in patients with anaphylaxis (SOR C). Glucagon can be considered for patients who are taking β-blockers.

A 48-year-old female presents with dyspnea with exertion. She has never smoked. A physical examination is normal, including vital signs and pulse oximetry. A chest radiograph reveals mild hyperexpansion of the chest, and pulmonary function testing reveals an FEV1/FVC ratio of 0.67, unchanged after bronchodilator use. An EKG and stress echocardiogram are normal. You suspect COPD. Which one of the following is the most likely underlying cause of this patient's pulmonary disease? (check one) A. Allergic bronchopulmonary aspergillosis B. α1-Antitrypsin deficiency C. Hemochromatosis D. Primary pulmonary hypertension E. Hypertrophic obstructive cardiomyopathy

This patient is a nonsmoker but has typical symptoms and findings of COPD. α1-Antitrypsin deficiency should be considered in patients with very premature COPD or in patients without risk factors for COPD such as smoking, secondhand smoke exposure, or other smoke exposure. Dyspnea would be present and lung function would be normal in patients with primary pulmonary hypertension or hypertrophic obstructive cardiomyopathy. Hemochromatosis may cause liver function abnormalities but not abnormal lung function. Allergic bronchopulmonary aspergillosis is associated with asthma, not COPD.

An elderly male presents with a shallow, irregularly shaped ulceration over the medial aspect of his right lower leg between the lower calf and medial malleolus. There is some surrounding edema with pigment deposition over the lower leg. He reports aching and burning pain in the lower leg with daytime swelling. His symptoms improve with leg elevation. You make a diagnosis of venous stasis ulcer. Which one of the following would be the most appropriate management? (check one) A. The use of foam dressings rather than other standard dressings B. The use of silver-based antiseptic products even if there is no infection C. Compression therapy D. A 3-week course of systemic antibiotics

This patient likely has a venous stasis ulceration. The use of compression therapy with a pressure of 30-40 mm Hg is the mainstay of treatment. There is no evidence for the use of systemic antibiotics for lower-extremity ulcerations. Likewise, there is no evidence to support the use of either silver-based or honey-based preparations in ulcerations with no infection. Foam dressings are no more effective than other standard dressings.

A 65-year-old male brings in results from a health fair screening. He was advised to see you because he had a hemoglobin level of 10.2 g/dL (N 14.0-18.0) and a mean corpuscular volume of 80 μm3 (N 80-94). A review of systems is unremarkable except for recent fatigue, and a physical examination is also unremarkable. You order laboratory testing, with the following results: Ferritin 15 ng/mL (N 20-150) Vitamin B12 420 pg/mL (N 200-900) Folate 12 ng/mL (N 2-20) Reticulocyte index 0.3% (N 0.5-1.0) The most likely diagnosis is (check one) A. iron deficiency anemia B. vitamin B12 deficiency C. anemia of chronic disease D. hemolysis E. myelodysplastic anemia

This patient most likely has iron deficiency anemia. The low normal mean corpuscular volume, low serum ferritin, and low reticulocyte index are all consistent with iron deficiency. Vitamin B12 deficiency would be indicated by low vitamin B12 and a macrocytic anemia. Serum ferritin would be higher with anemia of chronic disease and myelodysplastic anemia. The reticulocyte index would be high with hemolysis.

A 45-year-old electrician presents to your office with concerns about a bump on his left elbow. He does not recall any injury. The bump is painful to touch but causes no other symptoms. He is worried because it has been consistently present for at least a month. On examination the patient is afebrile. He has a 4-cm movable fluctuant mass at the tip of his left olecranon that is slightly tender to touch. There is no warmth or erythema and he has full range of motion of his elbow. There is no other joint involvement. Which one of the following would you recommend? (check one) A. No further evaluation B. Laboratory testing, including a CBC with differential C. Plain radiography D. Ultrasonography E. Aspiration

This patient presents with chronic olecranon bursitis. The diagnosis can be made based on his history and the physical examination. No other testing is indicated at this time. Chronic bursitis is due to repetitive microtrauma. The olecranon is the most common location for chronic bursitis. Patients typically have no history of injury, minimal pain, no systemic symptoms, and no signs of acute infection or inflammation. Treatment initially consists of avoiding recurrent trauma by protecting the area (elbow pad), not leaning on it, ice, compression, and over-the-counter analgesics. If the lesion is inflamed or appears septic then laboratory testing should be performed, including a CBC with differential, a glucose level, an erythrocyte sedimentation rate, and a C-reactive protein level. Joint aspiration and/or ultrasonography may be indicated if the diagnosis is not apparent. A plain radiograph would be indicated to rule out a fracture in a patient with traumatic bursitis.

A 33-year-old gravida 2 para 2 presents with a 1-year history of amenorrhea, hot flashes, and vaginal dryness. She previously had normal menses and takes no medications. Her past medical and surgical histories are negative. The patient is 178 cm (70 in) tall and her BMI is 22 kg/m2. Her vital signs are normal. A physical examination is normal except for vaginal dryness. Laboratory studies reveal a negative urine pregnancy test, normal TSH and prolactin levels, and elevated LH and FSH levels. The most likely diagnosis is (check one) A. intrauterine synechiae (Asherman syndrome) B. functional hypothalamic amenorrhea C. polycystic ovary syndrome D. primary ovarian insufficiency E. Turner's syndrome

This patient presents with secondary amenorrhea. The differential diagnosis includes polycystic ovary syndrome (PCOS), intrauterine synechiae (Asherman syndrome), functional hypothalamic amenorrhea, hypothyroidism, hyperprolactinemia, and primary ovarian insufficiency (also known as premature ovarian failure). This patient's presentation and the laboratory findings are most consistent with a diagnosis of primary ovarian insufficiency. This is defined as menopause before the age of 40 due to ovarian follicular depletion. Laboratory findings will usually reveal a low serum estradiol and elevated FSH and LH levels. This condition is different than menopause because of the age of presentation and the unpredictability of long-term ovarian function (up to 10% of cases spontaneously remit and patients have a temporary return of fertility). Patients with PCOS typically present with obesity, difficulty conceiving, and normal or low FSH and LH levels. This patient's normal weight and prior history of normal menses make this diagnosis less likely. Intrauterine synechiae is characterized by scar tissue inside the uterus. Risk factors include intrauterine procedures, pregnancy, inflammation, and infection. Patients present with abnormal uterine bleeding, recurrent pregnancy loss, dysmenorrhea, and infertility. FSH and LH levels are usually normal. Functional hypothalamic amenorrhea is characterized by suppression of the hypothalamic-pituitary-ovarian axis, usually due to extreme stress, excessive exercise, marked weight loss, and/or dysfunctional eating. LH and FSH levels are usually low or low-normal. Turner's syndrome is caused by the 45,X genotype, and patients have short stature, a webbed neck, a low hairline, and cardiac abnormalities. This is unlikely in a patient who is 178 cm (70 in) tall and has a normal examination.

A 34-year-old male has a 3-day history of a runny nose, postnasal drainage, sinus congestion, and left-sided facial pain. He also reports a mild cough and difficulty sleeping due to the congestion. He is afebrile and the examination reveals inflammation of the nasal mucosa, purulent rhinorrhea, and mild left maxillary sinus tenderness to percussion. Which one of the following would be the most appropriate pharmacotherapy? (check one) A. Amoxicillin/clavulanate (Augmentin) B. Levofloxacin (Levaquin) C. Loratadine (Claritin) D. Mometasone (Nasonex)

This patient presents with symptoms of acute rhinosinusitis. In the first 3-4 days, viral and bacterial rhinosinusitis are indistinguishable. Guidelines from the American Academy of Otolaryngology—Head and Neck Surgery suggest that antibiotics should not be routinely prescribed for acute mild to moderate sinusitis unless symptoms persist for 7 days or worsen after initial improvement. Watchful waiting without antibiotic treatment is appropriate when follow-up is accessible (SOR A). In this scenario antibiotic therapy is not indicated. Amoxicillin with or without clavulanate is appropriate for symptoms lasting 7 or more days without improvement and is the first-line antibiotic treatment for acute bacterial rhinosinusitis (SOR A). Due to the risk of adverse effects and no benefit over β-lactams, respiratory fluoroquinolones are not considered first-line antibiotic therapy. Symptomatic treatment is recommended within the first 10 days of the onset of symptoms and may be continued if antibiotics are started. Intranasal corticosteroid use has a modest therapeutic benefit for patients with acute rhinosinusitis. Decongestants and antihistamines have not been proven effective for the treatment of acute rhinosinusitis.

A 62-year-old white male with a 3-month history of diabetes mellitus has a hemoglobin A1c of 7.8%. Which one of the following is the best parameter for determining if he can safely take metformin (Glucophage)? (check one) A. 24-hour urine for creatinine clearance B. BUN/creatinine ratio C. Estimated glomerular filtration rate D. Serum creatinine E. Urine microalbumin

Until recently metformin was contraindicated for patients with renal dysfunction suggested by a creatinine level of 1.5 mg/dL for men and 1.4 mg/dL for women. However, available evidence now supports the use of metformin in individuals with mild to moderate chronic renal disease, defined by the estimated glomerular filtration rate (eGFR). Patients with an eGFR between 45 and 60 mL/min/1.73 m2 (chronic mild kidney disease) are now permitted to take metformin. Metformin should not be used in patients with an eGFR <45 mL/min/1.73 m2 (moderate kidney disease), as lactic acidosis is more likely to occur. The eGFR is used instead of the serum creatinine level because the equation includes age, sex, race, and other parameters.

A healthy 49-year-old female presents to your office for a routine health maintenance visit. Since her last visit a year ago she has had only two menstrual periods. She reports sudden sensations of extreme heat in her face, neck, and chest that last just a few minutes but occur throughout the day. These symptoms are very bothersome and interfere with the quality of her sleep. Which one of the following would you recommend to relieve her symptoms? (check one) A. Black cohosh B. Combined estrogen and progesterone C. Compounded bioidentical hormones D. Micronized progesterone

This patient presents with typical vasomotor symptoms that can begin in perimenopause and affect sleep quality. Hormone therapy is the gold standard for treatment of vasomotor symptoms. Combination estrogen and progesterone therapy is highly effective for vasomotor symptoms and provides protection against uterine neoplasia. Although micronized progesterone decreases vasomotor symptoms there are no long-term studies to assess the safety of progestin-only treatment for menopausal symptoms. Compounded bioidentical hormone therapy creates safety concerns and is not a first-line therapy due to limited government regulation and monitoring, the potential for overdosing and underdosing, impurities or lack of sterility, and the lack of labeling describing risks. Testosterone alone is not FDA-approved for use in women. Additionally, it has not been shown to be beneficial for treatment of vasomotor symptoms in combination with hormone therapy and is associated with significant side effects. It may be useful for hypoactive sexual desire in postmenopausal women. There is insufficient data to recommend the use of herbal remedies such as black cohosh.

A 58-year-old male with a history of tobacco and alcohol abuse presents with the sudden onset of many well circumscribed brown, oval, rough papules with a "stuck-on" appearance on his trunk and proximal extremities. On examination you also note an unintentional 6-kg (13-lb) weight loss over the last 3 months and conjunctival pallor. A review of systems is positive for more frequent stomachaches, decreased appetite, and mild fatigue. You order a laboratory workup. Which one of the following would be most appropriate at this point? (check one) A. Reassurance that the skin lesions are benign B. A skin biopsy C. Referral to a dermatologist D. CT of the abdomen and pelvis E. Upper and lower endoscopy

This patient's age, risk factors, red-flag symptoms, and other clinical findings indicate the need for endoscopy. The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic keratoses, which is an unusual finding that often indicates an underlying malignancy, most commonly an adenocarcinoma of the stomach. CT is not an initial approach for diagnosing a suspected malignancy of the stomach or colon. Further skin evaluation and lifestyle changes, which are indicated, will not address the need for evaluation of weight loss and other abnormal symptoms and findings.

A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There are no other historical or physical examination findings to suggest active tuberculosis infection and a chest radiograph is normal. Which one of the following would be most appropriate at this point? (check one) A. Monitoring with annual tuberculin skin testing B. Observation and repeat tuberculin skin testing in 3 weeks C. Isoniazid daily for 9 months D. Pyrethrins 0.33%/pipernyl butoxide 4% (RID) E. Once-weekly isoniazid and rifampin for 3 months

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

A 14-year-old male is brought to your office with a 2-month history of a lump in his left chest. An examination reveals a slightly tender 2-cm area of concentric firm mobile tissue under the left areola. He has no skin changes, nipple discharge, or associated adenopathy. The right side is unremarkable. A genital examination reveals Tanner 3 development but is otherwise unremarkable. Growth curves are appropriate for the patient's age, with a BMI of 19 kg/m2. Which one of the following would be most appropriate at this point? (check one) A. Follow-up in 6-12 months B. A prolactin level C. Ultrasonography of the left breast D. Tamoxifen (Soltamox), 10 mg/day for 3 months E. A biopsy

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

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

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

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

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

When titrating the dosage of opioids, the CDC recommends that you should also consider prescribing naloxone when the opioid dosage reaches what morphine milligram equivalent (MME) per day threshold? (check one) A. 30 B. 50 C. 80 D. 90 E. 100

To mitigate the risk of opioid harm, it is essential to understand morphine milligram equivalents (MME).The evidence shows that the risk of an opioid overdose increases at the threshold of 50 MME/day. It istherefore recommended by the CDC that a prescription for naloxone be ordered when an opioid dosagereaches 50 MME/day, which is a high dosage. In general one should avoid prescribing greater than or equal to 90 MME/daybecause of the substantially higher risk of an overdose at this dosage level.

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

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

An otherwise healthy 42-year-old male presents to your office with low back pain that started a week ago after he lifted a heavy box. Since the time of his injury he has been having consistent pain, numbness, and tingling that radiates down the back of his right leg to his calf. Which one of the following would you order at this time? (check one) A. No imaging B. Plain radiography C. CT D. MRI

Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition and early imaging is associated with worse overall outcomes and is likely to identify minor abnormalities even in asymptomatic patients. Imaging for acute low back pain should be reserved for cases that are suspicious for cauda equina syndrome, malignancy, fracture, or infection. In the absence of red flags such as progressive motor or sensory loss, new urinary retention or overflow incontinence, a history of cancer, a recent invasive spinal procedure, or significant trauma relative to age, imaging is not warranted regardless of whether radiculopathy is present, unless symptoms persist despite a trial of at least 6 weeks of medical management and physical therapy.

The drug class of choice for the management of breathlessness in end-of-life care is (check one) A. anticholinergics B. antipsychotics C. benzodiazepines D. corticosteroids E. opiates

When administered at appropriate doses, opiates do not reduce or compromise respiratory status and do not hasten dying. Opiates help to reduce the sense of air hunger in patients with dyspnea. The use of opiates for palliative therapy in advanced pulmonary disease is supported by clinical guidelines from the American Thoracic Society.

A 30-year-old white male presents to the emergency department with a 4-day history of fever to 101°F, a sore throat, rhinorrhea, and cough. An examination reveals rhinorrhea and a boggy nasal mucosa, but is otherwise unremarkable. A chest radiograph shows a questionable infiltrate. Which one of the following would help determine if antibiotic treatment would be appropriate? (check one) A. A C-reactive protein level B. A procalcitonin level C. A WBC count with differential D. An erythrocyte sedimentation rate E. CT of the chest

Using a procalcitonin-guided therapy algorithm reduces antibiotic use by 3.47 days without increasing either morbidity or mortality in adults with acute respiratory infections. If the procalcitonin level is <0.10 mg/dL, a bacterial infection is highly unlikely and it is strongly recommended that antibiotics not be prescribed. If the procalcitonin level is 0.10-0.24 mg/dL a bacterial infection is still unlikely and it is recommended that antibiotics not be used. If the level is 0.25-0.50 mg/dL a bacterial infection is likely and antibiotics are recommended. It is strongly recommended that antibiotics be given if the level is >0.50 mg/dL, because a bacterial infection is very likely.

An asymptomatic 42-year-old female sees you for a routine evaluation. On examination her uterus is irregularly enlarged to the size seen at approximately 8 weeks gestation. Pelvic ultrasonography shows several uterine fibroid tumors measuring <5 cm. The patient does not desire future fertility. Which one of the following would be the most appropriate management option? (check one) A. Observation only B. An oral contraceptive C. A gonadotropin-releasing hormone (GnRH) agonist D. Laparoscopic myomectomy E. Hysterectomy

Uterine fibroid tumors (leiomyomas) are the most common tumors of the female reproductive tract, with some evidence suggesting that the cumulative incidence in women age 25-45 years is approximately 30%. Symptoms related to fibroids can include menorrhagia, pelvic pain, obstructive symptoms, infertility, or pregnancy loss. However, many fibroids are asymptomatic and are discovered incidentally, with observation being the preferred management in this situation (SOR B). The risk of malignant leiomyosarcoma is exceedingly small (0.23% in one study) and there is a risk of side effects or complications from other treatment modalities. For women who are symptomatic, the data is insufficient regarding the most appropriate therapy. Surgical options include myomectomy, hysterectomy, uterine artery embolization, and myolysis, but data to allow direct comparison is lacking. With the exception of trials of GnRH-agonist therapy as an adjunct to surgery, there is not enough randomized trial data to support the use of medical therapies such as oral contraceptives, NSAIDs, or progestins in the treatment of symptomatic fibroids.

A 29-year-old female presents with redness of her left eye. She has just returned from a summerbeach vacation with her children and woke up with a red eye. Your examination reveals a watery discharge, a hyperemic conjunctiva, and a palpable preauricular lymph node. Her cornea is clearon fluorescein staining. Which one of the following is most appropriate for this patient? (check one) A. Reassurance only B. Culture-guided antibiotic therapy C. Quinolone eyedrops D. Corticosteroid/antibiotic eyedrops E. Urgent ophthalmologic referral

Viruses cause 80% of infectious conjunctivitis cases and viral conjunctivitis usually requires no treatment. Bacterial conjunctivitis is associated with mattering and adherence of the eyelids. Topical antibiotics reduce the duration of bacterial conjunctivitis but have no effect on viral conjunctivitis. Allergic conjunctivitiswould be more likely if the patient reported itching. Antibiotics or corticosteroids would not be helpful inthis patient, and would not prevent complications.The majority of cases of viral conjunctivitis are caused by adenoviruses, which cause pharyngealconjunctival fever and epidemic keratoconjunctivitis. Pharyngeal conjunctival fever is characterized by highfever, pharyngitis, and bilateral eye inflammation. Keratoconjunctivitis occurs in epidemics, and isassociated with a watery discharge, hyperemia, and ipsilateral lymphadenopathy in >50% of cases.

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

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